Aluminia ceramic on ceramic (COC) bearing surfaces have been used for 35 years in total hip arthroplasty (THA). Studies report 85% survival at a minimum follow-up of 18.5 years. Nonetheless, an audible noise is a finding associated with COC bearings with incidence rates of 2–10%. This study aims to determine the prevalence of noise and evaluate its effect on patients.

All patients who had a COC THA from August 2003 to December 2010 were contacted and asked to complete a standardised questionnaire. This asked about the presence and characteristics of a noise and if associated with activities, pain and whether this phenomenon should be mentioned preoperatively.

Four consultant surgeons performed 282 consecutive primary COC THAs in 258 patients. (Male=122, Female=136 mean age 68.5; age range 28–88). In all cases, the same brand of ceramic acetabular component and stems were implanted. 11.0% had a noise, of which 5.5% had a squeak. Pain was experienced in 38.7% of patients in hips that made a noise. There was no trauma and one dislocation in this group. In this study, 85% of noises occur during weight-bearing although no patients have reduced daily activities as a result of the noises. Of all the patients, 55.0% stated they would have preferred to have known about a noisy hip possibility before consenting but none would have refused consent.

Squeaking has not been a problem here despite the prevalence being higher than most in the literature. The authors recommend that squeaking should be discussed preoperatively. A checklist for Orthopaedic Trainees is being drafted to enable trainees to counsel patients appropriately, allowing patients a better opportunity to give informed consent.

Infection rates following arthroplasty surgery are between 1–4%, with higher rates in revision surgery. The associated costs of treating infected arthroplasty cases are considerable, with significantly worse functional outcomes reported. New methods of infection prevention are required. HINS-light is a novel blue light inactivation technology which kills bacteria through a photodynamic process. 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 to identify causative organisms. 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 (123mW/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.

Complete inactivation was achieved for all Gram positive and negative microorganisms

More than a 4-log reduction in Staphylococcus epidermidis and Staphylococcus aureus populations were achieved after exposure to HINS-light for doses of 48 and 55 J/cm², respectively. Current investigations using Escherichia coli and Klebsiella pneumoniae show that gram-negative organisms are also susceptible, though higher doses are required.

This study has demonstrated that HINS-light successfully inactivated all clinical isolates from infected arthroplasty cases. As HINS-light utilises visible-light wavelengths it can be safely used in the presence of patients and staff. This unique feature could lead to possible applications such as use as an infection prevention tool during surgery and post-operative dressing changes.

Intervention is rare following minimally displaced radial head fractures or positive elbow ‘fat pad’ signs. A pilot study (n=20) found no patient required active treatment after discharge following their first fracture clinic visit. We therefore initiated routine discharge from A&E with an advice sheet, and an ‘open-door policy’ if patients failed to progress.

51 patients were managed by A&E according to this protocol over a six-month period. A standardised assessment of symptoms, satisfaction and functional limitation was completed for 24 patients by phone; average time to follow-up 4.2 months (range 2–9 months). Fourteen (58.4%) reported no pain. The 10 patients (41.6%) with on-going pain reported a median visual analogue score (VAS 0–10) of 0.7 (0–4) at rest, 0.25 (0–4) at night, 3.0 (0–10) carrying heavy objects and 2.75 (0–10) during repetitive movement. 4 of 24 (16.7%) reported minor functional impairment. 3 of 24 (12.5%) patients requested orthopaedic review, but all were satisfied with outcome, seeking reassurance and discharged without any intervention. 3 of 24 (12.5%) were unhappy with their progress, but all had suffered from chronic pain or psychological conditions predating their injury. When offered further review, none of these patients accepted.

22 (91%) were satisfied with their treatment and 23 (95.8%) returned to work and hobbies. This data suggests routine discharge from A&E with advice does not compromise care, as no intervention is usually required beyond advice. These findings have obvious positive clinical and financial implications in streamlining clinical workload.

Decreased oxygenation and delayed wound healing may negate the advantages of using a medial parapatellar incision in Total Knee Replacement. Tissue biochemical and blood flow data are not currently available in the literature.

20 patients were included in the study and randomised to midline or medial parapatellar skin incision groups, being supervised by one of 3 Consultant surgeons. Cutaneous blood flow was measured using a Speckle Contrast Blood Perfusion Imager at pre-operative and Days 1 & 3 post-operative intervals. Interstitial fluid measurements for lactate, pyruvate, lactate/pyruvate ratio and glucose were obtained from subcutaneous catheters with a dialysis membrane. Pre-operative samples were obtained from a catheter inserted into the prospective lateral wound edge. A catheter inserted after wound closure supplied dialysates at 0.5, 1, 2, 4, 6, 12 and 24-hour intervals. One catheter was corrupted on insertion; therefore the patients with biochemical data numbered 19.

Cutaneous blood flow improved over the 3 post-operative days in both types of incision and both sides, the medial retaining comparatively better flow. At Day 3, the parapatellar incision group displayed better flow on both sides of the wound. The concentration of lactate was highest in the parapatellar incision group of patients at all intervals. Pyruvate concentrations did not appear to differ across the incision types. Similarly, glucose concentrations did not appear to differ until after 4 hours, when higher concentrations were recorded in the midline group. Lactate/pyruvate ratio appeared to be notably greater in the parapatellar incision group. Plotting change in blood flow relative to change in lactate concentration demonstrated an increase in lactate as flow deteriorates.

The study findings suggest medial parapatellar incisions have increased anaerobic metabolites due to tissue hypoperfusion. Previous studies have demonstrated decreased oxygen tension in lateral based flaps and more recently the medial to lateral arterial anatomy has been demonstrated.

Olecranon fractures account for 20% of elbow fractures. Displaced fractures can be treated by several methods – Tension Band Wiring (TBW), Open Reduction and Internal Fixation with a plate (ORIF) or conservative measures. Studies from UK specialist centres have demonstrated infection rates of up to 15% and metalware removal rates of up to 80%. In addition studies have shown that conservative treatment provides good function and pain relief in the elderly and infirm.

To look at all displaced olecranon fractures within our unit (the busiest district general hospital in Scotland) over a 4 year period and analyse for patient features, age stratification, identify treatment methods, complications and outcomes. To compare this to outcomes in studies published by specialist centres.

All olecranon fractures admitted to our unit in calendar years 2007–2010 were identified from our trauma database. Case sheets were analysed for patient's age, co-morbidities, treatment, complications & outcome. Xrays were analysed to classify the fractures and assess outcome of treatment.

71 patients were identified, Male: Female = 33:38. Age range was 7–93. Mean 62.8. Treatment used – TBW 42 (59.1%), ORIF 9 (12.7%), Conservative 20 (28.2%). In the surgical group of 51 patients there were 4 infections (7.8%). There were no incidences of nerve palsy. Metalware was removed in 15 patients (29.4%) – for TBW this was 11/42 (26.25) and ORIF 4/9 (44.4%) – however the difference was not significant (p=0.06). The conservative group had no complications.

In our study group we have demonstrated a lower infection rate and a far lower rate of metalware removal than published studies.?We have a high rate of patients treated conservatively who do well. Further work is being performed into the functional outcome of the whole group.

We present a novel use for an adult proximal humeral locking plate. In our case an 18-year-old female with cerebral palsy sustained a peri-prosthetic fracture of a blade plate previously inserted for a femoral osteotomy. Treatment was revision using a long proximal humeral locking plate. She had a successful outcome.

We present the history and operative management.

The female had a history of quadriplegic cerebral palsy, asthma, diabetes mellitus and congenital heart disease. She had a gastrostomy tube for enteral feeding. She was on nutritional supplements, baclofen, Omeprazole and movicol. She is looked after by her parents and requires a wheelchair for mobility. She is unable to communicate. Surgical History: Right adductor tenotomy, aged 11. Femoral Derotation Osteotomy & Dega Acetabular Osteotomy, aged 13. Right distal hamstring and knee capsule release, aged 14. Admitted to A&E (aged 18); unwitnessed fall. Painful, swollen, deformed thigh with crepitus. Xrays demonstrated peri- prosthetic fracture below blade plate.

No specific equipment available to revise. Decision made to use PHILOS (Synthes, UK). GA, antibiotics, supine on table. Lateral approach. Plate removed after excising overgrown bone. Reduced and held. 10hole PHILOS applied. Near anatomical reduction. Secure fixation with locking screws proximally away from blade plate defect. Blood loss 800ml. 5 days in hospital. Sequential fracture clinic review. Wound healed well. Fracture healed on Xray at 11 months and discharged.

To our knowledge this is the first reported use of a PHILOS plate for this specific fracture. The complexity of this case and underlying neurological disorder deemed long blade plate revision unsuitable. Fracture rates after femoral derotation osteotomies rare. 5/157 and 1/58 in the two largest studies to date. Conservative measures were the main recommendation. We have demonstrated a straightforward method for revision fixation with an excellent outcome. It would be recommended as an alternative to other surgeons in this position.

The Exeter Stem (Howmedica, UK) has been in use for over 35 years. Over the years it has undergone several modifications with the most recent being a highly polished, tapered stem in 1986. The manufacturers quote a rate of 0.0006%. In the current literature there are 16 (or less) instances of fractures of the Orthinox stem.

We present a case of fracture of an Orthinox Exeter Stem 9 years after insertion.

Our patient, BB, presented, aged 62, with symptoms & signs consistent with OA right hip. THR was performed through a lateral approach utilising a trochanteric osteotomy. A size 0 37.5 stem was inserted. Radiographs were very satisfactory. She suffered a post operative DVT/PTE from which she recovered uneventfully. She was independently mobile at 6 month review and was discharged at the 2 year stage pain free.

Aged 71, BB presented to outpatient clinic with a several month history of generalised groin pain. She had a Trendelenberg gait. Considerable pain was experienced on axial compression of the limb. Radiographs revealed a midstem fracture with cement loosening proximally. No trauma was reported. She underwent revision surgery through a posterior approach. Acetabular component was rigidly fixed. This was revised to a pressfit Trident (Zimmer, UK) cup with screws & polyethylene liner. An extended trochanteric osteotomy was used to remove the broken stem. An uncemented Restoration (Stryker, UK) stem was inserted with a 28mm head. Post-operative recovery was unremarkable and at 6 months osteotomy has healed. The stem was sent to Stryker UK Laboratories for analysis. They reported the stem broke in fatigue with the origin on the antero-lateral surface. No material or manufacturing defects seen. Dimensionally correct. Fracture may be due to abnormal bending stresses secondary to proximal loosening and firm distal fixation.

Our case demonstrates a set of circumstances that led to inevitable fatigue and stem fracture. The method of failure should reinforce the radiograph appearances that may cause concern or be acted upon.

This study aimed to overcome the subjective nature of routine assessment of knee laxity and develop a repeatable, objective method using a hand-held force application device (FAD).

Eighteen clinicians (physiotherapists, consultants, trainees) volunteered to measure the coronal angular deviation of the right knee of a healthy volunteer using a validated non-invasive infrared measuring system. Effort was taken to ensure the knee flexion angle (∼2°) and hand positions were constant during testing. Three varus and valgus stress tests were conducted, in which maximum angular deviation was determined and subsequently averaged, in the following order of conditions: manual stress without the FAD up to a perceived end-point (before); with the FAD to apply a moment of 18 Nm; and again without the FAD (after). A repeated measures ANOVA was used to analyse the results.

All three groups of clinicians produced measurements of valgus laxity with consistent mean values and standard deviations (<1°) for each condition. For varus mean values were consistent but standard deviations were larger.

Valgus deviations varied significantly between conditions (p < 0.01), with deviations achieved using the FAD greater than both before (p < 0.01) and after (p < 0.05) indicating that the perceived endpoints were less than that achieved at 18 Nm. However varus perceived endpoints were no different to that achieved at 18 Nm, suggesting that clinicians usually apply a greater valgus moment than varus. Furthermore, the non-significant increase in valgus deviation between before and after (p = 0.123) is suggestive of a training trend, especially for trainees.

Our standardised knee laxity assessment may have a role in improving the balancing techniques of TKA and the diagnosis of collateral ligament injuries. Also, by quantifying the technique of senior clinicians, and with use of the FAD, the perceptive skills of more junior trainees may be enhanced.

There is substantial concern about the state of musculoskeletal knowledge of junior doctors. There are also marked differences in the locomotor curricula of medical schools, raising the possibility that students may be selectively disadvantaged from gaining appropriate knowledge and/or attaining a musculoskeletal career path. The aims of this study were to assess the musculoskeletal knowledge of newly qualified doctors in the south of Scotland, and to compare this between the two medical schools (Glasgow and Edinburgh) that have different locomotor teaching programmes.

All final year medical students, from Glasgow and Edinburgh Universities (n=158 and 221, respectively), attending the compulsory ‘Preparation for Practice’ lecture course immediately after (Glasgow) or before (Edinburgh) final exams, were assessed by the Freedman and Bernstein musculoskeletal examination, previously validated with two different pass-standards: (i) 73.1% (by orthopaedic surgeons), and (ii) 70% (by physicians).

There was a significant difference (Wilcoxon two sample test; p<0.5×10⁻⁹) in the marks obtained at the two institutions, the median being 59% (IQR 50–67%) and 68% (IQR 60–76%) at Glasgow and Edinburgh respectively. The pass-rates for the two institutions (Glasgow vs. Edinburgh) were markedly different, being 17.1% vs. 32.6% for the higher pass-mark, and 21.5% vs. 48% for the lower.

The majority of newly qualified doctors in the south of Scotland have inadequate musculoskeletal knowledge. There is a substantial and statistically significant difference in the scores attained by students from two neighbouring medical schools (Glasgow and Edinburgh). The striking difference in the pass-rates can be best explained by differences in respective musculoskeletal courses. These explicit and comparative deficits raise substantial questions for musculoskeletal curriculum planning, teaching, assessment and quality assurance.

The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. Its effect on sesamoid function and the pathomechanics of this joint have not been described.

Fresh frozen cadaveric specimens without evidence of forefoot deformity were dissected to assess the articulating surfaces throughout a normal range of motion. The dissections were digitally reconstructed in various positions of dorsiflexion and plantarflexion using a MicroScribe, enabling quantitative analyses in a virtual 3D environment.

In 75% of specimens, there was some degree of chondral loss within the metatarsosesamoid articulation. The metatarsal surface was more commonly affected. These changes most frequently involved the tibial metatarsosesamoid joint.

The tibial sesamoid had an average excursion of 14.2 mm in the sagittal plane when the 1st MTP joint was moved from 10 degrees of plantarflexion to 60 degrees of dorsiflexion; the average excursion of the fibular sesamoid was 8.7 mm. The sesamoids also move in a medial to lateral fashion when the joint was dorsiflexed. The excursion of the tibial sesamoid was 2.8 mm when the joint was maximally dorsiflexed while that of the fibular sesamoid was 3.2 mm.

There appears to be differential tracking of the hallucal sesamoids. The tibial sesamoid has comparatively increased longitudinal excursion whilst the fibular sesamoid has comparatively greater lateral excursion.

This greater excursion of the tibial sesamoid could explain the higher incidence of sesamoiditis in this bone. The differential excursion of the 2 metatarsosesamoid articulations is also a factor that should be considered in the design and mechanics of an effective hallux MTP joint arthroplasty.

Collection of new data for the Scottish hip fracture audit stopped in December 2008. The proposed standard of operating on 98% of all hip fractures within 24 hours of admission, subject to medical fitness and during safe operating hours should now be maintained.

The purpose of this study was to evaluate the effect of body mass index (BMI) on patients undergoing primary total knee arthroplasty for osteoarthritis. Data was collected on 664 patients at 4 centres all of whom received a Depuy PFC Sigma prosthesis. Data collected included patient demographics, Oxford Knee Score (OKS), American Knee Society Score, SF-12, complications of surgery and the need for revision.

14% of patients had a BMI<25, 35% were overweight (BMI-25–30), 32% suffered from Grade 1 obesity (BMI-30–35) and 19% had grade 2 obesity (BMI>35). Obese patients were more likely to be female, have a higher ASA grade, present at a younger age and do sedentary work or no work at all. Pre-operative Oxford knee score was significantly worse in the BMI>35 group (p<0.001).

After surgery there was a significant improvement in functional outcome measures at 5 years post-operatively with all BMI groups improved by an average of 18 or 19 points in the OKS. However because those patients with high BMI have poorer pre-operative Oxford scores their post-operative scores were lower compared to patients with a normal BMI. Similar findings were noted with range of motion of the knee joint.

Overall complication rates were found to be significantly higher in obese patients and both revision surgery and deep infection rates increased stepwise with increasing BMI levels.

Deep Infection rates were as follows: BMI<25 0%, BMI-25–30 1.3%, BMI-30–35 1.4%, BMI-35–40 3.2% and BMI>40 6.1%.

Revision rates were as follows: BMI<25 0%, BMI-25–30 0.9%, BMI-30–35 0.9%, BMI-35–40 3.2% and BMI>40 6.1%.

Although obese patients with knee osteoarthritis do benefit from joint arthroplasty, they suffer from an increased rate of complications and need for revision surgery.

Reverse total shoulder arthroplasty (RTSA) provides a surgical alternative to conventional shoulder arthroplasty in the rotator cuff deficient shoulder. Short term data has shown consistent improvements in pain and function but higher complication and failure rates have also been reported. The aims of this study were to identify the early and late complications of RTSA, to establish the frequency of glenoid notching, and to assess the post-operative functional outcomes.

21 patients (22 joints) treated with RTSA at Glasgow Royal Infirmary (GRI) between April 2006 and October 2010 were retrospectively reviewed. Indications for surgery included cuff tear arthropathy, revision hemiarthroplasty and fracture malunion. Complication rates were obtained by analysis of follow up data from Bluespier and case notes. Glenoid notching was graded from x-rays by multiple observers using the Sirveaux classification. Outcome was assessed using the Oxford Shoulder Score (OSS) and range of motion (ROM).

The complication rate associated with RTSA was 14.3%, effecting 3 patients. One dislocation and 1 ulnar nerve palsy occurred within 30 days post-op. A late complication was represented by 1 dislocation, which required revision. Glenoid notching occurred in 71.4% (15 of 21patients), though the majority had a low Sirveaux classification (grade 1 or 2). OSS increased post-operatively and showed a linear improvement with time (R² = 0.81) and ROM increased significantly post-op compared with pre-op (p<0.001).

The complication rate associated with RTSA at GRI was lower than that reported in literature and the outcome was good as defined by ROM and OSS. The rate of glenoid notching was higher than literature reports but the significance of this is unclear as notching may not be associated with loosening.

The aim of this study was to characterise noise associated with ceramic-on-ceramic total hip arthroplasty (THA).

A questionnaire was constructed to assess noise associated with THA. 116 patients responded. All had ceramic-on-ceramic hybrid THA at Glasgow Royal Infirmary between 2005 and 2007 using a Trident prosthesis and Exeter stem. Oxford Hip Questionnaires (OHS) were also completed by the patients.

16.4% of respondents reported noise associated with their ceramic hip. The vast majority reported onset at least 1 year after implantation. The most common noise types were ‘clicking’ (47%) or ‘grinding’ (42%), while ‘squeaking’ was least frequently reported (11%). Noise was most commonly brought on by bending and during sit to stand movements.

No correlation was identified between the incidence of noise and any patient specific factor or demographic variable. The mean OHS at questionnaire follow-up was 39 and there was no significant difference in OHS when comparing noisy and silent hips (p=0.65). Only 1 patient limited social or recreational activities and overall patients felt the noise had minimal effect on their quality of life.

Acetabular component inclination angles were compared on post-operative x-rays. There was no significant difference (p=0.51) in inclination angles of the noisy (47.1°±6.3°, range 30–57°) and silent hips (47.8°±6.1°, range 35–68°). The groups were further analysed for deviation out with the desirable inclination range of 40–45°. Of the noisy hips, a total of 73% were out with this range compared to 63% in the silent hip group.

The incidence of noise within this ceramic-on-ceramic THA group did not appear to be related to patient specific factors, patient reported outcome (OHS) or acetabular inclination angles. Subjective appraisal of the noise revealed that ‘squeaking’ was not common but patients tended to report ‘clicking’ and ‘grinding’ more. The precipitation of noise with bending activities reinforces a possible mechanical cause.

A retrospective analysis was carried out to determine the influence of pre-existing spinal pathology on the outcome of Total Knee Replacement surgery. Data was collected from 345 patients who had undergone Total Knee Replacement, at four centres in the UK, between 2000 and 2007. Oxford Knee Scores (OKS), American Knee Society Scores (AKSS) and SF-12 questionnaires were recorded prospectively. Data was collected pre-operatively and then post-operatively at 3 months, 1 year and 2 years. Patients were divided into those with (n=40) and without a history of low back pain (n=305). In addition to determining the influence of low back pain on outcome after Total Knee Replacement we also examined the influence of concomitant hip and ankle pathology in the same cohort of patients.

OKS scores were significantly worse for patients with symptomatic low back pain at 3 (p=0.05), 12 (p=0.009) and 24 months (p=0.039) following surgery. SF-12 physical scores followed a comparable pattern with significance demonstrated at 3 (p=0.038), 12 (p=0.0002) and 24 months (p=0.016). AKSS followed a similar pattern, but significance was only reached at 1 year (p=0.013). The mental component of the SF-12 measure demonstrated a significant improvement in patients' mental health post-operatively for patients with no history of low back pain. In contrast patients with low back pain showed no improvement in mental health scores post-operatively.

In contrast to low back pain, hip and ankle pathology had no statistically significant detrimental effect on the outcome of Total Knee Replacement surgery.

This study demonstrates that low back pain significantly affects the functional outcome after Total Knee Replacement surgery and that patients with low back pain show no improvement in mental health post-operatively.

The purpose of this study was to provide an anatomical explanation for the presence of medial proximal tibial pain in patients with patellar mal-tracking without identifiable medial tibio-femoral compartment or proximal tibial pathology.

Using cadaveric dissection we were consistently able to identify a connection between the medial patella and the medial proximal tibia including the medial hamstrings and the posterior oblique expansion. This connection is independent of the inferior patello-tibial ligament and has not previously been described in either anatomical or orthopaedic literature. The dimensions of this medial patello-tibial connection were measured using a digital microscribe. This technique also facilitated the creation of a three dimensional virtual representation of the patello-tibial connection.

In the clinical setting, patients presenting with medial proximal tibial pain who had patellar mal-tracking as identified by clinical examination and merchant radiographs underwent MRI scanning of the knee to exclude any intraarticular or proximal tibial pathology. In those patients with patellar mal-tracking that had no evidence of proximal tibial or medial compartment pathology identified, we were able to correlate the MRI finding of oedema based at the proximal medial aspect of the tibia with the cadaveric dissection findings mentioned previously. In such cases we would recommend that treatment of the medial proximal tibial pain should focus on managing the primary pathology of patella mal-tracking.

In conclusion we present a newly identified medial patello-tibial ligamentous complex that can explain the presence of medial proximal tibial pain in patients with patellar mal-tracking and no other proximal tibial or medial compartment pathology.

We present a simple seated dial test that can be used by a single examiner in the acute or chronic situation to diagnose posterolateral corner knee injury.

In the acute setting a traditional prone dial test can be cumbersome and painful for patients. Therefore a supine technique can be utilised, however this requires an assistant in order to hold the knees together with the tibia in a reduced position. We therefore utilise a seated technique in which the patient sits with their knees flexed over the edge of the examination couch. The patient is then able to hold their knees together, negating the need for an assistant. The sensitivity of a dial test is improved if the knee is reduced and so with this technique the tibia will be held in the anatomical position by the examination couch.

The patients' feet are grasped with both medial malleoli together and then an external rotation moment is exerted at 30 and 90 degrees of flexion measuring the thigh-foot angle or visualising the tibial tuberosities. A positive test being 10 degrees or more of increased external rotation in the affected knee.

This test is similar to the Spin test however it relies on the tactile sensation of posterolateral tibial rotation. This can be difficult to elicit in the acute situation due to haemarthrosis. Simultaneous side-to-side comparison is also not possible. A further disadvantage of the Spin test is that it can only be performed at 90 degrees of flexion and so only applies in combined PCL and posterolateral corner repair.

In conclusion we believe that this modification of the standard dial test is a simple to perform accurate method for assessing posterolateral corner knee injury in the acute and chronic setting.

Femoroacetabular impingement (FAI) is a significant cause of osteoarthritis in young active individuals but the pathophysiology remains unclear. Increasing mechanistic studies point toward an inflammatory component in OA. This study aimed to characterise inflammatory cell subtypes in FAI by exploring the phenotype and quantification of inflammatory cells in FAI versus OA samples.

Ten samples of labrum were obtained from patients with FAI (confirmed pathology) during open osteochondroplasty or hip arthroscopy. Control samples of labrum were collected from five patients with osteoarthritis undergoing total hip arthroplasty. Labral biopsies were evaluated immunohistochemically by quantifying the presence of macrophages (CD68 and CD202), T cells (CD3), mast cells (mast cell tryptase) and vascular endothelium (CD34).

Labral biopsies obtained from patients with FAI exhibited significantly greater macrophage, mast cell and vascular endothelium expression compared to control samples. The most significant difference was noted in macrophage expression (p<0.01). Further sub typing of macrophages in FAI using CD202 tissue marker revealed and M2 phenotype suggesting that these cells are involved in a regenerate versus a degenerate process. There was a modest but significant correlation between mast cells and CD34 expression (r=0.4, p<0.05) in FAI samples.

We provide evidence for an inflammatory cell infiltrate in femoroacetabular impingement. In particular, we demonstrate significant infiltration of mast cells and macrophages suggesting a role for innate immune pathways in the events that mediate hip impingement. Further mechanistic studies to evaluate the net contribution and hence therapeutic utility of these cellular lineages and their downstream processes may reveal novel therapeutic approaches to the management of early hip impingement.

Total hip replacement (THR) is an option in a subset of patients with a neck of femur (NOF) fracture. The Scottish Intercollegiate Guidelines Network (SIGN) and National Institute for Clinical Excellence (NICE) provide guidance on the use of THR in patients with a NOF fracture. We compare our experience and recommend changes at a local level to allow successful implementation of the guideline to improve patient care.

From July 2008 to July 2011, 36 THRs preformed for trauma were identified retrospectively by cross-referencing several databases (Bluespier, Worcestershire, UK and surveillance of Surgical Site Infection (SSI), Scotland). 7 exclusions (3 failed internal fixation, 1 chronic NOF fracture, and 2 extra-capsular fractures) leaving 29 patients. All operations were carried out under the supervision of a hip surgeon. Outcome data (see results) was collected from electronic sources. Statistical analysis preformed using Fisher's exact test for categorical data.

Median age 62 years (44–88), time to surgery 4 days (2–8), American association of anaesthesia grade 2 (2–4) and hospital stay was 12 days (6–18). The first operator was a consultant in 23 cases and registrar in 6. 9 hips were cemented, 5 uncemented and 15 hybrid. 13 (44.8%) patients had a complication including 8 major (27.6%) complications. A blood transfusion was required in 11 (37.9%) patients. There were 2 (6.9%) deaths. A delay to surgery of more than 2 days was associated with increased risk of major complication (p< 0.03). ASA, Age, Grade of surgeon or Cement not associated with major complications.

Our results are inferior to those in the literature. We have identified potential causes; mainly a delay to surgery increasing risk of major complication. In keeping with the current guidelines we recommend that local pathways are instigated to ensure THRs for trauma may be preformed in a timely fashion.

Intraoperative cell salvage involves the collection of blood directly from the operative field. The purpose of this study was to determine if its use reduces the need for postoperative allogenic blood transfusion, assess any adverse events and its effect on duration of postoperative stay in primary hip arthroplasty.

We prospectively examined the effect of intraoperative cell salvage on the need for postoperative allogenic blood transfusion. Between February 2009 and August 2010, a total of 77 patients who underwent primary total hip arthroplasty were included in the study, under the care of the senior author (KB). All patients had a diagnosis of osteoarthritis.

Intraoperative cell salvage was used in 38 patients and not used in 39 patients. We prospectively collected data on patient demographics, ASA grade, preoperative and postoperative haematological features, number of units of packed red cells transfused and the volume of intraoperative reinfused cell salvaged blood was. Total inpatient stay and any postoperative adverse events were recorded.

No patients in the cell salvage group required postoperative allogenic blood transfusion compared to three patients (7.7%) in the conventional group. Postoperative decrease in haemoglobin was less in the cell salvage group (2.57 vs. 3.3 g/dL). The mean length of postoperative inpatient stay was shorter in the cell salvage group (5.1 vs. 6.41 days). Three patients in the cell salvage group had adverse events (1 UTI, 1 hyponatraemia, 1 colonic pseudo-obstruction). Three patients in the conventional group experienced adverse events (2 superficial wound infections, 1 DVT). An average of 361mls of cell salvaged blood was reinfused (110–900mls).

We have found that the use of intraoperative cell salvage in patients undergoing primary total hip arthroplasty reduces the need for post operative allogenic blood transfusion with no increase in adverse events when compared to conventional measures of blood preserving techniques.

Torus (Buckle) fractures of distal radius are common in children and form a major workload of any fracture clinic. They are usually stable and do not displace. Recent evidence has shown that these fractures can be safely treated in a futura splint. In UK, many of the hospitals are still treating these patients with full plaster. Bringing back these patients to fracture clinic for plaster removal means more workload and places more financial burden in the NHS. Our study is a completed audit cycle where we successfully implemented treatment with futura splint.

Over a period of 6 months, 25 torus fractures were diagnosed & treated in A/E back slab. Mean age was 8.24 (Range: 3–12 yrs). Most common MOI was fall on outstretched hand. All cases had presented to A/E within 24 hours. 5 were given futura splint at the fracture clinic. 21 cases received full plaster. They were seen back in clinic in 3–4 weeks for plaster removal. After this audit was presented, we started treating these fractures with futura splint

Reauditing 6 months later revealed that of 31 cases, we had successfully treated 28 with Futura splint. 2 were treated with plaster on parent's insistence. The remaining one was treated in plaster as we could not fit a futura splint. There were no problems reported with futura splint.

By definition, torus fractures are stable. The major problem with these fractures lies in the correct diagnosis. We have treated this fracture successfully with futura splint. Recent papers have shown that every patient treated with futura splint saves nearly £53 when compared to plaster treatment. Implementing this treatment has reduced plaster related problems. We hope this audit will help in changing practice in other hospitals in NHS

Deep infection represents one of the most devastating complications of total knee arthroplasty. Commonly implicated organisms are gram positive bacteria such as staphylococcus aureus, staphylococcus epidermidis and group B streptococcus. Occasionally, infection may be caused by rare organisms, particularly in the immunocompromised host.

We present a case of infected total knee arthroplasty in a penicillin allergic patient, caused by Pasteurella multocida, 13 weeks after the initial surgery. This was treated by open debridement and change of insert as well as aggressive antibiotic therapy. The patient admitted contact with a cat and three dogs at home.

Pasteurella multocida is a facultatively anaerobic gram negative coccobacillus. It is a commensal in the nasopharygeal tract of domestic pets such as cats and dogs. Human infection can often be attributed to a bite or scratch. Prosthetic joint infection caused by Pasteurella is uncommon. Only a few cases have been reported in the literature.

Our case has several learning points: (1) It is very important to definitively identify Pasteurella because standard therapy for prosthetic joint infection (e.g. flucloxacillin or vancomycin) is not optimal for this species.(2) Pasteurella are susceptible to penicillin, but the optimal antibiotic therapy for infections in patients allergic to beta lactam antibiotics is uncertain. A combination of ciprofloxacin and linezolid is recommended. (3) There is no consensus regarding appropriate management. There are reports of washout and antibiotic therapy alone, single and two stage revision procedures. In our case, at five months follow up, open debridement and change of insert along with antibiotic treatment appears to have been effective, although more long term follow up is required. (4)Post arthroplasty, all patients with pets at home should be advised to seek medical attention following any bite or scratch so that timely prophylaxis can be administered before sepsis becomes deep-seated.

The thickness of the cement mantle surrounding total hip replacements has been used to predict the incidence of aseptic loosening. However little work has been done regarding the significance of the cement mantle distal to the tip of the femoral prosthesis. Results are reported of a radiographic audit study analyzing the thickness of the distal cement column in primary total hip replacement.

In this study the thickness of cement distal to the tip of the femoral prosthesis was measured from 80 post-op AP radiographs taken over a period of 5 months using both the PACS system and plain film x-rays. The mean thickness was 2cm (max 8cm) (min −1.8cm) with a std dev of 1.7cm.

This study demonstrated the wide variation in the thickness of the distal cement column achieved by surgeons. It also highlighted the fact that while 2–5mm is the generally accepted optimal cement mantle surrounding the femoral prosthesis, there is little guidance from the literature with regards the optimal thickness of the cement mantle distal to the tip of the femoral prosthesis. Further work requires to be undertaken to determine the optimal thickness of cement in this area, as well as changes in local surgical practice to ensure the optimal thickness of cement distally is consistently achieved. A re-audit of this work after alterations of surgical technique is desirable.

The surgical management of musculoskeletal tumours is a challenging problem, particularly in pelvic and diaphyseal tumour resection where accurate determination of bony transection points is extremely important to optimise oncologic, functional and reconstructive options. The use of computer assisted navigation in these cases could improve surgical precision and achieve pre-planned oncological margins with improved accuracy.

We resected musculoskeletal tumours in ten patients using commercially available computer navigation software (Orthomap 3D, Stryker UK Ltd). Of the five pelvic tumours, two underwent biological reconstruction with extra corporeal irradiation, two endoprosthetic replacement (EPR) and one did not require bony reconstruction. Three tibial diaphyseal tumours had biological reconstruction. One patient with proximal femoral sarcoma underwent extra-articular resection and EPR. One soft tissue sarcoma of the adductor compartment involving the femur was resected with EPR.

Histological examination of the resected specimens revealed tumour free margins in all cases. Post-operative radiographs and CT show resection and reconstruction as planned in all cases. Several learning points were identified related to juvenile bony anatomy and intra-operative registration.

The use of computer navigation in musculoskeletal oncology allows integration of local anatomy and tumour extent to identify resection margins accurately. Furthermore, it can aid in reconstruction following tumour resection. Our experience thus far has been encouraging. Further clinical trials are required to evaluate its long-term impact on functional & oncological outcomes.

Whilst the SIGN Guidelines state that the use of prophylactic antibiotics in surgery unequivocally reduces major morbidity, reduces hospital costs and is likely to decrease overall consumption of antibiotics they state the chosen antibiotics must reflect local, disease-specific information about the common pathogens and their antimicrobial susceptibility.

Growing healthcare concern regarding the rates of Clostridium Difficile (C. Diff) within the hospital setting have led to rationalised and better streamlined prescribing practice within the NHS. In NHS Lanarkshire this led to revised guidelines for prophylactic antibiotic use in Orthopaedics in 2010. Routine use of 3^rd generation Cephalosporin has been replaced by Flucloxacillin 1g and Gentamicin 1mg/kg.

Anecdotally the surgeons within our department were concerned that they were recognising more post-operative renal impairment than before 2010.

Our study took 902 consecutive cases treated surgically with either Total Hip Replacement, Total Knee Replacement, Dynamic Hip Screw for fracture and Hemiarthroplasty for fracture since the introduction of the new antibiotic policy. We compared this with a similar number of cases treated with the same operations pre-2010. We looked at the pre admission Urea & Electrolystes compared with immediate post-operative results and applied the definition of Acute Kidney Injury (AKI) as defined by the Acute Kidney Injury Network. A. A rapid time course (less than 48 hours) and B. Reduction of kidney function either as an absolute increase in serum creatinine of ≥26.4μmol/l (≥0.3 mg/dl) or a percentage increase in serum creatinine of ≥50%. Based on this definition we found an increased rate of AKI of 13.7% after the introduction of the use of Gentamicin from 9.8% before its routine use.

We wish to highlight that the routine widespread use of Gentamicin may be increasing the rate of acute renal dysfunction seen in Orthopaedic patients undergoing major surgery.

Local infiltration analgesia is a relatively novel technique developed for effective pain control following total knee replacement, reducing requirements of epidural or parenteral post-operative analgesia. The study aimed to investigate the anatomical spread of Local Infiltration Analgesia (LIA) used intra-operatively in total knee arthroplasty (TKA) and identify the nerve structures reached by the injected fluid.

Six fresh-frozen cadaveric lower limbs were injected with 180ml of a solution of latex and India ink to enable visualisation. Injections were done according to our standardised LIA technique. Wounds were closed and limbs were placed flat in a freezer at −20°C for two weeks. Limbs were then either sliced or dissected to identify solution locations.

Injected solution was found from the proximal thigh to the middle of the lower leg. The main areas of concentration were the popliteal fossa, the anterior aspect of the femur and the subcutaneous tissue of the anterior aspect of the knee. There was less solution in the lower popliteal fossa. The solution was found to reach the majority of the terminal branches of the tibial, fibular and obturator nerves.

Overall, there was good infiltration of nerves supplying the knee. The lack of infiltration into the lower popliteal fossa suggests more fluid or a different injection point could be used. The solution that travelled distally to the extensor muscles of the lower leg probably has no beneficial analgesic effect for a TKA patient. This LIA technique reached most nerves that innervate the knee joint which supports the positive clinical results from this LIA technique. However, there may be scope to optimise the injection sites.

This study measured the three bony axes usually used for femoral component rotation in total knee arthroplasty and compared the accuracy and repeatability of different measurement techniques.

Fresh cadaveric limbs (n=6) were used. Three observers (student, trainee and consultant) identified the posterior condylar (PCA), anteroposterior (AP) and the transepicondylar (TEA) axes, using a computer navigation system to record measurements. The AP axis was measured before and after being identified with an ink line. The TEA was measured by palpation of the epicondyles both before and after an incision was made in the medial and lateral gutters at the level of the epicondyles, allowing the index finger to be passed behind the gutters. In addition the true TEA was identified after dissection of all the soft tissues. Each measurement was repeated three times. For all axes and each observer the repeatability coefficient was calculated.

The identification of the PCA was the most reliable (repeatability coefficient: 1.1°) followed by the AP after drawing the ink line (4.5°) then the AP before (5.7°) and lastly the TEA (12.3°) which showed no improvement with the incisions (13.0°). In general the inter-observer variability for each axis was small (average 3.3°, range 0.4° to 6°), being best for the consultant and worst for the student. In comparison to the true TEA, the recorded TEA and AP axis averaged within 1.5° whilst the PCA was consistently 2.8° or more internally rotated.

This study echoed previous studies in demonstrating that palpating the PCA intra-operatively is highly precise but was prone to errors in representing the true TEA if there was asymmetrical condylar erosion. The TEA was highly variable irrespective of observer ability and experience. The line perpendicular line to the AP axis most closely paralleled the true TEA when measured after being identified with an ink line.

Frail patients with neck of femur fracture, amongst other medical problems, are frequently fast-tracked to orthopaedic wards to meet government A&E waiting time targets.

This is a second cycle of audit since 2008 examining the safety of fast-tracking following individual critical incidents. Data was collected prospectively between March and June 2011 by the first on-call orthopaedic doctor.

56 patients (12 male), average age 81.2y (50–97) were fast tracked. 52 were correctly referred as intra/extracapsular fracture, however 4 did not have a neck of femur fracture. 9 patients were transferred with no verbal referral to the receiving orthopaedic doctor. On arrival to the ward, 8 patients were found to have abnormal observations and acute medical problems requiring immediate review from the physicians. There were a total of 150 omissions from a total of 456 points from the fast track protocol. Vital observations of patients fast-tracked after 2100h were worse (MEWS range 0 to 11) when compared with those fast-tracked prior to 2100h (MEWS range 0 to 3). This occurs at a time when medical staff support is minimal.

Fast-tracking is a common practice amongst many district-general and some teaching hospitals in Scotland. These data support concerns from orthopaedic surgeons highlighting a need for more complete initial assessment and management in A&E prior to transfer to the ward. Recent evidence suggests medical optimisation of the multiple acute and chronic medical comorbidities common amongst patients with neck of femur fracture is the main facilitator of early surgery which significantly reduces post-operative mortality.

The Medial Patellofemoral Ligament (MPFL) is the main restraining force against lateral patellar displacement. It is often disrupted following patellar subluxation or dislocation. MPFL reconstruction is frequently performed when conservative management fails and the patient experiences recurrent patellar dislocation. Various MPFL reconstruction procedures have been described in the literature and reported outcomes are encouraging. This study analyses the radiographic outcomes following MPFL reconstruction.

From January 2006 to January 2011, 76 consecutive patients (80 knees) with patellar recurrent dislocation underwent medial patellofemoral ligament reconstruction in three large teaching hospitals. Mean follow-up was 31.8 months (range, 13–72). Semitendinosus and gracilis autografts were used for the reconstruction and all procedures were carried out by the senior authors (WL, BR, CW, MB).

Plain radiographs (Anteroposterior (AP), Lateral and Skyline) performed preoperatively and postoperatively were used to compare the sulcus angle, congruence angle, lateral patellofemoral angle, trochlear dysplasia (Dejour classification), trochlear boss height and patellar height (Caton-Deschamps ratio). Plain radiographs (Lateral) performed postoperatively were used to evaluate the femoral tunnel placement used for MPFL reconstruction.

The sulcus angle improved from 143.2° (122.9–157.7) to 139.3° (115.7–154.6) and the congruence angle improved from 26.7° (−17.5–82.6) to 0.26° (−35.3–7.8). The lateral patellofemoral angle was 7.99° (3.2–19.2) preoperatively and 9.02° (3.2–18.2) postoperatively. The Caton-Deschamps ratio was 1.2 (1.0–1.5) preoperatively and 1.0 (0.8–1.1) postoperatively. Using the Dejour classification of trochlear dysplasia, all preoperative radiographs were considered to be grade C or D and all postoperative radiographs were considered to be grade A or B. Trochlear boss height was 5.9mm (1.8–11.6) preoperatively and 4.7mm (1.6–6.9) postoperatively. 59% of the femoral tunnels were considered to be in a good position on postoperative radiographs.

This study displayed a significant improvement in postoperative radiographic parameters, demonstrating the importance of anatomic restoration when performing MPFL reconstruction.

In recent years there has been growing interest in enhanced recovery regimes in lower limb arthroplasty due to potential clinical benefits of early mobilisation along with cost-savings. Following adoption of this regime in a district general hospital, it was observed that traditional dressings were a potential barrier to its success with ongoing wound problems in patients otherwise fit for discharge. The aim of this audit was to assess current wound care practice, implement a potentially improved regime and re-evaluate practice.

A prospective clinical audit was performed over a three month period involving 100 patients undergoing hip or knee arthroplasty. Fifty patients with traditional dressings were evaluated prior to change in practice to a modern dressing (Aquacel™ Surgical). Fifty patients were then evaluated with the new dressing to complete the audit cycle. Clinical outcome measures included wear time, number of changes, blister rate and length of stay. Statistical comparisons were performed using Mann Whitney or Fisher's Exact test (statistical significance, p<0.05).

Wear time for the traditional dressing (2 days) was significantly shorter than the modern dressing (7 days), p<0.001, and required more changes (0 vs. 3 days), p<0.001. 20% of patients developed blisters with the traditional dressing compared with 4% with the modern dressing (p=0.028). Length of stay was the same for the modern dressing (4 days) compared with the traditional dressing (4 days). However, in the modern group 75% of patients were discharged by day 4 whereas in the traditional group this took until day 6.

This audit highlights the problems associated with traditional dressings with frequent early dressing changes, blistering and delayed discharge. These adverse outcomes can be minimised with a modern dressing specifically designed for the demands of lower limb arthroplasty. Units planning to implement enhanced recovery regimes should consider adopting this dressing to avoid compromising patient discharge.

We report the short term follow up of nineteen consecutive PFC sigma unicompartmental knee replacements carried out in our institution with minimum one year follow up. The PFC Sigma medial unicompartmental knee replacement is a fixed bearing, cemented unicompartmenal knee replacement. There are currently no published reports of follow up for the PFC Sigma medial unicompartmental knee replacement.

Nineteen patients (nineteen knees) underwent PFC sigma medial unicompartmental knee arthroplasty. The pre-operative diagnosis was osteoarthritis in eighteen patients and osteonecrosis in one patient. There were ten males and nine females with a mean age of sixty four years. All patients had clinical and radiological review at one year. All operations were carried out by the two senior authors (BPR and BL).

The mean length of admission was 2.7 days (Range 2–5). There have been no infective or thromboembolic complications to date. The mean oxford scores improved from 41 (Range 26–52) pre-operatively to 18 (15–27) at one year follow-up. The mean range of motion improved from 115 degrees of flexion preoperatively to 125 degrees. All radiographs were satisfactory at one year follow up with no evidence of loosening.

We report the promising early results of a new medial unicompartmental knee replacement with at least one year follow up. No early complications or infections were identified in our cohort of patients.

Primary bone tumours of the clavicle are rare. Currently the existing literature is limited to a single case series and case reports or cases. Information regarding the patient's demographics and tumour types is therefore limited.

The aim of this study was to investigate the and also suggest a management protocol for suspected primary bone tumours of the clavicle. We retrospectively reviewed the Scottish Bone Tumour Register from January 1971 to January 2012 and included all primary bone tumours of the clavicle.

We identified only sixteen primary bone tumours over forty one year's highlighting the rarity of these tumours. There were ten benign and six malignant tumours with a mean age of 32 years (Range 4 to 66). The average presentation to orthopaedics after onset of symptoms was two months with five patients presenting following a pathological fracture. Malignant tumour types identified were consistent with previous literature with two cases of Ewing's sarcoma and osteosarcoma and a single case of osteosarcoma post radiotherapy and a single case of chondrosarcoma. Benign tumours were treated effectively with intralesional procedures. Malignant tumours were treated with wide local excision and subtotal or total clavicle excision.

We suggest an investigatory and treatment protocol for patients with a suspected primary bone tumour of the clavicle. This is the largest series of primary bone tumours of the clavicle in the literature.

Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower-limb arthroplasty. Starting January 2011, our unit has converted from aspirin to Rivaroxaban use routinely following lower-limb arthroplasty for venous thromboembolism (VTE) prophylaxis. The aim of this audit was to retrospectively review its efficacy and the morbidity associated with its use.

All patients undergoing primary and revision lower-limb arthroplasty between February 2011 and July 2011 were reviewed. All patients undergoing total knee replacement surgery and total hip replacement surgery received oral rivaroxaban 10 mg daily post-operatively for 14 days and 35 days respectively. Outcome measures recorded were; investigation for DVT/PE, rate of DVT/PE, wound complications (infection, dehiscence, leaking, bleeding), blood transfusion rate and readmission rate within 6 weeks of surgery.

Of the 162 patients identified, 19 were excluded due to insufficient information or because they did not receive rivaroxaban as VTE prophylaxis. 141 patients (mean age 71.7 years) were included. 69 primary and 5 revision total knee replacements were performed. 60 primary and 7 revision total hip replacements were performed. 9 patients (6.4%) underwent Doppler USS for a painful swollen leg with 1 (0.7%) DVT diagnosed. None were investigated for a pulmonary embolus. 25 (17.7%) patients developed wound complications: 10 superficial infections requiring oral antibiotics, 2 deep infections requiring theatre washout, 1 wound dehiscence, 5 continuously leaking wounds, 5 bleeding wounds/haematomas. 26 (18.4%) patients required post-operative blood transfusion (average 2.2 units). 12 (8.5%) patients were re-admitted within 6 weeks with post-op complications (6 wound complications, 5 painful/swollen limbs, 1 large per-vaginal bleed).

In keeping with previous literature, the rate of VTE following lower-limb arthroplasty using rivaroxaban as prophylaxis is low. However, the rate of morbidity was higher when compared with the use of aspirin in our centre between April and September 2010.

We report the survival, functional and radiological outcome of a series of Birmingham hip resurfacing procedures performed by a single surgeon at a district general hospital. The aim of this study was to retrospectively report the medium term outcome and survival of our patients.

There were 45 hip resurfacings performed in 38 patients between 2004 and 2010. Patients were followed for a mean duration of four years. Mean age of 52.6 years (range 26 to 65). Although no patients were lost to follow up, four did not complete the oxford hip scoring assessment.

The median Oxford hip score was 16.25 points (range 12–39 points, standard deviation 5.9) at 48 months follow up (range 11.5–84.2 months). The mean acetabular inclination was 46.9 (range 40.9–59.9) in the 45 hip resurfacings post operatively.

There was one patient with varus subsidence of the prosthesis and one patient with persistent hip pain post operatively under investigation currently. There was no definite radiological evidence of loosening or of narrowing of the femoral neck. No cases were revised and no cases developed any other complications.

These medium-term results from a district general hospital are comparable to the other studies performed. Few independent studies have reported the outcome of resurfacing arthroplasty of the hip in a district general hospital. Further evaluation and follow up of these patients is required to address the concerns raised by other centers related to fracture and metal debris.

Displaced proximal Humeral fractures at Inverclyde Royal Hospital prior to 2008 were previously treated with the antegrade Acumed Polaris Proximal Humeral, predominantly in 2 part fractures. The Philos plate was introduced in 2008, initially being used to treat select non unions, and then expanded to acute fractures. The aim of this study was to assess time to union and complications in the lower volume District General setting comparing to published outcomes.

From February 2008 – January 2011, 20 patients were identified. Age range 49–75 (mean 61.2) years, 8 male; 12 female. Left 9, Right 11 Neers 2 part 35%; 3 35%; 4 30%. 16 (80%) were performed in acute fractures with 4 for non-unions, 3 of which were previous polaris nail fixations. 2 patients were lost to follow up after 6/52 but were progressing well. Union was confirmed radiologically and clinically in all but 2 remaining patients (10%), one of whom suffered a significant complication of plate fracture, the second treated with revision for painful non union. 2 other significant complications were observed: transient axillary nerve palsy and deep infection. Both of these patients recovered with delayed union observed in the infection case (52 weeks). Time to union range was 8–52 weeks (mean 17.1).

The literature shows a high failure rate of up to 45% with intramedullary nail fixation and limited predominantly to 2 part fractures with risk of damage to the rotator cuff. This study shows a satisfactory union rate using the Philos of 90% with only 3 (15%) requiring further surgery for non-union, plate fracture and infection. 3 and 4 part fractures composed 65% of case load. Early results indicate satisfactory outcomes compared to current published literature.

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

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

There was 1397 neck of femur fractures. 546 hemiarthroplasties were carried out, of which 183 were cemented, and 363 uncemented. 15 patients (4% of uncemented hemiarthoplasties) had peri-prosthetic fractures. There were no peri-prosthetic fractures in the cemented group, p = 0.004 using Fisher's exact test. The case notes of these patients were analysed. We found there was a common link of significant cardiovascular risk, lack of falls assessment (only 14% of the patients had a completed falls assessment and 21% sustained their fracture during an admission to hospital) and confusion (50% had a degree of dementia that caused significant confusion).

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

We aimed to review the outcome of Agility total ankle replacements carried out in our institution between 2002 and 2006.

Follow-up consisted of clinical and radiological review pre-operatively, then at 6 weeks, 6 and 12 months, and annually until 10 years post op. Clinical review included the American Orthopaedic Foot and Ankle Score, satisfaction and pain scores. Case notes were reviewed to determine intra and post-operative complications.

30 arthroplasties were performed in 30 consecutive patients. Pre-operative diagnosis was rheumatoid arthritis(16), primary osteoarthritis(12) and post-traumatic osteoarthritis(2). After a mean follow up of 6.2 years (1.4–10.1), 4 patients had died, and 22 out of the remaining 24 were available for follow-up. Intra operative complications included lateral malleoli fracture(3) and superficial peroneal nerve injury(2). Post operative complications included 1 early death, but this was not related to the surgical procedure. Two patients developed deep infections of the prosthesis. One underwent removal of the implant; the other is on long term oral antibiotic therapy. One patient had delayed union of the syndesmosis and six patients had non-union. On clinical assessment, patients' AOFAS scores improved from mean 40.4 pre-op to 83.5 post-op (p<0.001). Radiological assessment of the tibial component revealed 25 (93%) patients had lucency in at least one zone in the AP radiograph.

We found a relatively high level of re-surgery and complications following Agility total ankle replacement. A 7% revision rate is much higher than would be tolerated in knee or hip arthroplasty, but compares favourably to other studies of TAR. Despite radiological features which suggest loosening, the high rate of re-surgery and complications; patients are generally satisfied with the procedure, reporting lower levels of pain and improved function. Overall we feel that the Agility ankle is an acceptable alternative to ankle arthrodesis, however patients need to be warned of the risk of re-surgery.

Olecranon fractures account for 20% of elbow fractures. Displaced fractures can be treated by several methods – Tension Band Wiring (TBW), Open Reduction and Internal Fixation with a plate (ORIF) or conservative measures. Studies from UK specialist centres have demonstrated infection rates of up to 15% and metal ware removal rates of up to 80%. In addition studies have shown that conservative treatment provides a good function and pain relief in the elderly and infirm.

We aimed to look at all displaced olecranon fractures within our unit over a 4 year period and analyse their case notes for patient features, age stratification, treatment methods, complications and outcomes. We also aimed to compare our results to outcomes in studies published by specialist centres.

All olecranon fractures admitted to our unit in calendar years 2007–2010 were identified from our trauma database. Case sheets were analysed for patient's age, co-morbidities, treatment, complications and outcome. X-rays were analysed to classify the fractures and assess outcome of treatment.

71 patients were identified, Male: Female = 33:38. Age range was 7–93, mean was 62.8 years. Treatment used – TBW 42 (59.1%), ORIF 9 (12.7%), and Conservative 20 (28.2%). In the surgical group of 51 patients there were 4 infections (7.8%). There were no incidences of nerve palsy. Metalware was removed in 15 patients (29.4%) – for TBW this was 11/42 (26.25%) and ORIF 4/9 (44.4%) – however the difference was not significant (p=0.06). The conservative group had no complications.

In our study group we have demonstrated a lower infection rate and a far lower rate of metal ware removal than published studies. We have a high rate of patients treated conservatively who do well. Further work is being performed into the functional outcome of the whole group.

We present a case of a 14 year old who sustained an isolated injury to her foot while horse riding. X-rays demonstrated a medial and plantar dislocation at the level of the talo-navicular and calcaneo-cuboid joint, with associated fractures of the cuboid and navicular. This was treated initially with open reduction and fixation with kirschner wires as the injury was grossly unstable and reduction difficult to maintain with casting alone. CT scan was then performed prior which confirmed satisfactory reduction of the dislocation and fixation with the k wires so these were left in situ and the navicular fracture reduced and fixed with a barouk screw.

The Chopart joint was first described by French surgeon Francois Chopart as the talo-navicular and calcaneo-cuboid joints were a practical level for amputation. Injury here is a rare but missed in 40% at presentation. Pure dislocation occurs in 10–25% with most having concomitant fractures. The Chopart joint has critical role in balance and stability in normal gait. Early recognition allows prompt reduction and fixation of these injuries which has been associated with a better outcome. However these are severe injuries and patients should be counselled on potential long term functional impairment even with optimal management.

The aim of this study is to assess the discrepancy between weight bearing long leg radiographs and supine MRI alignment. There is currently increasing interest in the use of MRI to assess knee alignment and develop custom made cutting blocks utilising this data. However in almost all units MRI scans are performed supine and it is recognised that knee alignment can alter with weight bearing. 46 patients underwent MRI scans as pre-operative planning for Biomet signature total knee replacement and the measure of varus or valgus deformity on MRI was obtained from the plan produced by Biomet Signature software system. 41 of these patients had long leg weight bearing radiographs performed. 37 of these radiographs were amenable to measuring the knee alignment on the picture archiving and communication system (PACS). These measurements were performed by two assessors and inter-observer reliability was satisfactory. There was a significant difference between the alignment as measured on supine MRI compared with weight bearing long leg films. In knee arthroplasty one of the aims is to correct the biomechanical axis of the knee and one of the appeals of custom made cutting blocks is that this can be achieved more easily. However it is important to realise that alignment is not a static value and thus correcting supine alignment may not necessarily result in correction of weight bearing alignment.

Low back pain admission to orthopaedics, aged >55, routinely received a myeloma screen (protein electrophoresis and urinary Bence Jones proteins). Myeloma association guidelines outline the symptoms that should trigger investigation. Acute admissions for back pain alone do not form part of this.

We aimed to establish the number of emergency back pain admissions, >55, in our unit over two years. We wished to identify all patients who had protein electrophoresis and/or urinary Bence Jones proteins taken, the number of positive results and diagnoses of myeloma.

From our database all patients >55 admitted with back pain in 2009 and 2010 were identified. Using the electronic laboratory reporting system we recorded FBC/ESR/Electrophoresis/Urinary Bence-Jones Proteins.

There were 7682 admissions from January 2009–December 2010. 87 were for back pain (1.4%). 55 patients were aged >55 years. Within this group – 22 had protein electrophoresis and 23 had Bence-Jones Proteins. All were negative. 36 patients had an ESR taken, 9 were elevated. None were subsequently found to have haematological malignancy. 53 patients had an FBC taken (5 were anaemic, 8 had leucocytosis and 3 had thrombocytopenia). 20 patients had a vertebral fracture (36.4%). There were no documented cases of myeloma.

The Information & Statistics Division of NHS Scotland published figures that demonstrate in 2006–2010, in patients > 55, there were 716 new cases of myeloma in the West of Scotland. Extrapolating this to our unit, on average, we would expect 24 new cases / year in this age group from all presentations. Performing myeloma screens on all back pains does not fulfil recognised screening criteria. We propose myeloma screens are not performed routinely in patients >55 admitted with back pain. It would be reasonable to do so where there is evidence of bone marrow failure, or plasmocytoma on Xray, associated with non-mechanical back pain.

Injuries of the posterolateral corner (PLC) of the knee are uncommon, but can lead to chronic disability from persistent instability and resultant articular cartilage degeneration if not appropriately treated. Although numerous reconstructive techniques have been described in the literature, there is no consensus on a single surgical approach due to a lack of consistent, long-term clinical outcomes. Nonanatomic reconstructions, in particular, have produced variable results, while anatomic reconstructions offer the most promise by restoring normal knee stability and kinematics and are now favoured by most.

We describe the novel use of the BICEPTOR™ Tenodesis screw (Smith & Nephew) as an effective and technically straight forward means of performing a PLC reconstruction. We describe the technique and present the first 10 consecutive cases from a single surgeon series. All of the patients had a positive dial test pre-operatively with increased external rotation of 10 degrees or more at 30 degrees of knee flexion indicating clinical PLC injury. They all had the PLC reconstructed at the same time as an arthroscopic ACL reconstruction. Mean time from injury to surgery was 4 months (range 2–12). Patients were seen in clinic at maximum follow-up (11.1 months mean, range 6–24 months) and assessed clinically using the dial test at 30 and 90 degrees of knee flexion. Lysholm Knee Questionnaire and Tegner Activity Scale were also performed at maximum follow-up. Mean Lysholm Score was 68 (range 32–96). Mean Tegner Score pre-operatively was 3.5 (range 3–6) and at maximum follow-up was 4.5 (range 3–7). Of particular note only one patient reported any symptoms at all of giving way at maximum follow-up. Dial test was negative on all patients.

Further work is warranted but we describe this as an effective and straight forward means of performing a PLC reconstruction.

The number of revision knee arthroplasties performed is projected to rise dramatically in the coming years. Primary knee arthroplasties are also being performed in younger patients increasing the likelihood of multiple revision procedures. Reconstruction can be challenging with bone stock deficiencies and ligament incompetence. The aim of this study was to present our results of revision total knee arthroplasty using metaphyseal sleeve components to aid reconstruction.

Sixty seven patients underwent revision total knee arthroplasty between September 2005 and November 2010 using metaphyseal sleeves. There were thirty one male and thirty six female patients. The indication for revision was aseptic loosening in thirty nine, sepsis in fifteen, malalignment in eight and instability in five patients. Thirty four patients had tibial sleeves, thirty patients had both tibial and femoral sleeves and three patients had femoral sleeves during revision.

The patients were followed up for a mean of 32 months (Range 12–60) with outcome data collected prospectively. The mean revised oxford knee scores for the patients improved from 15 (Range 2 to 29) preoperatively to 33 (Range 20 to 45) postoperatively. Mean arc of flexion following revision was 87 degrees (Range 55 to 120). Seventy six percent of patients were satisfied or very satisfied with the result of the revision surgery. There have been no radiographic complications specific to the sleeves and no re-operations. There has been one recurrence of infection in a patient revised for sepsis. This has been managed with suppressive antibiotics due to patient co-morbidities.

Metaphyseal sleeves are an effective adjunct in revision knee arthroplasty. We have had good results with their use. To our knowledge no larger series has been presented or published.

Wrist arthrodesis is a common surgical procedure that provides a high level of functional outcome and pain relief among patients.[1] Upon partial arthrodesis, the wrist experiences changes in load transmission that are influenced by the type of arthrodesis performed. Measuring the load through the wrist joint is difficult, however, combined with computational models [2], it is possible to obtain data regarding the load mechanics of the wrist joint. Although successful fusion rates among patients have been reported, it remains unclear what the biomechanical consequences are.

The aim of the study is to quantify pre and post operative load transmission through a cadaveric wrist which has undergone simulated arthrodesis of the radiolunate(RL) joint. An embalmed human wrist was dissected dorsally exposing distal radius, radiocarpal and carpometacarpal joints, and dorsal ligaments. The radioscaphoid(RS) ligament was sacrificed to accommodate insertion of a PPSEN-09375 force sensitive resistor (FSR) into the RS joint. The FSR was calibrated prior to measuring the contact force on the RS joint.

The wrist was aligned in the neutral position in cardboard piping, and secured proximally and distally with Dental Plaster (OthoBock Healthcare Plc, Surrey, UK). The midsection of piping was windowed to permit placement of the FSR in the RS joint, and fixation of the RL joint using 2 Kirschner wires. The window was completed circumferentially and the specimen was placed in the Instron where a graduated axial compression was applied at 20 N/min.

The results showed that when the radiolunate joint is fused, and a total axial load of 100N is applied, the load transmitted through the RS joint was approx 65N. i.e. 65% of the force. This is greater than the 56% measured experimentally by Blevens et al (1989) in an unfused specimen[3]. We plan to repeat our measurements and compare to an untreated cadaveric wrist.

We compared the postoperative wound discharge rates and 3 months clinical results of three types of wound closure and dressing – 2-octylcyanoacrylate with Opstie (G+O), 2-octylcyanoacrylate with Tegaderm (G+T), and Opsite without 2-octylcyanoacrylate (O) in patients having primary total hip arthroplasty.

We randomised 141 patients scheduled for primary total hip arthroplasty into 3 arms of this study- G+O, G+T, or O. The extent of wound discharge was recorded on a diagrammatic representation of the dressing in situ on paper and graded each day. Dressings were left in-situ provided the extent of wound discharge allowed for this. The patient was clinically reviewed at 3 months to assess their scar length, cosmesis, scar discomfort, and evidence of superficial or deep wound sepsis.

A greater number of patients dressings remained dry on day 1 postoperatively in the two groups with 2-octylcyanoacrylate compared to the no glue group p=0.001. G+T group had a significantly lower proportion of patients with increased leakage of wounds on 2^nd postoperative day p=0.044. At 3 months review, there was no statistical difference in the Hollander score or scar discomfort.

In patients who have had primary total hip arthroplasty, usage of 2-octylcyanoacrylate for wound closure along with Tegaderm dressing reduces wound discharge. The same effect is not noted in glue with Opsite group. Whilst dressing changes required in the non-glue group compared from the two glue groups did not reach statistical significance, this may have clinical relevance for patients and nursing staff. No effect on postoperative length of stay, or wound complications was noted.

Single shot interscalene blocks are an effective analgesic for arthroscopic shoulder surgery. However, patients receiving these blocks are often found to be in significant pain when the block wears off, usually in the late evening or early hours of the morning. Overnight admission is currently routine in our unit, to ensure adequate analgesia can be administered during this period. Recent studies have suggested that adding dexamethasone to the local anaesthetic agent can prolong the duration of the block. We carried out a prospective study to assess whether addition of dexamethasone to brachial plexus blocks could reduce patient's post-operative analgesic demands and allow safe discharge on the same day after surgery.

Twenty-six patients undergoing arthroscopic shoulder surgery during a morning theatre list, had ultrasound guided brachial plexus blocks using a mixture of 0.25% bupivacaine 20–30ml with 2–3mg of dexamethasone. All were admitted to the ward afterwards for analgesia and physiotherapy. Pain numerical rating scores (0–10) were recorded at rest in recovery one hour postoperatively by the attending anaesthetist and on active movement of the shoulder joint 24 hours after surgery by the attending physiotherapist. A standardised analgesia regime was prescribed with regular and as required medication, including as required strong opiates.

Mean pain scores in recovery were 0.31 and on the morning after surgery were 2.38. Sixteen out of 26 required no further analgesia, with only 3 out of the 10 who did requiring opiates.

The use of dexamethasone provides adequate analgesia for a prolonged period for most patients after brachial plexus block for shoulder surgery and does not result in a significant analgesic requirement when the block wears off. This may provide support for avoiding overnight admission in selected patients after arthroscopic shoulder surgery.

Although most peripheral nerve sheath tumours are benign, some are malignant. The management of malignant tumours usually involves wide excision and is facilitated by knowledge of the diagnosis prior to operation. Imaging modalities, including MRI, give anatomical information but do not distinguish between benign and malignant nerve tumours. We therefore introduced the use of ultrasound guided needle biopsy for suspected nerve tumours to our unit in 2004. Prior to this, excision biopsy was carried out in all cases. We aimed to review our experience with needle biopsy and determine whether it has an effective role in the management of peripheral nerve tumours.

All patients who had a needle biopsy for suspected peripheral nerve tumours from January 2004 to December 2011 were identified from our tumour database and clinical notes reviewed. In all cases, biopsy was carried out under ultrasound guidance with local anaesthesia to obtain a 1mm core of tissue.

From 25 patients reviewed, 21 (84%) had a successful biopsy. In 3 cases the biopsy was unable to be completed due to pain and in 1 patient insufficient tumour tissue was obtained. 1 patient had a temporary radial nerve palsy following needle biopsy which recovered fully.

In biopsies that were successful, 19 (90%) showed a benign peripheral nerve tumour. Following diagnosis of a benign lesion, only 2 patients required to have surgical excision of the tumour due to pain. The remainder were managed non-operatively.

In the 2 cases of malignant tumours detected by biopsy, a successful wide surgical excision was performed.

Ultrasound guided core needle biopsy appears safe and gives a tissue diagnosis in most cases of suspected peripheral nerve tumours. In malignant cases it facilitates surgical planning, while most benign tumours could be managed non-operatively, therefore avoiding potential complications of nerve surgery.

This case report describes a patient with thoracic plasmacytoma, an uncommon haematological malignancy, who presented with neck pain. Plasmacytoma is a neoplastic proliferation of B cell lineage but is much less common than multiple myeloma. The histological examination of multiple myeloma and plasmacytoma is identical however in plasmacytoma there is a solitary lesion with negative skeletal survey, negative bone marrow aspirate and little or no myeloma protein detected in the blood. This makes it more challenging to diagnose and a high index of suspicion is required.

There is continued concern over complication rates (20–30% of cases) in locked proximal humeral plating. The most common sequelae of this is screw penetration of the humeral head. This is associated with natural settling of the fracture, malreducition in varus, insufficent medial support of the fracture. The proximity of the screws to the articular surface can also be influential on outcome if collapse occurs. Our operative technique is to establish the rotation of the humeral head where the drill appears closest to the articular margin (by sequential xray screening) and subtract from this to avoid intra-articular penetration of the humeral head.

55 Consecutive patients of average age 56.4 years (14.7–86.1), 17 male and 38 females, who underwent PHILOS plating were identified using Bluespier database. Xrays were analysed for fracture pattern, restoration of neck-shaft angle, plate positioning, number and configuration of screws and presence of screw penetration both intra-operatively and at postoperative follow-up.

There were 6.07 screws used per head (total 330). There was one intraoperative screw penetration and 3 patients had evidence of screw penetration at follow-up, which required implant removal (total screw penetration rate of 7%). There was one case of AVN. The mean neck shaft angle was 137 degrees (anatomical 135 degrees).

Accurate reduction of fractures and placement of screws in the humeral head using image intensifier can act to minimise risk of screw penetration and make some of the complications of locked proximal humeral plating avoidable.

There has not been any published work quantifying the volume cement used/needed for knee arthroplasty. The number of mixes of cement used is at the discretion of the surgeon, based on their own experience/training.

The objective of this study was to quantify the volume of cement used for knee arthroplasty in our institution, and to observe variations between surgeons and implant size. The study then aimed to calculate the theoretical volumes required and observe the volume of cement actually implanted before commenting on cost implications of cement usage.

Prospective data for 85 consecutive knee arthroplasties performed by 9 consultants was examined. A single mix in this institution refers to 40g of Palacos R+G. Significant variation between surgeons was seen, with a range of one to three mixes being used. Several surgeons used one mix exclusively, independent of implant size, whilst others exclusively used two mixes. The departmental average was 1.4 mixes per knee. The total surface area of our largest implants (Size 8 Triathlon Femoral and Tibial components) was measured-108cm² and compared to the volume of a single mix of cement −49 cm³. Even using the largest component size, a single mix will provide 4.5mm of uniform cement coverage. The volume of cement actually implanted during 10 knee arthroplasties was examined by weighing the residual cement. The average volume of cement implanted was 18cm³ per knee.

In 2009 1085 knee replacements were performed in this institution. If all surgeons in the department used a single mix of cement this could potentially save £16,357.46 per year. (Presuming average usage was 1.4 mixes per knee, 434 ‘extra’ mixes were used, costing £37.69 each) We conclude that a single mix of cement will cover the area required for all Triathlon implants and that less than half a mix (on average) is actually implanted.

It is widely accepted that a tip apex distance of greater than 25mm is associated with dynamic hip screw (DHS) failure and cut-out. The aim was to devise an accurate and easy method for calculation of DHS tip apex distance (TAD) from intraoperative imaging using the tools available on Kodac Picture Archiving and Communications System. This method was applied to all patients treated with a DHS for intertrochanteric hip fracture during a six month period. Any subsequent radiographs were assessed for evidence of failure within 18 months.

The TAD was calculated using a modification of a previously described method using a similar imaging system (Johnston et al, Injury 2008) which has been shown to be accurate and reproducible. Scaling was based on the 12.5mm thread diameter of all Synthes (Switzerland) DHS screws.

60 patients underwent a DHS during the study. Nine patients were excluded who had an additional method of fixation or an intracapsular fracture. Four patients had insufficient xrays for analysis. Data was gathered for 47 patients and showed a mean TAD of 17mm (range 8.2–30.6mm). Three patients had a TAD greater than 25mm. 22 patients had a post-operative xray within 18 months. There were two cut-outs identified and both were from patients with a TAD of greater than 25mm (25.7 and 30.6mm). No incidences of implant failure or complications were identified for patients with acceptable TADs.

93.6% of screws were therefore inserted satisfactorily. Two out of the three patients with a TAD greater than 25mm had xray evidence of screw cut-out. This study supports previous evidence that a DHS lag screw should be positioned with a TAD within 25mm and a distance greater than this is associated with screw cut-out. TAD can be easily calculated using intraoperative xrays and scaled using the screw itself.

Osteogenesis is key to fracture healing and osteointegration of implanted material. Modification of surfaces on a nanoscale has been shown to affect cell interaction with the material and can lead to preferential osteogenesis. We hypothesised that osteogenesis could be induced in a heterogeneous population of osteoprogenitor cells by circular nanopits on a material surface. Furthermore, we intended to assess any correlation between nanopit depth and osteoinductive potential.

The desired topographies were embossed onto polycaprolactone (PCL) discs using pre-fabricated nickel shims. All pits had a diameter of 30μm and investigated pit depths were 80nm, 220nm and 333nm. Scanning electron microscopy confirmed successful embossing and planar controls were shown to be flat. A bone marrow aspirate was obtained from the femoral neck of a healthy adult undergoing a hip replacement. After establishing a culture, cells were seeded onto the PCL discs, suspended in basal media and incubated. Samples were fixed and stained after three and 28 days.

Cells were stained for the adhesion molecule vinculin after three days. Lowest concentrations of vinculin were seen in the planar control group. Osteoprogenitor cells on the shallowest pits, 80nm, had larger and brighter adhesion complexes. After 28 days, osteocalcin and osteopontin expression were used as markers of cell differentiation into an osteoblastic phenotype. 220nm deep pits consistently produced cells with the highest concentrations of osteopontin (p = 0.017) with a similar trend of osteocalcin expression. Cells on all topographies had higher expression levels than the planar controls.

We demonstrated stimulation of osteogenesis in a heterogeneous population of osteoprogenitor cells. This cell mix is similar to that present in fracture healing and after reaming for intramedullary devices or uncemented implants. All nanopit depths gave promising results with an optimum depth of 220nm after 28 days.

Deep surgical infections are a serious complication of total knee arthroplasty (TKA). Various protocols exist for treating these infections, each with its own advocates. In this series we report the one to five year follow-up of infected TKA that were treated with a two-stage revision knee replacement at the Glasgow Royal Infirmary between December 2003 and March 2009.

48 patients were identified from the hospital database. 6 of these were excluded as they did not meet the stipulated infection criteria. Another patient was excluded as no notes were available thereby the infection status could not be determined. Another 8 patients were excluded as these only had a first stage.

33 patients (16 male) average age 67y (49–88) met the inclusion criteria. Mean BMI was of 31.62 (19–47) and 8 patients suffered from rheumatoid arthritis. At presentation, the median for the ESR, CRP and WCC were 70.5, 133 and 8.5 respectively. The infective organism was identified in 22 patients. Following the first stage, the patients were treated with antibiotics (initially intravenous followed by oral) for an average of 11.8 weeks (4–52 weeks). This procedure failed to eliminate the infection in 6 patients (18.18%) who had further re-admissions for infection of the affected prosthesis. The resultant success rate is of over 80% which is comparable to literature data (success rates of 41% to 96% quoted). For these patients, the average time to review was 25.13 months (12–67months). At review these patients had a mean extension of 2.17° (0–10°) and a mean flexion of 98.26 (70–120°). These patients were all satisfied with their outcome.

Our results show a high successful rate of elimination of infection when a two-stage revision is used for infected knee prosthesis with over 80% of patients free of infection.

The Columbus is a relatively new implant with no published medium or long term follow-up. Its extensive use within our department led to this study to review the five-year clinical outcomesof patients who had a navigated Columbus primary total knee arthroplasty (TKA) implanted between March 2005 and December 2006.

Case notes, departmental and hospital databases and PACS were used to identify patients and collect routine five-year review data. Information Services Division was approached for all cases of re-admission and associated complications anywhere in Scotland.

219 (90 male, 116 left) patients were identified. Mean age was 69 years (48–89) and mean BMI 32.2 (SD 5.8). Of the 219 patients operated on, twenty-one had a complication; ten still had intermittent mild to moderate pain, three had wound problems, one had a washout, one had DVT/PE within ninety days and one was diagnosed with patellar clunk syndrome. The remaining five patients had revision TKA (revision rate 2.3%), four for infection and only one due to aseptic loosening (revision rate excluding infection 0.5%). 115 patients returned to clinic at five years. Of these 96.4% were satisfied with their operation. The mean Oxford knee score had reduced from 42.5 (SD 8.2) pre-operatively to 23.6 (SD 9.2). Mean fixed flexion was 1° (SD 2.8°, range 0° to 15°) with four patients having a fixed flexion of 6° or more. Mean maximum flexion was 100° (SD 10.2°, range 60° to 120°) with two patients having flexion less than 80°. X-ray analysis showed that fourteen patients had a radiolucent line. Nine of these were not present at one year, six being at the tibial component.

These results are satisfactory. The revision rate is similar to that cited by the National Joint Registry report 2011 (2.5%). Furthermore, the revision rate excluding infection is very low.

Acetabular retractors have been implicated in damage to the femoral and obturator nerves during total hip arthroplasty (THA). Despite this association, the anatomical relationship between retractor and nerve has not been elucidated.

A posterior approach to the hip was carried out in 6 fresh frozen cadaveric hemi- pelvises. Large Hohmann acetabular retractors were placed anteriorly over the acetabular rim, and inferiorly, as per routine practice in THA. The femoral and obturator nerves were identified through dissection and their relationship to the retractors was examined.

If contact with bone was not maintained during retractor placement, the tip of the anterior retractor had the potential to compress the femoral nerve, by passing either superficial to, or through the bulk of the iliopsoas muscle. If pressure was removed from the anterior retractor, the tip pivoted on the anterior acetabular lip, and passed superficial to iliopsoas, overlying and compressing the femoral nerve, when pressure was reapplied. The inferior retractor pierced the obturator membrane, medial to the obturator foramen in all specimens. Subsequent retraction resulted in the tip moving laterally to contact the obturator nerve.

Both the femoral and obturator nerves are vulnerable to injury around the acetabulum through the routine placement of retractors in THA. The femoral nerve is vulnerable where it passes over the anterior acetabulum. Iliopsoas can only offer protection if the retractor passes deep to the muscle bulk. If pressure is removed from the anterior retractor intra-operatively it should be reinserted. The obturator nerve is vulnerable as it exits the pelvis through the obturator foramen. Vigorous movement of the inferior retractor should be avoided. Awareness of the anatomy around the acetabulum is essential when placing retractors.

The Exeter Trauma Stem (ETS) is a monoblock unipolar prosthesis currently in use throughout various orthopaedic departments. It can be a useful procedure for specialty trainees in developing modern cementation techniques in hip arthroplasty. We propose that in order for this procedure to be a valid training tool that, as well as having a standardized surgical approach and operative technique, outcomes should be easily assessed and should be similar if performed by either a trainee or consultant.

All ETS procedures carried out at our institution from January 2009 until September 2011 were reviewed retrospectively. Patient demographics and operative details were recorded from patient notes. Radiographic evaluation involved the Barrack cementation grading system, Dorr's criteria, stem alignment and leg length measurement.

There was no significant difference in operative time between ETS performed by consultant or by specialty trainee. On postoperative x-ray, cement mantles were Barrack grade A or B in 55.6% (trainees) versus 61.9% (consultants). Stem alignment was neutral in 50% and varus in 50% of cases for trainees, versus 28.6% and 71.4% of cases for consultants. In total, 69.2 % of patients had lengthening of the operated limb with a mean increase of 10.4mm (2–25) for trainees and 9.3mm (2–18) for consultants.

Both trainees and consultants can attain a good cement mantle. However, from our results stem alignment is less accurate by trainees with half being placed in varus. Our results highlight the difficulty of obtaining correct leg length positioning with the ETS with trainees and consultants having similar discrepancies.

The ETS is a useful procedure for orthopaedic trainees to attain adequate skills in modern cementation techniques with similar post-operative radiographic outcomes to consultants. The tendency for trainees to be less accurate with stem positioning could be improved with supervision or careful pre-operative templating.

Neurological examination is essential in patients with upper limb injuries and should be clearly documented. We aimed to assess the quality and documentation of neurological examination performed for children presenting with upper limb fractures to the emergency department.

Clinical notes of all children admitted with upper limb fractures over a three month period were reviewed. Documentation of initial neurological assessment was analysed and clinical suspicion of any nerve injury noted. In parallel, we conducted an anonymous survey of emergency doctors evaluating their upper limb neurological examination in children.

The casenotes of 121 children with upper limb fractures were reviewed. 10 children (8%) had a nerve injury (median = 4, ulnar = 2, radial = 2, anterior interosseous = 2). Neurological examination was documented in 107 (88%) of patients. However, none of the nerve injuries were detected on initial examination. In patients with nerve injuries, 5 (50%) were documented as being ‘neurovascularly intact’, 2 (20%) as ‘CSM normal’, 1 (10%) as ‘moving fingers’ and 2 (20%) had no documented neurological examination.

30 emergency doctors completed the questionnaires (5 consultants, 9 registrars, 16 foundation doctors). All doctors stated that they routinely performed an upper limb neurological examination and assessed median, ulnar and radial nerves. However, 30% of doctors described incomplete examination of median nerve function, 30% inadequate ulnar nerve assessment and 50% incomplete radial nerve examination. In addition, 75% of doctors failed to identify the need for assessment of anterior interosseous nerve function.

While emergency doctors recognise the importance of neurological assessment in children with upper limb injuries, it is often performed inadequately. This in part may be due to difficulties performing neurological examination in paediatric patients. As a result of this study, we have introduced local guidelines to assist neurological assessment in children.

Bone cutting produces heat which macroscopically leads to charring and the formation of bone dust. As part of a project to design a novel bone cutting device, we studied the extent of histological thermal damage from bone cutting with different cutting blades.

Three blades were used: a bone hacksaw made in the nineteenth century which was used for amputation, a sagittal saw blade made by Ortho Solutions, and a sagittal saw blade made by Stryker. Sheep femurs were harvested from recently euthanised animals and cuts were made with these three devices, producing ring-shaped bone specimens. Specimens were immediately stored in formaldehyde, decalcified, and stained with hematoxylin and eosin. The edge of the specimens was then photographed microscopically, and the images examined with the computer programme Axiovision (Carl Zeiss AG, Oberkochen, Germany). Visual examination allowed identification of live and dead osteocytes, and also to measure their depth from the surface.

A minimal of 7 images was obtained per blade. The hacksaw specimens had the highest percentage of live osteocytes (n=214, 59.8%), and with the shortest average depth where live osteocytes were located (169μm, SD 78.15). In comparison, the percentage of live osteocytes for the Ortho Solutions (n=156, 17.4%) and Stryker (n=168, 29.5%) blades were much lower. The difference in average depths where live osteocytes were located was statistically significant between the three groups (p < 0.001). The average depths of dead osteocytes were shallowest for the Stryker (115μm, SD 67.56) and hacksaw (118.28 μm, SD 75.16) groups with no statistical difference between them.

In conclusion the hacksaw appeared to produce the least thermal damage histologically during cutting. The results reflect a relationship between certain features in cutting blade designs and the extent of thermal damage. Future experiments to directly measure heat produced during cutting are planned.

Magnetic resonance imaging (MRI) continues to become more widely accessible as an investigation, with an increasing number of scans being performed in the outpatient setting for suspected shoulder pathology.

We performed a retrospective review of all shoulder MRI scans performed in an orthopaedic outpatient setting in a district general hospital between October 2010 and October 2011. We also reviewed the medical notes for these patients. 75 MRI Shoulder scans were performed on 74 patients. In 5 cases (7%), no other form of imaging was performed prior to MRI scan. 11 patients (15%) had no provisional diagnosis included in the referral. The nature of referral, indication for MRI and subsequent management of these patients was also examined.

Our findings may support the use of guidelines for requesting MRI scans of the shoulder in outpatients.

3D printing and rapid prototyping in surgery is an expanding technology. It is often used for preoperative planning, procedure rehearsal and patient education. There have been recent advances in orthopaedic surgery for the development of patient specific guides and jigs. The logical next step as the technology advances is the production of custom orthopaedic implants.

I aimed to use freely available open source software and online cloud 3D printing services to produce a patient specific orthopaedic implant without requiring the input of a university department, specialised equipment or implant companies.

Using standard CT scan DICOM data, a 3D surface reconstruction was made of a patient's uninjured radial head using open source DICOM viewer OsiriX. This was then manipulated in other open source software packages called Meshlabs and Netfabb to create a mirror image 3D model of the radial head with a stem to produce a prosthesis suitable to replace the contralateral fractured radial head. This was then uploaded and printed in stainless steel via cloud printing service Shapeways.com.

The model produced was an exact replication of the patient's original anatomy, except a mirror image suitable for replacement of the contralateral side. The process did not involve any specialist equipment or input from an academic department or implant company. It took a total of 10 days to produce and cost less than £40.

From this study I was able to show that production of patient specific orthopaedic implants is possible. It also highlights that the technology is accessible to all, and does not require any special equipment or large investment. It can be achieved quickly and for a very small financial outlay. As a proof of concept it has been very successful.

Reconstruction of severe acetabular defects during revision hip arthroplasty presents a significant surgical challenge. Such defects are associated with significant loss of host bone stock, which must be addressed in order to achieve stable implant fixation. A number of imaging techniques including CT scanning with 3D image reconstruction are available to assist the surgeon in the pre-operative planning of such procedures.

We describe the use of a novel technique to assist the pre-operative planning of severe acetabular defects during revision hip arthroplasty.

Patient and Methods – We present the use of this technique in the case of a 78 year old patient who presented 20 years from index procedure with severe hip pain and inability to weight bear due aseptic loosening of a previously revised total hip arthroplasty. A Paprosky 3B defect was noted with intra-pelvic migration of the acetabular component. Pre-operative investigations included: inflammatory markers, pelvic CT scan with 3D reconstruction, pelvic angiography and hip aspiration.

Using DICOM images obtained from the CT scan, we used free open source software to carry out a 3D surface render of the bony pelvis. This was processed and converted to a suitable format for 3D printing. Using selective laser sintering, a physical 3D model of the pelvis, acetabular component and proximal femur were produced. Using this model the surgeon was able to gain an accurate representation of both the position of the intra-pelvic cup and more accurately assess the loss of bone stock. This novel technique is particularly useful in the pre-operative planning of such complex acetabular defects in order to determine if/which reconstruction technique is most likely to be successful.

3D printing is a relatively recent technology, which has numerous potential clinical applications. This is the first reported case of this technology being used to assess acetabular defects during revision hip arthroplasty. The use of this technology gives the surgeon a 3D model of the pelvis, quickly (7 days from CT) and at a tenth of the cost (£280) of producing such a model through the traditional commercial routes. The model allowed the surgeon to size potential implant, quantify the amount of bone graft required (if applicable) and to more accurately classify the loss of acetabular bone stock.