Isolated Weber B fractures usually heal uneventfully but traditionally require regular review due to the possibility of medial ligament injury allowing displacement. Following recent studies suggesting that delayed talar shift is uncommon we introduced a functional treatment protocol and present the early results.

86 patients presenting acutely with Weber B fractures without talar shift between January and July 2015 were included. Patients were splinted in a removable boot and allowed to weight bear. ED notes and radiographs were reviewed by an Orthopaedic consultant. Patients without signs of medial injury were discharged with an information leaflet and advice. If signs of medial ligament injury were noted or the medial findings were not documented the patient was reviewed in fracture clinic at 4 weeks post-injury. If talar shift developed the patient was to be converted to operative treatment. MOXFQ and EDQ5 scores were collected.

50 patients had signs of medial ligament injury or no documented medial findings and of these 43 attended fracture clinic. Of 36 patients without signs of medial ligament injury 28 were discharged according to protocol and 8 patients attended fracture clinic. One discharged patient re-accessed care. Of 52 patients reviewed in the fracture clinic none developed delayed talar shift and all continued with non-operative treatment. The outcome scores were comparable to those in the published literature.

We conclude the risk of delayed talar shift is low and satisfactory outcomes can be safely achieved with our functional protocol. Additional tests/imaging to establish the integrity of the medial ligament may be unnecessary.

We have previously reported that fibular nailing in the elderly is associated with a significantly reduced complication rate and greater cost-effectiveness when compared to ORIF. The aim of this study was to compare the outcomes of fibular nailing to ORIF in patients under the age of 65.

100 patients aged 18 to 64 were randomly allocated between groups. Outcomes assessed over two years post-operatively included: development of wound complications or radiographic arthritis, the accuracy of reduction and patient satisfaction. The mean age was 44, 25% of patients were smokers and 35% had some form of comorbidity of whom three were diabetic. 27 injuries occurred after sport and two after assault the remainder occurred after a simple fall from a standing height.

Superficial wound infections occurred in two patients in each group. Six patients requested removal of the nail, and six patients requested plate and screw removal. Patient reported outcome scores were comparable for the two groups. Two failures of fixation occurred in the fibular nail group; one in a patient with neuropathy. One failure of fixation occurred in the ORIF group. All other patients went on to an anatomical union without complication. Patient satisfaction with the surgical scar was higher after fibular nailing (visual analogue scale mean 0.75, range 0–5) than for ORIF (mean 1.5, range 0–7).

The fibular nail allows accurate reduction and secure fixation of ankle fractures with comparable radiographic and patient-reported outcomes to ORIF at two years and a greater patient satisfaction with the appearance of the surgical scars.

By the end of training, every registrar is expected to demonstrate proficiency in total knee replacement (TKR). It is unclear whether functional outcomes for knee arthroplasty performed by training grade doctors under supervision of a consultant have equivalent functional outcomes to those performed by consultants.

This study investigated the functional outcomes following TKR in patients operated on by a supervised orthopaedic trainee compared to a consultant orthopaedic surgeon. Patients undergoing surgery by a consultant (n=491) or by a trainee under supervision (n=145) between 2003 and 2006 were included. There was a single implant, approach and postoperative rehabilitation regime. Patients were reviewed eighteen months, three years and five years postoperatively.

There were no significant differences in preoperative patient characteristics between the groups. There was no difference in length of stay or transfusion or tourniquet time. Both consultant (p<0.001) and trainee (p<0.001) groups showed significant improvement in AKSK and AKSF scores between preoperative and 18 month review and there was no difference in the magnitude of observed improvement between groups (AKSK p=0.853; AKSF p=0.970). There were no significant differences in either score between the groups preoperatively or at any review point postoperatively. At five years postoperative, both groups had a median OKS of 34 (p=0.921).

This is the largest reported series of outcomes following primary TKR examining functional outcome linked with grade of surgeon. It shows that a supervised trainee will achieve comparable functional outcomes at up to 5 years post operatively.

British national guidelines recommend agents which antagonise factor Xa or warfarin as prophylaxis of venous thromboembolism (VTE) in lower limb arthroplasty. However, they discourage the use of aspirin prophylaxis.

We conducted a prospective, multi-centre audit between two national centres, Ninewells Hospital in Dundee and the Royal Infirmary in Edinburgh to compare bleeding and VTE risk. Only Edinburgh routinely uses aspirin as VTE prophylaxis. The study comprises a number of cycles from 2013 to 2015. Consecutive groups of patients were identified prospectively using elective theatre data and information extracted from their case-notes on type of VTE prophylaxis, VTE occurrence, wound complications and length of hospital stay for a period of nine weeks post-operatively.

262 Edinburgh patients and 92 Dundee patients were included. Most Edinburgh patients were prescribed aspirin in hospital and on discharge (188/262, 71.8%), in line with local protocol. In Dundee, dalteparin was most commonly prescribed in hospital (68/92, 73.9%) and rivaroxaban on discharge (57/92, 62.0%).

The Edinburgh group had a 1.5% incidence of pulmonary embolus (PE) and a 1% rate of deep venous thrombosis (DVT), 2% had problems with wound haematoma and one patient (0.4%) required a transfusion; no wound washouts were required. In Dundee there was 0% PE, 2% DVT, 5% had problems with haematoma, 3% required transfusion and 2% required washout. There was no difference in length of hospital stay, with a mode of 4 days for both centres.

Non-fatal PE was prevented in Dundee patients but possibly at the cost of greater incidence of wound complications.

The availability of seven-day NHS services for patients is currently receiving widespread national attention. Rehabilitation services including physiotherapy and occupational therapy are not routinely available at the weekend. The aim of this pilot study was to determine if seven-day rehabilitation services led to improved outcomes for hip fracture patients.

All proximal femur fractures were included and formed into two cohorts. Data were collected prospectively in each cohort. Cohort one underwent standard five-day rehabilitation (n=79). Cohort two received seven-day rehabilitation (n=338). Both groups were followed up to 120 days.

No significant differences were observed between the cohorts for pre-fracture place of residence, ASA score or age. Combined median length-of-stay in hospital and rehabilitation improved from 28 to 21 days (p=0.054) Combined median length of stay for patients admitted from home improved from 26 to 19 days (p=0.016).

This pilot study suggests that a seven-day physiotherapy and occupational therapy service may result in decreased total length-of-stay in hospital and subsequent rehabilitation. This is a clear benefit for our patients but also for our hospitals and rehabilitation units where beds are at such a premium. A wider study across multiple institutions within NHS Scotland is now needed to investigate this further.

There is a paucity of published literature regarding the long-term outcomes of the modern generations of total joint arthroplasty (TJA) of the first metatarsophalangeal joint. Between 1999 and 2001, we recruited 63 patients into a randomised controlled trial of arthrodesis vs TJA. The 2 year results were published in 2005.

At a mean follow-up 15.2 years (range 13.2–17.2), all patients from the original trial were contacted. Data were collected in the form of visual analogue score for pain (VAS), visual-Analogue-Scale Foot and Ankle (VAS FA) as well as information on any revision procedures.

Data were available from all surviving patients (66 toes 53 patients). There was no difference in pain scores between the arthrodesis group and arthroplasty group 7.4 ± 15.7 vs 15.7 ± 19.7 (p=0.06). There was also no difference in the VAS FA scores as a whole 88.9 ± 12.9 vs 86.1 ± 17.1 (p = 0.47), or when divided into its 3 components (pain, function and other complaints). There was however a significant difference with regards to patient satisfaction with the arthrodesis group outperforming the TJA group: 95.5 ± 10.4 vs 83.6 ± 20.9 (p<0.01). There was a significantly higher rate of revision surgery in the TJA group when compared to the arthrodesis group (p= 0.009).

At 15 years the patients that underwent arthrodesis were more satisfied and had a greater survivorship compared to TJA, however there was no difference in outcome with regards to pain or function between the two groups. Based on the results of this study arthrodesis remains the ‘gold standard’ due to excellent pain relief, high function and low risk of revision surgery.

Adequate perpendicular access to the posterolateral talar dome for osteochondral defect repair is difficult to achieve and a number of different surgical approaches have been described. This cadaveric study examined the exposure available from various approaches to help guide pre-operative surgical planning.

Four surgical approaches were performed in a step-wise manner on 9 Thiel-embalmed cadavers; anterolateral approach with arthrotomy, anterolateral approach with anterior talo-fibular ligament (ATFL) release, anterolateral approach with antero-lateral tibial osteotomy, and anterolateral approach with lateral malleolus osteotomy. The furthest distance posteriorly which allowed perpendicular access with a 2mm k-wire to the lateral surface of the talar dome was measured from the anterior aspect of the talar dome.

The mean antero-posterior diameter of the lateral talar domes included in this study was 45.1mm. An anterolateral approach to the ankle with arthrotomy provided a mean exposure of the anterior 1/3rd of the lateral talar dome. ATFL release increased this to 43.2%. A lateral malleolus osteotomy provided superior exposure (81.5% vs 58.8%) compared to an anterolateral tibial osteotomy.

Only the anterior half of the lateral border of the talar dome could be accessed with an anterolateral approach without osteotomy. A fibular osteotomy provided best exposure to the posterolateral aspect of the talar dome and is recommended for lesions affecting the posterior half of the lateral talar dome.

There is a lack of information about the association between patellofemoral osteoarthritis (PFOA) and both adolescent Anterior Knee Pain (AKP) and previous patellar dislocations.

This case-control study involved 222 participants from our knee arthroplasty database answering a questionnaire. 111 patients suffering PFOA were 1:1 matched with a unicompartmental tibiofemoral arthritis control group. Multivariate correlation and binary logistic regression analysis was performed, with odds ratios (ORs) and 95% confidence intervals (CIs) calculated. This analysis helps us assess the effect of both variables whilst adjusting for major confounders, such as previous surgery and patient-reported instability.

An individual is 7.5 times more likely to develop PFOA if they have suffered adolescent AKP (OR 7.5, 95% CIs 1.51–36.94). Additionally, experiencing a patellar dislocation increases the likelihood of development of PFOA, with an adjusted odds ratio of 3.2 (95% CIs 1.25–8.18). A 44-year difference in median age of first dislocation was also observed between the groups.

This should bring into question the traditional belief that adolescent anterior knee pain is a benign pathology. Patellar dislocation is also a significant risk factor. These patients merit investigation, we encourage clinical acknowledgement of the potential consequences when encountering patients suffering from anterior knee pain or patellar dislocation.

25–40% of unicompartmental knee replacement (UKR) revisions are performed for unexplained pain possibly secondary to elevated proximal tibial bone strain. This study investigates the effect of tibial component metal backing and polyethylene thickness on cancellous bone strain in a finite element model (FEM) of a cemented fixed bearing medial UKR, validated using previously published acoustic emission data (AE).

FEMs of composite tibiae implanted with an all-polyethylene tibial component (AP) and a metal backed one (MB) were created. Polyethylene of thickness 6–10mm in 2mm increments was loaded to a medial load of 2500N. The volume of cancellous bone exposed to <−3000 (pathological overloading) and <−7000 (failure limit) minimum principal (compressive) microstrain (µ∊) and >3000 and >7000 maximum principal (tensile) microstrain was measured.

Linear regression analysis showed good correlation between measured AE hits and volume of cancellous bone elements with compressive strain <−3000µ∊: correlation coefficients (R= 0.947, R2 = 0.847), standard error of the estimate (12.6 AE hits) and percentage error (12.5%) (p<0.001). AP implants displayed greater cancellous bone strains than MB implants for all strain variables at all loads. Patterns of strain differed between implants: MB concentrations at the lateral edge; AP concentrations at the keel, peg and at the region of load application. AP implants had 2.2 (10mm) to 3.2 (6mm) times the volume of cancellous bone compressively strained <−7000µ∊ than the MB implants. Altering MB polyethylene insert thickness had no effect. We advocate using caution with all-polyethylene UKR implants especially in large or active patients where loads are higher.

Alcohol-based cutaneous disinfectant use is well established in the surgical environment. However, during scrubbing, volatile alcohols are inspired into the pulmonary system. With the recent reduction in the national drink driving limit, even low levels of detected breath alcohol can have legal implications. This study aimed to determine the extent to which passive inhalation of alcohol-based surgical hand disinfectant affects estimated percentage blood alcohol concentration (%BAC) on breathalyser testing.

Over a one week period (September 2015), 24 theatre team members (13 surgeons, 6 scrub staff and 5 anaesthetists) were prospectively recruited. The mean cohort age was 43.7 years (50% female). Participants were instructed to scrub for 90 seconds with an alcohol-based hand disinfectant comprising of the active ingredients (per 100g): propan-1-ol 30.0g, propan-2-ol 45.0g and mecetroniumetilsulphate 0.2g. Estimated %BAC was recorded immediately before and after scrubbing, and every five minutes thereafter until levels returned to 0.00%BAC. Results ≥ 0.05%BAC were deemed above the Scottish legal driving limit.

All participants exceeded the 0.05%BAC threshold on immediate post scrub testing. The mean peak %BAC was 0.12% (± 0.05) with a maximum BAC documented at ≥0.20% in four subjects. In all participants, the %BAC descended to zero over a period ranging from 10–30 minutes with a mean time to zero of 16.7 (± 4.8) minutes.

Following the use of alcohol-based surgical hand disinfectant, estimated blood alcohol concentrations detected on breath sampling can rise up to four times the Scottish driving limit which may have legal and professional ramifications.

Our unpublished data has indicated that the perivascular stem cells (PSCs) have increased chondrogenic potential compared to mesenchymal stem cells (MSCs) derived in culture. There has been a recent change in the theory that stem cells work by a paracrine effect rather than differentiation. There are minimal data demonstrating the persistence of implanted stem cells when used for engraftment. This study aimed to develop an autologous large animal model for perivascular stem cells as well as to determine if cells were retained in the articular cartilage defects.

The reactivity of anti-human and anti-ovine antibodies was ascertained using immunohistochemistry and fluorescence-activated cell sorting (FACS). A panel of antibodies were combined and used to identify and purify pericytes (CD34-CD45-CD146+) and adventitial cells (CD34+CD45-CD146-) using FACS. The purified cells were cultured and their identity checked using FACS. These cultured cells demonstrated osteogenic, adipogenic and chondrogenic potential.

Autologous ovine PSCs (oPSCs) were isolated, cultured and transfected using a GFP virus. The transfection rate was 88%. The cells were implanted into an articular cartilage defect on the medial femoral condyle using a hydrogel, four weeks following implantation the condyle was explanted and confocal laser scanning microscopy demonstrated the presence of oPSCs in the defect. Histology did not demonstrate any repair tissue at this early time point.

These data have confirmed the viability our large animal model and that the implanted stem cells were retained in the defect four weeks following implantation.