Accurate documentation of operative findings is a fundamentally important part of any procedure and forms part of the Royal College of Surgeons of England's guidelines to good care, especially to “ensure that there are legible operative notes (typed if possible) for every operative procedure.” However, many hospitals fall short of this guideline when it comes to arthroscopic procedures because of the difficulty in reproducing visually representative and easy-to-understand images. There is an inability to properly record and archive findings of arthroscopic procedures. We, along with the British Orthopaedic Association, have developed an interactive, free Web-based operative note template that allows the surgeon to draw findings on diagrams of the joints commonly undergoing arthroscopy, type the findings, and then print as many copies as required. The use of the forms has allowed for quicker, easier, and more accurate documentation of arthroscopic procedures. The forms can then be saved to a database and used as a research tool.

Introduction: The aims of this study were to determine whether patients were transfused appropriately, after a Unilateral Cemented Primary Total Knee Replacement (TKR), and whether it would be cost effective to use autologous transfusion drains compared with standard group & save and cross match protocols.

Method: Retrospective study of the pre- and postoperative day 1 haemoglobin values of all patients who underwent unilateral primary cemented TKR between November 2004 – November 2005 at the Kent & Sussex Hospital, Tunbridge Wells. Haemoglobin data and length of stay was obtained from computerised records & transfusion data from the blood transfusion department.

Results: 150 patients were assessed: 97 (65%) female and 53 (35%) male. 20 (14.6%) patients required blood transfusion. The mean preoperative haemoglobin for non-transfused and transfused patient’s was 13.7 and 12.5g/dl respectively (P = 0.0029). The mean postoperative haemoglobin for non-transfused and transfused patient’s was 11.1 and 9.27g/dl respectively (P< 0.001). The mean blood loss for non-transfused and transfused patient’s was 2.64 and 3.26g/dl respectively (P< 0.001). There was no significant correlation between length of stay and either preoperative haemoglobin or blood loss after surgery; Spearman’s correlation coefficient was 0.0222 and 0.0036 respectively. The cost of a standard group & save and cross match, plus the 56 required units of blood in this study was £15,443.60. The theoretical cost of using a CellTrans Autologous Transfusion System on these 150 patients would be £14,355.00, a saving of only £1,088.60. However, by only using the autologous drains on patients with a preoperative haemoglobin ≤ 12.5g/dl, this saving could be increased to £4,131.20 per annum.

Conclusion: Using autologous transfusion drains on patients with a preoperative haemoglobin ≤ 12.5g/dl would save over £4,000 per annum at Maidstone & Tunbridge Wells Hospital Trust. There is no correlation between length of stay in hospital and either preoperative haemoglobin or blood loss after surgery. Patients transfused had significantly lower pre- and postoperative haemoglobins.

Every country has its own criteria for consent. In most, a written consent form is used to reflect patient understanding and permision for the procedure to happen.

While oral consent has as much legal sway as the written consent form, the presence of a signature acts as proof of discussion. All European hospitals should have a 100% compliance with patient’s signing consent forms, but their completion is often incomplete and inaccurate, have errors of omission and have lead to litigation, poor patient understanding and recall.

We (along witht the BOA) introduce an computer programme of procedure specific orthopaedic consent forms. They have been created for most common elective and trauma operations. The forms follow the UK Department of Health guidelines on consent and contain a brief explanation of the procedure, offer alternative therapies/consequences of not having the procedure (where appropriate), the serious risks and commonly occurring complications. They are written in layman’s English (aimed at a reading age of 14 years). Preliminary trials have also shown the time taken to print and complete a pre-designed form is much less than that of the current handwritten form, reducing errors of omission whilst still allowing discussion with the patient.

The forms are currently available as word documents from an easily navigable website. With a view towards European usage, the forms can be easily translated to other languages at minimal cost.

With support from the British Orthopaedic Association (BOA), the BOA medico-legal committee, the specialist societies and consultant users (via the website) we hope that the project will continue to evolve with a greater selection of procedural consent forms becoming available.

It is believed, from the evidence available, that this approach should decrease the incidence of patient misunderstanding, and the potential risk of successful litigation, while encouraging better communication between patients and surgeons.

We report the clinical and radiographic outcome of a consecutive series of 219 hydroxyapatite-coated total knee replacements with a follow-up of 5 to 8 years.

Patients who fulfilled the entry criteria were included in a prospective study from early 1997 to late 1999. Regular clinical & functional assessment was subsequently performed using the Knee Society Score, WOMAC & SF-12 self-assessment questionnaires. Analysis of fluoroscopically controlled radiographs was performed using the American Knee Society Score.

All living patients (186 knees) were followed-up. Exhaustive efforts were made to ensure that no patient was lost to follow-up. 28 patients (30 knees) were deceased. There have been 3 revisions.

The mean pre-operative Knee Score of 43.8 increased to 77.1 and the mean pre-operative Function Score of 20.3 increased to 63.4 at 5 years. The WOMAC scores also showed marked improvement from pre-operative status after 5 years minimum follow-up: pain 250 pre-op to 157, stiffness 115 pre-op to 56 and function 910 pre-op to 588.

There was no radiographic evidence of loosening or migration. The average American Knee Society Score for each component was 4. Small gaps between the bone-implant interface were observed to heal over the first year. A separate phenomenon of focal osteopenia is also described in a small number of well-fixed femoral components (12 of 219).

To date, 3 prostheses have been revised, 2 due to deep infection and 1 due to tibial tray subsidence. A survivor-ship of 98.6% has been achieved at 8 years.

We believe this to be the first medium term study for the Duracon HA coated knee arthroplasty system, showing excellent clinical and radiographic outcome, with 100% follow-up at 5 to 8 years.

Introduction Knee injuries are a common presentation to Accident and Emergency departments. Often many injuries that are referred are minor as a result of the difficulty in initial assessment, and cause an unnecessary increase in workload in Orthopaedic clinics. The purpose of this study was to evaluate current practice at our Knee Injury Clinic and to implement changes to make the service more efficient and effective. It forms a completed audit cycle of current practice.

Material and methods Part I: We assessed all referrals from our Accident & Emergency department in two separate 4 month periods to the Acute Knee Injury Clinic according to the following criteria (which need fulfilling for referral)-

Recent history of injury associated with one or more of the following:

Acute haemarthrosis

Referrals were assessed as fulfilling or not fulfilling the criteria, and also as to the ultimate diagnosed pathology.

Part II: From the results of these two audits, a multidisciplinary treatment proforma was created and distributed to Accident and Emergency. This included physiotherapy as a primary treatment option. Referrals were then reassessed as in the previous audits for a 4-month period.

Results and conclusions The Acute Knee Injury Pro-forma resulted in a 15% reduction in referrals not fulfilling the criteria (p=< 0.05). This equates to a reduced workload due to inappropriate referrals, while significant injuries such as Cruciate rupture are picked up due to the sensitivity of the criteria.

There was a significant increase in patients referred directly from Accident and Emergency to the physiotherapy department, which means minor injuries receive physiotherapy earlier than if they initially came to clinic.

The proforma was well received by the junior doctors in Accident and Emergency due to its simplicity.

Overall the use of the proforma has improved the standard of care at our unit.

Aims: Schuss radiographs are PA weight bearing views of the knee taken in 30 degrees of ßexion. Several studies have shown them to be more sensitive detectors of osteoarthritic changes in the knee than standard extension AP views. The aim of this study was to determine whether the increased severity of degenerate change shown on these radiographs is sufþcient to alter proposed orthopaedic management of patients. Methods: Fifty consecutive patients aged 45–75 presenting to clinic with symptoms suggestive of tibiofemoral osteoarthritis were included. Each underwent standard clinical assessment and weight bearing extension AP and lateral radiographs of the knee. In addition a digital photograph of the legs and a single schuss radiograph were taken. This information was collated onto slides, two per patient. One slide included the history and examination þndings plus the photograph, extension AP and lateral radiographs. The other was identical save that the extension AP was replaced by the schuss radiograph. The slides were randomised and shown to eight consultant orthopaedic surgeons. For each slide each consultant was asked to give his preferred management. Responses for the two slides of each patient were compared. Results: The panel changed their management plan in over 40% of cases. This represented a reduction of almost 50% in arthroscopies in the schuss group with a move towards deþnitive surgery. Total number of procedures proposed was also reduced. Conclusion: The schuss radiograph is a valuable tool in the assessment of knee osteoarthritis the use of which can alter clinical management. By reducing non-therapeutic arthroscopies it may signiþcantly reduce total number of operations to be performed in this patient group.

We have reviewed the intermediate term results of 56 out of 61 consecutive Wagner revision stems implanted without bone graft. After a mean of 5 years (range 4 to 7 years) 49 out of 56 hips were graded as excellent or good based on the Harris Hip Score. The clinical result was not related to the degree of femoral bone defect prior to revision.

49 Out of 56 hips were seen to subside, but this did not affect the hip score at final review. The mean subsidence was 4.8mm (range 0 – 19mm).Only one stem showed continued subsidence after 12 months post-operatively, and this stem achieved a stable position by 24 months. All osteotomies of the femur united with reconstitution of the femoral bone stock. There was a low incidence of complications; one stem showed catastrophic subsidence within 48 hours of surgery, requiring re-revision to a larger Wagner stem. There was one sciatic nerve palsy. 3 hips dislocated on one occasion in the early post-operative period, but were stable at latest follow-up.

In conclusion, the Wagner stem can bypass major proximal femoral bony defects and achieve initial axial and rotational stability in intact diaphyseal bone. Subsequent stem subsidence does not affect clinical outcome, and proximal femoral bony reconstitution is achieved without the need for bone grafting.

We present the long-term results of a single institute’s experience of the Mann 3 in 1 procedure. This prospective study initially selected 36 feet (25 patients) with severe hallux valgus, classified by a HV angle < 40° or IM angle> 15°, for the Mann 3 in 1 procedure. Preoperative and postoperative standing radiographs were taken to calculate the correction of the deformity, and a postoperative subjective questionnaire was completed which was based on the assessment criteria suggested by the American Orthopaedic Foot and Ankle Society in 1984. The initial follow-up was completed at up to one year.

The original cohort of patients was contacted again at 10 years (range 9–11 years) to repeat the same questionnaire and radiographs. In total 19 patients (27 feet) were contactable with an average age of 51 years (range 34–74). The questionnaire revealed one patient unable to perform the same occupation and three patients unable to perform the same activities due to ongoig problems with the operated feet. Thirteen patients had to wear modified footwear but only 2 required specially made shoes. Sixteen of the nineteen (84%) were pleased or satisfied with pain relief and appearance following the procedure, with 14 stating that they would undergo the procedure again given the same circumstance and 5 patients that would not. The complications included 8 patients requiring screw removal, 2 patients with metatarsalgia, one patient undergoing multiple further corrective procedures and one requiring a second ray amputation for osteomyelitis.

Sixteen patients (23 feet) were available for repeat radiographic assessment. This revealed that there had been some recurrence of the deformity with the initial correction of the HV angle being a mean of 40° (range 36–51°) to 15° (9–23°) at up to one year and 23° (0–52°) at ten years. Similarly with the mean IM angle initially corrected from 18° (15–25°) to 8.5°(6–12°), being 14° (7–20°) at ten years.

In conclusion, despite some recurrence of the deformity on x-ray the subjective satisfaction with this procedure is good. Care should be taken in patient selection but the Mann 3 in 1 appears to be a good procedure for the correction of severe Hallux Valgus.