Introduction: The suture properties associated with a successful tendon repair are: high tensile strength, little tissue response, good handling characteristics and minimal plastic deformation. Plastic deformation contributes to gap formation at a tendon repair site. Gaps greater than 4mm are likely to fail. This study investigates whether the plastic deformation demonstrated by two commonly used suture materials can be reduced by manual pre-tensioning.

Methods: Twenty sutures of both Prolene 3/0 (Ethicon, UK) and Ethibond 3/0 (Excel, Johnson and Johnson, UK) were tested. Half of the sutures in each group were manually pre-tensioned prior to knot tying and half were knotted without pre-tensioning. All knots were standard surgical knots with six throws. The suture lengths were measured before and after a standardised cyclical loading regime on an Instron tensile tester. The regime was designed to represent the finger flexion forces produced in a typical rehabilitation programme. All sutures were subsequently tested to their ultimate tensile strength.

Results: After cyclical loading the pre-tensioned sutures demonstrated a mean increase in suture length of 0.7% (range 0.1–1.9%). The sutures not pre-tensioned showed a mean increase of 5.4% (range 3.3–7%). This equates to 87% less plastic deformation (p < 0.05 Students’ T-test) upon pre-tensioning. There were no differences with Ethibond. Pre-tensioning had no effect on ultimate tensile strength for either group.

Conclusions: Manual pre-tensioning reduces plastic deformation in Prolene 3/0 sutures without affecting the ultimate tensile strength. This simple technique could theoretically diminish gap formation at the site of a tendon repair.

Background and Aims: Plate fixation of acute mid-shaft clavicle fractures is becoming increasingly popular. However limb and life threatening complications such as injury to the subclavian vessels have been reported. One possible solution to reduce the risk of this complication is the use of unicortical screw fixation.

The aim of this study was to compare biomechanical properties of pre-contoured plate fixation using different screw fixation modes in a mid-shaft clavicle fracture model.

Methods: Fourth generation biomechanical clavicle sawbones with a mid-shaft osteotomy were plated in one of three modes: nonlocking bicortical, locking bicortical and locking unicortical mode. The specimens were then tested to failure in four-point bending and pull-off tests.

Results: Failure due to fracture through the sawbone was more common in nonlocking bicortical mode while plate bending was more common in the locking bicortical group. The ultimate load at failure was significantly lower in the locking bicortical group compared to the nonlocking bicortical group, however there was no significant difference between the locking unicortical group and nonlocking bicortical group.

In the pull-off tests 100% of nonlocking bicortical and locking bicortical plates failed by fracture of the sawbone. 100% of the locking unicortical plates failed by plate and screw pull-off from the sawbone. The load at failure was highest for the locking unicortical plate but this was not significantly different to the other groups.

Conclusion: This study shows that specimens fixed with locking unicortical screw fixation withstood comparable or superior loads in four-point bending and pull-off test when compared to nonlocking bicortical and locking bicortical screw fixation. In addition both locking screws and unicortical screws appear to provide a protective effect against periprosthetic sawbone fracture. Locking unicortical screw fixation of pre-contoured plates may be a viable alternative in the fixation of mid-shaft clavicle fractures.

Introduction and Aims: This paper presents a treatment plan for femoral stem revision that has been developed based on long-term studies of revision total hip replacement (THR) using cemented stems, cementless proximal fixation stems, cemented stems with impaction grafting and modular titanium long stems.

Method: The clinical and radiographic results of femoral stem revision were compared using the following techniques: 1) a standard or long cemented collarless double taper Exeter or CPT stems (CCDT stems) [n=190]; 2) a proximally porous coated mid to long cementless stem [n=56]; 3) two series of CCDT stems with impaction grafting n=34]; and 4) a modular grit-blasted titanium taper stem [n=13] used for severe cortical damage. Treatment decisions were made based on the age of the patient, the appearance of the pre-operative radiograph and the extent of bone deficiency at surgery. Follow-up was from 17 to two years.

Results: Only one hip was lost to follow-up. In the CCDT group, at a median follow-up of five years (range 2–17 years), two standard length stems and one long stem had been re-revised for loosening (1.5%) and seven stems had been re-revised for other reasons. Survivorship to re-revision for loosening at eight years was 95% (95%CI=85–100%) for both standard and long stems. There was a trend for better longer-term results for long stems. The extent of pre-operative bone loss did not influence results. For the cementless proximal fixation group, at a median follow-up of 10 years, re-revision of the stem for loosening occurred in 20%. Importantly, these poor results could have been predicted from short-term results. The initial series of femoral impaction grafting with CCDT stems and irradiated bone had a small incidence of stem loosening and periprosthetic fracture. The majority of stems subsided, but at a median follow-up of eight years there were no further re-revisions. In the second series, usually with non-irradiated allograft with mesh containment, there was minimal stem subsidence and no re-revision. The grit blasted titanium taper stem has dealt with periprosthetic fratures and severe proximal cortical loss, but with some cases of subsidence and femoral fracture.

Conclusion: Based on these results, our treatment plan for routine femoral revision in middle-aged and elderly patients without severe proximal deficiency is a polished CCDT long stem. In younger patients, impaction grafting is recommended, provided deficient bone is protected. Cementless modular stems are reserved for femurs with severe proximal cortical deficiency.

Introduction and Aims: To aid the comparison of results of different techniques of femoral revision at total hip replacement and in choosing types of revision, a number of radiographic classifications have been proposed. We aimed to determine the reliability of five popular radiographic classification systems for grading the extent of femoral bone deficiency.

Method: Twenty pre-revision total hip replacement femoral radiographs were assessed by a senior consultant specialist in revision surgery, a junior consultant, a fellow and a trainee registrar. The femoral bone deficiency was classified using the systems of the American Academy of Orthopaedic Surgeons (AAOS) and EndoKlinik, and those described by Paprosky, Gross and Gustillo. Intra-observer agreement and inter-observer agreement between assessors were determined using the kappa coefficient. Radiographs were reassessed after a minimum of two weeks. Kappa coefficients of 0.6–0.8 (substantial) or > 0.8 (almost perfect) were considered to indicate acceptable agreement. Intra-operative measurement of deficiency was also undertaken.

Results: Intra-oberser agreement was rated as acceptable for the Paprosky, Gross and Gustillo systems, each giving substantial agreement, but was unacceptable for the AAOS and EndoKlinik systems. Inter-observer agreement was unacceptable for all systems except the Gross classification system, which was rated as having substantial agreement.

Conclusion: Comparing results of femoral revision between different surgeons based on bone deficiency according to the most popular radiographic classification systems is doubtful because of poor reliability. These classifications can be used by an individual surgeon as a guide to management, but most classifications should not be used to recommend the type of femoral revision to other surgeons.

Introduction Early complications of revision total hip replacement (rTHR) with femoral impaction allografting have included stem subsidence and loosening. In this comparative study, the impact of new techniques, including the use of longer stems, non-irradiated washed allograft, larger bone chips and medial mesh, on early clinical and radiographic outcomes was examined.

Methods The initial series of rTHRs with femoral impaction allografting comprised 20 hips (19 patients, median age 68 years) with a median follow-up of eight years. In the current series where the new techniques were used, there are 11 hips (11 patients, median age 69 years) with a median follow-up of 1.5 years. Three surgeons at one hospital undertook all rTHRs using a polished cemented collarless double tapered stem. Patients were mobilised on day one with partial weight bearing for 12 weeks. The femoral deficiencies commonly comprised extensive cavitatory loss combined with segmental deficiencies. Regular clinical and radiographic assessment was undertaken.

Results In the initial series, there were three early rerevisions for subsidence and stem loosening and one rerevision for infection. Periprosthetic fracture occurred early in three hips. EBRA FCA was used to assess stem subsidence. By two to four years, nine femoral stems had subsided more than five millimetres. At mid-term follow-up of eight years there have been no further rerevisions. In comparison, there has been minimal stem subsidence in the current series, with no stems subsiding more than five millimetres. To-date there have been no periprosthetic fractures and no complications requiring re-revision.

Conclusions Prospective monitoring of rTHR is important to identify factors that may be associated with poor outcome. Current techniques of femoral impaction grafting at rTHR, that includes washing of allograft and the use of long length stems and proximal mesh support yield good early-term radiographic and clinical results.

Introduction In this institution a structured program of conservative management of Achilles tendon rupture has been developed combining a conservative and orthotic treatment regime with a view to adding the advantages of a removable orthosis to traditional non-operative therapy. This study compares the results of this protocol to published surgical results. This is the largest detailed study of conservative management of Achilles tendon rupture in the literature to date.

Methods We assessed 140 subjects who had a complete rupture of their Achilles tendon treated with our combined conservative and orthotic regime between 1992 and 1998. Subjective assessments of symptoms and objective measurements of ankle range of motion, calf circumference and isokinetic measurements of ankle plantar flexion and dorsi flexion were recorded. Patients also completed a functional heel-rise test. Our results have been compared to published series.

Results Our overall results showed 56% had excellent, 30% good, 12% fair and two percent poor results. The overall complication rate was four percent, with three tendon reruptures. When compared with published results for operative repair, our combined conservative and orthotic treatment produces better results overall. Patients are subjectively happier, they have better strength results and have fewer complications.

In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source.

We report a 45-year follow-up of a patient with Engelmann’s disease previously described in 1950, showing progression of the disease with unique involvement of the femoral capital epiphyses. The case is compared with others to add some information about the later stages of a disease which is not fully understood

A randomised double-blind study was carried out on 60 patients undergoing elective lumbar discectomy. Patients in the study group (n = 30) received an injection of 10 ml of 0.5% bupivacaine into the wound; the control group (n = 30) received none. Postoperative pain was measured by a visual analogue pain scale and by the amount of morphine administered by a patient-controlled analgesia system. Patients in the study group had lower pain scores, used less morphine, waited longer until their first demand for analgesia and reported their postoperative pain to be less severe.

We report 40 cases in one family of an autosomal dominant bone dysplasia, which, though similar in some aspects to Paget's disease, seems unique in some features and in its natural history. The disease shows both general and focal skeletal changes, the latter being mainly in the limbs with an onset from the second decade. Progressive osteoclastic resorption is accompanied by medullary expansion which leads to pain, severe deformity and a tendency to pathological fracture. The serum alkaline phosphatase and urinary hydroxyproline are variably elevated, while other biochemical indices are normal. Most patients had an associated deafness of early onset and loss of dentition. No previous description of this disease has been found in the literature.