#### What you need to know The number of orthopaedic operations is increasing in the UK: the National Joint Registry reported just under 225 000 procedures in the period ending 2015-16.1 This practice pointer aims to inform the readership of the important considerations about arthroplasty of the knee, hip, and shoulder—the most common arthroplasty procedures performed in the UK. Arthroplasty in now routinely used to treat fractures and rotator cuff arthropathy. In 2015 in the UK over 83 000 primary total hip replacements took place, of which over 3700 were for neck of femur fractures, and over 4200 shoulder arthroplasties were performed for cuff arthropathy, representing around a quarter of all shoulder replacements.1 Enhanced recovery programmes have seen better standardisation of arthroplasty care and are now fully implemented in the NHS. They have been shown to reduce mortality, length of hospital stay, and transfusion requirements.2 They have four main steps, summarised in box 1. #### Box 1: Enhanced recovery programme steps: ##### Step 1. Improve preoperative care ##### Step 2. Reduce the physical stress of the operation ##### Step 3. Decreasing postoperative discomfort

This book provides orthopaedic surgeons in training with concise and relevant core knowledge on all aspects of children’s orthopaedics. Content includes the common orthopaedic conditions that affect c

Risk factors can be divided into general, intrinsic, and extrinsic. General factors include age, sex, and genetics. Hip osteoarthritis is almost twice as common in women than in men, 2 and genetic studies show a 50% heritability caused by European genetic variants. Intrinsic factors include incongruency (such as dysplasias) and joint laxity: they cause abnormal wear and loading, and therefore accelerate articular degeneration. Extrinsic factors such as increasing bodymass index, high levels of certain exercise, and heavy manual labour are thought to increase the incidence and progression of hip osteoarthritis. Most often the cause of hip osteoarthritis is multifactorial. A series of risk factors lead to instability, malalignment, increased joint load, microtrauma and structural damage. The joint responds through subchondral and synovial inflammation, and bone hypertrophy. This is visible on radiographs as narrowed joint space, sclerosis, and cyst or osteophyte formation. Hip osteoarthritis is associated with other diseases, but there is often no proven causal relationship. A population based cohort study showed that hip osteoarthritis is associated with frailty, with an odds ratio after adjustment for confounding variables of 1.57 (95% confidence interval 1.1 to 2.22).Hip osteoarthritis is also associated with an increased risk of all-cause mortality (hazard ratio 1.14) and higher rates of mental health problems. One large, population based cohort study also suggests an increase in cardiovascular mortality associatedwith osteoarthritis (hazard ratio 1.24). A prospective, population based cohort study suggests this is probably because of ensuing disability rather than the presence of osteoarthritis itself.

The therapeutic use of bone marrow-derived mesenchymal stem cells (BM-MSCs) has been applied to many different tissue types that are vulnerable to sports injuries. Avenues of treatment include direct injection of BM-MSCs into the defect, however although minimally invasive, research has highlighted flaws which have been improved upon with the use of scaffolds. BM-MSCs have been applied via many different scaffold types, for example PLGA, collagen gel and coral each with advantages and disadvantages of which can be improved through further research. As a cell source for tissue engineering, BM-MSCs are ideal due to the minimal invasion of aspiration, high in vitro proliferation rate and the ability to maintain their differentiating capacity. The vast majority of these studies are at the small animal stage and therefore further work using larger animal models, and ideally humans is required.

AIMS:Decision-making in management of clavicle fractures is often based on the degree of displacement and shortening present on plain radiographs. We aimed to evaluate whether plain radiographs provide an accurate representation of the true displacement present, which can be difficult to image in orthogonal planes.METHODS:Consecutive high-energy trauma patients with midshaft clavicular fractures requiring further CT imaging of the thorax/abdomen for other associated injuries between 2009 and 2012 were evaluated. The plain radiographs and CT scan were both performed at initial presentation. Displacement and shortening of the clavicle fracture were assessed on the standard clavicle views and then compared with the axial images obtained from CT scans.RESULTS:26 patients admitted following a high-energy trauma that necessitated CT scan of chest/abdomen/pelvis were included. All patients also underwent standard clavicle view radiographs at the same initial assessment. Displacement varied from 0 to 233%. Shortening was measured as between 0 and 29 mm. The displacement measured on the CT scan was a mean of 19% greater than the AP view and 11% greater than the 20° caudal. This difference was found to be statistically significant (p = 0.019) between the AP view and the axial view on CT. The difference between 20° caudal views did not extend to statistical significance (p = 0.211). There were no significant differences found between the two modalities on assessment of shortening.CONCLUSIONS:Plain radiographs give an accurate representation of the shortening present in midshaft clavicle fractures. Displacement may be underestimated if the standard AP and 20° caudal views alone are relied upon.

Rotator cuff tears follow three main patterns. They may be the result of a traumatic tear in a young healthy patient, a traumatic tear in the old degenerate tendon, or result from an atraumatic degenerate tear, again in the older patient. Both intrinsic and extrinsic factors contribute to tears. Those who are particularly at risk partake in overhead activities and overuse their rotator cuff. Treating acute tears surgically is now common practice. Arthroscopic surgery is most commonly employed and has very good results. Difficulties are however encountered in the degenerate tendons, and massive tears which may be deemed irrepairable. Tissue engineering has developed significantly in this field, and this chapter aims to highlight the differing therapies, which have been developed. These include gene therapy, cell therapy, engineering of both biological and non-biological scaffolds and use of growth factors. Results have shown promise in animal models, but few human clinical trials have offered groundbreaking changes.

Pelvic fractures in children are rare and differ considerably from adult fractures. They are generally either sport related avulsion fractures or fractures related to high-energy trauma. Hip fractures are even less common and are also related to high-energy trauma. They may have significant complications. This chapter aims to separately classify childhood pelvic, acetabular and hip fractures and aid you in their diagnosis and treatment.

Rheumatoid arthritis is the commonest inflammatory arthropathy, and affects synovium, cartilage and bone. Despite recent improvements with disease modifying biological agents, progressive joint destruction may continue eventually leading to the need for joint arthroplasty. The knee joint is involved in 90% of patients with rheumatoid arthritis, and total knee arthroplasty is being performed in many patients to alleviate pain and recover function. However, complications are not uncommon. In this review of the literature we look at pre-operative, intra-operative and post-operative factor that need to be taken into account to reduce the risk of complications in these patients. Due to the systemic nature of rheumatoid arthritis, a multi-disciplinary approach is crucial. This includes addressing medical and pharmacological issues, and anesthetic concerns pre-operatively, and anticipating and preventing relevant complications postoperatively.

This compact pocketbook provides orthopaedic surgeons in training with concise and relevant core knowledge on all aspects of children’s fractures. Content includes the common fractures that affect chi

Technological advances, in particular the rise of the internet, have led to dramatic changes in medical education. The recent global financial crisis and issues with medical staffing have meant that training programs and universities are increasingly exploring electronic means to provide efficient and cost effective education techniques. In this article, we explore methods by which orthopedic trainees can develop their educational portfolio through electronic resources and similarly, how training or residency programs can utilize these advances in technology to both increase efficiency and enhance their teaching reputation. Finally, we explore the merits of trainees keeping track of their careers through electronic portfolios.

Background Nerve injury is an acknowledged complication of total shoulder arthroplasty (TSA). Although the incidence of postoperative neurological deficit has been reported to be between 1% and 16%, the true incidence of nerve damage is considered to be higher. The present study aimed to identify the rate of intraoperative nerve injury during total shoulder arthroplasty and to determine potential risk factors. Methods A prospective study of nerve conduction in 21 patients who underwent primary or revision TSA was carried out over a 12-month period. Nerve conduction was monitored by measuring intraoperative sensory evoked potentials (SEP). A significant neurophysiological signal change was defined as either a unilateral or bilateral decrease in SEP signal of ≥50%, a latency increase of ≥10% or a change in waveform morphology, not caused by operative or anaesthetic technique. Results Seven (33%) patients had a SEP signal change. The only significant risk factor identified for signal change was male sex (odds ratio 15.00, 95% confidence interval). The median nerve was the most affected nerve in the operated arm. All but one signal change returned to normal before completion of the operation and no patient had a persisting postoperative clinical neurological deficit. Conclusions The incidence of intraoperative nerve damage may be more common than previously reported. However, the loss of SEP signal is reversible and does not correlate with persisting clinical neurological deficits. The median nerve appears to be most at risk. Monitoring SEPs in the operated limb during TSA may be a valuable tool during TSA.

Eponyms are widely used in medicine and their use has been the subject of much debate recently. Advocates stress their historical significance, their ability to simplify complex terminology and their addition of character to science. Opponents cite the controversy among those eponyms and highlight the lack of both scientific and historical accuracy. The law of Nonoriginal Malappropriate Eponymous Nomenclature (NOMEN) suggests that no phenomenon is named after the individual(s) who originally described it. We aimed to determine whether this law is applicable to various clinical conditions and signs relevant to paediatric orthopaedics. We selected a series of 10 eponyms and performed a thorough literature review. In all cases, a description was identified preceding that from whom the disease received its eponymous name. We were also able to identify what we believe to be the earliest recorded description of each disease and sign. Our examples confirm the law of NOMEN in the field of paediatric orthopaedics. We suggest that irregularities in the descriptions and meanings of eponyms are identified and updated.

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Presented in a question-and-answer format, Anatomy Vivas for the Intercollegiate MRCS will help candidates prepare for the anatomy section of the new Intercollegiate MRCS exam and will aid their learning in the format in which they will be tested. The book is unique in that it is based on the new examination. It is divided into the specialty areas and is based on clinical scenarios. Featuring photographs of dissections, detailed diagrams and radiographic images, the book is the most concise and accurate anatomy aid for the MRCS examination. Written by recent candidates, experienced surgical anatomists and authors of other successful MRCS guides, it features explanations presented in a memorable, logical and easy to learn manner, and highlights areas that regularly feature in the exam. Past questions, core topics and recurring themes are discussed in detail, ensuring that candidates are as prepared as possible. It is an indispensable guide to success.