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The suprascapular nerve is an ideal target for nerve blockade to alleviate shoulder pain given its widespread innervation to the shoulder girdle. Many techniques have been described. To widen the availability of this treatment we investigate whether an anatomical landmark technique can be easily learned by novice injectors to provide efficacious blockade.Five injectors were recruited with varying experience; from the novice medical student to an orthopaedic consultant. Five torsos (10 shoulders) were used. A single page of written instruction and illustration of the Dangoisse landmark technique was provided prior to injection of a Thiel embalmed cadaver bilaterally. A pre-mixed injectate with blue dye was used. Cadavers were dissected and the presence or absence of dye staining reported by 3 observers and a consensus agreement reached.Dissection demonstrated diffuse staining in the suprascapular fossa. 90% of shoulders were found to have adequate staining of the suprascapular nerve directly, or its distal branches, in a manner which would provide adequate anaesthesia. The inter-observer agreement was good (k = 0.73) for staining at the supraspinous fossa and excellent (k=0.87) for staining distally. The technique was easily performed by novice injectors with a 100% success rate.We demonstrate that this technique is reproducible by a range of clinicians to effectively provide anaesthesia of the SScN. The main risks are ineffective block (10% in this series) and of intravascular injection. Within a resource strained healthcare environment greater uptake of this technique is likely to be of benefit to a wider array of patients. more...

Objectives Small animal models of fracture repair primarily investigate indirect fracture healing via external callus formation. We present the first described rat model of direct fracture healing. Methods A rat tibial osteotomy was created and fixed with compression plating similar to that used in patients. The procedure was evaluated in 15 cadaver rats and then in vivo in ten Sprague-Dawley rats. Controls had osteotomies stabilised with a uniaxial external fixator that used the same surgical approach and relied on the same number and diameter of screw holes in bone. Results Fracture healing occurred without evidence of external callus on plain radiographs. At six weeks after fracture fixation, the mean stress at failure in a four-point bending test was 24.65 N/mm2 (sd 6.15). Histology revealed ‘cutting-cones’ traversing the fracture site. In controls where a uniaxial external fixator was used, bone healing occurred via external callus formation. Conclusions A simple, reproducible model of direct fracture healing in rat tibia that mimics clinical practice has been developed for use in future studies of direct fracture healing. more...

We present 2 cases of elderly females presenting with atraumatic, near-vertical (Pauwells grade 3), intracapsular neck of femur fractures. Following diagnosis of osteoporosis on DEXA scans, they had received alendronic acid for 7 and 10 years respectively. Routine blood tests and serum estimations of calcium, vitamin-D and thyroid-stimulating hormone, done at admission, were within the normal ranges. These patients were managed with a hemiarthroplasty and a dynamic hip screw (DHS) respectively, following discontinuation of bisphosphonates. We present these 2 cases in light of emerging evidence that associates long-term bisphosphonate use with atypical low energy femoral fractures. Only subtrochanteric/diaphyseal fractures have been reported to date. We present a new variant of atypical femoral neck fractures in metaphyseal bone related to prolonged bisphosphonate therapy. more...

Objectives There remains conflicting evidence regarding cortical bone strength following bisphosphonate therapy. As part of a study to assess the effects of bisphosphonate treatment on the healing of rat tibial fractures, the mechanical properties and radiological density of the uninjured contralateral tibia was assessed. Methods Skeletally mature aged rats were used. A total of 14 rats received 1µg/kg ibandronate (iban) daily and 17 rats received 1 ml 0.9% sodium chloride (control) daily. Stress at failure and toughness of the tibial diaphysis were calculated following four-point bending tests. Results Uninjured cortical bone in the iban group had a significantly greater mean (standard deviation (sd)), p < 0.001, stress at failure of 219.2 MPa (sd 45.99) compared with the control group (169.46 MPa (sd 43.32)) following only nine weeks of therapy. Despite this, the cortical bone toughness and work to failure was similar. There was no significant difference in radiological density or physical dimensions of the cortical bone. Conclusions Iban therapy increases the stress at failure of uninjured cortical bone. This has relevance when normalising the strength of repair in a limb when comparing it with the unfractured limb. However, the 20% increase in stress at failure with iban therapy needs to be interpreted with caution as there was no corresponding increase in toughness or work to failure. Further research is required in this area, especially with the increasing clinical burden of low-energy diaphyseal femoral fractures following prolonged use of bisphosphonates. Cite this article: Bone Joint Res 2015;4:99–104 more...

Background and purpose Our unit started to use routine multimodal techniques to enhance recovery for hip and knee arthroplasty in 2008. We have previously reported earlier discharge, a trend toward a reduction in complications, and a statistically significant reduction in mortality up to 90 days after surgery. In this study, we evaluated the same cohort to determine whether survival benefits were maintained at 2 years. Patients and methods We prospectively evaluated 4,500 unselected consecutive total hip and knee replacements. The first 3,000 underwent a traditional protocol (TRAD) and the later 1,500 underwent an enhanced recovery protocol (ER). Mortality data were collected from the Office of National Statistics (UK). Results There was a difference in death rate at 2 years (TRAD vs. ER: 3.8% vs. 2.7%; p = 0.05). Survival probability up to 3.7 years post surgery was significantly better in patients who underwent an ER protocol. Interpretation This large prospective case series of unselected consecutive patients showed a reduction in mortality rate at 2 years following elective lower-limb hip and knee arthroplasty following the introduction of a multimodal enhanced recovery protocol. This survival benefit supports the routine use of an enhanced recovery program for hip and knee arthroplasty. more...