SUSC 2011 Conference Booklet

The 3rd Annual

SCALPEL UNDERGRADUATE SURGICAL CONFERENCE October 22nd 2011, Manchester

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CONTENTS Welcome address

3

Organising Committee & Judges

4

Itinerary

5

Practical Workshops

6

Academic Workshops

7

Venue Map

8

Workshop Finder

9

Speaker biographies

10

Abstracts

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Research Session 1

11

Research Session 2

13

Audit Session

14

Case Report Session 1

16

Research Session 3

18

Research Session 4

20

Case Reports Session 2

21

Critical Discussion Session

23

Posters

26

Sponsors

30

WELCOME TO THE SCALPEL UNDERGRADUATE SURGICAL CONFERENCE 2011 Dear Colleagues, It is with great pleasure that I welcome you all to the third annual Scalpel Surgical Conference, here in Manchester. The conference has grown since its inception in 2009 to the fantastic event it is today; with inspiring lectures from the eminent surgeons Professor Sir Keith Porter, Miss Leela Kapila and Mr Douglas McGeorge, and a great selection of interesting and stimulating workshops.

Our conference aims to give delegates from across the country the opportunity to meet, learn and celebrate the vast field of student surgical endeavour. For this reason I am particularly pleased that so many of you have travelled from further afield: we are expecting delegates representing 15 UK medical schools, from Dundee to Southampton and for the first time some international students too.

I hope you are able to use this conference to develop professionally, establish personal ties with others in surgery, and gain experience in presenting your work – make the most of this opportunity!

I would like to thank all delegates, the judging panels and the keynote speakers for giving their time so freely for the event. Also, thanks to Smith & Nephew, Doctors Academy, BMJ Case Reports, Covidien, Ethicon and Fastbleep for providing the workshops. The conference would not have been possible without the sponsorship we received and we have a number of sponsors present today, in addition to a number who are not present; do take the time to visit them and find out how they might help you in your studies. Particular mention must go to our biggest sponsor, the Royal College of Surgeons of Edinburgh who this year named us as their „surgical society of the year‟ – a title we are delighted to accept.

I would also like to say a special thank you to our Patrons Mr Michael Rothera and Professor Gus McGrouther who have been incredibly supportive of Scalpels‟ work over the years that I have been on the committee and without whom much of our work would not be possible.

Final mention must go to the fabulously hard working committee, who have given so much of their time to making not only today but all of 2011 a massive success for Scalpel – it has been a privilege working with you all.

So, whether you‟re here to present work, to learn from our excellent speakers, or to pick up a scalpel for the first time: enjoy!

Francesca Liuzzi Scalpel President 2011

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CONFERENCE ORGANISATION ORGANISING COMMITTEE Miss Francesca Liuzzi Mr Edward Maile Mr Je Song Shin Mr Samuel Shillito Mr Neil Houghton Mr Grant Coleman Mr Babatunde Oremule Mr Liam McMorrow Miss Charlotte May Mr Antony Sorial Miss Zainab Sherazi Miss Emilia Heselden

Judges Michael Rothera, ENT Consultant Leela Kapila, Paediatrics Consultant Gregor Scott, O&G Consultant Douglas McGeorge, Plastics Consultant Vikas Malik, ENT Registrar Dale Kalloo, Orthopaedics Registrar Tracey Ellis, ENT Registrar Vineeta Joshi, Paediatrics Registrar Jonathan Ghosh, Vascular Registrar Sujala Kalipershad, General Registrar Stuart Grant, Vascular Registrar Clare Garnsey, Breast Registrar Ann Markey, ENT Registrar

Student Judges Neil Houghton, Final Year Medical Student Grant Coleman, 4th Year Medical Student Zainab Sherazi, 4th Year Medical Student Edward Maile, Final Year Medical Student Samuel Shillito, 4th Year Medical Student Oisin Keenan, Final Year Medical Student Nicholas Boxall, Final Year Medical Student

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ITINERARY Registration & Coffee

0800-0900

0900-0915

0915-1015

Welcome Francesca Liuzzi (Scalpel President) and Mr Michael Rothera (Scalpel Patron) Research Presentations 1 Main Lecture Theatre

Research Presentations 2 A101, 1st Floor

Audit Presentations A112, 1st Floor

Case Report Presentations 1 A113, 1st Floor

1030-1115

“Aesthetic Surgery: A Cinderella Subject” Mr Douglas McGeorge Main Lecture Theatre, Ground Floor

1115-1200

"From Bastion to Birmingham - Lessons Learnt and Future Aspirations" Prof. Sir Keith Porter Main Lecture Theatre, Ground Floor

1200-1300

Practical Workshops: Session A

Lunch

Lunch

Practical Workshops: Session B

1300-1400

1400-1500

1500-1545

Research Presentations 3 Main Lecture Theatre Academic Surgical Careers A113, st 1 Floor

Research Presentations 4 A101, 1st Floor

CV Clinic A202, 2nd Floor

Case Report Presentations 2 A113, 1st Floor

Debate Main Lecture Theatre

Publish or Perish A201, nd 2 Floor

1545-1600

Coffee Break

1600-1650

“For the Love of Surgery” Miss Leela Kapila Main Lecture Theatre, Ground Floor

1650-1745 1800

Critical Discussions A112, 1st Floor How to make a prizewinning poster A213A, 2nd Floor

Poster Presentations Close |5|

PRACTICAL WORKSHOPS Suturing Skills Covidien, Session Run by Doctors Academy A116, West Wing, 1st Floor In this workshop, delegates will receive tuition on basic and more advanced suturing materials and techniques, and hand knot tying. Following this, these skills will be perfected on tissue, under the guidance of experienced surgeons.

Orthopaedics Smith & Nephew A104, East Wing, 1st Floor This workshop will allow attendees to develop practical experience of the 4 main areas of Trauma & Orthopaedics: Hip, Knee, Nailing and Plating, by gaining “hands-on” experience using the instruments and systems being currently used in theatres.

Laparoscopic Skills Ethicon A102, East Wing, 1st Floor Delegates will have the opportunity to gain first-hand experience of the level of technical proficiency required to successfully perform minimally invasive surgery, with the opportunity to practice on advanced laparoscopic surgery simulators.

Trauma Management Session run by Doctors Academy A214 & A213, West Wing, 2nd Floor In this workshop groups will rotate through several emergency scenarios. Students will have a chance to actively participate in these „real-life‟ scenarios, learning how to manage a trauma situation.

Negative Wound Pressure Smith & Nephew A115, West Wing, 1st Floor Attendees will receive tuition on the uses of this advanced and technological method of managing complex wounds, and will have the opportunity to practice using the equipment on wound models.

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ACADEMIC WORKSHOPS CV Clinic Fastbleep A202, East Wing, Second Floor This workshop will give students the opportunity to learn how to develop and improve their CVs, with advice on structure, what to include and how best to present your achievements.

Publish or Perish?

BMJ Case Reports A201, East Wing, Second Floor

This session provides delegates with an invaluable opportunity to gain advice directly from a major publisher. Interactive discussions will offer hints and tips on how to get started with your own publications, particularly case reports.

How to Make a Prize Winning Poster Suzanne Vaughan & Elspeth Hill A213A, West Wing, Second Floor Delegates will have the opportunity to develop their poster presentation skills in this interactive workshop lead by tutors with experience of producing many successful poster presentations.

Debate: This House proposes that all Doctors are obliged to serve the NHS Mr McGeorge vs Mr Rothera Main Lecture Theatre, Ground Floor These enthusiastic speakers will debate the proposition from their own experience and view-points.

Combining Research and Surgery: Academic Surgery Q&A Mr Edward Maile, Dr Laura Derbyshire, Ms Ann Markey A113, West Wing, 1st Floor This question and answer session is an opportunity to find out more about combining the excitement of surgery with the challenge of academic research. The panel includes individuals at varying stages in their training and offers the chance to find out about the benefits of conducting research and how to become involved with academic surgery. The session will also offer practical advice on how to apply successfully to academic posts.

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VENUE MAP GROUND FLOOR Ground Floor

East Wing

West Wing

A18

Main Lecture Theatre

Male Toilets

Female Toilets

Atrium

North Entrance

West Wing

East Wing A101

A113

1st Floor

A102

A114

A104 A101

A115 A112

A116

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East Wing

A201

West Wing

2nd Floor

A202

A213 A

A213

A214

A215

WORKSHOP FINDER Suturing: A116, West Wing, 1st Floor Laparoscopy: A102, East Wing, First Floor Orthopaedics: A104, East Wing, First Floor Negative Pressure Wound Dressings: A115, West Wing, 1st Floor Emergency & Casualty: A213-A215, West Wing, 2nd Floor

CV Clinic: A202, East Wing, Second Floor Academic Surgical careers: A113, West Wing, 1st Floor Debate: Main Theatre, Ground Floor Publish or Perish: A201, East Wing, Second Floor How to make a prize winning poster: A213A, West Wing, Second Floor

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SPEAKER BIOGRAPHIES Prof Sir Keith Porter

Professor Sir Porter is the only professor of Clinical Traumatology in Britain. His work has earned him a knighthood for services to the armed forces, which he was awarded last year.

Having trained at St Thomas‟ in London, and subsequently working as a consultant in Birmingham, he has cared for servicemen for over 10 years. He is a passionate advocate of evidence based practice, but has often had to think differently in the face of uniquely complex traumas.

Professor Sir Porter is extensively involved in the delivery of prehospital care of trauma patients, and his passion for education has led to him publishing several educational books on this area.

Mr Douglas McGeorge Mr McGeorge is a Consultant Plastic Surgeon, who now works exclusively in the private sector. A Manchester graduate, Mr McGeorge‟s breadth of experience is extensive, having worked in many countries abroad and completed his training in London.

Mr McGeorge pioneered a new cosmetic surgery unit in Chester, and developed his special interest in breast reconstructive surgery, introducing immediate breast reconstruction into local practice.

Currently, he has active roles with many professional bodies, and is extensively involved in the training and education of surgeons.

Miss Leela Kapila Leela Kapila is a retired Paediatric Surgeon. Having trained as an undergraduate in India, she undertook her postgraduate training in England, including working at Great Ormond Street Hospital.

Working as a consultant in Nottingham, Miss Kapila‟s specialist interests were neonatal and oesophageal surgery.

Her work with the Royal College of Surgeons has been extensive, including serving as a college examiner, and culminating in being Vice President in 2003.

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ABSTRACTS Oral Presentations-Research Session 1 Main Lecture Theatre, 9.15am-10.15am Crossed-pin versus lateral-pin fixation in displaced paediatric supracondylar fractures Mayne A (Liverpool), Perry DC Background: Supracondylar humeral fractures are the most common elbow fracture in children. Closed reduction and percutaneous pinning is the most popular method of treating displaced supracondylar fractures. Controversy exists as to whether a lateral or crossed pin configuration is superior.

Purpose: To compare outcomes (rates of iatrogenic nerve injury and need for re-operation) between patients treated with crossed-pin fixation and those treated with lateral-only pin fixation in children with displaced supracondylar fractures.

Methods: A retrospective case-note review was performed on patients with Gartland Grade 2 and 3 supracondylar fractures observed in a two-year period from July 2008 – July 2010.

Results: 129 patients were included; 105 were treated with crossed-wire fixation and 24 were treated with lateralonly wire fixation. There were 12 cases of iatrogenic ulnar nerve injury in the crossed-wire group (11.4%). There were no cases of iatrogenic ulnar nerve injury in the lateral-only wire group but 2 children (8.3%) suffered an iatrogenic radial nerve injury. All cases of neuropraxia had recovered by date of discharge. Four children (3.8%) treated with crossed-wire fixation and 1 child (4.2% treated with lateral-only fixation required re-operation due to fracture rotation following initial reduction.

Conclusion: Results from this study confirm that there is an increased risk of iatrogenic ulnar nerve injury with crossed-pin fixation. However, this study highlights that lateral-only pin fixation is not without risk of nerve injury, and, combined with the superior stability of crossed-pin fixation shown in cadaveric studies, it is important that orthopaedic surgeons are familiar with both fixation methods.

The Surgical Treatment of Lesional Epilepsy: Patient Selection and Quality of Life Outcomes O’Connor L (Manchester), Josan V Background: Lesional epilepsy is a surgically remediable syndrome, caused by an underlying focal pathology.

(Schomer, 2008) Post-operative seizure freedom is reported to cause a marked improvement in quality of life.

(Daniel, 2007) Purpose: To determine the seizure outcome of resective surgery for lesional epilepsy, whether this correlates with pre-operative variables and post-operative quality of life for paediatric and adult patients treated at epilepsy surgery sites in Manchester.

Method: All patients who underwent surgery for lesional epilepsy between 2008 and 2011 were reviewed. Seizure freedom was defined as Engel I classification. Data was analysed using Fisher‟s exact test and Wilcoxon signed ranks test.

Results: 14 (77.8%) patients achieved seizure freedom at 6 months; 8 (61.5%) remained seizure free at 1 year, although there was insufficient follow up (< 1 year) for 7 (36.8%) of the cohort. There was a significant reduction in the frequency of seizures (P=0.028) after surgery, but no statistically significant difference in rates of seizure freedom between pre-operative variables. A non-significant trend was observed toward better seizure outcome with temporal lesions in younger patients, presenting with partial seizures without loss of consciousness. 71% of parents rated their overall satisfaction with their child‟s epilepsy surgery as „excellent‟; only 60% of these paediatric patients had achieved seizure freedom. 75% of adult patients, none of whom were seizure free, graded their post-operative quality of life as „good‟ or „average‟.

Conclusion: This series demonstrated a similar post-operative seizure freedom rate to published figures, but a larger long-term study is required to analyse significant outcomes. (Tllez-Zenteno, 2010)

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The effects of vein harvesting on endothelial microparticle generation during coronary artery bypass surgery Tsang JY (Manchester), Fildes J Background: the viability of endoscopic vein harvesting (EVH) for coronary artery bypass graft surgery (CABG) has recently been called into question after studies have shown a relationship with increased rates of occlusion, myocardial infarction and even death. One of the underlying mechanisms surrounding these associations may be the damage to the endothelial integrity during EVH. A novel marker of endothelial dysfunction is endothelial microparticles (EMPs).

Aims: Using the release EMPs as a quantification of endothelial injury, the study seeks to compare EVH with the standard open technique (SOT) of vein harvesting.

Methods: A prospective observational study was carried out in patients requiring CABG between June and July 2011 in the University Hospital of South Manchester, comparing the SOT (n=9) and EVH (n=5) techniques respectively. Before the conduit was grafted, 2cm was removed after being filled with heparinised patient serum and clipped. All the solution in the lumen was washed out using PBS and analysed using flow cytometry to quantify the EMPs. Results: There was a significant increase in AnnexinV+, CD31+ EMPs in the EVH group compared to the SOT group (mean number of events=454.00 vs 67.56, p=0.026), and an insignificant increase in AnnexinV+ MPs in the EVH group (mean number of events=4558.40 vs 1060.44, p=0.134).

Conclusion: The EVH technique causes an increase in the number of EMPs released into the conduit harvested, denoting endothelial damage. This could contribute to the negative associations with EVH. However, more longterm clinical data must be obtained to observe the effects to patients in vivo.

Predicting respiratory failure in Abdominal Aortic Aneurysm Repair Whing J (Manchester), McCollum C, Grant S Background: The study aims to develop a multivariate risk prediction model for postoperative respiratory failure following abdominal aortic aneurysm (AAA) repair.

Method: Data was collected on consecutive patients undergoing AAA repair between September 2000 and June 2011 in the North West of England. Data was split randomly in a 70:30 ratio into development and validation datasets. Logistic regression analysis was performed on development datasets for all AAA repairs and open repairs only to identify risk factors for postoperative respiratory failure (PRF). The area under the Receiver operator curve (ROC) was used to assess the performance of the models. Data on a sub-cohort of patients who underwent preoperative cardiopulmonary exercise testing was also analysed using univariate and multivariate statistical techniques.

Results: 164 patients (8.9%) had respiratory failure in the VGNW developmental group. Independent variables found to be associated with postoperative respiratory failure in all AAA repairs were respiratory disease, open repair and antihypertensive medication. The risk factors in open repair only were age >75, antihypertensive medication and respiratory disease. The area under the ROC curve for all repairs was 0.72 and 0.71 for the developmental and validation data sets respectively and 0.651 and 0.632 for open repairs indicating moderate discriminatory ability. In the CPET database 15.7% of patients undergoing open repair developed PRF. FeV1/FVC <75% was the only parameter predicting PRF. Conclusion: Our multivariate prediction model predicted respiratory failure in both the developmental and validation subsets, however it is limited by the impact of missing data in the validation dataset.

The Diagnostic Utility of Gram Stain Microscopy in Paediatric Septic Arthritis - A Retrospective Case Study Wong, JM (Norwich) Introduction: The diagnosis of septic arthritis in children remains challenging despite reasonable evidence for the use of laboratory tests in diagnosis. There is also limited data on the diagnostic utility of gram stain microscopy in diagnosis. We therefore aim to establish the diagnostic utility of gram stain and predictive clinical and laboratory features of paediatric septic arthritis.

Methods: We conducted a retrospective review of all patients of 16 years and under that underwent aspiration with or without washout of suspected septic joint from January 2005 to March 2011 identifying cases with an organism identified on microbiology culture. The association between clinical features, laboratory results, operative findings and gram stain examination were compared against final culture results with chi-square test and Mann Whitney test.

Results: 23 paediatric patients were identified during the time period, of which 9 (39%) had positive culture.

There was no statistically significant data to show that clinical features or operative findings were predictive of final results. Of the blood test results found, CRP has statistical significant rise (p=0.01) in culture positive (mean 33, IQR 8-293) septic joints compared to culture negative (mean 107, IQR 65-190) with CRP >65 rendering sensitivity 100% and specificity 78%. Gram stain microscopy showed 33.3% sensitivity and 100% specificity.

Conclusion: None of presenting features, operative findings and most laboratory tests but a high CRP (>65) showed to be useful diagnostic tool proven by high sensitivity. Positive gram stain is strongly predictive of culture positive septic arthritis although diagnosis cannot be excluded on the basis of negative gram stain.

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Oral Presentations-Research Session 2 Room A101, 9.15am-10.15am A Review of Open Reduction and Internal Fixation of the Os Calcis at Wirral University Teaching Hospital Basu R (Liverpool), Platt S Background: The commonest tarsal bone to be fractured is the calcanuem, and often an intra-articular fracture can lead to degeneration of the joint surface and intra-articular cartilage, leading to long term disability such as osteoarthritis. Traditionally, non-operative management has been the treatment of choice but over recent years surgical management has become increasingly popular. The aim is to restore the anatomy of the joint by improving Bohler's angle and Angle of Gissane which can be decreased in a fracture, subsequently leading to abnormality of the joint.

Purpose: To measure the effectiveness of surgical intervention of the fractured calcaneum by Open Reduction and Internal Fixation (ORIF) at Wirral University Teaching Hospital (WUTH).

Methods: A service review was conducted of ORIF for patients who had suffered a calcaneal fracture by comparing pre-operative and post-operative Bohler's angle and Angle of Gissane. Patients who underwent ORIF within the last five years at WUTH were identified. Radiological data was then analysed for these patients. Case notes were also requested to record demographic data and information about the operative procedure.

Results: Radiological data was analysed for forty patients. Pre and post-operative Bohler's Angle and Critical Angle of Gissane was analysed, demonstrating that in ninety three per cent of patients Bohler's angle was increased. The Critical angle of Gissane was improved in fifty per cent of patients.

Conclusion: The study demonstrates that ORIF of the calcaneum is able to successfully improve the anatomy of the fractured calcaneum.

Assessing the risk of damage to the Middle Meningeal Artery in Pterional Craniotomy: An anatomical study Glasson MJ (Southampton), Border S Background: The surface relationship between the pterion and its surrounding anatomical structures is important in respect to neurosurgery and forensics. In humans, the anterior branch of the middle meningeal artery (MMA) is assumed to always run deep to this vulnerable bony area [1], despite both structures demonstrating extensive variation. [2-4] Objectives: 1) To establish the anatomical relationship between the MMA and the pterion structure.

2) To identify the cranial territories occupied by the MMA. The findings are described in relation to existing and pioneering neurosurgical techniques. [5] Methods: Using 94 adult skulls from the University osteological collection, pterion type and position were established and a „central-point‟ created. MMA grooves were visualised using transillumination. Frequency data was collected using the groove distribution mapped against the cranial bones and pterion.

Results: MMA groove distribution in all four bone territories was not equal and statistically significant on both sides of the skull; involvement being greatest in Sphenoid and Parietal bones and minimal in Frontal bones.

Twenty-two vascular pathways were identified, the most common being Sphenoid to Parietal. This variation was found to be significant (X2<0.001). 80% of vessels exhibited pterion involvement; the greatest areas of vascular association being on, and posterior to, the pterion central-point.

Conclusions: These results highlight that middle meningeal vessels are not always associated with the pterion, contrary to what is described in the majority of anatomical literature. This is of significance in identifying regions of greatest vascular risk and has implications for a newly proposed pterional technique that utilises a large „keyhole‟ posterior and superior to the pterion site. [5] Investigating discomfort levels of nasal irrigation solutions: A blinded randomized trial between several marketed solutions Russell, NJ (Bristol), Stubbs TA Nasal irrigation is commonly used in the treatment of inflammation, rhinosinusitis and following surgery. Studies have demonstrated that irrigation with positive pressure is effective but a consensus has not been reached with regard to the constituents of the solution to be used. All solutions have been reported to have equal efficacy. We aimed to assess discomfort levels associated with nasal douching using a variety of commonly used saline based nasal solutions.

Sixty three volunteers were recruited to take part in a blinded study. Five solutions were prepared, anonymised millilitres of solution were administered into the nasal cavity. Subjects reported if pain was experienced and discomfort was rated using a visual analogue scale.

A statistically significant difference in discomfort between cooled boiled water and all other preparations was identified. Nasal douching with water alone is uncomfortable when compared with isotonic and hypertonic solutions of saline with bicarbonate or glucose. There was no identifiable difference between the other solutions.

For patients producing home-made solutions we therefore advocate the use of simple saline without the use of sugar or bicarbonate, as these are simpler to prepare and less likely to experience bacterial contamination if stored.

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Discovering agents active against bacterial biofilm infections Sutherland A (Leeds), Chopra I Biofilm infections of medical implants are particularly recalcitrant to antibiotics. As such they pose a devastating complication to surgeries such as total hip replacements (1) with their treatment often requiring removal of the colonised device (2). This research aimed to establish the antibacterial activity of Tocris compounds 2611, 0901, 0723, 2481, 2160, 0378 and antioxidant compounds 2,4-dihydroxychalcone, kaemferol, laurly gallate, curcumin and vitamin K5 hydrochloride against Staphylococcal aureus and Staphylococcal epidermidis biofilms and to test the hypothesis that the minimum biofilm eradication concentrations (MBECs) of the above antioxidants correlate with the extent of their membrane damaging activity. This involved growing S. aureus and S. epidermidis biofilms on a Calgary device to determine the biofilm minimum inhibitory concentration (bMIC) and (MBEC) of the test compound. A BacLightTM assay was used to determine the percentage membrane integrity remaining following ten minutes of incubation with the test compound. Tocris 2611 achieved MICs and bMICs against all three staphylococcal strains of 0.006µg/ml and MBECs of 4µg/ml against SH1000 and RP62A, and 2µg/ml against UAMS-1.

Tocris 0901 and 0723 were moderately active biofilm eradicators, having MBECs comparable to rifampicin against SH1000. Vitamin K5 hydrochloride was the least damaging agent of the antioxidants tested, reducing membrane integrity to 23% ± 12.20. Lauryl gallate was the most membrane damaging reducing membrane integrity to 4.67% ± 6.43. This study concludes that Tocris 2611 is a potent biofilm eradicator at low concentrations and warrants further investigation into its mechanism of action and toxicity.

Improving Paediatric Tracheostomy Care Tan, ZE (Manchester), Jarvis S, Penney S, Pal R, Bruce I, Rothera M Introduction: Despite advances in surgical technique, paediatric tracheostomy continues to be associated with significant potential complications. The care of children following surgery can be associated with considerable anxiety, reflecting lack of familiarity with the skills required. In order to improve the provision of nursing training, two new resources were introduced and evaluated: a tracheostomy teaching video and paediatric tracheostomy nursing documentation.

Methods: A teaching video was filmed with the help of the multidisciplinary team and parents of children with tracheostomies. It was then shown to nursing staff and student nurses on the five wards. At the viewing sessions, two questionnaires were issued, one before and one after the video screening. Nurses evaluated their own confidence in tracheostomy care using a Likert scale both before and after the video and these results were evaluated. In addition, the new paediatric tracheostomy documentation was piloted on these wards.

Results: A total of 86 responses were obtained. The average confidence rating of all respondents increased after watching the video. This was particularly marked in less experienced staff who had poor confidence ratings initially. Interestingly, the aspects of care with the worst confidence ratings (resuscitation and tube changes) experienced a substantial increase after the video. 95% of respondents felt that the documentation would increase their confidence.

Conclusion: Improving the training experience and teaching resources is fundamental to ensuring that children and their families receive the highest standard of care following tracheostomy.

Training videos and supportive documentation provide an effective adjunct to personally delivered training sessions.

Oral presentations –Audit Session Room A112, 9.15am-10.15am Retrospective Outcome Analysis of Staged Flexor Tendon Reconstruction Alexander D (Manchester), Srinivasan J Background: Staged flexor tendon reconstruction is an uncommon surgical procedure which is useful for restoring function to those who have had a delayed presentation of a flexor tendon injury.

Purpose: This study appraises the outcomes at Royal Preston Hospital from 2005 – 2010 and investigating the various factors which contribute to functional outcomes.

Method: The operative and follow-up notes of 21 patients (22 digits) who were coded as having undergone this procedure from 2005 – 2010 were analysed with an average follow-up of six months. A wide range of demographic data was collected.

Results: In this series, only 27.3% achieved good functional outcomes with complications comprising of: reduced range of motion (36.4%), rupture of graft (18.2%), bowstringing and infection (both 4.5%).

In terms of demographics; occupation seems to have a profound effect on outcomes with unemployed patients faring better than manual workers. Older patients also had an increased likelihood of achieving greater range of motion. Inter-stage duration was another factor with shorter intervals producing better results.

It was important to note that operative technique, specifically the use of Mitek anchors, influenced post-operative complication rates. This has not been evaluated in previous literature where the mainstay of distal fixation has been Bunnel‟s tendon button.

Conclusion: The functional outcomes in this centre are relatively poor; this in turn has highlighted a number of factors which play a vital role in determining the final outcome. The unstudied theme of Mitek anchors proves a good avenue for further research with its superior post-operative rupture rates.

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The Ferguson medial open reduction for the treatment of late developmental dysplasia of the hip. A follow up study and comparison with closed and anterior open reductions.

Chapman A (Manchester), Burgess E, Henry A. Davis N. Khan T. Foster A. and Zenios M Background: In our centre, the Ferguson medial approach has been used for the treatment of DDH as open reduction of low dislocations with no false acetabulum and was reported to be a safe and reliable approach in nonwalking age children (1), however previous literature from other centres has been controversial.

Purpose 1) Compare medial open reduction with closed and anterior open reduction, assessing avascular necrosis, reoperation rate and persistent acetabular dysplasia to identify success.

2) To investigate whether the presence of an ossific nucleus at the start of the treatment is protective against the development of avascular necrosis.

Methods: Data was collected from 118 patients, (128 hips) for age at initial operation, type of reduction and reoperation. Radiographic data identified AVN, presence of the ossific nucleus and acetabular index measurements both pre- and post-operatively.

Results: Medial open reduction had the lowest rate of AVN â&#x20AC;&#x201C; 8.6% compared to 22.8% following anterior open reduction and 23.8% following closed reduction (p=0.04). It also had the lowest rate of persistent acetabular dysplasia. Closed reduction had a reoperation rate of 71.4%. Presence of the ossific nucleus had no protective effect against the development of AVN. Conclusion: Fergusonâ&#x20AC;&#x;s medial open reduction for DDH is a safe and effective method for treating low dislocations in non-walking age children. Closed reduction requires review due to the high reoperation rate.

Retrospective study of the 5 year recurrence rate of periocular basal cell carcinoma following Mohs Micrographic Surgery Sin CW (Manchester), Barua A Introduction: The incidence of basal cell carcinoma has been increasing over the past decade and will continue to do so for many years to come. Mohs micrographic surgery is a specialised technique of tumour excision which involves mapping and horizontal sectioning of tumours. It establishes a 360 degree view to aid tumour eradication with no residual tumours.

Mohs Micrographic Surgery is the gold standard treatment option for periocular basal cell carcinoma. It minimises the recurrence of tumour whilst allowing surrounding normal tissue to be preserved, allowing better skin closure and healing as well as minimising trauma to surrounding functional structures. Currently there have been no studies done in the United Kingdom to investigate the 5 year recurrence rates of basal cell carcinoma following Mohs Micrographic Surgery.

Objectives: To analyse and find the 5 year recurrence rate of basal cell carcinoma (BCC) following Moh's Micrographic surgery (MMS).

Methods: A retrospective study of 390 patients undergoing MMS in Manchester from 2001 to 2006 for periocular basal cell carcinoma. The following parameters were recorded: age, gender, previous BCCs and treatment modality, post-operative complications and subsequent management, site, size of lesion, histological subtype and recurrences following MMS. Results: Only 6 recurrences were found (1.5%), of which 1 (0.3%) were primary BCCs and 5(6.5%) were recurrent BCCs. Conclusion: Mohs Micrographic Surgery is the treatment of choice for high risk basal cell carcinomas. The recurrence rate of BCCs that was found in this study is in line with international standards.

The effect of a regular anaesthetist on non-surgical time during ENT surgery Tan L (Cambridge), Forde C Many surgeons are of the opinion that the presence of a regular anaesthetist in the operating theatre can decrease non-surgical theatre time, thereby reducing turnover times and allowing greater operating theatre efficiency. Such opinion has led to various studies investigating the mutual effect pre-operative anaesthesia and surgical start times have on each other. It is against such a backdrop that this audit was undertaken, to determine the significance of the perceived difference in non-surgical times between operations where there is a regular anaesthetist as compared to other anaesthetists. Using theatre records, a retrospective study was conducted, looking at 296 operations over 59 days from April 2010 to March 2011, to compare the average non-surgical time per operation when the regular anaesthetist is present with the average non-surgical time per operation in the presence of other anaesthetists. Despite observing a decreased amount of non-surgical time of 4 minutes and 43 seconds per operation in the presence of a regular anaesthetist, this difference was not deemed to be significant (with criteria P<0.01). Two of the main factors contributing to the lack of significance include the training of

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anaesthetic registrars and the assignment of complicated cases to the regular anaesthetist, and these are areas that are worth further consideration. The lack of statistical significance shows that this audit does not yet provide enough evidence for changes to be implemented in clinical practice. Therefore, we suggest re-auditing with a multi-departmental approach with the above confounding factors taken into account.

Primary A/V fistulae: Maturation time and dialysis adequacy in a single university hospital vascular unit Twigg V (Keele), Aldridge K Background: Renal Association guidelines published in January 2011, for review in 2014, state that 85% of patients in one centre undergoing haemodialysis should be dialysing through a native arterio-venous fistula due to the distinct advantages conferred by this access. Owing to the importance of prompt and adequate AVF formation to meet these guidelines, this study aims to review the success of arterio-venous fistula (AVF) formation in a large university hospital.

Method: A retrospective study was undertaken over a period of 7 months at University Hospital of North Staffordshire, looking at the types of AVF and the breakdowns of maturation time, outcome and dialysis adequacy.

There were a total of 75 patients in this time period, with a mean age of 68 years.

Results: There were equal numbers of brachio-cephalic and radio-cephalic fistulae (33/75), only 12% (9/75) were brachio-basilic. 21% of radio-cephalic fistulae required secondary intervention to maintain patency, compared to 6% of brachio-basilic and 3% of brachio-cephalic. Time from formation to use was lower in radio-cephalic (44 days) than brachio-cephalic (50 days) and brachio-basilic (52 days). 87.5% of fistulae met Kidney Disease Outcomes Quality Initiative (KDOQI) recommended URR>65% and kT/V>1.2. Median kT/V was 1.47 for brachio-cephalic fistulae and 1.5953 for radio-cephalic. There were inadequate numbers of brachio-basilic fistulae to comment.

Conclusion: KDOQI guidelines are being followed with respect to fistula site. First-line radio-cephalic fistulae have a lower time to maturation and provide more adequate dialysis based on URR and kT/V values, but patency rates are lower than for brachio-cephalic fistulae.

Oral Presentations- Case Report Session 1 Room A113, 9.15am-10.15am What we can learn from the systematic safety net applied to the multidisciplinary management of burn patients: case report Doostdar B (London), Geddes J Introduction: Burn patients present complex challenges to the multidisciplinary team (MDT). Here we report a case exemplifying how their management differs from other specialties.

Case report: A 59-year old man with Parkinson‟s disease, Asperger‟s syndrome and a known history of anxiety and depression presented with self-inflicted petrol burns covering 62% body surface area to the lower limbs, chest, left arm and face (41% were full thickness injuries). Acute management involved ventilation; fluid resuscitation dictated by Parkland‟s formula; repeat surgical debridement, escharotomies, allografts and autografts. Dietician involvement is paramount due to a hypermetabolic state necessitating an increased calorific intake. Chronic management must address his walking through physiotherapy, and his overall reintegration through occupational therapy. The mental health team help him come to terms with his injuries, and tackle his underlying psychiatric history. Crucially the nurses see the wounds daily and must liaise with every MDT member to advise on management.

Conclusion: We observed a unique approach to the burns MDT meeting. This involved checklists to ensure no aspect of care was overlooked and that missing information was followed up – a high level of scrutiny that provided a safety net. MDTs can also suffer from different specialties working less with each other and more with themselves. Burn patients require a greater level of cooperativity, and this approach may prove beneficial in other areas of medicine.

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Peri-vascular tumours: a technical difficulty for surgeons Grimes N (Liverpool) Background: Sarcomas are a group of malignancies arising from the embryological mesoderm. Sarcomas may arise from several different tissues and are categorised accordingly, with each different type entailing a different form of management (including surgery, chemotherapy and radiotherapy) and prognosis. Because of the wide variety of tissues from which these tumours can arise, their location may present surgical difficulties.

Report: A 61 year old female presented with a 6 month history of gradual onset abdominal distension and suprapubic tenderness. The patient had no other clinical features and was otherwise healthy. A CT scan revealed a large retro-caval sarcoma causing significant compression of the inferior vena cava (IVC). This was successfully resected with no complications.

Discussion: This case illustrates the potential difficulty in managing sarcomas due to their anatomical location. In this case, the sarcoma was successfully separated from the IVC and vascular resection was not required. However, where IVC resection is required, successful outcomes can still be achieved. One small study reported on such patients; complete tumour resection was achieved in all patients with an 80% survival rate at 30 months. While evidence of such cases is limited, reported techniques range from IVC resection and reconstruction with grafts to no reconstruction whatsoever due to sufficient collateral vasculature.

Conclusion: Sarcomas can present technical difficulty in their resection due to the structure and location from which they arise. Peri-vascular sarcomas can be successfully resected with good results and even where vascular resection and reconstruction is required, good outcomes can be achieved.

“A case of ultra-short bowel syndrome: Survival using an integrated intestinal rehabilitation programme.”

Honeyman C (Manchester), Morabito A Short Bowel Syndrome (SBS) is a devastating malapsorbative state caused by significant loss of small bowel. In the neonate, this is most commonly caused by conditions such as Necrotising Entercolitis and Midgut Volvulus.

SBS renders its patients reliant on Parenteral Nutrition (PN) to fulfil requirements for satisfactory growth and development. Despite forming the crucial backbone of management in these patients, PN is a process fraught with potentially fatal complications, drastically increasing the mortality associated with this condition. The most devastating complication associated with PN is associated liver failure.

Current management using intestinal rehabilitation programmes (IRP) has been pioneered by The Royal Manchester Children‟s hospital. IRP‟s involve cutting edge surgical lengthening procedures, individualised care plans and early, aggressive management of complications.

We present a case of a female neonate born with an antenatal midgut volvulus that subsequently left her with only 16.5cm of duodenum up to the DJ flexure, a case of ultra-short bowel syndrome. She underwent intestinal rehabilitation involving Controlled Tissue Expansion and subsequent STEP (bowel lengthening) procedure.

Following surgery she was left with an impressive 30 cm of bowel.

Seven months later, after individualised MDT care she was released from hospital, with steady weight gain, on decreasing home PN and a weaning diet.

This case illustrates how early application of modern IRP's offers SBS patients with even the smallest lengths of residual bowel a high chance of survival and hope of complete PN independence. Currently, 92 % of SBS patients treated with IRP are completely independent of PN. A CASE OF ANKYLOBLEPHARON FILIFORME ADNATUM Jaberansari H (Manchester), Chaturvedi R Intro: Ankyloblepharon filiforme adnatum is a rare condition found in newborn babies in which Single or multiple strands of fine connective tissue join the upper and lower eye lids preventing the eyelids from opening. Delayed treatment of this condition can lead to occlusion amblyopia Case: A new born baby, otherwise healthy and feeding well, was referred by the paediatrician due to an inability to open her eyes. The baby was delivered in full term with normal delivery and no history of antenatal infection or drug ingestion. Patient‟s family history was completely insignificant. On ophthalmic examination, multiple bands of elastic tissue connecting the upper and lower lid margins were noted. The posterior surface of the eyelids appeared completely normal with no evidence of any abnormality of ocular movements, anterior segment and the fundus. The bands of tissue were successfully divided using scissors and no bleeding occurred with no need for sedation or local anaesthetic. No patient distress was evident Subsequent examination was satisfactory and patient was consequently discharged.

Conclusion: Ankyloblepharon filiforme adnatum is a condition that can be treated very easily by a simple operative procedure. Timely separation of the eyelids is crucial to avoid the development of occlusion amblyopia.

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Reverse Shoulder Arthroplasty (RSA) for the Treatment of Fractures with Distortion of the Proximal Humerus Lim JW (Dundee) Background: When there are fractures with distortion of the proximal humeral around the cuff insertion, RSA should be considered as the biomechanical fulcrum for arm elevation is already destroyed.

Report: A 75-year-old man suffered trauma to his right shoulder on June 2010 and was treated conservatively.

Over the year, patient complaint about pain and daily life impairment.

On examination, patient had significant muscle weakness and limited shoulder movement, which included abduction, adduction, internal rotation, external rotation and flexion.

X-ray showed significant comminuted fracture, affect the head and neck of right humerus. RSA was performed on May 2011, with the intention of relieve pain and restore as much shoulder function as possible.

Discussion: RSA completely changes the orientation and original mechanism of the shoulder. The glenoid is replaced with an artificial ball, whereas the humeral head is replaced with implant that has socket for the artificial ball to rest. RSA moves the center of rotation of the glenohumeral joint medially and inferiorly. This will increase the length of deltoid muscle (the main muscle for abduction). This provides better functioning shoulder.

Due to the new and unconventional approach to shoulder problem, the intraoperative and postoperative complication rates of RSA is 9% higher than the conventional total shoulder arthroplasty. The most common complication is the scapular notching.

Conclusion: Despite higher complication rates, the outcome is encouraging as most patients are able to perform better abduction and flexion, which has significant improvement in functional quality of life.

The importance of hip evaluation in children with knee pain Mayne A (Liverpool), Perry D, Bruce C Case: A fourteen-year-old boy presented to his GP with recurrent left knee pain. Knee examination was unremarkable and knee radiographs were normal. The GP diagnosed a knee sprain and reassured the patient. The pain remained intermittent.

Six months later the patient presented to A + E following a fall whilst playing football. He was unable to weight bear with localised hip pain. Examination revealed an externally rotated left leg with limitation of all hip movements. A pelvic radiograph identified an acute-on-chronic Slipped Capital Femoral Epiphysis (SCFE). The SCFE was pinned in-situ. Follow-up is underway observing for avascular necrosis (AVN).

Discussion: Hip pathologies are key differential diagnoses in children with knee pain. Clinicians must examine the hips of such children. Limitation of internal rotation is the most sensitive clinical sign of hip pathology in children.

Any restriction on examination should prompt urgent AP and lateral pelvic radiographs.

SCFEâ&#x20AC;&#x;s commonly cause isolated knee pain. The symptoms may begin many months before an acute slip occurs.

Prompt recognition of a SCFE results in an AVN rate close to 0%, whereas the AVN rate following an acute slip approaches 50% AVN. Misdiagnosed SCFE is a common cause of medico-legal claims, often in excess of ÂŁ100,000 and is therefore a concern for General Practitioners, Emergency Physicians and Orthopaedic Surgeons alike.

Summary: Knee pain in children commonly arises from the hip. Hip examination and prompt investigation of knee pain in children may minimise patient complication, and doctor litigation.

Oral Presentations- Research Session 3 Main Lecture Theatre, 14.00-15.00 Incidental Durotomy: Does a longer period of postoperative bed rest reduce the rate of complication?

Low J (Manchester), King A Introduction: An incidental durotomy is a common complication of degenerative lumbar spine surgery. Typically, patients are instructed to lay flat for up to 7 days to reduce the risk of complication. Our objective is to determine if longer periods of mandatory bed rest decreases the rate of complication in patients who incur an incidental durotomy during degenerative lumbar spine surgery. We present the largest retrospective study to date to evaluate the period of bed rest and the rate of complication.

Method: Retrospective case review of patients who underwent degenerative spinal surgery between May 2009-May 2010. Patients who incurred an incidental durotomy and were repaired using Tisseel were included and followed up for 12 months.

Results: 62 patients matched our criteria. 26 patients were mobilised after 24 hours of surgery, 9 patients after 48 hours and 27 patients were mobilised 72 hours or more postoperatively. The overall incidence of complication was 19.4%. 15% of patients mobilised 1 day post-op, 33.3% of patients who were mobilised 2 days post-op and 18.5% of patients mobilised 3 or more days post-op experienced complications.

Conclusion: A longer period of mandatory bed rest does not decrease the rate of complications. There is no statistical significance between the period of mandatory bed rest and the rate of complication (P=0.496). Patients should be mobilised as soon as they are able to prevent contracting hospital infections, reduce the risk of developing a DVT from immobility and to reduce the cost of post surgical care.

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Does Size Matter? A study to investigate the influence of patient and prosthetic size on patient outcomes after isolated aortic valve replacement Radotra I (Sheffield), Briffa N Introduction: Aortic valve replacement (AVR) is a heart operation where a diseased native aortic valve is replaced by an artificial prosthetic valve. The size of the implanted prosthesis is crucially important for the patient as implantation of an inadequately sized valve has been associated with poor outcomes. This however has never been demonstrated in a British study. Obesity is a risk factor for the development of cardiovascular diseases and poorer outcomes in other cardiac surgeries. Despite a significant increase in the prevalence of obesity in the UK and AVR being a common cardiac surgery, the effect of patient and prosthetic size on outcomes after AVR is still poorly understood.

Objectives: To assess the influence of patient and prosthetic size on patient outcomes after isolated AVR. Patients and Methods: Retrospective data on 924 patients undergoing isolated AVR from March 2001 to April 2010 was analysed. Patient and prosthetic size were expressed as BMI and Geometric orifice area (GOA) respectively.

The effect of BMI, GOA and other pre-operative variables on early mortality and morbidity was determined using Kaplan Meier, univariate and multivariate Cox proportional hazards regression.

Results: There was a 16.4% increase in obese and morbidly obese patients from 2001 to 2010 in Sheffield. Age, gender, surgeon (p<0.001) and height (p=0.024) determined the size of a prostheses inserted. Prosthetic size (GOA) was an independent predictor of early (30 day) mortality, whilst patient size was an independent predictor of morbidity (p= 0.04). Independent predictors of long-term survival included age, gender, NYHA status and type of cardioplegia.

Conclusion: Patient and aortic valve prosthetic size influences patient outcomes after isolated AVR. A systematic review of the benefits in the use of thoracic epidural anaesthesia for surgery Yeung A (Manchester), Vohra A Background: Perioperative thoracic epidural anaesthesia (TEA) has long been proposed to have additional benefits for multiple organ systems due to sympatholytic effects. A meta analysis comparing the risk of acute myocardial infarction, mortality, new dysrhythmias, systemic hypotension, and new respiratory complications following combinations of TEA compared to conventional general anaesthesia (GA) regimens has been conducted.

Methods: MEDLINE and PubMed were searched for randomized studies trialing the effects of TEA for any diagnostic or surgical procedure against non-TEA groups. Studies were combined, weighted, and compared to calculate an overall pooled risk ratio using the Mantel-Haenszel method in a fixed effects model.

Results: The search process led to 1431 studies; of which 33 studies including 2583 patients were included in the analysis. 1,492 patients received a combination of TEA, while 1,091 received a combination of GA. TEA significantly reduced the risk of new dysrhythmias with an overall risk ratio of 0.63 (95% CI 0.52 – 0.77), and new respiratory complications with a risk ratio of 0.55 (95% CI 0.41 – 0.73). TEA increases the risk of systemic hypotension with a risk ratio of 4.52 (95% CI 0.93 – 21.87). TEA did not change the risk of death, or acute myocardial infarctions, with overall pooled risk ratios of 0.56 (95% CI 0.25 – 1.27), and 0.74 (95% CI 0.40 – 1.36) respectively.

Conclusions: TEA was shown to increase rates of systemic hypotension, reduce rates of new dysrhythmias and respiratory complications. No conclusive differences in acute myocardial infarction and mortality rates were found after TEA use.

TOTAL OESOPHAGOGASTRIC DISSOCIATION IN CHILDREN WITH SEVERE NEUROLOGICAL IMPAIRMENT: THE POSTOPERATIVE COURSE Veitch J (Manchester), Kauffmann L, Morabito A, Hawkins KC Background: Total oesophagogastric dissociation (TOGD) is a surgical procedure which produces excellent results in resolving the severe, and notoriously difficult to treat, gastro-oesophageal reflux disease (GORD) from which many children with neurological impairment (NI) suffer. There is concern that TOGD is associated with significant post-operative morbidity. This results in controversy around the procedure and a degree of reluctance to perform it, despite its positive outcomes.

Aims: The objective of this study is to assess the immediate post-operative course following TOGD in children with NI. Methods: Records of 33 patients with NI who underwent TOGD at a tertiary paediatric surgical centre were reviewed retrospectively. Variables examined included interventions required and length of stay in the paediatric intensive care unit (PICU), early post-operative complications and total length of stay in hospital.

Results: 91% of patients were electively admitted to PICU following surgery for a median of 2.5 days. 77% were electively ventilated and 7% required inotropic support. 18% of patients had early surgical complications which required further operative management. Complication rates were much higher in patients undergoing rescue TOGD following failed fundoplication (60%) opposed to patients undergoing TOGD as a primary anti-reflux procedure (11%). Median total length of stay in hospital following TOGD was 9 days.

Conclusions: TOGD is a major procedure which is performed in high risk patients. Overall its benefits outweigh its risks and with careful patient selection and advancing surgical, anaesthetic and intensive care practice TOGD offers an acceptable and effective treatment for GORD in children with severe NI.

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Oral Presentations- Research Session 4 Room A101, 14.00-15.00 The Treatment of Non-Lesional Temporal Lobe Epilepsy with Surgery Curl-Roper T (Manchester), Mr Josan Introduction: 20-40% of patients with temporal lobe epilepsy are refractory to medication. In these patients, surgery has a 70-90% probability of inducing freedom from seizures. Despite this, surgery remains underutilised.

This study aims to illustrate the efficacy and low complication rate of temporal lobectomy in the treatment of epilepsy.

Method: The medical notes of patients from operated on by a single neurosurgeon were retrospectively reviewed.

Both paediatric and adult patients with non-lesional temporal lobe epilepsy refractory to medication were included. Post surgical outcomes were assessed using Engel Classification, and Fisher's Exact Test performed to determine if any variables were predictive of a favourable or unfavourable outcome.

Results: All patients had a good surgical outcome, with 87.5% of patients assessed as Engel Class I. Unexpectedly, adults on average had slightly better outcomes with 100% achieving Engel Class I outcomes and 66.7% Class Ia. In comparison, 71.4% of paediatric patient were classified as Class I, and only 28.6% attained Class Ia. Conclusion: Surgery significantly reduces seizure frequency in appropriately selected patients with temporal lobe epilepsy.

The Use of HD Video to Assist in Orthopaedic Teaching Stubbs T (Bristol), Aird J, Williams JL Background: The European working time directive has imposed a restriction on training doctor‟s hours to a maximum of 48/week (1). This legislation has had a profound impact on post-graduate training (2). Technological advances in recent years has made video an easy medium with which to facilitate learning, and preliminary surveys suggest this is not a teaching method currently employed.

Purpose: We aimed to record HD video of the Orthopaedic Surgeons at Musgrove Park Hospital performing a range of typical foot and ankle operations. Our aim was to use this edited video to facilitate practical learning, to evaluate its effectiveness, and to assess the time and expense required for its production.

Method: With patients consent, preselected operations were captured on HD video camera. The clips, encompassing the key stages of the procedure, were then edited to 4-6 minute in length and supplemented with text explanations on screen.

Results: A survey (n=30) conducted during a registrar teaching session has shown that 0% have had previous exposure to this teaching medium, and everyone thought it would be a useful adjunct to their training. Feedback from registrars who have subsequently used this tool has been positive.

Conclusion: Surgical video is available to the trainee without constraints on time. It should also be useful within the medical student population, where it has been shown a great proportion of students feel they are in the way of theatre staff whilst observing surgery (3). There are also opportunities to extend this study include broadcasting teaching materials on the Internet.

The width:thickness ratio of the patella and its relationship to pain and functional outcome post patellofemoral joint arthroplasty Eddie L (Bristol), Murray J Patella resurfacing as part of total knee arthroplasty (TKA) remains a matter of controversy in orthopaedic surgery. Research has shown that patella width is twice its thickness in the non-pathological patella, and therefore perhaps this ratio should be applied when resurfacing it for optimal clinical outcomes. The aim of this study is to investigate if the anatomical width:thickness ratio of the patella is reproducible, and whether or not it has any correlation with clinical outcomes.

To establish patella width:thickness ratio, 100 digital skyline radiographs in 89 patients who underwent unicompartmental knee replacements were selected. The Centricity® Picture Archiving and Communication Systems (PACS) on screen tool was used to measure patella width and thickness. To establish the effect of the ratio upon clinical outcome following patellofemoral joint (PFJ) arthroplasty, 81 post-operative digital skyline PFJ radiographs were used to measure patella-bone prosthesis construct width and thickness.

PFJ measurements in the uni-compartmental knee replacement cohort showed patella thickness correlated (r=0.84, p<0.001) with its width. The mean width to thickness ratio was 2.07. Ratios were categorised in to understuffed, normal and over-stuffed as dictated by the ratio established in non-pathological patellae. Statistical analyses assessed correlation between the ratios with WOMAC and OKS. Results showed that the „normal‟ subset had better outcomes in all scores; this was not statistically significant on ANOVA testing (p>0.05). The results of this study imply that if PFJ‟s are resurfaced using the thickness to width ratio range of 1:2.04-1, better clinical outcomes may result.

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Flap reconstruction in sarcoma patients Morhij R (Glasgow) Jane M, Prof Hart Introduction: Sarcoma management has recently moved towards limb sparing surgery, facilitated by adjuvant radiotherapy. Soft tissue reconstruction can further extend the scope of limb salvage, by permitting the excision of larger tumours, and providing rapid healing, and tolerance to radiotherapy. A question persists over whether this occurs at the expense of greater tumour recurrence.

Methods: All patients undergoing excision and major flap reconstruction between June/2009 & February/2011 were identified from theatre records (Group1). Demographic, tumour, and reconstructive data were extracted, along with regional & systemic recurrence, and survival figures. Comparison was made with tumour-matched patients not undergoing flap reconstruction (Group2).

Results: Group 1 contained 30 patients (mean age 63, SD19; 20males 10females) underwent excision and flap reconstruction. Group 2 contained 28 patients (mean age 56, SD14; 19males 9females). In Groups were not significantly different.

5/30 patients in group 1 and 4/28 in group 2 developed local recurrence. 2/30 patients in group1 and 1/28 in group2 developed systemic recurrence. 6/30 in group1 and 1/28 in group2 died, all of either systemic or local recurrence.

Discussion: The greater mortality in Group1 reflects more aggressive tumour biology, which is unaffected by the mode of local treatment. Results document that even for large, high-grade tumours flap reconstruction permits limb & functionally sparing surgery without significantly increased local recurrence. Salient cases are presented to illustrate flap techniques found to be beneficial.

Oral Presentations- Case Reports Session 2 Room A113, 14.00-15.00 A rare case of longitudinal atlantoaxial dislocation in a Type III odontoid fracture Hall S (Southamptom), Russo S Background: Type III odontoid fractures are a common complication of traumatic cervical injury and are usually associated with anterior displacement (1). Longitudinal dislocation in these cases has a similar prognosis to atlanto-occipital dislocation which includes quadriplegia, cranial nerve deficits and often, death (2). Only a handful of cases of longitudinal atlantoaxial dislocation have been reported.

Report: This patient is a 21 year old male who presented following a bicycle-vs-car road traffic accident with multiple injuries. Radiology revealed a Type III odontoid fracture extending into the C1-C2 facet joint with an associated longitudinal dislocation. He was initially managed with a halo vest and reduction under fluoroscopy but went on to undergo surgical C1 trans-lateral mass and C2 trans-laminar screw and rod fixation. 7 days following surgery some movement had returned to his toes and at 5 month follow-up he was ambulatory with only minor motor deficits.

Discussion: This case illustrates the need for an awareness of the potential presentations of odontoid fractures especially considering that a standard treatment for Type III is axial traction which would cause devastating neurological sequelae in this case(1). The uncharacteristically good outcome in this patient highlights the need for individualised treatment in rarely seen pathologies.

Conclusion: Type III odontoid fractures with longitudinal dislocation are unstable, rare and require careful management.

Combined Pancreaticoduodenectomy with Venous Resection and Reconstruction using Non-autologous Vein Manoharan D (St. Andrews), Wigmore S, McNally S Background: Pancreatic cancer is difficult to diagnose and often presents too late for surgical resection. However, in selected patients, radical surgery including resection of adjacent structures may make cure possible.

Report: A 36-year-old male presented with epigastric pain. Investigations revealed a neuroendocrine tumour of the pancreatic head with portal vein (PV), superior mesenteric vein (SMV), and transverse mesocolon involvement.

A decision was made to proceed with a Whipples procedure, incorporating portal venous resection. This venous resection involved excision of the tumour and a significant length of the extrahepatic PV. A donor iliac vein graft was utilized for reconstruction. Intraoperatively, the extent of the tumour necessitated an additional right hemicolectomy. Postoperatively, apart from a period of ileus, the patient has made excellent recovery. The pathology report confirmed an R0 resection.

Discussion: Pancreatic head resection combined with venous resection remains controversial.(1,2) It offers the possibility to achieve complete oncological resection of the extended malignancy and thus improve long term survival.(3,4) The already high rates of morbidity and accompanying mortality following a conventional Whipples resection and the poor prognosis associated with pancreatic cancer, has led many centres considering venous involvement a contra-indication to resection.(2) However, in selected cases, aggressive surgery involving an extension to the customary Whipples resection is warranted and can offer these patients satisfactory long-term outcomes.(1,5,6) Conclusion: Portal vein involvement should not be a contra-indication to pancreatic resection. This case demonstrates this notion and provides an opportunity for change in the surgical practice for pancreatic cancer treatment.

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A complex case of chronic radiation enteritis Matthews D (Manchester), Anderson I Introduction: Seen in up to a quarter of patients following pelvic and abdominal radiotherapy, chronic radiation enteritis can present with symptoms ranging from abdominal pain and diarrhoea to those of small bowel obstruction.

Background: Depending on severity of dysfunction, treatments range from nutritional support, anti-diarrhoeals, biological agents and hyperbaric oxygen therapy to surgical resection of damaged intestine. As surgery is associated with significant morbidity it requires careful consideration before being undertaken.

Case: Following a Hartmannâ&#x20AC;&#x;s procedure for carcinoma of the sigmoid colon, a 58-year-old gentleman underwent a course of pelvic radiotherapy. Six months subsequently abdominal pain was investigated and small bowel obstruction discovered and duly treated with a jejuno-ileal bypass. Eighteen months later the patient developed multiple enterocutaneous fistulas which were treated medically for four years. However, to improve quality of life the patient underwent an entero-enteric bypass of the fistulating segment of bowel.

Discussion: Typically presenting six to eighteen months after radiotherapy has stopped, chronic radiation enteritis is associated with significant morbidity and mortality. Intestinal obstruction is seen in 13% of patients, intestinal fistulation in 4.8% and 5.9% of those on home parenteral nutrition in the UK are sufferers. With increasing numbers of patients undergoing radiotherapy for cancer treatment and improved long-term survival rates chronic radiation enteritis and its complications are becoming more prevalent.

Conclusion: This case demonstrates the rare situation of a patient developing both a small bowel obstruction and fistulas as a result of chronic radiation enteritis, together with the complex intestinal surgeries required in their management.

Acute carpal tunnel syndrome in haemophiliacs: a case report and literature review Mayne A (Liverpool), Howard A, Banks J Background: Acute carpal tunnel syndrome (acute CTS) is a rare surgical condition which most commonly results from trauma to the hand and wrist, with atraumatic causes being rare.

Case Report: A 23 year old man with Haemophilia type-A presented to the emergency department with a painful left hand following a fall. Radiographs revealed no fracture and he was discharged with simple analgesics. The patient re-presented eight hours later with severe pain unresponsive to 30mg morphine. On examination, there was bruising over the volar aspect of the wrist, with mild tenderness in the region. The patient had reduced sensation in the distribution of the median nerve, with normal motor function. There was no pain on passive stretching of the fingers. Investigations revealed an APTT of 46.3 seconds and factor VIIIc levels of 2.5%. The patient was initially managed conservatively but symptoms progressed over several days and the patient underwent surgical decompression for acute CTS. Discussion: A literature review revealed only a handful of cases reported in the last 30 years. Initial management of acute CTS in haemophiliacs should initially be conservative, with administration of recombinant factor VIII for three to five days in conjunction with immobilisation. If symptoms fail to improve or deteriorate, surgical decompression is required.

Conclusions: Acute CTS is a rare complication of haemophilia but should be considered in haemophilic patients presenting with pain and/or neurological symptoms in the hand. This is an important complication of haemophilia for orthopaedic surgeons, emergency department clinicians and haematologists to be aware of.

Sub-total scalp reconstruction and cranioplasty for large complex calvarial defects: a case report Russell J (Bristol), Izadi D, Wilson P Background: Reconstructive surgery of the scalp and cranium aims to establish both normal function and aesthetic outcome following disfigurement. Several methods of scalp reconstruction are commonly used depending on the location, size and depth of the defect, and include direct closure, skin grafts, local or regional flaps and free tissue transfer.

Report: We present the case of an 82-year old woman who underwent resection of a basal cell carcinoma measuring 94 x 84mm in the parietal region of the scalp. MRI showed involvement of the underlying bone and dura.

Wide excision of the specimen was followed by reconstruction using a novel method of acrylic cranioplasty and coverage of the defect using a single large anterior-based transposition flap.

Discussion: Whilst many reports have emphasised the use of free tissue transfer for large scalp defects (Lutz et al., 1993; Ionnides et al., 1999), this example demonstrates the effectiveness of local flap techniques. In cases where cranial bone has been removed, local flap reconstruction has a number of advantages. These include reliable blood supply through one or more named vascular pedicles, good aesthetic match and reduced surgical time and morbidity at the donor site (Ionnides et al., 1999). This is desirable in cases where the patient is unable to tolerate lengthy general anaesthesia.

Conclusion: In summary, we have presented a modification to a well-known cranioplasty technique and the planning and demonstration of a sub-total scalp reconstruction. This obviates the requirement for free tissue transfer in the elderly or otherwise infirm patient.

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Resection of Thoracic Spine Metastatic Adenocarcinoma of Unknown Origin for Spinal Cord Decompression Amerikanou R (Cambridge), Anagnostopoulos G Α 62 year old male presented with sudden onset paraparesis and long-standing pain along thoracic dermatomes.

Imaging showed an osteolytic lesion on the right half of the T5 vertebra that involved the spinal canal, costovertebral joint and paraspinal soft tissues. Pathologists reported a metastatic signet ring cell carcinoma for which the primary tumour's site was not found.

The neurological manifestations necessitated tumour resection for spinal cord decompression. A modified posterolateral thoracotomy extending towards T6 was followed by posterior hemilaminectomy of T4-T6. The thoracic tumour was then cleared with removal of 2/3rds of the 5th and 6th ribs. This created space for a more anterior approach to the vertebrae allowing wider bone resection, although a probability of not achieving clear margins in tumours with >10% vertebral involvement remains. Posterior decompression was selected because albeit worse outcomes when compared to anterior decompression, it has lower morbidity and mortality. No spinal column reconstruction was attempted as the lesion was high in the spine with adequate weight support from the musculature.

Metastatic neoplasia, for which prostate and breast adenocarcinomas have the highest incidence, is the most common tumour seen in the spinal column. The final biopsy however, indicated an adenocarcinoma which is believed to be of upper gastrointestinal origin.

Despite the unsurprising lack of paraparesis reversal, the patient is mobile and the halt of neurological decline and sphincter function preservation was successful. This report highlights that through thorough surgical planning maintaining a good quality of life in patients with spinal column metastases is achievable.

Oral Presentations- Critical Discussion Session Room A112, 14.00-15.00 The Neuroanatomical Plates of Guido da Vigevano: A Contagious Influence Saleh M (Keele) “Anatomy to the surgeon is like the Sun for our planet.” - R.F. Spetzler As valid as R.F. Spetzler might have been, Guido da Vigevano ascertains the unbreakable relationships that exist between anatomy, anatomical illustrations and surgery. The pivotal role his drawings played not only served to expedite the advancement of neurosurgery, but also lead to the establishment of a strong visual foundation of anatomy being crucial to the practice of all surgical fields.

Guido da Vigevano (1280–1349), an Italian scientist, became the first anatomist in the history of neuroscience to depict anatomical knowledge via illustrations. His work eventually culminated in the Anathomia Designata per Figures, a book containing 24 neuroanatomical plates. These plates portrayed neuroanatomical structures for the first time such as the meninges, ventricles and spinal cord as well as neurosurgical techniques including dissection of the cranium by trephination. Throughout the Renaissance, his work influenced the likes of Donatello (1386– 1466), Leonardo da Vinci (1452–1519), and Michelangelo (1475–1564) to also implement artistic illustrations into the very pillars of their anatomical teaching and surgical technique visualisation.

The fact that drawings convey a much more complete understanding of the human body relieved the idea that complex surgical procedures yielded insurmountable problems. Many innovative surgical techniques, such as natural orifice transluminal endoscopic surgery, are now rendered feasible since they rely heavily on guided imagery. Illustration-based learning in anatomy can still be observed today as early as medical school, when students haven‟t even contemplated a career in surgery.

Pennies or Patients? What is the Place of Elective Surgery in the Cash-Strapped NHS? Ali S (Southampton) “No longer will wealth be an advantage nor poverty a disadvantage. Healthcare will be provided free of charge based on clinical need and not on ability to pay.” – Anuerin Bevan, 1948.

Since the NHS was founded, demand for healthcare has increased dramatically; patients are living longer in an expensive economic climate and are requiring costlier treatments. These exigencies are exacerbated by an increasing demand for quality as expectations of the standard of care increases.

We can no longer continue to deliver high quality surgical care and maintain Bevan‟s principles in these times of austerity. The RCSEng recommends greater allocation of resources to emergency surgery – surgical training and research cannot be ignored either. Simply cutting the ES budget will save money initially but create a huge money bill in the future. Thus, restructuring of ES is imperative – the main agenda of the Health Bill 2011.

The Bill aims to outsource ES to independent treatment centres (ITCs) capable of lower costs and complication rates, with higher throughput than NHS hospitals. The Government has decided that outsourcing funds to ITCs will be co-ordinated by GP consortiums working alongside selected private providers (PPs) to aid commissioning.

Hospitals and PPs will compete for business, breeding efficiency and value for taxpayers.

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Outsourcing ES to ITCs has major issues though. PPs could exploit GP commissioning by selecting the most „profitable‟ patients to procure, potentially skimming-off routine ES cases and accompanying funding, a concern labelled „cherry-picking‟. Surgery in NHS DGHs without routine cases may become unfeasible; with redundant revenue streams, the provision of complex and poorly rewarded procedures may be impossible and force hospitals to close. The Government has pledged to add additional safeguards to prevent this “... competition [will be based] on quality, not price”.

Without substantiating such pledges, major concerns remain over a decline in quality. Reformation could also be more expensive; creating a publicly funded, privately provided system paying a premium to PPs for commissioning on behalf of GPs – born by a limited expertise in health economics. We are in danger of creating a two-tier system of surgical care prioritising pennies over patient‟s best interests.

Will advances in medical therapy extinguish the role of the surgeon in the future?

Brammar L (Bristol) The surgical role is continually evolving, reflecting developments in other branches of medicine such as cancer therapy which have undergone particularly rapid change over the last decade, but also technical improvements.

Surgeon‟s skills must adapt to the variety of new surgical interventions available. Use of computer assisted surgery in procedures such as knee arthroplasty demands the ability to manipulate specialist software (1). Advancements in medical imaging, such as PET scanning, has increased information regarding localisation of disease modifying surgical intervention and technique, demanding a more complex hand-eye dexterity, but achieving a more direct and focused procedure.

The development of molecular-based therapies and appreciation of new areas such as epigenetics, may divert some treatment away from the operating table. However, such treatments are expensive, so long term benefits and risks will need to be viewed in terms of resources and value for money. Herceptin took over thirty years to develop (2) as a highly specific HER-2 receptor target, but still applies to only 20% of breast cancers (3).

The primary treatment of breast cancer for many patients remains surgical (4).

Traumatic injury has a „golden hour‟ of optimal intervention. Management of conditions such abscesses remains surgical. Limitations in the discovery of newer antibiotics make surgical management of infective complications of continuing importance, although there remains the risk of post-operative infection.

In conclusion the role of the surgeon is unlikely to extinguish in the foreseeable future. Whilst medical therapy may advance, surgeons will always be required to work alongside these changes to achieve positive patient outcomes.

Why surgery will continue to have a position in medical treatment with specific relevance to orthopaedics.

Sureshkumar D (Nottingham) With innovations in diagnostic tests and equipments alongside the development of newer medications; an early, definitive diagnosis can be made therefore resolving issues without necessitating surgical intervention.

Additionally the widespread benefits of epidemiology, such as education on cholesterol, promotes prevention over cure thus reducing the surgical volume for procedures like coronary artery bypass graft.

Yet there are limitations to the marvels of non-operative procedures. Often surgery can be the only solution, for example, to a common orthopaedic problem such as a slipped capital femoral epiphysis. In some situations surgery is still opted to improve outcomes; a study showed that disc prosthesis surgery provided a better result in terms of pain and patient satisfaction in patients suffering from degenerative discs.

Furthermore technology has introduced novel surgical techniques such as Computer Assisted Surgery (CAS) or Robotic surgery whereby computers aid navigation around the body with more ease. Having used CAS to insert lumbar pedicle screws, surgeons are now modifying techniques to use it on the hip and knee. As surgeries are carried out with more finesse and new procedures can be devised, surgeons are continually needed to explore these territories.

In parallel to the advances in medical therapy, surgery too has grown in both breadth and depth. Newer procedures are replacing old methods, like certain vascular procedures which are going out of trend. Whilst an expansion in medical therapy has changed the surgical climate, this merely corresponds to different surgical approaches with the role of the future surgeon remaining strong.

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"Making the dry bones live" Hamill JR (Manchester) Pickstone JV Sir Grafton Elliot Smith (1871-1937) has largely been forgotten as the founder of modern anatomical curricula. A contemporaneous spirit of „Flexnerian revolution‟ in American medical schools, led by Franklin P. Mall‟s (18621917) reforms to the medical course at Johns Hopkins University, saw American medical curricula propelled to the forefront of pedagogical prowess during the early twentieth century. Previously, German university laboratories were hailed as the prototype for the waning subject of anatomy which had been largely superseded by newer, more glamorous subjects including physiology, embryology and pharmacology.

Anatomy, the centuries-long „handmaiden to surgery‟ was in the ‟dry bones‟ doldrums and required a radical overhaul to survive its apparent relegation to an ancillary science of osteometry. In his amazingly broadspanning career, Elliot Smith came to be regarded as a leading authority on matters anthropological, philosophical, psychological, and most importantly, anatomical. He revamped the teaching of the subject through his occupancy of three Chairs of Anatomy at Cairo (1900-1909), Manchester (1909-1919) and UCL (1919-1934) and was at the vanguard of changes which renovated anatomy to offer „the first glimpse of the promised land‟ to medical students worldwide. Elliot Smith promoted an intensive anatomical research program at Manchester and UCL and introduced such teaching methods as surface anatomy, embryology, radiography, pathological examinations, and the reclaiming of histology from physiology departments. His syllabus was widely adopted throughout British medical schools and is the progenitor of problem-based learning. This report highlights the making of anatomy departments as essential to the practice of modern-day surgery.

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Poster Presentations Improving surgical management of rectal cancer Arulnesan R & Bhudia J (Barts & The London), Ahmed S The management of rectal cancer can vary significantly with position, size, and stage. We wanted to find out if any changes could be made to the current guidelines, to optimise outcomes and maximise efficiency.

A database of 80 patients who have had rectal carcinomas surgically resected, between 2006-2011 was compiled.

Parameters included method of surgery, post operative complications, histological findings, use of chemotherapy/radiotherapy and oncological outcomes.

From this a number of notable conclusions can be drawn. Incidence of intra and postoperative complications are increased with open method surgery, compared with laparoscopic based surgery. Another notable finding was the increased incidence of local and distant recurrence of disease, when higher numbers of lymph nodes are found to positive on histology post resection.

These findings obtained add weight to the case for laparoscopic based surgery, despite the much publicised difficulties when used in rectal carcinoma.

It can also be concluded that on finding positive lymph node involvement on histology, greater follow-up care and observations should be indicated, given the increased likelihood on recurrence. The collection and analysis of data is still on-going, and will be completed in the near future, but has been very promising thus far.

Surgical hand preparation: is Queen Square following WHO guidelines?

France O (Aberdeen), Wilson S, Nowak V, Sethi H, Curtis C, Kitchen N Purpose: to assess how closely WHO guidelines on surgical hand preparation are followed by neurosurgical theatre teams at Queen Square.

Background: WHO Guidelines for Safe Surgery 2009 identify preoperative hand and forearm antisepsis on the part of the surgical team as integral to the prevention of surgical site infections. Specifically it states that hands and forearms should be scrubbed for 2â&#x20AC;&#x201C;5 minutes. The UCLH Scrubbing, Gowning and Gloving Policy and Procedure Guidelines 2008 recommend 4 minutes of scrubbing.

Methodology: Over a 24 day period in July 2011, Scrub nurses, Consultants and trainees from theatres at Queen Square were asked for permission to record their scrub time, defined as beginning when hands were put into water and ending at first drying off.

Results: All but one individual agreed to have their scrub time measured. Not all operations could be included due to two or more scrubs happening simultaneously and the need to minimise observer numbers in theatre for operations with higher infection risk. 178 individual scrub times were recorded for 84 separate operations. 84/127 (66%) daytime operations were observed. The median scrub time was 101 seconds (range 16 â&#x20AC;&#x201C; 458 s); shorter scrub times were associated with operations of shorter duration. Preliminary data suggest Scrub Nurses spend the longest time scrubbing and Registrars the least.

Conclusion: the median scrub time was less than recommended by international and local guidelines; more data are needed to establish whether this results in a greater number of surgical site infections.

Oesophageal reconstruction using colonic interposition Ikidde S (Keele), Mr Cheruvu Colonic interposition is rarely performed in adults with oesophageal cancer. The most acceptable method of oesophageal reconstruction after an oesophagectomy is by using the stomach. The indications for colonic interposition are patients that have oesophageal cancer with a history of gastric surgery or patients with stomach and oesophageal tumours. This case report looks at a 70 year old man with an incidental finding of oesophageal cancer. After an oesophagectomy, an anastomotic leak occurred from the oesophago-gastric anastomosis, eventually necessitating the procedure of colonic interposition. Complications arose when the caecum within the thorax became grossly distended by adhesion obstructions. This compressed the left lung and right ventricle, requiring emergency, surgical decompression to relieve the obstruction. Efforts to avoid adhesions could have made complications from the surgery less severe or alternatively, reconstruction using a pedicled jejunum.

Although it is a more demanding procedure, reconstruction using the jejunum has been found to have better patient outcomes. Increases in patient weight 6 months post surgery were observed in the jejunal group, in comparison to declines seen in the colon group.

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An audit reviewing fitness and staging investigations in patients with oesophago-gastric cancer undergoing curative treatment.

Ganesh S (Bristol), Hotton E BACKGROUND: Accurate pre-operative cancer staging improves patient selection for curative treatment and current national guidelines recommend the use of Positron Emission Tomography Computed Tomography (PET-CT) in all fit patients with oesophago-gastric cancer (OGC) without CT evidence of metastatic disease.

PURPOSE: This study assessed the upper gastrointestinal (UGI) cancer multi-disciplinary team‟s (MDT) adherence to the national audit standard. In addition it reviewed the number of futile investigations undertaken in patients ultimately deemed unfit for curative treatment.

METHODS: Records from consecutive OGC patients discussed at a central MDT and deemed for curative intent between 2008 and 2010 were examined. Details of staging investigations, treatment decisions and treatment implementation were examined.

RESULTS: 102 MDT meetings discussed 460 OGC patients of whom 241 were initially considered for curative treatment. 238 (99.8%) patients underwent PET-CT, although 24 were subsequently considered unfit for curative treatment, achieving the audit target in 214 (88.7%). In the 24 undergoing futile PET-CT: all received initial CT imaging; 18 (75.0%) underwent endoscopic ultrasound; 4 (16.7%) received a second CT scan; 5 (20.8%) a staging laparoscopy and 4 (16.7%) underwent additional investigations.

CONCLUSION: Adherence to national PET-CT guidelines by the UGI MDT was good. More judicial use of PET-CT could be achieved by refining current guidelines for the regular assessment of patient fitness prior to expensive staging investigations. This has the scope to avoid unnecessary procedures and has additional cost-saving implications.

Radiological evaluation of the mid-term results of Pinnacle uncemented acetabular cups

Khan J (Liverpool), Bellevue de Sylva J Hip replacements are one of the most successful surgical interventions with an ever advancing field of technology.

The practice utilises many forms of artificial implants which inevitably have varying rates of success. Prostheses vary greatly in design areas such as material of the implant, bearing surface, head size and method of fixation to name a few. Many factors such as age and bone quality can influence the efficacy of each design. Ultimately the choice of prosthesis must be made by the orthopaedic surgeon. The surgeon requires accurate and reliable data on all forms of modern hip prostheses in order to make the best decision for his patients, and to insure the procedure yields the best results possible. The aim of our study is based upon this very fact.

The project we have undertaken aimed to contribute to the knowledge base by providing information taken from x-rays of over 200 patients fitted with the DePuy Pinnacle Cup at Broadgreen hospital in a 5 year follow up study.

TraumaCad software was used for measurements such as cup position, version and inclination which were then statistically compared.

The follow up study found that there was no statistically significant difference between our results and baseline findings thus demonstrating and reinforcing the reliability of the DePuy Pinnacle Cup. Our full set of findings help shed light on the crowded market of hip prostheses, thus enabling surgeons to make more informed choices and ultimately improve the quality of life for those receiving a total hip replacement

Bartholin’s Gland Squamous Cell Carcinoma Ng SM (Nottingham), Nunns D Introduction: Vulva carcinoma is relatively uncommon, accounting for around 5% of gynaecological malignancies.

Out of this 5%, 2%-7% are primary Bartholin‟s gland carcinomas, making this a rare cancer. Histologically, Bartholin‟s gland carcinomas can be divided into squamous cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, undifferentiated carcinoma and adenosquamoud carcinoma.

Case: A 66-year-old lady, gravida 4 para 3+1, with no personal or family history of cancer was referred urgently by her GP to the gynaeoncology clinic after presenting in August 2010 with intense pruritus and a lump in her left vulva. Lump biopsies were diagnostic of squamous cell carcinoma. MRI scan measured the tumour mass to be 22x16x22mm with an apparent „polyp-like‟ component lying centrally, measuring 21mm in diameter. MRI scan also showed an enlarged node in the left groin, measuring 13mm in diameter. Patient underwent a wide local excision surgery of the primary site with a left inguinofemoral lymph node dissection.

Discussion: There is not an existing guideline for the treatment of Bartholin‟s gland carcinoma in the UK. Certain centres offer primary chemoradiation. However, the common consensus is radical wide local excision and ipsilateral or bilateral lymphadenectomy. Radiotherapy is offered depending on the size of the tumour, resection margins and lymph node status. The potential of sentinel node biopsy could possibly be extrapolated to Bartholin‟s gland carcinoma.

Conclusion: This case was suitable for radical wide local excision and required post op chemoradiotherapy because of the proximity of the surgical margins.

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A Simple Technique of Closing Large Full Thickness Lower Eyelid Defect Ngu WCD (Dundee), Chua CN, Ngu ST, Mohammad A, Gundum I Background: Traditionally, the replacement of anterior and posterior lamella is crucial in eyelid reconstructive surgery. Such procedure is laborious and may require revisions and is therefore unsuitable for elderly, frail patients. Surgical approach on nasojugal myocutaneous flap is used to close the defect with fast recovery.

Report: A 70 year-old man who was wheelchair-bound after amputation of non-healing osteomyelitis was admitted due to pneumonia. Upon admission, he was noted to have a left lower eyelid lesion occupying most of the eyelid margin with ulceration and loss of eyelashes. Further investigations confirmed the diagnosis of a basal cell carcinoma. The lesion was excised with a 3mm margin. The raw area involved more than 90% of the lower eyelid with the remainder of only a small lateral remnant.

Discussion: Several options were considered to close the defect including Hughâ&#x20AC;&#x;s flap. However, in view of the frailty of the patient, we decided on nasojugal myocutaneous flap to close the defect. The length of the nasojugal flap was measured less 3mm of the width of the lower eyelid defect to prevent lower eyelid loosening. Although there was no substitute tarsal support for the closure, the eyelid functions well at two months follow-up except for mild epiphora.

There was no corneal abnormalities.

Conclusion: Lower eyelid defects involving the eyelid margin and extending more than one third of the horizontal length of eyelid margin requires adjacent tissues advancement. Direct closure of full thickness defects larger than one third of eyelid is not recommended.

Impaction bone grafting of the acetabular component in revision total hip arthroplasty Berger J (Manchester), Bamford D 66,000 hip replacements are performed each year in the UK, and over 10% of these are revision operations.

Younger patients are receiving total hip arthroplasties (THAs) and demanding a higher degree of physical activity from them than previously. This has inevitably led to an increased need for revision procedures, so restoration of acetabular bone stock, an associated technique, is becoming a more and more important surgical practice.

This report looks at a particular method that replaced lost bone stock in the acetabulum of a patient during revision surgery of the right hip. 19 years after an initial THA, when he began to suffer recurrent pain, radiological evidence showed loosening of his hip implant with bone loss, and a revision was indicated.

Impaction bone grafting depends on several concepts, which allow grafted bone implants from human donors to induce new bone growth into a joint replacement. Osteolytic loosening of an acetabular cup or septic loosening and substinence, amongst other causes, can indicate a revision operation. The aims of this procedure are mechanical stability and pain-free mobility. Results have so far been very successful since its development in the 1980s, especially in pioneering surgical groups in Exeter and Nijmegen where complication rates from the procedures are low. Strict adherence to the recommendations of these centres has given positive results at other hospitals including Stepping Hill Hospital, Stockport, and with the prospect of new synthetic materials and growthinducing chemicals incorporated into future bone grafts, this is a field with exciting prospects.

Short Bowel Syndrome: What Google Says Veitch J (Manchester), Morabito A Background: Short bowel syndrome (SBS) is a serious condition with differing and at times conflicting treatment options. The paediatric condition has different aetiology, course and management to the adult condition. Families are likely to turn to the internet for information regarding this condition and to inform their decision making regarding treatment options.

Aim: This study aims to find out exactly what information is available online to the families of a child diagnosed with short bowel syndrome (SBS).

Methodology: A popular internet search engine was queried to gather information regarding SBS. A pro-forma was designed including questions that a family of a child with this condition would be expected to want answering.

Four searches were performed using different search terms and the top ten results from each search analysed using the pro-forma. Some websites came up on more than one search; a total of 25 websites have been analysed.

Results: There is little specific information for paediatric SBS on the internet available to the non-specialist.

Descriptions of the condition including causes and clinical features are well covered. The complexity of management options is not made clear. There is minimal information on surgical treatment options including transplantation and particularly autologous gastrointestinal reconstruction surgery which was mentioned in only five out of 25 websites.

Conclusion: More information should be available online on paediatric SBS to parents particularly regarding surgical treatment options to allow parents to make informed decisions about the care of their child.

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Combined treatment with chondroitinase and rehabilitation improved forelimb function in rat chronic spinal cord injury Wang D (Cambridge), Fawcett J One of the most devastating conditions affecting young people is spinal cord injury (SCI). Damage to the spinal cord can lead to lifelong disability at great cost to both the patient and society. Current treatments are mostly supportive, including intensive rehabilitation, aiming to maximise daily function despite disability and provide patients with much needed help, support and training. In researching future treatments for SCI, it is important not to overlook rehabilitation and the opportunities it offers. Many treatments aimed at promoting functional recovery are currently under development. One such treatment is Chondroitinase ABC (ChABC), a bacterial enzyme which breaks down the sugar chains attached to extracellular proteins in the central nervous system.

ChABC in combination with rehabilitation has been shown to improve recovery in animal models of acute SCI. Here we investigate whether ChABC could extend its effectiveness to the more clinically relevant case of chronic SCI. One month after SCI in rats, animals received either ChABC or penicillinase as a control. After treatment, some animals received hour-long daily rehabilitation. Animals that received both ChABC and task-specific rehabilitation showed significant functional recovery, approaching similar levels to that in animals that were treated after acute injury. Behavioural benefits of ChABC and task specific rehabilitation extended beyond the rehabilitated task of skilled paw reaching. Our results indicate that ChABC treatment is able to open a window of opportunity in chronic spinal cord lesions, allowing rehabilitation to improve functional recovery.

Characterisation of cobalt, chromium and silver nanoparticles and their ionic leaching properties Godhania V (Barts & The London), Shelton J Cobalt and chromium are used in metal-on-metal hip replacements and silver is used in experimental coatings.

Nanoparticle-sized wear particles generated by these implants are composed of mostly cobalt, chromium and silver. The ability to generate these wear particles and their leaching properties was investigated.

Ion leaching experiments were performed using cobalt, chromium and silver nanoparticles to see how these nanoparticles leach in either 25 % calf serum or cell culture medium. Cobalt and chromium particles together showed that cobalt leached 77% more into cell culture medium than calf serum, chromium did not leach in either medium. Cobalt release into serum and cell culture medium occurred within 1 hour. Silver and chromium particles together showed that silver leached into serum 170 % more than into cell culture medium. The presence of Cr inhibited the leaching of Ag into serum reducing Ag leaching by 65 %.

CoCrMo wear particles were generated and characterised so that clinically relevant sized particles could be generated. Two bearing types of CoCrMo and CrN-Ag coated CoCrMo bearings were spun on a lathe with calf serum acting as a lubricant. This produced wear particles with a mean length of 69.9 nm which is within the clinical range.

These results help explain why wear particles are often Co depleted since the Co leaches from the particles whilst the Cr remains in solid form. This also suggests that since Cr does not leach Cr ions may only be formed by the corrosion of the base alloy.

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NOTES

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NOTES

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Produced by Neil Houghton / Copyright Š 2011 Scalpel Manchester

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