Combined Partial Knee Arthroplasty (CPKA) is a promising alternative to Total Knee Arthroplasty (TKA) for the treatment of multi-compartment arthrosis. Through the simultaneous or staged implantation of multiple Partial Knee Arthroplasties (PKAs), CPKA aims to restore near-normal function of the knee, through retention of the anterior cruciate ligament and native disease-free compartment. Whilst PKA is well established, CPKA is comparatively novel and associated biomechanics are less well understood. Clinically, PKA and CPKA have been shown to better restore knee function compared to TKA, particularly during fast walking. The biomechanical explanation for this superiority remains unclear but may be due to better preservation of the extensor mechanism. This study sought to assess and compare extensor function after PKA, CPKA, and TKA. An instrumented knee extension rig facilitated the measurement extension moment of twenty-four cadaveric knees, which were measured in the native state and then following a sequence of arthroplasty procedures. Eight knees underwent medial Unicompartmental Knee Arthroplasty (UKA-M), followed by patellofemoral arthroplasty (PFA) thereby converting to medial Bicompartmental Knee Arthroplasty (BCA-M). In the final round of testing the PKA implants were removed a posterior-cruciate retaining TKA was implanted. The second eight received lateral equivalents (UKA-L then BCA-L) then TKA. The final eight underwent simultaneous Bi-Unicondylar Arthroplasty (Bi-UKA) before TKA. Extensor efficiencies over extension ranges typical of daily tasks were also calculated and differences between arthroplasties were assessed using repeated measures analysis of variance. For both the medial and lateral groups, UKA demonstrated the same extensor function as the native knee. BCA resulted in a small reduction in extensor moment between 70–90° flexion but, in the context of daily activity, extensor efficiency was largely unaffected and no significant reductions were found. TKA, however, resulted in significantly reduced extensor moments, leading to efficiency deficits ranging from 8% to 43% in flexion ranges associated with downhill walking and the stance phase of gait, respectively. Comparing the arthroplasties: TKA was significantly less efficient than both UKA-M and BCA-M over ranges representing stair ascent and gait; TKA showed a significant 23% reduction compared to BCA-L in the same range. There were no differences in efficiency between the UKAs and BCAs over any flexion range and TKA efficiency was consistently lower than all other arthroplasties. Bi-UKA generated the same extensor moment as native knee at flexion angles typical of fast gait (0–30°). Again, TKA displayed significantly reduced extensor moments towards full extension but returned to the normal range in deep flexion. Overall, TKA was significantly less efficient following TKA than Bi-UKA. Recipients of PKA and CPKA have superior functional outcomes compared to TKA, particularly in relation to fast walking. This in vitro study found that both UKA and CPKA better preserve extensor function compared to TKA, especially when evaluated in the context of daily functional tasks. TKA reduced knee extensor efficiency by over 40% at flexion angles associated with gait, arguably the most important activity to maintain patient satisfaction. These findings go some way to explaining functional deficiencies of TKA compared to CPKA observed clinically

A larger radial tuberosity, and therefore a smaller radioulnar space, may cause mechanical impingement of the DBT predisposing to tear. We sought to investigate anatomic factors associated with partial DBT tears by retrospectively reviewing 3-T MRI scans of elbows with partial DBT tears and a normal elbow comparison group. 3-T MRI scans of elbows with partial DBT tears and elbows with no known pathology were reviewed retrospectively by two independent observers. Basic demographic data were collected and measurements of radial tuberosity length, radial tuberosity thickness, radio-ulnar space, and radial tuberosity-ulnar space were made using simultaneous tracker lines and a standardised technique. The presence or absence of enthesophytes and the presence of a single or double DBT were noted. 26 3-T MRI scans of 26 elbows with partial DBT tears and 30 3-T MRI scans of 30 elbows without pathology were included. Basic demographic data was comparable between the two groups. The tear group showed statistically significant larger mean measurements for radial tuberosity length (24.3mm vs 21.3mm, p=0.002), and radial tuberosity thickness (5.5mm vs 3.7mm, p=<0.0001. The tear group also showed statistically significant smaller measurements for radio-ulnar space (8.2mm vs 10.0mm, p=0.010), and radial tuberosity-ulnar space (7.2mm vs 9.1mm, p=0.013). There was a statistically significant positive correlation between partial DBT tears and presence of enthesophytes (p=0.007) as well as between partial DBT tears and having two discrete DBTs rather than a single or interdigitating tendon (p=<0.0001). Larger radial tuberosities, and smaller radio-ulnar and radial tuberosity-ulnar spaces are associated with partial DBT tears. This may be due to chronic impingement, tendon delamination and consequent weakness which ultimately leads to tears. Enthesophytes may be associated with tears for the same reason. Having two discrete DBTs that do not interdigitate prior to insertion is also associated with partial tears

There has been a significant increase in the demand for arthroplasty as a result of the Covid 19 pandemic and lack of beds on the green pathway. The average length of in-hospital stay following knee replacements has been successfully reduced over the years following introduction and adoption of enhanced recovery protocols. Day case arthroplasty has the potential to be efficient as well as cost-effective. We present our day case pathway for elective knee arthroplasty and early results of its adoption at a district general hospital. Our pathway was developed through a multidisciplinary input from surgeons, anaesthetists, physiotherapists, nursing staff, administrative staff, surgical care practitioners and pharmacists. Inclusion criteria were defined to identify patients suitable for cay case arthroplasty. Results of 32 patients who underwent day case partial and total knee replacement at our institution between 2018 to 2022 are presented. 31 out of 32 (97%) were discharged safely on the day of surgery. Patients were discharged at a mean of 7 hours following surgery. There were no re-admissions following discharge. There were no surgical complications at a mean follow-up of 2 years. Patient feedback revealed high levels of satisfaction and that they would recommend the pathway to others. Cost analysis revealed savings towards bed costs. Our early results demonstrate day case knee arthroplasty to be safe and cost effective. With limited resources to tackle the enormous backlog of arthroplasty, it offers the potential to make theatre utilization efficient

Rotator cuff disease encompasses a spectrum from partial to full thickness tears. Despite being 2–3 times more common than full–thickness tears, effective non-operative treatment for partial thickness tears has remained elusive. Platelet enriched plasma (PRP) has been proposed to enhance rotator cuff healing by enhancing the natural healing cascade. However, its utility in rotator cuff disease remains controversial. The purpose of this study was to compare the patient reported outcomes between PRP and corticosteroid injection in patients with symptomatic partial thickness tears. This double blind randomized controlled trial enrolled patients with symptomatic, partial thickness rotator cuff tears or rotator cuff tendinopathy proven on ultrasound or MRI. Patients were randomized to either corticosteroid or PRP ultrasound-guided injection of the affected shoulder. Patients completed patient reported outcomes at 6 weeks and 12 weeks. The primary outcome was Visual Analog Scale (VAS) pain scores. Secondary outcomes included the Western Ontario Rotator Cuff (WORC) index, American Shoulder and Elbow Surgeons (ASES) score, and failure of non-operative management as determined by consent for surgery or progression to operative intervention. Ninety-nine patients were enrolled in the study with equal demographics between the two groups. Taking into account pre-injection scores, patients with PRP injections demonstrated a statistically significant improvement in VAS scores compared to patients receiving corticosteroid injections at 12 weeks (p=0.045) but not at 6 weeks (p=0.704). There was no difference in other outcome measures or progression of the two groups to surgical intervention. The use of PRP in the management of partial thickness rotator cuff tears demonstrates significant improvement of pain scores at 12 week follow up compared to corticosteroid injections. However, this did not affect the rate of progression to surgical intervention. Continued study is required to determine the utility of PRP in this patient population

Abstract. Aim. Excessive glenoid retroversion and posterior wear leads to technical challenges when performing anatomic shoulder replacement. Various techniques have been described to correct glenoid version, including eccentric reaming, bone graft, posterior augmentation and custom prosthesis. Clinical outcomes and survivorship of a Stemless humeral component with cemented pegged polyethylene glenoid with eccentric reaming to partially correct retroversion are presented. Patients and Methods. Between 2010– 2019, 115 Mathys Affinis Stemless Shoulder Replacements were performed. 50 patients with significant posterior wear and retroversion (Walch type B1, B2, B3 and C) were identified. Measurement of Pre-operative glenoid retroversion and Glenoid component version on a post op axillary view was performed by method as described by Matsen FA. Relative correction was correlated with clinical and radiological outcome. Results. 4 were lost to follow up. 46 patients were therefore reviewed. The mean follow up was 4 years (2–8.9 years). Walch B1, Pre op Retroversion: 12 (8–20), post op retroversion :11.8 (−4 to 19), correction= 0.2. Walch B2, Pre op Retroversion :18.4 (10–32), post op retroversion: 13.2 (1 −22), correction= 5.2. Walch B3, Pre op Retroversion: 19.1 (13–32)post op retroversion : 16.1 (9–25), correction= 3.0. Walch C, Pre op Retroversion: 33.3 (28–42) post op retroversion: 16.0 (6–27), correction= 17.3. 3 patients required revision surgery for rotator cuff failure. Conclusion. Partial correction of glenoid retroversion with eccentric reaming and implantation of cemented pegged polyethylene component leads to satisfactory clinical outcomes at midterm follow up. No revisions for aseptic loosening of the glenoid were required

Aim. Chronic osteomyelitis of the calcaneus is a frequent problem in a population of diabetic patients, patients with neurologic disorders or bedridden patients with ulcers. Partial calcanectomy is an alternative option which avoid major amputation. The aim of this retrospective study was to determine the effectiveness of partial calcanectomy for treating chronic osteomyelitis of the calcaneux. Method. We conducted a retrospective review of patients who underwent in our department a partial calcanectomy between 2006 and 2015. All patients with a complete set of radiographs and adequate follow-up (minimum 2 years) were included. We reviewed these cases to determine healing rate, microbiological analysis, risk factors of failure (comorbidities), limb salvage rate and survival rate. We analyzed specifically the footwear and the functional subjective evaluation according to the LEFS score (Lower Extremity Functional Scale). Results. Twenty-four patients were included (24 foot). There were 17 men and the mean age was 65.2 years. The control of the infection and the healing was obtained in 15 cases. An additional surgery was required in 46% of the cases. A transtibial amputation has been realized in 9 cases because of uncontrolled infection. The existence of a preoperative vascular disease increased 5,9 times the risk of amputation after a partial calcanectomy (p=0,033). The type of germ was not related to the risk of recurrence. Soles were necessary for 60% of the patients with a successful partial calcanectomy (n=15). The average LEFS score was 51/80. Conclusion. The treatment of the chronic osteomyelitis of the calcaneus was a therapeutic challenge for these patients. The partial calcanectomy is a useful procedure for limb salvage, but the selection of patients must be rigorous. In our study, arteriopathic patients had a high risk of amputation after partial calcanectomy. When the healing is acquired, the patients were satisfied and presented a good function

Radial head fractures are relatively common, representing approximately one-third of all elbow fractures. Outcomes are generally inversely proportional to the amount of force involved in the mechanism of injury, with simple fractures doing better than more comminuted ones. However, the prognosis for these fractures may also be influenced by associated injuries and patient-related factors (age, body index mass, gender, tobacco habit, etc.) The purpose of this study is to evaluate which factors will affect range of motion and function in partial radial head fractures. The hypothesis is that conservative treatment yields better outcomes. This retrospective comparative cohort study included 43 adult volunteers with partial radial head fracture, a minimum one-year follow up, separated into a surgical and non-surgical group. Risk factors were: associated injury, heterotopic ossification, worker's compensation, and proximal radio-ulnar joint implication. Outcomes included radiographic range of motion measurement, demographic data, and quality of life questionnaires (PREE, Q-DASH, MEPS). Mean follow up was 3.5 years (1–7 years). Thirty patients (70%) had associated injuries with decreased elbow extension (−11°, p=0.004) and total range of motion (−14°, p=0.002) compared to the other group. Heterotopic ossification was associated with decreased elbow flexion (−9°, p=0.001) and fractures involved the proximal radio-ulnar joint in 88% of patients. Only worker's compensation was associated with worse scores. There was no difference in terms of function and outcome between patients treated nonsurgically or surgically. We found that associated injuries, worker's compensation and the presence of heterotopic ossification were the only factors correlated with a worse prognosis in this cohort of patients. Given these results, the authors reiterate the importance of being vigilant to associated injuries

The purpose of this study was to evaluate the results of selective anatomic augmentation of partial anterior cruciate (ACL) ligament tears in 36 consecutive patients with mean 3years follow-up. Our hypothesis is that this selective augmentation of partial ACL tears could restore knee stability and function. In a consecutive series of 314 ACL reconstructions, 40 patients in which intact ACL fibers remained in the location corresponding to the anteromedial or posterolateral bundle were diagnosed perioperatively. All patients underwent selective augmentation of the torn bundle, while keeping the remaining fibers intact using autogenous hamstring graft. 38 patients (28 males, 10 females) were available with minimum 3 year follow- up. 26 cases had AM bundle tears and 12 cases had PL bundle tears respectively. Patients were assessed with International Knee Documentation Committee (IKDC) 2000 Knee Evaluation Form, Lysholm score; instrumented knee testing was performed with the arthrometer (KT 2000). Statistical analysis was performed to compare the preoperative and postoperative objective evaluation. At 3 year follow-up, 12 (31.6%) patients were graded A, 25 (65.8%) graded B and 1 C (2.6%) at IKDC objective evaluation. Lysholm's score and mean side to side instrumental laxity improved significantly. The results of anatomic single bundle augmentation in partial ACL tears are encouraging with excellent side to side laxity

Two-staged revision including removal of all components is a common approach for treatment of infected THA. However, removal of well-fixed femoral stems can result in bone loss and compromised fixation. An alternative in selected cases is partial two-stage exchange, in which the well-fixed femoral stem is left in situ, only the acetabular component is removed, the joint space is debrided thoroughly, a spacer is placed, IV antibiotics are administered during the interval, and delayed reimplantation is performed. We recently reported our results using the technique of partial two-stage exchange of infected THA. From 2000 through January 2011 in 19 patients with infected THA treated with partial two-stage exchange including complete acetabular component removal, aggressive soft tissue debridement, retention of the well-fixed femoral stem, placement of an antibiotic-laden cement femoral head on the trunnion of the retained stem, postoperative course of antibiotics, and delayed reimplantation. Indications for this treatment included those patients whose femoral component was determined to be well fixed and its removal would result in significant femoral bone loss and compromise of future fixation. During the study period, this represented 7% (19 of 262) of the patients whom we treated for a chronically infected THA. Minimum follow-up was 2 years (mean, 4 years; range, 2–11 years). None of the 19 patients in this series were lost to followup. We defined failure as recurrence of infection in the same hip or use of long-term suppressive antibiotics. Two patients (11%), both with prior failure of two-staged treatment of infection, failed secondary to recurrence of infection at an average of 3.3 years. There were no patient deaths within 90 days. Postoperative Harris hip score averaged 68 (range, 31–100). As 89% of patients in this series were clinically free of infection at a minimum of 2 years, we believe partial two-stage exchange may represent an acceptable option for patients with infected THA when femoral component removal would result in significant bone loss and compromise of reconstruction. Further study is required on this approach

Introduction. Menisci performs multiple functions in the knee.'These depend largely on the structural integrity of the meniscus. Arthroscopic partial menisectomy is the treatment of choice for meniscal tears in adults. There is conflicting evidence about the progression of degenerative changes in the medial or lateral compartment of the knee following menisectomy. Aim. The aim of our study was to demonstrate the subjective, objective and radiographic outcome of arthroscopic partial lateral menisectomy in the intermediate term and to identify any association between age, sex, activity level, the type of meniscal tear, pre operative articular surface damage and the amount of meniscus resected on the outcome. Materials and Methods. Between 1999 and 2003,152 patients in the18 to 40 year age group underwent arthroscopic partial lateral menisectomy. A senior consultant orthopaedic surgeon performed all procedures. 72 patients were available for final clinical and radiological review. Patient's subjective & objective assessments were undertaken using validated scoring systems. Musculoskeletal physiotherapist & radiologists performed clinical & radiological assessments independently. Progression of degenerative changes was recorded. Results. All patients demonstrated initial improvement of symptoms lasting upto 2 ½ years followed by gradual deterioration of subjective symptoms. There was statistically significant deterioration in the IKDC & Lysolm scores. Radiological changes developed or progressed in 36.6% of the patients (P value < 0.005). These changes were most marked in the 35 to 40 year age group. There was no statistical correlation between clinical symptoms and radiological changes. No other statistically significant associations were demonstrated. Conclusions. Arthroscopic partial lateral menisectomy leads to progressive deterioration in clinical and radiological outcome in the Intermediate term. However there is no correlation between clinical & radiological outcomes

Purpose. The management of moderate to large engaging Hill-Sachs lesions is controversial and surgical options include remplissage, allograft reconstruction, and partial resurfacing arthroplasty. Few in-vitro studies have quantified their biomechanical characteristics and none have made direct comparisons. The purpose of this study was to compare joint stability and range of motion (ROM) among these procedures using an in-vitro shoulder simulator. It was hypothesized that all procedures would prevent defect engagement, but allograft and partial resurfacing would most accurately restore intact biomechanics; while remplissage would provide the greatest stabilization, possibly at the expense of motion. Method. Eight cadaveric shoulders were tested on an active in-vitro shoulder simulator. Each specimen underwent testing in 11 conditions: intact, Bankart lesion, Bankart repair, and two unrepaired Hill-Sachs lesions (30% & 45%) which were then treated with each of the three techniques. Anterior joint stability, ROM in extension and internal-external rotation, and glenohumeral engagement were assessed. Stability was quantified as resistance, in N/mm, to an anteriorly applied load of 70N. Results. Remplissage significantly increased joint stiffness compared to both defects (6.43.8 N/mm, p=0.01) and the allograft and partial resurfacing (p <= 0.04). No technique significantly surpassed the stability of the intact state (p>0.05). In adduction, the remplissage significantly reduced internal-external rotation compared to both defects (p <= 0.01), but only the 30% repair caused a significant change compared to the intact state (14.511.3 N/mm, p=0.05). In abduction, all repairs reduced rotation ROM compared to the Hill-Sachs defect (>= 8.24o, p <= 0.04), but none with respect to the intact condition (p >= 0.05). Remplissage had significantly less extension than either resurfacing procedure (>= 15.4o, p <= 0.02) and resulted in a greater reduction in extension ROM for 45% defects compared to 30% defects (11.918.91, p=0.06). All unrepaired lesions engaged during extension. None of the remplissage or allograft reconstructions engaged, however, 75% of partial resurfacing arthroplasties partially engaged. Conclusion. This study is the first biomechanical evaluation to directly compare three surgical procedures for engaging Hill-Sachs lesions. Each procedure enhanced stability; however, the enhancement provided by the resurfacing repairs more closely resembled the intact state. Remplissage of the 30% and the 45% defects improved stability and eliminated glenohumeral engagement but caused significant and progressive reductions in ROM. In comparison, both the allograft and partial resurfacing procedures re-established ranges of motion approaching those of the intact joint; however, the partial resurfacing could not fully prevent engagement. These findings indicate that the effects of each technique are not equivalent and further clinical and biomechanical studies are required

The failure of any joint arthroplasty secondary to infection is devastating to both patient and surgeon. Eradication of infection is the primary treatment objective. Classic teaching has called for removal of all prosthetic components, thorough soft tissue and bone debridement and either immediate or delayed reimplantation with an interim antibiotic polymethylmethacrylate laden spacer. The presence of a residual biofilm on implants is a rationale for component removal. Several sophisticated removal systems have been developed for the acetabulum which facilitate component removal with minimal to no bone loss. However, such systems do not exist for the femoral component. Removal of well-fixed femoral components remains a significant challenge frequently requiring extensive osteotomies which can result in bone loss and compromise of future femoral component fixation. Therefore, it would seem attractive to leave a well fixed femoral component in situ and remove only the acetabular component, perform a thorough debridement, place an antibiotic laden polymethylmethacrylate spacer within the acetabulum and perform a delayed reimplantation. A retrospective analysis of our practice from 2000 to 2010 revealed nineteen patients treated with a partial radical debridement and delayed reimplantation with a minimum of two year follow-up. There were no patient deaths within 90 days. Follow-up averaged 3.9 years. Three patients expired during the study period at an average of 3.5 years post-operative. Two patients, both multiply revised with prior 2-stage treatment of infection, failed secondary to recurrence of infection at an average of 3.3 years. Our results suggest that partial radical debridement represents an acceptable option for patients with infected THA. We have employed this technique when it was deemed that removal of the femoral component would require extensive osteotomy resulting in significant bone loss and compromise of future femoral reconstruction. It has been successful 89% of the time. We are aware that further study is required and we remain cautiously optimistic regarding this treatment modality

Neck pain can be caused by pressure on the spinal cord or nerve roots from bone or disc impingement. This can be treated by surgically decompressing the cervical spine, which involves excising the bone or disc that is impinging on the nerves or widening the spinal canal or neural foramen. Conventional practise is to fuse the adjacent intervertebral joint after surgery to prevent intervertebral motion and subsequent recompression of the spinal cord or nerve root. However fusion procedures cause physiological stress transfer to adjacent segments which may cause Adjacent Segment Degeneration (ASD), a rapid degeneration of the adjacent discs due to increased stress. ASD is more likely to occur in fusions of two or more levels than single level fusions and is more common where there is existing degeneration of the adjacent discs, which is not unusual in people over 30 years of age. Partial dynamic stabilisation, which generally involves a semi-rigid spinal fixation, allows a controlled amount of intervertebral motion (less than physiological, but more than fusion) to prevent increased stress on the adjacent segments (potentially preventing ASD) whilst still preventing neural recompression. Partial dynamic stabilisation is suitable for treating spinal instability after decompression as well as certain degenerative instabilities and chronic pain syndromes. Dynamic stabilisation and semi-rigid fixation systems for the spine are typically fixated posteriorly. However, choice of posterior surgical stabilisation techniques in the cervical spine is limited due to the size of the osseous material available for fixation and the close proximity of the neural structures and the vertebral artery. Posterior dynamic stabilisation systems for stabilisation of the lumbar spine often use the pedicle as an anchor point. Using the pedicle of the cervical spine as an anchor point is technically difficult because of its small size, angulation and proximity to neurovascular structures. Therefore, one of the main challenges to provide stabilisation in the cervical spine is the limitations of the anatomy. This presentation will introduce a novel spinal implant (patent pending) which is proposed for the cervical spine to provide partial dynamic stabilisation in the C3 to T1 region from a posterior approach. The implant is a single unit with a safe and technically simple insertion technique into the lateral masses. The implant uses a simple mechanism to allow limited intervertebral motion at each instrumented level. It is hoped that the simplicity of the device and removing the need to provide a bone graft anteriorly may reduce the cost of the procedure compared to traditional fusion and competing surgeries

Background. Partial humeral head resurfacing using a stemless implant is a bone-conserving option in treatment of focal chondral defects. We report our experience using the Arthrosurface HemiCAP® device. Methods. This is a retrospective study of patients with focal chondral defects of the humeral head, treated with partial resurfacing arthroplasty, with a minimum follow-up of 2 years. Mean patient age was 45.4 years (range 27–76). Patients were analyzed in 2 groups: those who underwent HemiCAP for an isolated humeral head defect, and those who had HemiCAP combined with biologic resurfacing of concomitant glenoid disease. Results. 39 patients met inclusion criteria, 5 of whom had concomitant biologic glenoid resurfacing. 24 of 34 shoulders (70.6%) with HemiCAP alone demonstrated functional improvement and decreased pain. Mean forward flexion showed some improvement from 131 degrees pre-operatively to 158 degrees post-operatively (p=0.004). Mean Subjective Shoulder Value improved from 35.0% to 83.6% (p< 0.001). ASES score improved from 29.8 to 77.7(p< 0.001). However, follow-up radiographs showed progression of glenoid disease in 20.6%(7 shoulders). 5 shoulders(14.7%) failed and were revised: 3 to total shoulder arthroplasty, 1 to hemiarthroplasty, and 1 patient underwent glenohumeral fusion. 5 (14.7%) had some pain at latest follow-up but were pursuing a course of conservative management. In the group with associated biologic glenoid resurfacing, all 5 patients had ongoing pain and progression of glenohumeral arthritis requiring revision or glenohumeral fusion. Conclusion. While 70% of patients with an isolated humeral head chondral defect had significant improvement in pain and function after HemiCAP, the outcomes were not superior to those published for complete humeral head resurfacing, or for stemmed prostheses. HemiCAP was not successful for patients with concomitant glenoid disease. Results for these patients were inferior to those published for total shoulder arthroplasty, and ultimately all were revised to a stemmed prosthesis or fused

We compared cancellation rates with two different systems for operating booking. During 9 months of ‘Full Booking’ we gave each patient in the Outpatient Clinic an operating date. After a transition period, we then tried ‘Partial Booking’ (putting each patient on the waiting list and only giving dates after a Consultant-delivered Pre-Assessment Clinic (PAC) review at least 6 weeks before their target operating date.). This was one Consultant's firm, with Day Cases and urgent cases excluded, and a waiting time of nine months. Cancellations were defined as an operating date given that was not honoured. Cancellations due to bed crises were excluded. During the Full Booking phase there was a cancellation rate of 55%, with 64 cancellations out of a potential 116 operating slots. Of these: 29% condition improved, 22% date inconvenient, 19% unwell, 5% gone elsewhere/Private, 9% were moved due to Consultant leave dates, 3% Did Not Attend, and 12.5% date brought forward to fill a cancellation slot. During the Partial Booking phase, 23% of patients attending the PAC were removed from the waiting list without ever being given operating dates. (17 of 132 did not want the operation, 7 Did Not Attend, 6 were unfit). Of the 94 patients given dates, only 8 cancelled (8%). Four subsequently decided against surgery, and four had tests that suggested surgery would not be helpful. The improved efficiency could be due to PAC changes: Consultant presence, having six weeks to act on test results, and dates being agreed only after ‘passing’ PAC. Partial Booking had other benefits, with fewer queries, better informed consent and the optimum time to plan teaching lists, order kit and improve patients' fitness. The Government is still committed to Full Booking. Our cancellation rate improved from 55% to 8% when changing from Full Booking to Partial Booking

An interesting case with excellent accompanying images, highlighting the significance of tourniquets in controlling exsanguination, whilst also raising the issue of amputation versus reconstruction in severely injured limbs. A 39 year old male motorcyclist was BIBA to the Midland Regional Hospital in Tullamore, following a head-on collision with a bus at high velocity. On arrival, he was assessed via ATLS guidelines; A- intubated, B- respiratory rate 32, C - heart rate 140bpm, blood-pressure 55/15 and D- GCS 7/15. Injuries included partial traumatic amputation of the right lower limb with clearly visible posterior femoral condyles, a heavily comminuted distal tibial fracture and almost complete avulsion of the skin and fat at the popliteal fossa. Obvious massive blood loss at the scene had been tempered by a passer-by who applied a beach towel as a makeshift tourniquet. CT Brain demonstrated extra-dural and subarachnoid haemorrhages with gross midline shift. Unfortunately, the neurosurgical team in Beaumont concluded that surgical intervention would be inappropriate. However, his kidneys had not sustained ATN and were made available for donation. Two vital surgical issues were featured in this case. Firstly, it highlighted the importance of tourniquets in controlling exsanguination in a trauma situation. 1. Secondly, it raised the critical issue of amputation versus reconstruction in severely injured limbs. 2,3. . Without prompt placement of a make-shift tourniquet by a passer-by, this patient would have almost certainly died at the scene of the accident. Two kidneys were successfully donated as a result. The importance of appropriate tourniquet use cannot be overstated. This case highlights its potential life or limb-saving capabilities in emergency trauma situations. It also raises the critical issue of amputation versus reconstruction in acute emergency situations

Osteochondral fracture of the femoral head is an uncommon injury with a high potential for a poor functional outcome. Management is often challenging with limited options. We present two cases in which osteochondral fractures of the femoral head were treated with partial resurfacing using the HemiCAP System (Arthrosuface, Franklin MA, USA). Patient 1. A 22-year-old male professional motorbike rider presented with an anterior left hip dislocation that occurred during a race. A CT scan after a closed reduction revealed a large osteochondral impaction fracture/defect that was addressed via partial resurfacing using the HemiCAP System. Patient 2. A 34-year-old male presented with an anterior left hip dislocation after a motor vehicle accident and underwent a closed reduction. CT showed a loose osteochondral fragment, that was fixed back with headless screws, and an adjacent defect was addressed with a HemiCAP implant. Both patients were kept non weight-bearing for two months and had an uneventful recovery. Patient 1 was last reviewed at our institution one month post-operatively with a pain-free hip. His follow-up is being continued interstate and at telephone interview, 18 months after surgery, he had returned to full function and resumed riding on the professional racing circuit. Patient 2, at three-month review, had a pain-free hip with a full range of motion. CT scan showed excellent joint surface congruity at the implant articular surface junction. We report the use of the HemiCAP System as a novel method of treating osteochondral defects, which has never been reported before. There has only been one other reported case of using a HemiCAP in an osteoarthritic femoral head. This is a short follow-up with only two patients treated; however we are encouraged by the results so far, as there are no other satisfactory alternative treatment options

Computer-aided surgical systems commonly use preoperative CT scans when performing pelvic osteotomies for intraoperative navigation. These systems have the potential to improve the safety and accuracy of pelvic osteotomies, however, exposing the patient to radiation is a significant drawback. In order to reduce radiation exposure, we propose a new smooth extrapolation method leveraging a partial pelvis CT and a statistical shape model (SSM) of the full pelvis in order to estimate a patient's complete pelvis. A SSM of normal, complete, female pelvis anatomy was created and evaluated from 42 subjects. A leave-one-out test was performed to characterise the inherent generalisation capability of the SSM. An additional leave-one-out test was conducted to measure performance of the smooth extrapolation method and an existing “cut-and-paste” extrapolation method. Unknown anatomy was simulated by keeping the axial slices of the patient's acetabulum intact and varying the amount of the superior iliac crest retained; from 0% to 15% of the total pelvis extent. The smooth technique showed an average improvement over the cut-and-paste method of 1.31 mm and 3.61 mm, in RMS and maximum surface error, respectively. With 5% of the iliac crest retained, the smoothly estimated surface had an RMS surface error of 2.21 mm, an improvement of 1.25 mm when retaining none of the iliac crest. This anatomical estimation method creates the possibility of a patient and surgeon benefiting from the use of a CAS system and simultaneously reducing the patient's radiation exposure

Unicompartmental knee replacement components have gained favor because they replace only the most damaged areas of articular cartilage and the less invasive operation results in a faster patient recovery than traditional TKR. Additionally, they can provide a solution when a full TKR is not yet needed. However, the wear magnitude of such implants is not well understood, primarily due the variation in design and the difficulty of testing them in knee simulators designed to test full TKRs. Modern innovative partial cartilage replacement knee components which are typically even smaller and more bone conservative than unicompartmental implants, are even less common in testing with added challenges. This study investigates the fatigue characteristics of partial cartilage replacement knee components, and the wear of the UHMWPE bearing of a new, truly less invasive unicompartmental design by Arthrex Inc./Florida. Fatigue testing was performed on MTS 858 MiniBionix machines. Two 12mm diameter UHMWPE tibial components were cemented into jigs at 0° posterior slope and were axially loaded at 2Hz for 10 million cycles (Mc) with a sinusoidal profile peaking at 60% of 8 average human bodyweights (3800N) and a load ratio R of 0.1. Two femoral components were tested with the same load profile at 10Hz for 10 million loading cycles (Mc). The femoral components were mounted at 15° flexion and only the anterior half of the implant was supported, replicating a worst-case scenario where fixation had failed on the posterior half of the implant. This resulted in a large bending moment when force was applied that would fatigue the femoral implant. Following the fatigue test, two full wear simulation tests were conducted on four 12mm and four 20mm unicompartmental components on a four-station Instron-Stanmore force-control knee simulator. The spring-based system to simulate soft-tissue restraining forces and torques was adapted to operate the machine in a displacement control mode to achieve the motions of the medial compartment based on ISO 14243-3. The specimens were lubricated with bovine serum (20g/L protein, 37°C) and the simulator was operated at 1Hz. Liquid absorption was corrected through passive-soak-control bearing inserts. The tibial specimens were cleaned and weighed at standard intervals with the usual ISO test protocols. After 10Mc of fatigue testing, both tibial components had deformed by some flattening out but were able to sustain the full load without failure and displayed average stiffness (over the whole 10Mc) of 27,600±1,180 N/mm. Neither partially supported femoral component failed, and the femorals displayed average stiffness (over 10Mc) of 37,500 ±3,280N/mm. After 5Mc of wear testing, the 12mm tibial components displayed a wear rate of 4.56±1.45mg/Mc while the larger 20mm size wore at a lower 2.80±0.39mg/Mc. The results from the fatigue test suggest that this unicompartmental cartilage replacement design will not fail under simple axial loading, even under the extreme case where the tibial implant is receiving the entire share of the load, and the femoral component is only partially supported. In the clinical application, of course some load-sharing with the native unworn cartilage would occur, reducing the stresses on the implant. The results from the wear test showed very low wear for tibial components of this design, lower than many successful TKRs. The larger size tibial components wore less likely due to reduced contact stress. Based on the results of this test, an implant of this type could be a viable option prior to TKR

Degenerate chondral surfaces can be assessed in many ways, but arthroscopy is often performed without proper categorisation, mapping, zoning or sizing of lesions. Progression of disease in un-resurfaced compartments is well-recognised to occur, but is only one of several failure mechanism in partial knee replacement. A validated ‘Functional Zone’ mapping method was used to document articular surface damage in 250 sequential cases of knee arthroscopy in patients over the age of 40. Size, shape, location and severity of each chondral lesion were noted using the Outerbridge classification. Analysis determined rates of involvement of particular compartments and assessed potential for partial replacement or local treatment and also to consider the risk of future progression. Radiographs including antero-posterior standing, postero-anterior flexion views (Rosenberg), lateral and skyline views were graded (Kellgren and Lawrence) and compared with the arthroscopic findings. Our results showed that out of the 210 knees with Grade 3 or greater damage 13.3% of knees showed ‘isolated’ medial disease of Outerbridge Grade 3 or worse. Isolated lateral disease was noted in 1.4%, patello-femoral disease in 24.3%, bi-compartmental (Medial/PFJ) disease in 30.9% with tibio-femoral and tri-compartmental disease seen in 15.2%. The combination of lateral and patello-femoral disease was seen in 14.8%. Provided that Grade 1 and 2 changes (which were found in other compartments in high percentages) were ignored and ACL status considered, this information seemed to indicate that at the time these procedures were performed, 13.3% of cases were suitable for a medial uni-compartmental device, with sub-analysis of lesion sizes indicating that 17 out of 28 cases (60.7%) were suitable for a localised resurfacing. Lateral uni-compartmental replacement seemed suitable for only 1.4%, patello-femoral replacement in 24.3%, bi-compartmental in 30.9% and total knee replacement in 30%. The mean age for partial resurfacing was 53years and 59 years for total joint replacements. Radiological analysis found that the antero-posterior standing views had only 66% sensitivity and 73% specificity for the presence of Grade 3 changes or worse in the medial compartment in comparison with Rosenberg views having a sensitivity of 73% and a specificity of 83%. Skyline views had a sensitivity of 56% and 100% specificity. This study indicates that a large proportion of cases may be suited to local and limited resurfacing. Cases suitable for Patello-femoral and Bi-compartmental replacements were very common, but with the patella-femoral joint's tendency to be more forgiving in terms of symptoms, meaning that indications for uni-compartmental replacement might well be much higher than the arthroscopic findings suggested. On the other hand, the presence of high levels of Grade 1 and 2 changes in other compartments seems to indicate a need for caution particularly in younger patients. This study also indicates a need for better methods of assessing local cartilage health such as enhanced MRI scanning or spectroscopy