Aims

The aim of this study was to describe the prevalence and patterns of neuropathic pain over one year in a cohort of patients with chronic post-surgical pain at three months following total knee arthroplasty (TKA).

Abstract

Abstract

Abstract

Abstract

Introduction

We present the first 12 consecutive patients, undergoing elective paediatric limb reconstruction with an external fixator, for the 12-month period October 2020-October 2021. This is a single surgeon series for a newly appointed Consultant with limited previous experience. Arrangements were made for mentoring by a senior surgeon recently retired from the NHS but still active in private practice.

Prosthetic joint infection (PJI) is an uncommon but serious complication of hip replacement. Over 1,000 operations are performed annually in the United Kingdom for PJI following hip replacement, using either one- or two-stage revision arthroplasty. It is unclear which is preferred by patients and which has the best long-term outcome. This qualitative study aims to describe patient experiences of treatment and recovery following one- and two-stage revision arthroplasty for PJI within the context of a pragmatic randomised controlled trial comparing these two approaches. Semi-structured interviews were conducted with 32 patients undergoing one- or two-stage revision treatment for PJI as part of a UK multi-centre randomised controlled trial. Patients were recruited from 12 participating National Health Service (NHS) Orthopaedic Departments and were interviewed 2–4 months after their first revision surgery and again approximately 18 months later. Final sample size was justified on the basis of thematic saturation. All patients consented to the interview being audio-recorded, transcribed, anonymised and analysed using an inductive thematic approach. Ethical approval was provided by NRES Committee South-West Frenchay, 14/SW/116. Patients in both the one- and two-stage treatment groups described prolonged hospital stays, with burdensome antibiotics and brief physiotherapy treatment. However, following discharge home and during recovery, participants undergoing two-stage revision with an ‘empty hip' or with a spacer reported being physically restricted in almost every aspect of their daily life, resulting in inactivity and confinement to home. Mobility aids were not sufficiently available through the health service for these patients. A key difference is that those with a spacer reported more pain than those without. Approximately one year following their second-stage revision, participants described being more independent and active, but two directly attributed muscle weakness to the lengthy period without a hip and described resulting falls or dislocations that had complicated their recovery. In contrast, those undergoing one-stage revision and CUMARS appeared to be more alike, reporting better mobility, functionality and independence, although still limited. Participants in these groups also reported minimal or no pain following their revision. A key difference between CUMARS and one-stage revision was the uncertainty of whether a second operation was necessary, which participants described as “hanging over them”, while those in the two-stage empty hip or spacer group described a more positive anticipation of a second definitive operation as it marked an end to what was described as a detachment from life. Our findings highlight the differences between patient experiences of recovery following revision arthroplasty, and how this is influenced by the surgical approach and presence or lack of spacers. An understanding of lived experiences following one- and two-stage surgical interventions will complement knowledge about the clinical effectiveness of these different types of revision surgery.

In the UK and USA in 2016 more than 263,000 primary knee replacements were performed. Around 20% of patients report chronic post-surgical pain (CPSP) at three or more months after total knee replacement (TKR). A large proportion of adults with all types of chronic musculoskeletal pain do not use services for a number of reasons, despite being in constant or daily pain. Given the high prevalence of CPSP, there is potentially a large hidden population with an unexpressed need for care, experiencing ongoing pain and disability; understanding why they do not use health services may herald further insight into why many remain dissatisfied with knee replacement surgery. The aim of this study is to understand why some people with CPSP after TKR do not access services or make little use of healthcare. We conducted face-to-face in-depth interviews with 34 patients from 2 high-volume orthopaedic hospitals in England, to investigate their experience of long-term pain after knee replacement; their knowledge and understanding of CPSP; and their decisions about consulting for CPSP. The sample size was based on achievement of saturation and participants provided written informed consent. Interviews were transcribed and analysed using an inductive thematic approach with double coding for rigor. Ethical approval for the study was granted by the West Midlands Solihull Research Ethics Committee (15/WM/0469). A core theme within the analysis suggests that participants do not seek healthcare because they believe that nothing further can be done, either by themselves or by healthcare professionals. Surgeons' satisfaction with the knee surgery and reassurances that pain would improve, left patients feeling uncertain about whether to re-consult, and some assumed that further consultation could lead to further surgery or medication, which they wish to avoid. Some participants' comorbidities took precedence over their knee pain when seeking healthcare. Others felt they had received their “share” of healthcare resources and that others were more deserving of treatment. People's descriptions of pain varied, from dull, or aching to shooting pains. Many described their pain as “discomfort” rather than pain. The majority described pain that was better than their pre-surgical pain, though others described pain that was worse, which they believed to be nerve damage. Many expressed disappointment in the outcome of their TKR. Expectations of pain varied, where most had expected some post-surgical pain, others underestimated it, and some had expected to be completely pain free following their TKR. Our analysis suggests that the reasons that some people with CPSP after TKR do not consult are varied and complex, spanning psychosocial, structural, moral, and organisational domains. There was an overriding sense that further consultation would be futile or may lead to unwanted treatment. Results suggest that improved information for patients about CPSP and appropriate post-surgical healthcare services may help patients and clinicians to manage this condition more effectively.

Background

To aid recovery, rehabilitation is an important adjunct to surgery. Acknowledging the MRC framework for complex interventions we assessed the evidence-base for components of comprehensive rehabilitation in total hip (THR) and total knee replacement (TKR) pathways.

Background

Inpatient physiotherapy is routinely provided after total knee replacement (TKR) surgery to enhance recovery prior to discharge. However, the provision of outpatient physiotherapy is variable in the UK, and the longer-term benefits of outpatient physiotherapy are unclear. This study aimed to evaluate the feasibility of conducting a randomised controlled trial (RCT) to assess the effectiveness and cost-effectiveness of group-based outpatient physiotherapy after TKR.

Background

Chronic pain after joint replacement is common, affecting approximately 10% of patients after total hip replacement (THR) and 20% of patients after total knee replacement (TKR). Heightened generalised sensitivity to nociceptive input could be a risk factor for the development of this pain. The primary aim of this study was to investigate whether preoperative widespread pain sensitivity was associated with chronic pain after joint replacement.

Background

To investigate whether the interaction between pre-operative widespread hyperalgesia and radiographic osteoarthritis (OA) was associated with pain severity before and after total hip replacement (THR) and total knee replacement (TKR).

Background

While many studies have investigated long-term outcomes after lower limb arthroplasty, rather less is known about the trajectory of short-term outcomes in the first post-operative year. It is difficult for a surgeon to know when, in terms of disease severity, it is best to operate, or to make an accurate prediction of the patient pattern of post-operative recovery. We explored the trajectory of change in pain and function following primary hip and knee arthroplasty and the influence of pre-operative self-reported symptoms on post-operative improvements.

Background

Around 1% of patients who have hip replacement have deep prosthetic joint infection afterwards. Infection is treated with antibiotics and revision surgery. We aimed to characterise the impact of deep joint infection and its treatment, to identify treatment preferences, and to describe surgeons' treatment decisions.

Objective

There is limited information about the extent to which the association between pre-operative and chronic post-operative pain is mediated via pain-on-movement or pain-at-rest. We explored these associations in patients undergoing total hip (THR) and total knee (TKR) replacement.

Background

Total hip replacement (THR) and total knee replacement (TKR) are usually effective at relieving pain; however, 7–23% of patients experience chronic post-surgical pain. These trials aimed to investigate the effect of local anaesthetic wound infiltration on pain severity at 12 months after primary THR or TKR for osteoarthritis.

Background

This article reviews four commonly used approaches to assess patient responsiveness to a treatment or therapy [Return To Normal (RTN), Minimal Important Difference (MID), Minimal Clinically Important Difference (MCID), OMERACT-OARSI (OO)], and demonstrates how each of the methods can be formulated in a multi-level modelling (MLM) framework.

Introduction

The management of peri-prosthetic distal femur fractures following TKR (Total Knee Replacement) in the elderly remains a challenge with little or no consensus on the best available treatment. Various methods have been described in the management of these complex fractures. Our study compares the outcome and cost of distal femoral arthroplasty to that of Fixation (Plating/Retrograde Nailing).

Physical functioning in patients undergoing hip surgery is commonly assessed in three ways: patient-reported outcome measure (PROM), performance test, or clinician-administered measure. It is recommended that several types of measures are used concurrently to capture an extended picture of function. Patient fatigue and burden, time, resources and logistical constraints of clinic and research appointments mean that collecting multiple measures is seldom feasible, leading to focus on a limited number of measures, if not a single one. While there is evidence that performance-tests and PROMs do not fully correlate, correlations between PROMs, performance tests and clinician-administrated measures are yet to be evaluated. It is also not known if the associations between function and patient characteristics depend on how function is measured. The aim of our study was to use different measures to assess function in the same group of patients before their hip surgery to determine 1. how well PROMs, performance tests and clinician-administrated measures correlate with one another and 2. Whether these measures are associated with the same patient characteristics.

We conducted a cross-sectional analysis of the pre-operative information of 125 participants listed for hip replacement. The WOMAC function subscale, Harris Hip Score (HHS) and walk-, step- and balance-tests were assessed by questionnaire or during a clinic visit. Participant socio-demographics and medical characteristics were also collected. Correlations between functional measures were investigated with correlation coefficients (r). Regression models were used to test the association between the patient's characteristics and each of the three types of functional measures.

None of the correlations between the PROM, clinician-administrated measure and performance tests were very high (r<0.90). The highest correlations were found between the WOMAC-function and the HHS (r=0.7) or the Walk-test (r=0.6), and between the HHS and the walk-test(r=0.7). All the other performance-tests had low correlations with the other measures(r ranging between 0.3 and 0.5).

The associations between patient characteristics and functional scores varied by type of measure. Psychological status was associated with the WOMAC function (p-value<0.0001) but not with the other measures. Age was associated with the performance test measures (p-value ranging from ≤0.01 to <0.0001) but not with the WOMAC function. The clinician-administered (HHS) measure was not associated with age or psychological status.

When evaluating function prior to hip replacement clinicians and researchers should be aware that each assessment tool captures different aspects of function and that patient characteristics should be taken into account. Psychological status influences the perception of function; patients may be able to do more than they think they can do, and may need encouragement to overcome anxiety. A performance test like a walk-test would provide a more comprehensive assessment of function limitations than a step or balance test, although performance tests are influenced by age.

For the most precise description of functional status a combination of measures should be used. Clinicians should supplement their pre-surgery assessment of function with patient-reported measure to include the patient's perspective.

Joint arthroplasty is a common surgical procedure, with over 185,000 primary hip and knee arthroplasties performed in England, Wales and Northern Ireland in 2014. After total hip or knee arthroplasty, about 1% of patients develop deep prosthetic joint infection (PJI), which usually requires further major operations to clear the infection. Although PJI affects only a small percentage of patients it is one of the most devastating complications associated with this procedure. Research evidence has focussed on clinical effectiveness of revision surgery while there has been less focus on the impact on patients and support needs. Using a systematic review approach, the aim of this study was to assess support needs and evaluate what interventions are routinely offered to support patients undergoing treatment for PJI following hip or knee arthroplasty.

We systematically searched MEDLINE, Embase, Web of Science, PsycINFO, Cinahl, Social Science Citation Index, and The Cochrane Library from 1980 to February 15, 2015 for observational (prospective cohort, nested case-control, case-control, and retrospective cohort) studies, qualitative studies, and clinical trials that report on the support needs and interventions for patients being treated for PJI or other major adverse occurrences following joint arthroplasty. Data were extracted by two independent investigators and consensus reached with involvement of a third.

Of 4,161 potentially relevant citations, we identified one case-control, one prospective cohort and two qualitative studies for inclusion in the synthesis. Patients report that PJI and treatment had a profoundly negative impact affecting physical, emotional, social and economic aspects of their lives. No study evaluated support interventions for PJI or other major adverse occurrences following hip and knee arthroplasty.

The interpretation of study results is limited by variation in study design, outcome measures and the small number of relevant eligible studies. Findings show that patients undergoing treatment for PJI have extensive physical, psychological, social and economic support needs. Our review highlights a lack of evidence about support strategies for patients undergoing treatment for PJI and other adverse occurrences. There is a need to design, implement and evaluate interventions to support these patients.

Around 20% of patients who have total knee replacement find that they experience long-term pain afterwards. There is a pressing need for better treatment and management for patients who have this kind of pain but there is little evidence about how to improve care. To address this gap we are developing a complex intervention comprising a clinic to assess potential causes of a patient's long-term pain after knee replacement and onwards referral to appropriate, existing services. The Medical Research Council recommends that development of complex interventions include several stages of development and refinement and involvement of stakeholders. This study comprises the penultimate stage in the comprehensive development of this intervention. Earlier stages included a survey of current practice, focus groups with healthcare professionals, a systematic review of the literature and expert deliberation.

Healthcare professionals from diverse clinical backgrounds with experience of caring for patients with long-term pain after knee replacement were sent a study information pack. Professionals who wished to participate were asked to return their signed consent form and completed study questionnaire to the research team. Participants rated the appropriateness of different aspects of the assessment process and care pathway from 1–9 (not appropriate to very appropriate). Data were collated and a document prepared, consisting of anonymised mean appropriateness ratings and summaries of free-text comments. This document was then discussed in 4 facilitated meetings with healthcare professional held at the future trial centres. A summary report and revised care pathway was then prepared and sent to participants for further comments.

28 professionals completed the questionnaire and/or attended a meeting. Participants included surgeons, physiotherapists, nurses, pain specialists and rheumatologists. Mean appropriateness scores ranged from 6.9 to 8.4. Taking a score of 7–9 as agreement, consensus was achieved that the assessment should be performed at 3 months post-operative by an extended scope practitioner/nurse, treatment be guided by a standardised assessment of pain, and treatment individualised. There was also agreement that referrals in the care pathway to surgical review, GP and pain clinics were appropriate. Nurse-led/self-monitoring was rated lower (6.9) because of considerations about the need to ensure that patients receive appropriate support, follow-up and referral to other services.

This work demonstrates the research methods that can be used to refine the design of a complex intervention. The process and findings enable refinement of an intervention for patients with long-term pain after knee replacement. The next stage of intervention development will assess the acceptability and reliability of the assessment process, and the usability of the intervention's standard operating procedures. The intervention will then be evaluated by a larger research team in a multi-centre randomised controlled trial, starting in late 2016.

Patients report similar or better pain and function before revision hip arthroplasty than before primary arthroplasty but poorer outcomes after revision surgery. The trajectory of post-operative recovery during the first 12 months and any differences by type of surgery have received little attention. We explored the trajectories of change in pain and function after revision hip arthroplasty to 12-months post-operatively and compared them with those observed after primary hip arthroplasty.

We conducted a single-centre UK cohort study of patients undergoing primary (n = 80) or revision (n = 43) hip arthroplasty. WOMAC pain and function scores and 20-metres walking time were collected pre-operatively, at 3 and 12-months post-operatively. Multilevel regression models were used to chart and compare the trajectories of post-operative change (0–3 months and 3–12 months) between the types of surgery.

Patients undergoing primary arthroplasty had a total hip replacement (n=74) or hip resurfacing (n=6). Osteoarthritis was the indication for surgery in 92% of primary cases. Patients undergoing revision arthroplasty had revision of a total hip arthroplasty (n=37), hemiarthroplasty (n=2) or hip resurfacing (n=4). The most common indication for revision arthroplasty was aseptic loosening (n=29); the remaining indications were pain (n=4), aseptic lymphocyte-dominated vasculitis-associated lesion (n=4) or other reasons (n=6). Primary (87%) and revision arthroplasties (98%) were mostly commonly performed via a posterior surgical approach.

The improvements in pain and function following revision arthroplasty occurred within the first 3-months following operation (WOMAC-pain, p<0.0001; WOMAC-function, p<0.0001; timed 20-metres walk, p<0.0001) with no evidence of further change beyond this initial period (p>0.05)

While the pattern of recovery after revision arthroplasty was similar to that observed after primary arthroplasty, improvements in the first 3-months were smaller after revision compared to primary arthroplasty (p<0.0001). Patients listed for revision surgery reported lower pre-operative pain levels (p=0.03) but similar post-operative levels (p=0.268) compared to those undergoing primary surgery. At 12-months post-operation patients who underwent a revision arthroplasty had not reached the same level of function achieved by those who underwent primary arthroplasty (WOMAC-function p=0.015; Time walk p=0.004).

Patients undergoing revision hip arthroplasty should be informed that the majority of their improvement will occur in the first 3-months following surgery and that the expected improvement will be less marked than that experienced following primary surgery. More research is now required to 1.) identify whether specific in-patient and post-discharge rehabilitation tailored towards patients undergoing revision arthroplasty would improve or achieve equivalent outcomes to primary surgery and 2.) whether patients who are achieving limited improvements at 3-months post-operative would benefit from more intensive rehabilitation. This will become all the more important with the increasing volume of revision surgery and the high expectations of patients who aspire to a disease-free and active life.

Around 1% of the 185,000 primary hip and knee arthroplasties performed in the UK are followed by prosthetic joint infection (PJI). Although PJI affects a small percentage of patients, it is one of the most devastating complications associated with this procedure. Treatment usually involves further major surgery which can adversely affect patients' quality of life. Understanding current service provision provides valuable information needed to design and evaluate support interventions for patients. The aim of this survey was to identify usual care pathways and support in UK NHS orthopaedic centres for this population.

The 20 highestvolume UK NHS orthopaedic centresfor hip and knee arthroplasty account for 33–50% of all cases treated for prosthetic joint infection. Infection leads at each centre were invited to participate in a survey about usual care provision and support for PJI. Questions exploredfollow up time-points; use of standard outcome measures; multidisciplinary care plans; supportive in-patient care and care after treatment; and onward referrals. Survey responses were recorded on a standardised proforma. Data were entered into Excel for analysis, then reviewed and coded into categories and frequency statistics to describe categorical data. A descriptive summary was developed based on these categories.

Eleven of the highestvolume orthopaedic centres completed the survey. Follow-up of patients varied greatly across centres; some centres reviewed patients at weekly or 2 week intervals, while all centres saw patients at 6 weeks. Long-term follow-up varied across centres from 3–4 monthsto 12 monthly. Length of follow-up period varied from until the infection had cleared toindefinitely. Follow-up timepoints were only standardised in 4 out of 11 centres. Only 1 centre had a dedicated infection clinic. Advice on who patients should contact if they had concerns included the consultant, community nurse, extended scope practitioner or the ward, while 3 centres told patients to avoid calling their GP. Only half of the centres routinely used standardised outcome measures with patients with PJI. The majority of centres provided standard physiotherapy and occupational therapy (OT) to in-patients while approximately half also offered social support. Only one centre provided dedicated physiotherapy and OT on a separate infection ward. Three centres provided hospital at home or community services to patients in-between operative stages. Only 3 out of 11 centres stated they had specific multidisciplinary care plans in place for patients. Once discharged most patients were provided with physiotherapy, OT and social services if needed. Common barriersto referral included complexities of referring patients outside the hospital catchment area;lack of availability of community services, and shortage of staff including physiotherapists. Delays in rehab and social services could also be problematic.

Findings show wide variation intreatment pathways and support for patients treated for PJI, both as inpatients and in the community. Only one of the 11 centreswho participated had a dedicated infection clinic. Only one centre suggested they individualised their physiotherapy support. A number of barriers exist to referring patients on to other support services after revision surgery.

Total hip replacement (THR) is a common elective surgical procedure and can be effective for reducing chronic pain. However, waiting times for THR can be considerable, and patients often experience significant pain during this time. A pain self-management intervention may provide patients with the skills to enable them to manage their pain and its impact more effectively before surgery. However, studies of arthritis self-management programmes have faced challenges because of low recruitment rates, poor intervention uptake, and high attrition rates. This study aimed to evaluate the feasibility of a randomised controlled trial (RCT) to assess the effectiveness and cost-effectiveness of a group-based pain self-management course for patients undergoing THR. Specific objectives were to assess trial design, ascertain recruitment and retention rates, identify barriers to participation, refine data collection methods, and evaluate uptake and patient satisfaction with the course.

Patients listed for THR in an elective orthopaedic centre Bristol, UK were sent a postal invitation about the study. Participants were randomised to attend a pain self-management course plus standard care or standard care only using a computer-generated randomisation system. The pain self-management course was delivered by Arthritis Care and consisted of two half-day group sessions prior to surgery and one full-day group session 2–4 months after surgery. A structured course evaluation questionnaire was completed by participants.

Outcomes assessment was by postal questionnaire prior to surgery and 1-month, 3-months and 6-months after surgery. Self-report resource use data were collected using a diary prior to surgery and inclusion of resource use questions in the 3-month and 6-month post-operative questionnaires. Brief telephone interviews were conducted with non-participants to explore barriers to participation.

Postal invitations were sent to 385 eligible patients and 88 patients consented to participate (23% recruitment rate). Participants had a mean age of 66 years and 65% were female. Brief interviews with 57 non-participants revealed the most common reasons for non-participation were perceptions about the intervention and difficulties in getting to the hospital for the course.

Of the 43 patients randomised to the intervention group, 28 attended the pre-operative pain self-management sessions and 11 attended the post-operative sessions. Participant satisfaction with the course was high, and patients enjoyed the group format.

Retention of participants was acceptable, with 83% completing follow-up. Questionnaire return rates were high (76–93%), with the exception of the pre-operative resource use diary (35%). Completion rates for the resource use questions varied by category and allowed for an economic perspective from the health and social care payer to be taken.

Undertaking feasibility work for a RCT is labour-intensive; however this study highlights the importance of conducting such work. Postal recruitment resulted in a low recruitment rate and brief interviews with non-participants provided valuable information on barriers to participation. Embedding collection of resource use data within questionnaires resulted in higher completion rates than using resource use diaries. While patients who attended the course gave positive feedback, attendance was low. Findings from this feasibility study enable us to design successful definitive group-based RCTs in the future.

Around 1% of total hip replacements are follow by prosthetic joint infection (PJI). There is uncertainty about best treatment method for PJI, and the most recent high quality systematic reviews in unselected patients indicates that re-infection rates following one-stage and two-stage revision arthroplasty are relatively similar. In the absence of evidence randomised controlled trials will help to identify the most clinically and cost-effective treatment for PJI. Before such trials are conducted, there is a need to establish reasons for current practice and to identify whether trials are feasible. This study aimed to deliver research that would inform trial design. Specifically, we aimed to characterise consultant orthopaedic surgeons' decisions about performing either one-stage or two-stage exchange arthroplasty for patients with PJI after hip replacement and to identify whether a randomised trial comparing one-stage with two-stage revision would be possible.

Semi-structured interviews were conducted with 12 consultant surgeons from 5 high-volume National Health Service (NHS) orthopaedic departments in the UK. Surgeons were sampled on the basis that they perform revision surgery for PJI after hip arthroplasty and final sample size was justified on the basis of thematic saturation. Surgeons were interviewed face-to-face (n=2) or via telephone (n=10). The interview study took place before design of a multicentre prospective randomised controlled trial comparing patient and clinical outcomes after one-stage or two-stage revision arthroplasty. Data were audio-recorded, transcribed, anonymised and analysed using a thematic approach, with 25% of transcripts independently double-coded.

Results: There is no standard surgical response to the treatment of PJI and surgeons manage a complex balance of factors when choosing a surgical strategy. These include multiple patient-related factors, their own knowledge and expertise, available infrastructure and the infecting organism. Surgeons questioned whether evidence supports the emergence of two-stage revision as a method. They described the use of loosely cemented articulating spacers as a way of managing uncertainty about best treatment method. All surgeons were supportive of a randomised trial to compare one-stage and two-stage revision surgery for PJI after hip replacement. Surgeons reported that they would put patients forward for randomisation when there was uncertainty about best treatment.

Surgeons highlighted the need for evidence to support their choice of revision. Some surgeons now use revision methods that can better address both clinical outcomes and patients' quality of life, such as loosely cemented articulating spacers. Surgeons thought that a randomised controlled trial comparing one-stage and two-stage exchange joint replacement is needed and that randomisation would be feasible. The next stage of the work was to design a multi-centre randomised controlled trial, this has been achieved and the trial is now ongoing in the UK.

Robust evidence on the effectiveness of peri-operative local anaesthetic infiltration (LAI) is required before it is incorporated into the pain management regimen for patients receiving total knee replacement (TKR). To assess the effectiveness of peri-operative LAI for pain management in patients receiving TKR we conducted a systematic review, fully powered randomised controlled trial (RCT) and economic evaluation.

We searched MEDLINE, Embase and Cochrane databases for RCTs of peri-operative LAI in patients receiving TKR. Two reviewers screened abstracts and extracted data. Outcomes were pain, opioid use, mobilisation, hospital stay and complications. Authors were contacted if required. When feasible, we conducted meta-analysis with studies analysed separately if a femoral nerve block (FNB) was provided.

In the APEX RCT, we randomised 316 patients awaiting TKR to standard anaesthesia which included FNB, or to the same regimen with additional peri-operative LAI (60mls 0.25% bupivacaine plus adrenaline). Post-operatively, all patients received patient-controlled morphine. The primary outcome was joint pain severity (WOMAC-Pain) at 12 months. Patients and outcome assessors were blinded to allocation.

Within APEX, cost-effectiveness was assessed from the health and social-care perspective in relation to quality adjusted life years (QALYs) and WOMAC-Pain at 12-months. Resource use was collected from hospital records and patient questionnaires.

In the systematic review, 23 studies including 1,439 patients were identified. Compared with patients receiving no intervention, LAI reduced WOMAC-Pain by standardised mean difference (SMD) −0.40 (95%CI −0.58, −0.22; p<0.001) at 24 hours at rest and by SMD −0.27 (95%CI −0.50, −0.05; p=0.018) at 48 hours during activity. In three studies there was no difference in pain at any time point between randomised groups where all patients received FNB. Patients receiving LAI spent fewer days in hospital, used less opioids and mobilised earlier. Complications were similar between groups. Few studies reported long-term outcomes.

In the APEX RCT, pain levels in hospital were broadly similar between groups. Overall opioid use was similar between groups. Time to mobilisation and discharge were largely dependent on local protocols and did not differ between groups. There were no differences in pain outcomes between groups at 12 months.

In the economic evaluation, LAI was marginally associated with lower costs. Using the NICE £20,000 per QALY threshold, the incremental net monetary benefit was £264 (95%CI, −£710, £1,238) and the probability of being cost-effective was 62%.

Although LAI appeared to have some benefit for reduced pain in hospital after TKR there was no evidence of pain control additional to that provided by femoral nerve block, however it would be cost-effective at the current NICE thresholds.

Robust evidence on the effectiveness of peri-operative local anaesthetic infiltration (LAI) is required before it is incorporated into the pain management regimen for patients receiving total hip replacement (THR). We assessed the effectiveness of LAI using a systematic review and a fully powered randomised controlled trial (RCT) with economic evaluation.

We searched MEDLINE, Embase and Cochrane databases for RCTs of peri-operative LAI in patients receiving THR. Two reviewers screened abstracts, extracted data, and liaised with authors. Outcomes were pain, opioid use, mobilisation, hospital stay and complications. If feasible, we conducted meta-analysis.

In the APEX RCT, we randomised 322 patients awaiting THR to receive additional peri-operative LAI (60mls 0.25% bupivacaine plus adrenaline) or standard anaesthesia alone. Post-operatively, all patients received patient-controlled morphine. The primary outcome was joint pain severity (WOMAC-Pain) at 12 months. Patients and outcome assessors were blinded to allocation.

Within APEX, cost-effectiveness was assessed from the health and social-care perspective in relation to quality adjusted life years (QALYs) and WOMAC-Pain at 12-months. Resource use was collected from hospital records and patient questionnaires.

In the systematic review, we identified 13 studies (909 patients). Patients undergoing THR receiving LAI experienced greater pain reduction at 24 hours at rest, standardised mean difference (SMD) −0.61 (95%CI −1.05, −0.16; p=0.008) and at 48 hours during activity, SMD −0.43 (95%CI −0.78, −0.09; p=0.014). Patients receiving LAI spent fewer days in hospital, used less opioids and mobilised earlier. Complications were similar between groups. Long-term outcomes were not a focus of these studies.

In the APEX RCT, pain levels in hospital were broadly similar between groups, probably due to patient-controlled analgesia. Opioid use was similar between groups. Time to mobilisation and discharge were largely dependent on local protocols and did not differ between groups. Patients receiving LAI were less likely to report severe pain at 12 months than those receiving standard care, odds ratio 10.2 (95%CI 2.1, 49.6; p=0.004). Complications were similar between groups.

In the economic evaluation, LAI was associated with lower costs and greater cost-effectiveness than standard care. Using a £20,000 per QALY threshold, the incremental net monetary benefit was £1,125 (95%CI £183, £2,067) and the probability of being cost-effective was greater than 98 %.

The evidence suggests that peri-operative LAI is a cost-effective intervention for reducing acute and chronic post-surgical pain after THR.

Aims

Meningococcal septicaemia can result in growth arrest and angular deformities. The aim of this case series was to review the pattern of involvement in the lower leg.

This study retrospectively reviews all forearm lengthenings carried out by the author in order to assess results and complications and determine the efficacy of this treatment in children with various pathologies. The records of all patients who had undergone a forearm lengthening between 1995 and 2009 were reviewed. 23 forearm lengthenings in 20 patients were identified but in one case there was insufficient information for the study. The study is therefore based on 22 lengthenings. The patients were divided into two groups, Group A in whom the purpose of treatment was to restore the length relationship between the radius and ulna and Group B in whom the purpose was to gain forearm length. In Group A patients the aim was to protect the radial head against dislocation by lengthening the ulna (with if necessary a corrective radial osteotomy) or to protect the wrist from subluxation by a radial lengthening. In Group B patients the aim was to improve function and cosmesis.

The average age of the patients at time of surgery was 9.78 years, average follow up was 26 months post frame removal. There were 11 patients in Group A with an average radio ulnar discrepancy of 2.34 cms and 11 patients in Group B. In Group A patients the average length achieved was 2.69 cms i.e. overcorrection and in Group B the average lengthening was 3.84 cms. In Group A patients lengthening was only partially successful at preventing subluxation or dislocation of the radial head. Common complications were pin site infection and poor regenerate formation. Forearm lengthening by distraction osteogenesis is a worthwhile procedure in paediatric patients with improved cosmesis and function particularly in Group B patients.

Introduction

We report 3 cases from different centres of infantile tibia vara in which the deformity was due to slippage of the proximal tibial epiphysis on the metaphysis; the aim of this study was to define the features of this previously unreported condition, and their implications for management.

PURPOSE

To report the experience and evolution of treatment of Congenital Pseudarthrosis of the Tibia in a single surgeon, consecutive series of 19 patients.

The Quebec Task Force defined whiplash as “an acceleration–deceleration mechanism of energy transfer to the neck”. It is logical that the lower the velocity change following impact, the lower the risk of injury. The accepted velocity change (delta-v) for whiplash injuries following rear impact has been quoted as 5 mph. There is some debate as whether this is valid in the clinical setting. We aimed to investigate this further.

A series of low speed controlled crash simulations were undertaken. There were a total of 27 runs on 23 individuals. Accelerometers were placed on the head and chest of the volunteers. Video recordings were analysed to assess relative displacement of the head and chest. The presence of symptoms was documented over a period of 7 days. The volunteers consisted of 23 males and 1 female with an average age of 38 (range 20–56). The average delta-v achieved was 2.3 mph (range 1.8–3.1 mph). The average maximum accelerations recorded were 3.46g at the chest and 2.93g at the head. The average difference was 0.53g. There was no significant displacement between the head and body. No symptoms were reported beyond 1 hour.

Whiplash is triggered if the disparity between movements of the head and neck is of sufficient magnitude. It seems logical that there is a threshold below which whiplash will not occur. Our results have shown that below a delta-v of 3 mph there is little difference in the magnitude and timing of the movements of the head and chest.

Therefore the whiplash mechanism of injury does not occur at these changes of velocity.

Lumbar facet joint pain cannot be reliably diagnosed clinically, the International Spinal Injection Society recommends two diagnostic local anaesthetic blocks before radiofrequency (RF) denervation [1].

Scoring systems may improve diagnostic accuracy. The two most popular scores disagree on the interpretation of pain induced by extension/rotation:

‘Cochin Criteria’ [2]: pain on extension/rotation _ not facet joint problem

Helbig & Lee [3]: pain on extension/rotation _ facet joint problem

Methods: Retrospective study of all patients who had RF denervations of the lumbar facet joints in 2004.

Patients were selected clinically and did not undergo diagnostic blocks.

Cochin criteria, Helbig & Lee scores, work status, and outcome were taken from the case notes.

Likelihood ratios were calculated for the scores, their individual components, and work status.

Results: 145 patients underwent RF facet joint denervation, for 127 all data was available. In 68 patients the procedure was successful (53.5%).

Conclusion: Neither the Cochin Criteria nor the Helbig & Lee score can predict the response to radiofrequency denervation of the lumbar facet joints.

Pain on extension/rotation weakly indicates a poor response to facet joint denervation.

X-rays do not help with the diagnosis.

Social factors may be more important than clinical signs.

Aim: Severity of knee osteoarthritis (OA) can be defined clinically, radiologically, or pathologically. The Système Française D’Arthroscopie (SFA) is a validated method of grading and scoring the severity of changes on the articular surface as observed through the arthroscope. We have validated a modification of the SFA system for use with digital photographs of pathological samples.

Material and Method: After Ethics Committee approval, both tibial plateaux and femoral condyles were collected from 84 patients undergoing total knee replacement or at post mortem. Extent and grading of cartilage changes were documented for the 4 compartments of each sample on a diagram using direct visualisation and probing (Pathological Scores). In addition, each sample was digitally photographed at standard magnification and illumination, archived, graded and scored (Photographic Scores). A second observer (AY) also graded and scored photographic images for 72 compartments of the first 18 cases.

Data analysis: Repeatability was measured as Repeatability Coefficients (Bland and Altman, Lancet1986; 1; 307–10). 95% of the differences between 2 measurements of a case are expected to fall within the Repeatability Coefficient. Associations between compartments are expressed as Pearson correlation coefficients.

Results: For each of the 4 compartments studied, scores ranged from -2.2 to +717.8, representing the full range of possible scores. Allocation of scores to diagrams was highly repeatable (Repeatability Coefficient = 50). There was good agreement between Pathological and Photographic Scores (Repeatability Coefficient = 88). There was moderate agreement between Photographic Scores allocated by the 2 observers, with greatest agreement for low (< 200) and high (> 500) scores. Scores for each compartment correlated with scores for each of the other 3 compartments (R values 0.7 to 0.9, all P < 0.005).

Conclusion: Our modified SFA system permits scoring of OA severity using digital photographs of pathological samples. Our data support the view that OA affects the entire joint, and that a single compartment (e.g. medial tibial plateau) can be taken as broadly representative of the tibiofemoral joint as a whole.

Aim: The Système Française D’Arthroscopie (SFA) is a validated method of arthroscopic grading and scoring the knee OA. We have validated a modification of the SFA system for use with digital photographs of pathological samples.

Material and Method: After Ethics Committee approval, both tibial plateaux and femoral condyles were collected from 84 patients undergoing total knee replacement or at post mortem. Extent and grading of cartilage changes were documented for the 4 compartments of each sample on a diagram using photographs at standard magnification and illumination, archived, (Photographic Scores). Validation obtained by direct visualisation and probing (Pathological Scores). Radiographic and Histological scoring In addition, each sample was digitally. A second observer (AY) also graded and scored photographic images for 72 compartments of the first 18 cases.

Results: For each of the 4 compartments studied, scores ranged from -2.2 to +717.8, representing the full range of possible scores. A statistically significant correlation observed in the study between radiological variables and the severity of chondropathy assessed by our (SFA-path) [ P < 0.005] suggests satisfactory extrinsic validity of this scoring system. And statistically significant correlation [p> 0.0001] between the SFA Path scores of the medial compartment tibial plateau OA and Histologi-cal grade [Minkin] of the same samples. Allocation of scores to diagrams was highly repeatable (Repeatability Coefficient = 50). There was good agreement between Pathological and Photographic Scores (Repeatability Coefficient = 88). There was moderate agreement between Photographic Scores allocated by the 2 observers, with greatest agreement for low (< 200) and high (> 500) scores. Scores for each compartment correlated with scores for each of the other 3 compartments (R values 0.7 to 0.9, all P < 0.005).

Conclusion: We validated our modified SFA system which permits scoring of OA severity using digital photographs of pathological samples. SFApath is reliable and repeatable scoring system Our data support the view that OA affects the entire joint, and that a single compartment (e.g. medial tibial plateau) can be taken as broadly representative of the tibiofemoral joint as a whole.

Purpose: There are numerous papers from specialist arthroplasty centres outlining results of total knee arthroplasties but little information from outside these major centres. We carried out a review of a fixed bearing total condylar knee replacement used in Dunedin by a variety of surgeons for over 10 years.

Method: All patients who received a Duracon/PCA fixed bearing total knee replacement between 1992 and 1996 were assessed clinically, fluoroscopically and completed an SF12, WOMAC and IKSS questionnaire.

Results: At a mean 9.7 (8–12) years follow up, 126 (69.6%) patients were available for review and 46 (25%) were deceased. The average age was 72 years (52–88) and the primary diagnosis was osteoarthritis in 95% of the cases. There were 34% Charnley Grade A, 37% Grade B and 29% Grade C respectively.

The average IKS Knee score was 72 (23–97) and the functional score was 68 (0–100) with 74% experiencing none or only mild pain. The SF12 assessment revealed a mean physical score of 55 (14–99). Ninety per cent of patients were satisfied with their knee and 89% would have the operation again if required.

There was one operative death (PE), one deep infection, 3 PE’s, 3 DVT’s and 5 superficial infections. An MUA was required in 9 cases.

Eight knees were revised. Using ‘all revisions’ as an end point. The survival rate was 95.3% at 10 years.

Conclusion: These results suggest that knee replacements carried out outside specialist arthroplasty centres perform very well with a survival rate of the implant of 95% at 10 years.

Normal acetabular development in developmental dysplasia of the hip (DDH) depends upon early and maintained congruent reduction. Computed tomography is an accepted method for evaluating this and attempts to quantify hip reduction, by various angular and linear measurements, have been reported.

The aim of this study was to assess initial CT scans, following open reduction in the older child with DDH, with comparison of outcome to evaluate prognostic value.

Method: Thirty consecutive patients underwent open reduction for DDH, with a mean age of 25.9 months at the time of operation. Acetabular morphology and the position of the femoral head were evaluated on the initial CT scan, taken on the first postoperative day, and AP pelvic radiograph taken at the latest follow-up.

Results: The acetabulae of the dislocated hips were found to be significantly more anteverted than the normal. The dislocated hips also had significantly increased lateral displacement both initially and at latest follow-up. Posterior displacement of the proximal femoral metaphysis should raise concern due to an association with the need for further surgical intervention. These results did not however correlate with outcome.

In conclusion, despite the significant differences noted between DDH and normal hips they did not predict acetabular development or persistent acetabular dysplasia.

Introduction and Aims: The aim was to prospectively assess shoulder hemiarthroplasty for un-reconstructable proximal humeral fractures at a minimum of 12 months and identify factors that aid prognosis.

Method: Inclusion criteria were patients with a displaced fracture requiring shoulder hemiarthroplasty. Constant scoring was done at a minimum follow-up of one year. Patients were treated using a Neer or Osteonics prosthesis, the decision for hemiarthroplasty being made at the time of surgery. Post-operative management was standardised. An independent functional assessment, record review establishing a physiological index according to co-morbidities, and radiological analysis were carried out. Survival analysis was performed for one and five-year results and data was analysed by linear regression to identify prognostic factors.

Results: From 163 patients there were 138 fitting the criteria, 42 males and 96 females, average age of 68.5 (range 30–90) years and follow-up of 6.3 (range 1–15) years. The fracture pattern was three and four part in 133 cases and five head split fractures; 58 were associated with dislocation. Survival was 96.4 percent at one year and 93.6 percent at five years, with no significant difference between prostheses. There were eight revisions, (one deep infection, four dislocations and three peri-prosthetic fractures), by 12 months. The average Constant score was 67.1 at one year.

Conclusion: Prognostic factors on presentation were age of the patient and their physiological index, and at three months any complication, the position of the implant, tuberosity union and persistent neurological deficit. Overall optimum outcome was in patients aged 55 to 60, with minimal co-morbidities and uncomplicated recovery.

Introduction The purpose of this study was to compare the time to union following acute shortening and subsequent lengthening versus Bone Transport using the Ilizarov external fixator.

Methods Eighteen patients with tibial non-unions (age range 26 to 63 years) were recruited between March 1995 and September 2001. Three subgroups of six patients each, were formed. Group 1 underwent Acute Shortening and subsequent Lengthening, whereas Group 2 underwent Bone Transport. Group 3 patients had defects < 1 cms but were still high energy injuries, therefore underwent application of a frame. This group was used as a comparison group. A proximal corticotomy was used for distraction osteogenesis. Bone grafting at the fracture or regenerate site was used if required to aid healing. All patients were followed-up to union. All three groups were similar for age, pre-injury health status including cigarette smoking. Ten infected non-unions were present. Most patients had at least two conventional operative interventions prior to referral to us for Ilizarov surgery. The mean bone resection in the Acute Shortening group (Group 1) was 4.6 cms and in the Bone Transport group (Group 2) was 5.9 cms. Patients in Group 2 had more procedures done before union was achieved. This included adjustment of frame/ reinsertion of wires to align transport segment for optimal docking and bone grafting at the docking/regenerate site. Four patients in Group 2 required bone grafting at the docking site compared to none in Group 1.

Results Eradication of infection and union was achieved in all patients with average time in frame being 12.1 months in the Acute Shortening group, 17.2 months in the Bone Transport group and 8.0 months in the Frame stabilisation group. Using Paley’s bone result evaluation system, an excellent result was achieved in all patients of all groups. However, patients in the Acute Shortening group had a shorter time to union and needed fewer procedures.

Conclusions We recommended that where feasible, acute shortening and lengthening is preferable to bone transport due to shorter union time and fewer procedures undertaken to achieve union. If this is not possible due to large defects, then a combination of acute shortening with transport to bridge the gap should be considered.

Abstract: Dealing with peri-articular pathology in the skeletally immature is challenging. Where the process is benign the emphasis rests on preservation of the joint while minimising the risk of recurrence. However when dealing with lesions of the femoral head this may lead to avascular necrosis (AVN), negating the effects of conservative surgery, and potentially subjecting a child to a prolonged period of fruitless treatment, increased hospital stay, reduced mobility and significant time out of education and social interaction. Case & Method: A 13 year-old Caucasian female presented with a six-month history of pain in her right hip, initially in the groin, and a limp necessitating the use of crutches. Radiographs revealed a lytic lesion in the femoral head with a thinned but intact articular surface. This was biopsied, and a diagnosis of chondroblastoma reached. The operative alternatives of arthrodesis and arthroplasty were discarded in preference for hip salvage. An anterior approach to the hip, with dislocation of the femoral head allowed identification of the fragile cortical margin of the chondroblastoma. This was opened with a scalpel and curetted. Corticocancellous strips of bone graft were placed into the defect as struts around cancellous graft. An autogenous fascia lata graft was sutured over the articular defect in the femoral head. The capsule was repaired. Results: One year post-operatively she is pain free and has returned to normal activities. Radiographs show good incorporation of the bone graft. Conclusion: Femoral head preservation is effective with benefits outweighing the risk of AVN.

Aim: We present a review on RSD in children and emphasise the role of multidisciplinary team approach in the management of 13 children. Method: 3 boys and 10 girls with a mean age of 13 years and 4 months were reviewed before and after treatment. They were assessed for pain (visual analogue score) and function. A team-care approach was utilised and co-ordinated by the Orthopaedic Surgeon. Other members included a physiotherapist, clinical psychologist and the pain care team. Results: All the patients received physical therapy (land and hydrotherapy). 5 patients received guanethidine blocks and 10 required psychological support. The time to diagnosis ranged from 2 to 11 months. All the patients improved over a period of 2.5–7 months. Conclusion: Early diagnosis with aggressive multidisciplinary goal oriented team approach should form the basis of management in children with RSD.

Aim: To review an uncommon deformity arising in four patients. Method: A clinical and radiological review. Abstract: We describe four cases of distal radial epiphyseal dysplasia associated with a localised area of cutis aplasia congenita (CAC) over the dorsum of the distal forearm. The cutis aplasia was diagnosed at birth in all cases, but the radial dysplasia was not recognised until presentation to our orthopaedic department between the ages of 5 and 10 years. Radial dysplasia describes a spectrum of osseous, musculotendinous, and neurovascular dysplasias of the pre-axial border of the upper limb, and is the most common form of longitudinal deþ ciency. Cutis aplasia congenita involves an ulcerated area lacking in normal skin formation, present at birth. The most common site is on the scalp, but it has been described on the extremities, and overlying embryological malformations. This association, the long-term implications and the requirement for follow-up until skeletal maturity have not previously been described. We emphasise the importance of continued monitoring of these patients as the effects of radial dysplasia did not become obvious for several years, and the potential beneþt from achieving early skin cover with grafting rather than allowing healing by secondary intention is discussed. It is important to increase awareness of this condition so that early orthopaedic and plastic surgical opinions can be sought, in order to reduce the disabling effect on the underlying radius. Conclusions: Heightened awareness and early treatment with monitoring is required.

There are numerous papers from specialist arthroplasty centres outlining results of total knee replacement. This review was performed as there is little information on results in general orthopaedic centres. All patients received a Duracon/PCA replacement between 1992 and 1996. Patients were assessed clinically, fluoroscopically and completed SF12, WOMAC and IKSS questionnaires. At a mean of 6.7 (5–9) years follow up 93 (78%) were available for review. The average age was 70 years (52–88) with 58% being male. The primary diagnosis was osteoarthritis in 94.3%, with 41 %, 38% and 21 % being Charnley grades A, B and C respectively.

The average IKS knee score was 71.4 (23–96) and functional score 70 (0–100), with 72.7% experiencing none or only mild pain. The SF12 assessment revealed a mean physical score of 38 (14–63) and mental score of 53 (25–67). There were 88.6% of patients satisfied with their knee and 92% would have the operation again if required. There were no deep infections or PE’s but there were 7 superficial infections and 2 DVT’s. A MUA was required in 8 patients. One patient retains a radiologically loose prosthesis at 8 years but had mild pain with stairs only, a WOMAC functional score of 85 and was happy. There was a best-case survival of 94.4% at 5 years. There were 5 knees revised in 5 patients and no revisions of the deceased patients, all surviving greater than 5 years from surgery. These results suggest that those in general orthopaedic centres are a little less reliable than those in specialist centres. However they are acceptable and patient satisfaction remains high.

Limb lengthening and limb reconstruction using the Ilizarov system is a recognized treatment for children with congenital and acquired lower limb discrepancy and/or deformity. It is a complicated, costly, time consuming and challenging procedure for the multidisci-plinary team, the child and their family. Traditional outcome measures for this group of children tend to focus on X-ray appearances, lengthening indices and problems, obstacles and complications occurring during the treatment phase. At the present time there are unanswered questions as to their functional status as adults. The literature does not appear to have addressed this question as yet. For families considering this difficult treatment option, the potential function for their child as an adult may be valuable in the decision making process The aim of this study was to discover the physical, occupational and psychosocial function of a group of young adults who underwent Ilizarov procedures as children at Great Ormond Street Children’s Hospital.

Forty young adults, aged 18 – 27 years (mean age 19.9 years), who had Ilizarov procedures between 1992 and 2000, were sent questionnaires. Items included in the questionnaire were taken from the Toronto Extremity Salvage Score (TESS) to assess function and the Pediatric Orthopaedic Society of North America (POSNA) Adolescent Musculoskeletal Functional Health Questionnaire to assess psychosocial and occupational domains. Questions were also included to gather demographic information.

A total of 27 responses were received from 14 males and 13 females. Twenty four patients had Ilizarov procedures for limb lengthening or lengthening with deformity correction. Deformity correction only was carried out in three patients. Mean time since treatment was 5.6 years (range 9 – 2 years). A total of 24 tibial frames, 6 femoral, 4 whole leg and 2 foot frames were applied. Four patients had had repeat Ilizarov procedures. Six patients had had previous lengthenings using uniaxial fixators.

Functional ability indicators were high but activities such as kneeling, walking up and down slopes or hills, walking long distances and running were significant problems reported by more than half. Assistive devices (crutches, shoe raises, AFO, knee brace) were needed full time by five, with crutches, sticks and wheelchair used occasionally by three others.

Seven adults chose not to partake in sporting activity, with a further three finding it extremely hard and two impossible. Swimming was the most popular activity. Activity related pain was uncommon but pain in the limb requiring occasional analgesia was reported. All but one respondent worked full time or were students. Most occupations were office or shop based. Three men were manual workers. Time off work for problems related to their limb problem was minimal. Socialising with friends and family was high with only one respondent expressing extreme difficulty. Four men and five women identified scarring from the Ilizarov treatment as a cause of concern. Ten women and eight men raised body image issues. Twenty six adults said they would recommend Ilizarov treatment to others, if asked. Conclusions: We view this data as important to provide information for use when counselling It weill also help prospective patients and families of expectation for function in adult life.

Reflex sympathetic dystrophy is a syndrome characterised by pain and hyperaesthesia associated with swelling, vasomotor instability and dystrophic changes of the skin. It is rare in children, can occur without any previous history of significant trauma and may be recurrent and migratory.

We reported 13 new cases of RSD in children and emphasised the role of a multidisciplinary team approach in management. A review of the literature was included.

13 children (3 boys and 10 girls) with reflex sympathetic dystrophy were presented. They were aged between 8 and 17 years. Mean age at onset was 13 years 4 months. All of them had RSD involving the lower limbs. Thermography was performed in 10 cases. The average time to correct diagnosis was 4 months. Five ankles, 4 knees and 5 hips were involved (14 joints in 13 cases). Psychological assessments revealed abnormalities in all cases. Pain (visual analogue score) and function were assessed before and after treatment.

The most common therapy in children is progressive mobilisation supported by analgesic drugs, psychological and physical therapy. We individualised the therapy for each child. A team-care approach with the physiotherapist, psychologist and pain-care team co-ordinated by the Orthopaedic Consultant was the essence of our management. All children received physical therapy including a wide variety of non-standarised approaches involving analgesics and hydrotherapy. 5 patients received guanithidine blocks. Individual therapy was monitored with set achievable goals and weekly assessment of progression of mobility and joint motion.

Time from the first RSD episode to resolution averaged 6 months in our series [it was mean 10 weeks in the non-adolescent cases (8 cases) and 7 months in the adolescent one (5 cases)]. The pain and function scores improved remarkably in all patients.

RSD in children is not a widely recognised condition. There is often a delay in diagnosis in view of the rarity of the condition as well as the fact that specific diagnostic modalities are not readily available in all centres. Psychological factors should not be underestimated. Early diagnosis with an aggressive, multidisciplinary, monitored, ‘goal-oriented’ team approach should be the basis of management in these cases.

Humeral hemi arthroplasty has become widely used as a form of surgical management for severe fractures. However there is still no consensus as to the role for prosthetic replacement in displaced proximal humeral fractures.

The aim was to assess shoulder hemi arthroplasty for un-reconstructable three and four part proximal humeral fractures at a minimum of twelve months and identify factors that guide to prognosis.

Criteria for inclusion were patients with a fracture that went onto shoulder hemi arthroplasty with Constant scoring at a minimum follow up of one year. Patients were treated using a Neer or Osteonics prosthesis, with the decision for hemi arthroplasty being made at the time of surgery. Post-operative management was standardised. An independent functional assessment, record review establishing a physiological index according to comorbidities, and a radiological analysis were carried out. A survival analysis was performed for the one and five year results and data was analysed by linear regression to identify prognostic factors.

Of 163 patients there were 138 fitting the criteria, 42 males and 96 females with an average age of 68.5 (range30–90) years and average follow up of 6.3 (range1–15) years. The fracture pattern was three or four part in 133 cases and 5 head split fractures; 58 were associated with a dislocation. Survival was 96.4% at 1 year and 93.6% at 5 years, with no significant difference between prostheses. There were 8 revisions, (1 deep infection, 4 dislocations and 3 peri-prosthetic fractures), most within 12 months. The average Constant score was 67.1 at one year.

Prognostic factors on presentation were the age of the patient and their physiological index. Factors at 3 months were any complication, the position of the implant, tuberosity union and persistent neurological deficit. Overall optimum outcome was gained by patients aged 55–60, with minimal comorbidities and an uncomplicated recovery.

Poor shoulder function may complicate the non-operative treatment of a humeral diaphyseal fracture. This has often been regarded as an unavoidable consequence of the relative immobility of the shoulder during brace treatment. Tears of the rotator cuff have not previously been recognised as an underlying cause of persistent shoulder pain and stiffness in this situation.

In this report, we identified six patients, from a consecutive series of 294 patients with humeral fractures treated in our Institution over a five-year period, who were found to have symptomatic rotator cuff tears following non-operative treatment of their humeral diaphyseal fracture. All had normal pre-injury upper limb function, but had persistent pain and loss of active shoulder movement after their fracture had united. Large, retracted cuff tears, affecting the cuff muscles attached to the greater tuberosity, were identified pre-operatively from imaging of the rotator cuff and intra-operatively at open surgery. Surgical reconstruction of the cuff was carried out in all cases and yielded satisfactory return of shoulder function, on assessment at least eighteen months after injury.

We present the results of treatment for relapsed infantile Blounts disease using a technique of hemiplateau elevation with the Ilizarov frame.

7 patients with a mean age of 10 years 6 months were reviewed at 30 months following hemiplateau elevation with/without ipsilateral tibial lengthening. Preoperatively clinical photographs, long leg standing radiographs and 3D computed tomography images were acquired. The patients were evaluated clinically (presence of knee pain, range of knee motion, knee stability and leg length discrepancy) and radiologically. Schoeneckers objective assessment was undertaken. The results were analysed statistically.

Clinically all the patients improved significantly. No patient had knee pain and the range of knee motion was from 0° to more than 100° of knee flexion. The radiological results and Schoeneckers grading are depicted below.

The improvement in radiological measurements were statistically significant. Pin site infection was present in all but settled with antibiotics.

The results of hemiplateau elevation for relapsed infantile Blounts disease are encouraging.

We report two cases of deformity of the ankle caused by physeal damage secondary to extravasation of an intravenous infusion in infancy. The possible mechanisms of injury to the physis are discussed.

We report the ulnar impingement syndrome, which is caused by a shortened ulna impinging on the distal radius and causing a painful, disabling pseudarthrosis. Of the 11 cases reported, 10 were due to excision of the distal ulna after injury to the wrist; the other was a result of a growth arrest after a fracture of the distal ulna in a child. The symptoms are a painful, clicking wrist and a weak grip; clinical examination reveals a narrow wrist with pain on compression of the radius and ulna and on forced supination. Radiographs in the majority of cases show scalloping of the distal radius corresponding to the site of impingement. The mechanism by which ulnar impingement occurs after radio-ulnar convergence is illustrated. The plan of management for the young patient with traumatic dysfunction of the distal radio-ulnar joint is discussed; excision of the lower end of the ulna is not advised in such patients.

Thirty-one patients with rheumatoid arthritis were reviewed after Shiers arthroplasty of the knee joint for which the main indication was intractable pain. Seven patients had the operation done to both knees. This review was done to assess the long-term results two to seven years later. All patients were clinically and radiologically assessed, and our results showed that pain and instability recurred within eighteen months. Thus it is likely that a prosthesis which allows rotation, and in which the bearing surfaces are metal on plastic, will replace the Shiers prosthesis.