The L4/5 disc inter-space is commonly believed to be represented by a line drawn between the two highest points of the iliac crests. This line is frequently used as a pre-operative guide for incision placement, in patients undergoing spinal surgery. We reviewed the antero-posterior and lateral lumbar spine films of 450 patients, ranging in age from 20 to 90 years, measuring the distance from the supracristal plane to the midpoint of the L4/5 disc interspace. The plane intersected the spine at the L4/5 interspace in only 31.9% of cases and was found to lie at the lower half of the body of L4 or above in 49.5% of cases. There was significant variation in the position of the supracristal plane between the different patient age groups studied (P≤0.05). The use of additional imaging, along with plain radiography is advised when attempting identification of this spinal level, as reliance on palpation of the iliac crests alone to identify this landmark may lead to unintentional cranial placement of a surgical incision during spinal procedures, or cannulation at a level above the intended interspace, during epidural and spinal anaesthesia.

Proprietary femoral plug introducers are routinely used to insert intramedullary plugs during total hip arthroplasty The cement restrictor pin from an Exeter intramedullary plug introducer may become detached during insertion of the cement restrictor plug, or during sponge packing of the femur. We suggest some precautions that should be taken to prevent this from occurring and advise that the patient is unlikely to experience any long-term adverse reactions to the presence of the restrictor pin in the intramedullary canal.

BACKGROUND:Efficacy of intra-articular injections is controversial and published studies on efficacy and risks are few.AIMS:We sought the opinion of practicing orthopaedic consultants in order to establish the perceived benefits and risks of infection following intra-articular steroids.METHODS:A questionnaire was sent to all the orthopaedic consultants in the UK and Ireland on the use of intra-articular steroids.RESULTS:A total of 853 completed questionnaires (response rate 57.4%) were analysed. The perceived risk of infection was 1:1000 in almost half of the surgeons polled and 1:10,000 in one third. The 759 consultants who administer intra-articular steroids recalled sixty-eight cases of infection; 85.2 % of the surgeons rated efficacy 5 or above on a visual analog score of 1-10.CONCLUSIONS:Correct patient selection, proper indications for use, and a limited number of appropriately spaced injections were all perceived to be important to achieve maximum benefit without serious side-effects.

Background Most femoral neck fractures in younger patients have a different mechanism, treatment, and prognosis from those in elderly patients.Aims To evaluate the results of internal fixation of femoral neck fractures inpatients aged between 20 and 60 years, and to determine reasons for failure.Patients and Methods Thirty three patients aged between 20 and 60 years who sustained a femoral neck fracture between 1995 and 2000 were reviewed. This represents 5.6% of the total femoral neck fractures admitted to the unit during this period.Results In 26 patients (78.8%) the fracture resulted from higher energy trauma. Of 23 patients with displaced fractures four patients (17.4%) developed avascular necrosis and one patient (4.3%) developed non-union. Factors influencing outcome were mechanism of injury, pre-operative fracture displacement, adequacy of fracture reduction and delay in surgery.Conclusion Our study emphasises the importance of timely surgery and adequate reduction of displaced femoral neck fractures in younger patients.