Plymouth Hospitals NHS Trust developed a pelvic and acetabular service in 2008, with the aim to provide a tertiary service for Devon and East Cornwall.

We describe the demographics of the patients, referral and fracture patterns, the operative management undertaken and complications seen in a newly developed tertiary pelvic and acetabular service in the South West.

Over 150 patients have been referred and treated, with follow up in a specialised tertiary clinic. Clinical scoring and radiological follow up were performed, and complications recorded.

Several difficulties and problems were encountered in the development of the service including training issues, equipment availability, surgeon availability, referral pathways and theatre time.

The presentation will describe the clinical results of the service, along with the logistical obstacles encountered in setting up a new service.

We present a complete audit cycle of Emergency Department (ED) management of paediatric buckle fractures of the distal radius at Derriford Hospital.

Local hospital management guidelines state that the limb should be supported in a wrist splint for 3 weeks following injury and, provided parents are adequately educated, no formal follow-up is required.

Auditable standards were obtained from the local guidance. An initial audit cycle of 54 cases identified shortcomings in compliance with guidelines. These included: Inappropriate immobilisation in 34 (63%) cases, omission of written advice in 35 (65%) cases and arrangement of unnecessary follow-up in 31 (57%) cases.

Following circulation of the results, ‘aide-memoir’ icons were added to the emergency department computer coding system, teaching sessions for emergency department staff were organised and new paediatric specific wrist splints were introduced.

A re-audit of 33 patients evaluated the effect of the changes. This demonstrated a 27% improvement in correct wrist support usage (27/33, 82%) and 25% fewer unnecessary referrals to fracture clinic (27/33, 82%).

Staff training and provision of appropriate wrist splints were crucial to improving the adherence to guidance. This resulted in standardisation of care, fewer unnecessary appointments for patients and cost savings to the hospital trust.

Intra-operative Tip-Apex Distance (TAD) estimation optimises dynamic hip screw (DHS) placement during hip fracture fixation, reducing risk of cut-out. Thread-width of a standard DHS screw measures approximately 12.5 millimetres. We assessed the effect of introducing screw thread-width as an intra-operative distance reference to surgeons. The null hypothesis was that there were no differences between hip fracture fixation before and after this intervention. Primary outcome measure was TAD. Secondary outcome measures included position of the screw in the femoral head, quality of reduction, cut-out and surgeon accuracy of estimating TAD.

150 intra-operative DHS radiographs were assessed before and after introducing screw thread-width distance reference to surgeons.

Mean TAD reduced from 19.37mm in the control group to 16.49mm in the prospective group (p=<0.001). The number of DHS with a TAD > 25mm reduced from 14% to 6%. Screw position on lateral radiographs was significantly improved (p=0.004). There were no significant differences in screw position on antero-posterior radiographs, quality of reduction, or rate of cut-out. Significant improvement in accuracy (p=0.05) and precision (p=0.005) of TAD estimation was demonstrated.

Awareness and use of screw-thread width improves estimation and positioning of a DHS screw in the femoral head during fixation of hip fractures.

Recent NICE guidelines have suggested abandoning the Thompson hemiarthroplasty (TH) in favour of a ‘proven prosthesis’ such as the Exeter Trauma Stem (ETS). This is controversial because of significant cost implications and limited research assessing outcomes of the ETS. The aim of this study was to assess the treatment of intracapsular neck of femur fractures with the TH.

Between 2002 and 2006 (minimum 5 year follow-up), 431 cemented TH's were performed. Death rate at 1 year and 5 years were 26.0% and 67.7% respectively. Dislocation (1.4%) and infection (0.2%) rates were low and revision rate was 1.2%. Comparison was made to Bipolar hemiarthroplasties over the same period (total 194). These had lower rates of dislocation (0.5%) and infection (0.5%) with a significantly higher (3.6%) revision rate.

We feel that the TH remains the current gold standard treatment for intracapsular fractures, in appropriate patients, due to low complication and revision rates. Modern implants may provide better function or longevity, but there is no evidence in the literature to support abandoning the TH. Surgeons should assess patients and decide on its use, despite NICE guidelines, as it remains a cost effective treatment method, particularly for older, less mobile and cognitively impaired patients.

Treatment of trochanteric fractures is associated a high complication rate. This prospective multicenter study evaluates the new Zimmer Cephalomedullary Nail (CMN).

Patients over 50 years sustaining a pertrochanteric or subtrochanteric femoral fracture were prospectively enrolled and patients with multiple injuries, pathological fractures or severe dementia were excluded.

101 patients (70% female, 30% male) from 5 different hospitals were prospectively recruited between January 2011 and August 2012. Mean age was 78 (51–98) years and mean Charlson Score was 2.6 (1–6). 65% of the trochanteric fractures were unstable, 35% were stable. There were 4 (5%) minor (3 superficial infections and 1 pain over distal locking screw) and 3 (4%) major (2 lag screw cut out, 1 nail breakage) complications Fracture healing was completed in 27 of 31 patients (87%) after 12 month (3 month: 14/42 (33%); 6 month: 27/39(69%)). The Barthel Index (85, SD 19) and EQ-5-D (0.61, SD 0.30) values reached prefracture level after 6 month.

The study population and fracture type were comparable to other studies and complication and early union rates were also comparable. Technical complications were low and early functional results encouraging. Final results of this trial at one year follow up are awaited.

In treating open long bone fractures our current policy includes early administration of intravenous antibiotics and surgery on a scheduled trauma list. We have reviewed our infection rates 6 years following the initiation of this policy. 220 fractures were studied. Our records included time of administration of antibiotics, time to theatre and seniority of surgeon. We identified cases of superficial or deep infection. Surgical debridement occurred within 6 hours of injury in 45% of cases and after 6 hours in 55%. Overall infection rates were 11% and 15.7% respectively. Intravenous antibiotics were administered within 3 hours of injury in 80% of cases and after 3 hours in 20% of cases. Overall infection rates were 14% and 12.5% respectively. Infection rates where the most senior surgeon present was a consultant were 9.5% compared to 16% with the consultant absent. Our results suggest that the change in policy may have contributed to an improvement of the deep infection rate to 4.3% from the previous figure of 8.5%, although this decrease was not statistically significant. Time to theatre has not adversely affected the infection rate, and presence of a senior surgeon may have improved infection rates, although both trends were not statistically significant.

An audit was carried out to assess the management of patients with fragility fractures in fracture clinic and primary care. NICE guidelines advise these patients require treatment for osteoporosis if 75 years or older, and a DEXA scan if below this age.

Distal radius and proximal humeral fractures were identified in a retrospective review of letters from 10 fracture clinics. Current medication of all patients ≥ 75 years was accessed and DEXA scan requests identified for patients < 75 years.

There were 69 fragility fractures: 53 distal radius and 16 proximal humerus. 4 letters (6%) mentioned fragility fracture and advised treatment and 3 (3%) correctly advised a DEXA scan. Only 3 of 25 (10%) patients ≥ 75yrs not previously on osteoporosis medication had treatment started by their GPs. 3 of a possible 29 (10%) patients < 75 years were referred for a DEXA scan.

A text box highlighting fragility fractures and NICE guidelines was added to all clinic letters for patient ≥ 50 years old. Re-audits showed an improvement in management of these fractures, with 45% of patients ≥ 75 years being started on treatment and 39% of patients < 75 years being referred for a DEXA scan.

The Delto-pectoral approach is the workhorse of the shoulder surgeon, but surprisingly the common variants of the cephalic vein and deltoid artery have not been documented. The vascular anatomy encountered during one hundred primary elective delto-pectoral approaches was documented and common variants described.

Two common variants are described. A type I (71%), whereby the deltoid artery crosses the interval and inserts directly in to the deltoid musculature. In this variant the surgeon is unlikely to encounter any vessels crossing the interval apart from the deltoid artery itself. In a type II pattern (21%) the deltoid artery runs parallel to the cephalic vein on the deltoid surface and is highly likely to give off medial branches (95%) that cross the interval, as well as medial tributaries to the cephalic vein (38%).

Knowledge of the two common variants will aid the surgeon when dissecting the delto-pectoral approach and highlights that these vessels crossing the interval are likely to be arterial, rather than venous. This study allows the surgeon to recognize these variations and reproduce bloodless, safe and efficient surgery.

The use of scoring systems for surveillance of post-operative outcomes is increasing. However, the methodology of this follow-up is not universal. We set out to assess whether a postal Oxford Shoulder Score (OSS) was sufficient to identify patients who were dissatisfied and wanted further treatment.

Of 88 patients who had undergone GlobalCap resurfacing in the previous 5 years, we received a completed postal OSS (Median score 33, Range 5–48) from 80 patients. Those with a score <24 (an agreed threshold for surgery pre-operatively) were brought to clinic for review.

The 16 recalled patients (2 males, 14 females; age 58–85) had their OSS repeated, supervised by a clinic nurse, and had a Constant Score and an American Shoulder and Elbow Surgeons (ASES) Score performed. Satisfaction was also questioned.

OSS correlated well with the Constant Score (r=0.79) and ASES (r=0.86). However, supervision increased the OSS by an average of 6 points (Mean 13.9 to 19.9) and only three of the patients proved dissatisfied with the outcome of their surgery.

Used alone, an unobserved OSS may have limited value for this purpose and the use of comparative pre-operative scores or additional patient-reported outcome measures may be necessary to detect poor outcomes.

Shoulder resurfacing arthroplasty is a bone conserving option for patients with glenohumeral arthritis. We report the early results of this procedure at our unit with a minimum follow up of 2 years (mean follow up of 36 months).

A historical analysis of prospectively collected clinical data was reviewed on a consecutive series of 22 patients (mean age of 73 years) with end stage gleno-humeral arthrosis who had undergone humeral resurfacing hemiarthroplasty performed by a single surgeon. Pain and function were assessed using the Oxford shoulder score and patient satisfaction was recorded. Radiographs were evaluated for implant loosening.

82% of patients had significant improvement in their oxford shoulder score from pre-operatively to two years post-operatively. Complications included one case of intra-operative conversion to a stemmed hemiarthroplasty due to fracture of the humeral head, one case of adhesive capsulitis that required MUA and arthroscopic capsular release and two cases of revision to a total shoulder replacement for pain. Humeral resurfacing arthroplasty is a viable treatment option for glenohumeral arthritis with good short term results.

Literature has suggested that obese (BMI >30) and morbidly obese (BMI > 35) patients should not be offered surgery as a day case due to increases in complication and readmission rates. At Torbay hospital, patients are routinely offered day case surgery, in a specialist day case unit, regardless of BMI. This is done with minimal complications and enables a higher throughput of patients and at least 75% of surgical procedures to be performed as a day case, as per NHS guidelines.

We present 12 year data of day case knee arthroscopy surgery performed at Torbay hospital. Over 12 years, 3421 knee arthroscopies were performed. 649 were performed on obese patients and 222 on morbidly obese patients. No anaesthetic complications were observed in any of the obese patient groups and readmissions rates (up to 28 days) were 0.8% in the morbidly obese group and 0.9% in the Obese group, compared to 0.9% for patients with BMI <30.

Our data shows that day case surgery can be performed on all patients regardless of BMI and patient obesity. We believe that other units should offer surgery to obese and morbidly obese patients to allow increased efficiency and achievement of NHS day case guidelines.

Prosthetic joint infection(PJI) still remains a concern in orthopaedic practice. Antibiotic-loaded acrylic-cement(ALAC) is a proven means of lowering the incidence of PJI. However, increasing antimicrobial resistance has complicated both prophylaxis and treatment, prompting the use of combination antimicrobial therapy, with the addition of vancomycin to gentamicin-containing ALAC commonly used. The new antimicrobial, daptomycin, has better activity than vancomycin and we studied its elution from ALAC in comparison with vancomycin, along with its impact on the co-elution of gentamicin.

Cement beads were prepared from PalacosRG containing, 1g/2g daptomycin, 1g/2g vancomycin and without additional antibiotics. Six replicates of each combination were eluted in PBS at 37oC, at timed intervals, for up to 90days, the antibiotic loss was assessed using validated assays.

The mean recovery of gentamicin after 90days was 1.1mg with half eluted within the first 6 hours. Recovery was significantly increased by 60% and 40% with addition of 1g&2g of daptomycin(two-tail t-test: p=0.004 and p=0.02), respectively. Although there was a slight increase in gentamicin recovery in vancomycin loaded samples, this was not statistically significant(p>0.05).

The significant increases in gentamicin elution from Palacos RG when supplemented with daptomycin, along with a superior activity, may provide a better synergistic effect than PalacosRG supplemented with vancomycin in the management of PJI.

In September 2011 our departmental protocol for peri-operative prophylactic antibiotic administration was altered from cefuroxime to gentamicin/flucloxacillin, in response to reported links between cephalosporin use and Clostridium difficile (C. diff) infection.

As both gentamicin and flucloxacillin are known to be nephrotoxic in some patients, we investigated whether the new regimen increases the risk of Acute Kidney Injury (AKI) in patients undergoing elective and trauma hip and knee surgery, classified by severity (AKI Network criteria). The incidence of C. diff was noted.

10 out of 202 (5%) patients receiving cefuroxime (group A) developed AKI, compared with 23 of 210 (11%) patients receiving gentamicin and flucloxacillin (group B) (p=0.012). The severity of the renal injury was higher in the group B patients with 16 sustaining stage II/III AKI, whereas in Group A only one patient sustained a stage II injury and none stage III.

The increased AKI rate in group B was observed equally in hip fracture patients and elective hip/knee replacement patients. However, 3 of 80 (4%) patients with hip fractures who received doses of cefuroxime developed C. diff, with none in the other groups (p=0.04).

The choice of prophylactic antibiotics depends on a careful assessment of benefits and risks. Our data suggests that whereas hip fracture patients may have benefitted from the protocol change with reduced C. diff incidence, elective hip and knee replacement patients sustained additional harm. Different antibiotic regimens may be appropriate for these two groups.

Debate currently exists regarding the economic viability for screening for developmental dysplasia of the hip in infants.

A retrospective study of infant hip dysplasia over the period of 1998–2008 (36,960 live births) was performed to determine treatment complexity and associated costs of disease detection and hospital treatment, related to the age at presentation and treatment modality.

179 infants (4.8/1000) presented with hip dysplasia. 34 infants presented late (>3 months of age) and required closed or open reduction. 145 infants presented at <3 months of age, 14 of whom failed early pavlik harness treatment. A detailed cost analysis revealed:

131 early presenters with successful management in a pavlik harness at a cost of £601/child.

34 late presenters who required surgery (36 hips, 19 closed/ 17 open reductions, 1 revision procedure) at a cost of £4352/child.

14 early presenters with failed management in a pavlik harness requiring more protracted surgery (18 hips, 4 closed/ 14 open reductions, 7 revision procedures) at a cost of £7052/ child.

Late detection causes increased treatment complexity and a seven-fold increase in the short-term costs of treatment, compared to early detection and successful management in a pavlik harness. However improved strategies are needed for the 10% of early presenting infants who fail pavlik harness treatment and require the most complex and costly interventions.

Since NICE issued guidance on preventing venous thromboembolism (VTE), the use of chemoprophylaxis has increased dramatically in trauma and orthopaedics. However, enthusiasm is tempered by a lack of data regarding the true incidence of VTE in everyday practice. We investigated the epidemiology of VTE among ambulatory patients with lower limb injuries within our Trust.

We identified all patients who suffered pulmonary embolism (PE) or deep vein thrombosis (DVT) over an 18 month period, and cross-referenced them with our trauma database. All lower limb injuries were included, whether operated or not. Hip fractures routinely receive dalteparin and were excluded.

There were 11,594 new attendances or post-operative attendances in all fracture clinics over 18 months. Of these, 4530 had lower limb injuries and were immobilised. There were 21 DVTs and 7 PEs in these patients, an incidence of 0.43% and 0.14% respectively. Of note, three DVTs were in patients with Achilles tendon rupture.

The incidence of symptomatic VTE is low in a population of ambulant patients with lower limb injuries in casts, without chemical thromboprophylaxis. Prophylaxis for VTE would thus have a large number needed to treat. The costs and complications of chemoprophylaxis should also be considered before it is introduced universally.

There are longstanding debates regarding surgical versus conservative management of Achilles tendon ruptures, however there is limited focus on rehabilitation. A specific rehabilitation programme was initiated in 2008 to unify management and improve patient outcomes. We present the results at three and a half years.

In October 2008 management was streamlined under the foot and ankle surgeons and a dedicated physiotherapy service. Operative management used mainly the Achillon device (Integra) and VACOped boot with a specific rehabilitation protocol.

We prospectively collected data on all patients with Achilles tendon ruptures from October 2008 to March 2012. There were 246 patients in total with four lost to follow up. 80 were treated with the Achillon system, 18 had an open repair and 144 were treated conservatively (of which 56 were partial or musculocutaneous junction tears).

Three patients sustained re-rupture (1.2%), all initially treated conservatively. There were two operative complications (2%), both wound breakdowns. Two patients suffered PE's (0.8%), confirmed on VQ scan or CTPA (one operative, one conservative). One non-compliant patient healed functionally long and required a shortening procedure.

The authors experience has been that using the VACOped boot with our custom rehabilitation programme in dedicated physiotherapy clinics has produced excellent results.

Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe an entirely arthroscopic technique for excising talocalcaneal coalitions and present a retrospective two-surgeon case series of the first eight patients (nine feet).

Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 year to 5.5 years.

Subtalar movements were improved in all feet. Deformity was not always fully corrected but pain and SAFAS scores improved in all patients bar one. They all had a rapid return to good function apart from this same patient who required subsequent fusions. The posterior tibial nerve was damaged in one patient.

Minimal destruction of bone and soft tissues allows early mobilization and minimizes pain. We acknowledge the risk of neurological damage from any operative technique. Patient selection and preoperative planning are crucial. This series from two independent surgeons supports the feasibility and effectiveness of this technique.

There is increasing interest in the placement of the femoral and tibial tunnels for anterior cruciate ligament (ACL) reconstruction, with a trend towards a more anatomically accurate reconstruction. Non-anatomical reconstruction of the ACL has been suggested to be one of the major causes of osteoarthritis in the knee following ACL rupture.

Knee surgeons from an international community were invited to demonstrate their method for arthroscopic ACL tunnel placement in an ACL deficient cadaveric knee. These positions were recorded with image intensification and compared with the native ACL insertion sites, which had previously been recorded with image intensification, before the ACL had been resected.

Some clear trends were observed; the use of three tunnel placement techniques (anatomic ridges, ‘ruler method’ and use of image intensification) was associated with most accurate position of the femoral tunnel in the centre of the native ACL femoral insertion site. The choice of arthroscopy portals also affected tunnel placement.

There is considerable variation in ACL reconstruction tunnel placement amongst experienced knee surgeons. This study provides useful information as to which tunnel placement methods are associated with the most anatomically accurate ACL reconstruction.

Recurrent patella dislocation is a well-recognized complication after primary dislocation of the patellofemoral joint. We propose that acute surgical management of the injury minimizes this risk.

Between February 2006 and August 2010 47 patients (49 knees) with a mean age of 17.9 (range 12–31) at the time of surgery who sustained a patellofemoral joint dislocation for the first time were treated with an acute repair of the medial patellofemoral ligament.

Patients presenting to our fracture clinic following a primary lateral dislocation of the patella were investigated with an MRI scan and with consent, proceeded to have an examination under anaesthesia and arthroscopy of the injured knee. An easily dislocatable patella in the presence of a confirmed medial patellofemoral ligament rupture was the indication for open repair.

All patients treated surgically were followed up for a period of 24–72 months where the primary outcome measure was further dislocation. An evaluation of symptoms, functional recovery, restoration of range of movement and patient satisfaction was made supported by the Lysholm knee score.

Our results confirm that acute repair of the medial patella femoral ligament in selected patients reduces the risk of further dislocations and results in a overall good functional outcome and patient satisfaction with minimal complications.

Chondral damage within the knee commonly occurs during sport following direct trauma or following degeneration through overuse. Radio frequency energy chondroplasty (RFC) can be used as an alternative to mechanical chondroplasty in the arthroscopic treatment of chondral lesions. Current literature supports the theoretical advantage of RFC and purports to in vitro improvements in cartilage structure and function following RFC. We conducted a retrospective study of patients undergoing RFC for isolated chondral lesions in the knee and assessed the short term clinical benefits.

Retrospective analysis was completed of operative notes and arthroscopic images of all patients who underwent arthroscopic chondroplasty at the royal Devon and Exeter Hospital between January 2009 and June 2012. Inclusion criteria included 1 to 2 defined chondral lesions, less than 2cm2, of Outerbridge grade II-IV, treated via arthroscopic RFC. Exclusion criteria included diffuse articular cartilage damage, additional pathologies affecting the knee or subsequent further injuries or invasive procedures to the knee. Data was collected via a subjective and objective questionnaire assessing patient outcome.

35 patients met the inclusion criteria, 32 were successfully followed up. Male: female ratio was 16:16, with a mean age of 39.5 (range 19–60).

84% (n=27) of patients experienced a significant reduction in pain (mean reduction of 51%, p < 0.001) lasting until the time of study (median of 21 months, range 9 to 31 months). There was no correlation between change in symptoms and site and grade of chondral lesion. Pre-operative instability symptoms did not significantly improve following RFC. Satisfaction with treatment was in direct correlation with pain relief achieved.

Our study appears to support current literature by suggesting short term improvements to pain following the use of RFC on chondral lesions. Greater population size and longer follow-up are required to provide more significant conclusions.

A prospective cohort study was undertaken to assess the success of Ossur Unloader knee brace as non-operative management of isolated medial compartment osteoarthritis.

We recruited 12 volunteers (14 knees, mean age 63) with isolated medial compartment arthritis. They were clinically assessed, demographic data and Oxford knee scores were collected before the use of the braces. At 6 months, patient satisfaction, change in symptoms and repeat Oxford scores were noted.

Improvement was noted in 5 patients (6 knees, 42%) whose mean BMI was 29. They gained confidence, knee stability and pain relief. Their mean Oxford score had improved from 28 to 41.

Bracing was unsuccessful in 7 patients (8 knees, 58%) whose mean BMI was 33. These patients were disappointed and had discontinued its regular use. Their mean Oxford score only improved from 21 to 23.

As yet no patient has undergone a knee Arthroplasty. Comparative weight bearing radiographs with and without brace reveal no change in the weight bearing alignment. 42% of the patients with a mean baseline Oxford score of above 25 and a mean BMI of below 30 responded favourably. The main causes of failure were lack of improvement in symptoms, discomfort, skin irritation and poor patient compliance.

Medical and Health care products Regulatory Agency (MHRA) released an alert in 2010 regarding metal on metal (MoM) bearings in hip arthroplasty owing to soft tissue reactions to Metal debris. Following this, we adopted a targeted screening protocol to review patients with this bearing couple.

218 Patients (252 hips), mean age 53.2 (25–71) years were assessed clinically using Oxford hip score (OHS) and X-ray examination. The mean follow up was 44.5 (12–71) months. Patients were considered at higher risk (118 patients/133 hips) if they had deterioration of OHS (50 hips), Small sized heads <50mm (114 hips), acetabular inclination >500 (37 hips), neck thinning (17 hips). These patients (107/118), (120/133 hips) were further investigated through measuring metal ion levels and magnetic resonance imaging (MRI).

The mean blood levels of cobalt and chromium in this group were 6.7, 8.62 ug/L respectively. Metal ions increased significantly with high acetabular inclination angles (p=0.01, 0.004 respectively), but was not affected by the size of the head (p=0.13). MRI showed periprosthetic lesions around 28 hips (26 fluid collections, 2 pseudotumours).

The screening protocol detected all patients who subsequently required elective revision. We believe that this protocol was beneficial in detecting problematic MoM hip replacements.

Treatment for an infected Total Hip replacement (THR) remains controversial with two stage revision surgery traditionally recommended. We describe a series of one stage revisions performed in a District General Hospital to help inform other surgeons and help treatment decisions.

8 patients with a bacteriologically proven infection in their hip underwent single stage revision THR. Cemented Exeter prostheses were used with additional antibiotics added to the cement mixture prior to implantation.

Follow-up ranged from 6 to 36 months (average 16.6 months) and there were no re-infections. No radiological changes consistent with re-infection were noted throughout patient follow-up. One patient suffered a periprosthetic fracture (thought to be secondary to myeloma) 3 months post-surgery and underwent further revision surgery. Post-operative antibiotics were given for a minimum of 6 weeks with 2 patients having a 3 month supply after Microbiology advice.

Single stage revision THR surgery is a viable and useful option for treatment of infected THR's. Re-infection rates are low. Avoiding the traditional second stage surgery is beneficial to both patients and the NHS trust in terms of health and cost outcomes. We will continue to undertake single stage revisions in this trust and advocate its use by other surgeons.

We Present the results of radiographic assessment of limb length and offset measurements of the first 50 Corin Mini Hips done at Yeovil District Hospital.

All reconstructed Hips were compared with the contra lateral hip for leg length and offset restoration using the method of Murphy et al 2007. Excellent matching with the contralateral hip in terms of leg length and offset were found in 78% of hips and fair matching in 22%. The mean leg length discrepancy was 4 mm and mean offset discrepancy was 2 mm.

Our results show that despite using a different paradigm to conventional hip replacements, this stem allows accurate restoration of hip geometry.

The design of hip replacements is based on the morphology of the proximal femur. Populations living in hard water regions have higher levels of serum calcium and magnesium which promote bone mineralization. A case control study was performed comparing proximal femoral morphology in patients living in soft and hard water regions to determine whether the effect of water hardness had an implication in the future design of hip-prostheses.

The proximal femoral morphology of 2 groups of 70 aged and sex matched patients living in hard and soft water regions at mean age 72.24 (range, 50 to 87 years) were measured using an antero-posterior radiograph of the non-operated hip with magnification adjusted.

The medullary canal diameter at the level of the lesser trochanter was significantly wider in patients living in the hard water region (mean width 1.9 mm wider; p=0.003). No difference was found at the isthmus, Dorr index, or cortical bone ratio.

In conclusion proximal femoral morphology does differ: a wider medullary canal at the level of the lesser trochanter in hard water regions. This size difference is relatively small and is unlikely therefore to affect the mechanics of the current femoral stem prostheses components.