Aim: We wanted to ascertain if clinical examination confers any additional benefit to secondary/targeted ultrasound screening of neonatal hips.

Materials/Methods: Of the 30585 births (over a 6 year period) in the population served by our hospital, 2742 babies (8.96percent) were referred to the Hip Screening Clinic by the neonatologists and general practitioners. They were examined clinically and by US scans by the specialist consultants. The findings were documented prospectively. Of these, 1862 hips were normal on clinical examination, 841 hips tense (clinical examination inconclusive).

Results: 233 hips were identified as abnormal by the US scans (Graf method). 106 (45percent) of these were normal on clinical examination. In 88 of the hips with abnormal US scans (38percent), clinical examination could not be performed reliably as the babies were tense. None of the hips identified as abnormal on clinical examination were normal on US scans.

Conclusion/Discussion: US scanning of hips in at-risk babies by an experienced paediatric radiologist will identify all the abnormal hips. This will release the paediatric orthopaedic surgeon from routine clinical examination of all these babies. This time can be utilised for running other clinics. Babies found to have abnormal hips on US scanning may be seen by the orthopaedic surgeon for treatment and follow-up. Parents of babies with normal hip US scans may be reassured by a nurse practitioner or a paediatric physiotherapist. This should lead to better utilisation of resources and cost savings.

The aim of the paper is to provide an independent single surgeon experience with BHR after a seven-year follow-up.

A cohort of 117 hips in 101 consecutive patients operated by the senior author between Jan 1998 and Dec 2002 were assessed to note their clinical, radiological and functional outcome after a mean follow-up of 7 years (5–9.4 years). Primary osteoarthritis was seen in 73 hips and secondary in 44 hips. Their mean age at surgery was 54 years (range 20–74years). At latest follow-up their mean flexion was 100°and their mean functional outcome scores were respectively: Oxford hip score of 21.5 (12–52, mode 12); Harris hip score of 84.8 (25–100, mode 97), Charnley modification of Merle d’ Aubigné and Postel scores were 4.8 for pain, 4.3 for walking and 5.4 for movement; and SF-36 (physical component 43.9 and mental component 51.45). Failure in the study was defined as revision for any reason. Revision was undertaken in 8 hips (6.8%), five within the first year for periprosthetic fracture neck of femur and 3 hips after the end of 5-year follow-up (2 for advance collapse of the femoral component in patients’ with avascular necrosis of the femoral head and 1 hip for sepsis).

The Kaplan-Meier survival with revision as end point at minimum 5-years of follow-up was 95.7% (95% CI 92–99%) and overall survival at an average 7-years was 91.7% (95% CI 86–97.6%). All the failures were due to the femoral component. However, the reported survival with the use of traditional uncemented and cemented femoral stems is beyond 99% at similar period of follow-up. Patient selection particularly in patients with secondary osteoarthritis is therefore a critical factor when choosing BHR components.

Introduction: We aim to report the clinical and radiological outcome of consecutive primary hip arthroplasties using the JRI-Furlong Hydroxyapatite ceramic (HAC) coated acetabular components.

Methods: We reviewed 412 consecutive cementless primary THA using fully coated acetabular shell in 392 patients, with a minimum 12-year follow-up to 18 years, performed at two institutions between 1986 and 1994. Twenty (22 THA) were lost prior to 12-year follow-up, leaving 372 patients (390 THA) available for study. Fully HAC coated stems were used in all patients. The clinical outcome was measured using Harris, Charnley and Oxford hip scores. Quality of life using EuroQol EQ-5D. Radiographs were systematically analysed for implant position, loosening, migration, osteolysis. Polythene wear was digitally measured. The radiographic stability of the acetabular component was determined by Enghs criteria

Results: The mean age was 74.4 yrs. Dislocation occurred in 10 patients (3 recurrent). Re operations were performed in 9 patients (1.9%). Four acetabular revisions were performed for aseptic loosening. Other re-operations were for infection (3), periprosthetic fractures (1), cup malposition (1), revision of worn liner (3). The mean Harris and Oxford scores were 87 (78–97) and 19.1 (12–33) respectively. The Charnley score was 5.6 (5–6) for pain, 5.2 (4–6) for movement and 5.3 (4–6) for mobility. Migration of acetabular component was seen in 4 hips. Acetabular radiolucencies were present in 54 hips (9.7%). The mean linear polythene wear was 0.06mm/year. Mean inclination was 48.4deg(38–65). Radiolucencies were present around 37 (6.6%) stems. Mean EQ–5D description scores and health thermometer scores were 0.81 (0.71–0.89) and 86 (64–95). With an end point of definite or probable loosening, the probability of survival at 12 years was 96.1% for acetabular Overall survival at 12 years with removal or repeat revision of either component for any reason as the end point was 94.2%.

Discusssion and conclusion: The results of this study support the continued use of a fully coated prosthesis and documents the durability of the HAC coated components. In our clinical experience, the Furlong prosthesis revealed encouraging radiographic stability over a long term period.

Aim: We wanted to ascertain if clinical examination confers any additional benefit to secondary/targeted ultrasound screening of neonatal hips.

Materials and Methods: Of the 30585 births (from 1997–2002) in the population served by our hospital, 2742 babies (8.96 percent) were referred to the Hip Screening Clinic by the neonatologists and general practitioners. They were examined clinically and by US scans by the specialist consultants. The findings were documented prospectively. Of these, 1862 hips were normal on clinical examination, 841 hips tense (clinical examination inconclusive).

Results: 233 hips were identified as abnormal by the US scans (Graf method). 106 (45 percent) of these were normal on clinical examination. In 88 of the hips with abnormal US scans (38 percent), clinical examination could not be performed reliably as the babies were tense. None of the hips identified as abnormal on clinical examination were normal on US scans.

Conclusion/Discussion: US scanning of hips in at-risk babies by an experienced paediatric radiologist will identify all the abnormal hips. This will release the paediatric orthopaedic surgeon from routine clinical examination of all these babies. This time can be utilised for running other clinics. Babies found to have abnormal hips on US scanning may be seen by the orthopaedic surgeon for treatment and follow-up. Parents of babies with normal hip US scans may be reassured by a nurse practitioner or a paediatric physiotherapist. This should lead to better utilisation of resources and cost savings.

Aim: To compare the clinical effectiveness, functional outcome and patient satisfaction following intra articular injection with Hylan G-F-20 and Sodium Hyaluro-nate in patients with osteoarthritis (OA) of the knee.

Methods: In this independent study, 382 consecutive patients with OA of the knee were prospectively randomized into two groups to receive Hylan G-F-20 -Syn-visc (n=196) or Sodium Hyaluronate -Hyalgan (n=186) and reviewed by blinded independent assessors at pre injection, 6 weeks, 3, 6, 12 months. Knee pain, patient satisfaction was measured on a VAS. Functional outcome was assessed using WOMAC, UCLA, Tegner, Oxford knee score and EuroQol- 5D scores. Mean follow up was 14 months.

Results: Patients in both groups predominantly had grade III OA. Knee pain on VAS improved from 6.7 to 3.2 by 6 weeks (p=0.02) and was sustained until 12 months (3.7, p=0.04) with Synvisc. In the Hyal-gan group, pain improved from 6.6 to 5.7 at 6 weeks (p> 0.05) and to 4.1 at 3 months (p=0.04) but was sustained only until 6 months (5.9, p> 0.05). Improvements in the WOMAC pain and physical activity subscales were significantly superior in the Synvisc group at 3 months (p=0.02), 6 months (p=0.01) and 12 months (p=0.02). General patient satisfaction was better in the Synvisc group at all times although statistically significant at 3 months (p=0.01) and 6 months (p=0.02). There was local increase in knee pain in one patient who received Synvisc, which settled by 4 weeks. Total treatment cost was 23% more in the Hyalgan group due to the two additional visits.

Conclusion: Although both treatments offered significant pain reduction, it was achieved earlier and sustained for a longer period in patients with Synvisc with early increase in activity levels. However, a local reaction of pseudo sepsis was observed with Synvisc in one patient. The total treatment cost, both for the patient and the hospital are higher with Hyalgan. From this study, it appears that the clinical effectiveness and general patient satisfaction are better amongst patients who received Synvisc.

Of the 30585 births (from 1997–2002) in the population served by our NHS trust, 2742 babies (8.96%) were referred to the hip screening clinic by the neonatologists and general practitioners. They were examined clinically and by US scans by the specialist consultants. The findings were documented prospectively. 233 hips were identified as abnormal by ultrasound scans (Graf). 45% (106) of these were normal on clinical examination. None of the hips identified as abnormal on clinical examination were normal on US scans. In 38% (88) clinical examination could not be reliably performed as the babies were tense.

Of the 1862 hips which were clinically normal, 106 (5.69%) had abnormal ultrasound findings. Furthermore, of the 841 babies who were tense on clinical examination, 88 (10.46%) babies had abnormal ultra-sonographic findings.

Ultrasound scanning of hips in at-risk babies by an experienced paediatric radiologist will identify all the abnormal hips. This will release the paediatric orthopaedic surgeon from routine clinical examination of all these babies. This time can be utilised for running other clinics. Babies found to have abnormal hips on US scanning may be seen by the orthopaedic surgeon for treatment and follow-up. Parents of babies with normal hip US scans may be reassured by a nurse practitioner or a paediatric physiotherapist.

Back pain is a complex problem affecting the majority of the population at some point in their life. This cross-sectional study evaluated patients presenting to a tertiary spine clinic with a primary complaint of back pain for modifiable lifestyle factors which may be associated with their back pain. Patients were also asked if any of these lifestyle factors had been addressed by primary care practitioners prior to referral to the spine surgeon’s office.

The purpose of this cross-sectional study is to evaluate the modifiable lifestyle factors which may be associated with back pain in patients presenting to a tertiary spine clinic with a primary complaint of back pain and to compare these lifestyle factors with the general population. A secondary objective is to determine whether patients with back pain were given any instructions with regard to modifiable lifestyle factors by their primary care practitioner.

Consecutive patients presenting to the orthopaedic spine surgery clinic at the Ottawa Hospital – Civic Campus are asked to complete a questionnaire upon presentation to the surgeon’s clinic and prior to their visit with the surgeon. Data being collected includes Body Mass Index, smoking history, physical activity history, perceived stress, and disability. Information is also being collected on sources of information about back pain including instructions given by primary care practitioners (physician, chiropractor, physiotherapist, massage therapist, acupuncturist, naturopath, and other). Data will be analyzed to determine the difference in modifiable risk factors between patients presenting to the spine surgery clinic and the general population. Data will also be tabulated for numbers of patients being given information on modifiable lifestyle factors by primary care practitioners.

To date fifty-two patients have completed the questionnaire. A significant difference has been noted between the number of morbidly obese (BMI > 30) patients presenting to the clinic and the general population. It has been noted that less than 20% of primary care physicians have talked about lifestyle modification with their patients prior to referring them to a spine surgeon.

It will be important to know what modifiable lifestyle risk factors this group of patients possesses and which of these modifiable lifestyle risk factors are actually being addressed by primary care practitioners prior to referral to spine surgeons.

The current waiting list for an appointment with a spine surgeon at the Ottawa Hospital is six to eighteen months. If surgeons can help primary care practitioners address some modifiable lifestyle factors with their patients prior to their referral, waiting times may be reduced or at the very least made more comfortable for patients.

The aim of this study was to ascertain the results and effectiveness of targeted screening of babies.

All the newborn babies (30585 births from 1997 to 2002) in the geographical area served by our trust were assessed by the paediatricians (neonatologists) and general practitioners (GP). They were assessed for abnormal hip examination finding including clinical instability and risk factors for DDH. The risk factors were positive family history, abnormal lie or presentation other than vertex during pregnancy or at birth, oligohydramnios or other congenital abnormalities. On referral, they were assessed clinically and by ultrasound (US) scan in a special Hip screening clinic.

The data were obtained prospectively. Over the period of these six years, 2742 babies were examined in the clinic. Many had more than one risk factor or abnormal hip examination finding (15.9% of babies with abnormal hips and 7.4% of babies with normal hips). Only five babies presented at or after 4 months of age (delayed presentation). They had been treated by the GP (1 patient), at a private hospital (1 patient) or were from outside our area (3 patients). All had abnormal hips on clinical examination. Of these, 3 were 3A or 3B Graf grade (US scan), 1 was 2B and another 2A+.

Screening of babies with above risk factors has identified all patients with abnormal hips in our area, thus avoiding late presentation of DDH. Raising awareness of GPs and paediatricians about these factors should also reduce the number babies to be seen in the hip screening clinic to minimum yet safe levels.

To establish whether Patients or Medical Professionals are the main source of delay for patients referred to a Specialist Centre for Soft Tissue Sarcoma.

Methods: Patients were recruited from both outpatient clinics and from the surgical ward. A semi-structured interview was used to take a detailed history of the patients’ treatment pathway, before arriving at the Specialist Centre. Results: The average time for patient to present to a SC from the onset of symptoms was 110 weeks, (min 3 days, max 1089 weeks), with a median of 40 weeks. Average delay to presentation to a medical professional (patient delay) was 24.5 weeks (min 0, max 530), median 2 weeks. Average delay in referral to a SC (service delay) was 84 weeks (min 0 max 1083), median 25weeks.

Discussion: Medical professionals rather than patients contribute the greatest source of delay in patients reaching a Specialist Centre for treatment of Soft Tissue Sarcoma. Adherence to previously published guidelines could decrease this delay. Medical professional awareness of these guidelines and their contents needs to be increased.

The purpose of this study was to investigate the influence of ligamentous restraints on first metatarsal (MT1) movements in the context of hallux valgus (HV), the surgical correction of which relies on a sound understanding of factors leading to MT1 deformity. Hypermobility or instability of the first metatarsal at its tarsometatarsal joint (TMJ1) is associated with greater degrees of deformity and also greater risk of recurrence after surgery. Recent anatomical work has shown the importance of the plantar aponeurosis (PA), and the transverse ‘tie-bar’ system (TTB) of the metatarsophalangeal (MPJ) plantar plates and intervening deep transverse inter-metatarsal ligaments in the structure and function of the foot. These ligamentous systems are important in MPJ stability, but may also be important at TMJ1.

Ten normal cadaveric feet were dissected to expose the capsules and ligaments of the MPJs and TMTJs and the PA. They were then mounted in plaster of Paris leaving the MT1, MT2, and their articulations free. A loading fixture was constructed so that loads could be applied to MT1 in the transverse plane to produce moments in flexion, abduction or extension. The movements resulting from a load of 40N were measured relative to MT2 using an Isotrak II (Polhemus, US) magnetic measurement system. The tests were performed with the hallux mobile, fixed neutral and fixed dorsiflexed at the MPJ. After an initial test with all structures intact, the PA and the TTB were severed in random order and the test repeated. “Movement maps” were produced showing the range of motion available in different directions and with different ligamentous restraints.

Movement maps suggest that the TMJ1 behaves as a ball and socket joint with no preferred axis of motion. The contributions of the PA and TTB to stiffness in the sagittal plane are small (about 1° movement). However, the TTB provides significant control of the abduction of MT1. The control afforded by the TTB is particularly important since it can ensure that the PA acts to provide an adduction moment about the TMJ1. The integrity of these ligamentous structures is likely to be important in the success of corrective surgical procedures for HV, where disruption can allow up to 10° increase in MT1-2 angles.

Between 1979 and 1989, we treated 22 patients with symptomatic lumbar spondylolysis which had not responded to conservative treatment by a modified Scott wiring technique to give direct repair of the lytic defects with stabilisation. The patients' mean age at the time of operation was 15 years; the mean follow-up period was four years. All 19 patients under 25 years old had satisfactory results. Two of the three patients over 25 years old had poor results. The age of the patient at surgery seems to be an important determinant of outcome. Radiologically confirmed fusion is of secondary importance. The presence of a grade I spondylolisthesis did not prejudice the result. We recommend the Scott wiring technique to stabilise the direct repair of a lumbar spondylolysis.

We have studied the role of computerised axial tomography in the assessment of the acetabulum before an uncemented Mittelmeier arthroplasty was performed in 20 patients. In the absence of gross anatomical abnormality, computerised tomography did not provide additional information, but in eight patients it was useful in determining adequacy of acetabular depth, anterior acetabular cover, and thickness of the anterior and posterior walls. In these patients, the CT scans provided information which was not available from plain radiographs and greatly assisted in pre-operative planning.