National guidelines suggest which investigations should be performed for patients admitted with an acute hip fracture. We have observed practice often deviates from these guidelines. Our study aims to identify the incidence of deviation with regards to blood investigations and review the effect of deviation on management, and the financial burden on the healthcare system.

A total of 250 acute hip fracture admissions over 12-months period reviewed retrospectively. Admission blood tests, time of presentation, and time of operation were recorded. The cost of admission blood investigations was calculated.

Seventy-nine percent of admissions had one or more non-routine blood investigation tested. Twenty-Nine percent of these tests had abnormal results and these were found to be clinically relevant in 6% of patients. The most commonly requested non-routine investigations were: LFT in 79%, Coagulation screen in 56%, and CRP in 48%. Fifteen percent of patients did not have surgery within the time frame of 36 hours. The total cost of non-routine investigations was £1995.04.

Deviation from admission investigations guidelines for hip fractures without clinical indication adds little clinical value, has no effect on management, and can be a potential cause of unnecessary investigations. This in turn leads to further delays and extra costs.

In recent years, many changes have taken place regarding agents used for chemical thromboprophylaxis in elective joint replacement. Enoxaparin, Rivaroxaban, Dabigatran and Apixaban are all now recommended in NICE CG92 and their use varies nationally. While data exist comparing oral anticoagulants to Enoxaparin, there is little data on the comparative efficacy of the individual oral anticoagulants.

This study analyses data from Warrington Hospital, where each of the above oral anticoagulants was used trustwide in 3 successive years following hip and knee arthroplasty. We analysed similar 4–5 month periods in 2010 (Rivaroxiban), 2011 (Dabigatran) and 2012 (Apixaban). The study was done prospectively and data was collected contemporaneously. The total sample size was 475 patients. Data was collected through electronic hospital patient records. Patients were excluded if data was incomplete. We defined our primary outcome as any complication requiring the drug to be omitted or stopped.

We found that for Rivaroxaban, 7 of 129 patients had the drug omitted or stopped (5.4%, 95% confidence interval 1.0–9.8), for Dabigatran 19 of 150 patients, (12.7%, 95% confidence interval 6.4–19.0) and for Apixaban 10 of 196 patients (5.1%, 95% confidence interval 0.9–9.3). For Rivaroxaban and Apixaban, there were no confirmed thromboembolic events; however, for Dabigatran, there were six VTEs. All three had bleeding complications, which were well below the figures published for Enoxaparin. Apixaban registered the lowest rate in our study (5.1%). This data suggests that Apixaban is a safe oral anticoagulant in elective total knee and hip replacement.

The use of tourniquet in lower limb orthopaedic surgery is well established, however, it does have associated risks and complications and its use has been previously questioned. The purpose of this study was to compare postoperative pain scores, analgesic requirements and time to discharge in patients undergoing tourniquet assisted and non-tourniquet assisted routine knee arthroscopy.

A total of 40 patients were randomised to tourniquet assisted and non-tourniquet assisted groups. Arthroscopy was performed using a standardised local anaesthetic infiltration in the non-tourniquet assisted group. All patients completed a postoperative pain score.

Findings demonstrated that the incidence and mean scores for postoperative pain were significantly lower in the non-tourniquet group. Additionally postoperative analgesic requirements of patients in the non-tourniquet group were also found to be significantly lower and time spent in recovery and on the ward postoperatively was also lower in the non-tourniquet group compared to the tourniquet group.

On the basis of the results in our study we recommend abolishing the use of tourniquet in routine knee arthroscopies in the virgin knee.

Optimising post-operative joint function is challenging when treating periarticular soft tissue sarcoma (STS). Radiotherapy reduces local recurrence rates but periarticular fibrosis may adversely affect joint function. Neo-adjuvant radiotherapy requires lower doses and smaller treatment volumes and therefore has potential benefits for the management of periarticular STS, but may lead to an increased risk of post-operative wound complications. This study assesses initial outcome and complications after treatment with neo-adjuvant radiotherapy and surgery for patients with periarticular STS.

17 patients treated with neo-adjuvant radiotherapy and surgery were identified. 3D conformal radiotherapy was delivered at a single centre with a dose of 50Gy in 25 fractions over 5 weeks. Patients were assessed weekly for adverse effects. Resection was planned 4–6 weeks after radiotherapy.

Median follow-up was 13 months (range 5–44 months). No patients had significant adverse effects during radiotherapy. One patient had surgery delayed due to local skin reaction. Minor complications in five patients (three superficial infections, one seroma, one neuropraxia). One patient required further surgery due to incomplete margins. TESS scores for upper and lower limb patients were 86.1 and 78.1 respectively. No cases of local recurrence have occurred to date. Two patients have developed distant metastatic disease.

The early results for periarticular STS managed with neo-adjuvant radiotherapy and surgery are excellent. There does not appear to be a significant increase in post-operative complication rates. With neo-adjuvant radiotherapy. Long term follow-up is required to demonstrate final functional outcome and local control rates.

Patients who have an injured limb treated in a cast may need to travel on an aircraft. The Civil Aviation Authority (CAA) have issued guidelines to help clinicians and airline companies decide if patients are safe to travel on an aircraft, or if they need to have the cast altered. Patients may seek advice from the airline companies without consulting their clinicians.

This study looked at the published advice on the websites of commercial airline companies, and requested written guidelines from those with whom no published advice was available. Out of the top 16 companies flying in and out of the UK, only six followed the CAA advice, seven did not have a clear policy, and some offered advice that could be worrying to some clinicians.

This study shows that there is little evidence available to help airline companies and clinicians decide if it is un-safe to allow people to fly with a cast. The advice from airlines is conflicting and confusing for patients, therefore a more consistent approach may be needed to allow safe air travel, to avoid inappropriate alterations of casts and to avoid unnecessary visits to the fracture clinic.

Surgery for DDH is one of the common paediatric orthopaedics procedures in a tertiary care paediatrics hospital.

There are no uniformly agreed guidelines about the pre-operative work up related to blood transfusion in DDH surgery. This leads to lack of uniformity in practice, sometimes causes cancellations of operations on the day of surgery (due to no cross matched blood available) and on other occasions wastage of the cross matched blood.

The aims of our study were to know the incidence of perioperative blood transfusion in a series of DDH operations and to determine what types of operations/kids have more chances of needing a blood transfusion peri-operatively.

We included all children who had surgery for DDH between April 2009 and October 2012 in our institution. We found out which of these children had blood transfusion peri-operatively and reviewed their notes to determine any trends in transfusion requirements

165 children had operations for DDH during the study period. This included operations ranging from hip open reduction to Ganz osteotomy.

6 out of 165 (4%) were transfused blood. Children needing blood transfusion tended to be older and had multiple hip operations previously. Only 3 (2 during Ganz and 1 during bilateral hip reconstruction) of these 6 children needed intra-operative blood transfusion. None of the under 4 years old children needed intra-operative blood transfusion.

We conclude that children for unilateral primary hip operations for DDH do not need pre operative blood cross match. A group and save is enough in these cases.

Hemiarthroplasty and proximal femoral fixation are common procedures performed in trauma units, but there is very little information regarding post-operative pain experience. Pain control is a keystone in the successful management of hip fractures. A sound strategy of pain management is easier to implement in patients where pain levels can be predicted, allowing for an effective balanced analgesic regime.

Analysis was performed on patients presenting with a hip fracture in two hospitals. Patients with a diagnosis of dementia were excluded. Post-operative pain scores were taken from patient observation charts using a verbal analogue scale. Post-operative opiate consumption was calculated from inpatient drug charts.

357 patients were included, 205 patients underwent a cemented hemiarthroplasty (HG) and 152 had fixation with a dynamic hip screw (DG). No significant difference was found in the length of hospital stay. HG patients recorded a mean morphine requirement of 20.2mg compared with 40.3mg for the DG group. Although the early pain score difference was significant (p=0.009), after 4 days, the scores were equivalent. This may support the notion of non-surgical factors determining the total length of hospital stay.

The reason for the elevated pain scores and higher morphine requirement in the DHS group remains unclear. One theory is the fracture site still exists, and it is possible that pre-existing hip arthritis may continue to be symptomatic. It is important to recognise the difference in pain experienced between the groups and analgesia should be tailored towards the individual, allowing for improved peri-operative surgical care and patient experience.

The accurate and detailed documentation of surgical procedures is essential, forming part of good clinical practice set out by the General Medical Council (GMC). In the case of knee arthroscopy, it is vital for planning further management when referring to a soft tissue knee specialist. This study assesses the quality of documentation of knee arthroscopy and evaluates the implementation of a novel operative template.

A retrospective study of 50 operative-notes of patients undergoing knee arthroscopy was completed. A 41-point assessment was made based on guidelines from the GMC, Royal College of Surgeons of England (RCSE), British Orthopaedic Association (BOA) and British Association for Surgery of the Knee (BASK).

An operative-note template was devised to address the criteria important for further interventions and then assessed for its efficacy in providing appropriately detailed findings.

Detailed documentation deemed essential by current guidelines were lacking the minimum standards expected. Criteria that were considered necessary for an arthroscopic procedure were as low as 4%. After instigating the new operative template, there was a statistically significant increase (p < 0.001) in documentation accuracy throughout the necessary criteria set out by the GMC, RCSE, BOA and BASK.

We have devised an operative template for knee arthroscopy that improves the quality of documentation and allows for optimal further surgical planning. Clear documentation is important for patient safety, adequate referral to a specialist, research and coding purposes. This will ideally reduce the number of repeat knee arthroscopies performed and optimise patient care from the outset.

The National Joint Registry (NJR) was set up by the Department of Health to collect information on all joint replacements. The NJR data is externally validated against nationally collated Hospital Episode Statistics (HES).

Errors associated with the use of HES data have been widely documented. We sought to explore the accuracy of the NJR data, for a single surgeon, against a prospectively collected personal logbook.

The NJR and logbook were compared over a 3-year period (01/07/2009 to 30/06/2012).

Total procedure recorded in the personal logbook was 684 and in the NJR was 681. TKR in personal log book was 304 and in NJR 316, revision knee's in personal logbook 45 and in NJR 36, THR 274 in personal logbook and 271 in NJR, revision hip procedures in personal logbook 64 and 58 in NJR.

Whilst the total number of procedures captured correlates closely (681 vs 684) there is more variation with the different individual procedures. This may be due to the addition of 11% of HES data used for this time period by the NJR as it is known to be inaccurate. This therefore demonstrates the importance of maintaining your own accurate records.

Enhanced recovery programmes have improved outcomes following elective arthroplasty surgery. Most studies assess whole advanced recovery programmes. There are few studies assessing the role of patient education. We therefore assessed our outcomes.

As part of our enhanced recovery programme at Wrexham Maelor Hospital, all patients are offered the chance to attend ‘joint school’, a preoperative education class. Not all patients attend these sessions allowing comparison of outcomes in these two groups using our prospectively collected database of outcome measures.

Between April 2009 and March 2013, 915 patients underwent elective hip or knee arthroplasty. Revision cases were excluded, leaving 567 knee replacements, 315 hip replacements and 27 unicompartmental knee replacements.

In patients undergoing knee replacement, those attending joint school had shorter length of stay (4.38 vs 4.85 days, p=0.145) and better Oxford Knee Score at 6 months (p=0.026) and two years (p=0.035). Patients undergoing total hip arthroplasty had a statistically significantly shorter length of stay (3.64 vs 4.54 days, p=0.011); increased frequency of mobilising on the day of surgery (28.1% vs 22.6%, p=0.203) and higher Oxford Hip Scores (non-significant) if they attended joint school.

Our retrospective analysis demonstrates that preoperative education for patients undergoing elective total hip arthroplasty produces significantly shorter lengths of stay. There are also effects on mobilisation and outcome scores. These effects are also seen in knee arthroplasty. These results will have clinical and financial implications. Assessing cost of saved bed days alone, joint school saves the trust over £10,000 per year.

The majority of hip fracture patients receive operative treatment, although the National Hip Fracture Database (NHFD) 2012 suggest 2.6% were treated conservatively. One of only a few published reports on the outcomes of these patients has demonstrated that mortality rates beyond 30 days remain comparable to patients receiving surgery. We have assessed the outcomes of conservatively managed patients in our unit.

Patients treated conservatively at our hospital between 2010 and 2012 inclusive were identified using the NHFD. Data collection included mobility status, ASA grade, Nottingham Hip Fracture Score (NHFS), mortality (30 days and 1 year) and pain scores.

The study group (N=31) had a mean age 85, mean ASA was 4 and mean NHFS mortality risk 21.3%. Morbidity included one case of pneumonia and one infection from another source, however there were no pressure sores or VTE. Three patients later received surgery once their health had improved. Pain control was achieved in 91% patients (21/23) and although mobility decreased, 34.8% of patients were able to mobilise with either two aids or a frame.

Given the selection bias for conservative treatment in unwell patients, the higher mortality figure is not unexpected. Although the 30 day mortality data is higher than the national average for operative management, those patients surviving 30 days have a mortality similar to those managed operatively. Despite mobility decreasing from the pre-admission status, a significant number of patients were pain free and could mobilise. Therefore conservative management can produce acceptable results in these patients.

An enhanced recovery programme for knee arthroplasty was introduced two years ago to our orthopaedic department. It involved the setting up of an educational programme for patients along with an extensive rehabilitation programme. The main aim of the programme is to provide an efficient and personalised service that results in an improved patient experience and fewer bed days following surgery.

We carried out a retrospective study, randomly selecting 100 patients over a period of a year who were enrolled in the enhanced recovery programme. We analysed three main areas involving the pre-, peri- and post-operative period. We looked for any key factors that led to an increase or decrease in bed days. The re-admissions were analysed and the cost benefit was calculated.

99 patients were randomly selected and satisfied the inclusion criteria. We found that with the enhanced recovery programme the average length of stay for a knee arthroplasty was four days. There were no re-admissions within the population.

We would like to share our enhanced recovery programme model as we feel it is a robust and effective way of providing a high level of care and decreasing the length of stay post-operatively.

Randomised controlled trials (RCT) published in the British volume of the JBJS from United Kingdom based institutes have been analysed to review the level of involvement of junior doctors over the past 25 years (1988 to 2012) which included three different training eras: Pre-Calman (1988 to 1995), Calman (1996 to 2006), and MMC (2007 to 2012). Authors were divided into: Senior doctors, Registrars, Fellows, Senior House Officers/ Foundation Doctors, and Others. The level of involvement has been identified as being first author, senior author or co-author.

One hundred and fifty nine RCTs have been identified with a total of 705 authors. Eighty eight registrars, 32 fellows and 19 SHO/ Foundation doctors have been involved in RCT published over the last 25 years (19.7%). Registrars constituted 15% of all authors in the pre-Calman, 12% in the Calman and 11% in the MMC periods. They constituted 33% of all first authors in the pre-Calman, 21% in the Calman, and 12% in the MMC periods. With regards to SHO/ Foundation doctors, they were only 2% of all authors in the pre-Calman, 3% in the Calman, and 4% in the MMC periods. They were not the first author in any RCT in the pre-Calman period, rising to 7% in both the Calman and MMC periods.

Our study shows that registrars involvement was at its highest in the pre-Calman era with gradual decline in their involvement in the subsequent training eras. SHO/Foundation doctors involvement remains very low, however showing increasing rate in the MMC era.

Our aim was to accurately determine whether muscle atrophy and fatty infiltration are reversible following cuff repair. Patients with a repairable cuff-tear were recruited and assessed clinically and radiologically (Magnetic Resonance Imaging). At surgery, supraspinatus was biopsied. Post-operatively, patients underwent clinical evaluation at standardised intervals, with further MRI and an ultrasound guided biopsy of supraspinatus at 12 months.

MRI was used to characterize cuff-tears and determine the degree of muscle atrophy and fatty infiltration. Biopsy samples were fixed on-site and transported for processing. Morphometric assessments of myofibres were made and mean cross-sectional areas calculated using validated techniques. The pathologist was blinded to sample details. Statistical analysis was performed to assess differences in mean myofibre area following cuff repair and correlated with radiological findings.

Eight patients were available for completed histological and radiological analysis. Six (two re-tears) demonstrated sizeable and highly statistically significant improvements in mean myofibre cross-sectional area (P=0.000–0.0253). Of the two not showing any increase in myofibre area, neither result was statistically significant (P=0.06, 0.2); one was a re-tear and one was a repair of a partial-thickness tear. Radiologically, the muscle and fatty changes had not demonstrably changed.

Our finding that myofibre cross-sectional area increases following cuff repair suggests muscle atrophy is a potentially reversible process. Even with re-tears, improvements were seen. MRI features of fatty infiltration and muscle atrophy were not seen to improve however. It is likely that radiological assessment is not sensitive enough to demonstrate the reversibility of muscle atrophy seen on histological analysis at one year.

In professional football a key factor regarding injury is the time to return to play. Accurate prediction of this would aid planning by the club in the event of injury. It would also aid the club medical staff. Gaussian processes may be used for machine learning tasks such as regression and classification. This study determines whether machine-learning methods may be used for predicting how many days a player is unavailable to play.

A database of injuries at one English Premier League Professional Football Club was reviewed for a number of factors for each injury. Twenty-five variables were recorded for each injury, including time to return to play. This was determined to be the response variable. We used a Gaussian process model with a Laplacian kernel to determine whether the return to play could be predicted from the other variables.

The root mean square error was 13.186 days (S.D.: 8.073), the mean absolute error was 8.192 days (S.D.:13.106) and the mean relative error 171.97% (S.D.:75.56%). A linear trend was observed and the model demonstrated high accuracy with greater errors being observed for cases where the value of the response variable was higher, i.e. in those cases where the time to return to play was lengthy.

This is the first step in attempting to design a computer-based model that will accurately predict the time for a professional footballer to return to play. The model is extremely accurate for most cases, with errors increasing as the severity of the case increases too.

Applying the concept of a regional trauma network to the UK paediatric trauma population has unique difficulties in terms of low patient volume and variation in paediatric service provision. In addition, no consensus exists as to which radiological investigations should be employed and an increasing trend towards computerised tomography raises concerns over radiation exposure. We carried out a retrospective review of all paediatric trauma calls from April 2010 and March 2013 around becoming a Major Trauma Centre. We aim to analyse the impact this has on trauma calls and assess the radiological investigations currently used in this population.

The number of yearly paediatric trauma calls doubled during our study and totalled 132. The commonest mechanisms of injury were road traffic collisions, fall from a height or fall off a horse. 91.7% of children had some form of radiological investigation; 67% plain radiograph, 37.1% trauma CT, 21.2% focused CT and 5.3% abdominal ultrasound scan. Of the 77 CT scans performed 57.1% were reported as normal and 54.5% of these patients were discharged home the same day. Five children re-attended the emergency department within 30 days with two positive findings; a subdural haematoma and a tibial plateau fracture.

The current use of harmful radiological investigations in paediatric trauma patients is not uniform. We propose implementation of radiology protocols and clinical guidance to imaging in paediatric trauma to limited radiation exposure.

Graphene is a two-dimensional structure that is made of a single-atom-thick sheet of carbon atoms organised in hexagonal shapes. It is considered to be the mother of all graphite or carbon-based structures. It has shown exceptional physical and chemical properties which possess potential future applications. Graphene has an elasticity index similar to rubber and a hundred times tensile strength of steel and is even sturdier than diamonds. It is a very efficient biosensor with its exceptional electronic conductivity far greater than even copper. It is a potential future low cost material and its scalable production ability makes it even more attractive. The rediscovery of Graphene in 2008 saw few potential medical applications, specifically in the field of drug delivery, gene and cancer therapy.

Nao graphene has extensive thermal conductivity and reflexivity, which can conceivably change imaging especially muskeloskeletal imaging and notably as a contrast material. It has been found to be a safe and a cheaper IV contrast agent in USA in 2012. Being an efficient biosensor especially in conducting electricity, it could assist in prosthetic and bionic limbs or prosthesis. Its durable stubborn properties, a composition which exceeds the strength of steel and light weight structure may create a potential material to develop into a new generation of a low profile internal fixing devices like plats. Most importantly, its scaffolding cell culturing assets could change the whole concept of prosthesis from mechanical press fit fixation to more dependence on bio adhesiveness.

Hip fractures are a leading cause of hospital admission and an increasing problem within the ageing population. The two main treatment options for displaced intracapsular fractures are total hip arthroplasty and hemiarthroplasty.

This service evaluation aims to compare the outcomes of patients over 80 years old with a younger cohort undergoing the two main treatment modalities.

The study included 378 patients admitted to a major UK trauma centre between April 2011 and March 2013. The main outcome measures were: mortality rate at 30 days and 1 year; reoperation rate at 30 days; proportion living in their own home/sheltered accommodation at 30 days, 1 year and upon NHS discharge; change in walking ability indoors and outdoors at 30 days and 1 year.

All patients receiving THA were discharged home compared to 74.3% under 80 receiving hemiarthroplasty and 57.3% over 80 receiving hemiarthroplasty. No THA patients required reoperation at 30 days. 4.4% under 80 receiving hemiarthroplasty required reoperation, as did 2.0% over 80 receiving hemiarthroplasty. Mortality rates were higher following hemiarthroplasty. Patients receiving THA in both age groups were more likely to retain their pre-injury walking ability at 1 year; however loss of walking ability was similar at 30 days regardless of age or treatment.

Patients receiving THA in the trust had less risk of mortality and reoperation with an increased chance of retaining pre-injury walking ability and place of residence; however these patients were healthier prior to the operation. Age had a larger impact on walking ability for those receiving hemiarthroplasty.

Trauma ward rounds (TWR) are usually preceded by trauma meetings where previous day admissions are discussed and management decisions made. Therefore, one would expect TWR to be relatively quick and efficient. We measured the distance walked during TWR over a one week period and examined effects of number of patients and their location on distance walked.

We used a pedometer (after calibration) to measure the distance walked by a single consultant orthopaedic surgeon during his trauma week. The consultant conducted a daily TWR after the trauma meeting where previous day admissions and postoperative patients were reviewed. We initially measured the distance required to visit five wards where trauma patients could be found (trial distance) and used that for comparison. We recorded number of patients reviewed and wards visited daily.

The distance walked daily during TWR was 1.37–2.4 times longer than trial distance. There was no correlation between number of patients reviewed or number of wards visited and distance walked. Despite the larger number of patients towards the end of the week (33 patients on 3 wards on last TWR), the distance walked remained shorter than on the first TWR (11 patients on 3 wards). The distance walked during the whole week was 30.8 miles!

We found no correlation between number of patients reviewed or their location and distance walked during TWR. The relatively shorter distances walked towards the end of the week could be explained by more familiarity and therefore, better organisation by the team as the week progressed.

Reverse polarity shoulder replacements are indicated in cases of gleno-humeral arthritis with the presence of rotator cuff muscle dysfunction. Despite some studies demonstrating early improvement in function and pain, limited information still exists regarding the durability and longer term outcomes of these prostheses. The reported complication rates have been reported to range from 0–68%.

Post-operative clinical complication rates of three commonly used reverse polarity total shoulder replacements (Delta, Verso and Equinoxe) were evaluated against those mentioned in the literature to predict satisfactory outcome.

A retrospective review of 54 patients (3.5F:1M) and 64 operations (27L:37R) between 2004–2011 was carried out. Post-operative complications were searched for through medical records, the local hospital database (BLuespearIT) and the Picture Archiving and Imaging System (PACS). All operations were performed by two experienced consultant-grade orthopaedic shoulder surgeons.

The mean age at time of operation was 75.9 years (range 64–94). 33 Delta, 19 Equinoxe and 12 Verso prostheses were inserted. Three patients were excluded from the study due to insufficient information from medical records and radiography. Total complications were seen in 25 % of operated cases:- dislocation (6), fracture (4), deep infection (2), significant post-operative pain (1) and deltoid muscle dysfunction (3). Complications categorised according to prosthesis type were:- Delta (24%), Equinoxe (32%) and Verso (8%).

Short to medium term complication rates using reverse polarity total shoulder replacements are higher than the majority of the current literature suggests. The Verso is associated with the least number of complications which may correlate with its minimally invasive approach.

The Lubinus SP2 femoral stem has a 10 year survivorship of 96%. Curiosity lies in that force-closed stem designs such as the Exeter appear to be more superior to that of the composite-beam like the Lubinus which performs best compared with all other stem types. Biomechanical comparisons of the stress distributions between native and implanted human femora with a cemented Lubinus stem simulating an everyday clinical activity were made. Rosette strain gauges were placed onto fourth generation composite cortical sawbone femora and placed within a hemipelvis rig simulating the dynamic position of the femur during single-legged stance. The femora were then implanted with the Lubinus and principal strain measurements calculated for both intact and implanted femora. These values correlate directly with stress. Statistical calculations were carried out including a two-way ANOVA and Student's unpaired t-test so as to ascertain any relationship between the intact and implanted femora strain values.

There were significant decreases (p<0.05) in principal tensile and principal compressive strains upon implantation in the proximal and distal areas of the femur. However, there were insignificant changes (p>0.05) in principal tensile strains at the mid-stem and insignificant changes (p>0.05) in principal compressive strains at both the mid-stem and distal areas.

This is the largest biomechanical study to be carried out on this stem and the first in the English language. Changes in principal stresses were not significant in all aspects of the femur upon implantation which appears to give some biomechanical explanation to its clinical success.

In 1902 Shenton described his “line” which, “is formed by the outlines of the upper margin of the obturator foramen and the inner margin of the neck of the femur” stating, “broken continuity of which infallibly indicates displacement or trouble in the hip region. Some 110 years later with significant advancements in Radiology, we assessed whether there is still a role in modern Orthopaedics.

We reviewed 900 anterior-posterior bilateral hips on pelvis radiographs and noted whether Shenton's line was intact or broken. We recorded the presence or absence of pathology in each hip along with age and sex of the patient. In addition 15 independent observers were asked to blindly independently review 15 pelvic radiographs on two separate occasions. They noted whether Shenton's line was intact or disrupted. From this data we analysed the intra and inter-observer reliability.

1547 hips were analysed. 63% (971/1547) had an intact Shenton's line, 37% (576/1547) had a disrupted line. Of 271 femoral neck fractures, 44 (16%) were seen to have an intact Shenton's line. Regarding other pathologies, 2% of osteoarthritic hips, 0.1% of dysplastic hips and 20% of prosthetic hips had a disrupted Shenton's line. No ‘normal’ hips had a broken line. There was significant inter-observer error yet little intra-observer error found.

Our evidence reaffirms Shenton's original work. With a disrupted line there is a high probability of pathology within the hip. However, there may still be a fracture with an intact line, suggesting that Shenton's line is highly sensitive yet not greatly specific.

Total disc replacement (TDR) is the gold standard for lumbar degenerative disc disease in selected patient groups. Traditional TDR designs benefit from a wealth of literature and use a polyethylene inlay pseudo-disc between two metal endplates. There is scarce literature for novel monomodular implants that form an artificial construct of woven annulus and central nucleus, providing physiological motion preservation.

The aim was to compare the evolving changes to radiological position between monomodular and traditional implants and assess the relationship of migration with bone densitometry.

This retrospective series of consecutive patients undergoing TDR under a single surgeon recorded demographics, co-morbidities, previous surgery and clinical outcomes. Measurements of endplate subsidence, lordosis and spondylolisthesis taken from weight-bearing erect x-rays at 0, 3, 6 and 12 months. Radiological outcomes were compared against CT bone densitometry.

33 monomodular and 13 traditional implants. Mean age 40 years. All patients had degenerative disc disease. Monomodular and traditional implants were as likely to develop lordosis (p=0.32), endplate subsidence (p=0.78) or spondylolisthesis (p=0.98). Comparison between endplate subsidence and low bone densitometry were insignificant (p=0.47). Developing lordosis in the monomodular implant was related to low bone density; mean 134vs.184mg/cm³ (p=0.018). Three monomodular implants developed a posterior hinge after migrating into lordosis. One traditional implant dislocated, requiring emergency fusion.

Radiological outcomes are comparable between traditional and monomodular implants. The larger endplate-footprint of the monomodular implant did reduce subsidence. Monomodular implants pivoting on a posterior hinge may fail early. Bone densitometry may identify patients who will drift into lordosis.

Traditional use of tourniquets and reinfusion drains in total knee replacement (TKR) has recently been challenged. Many studies have challenged the benefits of their use. Our aim was to compare the outcomes of three different blood management techniques in primary TKR.

We conducted a prospective randomised study of 87 patients with a mean age of 71 years. All patients were randomised into three groups: Group A (29 patients without tourniquet and drain), Group B (27 patients without tourniquet or drain but cell salvage system) and Group C (31 patients with the use of tourniquet and drain).

The results showed no difference between the postoperative haemoglobin drop and blood transfusion rate between the groups. At day two, range of knee movements (Group A: 80.2 degree; Group B: 79.6 degree; Group C: 77.9 degree) showed no significant difference. Two Group C patients (6.4%) had postoperative thromboembolic events (one DVT, one TIA). Knee stiffness leading to readmission (Group A: 6.8%; Group B: 7.4%; Group C: 3.2%) and superficial wound problems did not reveal any significant difference. The average operative time and hospital stay were the same in all groups and there was no wound haematoma or deep infection in any groups.

There was no statistical difference between the groups for any outcome measure assessed thus the use of tourniquets and drains in total knee arthroplasty are controversial and questionable. We can conclude that all techniques are safe and it is the surgeon's choice as to which they apply routinely in their clinical practice.