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Volume 94-B, Issue SUPP_XXXIX September 2012 British Orthopaedic Association/Irish Orthopaedic Association Annual Congress (BOA/IOA)

J Ramaskandhan A Malviya R Bowman E Lingard J Holland


Cemented stems have shown 90–100% survivorship when coupled with polyethylene acetabular component. This study aims to compare cemented stem behaviour in combination with large metal on metal (MOM) vs. metal on poly (MOP) bearings.

Patients and Methods

100 patients were recruited into a single centre RCT (we required 40 in each group for power .90 to confirm stem subsidence of >0.5mm at 2 years; p< 0.05). Recruits were randomized to MOP (28mm) or MOM femoral heads with CPCS cemented femoral stem. Assessments included X-rays (AP pelvis), Harris Hip Scores, blood metal ion levels and patient questionnaires (WOMAC, SF-36, satisfaction questionnaire). Evaluations were done pre-operatively and 3, 12 and 24 months post operatively; blood metal ion measures at 1 year.

JE Higgins AR Pearce M Price KS Conn GJ Stranks JM Britton


Large head total hip arthroplasty (THA) reduces dislocation rates and provides a theooretically larger range of motion. We hypothesised that this would translate into greater improvement in functional scores when compared to 28mm metal-on-polyethylene THA at 5 years. We believe ours to be the first in vivo comparison study.


A multi-surgeon case-control study in a District General Hospital. The study group consisted of 427 patients with 452 hips, the 38mm uncemented metal-on-metal articulation THA (M2A/Bi-metric, Biomet UK). The control group consisted of 438 age and sex-matched patients with 460 28mm metal-on-polyethylene articulation THA (Exeter/Exeter or Exeter/Duraloc - Stryker UK. All patients were assessed in a physiotherapist led Joint Review Service as part of their standard follow up, with functional scoring using Oxford Hip (scored 0–48) and WOMAC scores (0–100).

DJ Langton J Ghandi RP Sidaginamale P Mereddy TJ Joyce J Lord S Natu A Nargol


We conducted independent wear analysis of retrieved metal on metal (MoM) hip components from around the world. All patients with resurfaced hips who developed adverse reactions to metal debris (ARMD) were found to have increased wear of the bearing surfaces. This was untrue in patients with large diameter (?36mm) MoM total hip replacements. This led us to search for other factors leading to ARMD.


MoM THR explants retrieved from 78 patients suffering ARMD underwent full volumetric wear analysis of bearing surface and taper-junctions using coordinate measuring machine. Scanning electron microscopy (SEM) used to characterise material composition of specific areas.

BJRF Bolland DJ Culliford DJ Langton JPS Millington NK Arden JM Latham

This study reports the mid-term results of a large bearing hybrid metal on metal total hip replacement (MOMHTHR) in 199 hips (185 patients) with mean follow up of 62 months. Clinical, radiological, metal ion and retrieval analysis were performed.

Seventeen patients (8.6%) had undergone revision, and a further fourteen are awaiting surgery (defined in combination as failures). Twenty one (68%) failures were females. All revisions and ten (71%) awaiting revision were symptomatic. Twenty four failures (86%) showed progressive radiological changes.

Fourteen revision cases showed evidence of adverse reactions to metal debris (ARMD). The failure cohort had significantly higher whole blood cobalt ion levels (p=0.001), but no significant difference in cup size (p=0.77), inclination (p=0.38) or cup version (p=0.12) compared to the non revised cohort. Female gender was associated with increased risk of failure (p=0.04). Multifactorial analysis demonstrated isolated raised Co levels in the absence of symptoms or XR changes were not predictive of failure (p=0.675). However the presence of pain (p<0.001) and XR changes (p<0.001) in isolation were significant predictors of failure. Wear analysis (n=5) demonstrated increased wear at the trunnion/head interface (mean out of roundness measurements 34.5 microns (normal range 8–10 microns) with normal wear levels at the articulating surfaces. Macroscopically corrosion was evident at the proximal and distal stem surfaces. Cumulative survival rate, with revision for any reason was 92.4% (95%CI: 87.4–95.4) at 5 years. Including those awaiting surgery, the revision rate would be 15.1% with 89.6% (95% CI: 83.9–93.4). Cumulative survival at 5 years.

This MOMHTHR series has demonstrated unacceptable high failure rates with evidence of high wear at the head/trunnion interface and passive corrosion to the stem surface. Female gender was an independent risk factor of failure. Metal ion levels remain a useful aspect of the investigation work up but in isolation are not predictive of failure.

J Smith P Railton D Kinniburgh P Faris L David D Marshall B Burkart J Powell

In a cross sectional cohort study three different metal on metal total hip systems were assessed. Two monoblock acetabular designs; the Durom socket (Zimmer, Warsaw, In) and the Birmingham socket (Smith and Nephew, Memphis, TN), and one modular metal on metal total hip system (Pinnacle, Depuy Orthopaedics, Warsaw, In) in patients who have received these implants in the our region. 56 patients were recruited in total. All patients were assessed clinically, radiologically and biochemically. Whole blood Cobalt, Chromium and titanium levels were tested.

The median head size used in the Birmingham group was 52mm (Range 44mm to 56mm), and in the Durom group, 48mm (Range 42 to 54mm). The median head size used in the modular Pinnacle group was 40mm (Range 36–44mm).

The blood metal ions levels in the larger non modular acetabular sockets were significantly raised compared to the Pinnacle group. For Co 1.95 µg/l and 2.70 µg/l in the Durom and Birmingham groups respectively compared to only 0.52 µg/l in the Pinnacle group (P< 0.001). Mean Cr levels were the same for the two monoblock systems, 1.9 µg/l compared to the Pinnacle sockets 1.2 µg/l (P< 0.001).

Our study clearly demonstrates that there is a significant difference in metal ion levels in patients following a monobloc large head arthroplasty system compared to a smaller modular metal on metal hip arthroplasty. The smaller head size appears to produce less metal ions whilst at the same time a 36mm–44mm head size is large enough to increase hip stability and range of movement as well as decreasing the risk of impingement. In our practice we are no longer using this design and the safest strategy, when considering metal on metal bearings, is to use a modular, smaller head system such as the Pinnacle.

D Woodnutt K Hamelynck

The ACCIS system comprises a bearing of a 5 micron surface ceramic upon a Chrome Cobalt Molybdenum (CrCoMo) substrate which allows for a homogeneous couple. The Titanium Niobium Nitride (TiNbN) microceramic applied by Plasma Vapour Deposition. In comparison with CrCoMo alloy, TiNbN gives a hard (2800 vs 489V), smooth (0.23 vs 0.55Rz), low friction (0.079–0.1 vs 0.11–0.56mu pin on disk test), wetable surface which when combined allows for the potential of gaining fluid film lubrication (lambda>3) on a smaller head diameter than an untreated surface. These properties are postulated to reduce wear and hence lower the release of Cr and Co ions in vivo. The surface microceramic also prevents exposure to release of Cr and Co by corrosion. The surface modified implants were first used in 2003 in large head arthroplasty and later in 2005 with resurfacing implants. Two series of patients implanted by a single surgeon were examined to elucidate the metal ion release of the ACCIS system. The first series retrospectively examined 52 consecutive Large Head Arthroplasty cases for [Cr], [Co] and [Mo] levels. A mean follow-up time of 7.5 yrs (77–101mths) with 9 patients being lost to revision and death by the time of the study. Median levels of [Cr] 1.6, [Co] 4.76 and [Mo] 2.5 µg/l were obtained. The second series prospectively examined the [Cr] and [Co] levels with the pre-operative values as controls in 125 resurfacing cases with the ACCIS microceramic. The second series gave no rising trend observed at up to 5 years ([Cr & Co] (range < 0.5–1.6 µg/l). It is postulated that the ACCIS surface microceramic reduces wear and also reduces the effective patch size for a given load thus allowing for a greater Patch to Edge Distance allowing a greater tolerance to cup positioning. A RCT is currently underway.

JN Gandhi RP Sidaginamale PK Mereddy D Langton T Joyce J Lord S Natu A Nargol


The failure and subsequent withdrawal of the ASR device in both its resurfacing and THR form has been well documented. The National Joint Registry report of 2010 quoted figures of 12–13% failure at five years. Adverse reaction to metal debris (ARMD) is a poorly understood condition and patients developing severe metal reactions may go unrecognised for sometime.

Patients and Methods

In 2004 a single surgeons prospective study of the ASR bearing surface was undertaken. We present the ARMD failure rates of the ASR resurfacing and ASR THR systems. The diagnosis of ARMD was made by the senior author and was based on clinical history, examination, ultrasound findings, metal ion analysis of blood and joint fluid, operative findings and histopathological analysis of tissues retrieved at revision. Mean follow up was 52 months (24–81) and 70 patients were beyond 6 years of the procedure at the time of writing. Kaplan Meier survival analysis was carried out firstly with joints designated “failure” if the patient had undergone revision surgery or if the patient had been listed. A second survival analysis was carried out with a failure defined as a serum cobalt > 7µg/L. Full explant analysis was carried out for retrieved prostheses.

P Mereddy RP Sidaginamale JN Gandhi D Langton R Logishetty N Cooke A Nargol


Adverse reaction to metal debris (ARMD) is an increasingly recognised complication of metal-on-metal hip arthroplasty. A previous study described poor results following revision and recommended early intervention1. We determined the outcome of revision for ARMD and present the largest case series to date.


Between 2005 and 2010, 98 patients (101 hips) underwent revision for ARMD. The diagnosis of ARMD was based on clinical history, examination, appearance at revision and histology. Patients were reviewed at 3, 6 and 12 months and annually thereafter. Patient satisfaction, Harris hip scores (HHS) and metal ions were analysed.

B Purbach BM Wroblewski PD Siney PA Fleming PR Kay

The C-Stem in its design as a triple tapered stem, is the logical development of the original Charnley flat-back polished stem. The concept, design and the surgical technique cater for a limited slip of the stem within the cement mantle transferring the load more proximally.

Five thousand two hundred and thirty three primary procedures using a C-stem have been carried out since 1993. We reviewed all 621 cases that had their total hip arthroplasty before 1998.

Sixty nine patients (70 hips) had died and 101 hips had not reached a ten-year clinical and radiological follow-up and had not been revised. Thirty-two hips had been revised before 10 years, none were revised for aseptic stem loosening and no stems. The indications for revision were Infection in 4, dislocation in 3, aseptic cup loosening in 24 and unexplained pain in 1.

The remaining 418 hips had a mean follow-up of 12 years (range 10–15 years). There were 216 women and 173 men, and 34 patients had bilateral LFAs. The patients' mean age at surgery was 53 years (range 16–83 years). Thirty four hips had been revised at the time of review. The reasons for revision were infection in 5, dislocation in 2, aseptic cup loosening in 24 and 1 for neuralgia paraesthetica where the stem was well fixed. Two hips were revised for stem fracture.

There were no revisions for stem loosening but 2 stems were revised for fracture - both with a defective cement mantle proximally. The clinical results are very encouraging and they support the concept of the Charnley cemented low friction arthroplasty, but place a demand on the understanding of the technique and its execution at surgery.

B Bloch D Angadi S Brown E Crawfurd


286 patients underwent total hip arthroplasty with a cemented titanium femoral implant (Ultima, Johnson & Johnson) between July 1995 and July 2001. The acetabular component was either a porous coated cup or a cemented all-polyethylene cup. A 28mm cobalt chromium head was used in all patients. Patients were prospectively evaluated with clinical examination, Harris hip scores and radiographic assessment. Analysis of the data was performed.


Of the 286 patients, 11 patients were excluded from analysis for reasons including incomplete data (8) and death (3). The remaining 275 patients were comprised of 118 males and 157 females with an average age of 70.8 years (55–89 years). The average follow up was 10.5 years (1.03–14.23). The median follow up was 10 years. 177 cemented all-polyethylene and 98 porous coated acetabular cups were used. The average Harris hip scores were 34.4 and 81.25 for preoperative and last follow up visit respectively. 11 stems were revised (aseptic loosening 9, infection 2). Radiographic assessment showed vertical subsidence in 30 patients (10.9%) (>5mm in 6 and < 5mm in 24 patients). Complete cement-bone radiolucency was noted in 11 stems (4%). Radiolucent lines covering < 50% of cement-bone interface were noted in 18 stems (6.5%). There were no cases of cement fracture. Kaplan-Meier survivorship was 91% at 10 years & 89.8% at 12 years.

S Mehmood H Gill D Murray S Glyn-Jones


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.

M Hossain D Beard D Murray G Andrew


Acetabular cup lucency predicts cup survival. The relationship of subchondral plate removal and cup survival is unclear. Using data from a prospective study conducted between January 1999 and January 2002 we investigated the role of subchondral plate removal in cemented acetabular cup survival at five years.


A number of cemented cups were implanted using antero-lateral and posterior approaches.1400 cups were inserted. 935 cups (67%) were followed up at 5 years and acetabular radiolucency (AR) recorded.

S Jameson A Bottle P Aylin M Reed M Walters K Lees M Maze R Sanders


There is a lack of information on the independent preoperative predictors of perioperative mortality, including the influence of previous stroke and acute coronary syndromes (myocardial infarction + unstable angina, ACS). Previous studies have grouped variables under the umbrella term “ischaemic heart disease”. In this study, we investigated the influence of vascular risk factors separately.


The Hospital Episode Statistics database was analyzed for elective admissions for total hip (THR) and total knee (TKR) replacements between 2004 and 2009. Independent preoperative predictors of perioperative outcome were identified from admission secondary diagnosis codes. Perioperative mortality was defined as 30-day in-hospital death. Logistic regression analysis was used to identify independent predictors of 30-day mortality. Data was adjusted for age, social deprivation and Charlson co-morbidity score.

M Hossain D Beard G Andrew


There is uncertainty about the relationship between improvement in range of motion (ROM) and functional outcome or patient satisfaction after total hip arthroplasty (THA). Using data from a prospective multi-centre study we investigated this relationship.


We recorded the Oxford Hip Score (OHS), Merle d'Aubigne and Postel score (MDA) and range of motion (ROM) preoperatively and at one and five years and a patient satisfaction questionnaire at five years. Complete 5 year data were available for 342 patients.

RJ Holleyman PD Gikas P Tyler P Coward R Carrington J Skinner T Briggs J Miles


It is known that excessive varus alignment of the femoral stem in total hip replacement (THR) creates a sub-optimal biomechanical environment which is associated with increased rates of revision surgery and component wear. Little is known regarding the effect of femoral stem alignment on patient functional outcome.


A retrospective study of patients undergoing primary THR at the RNOH. Alignment of the femoral stem component in-situ was measured subjectively by a consultant musculoskeletal radiologist in both coronal and sagittal planes using post-operative anterior-posterior and lateral pelvic radiographs. Each THR was grouped into valgus, minor-valgus, neutral, minor-varus or varus coronal plane alignment and posterior, minor-posterior, neutral, minor-anterior or anterior sagittal plane alignment. Patient reported functional outcome was assessed by Oxford Hip Score (OHS) and WOMAC questionnaires after a minimum follow-up of 11 months. Maximum range of passive hip flexion, abduction, adduction, external and internal rotation were measured in clinic. A factorial linear regression model was used to analyse data.

D Lees S Jameson P James I Serrano-Pedraza P Partington S Muller D Meek M Reed


Dislocation is a major complication following total hip arthroplasty (THA). Aetiology is multi-factorial, but increasing femoral head size may result in lower dislocation rates. The latest England and Wales National Joint Registry (NJR) annual report has highlighted a statistically significant increase in the use of femoral heads of size 36mm+ from 5% in 2005 to 26% in 2009, together with an increase in the use of the posterior approach. The aim of this study was to determine whether national dislocation rates have fallen over the same period.


Hospital episode statistics (HES) data for England was analysed so as to determine trends in national rates of 3-, 6-, 12- and 18-month dislocation rates following primary THA performed between 2005 and 2009 (247,546 THAs). 18-month revision rates were also examined.

M Moran J Bakker-Dyos

We evaluated the use of a cemented Constrained Acetabular Component to treat recurrent or potential instability after hip replacement. Over a seven year period, 109 patients who had undergone 110 operations were identified from hospital records. Patients were reviewed based on clinical and radiological follow-up. Post-operative mobility and quality of life was assessed using the Oxford Hip Score (OHS) and SF-12.

From an original cohort of 109 patients, 9 patients were lost to follow up. Of the remaining 100 patients, the mean follow up was 2.9 years (SD+/−2 years). There were 4 failures, requiring 3 further revisions. The mean post-operative OHS was 33, SF-12 PCS 34 and SF12 MCS 52. 5-year survivorship was 90%. Cementing a Constrained Acetabular Component provides satisfactory mid term results in patients at high risk of hip dislocation.

RG Middleton NL Vasukutty PS Young EC Matthews CE Uzoigwe THA Minhas

Large studies have reported high dislocation rates (7 to 24%) following revision total hip arthroplasty (THA), particularly when the revision is undertaken in the presence of pre-existing instability. We retrospectively reviewed the clinical and radiographic outcome of 155 consecutive revision THA's that had been performed using an unconstrained dual-mobility acetabular implant. It features a mobile polyethylene liner articulating with both the prosthesis head and a metal acetabular cup, such that the liner acts as the femoral head in extreme positions. It can be implanted in either a press fit or cemented manner. Mean follow-up was 40 months (18–66) and average age 77 (42–89). Uncemented (n=122) and cemented (n=33) implants with a reinforcing cage, were used. Indications were aseptic loosening (n=113), recurrent instability (n=29), periprosthetic fracture (n=11) and sepsis (n=2). Three of the 155 cases (1.9%) dislocated within 6 weeks of surgery and were successfully managed with closed reduction. The 3 dislocations occurred in the groups revised for recurrent dislocation and periprosthetic fracture. There were no cases of recurrent dislocation and no revisions for implant failure. Despite a pantheon of options available, post-operative dislocation remains a challenge especially in patients with risk factors for instability. The use of large diameter heads is proven to improve stability but there are concerns regarding wear rates, metal toxicity and recurrent dislocation in the presence of abductor dysfunction. With constrained liners there are concerns regarding device failure and aseptic loosening due to implant overload. Our dislocation rates of 1.9% and survivorship to date compare favourably with alternative techniques and are also in line with studies from France using implants of a similar design. In our hands, where there are risk factors for dislocation, the use of a dual-mobility implant has been very effective at both restoring and maintaining stability in patients undergoing revision THA.

D Barlow G Andrew S Badr S-J Rhee D Beard D Murray

We examined data from a large prospectively collected dataset which followed up patients after Exeter total hip replacement (THR) - the Exeter Primary Outcome Study. We studied 78 patients who had total hip replacement for osteoarthritis on a morphologically normal hip, and in whom the other hip was also morphologically normal for comparison. All selected patients had complete patient outcome data at 1 and 5 years, and x-rays at 1 year were available.

We measured accuracy of reconstruction on AP Pelvis radiographs. The parameters measured were difference in height of lesser trochanter from horizontal pelvic line (LLD); length from ASIS to greater trochanter (indicating abductor length, AL); length from symphysis to centre of femoral head (SFH); length from centre of head to axis of femur (offset). We examined clinical outcomes including gain of Oxford Hip Score (DOHS) at 1 and 5 years, absolute OHS at 1 and 5 years, and absolute SF-36 Physical Functioning and Role Physical scores at 1 and 5 years.

Examining the ratios of AL, SFH, Offset, Offset to SFH ratio and LLD between side of THR and unaffected side all showed marked variation. Thus the ratio of SFH varied from 0.85 to 1.11. For further analysis we divided the patients into 3 groups on the basis of variability of the ratio from 1; we examined whether the clinical scores above varied between these 3 groups. 1 way ANOVA demonstrated no significant difference for any of the clinical outcomes for any of the 5 grouped x-ray variables.

Accuracy of reconstruction has been shown to affect the risk of dislocation after THR. Our results indicate that clinical outcomes of total hip replacement appear resilient to some degree of surgical inaccuracy. Future trials of navigation should be designed to demonstrate not only improved accuracy but also improved clinical outcome.

K Davda M Masjedi AJ Hart JP Cobb

Metal on Metal hip resurfacing (MoM HR) can be an effective operation for the young arthritic hip population. However, errors in cup orientation have been associated with increased wear, circulating blood metal ions, and soft tissue abnormalities that can lead to premature failure of the bearing surface and subsequent revision surgery. While image free computer guidance has been shown to increase surgical accuracy in total hip arthroplasty, the role of image based technology in MoM HR is unclear. In this study, we compared the accuracy of cup orientation in MoM HR performed by either freehand technique or CT based navigation.

Seventy five patients (81 hips) underwent either freehand (n=42) or navigation (n=39) surgery, both requiring a three dimensional (3D) CT surgical plan. Surgery was conducted by hip specialists blind to the method of cup implantation until the operation. Deviation in inclination and version from the planned orientation, as well as, number of cups within a 10° safe zone and 5° optimal zone of the target position was calculated using post operative 3D CT analysis.

Error in inclination was significantly reduced with navigation compared to freehand technique (4° vs 6°, p=0.02). We could not detect a difference between the two groups for version error (5° vs 7°, p=0.06). There was a significantly greater number of hips within a 10° (87% vs 67%, p=0.04) and 5° (50% vs 20%, p=0.06) safe zone when navigated.

Image based navigation can substantially improve accuracy in cup orientation. The results of our freehand group appear better than historic controls, suggesting the use of a 3D plan may help to reduce technical error and improve the learning curve in this technically demanding procedure. We advocate the use of image based navigation in MoM hip resurfacing arthroplasty.

K Davda N Smyth AJ Hart JP Cobb

The radiographic analysis of over 5000 metal on metal (MoM) hips using Ein Bild Roentgen Analyse (EBRA) software have been recently published in an attempt to determine the influence of cup orientation on bearing function. The validation of this software relies one study, conducted in a phantom pelvis without a femoral head in situ. Three dimensional computed tomographic (3D-CT) has been shown to be more accurate for hip and knee arthroplasty than plain radiographs for measurements of component orientation and position. The accuracy of EBRA when compared to 3D-CT for MoM hips specifically is unclear.

We measured the cup orientation of 96 large diameter MoM hips using EBRA analysis of plain radiographs and compared this to 3D-CT. All measurements were made using the radiographic definition of cup orientation. The mean difference in version between the two imaging modalities was 8°; with wide limits of agreement of −21.2° and +5.6°. Three retroverted cups were not detected by EBRA. The mean difference in inclination values was 0.3°, but there was up to 9°difference between imaging modalities. When measured by 3D CT, 64% of hips were within a 10° safe zone around 45° inclination and 20° version, compared to only 24% when measured by EBRA (Fishers Exact test, p< 0.0001).

The measurement of cup orientation of MoM hips using EBRA software is insufficiently accurate, particularly for the assessment of cup version. The cup rim is obscured by the large diameter femoral head on plain radiographs. Research studies using EBRA analysis for version have limited value if accuracy of more than 20 degrees is required to draw conclusions. This software may not be suitable to measure the performance of a device or surgeon. The limitations of EBRA can be overcome, if 3D-CT with an extended Hounsfield scale for data capture is used.

N Sandiford S Muirhead-Allwood JA Skinner J Hua W Peter


Optimal results from uncemented total hip arthroplasty (THA) requires the prosthesis to obtain initial stability, restoration of biomechanics, bone contact along the ingrowth surface and uniform stress transfer to the proximal femur. Anatomic variation within the population makes this difficult to reproduce in every patient. To achieve optimal fit and fill of the proximal femur, options are reshaping the canal or creating an implant which precisely fits the patient's anatomy. The former increases bone loss and risks weakening the supporting bone, creating areas of stress concentration or shielding. Computer assisted design-computer assisted manufacture (CAD-CAM) femoral components were designed to overcome these issues. We present the long term results of CAD-CAM femoral components used in primary THA.


This was a prospective study looking at a consecutive, single surgeon series of THA's. Patients were reviewed pre operatively then at 6 weeks, 3 and 12 months post operatively and then yearly. Clinical as well as radiological review was performed at each visit and Harris Hip Score (HHS), Oxford Hip Score (OHS) and Western Ontario McMaster's (WOMAC) scores were calculated. Kaplan-Meier survival analysis was performed.

P Lee P Smitesh J Hua A Gupta A Hashemi-Nejad


Many patients who had previous proximal femoral osteotomies develop deformities that may not be amenable to total hip replacement (THR) with standard off-the-shelf femoral stems. Previous studies have shown high revision rates (18% at 5–10 years follow-up). Computer-assisted-design computer-assisted-manufacture (CAD-CAM) femoral stems are indicated but the results are not known. We assessed the clinical results of THR using CAD-CAM femoral stems specifically for this group of patients.


We included patients with previous proximal femoral osteotomy and significant deformity who underwent THR with CAD-CAM femoral stem operated by the senior author (AHN) from 1997 with a minimum of 5 years follow-up. We noted revision rates, associated complications and functional outcome. Radiological outcomes include assessment for loosening defined as development of progressive radiolucent lines around implant or implant migration.

J Buchanan


Will Hydroxyapatite ceramic coated (HAC) arthroplasty perform well in patients under the age of fifty?


This is a study of 269 Hydroxyapatite ceramic coated (HAC) hip arthroplasties in patients under, the age of fifty with annual review using Harris Hip Score (HHS) and plain X-rays.

Assessments were over a maximum of 19 years.

Early patients (46) had implants with ceramic/plastic bearings. Later patients (223) all had ceramic on ceramic bearings.

R Chana S Tilley M Facek WL Walter B Zicat WK Walter


Alumina ceramic on ceramic bearings in total hip arthroplasty (THA) may reduce the prevalence of osteolysis due to its properties of low wear and chemical inertness. This is critical in the younger patient population as they place increased demands over a longer period. This study reports on the clinical and radiographic outcomes of a series of modern cementless ceramic on ceramic THA at a minimum of 10 years in this younger group.


A series of 120 consecutive third generation ceramic cementless THA were performed at a single centre in 110 patients from 1997 to 1999. The average age of the patients at the time of surgery was 45 years (20 to 55 years). All procedures were carried out via the posterior approach using the same implant by the two senior authors.

N Sandiford S Muirhead-Allwood JA Skinner J Hua W Peter


The variability of the endosteal geometry after removal of the femoral component can make proximal fit difficult to achieve with an ‘off the shelf’ prosthesis. Whatever the anatomy of the proximal femur, it is important to achieve immediate stability, preserve bone stock and protect the femur from cortical defects which can lead to subsequent fracture. In revision Total Hip Arthroplasty (THA) this requires a large inventory of modular components. The use of custom computer-assisted design-computer-assisted manufacture (CAD-CAM) components negates this need. Little has been published on the use of custom-made components in revision THA. We report the results of a cohort of patients who underwent revision THA using CAD-CAM femoral components.


A prospective study was performed between 1991 and 1998. A consecutive series of patients who had revision THA using custom components were assessed clinically and radiologically. The design of the femoral components was governed by the existing femoral bone stock. Patients were reviewed pre operatively then at 6 weeks, 3months and 12 months postoperatively and then annually. Radiographs were assessed at each visit and Oxford, Harris and WOMAC hip scores were calculated

S Dawson-Bowling D Yeoh H Edwards D East N Ellens K Miles PA Butler-Manuel H Apthorp


Debate continues regarding the relative advantages of ceramic-on-ceramic (CoC) and metal-on-polyethylene (MoP) articulations in total hip arthroplasty (THA). Perceived benefits of CoC include longevity, and low wear - in turn limiting the effects of particulate wear debris. However, CoC bearings cost significantly more, and concern remains over the risk of ceramic fracture; a complication not seen with MoP bearings, which are also cheaper.


We electronically randomised 268 consecutive patients undergoing THA to receive either a CoC or MoP articulation. Patients aged over 72 were excluded. In all patients the prosthesis used was an uncemented ABG II (Stryker, USA), implanted by one of the two senior authors (HDA, ABM). Patients were scored preoperatively, and at annual follow-up clinics, using SF36, Visual Analogue (VAS), Merle d'Aubigné (MD) and Oxford Hip (OHS) Scores. Satisfaction levels were also documented.

N Sandiford S Muirhead-Allwood JA Skinner


Metal on metal hip resurfacing arthroplasty (MoM HR) has the highest revision rates according to the UK National Joint Registry. Revisions for lesions associated with soft tissue necrosis (pseudotumors) have been associated with poor outcomes. There is a relative paucity of information on early revision of painful HR prostheses. We present the results of a series of patients who underwent early revision of painful MoM HR procedures.


This prospective study involved a consecutive series of patients undergoing revision of HR to THA. The diagnoses leading to revision are discussed. Clinical and radiological assessments were performed pre operatively as well as 6 weeks, 12 months postoperatively and yearly thereafter. Pre and post operative Harris Hip Score, Oxford Hip Score and WOMAC scores were calculated. Patient satisfaction was assessed using a visual analogue scale.

S Jameson P James A Rangan S Muller M Reed


In 2011 20% of intracapsular fractured neck of femurs were treated with an uncemented hemiarthroplasty in the English NHS. National guidelines recommend cemented implants, based on evidence of less pain, better mobility and lower costs. We aimed to compare complications following cemented and uncemented hemiarthroplasty using the national hospital episode statistics (HES) database in England.


Dislocation, revision, return to theatre and medical complications were extracted for all patients with NOF fracture who underwent either cemented or uncemented hemiarthroplasty between January 2005 and December 2008. To make a ‘like for like’ comparison all 30424 patients with an uncemented impant were matched to 30424 cemented implants (from a total of 42838) in terms of age, sex and Charlson co-morbidity score.

T Al-Atassi DTS Chou C Boulton CG Moran


Cemented hemiarthroplasty for neck of femur fractures has been advocated over uncemented hemiarthroplasty due to better post-operative recovery and patient satisfaction. However, studies have shown adverse effects of bone cement on the cardio-respiratory system which may lead to higher morbidity and mortality. Therefore, in some institutes, the use of an uncemented prosthesis has been adopted for patients with a high number of co-morbidities. The aim was to compare early mortality rates for cemented vs. uncemented hemiarthroplasties.


Cohort study of displaced intracapsular hip fractures treated with hemiarthroplasty between 1999–2009 at one institute. A total of 3094 hemiarthroplasties performed; out of which 1002(32.4%) were cemented and 2092(67.6%) were uncemented. 48hour and 30day mortality rates for the two groups were compared and a multivariate Cox regression model used to eliminate confounding factors. Significant confounding factor included age, sex, mini mental test score, medical co-morbidities, Nottingham Hip Fracture Score and delay to surgery.

M Hossain G Andrew


Following National patient safety alert on cement use in hip fracture surgery, we investigated the incidence and pattern of 72 hours peri-operative mortality after hip fracture surgery in a District General Hospital.


We reviewed all patients who had hip fracture surgery between 2005-April, 2010. We recorded demographic variables, type of fracture, implant used, medical co-morbidity, seniority of operating surgeon and anaesthetist, peri-operative haemodynamic status, time and cause of death.

S McKenna S Kelly DF Finlayson

Current evidence suggests that we should be moving away from Thompson's hemiarthroplasties for patients with intracapsular hip fractures. Furthermore, the use of cement when inserting these prostheses is controversial. This study aims to show the Inverness experience.

We performed a retrospective review of all NHS Highland patients who underwent a hemiarthroplasty for an intracapsular neck of femur fracture over the last 15 years. Demographics and the use of cement were documented. Further analysis of this group was performed to identify any of these patients who required revision of their prosthesis. Patients requiring revision had their case-notes reviewed to identify the cause for further surgery.

From 1996 until present 2221 patients from the Highland area had a hemiarthroplasty for an intracapsular neck of femur fracture. 1708 where female (77%) and 513 male (23%). The ages ranged from 28 years to 104 years (mean 80 years, median 81). 2180 of this group had their operations in Raigmore Hospital with the remaining 41 at various centres throughout Scotland. 623 (28%)had a cemented hemiarthroplasty, with the remaining 1578 (72%) having an uncemented Thompson's hemiarthroplasty. The revision rate for the cemented group was 2% (13 of 623 patients). In the uncemented group it was 0.4% (6 of 1578). Reasons from revision included dislocation, periprosthetic fracture, infection and pain.

Current evidence from some joint registers regarding the use of Thompson's hemiarthroplasty in the elderly is discouraging. The use of bone cement in this group with multiple co-morbidities is not without it's risks. Our data suggests that uncemented Thompson's hemiarthroplasties in low demand elderly patients with multiple co-morbidities can yield excellent results with less risk to the patients.

S Kazzaz G Cox M Deakin


Current literature supports the use of total hip replacement (THR) for the treatment of displaced intra-capsular proximal femoral fractures (DIPFF). Case series of patients receiving this treatment show dislocation rates higher than that of patients who have THR to treat osteoarthritis. Large diameter THR have mechanical advantages in terms of dislocation and their role in PFF has yet to be assessed.


To assess the role of large-diameter total hip replacements on the rate of dislocation when used to treat displaced intra-capsular proximal femoral fractures.

Design: Single surgeon, case series

Setting: Level I trauma centre

Inclusion criteria:

Displaced intra-capsular proximal femoral fracture (Garden III & IV).

Independently mobile pre-operatively for distances greater than a mile, with no more than 1 stick as a mobility aid.

Abbreviated mental test score of 9/10 or greater

Exclusion criteria:

Patient under 60

Pathological fractures

Additional fractures of the femur



Morbidity (Including dislocation)

Oxford Hip Score


Patients/Participants: Retrospective study to assess patients who presented between May 2006 and December 2008 and met the requirements had a CPTÒ (Zimmer) cemented femoral stem, using 3rd generation cementation techniques, and large diameter Duronò (Zimmer) head and cup (uncemented) inserted as a primary procedure via a modified Hardinge technique. Follow up was via routine clinic appointments, letter to GP and phone conversation with patient.

K Singisetti P Mereddy N Cooke


Internal fixation of pertrochanteric fractures is evolving as newer implants are being developed. Proximal Femoral Nail Antirotation (PFNA) is a recently introduced implant from AO/ASIF designed to compact the cancellous bone and may be particularly useful in unstable and osteoporotic hip fractures. This study is a single and independent centre experience of this implant used in management of acute hip fractures.


68 patients involving 68 PFNA nailing procedures done over a period of 2 years (2007–09) were included in the study. Average follow-up period of patients was 1 year. AO classification for trochanteric fractures was used to classify all the fractures. Radiological parameters including tip-apex distance and neck shaft angle measurement were assessed.

D White L Cusick R Napier J Elliott A Adair

To determine the outcome of subtrochanteric fractures treated by intramedullary (IM) nailing and identify causes for implant failure.

We performed a retrospective analysis of all subtrochanteric fractures treated by intramedullary nailing in Belfast trauma units between February 2006 and 2009. This subgroup of patients was identified using the Fractures Outcome Research Database (FORD). Demographic data, implant type, operative details, duration of surgery and level of operator were collected and presented. Post-operative X-rays were assessed for accuracy of reduction.

One hundred and twenty two (122) patients were identified as having a subtrochanteric fracture treated by IM nailing. There were 79 females and 43 males. Age range was 16 to 93 (mean 78). 95 (78%) cases were performed by training grades and 27 (22%) by consultants. Duration of surgery ranged from 73–129mins (mean 87mins). 47 patients (38.5%) were found to have a suboptimal reduction and 75 patients (61.5%) had an anatomical reduction on immediate post-operative x-ray. One year from surgery 73/122 patients were available for follow up. Of those patients with suboptimal reduction, 13/47 (27.7%) required further surgery. 8 required complete revision with bone grafting, and 5 underwent dynamisation. A further 6 patients had incomplete union. In the anatomical group, 4 patients underwent further surgery (5%). 3 required dynamisation and one had exchange nailing for an infected non-union. 3 patients had incomplete union at last follow up. 5/47 (10.6%) had open reduction in the suboptimal group compared to 25/75 (33.3%) in the anatomical group. Of the 27 cases performed by consultants, 13 (48%) were open reduction, compared to 17/93 (18%) by training grades.

This study has shown that inadequate reduction of subtrochanteric fractures, leads to increased rates of non union and ultimately implant failure. We recommend a low threshold for performing open reduction to ensure anatomical reduction is achieved in all cases.

MA Ahmad O Obakponovwe M Mokawem N Kanakaris PV Giannoudis


The management of non-unions of subtrochanteric femoral fractures with associated implant failure is challenging. This study assessed the outcome of a cohort of patients treated according to the diamond concept.


Between 2005–2010 all patients with subtrochanteric aseptic non-unions presented post implant failure (Gamma Nail breakage) were eligible in the absence of severe systemic pathologies and comorbidities. Demographics, initial fracture pattern, method of stabilisation, mode of failure of metal work, time to revision of fixation, complications, time to union, and functional outcome were recorded over a minimum period of follow-up of 12 months. The revision strategy was based on the “diamond concept;” optimising the mechanical and biological environment (revision of fixation, osteoinduction/BMP-7, osteoconduction/RIA harvested graft, and osteogenicity/concentrate of bone marrow aspirate).

P Jettoo R Kakwani S Junejo I Talkhani P Dixon

The incidence of hip fractures is rising worldwide. Hip fracture patients with a cardiac murmur have an echocardiogram pre-operatively in our unit. We assessed the impact of obtaining a pre-operative echocardiogram on treatment of such patients, using National Confidential Enquiry into Patient Outcome and death (NCEPOD) report 2001 as gold standard. We undertook a retrospective audit of hip fracture patients (N=349) between 01/06/08 and 01/06/09. 29 patients had pre-operative echocardiogram (echo group). A computer generated randomised sample of 40 patients was generated from N, ‘non-echo’ group. Data was obtained from medical records and the Hospital Information Support System. The groups were compared using Student's t test. Age and gender distribution were similar in both groups. 29 patients had pre-operative echo. The indication for requesting an echocardiogram pre-operatively was an acute cardiac abnormality in 4 cases. 25 patients had echocardiogram for no new cardiac problem. In the latter group, the reason for requesting an echo was a cardiac murmur in 23 patients and extensive cardiac history in 2 cases. A specialist input from the cardiologist was sought in 5 cases. Most patients with aortic valve abnormality had surgery under general anaesthetic. No patient required cardiac surgery or balloon angioplasty pre-operatively. There was a significant delay to surgery in the patients who had a pre-operative echo (average 2.7 days, range 0–6 days) compared to ‘non-echo’ group (average 1.1 days, range 0–3 days), (P< 0.001). There was no significant difference in length of stay and mortality at 28 days between the two groups. We are now developing departmental guidelines for requesting echo in hip fracture patients with cardiac murmur to prevent unnecessary avoidable delay. We are developing a link with the cardiology department to expedite echocardiogram requests in hip fracture patients.

T Harrison P Robinson A Cook M Parker

The purpose of the study was to identify factors that affect the incidence of deep wound infection after hip fracture surgery.

Data from a hip fracture database of 7057 consecutively treated patients at a single centre was used to determine the relationship between deep wound sepsis and a number of factors. Fisher's exact test and the unpaired T test were used. All patients were initially followed up in a specialist clinic. In addition a phone call assessment was made at one year from injury to check that no later wound healing complications had occurred.

There were 50 cases of deep infection (rate of 0.7%). There was no significant difference in the rate of deep sepsis with regards to the age, sex, pre-operative residential status, mobility or mental test score of the patient. Specialist hip surgeons and Consultants have a lower infection rate compared with surgeons below Consultant grade, p=0.01. The mean length of anaesthesia was longer in the sepsis group (76minutes) compared to the no sepsis group (65minutes), this was significant, p=0.01. The patient's ASA grade and fracture type were not significant factors. The rate of infection in intracapsular fractures treated by hemiarthroplasty was significantly greater than those that had internal fixation, p=0.001. The rate of infection in extracapsular fractures fixed with an extra-medullary device was significantly greater than those fixed with an intra-medullary device, p=0.021. The presence of an infected ulcer on the same leg as the fracture was not associated with a higher rate of deep infection. In conclusion we have found that the experience (seniority) of the surgeon, the length of anaesthesia and the type of fixation used are all significant factors in the development of deep sepsis. These are all potentially modifiable risk factors and should be considered in the treatment of hip fracture patients.

DD McCaffrey D White D Kealey

Currently there is an elevated public awareness of the consequences of nosocomial infection, of which, 14.5% is due to surgical site infection (SSI). Hip fracture patients are at increased risk of SSI due to their age related poor medical health, immune response impairments and decreased capacity of wound healing. Superficial SSI following hip fracture surgery can affect up to 16.9% with deep infection affecting 3.7%. Deep infection represents a major complication, from which hip fracture patients are 4.5 times less likely to survive to discharge and carries a 50% mortality at 1 year, compared to 33% without infection. Treatment requires a prolonged hospital stay, additional diagnostic testing, antibiotic therapy and surgery, resulting in the total cost of treating deep infection to be more than double that of non-infected hip fracture surgery.

Wound closure aims to accurately appose the skin edges thereby promoting rapid healing and restoration of the protective dermal barrier. Failure to provide accurate skin apposition can result in delayed wound healing which has been shown to have a 3 fold risk of developing late infection. Importantly, delayed wound healing is reflected by prolonged wound ooze. We hypothesized that skin closure via sutures is better at achieving skin edge apposition than wounds closed with staples, providing more rapid wound healing. We compared staples and sutures for wound closure in hip fracture patients by using ooze duration as an outcome measure for wound healing.

Duration of wound ooze was recorded in 170 patients. 65 wounds, closed with sutures, had an average duration of ooze of 1.82 days. 105 wounds, closed with staples, had an average duration of ooze of 4.97 days. This study suggests that sutures are superior to staples with regard to early wound healing in hip fracture patients.

S Nanjayan C Brankin R Warriar T Abuzakuk


There is conflicting evidence in the literature regarding outcome of patients living in their own home prior to a fracture neck of femur, when using discharge destination and rehabilitation as measures of outcome. We investigated the factors predicting outcome following neck of femur (NOF) fractures, in patients previously living in their own home


Medical records of all 292 patients admitted to Royal Derby Hospital between January and October 2010 with a fractured NOF (who lived in their own home prior to admission) were obtained retrospectively. Data included patient demographics; type of surgical intervention; mobility status and level of independence before admission; nature of fracture and patients' ASA grade. Outcome measures including: number of days spent in hospital; number of days spent in rehabilitation; mortality; mobility on discharge; and discharge destination, were also sought. Data was analysed using SPSS Version 18.

A Dhal

It is the prime responsibility of the treating surgeon to identify and treat the vascular injury along with the skeletal trauma. Limbs with combined Orthopaedic and Vascular injuries are traditionally admitted as an Orthopaedic emergency.

In a 17 year period we treated 67 cases of vascular injuries (including 16 pseudo aneurysms) associated with fractures and dislocations or soft tissue injuries of the limbs. Three cases have been followed up for over 20 years. All patients were operated by Orthopaedic residents on duty with limited resources, without the help of vascular surgeons. We relied on clinical diagnosis and immediate exploration of the blood vessels rather than time consuming procedure of arteriography. Skeletal stabilisation was achieved by internal or external fixation. Vascular reconstruction involved end to end repair or vein grafting. Fasciotomy was performed in selected cases where the injury-revascularisation time was more than 6 hours. Post-operative care involved limb placement at body level, Sympathetic blockade for 48 hours, vasodilators, Lomodex, Mannitol, Aspirin and antibiotic therapy. Urine was monitored for smoky color indicating myoglobinuria.

Though only 17 were repaired within six hours, limb viability with good function was obtained in 51 cases. Complications included 7 deaths, 6 amputations, 2 acute renal failures and delayed occlusion in one case.

P Smitham W Khan A Hazlerigg S Bajaj I McCarthy P Calder


Patients undergoing limb reconstruction with the Taylor Spatial Frame (TSF) often perceive that their frame is loose due to the rattle they hear when mobilising. Our aim was to determine how much and where this movement is in the various frame/bone constructs currently on the market.


Using standard tibial saw bones three frames (TSF, Ilizarov and Hexapod) were made in an identical fashion. Constructs were cyclically loaded 4 times to 200 N in tension and compression using the Instron MTS. This was repeated three times. A seventh strut was also placed in the TSF construct and the tests repeated. Bones were then removed and the tests repeated for the frames alone.

MA Rashid A Shoaib WDI Groom RK Varma AFG Groom

Limb lengthening with external fixators has many complications, like pin track infection, joint stiffness, severe pain and stress fracture after removal of external fixator. Prolonged period in external fixator interferes with rehabilitation and activities of daily living.

We describe our results with ISKD (intramedullary skeletal kinetic distractor) system, an internal limb lengthening device, activated with rotations of 3 degrees. In this retrospective cohort we performed lengthening with the use of ISKD in 12 patients from March 2006 to date. Ten patients were included in this study as two patients had not completed the stage of consolidation. There were 7 male and 3 female patients. Their average age was 44 years (range 23–63). The mean follow up period was 16 months (range 12–24 months). Two patients had tibial lengthening and eight patients had femoral lengthening. The average lengthening desired was 42.5 mm (range 2.5 mm–75 mm). The average lengthening achieved was 38 mm. Mean hospital stay was 7 days (range 5–11 days). The distraction index was 1.2 mm/day. The average time to full weight bearing was 6 months (range 4 to 10 months). Mean healing time was 10.25 months. The mean healing index was 90.7 days/cm. If we remove two patients who took long time to heal, the mean healing index drops to 61 days/cm. Two patients needed bone grafting at the distraction site. None of the patients had infection, non-union of the distraction site or breakage of the nail. None of the patients had joint stiffness. All patients were completely satisfied with the treatment and had excellent functional results. We conclude that the low rate of complications, higher patient acceptability and avoidance of external fixation make ISKD a very attractive option for limb lengthening.

A Shoaib MA Rashid O Lahoti

Taylor Spatial Frame (TSF) is a six axis deformity correction frame and accuracy of correction depend on the accuracy of parameters input in to the web based software. There are various methods of obtaining frame and deformity parameters (13 in total) including the use of dedicated software known as SpatialCAD™. We tested the accuracy of SpatialCAD™ using a saw bone two ring frame construct of known parameters. We mounted a two-ring (155mm) frame on a saw bone tibia and fibula unit and worked out the accurate mounting and deformity parameters. Then we obtained orthogonal and nonorthogonal antero-posterior and lateral images of frame using a metallic sphere of known dimensions placed at the level of the bone, to aid calibration of x-ray images. We also obtained orthogonal and non-orthogonal images without a calibrating sphere. We then uploaded the images in to SpatialCAD™ software and obtained the mounting and deformity parameters and compared with the real parameters. SpatialCAD™ is capable of yielding measurements within 1–2mm of actual measurements when Calibrated orthogonal images were used. The software was inaccurate when frame hardware of known dimensions was used for calibration because the hardware was not in the same plane as the bone

S Bajaj S Patel DM Eastwood PR Calder


To evaluate the results and complications of bone transport in the treatment of massive tibial bone defects, using the Ilizarov method.


15 patients underwent bone transport using the Ilizarov technique to treat massive tibial bone defects. The average age of the patients was 8.7 years (3–24 years) and the mean bone defect was 10.8 cms. Following a latent period of 1 week, distraction of the transport doughnut was commenced at 1mm/24 hours in 4 quarterly turns. A docking procedure was performed in 7 cases which involved freshening of the bone ends and autogenous bone grafting from the iliac crest. Following docking the fixator was removed once the regenerate had consolidated.

JG Penn-Barwell CK Murrary JC Wenke


Open fractures are common, and infection a frequent complication. There is still uncertainty regarding the urgency of initial treatment. The majority of animal studies indicate that early irrigation and debridement reduces infection; unfortunately, these studies often do not involve antibiotics. Clinical studies indicate that the timing of initial debridement does not affect the infection rate. These studies are observational and fraught with confounding variables. The purpose of this study was to control for these variables using an animal model incorporating both systemic antibiotics and surgical treatment.


This study used a segmental defect rat femur model contaminated with Staphylococcus aureus and treated with a 3 day course of systemic cefazolin (5 mg/Kg 12 hourly) and surgical treatments, both of which were initiated independently at 2, 6 and 24 hour time points. After 14 days bone and hardware was harvested for separate microbiological analysis.

P Hull R Jenkinson J Essue S Johnson H Kreder


Traditional recommendations suggest that open fractures require urgent surgical debridement to reduce infection. However, this has recently been challenged by a number of investigations. However, in many cases, these studies were not able to control for important confounding factors. The purpose of our study was to evaluate the relationship between delay to definitive surgical debridement while controlling for important confounders.


364 patients with 459 open fractures treated at a level one trauma centre over four years were reviewed. Time to definitive surgical debridement was modelled as a predictor of infection while controlling for fracture grade, anatomic site of fracture, and presence of significant contamination. Time to debridement was modelled as both a continuous variable and a categorical variable with cut off points at 6 and 12 hours of delay.

E Laugharne D Bose M Gill


To identify the most common infecting organisms associated with deep infection and infected non-union of the tibia, as well as the rate of ‘culture-negative’ infections, at a tertiary referral trauma centre dealing with military and civilian trauma.


Between 2008 and 2010 all patients with a confirmed clinical diagnosis of implant-related infection or infected non-union of the tibia were identified retrospectively from a database and their records analysed. After a period of at least 10–14 days without antibiotics, all patients underwent surgical debridement in which ‘clean’ samples were went for microbiological analysis. Skeletal stablity was achieved with a circular frame and intravenous antibiotics were started pending culture and sensitivity results.

K Brown B Li T Guda D Perrien S Guelcher J Wenke

Infection is a common complication of severe open fractures and compromises bone healing. The present standard of care is a two-stage approach comprising of initial placement of antibiotic-impregnated PMMA beads to control infection followed later by bone grafting. Although the systemic antibiotics and PMMA/antibiotic beads control the infection initially, there are often residual bacteria within the wound. After grafting and definitive closure, the implanted graft is placed in an avascular defect and could function as a nidus for infection. Bioactive porous polyurethane (PUR) scaffolds have been shown to improve bone healing by delivering recombinant human bone morphogenetic protein-2 (BMP-2) and reduce infection by delivering antibiotics. The release kinetics of the BMP-2 were an initial burst to recruit cells and sustained release to induce the migrating cells. The Vancomycin (Vanc) release kinetics were designed to protect the graft from contamination until vascularisation by having an initial burst and then remaining over the MIC for Staph. aueus for two months. In this study, PUR+BMP-2+Vanc scaffolds were first tested in a non-infected critical size rat femoral segmental defect and was found to perform comparably to PUR+BMP-2, thus indicating that Vanc did not hinder bone healing. PUR+BMP-2+Vanc scaffolds were subsequently evaluated in an infected critical size rat femoral segmental defect. The dual delivery approach resulted in significantly more new bone formation and infection control than both PUR+BMP-2 and the collagen+BMP-2 treatments. These data indicate that the dual-delivery strategy effectively protects the graft from infection during wound healing and regenerates more bone in contaminated defects. This moderately osteoconductive bone graft is capable of being injected, provides a more sustained release of BMP-2 than the collagen sponge, and can release antibiotics for over 8 weeks. The dual-delivery approach may improve patient outcomes of open fractures by protecting the osteoinductive graft from colonization until vascularization occurs.

AJ Roche V Selvaratnam S Mukhopadhaya N Unnikrishnan Z Abiddin B Narayan N Giotakis H Aniq S Nayagam


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 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).

G Edwards A Hall R Morgan-Jones

We describe the results for the management of chronic osteomyelitis in long bones using a new single stage procedure, the Cardiff technique. Fourteen consecutive patients were treated prospectively. The patients had a mean age of 52; all patients had a mean stay in hospital of 5 days with outpatient dressings. All patients had tibial fractures, 2 were infected non unions. The origin of infection was traumatic in 13 cases and haematogenous in 1 case. This one stage procedure or The Cardiff technique, uses techniques described by both Papineau's 3 stage method and Lautenbach's procedure. It involves removal of all avascular and infected tissue via marginal debridement, opening of the medullary cavity proximally and distally, compartmental debridement and copious saline irrigation. The wound is then packed with Jelonet and kaltostat and fresh dressings applied weekly. The wound is left to heal via secondary intention. There is no routine use of antibiotics. Antibiotics were only used when required, i.e. Clinical evidence of cellulitis or infection. 11 patients healed with no further surgery, no skin grafting, no bone grafting and no flap coverage. Mean time to healing was 5 months; both non unions united giving results similar to other accepted techniques. There were 3 residual infections, 2 due to inadequate debridement which required a single further compartmental debridement (Lautenbach method), 1 had an avascular bone edge requiring further local debridement. We feel this procedure confers the following advantages; minimal surgical insult, early discharge, out patient management, good outcomes and most importantly, high patient satisfaction. It also serves as a reminder that simple wounds do well with simple solutions.

A Mahmood JJ George Malal S Abdul Majeed


The purpose of the study was to evaluate the results of Expert tibial nailing for distal tibial fractures.


All patients who had a distal third or distal end fracture of the tibia treated with the Expert tibial nail over a three year period at our institution were included in the study. A total of 44 distal tibial fractures in the same number of patients were treated with the nailing system. One patient died in the immediate post operative period from complications not directly related to the procedure and 3 were lost to follow up leaving a cohort of 40 patients for evaluation. 31 of the fractures were closed while the remaining 9 were open. The average age group of the cohort was 46.8 years with 26 males and 14 females.

SK Nanjayan D Deakin S Milner


Minimally invasive plate osteosynthesis (MIPO) is a relatively new surgical technique for the management of distal tibial fractures. Conventional open technique is unfavourable to the fracture biology because of excessive soft tissue stripping and can be associated with significant devastating complications.


The aim of this study was to determine the effectiveness of the MIPO technique for distal tibial fractures

E Ieong J Afolayan A Carne M Solan


Plantar fasciopathy is a common cause of heel pain, and is usually treated in primary practice with conservative measures. Intractable cases can prove very difficult to treat. Currently plantar fasciopathy is not routinely imaged and treatment is empirical. At the Royal Surrey County Hospital patients with intractable plantar fasciopathy are managed in a unique ‘one-stop’ Heel Pain clinic. Here they undergo clinical assessment, ultrasound scanning and targeted therapy.


Patients referred to the clinic since 2009, with symptoms lasting longer than 6 months and failed conservative management, were prospectively followed. Plantar fasciopathy was confirmed on ultrasound scanning. The ultrasound scans were used to classify the disease characteristics of the plantar fascia.

R Monto

Chronic plantar fasciitis is a common condition but can be difficult to successfully treat. Platelet rich plasma (PRP), a concentrated bioactive component of autologous blood rich in cytokines and other growth factors, was compared with cortisone injection in the treatment of severe cases of plantar fasciitis resistant to traditional non-operative paradigms. Thirty-six patients (16 males 20 females) were prospectively randomized into two study groups. All patients had pre-treatment MRI and ultrasound studies consistent with plantar fasciitis. The first group was treated with a single ultrasound guided injection of 40 mg Depo-Medrol at the injury site and the second group was treated with a single ultrasound guided injection of un-buffered autologous PRP at the injury site. The cortisone group had an average age of 59 (24–74) and had failed 4 months (3–24) of standard non-operative management (rest, heel lifts, PT, NSAIDS, cam walker immobilization, night splinting, local modalities) and had pre-treatment AOFAS scores of 52 (24–60). The PRP group had an average age of 51 (21–67) and had failed 5 months (3–26) of standard non-operative management (rest, heel lifts, PT, NSAIDS, cam walker immobilization, night splinting, local modalities) and had pre-treatment AOFAS scores of 37 (30–56). All patients were then immobilized fully weight bearing in a cam walker for 2 weeks, started on eccentric home exercises and allowed to return to normal activities as tolerated and without brace support. Post-treatment AOFAS scores were PRP 95 (84–100) and cortisone 81(60–90) at 3 months (CI 95% p< .0001), PRP 95 (86–100) and cortisone 81 (60–90) at 6 months (CI 95% p< .0001), and PRP 94 (86–100) and cortisone 58 (45–77) at 12 months (CI 95% p< .0001). Platelet rich plasma injection is more effective and durable than cortisone injection for the treatment of severe chronic plantar fasciitis refractory to traditional non-operative management.

A Yeo N Kendall S Jayaraman


Chronic Achilles tendinopathy is a common overuse injury. There are several modalities of treatment, reflecting difficulties in its management. In particular, due to the well-recognised morbidity associated with surgical decompression, treatment has steered towards a less invasive route.

Dry needling has been efficacious in managing other tendinopathies. This study therefore assessed dry needling and percutaneous hydrostatic decompression of the Achilles tendon as a novel treatment for this condition.


Twenty-two patients with 27 sonographically-confirmed chronic Achilles tendinopathy were prospectively enrolled. All were symptomatic for >6 months and have failed alternative conservative treatments.

Ultrasound-guided dry needling of neovascular areas and paratenon hydrostatic decompression was performed by a dedicated musculoskeletal radiologist on a 6-weekly basis until symptomatic resolution or no improvement was evident. Sonographic assessment of the tendon's thickness and neovascularity was undertaken. Following treatment, a standardized physiotherapy regime was adopted. At baseline and 6 weeks post-final procedure, visual analogue scores (VAS) at rest and during activity were obtained. Telephonic interviews were carried out 12 and 24 months post-treatment.

Y Agrawal H Davies C Blundell M Davies


Growing evidence in the literature suggests better clinical and functional outcomes and lower re-rupture rates with repair compared to non-operative treatment of ruptured Achilles tendon. There are however, concerns of wound infection, nerve injury and scar tenderness with the standard open and percutaneous techniques of repair. We aim to evaluate clinical and functional outcomes and complications in patients treated with minimally invasive Achillon device.

Materials and Methods

Prospectively collected clinical data was reviewed of all consecutive patients who underwent repair of the ruptured Achilles tendon using the Achillon device. Patients were contacted using a postal questionnaire for assessment of their functional status using the validated Achilles Tendon Total Rupture Score (ATRS) and compared with their uninjured side. The outcomes were compared to the published results.

A Young S Evans

This study was undertaken to assess for equivalence or superiority in tendon reconstruction techniques. This is an in vitro analysis of several, different, reconstruction techniques for chronic Achilles tendon ruptures. The surgical techniques have been borne out of surgical preference rather than biomechanical principles with little published research into their comparability. Surgical preferences are a result of the supposed benefits of reduced operative time, single operative incision and decreased morbidity. An animal model, after human cadaveric tissue dissection to guide the specimen construction, was used to compare the different techniques using bovine bone and tendon and tested using a material testing machine. Ultimate load to failure was recorded for all specimens and statistical analysis of the results was undertaken.

A statistically significant difference was shown between all the techniques by analysis of variance. This will guide clinical application of these techniques. The use of bone tunnels, through which the flexor hallucis longus tendon can be passed, were found to be biomechanically superior, with regard to ultimate load to failure, to either bone anchors or end-to-end tendon suture techniques. Interference screws were found to have a large range in their ultimate load suggesting a lack of consistency in the results. The mean of the bone tunnel group (482.8N, SD 83.6N) is significantly (p < 0.01) higher than the mean of the bone anchor group (180.2N, SD 19.3N), which is, in turn, significantly (p < 0.01) higher than the mean of the Bunnell group (73.7N, SD 20.9N). This study is larger than any previous study found in the literature with regard to number of study groups and allows the techniques to be compared side by side.

F Lintz T Barton W Harries S Hepple M Millett I Winson


Traditional measurements of hindfoot alignment are based on the tibio-calcaneal angle and do not take the forefoot into account. We have developed an algorithm based on standard radiographs to calculate calcaneal offset using Ground Reaction Force (GRF).


The GRF algorithm measures hindfoot alignment without using the tibial axis

JM Taylor RE Knox PM Guyver M Czipri NJ Talbot IT Sharpe


Tibiotalocalcaneal arthrodesis is an important salvage method for patients with complex hindfoot problems including combined arthritis of the ankle and subtalar joints, complex hindfoot deformities and failed total ankle arthroplasty. The aim of this study was to report the elective results of combined subtalar and ankle arthrodesis using one design of dynamic retrograde intramedullary compression nail-the T2 Ankle Arthrodesis Nail(Stryker)


Retrospective review identified 53 consecutive patients who had 55 tibiotalocalcaneal arthrodesis procedures by two surgeons(ITS and NJT) using T2 Ankle nail fixation. 3 patients died of unrelated causes before follow up was complete which left 50 patients(52 nails); the largest consecutive series in the use of this device. Mean follow up was 23.5(3–72) months with the average age of patients being 61(range 22–89) years. An 84% response was achieved to a function and patient satisfaction questionnaire. Main indications for treatment were combined ankle and subtalar arthritis(63%-33/52) or complex hindfoot deformities(23%-12/52). Outcome was assessed by a combination of Clinical notes review, clinical examination, and telephone questionnaire.

MO Ahmed Y Morar M Edmonds V Kavarthapu

Hind foot Charcot deformity is a disastrous complication of diabetic neuropathy and can lead to instability, ulceration and amputation. The treatment of these patients is controversial. Internal stabilisation and external fixation have demonstrated variable results of limb salvage and some authorities thus advise patients to undergo elective amputation. We report a series of 9 diabetic patients with severe hind foot deformity complicated by ulceration in 5/9, who underwent acute corrective internal fixation with successful correction of deformity, healing of ulceration in 4/5 patients and limb salvage in all cases.

Conservative measures such as total contact casting were tried in 5 patients had predominant varus deformity, 2 with valgus deformity and 2 with unstable ankle joints. 5 patients had developed secondary ulceration.

All patients underwent corrective hind foot fusion with tibio-talo-calcaneal arthrodesis using a retrograde intramedullary nail fixation and screws and bone grafting. One patient also with fixed planovalgus deformity of the foot underwent a corrective midfoot reconstruction.

Patients were followed up in a diabetic/orthopaedic multidisciplinary foot clinic and were treated with total contact casting. (Mean follow up time was 15.6 ±6.9months) In all patients the deformity was corrected with successful realignment to achieve a plantigrade foot. Healing of the secondary ulcers was achieved in 4/5 cases and limb salvage was achieved in all cases.

Three patients underwent further surgical procedure to promote bone fusion. One patient required removal of a significantly displaced fixation screw. Two patients had postoperative wound infections which that were treated with initially intravenous antibiotic therapy and then negative pressure wound therapy.

In conclusion, internal fixation for severe hind foot deformity together with close follow up in a multidisciplinary diabetic/orthopaedic foot clinic can be successful in diabetic patients with advanced Charcot osteoarthropathy and secondary ulceration.

I Winson M Morssinkhof O Wang L James H van der Heide


Many scoring systems exist that assess ankle function, none of them are validated for use in a group of higher demand patients. This group of patients there have potential problems with ceiling effects, not being able to detect change or that a sports-subscale is not included. This study was to create a validated self-administered scoring system for ankle injuries in athletes by studying existing scoring systems and key-informant interviews.


The Sports Athlete Foot and Ankle Score (SAFAS) was developed from interviews with athletes as well as expert-opinions. Initially 26 patients were interviewed before creating the scoring system, this was modified from the Foot and Ankle Outcome Score, this had been partially validated previously and the subjects regarded the content as relevant but incomplete. Secondly, SAFAS the content was validated in a group of 25 patients with a range of injuries and 14 athletes without ankle injury. It is a self-administered region specific sports foot and ankle score that containing four subscales assessing the levels of symptoms, pain, daily living and sports.

MT Kennedy S Leong A Mitra M Dolan

Classical AO teaching recommends that a syndesmosis screw should be inserted at 25 to 30 degree angle to the coronal plane of the ankle. In practice accurately judging the 25/30 degree angle can be difficult, and there are several reports based on post operative CT scans demonstrating that a significant minority of patients have poorly operatively reduced syndesmotic injuries.

The CT scans of 200 normal ankles in one hundred individuals which had been performed as part a CT angiogram were retrospectively examined. The centroid of the fibula and tibia in the axial plane 15mm proximal to the talar dome was calculated. Since a force vector between the centroid of the fibula and the tibia in the axial plane should not displace the fibula relative to the tibia, a line connecting the two centroids was therefore postulated to be the ideal syndesmosis line, and also the optimum position in which to place a compression clamp after reducing the syndesmosis. Where this ideal line passed through the lateral border of the fibula, and through the medial malleolus was then noted.

The ideal syndesmosis line was shown to pass through the fibula with in 2mm of the lateral cortical apex of the fibula, and the anterior half of the medial malleolus in 100% of the ankles studied. The results support the concept that in the operatively reduced syndesmosis, the anterior half of the medial malleolus can be used as a reliable guide for aiming the syndesmosis drill hole, provided that the fibular entry point is at or adjacent the lateral fibular apex.

The corollary of these findings is that a screw inserted through a plate on the standard antero-lateral border of the fibula, or a plate in the anti-glide position posteriorly, cannot lie in the centroidal axis of the ankle.

S Mukhopadhyay A Metcalfe AR Guha K Mohanty S Hemmadi K Lyons D O'Doherty


Previous studies have demonstrated the need of accurate reduction of ankle syndesmosis. Measurement of syndesmosis is difficult on plain radiographs. Recently, a difference of 2mm in anterior and posterior measurements at incisura of the inferior tibio-fibular joint on CT has been described as a measure of malreduction (depicted as ‘G’ for ease of description). Our practice changed towards routine post operative bilateral CT following syndesmosis fixation to assess the reduction and identify potential problems at an early stage. The aim of this primarily radiological study was to determine if the use of bilateral cross sectional imaging brings additional benefit above the more conventional practice of unilateral imaging.


Between 2007 and 2009, nineteen patients with ankle fractures involving the syndesmosis were included in the study group who had bilateral CT post operatively. The values of ‘G’ and the mean diastasis (MD) were calculated, representing the average measurement between the fibula and the anterior and posterior incisura.

PJ Moroney Y Tourné


Arthrodesis of the 1st metatarso-phalangeal joint (MTPJ) is a common procedure in forefoot surgery for hallux rigidus and severe hallux valgus. Debate persists on two issues - the best preparation method for the articular surfaces, and the optimal technique for operative stabilisation of the joint.


We performed 1st MTPJ arthrodesis in 100 patients randomized into two equal groups. In the first group, the articular surfaces were prepared using cup-and-cone reamers, whilst in the second group, ‘flat cut’ osteotomies were performed with an oscillating saw. In all other respects, their treatment was identical. Fixation was secured using a plantar double compression Fixos™ screw and dorsal Anchorage™ plate. Full weight-bearing was allowed on the first post-operative day. Patients completed self-administered satisfaction questionnaires, including an AOFAS and SF-36 score pre-operatively and at two and six months post-operatively. Clinical examination and radiographs were compared at zero, two and six months. Statistical analysis was performed using Instat.

VK Singh S. Ridgers A Bansal A Sott

Forefoot surgery causes postoperative pain which requires strong painkillers. Regional blocks are now increasingly used in order to control postoperative pain especially in the first twenty four hours when the pain is at its worst. We conducted a study to see whether timing of ankle block i.e. before or after application of tourniquet shows any difference in efficacy in postoperative analgesia in first twenty four hours.

A prospective study was conducted between September and March 2011 involving 50 patients. Group A had ankle block after and Group B had block before application of tourniquet. Both group had twenty five patients each. Patients were given assessment forms to chart their pain on Visual Analogue Scale (VAS) at 4hrs and twenty four hours after surgery.

Both groups demonstrated good postoperative pain control. Average pain score at four and twenty fours after surgery was 2.5 and 5 in Group A and 3.5 and 6.1 in Group B respectively. Pain control, both at four and twenty four hours surgery was better in Group A but this was not statistically significant.

Ankle block should be routinely used in forefoot surgery to control postoperative pain. Ankle block before or after the application of tourniquet had comparable pain relief with no statistical difference.

D Marsland N Little A Dray M Solan

The saphenous nerve is classically described as innervating skin of the medial foot extending to the first MTP joint and thus is at risk in surgery to the medial ankle and forefoot. However, it has previously been demonstrated by the senior author that the dorsomedial branch of the superficial peroneal nerve consistently supplies the dorsomedial forefoot, leading to debate as to whether the saphenous nerve should routinely be included in ankle blocks for forefoot surgery. We undertook a cadaveric study to assess the presence and variability of the saphenous nerve.

29 feet were dissected from a level 10 cm above the medial malleolus, and distally to the termination of the saphenous nerve. In 24 specimens (83%), a saphenous nerve was present at the ankle joint. In 5 specimens the nerve terminated at the level of the ankle joint, and in 19 specimens the nerve extended to supply the skin distal to the ankle. At the ankle, the mean distance of the nerve from the tibialis anterior tendon and saphenous vein was 14mm and 3mm respectively. The mean distance reached in the foot was 5.1cm. 28% of specimens had a saphenous nerve that reached the first metatarsal and no specimens had a nerve that reached the great toe.

The current study shows that the course of the saphenous nerve is highly variable, and when present usually terminates within 5cm of the ankle. The saphenous nerve is at risk in anteromedial arthroscopy portal placement, and should be included in local anaesthetic ankle blocks in forefoot surgery, as a significant proportion of nerves supply the medial forefoot.

J Davidson R Chana K Miles D East HD Apthorp PA Butler-Manuel


The Oxford Total Meniscal Knee (TMK by Biomet), is a total knee replacement with a multidirectional mobile bearing. As part of the evaluation of the TMK we compared our group of TMK knee replacements with an equivalent cohort of AGC total knee replacements.


Patients recruited to AGC trial from 1994 to 2001. 254 AGC knee replacements sequentially recruited in 210 patients. Patients recruited to TMK trial from 2001 to 2007. 221 TMK knee replacements sequentially recruited in 193 patients. Patients prospectively randomised to having uncemented HA coated (HAC) or cemented versions in both groups. Each patient was reviewed pre-operatively, at 6 weeks, 6 months, 1 year and then annually.

All AGC & TMK TKR's were assessed clinically using HSS scores and radiographically. TMK group also assessed using AKSS and OKQ scores.

H Gbejuade M Hassaballa J Robinson J Murray A Porteous


Patients with severe knee instability and extensive bone loss remain a surgical challenge. In such cases, regular knee implants and constrained condylar implants may not be suitable or have been attempted and failed.

Hinged knee replacements have developed an important role in the management of such complex knee cases. They also have an increasingly important role in cases such as rheumatoid arthritis and other cases of severe joint destruction.

We present a review of 138 consecutive hinge knee arthroplasties of 8 different Hinge models performed in our unit between 2004 and 2010.


Combined prospective and retrospective study of 138 (42 primary and 96 revisions) consecutive cases of Hinge knee replacements at a mean follow up of 4.2 years. Outcomes were recorded and scored using the American knee score preoperatively, 1, 2 and 5 years. Complications, re-revisions, implant failures and survivorship were also assessed.

AJC Vaughan P Guyver M Divekar K Farmer A Lee


We aim to show that our series of Avon Patellofemoral Joint Replacements (APFJR) with over 5 year follow up, have comparable functional, radiological and revision rate results to other published reports.


Retrospective analysis occurred of all consecutive cases of APFJR from October 1999 and January 2010. All operations were performed by the senior author (AL). Each patient had both clinical and radiological follow up. Patient demographics, pre and post op Oxford Knee scores and complications were all recorded. An independent post operative radiological review took place to check for loosening and progression of disease. Revision to Total Knee Replacement (TKR) was taken as the endpoint.

B Hanratty N Thompson D Bennett A Robinson C Mullan D Beverland

Increasing knee flexion following total knee arthroplasty (TKA) has become an important outcome measure. Surgical technique is one factor that can influence knee motion. In this study, it was hypothesised that stripping of the posterior knee capsule could improve flexion and range of motion (ROM) following TKA. Patients who were undergoing TKA were prospectively randomised into two groups - one group (62 patients) were allocated stripping of the posterior knee capsule (PCS), the other group (66 patients) no stripping (no-PCS). The primary outcome was change in flexion and ROM compared to pre-operative measurements at three time points; after wound closure, 3months and 1year post-operatively. Secondary outcomes were absolute measurements of flexion, extension, ROM and complications. All operations were performed by a single surgeon using the same implant and technique. All patients received identical post-operative rehabilitation. There was a significant gain in flexion after wound closure in the PCS group (p=0.022), however there was no significant difference at 3months or 1year post-operatively. Absolute values of extension (p=0.008) and flexion (p=0.001) 3months post-operatively were significantly reduced for the PCS group. The absolute value of ROM was significantly higher for the no-PCS group at 3months (p=0.0002) and 1year (p=0.005). There were no significant difference in the rate of complications. Posterior capsular stripping causes a transient increase in flexion that does not persist post-operatively. We do not recommend routine stripping of the posterior knee capsule in patients undergoing TKA.

D Cohen M Cartwright-Terry J Pope J Davidson A Santini


To review the outcomes of patients undergoing manipulation under anaesthetic (MUA) after primary total knee arthroplasty (TKA) and predict those that may require such a procedure.


Prospective analysis of patients who required MUA post TKA performed by two surgeons using the same prosthesis from 2003 to 2008. Compared to a control group of primary TKA matched for age, gender and surgeon. All patients in both groups had pre- and post-operative measurements of range of movement. Risk factors were identified including warfarin and statin use, diabetes and body mass index.

J Littlechild J Keating K Kahn

The outcome of 77 high energy tibial plateau fractures treated by locking or conventional plating was reviewed. The aim of the study was to determine if there was any advantage of locking plates in reducing the complication rates associated with fixation of these injuries. All patients had a high energy injury pattern (medial or bicondylar plateau fractures). There were 32 locked plates and 45 non-locking plates used.

Compartment syndrome complicated 5 patients (16%) in the locked plate group and 3 (7%) in the non-locked group (p = 0.198). Superficial infection occurred in 4 (13%) patients with locked plates and 7 (16%) patients with non-locked plates. Thromboembolic complications occurred in 3 (7%) patients treated with non-locked plates. There were no thrombembolic complications in the locked plate group (p = 0.135).

Overall, malunion of the plateau occurred in 10 (22%) patients treated with non-locked plates compared to 7 (22%) patients who received locked plates. This was due to residual malreduction in 4 (13%) patients in the locked plate group and 6 (13%) patients in the non-locked plate group at the time of surgery. In the remaining cases loss of reduction after fixation occurred in 4 (9%) patients who received non-locked plates and in 3 (9%) patients who were treated with locked plates. No statistically significant difference was noted in the treatment outcomes of patients managed with locked plates or non-locked plates, regardless of fracture severity.

We concluded that there is no definite advantage associated with the use of locked plating for high energy tibial plateau fractures.

M Akula BD Chatterton S Gopal E Tsiridis P Stott C Hatrick W Reeves

We report our retrospective multicentre experience of managing periprosthetic knee fractures using locking plates, cemented nails and distal femoral prosthesis. The Aim of this study is to analyze the practicality of management of these injuries using modern methods of fixation or salvation. 62 patients presented to 3 centres between 2003 and 2010. After implementation of inclusion criteria, clinical, radiological and functional outcomes were evaluated in 54 patients, with a minimum follow-up of 6 months. 34 patients were treated with locking plates (10 males, 24 female; mean age 76), 16 with cemented/locking nails (4 males, 12 females; mean age 84.5), and 4 with distal femoral replacement prosthesis (2 males, 2 females; mean age 79).

Locking plates which were used with a minimally invasive pattern produced the best outcomes in our study. A statistical significance of p value of less than 0.01 was found in union time between patients operated on with an open technique (6.69±2.69 months) and those operated on with a minimally invasive technique (3.6±0.91 months). Nailing with augmented cement is a useful technique in patients who are not suitable for challenging surgery & rehabilitation programmes. There was a significant difference in mean time to functional weight bearing (p< 0.01) between the plate group (4.79±2.6 months) and the nail group (2.63±0.5 months). Post-operative range of motion was also better for nails (106.36±14.33O flexion) compared to plates (93.24±26.8O), a result that approached significance (p=0.065). We recommend minimal invasive plating in uncompromised physiological conditions, as an ideal method of fracture fixation in view of statistically significant union rates. Cemented nailing is recommended in patients where early rehabilitation is essential. Distal Femoral prosthesis replacement is a useful salvage method.

R Khakha J Gibbs J Hull A Perry H Chissell P Hill


It is now widely accepted that acute knee dislocations should be managed operatively. Most published studies are from outside the UK and from major trauma or specialist centres. The aim of the study is to report the functional outcomes of all patients presenting with an acute knee dislocation at our institution all of whom were surgically managed. The results were then compared to other published series. The hypothesis being that there would be no significant difference in the functional outcome scores between the groups.


All patients presenting with an acute knee dislocation over the last 15 years were included in the study. The patients were followed up using functional assessment scores: Knee outcome score (ADL), Knee outcome score (sports), Tegner Lysholm Scores and overall Patient Satisfaction. The patients were classified according to the Schecnk classification of knee dislocations.

S Lidder N Heidari W Grechenig H Clements N Tesch A Weinberg


Posterolateral tibial plateau fractures account for 7 % of all proximal tibial fractures. Their fixation often requires posterolateral buttress plating. Approaches for the posterolateral corner are not extensile beyond the perforation of the anterior tibial artery through the interosseous membrane. This study aims to provide accurate data about the inferior limit of dissection by providing measurements of the anterior tibial artery from the lateral joint line as it pierces the interosseous membrane.

Materials and Methods

Forty unpaired adult lower limbs cadavers were used. The posterolateral approach to the proximal tibia was performed as described by Frosch et al. Perpendicular measurements were made from the posterior limit of the articular surface of the lateral tibial plateau and fibula head to the perforation of the anterior tibial artery through the interosseous membrane.

H-H Aschoff RL McGough

Patients with above knee amputation face many challenges to mobility including difficulty with socket fit and fatigue due to high energy consumption. The aim of the Endo - Exo-Femur Prosthesis is to avoid problems at the interface between the sleeve of the socket-prosthesis and the soft tissue coat of the femur stump which often impedes an inconspicuous and harmonic gait. In 1999 we began using a transcutaneous, press-fit distal femoral intramedullary device whose most distal external aspect serves as a hard point for AKA prosthesis attachment. The bone guided prosthesis enables an advanced gait via osseoperception and leads to a decreased oxygen consumption of the patient. 43 patients were implanted between 1999 and 2009. Four of the 43 required removal:one for intramedullary infection, one due to stem fracture (replaced), and the two for soft tissue infection. The remaining 39 original prostheses remained. Two pertrochanteric fractures occurred, treated with ORIF. Two bilateral procedures were performed. Initially, twenty patients had chronic soft tissue irritation requiring debridement. This completely resolved by changing the connecting components to a highly polished cobalt chrome. All patients reported increased comfort when compared to socket use. The following additional advantages were observed: improved mobility and endurance, improved proprioception, decreased time required for prosthetic donning, lack of concern regarding changing body weight, and the absence of skin irritation. All patients reported an improvement in sense of position and tactile sensation, leading to an improved gait pattern.

Subjectively, the EEFP represents a significant improvement in terms of comfort. Since the introduction of high-gloss polished surfaces, soft tissue irritation is largely eliminated. Intramedullary infection has been negligible, as osseointegration seals the medullary cavity. In summary, the EEFP appears to be an attractive option in transfemoral amputees.

G McKay P Harvie K Sloan R Beaver

We report our five-year functional results comparing navigated and conventional total knee replacement. To our knowlege this represents the first Level 1 study comparing function in navigated and conventional total knee replacement at five years.

An origianl cohort of 71 patients undergoing Duracon (Stryker Orthopaedics, St. Leonards, Australia) total knee replacement without patellar resurfacing were prospectively randomised to undergo operation using computer navigation (Stryker Image Free Computer Navigation System (version 1.0; Stryker Orthopaedics))(n=35) or a jig-based method (n=36). The two groups were matched for age, gender, height, weight, BMI, ASA grade abd pre-operative deformity. All operations were performed by a single surgeon. Reviews were undertaken by senior physiotherpist blinded to participant status using validated outcome scoring tools (Knee Society Score, WOMAC Score and Short Form SF-36 Score). All patients underwent CT scanning of the implanted prosthesis as per Perth CT Knee Protocol to assess component alignment.

After 5 years 24 patients in the navigated group and 22 patients in the conventional group were available for review. At 5 years no statistically significant difference was seen in any of the aforementioned outcome scores when comparing navigated and conventional groups. No statistically significant differencewas seen between 2- and 5-year results for either group.

Due to the relatively low numbers in each group these data were compared with retrospective cohorts of navigated (n=100) and conventional (n=70) Duracon total knee replacements performed outwith this study over the same 5-year period. WITHIN the retrospective cohorts no statistically significant differences were found when comparing any of the aforementioned outcome scores. In addition, when comparing parallel scores between prospective and retrospective groups again no statistically significant differences were identified.

At 5-years post-operatively the functional outcome between computer navigated and conventional total knee replacement appears to be no different despite the better alignment achieved using navigation.

T Hiranaka Y Hida H Uemoto M Doita M Tsuji

The ligament balance as well as the alignment is essential for successful total knee arthroplasty (TKA). However it is usually assessed and adjusted only at 0? and 90?. In order to evaluate the ligament balance at the other angles we have used a navigation system. Twenty-one patients underwent posterior stabilised mobile bearing TKA using a CT-based navigation system were included in this study. Immediately post-operation and still under anaesthesia, varus and valgus stresses were applied on operated knees manually at 0?, 30?, 60?, 90? and 120?. The ligament balance was calculated based on the angles under varus and valgus stress displayed on the navigation screen, presenting a relationship between the femoral and tibial cutting planes. The mean ligament balance angle at 0?, 30?, 60?, 90? and 120? were −2? ± 3.6?, −5.8? ± 7.9?, 5.0? ± 6.9?, −1.3? ± 5.4?, 7.9? ± 7.2?, respectively. At 0? and 90? balance was well adjusted, however in the other angles, it was quite varied. At 30? and 120?, the lateral side was loose, on the other hand, medial side was looser at 60? knee flexion angle. The good balance at 0? and 90? is understandable because the balance is assessed and adjusted in these angles. Regarding the other angles, the 30? and 120? results corresponded with previous studies; however, the 60? results did not correlate. Although the reason is unknown, it must be aware the mid-flexion and deep flexion instability is quite common. Further investigations about the impact on clinical outcomes of such instabilities and how to adjust them if they are critical are needed.

DF Russell QA Fogg CI Mitchell B Jones


The superficial anterior vasculature of the knee is variably described; most of our information comes from anatomical literature. Descriptions commonly emphasise medial-dominant genicular branches of the popliteal artery. Quantifying the relative contribution of medial and lateral vessels to the anastomotic network of the anterior knee may help provide grounds for selecting one of a number of popular incisions for arthrotomy.


To describe the relative contribution of vessels to anastomoses supplying the anterior knee.

R Singhal KL Luscombe


Many determinants of the length of stay (LOS) for primary total knee arthroplasty (TKA) have been described. Multimodal, pre-emptive analgesia, age, walking aid score and stair score are some of them. Single shot peripheral nerve block is a popular method to provide prolonged analgesia in immediate post operative period after TKA. Delayed recovery from the nerve block can delay the rehabilitation programme and subsequently lengthen the LOS when the multi disciplinary team discharge criteria are well defined and standardized.

The aim of this study is to calculate the incidence of delayed recovery from the sciatic and femoral nerve block administered in cases of primary TKA and its influence on LOS.


All the patients undergoing primary TKA and receiving forty milliliters of 0.375% of Bupivacaine for sciatic and femoral nerve block since April 2010 till January 2011 have been included in the study. Patients demographics, date and day of operation, time of nerve block, complete recovery from the nerve block post operatively and date of discharge were recorded prospectively.

P Chandran K Patel V Kumar Y Hamed P Kay ML Porter


We aim to assess the functional outcome, patient perceived satisfaction and implant survival at a mean follow up of 13[10–16] years following revision knee replacement.

Patients and Methods

Between 1995 and 2001, 243 revision knee replacements were performed in 230 patients using Endolink [Link, Hamburg] or TC3 [Depuy, Leeds] prosthesis at Wrightington hospital, Wrightington, were consented to take part in this study. Data was collected prospectively which includes complications and functional assessment by Oxford knee score, WOMAC, HSS, UCLA, SF12 scores, and patient satisfaction questioner. The scores were obtained pre-operatively and post-operatively at 1 year, 5 years and at the latest follow-up. The mean age was 69 yrs, 51% were males, TC3 prosthesis as used in 175 and Endolink in 68, the revision was for Infection in 71[29%], 53 patients had intra-operative positive culture, 35 had 2 stage revision.

A Malviya N Brewster D Weir J Holland D Deehan


Although classic teaching holds that the least amount of constraint should be implanted, there is very little in the literature to substantiate this. This study attempts to quantify the influence of constraint and various indications upon functional outcome following aseptic first time revision knee arthroplasty. The null hypothesis was that the level of constraint and indication for surgery would not influence the functional outcome following revision knee replacement.


A single centre prospective study was performed to examine the outcome for 175 consecutive total revision knee replacements performed between 2003 and 2008 with a minimum follow-up of two years. Patient reported outcome data was used to determine the influence of final level of component constraint and its relationship with primary indication for surgery.

O Abouazza T O'Donnell


Reported advantages of unicompartmental knee replacement (UKR) over total knee replacement (TKR) include better kinematics and less postoperative pain. The reported longevity of UKRs, regardless of design, still does not compare as favourably as that of TKR. Resurfacing-type UKR differ to other UKR in that they result in minimal bone resection.


The aim of this study was to review our experience with conversion of a resurfacing UKR prosthesis to a TKR. We sought to determine the causes of failure and compare outcomes in terms of functional scores, range of motion and radiographic measures. We also determined the use of graft and prosthetic revision supplements as well as stemmed implants.

J Stammers S Kahane S Malek W Aston J Miles R Pollock R Carrington T Briggs J Skinner

Infection after knee arthroplasty is a devastating complication. Our aim is to present our outcomes of treating infected knee replacements at a tertiary referral centre.

We performed a consecutive, retrospective case series of all revision knee arthroplasty for infection between January 2006 and December 2008. Case notes were reviewed and data collated on the date and institution of primary arthroplasty, procedures undertaken at our institution, microbiology and bone loss post first stage, serological markers (C-reactive protein, ESR) prior to second stage and outcome.

During this three year period we performed 430 knee revision operations. 51 were in the presence of deep chronic infection. 90% were referred from other hospitals. Overall infection was successfully eradicated in 69%.

Nineteen patients underwent repeat two-stage and overall eleven (58%) patients had successful eradication of infection with multiple two-stages. Of these 47% had F3/T3, the highest grading of Anderson Orthopaedic Research Institute bone loss indicating no metaphyseal bone. A further 12% had bicondylar deficiency on the tibia and no femoral metaphyseal bone (F3/T2b).

Multidrug resistance present in 69% and 47% were infected with multiple organisms. All members of the unsuccessful outcome group had at least one multidrug resistant organism compared to 43% in the successful cohort (P=0.0002). Multiple organisms are associated with an unsuccessful outcome (P=0.056).

Serological markers were not significantly different between the successful and unsuccessful outcome groups.

Where the referring hospital had attempted revision and failed, the chance of eradicating infection dropped from 75% to 58% and the rate of above knee amputation was twelve times higher (3% vs. 36%).

Custom constrained, rotating hinge prostheses enable aggressive soft tissue debridement including ligaments. Successful two-stage requires a multidisciplinary approach including tissue viability nurses, microbiologists and plastic surgeons. Where units lack revision expertise this series suggests early referral increases the chance of limb salvage.

A Azam S Agarwal RL Morgan-Jones


This study was undertaken to evaluate the early results of a new implant system - the metaphyseal sleeve - in revision total knee replacement. The femoral and tibial metaphyseal sleeves are a modular option designed to deal with metaphyseal bone loss and achieve cementless fixation over a relatively wide area in the metaphysis.


Over three years, femoral and/or tibial metaphyseal sleeves were implanted in 104 knees in 103 patients (54 male and 49 female). The clinical notes and radiographs of these patients were reviewed retrospectively. Thirty one patients had revision for infection, 42 for aseptic loosening, and 31 for instability, pain or stiffness. Eighty nine knees were revised as a single stage and 15 were done as two stage procedure. Minimum follow up is 12 months (average 18.5 months).

SC Mertes S Raut V Khanduja


The aim of this study was to determine the effects of using the Bellovac autologous blood salvage system on blood transfusion requirements, adverse event rate, post-operative length of stay (POLOS) and mobilisation in patients who have undergone a total knee replacement.


This is a retrospective cohort study of 471 patients who underwent a total knee replacement (TKR) at our institution between January 2008 and August 2009. All patients received an autologous blood salvage drain in theatre. Their medical records were reviewed and a database created to assess the efficacy of the blood salvage system.

AJ Highcock EJ Craghill DJ Simmons


Oral factor Xa inhibitors have recently been licensed for use as thromboprophylaxis in arthroplasty surgery. Phase IV trials have proven there efficacy in DVT/PE prevention with comparable rates in major adverse events, including major bleeding. We examined whether the introduction of rivaroxoban, an oral factor Xa inhibitor, increased total blood loss in patients undergoing primary arthroplasty surgery.


Two groups were studied. The intervention group were prescribed rivaroxoban thrombophrophylaxis 6–10 hours post-surgery, and the control group were prescribed low molecular weight heparin (daltaparin 5,000u) 6–10 hours post-surgery. All other factors were kept constant.

Pre- and post-operative haemoglobin levels (post-operative day 2) were recorded. Any requirement for transfusion was also documented. Actual drop in haemoglobin levels was compared between the two groups.

W Marlow R Adam J Walker S Musthyala


This phase II safety study aimed to investigate the bleeding side effect profile in patients treated with Rivaroxaban as a new agent for venous thromboembolism (VTE) prophylaxis following hip or knee arthroplasty.


A retrospective study of complications was conducted in 88 consecutive patients undergoing hip and knee arthroplasty at one centre. Patients received chemical and/or mechanical VTE prophylaxis according to local guidelines. Data was collected from notes and evaluated using Fisher's exact test and t-Test. Significance was determined if p< =0.05. The primary end-point was local wound site oozing or bleeding. Secondary end-points were drop in haemoglobin, drain output and infection.

SZ Nawaz K Gallagher B Dhinsa R Carrington JA Skinner TW Briggs G Bentley

Chondral injuries of the knee are extremely common and present a unique therapeutic challenge due to the poor intrinsic healing of articular cartilage. These injuries can lead to significant functional impairment. There are several treatment modalities for articular osteochondral defects, one of which is autologous chondrocyte implantation. Our study evaluates the mid to long term functional outcomes in a cohort of 828 patients who have undergone an autologous chondrocyte implantation procedure (either ACI or MACI), identifying retrospectively factors that may influence their outcome.

The influence of factors including age, sex, presence of osteoarthritis and size and site of lesion have been assessed individually and with multivariate analysis. All patients were assessed using the Bentley Functional Score, Visual Analogue Score and the Cincinnati Functional Score. Assessment were performed pre-operatively and of their status in 2010.

The longest follow-up was 12 years (range 24 to 153 months) with a mean age of 34 years at time of procedure. The mean defect size was 409 mm2 (range 64 to 2075 mm2). The distribution of lesions was 51% Medial Femoral Condyle, 12.5% Lateral Femoral Condyle, 18% Patella (single facet), 5% Patella (Multifacet) and 6% Trochlea. 4% had cartilage transplant to multiple sites.

High failure rates were noted in those with previous cartilage regenerative procedures or evidence of early osteoarthritis and those with transplantation to multiple sites.

Autologous chondrocyte implantation is an effective method of decreasing pain and increasing function, however patient selection plays clear role in the success of such procedure.

R Raman J Singh G Johnson H Sharma N Day C Shaw


Viscosupplementation is used widely to provide symptomatic relief to patients with knee OA. This study aimed to compare the efficacy and safety of the standard (3×2ml) and single (1×6ml) dosing regimens of hylan G-F 20.


Prospective, randomized, blinded (reviewers), comparative independent study. Inclusion criteria was OA knee pain e 60mm on a 100mm VAS; no prior intra articular (IA) injection. Patients were randomised to recieve 1 × 6mL or 3 × 2mL hylan G-F 20. Follow-up at 1, 6, 12, 26 and 52 weeks. Analgesics prohibited for 24 hours prior to follow-up assessments and NSAID's for 26 wks. All adverse events (AE) were recorded. Primary outcome measure: Target knee pain (VAS) at 26 weeks. Secondary outcome measures included WOMAC, Oxford knee score, SF12

MC Papanna N Al-Hadithy N Yasin S Sundararajan


To determine if the location and pattern of knee pain as described by the patients using the knee pain map was comparable with the intra articular pathology found on arthroscopy as well as to facilitate diagnosis based on pain.


There were fifty five consecutive patients with acute and chronic knee pain participating in the study and they subsequently underwent arthroscopy of the knee joint as therapeutic or diagnostic procedure in day surgery.

Those patients with extra articular pathologies, referred pain hip, back and foot were excluded from the study.

All the participants were consented for the study; subjective data was recorded on the standardised knee pain map that included visual analogue pain scale preoperatively on the day of admission for arthroscopy.

The findings of the arthroscopy including EUA were recorded on the on standard arthroscopy forms used in our department by the operating surgeon.

A Weusten S Jameson P James R Sanders A Port M Reed


Medical complications and death are rare events following elective orthopaedic surgery. Diagnostic and operative codes are routinely collected on every patient admitted to English NHS hospitals. This is the first study investigating rates of these events following total joint replacement (TJR) on a national scale.


All patients (585177 patients) who underwent TJR (hip arthroplasty [THR], knee arthroplasty [TKR], or hip resurfacing) between 2005 and 2010 were identified. Patients were subdivided based on Charlson co-morbidity score. Data was extracted on 30-day complication rates for myocardial infarction (MI), cerebrovascular event (CVA), chest infection (LRTI), renal failure (RF), pulmonary embolus (PE) and inpatient 90-day mortality (MR).

L Henderson S Mc Donald N Eames


Traditionally complex spinal surgery in Belfast has been performed at the Royal Victoria Hospital (RVH). Since an amalgamation the RVH has become effectively the level 1 trauma centre for the province. The ever increasing complexity of spinal surgery in addition to changes in practice such as the management of metastatic spinal cord, are placing significant demands on the service. At a time when resources are scarce trends in patient profiles are highly important to allow adequate planning of our service.


To establish trends in patient profiles in a level one trauma centre also managing spinal pathology over the last 10 years and to examine the impact of this on our service.

M Venkatesan J Northover MS Patel B Wild J Braybrooke


Fractures of the odontoid peg are one of the commonest cervical spinal injuries in the elderly population. In this population there is a higher risk of morbidity and mortality as a result of the injury. The magnitude of the mortality risk has not been quantified in the literature.


To show a survivorship analysis in a cohort of elderly patients with odontoid peg fractures.

A Kumar C Lee

We hypothesised whether MIS techniques confer any benefit when treating thoracolumbar burst fractures.

This was a prospective, non-randomised study over the past seven years comparing conservative (bracing:n=27), conventional surgery (open techniques:n=23) and MIS techniques (n=21) for stabilisation and correction of all thoracolumbar spinal fractures with kyphosis of >200, using Camlok S-RAD 90 system (Stryker Spine). All patients previously had normal spines, sustained only a single level burst fracture (T12, L1 or L2) as their only injury. Age range 18–65 years.

All patients in both operatively treated groups were corrected to under 100 of kyphosis, posteriorly only. All pedicle screws/rods were removed between 6 months and 1 year post surgery to remobilise the stabilised segments once the spinal fracture had healed, using the original incisions and muscle splitting/sparing techniques. Patients were assessed via Oswestry Disability Index (ODI) and work/leisure activity status 1 year post fracture.

The conservatively treated group fared worst overall, with highest length of stay, poorest return to work/activity, and with a proportion (5/27) requiring later intervention to deal with post-traumatic deformity. 19/27 returned to original occupation, at average 9 months. ODI 32%.

Conventional open techniques fared better, with length of stay 5 days, most (19/23) returning to original work/activity, and none requiring later intervention. Average return to work was at 4 months. ODI 14%.

MIS group fared best, with shorter length of stay (48 hours), all returning to original work/activity at average 2 months, and none requiring later intervention. ODI negligible.

There was no loss of correction in either operatively treated groups.

The Camlok S-RAD 90 system is a powerful tool for correction of thoracolumbar burst fractures, and maintains an excellent correction.

MIS techniques provide the best outcomes in treating this group of spinal fractures, and offer patients the best chance of restoration to pre-fracture levels of activity.

K Kabir H Goost O Weber R Pflugmacher DC Wirtz C Burger


The management of thoracolumbar burst fractures is controversial. The goal of our study was to evaluate whether the psychological factors or the late spinal deformities influence outcome and in particular quality of life following surgical treatment of burst fractures of the thoracolumbar spine.

Material and methods

In a retrospective analysis, we evaluated outcome in 45 patients in whom burst fractures of the thoracolumbar spine without neurological deficits were surgically treated between April 2001 and November 2004. For this purpose, patient charts, surgery reports and x-ray images were analyzed consecutively. 29 patients could be examined physically and the outcome could be evaluated with VAS spine core, quality of life according to short-form 36 (SF36) and Beck Depression Inventory (BDI) with a minimum follow up of 30 months.

MS Patel P Sell


In all traumatic injury there is a clear relationship between the structural tissue damage and resultant disability after recovery. There are no publications that compare significant thoracolumbar osseous injury to non specific soft tissue injury.


To compare spinal outcome measures between patients with self reported back pain in the workplace perceived as injury to those having sustained structural injury in the form of an unstable thoracolumbar fracture requiring surgical stabilisation.

S Lakkol R Taranu G Reddy B Chandra T Friesem


The factors that are considered to be associated with successful clinical outcome fallowing cervical arthroplasty surgery are patient selection, absence of facet joint changes and lack of pre-operative kyphosis. Even though many studies have cited the pre-operative demographic details of their patient groups, the effect of associated psychological co-morbidities (Depression/Anxiety), smoking history, gender, social benefits and employment status on the clinical outcome measures have not been reported. The aim of the study was to assess the influence of pre-operative patient characteristics on the clinical outcomes following cervical disc replacement.


We included 126 patients who underwent single or multiple level cervical arthroplasty in our unit were included in the study. The clinical outcome measures such as Visual Analogue Score for neck pain (VAS-NP) and arm pain (VAS-AP); Neck disability Index (NDI), Hospital depression and anxiety scale and Bodily pain component of Short Form 36 questionnaires (SF-36 P) were recorded pre and post operatively. Statistical analysis was completed using SPSS 16.0 statistical package (SPSS Inc, Chicago, IL).

S Lakkol S Aranganathan G Reddy R Taranu T Friesem


In the last decade, single level cervical arthroplasty has proven its efficacy as one of the surgical treatment option for for patients suffering from cervical degenerative disc disease. Recent published reports on multilevel cervical arthroplasty using single implants have shown statistically significant results when compared to single level surgery. The aim of this study is to compare the clinical outcomes of multilevel cervical arthroplasty to single level cervical arthroplasty, when more than one type of implants were used.


This is a prospective study of consecutive patients who presented to our unit in between June 2006 and November 2009. The maximum follow-up period was 51 months (mean=18 months). Several types of cervical arthroplasty devices have been used in this study. The clinical outcome measures such as Visual Analogue Score for neck pain (VAS-NP) and arm pain (VAS-AP); Neck disability Index (NDI) and the Bodily pain component of Short Form 36 questionnaires were recorded pre and post operatively. After confirming the normality of the data appropriate parametric (paired t-test) were used to assess the statistical significance (p< 0.05) between pre and post-operative values. Two sample T-test was used to assess the significance between the differences in mean scores between each group.

D Thavarajah M Yousif P McKenna


MRI imaging is carried out to identify levels of degenerative disc disease, and in some cases to identify a definite surgical target at which decompression should take place. We wanted to see if repeat MRI scans due to a prolonged time between the initial diagnostic MRI scan of the lumbar sacral spine, and the MRI scan immediately pre-operatively, due for the desire for a ‘fresh’ MRI scan pre-operatively, altered the level or type of procedure that they would have.


This was a retrospective observational cohort study. Inclusion criteria- all patients with more than one MRI scan before their surgical procedure on the lumbar sacral spine, these were limited to patients that had either, discectomy, microdiscectomy, laminotomy decompression, laminectomy decompression and fusion, and posterior lumbar interbody fusion. Exclusion criteria- all patients with anterior approaches, all patients without decompression and all non lumbar sacral patients. Outcome measures were if there was a change between the pre-operative MRI scans, which would have changed the operative level of decompression, added other levels of decompression or type of surgery than primarily decided.

EE Kuong KMC Cheung D Samartzis KWK Yeung KDK Luk

Despite the myriad new spinal instrumentation systems, scoliosis can rarely be fully corrected, especially when the curves are stiff. A novel superelastic nickel-titanium (nitinol) rod that maximises the ability to slowly correct spinal deformities by utilising the viscoelastic properties of the spine has been developed. This parallel, double-blinded, randomised controlled trial compared the safety and efficacy of these new rods to conventional titanium rods in 23 patients with adolescent idiopathic scoliosis. The superelastic nitinol rods were found to be safe, could gradually correct scoliosis curves, and ultimately resulted in better coronal and sagittal alignments compared to traditional rods.

Despite the myriad new spinal instrumentation systems, scoliosis can rarely be fully corrected, especially when the curves are stiff. A novel superelastic nickel-titanium (nitinol) rod that maximises the ability to slowly correct spinal deformities by utilising the viscoelastic properties of the spine has been developed. This parallel, double-blinded, randomised controlled trial compared the safety and efficacy of these new rods to conventional titanium rods in 23 patients with adolescent idiopathic scoliosis. The superelastic nitinol rods were found to be safe, could gradually correct scoliosis curves, and ultimately resulted in better coronal and sagittal alignments compared to traditional rods.

M Newton Ede ERS Ross B Rischke B Joellenbeck J Hipp Z Kari


To determine if clinical outcomes are correlated with center of rotation (COR) in patients implanted with a viscoelastic total disc replacement (VTDR).


Fifty patients with single-level, symptomatic lumbar DDD between L4 and S1 were enrolled in a clinical trial of a VTDR across three surgical centres. A comprehensive, independent review and statistical analysis of both clinical and radiographic outcomes was performed and analyzed for correlations. Data from preoperative through 2 years were available. The COR was calculated for the index levels and compared to data for an asymptomatic population. Each COR coordinate was classified as abnormal if outside of the 95% confidence interval for an asymptomatic population.

R Walker P Sturch D Marsland


Cauda equina syndrome (CES) is a rare condition which requires urgent treatment to reduce the risk of long term neurological morbidity. Most authors recommend surgical decompression within 24–48 hours of the onset of symptoms, which may not be possible if there are delays in referral to hospital, performance of diagnostic imaging or poor access to a spine surgeon. We present a snap shot of referrals of patients with suspected cauda equina syndrome to the Orthopaedic department in a district general hospital including the diagnoses, management and outcome.


A retrospective review of 20 consecutive patients (mean age 49, 11 males, 9 females) referred via Primary Care to the orthopaedic on call team between April and December 2010 was carried out. Data were recorded including the clinical symptoms and signs on admission, time taken to undergo MRI, diagnosis and treatment.

M Venkatesan S Balasubramanian MS Patel J Braybrooke M Newey


The relationship between obesity and cauda equina syndrome (CES) has not been previously evaluated or defined.


Purpose of this study was to examine the presentation, timing of surgery, peri-operative complications and outcome of Cauda Equina Syndrome in relation to Body Mass Index.

I Vanhegan G Cannon S Kabir J Cowan A Casey


Evidence suggests that intra-operative spinal cord monitoring is sensitive and specific for detecting potential neurological injury. However, little is known about surgeons' responses to trace changes and the resultant neurological outcome.


To examine the role of intra-operative somatosensory evoked potential (SSEP) monitoring in the prevention of neurological injury, specifically sensitivity and specificity, and whether the abnormalities were reversible.

D Thavarajah P McKenna R Marshall T Andrade S Iyer


The purpose of our study was to see what the microbiological epidemiology of our discitis biopsy specimens were. In doing this we could identify if biopsy served a strategic and necessary purpose in the management of this potentially serious pathology.


At our institution the Combined Orthopaedic and Medical Microbiology Service (COMMS) reviews all patients on antibiotic treatment on a weekly basis and records data prospectively. We present a review of discitis patient data from a 28 month period (August 2008-December 2010). Inclusion criteria included a first diagnosis of discitis, based on a history of pain, raised inflammatory markers (erythrocyte sedimentation rate, C reactive protein), MRI confirmation, radiological biopsy of disc, patients that had spinal procedures and patients that had no spinal procedures. Exclusion criteria included patients who did not have a disc biopsy or MRI scan diagnosis. The outcome measure was discitis biopsy micro-organism.

B Dala-Ali W Yoon A Iliadis J Lehovsky


Pedicle subtraction osteotomy is a powerful technique for correcting sagittal imbalance in ankylosing spondylitis. There has been significant perioperative morbidity associated with this technique in the peer review literature. We present the Royal National Orthopaedic Hospital experience with a single surgeon retrospective study that was conducted to evaluate the outcomes in patients who underwent lumbar pedicle subtraction osteotomy for the correction of thoracolumbar kyphotic deformity in ankylosing spondylitis.


Twenty seven patients underwent a lumbar pedicle subtraction osteotomy and adjacent level posterior instrumentation between 1995 and 2010. There were 18 males and 9 females in the study. Events during the peri-operative course and post-operative complications were recorded. The radiological outcome and patient satisfaction were analysed with mean follow-up of one and a half years.

PS Young SW Bell EM MacDuff A Mahendra


Bony tumours of the foot account for approximately 3% of all osseous tumours. However, literature regarding os calcis and talar tumours comprises individual case reports, short case series or literature reviews with no recent large series.


We retrospectively reviewed the medical notes and imaging for all patients with calcaneal or talar tumours recorded in the Scottish Bone Tumour Registry since the 1940's. Demographics, presentation, investigation, histology, management and outcome were reviewed.

N Al-Hadithy P Gikas J Perera W Aston R Pollock J Skinner K Lotzof S Cannon T Briggs

The surgical treatment of bone tumours can result in large perioperative blood loss due to their large sizes and hypervascularity. Preoperative embolisation has been successfully used to downgrade vascularity, thus reducing perioperative blood loss and its associated complications. Prior to embolization era, blood loss as high as 18,500mL have been reported peri-opratively.

Twenty-six patients with a variety of bone tumours (average size 10.5×7.5×5.5cm), who underwent pre-operative embolisation between 2005 and 2009, were retrospectively studied. The group comprised of 17 females and 9 males. Their mean age was 38 years old. All patients underwent surgical resection within 48 hours of embolization. Mean blood loss was 796mL and required on average 1.1units of blood. We experienced no complications.

Pre-operative arterial embolisation of large, richly vascular bone tumours in anatomically difficult positions, is a safe and effective method of downstaging vascularity and reducing blood loss.

R Pearson C Gerrand


Decisions about local treatment are important in osteosarcoma treatment. The purpose of this study was to review decisions about local treatment in one centre.


This was a retrospective review of the records of all patients with high-grade extremity osteosarcoma presenting to our centre between 1997 and 2008. Particular attention was paid to local control decisions.

J Chakravarthy L Jeys

The distal humerus represents 1% of all primary bone tumours. Endoprosthetic replacement can potentially improve function and provide good pain relief. We present out experience with the custom made Stanmore elbow endoprosthesis used after resection of malignant tumours of the distal humerus. Between 1970–2009 we carried out 19 endoprosthetic replacments for malignant tumours of the distal humerus. 10 were a result of metastasis and 9 were primary bone tumours. 7 patients had a pathological fracture as their first presentation and 3 had pathological fractures after the diagnosis was made. 11 patients died between 3 months to 16 year following surgery. The mean survival of the patient group was 7.1 years (range 3 months to 37 years). 4 patients underwent a revision EPR and one patient underwent two revision EPR's due to loosening. Two patients underwent maintenance procedures (rebushing) due to wear of the poly bushing. We have had no revisions since the design of hte implant was changed to a floppy hinge design. One patient underwent an above elbow amputation four years after surgery due to local recurrence. There were no early post operative infections. One patient developed a sinus requiring multiple wound explorations, one year after insertion of the endoprosthesis for a sarcoma. This patient was infection free till the time of death 3 years later. There were no nerve palsies, periprosthetic fractures or wound problems. The mean TES score was 72% (59–78%) in the surviving patients at review. As the majority of the patients were implanted for metastatic disease the initial reliablity and low complication rate of the procedure, in our series, confirms that this is a suitable reconstruction for patients in significant metastatic pain from a destructive lesion of the distal humerus, rapidly restoring function and relieving pain in a predictable manner

B Sankar R Refaie S Murray C Gerrand


Aseptic loosening is the most common mode of failure of massive endoprostheses. Introduction of Hydroxyapatite coated collars have reduced the incidence of aseptic loosening. However bone growth is not always seen on these collars.


The aims of our study were to determine the extent of osseous integration of Hydroxyapatite coated collars, attempt a grading system for bone growth and to determine the effect of diagnosis, surgical technique and adjuvant therapy on bone growth.

J Chan CR Chandrasekar Q Yin


The aim of this study was to review the referral pattern of Soft Tissue Sarcoma (STS) in the Mersey region. We were interested in the referrals that came from other specialties [not primary care] and how they were managed before being finally referred on to the Tumour Unit.


This was a retrospective review of 175 patients with a histological diagnosis of a STS. Case notes were reviewed and information was collected about the management by the first referred specialty doctor and the length of time to be referred to the specialist unit.

E Gillott S Kahane W Aston TWR Briggs J Skinner R Pollock


Present the outcomes of those patients diagnosed with Ewing's Sarcoma of the foot within the past 10 years and treated at the Royal National Orthopaedic Hospital's Bone Tumour Unit, Stanmore.


Retrospective study of the cases identified from the pathology database. Notes reviewed for presentation, treatment and follow up. TESS (Toronto Extremity Salvage Score) and MSTS (Musculoskeletal tumour score) were calculated.

S Dawson-Bowling O Berber A Jalgaonkar J Miles W Aston R Pollock J Skinner T Briggs

Bizarre parosteal osteochondromatous proliferation (BPOP), or Nora's lesion, is a rare condition characterised by the formation of surface-based osteocartilaginous lesions typically affecting the hands and feet. 22 cases were identified from the records of a regional bone tumour unit, dating from 1985 to 2009. Of 22 cases, 9 lesions involved the long bones of the hand, 7 the long bones of the feet, 1 case originated from a sesamoid bone of the foot and 5 from long bones (radius, ulna, femur [2] and tibia). Age ranged from 6 to 66 (mean: 31.8) and male to female ratio was 1.8:1. Diagnosis was based on combined radiological and histological features, and initial surgical treatment was excision in 21 cases, and 1 amputation. Follow-up ranged from 12–162 months (mean 32). Recurrence occurred in 6 patients (27%), with mean time to recurrence 49 months (range 10–120). 2 of 8 patients with complete resection margins developed recurrence (25%), versus 4 of 14 with marginal or incomplete resection (28%). Given the potential surgical morbidity inherent in resection, our data suggest that there may be a role for a relatively tissue-conserving approach to the excision of these lesions.

S Gulhane D Meek S Patil

This case series highlights the use of the Ganz approach (trochanteric slide approach) and surgical dislocation for excision of fibrous dysplasia of the femoral neck, pigmented villonodular synovitis and synovial chondromatosis of the hip.

The first patient was a 16-year-old girl, who presented with pain in her hip, having fallen whilst playing football. Investigations revealed a fibrous dysplasia, which was successfully excised returning her to an active lifestyle.

The second patient was a 27-year-old lady, who presented having suffered left hip pain for four years. She was diagnosed with a pigmented villonodular synovitis, which was excised and the patient was able to return to the gym.

The third patient was a 41-year-old lady, who presented after experiencing right hip pain both at night and at rest for a year, without any trauma. She was diagnosed with synovial chondromatosis and returned to all activities of daily living.

The Ganz approach allows safe dislocation of the hip joint without the risk of osteonecrosis of the femoral head. We demonstrate that it is possible to obtain excellent exposure of the femoral neck, head and acetabulum to surgically treat these three tumours of the hip. The surgeon can thus be reassured that complete excision of the tumour has occurred.

This series can recommend the Ganz approach with trochanteric slide and full surgical dislocation of the hip to excise pigmented villonodular synovitis, synovial chondromatosis and fibrous dysplasia of the hip.

N Brownson R Anakwe L Henderson M Rymaszewska J McEachan J Elliott L Rymaszewski


Although the majority of adult distal humeral fractures are successfully treated with ORIF, the management in frail patients, often elderly with multiple co-morbidities and osteoporotic bone, remains controversial. Elbow replacement is frequently recommended if stable internal fixation cannot be achieved, especially in low, displaced, comminuted fractures. The “bag-of-bones” method ie early movement with fragments accepted in their displaced position, is rarely considered as there has been little in the literature since 10 successful cases were reported by Brown & Morgan in 1971 (JBJS 53-B(3):425–428). We present the experience of three units in which conservative management has been actively adopted in selected cases.


44 distal humeral fractures were initially treated conservatively - 2004–2010. Mean age 73.9 yrs (40–91) and 34 F: 10 M. Clinical and radiological review at a mean follow-up of 2 years (1–6).

SS Al-Nammari N Al-Hadithy


Isolated trochlea fractures are very rare and have only been described previously as case reports.


To report on a case of isolated trochlea fracture and to present a review of the literature.

N Burke J Kennedy D Fitzpatrick H Mullett


Locking plates are widely used in clinical practice for the surgical treatment of complex proximal humerus fractures, especially in osteoporotic bone. The aim of this study is to assess the biomechanical influence of the infero-medial locking screws on maintaining reduction of the fragments in a proximal humerus fracture.

Materials & Methods

A standard 3-part proximal humerus fracture was created in fourth generation humerus saw bones. Each specimen was anatomically reduced and secured with a PHILOS locking plate. Eleven of the specimens had infero-medial locking screws inserted, and 11 specimens did not. Each humerus sawbone underwent cyclical loading at 532N, as previous studies showed this was the maximum force at the glenohumeral joint. The absolute inter-fragmentary motion was recorded using an infra-red motion analysis device. Each specimen was then loaded to failure.

A Memon D Lui S Kwan H Mullett


Sling immobilization of the upper limb may affect balance. Computerized dynamic posturography (CDP) provides a validated, objective assessment of balance control and postural stability under dynamic test conditions. We tested the balance of individuals with a shoulder stabilization sling (SSS) using an Equitest Machine to objectively assess imbalance wearing a sling.


42 right hand dominant (RHD) adults (16 females, 26 males; average age 22; range 20–35 years) were included in the study. 6 controls and two SSS groups with 18 Dominant Hand (DH) and 18 Non Dominant Hand (NDH). CDP assessed balance by Sensory Organization Test (SOT), Motor Control Test (MCT) and Adaptation Test (ADT).

S Ahmad S Jameson P James M Reed J McVie A Rangan


A recent Cochrane review has shown that total shoulder arthroplasty (TSA) seems to offer an advantage in terms of shoulder function over hemiarthroplasty, with no other obvious clinical benefits. This is the first study to compare complication rates on a national scale.


All patients (9804 patients) who underwent either TSA or shoulder hemiarthroplasty as a planned procedure between 2005 and 2008 in the English NHS were identified using the hospital episodes statistic database. Data was extracted on 30-day rates of readmission, wound complications, reoperation and medical complications (myocardial infarction (MI) and chest infection (LRTI)), and inpatient 90-day DVT, PE and mortality rates (MR). Revision rate at 18 months was analysed for the whole cohort and, for a subset of 939 patients, 5-year revision rate. Odds ratio (OR) was used to compare groups.

LAK Khan RS Page LN Miller SE Graves


To report the rate of early revision (within two years) after shoulder arthroplasty and identify any patient, disease or prosthesis factors that may be associated with these early failures.


The AOA National Joint Replacement Registry has recorded 7113 shoulder arthroplasty procedures up to December 2009. Data recorded includes diagnosis, patient demographics and prosthesis details. The main outcome of this analysis was the time to first revision of all primary shoulder arthroplasty recorded by the Registry.

The cumulative per cent revision (CPR) of shoulder arthroplasty procedures was estimated using the Kaplan-Meier method. Cox proportional hazard models were used to test significance between groups

RA Delaney LD Higgins JJP Warner


Partial humeral head resurfacing using a stemless implant is a bone-conserving option in treatment of focal chondral defects. We report our experience using the Arthrosurface HemiCAP® device.


This is a retrospective study of patients with focal chondral defects of the humeral head, treated with partial resurfacing arthroplasty, with a minimum follow-up of 2 years. Mean patient age was 45.4 years (range 27–76). Patients were analyzed in 2 groups: those who underwent HemiCAP for an isolated humeral head defect, and those who had HemiCAP combined with biologic resurfacing of concomitant glenoid disease.

O Templeton-Ward D Griffiths D Higgs M Falworth I Bayley S Lambert

Reverse polarity total shoulder arthroplasty (RTSA) has gained popularity over recent years for the treatment of the painful cuff deficient shoulder. Although proposed over 20 years ago and despite good clinical outcomes the RTSA has struggled to gain popularity due to reported high levels of complications.

One such complication is post-operative instability with frequencies of up to 30% (De Wilde 2002). The Bayley-Walker RTSA was designed specifically for patients with difficult reconstruction problems in whom an unconstrained prosthesis would not offer sufficient stability. It is a reverse anatomy fixed fulcrum constrained prosthesis. The glenoid component has a long HA-coated tapered helical screw, with large pitch and depth, fixation is augmented by a grooved HA coated glenoid plate.

The purpose of this study was to review the clinical experience from The Royal National Orthopaedic Hospital Stanmore and to ascertain the rate of glenoid component loosening. We also carried out a radiographic review to correlate loosening with patterns of lucency on post-operative radiographs. One hundred and five B-W TSRs in 103 patients were included, 24% of which were performed as revision of previous failed arthroplasty. In total, 8/105 glenoids required revision. Of those eight patients, two were cases of septic loosening. Of all nine specified areas of glenoid, tip lucency on x-ray appeared to be most strongly associated with need for glenoid revision. 5/9 cases with tip lucency progressed to loosening of the glenoid. Where tip lucency was not seen, 93/96 glenoid components remained secure, giving tip lucency a negative predictive value of 97%. Excluding the two infected cases, the glenoid remained secure in 97/103 patients undergoing BW-TSR with follow-up up to 13 years. The BW-TSR is a satisfactory and durable solution to the cuff-deficient shoulder in variety of challenging groups including younger patients and as a salvage procedure following failed, cuff-deficient arthroplasty.

AJ Cassar Gheiti DC Molony J Kennedy A Schepens HJ Mullett


Reverse Geometry shoulder replacement requires fixation of a base plate (called a metaglene) to the glenoid to which a convex glenosphere is attached. Most systems use screws to achieve this fixation. The suprascapular nerve passes close to the glenoid and is known to be at risk of injury when devices and sutures are inserted into the glenoid. We investigate the risk posed to the suprascapular nerve by placement of metaglene fixation screws.

Materials and Methods

Ten cadaveric shoulder specimens were used. A metaglene was inserted and fixed using 4 screws. The suprascapular nerve was dissected and its branches identified. The screw tips and their proximity to the nerve and branches were identified and recorded.

M Anderton M Newton Ede E Holt


Accurate knowledge of the normal shoulder range of movement (ROM) is imperative for evaluating pathology and clinical success. However, in orthopaedic texts, the quoted normal shoulder ROM has significant variation. Furthermore we suspect there is a high incidence of intra and inter observer error during shoulder ROM examination.

The aims of our study were thus:

To perform a literature review and record the published values for normal shoulder ROM. Subsequently, to calculate the average of these published values.

To perform visual and goniometer measurement of shoulder ROM in 10 volunteers and assess the agreement between the two methods.


A literature search of textbooks, Pub Med and scoring systems was undertaken. Statistical analysis was performed to identify the average value of shoulder movements. Two researchers (specialist trainees in T&O) prospectively assessed 20 shoulders in 10 healthy volunteers. Second observations were made after two weeks. Visual estimation and goniometry assessments were conducted. Bland Altman analysis was performed.

T Yeoman C Wigderowitz


Several orthopaedic studies have found significant correlation between pre-operative psychological status and post-operative outcomes. The majority of research has focused on patients requiring lower limb and spine surgery. Few studies have investigated the effect of psychological status on the outcome of upper limb operations. We prospectively investigated the association between pre-operative psychological status and early postoperative shoulder pain and function in patients requiring arthroscopic subacromial decompression (ASAD) for impingement syndrome.


A consecutive series of patients in 2009/10 completed questionnaires 2 weeks pre-operatively and 3 and 6 weeks post-operatively that assessed psychological state, shoulder function and pain. The hospital anxiety and depression scale, the Oxford shoulder score and a pain visual analogue scale assessed psychological status, shoulder function and shoulder pain, respectively. Data was analysed using non-parametric statistical methods.

S Punwar PW Robinson N Blewitt


The present study aimed to assess the accuracy of preoperative departmental ultrasound scans in identifying rotator cuff tears at our institution.


Preoperative ultrasound scan reports were obtained from 64 consecutive patients who subsequently underwent arthroscopic subacromial decompression and/or rotator cuff repair. Data was collected retrospectively using our 2010 database. The ultrasound reports were compared with the arthroscopic findings. The presence or absence of partial and full thickness rotator cuff tears was recorded.

BC Hanusch J O'Donovan M Brown R Liow


Adhesive capsulitis (frozen shoulder) is a debilitating condition affecting 2–5% of the adult population. Its aetiology is still unclear and there is no consensus on the most effective treatment. The aim of this retrospective study was to investigate the mid-term functional outcome of one specific treatment protocol.


Patients with a diagnosis of idiopathic adhesive capsulitis treated by one orthopaedic surgeon between 2004 and 2008 were identified from outpatient clinic letters. All patients had initially received conservative treatment, consisting of physiotherapy with capsular stretches and subacromial injections. Patients in whom conservative treatment failed underwent an arthroscopic capsular release. At a minimum of two years following diagnosis patients were sent the Oxford Shoulder Score (OSS [0 to 48]), Western Ontario Rotator Cuff Index (WORC [0 to 2100]) and a satisfaction questionnaire by post. In addition case notes were reviewed and type of treatment and range of movement (ROM) recorded.

Full Access
A Mohan J Vadher H Ismail D Warwick


To construct and validate a simple patient related outcome measure scheme to quantify the disability caused by Dupuytren's Disease thus enabling prioritisation of treatment, allow reliable audit of surgical outcome and support future research.


The Southampton Dupuytren's Scoring System (SDSS) was developed in a staged fashion according to the recommendations of Derby Outcomes Conference.

item generation from questionnaire filled in by 20 patients;

item reduction to create a 20-question proforma;

Internal consistency (Cronbach's alpha)

Test-retest (3 week interval testing on 61 patients)

Field management was used to assess the user friendliness of the scoring system.

Sensitivity to change Standardised response mean

Construct validity: ability of the SDSS to measure what it is supposed to measure. comparing SDSS with QuickDASH (Disability of Arm, Shoulder and Hand)

J Foote V Nunez L Dodd J Oakley


An educated public are becoming increasingly aware of percutaneous needle fasciotomy (PNF) for the treatment of Dupuytren's contracture. We believe that it has an important place in the management of this condition and have set up a dedicated one-stop clinic to perform this procedure.


A prospective study of 61 patients with Dupuytren's, who have undergone PNF have been recruited so far. The study population includes 50 men and 11 women. The average age is 65. The senior author has operated on 81 fingers including 69 MCP joints, 62 PIP joints and 6 DIP joints. We recorded contractures prior to PNF and immediately following the procedure, as well as any complications. At follow up we recorded the Patient global impression of change (PGIC), DASH scores, degree of straightness of the operated finger and whether they would have the procedure again or recommend it.

SKL Chan G Nitish L Wicks SC Deshmukh


To assess the long term functional and objective outcomes for 2 stage Dupuytrens contracture correction.


Patients with severe contracture were offered a 2 stage correction. This involved application of external fixator to distract the contracture over the course of 2 weeks and subsequent partial fasciectomy (in primary contractures) and dermofasciectomy with full thickness skin graft (in recurrent contractures). A series of 54 corrections in 47 patients were identified. Of these, 6 were lost to follow-up, 1 deceased. Pre-operative total range of active movement (TRAM), total flexion contracture and PIP flexion contracture, Tubiana grade and DASH/Michigan Hand Scores were recorded and compared to post-operative data.

T Lindau C Bainbridge B Cohen H Kushner T Smith D Nguyen P Szczypa R Gerber


Injectable collagenase clostridium histolyticum (CCH) is a minimally invasive non-surgical therapy with efficacy in correcting Dupuytren's contracture (DC). In the concurrently run JOINT I and JOINT II studies, designed to follow clinical practice, we evaluated the efficacy of ?5 CCH injections in patients with DC.


JOINT I and II were multicenter, 9-month, open-label studies in which DC patients with primary flexion deformities ?20° received ?3 CCH (0.58 mg) injections/joint (?5 injections/patient) at 30-day intervals into joints prioritized by extent of contracture. After the first injection, patients could opt to receive up to 2 additional injections in same cord or other cords regardless of outcome for the first joint. The primary endpoint was reduction in contracture to ?5° 30 days after the last injection. Data from JOINT I and II were pooled.

S Elnikety M El-Husseiny T Kamal G Talawadekar N Triggs H Richards A Smith


“No routine post-operative follow up appointments” policy has been implemented in NHS hospitals in different specialties for uncomplicated surgical procedures. In trauma and orthopaedics few studies to date reviewed this practice and reflected on the patients' opinions.


A total of 121 patients were recruited over 2 years, each patient had post operative follow up by the hand therapist for 3 months. 50 patients post Trapeziectomy and 71 patients post single digit Dupuytren's fasciectomy were prospectively surveyed for their opinion on their post operative care and whether they would have liked to be reviewed by the surgeon in a routine post operative follow up appointment or not. All operations were done by one surgeon in one hospital. All patients were reviewed by a hand therapist within 2 weeks post operatively and treatment protocols were followed with all the patients. During their final appointment with the hand therapist all patients completed a questionnaire.

C Munro S Baliga A Johnstone C Carnegie

Volar Locking Plates (VLP) have revolutionised the treatment of distal radius fractures allowing the anatomic reduction and stable fixation of the more comminuted and unstable of fractures. The benefits of this in terms of range of movement (ROM), pain and earlier return to work and daily activities is documented. However we were interested in was what improvements in wrist function patients made from 6 to 12 months after injury?


We retrospectively looked at a series of 34 consecutive patients that had undergone VLP fixation through a standard anterior approach followed by early physiotherapy. We documented standard demographics and assessed function in terms of Range of Movement, Grip strength (GS), Modified Gartland and Werley score (MGWS), Patient Rated Wrist Evaluation (PRWE) and the quick DASH questionnaire at six and twelve months


Two patients were excluded from analysis as they failed to make both assessments. Of the 32 remaining (26 female:6 male) the mean age was 53.2yrs; range (26–78). On average GS, PGS, VAS function and pain did not improve. There was a modest improvement in Movement; Wrist Flexon-13 deg, Wrist Extension-14deg, Radial Deviation-7deg, Ulnar Deviation-9deg. There was no improvement in pronation and supination.

There was little improvement in qDASH, PRWE and mGW Scores with only a mean 1.8, 5.6 and 3.6 point improvement respectively.

HP Singh N Taub JJ Dias


Scaphoid fractures with displacement have a higher incidence of nonunion and unite in a humpback position that can cause pain and reduced movement, strength and function. The aim of this study is to review the evidence available and establish the risk of nonunion associated with management of displaced scaphoid fractures in a plaster cast.


Electronic databases were searched using the MeSH (Medical Subject Headings) controlled vocabulary (scaphoid fractures, AND'd with explode displaced, or explode nonunion, or explode non-healing or explode cast immobilisation, or explode plaster, or explode surgery). As no randomised or controlled studies were identified, the search was limited to observational studies based on consecutive cases with displaced scaphoid fractures treated in a plaster cast. The criterion for displacement was limited to gap or step of more than 1mm. The ‘random effects’ calculation was used to allow for the possibility that the results from the separate studies differ more than would be expected by chance.

PS Waters SJ Roche ME O Sullivan

Acute scaphoid fractures are commonly treated with cast for 8–12 weeks. With this prolonged period of immobilisation patients can encounter joint stiffness and muscle wasting requiring extensive physiotherapy. Despite best practice, these fractures also pose a risk of non-union and suboptimal function. Fracture location, duration of time lost from work and impairment in activities of daily living are key factors in scaphoid fracture management.

The aim of our study was to compare percutaneous screw fixation of the scaphoid with other operative fixation techniques. Parameters documented were length of conservative treatment, mechanism of injury, post-op complications and patient satisfaction levels with each technique using a standardised questionnaire. Economic benefit was also measured by examining time to return to work, number of x-rays and outpatient visits required per treatment group.

In this study, 76 patients requiring operative scaphoid fixation were evaluated. 27 patients underwent percutaneous fixation. Waist fractures accounted for 66% (n= 18), proximal pole fractures 33% (n=8) and distal pole fractures 4% (n=1). There were 16 non-displaced fractures (59%) and 11 displaced fractures (41%). The average length of conservative treatment was 77 days (range: 2–256 days). Within the percutaneous group 2 patients developed non-union. We did not encounter any wound infection or superficial radial nerve damage. Patients treated with early percutaneous fixation had highest satisfaction levels, returned to work earlier and required less follow-up (P< 0.001).

In conclusion percutaneous screw fixation provides earlier bone union and avoids the need for prolonged immobilisation when compared to other treatment modalities. The economic benefit of early percutaneous fixation must also be considered when managing patients with scaphoid fractures.

D Srikantharajah PJ Jenkins AD Duckworth AC Watts JE McEachan


The association of occupation and carpal tunnel syndrome (CTS) is unclear. Population based studies have failed to prove causal relationships between certain types of work and the onset of CTS. The aim of this study was to compare the incidence of CTS with the underlying regional occupational profile and assess differences in disease severity.


The study took place from 2004 to 2010 in a regional hand unit that was the sole provider of hand services to a health board. Occupation was classified according to the SOC2000 classification as published by the Office for National Statistics and compared with the National Census 2000 statistics. 1564 patients were diagnosed with CTS during the study period of which 852 were aged 16 to 74, in full time employment.

J Klena JD Beck P Maloney J Brothers JH Deegan


Does the result of steroid injection in the carpal tunnel in a patient with recurrent carpal tunnel symptoms provide a good predictor of the outcome of later carpal tunnel release (CTR).


A retrospective review of all patients who underwent revision CTR for recurrent or persistent carpal tunnel syndrome (CTS) over a two year period was conducted. A total of 23 patients and 28 wrists met inclusion criteria. Patients were evaluated to determine if pre-operative factors or result of injection predicted the outcome of revision CTR. A multivariate logistic regression analysis (MLRA) was used to predict surgical success when multiple pre-operative findings were considered.

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R Kakwani L Tourret L Irwin A Stirrat


Retrospective study to assess the outcomes of ulnar shortening for TFCC tear and distal radial malunion.


Retrospective note and x-ray review of all patients undergoing ulnar shortening over a ten year period along with a clinic assessment and scoring to date. The ulnar shortening was performed using the Stanley Jigs (Osteotec). A 5–6 holed DCP was used to stabilize the osteotomy site. Physiotherapy was commenced immediately following the surgery to promote prono-supination and wrist exercises.

N Burke J Walsh D Moloney E Kelly

This retrospective study evaluated 69 Swanson trapezium replacements performed between 1990 and 2009 for trapeziometacarpal osteoarthritis in 58 patients. Pain and function were assessed using the Michigan Hand Questionnaire (MHQ) and the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. Patients had a mean age of 62 years at the time of surgery, with a mean time of 7.7 years from time of surgery to completion of the follow-up interview. The results showed good relief of pain and function with no significant deterioration with time from surgery. There were no gender differences or differences by age. The only differences observed were that those patients following surgery on a dominant hand indicated higher activities of daily living and work related activities. The authors conclude silicone trapezium replacement remains a good option for patients with painful trapeziometacarpal osteoarthritis that has not responded to non-operative treatment.

K Kailash A Raza S Mahalingham S Talwalkar


Total Wrist Arthroplasty (TWA) for Rheumatoid Arthritis (RA) of wrist allows pain relief and preservation of the movements.


The aims of current study were to evaluate outcomes of Universal-2® TWA at a tertiary centre.

J Broomfield P Ralte C Neophytou M Waseem

Since November 2003 there have been 62 Metacarpophalangeal Joint (MCPJ) replacements carried out on 16 patients at Macclesfield District general hospital. 11 of the patients were female and 5 were male. The mean patient age at procedure was 64.9 years, with an age range of 28 to 80. Of the 62 MCPJ replacements carried out, 58 (93.5%) were as a result of rheumatoid arthritis, with only 4 (6.5%) as a result of osteo-arthritis. The primary objective of this study is to assess their outcomes to date. Data was collected retrospectively by means of case note review. Outcomes measured were patient rating of pain and function at post operative review and post operative complications. All operations were carried out by a single surgeon, using his standard operative technique, and all replacements used the Neuflex Finger Joint Implant System. All 16 patients attended for post operative review. At the time of discharge 13 patients rated their outcome as excellent to good, 1 patient was deceased and 2 patients are currently under follow up with no reported complications. Mean time to discharge was 19 months (2–68). Of the total 62 joints replaced, 10 revisions were carried out. Of these, 3 were as a result of dislocation, 6 were for subluxation and 1 as a result of failure of the prosthesis. There were 3 other post operative complications; 1 was for superficial wound infection, 1 resulting from a prominent prosthesis and 1 hypertrophic scar. Results showed that 81.3% of patients rated their range of movement as good to excellent and 87.5% reported an improvement in pain. Overall, 81% of patients rated their outcome at discharge as good to excellent. From the data available we conclude that the Neuflex system is an effective treatment method with a low complication rate.

C Green D O'Rourke P Courtis D Fitzpatrick P Kelly

The management of the dysplastic hip represents a clinical and a technical challenge to the paediatric orthopaedic surgeon. There is a great deal of variation in the degree and direction of acetabular dysplasia. Preoperative planning in the dysplastic hip is still largely based on plain radiographs. However, these plain films are a 2D projection of a 3D structure and measurement is prone to inaccuracy as a result. Hip arthrography is used in an attempt to analyse the 3D morphology of the hip. However, this still employs a 2D projection of a 3D structure and in addition has the risk of general anaesthesia and infection. Geometrical analysis based on multiplanar imaging with CT scans has been shown to reduce analysis variability. We present a system for morphological analysis and preoperative of the paediatric hip using this model. Our system can be used to determine the most appropriate osteotomy based on morphology. This system should increase the accuracy of preoperative planning and reduce the need for arthrography.

GA Naqvi SA Malik O Adamec


The aim of this study is to assess the effectiveness of clinic based ultrasound screening by Orthopaedic surgeon for early diagnosis and treatment of developmental dysplasia of hip (DDH) in one stop clinic.


This prospective study included 395 infants (185 male and 210 female) (5.2% of study population) who were referred for screening on the basis of abnormal findings or the presence of risk factors for DDH. Average age was 12.5 weeks (1 day to 15 months). All infants were assessed for risk factors of DDH. Clinical examinations were performed by the senior author followed by ultrasonography of both of the infant's hips, using the Graf's technique. Alpha and beta angles were calculated and hips were classified according to Graf's classification system.

H Naseem RW Paton

Developmental dysplasia of the hip (DDH) is the commonest musculoskeletal condition diagnosed in neonates. Two previous studies showed no statistical advantage with the addition of ultrasound to clinical screening. In the UK, the Standing Medical Advisory Committee (SMAC) (1969) recommended clinical examination at birth and at 6 weeks. The Newborn Infant Physical Examination (NIPE) (2008) guidelines in addition advised ultrasound scanning for clinically unstable hips or for those with risk factors (breech presentation or family history).

We compared SMAC and NIPE in the two main hospitals of the East Lancashire Hospitals NHS Trust: Burnley General Hospital (BGH) and the Royal Blackburn Hospital (RBH), respectively. Our outcome measure was the number of irreducible hip dislocations over a two year period (2007–2008).

The records of the lead Paediatric Orthopaedic Surgeon were used to identify all cases of irreducible hip dislocations born in 2007 and 2008. Maternity records provided information on birth statistics. Syndromal cases were excluded from further analysis.

BGH had 5382 live births and 7 irreducible hip dislocations (incidence 1.3/1000 births). 4/7 met SMAC recommendations and 6/7 met NIPE guidelines. 2/7 had equivocal clinical examinations at birth. 13 children were referred to the clinic with unstable hips (2.42/1000 births).

RBH had 7899 total births and 3 irreducible hip dislocations (incidence 0.38/1000 births). 2/3 met NIPE guidance and 1/3 met SMAC recommendations. 33 were referred to the clinic with unstable hips (4.18/1000 births).

The difference in the numbers of irreducible hips did not reach statistical significance (p=0.12).

This study found no statistically significant advantage with the addition of selective ‘at risk’ ultrasound screening to clinical screening alone. Confounding factors in this study included the age of referral of cases to clinic and the numbers of cases referred as primary instability. These findings are in keeping with two previous studies in Norway.

CK Chukwunyerenwa T Murphy P Connolly D McCormack

Innominate Osteotomy first described by Salter is one of the commonest procedures performed for treatment of Developmental Dysplasia of the Hip (DDH) in children. We recently described a less invasive technique for Innominate Osteotomy, which significantly reduces the operation time without compromising outcome (J Pediatr Orthop B. 2010 Jul;19(4):318–22). As part of the evolution of this procedure we now routinely use bioabsorbable pins (INION OTPS PIN, made from co-polymers of L-lactic acid, D-lactic acid and trimethylene carbonate) instead of K-wires to secure the graft.

We prospectively followed-up 120 consecutive cases done using bioabsorbale pins over a 2 year period. The surgical technique was as described in our less invasive innominate osteotomy paper. Average age at surgery was 24 months (18–52) with mean follow-up period of 15 months (6–24 months). The mean preoperative acetabular index was 36.2o. Our results show a mean acetabular index of 18.7o (P< 0.0001) at latest follow-up with no loss of correction. We recorded three superficial wound infections (one MRSA), all resolved uneventfully. There was no foreign body reaction.

The use of bioabsorbable pins eliminates the need for a second anaesthetic to remove the pins with significant cost benefit without compromising outcome.

S Chan E Shears CE Bache JN O'Hara

The management of developmental dysplasia of the hip (DDH) requiring open reduction between 12 and 18 months of age is controversial. We compare the outcome of medial approach open reduction (MAOR) versus delayed anterior open reduction with Salter osteotomy in such patients.

17 consecutive patients who underwent MAOR aged 12–20 months were reviewed (mean follow-up of 40 months, range 6–74). This group was compared to 15 controls who underwent anterior reduction and Salter osteotomy aged 18–23 months (mean follow-up of 44 months, range 14–134).

13 of the 17 (76%) MAOR patients required subsequent Salter osteotomy at a mean of 22 months post-reduction, with a further 2 patients under follow-up being likely to require one. Acetabular index improved from 42 (32–50, SD − 5.5) to 16 (7–24, SD − 4.5) in the MOAR group after Salter osteotomy compared to an improvement of 40 (30–53, SD − 6) to 13 (4–24, SD − 5) in the control group (p>0.05). Acetabular index at last follow-up was within normal limits in 15 of 17 (88%) MAOR patients. All patients in the control group had acetabular indices (or centre-edge angles of Wiberg) within the normal range.

There was 1 subluxation (7%) in the control group. There were 6 cases (33%) of post-operative avascular necrosis (5 Kalamchi & MacEwen Grade I, 1 Grade 2) in the MAOR group and 6 (40%) in the control group (5 Grade 1, 1 Grade 4).

All of the MAOR patients had good or excellent clinical results according to McKay's criteria, compared to 14 out of 15 (93%) controls.

This study suggests that MAOR or delayed open reduction and Salter osteotomy is a reasonable treatment for children with DDH presenting between the ages of 12 and 18 months. However, the majority of MAORs are likely to require a subsequent Salter osteotomy.

R Boden G Nuttall R Paton


The optimal management of idiopathic clubfoot has changed over three decades. Recently there has been an enthusiastic embracing of the Ponseti technique. The purpose of this 14-year comparative prospective longitudinal study was to directly assess the differences in results between these two treatment methods.


Over the period of this study there were 52,514 births in the local population and all newborns with clubfoot were referred directly to the Pediatric Orthopedic Surgeon. Patient demographics, the Harrold & Walker Classification, and associated risk factors for clubfoot were collected prospectively and analyzed. If conservative treatment failed to correct the deformity adequately, a radical subtalar release (RSR) was undertaken (the primary outcome measure of the study).

A Prasthofer M Brewster N Parsons GT Pattison ID van der Ploeg

This study is a mid-term follow up of an original series of 51 babies treated with a modified Ponseti technique for idiopathic congenital talipes equinovarus using below-knee Softcast (easier to remove and hygienic)1 to determine whether this method is as effective as traditional above-knee plastering.


51 consecutive babies were treated (April 2003-May 2007) and serial Pirani scores were recorded. Dennis Browne Boots (DBB) were applied when correction was achieved and an Achilles tenotomy was performed if necessary to complete the correction. DBB were worn fulltime for 3 months and at night for 3.5 years.


Of the original 51, 3 were lost to follow up and 3 were diagnosed with a neuromuscular condition and excluded. 45 patients, 34 boys and 11 girls were followed up for a mean of 55.3 months (range 36–85 months). Mean age at presentation was 16 days with a median Pirani score of 6.0 (5.5, 60). 75.7% required an Achilles tenotomy before DBB. Median Pirani score at tenotomy was 2.5 (2.0, 2.5). Time to boots (weeks) was mean 5.0 (4.2, 6.0) in the non-tenotomy group and 10.7 (9.8, 11.8) in the tenotomy group. 2 patients had residual deformity after plastering requiring surgery and there were 6 recurrences requiring surgery (4 tibialis anterior tendon transfers and 2 open releases). There appears to be a greater risk of operative intervention for girls and non-compliance with DBB. The estimate of 5-year (60 month) survival without surgery was 85% (96% CI; 70,99%).

A Singh A Roshan S Ram

Congenital talipes equinovarus occurs in 1.2 per 1000 live births in Europe and is twice as common in boys. Over the last decade, non-surgical management has re-established itself as the first line treatment; after long-term follow-up of surgically treated patients, revealed high rates of over correction, stiffness and pain. The commonly practiced non-surgical approaches are the Ponseti technique of serial manipulation and casting, and French taping. Ram's technique of taping is a truly conservative approach with a higher success rate to address this problem. Unlike French taping, it involves taping alternate days during the first week followed by twice in the second week, then once the following week, which is left in situ for a further two weeks. After the initial five weeks of taping, patients are provided with talipes splint for all time use, up till a year. This is followed by talipes shoes for walking and splint for nighttime use for another year. At the end of two years patients can wear normal shoes.

The study includes 225 patients with 385 clubfeet, who were treated with Ram's taping technique from September 1991 to August 2008. Inclusion criteria were age up to three months and previously untreated clubfeet. Average follow up was of 5.6 years. Outcome ratings at a minimum of two years were performed. Initial correction rate at the end of five weeks was 99%. A relapse of 21% was noted, two-third of which was salvaged via further taping and exercise, while remaining one third needed some form of surgical intervention. The comparative outcome for Ram's taping is better to Ponseti or French taping with good outcome in 93%, in comparison to 72% and 67% respectively.

To conclude Ram's taping is a fast, more effective, less cumbersome and fully conservative approach of correcting the clubfoot deformity.

G Cousins J MacLean D Campbell


Prophylactic pinning of the contralateral hip in the treatment of slipped upper femoral epiphysis (SUFE) has been shown to be safer than continued observation of the contralateral hip. This treatment remains controversial due to the potential for harm caused to an apparently unaffected hip.

There is evidence that pinning of an already slipped epiphysis causes growth disturbance of the proximal femur, however this has been questioned in that the slip occurs at the hypertrophic layer of the growth plate with no damage to the germative layer.


To determine whether prophylactic pinning affects subsequent growth of the unaffected hip in cases of unilateral SUFE.

K Tsang S Alshryda M Ahmad S Adedapo R Montgomery


(1) To determine whether any difference exists in AVN risk between surgical reduction [Fish] or pinning-in-situ [PIS] of severe slips. (2) To review the different classifications of SUFE in relation to AVN.

Materials and Methods

56 children presented with slipped upper femoral epiphysis (SUFE) from 1998 to 2008; 29 males, 27 females; mean age 12.8 years. The Loder & Southwick classifications were used. All slips were treated surgically. The mild and moderate groups were treated with a single pin-in-situ. The severe group had either surgical reduction [Fish femoral neck osteotomy], alternatively a single pin-in-situ, randomised by day of admission. Avascular necrosis of the femoral head (AVN) was the primary outcome measurement.

O Obakponovwe G Mouzopoulos H Tan P Giannoudis


In children presenting with irritable hip symptoms we wished to determine the incidence of hip septic arthritis, pathogen characteristics and the functional outcome.


Between May 2007 and January 2010, children presenting to our institution with irritable hip symptoms were eligible to participate. Exclusion criteria were history of trauma to the hip, systemic inflammatory diseases. Data collected included; demographics, clinical symptoms, temperature, haematological profile, ultrasound and culture reports, microorganism isolated and outcome. The minimum follow up was 6 months (6–24).

KA Lammin J Taylor M Zenios


Osteomyelitis can be difficult to diagnose. Unlike septic arthritis no defined diagnostic criteria exist as a guide. Inflammatory markers are frequently utilized at initial presentation, (in addition to white cell count).


All radiologically confirmed cases of long bone osteomyelitis without septic arthritis, joint effusion or abscess, in paediatric patients, presenting to one hospital over an eighteen-month period were included. These patients were compared with all culture positive septic arthrides presenting to the same hospital within the same time period. Inflammatory markers taken on the day of admission were studied.

R Singhal D Perry FN Khan D Cohen HL Stevenson LA James JS Sampath CE Bruce


Establishing the diagnosis in a child presenting with an atraumatic limp can be difficult. Clinical prediction algorithms have been devised to distinguish septic arthritis (SA) from transient synovitis (TS). Within Europe measurement of the Erythrocyte Sedimentation Rate (ESR) has largely been replaced with assessment of C-Reactive Protein (CRP) as an acute phase protein. We produce a prediction algorithm to determine the significance of CRP in distinguishing between TS and SA.


All children with a presentation of ‘atraumatic limp’ and a proven effusion on hip ultrasound between 2004 and 2009 were included. Patient demographics, details of the clinical presentation and laboratory investigations were documented to identify a response to each of the four variables (Weight bearing status, WCC >12,000 cells/m3, CRP >20mg/L and Temperature >38.5°C). SA was defined based upon culture and microscopy of the operative findings.

JM Reed J Davies NMP Clarke E Blake A Jackson


Vitamin D deficiency may increase predisposition to a number of paediatric orthopaedic conditions and the prevalence of vitamin D deficiency is increasing in children in developed countries. The aim of this study was to determine the epidemiology of vitamin D deficiency and insufficiency in children presenting to a regional paediatric orthopaedic service. We also examined the relationships between vitamin D status, social deprivation and ethnicity


Individuals, age < 18 years, presenting to the regional paediatric orthopaedic service at Southampton, UK from 2008 to 2010 were investigated. Deprivation index scores were calculated from indices of deprivation.

JF Baker J Green KA Synnott MM Stephens AR Poynton KJ Mulhall


The internet has revolutionized the way we live our lives. Over 60% of people nationally now have access to the internet. Healthcare is not immune to this phenomenon. We aimed to assess level of access to the internet within our practice population and gauge the level of internet use by these patients and ascertain what characteristics define these individuals.


A questionnaire based study. Patients attending a mixture of trauma and elective outpatient clinics in the public and private setting were invited to complete a self-designed questionnaire. Details collected included basic demographics, education level, number of clinic visits, history of surgery, previous clinic satisfaction, body area affected, whether or not they had internet access, health insurance and by what means had they researched their orthopedic complaint.

L Glen N Ismail W Ashraf B Scammell R Bayston


To test the hypothesis that surface skin swabs taken after skin preparation with alcoholic povidone iodine (APVPI) would not grow bacteria, whereas full thickness biopsies taken from the line of surgical incision would grow bacteria.


Informed consent was obtained from 44 patients undergoing primary hip (n=13) and knee (n=31) arthroplasty. Each received antimicrobial prophylaxis before skin preparation with APVPI under laminar flow. After the APVPI had dried, a skin swab and a full thickness 8mm x 4mm elliptical skin biopsy were taken from the line of incision. The skin swab was rolled in 5mL anaerobe basal broth to inactivate the APVPI, incubated at 37 degrees and checked for growth for 2 weeks. One half of the skin biopsy was snap frozen and used for gram and nitroblue tetrazolium staining. The other half was placed into 5mL of anaerobe basal broth, incubated at 37 degrees and monitored for growth for 2 weeks.

S Gupta M MacLean JG Anderson SJ MacGregor RMD Meek MH Grant


Infection rates following arthroplasty surgery are reported between 1–4%, with considerably higher rates in revision surgery. The associated costs of treating infected arthroplasty cases are over 4 times the cost of primary arthroplasties, with significantly worse functional and satisfaction outcomes. In addition, multiple antibiotic resistant bacteria are developing, so to reduce the infection rates and costs associated with arthroplasty surgery, new preventative methods are required. HINS-light is a novel blue light inactivation technology which kills bacteria through a photodynamic process, and is proven to have bactericidal activity against a wide range of species. The aim of this study was to investigate the efficacy of HINS-light for the inactivation of bacteria isolated from infected arthoplasty cases.


Specimens from hip and knee arthroplasty infections are routinely collected in order to identify possible causative organisms and susceptibility patterns. This study tested a range of these isolates for sensitivity to HINS-light. During testing, bacterial suspensions were exposed to increasing doses of HINS-light of (66mW/cm2 irradiance). Non-light exposed control samples were also set-up. Bacterial samples were then plated onto agar plates and incubated at 37°C for 24 hours before enumeration.

F Lyons J Gleeson S Partap K Synnott J O'Byrne F O'Brien

Treatment of segmental bone loss remains a major challenge in orthopaedic surgery. This study evaluated the healing potential of a series of highly porous tissue engineering scaffolds with the current clinical gold standard. We compare healing of collagen-glycosaminoglycan (CG) and collagen micro-hydroxyapatite (CHA) scaffolds, with and without recombinant bone morphogenetic protein-2 (BMP2), with autogenous bone graft (ABG) in the healing of a 15mm rabbit radius defect, which were filled with either CG scaffold, CHA scaffold, CG-BMP2, CHA-BMP2 or ABG. Serial radiographs and micro-computed tomography (µCT) at six week radiographs demonstrated complete defect bridging with callus using CHA and CG-BMP2 while the CHA-BMP2 was already in an advanced state of healing with cortical remodeling. By sixteen weeks CHA, CG-BMP2 and ABG all had advanced healing with cortical remodeling while CHA-BMP2 had complete anatomic healing. Quantitative histomorphometry values demonstrated similarly high healing levels of healing in CHA, CG-BMP2 and ABG with highest overall values in the CHA-BMP2 group. Thus, treatment of a critical sized, weight bearing, rabbit radius defect with a CHA scaffold can result in full cortical bridging with medullary cavity development. In addition, a CHA-BMP2 combination can result in fully mature, anatomic healing. The use of an off-the-shelf CHA scaffold for direct surgical placement into a defect site may be an effective bone graft substitute in the treatment of skeletal defects. The ease of manufacture, storage and peri-operative preparation may offer an alternative to traditional strategies, as well as to more recent BMP2 devices. This study provides clear evidence that CHA scaffolds can perform as well as autogenous bone grafts and supports their use as a viable alternative. Where the use of BMP2 may be desirable, these materials provide an ideal delivery mechanism and using a very low (near physiological) dose, healing superior to autogenous graft may be achieved.

JO Smith BG Sengers A Aarvold ER Tayton DG Dunlop ROC Oreffo

Recently, the osteoregenerative properties of allograft have been enhanced by addition of autogenous skeletal stem cells to treat orthopaedic conditions characterised by lost bone stock. There are multiple disadvantages to allograft, and trabecular tantalum represents a potential alternative. This metal is widely used, although in applications where there is poor initial stability, or when it is used in conjunction with bone grafting, loading may need to be limited until sound integration has occurred. Strategies to speed up implant incorporation to surrounding bone are therefore required. This may improve patient outcomes, extending the clinical applications of tantalum as a substitute for allograft.


To use tissue engineering strategies to enhance the reconstructive properties of tantalum, as an alternative to allograft.


Human bone marrow stromal cells (5×105 cells/ml) were cultured on blocks of trabecular tantalum or allograft for 28 days in basal and osteogenic media. Molecular profiling, confocal and scanning electron microscopy, as well as live/dead staining and biochemical assays were used to detail cell adherence, proliferation and phenotype.

D Gibson C Keogh S Morris


Lag screw cut-out following fixation of unstable intertrochanteric fractures in osteoporotic bone remains an unsolved challenge. A novel new device is the X-Bolt which is an expanding type bolt that may offer superior fixation in osteoporotic bone compared to the standard DHS screw type device.


The aim of this study was to test if there was a difference in cut-out using the X-Bolt implant compared with the standard DHS system

A Gulihar M Hadi G Taylor


Continuous post-operative infusion of local anaesthetic solutions has been implicated as the causative factor in many cases of chondrolysis. Recent in-vitro studies have shown that even a single exposure to local anaesthetic can cause apoptosis and mitochondrial dysfunction leading to chondrocyte death. Glucosamine has been shown to have a protective and reparative effect on articular cartilage.


To compare the effect of a single exposure of different local anaesthetic solutions on human articular cartilage and to investigate the protective and reparative effects of Glucosamine on articular cartilage exposed to 0.5% Bupivacaine.

JF Baker PM Walsh KJ Mulhall


Matrix metalloproteinases (MMP) play a key role in cartilage degradation in osteoarthritis. Statins are a potential suppressor of MMPs. The aim of this research was to assess the efficacy of Pravastatin in suppressing MMP gene and protein expression in an in vitro model.


We stimulated normal human chondrocytes with IL-1b for 6 hours to induce MMP expression and then treated with Pravastatin (1, 5 & 10 mM) for a further 18 hours. Cells stimulated with IL-1b but not treated with Pravastatin served as controls. Real-time PCR was used to assess expression of MMP-3 and MMP-9 mRNA. MMP enzyme activity was assessed using a fluorescent MMP-specific substrate. Staistical analysis was performed using ANOVA.

BJRF Bolland SL Whitehouse JR Howell MJW Hubble GA Gie AJ Timperley

This study utilised NJR primary hip data from the 6th Annual Report to determine the rate and indication for revision between cemented, uncemented, hybrid and resurfacing prosthetic groups. Regression analysis was performed to identify the influence of gender and ASA grade on these revision rates. Validity of the data was interrogated by exploring for episodes of misclassification.


We identified 2,264 misclassified episodes within the four groups (Misclassification rate 2.7% primary, 4.3% revision procedures). Analysis was performed using the “reclassified dataset”.

The Kaplan-Meier revision rates at 3 years were 0.9% (95%CI: 0.8%-1.0%) for cemented prostheses, 1.9% (95%CI: 1.8%-2.0%) for uncemented hips, 1.2% (95%CI: 1.0%-1.4%) for hybrids and 3.0%, (95%CI: 2.7%-3.3%) in the resurfacing group. The trends in revision rates were comparable to those published in the NJR (6th Edn.) with significant differences across all groups (p< 0.0001). Revision rates in the under 55 year age group showed an identical hierarchy with cemented and hybrid arthroplasty having the lowest revision rates.

Cox Regression analysis indicated that both the prosthesis group in isolation and the interaction between prosthesis group and ASA grade significantly influenced the rate of failure (p< 0.001).

Indications for revision showed significant differences in rates for, pain, aseptic loosening, dislocation and malalignment between prosthesis types (p< 0.001). The indications including Aseptic loosening, pain, malalignment and dislocation all demonstrated similar trends in revision rates between prosthetic groups with cemented hips having the lowest rates followed by ascending rates for hybrid, uncemented and resurfacing groups. The exception being dislocation with resurfacings having the lowest revision rates.


This study provides important baseline revision rates by indication for each prosthetic group from which future comparisons can be made. Areas of misclassification within the NJR dataset have been reported back for future annual analysis.

BJRF Bolland JR Howell MJW Hubble AJ Timperley GA Gie RSM Ling


Since 1991 to 2008 approximately 800,000 Exeter stems have been sold worldwide with 80 reported cases of fracture (neck or stem). This study aimed to determine factors predisposing to fracture.


Clinical, surgical, radiological and retrieval data was collated from Stryker Benoist-Girard and Exeter research databases. Risk factors associated with fracture were categorised to patient related (weight and activity levels), surgical related (poor medial support, component size, placement) and implant related (+ head).

G Bartlett M Wilson S Whitehouse M Hubble G Gie J Timperley J Howell

We present 346 consecutive revision procedures for aseptic loosening with acetabular impaction bone grafting (AIBG) and a cemented polyethylene cup. Defects were contained with mesh alone. Mean follow up of 6.6 years, range 8 days-13 years. The Oxford Hip (OHS) and Harris Hip (HHS) scores were collected prospectively. Radiological definition of cup failure was either > 5mm displacement, or > 5° rotation. Cox regression analysis was performed on ten separate patient and surgical factors to determine their significance on survivorship.

Kaplan Meier survivorship at 10 years (42 cases remaining at risk) for aseptic loosening was 87% (95% confidence Interval (CI): 81.6 to 92.2) and 85.6% (95% CI: 80.3 to 90.9) for all revisions. These results are comparable to other reported series utilising AIBG. However, there were 88 cases (25%) that exceeded the radiological migration parameters, but their functional scores were not significantly different to the non-migrators: OHS p=0.273, HHS p=0.16. The latest post-operative mean OHS was 33 (SD 10.66). Female gender (p=0.039), increasing graft thickness (p=0.006) and the use of mesh (p=0.037) were significant risk factors for revision, but differing techniques in graft preparation, including artificial graft expanders (p=0.73), had no significant effect when analysed using Cox regression.

R Nickinson P Fleming P Siney T Board B Purbach M Wroblewski P Kay


We present the outcome of 297 acetabular revisions using bone grafting and cemented acetabular components in 297 patients, with a mean follow-up of 8 years 3 months (5–20 years).


All patients underwent acetabular revision with allograft bone grafting and insertion of cemented acetabular components. Of the 297 patients, 134 patients (45%) were male and 163 (55%) were female. The mean age of undergoing revision surgery with bone grafting was 60 years (25–87 years). The mean weight at revision surgery was 71.9 kg (40–128 kg). Post-operatively, all patients were reviewed regularly in out-patients, where they were examined clinically for any complications and their radiographs were examined for evidence of graft union, radiological lucency and cup migration.

S Masterson S Lidder W Yoon G Scott


There are conflicting reports in the literature regarding the migration of femoral stems in revision hip arthroplasty following the use of impaction allografting with or without cement. In some cemented series distal migration of the prosthesis within the cement mantle has been recorded, as well as migration of the whole cement/prosthesis construct into the graft.

Method and Results

The results of 26 cases of revision hip replacement using femoral impaction allografting in the absence of bone cement are reported. The mean follow up was 8.5 years (range 4 to 17 years). The technique employed a Freeman stem coated proximally with hydroxyapatite.

Three cases required further revision at 2, 4 and 5 years for high subsidence and unacceptable thigh pain. The remaining 23 cases stabilised following a period of initial settlement and overall results have been comparable to other series that have utilised cement. The initial sinkage in this series occurred mainly in the first six postoperative months. These results, from a single surgeon series, demonstrate that the method is highly technique dependent and relies on adequate graft impaction.

P Vinayakam K Kneale A Zaveri R Slack


Osteolysis causing proximal femoral deficiency is a major problem in revision hip arthroplasty. Various methods including impaction bone grafting and bone allografts have been used to address this issue. We have analysed bone reformation using extended trochanteric osteotomy and distally fixed proximal hydroxyapatite-coated modular revision hip system (Stryker Restoration System) in 100 consecutive revisions by a single surgeon.


Consecutive patients undergoing revision of femoral stem using posterior approach, extended trochanteric osteotomy and modular hip revision system were included in the study. Exclusion criteria were infection and loss of follow up. Paprosky grading system was used to assess bone loss. Standardized pre-op radiographs and follow-up radiographs at 6 weeks, 6 months and yearly post surgery were used for analysis. Minimum follow-up of 18 months (1.5–3.5 years). Bone reformation is quantified as definite reformation, some evidence of reformation and no bone reformation. Extended trochanteric osteotomy union rates and subsidence rates were also observed.

B Rogers S Garbedian R Kuchinad M MacDonald D Backstein O Safir A Gross


Revision hip arthroplasty with massive proximal femoral bone loss remains challenging. Whilst several surgical techniques have been described, few have reported long term supporting data. A proximal femoral allograft (PFA) may be used to reconstitute bone stock in the multiply revised femur with segmental bone loss of greater than 8 cm. This study reports the outcome of largest case series of PFA used in revision hip arthroplasty.


Data was prospectively collected from a consecutive series of 69 revision hip cases incorporating PFA and retrospective analyzed. Allografts of greater than 8 cm in length (average 14cm) implanted to replace deficient bone stock during revision hip surgery between 1984 and 2000 were included. The average age at surgery was 56 years (range 32–84) with a minimum follow up of 10 years and a mean of 15.8 years (range).

B Rogers R Kuchinad S Garbedian D Backstein O Safir A Gross


A deficient abductor mechanism leads to significant morbidity and few studies have been published describing methods for reconstruction or repair. This study reports the reconstruction of hip abductor deficiency using human allograft.


All patients were identified as having deficient abductor mechanisms following total hip arthroplasty through radiographic assessment, MRI, clinical examination and intra-operative exploration. All patients underwent hip abductor reconstruction using a variety of human allografts including proximal humeral, tensor fascia lata, quadriceps and patellar tendon.

The type of allograft reconstruction used was customized to each patient, all being attached to proximal femur, allograft bone adjacent to host bone, with cerclage wires. If a mid-substance muscle rupture was identified an allograft tendon to host tendon reconstruction was performed.

JW Kennedy L Johnston L Cochrane PJ Boscainos

Although total hip arthroplasty (THA) has been shown to be a cost-effective means of treating hip arthritis, there is some ambiguity within the literature as to its success in those over 80 years of age. With the rapid expansion of this population group and an estimated 40% rise in THA figures expected by 2026, this study aims to review the results of primary THA in the octogenarian population. A series of 510 consecutive cases was obtained from the local arthroplasty database, consisting of all patients aged 80 years and over who underwent primary THA between 1994 and 2004. A control group of 3404 individuals under 80 years was also established using the same database and inclusion criteria. Mean follow-up for the octogenarian group was 5.9 years. Pain scores were comparable five years post-operatively in both groups (P=0.479); in particular 81.5% of octogenarians and 80.2% of the control noted no pain. Pre-operatively, the mean Harris Hip Function and Harris Hip Score were significantly lower in the octogenarian group by 4.3 and 4.2 points (P< 0.001), respectively, and at five years follow-up were also lower by 8.4 and 8.0 points, respectively (P< 0.001). Median hospital stay was three days longer in the elderly population (12 cf 9, P< 0.001). More complications occurred in the octogenarian group (38.1% cf 28.7% of controls, P< 0.001) however fewer cases of revision were noted (1.4% cf 3.8%, P=0.005). Kaplan-Meier analysis found implant survival time to revision to be comparable in both groups (mean 16.4 years in control cf 14.3 years in octogenarian, P=0.17). Patient satisfaction was also similar (97.8% in octogenarians and 98.1% in controls, P=0.741). This study suggests that individuals over 80 years of age have comparable pain improvement and overall satisfaction, low revision rates, reduced functional improvement and are more prone to complications compared to younger patients.

R Silverwood R Lawton K Barnett D Finlayson


BOA Guidelines recommend clinical and radiological follow-up after primary total hip arthroplasty (THA) at 1 and 5 years, and every 5 years thereafter to detect asymptomatic failure and allow early intervention. As revision surgery in asymptomatic patients is rare the need for routine follow-up in well-functioning individuals has recently been questioned. To evaluate the role of routine follow-up out-patient appointments (OPA) in identifying failing implants the modes of presentation for patients undergoing revision THA were reviewed.


176 patients who received 183 revision THAs (2003–2010) were identified from an arthroplasty database. 124 patients who received 131 first time revision THAs after primary cemented total hip arthroplasty met inclusion criteria. Retrospective notes review was performed to investigate symptoms at failure and mode of presentation.

M-C Nogaro M Wijeratna S Santhapuri M Sood


It has been suggested that routine follow-up of primary THR patients could be performed by GPs in primary care, rather than by orthopaedic specialists. Essential radiographic follow-up would likely be based on radiographic reports, rather than on inspection of the radiographs themselves.


To look at the quality of the radiographic reports to determine their usefulness as a method of radiographic follow-up of THRs.

C Heaver J-P St Mart P Nightingale A Sinha E Davis


Leg length inequality following total hip replacement remains common. In an effort to reduce this occurrence, surgeons undertake pre-operative templating and use various forms of intra-operative measurements, including computer navigation. This study aims to delineate which measurement technique is most appropriate for measuring leg length inequality from a pelvic radiograph.


Three observers took a total of 9600 measurements from 100 pelvic radiographs. Four lines were constructed on each of the radiographs, bisecting the acetabular teardrops (Methods 1/2), ishial spines (Method 3/4), inferior sacroiliac joint (Method 5/6) and inferior obturator foramen (Method 7/8). Measurements were taken from these lines to the midpoint on the LT and to the tip of the GT.

The effect of pelvic positioning was also assessed using radiographs of a synthetic pelvis and femur using the same eight methods by a single observer (ED).

Intra-observer variability was analysed using within subject standard deviation. Inter-observer variability was analysed using the coefficient of inter-observer variability (CIV).

O Breathnach A-M Byrne T Kennedy F Doyle F Condon


Wound closure following orthopaedic surgery is an important step requiring careful technique and suitable suture material. The use of subcuticular sutures has been advocated following use in animal models and has also been reported in the literature having been used in specialities such as Orthopaedic Surgery, Plastic Surgery and Obstetrics.


The aim of this study is to assess the use of absorbable subcuticular INSORB® sutures in THR when compared with the standard AutosutureTM SignetTM metal skin staples. Patient satisfaction with wound appearance was measured at the six week review stage. Wound healing was also noted in the initial stages of recovery and at the six week review stage.

D Banks R Boden R Mehan M Fehily


Magnetic resonance arthrography is the current method of choice for investigating patients with a clinical diagnosis of femoroacetabular impingement prior to performing hip arthroscopy. The aim of our study was to assess the efficacy of this investigation by comparing the findings of MR arthrogram with those found at arthroscopy, with reference to labral tears and chondral damage.


A prospective trial to investigate the sensitivity, specificity, accuracy and predictive value of MRA for diagnosis of labral tears and chondral defects. Over a 25-month period 69 hips undergoing hip arthroscopy were investigated with MRA prior to the definitive operative procedure. MRA findings were compared to the intraoperative findings.

B Ollivere K Rollins K Elliott A Das P Johnston G Tytherleigh-Strong


The evolution of locked anatomical clavicular plating in combination with evidence to suggest that fixation of clavicle fractures yields better outcome to conservative treatments has led to an increasing trend towards operative management. There is no evidence however to compare early fixation with delayed reconstruction for symptomatic non- or mal-union. We hypothesize that early intervention yields better functional results to delayed fixation.


Between August 2006 and May 2010, 97 patients were managed with operative fixation for their clavicular fracture. Sixty eight with initial fixation and 29 delayed fixation for clavicular non- or mal-union. Patients were prospectively followed up to radiographic union, and outcomes were measured with the Oxford Shoulder Score, QuickDASH, EQ5D and a patient interview. Mean follow-up was to 30 months. All patients were managed with Acumed anatomical clavicular plates.

LAK Khan R Wallace AWH Simpson CM Robinson


The aim of this study was to compare biomechanical properties of pre-contoured plate fixation using different screw fixation modes in a mid-shaft clavicle fracture model.


Fourth generation biomechanical clavicle sawbones with a mid-shaft osteotomy were plated in one of three modes: nonlocking bicortical, locking bicortical and locking unicortical mode. The specimens were then tested to failure in four-point bending and pull-off tests.

JF Baker H Mullett


The aim of this study was to report the outcomes of a series of patients with clavicle fracture non-union who had undergone open reduction and internal fixation using a contoured locking plate without the use of distant bone graft.


Patients were identified using the hospital database. Records were reviewed to determine basic demographics, operative findings, and radiological outcome. Patients were contacted and details about initial injury and treatment, and return to work and sport were recorded. Disabilities of Arm, Shoulder and Hand (DASH) for both operated and non-operated shoulders were completed.

P Ralte S Grant D Withers R Walton S Morapudi R Bassi J Fischer M Waseem


Plating remains the most widely employed method for the fixation of displaced diaphyseal clavicle fractures. The purpose of this study was to assess the efficacy and outcomes of diaphyseal clavicle fractures treated with intramedullary fixation using the Rockwood clavicle pin.


We conducted a retrospective analysis of all diaphyseal clavicle fractures treated with intramedullary fixation using the Rockwood pin between February 2004 and March 2010. Sixty-eight procedures were carried out on 67 patients. Functional outcome was assessed using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and an overall patient satisfaction questionnaire.

U Garbharran S Chinthapalli I Hopper M George F Dockery


Red cell distribution width (RDW), an automated measure of variability in red blood cell size on full blood count (FBC), has recently emerged as a strong independent predictor of mortality in large population studies as well as several disease states. We wanted to determine the prognostic value of RDW in patients following a hip fracture - a condition associated with high mortality. This relationship has not been assessed to date.


We examined the relationship between admission RDW and all-cause mortality on 1-year follow-up, in consecutive hip fracture cases who presented between January 2007 and November 2009. We used Cox regression analysis to adjust for baseline Haemoglobin (Hb), Mean corpuscular Volume (MCV), creatinine, age, gender, ASA grade, Charlson index, pre-morbid independence level, Mental test score (MTS), delay to surgery and post-operative cardio-respiratory complication.

L Banks N Byrne S Henari A Cornwell-Clarke S Morris J McElwain


Malnutrition has been suggested to increase the risk of falls in frail elderly. It has been hypothesised that elderly, orthopaedic trauma patients may be malnourished. We conducted an observational study to identify if this was the case.


30 trauma patients (? 65 years) admitted for surgical intervention for a fracture were recruited. Consent/ethical approval was obtained. Serum markers (LFTs, CRP, U&Es, FBC, magnesium), anthropometric measurements (triceps skin-fold thickness [TSF], mid-arm circumference [MAC], body mass index [BMI]) and short form mini-nutritional assessment (MNA-SF®) were carried out at presentation and at 3 months post-operation. Serum markers were also repeated at day 1 and day 3 post-operation.

D Lui D Bouchier Hayes M Seamus P Kenny J McElwain D Bennett


Hip fractures pose a significant burden on the healthcare system. Hyperglycaemia and a state of Type 2 diabetes exists post operatively. Being normoglycaemic has well documented benefits. Pre operative carbohydrate loading has been shown to have two good effects. It decrease hyperglycaemia post operatively and allows the patient to undergo less strict fasting protocols. Insulin resistance to date has not been examined in these patients and this was determined using a validated formula (HOMA/IR).


Three trauma hospitals were enrolled and patients with hip fractures requiring operative fixation were enlisted. Exclusion criteria: diabetic patients and inability to imbibe. 100 neck of femur fractures were examined. 46 patients were fasted normally. 32 test patients were given a carbohydrate rich drink pre operatively the night before surgery and in the morning up to 2 hours prior to surgery. 22 patients were excluded. Serum random glucose and insulin levels were taken on admission. Fasting serum glucose and insulin levels were taken on day one post operatively.

FS Hossain R Rambani H Ribee L Koch FS Haddad


Premature cessation of clopidogrel in certain patients with cardiac conditions is associated with an increased risk of recurrent coronary events. Such patients often present with proximal femoral fractures requiring surgical intervention. Our aim was to ascertain whether it is necessary to stop clopidogrel preoperatively to avoid postoperative complications following hip hemiarthroplasty surgery.


A retrospective review of 102 patients with ongoing clopidogrel therapy and patients not on clopidogrel who underwent hip hemiarthroplasty for an intracapsular proximal femoral fracture was undertaken. Statistical comparison on pre- and postoperative haemoglobin (Hb), ASA grades, comorbidities, operative times, transfusion requirements, hospital length of stay (LOS), wound infection, haematoma and reoperation rates between the two groups was undertaken.

CG Murphy SJ O'Flanagan P Keogh P Kenny


The emergence of a new variant of subtrochanteric stress fractures of the femur affecting patients on oral bisphosphonate therapy has only recently been described. This fracture is often preceded by pain and distinctive radiographic changes, and associated with a characteristic fracture pattern. We undertook a review of this cohort of patients in our service.


A retrospective review was carried out looking for patients with subtrochanteric fractures who were taking oral bisphosphonates presenting with a low velocity injury over a two year period. Clinical data and radiographs were assessed.

D Dargan F Callachand C Connolly


Intracapsular fractures of the femoral neck in young adults are a surgical emergency. Recent literature reviews have questioned whether the timing of surgery reduces the incidence of avascular necrosis, non-union and revision.

A study was performed to determine how many patients met a 12-hour target for operative fixation with this injury. Possible sources of delay to theatre were reviewed.


A Fractures Outcomes Research Database was used to identify patients aged 18–64 who were admitted to the Royal Victoria Hospital in Belfast between 1st Jan 2008 and 31st Dec 2009. Intracapsular fractures of the femoral neck which were treated with a 2-hole dynamic hip screw were included. Time of injury, time of presentation in A&E, time of admission to fracture ward, operation time, demographic data, and the mechanism of injury were extracted from the database.

J Foote O Berber G Datta M Bircher


Haemodynamically compromised patients with biomechanically unstable pelvic fractures need reduction of the pelvic volume to effect tamponade of bleeding bone and vessels. Knee binding, to help achieve this, is advocated in standard Advanced Trauma and Life Support teaching but is rarely used. There are no reports in the literature as to the benefits derived from this simple manoeuvre. The aim of this study was to investigate whether there was an effect on symphysis pubis closure by binding the knees together and to quantify this.


13 consecutive patients who underwent open reduction and internal fixation of pubic symphysis diastasis +/− sacroiliac joint fixation were recruited prospectively. These patients were transferred from peripheral hospitals to this National tertiary referral level 1 trauma centre for definitive pelvic fracture management. All patients had sustained Antero-Posterior Compression (APC) type pelvic injuries. In theatre, a centred antero-posterior (AP) radiograph was taken without any form of binding on the pelvis. A second AP radiograph was then taken with the knees and ankles held together with the hips internally rotated. A third, final AP radiograph was taken post fixation. Measurements of symphysis pubis widening were made of the digital images taken in theatre.

M Jones A Johnston D Swain D Kealey

The royal victoria hospital is a tertiary trauma centre receiving pelvic injury referrals for a population of 1.7 million. The use of ilio-sacral screw fixation with low anterior frame stabilisation has been adopted as the principle treatment for unstable pelvic ring injuries in our institution. We aim to describe our practice and outcomes following the use of percutaneous screw fixation of the pelvis.

The review included standardised assessment of health-related quality of life (SF-36) as well as the Iowa pelvic score and Majeed pelvic injury outcome scores. Data was also collected on associated injuries, post-operative complications, nerve injury and pain scores.

A total case series of 45 patients undergoing percutaneous ilio-sacral screw fixation following traumatic pelvic injury were identified over a 5 year period. Of these 23 were contactable to follow-up or responded to questionnaire review.

The mean follow up was 680 days (range 151–1962). The mean age was 33 (range 18–57).

The mean SF-36 physical and mental scores were 38 and 46 respectively. The mean Majeed score was 69 and Iowa pelvic score was 65. The mean pain score was 3.5 (range 0–7). There were no incidences of deep infection, post-operative PE or nerve injury related to screw insertion.

Patients with isolated pelvic injuries performed better on outcome scoring however the low SF-36 scores highlight the severity of pelvic injuries

MS Patel M Jiggins M Jones S Williams


Despite the lack of robust evidence, numerous different track and trigger warning systems have been implemented. The MEWS (Modified Early Warning Score system) is one such example, and has not been validated in an emergency traumasetting. A considerable proportion of trauma admissions are elderly patients with co-morbidities. Early recognition of physiological deterioration and prompt action could therefore be lifesaving.


Identify whether the implementation of a MEWS system coupled with an outreach service had resulted in a reduction in the mortality within our unit.

M O'Flaherty A Wilson


To assess the usefulness of radiographs alone to evaluate acute midfoot/forefoot injuries. We believe that foot injuries are often under-estimated and that CT scans should be routinely obtained to aid in their management and avoid additional morbidity for patients.

Materials & Methods

In 26 months, 255 patients had foot injuries requiring X-Rays. Of these patients, 94 (37%) had primary radiographs indicating midfoot or forefoot fractures, and 28 had subsequent CT scans. Radiographs were retrospectively re-evaluated with respect to fracture location, type, mechanism of injury and then compared with CT results.

H Edwards D Yeoh S Dawson-Bowling N Ellens D East K Miles A Butler-Manuel H Apthorp


Deep vein thrombosis(DVT) and pulmonary embolism(PE) are well-recognised complications following lower limb arthroplasty (Cohen et al, 2001). The National Institute for Clinical Excellence and British Orthopaedic Association recommend the use of both mechanical and chemical prophylaxis. At our institute regimens have changed reflecting new developments in the use of thombo-prophylaxis. Our aim was to assess the efficacy of these methods in preventing complications.


Since moving from Aspirin and compression stockings (TEDS) only, three different treatment methods were prospectively audited. Regimen 1 consisted of Aspirin (150 mg OD) and TEDS for 6 weeks (n=660). Regimen 2 used Clexane 40mg OD (n=448). Regimen 3 used Rivaroxaban (n=100) as licensed and Regimen 4 Dabigatran (n=185) as licensed.

We looked at rates of venous thromboembolism (VTE), rates of post op bleeding/haematoma and wound complications. Patients were reviewed prior to discharge, and at a six-week follow-up. Any casualty attendances were also recorded up to 12 weeks post-operatively.

T Akram O Templeton-Ward S Yousaf R Hargrove

Following the outcomes of the RECORD trials the protocol of extended thromboprophylaxis in patients undergoing elective primary total hip or knee arthroplasty has been changed in our institution.

Between June 2008 and May 2009 patients were offered extended thromboprophylaxis with 150mg of aspirin daily, commencing preoperatively on admission and continuing for a total of six weeks. From June 2009 onwards patients were treated with 10mg of rivaroxaban once daily for two weeks following total knee and five weeks following total hip arthroplasty commencing 4 to 6 hours postoperatively. Our cohorts were 700 patients before and after the introduction of the new regimen. The two groups were matched for age, sex and type of operation. All patients with no contraindication to treatment with aspirin or rivaroxaban respectively undergoing elective primary total hip or knee arthroplasty were included in the study. Patients receiving warfarin on admission were treated with warfarin postoperatively and were excluded.

We have compared the two treatment protocols in terms of safety and efficacy. Results focus on 4 safety outcome measures including mortality, haemorrhagic complications, transfusion requirements and infection rates and 2 efficacy outcome measures including thromboembolic complications and length of inpatient stay.

Rates of DVT were equal in the two cohorts (P< 0.005) as were the mortality rates. Transfusion requirements post-operatively were not affected by the introduction of the new regimen however there was a significant increase in both return to theatre rates and prolonged wound ooze (P< 0.005). Infection rates were slightly higher in the cohort treated with rivaroxaban but this was not statistically significant.

We conclude that further trials need to be done to confirm the suitability of routine use of rivaroxiban.

C Jensen R Morrell A Steval P Partington M Reed S Muller


Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower limb arthroplasty. Trials supporting its use have not fully evaluated the risks of wound complications related to rivaroxaban.


A retrospective cohort analysis of 1558 consecutive patients who underwent total hip or knee replacements within the same hospital during a 19 month period (2009–2010) was performed. The first 489 patients (Group 1) were given tinzaparin postoperatively as per NICE guidance. The following 559 patients (Group 2) were given rivaroxaban. Concerns regarding wound complications prompted a change back to tinzaparin for the next 510 patients (Group 3.) Other than the thromboprophylactic agent used there were no other differences in the pre and postoperative treatments of all these patients.

M Rymaszewska S Jameson P James I Serrano-Pedraza S Muller A Hui M Reed


The National Institute for Health and Clinical Effectiveness recommends both low molecular weight heparin (LMWH) and Rivaroxaban for venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. Despite evidence in the literature that suggests Rivaroxaban reduces VTE events, there are emerging concerns from the orthopaedic community regarding an increase in wound complications following its use.


Through the orthopaedic clinical directors forum, Trusts replacing LMWH with Rivaroxaban for lower limb arthroplasty thromboprophylaxis during 2009 were identified. Prospectively collected Hospital episode statistics (HES) data was then analysed for these units so as to determine rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary embolism (PE), major bleed (cerebrovascular accident or gastrointestinal haemorrhage), all-cause mortality, and 30-day wound infection and readmission rates before and after the change to Rivaroxaban. 2752 patients prescribed Rivaroxaban following TKR or THR were compared to 10358 patients prescribed LMWH. Data was analysed using odds ratios (OR).

T Nancoo K Ho SK Young J Waite

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

The NICE guidance and the Pradaxa® Summary of Product characteristics (SPC) report that 13.8% of patients receiving recommended doses of Dabigatran experience adverse bleeding events. In the manufacturer's pivotal clinical trials, wound secretion accounted for 4.9% of patients treated with Dabigatran as compared to 3.0% treated with Enoxaparin.

The aim of this audit was to assess the impact of Dabigatran on wound complications at a UK district general hospital and to quantify the effect on the postoperative discharge home support services provided by the award-winning South Warwickshire Accelerated Transfer Team (SWATT).

We report our experience of Dabigatran use at Warwick Hospital from March 2009 to March 2010.

Of the 788 lower limb arthroplasties performed, 681 patients (81.0%) were accepted for SWATT follow-up. Fifty-five (8.6%) of patients accepted by SWATT showed increased wound secretion for greater than 5 days. This included 12.7% of THR and 5.5% of TKR patients. Increased wound secretion resulted in 226 extra home visits by SWATT, at an extra cost of £23,104 (7.5% increase in SWATT budget).

Twenty-six of the 55 patients had positive microbial growth when wound secretions were swabbed. Five patients were admitted for management of wound infections. Incidentally, there were 2 reported cases of DVT and PE. These were not in the increased wound secretion patients.

In summary, Dabigatran at Warwick Hospital was associated with a higher than predicted incidence of surgical site morbidity, increased resource output and increased postoperative discharge costs. As a consequence, Dabigatran use has been reduced and other oral anticoagulants are being trialled.

J Queally F Cummins S Brennan M Shelly J O'Byrne

Despite the high prevalence of musculoskeletal disorders seen by primary care physicians, numerous studies have demonstrated deficiencies in the adequacy of musculoskeletal education at multiple stages of medical education. The aim of this study was to assess a newly developed undergraduate module in musculoskeletal medicine.


A two-week module in musculoskeletal medicine was designed to cover common musculoskeletal disorders that are typically seen in primary care. A previously validated examination in musculoskeletal medicine was used to assess the cognitive knowledge of ninety-two students on completion of the module. A historical control group (seventy-two students) from a prior course was used for comparison.


The new module group (2009) performed significantly better than the historical (2006) control group in terms of score (62.3% versus 54.3%, respectively; p < 0.001) and pass rate (38.4% versus 12.5%, respectively; p = 0.0002).

In a subgroup analysis of the new module group, students who enrolled in the graduate entry program (an accelerated four-year curriculum consisting of students who have already completed an undergraduate university degree) were more likely to perform better in terms of average score (72.2% versus 57%, respectively; p < 0.001) and pass rates (70.9% versus 21.4%, respectively; p < 0.001) compared with students who had enrolled via the traditional undergraduate route. In terms of satisfaction rates, the new module group reported a significantly higher satisfaction rate than that reported by the historical control group (63% versus 15%, respectively; p < 0.001).

A Malviya A Kulkarni M Reed

Since its introduction in 2007 the UKITE exam has been an annual event in the diary of Orthopaedic trainees. It aims to simulate the written FRCS (T&O) examination style and offers trainees practice, immediate feedback and an update of the progress they have made through their training. It also allows bench marking against their peers nationally.

UKITE 2010 has made further progress and for the first time trainees from all the deaneries in UK participated. A total of 645 trainees appeared for the examination that was held in December 2010. We introduced remote access from home for trainees (N=171, 26.5%) who could not appear in an “examination centre”. An online editorial process was also introduced, which made the work of the question editing team easier.

The scores ranged from 25.5 to 93.4% with a mean of 54.2% (sd=11.8). The score consistently improved from ST1 (41.8%) to ST7 (64.3%) level and then declined at ST8 (54.7%) level. The mean score for candidates sitting at home (53.3%, sd=11.4) was similar (p=0.23) to those sitting at an invigilated examination venue (54.6%, sd=11.9). The extreme low and high scores were more frequent invigilated exam. The feedback suggested that 95% trainees felt that UKITE has educational benefit and 98% wish to sit again. 75% want it as an annual self-assessment tool. 80% feel that it was better than last year and of those who had sat FRCS (T&O) nearly 80% felt it was very similar.

UKITE continues to evolve and has become a regular feature in the post-graduate orthopaedic calendar. It is perceived as a useful way of revising and maintaining a core level of knowledge as part of the exam preparation.

D Griffin G Pattison W Ribbans B Burnett