Abstract

Abstract

Abstract

Aims

Malignancy and surgery are risk factors for venous thromboembolism (VTE). We undertook a systematic review of the literature concerning the prophylactic management of VTE in orthopaedic oncology patients.

Aims

Elective operating was halted during the COVID-19 pandemic to increase the capacity to provide care to an unprecedented volume of critically unwell patients. During the pandemic, the orthopaedic department at the Aneurin Bevan University Health Board restructured the trauma service, relocating semi-urgent ambulatory trauma operating to the isolated clean elective centre (St. Woolos’ Hospital) from the main hospital receiving COVID-19 patients (Royal Gwent Hospital). This study presents our experience of providing semi-urgent trauma care in a COVID-19-free surgical unit as a safe way to treat trauma patients during the pandemic and a potential model for restarting an elective orthopaedic service.

The arrival of major trauma centres (MTC) to Scotland highlights the need for structured management of polytrauma patients. The aim was to report the epidemiological profile of polytrauma patients (Injury Severity Score (ISS) 15) admitted to a large trauma unit in the UK and gather information about the initial management of this severely injured cohort.

Prospectively collected data from the Scottish Trauma Audit Group (STAG) database of 366 polytrauma patients (ISS <15 & aged ≥13 years) admitted to a single trauma unit, from 1st January 2013 to 31st October 2017 was analysed. Data included patient demographics, injury characteristics, length of stay (LOS) and survivorship.

The median age was 49 years (range 13–93) and females made up 31.1% of the population. There was a mean ISS of 25.7 (range 15–75) and mean LOS of 19 days. The overall mortality rate was 21%. Higher mortality occurred among females (p<0.001), patients ≥60 years age (p<0.001), patients who sustained their injury at home (p<0.0001), and those with head injuries (p<0.01). Orthopaedic injuries were present in 187 patients (51.1%) with a mortality rate of 10.7%. The most common mechanism of injury was road traffic collision (41.5%) and these patients had a significantly higher ISS (p<0.01). A fall from height <2m was associated with higher mortality (p=0.01).

This study is the largest of its kind and presents a detailed epidemiological profile of patients attending a large UK trauma unit. This knowledge will help guide initial management and aid in resource and capacity planning for the future.

Introduction

Surgeons fixing scaphoid fractures need to be familiar with its morphological variations and their implications on safe screw placement during fixation of these fractures. Literature has limited data in this regard. The purpose of this CT-based study was to investigate scaphoid morphometry and to analyse the safe trajectories of screw placement in scaphoid.

Aim

To assess the effectiveness of role of frozen section in revision arthroplasty.

Metaphyseal fracture healing is important in joint-adjacent fractures and appears to differ from diaphyseal healing. We recently found that a biomaterial delivering bone morphogenic protein-2 (BMP-2) and zoledronic acid (ZA) healed the metaphyseal bone in a tibial defect but failed closing the cortical defect. In this study we added a BMP-2 soaked collagen membrane to study cortical healing from the muscle tissue surrounding the bone. We used SD rats and a 4.5 mm metaphyseal circular tibial defect. In group 1 (G1), a porous gelatin-calcium sulphate-hydroxyapatite (GCH) biomaterial containing rhBMP-2 and ZA was used to fill the defect (GCH+5 μg BMP-2+10 μg ZA). In group 2 (G2), we used a collagen membrane (2 μg BMP-2) to cover the GCH filled defect (GCH+3μg BMP+10 μg ZA). Group 3 (G3) was an empty control. Animals were sacrificed after 8-weeks and bone regeneration was evaluated with micro-CT and histology. In both G1 (P<0.001) and G2 (p<0.001) a significantly higher mineralized volume was found in the defect compared to empty G3. In G2 higher mineralized volume was found in the cortical region compared to both G1 (p<0.01) and G3 (p<0.001) as seen via micro-CT. Histologically, G1 and G2 showed islands of trabecular bone in the defect peripherally but only G2 showed cortical healing. G3 was empty in the middle but showed healed cortex. In conclusion, GCH can be used to deliver BMP-2 and ZA to promote metaphyseal bone growth. A membrane (CM) doped with low dose BMP-2 improved cortical regeneration.

During the last decades, several research groups have used bisphosphonates for local application to counteract secondary bone resorption after bone grafting, to improve implant fixation or to control bone resorption caused by bone morphogenetic proteins (BMPs). We focused on zoledronate (a bisphosphonate) due to its greater antiresorptive potential over other bisphosphonates. Recently, it has become obvious that the carrier is of importance to modulate the concentration and elution profile of the zoledronic acid locally. Incorporating one fifth of the recommended systemic dose of zoledronate with different apatite matrices and types of bone defects has been shown to enhance bone regeneration significantly in vivo. We expect the local delivery of zoledronate to overcome the limitations and side effects associated with systemic usage; however, we need to know more about the bioavailability and the biological effects. The local use of BMP-2 and zoledronate as a combination has a proven additional effect on bone regeneration. This review focuses primarily on the local use of zoledronate alone, or in combination with bone anabolic factors, in various preclinical models mimicking different orthopaedic conditions.

Cite this article: I. Qayoom, D. B. Raina, A. Širka, Š. Tarasevičius, M. Tägil, A. Kumar, L. Lidgren. Anabolic and antiresorptive actions of locally delivered bisphosphonates for bone repair: A review. Bone Joint Res 2018;7:548–560. DOI: 10.1302/2046-3758.710.BJR-2018-0015.R2.

Objectives

We have observed clinical cases where bone is formed in the overlaying muscle covering surgically created bone defects treated with a hydroxyapatite/calcium sulphate biomaterial. Our objective was to investigate the osteoinductive potential of the biomaterial and to determine if growth factors secreted from local bone cells induce osteoblastic differentiation of muscle cells.

Optimal management of acute patellar dislocation is still a topic of debate. Although, conventionally it has been managed by non-operative measures, recent literature recommends operative treatment to prevent re-dislocations. Our study recommends that results of non-operative measures comparable to that of operative management.

Our study is the retrospective with 46 consecutive patients (47 knees) of first time patellar dislocation managed between 2012 and 2014. The study methodology highlighted upon the etiology, mechanism of injury and other characteristics of first time dislocations and also analysed outcomes of conservative management including re-dislocation rates. The duration of follow up ranged from 1 to 4 years.

Average age at first-time dislocation was 23 years (Range 10–62 years). Male:Female ratio was 30:17. Twisting injury was the commonest cause. 1 patient required open reduction but all others relocated spontaneously or had successful closed reduction. Medial Patello-Femoral Ligament injury was frequent associated feature. 11 knees (24%) re-dislocated during follow up. Age was the significant risk factor for re-dislocations. All patients with re-dislocation were less than 30 years old. Maximum redislocations happened between 6 months to 1 year after index dislocation. Skeletal abnormality was the commonest pathology in re-dislocators. Only 4 patients (8.6%) finally required surgical intervention. One patient had persistent knee pain as a complication.

Conservative management of primary patellar dislocation is successful in majority of patients. Surgery should be reserved for the carefully selected patients with specific indications.

Introduction

To reduce several disadvantages many surgeons are not using tourniquet in TKA. Here we compared functional outcome along with pain and blood loss in sixty patients.

To demonstrate the role of an antibiotic containing bone substitute, native bone active proteins and muscle transforming into bone.

Recurrent osteomyelitis was eradicated and filled with a gentamycin eluting bone substitute (Cerament™l G) consisting of sulphate and apatite phases and covered by a muscle flap.

A chronic, longstanding, fistulating osteomyelitis was operated with radical eradication and filling of the cavity with gentamycin eluting bone substitute. At one year, the patient had no leg pain and a healed wound. Significant bone was also seen in the overlaying muscle, at one month post-op disappearing after 6-months. Local delivery of gentamycin had a protective effect on bone formation.

Bone substitute with gentamycin leads to differentiation of mesenchymal cells into bone in-vitro.

Background:

Modified posterior approach and its effect on stability and functional outcome in total hip arthroplasty.

Background:

Role of intra-articular Tranexamic acid in total knee replacement arthroplasty

Purpose

To validate accuracy of transepicondylar axis as a reference for femoral component rotation in primary total knee arthroplasty.

Purpose:

To compare accuracy of transepicondylar axis as a reference for femoral component rotation in primary navigated versus non navigated total knee arthroplasty in severely deformed knees.

Purpose

To assesment of geometric center of knee as a reference for femoral component rotation in primary total knee arthroplasty.

Background:

Is routine use of suction drain after joint replacement is justified.

Background:

In recent times there has been an increasing trend towards surgical intervention in paediatric femoral shaft fractures with widening indications. Titanium elastic nails and external fixation are two widely practiced procedures for such fractures.

Introduction

Recurrent dislocation after hip arthroplasty is a difficult problem. The purpose of the present study was to evaluate the results with the use of a constrained cup for treatment for instability after hip arthroplasty.

Aim

The aim of the study was to characterise gait in patients with achondroplasia post lengthening.

We hypothesised whether MIS techniques confer any benefit when treating thoracolumbar burst fractures.

This was a prospective, non-randomised study over the past seven years comparing conservative (bracing:n=27), conventional surgery (open techniques:n=23) and MIS techniques (n=21) for stabilisation and correction of all thoracolumbar spinal fractures with kyphosis of >20⁰, using Camlok S-RAD 90 system (Stryker Spine). All patients previously had normal spines, sustained only a single level burst fracture (T12, L1 or L2) as their only injury. Age range 18–65 years.

All patients in both operatively treated groups were corrected to under 10⁰ of kyphosis, posteriorly only. All pedicle screws/rods were removed between 6 months and 1 year post surgery to remobilise the stabilised segments once the spinal fracture had healed, using the original incisions and muscle splitting/sparing techniques. Patients were assessed via Oswestry Disability Index (ODI) and work/leisure activity status 1 year post fracture.

The conservatively treated group fared worst overall, with highest length of stay, poorest return to work/activity, and with a proportion (5/27) requiring later intervention to deal with post-traumatic deformity. 19/27 returned to original occupation, at average 9 months. ODI 32%.

Conventional open techniques fared better, with length of stay 5 days, most (19/23) returning to original work/activity, and none requiring later intervention. Average return to work was at 4 months. ODI 14%.

MIS group fared best, with shorter length of stay (48 hours), all returning to original work/activity at average 2 months, and none requiring later intervention. ODI negligible.

There was no loss of correction in either operatively treated groups.

The Camlok S-RAD 90 system is a powerful tool for correction of thoracolumbar burst fractures, and maintains an excellent correction.

MIS techniques provide the best outcomes in treating this group of spinal fractures, and offer patients the best chance of restoration to pre-fracture levels of activity.

Damage to the dorsomedial branch of the medial dorsal cutaneous nerve is not uncommon in surgery of the hallux. The resultant morbidity can be disabling. In the light of the senior author’s operative observation of a sentinel vein, we undertook a cadaver study to investigate the anatomical relationships of the dorsomedial branch of the medial dorsal cutaneous nerve. This established that in 14 of 16 cadaver great toes exposed via a modified medial incision, there is an easily identified vein which runs transversely superficial and proximal to the nerve. In a prospective clinical study of 171 operations on the great toe using this approach, we confirmed this anatomical relationship in 142 procedures (83%), with no complaint of numbness or pain in the scar at follow-up. We attribute this to careful identification of the ‘sentinel’ vein and the subjacent sensory nerve, which had been successfully protected from damage. We recommend this technique when operating on the great toe.

Clear-cell sarcoma is a very rare tumor, and is almost always associated with tendons or aponeuroses or is metastatic from other organs. Sporadic cases only have been reported involving primarily the bone or extending from soft tissues to surrounding bones. To our knowledge, the ilium has not been previously reported as the primary site for clear cell sarcoma.

We report a rare case of Primary clear cell sarcoma involving right ilium region in a 18-year-old boy presented with a painful swelling over right ilium and limp on right lower limb of ten month duration. He was initially suspected having tuberculosis based on clinicoradiological evaluation and diagnosis of primry clear cell sarcoma could be established on histopathology. Patient was treated with partial excision of the ilium, the remaining ilium was fused with sacrum. Stabilization was achieved with a cortical autograft harvested from the right fibula and fixation with a titanium plate.

The patient had no local recurrences but the plate holding ilium to sacrum broke and was removed in the subsequent surgery after which he developed Trendelenberg’s gait.

Introduction: Inaccuracies in kinematic data recording due to skin movement artefact are inherent with motion analysis. Image registration techniques have been used extensively to measure joint kinematics more accurately. The aim of this study was to assess the feasibility of using MRI for creating 3D models and to quantify errors in data collection methods by comparing kinematics computed from motion analysis and image registration.

Methodology : 5 healthy and 5 TKR knees were examined for a step up/down task using dynamic fluoroscopy and motion capture. MRI scans of the knee, femur and tibia were performed on the healthy subjects and were subsequently segmented using ScanIP(Simpleware) to produce 3D bone models. Registration of the models produced from fine and coarse scan data was used to produce bony axes for the femoral and tibial models. Tibial and femoral component CAD models were obtained for the TKR patients. The 3D knee solid models and the TKR CAD models were then registered to a series of frames from the 2D fluoroscopic image data (Figure 1) obtained for the 10 subjects, using KneeTrack(S. Banks, Florida) to produce kinematic waveforms. The same subjects were also recorded whilst performing the same action, using a Qualisys (Sweden) motion capture system with a pointer and marker cluster-based technique developed to quantify the knee kinematics.

Results: The motion analysis method measured significantly larger frontal and transverse knee rotations and significantly larger translations than the image registration method.

Conclusion: The study demonstrated that MRI, rather than CT scan, can be used as a non-invasive tool for developing segmented 3D bone models, thus avoiding highly invasive CT scanning on healthy volunteers. It describes an application of combining fine and coarse scan models to establish anatomical or mechanical axes within the bones for use with kinematic modeling software. It also demonstrates a method to investigate errors associated with measuring knee kinematics.

Aim: The carpal bone arrangement can be described as a matrix of two rows and three columns. There a various theories as to how the bones within the matrix move during ulna to radial deviation. One theory suggests that there are two types of wrist movement, namely Row & Column¹.

The aim of this study was to investigation how the rotational axis of the wrist moves as the hand goes from full ulna to full radial deviation.

Materials and Methods: Ulna to radial deviation was assessed in 50 normal wrists in 25 normal subjects aged 19 to 57. Movement was measured with a Polhemus Fastrak (TM) magnetic tracking system. The system has translational and rotational measurement accuracies of 1 mm and 1 degree respectively. Subjects placed their palms on a flat wooded stool and had movement sensors attached over their 3rd metcarpal and distal radius. These sensors then recorded movement as the hand moved from full ulna to full radial deviation.

Results: The mean range of movement was 45 degrees (SD 7). In full ulna deviation the wrist rotational axis was in the region of the lunate. As the hand moved towards radial deviation, the axis moved distally. At the end of the movement the mean distal displacement was 21 mm (SD 15). In 32 wrists the distal displacement was accompanied by mean displacement towards the ulna of 12 mm (SD 8). In 18 wrists the distal displacement was accompanied by a mean displacement towards the radius of 8 mm (SD 5).

Conclusion: The rotational axis position indicates how the wrist is moving during radial deviation. In early movement, when the axis is proximal, there is a high degree of sideways translation. In later movement, when the axis is distal, there is more rotational movement. In some cases the axis moved distally and toward the radius, whereas in other cases it moved distally and toward the ulna. This spectrum of movement may support the theory of 2 types of carpal movement. i.e. Column movers and row movers¹.

Introduction: After adopting a new low suspensory bio-absorbable femoral fixation technique for single bundle, four strand, hamstring Anterior Crutiate Ligament (ACL) in conjunction with a rapid rehabilitation program, we observed at routine follow up that there was no evidence of femoral tunnel widening, as often observed with conventional high suspensory fixation systems.

Method: We conducted a retrospective observational cohort study to test the hypothesis that the Rigid-Fix (Mitek) system of femoral fixation, a low suspensory technique, is less prone to tunnel widening than traditional suspensory techniques.

14 subjects were recruited at routine follow up, and assessed by interview, clinical examination and plain digital raiodgraphs.

All radiographs were taken under clinical supervision, with a scale reference, hence allowing digital rescaling.

Results: All subjects had regained knee stability, and all but one had returned to their pre-injury level of sport. Clinically all knees were ligamentaly stable, exhibiting negative Luchman and pivot shift tests.

Examination of the radiographs demonstrated only a 1.1mm (+/− 0.9mm) mean femoral tunnel widening, which represents a 12% increase in diameter (21% increase in area), and compares very favourably to the observed tunnel widening in high suspensory techniques, as cited in the literature.

Conclusions: We conclude that the Rigid-Fix femoral ACL fixation system does not exhibit any evidence of clinically significant tunnel widening, even when used in conjunction with a rapid rehabilitation program.

Systems of low suspension benefit from the advantage of not relying on interference fit which risks posterior cortical ‘Blow Out’. A shorter graft working length within the tunnel lessens graft micro-movement, making early low biological fixation within the femoral tunnel more likely, and reduces the amount of tunnel widening. These micro-movement have been described as the ‘Windscreen Wiper’ and ‘Bungee Cord’ effects, and are well documented in traditional high suspensory fixation.

Background: Back pain in adult patients with a pars-interarticularis defect may be due to movement at the defect or abnormal inter-segmental movement at the adjacent degenerate disc. The suggested treatment of segmental fusion may not be necessary, if the defect alone was source of pain. We hypothesize that the defect may be the only source of pain in certain adults, even if the MRI scan shows an abnormal disc.

Objective: To form a protocol of management in adults with pars defect and adjacent level disc degeneration. To study the results of primary lysis repair using ‘AO Morscher clamp’ in patients with ‘spondylolysis’ or ‘Grade 1 ‘spondylolisthesis’.

Methods: This is a prospective study involving adults with ‘spondylolysis’ or ‘Grade 1 ‘spondylolisthesis’ not responding to conservative management and requiring interventional treatment. We investigated this subgroup of patients with lysis block and discography. On this basis, of a total of ten patients, seven were offered lysis repair and bone grafting using ‘Morscher’s clamp’; three were offered spinal fusion. Outcome was assessed using Visual Analogue Score (VAS) and Oswestry Disability Index (ODI) done pre-operatively and six months post-op.

Results: Out of ten patients (28 to 45 years; 4males and 6 females), seven patients underwent primary lysis repair using ‘AO Morscher clamp’. Union of pars achieved in all the patients by 4 months (Follow-up 4 months to 2 years). Three underwent fusion. Mean VAS improved from 7.2 to 1.2 in lysis repair group. Mean ODI improved from 68 % to 24%. All patients had full range of spinal movement postop.

Conclusion: A thorough pre-operative workup of patients with pars defect and adjacent level disc degeneration showed that pain is due to the pars defect in 70% of our cohort. This subgroup of patients could successfully be treated with ‘lysis repair’ rather than a more morbid procedure of ‘spinal fusion’.

The aim of this study was to investigate how the rotational axis of the wrist moves as the hand goes from full ulna to full radial deviation.

Fifty normal wrists in 25 subjects were assessed with a Polhemus Fastrak (TM) magnetic tracking system. The subjects, aged 19 to 57, placed their palms on a flat wooded stool. Sensors were attached over their 3rd metcarpal and distal radius. The sensors then recorded movement from ulna to radial deviation. The translational and rotational measurement accuracies were 1 mm and 1 degree respectively.

The mean range of movement was 45 degrees (SD 7). In ulna deviation the axis was in the region of the lunate. As the hand moved towards radial deviation, the axis moved distally. At the end of the movement the mean distal displacement was 21 mm (SD 15). In 32 wrists the distal displacement was accompanied by a mean displacement towards the ulna of 12 mm (SD 8). In 18 wrists the distal displacement was accompanied by a mean displacement towards the radius of 8 mm (SD 5).

The rotational axis position indicates how the wrist is moving during radial deviation. In early movement, when the axis is proximal, there is a high degree of sideways translation. In later movement, when the axis is distal, there is more rotational movement. In some cases the axis moved distally and toward the radius, whereas in other cases it moved distally and toward the ulna. This spectrum of movement may support the theory of 2 types of carpal movement proposed by Craigen and Stanley (J. Hand Surg, 20B, 165–170, 1995).

Aim: To evaluate results of fully congruent Mobile bearing knee arthroplasty for valgus arthritic knees using lateral capsular approach and realignment of vastus lateralis.

Material and Method: We reviewed results of 50 mobile bearing total knee arthroplasties performed consecutively between 2001 and 2006 for Valgus arthritic knees, using lateral capsular approach and realignment of vastus lateralis. Patients were evaluated using oxford and International knee society Score. Radiographs were examined for alignment of the component, evidence of loosening and scanograms assessed to evaluate the restoration of mechanical axis.

Results: The study group consisted of 47 patients, 20 men and 27 women who received fifty knees. The mean age at the primary operation was 71.57 years (range 47–82 years; SD, 9.5). The mean follow up was 4.2 years (range 1–6 years; SD, 1.35). The mean Valgus deformity was 15.92° (rang from 15–20 SD 1.89). Fixed flexion deformity was seen in 15 knees.

The mean Oxford Knee Society ratings was 52 (range 47–55; SD, 3.18) preoperatively, and 19 (range 14–24; SD, 3.72) at final follow up. The pre op mean range motion was 84.28° (range 45°–120°; SD 21.73). At final follow up the average range of motion was 107.5° (range 95°–120°; SD 8.93). According to the system of the Knee Society, the average knee score was 94 points and the average functional score was 89 points at final follow up.

There were no clinical failures or cases of postoperative instability and no cases of radiographic loosening or wear.

Radiological evaluation: None of these knees had radiographic evidence of loosening or osteolysis. Mechanical axis was restored in all the patients.

Conclusion: This study demonstrates satisfactory results of Mobile bearing knee arthroplasty using lateral parapatellar with proximal realignment of vastus lateralis for Valgus arthritic knees.

Aim: The aim of this investigation was to determine how the rotational axis of the wrist moves as the hand goes from full ulna to full radial deviation.

Materials & Methods: Ulna to radial deviation was assessed in 30 normal wrists in 15 normal subjects aged 19 to 32. Movement was measured with a Polhemus Fastrak (TM) magnetic tracking system. The system has translational and rotational measurement accuracies of 1 mm and 1 degree respectively. Subjects placed their palms on a flat wooded stool and had movement sensors attached over their 3rd metacarpal and distal radius. These sensors then recorded movement as the hand moved from full ulna to full radial deviation.

Results: The mean range of movement was 47 degrees (SD 8). In full ulna deviation the wrist rotational axis was in the region of the lunate/capitate. As the hand moved towards radial deviation, the axis moved distally. At the end of the movement the mean distal displacement was 22 mm (SD 14). In 17 wrists the distal displacement was accompanied by mean displacement towards the ulna of 13 mm (SD 8). In 13 wrists the distal displacement was accompanied by a mean displacement towards the radius of 7 mm (SD 5).

Conclusion: The rotational axis position indicates how the wrist is moving during radial deviation. In early movement, when the axis is proximal, there is a high degree of sideways translation. In later movement, when the axis is distal, there is more rotational movement. In some cases the axis moved distally and toward the radius, whereas in other cases it moved distally and toward the ulna. This spectrum of movement may support the theory of 2 type of carpal movement. i.e. Column movers and row movers [Craigen & Stanley].

Purpose of the Study: To ascertain the role of Dynesys system (Zimmer Spine, Minneapolis) in the surgical management of chronic low back pain

Methods: 55 patients with persistent low back pain despite conservative measures were treated with Dynesys over a period of two and a half years. Participants either underwent Dynesys procedure alone or in combination with fusion or decompression surgery. Oswestry Disability Index (ODI), Visual Analogue Scores (VAS) and SF-36 questionnaires were completed pre-operatively and at one and two years post-operatively. Pre-operative testing using the Distress and Risk Assessment Method (DRAM) identified psychological distress prior to surgery. Patient Oriented Outcome questionnaires were circulated retrospectively following surgery to obtain data regarding patient’s perceptions and expectations of their outcome.

Results: Overall, the mean ODI reduced by 10.23% after one year and 16.15% after two years following surgery. VAS improved by 12mm one year and by 17mm two years after operation. Patients with psychological distress pre-operatively showed less improvement in their ODI and VAS at two-year follow up. The results of fusion were similar to Dynesys alone, and patients who also had decompression had best results. 72.2% patients reported an improvement following their surgery and the same percentage would have the operation again in retrospect.

Conclusion: This is the first study exploring clinical outcomes following surgery using Dynesys dynamic stabilization system in patients with disabling low back pain. Previous studies have reported good outcome in the treatment of spinal stenosis. Over 70% patients in our study reported improvement following the procedure but more evidence is needed to determine if it is a viable alternative to spinal fusion.

We describe results of a new ‘two needle technique’ of selective nerve root blocks done through posterior triangle of neck in the management of cervical radiculopathy with 2 year results.

Methods: Patients presenting with cervical radiculopathy were evaluated clinically and radiologically and were initially managed with supervised physiotherapy, analgesics and rest. Selective cervical nerve root block was offered to the patients, who did not respond to conservative management. The procedure was performed as a day case, under local anesthesia, with image intensifier guidance, using ‘two needle technique’. A thinner needle is rail-roaded through the lumen of large diameter guide needle to reach the target nerve root foramen and a mixture of Bupivacaine and Triamcinolone acetonide is injected. The outcome was measured using visual analogue score (VAS) and neck disability index (NDI) done on the day of the procedure and compared to the scores at 3 months and 1 year after the procedure.

Results: Outcome in 30 patients who underwent this procedure over three years’ period is presented. Average Visual Analogue Score was 7.36 (range 6 – 10) before the intervention, which improved to 2.27 (range 0 – 7) at 3 months and 1.9 (range 0 – 4) at 1 year. The average Neck Disability Index score prior to intervention was 66.87 (range 44 to 82), which improved to 31.67 (range 18 – 66) at 3 months and 30.44 (range 20 – 48) at 1 year. There were no major complications noted. We conclude that selective cervical nerve root block using ‘two-needle technique’ is safe and reproducible. The therapeutic effect achieved is long lasting, making this procedure a good alternative to surgical management in patients with cervical radiculopathy who do not respond to conservative management.

Purpose of the Study: To assess the use of synthetic hydroxyapatite for postero-lateral spinal fusion using a new classification system

Methods: This is a prospective study on 30 patients who underwent bilateral postero-lateral spinal fusion between October 2002 and January 2004. The sides were randomised to synthetic phase pure Hydroxyapatite (Apapore® 70) mixed with bone marrow and autologus bone on one side and Apapore® 70 with bone marrow on the other. Plain Antero-posterior and Lateral x-rays were done in the immediate post-operative period and at 3, 6, 12 and 24 months. Two independent observers assessed the Antero-posterior films using a new classification system. Spine was considered fused when either or both sides showed good evidence of bone formation between the graft particles and graft and transverse process.

Results: In 6 patients x-rays were lost and 2 did not have two year follow-up. Twenty of the remaining 22 patients (90.9%) showed evidence of fusion as documented by both the observers. Good evidence of bone formation was noted as early as 6 months on the side where Apapore was used with bone marrow with 90.9 % achieving fusion at 2 years as against 57.1 % on the opposite side. The inter-observer agreement was good (mean 81.6%) with kappa score of 0.736.

Conclusion: The Hydroxyapatite based bone graft substitutes behave differently than autologus bone graft and poses difficulty in assessing fusion according to the radiographic classification systems described. The classification described above is useful in such situations and has shown to have good inter-observer reliability. With the increasing use of bone substitutes this classification system may be valuable in assessment of fusion and inter-study correlation.

Delays in the surgical treatment of acetabular fractures often results in extensile or combined approaches being required. This study reports the outcome from a regional centre aiming to treat these fractures via a single surgical approach where possible.

Seventy-two patients (73 displaced acetabular fractures) with an average age of 39.5 years (range 15–76 years) were studied with an average follow up period of 45.5 months (range 24–96). All radiographs were reviewed together with a full clinical assessment of each patient including the Harris Hip Score.

Thirty-four fractures were simple and 39 were complex including 27 both column fractures. Eight were noted to have an associated injury to the femoral head. The average time from injury to surgery was 11.7 days (range 1–35 days) with 80 percent of cases being operated on within two weeks after injury.

In 67 fractures (92%), including 24 both column fractures, a single approach alone was used (Anterior Ilioin-guinal 26 cases; Posterior Kocher-Langenbeck 41 cases). Five fractures needed an extensile triradiate approach and only one case required a combined anterior and posterior approach. A congruent reduction (gap or step of 2mm or less) was achieved in 65 cases (89%). Functional outcome was good with an average Harris Hip Score of 85 (range 20–100). There were 2 cases of deep infection (2.7%) and 4 patients (5.5%) required later hip replacement. There were no cases of venous thrombosis. Twenty cases exhibited heterotopic ossification of varying degree but none of these were grade IV.

Conclusion: In most cases, internal fixation of a displaced acetabular fractures is possible via a single surgical approach. Morbidity and complications are much reduced but single approach surgery requires that patients are assessed and treated early and prompt referral to a specialist unit is recommended.

Midline skin incision and medial arthrotomy for knee arthroplasty may be preformed in flexion or extension. Anatomical studies have revealed a risk to the infra patellar branch of the saphenous nerve. This study addresses

whether sensory loss is greater following skin incision in flexion or extension.

Null hypothesis- there is no detectable difference in sensation before and after knee arthroplasty. Pilot study- light touch, sharp touch and two point discrimination were evaluated pre-operatively, at one week, six weeks and six months postoperatively in twelve patients recruited prospectively. Randomization was achieved using an envelope system. Six patients underwent approach and closure in flexion and six in extension. Prospective cohort study – 50 patients underwent sensory mapping for light touch and sharp touch pre-operatively. These control results were compared with the post-operative findings at six months. All measurements were standardised to anatomical landmarks with the knee in 90 degrees flexion.

There is a constant area of sensory loss lateral to the midline scar, which shows some recovery with time. The sensory loss affects both light and sharp touch. Initially, this is in a similar distribution anteriorly and laterally extending from the superior pole of the patella to the tibial tubercle, approximately 2cm lateral to the midline. The loss is most marked immediately after surgery. There is a noticeable recovery in sharp touch by six weeks. The recovery in light touch is slower and less complete at the six month review. There is no demonstratable difference in sensory loss regardless of whether the incision is made in flexion or extension, (p=0.1)

Lateral sensory loss is a constant feature in this series six months following knee arthroplasty. Patients may benefit from pre-operative counselling regarding the likelihood of lateral cutaneous sensory deficit following knee arthroplasty.

A series of 14 patients suffering from tuberculosis of the sternum with a mean follow-up of 2.8 years (2 to 3.6) is presented. All were treated with antitubercular therapy: ten with primary therapy, two needed second-line therapy, and two required surgery (debridement). All showed complete healing and no evidence of recurrence at the last follow-up. MRI was useful in making the diagnosis at an early stage because atypical presentations resulting from HIV have become more common. Early adequate treatment with multidrug antitubercular therapy avoided the need for surgery in 12 of our 14 patients.

Vertebral disease constitutes approximately 50% of all skeletal tuberculosis. We describe a patient who developed a discharging sinus at the tip of the coccyx. Extensive examination revealed isolated tuberculosis of the coccyx. Although rare, the condition should be suspected in patients presenting with a chronic sinus in the sacrococcygeal area and a lytic lesion in the coccyx on CT or MRI, particularly in the developing world.

Introduction and aims: Numerous questionnaires are available to assess outcome of hip arthroplasty, but as yet there is no consensus as to which are the most appropriate to use following acetabular osteotomy. We have prospectively evaluated a quality of life measure validated for patients from the United Kingdom and self-administered disease and hip specific questionnaires in patients undergoing Bernese periacetabular osteotomy and compared these to outcome as measured by the Harris hip and Merle d’Aubigne and Postel hip scores.

Method: Since 1997, 24 Bernese periacetabular osteotomies have been performed at our institution. Only patients with a primary diagnosis of development dysplasia of the acetabulum, no evidence of degenerative disease and a minimum of 24 months of follow-up were included in this study. Any non life-threatening co-morbid conditions were documented and recorded. Harris hip (HHS), Merle d’Aubigne and Postel (MDP), Nottingham Health Profile (NHP) and Oxford Hip scores (OHS) were calculated pre-operatively and post-operatively at 6 weeks, 12 weeks, 6 months, one year and then yearly.

Results: Patients have been followed up for an average of 3.2 years (range: 1–5.5 years). The male: female ratio was 1: 8.5. The average age at time of operation was 32.3 years (range 18 – 48). No patient required further surgery or conversion to total hip arthroplasty. Mean postoperative HHS was 89.9. MDP 16.4 and OHS 16.3. All dimensions of the NHP demonstrated improvement of greater than 50 %. The MDP and OHS were most sensitive to time of assessment in the post-operative period. There was no significant difference in the order of magnitude of improvement between any of the scores.

Conclusion: This study has demonstrated that the Bernese periacetabular osteotomy, in a carefully selected group of patients, has a reproducibly good outcome as measured by a variety of scoring methods dependent upon both clinician and patient derived assessment.

Aims: There are multiple proximal prosthetic geometries for humeral head replacement for treatment of four-part proximal humerus fractures. We compared four proximal prosthetic geometries in stable and unstable fracture patterns with a standard tuberosity þxation method. Methods: Twelve synthetic shoulders and 4 cadaver shoulders had a simulated four-part fracture created with an oscillating saw. The following proximal prosthetic geometries were used: smooth circular shape (SCS), diamond shape (DS), irregular multiple þn shape (IMFS), and IMFS with deeper þns (IMSDF). A standardized þxation method using vertical sutures, horizontal sutures and medial based cerclage straps was performed. Passive motion from 0–45 degrees was carried out using a robotic articulator at a rate of 10 degrees per second. Interfragmentary displacement was measured from tuberosity to tuberosity as well as tuberosity to the shaft using mercury strain gauges. This was repeated for stable and unstable fracture patterns. Results: When comparing interfragmentary motion between the four different geometries the greatest amount of motion occurred with the SCS in a stable fracture (0.69mm, p< 0.0001) and unstable fracture (0.71 mm, p< 0.0001). The geometry that provided the most stability was the IMFSDF in stable (0.08mm) and unstable (0.09 mm) fracture patterns. Conclusion: The geometry of the prosthetic device does affect the stability of the tuberosity reconstruction. A smooth circular prosthetic design in a stable or unstable fracture pattern does not prevent excessive interfragmentary motion, while an irregular multiple þn shaped prosthesis with deep þns augments the þxation construct even in an unstable fracture pattern.

Aim: To report the results of supracondylar nailing of periprosthetic fractures of the distal femur above total knee replacement. Methods: Six displaced peri-prosthetic fractures of the distal femur in six female patients were treated with titanium supracondylar nail (Depuy ACE) between October 1997 and November 1999. The mean age was 68 years (42–92). Four patients had history of rheumatoid arthritis and two had previously undergone bilateral total hip replacement. None of the patients was reported to have anterior notching of the distal femur. Six fractures were equally distributed between right and left side. Low velocity trauma was the cause of fracture in all patients. The knee implants were in place for an average period of 36 months (3 wk to 48 months). The average follow up was 20 months (6–36). Results: All fractures healed in an average period of 14.6 weeks (12–18). One patient suffered another fall and sustained a fracture of the shaft of the femur above the nail. This was treated with exchange nailing using a long supracondylar nail with good result. All fractures healed in a satisfactory alignment. There were no cases of infection, loss of reduction and implant failure. All patients achieved their pre-injury functional status. The average ROM at the knee was 86.6 degrees (70–100). At latest follow up, none of the prostheses showed any signs of loosening and two patients had undergone total knee replacement on the contralateral side. Conclusion: Supracondylar nailing is a satisfactory method of managing periprosthetic fractures of the distal femur above a well-þxed implant.

Aims: The modes of failure of bipolar arthroplasty and outcomes following revision surgery have not been described. Methods: 7 patients (2f, 5m) who previously underwent bipolar arthroplasty were treated with revision surgery. Patient self-assessment was obtained pre- and postoperatively with a satisfaction survey, SF-36, SST, ASES scores, and preoperative/postoperative x-rays. Results: Modes of failure included rotator cuff failure 6/7, superior arch deficiency (4/7) and glenoid erosion (3/7). Revision surgery was performed to reconstruct instability, resurface eroded bone and repair available rotator cuff tissue. Anterior superior arch deficiencies were all revised to a semiconstrained reverse prosthesis. Other patients (3/7) were revised to unconstrained TSA. In this group, additionally soft tissue reconstructions were performed. ASES scores improved from 33 preoperatively to 55.5 postoperatively (P < 0.05). The mean SF 36 domains for PHC improved from 33.9 to 38.4 (P < 0.05). The mean VAS score for pain improved from 5.9 to 2.9 (p< 0.05). Mean active elevation increased from 60° to 78°. External rotation improved from 45° to 60°. 80% reported excellent/good, 20% reported satisfactory and none reported unsatisfactory outcome. Complications included 2 patients with recurrent instability. Conclusion: Revision shoulder arthroplasty following failure of a bipolar prosthesis requires reconstructive options of a semiconstrained prosthesis and conventional TSA with complex soft tissue reconstructions. Soft tissue problems such as superior arch deficiency and rotator cuff tears are the most common mode of failure. Patients may be improved from pain but limited improvement of shoulder function is to be expected

Outcomes for a RSP to treat either a previous operated shoulder (revision procedure) was compared to a primary RSP.

Twenty primary RSP (6M, 14F) for an irreparable rotator cuff tear (IRCT) with glenohumeral arthritis /anterior superior arch deficiency and 31 revision RSP (10M, 21F) (previous rotator or cuff surgery, hemi or total shoulder arthroplasty) were evaluated at an average of 24 months postoperatively. Mean age at the time of RSP was 72.3 for primaries 67.2 for revisions. Assessment with pre- and postoperatively SF-36, SST, ASES scores, physical exam, satisfaction surveys, and radiographs was performed.

Primary RSP improvements /Revision RSP improvements were: 9.4 sf-36 PCS/ 6.3 sf-36 PCS, 1.8 SST/ 1.6 SST,31.8ASES / 17.5ASES (p< 0.05),49.2 elevation/ 14.2 elevation (p< 0.05) and 57.8 external rotation/ 30 external rotation. 71.3% Excellent/good/. 56% Excellent/ good (p< 0.05), 21.4% satisfactory/ 33.3% satisfactory, 7.1% unsatisfactory outcome/ 9.5% unsatisfactory outcome. Complications only occurred in the revisions including component disassociation, glenoid loosening, recurrent instability, and infection

Primary RSP provides predictable improvements in pain and function with minimal complications. Revision RSP has a higher complication rate and improvements in pain and function are less reliable. Conventional shoulder arthroplasty for patients with IRCT with gle-nohumeral arthritis/anterior superior arch deficiency has resulted in adequate pain relief but functional improvement has not been predictable. Thus, the initial operative selection for these patients must consider the effect of a failed reconstructive attempt on patient outcomes.

There are multiple proximal prosthetic geometries available for a surgeon to select when humeral head replacement is indicated for four-part proximal humerus fractures. We compared different proximal prosthetic geometries in stable and unstable fracture patterns, with a standard tuberosity fixation method.

Simulated four-part fractures were created with an oscillating saw in six synthetic shoulder models. Three different proximal prosthetic geometries used polymetylmethacrelate (PMMA) – a smooth circular shape (SCS), a diamond shape (DS) and an irregular multiple fin shape (IMFS) prostheses. A standardised fixation method using vertical, and horizontal straps along with a medial based cerclage strap was performed. Passive motion was then carried out using a robotic articulator. Interfragmentary displacement was measured from tuberosity to tuberosity as well as tuberosity to shaft using mercury strain gauges.

The least amount of interfragmentary motion occurred when an IMFS was used in a stable fracture pattern. This geometry provided more interfragmentary stability even with the unstable fracture pattern than the DS or SCS. The least stable construct was the SCS prosthesis with an unstable fracture pattern.

Prosthetic geometry does affect stability of tuberosity reconstruction in proximal humerus fractures. An irregular shaped prosthesis augments the fixation construct. When using a smooth prosthetic design a stable fracture pattern must be achieved to prevent excessive interfragmentary motion. A smooth prosthetic design for tuberosity reconstruction is not recommended.

To compare the results of standard open carpal tunnel release against minimal access release using the ‘Stryker Knifelight’ in the same patients.

A prospective, randomised trial was carried out recruiting all patients with bilateral carpal tunnel syndrome. There were 26 patients (18 females and 8 males), with a mean age of 48 years. The patients were randomised to having the ‘Knifelight’ on one side and therefore acted as their own controls. They were assessed preoperatively, and at 2 and 6 weeks postop by questionnaire, and grip strength measurements.

All sides were improved following release but those done by the open method were more likely to have complete resolution at 6 weeks. In contrast, the ‘Knife-light’ sides had better grip strength and allowed earlier return to work. In terms of preference, the patients were split equally between the 2 techniques. 2 patients had minor complications following minimal access release including one with numbness over the thenar eminence for 6 weeks.

This study shows that open carpal tunnel release remains the ‘gold standard’ but the minimal access technique offers some advantages in terms of quicker recovery.

To compare the effectiveness of immediate open anterior capsulolabral reconstruction (ACLR) with conventional treatment in young military personnel who had sustained a first-time traumatic shoulder dislocation, we carried out a prospective non-randomised study of 34 recruit and active-duty servicemen (average, 20 years).

All patients met the following criteria: 1) an acute first- time traumatic anterior dislocation, 2) no history of impingement or occult subluxation, 3) the dislocation required a manual reduction, and 4) no concomitant fracture or neurological injury. Group 1 (16 patients) were immobilised in a sling for 6 weeks followed by an intensive rehabilitation programme. Group 2 (18 patients) underwent open ACLR within 10 days of dislocation followed by the same rehabilitation protocol as Group 1.

The average follow-up was 36 months; all patients were available for review. Twelve (75%) non-operatively treated patients developed recurrent instability all of whom required subsequent open repair. In the surgical repair group, there were no cases of recurrent instability.

Early open repair (ACLR) significantly reduces the incidence of recurrent instability in young military personnel who sustain an acute initial anterior shoulder dislocation.

Purpose: To determine if it is necessary to assess instability of the chronic anterior cruciate ligament deficient knee under general anaesthesia.

Materials and methods: 27 anterior cruciate ligament deficient knees in 27 patients were evaluated both subjectively using the Lachmanns and pivot shift test and objectively using the KT 1000 arthometer. This was done in the preoperative clinic (without the patient anaesthetised) and subsequently in the anaesthetic room with the patient anaesthetised (under general anaesthesia) prior to anterior cruciate ligament reconstruction. The data was prospectively collected. Only data on 21 knees was available for analysis. There were 20 females and one male with an average age of 29 years.

Results: There was no statistical significant difference (using students T test) between the data collected using the KT 1000 arthometer with and without the patient anaesthetised.

A significant difference was noted both for the Lachmanns (p< 0.01) and pivot shift test (p< 0.001) between the results obtained with and without anaesthesia. This however did not change the management.

Conclusion: Assessing the chronic anterior cruciate ligament deficient knee using the KT 1000 arthrometer, Lachmann and pivot shift test under general anaesthesia is not necessary if these assessments have been carried out in clinic.

In Musgrave Park Hospital, Belfast, younger patients requiring THR were treated by custom-made titanium alloy femoral prosthesis. The identifit hips, which were used initially, were intraoperatively customised by preparing a silicon mould of the endosteal cavity and immediate computer assisted fabrication. The Xpress hips used measurements from preoperative marker x-rays allowing creation of templates and subsequent computer analysis to mill a stem prior to surgery.

7 identifit and 51 Xpress primary uncemented custom THRs were inserted in 50 patients between May 92 and June 96. The average age for the indentifit cases was 47 years (range 24–72) and the Xpress cases 39 years (range 23–51). The Xpress cases were followed up to an average of 47 months (range 12–74 months) and identifit cases to an average of 59 months (range 14–77 months). The indications for arthroplasty were osteoarthrosis in 15 hips, CDH in 14, dysplasia in 11, AVN in 4, rheumatoid arthritis in 3 and other diagnosis in 11. Clinical assessments were made using the Oxford score and the Modified Harris Hip score. The postoperative radiographs were evaluated for subsidence of the prosthesis; and adaptive osseous changes like osteolysis, hypertrophic cortical remodelling, sclerotic radiolucent line formation around the prosthesis and formation of a bone pedestal below the tip of the prosthesis.

The average post-op Oxford hip score for those patients not revised was 32.5 /60 (range 12–51).

16 of the 51 Xpress hips underwent revision and 2 were awaiting revision, which is a failure rate of 35.3%. Of the identifit hips 1 out of the 7 was revised (14.3%). Overall 32.8% was the rate of failure. The average duration from primary operation to revision was 47 months for Xpress hips and 90 months for the identifit hips. Of the Xpress hips, revision was done for acetabular component in 1, femoral component in 4, both components in 1, acetabular liner + femoral head in 1 and acetabular liner + femoral component in 9. The 1 revision in the identifit hip was for recurrent dislocation.

The reasons for revision in the Xpress hips were dislocation in 2 cases, loose femoral component in 13 cases and infection in 1.

Average subsidence of the femoral component was 6mm (range 0–25.9) and this did not have significant correlation with predicting outcome. Pedestal formation (intramedullary formation of bone beneath the tip of the femoral stem) was seen in 87%, sclerotic rediolucent lines were seen in 64%, osteolysis was found in 31% and hypertrophic cortical remodelling was seen in 31%. These also did not reach significance in predicting outcome.

Thus even though the idea of an uncemented custom THR is attractive, especially in the younger age group, the failure rate was found to be unacceptably high. On the basis of these data we have discontinued the use of this custom made non-porous uncemented femoral prosthesis.

A 35-year-old man was seen with pain in the back of the knee. MRI showed a mass in the anterior cruciate ligament. Biopsy indicated mucoid degeneration. Arthroscopic resection of the ligament was carried out, with relief of symptoms.

Total knee arthroplasty (TKR) using a medial capsular approach gives worse results in arthritic knees with valgus deformity than in those in varus, usually because of swelling, poor wound healing and stiffness, instability, recurrent valgus deformity and poor patellar tracking.

A technique for replacement TKR of valgus knees using a lateral capsular approach was described several years ago, but was not routinely adopted because of the difficulties with and complexity of the procedure which included deliberate elevation of the tibial tubercle. In order to avoid this we have modified and simplified the procedure. Our preliminary results suggest that this lateral approach is safe and may give a better outcome than that through the medial capsule for the replacement of valgus knees.