Objectives

Congenital cruciate ligament deficiency is a rare condition that may occur in isolation or in association with longitudinal limb deficiencies such as fibular hemimelia or proximal femoral focal deficiency. Often anomalies of the menisci and their attachments can be very abnormal and impact on surgical management by standard techniques. Arthroscopic surgical knee reconstruction is undertaken to improve symptomatic instability and/or to stabilise and protect the knee for future planned limb lengthening surgery.

The aim of this study is to evaluate the arthroscopic findings of patients undergoing surgery for congenital cruciate ligament deficiency, and specifically to determine the frequency and types of meniscal anatomical variations seen in these cases.

With the recent reductions in junior doctor hours levels of staffing have become ever more critical as clinical duties are covered with fewer junior doctors available on a daily basis. Trainees also have to meet specific requirements of the curriculum and thus need to be allocated to posts with suitable opportunities. There is little evidence available to account for the allocation of posts to individual trusts and departments with training post numbers seem driven by historical allocation, rather than based on trainee and local population needs.

‘SHO’ tier numbers were obtained for each orthopaedic department within the Yorkshire deanery through direct contact with the departments. Data was also obtained to establish the workload of these departments. Information was gathered from the national neck of femur database, hospital episode statistics, the national joint registry, the trauma audit and research network (TARN) and finally Dr Foster and the national census. The workload data was then analysed and compared to the staffing levels in each department.

Data was obtained for fourteen trusts across the Yorkshire Deanery. The percentage of SHO tier doctors in training posts ranged from 0 to 78% (mean 37%) across the trusts surveyed, with wide variation in make up of the SHO tier in each department.

Workload was standardised using the unit of cases/SHO/annum. The workload for neck of femur fractures ranged from 8 to 52 cases/SHO/annum (mean 36). General trauma admissions ranged from 199 to 383 cases/SHO/annum (mean 288). Elective arthroplasty admissions ranged from 11 to 174 (mean 70). Pearson correlation coefficients were 0.5 for elective arthroplasty and neck of femur admissions and 0.8 for trauma admissions.

There is wide variation in workload between trusts when standardised for the number of SHO's with weak to moderate correlations between the number of juniors and workload in each department. This wide variation will impact on patient care, but also the training opportunities available in different posts – where workload is higher it is likely there will be an increased need for ward based work away from clinics and theatre lists.

The introduction of the foundation programme and MMC has changed the structure of the SHO grade at a time when the EWTD introduction has also had a profound impact on working patterns and hours. At this time we believe there is a need for a review of trainee allocations nationally with comparison to workload in each trust, trainee logbook data and data on curriculum competencies met. With the proposed reductions in trainee numbers now is the time for a centrally led review of these posts via the Royal College, BOA and BOTA to ensure high quality training, maintain high standards of patient care and secure the future of the orthopaedic profession.

Background: Giant-cell tumour (GCT) of bone is a benign but aggressive tumour, usually treated by radical surgical curettage. Surgical treatment of GCT involving the ischium is associated with a high local recurrence rate. We describe a case in which serial arterial embolisation and bisphosphonate treatment resulted in radiological healing of the tumour. So far we have avoided surgical treatment.

Case Report: A 40-year-old lady was referred to the bone tumour unit following a fall. A plain radiograph of the pelvis revealed a lytic lesion in the ischium, extending into the posterior column of the acetabulum and associated with a pathological fracture. Biopsy confirmed a diagnosis of GCT. Given the anatomic location, the tumour was treated with serial arterial embolisation and intravenous zoledronate infusions. Follow up at one-year shows healing of the lesion, with no radiological evidence of recurrence. The patient has so far avoided surgery.

Discussion: Serial arterial embolisation has been described in the treatment of giant cell tumours in anatomical regions where surgery is likely to be associated with significant morbidity, such as the sacrum. There is a sound theoretical basis for the use of bisphosphonates in this disease; they have been shown to cause apoptosis of the osteoclast-like giant cells and interfere with osteoclast recruitment. As far as we are aware this is the first case described in which embolisation and bisphosphonate treatment appears to have led to healing and stabilisation of the lesion. The durability of this response remains uncertain.

CTEV is a difficult condition to treat with chances of recurrence, re-operation rate and over correction. Recent literature based on evidence is favourable with the Ponseti management. The aim of the study was to review our surgical results over a 5-year period using the Cincinnati approach.

Children with failure of conservative serial stretching and casting for 6 months underwent open release. The records and radiographs were reviewed retrospectively from 1997–2002. 60 patients were identified with 92 feet undergoing primary sub radical releases using the Cincinnati approach in 40 male and 20 female children. The mean age at surgery was 10 months. 55 patients were idiopathic with 3 syndromal and 2 teratological.

Consultants performed > 75% of operations, with k-wire stabilisation done in 46 patients and primary wound closure in 25; the majority of wounds were left open. The timing of plaster change varied, with the majority at 2 weeks. Wound problems occurred in 4 patients (significant in 2). All patients but one wore splints for an average length of 13 months. Complication rate was 20% comprising infection, over- correction and recurrence. Re-operation rate for early recurrence was 12%. Further surgery in the form of tibialis anterior transfer and derotation osteotomy was performed on 15% and 10% of feet respectively. 6 feet in 4 patients showed signs of significant over correction.

Wound healing by secondary intention of the Cin-cinnati approach is safe. Results and complications are comparable to other series, but not to the Ponseti non-operative management. Practice is now changed to the latter based on evidence.

We compared the long-term clinical outcome scores of the Stanmore total hip arthroplasty (THA) in patients with rheumatoid arthritis (RA, n=26 subjects) versus osteoarthritis (OA, n=35 subjects) at a mean of 12 years after THA. Patients with RA were a mean of 11 years younger at review (66 years, P< 0.001) than those with OA. A greater proportion of RA patients had bilateral THA (19/26 versus 12/35, p=0.03), and were of Charnley grade C (23/26 versus 2/35, p< 0.001). The proportion of male versus female subjects and body mass index were similar between groups (p> 0.05 all comparisons). The overall SF-12 score and SF-12 physical component score were 8% and 15% poorer, respectively, in subjects with RA versus those with OA (P< 0.05). The hip-specific Oxford and Harris hip scores, however, were similar between groups (p> 0.05). Within the individual domains of the Harris hip score, patients with RA had poorer scores for walking distance, stair climbing, putting on of socks/shoes, and ability to enter public transport (p< 0.05 all comparisons). The other domains of pain, limp, use of walking aids, sitting, deformity and range of movement were similar between groups (p> 0.05). The observed differences in outcome scores between RA and OA groups were independent of age and whether the patient had bilateral THA (ANOVA, p> 0.05). Clinical outcome scores in the long term after THA are poorer in RA subjects versus OA. The principal differences occur in the ability to walk long distances, and the use of stairs and public transport.

Aims: To test the hypothesis that there is a trend to over correction in patients who demonstrate signs of generalised joint laxity.

Patients and methods: 41 patients with an average age of 6.5yrs (3–15) were examined for generalised joint laxity using the Biro score. This gave 52 feet (11 bilateral) for clinical assessment using the podoscope and graded based on Tachdijans flat foot score.

Results: The results were assessed and the patients divided into 2 groups depending on whether or not they had joint laxity. This left 15 patients with 18 feet in the non-lax group and 26 patients with 34 feet in the lax group. The 2 groups were then compared to see if there was a difference in flat foot grade. In the non-lax group 2 patients showed evidence of over-correction whereas in the lax group 25 patients were over corrected to some extent. Using the fisher’s exact test there was a significant difference between the 2 groups with a trend towards over correction in those with generalised joint laxity (p = 0.002).

Conclusion: Based on the findings of this study there is a correlation between generalised joint laxity and over correction in congenital talipes equino-varus.

Aims: To test the hypothesis that there is a trend to over correction in talipes patients who demonstrate signs of generalised joint laxity.

Patients and Methods: 45 patients with an average age of 6.9yrs(3–16) were examined for generalised joint laxity using the Biro score. This gave 65 feet (20 bilateral) for clinical assessment using the podoscope and graded based on Tachdijans flat foot score.

Results: The results were assessed and the patients divided into 2 groups depending on whether or not they had joint laxity. This left 19 patients with 26 feet in the non-lax group and 26 patients with 39 feet in the lax group. The 2 groups were then compared to see if there was a difference in flat foot grade. In the non-lax group 2 patients showed evidence of over-correction whereas in the lax group 18 patients(25 feet)were over corrected to some extent. Using the fisher’s exact test there was a significant difference between the 2 groups with a trend towards over correction in those with generalised joint laxity (p=. 002).

Conclusion: Based on the findings of this study there is a correlation between generalised joint laxity and over correction in congenital talipes equinovarus.

To compare the results of anterior cruciate ligament reconstructive surgery with or without fluoroscopic control.

We retrospectively compared 2 groups of 15 patients who had ACL reconstruction between 1997–2001. Our primary concern was to see if a perioperative lateral x-ray significantly improved the position of the graft when compared with a similar group having no such x-ray.

All patients were reconstructed using an open bone-patella-bone technique.

Data was collected on patient demographics, previous surgery, time to reconstruction, operative time, and complications. The post–operative lateral x-ray was assessed and the relative position of the centre of the graft determined using a percentage for the tibial and femoral tunnels. The graft divergence angle and distance between the posterior femoral cortex and the centre of the graft was calculated.

All patients were male with equal mean age at reconstruction (29 yrs). The 2 groups were also similar in terms of previous surgery and time to reconstruction. In the group without x-ray control there were 2 graft failures due to anterior placement of the graft whereas in the x-ray control group there were no failures. The operative time was slightly longer in the x-ray group.

There was no significant difference between the 2 groups when comparing tibial tunnel placement and graft divergence. However the position of the femoral tunnel was significantly improved in the x-ray group when compared with the control group as measured by the distance between posterior femoral cortex and centre of graft (7mm vs 9mm) and also the relative position along Blumenstaat’s line (90% vs 75%).

The authors conclude that in our institution the use of Fluoroscopic control during ACL reconstructive surgery improved femoral tunnel placement.