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CASE: A 52-year-old man underwent right total hip replacement with a 32-mm BIOLOX delta ceramic head with a polyethylene liner. At 8 months, he fell onto his right hip. Radiographs at the time were unremarkable. One month later, he noticed a sharp pain and a sensation of grinding in his right hip; radiographs of the hip showed a fracture of the ceramic head. CONCLUSIONS: This case further demonstrates that fourth-generation ceramic heads can fracture, and delays in catastrophic failure of ceramics in total hip arthroplasty (THA) following trauma may be secondary to the "slow crack growth" hypothesis.

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Introduction Although total knee arthroplasty (TKA) is an index procedure for orthopaedic registrars, there is a lack of published research as to the effects of surgery when performed by supervised trainees. The aim of this study was to compare functional outcomes up to five years after primary TKA performed by consultants and trainee surgeons. Methods A retrospective analysis was conducted of prospectively collected data for 609 consecutive patients (339 female, 270 male) undergoing TKA. Patients were assessed preoperatively as well as at 18 months, three years and five years postoperatively, and American Knee Society objective knee and functional scores (AKSK and AKSF) were recorded. Results Surgery was performed by a consultant in 465 cases and a supervised trainee in 144 cases. There were no significant differences between the two groups in preoperative patient characteristics, operative time (p=0.15), transfusion rates (p=0.84), length of stay (p=0.98), manipulation under anaesthesia (p=0.69), or mortality rates at one year (p=0.73) or five years (p=0.81). Postoperatively, the median magnitude of improvement in AKSK (48 points for consultant group vs 45 points for trainee group, p=0.74) and in AKSF (both groups 15, p=0.995) was similar between the groups. AKSK and AKSF scores were similar at all timepoints up to five years following surgery, and there was no difference in the median range of motion (both groups 100°, IQR: 18°) at five years (p=0.43). Conclusions TKA performed by supervised registrars gives functional outcomes that are equivalent to consultant performed TKA, without affecting postoperative range of movement, or increasing operative time, length of stay or transfusion rates. Rates of postoperative MUA and mortality are also comparable.

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The natural history of primary anterior dislocation of the glenohumeral joint in adolescent patients remains unclear and there is no consensus for management of these patients. The objectives of this study were to report the natural history of primary anterior dislocation of the glenohumeral joint in adolescent patients and to identify the risk factors for recurrent dislocation. We reviewed prospectively-collected clinical and radiological data on 133 adolescent patients diagnosed with a primary anterior dislocation of the glenohumeral joint who had been managed non-operatively at our hospital between 1996 and 2008. There were 115 male (86.5%) and 18 female patients (13.5%) with a mean age of 16.3 years (13 to 18) and a mean follow-up of 95.2 months (1 to 215). During follow-up, 102 (absolute incidence of 76.7%) patients had a recurrent dislocation. The median interval between primary and recurrent dislocation was ten months (95% CI 7.4 to 12.6). Applying survival analysis the likelihood of having a stable shoulder one year after the initial injury was 59% (95% CI 51.2 to 66.8), 38% (95% CI 30.2 to 45.8%) after two years, 21% (95% CI 13.2 to 28.8) after five years, and 7% (95% CI 1.1 to 12.9) after ten years. Neither age nor gender significantly predicted recurrent dislocation during follow-up. We conclude that adolescent patients with a primary anterior dislocation of the glenohumeral joint have a high rate of recurrent dislocation, which usually occurs within two years of their initial injury: these patients should be considered for early operative stabilisation.

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Oxidative Heck couplings have been successfully developed for 2,2-disubstituted cyclopentene-1,3-diones. The direct coupling onto the 2,2-disubstituted cyclopentene-1,3-dione core provides a novel expedient way of enantioselectively desymmetrising all-carbon quaternary centres.

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BACKGROUND: Wrist arthrodesis has been established as a mainstay form of surgical intervention in the rheumatoid wrist. Despite this however, there is a distinct lack of patient-reported outcome measure (PROM) studies justifying the efficacy of this procedure in rheumatoid disease. The aim of this study was to report any change in function or pain following the tunnel Mannerfelt wrist arthrodesis in a single surgeon series of rheumatoid patients over a 6 year period. METHODS: 14 consecutive patients (15 wrists) who had undergone the Mannerfelt wrist arthrodesis were followed prospectively with a mean follow up period of 45 months. No patients were lost to follow up. The primary outcome measures included the validated Patient Rated Wrist Evaluation (PRWE) questionnaire and a satisfaction questionnaire. RESULTS: The mean total pain score improved from 41 points preoperatively to 14.2 points postoperatively correlating with a 65.4% improvement in overall pain outcomes. The mean total functional score improved from 83.7 points preoperatively to 45.5 points postoperatively demonstrating a 45.6% improvement in overall function at the time of follow up. CONCLUSIONS: All patients reported an overall improvement in pain and functional capacity. The satisfaction results were excellent. All patients reported that they would elect to have the procedure again with the vast majority being 'very pleased' with the outcome of their surgery (93.7% very pleased and 6.3% fairly pleased). The procedure enjoyed favourable mid-term results and we recommend the tunnel Mannerfelt wrist arthrodesis for improving both pain and level of function in this group of patients.

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CONTEXT: This article describes a unique, remote, water safety-training program delivered to 11 remote Australian communities during 2006-2007. The program, known as 'Water Safety in the Bush', was developed by Combined Universities Centre for Rural Health in Geraldton Western Australia in consultation with the Commonwealth Government Department of Health and Ageing, and the Royal Life Saving Society of Australia. PROGRAM DESCRIPTION: Drowning and near drowning are major causes of childhood death and injury in rural and remote Australia, making improved water safety awareness and skills a public health priority. Water Safety in the Bush employed a flexible, community development model to meet the special requirements of remote and isolated communities. The model had three elements: coordination by a local organisation; a water safety instruction program based on a Royal Life Saving Society of Australia curriculum adapted to meet local priorities; and strategies for sustainability. PROGRAM EVALUATION: In the delivery of the program a total of 873 children and 219 adults received swimming and water safety instruction; 47 adults and older children received first-aid training; and 38 community members became AUSTAWIM (the Australian Council for the Teaching of Swimming and Water Safety) accredited instructors. Project evaluation showed parents and community organisations were very satisfied with the program which met a real need. Parents and instructors gave evidence of children's increased skills in water safety, swimming ability, life-saving and water confidence. Training programs with greater contact hours showed greater skill gains. Sustainability strategies included accreditation of local AUSTSWIM instructors, the erection of water safety signs, sourcing of continuing funding, and the introduction of water safety theory into the school curriculum. LESSONS LEARNED: Flexibility was the major success factor. Within the parameters of minimum guidelines, communities were encouraged to choose the timing, venue and delivery mode of the training to ensure the program was best suited to the local community. Community ownership was achieved by requiring that local organisations design and implement the projects. Designing programs that addressed local constraints ensured high participation rates. A number of challenges were also identified. Not all community organisations had the capacity to take on the coordinating role, and struggled to effectively deliver a sustainable program. Other models may be needed for these communities. Accessing appropriately qualified water safety instructors in local areas also proved difficult at several of the sites. Further, designing standardised outcome evaluation strategies that could be implemented across all participating sites was problematic. IMPLICATIONS: Remote and isolated communities have a pressing need to gain the knowledge and skills necessary for water safety and survival. Standard training programs, which in the case of swimming and water safety instruction are generally run in two-week blocks, are often not feasible. Models for delivering training, which give resources and power to local organisations to find innovative ways to meet their priorities, build capacity and ensure high participation rates.

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CONTEXT: Therapy assistants (TAs) are widely used in the delivery of therapy services in rural Western Australia (WA). Appropriate training for TAs is an essential part of their practice; however, to date most TAs are trained 'on-the-job', thus taxing the scarce resources of rural and remote allied health professionals (AHPs). There has been limited recognized training that is suitable to their role and easily accessed by rural and remote TAs. ISSUE: This project report describes the development and evaluation of training for TAs across country WA to address these issues. Sixteen training modules were developed congruent with the requirements of TA work in rural WA. Modules were designed, developed and delivered via videoconference by rural and remote AHPs. A partnership with a registered training provider has allowed TAs to use this training as credit toward a recognized qualification. LESSONS LEARNT: A high level of attendance across all country regions of WA confirmed a need for this training. Modules that focussed on a clinical topic, presenters that were well organized, who supplied resources to support the training, and used interactive case scenarios were received most positively. For AHPs this training reduced the work required for training TAs at individual sites. The training resources developed in this project are relevant to other rural and remote health services utilizing a similar model of allied health service delivery. The model of training developed is based on a 'ground-up' approach to ensure training meets the established need. Developing stand-alone training packages that are also adapted for distance learning improves the sustainability and accessibility to training. Therapy assistants are now able to use on-the-job training to achieve a recognized qualification. Despite this it is not believed feasible for health services to insist that rural and remote TAs have a standardized qualification for their work. This article adds to a growing body of work describing the key features of rural and remote TA models of service delivery.

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We tested, under independent conditions, the reproducibility of evidence from two previous trials that homoeopathy differs from placebo. The test model was again homoeopathic immunotherapy. 28 patients with allergic asthma, most of them sensitive to house-dust mite, were randomly allocated to receive either oral homoeopathic immunotherapy to their principal allergen or identical placebo. The test treatments were given as a complement to their unaltered conventional care. A daily visual analogue scale of overall symptom intensity was the outcome measure. A difference in visual analogue score in favour of homoeopathic immunotherapy appeared within one week of starting treatment and persisted for up to 8 weeks (p = 0.003). There were similar trends in respiratory function and bronchial reactivity tests. A meta-analysis of all three trials strengthened the evidence that homoeopathy does more than placebo (p = 0.0004). Is the reproducibility of evidence in favour of homoeopathy proof of its activity or proof of the clinical trial's capacity to produce false-positive results?

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