It is well recognised that patients with diabetes mellitus have a predisposition towards stenosing flexor tenosynovitis (FTS). However, recent research has suggested an association between the development of FTS and haemoglobin A1c (HbA1c) level which is used as a marker of glycaemic control. National guidelines on management of diabetes suggest treatment should aim to maintain HbA1c at <6.5%.

The aim of our study is to quantify glycaemic control in patients undergoing surgical A1 pulley release.

We retrospectively reviewed the blood results of 78 patients who underwent FTS surgery. 27 of these had an HbA1c checked within 6 months of their surgery and we therefore presumed these patients were diabetic. For diabetic patients the average HbA1c was 7.9% (range 5.3–11.4) and only 7 of the 27 patients had an HbA1c within the recommended range.

In this cohort 33% of patients were presumed diabetic and 74% of these had a documented HbA1c above the national target suggesting a significant number presenting for surgery have poor glycaemic control. Therefore it may be of benefit to screen for this in patients undergoing FTS surgery.

Polyetheretherketone (PEEK) is a thermoplastic polymer that is predominant in spinal surgery as the material of choice for spinal fusion cages, and is also used for bone anchors, cruciate ligament interference screws, and femoral stems. It has the distinct advantage of having similar mechanical properties to bone, but its clinical application as implant material is limited by a lack of bioactivity. This project aims to create an PEEK surface capable of osseointegration using a surface modification technique known as oxygen plasma treatment.

PEEK surfaces were injection molded, washed and then treated in a plasma chamber for up to 10 min. Surfaces were characterised using atomic force microscopy (AFM), scanning electron microscopy (SEM), water contact angle measurements and X-ray photo-electron spectroscopy (XPS). Human bone marrow cells were cultured on the surfaces and assessed for calcium production (using alizarin red stain).

Water contact angle measurements show that after plasma treatment, the surfaces become very hydrophilic, before developing a meta-stable state at approx. 6 weeks. AFM and SEM showed destruction of the nano-pits at treatment durations longer than 2 mins. XPS detected a progressive increase in the atomic proportion of oxygen at the surface with increasing plasma treatment duration. There was significantly less alizarin uptake (and hence calcium production) on the untreated PEEK compared to the plasma treated PEEK surfaces (p < 0.05).

These results show that oxygen-plasma treatment can increase calcium production on PEEK surfaces and may improve long term osseointegration of PEEK implants.

Neurological examination in children presenting with upper limb fractures is often poorly performed. In the peripatetic emergency department environment this may be confounded by patient distress or reduced comprehension. We aimed to assess the quality of documented neurological examination in children presenting with upper limb fractures and whether this could be improved following introduction of a simple guideline for paediatric neurological assessment.

We reviewed the clinical notes of all children presenting to the emergency department with upper limb fractures over a three month period. Documentation of initial neurological assessment and clinical suspicion of any nerve injury were noted. Subsequently, we introduced a guideline for paediatric upper limb neurological examination (‘Rock, Paper, Scissors, OK’) to our hospital and performed a further 3 month review to detect resulting changes in practice.

In the initial study period, 121 children presented with upper limb fractures. 10 (8%) had a nerve injury. Neurological examination was documented in 107 (88%) of patients. However, information on nerves examined was only recorded in 5 (5%) with the majority (85%) documented as ‘neurovascuarly intact’. None of the nerve injuries were detected on initial assessment.

Following guideline introduction, 97 patients presented with upper limb fractures of which 8 children (8%) had a nerve injury. Documentation of neurological examination increased to 98% for patients presenting directly to our own hospital (Fisher's Exact Test, p=0.02) with details of nerves examined increasing to 69%. Within this cohort all nerve injuries with objective motor or sensory deficits were detected on initial examination.

The recent British Orthopaedic Association Standards for Trauma (BOAST) guideline on peripheral nerve injuries emphasises the importance of clearly recorded neurological assessment in trauma patients. Our study shows that introduction of a simple guideline for neurological examination in children with upper limb fractures can significantly improve the quality of documented neurological assessment and detection of nerve injuries.

Repeat revision hip replacements can lead to severe bone loss necessitating salvage procedures such as proximal or total femoral replacement. We present medium term outcomes from our experience of the Limb Preservation System (LPS) in patients with failed revision hip arthroplasties.

All patients undergoing proximal femoral or total femoral replacement from 2003–2007 at our unit were reviewed. Data was collected preoperatively and at annual assessment post procedure for a minimum of 5 years. This included clinical review, functional outcome scores (WOMAC, Oxford Hip Score, Harris Hip Score) and radiographic evaluation.

A total of 17 patients underwent femoral replacement (13 proximal, 4 total) using the LPS during the study period. Within this cohort there were 13 males and 4 females with a mean age of 64 years (range 47–86). Median follow up was 7 years (range 5–9 years). Primary diagnoses were DDH (7), Primary OA (5), RA (2), proximal femoral fracture (2) and phocomelia (1). Five patients (29%) required further revision surgery for infection (2 patients) or recurrent dislocations (3 patients). No stems required revision due to aseptic loosening or stem failure at 5–9 years. Compared to preoperative assessment, there was significant improvement in median outcome scores at 5 years (WOMAC increased by 33 points, Oxford hip score by16 points and Harris hip score by 43 points). 82% of patients maintained functional independence at latest review.

The Limb Preservation System offers a salvage procedure for failed revision total hip arthroplasty with significant symptom and functional improvement in most patients at medium term follow up.

Staged bilateral total knee arthroplasty is performed increasingly frequently but no data has been published comparing the specific outcome for the first knee replacement to that of the second.

Pre-operative and post-operative Oxford Knee Scores (/ 48) were reviewed for each knee in a series of 91 patients undergoing staged bilateral total knee arthroplasty over a 5-year period.

Pre-operative scores for the first total knee arthroplasty were significantly worse with a mean of 14.9 in comparison to 17.0 for the second knee (P=0.0083). While there was no significant difference between the mean post-operative scores for the first knee (37.4) and the second knee (36.6) (P=0.195), the mean improvement was significantly less for the second knee (22.6 points versus 19.6 points) (P=0.0045).

Our results demonstrate that in patients undergoing staged bilateral knee arthroplasty, the second knee replacement is commonly performed at a lower threshold and functional improvement is less than for the first knee. This data will be important to inform the expectations of patients considering proceeding to bilateral knee arthroplasty after previously having undergone a primary total knee replacement.

Patient reported outcome measures (PROMs) are important for assessing the results of lower limb arthroplasty. Unrealistic or uneducated expectations may have a significant negative impact on PROMs even when surgery is technically successful. This study's aim was to quantify pre-operative expectations of Scottish patients undergoing total hip and knee replacement (THR/TKR).

100 THR and 100 TKR patients completed validated questionnaires (from the Hospital for Special Surgery) prior to their operation after receiving standard pre-operative information (booklet, DVD, consultations). Each patient rated expectations from very important to not having the expectation. A total score was calculated using a numerical scale for the grading of each expectation. Univariate regression analysis was used to investigate the relationship between demographics and expectation score.

The THR cohort had mean age 66.2 (SD 10.5), 53% female, mean BMI 29.0 (SD 5.1) and mean Oxford score 44 (SD 7). The TKR cohort had mean age 67.6 (SD 8.5), 59% female, mean BMI 32.8 (SD 5.8) and mean Oxford score 44 (SD 8). 100% THR and 96% TKR patients had 10 or more expectations of their operation. All expected pain relief. Other improvements expected were: walking for 100% THA and 99% TKA patients; daily activities for 100% THAs and 96% TKAs; recreational activities for 96% THAs and 93% TKAs; sexual activity for 66% THAs and 59% TKAs; psychological well-being for 98% THAs and 91% TKAs. Regression analysis showed increasing age lowered expectations in both THR (p=0.025) and TKR (p=0.031) patients but that gender, BMI and Oxford score were not significantly related to expectations.

This study highlights that patients expect far more than pain relief and improved post-operative mobility from their operation. It is important to discuss and manage these expectations with patients prior to surgery. By doing so, patient satisfaction and PROMs should further improve.

The long-term clinical and radiological results of 63 uncemented Low Contact Stress (LCS) total knee replacements in 47 patients with rheumatoid arthritis were reviewed. The average age at the time of surgery was 69 years (53–81). At a mean follow up of 22 years (20–25), 12 patients (17 knees) were alive, 27 (36 knees) had died, and 8 patients (10 knees) were lost to follow-up.

Revision was necessary in seven patients (7 knees) (11.1%) at mean 12.1 years following surgery. Four revisions were performed due to meniscal bearing wear, two for collapse of the tibial component, and one for aseptic loosening. Evidence of post-operative infection occurred in two knees (3.2%) within 6 weeks of surgery but resolved with antibiotics. Within the group of deceased patients, five had undergone revision (included in total revisions) but otherwise the primary implant remained in vivo.

For all living patients, the mean Oxford Knee Score (/48) was 30.2 (16–41) at latest follow up at mean 19.5 years (15–24.7) following surgery. Mean active flexion was 105 degrees (90–150) at this time point.

Our recorded survival rate of the uncemented LCS total knee replacements in patients with rheumatoid arthritis was therefore 88.9% at mean 22 years, or worst-case survival of 73.0% if patients lost to follow-up were considered failures. From a review of the literature and as far as we are aware, this study represents the longest follow up of any uncemented knee arthroplasty performed in a cohort of patients with rheumatoid arthritis.

Post-operative pain is well recognised in patients undergoing shoulder surgery. With the recent advances in arthroscopic shoulder surgery over the last decade, a larger number of cases are being performed in day surgery units. These procedures are generally performed under general anaesthetic with either an interscalene or suprascapular nerve block or local anaesthetic infiltration.

The aim of our prospective audit was to investigate the adequacy of analgesia provided for patients, undergoing day case arthroscopic shoulder procedures in a rural district general hospital, to ensure best medical care and to tailor certain procedures to appropriate analgesic pathways in the future.

Fifty consecutive patients, who underwent day case arthroscopic shoulder surgery, were contacted by telephone one week post surgery, to assess their post-operative pain scores and analgesic requirements.

Patients who received a nerve block were found to have a significantly longer duration of pain relief (p < 0.001). These patients also had significantly less pain performing their usual activities of daily living in the immediate post-operative period (p = 0.05), compared to patients who only had local anaesthetic infiltration. There was no trend found between the type of procedure and post-operative pain scores.

Our audit has confirmed that nerve blocks provide longer pain relief, but has also highlighted the need to take into consideration pre-operative pain and pain perception to enable analgesia to be tailored.

Recent projections expect the number of revision knee replacements performed to grow from 38,000 in 2005 to 270,000 by the year 2030¹. Although the results of primary total knee arthroplasty are well documented, with overall implant survivorship at 15 years greater than 95%² the results of revision procedures are not as well known. What if the revision TKR fails and what is the prevalence of failure of revision TKRs, the complications and re-operation rates? There are various studies which has either exclusively dealt with the causes or outcomes of revision with a particular prosthesis and survivorship analysis. The effectiveness of revision total knee replacement must be considered in the light of complications rates which could be either medical, orthopaedic surgery related complications or combination of both.

The purpose of this study was to evaluate the prevalence of complications, reoperation rates and outcomes in a single surgeon's series between 1984 and 2008.

Ninety nine index revision cases were studied. Incidences of surgical complications were 52.5%. The total reoperation rate was 34.3% whilst single re revision accounted for 19.9% whereas multiple re-revision incidences were 4%. The mean outcome in terms of Knee Society Score, Knee Society Function, and Knee society range of motion was statistically and clinically significant between pre operative and posts operative score at one year and remained consistent with time. These results suggest that modern revision total knee replacement are satisfactory operations and the outcomes perhaps can be improved if relatively simple strategies are followed by focusing these operations to specialized that accumulate enough experience from these demanding surgeries. Overall the results asserts that even in the hands of an experienced surgeon the complications do occur which is usually multi factorial, whilst in the light of complications and reoperation incidence the patients can be counselled thoroughly before the procedure.

Knee osteoarthritis is common, disabling and can be effectively treated by total knee arthroplasty (TKA). In North America, consideration has been given to the varying outcomes amongst racial groups. However, scant attention has been paid to the outcomes of surgery in different racial groups found in the United Kingdom (UK). We investigated the results of surgery in one of the principal ethnic minorities in the UK; that of a south Asian population.

We retrospectively analysed our prospectively collected database at the Southern General Hospital, Glasgow. We identified 39 Asian patients who had TKA. They were age and sex matched to a Caucasian group. Mean follow up was 40.3 months.

Mean pre-operative oxford knee scores were poorer than in the Caucasian group (8.5 vs. 14.7, p=0.001.) Post operative oxford knee scores were similarly poorer in the Asian group (29.9 vs. 36.1, p=0.07.) Interestingly, the change in oxford knee scores was similar in both groups.

SF-12 and WOMAC scores demonstrated poorer pre and post operative scores in the Asian group. Knee flexion was greater in the Asian group, however (107.5° vs. 106.2°, p=0.742.)

We conclude that while patients of Asian origin have poorer post operative pain and function following TKA, they have a similar gain from surgery as do a Caucasian group and therefore surgery is effective intervention in this group. An important topic for further work is to identify why Asians present later in their arthritic disease process to healthcare professionals than do their Caucasian counterparts.

In 2012 collagenase Clostridium histolyticum (Xiapex) was approved by the SMC for restricted use for the treatment of Dupuytren's contracture. Xiapex was approved on a case by case basis for patients with a palpable pretendinous cord, giving rise to MCPJ contracture of greater than 30 degrees. As of September 2012 we began to offer Xiapex injections to patients in Ayrshire who enquired about the injection, and met the SMC criteria.

To date injections have been performed on 3 patients, in a total of 7 digits. Patients were assessed prior to injection and manipulation, with the degree of contracture recorded and DASH scores noted. Each patient then underwent a standard injection of 0.58 mg of Xiapex. 48 hours post injection each patient underwent manipulation under local anaesthetic, with contractures remeasured, pain scored using a visual analogue scale and complications noted. Each patient was then reviewed at 4 weeks post injection where the residual degree of contracture was recorded and a further DASH score completed.

Mean contracture at the MCPJ prior to injection was 57° (range 34–80), and mean DASH score of 20.8 (range 16.7–24.2). Following manipulation mean residual contracture at the MCPJ measured 21° (range 18–28). The average pain score following was manipulation was rated at 1.1. Mild bruising and swelling were reported in all cases following injection, and manipulation resulted in 2 minor skin tears. At the 4 week review prolonged improvement of contracture was achieved with a mean residual contracture of 14° (range −2–40); with a significant improvement in DASH scores – mean 0.6 (range 0–1.8)

Despite small numbers, we have found Xiapex injections to be a successful and well tolerated treatment for moderate Dupuytren's disease. Further follow up is required to assess the longevity of the correction and ensure the cost effectiveness of Xiapex.

Introduction of new implants has been widely debated lately, mainly in response to the problems surrounding hip resurfacing and one company recalling its product. Medicines and Healthcare products Regulatory Agency (MHRA) also issued advice about the management and monitoring of patients implanted with metal-on-metal articulations.

In response to MHRA advice all the patients who underwent hip resurfacing in our hospital were assessed by two consultants according to MHRA guidelines. Here we present the findings from our District General Hospital.

Between November 2006 and March 2009 we performed 42 hip resurfacings in 39 patients. Nearly all the procedures were performed by a single surgeon (39 out of 42). There were 27 males (28 hips) and 12 females (14 hips). Mean age of the patients at the time of surgery was 55.6 years (age range 40–67 years). Patients were followed up for a mean of 49 months (range 33–66 months). 27 patients (28 hips) were asymptomatic at the time of last follow up.

Serum cobalt and chromium ion levels were measured in 21 patients (24 hips). Both the ion levels were within the recommended levels in 20 patients and over the recommended limit in 2 patients (one with bilateral hip resurfacing). MRI was diagnostic in 2 out of 5 patients. 5 patients (7 hips) were revised (one hip for neck resorption, 4 hips in 3 patients with lesions on MRI, 1 patient with bilateral hips for elevated serum ion levels)

Considering the revision rate (7 hips out of 42 hips, 16%), we do believe that the review of the hip resurfacings in spite of the controversies surrounding the diagnostic criteria is necessary. This group of patients need to have continued surveillance, preferably by a select group of surgeons.

Arthritis of the glenohumeral joint accompanied by an irreparable tear of the rotator cuff can cause severe pain, disability and loss of function, particularly in the elderly population. Anatomical shoulder arthroplasty requires a functioning rotator cuff, however, reverse shoulder arthroplasty is capable of addressing both rotator cuff disorders and glenohumeral deficiencies. The Aequalis Reversed Shoulder Prosthesis design is based on two bio-mechanical principles by Grammont; a medialized center of rotation located inside the glenoid bone surface and second, a 155 degree angle of inclination. Combined, they increase the deltoid lever arm by distalizing the humerus and make the prosthesis inherently stable.

24 consecutive primary reverse total shoulder arthroplasties were performed by a single surgeon for arthritis with rotator cuff compromise and 1 as a revision for a failed primary total shoulder replacement between December 2009 and October 2012. Patients were assessed postoperatively with the use of the DASH score, Oxford shoulder score, range of shoulder motion and plain radiography with Sirveaux score for scapular notching.

Mean age at the time of surgery was 72.5 years (range 59 to 86). Average follow up time was 19.4 months (range 4 to 38). Functional outcome scores from our series were comparable with patients from other follow up studies of similar prosthesis design. All patients showed improvement in range of shoulder movement postoperatively. Complications included one dislocation, one acromion fracture and one humeral shaft fracture. No cases of deep infection were recorded. Overall, the short-term clinical results were promising for this series of patients and indicate reverse shoulder arthroplasty as an appropriate treatment for this group of patients.

Posterior soft tissue repair is often performed in Total Hip Arthroplasty (THA). Many reports have shown the advantage of posterior soft tissue repair in reducing their prosthetic hip dislocation rates.

We describe an easy and inexpensive way of passing sutures through small drill holes in the Greater Trocanter to re-attach muscle, tendon and capsule in a posterior soft tissue repair.

By using a reversed monofilament suture on a straight needle held in artery forceps and passing this in a retrograde direction through a drill hole, a suture capturing device is produced.

By capturing the long ends of sutures tied in the short external rotators and the posterior capsule of the hip through 2 drill holes in the Greater Trochanter, a posterior soft tissue repair can be performed. We have used this technique successfully in over 100 consecutive THAs.

We conclude that the use of a monofilament suture used in the manner describe is an excellent and inexpensive way to aid in a posterior soft tissue repair in THAs. This is done without the cost of an additional dedicated suture passing device. The suture could also be used in the skin closure if desired.

Image-free navigation technology relies heavily on the surgeon carefully registering bony anatomical landmarks, a critical step in achieving accurate registration which affects the entire procedure. Currently this step may depend on placing a pointer superficially, with soft-tissue and skin obscuring these bony landmarks. We report initial results of using newly developed experimental software which automatically recognises the bone soft-tissue interface. This is the first critical step in development of automatic computer generation of the bone surface topography from ultrasound scanning.

Individual 2D ultrasound images (n=651) of the anterior femoral condyles and trochlear notch were used. Images were taken from 29 volunteers (20 male, 9 female). The software extracted bone-soft tissue interface by a two-step method based on a gradient evaluation and the elimination of false-positives with a graph closure. The trochlear notch was automatically defined by geometrical modelisation. Coordinates of both bone interface and trochlear notch position for each separate image were compared to a separate analysis performed manually by a single investigator. Error was calculated using root mean squared (RMS).

Median error (RMS) in locating bone soft-tissue interface was 0.67 mm, (mean 0.93 mm, SD 0.84 mm). Median error for trochlear notch topography was 1.01mm, (mean 1.41 mm, SD 1.37 mm).

Bone soft-tissue interface can be accurately defined and displayed by this software. Direct visualisation of critical bony landmarks could replace the current comparatively subjective placement of a pointer on superficial tissues. This has powerful application in both non-invasive and surgical computer-assisted acquisition of knee kinematics, and may have further applications in orthopaedic surgery.

Conventional computer navigation systems using bone fixation have been validated in measuring anteroposterior (AP) translation of the tibia. Recent developments in non-invasive skin-mounted systems may allow quantification of AP laxity in the out-patient setting.

We tested cadaveric lower limbs (n=12) with a commercial image free navigation system using passive trackers secured by bone screws. We then tested a non-invasive fabric-strap system. The lower limb was secured at 10° intervals from 0° to 60° knee flexion and 100N of force applied perpendicular to the tibial tuberosity using a secured dynamometer. Repeatability coefficient was calculated both to reflect precision within each system, and demonstrate agreement between the two systems at each flexion interval. An acceptable repeatability coefficient of ≤3 mm was set based on diagnostic criteria for ACL insufficiency when using other mechanical devices to measure AP tibial translation.

Precision within the individual invasive and non-invasive systems measuring AP translation of the tibia was acceptable throughout the range of flexion tested (repeatability coefficient ≤1.6 mm). Agreement between the two systems was acceptable when measuring AP laxity between full extension and 40° knee flexion (repeatability coefficient ≤2.1 mm). Beyond 40° of flexion, agreement between the systems was unacceptable (repeatability coefficient >3 mm).

These results indicate that from full knee extension to 40° flexion, non-invasive navigation-based quantification of AP tibial translation is as accurate as the standard invasive system, particularly in the clinically and functionally important range of 20° to 30° knee flexion. This could be useful in diagnosis and post-operative follow-up of ACL pathology.

Non-invasive assessment of lower limb mechanical alignment and assessment of knee laxity using navigation technology is now possible during knee flexion owing to recent software developments. We report a comparison of this new technology with a validated commercially available invasive navigation system.

We tested cadaveric lower limbs (n=12) with a commercial invasive navigation system against the non-invasive system. Mechanical femorotibial angle (MFTA) was measured with no stress, then with 15 Nm of varus and valgus moment. MFTA was recorded at 10° intervals from full knee extension to 90° flexion. The investigator was blinded to all MFTA measurements. Repeatability coefficient was calculated to reflect each system's level of precision, and agreement between the systems; 3° was chosen as the upper limit of precision and agreement when measuring MFTA in the clinical setting based on current literature.

Precision of the invasive system was superior and acceptable in all conditions of stress throughout flexion (repeatability coefficient <2°). Precision of the non-invasive system was acceptable from extension until 60° flexion (repeatability coefficient <3°), beyond which precision was unacceptable. Agreement between invasive and non-invasive systems was within 1.7° from extension to 50° flexion when measuring MFTA with no varus / valgus applied. When applying varus / valgus stress agreement between the systems was acceptable from full extension to 30° knee flexion (repeatability coefficient <3°). Beyond this the systems did not demonstrate sufficient agreement.

These results indicate that the non-invasive system can provide reliable quantitative data on MFTA and laxity in the range relevant to knee examination.

Utilization of nerve conduction studies in the investigation and management of carpal tunnel syndrome varies according to their perceived usefulness and availability. The use of steroid injections and splinting also varies according to service availability and their perceived effectiveness. We present a three year follow up of 230 patients managed in an environment where nerve conduction testing was not readily available. The majority received splinting and a steroid injection in an effort to manage their symptoms conservatively in the first instance.

Our results show that a clear majority of patients who were treated with initial splinting and steroid injections saw a recurrence of their symptoms (71.9% and 79.7% respectively) requiring eventual surgical decompression. These results would seem to suggest that conservative management of carpal tunnel does not produce the desired curative results and that there may be an argument for proceeding directly to surgery.

We also showed that 55% of patients referred for Nerve Conduction Studies seem to progress to surgical decompression. This would seem to suggest that Nerve Conduction Studies could form a robust part of the standard investigation of carpal tunnel in order to identify those who would benefit from surgery.

Hip and knee arthroplasties are very common operations in the UK with over 70000 hip and over 80000 knee arthroplasties taking place in England and Wales in 2011. Fortunately mortality following these operations is rare. However it remains important to understand the incidence and causes of death, in order to manage risk where possible and to inform the consent process.

This study aimed to evaluate the incidence and causes of death within 30 days after undergoing hip or knee arthroplasty in our unit and to highlight possible risk factors.

We looked at 30 day mortality in all patients undergoing hip or knee arthroplasty in our institution between 2005 and 2011. Data on post-operative deaths was derived from the Scottish Arthroplasty Project and correlated with procedural and demographic data from our hospital Patient Administration System (PAS). The notes of all patients who had died within a period of 30 days post-operatively were reviewed to collect data on co-morbid conditions, pre-operative investigations, post-operative thromboprophylaxis and cause of death. All primary and revision knee and hip arthroplasties including bilateral procedures were included. Arthroplasty for trauma was excluded.

A total of 12,243 patients underwent hip or knee arthroplasty within the study period. 59% were female and the mean age was 68 (range 21–91). During this time period the standard protocol was to use aspirin for thromboprophylaxis. Eleven patients died following surgery giving a mortality rate of 0.09%. The most common cause of death was myocardial infarction (7/11 patients).

Our finding of a mortality rate of 0.09% is similar or lower to those found in previous studies. To our knowledge this is the first series of this size looking at mortality from hip and knee arthroplasty within a single centre in the UK.

Procedure Based Assessments (PBAs) are one type of Workplace Based Assessment (WBA) introduced recently to orthopaedic training in the UK. They play an increasing role in the assessment of a trainee's surgical competence.

The study aims to determine the most valuable aspects of a PBA to a trainee, and the changes trainees suggest to improving the use of PBAs.

A link to an online questionnaire was sent by email via the eLogbook system to all orthopaedic trainees in the UK with a National Training Number (NTN). The free text responses were coded and categorised. Analysis of results was conducted using the online survey software and Microsoft Excel.

Of 668 responses, 616 met the inclusion criteria, making a response rate of 66% of all trainees with a NTN in the UK. There was a broad, representative spread of seniority and of geographical location. Trainees found the verbal feedback gained from their trainer to be most valuable (47%), followed by the assessment of competence (21%). Trainees identified the PBA form itself as the most important area for change (52.4%). This included increased numbers of PBAs (17.5%), more specific to the procedure (8.6%), more user friendly (15%), more levels of competence (4.5%) and a generic PBA (3.4%). Further suggestions included changing the role of PBAs, with 8.2% suggesting discontinuing their use entirely. Improving trainer investment in the use of PBA was also highlighted.

Trainees value PBAs to gain formal feedback more than their use as evidence of competence in a procedure. There are a number of changes suggested by trainees that could improve the use and effectiveness of PBAs, and we have incorporated these into recommendations made by the British Orthopaedic Trainees’ Association, which should inform the debate on the further development of this assessment tool, and on WBAs in general.

Xiapex is a novel non-surgical intervention for the treatment of Dupuytren's contracture. It comprises a fixed-ratio mixture of two purified collagenolytic enzymes (AUX-I [clostridial type I collegenase] and AUX II [clostridial type II collagenase]) isolated from the medium of Clostridium histolyticum. Xiapex targets the contracture through the injection of enzymes into the pathologic diseased cords.

The objectives of this study were to evaluate the safety and efficacy of Xiapex in patients with Dupuytren's Contracture, the recovery and associated use of health care resources. The study commenced in June 2011 and was completed in 11 months. 15 patients were screened for the study, 12 patients were eligible (10 male:2 female). All 12 patients completed the trial and 2 patients received multiple injections, one had two fingers affected and the other had two joints affected in one finger.

Following screening visit to determine patient suitability, the patient received their first injection usually within 7 days. Xiapex was injected directly into the palpable cord. 24 hours after injection patients were reviewed and a “finger extension procedure” was performed if the cord had not spontaneously ruptured. Patients were then followed up at 7 days, 30 days and 6 months. Assessments at each visits included: Finger Goniometry, Physician and Subject Global Assessment and Satisfaction, Health Care Resource Utilization and URAM (function assessment) and adverse events.

Of the 14 cords injected all ruptured after finger extension. No patient experienced any serious adverse events, but a number of more minor adverse events were recorded including skin tears, pain at injection site, swelling and bruising. At the time of final follow-up recurrence rates were 14%

In conclusion, Xiapex is suitable for appropriately selected patients who are affected by Dupuytren's contractures and who have a well-developed palpable cord.

Digital radiographs are routinely used for preoperative planning, both in trauma and elective patients; particularly in preoperative templating for total hip replacement. Traditional wisdom holds that radiographs are oversized, though the degree to which this occurs is unclear. Although digital templating systems offer the use of calibration markers, this option is not always availed. We aimed to ascertain the typical magnification in departmental xrays of the hip, both to determine the typical degree of magnification as well as ascertain its consistency.

All patients undergoing dynamic hip screw fixation (DHS) in our unit over the past 12 months were identified. Using the PACS system, subsequent xrays of the patient with the implant in situ were identified; both anteroposterior abdominal and pelvic films were used. The width of a standard DHS screw (12.5 mm) was compared with the width measured on the xrays to determine a magnification factor. 164 patients were identified, of these 39 had undergone DHS fixation with subsequent xrays. 3 films were focused on the abdomen but provided good coverage of the hip also. 2 xrays were excluded – both due to limited quality. The average magnification was 26.4% (range 15.5%–42%). There was limited consistency between images.

Radiographs are a core investigation in the assessment of the orthopaedic patient. The advent of picture archiving and communications systems (PACS) has allowed the enterprising surgeon to pre-emptively plan their surgical technique and implant use. However, the utility of non-calibrated images in planning implant size is limited by variation in magnification. Surgeons should be cautious in using such images to guide their implant usage.

Soft tissue balancing is critical to successful knee arthroplasty. Pre-operative planning ensures that the surgeon is prepared for any eventuality. We report a large femoral exostosis resulting in gross instability, requiring revision to a constrained implant.

An 81 year old female presented with osteoarthritis of the left knee. Xray showed a medial bony mass. CT noted a large bony exostosis arising from the posteromedial femoral condyle. Review showed the exostosis was not related to the medial collateral ligament (MCL). At surgery, the exostosis was noted to be tenting the MCL – excision resulted in complete flaccidity. A trial of the Biomet AGC prosthesis revealed gross medial instability. The decision was taken to convert to a DePuy Sigma TC3 system. Whilst removing TC3 trial components, a lateral condyle fracture occurred. This was fixed with a 1/3 tubular plate and interfragmentary screw. The TC3 system and an AGC patellar button were found to be congruent. A small lateral release was performed, the deep MCL was replaced with tagging sutures through the MCL and the pes anserinus. At 9 weeks post operatively, the patient was pain free and mobilising independently. The knee was stable, with range of movement from 0 to 110 degrees.

To our knowledge, this is the first report of such a complication in the literature. It highlights that despite optimal preoperative planning, the surgeon must be prepared to adapt to the situation at hand. It also highlights the importance of having ‘bail out’ options available on shelf when performing routine surgery.

To evaluate if young patients have a poorer functional outcome following Total Knee Arthroplasty surgery.

Database of 700 consecutive Total Knee Arthroplasty patients from Scotland, UK was collected with Oxford Knee scores and American Knee Society Scores both pre-operatively and at sequential follow up reviews (PFC database, DePuy). Complication data was also collated. Patients were then age stratified into below 55, 56–64, 65–74 and over 75 groups. Analysis was performed using General Linear Model ANOVA (Minitab v10) comparing functional score change between pre operative and 2 year score data.

No statistical difference was identified between the patient age groups and change in functional outcome scores (AKSS p=0.994; OKS p=0.368). All groups showed an improvement in functional scores over the 2 year period using both patients assessed (OKU) and physician scored outcomes (AKSS). There was no statistical difference in revision or infection rates.

Recent data has suggested higher revision and infection rates in young patients undergoing Total Knee Arthroplasty (Scottish Arthroplasty Report 2012). The data from the PFC database does not show any change in infection or revision rates within this sample population and the data does also not support any variance in change in functional outcome with all groups showing improvement following TKA. The findings may be limited due to sample size of 700 patients.

The aim is to report a rare technique for correction of intramedullary nail acute angular deformity.

Intramedullary tibial nail fixation of diaphyseal tibial fractures is the gold standard treatment allowing early mobilisation whilst preserving the soft tissues around the fracture site. Most commonly, intramedullary nails fail by metal fatigue secondary to non union, without significant deformity of the metalwork. Plastic deformity of the nail can result following new acute trauma, particularly before bone union has occurred. This is a clinical challenge as a reamed intramedullary nail is designed to achieve three point fixation with close anatomical fit, such that removal of a bent nail is technically difficult and also risks further damage to bone and soft tissues.

We report a case of a 20 year old patient treated with intramedullary nail fixation of a diaphyseal right tibial fracture who was subsequently assaulted 4 weeks post operatively. This produced an unacceptable deformation of the nail into 25 degrees valgus and procurvatum. To remove the nail, the authors used a previously reported but rare technique of partial (up to 50%) nail division on the convex surface of the apex using Midas Rex High Speed Drill to weaken the nail then manipulation to correct deformity with minimal stress. The technique produced minimal metal debris and allowed simple exchange nail replacement without further complication. The authors believe this is the first reported use of the technique from the United Kingdom.

Theatre efficiency is an increasingly important factor as the health service is faced with an ever greater number of patients, but tighter fiscal restrictions. We carried out an audit was to utilise data collected routinely on the Opera Surgical Management System (CHCA, Canada) to look at the efficiency of orthopaedic theatre usage, and to look for potential areas of improvement. The data related to all elective procedures carried out by a single Orthopaedic Consultant in a city hospital, over a one year period.

We found that lists frequently started late, with the first patient of the day entering the anaesthetic room after 9 am on over 50% of occasions. The reasons for this were not regularly recorded. There was a wide variability in the length of time taken to anaesthetise and position the patients. Although there was a weak association with the underlying health of the patients (ASA score), the seniority of the anaesthetist was not available for correlation. The turnaround time between cases was variable, with a tendency for it to take longer over the lunchtime hours. Almost a third of lists finished before 4.30 pm, mainly due to patient cancellations, however nearly a third of lists finished after 5.30 pm.

We found that data routinely collected on our theatre management system provides useful information that could potentially be used to fine-tune our peri-operative processes, however greater detail about specific timings and delays affecting the patient journey would be required before any recommendations could be made to improve theatre efficiency.

With an ageing population and increasing pressures on all orthopaedic services, it is vital that we are able to develop efficient and acceptable means to streamline the patient journey. Our department uses telephone review appointments for selected patients to reduce the need for additional visits to the outpatient clinic. The aim of this study was to assess the efficacy of this approach, and to determine whether it was acceptable to patients.

We identified all patients who had received a first-time telephone review appointment within a four month period. Using a short structured telephone questionnaire they were asked about their experiences of the process, whether they had subsequently required a clinic visit, and whether they would have preferred to be seen in person in the clinic.

50 of the 55 (91%) patients were successfully contacted, and all gave consent to participate. Reasons for follow-up included post-operative discectomy and lumbar decompression, post-nerve root injection, and MRI results. All patients (100%) were satisfied with the telephone consultation. Only 8 (16%) would have preferred a clinic appointment with 5 of these subsequently visiting the clinic. 32 (64%) of the patients did not require a further clinic appointment for the same problem. 32 (64%) of patients stated that they were very satisfied with the overall follow-up process with the remaining 18 (36%) being satisfied.

Our study has shown that using telephone review follow-up for selected patients is effective at reducing the number of clinic visits, and is acceptable to patients.

This project began as an audit of performance against the 18-week referral to treatment time (RTT) target but became an interesting development in clinical training.

The electronic documents and PACS images for 50 consecutive routine GP referrals to an orthopaedic clinic were traced using the UCPN (Unique Care Pathway Number).

The average time from referral to 1^st clinic appointment was 57 days (range 29–117).

16 were discharged at 1^st visit. 26 were listed for surgery: 20 at the 1^st clinic, 3 at the 2^nd clinic, 2 at the 3^rd clinic, 1 after test results without clinic review. Average time from referral to listing was 68 days (range 28–177). For 25 patients who had surgery, average RTT was 164 days (61–394). 14 patients breached the target.

The UCPN allows an overview of the diagnostic work-up for the whole care pathway. Time constraints and less opportunity for continuity of care have hampered effective training in the outpatient clinic. Using the UCPN in this way allows detailed case-based discussions to develop the non-technical surgical skills (NOTSS) of situation awareness and decision-making.

In a system where 57 days are typically wasted waiting for a new clinic appointment, clinical reasoning skills must be scalpel sharp to meet the 18-week RTT target. This study hints that better characterising the third of patients discharged and the third directly listed for surgery at the first visit might help with demand management. Better characterising the third of patients needing further tests might allow those test results to be available by the first visit.

The next step is to test if, indeed, the UCPN is an effective tool to hone mental dissection.

The Dumfries and Galloway Royal Infirmary (DGRI) catchment area encompasses 5 of the “7 Stanes” mountain bike trails which had approximately 165000 visitors in 2010. Using our hospital coding system we identified potential mountain bike injuries in 2010. Patient postcode, injuries, operating theatre time and number of clinic appointments was recorded.

We confirmed mountain bike related hospital admissions in 29 patients. 13 patients had local (DG) postcodes and 16 had non-DG post codes. The DG postcode patients required 41 bed days, 8 operations, 400 minutes theatre time, and 35 DGRI clinic appointments. The non-DG postcodes required 50 bed days, 11 operations, 730 minutes theatre time, 3 DGRI clinic appointments and 8 outpatient referrals to other hospitals. Totals for all postcodes were 91 bed days, 19 operations, 1130 minutes theatre time and 38 DGRI clinic appointments. The surgeries comprised: 2 ankle ORIF; 1 subsequent removal of syndesmosis screw; 5 wrist/forearm manipulations (+/−kwires); 2 distal radius ORIF; 1 DHS; 2 shoulder MUA, 1 calcaneus ORIF, 4 wound debridements, 1 facial wound closure. Other noteworthy admissions were 5 head injuries including 2 cervical spine fractures.

We anticipate this is an underestimate and suggest a new code is created to specifically identify mountain bike injuries for A&E and inpatient care. This would allow a more accurate assessment of the impact on all healthcare providers in the county.

Despite widespread use, the benefit of knee arthroscopy for symptomatic osteoarthritis (OA) remains controversial. The theoretical benefit of removal of particulate debris and washout of inflammatory cytokines has not been supported by strong evidence. Arguments exist for its short term benefit in well selected patients. We sought to determine if arthroscopy provided any short term symptomatic relief in patients with a clinical diagnosis of OA in our unit.

A total of 20 patients were listed for routine arthroscopy over a one year period for OA. Mean age was 60 (range 48–74) years and 3 in 5 patients were female. 9 patients were listed by registrars, 6 by locum consultants and 5 by substantive consultants. One procedure was cancelled on the day of surgery due to lack of indication, with 19 knees proceeding to surgery. There was evidence of significant arthritis in 17 knees, 6 of which had associated degenerate meniscus tears. Two knees had meniscus tears without significant arthritis. All patients had washout and debridement and in addition, 8 partial menisectomies were carried out together with 3 loose body removals. Patients were followed up after an average of 12 weeks. The 2 patients (both male, mean age 52) with meniscus tears in the absence of significant arthritis fully recovered. Both had symptoms of true locking. 2 patients with loose bodies also fully recovered. With the exception of 2 patients with partial relief, the remainder had no symptomatic relief. One reported a worsening of symptoms and progressed to total knee arthroplasty.

These results suggest that arthroscopic debridement and washout plays a limited role in the short term symptomatic relief of OA. Surgeons should limit its use to younger patients with mild radiographic disease and true mechanical symptoms who are otherwise unsuitable for arthroplasty and not keen on undergoing joint conserving surgery.

Magnetic resonance imaging (MRI) is a useful diagnostic tool in evaluating meniscus pathology in the knee. Data from available literature suggests sensitivity and specificity rates around 90% when compared to the gold standard findings at knee arthroscopy. We sought to evaluate the sensitivity, specificity and precision rate (positive predictive value) of MRI at diagnosing meniscus tears within our unit.

A retrospective audit of a total of 79 MRI reports and arthroscopic findings spanning a one year period was carried out. There were 66 positive MRI reports and 13 negative reports. There were 6 false positives 4 false negatives when compared to arthroscopic findings. The sensitivity of MRI for detecting meniscus tears was 93.7% with 60 out of 64 tears detected. All 4 false negatives also had at least grade III osteoarthritic changes at arthroscopy. Specificity was rather low at 60% with MRI reporting 6 tears (false positives) out of 15 patients who had no tears found at arthroscopy. The positive predictive value (precision rate) of MRI detecting tears was 90.9%.

This data shows that MRI in our unit has a comparable high sensitivity to that in various literature making it a useful tool at ruling out disease with a negative result in the clinical setting. A more useful parameter in the clinical setting is its high precision rate when faced with a positive result. However, its specificity is much lower than that in most published data. A total of 6 tears on MRI turned out not to be on arthroscopy meaning patients could have been subjected to an avoidable invasive procedure in the absence of any other indication. This highlights the importance of obtaining reports from experienced musculoskeletal radiologists and the need for surgeons to review MRI images and match them to clinical information prior to subjecting patients to surgery.

Intra-operative fluoroscopy in thumb metacarpophalangeal joint arthrodesis has been recommended as a means of achieving optimal alignment more consistently. This is not our current practice. A patient attending dissatisfied with an arthrodesis in excessive flexion performed outwith our unit highlighted the potential for problems, and we therefore elected to review our own outcomes.

An evaluation of the alignment achieved in thumb metacarpophalangeal joint arthrodeses, to determine if current outcomes satisfactory or if fluoroscopic assistance should be considered.

Radiological review of alignment of thumb metacarpophalangeal joint arthodeses carried out by two Consultant Surgeons with specialist interests in upper limb surgery in a District General hospital. Cases were predominantly identified retrospectively from sequential review of operating lists. The radiological images were, or had been taken, as part of routine follow-up and were not standardised. The alignment was also assessed independently by a junior doctor with no involvement in the patient's surgical treatment and no knowledge of the intended alignment. Recommended positions for arthrodesis have covered a range from 0 to 30 degrees, so for the purposes of analysis that range was considered acceptable.

14 cases had an average fusion position of 18 degrees flexion (range 6 to 30 degrees). 6 underwent concurrent ipsilaterel trapeziectomy.

The series achieved satisfactory alignment radiologically without the routine use of intra-operative fluoroscopy.

Allogenic blood is a finite resource, with associated risks. Previous studies have shown intra-operative cell salvage (ICS) can reduce allogenic transfusion rates in orthopaedic surgery. However, recent concerns regarding the efficacy and cost-effectiveness of ICS mean we must continually re-assess its usefulness in current practice. This study was carried out to review the use of ICS, to establish if its use has led to a reduction in patient exposure to post-op allogenic transfusion.

All orthopaedic patients who underwent ICS and re-infusion between 2008–2010 in the Southern General Hospital (SGH) were audited. The Haemoglobin (Hb) drop, volume of blood re-infused and post-op allogenic transfusion rates were recorded. The revision hip group was compared to a similar SGH cohort, who underwent surgery by the same surgeons between 2006–2008, and a pre-2005 control group. The Cell Saver (Haemonetics) machine was used.

The proportion of patients who received a post-op allogenic transfusion fell by 55% in the 2008–2010 ICS cohort compared with the control, and by 40% compared with the previous ICS study group. In both instances, this was accompanied by a statistically significant (p<0.001) reduction in mean number of units transfused per patient.

ICS has been shown to be effective in reducing rates and volume of post-op allogenic transfusion in patients undergoing revision hip surgery at the SGH. ICS has been used with increasing efficiency over time.

Over 70,000 hip fractures occur annually in the UK. Both SIGN (111) and NICE (124) give guidance on optimal management of these patients. Both suggest cemented hemiarthroplasty should be used in those without contra-indications, as cemented implants are associated with less thigh pain, subsidence and a better functional outcome. Cardiorespiratory compromise secondary to bone cement implantation syndrome (BCIS) is however a concern in those with pre-existing cardiorespiratory disease (NYHA grade 3–4, pulmonary hypertension) or pathological fracture [3].

The aim of our study was to audit the practice of a University of Glasgow hospital with regard to cemented hemiarthroplasty.

We retrospectively reviewed data on all patients treated with hemiarthroplasty for hip fracture at the Southern General Hospital between 01/01/12-02/04/12. Patient demographics, pre-operative plan, procedure performed, ASA grade and pre-morbid mobility were recorded.

Cubitus varus following paediatric supra-condylar humeral fracture represents a complex three-dimensional malunion. This affects cosmesis, function and subsequent distal humeral fracture risk. Operative correction is however difficult with high complication rates. We present the 40-year Yorkhill experience of managing this deformity.

From a total of 3220 supracondylar humeral fractures, 40 cases of post-traumatic cubitus varus were identified.

There were ten undisplaced fractures, treated in cast, and thirty displaced fractures. Five were treated in cast, thirteen manipulated (MUA), four MUA+k-wires, seven ORIF (six k-wire, one steinman pin) and one in skeletal-traction.

Sixteen malunions were treated operatively. The mean pre-operative varus was 19°. All had cosmetic concerns, three mild pain, one paraesthesia/weakness and three reduced movement (ROM). The operative indication was cosmetic in fifteen and functional in one (concern about instability).

Twelve patients had lateral closing-wedge osteotomies; three complex/3D osteotomies (dome, unspecified rotational, antero-lateral wedge) and two had attempted 8-plate guided-growth correction.

Complications occurred in eight patients (50 %): Fixation was lost in three (two staples, one k-wiring), incomplete correction in six (both 8-plates, both staples, two standard plates) and one early wound infection requiring metalwork removal resulting in deformity recurrence. One patient underwent revision lateral wedge osteotomy with full deformity correction but marked ROM restriction (20–100°) secondary to loose bodies.

Those without complications were satisfied (50 %). All patients with residual deformity were unsatisfied. 1 patient with keloid scarring was unsatisfied despite deformity correction.

Varus malunion is uncommon (1 %) but needs to be guarded against. It tended to occur in displaced fractures treated with MUA and cast alone. We therefore recommend additional pin fixation in all displaced fractures.

Deformity correction should only be attempted in those with significant symptomatic deformity due to the high complication/dissatisfaction rates. Staple osteotomy fixation and 8-plate guided growth correction are not recommended.

To validate the Modified Forgotten Joint Score (MFJS) as a new patient-reported outcome measure (PROM) in hip and knee arthroplasty against the UK's gold standard Oxford Hip and Knee Scores (OHS/OKS).

The original Forgotten Joint Score was created by Behrend et al to assess post-op hip/knee arthroplasty patients. It is a new assessment tool devised to provide a greater discriminatory power, particularly in the well performing patients. It measures an appealing concept; the ability of a patient to forget about their artificial joint in everyday life. The original FJS was a 12-item questionnaire, which we have modified to 10-items to improve reliability and missing data.

Postal questionnaires were sent out to 400 total hip/knee replacement (THR/TKR) patients who were 1–2 years post-op, along with the OHS/OKS and a visual pain analog score. The data collected from the 212 returned questionnaires (53% return rate) was analysed in relation to construct and content validity. A sub-cohort of 77 patients took part in a test-retest repeatability study to assess reliability of the MFJS.

The MFJS proved to have an increased discriminatory power in high-performing patients in comparison to the OHS and OKS, highlighted by its more normal frequency of distribution and reduced ceiling effects in the MFJS. 30.8% of patients (n=131) scored 42–48 (equivalent to 87.5–100 in the MFJS) or more in the OKS compared to just 7.69% in the MFJS TKR patients. The MFJS proved to have an increased test-retest repeatability based upon its intra-class correlation coefficient of 0.968 compared to the Oxford's 0.845.

The MFJS provides a more sensitive tool in the assessment of well performing hip and knee arthroplasties in comparison to the OHS/OKS. The MFJS tests the concept of awareness of a prosthetic joint, rather than pain and function and therefore should be used as adjunct to the OKS/OHS.

The incidence of wound complications after a hip or a knee replacement is well established, but there is no such data about foot/ankle surgery. Without this data it is difficult to compare performance between different care-providers. It is also difficult to benchmark services that could potentially be provided by a wide range of care providers (chiropodists, podiatrists, podiatric surgeons, general orthopaedic surgeons with a small foot/ankle practice, etc).

Our aim was to establish the incidence of wound complications after foot/ankle surgery and provide a baseline for future comparison.

Our study was done in two parts. First part was to conduct an opinion-survey of BOFAS members with a substantial foot/ankle practice, on wound complications from foot/ankle surgery in their own practice. Second part was to conduct a prospective study on the incidence of wound complications from our own foot/ankle practice. The study was registered as an audit and did not require ethical approval. All wound complications (skin necrosis, wound dehiscence, superficial and deep infections) were recorded prospectively. Record of such data was obtained by an independent observer, and from multiple sources, to avoid under-reporting.

60 % of the responders to our survey had a predominant foot/ankle practice (exclusive or at least 75 % of their practice was foot/ankle surgery) and were included for further analysis of their responses. A large majority of these responders (64%) reported a rate of 2–5 % for superficial infection, and a significant majority (86 %) reported a deep infection rate of less than 2 %. Results from our own practice showed an incidence of superficial infection of 2.8 % and deep infection of 1.5 %.

With increasing focus on clinical outcome measures as an indicator of quality, it is imperative to publish data on wound complications/ infection after foot/ankle surgery, and in the absence of such data, our two-armed study (survey-opinion and prospective audit) provides a useful benchmark for future comparisons.

Cheilectomy of the big toe is offered in the early stages of arthritis affecting the big toe MTPJ, with the understanding that if it fails then a more definitive surgical treatment (e.g. MTPJ fusion or replacement) may be required. When considering treatment options, patients want to know how long will a cheilectomy procedure last. There is limited evidence available about the long term results after cheliectomy, particularly with regards to time to revision surgery. Our aim was to establish the long-term results of cheilectomy with regards to revision surgery and patient-satisfaction over a period of 10 years.

A retrospective review of big toe MTPJ cheilectomies was performed at our institute from 2002 to 2012. The patients were identified using a combination of medical coding system, clinical records, operative log, and radiographs. A systemic review of chielectomy by Roukis (2010) was identified as the clinical standard and revision surgery after cheilectomy, average time to revision and patient satisfaction was assessed.

204 cheilectomies were identified in 192 patients over a period of 10 years. Majority had grade 2 OA (n = 106, 54 %) with grade 3 (n= 65, 33 %) and grade 1 (n= 24, 12 %). The mean follow-up was 4 yrs. (range 6 m to 9 yrs. and 8 m). The overall revision rate to any surgery was 4.4% (n=9), and revision to MTPJ arthrodesis was 3.4% (n =7). The average time to revision was 1 yr. 4 m. 101 patients (55%) were contactable over the phone, and majority (82 %) of them were satisfied with the clinical outcome.

This study shows slightly better overall revision rate (4.4% vs. 8.8%), with revision to arthrodesis being similar (3.4% vs. 3.25%) as compared to the clinical standard. It also suggests that cheilectomy of the big toe can last for a minimum of up to 4 years in 95 % of cases. The 5 % of cases that may require revision surgery are likely to present within the first 2 years. This information is very useful to a patient who wants to know “how long will my cheilectomy last?” whilst making an informed choice

Fifth metatarsal fractures are common and the majority unite regardless of treatment. A sub-type of these fractures carries a risk of non-union and for this reason many centres follow up all 5^th metatarsal fractures. In 2011, a standardised protocol was introduced to promote weight-bearing as pain allowed with a tubigrip or Velcro boot according to symptoms. No routine fracture clinic appointments were made from A&E but patients were provided with information and a help-line number to access care if required. Some patients still attended fracture clinics, but only after review of their notes/X-rays by an Orthopaedic Consultant, or after self-reported “failure to progress” using the special help-line number.

Audit of a year prior to the introduction of the protocol and the year following it was performed. All x-rays taken at presentation in A&E were reviewed and classified independently (KBF/JM) for validation.

During 2009/2010, 279 patients presented to A&E with a 5^th metatarsal fracture and were referred to a fracture clinic. 106(38%) attended 1 appointment, 130(47%) attended 2 appointments and 31 (11%) attended 3 or more appointments – 491 appointments in total. 3% failed to attend the clinic. Operative fixation was performed in 3 patients (1.07%).

In 2011/2012, of 339 A&E fractures, only 63 (19%) attended fracture clinic. 37 (11%) attended 1 appointment, 12 (4%) 2 and 9 (3%) 3 or more appointments – 96 appointments in total. Four patients (1.17%) required operative fixation.

Our study did not demonstrate any added value for routine outpatient follow-up of 5^th metatarsal fractures. Patients can be safely allowed to weight bear and discharged at the time of initial presentation in the A&E department if they are provided with appropriate information and access to a “help line” run by experienced fracture clinic staff. The result is a more efficient, patient-centred service.

Distal femur resection for correction of flexion contractures in total knee arthroplasty (TKA) can lead to joint line elevation, abnormal knee kinematics and patellofemoral problems. The aim of this retrospective study was to establish the contribution of soft tissue releases and bony cuts in the change in maximum knee extension in TKA.

Data were available for 211 TKAs performed by a single surgeon using a medial approach. Intra-operatively pre- and post-implant extension angles and the size of bone resection were collected using a commercial navigation system. The thickness of polyethylene insert and the extent of soft tissue release performed (no release, moderate and extensive release) were collected from the patient record. A linear model was used to predict change in maximum extension from pre- to post-implant.

The analysis showed that bone cuts (p<0.001), soft tissue release (p=0.001) and insert thickness (p=0.010) were all significant terms in the model (r²_adj=0.170). This model predicted that carrying out a TKA with 19 mm bone cuts, 10 mm insert and no soft tissue release would give 4.2° increase in extension. It predicted that a moderate release would give a further 2.8° increase in extension with an extensive release giving 3.9°. For each mm increase in bone cuts the model predicted an 0.8° increase in extension and for each mm increase in insert size a decrease extension by 1.1°.

The modelling results show that in general to increase maximum extension by the same as an extensive soft tissue release that bone cuts would have to be increased by 4–5 mm. However this model only accounted for 17% of the variation in change in extension pre- to post-implant so may not be accurate at predicting outcomes for specific patients.

Many orthopaedic procedures require implants to be trialled before definitive implantation. Where this is required, the trials are provided in a set with the instrumentation. The most common scenario this is seen in during elective joint replacements. In Scotland (2007) the Scottish Executive (http://www.sehd.scot.nhs.uk/cmo/CMO(2006)13.pdf) recommended and implemented individually packed orthopaedic implants for all orthopaedic sets. The premise for this was to reduce the risk of CJD contamination and fatigue of implants due to constant reprocessing from corrosion. During many trauma procedures determining the correct length of plate or size of implant can be challenging. Trials of trauma implants is no longer common place. Many implants are stored in closed and sealed boxes, preventing the surgeon looking at the implant prior to opening and contaminating the device. As a result many implants are incorrectly opened and either need reprocessed or destroyed due to infection control policy, thus implicating a cost to the NHS. With even the simplest implants costing several hundreds of pounds, this cost is a very significant waste in resources that could be deployed else where. My project was to develop a method to produce in department accurate, cheap and disposable trials for implants often used in trauma, where the original manufacturer do not offer the option of a trial off the shelf. The process had to not involve contaminating or destroying the original implant in the production of a trial.

Several implants which are commonly used within Glasgow Royal Infirmary and do not have trials were identified. These implants were then CT scanned within their sealed and sterile packaging without contamination. Digital 3D surface renders of the models were created using free open source software (OsiriX, MeshLab, NetFabb). These models were then processed in to a suitable format for 3D printing using laser sintering via a cloud 3D printing bureau (Shapeways.com). The implants were produced in polyamide PA220 material or in 316L stainless steel. These materials could be serialized using gamma irradiation or ethylene oxide gas. The steel models were suitable for autoclaving in the local CSSU.

The implants produced were accurate facsimiles of the original implant with dimensions within 0.7mm. The implants were cost effective, an example being a rim mesh was reproduced in polyamide PA220 plastic for £3.50 and in 316L stainless steel for £15. The models were produced within 10 days of scanning. The stainless steel trials were durable and suitable for reprocessing and resterilisation.

The production of durable, low cost and functional implant trials all completed in department was successful. The cost of production of each implant is so low that it would be offset if just one incorrect implant was opened during a single procedure. With some of the implants tested, the trials would have paid for themselves 100 times. This is a simple and cost saving technique that would help reduce department funding and aid patient care.

A tip-apex distance (TAD) greater than 25 mm is a strong predictor of screw cut-out in patients with intertrochanteric femoral fracture treated with a dynamic hip screw (DHS). We aim to show you a simple and reliable way to check this.

By calculating the sum of the distance from the tip of the screw to the apex of the femoral head on anteroposterior and lateral views the TAD is found. X-rays often have magnification errors and therefore measuring tools in digital x-ray systems will be inaccurate. The original method of calculating the TAD uses the known diameter of the screw to avoid magnification errors.

We found that due to the no-cylindrical shape of the screw shaft there is potential of an inaccurate measurement. By using the distance across the highest points of the thread a more accurate TAD can be calculated.

The distance across the highest points of the threads in all three of the most commonly used DHSs in the UK is 13 mm. If the measured distance from the tip of the screw to the apex of the femoral head in both the anteroposterior and lateral views is less than the measured distance across of the treaded diameter of the screw then the surgeon knows the TAD is less than 26 mm. This method can be used intraoperatively to check the TAD by looking at the fluoroscopy images in these two views.

Previous work has demonstrated vulnerability of the femoral nerve to damage by anterior acetabular retractors during THA. The aim of this study was to quantify the proximity of the femoral nerve to the anterior acetabulum, on cadaveric material and MRI studies.

A standard posterior approach to the hip was carried out in 6 fresh frozen cadaveric hemipelves. Following dislocation and removal of the femoral head, measurements were taken from the anterior acetabular lip to the posterior aspect of the femoral nerve as it passed over this point. 14 MRI studies of the hip were obtained from the local PACS database (7 male, 7 female; mean age 58 (range 32–80)). T1 weighted axial scans were reviewed. Measurements were obtained from the anterior acetabular lip to the posterior surface of the femoral nerve and artery, and the cross-sectional area of iliopsoas was calculated.

There was no significant difference between the mean distances to the femoral nerve in the cadaveric (24 mm) and MRI groups (25.3mm) (p=0.7). On MRI images, the distance between the acetabular wall and both the femoral artery (p=0.003) and femoral nerve (p=0.007) was significantly larger in men. The femoral artery is strikingly close to the acetabulum in females, passing a mean distance of 14.8 mm, whereas in males this was 23.9 mm. The mean femoral nerve distance was 28.7 mm in males and 21.9 mm in females. The cross-sectional area of iliopsoas was significantly smaller in women (5.97 cm² compared to 11.37 cm², p<0.001).

Both the femoral artery and nerve run in close proximity to the anterior acetabular lip. Care should be taken when placing instruments in this area to avoid neurovascular injury. The increased incidence of femoral nerve damage in women following THA may be due to the significantly smaller bulk of iliopsoas.

The Caledonian Technique ^TM has been widely accepted as a safe and effective way of improving post-operative recovery and reducing length of stay following total knee arthroplasty. In keeping with the principles of the enhanced recovery programme its use has slowly spread from specialised units into district general hospitals. There is little evidence using PROMs that supports the use of the Caledonian Technique in the DGH setting. The primary aim of this study was to find out whether the Caledonian Technique was being successfully implemented in this district general setting for TKA. The secondary aim was to identify whether there was a difference in the patients’ perspectives of success post discharge.

This is a prospective questionnaire-based cohort study of patients undergoing total elective TKA in this DGH. It was carried out at Forth Valley Royal Hospital, Larbert, Scotland between June 2011 and 2012. All patients undergoing elective TKA were asked to complete a questionnaire assessing pain, mobilisation, function and satisfaction at 6 weeks post-operatively. Case notes of all returned questionnaires were reviewed and surgeon, protocol followed (Caledonian or non-Caledonian), length of stay, analgesic requirements, discharge analgesia and complications recorded.

We have shown that length of stay, analgesic requirement and cost were all less in the Caledonian group (n=17) compared to non-Caledonian (n=17). In addition there were statistically significant increases in patients mobilising on day 1 and achieving opiate free discharge in the Caledonian group. Patient satisfaction was higher in 11 out of 12 PROMs post discharge.

This confirms that previously shown improvements in length of stay and early mobilisation seen in specialised units can also be achieved in the DGH setting. Secondly it also shows that there is no negative impact on patient satisfaction and outcomes following early mobilisation and discharge.

Few doctors answer their bleep by stating who they are. Answering the phone in a formal manner is of utmost importance in the hospital setting especially by on-call teams who are normally referred patients by other specialties, general practitioners and in some cases by other hospitals.

An audit to evaluate the internal hospital communication was completed. In the first part of this audit, junior doctors within the orthopaedic department at the RAH were bleeped. Doctors were expected to answer by initiating the conversation by stating (1) name, (2) department, (3) grade and (4) a greeting. A list of omissions was recorded. If the call went through switchboard, it was expected that the hospital name was stated. The second part of the audit extended to other specialties in the RAH as well as orthopaedic departments in hospitals within the Greater Glasgow and Clyde health board (NHS GGC).

Forty-three bleeps were made to doctors of various grades over a period of two months. Nine bleeps (two from other hospitals) were not answered. Five doctors answered their bleep in full. Only twenty-one doctors stated their name whilst eleven stated their grade. In both instances the department was not necessarily stated. The results were similar between the different departments as well as between the seven hospitals offering an orthopaedic service within NHS GGC. Of the thirteen on-call doctors that were bleeped as an external call through switchboard, only one doctor stated the hospital name. This has implications since most hospitals within NHS GGC share a common switchboard.

These results emphasise the need for a protocol within NHS GGC for a standard etiquette for intra and inter hospital communication to ensure that patient safety and confidentiality is safeguarded.

To collate and present epidemiological data collected by Scottish National Brachial Injury Service over the past decade.

The Brachial Plexus Injury Service is based at the Victoria Infirmary, Glasgow and has been a designated National Service since 2004. It provides an integrated multidisciplinary service for traumatic brachial plexus injury and plexus tumours. The Service maintains an active archive recording details of all clinical referrals and procedures conducted by the Service over the past decade. The data presented here was derived from analysis of this database and information contained in the National Brachial Plexus Injury Service Annual Report 2010/11 & 2011/12.

Data shows that there has been a steady rate in the number of referrals to the Service, particularly since 2004, with an average of 50 cases referred per annum. Of these, approximately 25% required formal surgical exploration for traumatic injury and a further 10% required surgery for brachial plexus tumour removal. The vast majority of referred cases are treated non-operatively, with appropriate support from specialist physiotherapy and occupational therapy. Referrals to the Service appear well distributed from around Scotland. However, data from 2011 shows that Greater Glasgow & Clyde is the greatest individual source of referrals and subsequent hospital admissions for surgical treatment. The commonest mechanism of brachial plexus injury appears to be secondary to falls and motorcycle RTA. Using the Disabilities of the Arm, Shoulder and Hand (DASH) Score, improved functional outcomes have been demonstrated consistently in patients who have undergone surgery for brachial plexus injuries within the Service.

Over the past decade, the Brachial Plexus Injury Service has had a steady patient referral record from across the Scotland, particularly Glasgow. Data indicates that there is an on-going clinical need for provision of the service with improved outcomes and reduced functional disability in patients treated by the service. It is envisaged that data from the Service will also act as a useful planning model for the provision of UK national services in the future.

Metal on metal (MoM) bearings in hip surgery may result in increased blood levels of metal ions. The nature of the relationship between ion levels and failure is still not fully understood.

We compared three cohorts of resurfacing patients, grouped for brand and diameter of femoral component. We measured the blood level of Cobalt and Chromium ions at an average of 4 years postoperatively. The results were grouped as follows: Birmingham Hip Resurfacing ≥50 mm diameter, Durom resurfacing ≥50 mm diameter and Durom resurfacing <50 mm diameter.

120 patients were included in each group. There were significant differences in Cobalt levels between the groups. The median cobalt level for the BHR group was 8 nmol/L higher than the Durom ≥50 mm group (P<0.005). The Durom <50 mm group recorded cobalt levels 8.5 nmol/L higher than the Durom ≥50 mm group (P=0.0004). Revision rates were equal in the Large BHR's and Large Durom HRA (both 3.3%) however the small Durom HRA had a revision rate of 8.3%.

Elevated blood ion levels can indicate a failing MoM bearing. When similar ion levels were reported for BHR and small Durom the latter had significantly higher revision rates. The large BHR and large Durom HRA have similar revision rates yet the large Durom HRA had significantly lower metal ion levels. Only one of the patients having revision surgery (n=18) had metal ion levels above the MHRA threshold. This suggests ion levels do not absolutely predict the rate of HRA failure. Given similar revision rates with different ion levels between the large BHR and large Durom hips, mechanisms of failure leading to revision must be isolated from the release of metal ions. Therefore clinical and image based follow up are recommended in addition to ion level monitoring.

The link between squeaking and ceramic on ceramic (CoC) bearings has been widely reported in orthopaedic literature and is described as a hard bearing phenomenon. We aim to look at the incidence of noise in CoC bearings compared to Metal on Polyethylene (MoP) bearing, which have yet to be linked to squeaking.

We developed a noise characterizing hip questionnaire and sent that along with the Oxford Hip Score (OHS) to 1000 patients; 3:2 ratio of CoC to MoP. 282 CoC patients and 227 MoP patients returned the questions: 509 patients in total. Our patient database provided details on femoral head size and the acetabular inclination angle, for each respondent

47 (17%) of the CoC hip patients reported noise compared to 19 (8%) of the MoP hip patients (P=0.054). 9 CoC patients and 4 MoP patients reported squeaking, while clicking was the most frequent answer in both groups. 27% patients with noise reported avoiding recreational activities because of it. Patient's with noisy hips scored on average, 5 points worse in the OHS (CoC: P = 0.04 and MoP: P = 0.007) and were on average 5 years younger (CoC: P<0.001 and MoP: P=0.007). No correlation was found between noisy hips and femoral head size or inclination angle.

The squeaking hip phenomenon is not exclusive to hard bearing THA. Noise from patient's hips may have social implications and this should be highlighted when consenting a patient for either of these hip procedures. In both implants, we showed there to be a correlation between noise production and a lower OHS. However, longer follow up studies are needed to link noise to a poorly functioning implant

We reviewed renal function of 22 patients who had undergone total knee replacements using the enhanced recovery protocol (Caledonian technique) between August 2012 and November 2012 at a district general hospital in the west of Scotland. Pre-operative and post operative data were compared to determine if there was any change. We observed that 4 out of 22 (18%) of patients had a significant rise in creatinine, and 6 out of 22 (27%) had an abnormal eGFR. These findings were significant and were classed as (Acute Kidney Injury) AKI type 1, which should be treated actively.

Subsequently, we collected data in the same way for 22 patients who underwent total knee replacements without using the enhanced recovery protocol. In this group, only one (5%) had a significant rise in creatinine and 2 (9%) had an abnormal eGFR.

Significant difference is noted in the two groups.

We conclude that the enhanced recovery protocol has some adverse effect on a patient's renal function. Our hypothesis is that this is due to restriction of fluids after surgery but a larger study is needed to find the cause and ways to avoid this.

Currently, the cement being used for hemiarthroplasties and total hip replacements by the authors and many other surgeons in the UK is Palacos® (containing 0.5g Gentamicin). Similar cement, Copal® (containing 1g Gentamicin and 1g Clindamycin) has been used in revision arthroplasties, and has shown to be better at inhibiting bacterial growth and biofilm formation. We aim to investigate the effect on SSI rates of doubling the gentamicin dose and adding a second antibiotic (clindamycin) to the bone cement in hip hemiarthroplasty.

We randomised 848 consecutive patients undergoing cemented hip hemiarthroplasty for fractured NOF at one NHS trust (two sites) into two groups: Group I, 464 patients, received standard cement (Palacos®) and Group II, 384 patients, received high dose, double antibiotic-impregnated cement (Copal®). We calculated the SSI rate for each group at 30 days post-surgery. The patients, reviewers and statistician were blinded as to treatment group.

The demographics and co-morbid conditions (known to increase risk of infection) were statistically similar between the groups. The combined superficial and deep SSI rates were 5 % (20/394) and 1.7% (6/344) for groups I and II respectively (p=0.01). Group I had a deep infection rate 3.3 %(13/394) compared to 1.16% (4/344) in group II (p=0.082). Group I had a superficial infection rate 1.7 % (7/394) compared to 0.58% (2/344) in group II (p=0.1861). 33(4%) patients were lost to follow up, and 77 (9%) patients were deceased at the 30 day end point. There was no statistical difference in the 30 day mortality, C. difficile infection, or the renal failure rates between the two groups.

Using high dose double antibiotic-impregnated cement rather than standard low dose antibiotic-impregnated cement significantly reduced the SSI rate (1.7% vs 5%; p=0.01) after hip hemiarthroplasty for fractured neck of femur in this prospective randomised controlled trial.

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 arthroplasty 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 (123 mW/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 (greater than a 4-log reduction) was achieved for all of the clinical isolates from infected arthroplasty cases. The typical inactivation curve showed a slow initial reaction followed by a period of rapid inactivation. The doses of HINS-light exposure required ranged from 118–2214 J/cm² respectively. Gram-positive bacteria were generally found to be more susceptible than Gram-negative.

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.

Consequent upon a retrospective audit of all acute tibial nail patients within GRI in 2010, it was agreed, due to variable follow-up, imaging and requirement for secondary intervention, a standardised protocol for management of acutely nailed tibial fractures within GRI was to be established. Subsequently, a Nurse Led Tibial Nail Clinic commenced in July 201. The majority of consultants (11 of 13) devolving follow up of these patients to a protocol based algorithm designed on evidence based principles and consensus expert opinion.

Aims were to standardise/improve management of tibial nail patients in terms of patient education, weight bearing, imaging, follow-up intervals and also coordinate secondary intervention via a single consultant with an interest in limb reconstruction/non union. A secondary goal was to achieve measureable outcome data for this subgroup of patients.

All patients underwent post operative radiographs prior to discharge, review in clinic at 10 days for wound assessment, 6 weeks for physiotherapy and 12 weeks where standard AP and lateral tibial radiographs were repeated. Patients are discharged at 12 weeks if the radiographs confirm bony healing on three cortices or more and fractures are clinically united. If not, repeat x rays are undertaken at 20 weeks. A parallel consultant led limb reconstruction clinic is available to review patients failing to demonstrate satisfactory progression to union with secondary intervention instigated thereafter as appropriate.

Since commencement of the Nurse Led Tibial Nail Clinic, 60 patients have been treated with a tibial nail, 44 managed in the Tibial Nail Clinic. The mean number of radiographs has reduced from 6.4 to 3.1 per patient to discharge. Clinic visits are reduced from 6.4 to 3.9 per patient to discharge. Non compliance is low with 4.6% of patients failing to attend. Secondary interventions have been low (13%), confirming a relatively benign course of healing for most patients treated with an IM nail for acute tibial fractures. There has been one non union, no deep infections, two nail removals and one DVT.

A protocol based specialist nurse led clinic is safe for patients, cost effective for the NHS and gives increased opportunity for measuring outcome and improving care in a previously heterogenously managed group of patients.

Low molecular weight heparin (LMWH) is frequently used as thromboprophylaxis after major orthopaedic surgery. Varying levels of non-adherence (5% to 45%) with outpatient LMWH has been reported. Oral direct thrombin inhibitors have been recommended by industry due to ease of administration. We aim to audit the compliance rate with outpatient LMWH treatment following primary total hip arthroplasties (THA) in our district general hospital (DGH).

Using the ORMIS computer system, we identified all primary THA performed in Monklands Hospital between July 2011 and August 2012. Patients’ case notes were analysed retrospectively, looking at operating surgeon's postoperative thromboprophylaxis instructions. We then conducted a telephone interview on patients discharged with outpatient LMWH to assess compliance.

There were 58 primary THAs performed during the audit period. 33 patients were discharged on outpatient LMWH, whilst 15 patients and 3 patients were discharged on aspirin and warfarin respectively. Seven patients were excluded as their discharge prescriptions were missing.

We successfully contacted 20 of the 33 patients discharged with outpatient LMWH. All respondents showed 100% compliance to the full course of treatment. 50% of patients self-administered; 30% were administered by district nurses and 20% by family members. 35% of patients preferred an oral tablet alternative, for its perceived ease of administration. Bruising and skin irritation were the reported problems in some patients, but these did not affect compliance.

Contrary to the previous published non-adherence rates, the compliance rate with outpatient LMWH after THA was high in our DGH. The patient counseling, and family/district nurse involvement in may have contributed to this. However, our numbers of patients are low but data collection continues.

Adequate range of knee motion is critical for successful total knee arthroplasty. While aggressive physical therapy is an important component, manipulation may be a necessary supplement. There seems to be a lack of consensus with variable practices existing in managing stiff postoperative knees following arthroplasty. Hence we did a postal questionnaire survey to determine the current practice and trend among knee surgeons throughout the United Kingdom.

A postal questionnaire was sent out to 100 knee surgeons registered with British Association of Knee Surgeons ensuring that the whole of United Kingdom was well represented. The questions among others included whether the surgeon used Manipulation Under Anaesthaesia (MUA) as an option for stiff postoperative knees; timing of MUA; use of Continuous Passive Motion (CPM) post-manipulation.

We received 82 responses. 46.3% of the respondents performed MUA routinely, 42.6% sometimes, and 10.9% never. Majority (71.2%) performed MUA within 3 months of the index procedure. 67.5% routinely used CPM post-manipulation while 7.3% of the respondents applied splints or serial cast post MUA. 41.5% of the surgeons routinely used Patient Controlled Analgaesia +/− Regional blocks. Majority (54.8%) never performed open/arthroscopic debridement of fibrous tissue for adhesiolysis.

Knee manipulation requires an additional anaesthetic and may result in complications such as: supracondylar femur fractures, wound dehiscence, patellar tendon avulsions, haemarthrosis, and heterotopic ossification. Moreover studies have shown that manipulation while being an important therapeutic adjunct does not increase the ultimate flexion that can be achieved which is determined by more dominant factors such as preoperative flexion and diagnosis. Manipulation should be reserved for the patient who has difficult and painful flexion in the early postoperative period.

Hip fracture is a common and serious injury affecting the elderly. Many patients have co-morbidities which may need to be investigated and treated before surgery but, conversely, delay in surgical management of these patients leads to increased morbidity and mortality. The Scottish Hip Fracture Audit (SHFA)¹ conducted in 2007 showed variations between hospitals in postponement rates for medical reasons. The report referred to 11 major clinical abnormalities described by McLaughlin² that were associated with poor postoperative outcomes and should be corrected before surgery.

This prospective audit took place in Monklands hospital for a duration of 6 weeks. All patients admitted to the orthopaedic firm from 14^th Oct 2012 to 26^th November 2012 with confirmed fracture neck of femur were prospectively included in the audit. A detailed review of the notes took place to identify whether delays were appropriate according to McLaughlin.

There were a total of 23 patients admitted during the audit period of which 21 were operated on and 2 patients treated conservatively. The mean age of this cohort was 82.8 (range 55–91) with a male to female ratio of 1:1.3. Sixteen cases (76%) were operated on within 48 hours of admission (11 cases – 52% within 24 hours). Five cases (24%) were delayed by more than 48 hours. Three cases (14%) were delayed due to lack of theatre time. Two patients (9.5%) were delayed due to request of ECHO for ?new murmur.

Our practice of managing hip fracture patients is similar to other units in Scotland with a deferral rate of approximately 25%. The patients who have a major clinical abnormality were appropriately investigated and treated before the surgery. Further improvement in management of the theatre time is needed as surgery is delayed for >24 hours in approximately 15% of medically fit hip fracture patients.

To assess the outcome of Offloading Knee brace (V-VAS) in the treatment of osteoarthritis of the knee.

A total of 147 patients with knee arthritis were included in this study. Eighty six patients were followed up retrospectively and 61 patients were followed up prospectively. Average follow up was about 3.4 years in retrospective group and 1.2 years in prospective group. The Oxford knee score, Pain score, Walking distance and Patient satisfaction were evaluated.

Average oxford scores before the brace was 19 and after the brace was 32. The pain scores before and after the brace was 8 and 3 respectively. The walking distance had improved to 900 yards. The patient satisfaction was 78%. Thirteen of eighty six patients in the retrospective group discontinued the brace, of these two had high tibial osteotomy, six patients had total knee replacement, one had unicondylar knee replacement, one patient had dislocation of patella and two elderly patients were house-bound because of medical problems.

The Off loading knee brace is effective in the management of osteoarthritis of the knee. Patient satisfaction is high when using the brace. However compliance may be an issue in some of the patients. Education and early appointment for brace re-fitting increases patient compliance.

Bracing is a beneficial treatment for severe medial OA of the knee.

Osteoarthritis of the trapezometacarpal joint is a common form of arthritis. At present, there is a significant void between conservative and operative managements. Viscosupplementation is occasionally considered as an in-between therapy.

We aimed to compare the therapeutic benefit of a single intra-articular injection of Sodium Hyaluronate (SH; Ostenil®mini) to a single intra-articular injection of Methylprednisolone Acetate (MA; Depomedrone) in the management of rhizarthrosis (TMOA; Trapezometacarpal Osteoarthritis).

A retrospective review was performed over a 12 month period. We reviewed 25 patients who had received a single injection of viscosupplementation (SH) performed with fluoroscopic guidance and had been followed up at 12 weeks. These patients were compared with 21 patients who had received a single steroid injection (MA) and had been followed up at 12 weeks.

Of the SH group, 52% (n = 13) reported some benefit from the injection. The MA group reported an 86% (n=18) benefit from the injection.

We found that a single injection of viscosupplementation (SH) is effective in relieving pain and improving function in about half of patients with rhizarthrosis (TMOA). The efficacy of a single steroid injection (MA), however, was superior with a far greater proportion of patients reporting analgesic and functional benefits.

Recent debate about changing population demographics and growing demands of younger patients has suggested a future explosion in the requirements for primary and revision lower limb arthroplasty (TKA/THA). This could represent a significant challenge for healthcare providers. This study aimed to predict the demands for lower limb arthroplasty in Scotland from 2010–2035.

Population figures (2004–2010) and projected population data (five year increments) were obtained from the National Records of Scotland. The numbers of arthroplasties from 2004–2010 were provided by the Scottish Arthroplasty Project. Data were divided into three age groups (40–69, 60–79, 80+). The first model used mean incidence for each age group from 2006–2010 applied to the projected population figures. The second used linear regression to give predicted incidences 2015–2035 which were then applied to the projected population. The third-for revisions – used incidence per number of primary arthroplasties.

For primary TKA model 1, comparing to 2010, showed demand increasing by 10% in 2020 and by 31% (to 8,650 procedures) in 2035. Model 2 gave increases of 60% and 161% respectively. An increase was found across all age groups with 60–79 more than doubling and 80+ increasing fourfold by 2035 (model 2). The revision TKA models predicted between 670 and 2,000 procedures by 2035. For primary THA models 1 and 2 showed demand increasing by 40% in 2020 and then by 60% and 110% (11,000 and 14,500 procedures) in 2035 respectively. All age groups had increasing demand with 60–79 doubling and 80+ tripling by 2035 (model 2). The revision THA models predicted between 1,300 and 2,100 procedures by 2035.

These projections show large increases in the numbers of both primaries and revisions over the next two decades. They highlight that current resources may be insufficient or the selection criteria for surgery may need to be revisited.

Component malrotation in total knee arthroplasty (TKA) is a reason for early failure and revision. Assessment of possible component malrotation using computed tomography (CT) might be useful when other differentials have been excluded. The aims of our study were to determine the proportion of symptomatic patients with component malrotation on CT, and review the subsequent management of such patients.

A retrospective review of case notes was performed locally for all patients who had a CT scan for a painful TKA. Measurements of the femoral and tibial component rotations were done according to the standard Berger protocol, giving net degrees of either external rotation (ER) or internal rotation (IR). Any subsequent surgery was noted, and patients were followed up as per local practice.

Between 2007 and April 2012, 69 knees in 68 patients had CT scans. There were 25 males and 43 females, and mean age at primary surgery was 65.03 years. The mean femoral component rotation for all knees was 0.1° ER (range 7.0° ER – 6.7° IR), and the mean tibial component rotation for all knees was 19.1° IR (6.6° ER – 37.0° IR). No statistically significant difference was found comparing the mean femoral and tibial component rotations between patients with and without further surgery. Further surgery was performed on 39 (56.5%) knees.

Overall, there were ten cases (14.5%) of isolated femoral malrotation, 26 tibial malrotation (37.7%), and two cases (2.9%) had malrotation of both components. Out of these 38 cases, secondary surgery was performed in 22 knees (57.9%), of which a satisfactory outcome was achieved in fifteen cases (68.1%).

It is impossible to establish component malrotation as the only cause of pain following TKA, however, our study does show that the Berger protocol has its uses when other causes have been excluded.

Most lumps found in the extremity are benign. Some, however, are not. An approach to tertiary referral is required to accommodate the need for specialist evaluation of all concerning lumps, while maintaining an acceptable time to diagnosis and definitive management. We describe a new approach to tertiary sarcoma service, utilising modern communication technology and the “virtual clinic” approach.

The surgical treatment options for patients who have sustained an intra-capsular hip fracture can vary depending on a number of patient and fracture related factors. Currently most national guidelines support the use of cemented prostheses for patient undergoing hemiarthroplasty surgery. Uncemented prostheses are commonly used for a variety of indications including those patients who have significant medical co-morbidities.

To determine whether cemented hemiarthroplasty is associated with a higher post operative mortality when compared to uncemented procedures. Data were extracted from the Scottish SMR01 database from 01/04/1997 from all patients who were admitted to hospital after sustaining a hip fracture. We investigated mortality at day 1,2,4,7,30, 120 and 1 year from surgery vs. that on day 0. In order to control for the effects of confounding variables between patients cohorts, 12 case-mix variable were used to construct a multivariable logistic regression analysis model to determine the independent effect of prosthesis design.

There were 52283 patients included in the study. Mortality for osteosynthesis of extra-capsular fractures was consistently lower when compared to that for surgical procedures for intra-capsular fractures. At day 0, uncemented hemiarthroplasty had a lower associated mortality (p<0.001) when compared to cemented implant designs. However, this increased mortality was equal to 1 extra death per 2000 procedures. From day 1 onward mortality for cemented procedures was equal to or lower than that of uncemented. By day 4, cumulative mortality was less for cemented than for uncemented procedures. Complication and re-operation rate was significantly higher in the uncemented cohort.

The use of uncemented hemiarthroplasty for the treatment of intra-capsular hip fractures cannot be justified in terms of early/late post-operative mortality.

Recent studies have shown that random disorder nanotopography increases osteoblast differentiation and bone formation. This has great potential merit in producing surfaces where osteointegration is required such as spinal fusion surgery and arthroplasty. However, the long-term failure of orthopaedic implants is often related to osteoclast mediated osteolysis and loosening. It is vitally important that we understand the effect of nanotopography on osteoclast formation and bone remodeling.

We developed an unique osteoblast/osteoclast co-culture system derived from human mesenchymal and haematopoetic stem cells. This was co-cultured on both nanopatterned and unpatterned polycarbonate substrates. We assessed the co-culture using electron microscopy (SEM), protein expression using immunofluorescence and histochemical staining and gene expression using polymerase chain reaction (PCR).

Co-culture of both osteoclasts and osteoblasts was confirmed with mature bone nodules and resorption pits identified on both surfaces. Significantly increased osteoblast differentiation and bone formation was noted on disordered nanotopography. Antagonistic genes controlling osteoclast activity were both upregulated with no significant difference in osteoclast marker gene expression.

Our results confirm successful co-culture of osteoblasts and osteoclasts using an unique method closely resembling the in vivo environment encountered by orthopaedic implants. Nanotopography increases osteoblast differentiation and bone formation as previously identified, with possible subsequent increase in osteoclast mediated bone turnover.

Current knowledge regarding upper limb myotomes is based on historic papers. Recent advances in magnetic resonance imaging (MRI) and surgical exploration with intraoperative nerve stimulation now allow accurate identification of nerve root injuries in the brachial plexus. The aim of this study is to identify the myotome values of the upper limb associated with defined supraclvicular brachial plexus injuries.

57 patients with partial supraclavicular brachial plexus injuries were identified from the Scottish brachial plexus database. The average age was 28 years and most injuries secondary to motor cycle accidents or stabbings. The operative and MRI findings for each patient were checked to establish the root injuries and the muscle powers of the upper limb documented.

The main patterns of injuries identified involved (C5,6), (C5,6,7), (C5,6,7,8) and (C8, T1). C5, 6 injuries were associated with loss of shoulder abduction, external rotation and elbow flexion. In 30% of the 16 cases showed some biceps action from the C7 root. C5,6,7 injuries showed a similar pattern of weakness with the additional loss of flexor carpi radialis and weakness but not total paralysis of triceps in 85% of cases. C5,6,7,8 injuries were characterised by loss of pectoralis major, lattisimus dorsi, triceps, wrist extension, finger extension and as well as weakness of the ulnar intrinsic muscles. We identified weakness of the flexor digitorum profundus to the ulnar sided digits in 83% of cases. T1 has a major input to innervation of flexors of the radial digits and thumb, as well as intrinsics.

This is the largest study of myotome values in patients with surgically or radiologically confirmed injuries in the literature and presents information for general orthopaedic surgeons dealing with trauma patients for the differentiation of different patterns of brachial plexus injuries. In addition we have identified new anatomical relationships not previously described in upper limb myotomes.