Abstract

Introduction and Objective

Total shoulder replacement is a common elective procedure offered to patients with end stage arthritis. While most patients experience significant pain relief and improved function within months of surgery, some remain unsatisfied because of residual pain or dissatisfaction with their functional status. Among these patients, when laboratory workup eliminates infection as a possibility, corticosteroid injection (CSI) into the joint space, or on the periprosthetic anatomic structures, is a common procedure used for symptom management. However, the efficacy and safety of this procedure has not been previously reported in shoulder literature.

Aims

Joint-preserving surgery of the hip (JPSH) has evolved considerably and now includes a number of procedures, including arthroscopy, surgical dislocation, and redirectional osteotomies of the femur and acetabulum. There are a number of different factors which lead to failure of JPSH. Consequently, it is of interest to assess the various modes of failure in order to continue to identify best practice and the indications for these procedures.

We report the outcome of 39 patients who underwent a modified Pauwels’ intertrochanteric osteotomy for nonunion of a femoral neck fracture following failed osteosynthesis. There were 31 men and eight women with a mean age of 47.2 years (34 to 59). By Pauwels’ classification, there were 11 Type II fractures and 28 Type III fractures. The mean follow-up was 7.9 years (2 to 19). In the 11 patients whose initial treatment had been osteotomy, union was achieved in nine (81.8%). In 28 patients whose initial treatment had been with a lag screw or a dynamic hip screw, union was achieved in 27 (96.4%). Limb lengths were equalised in 14 of 16 patients (87.5%) with pre-operative shortening. The mean neck-shaft angle improved significantly from 100.5° (80° to 120°) to 131.6° (120° to 155°) (p = 0.004). The mean modified Harris hip score was 85.6 points (70 to 97) and the mean modified Merle d’Aubigné score was 14.3 (11 to 18). Good to excellent functional outcomes were achieved in 32 patients (88.8%). A modified Pauwels’ intertrochanteric osteotomy is a reliable method of treating ununited fractures of the femoral neck following failed osteosynthesis: coxa vara and shortening can also simultaneously be addressed.

Cite this article: Bone Joint J 2014;96-B:1198–1201.

Introduction

Very limited treatment options are available for osteoarthritis and most of them are for symptoms of osteoarthritis not for cause. Adult mesenchymal stem cells (MSCs), which have the ability to differentiate into cells of the chondrogenic lineage, have emerged as a candidate cell type with great potential for cell-based articular cartilage repair technologies. We conducted a study to see the effect of direct injection of stem cells on artificially created osteoarthritis model in rabbits.

Introduction

Osteoarthritis (OA) is a progressively debilitating disease that affects mostly cartilage, with associated changes in the bone. The increasing incidence of OA and an ageing population, coupled with insufficient therapeutic choices, has led to focus on the potential of stem cells as a novel strategy for cartilage repair.

Introduction:

In this cohort study, we present comprehensive injury specific and surgical outcome data from one of the largest reported series of distal tibial pilon fractures, treated in our tertiary referral centre.

Introduction:

The aim of this study was to assess patients reported fitness to return to work and to driving after ankle replacement.

Introduction:

Total Ankle Replacement is proving to be a viable option for younger patients with Post Traumatic Osteoarthritis of the Ankle. The aim of our study was to study the clinical and patient reported outcomes between patients of < 60 and > 60 years who underwent TAR.

A series of 76 distal tibial pilon fractures treated with surgical fixation were retrospectively reviewed from case notes, plain radiographs and CT imaging. Patient demographics, injury and fracture patterns, methods and timing of fixation and clinical and radiological outcomes were assessed over a mean follow up period of 8.6 months (range 2–30).

Definitive fixation was most commonly performed through an open technique (71 cases) with plate fixation. CT imaging was used to plan the most direct approach to access the fracture fragments. Single or double incision techniques were used to access the tibia, with fixation of the fibular performed when necessary.

Superficial infection occurred in 5 cases (6.9%) and deep infection in 2 (2.8%). Aseptic wound breakdown occurred in 5 cases (6.9%). The rate of wound breakdown after three-incision technique was 37.5%.

There were 10 cases of non-union (13.9%) and 8 of mal-union (10.5%). Post-traumatic arthritis was present on the most recent x ray in 17 cases (23.4%). Further surgery was required in 20 cases (27.8%), most commonly for metalwork related problems and also for treatment of non-union, post-traumatic arthritis and infection.

This review gives comprehensive injury specific and surgical outcome data from one of the largest reported series of these complex and problematic injuries.

Recent projections expect the number of revision knee replacements performed to grow from 38,000 in 2005 to 270,000 by the year 2030¹. Although the results of primary total knee arthroplasty are well documented, with overall implant survivorship at 15 years greater than 95%² the results of revision procedures are not as well known. What if the revision TKR fails and what is the prevalence of failure of revision TKRs, the complications and re-operation rates? There are various studies which has either exclusively dealt with the causes or outcomes of revision with a particular prosthesis and survivorship analysis. The effectiveness of revision total knee replacement must be considered in the light of complications rates which could be either medical, orthopaedic surgery related complications or combination of both.

The purpose of this study was to evaluate the prevalence of complications, reoperation rates and outcomes in a single surgeon's series between 1984 and 2008.

Ninety nine index revision cases were studied. Incidences of surgical complications were 52.5%. The total reoperation rate was 34.3% whilst single re revision accounted for 19.9% whereas multiple re-revision incidences were 4%. The mean outcome in terms of Knee Society Score, Knee Society Function, and Knee society range of motion was statistically and clinically significant between pre operative and posts operative score at one year and remained consistent with time. These results suggest that modern revision total knee replacement are satisfactory operations and the outcomes perhaps can be improved if relatively simple strategies are followed by focusing these operations to specialized that accumulate enough experience from these demanding surgeries. Overall the results asserts that even in the hands of an experienced surgeon the complications do occur which is usually multi factorial, whilst in the light of complications and reoperation incidence the patients can be counselled thoroughly before the procedure.

National guidelines suggest which investigations should be performed for patients admitted with an acute hip fracture. We have observed practice often deviates from these guidelines. Our study aims to identify the incidence of deviation with regards to blood investigations and review the effect of deviation on management, and the financial burden on the healthcare system.

A total of 250 acute hip fracture admissions over 12-months period reviewed retrospectively. Admission blood tests, time of presentation, and time of operation were recorded. The cost of admission blood investigations was calculated.

Seventy-nine percent of admissions had one or more non-routine blood investigation tested. Twenty-Nine percent of these tests had abnormal results and these were found to be clinically relevant in 6% of patients. The most commonly requested non-routine investigations were: LFT in 79%, Coagulation screen in 56%, and CRP in 48%. Fifteen percent of patients did not have surgery within the time frame of 36 hours. The total cost of non-routine investigations was £1995.04.

Deviation from admission investigations guidelines for hip fractures without clinical indication adds little clinical value, has no effect on management, and can be a potential cause of unnecessary investigations. This in turn leads to further delays and extra costs.

Aim

We aimed to study the effect of BMI on clinical and patient-reported outcomes in patients with TAR with a minimum follow-up of three years.

Introduction

Excision of prominent metatarsal heads for severe rheumatoid forefoot deformity is well established in clinical practice but results may deteriorate with time. The Stainsby forefoot arthroplasty however, recognises the pathological anatomy of the deformity and is designed to preserve the metatarsal heads by repositioning the plantar plates and forefoot fat pad underneath them.

Introduction

We describe a minimally invasive technique that permits intra-focal bone graft of non-union sites with minimal disturbance of soft tissues and vascularity, and present the results of this technique.

Hypothesis

Recurrent shoulder dislocation is associated with bony defect of the glenoid rim, commonly seen along with bankart tear - a soft tissue injury of glenoid labrum. This cadaveric study compares the bone block effect of coracoid transfer using using two common techniques, Classical Latarjet technique and the Congruent-Arc Latarjet. We hypothesized that the force needed to dislocate the shoulder would be greater in Congruent Arc technique than the Classical Latarjet, because of increased contact surface area as a result of greater linear dimensions.

Objective

To evaluate the volume of cases, causes of failure, complications in patients with a failed Thompson hemiarthroplasty.

Congenital talipes equinovarus occurs in 1.2 per 1000 live births in Europe and is twice as common in boys. Over the last decade, non-surgical management has re-established itself as the first line treatment; after long-term follow-up of surgically treated patients, revealed high rates of over correction, stiffness and pain. The commonly practiced non-surgical approaches are the Ponseti technique of serial manipulation and casting, and French taping. Ram's technique of taping is a truly conservative approach with a higher success rate to address this problem. Unlike French taping, it involves taping alternate days during the first week followed by twice in the second week, then once the following week, which is left in situ for a further two weeks. After the initial five weeks of taping, patients are provided with talipes splint for all time use, up till a year. This is followed by talipes shoes for walking and splint for nighttime use for another year. At the end of two years patients can wear normal shoes.

The study includes 225 patients with 385 clubfeet, who were treated with Ram's taping technique from September 1991 to August 2008. Inclusion criteria were age up to three months and previously untreated clubfeet. Average follow up was of 5.6 years. Outcome ratings at a minimum of two years were performed. Initial correction rate at the end of five weeks was 99%. A relapse of 21% was noted, two-third of which was salvaged via further taping and exercise, while remaining one third needed some form of surgical intervention. The comparative outcome for Ram's taping is better to Ponseti or French taping with good outcome in 93%, in comparison to 72% and 67% respectively.

To conclude Ram's taping is a fast, more effective, less cumbersome and fully conservative approach of correcting the clubfoot deformity.

In order to achieve a true AP and lateral radiograph of the wrist, there must be no movement at the radio-ulnar joint. Projections taken with only pronation and supination at the wrist provide two views of the radius but a single view of the ulna. True radiographs are achieved by rotating the humerus through 90 degrees and extending at the elbow between the two views. Our aim was to look at whether true lateral and AP radiographs are taken by our radiology department.

Between April 2009 to November 2010, we identified all patients with ulna shortening osteotomies. This was because the plate and screws placed only in ulna making it easy to identify if two projections of the ulna have been achieved. Radiograph at first follow up were reviewed using PACS.

Of the 29 patients identified, 5 patients were excluded. Only 6 out of 24 patients had TRUE wrist projections

Most radiographs taken were inadequate and this has to be communicated with the radiology department. Two different views are needed to accurately comment on radiographs. Patients have to be sent back to radiology department. This causes an increase in clinic time, radiation to the patient and inconvenience.

To examine the relationship between obesity (BMI> 30) and the incidence of peri-operative complications, outcome of surgery and return to work in patients undergoing elective less invasive posterior lumbar inter-body fusion of the lumbar spine for low back pain and leg pain (“LI-PLIF”).

15 patients with BMI> 30 who underwent (“LI-PLIF”) were identified by reviewing the clinical notes and the pre-operative admission sheet from April 2005- to March 2007. All had suffered chronic low back pain for a minimum of 2 years that had proven unresponsive to conservative treatment. All patients underwent pre- and postoperative evaluations for Oswestry Disability Index (ODI), short-form 36 (SF-36), and visual analogue scores (VAS). Minimum follow-up was for 12 months.

Blood loss was dependent on BMI, number of levels, and surgical time. Post operative complication was more in the morbidly obese group than the in the obese. 10 patients (66.6%) returned to their normal pre-operative employment within the 12 months of the index procedure. There was a significant improvement in the ODI and in the VAS for back pain. Length of hospital stay was a mean of 3.3 days

Although surgery is technically more demanding our experience with less invasive posterior inter-body fusion has shown less incidence of post operative complication, less intra-operative blood loss and short in-patient hospital stay.

We conclude that a high BMI should not be a contraindication to surgery in patients with degenerative low back pain.

Ethics approval: None: Audit Interest Statement None

Background

It was hypothesised that preserving a layer of gliding tissue, the parietal layer of the ulnar bursa, between the contents of the carpal tunnel and the soft tissues incised during carpal tunnel surgery might reduce scar pain and improve grip strength and function following open carpal tunnel decompression.

Objective: We prospectively compared the techniques of skip laminectomy and laminoplasty for the treatment of cervical spondolytic myelopathy in terms extent of decompression achieved, axial pain, postoperative range of cervical motion, patient and surgical outcomes.

Methods and results: We studied fifty consecutive patients operated on for cervical spondolytic myelopathy and spinal cord compression as demonstrated on MRI between the levels C3–4 to C6–7. Each patient had a minimum follow-up of two years (2.2 – 4.3 years). Twenty-five patients underwent skip laminectomy and twenty-five patients underwent laminoplasty. Decompression was assessed by pre- and post-operative MRI. Cervical range of motion was assessed by pre- and postoperative flexion and extension radiographs. Patient outcomes were assessed by evaluation of pre-and postoperative neurology and SF12 scores for mental health, physical health and axial pain.

Less blood loss and operative times were found with skip laminectomy. Similar degrees of decompression with both techniques. Significantly improved axial pain scores with skip laminectomy. Significantly improved preservation of range of movement with skip laminectomy.

Conclusion: Skip laminectomy is an effective procedure for reducing the incidence of postoperative morbidities, such as persisting axial pain, and restriction of neck motion often seen after laminoplasty, and provides adequate decompression of the spinal cord as demonstrated on MRI for a minimum follow-up of two years.

Intramedullary nailing is acknowledged as a safe and effective mode of treatment for many tibial fractures. Implant removal is frequently indicated either as an elective procedure following union or because of problems such as infection or delayed fracture union. It is therefore essential that intramedullary rod removal should be reasonably straightforward and atraumatic.

We describe three cases in which bony growth into the implant has made rod removal either difficult or impossible. We include photographs of two removed implants with clearly visible areas of osseo-integration with bony growth into the cannulation through the interlocking holes as well as radiographs demonstrating the same phenomenon.

The average time between insertion and removal was 16 months. In all cases an end cap had been used such that insertion of the extraction device was straightforward but for two patients nail removal was extremely difficult due to bone ingrowth and in the third patient the nail had to be left in-situ. All three implants were made of titanium and the patients were all active young males. The authors have never encountered this problem with steel rods and speculate that the osteointegrative property of titanium is the major causative factor.

We suggest that unremoved intramedullary rods represent a major risk in fracture management and that close monitoring of these implants should be undertaken.

Rupture of an aneurysm of the common iliac artery is a rare cause of pain in the hip. We describe an elderly hypertensive patient with an aneurysmal rupture of the left common iliac artery who presented with unilateral hip pain masquerading as septic arthritis.

Purpose: To study the judicious use of re-infusion drains in knee replacement on a target population with strict inclusion criteria and its impact on the transfusion rate and cost savings.

Method: We devised an inclusion criterion after a preliminary study on 200 knee replacements and identified the target population likely to need transfusion after the index procedure. All bilateral total knee replacements, revision total knee replacements and primary total knee replacements were the pre-operative haemoglobin was less then 5 gm/l above the patient’s transfusion trigger were included. These criteria were further validated by retrospective application.

56 patients fulfilled the criteria and 50 patients were included in the study between September 2006 – May 2007. Male/female ratio was 18: 32. Mean age was 66.2 years. Procedure included 33 total knees, 13 bilateral and 4 revision knee replacements.

Results: The overall transfusion rates dropped to 3% (bilateral, revisions 12%) during the period of this study. Mean volume re-infused was 600 ml (0–2600). Average drop in haemoglobin was 2.9 g/dl. No adverse incidents were reported.

Prior to our study the expenditure on allogenic blood transfusion was £13,230. The estimated cost of using the re-infusion system was £6230

A saving of £ 7500 was achieved as a result of using the drain in the “at risk” patient.

Conclusion: Post-operative autologous transfusion is a safe and efficient way to reduce patient’s exposure to donor blood. Use of re-infusion drains directed at a target population reduces need for allogenic blood and is cost effective.

Background: Total knee replacement remains one of the most common knee surgery practices worldwide. The operative procedure universally requires the use of cutting jigs to resect predetermined amounts of bone irrespective of the preoperative anatomy and morphology of the femur and tibia.

Aims: The aims of this study were to elucidate anatomical morphological differences between ethnicities pre-operatively and to assess whether any change elucidated was preserved post-operatively.

Method: This was a retrospective study comparing the pre and postoperative lateral view X-Rays of TKRs performed. Distances measured from most prominent anterior point to midline and the most prominent posterior point to midline and their ratio was compared between two ethnic groups. Each x-ray measurement was triple checked.

Results: The study groups comprised of 60 Caucasian knees and 40 Asian knees. Preoperatively the mean ratio was 0.55 in Caucasians and 0.44 in Asians, with this difference being statistically significant (p value < 0.005). Post operatively the mean ratio was 0.59 in Caucasians and 0.55 in Asians and this difference was not statistically significant (p value =0.166). These findings were also cross-checked with range of movement measurements post-operatively in the same group of patients. There was no comparable improvement in range of movements (ROM) post-operatively in the Asian group.

Conclusion: We infer that the present TKR cutting jigs are not taking into account the anatomical differences within the knee of Asians individuals. This is converting the post operative distal femurs of this group to become morphologically comparable to the Caucasian knee and this is possibly affecting the kinematics of those knees leading to no significant improvement in the post operative ROM and affecting satisfaction with surgery.

Intramedullary infection is a challenging problem and management usually includes removal of the infected hardware and reaming of the medullary canal.

The purpose of this study is to describe a new technique for canal debridement and evaluate its efficacy in the treatment of posttraumatic osteomyelitis of the tibia and femur.

This retrospective study included 11 patients (10 male and 1 female, mean age: 42 years) with posttraumatic osteomyelitis of the tibia (n=8) or femur (n=3). Surgical treatment consisted of debridement, implant removal, and reaming of the medullary canal with the RIA (Reamer Irrigator Aspirator) device. All procedures were performed by a single surgeon with a standardised technique. Reaming of the canal was performed with one pass of the RIA. Following reaming, the RIA was used for irrigation of the medullary canal with 10 liters of fluid.

At a mean follow-up time of 9 months (6 to 13 months) there was no recurrence of osteomyelitis. Complications included one partial loss of a flap, one refracture of a tibia following an auto versus pedestrian accident, and external fixator pin tract infections in one patient.

The RIA device allows for reaming under simultaneous irrigation and aspiration, which may minimise the residual amount of infected tissue in the medullary canal. The disposable reamer head is always sharp, in contrast to standard reamers, which may reduce the thermal effects of reaming on the adjacent bone. In addition, the RIA allows delivery of fluid throughout the length of the medullary canal, thus facilitating irrigation. The RIA device is useful alternative for debridement of intramedullary infections of the tibia and femur.

Introduction: There is growing interest in Health Related Quality of Life (HRQL) questionnaires to quantitate the impact of a variety of diseases and their treatments. The Short Form-36 (SF3) is a comprehensive measure of health status, consisting of 36 questions related to Physical (PCS) and Mental Component Summary (MCS).1 An abbreviated version of SF36, the SF12 has been described.2 We report on the use of SF12 and SF36 to assess the impact of surgery in patients with cervical spondylotic myelopathy (CSM).

Methods: In this prospective study, patients undergoing anterior or posterior decompressive surgery self completed the SF36 questionnaire pre-operatively and at 6 months post-operatively. The data from the SF36 is categorised into 8 scales: physical functioning (PF), physical role (PR), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), emotional role (ER) and mental health (MH).1 Each scale is scored on a 0 (maximum disability) to 100 (no disability) metric. These 8 scales are reduced to a Physical (PCS) and Mental Component Summary (MCS).1 SF12 utilises only 12 questions of the 8 scales of the SF36.2 We compared the validity, reliability and sensitivity to change in CSM patients.

Results: We studied 105 patients with a median age of 58. Post-operatively, there were improvements in the PCS components of both the SF36 (40 ± 2 to 54 ± 2) and SF12 (34 ± 2 to 48 ± 3) (p< 0.0001; Wilcoxon Signed Ranks test) and MCS component of SF36 (48 ± 2 to 63 ± 2) and SF12 (43 ± 2 to 59 ± 2) (p< 0.001). There were linear relationships between the SF36 and SF12.

Conclusions: Both the SF12 and SF36 scales are valid and sensitive to changes in CSM patients, undergoing decompressive surgery. Despite its abbreviated nature, SF12 appears to be an adequate substitute for SF36 and its brevity should increase its attractiveness to both the clinicians and patients.

Aim: To compare the outcomes between two different surgical techniques for cervical myelopathy (skip laminectomy vs laminoplasty).

Methods: Cervical skip laminectomy is a new technique described by Japanese surgeons in 2000. The advantage of this procedure over the other conventional techniques is it addresses multilevel problem in a least traumatic way without need for instrumentation.

We are comparing the above two techniques with 25 patients in each group operated by 3 surgeons. The first group had conventional laminoplasty and the second group underwent the skip laminectomy. The groups were comparable in age, sex, pathology and clinical presentation. Both these group had clinical outcome measurements using SF 12 questionnaires, pre and postoperative clinical assessment with standard tools performed by independent surgeon and a specialist spinal physiotherapist. We also routinely performed pre and postoperative MRI scans to assess the adequacy of decompression.

Results and Conclusion: here was no significant difference in the outcome of these patients in terms of the operative technique, hospital stay, clinical and radiological outcome. However skip laminectomy is relatively a easier procedure to perform, while the laminoplasty does need instrumentation.

Aim: The purpose of this study was to evaluate the extent of neurological deficit following excision of spinal neurofibromas.

Methods: Retrospective case series, combined with contemporary neurological examination and outcome questionnaires.

Results: 46 patients (26 males, 20 females) with a mean age of 46 between the years of 1985 – 2005. The incidence of neurological deficit subsequent to nerve sectioning to remove the tumour was 28/46 (60.9%) in the acute period. In the long term this reduced to 28%.

Conclusions: Despite the sectioning of nerves during surgery motor or sensory deficit was surprisingly rare. It was mainly sensory and recovered with time. This is presumably due to neural plasticity and dermatomal overlap. These results provide useful information for surgeons to counsel their patients preoperatively.

We sought to determine the incidence of complications and re-operation up to one year following primary total knee replacement in a single health region.

The Trent Arthroplasty Audit group collects prospective data on all knee replacements performed within this health region (population 5.2 million). All patients are sent a validated, self-administered questionnaire one year after surgery. The questionnaire addresses patient satisfaction and any complications and re-operations following surgery. We analysed the returned questionnaires of 5352 patients [5896 knees] who had their primary knee arthroplasty between 1998 to 2000. Responses were received from 4169 patients [4592 knees] (response rate 80%). Clinical records were also examined to gain further information.

516 patients reported complications in 546 knees. Complication rate of (12%) and 3.5% had a further operation on the joint within one year. Complications were highest following knee replacement for trauma (36%) followed by osteoarthritis (12%) and lowest for rheumatoid arthritis (8%). We have no knowledge of the complexity of the surgery but 60% of the complications occurred in patients operated on by a Consultant, 29% by a Specialist Registrar and 10% by an Associate Specialist & Staff Grade. On the whole Consultants performing fewer than 10 joint replacements per year registered a higher complication rate (21%) as compared to Consultants performing more than 25 joints per year (12%), but they performed 18% of the arthroplasties. The incidence of complications, as stated by the patient was as follows: Pain 7%, Stiffness 2%, Superficial infection 1%, Swelling 0.7%, Deep infection 0.7%, DVT 0.4%. 1.2% (infection 0.4%: Instability 0.7%: Patellar resurfacing 0.2%), Manipulation (1.3%), Arthroscopy (0.7%), ORlF of Peri-prosthetic fracture (0.06%). 12 % of the patients who had a primary knee replacement in Trent region between 1998 and 2000 considered that they had a complication. Complications rates appear to be higher for surgeons performing less than 10 joint replacements per year. Only 43% of Consultants performed more than 10 knee arthroplasties themselves in any one of these three years. The deep infection rate was 0.4% and one-year post surgery the revision rate, for all causes was 1.2% and the manipulation rate was 1.3%.

The purpose of this study was to examine the effects of hyaluronic acid supplementation on chondrocyte metabolism in vitro. The clinical benefits of intra-articular hyaluronic acid injections are thought to occur through improved joint lubrication. Recent findings have shown that exogenous hyaluronic acid is incorporated into articular cartilage where it may have a direct biological effect on chondrocytes through CD44 receptors.

Bovine articular chondrocytes were isolated and seeded into alginate constructs. These were cultured in medium containing hyaluronic acid at varying concentrations. Samples were assayed for biochemical and histological changes.

There was a dose-dependent response to the exposure of hyaluronic acid to bovine articular chondrocytes in vitro. Low concentrations of hyaluronic acid (0.1 mg/mL and 1 mg/mL) significantly increase DNA, sulphated glycosaminoglycan and hydroxyproline synthesis. Immunohistology confirmed the maintenance of cell phenotype with increased matrix deposition of chondroitin-6-sulphate and collagen type II. These findings confirm a stimulatory effect of hyaluronic acid on chondrocyte metabolism.

Purpose: To determine the incidence of complications and re-operation up to one year following primary total knee replacement in a single health region.

Methods: The Trent Arthroplasty Audit group collects prospective data on all knee replacements performed within this health region (population 5.2 million). All patients are sent a validated self-administered questionnaire one year after surgery. The questionnaire addresses patient satisfaction and any complications and re-operations following surgery. We analysed the returned questionnaires of patients who had their arthroplasty in the years 1998 to 2000. Responses were received from 4317 patients (response rate 75%). Clinical records were also examined to obtain additional information.

Results: Patients reported complications in 516 knees (500 patients). Complication rate (12%). We have no knowledge of the complexity of the surgery but 60% of the complications occurred in patients operated on by a Consultant, 29% by a Specialist Registrar and 10% by an Associate Specialist/ Staff Grade. 2.2% (125 patients) of the patients died within one year of their arthroplasty. The incidence of complications, as stated by the patient was as follows:

Complication: Pain 7%,Stiffness 2%,Superficial infection 1%, Swelling 0.7%, Deep infection 0.7%, DVT 0.4%.

Re-operation / Revision Surgery: Revision: 1.2% (infection 0.5%: Instability 0.7%: Patellar resurfacing 0.4%), Manipulation (1.3%), Arthroscopy (0.7%), ORIF of Periprosthetic # (0.06%).

Conclusion: 12 % of the patients who had a primary knee replacement in Trent region between 1998 and 2000 considered that they had a complication. The deep infection rate was 0.5% and one-year post surgery the revision rate, for all causes was 1.2%. The Manipulation rate was 1.3%.

Aim: To test the null hypothesis that older instrumentations with their complications do not produce a clinical improvement.

Introduction: Surgical treatment of adult scoliosis is difficult with a high incidence of complications. The presenting complaints and expectations from the surgery are different to those in adolescent scoliosis.

Methods and results: Inclusion: All cases of adult idiopathic scoliosis presenting at or after the age of 20 and requiring surgical treatment. Exclusions: Revisions. Average age of follow-up is 6 years (range 2 to 14 years) with 107 patients. For analysis three groups were decided on the basis of the age. A number of different instrumentation systems were used with time. Treatment varied according to senior author’s planning for the individual patient, ranging from posterior instrumentation, anterior release and posterior instrumentation, and combined anterior and posterior instrumentation.

Group I: Age 20–30 years, consisted of 64 patients. Average pre-operative primary curve was 56° with post-operative correction 50%. Deformity was the most common presenting complaint. Seventy-one per cent felt an overall improvement, the rest noticed no benefit.Twenty-two per cent would prefer not to have the surgery. Complications included four pseudoarthrosis, nine required further surgery, and one late infection.

Group II: Age 31–40 years, 20 patients with an average primary curve of 63°, and a correction of 56%. Fifteen per cent had significant pain at presentation. Seventy per cent felt an overall benefit although all noticed a cosmetic improvement. Complications: two pseudarthrosis, three subsequent surgical procedures.

Group III: Age > 41 years, 23 patients, an average primary curve of 72° with a correction of 39%. Eleven out of 23 had significant pain on presentation. Complications: four pseudoarthrosis, metal pull out in one. Further surgery was performed in nine. All felt some benefit from the treatment and despite the high proportion of complications, would have the surgery again.

Conclusions: There is a clinical benefit from surgical treatment of adult idiopathic scoliosis. There is a higher number of complications in the older age group.

The use of intra-articular hyaluronic acid injections for the treatment of early osteoarthritis is in widespread clinical use. Hyaluronate (HA) is a major component of connective tissue¹ and is available commercially for the intra-articular injective treatment of osteoarthritis of the knee and periarthritis of the shoulder. Although it is known to improve intra-articular lubrication it is also thought to promote articular cartilage structure and prevent catabolism of matrix proteoglycans in osteoarthritis. Clinical studies have shown beneficial effects lasting for many months after cessation of therapy unlike anti-inflammatory drugs that have relatively short term relieving effects^2,3 . Documentation of the true chondroprotective effects of hyaluronic acid (HA) at the cellular level is lacking and therefore this study aimed to identify the effects of HA on chondrocytes cultured in vitro.

Bovine articular chondrocytes were isolated by sequential digestion with pronase and collagenase and seeded in 2% alginate at 1x10⁷ cells/ml. The constructs were cultured for up to 14 days in standard culture medium (DMEM + 20% Fetal calf serum) containing varying concentrations of HA (Sigma), including doses equivalent to those found in vivo. The medium was replaced every 3 days and representative constructs were removed from culture, digested and assayed for DNA, glycosaminoglycans and Collagen. Further constructs were fixed in 4% paraformaldehyde for standard histology and immunolocalisation of collagen types I, II and chondroitin-6-sulphate.

Chondrocytes cultured in the HA system proliferated (increase in DNA) at a faster rate than the controls. There was a 2.2 fold increase in cell concentration at 14 days compared to a 1.2 fold increase in the controls. Total GAG levels at each time point were significantly greater for cells cultured in HA than in controls. Histologically, constructs were characterised by extensive cell cluster formation and intense Safranin-O staining. The newly synthesised matrix also stained positive for type II collagen. By contrast, control constructs exhibited minimal cluster formation, Safranin-O and type II collagen staining.

Cells maintained with HA exhibited a significantly greater rate of proliferation and matrix production. The presence of matrix rich in type II collagen indicates maintenance of chondrocytic phenotype. By contrast, cells cultured without HA did not show these features. These results support the use of intra-articular injections for the treatment of osteoarthritis. The benefits of HA injections may be due to cellular mechanisms as well as mechanical.

The use of intra-articular corticosteroid injections for their anti-inflammatory effects is widespread amongst clinicians. Despite their use in both rheumatoid arthritis and osteoarthritis, the effect of these agents on articular chondrocytes is not fully established. Previous reports suggest a detrimental effect on cartilage explants resulting from inhibition of matrix synthesis¹. However it has also been suggested that the beneficial effects in vivo may be due to prevention of inflamed synovium causing cartilage degradation². Our aim was to assess the effect of a commercially available preparation of methylprednisolone (MP), at clinical doses, on articular chondrocytes cultured in vitro.

Bovine articular chondrocytes were isolated by sequential digestion with pronase and collagenase and seeded in 2% alginate at 1x10⁷ cells/ml. The constructs were cultured for up to 15 days in standard culture medium (DMEM + 20% Fetal calf serum) containing varying concentrations of MP, including doses equivalent to those found in vivo. The medium was replaced every 3 days and representative constructs were removed from culture, digested and assayed for DNA and glycosaminoglycans. Further constructs were fixed in 4% paraformaldehyde for standard histology and immunolocalisation of collagen types I, II and chondroitin-6-sulphate.

Chondrocytes cultured in MP containing medium showed a significant abnormality in cell morphology compared to controls at the day 15 time point. Histologically there was evidence of cell necrosis, reduced amounts of extracellular matrix and loss of collagen type II staining. The effects were dose dependant, with significant damage occurring even at clinical doses. Biochemical analysis revealed a reduction in DNA content and an inhibition of glycosaminoglycan and collagen type II synthesis. In contrast, in the controls, there was cell proliferation with a cell doubling time of 14 days, collagen type II containing extracellular matrix synthesis occurred and the chondrocytes maintained their phenotype throughout the culture period.

Methylprednisolone has a significant detrimental effect on cultured articular chondrocytes in vitro. There was significant cell necrosis associated with inhibition of extracellular matrix synthesis. Based on these results, intra-articular corticosteroid injections should be used with extreme caution.

Objective: To assess the safety and efficacy of a novel Artificial Cervical Disc.

Design: Compare the Bryan prosthesis to Anterior Cervical Discectomy and Fusion (ACDF), by using the pre-defined objective performance criteria (OPC) derived from a literature meta-analysis of ACDF in which a success rate of 73% was established. The Null hypothesis is that the success rate for the Bryan prosthesis is greater or equal to the OPC (Objective Performance Criteria) of 85%. Secondary Objectives studied included the range of motion after implantation; adverse events from implantation onwards; maintenance of the disc space height; amount of subsidence. Radiology was assessed by an independent radiologist. Improvement in the quality of life for the patient (SF-36) was also recorded at six weeks, six months and one year. Data was collected by an independent research practitioner.

Subjects: Multicentre study seven European centres: 107 patients Male 51, Female 66. Age ranged from 27 to 71. Mean age was 42 years with a clinical diagnosis of cervical radiculopathy or myelopathy, and single level disc disease on MRI.

Outcome Measures: Odom Criteria, SF-36, radiological range of movement.

Results: The Bryan Cervical Disc was associated with a clinical success according to Odom’s criteria of 87%. Radiological success occurred in 97%. SF-36 analysis revealed a statistically significant improvement in all domains.

Conclusion: The Bryan Disc has been successfully implanted in 107 patients with good clinical results and at one-year follow-up there is radiological evidence of preserved motion.

Introduction: To examine if an individual’s timed walk in sufficiently reproducible to correlate with the degree of spondylitic myelopathy and if surgical decompression has measurement effect on performance.

Methods: A 30mm timed walk, including a turn. The number of paces counted.

Forty-one non-myelopathic individuals were obtained. There was good inter-and intra-observer reliability.

Results: The mean control walking time and steps was 64.7 ± 8.4 seconds 46.9 ± 1.2 steps. The mean patients preoperative walking time and steps was 85.4 ± 11.2 seconds; 74.8 ± 5.3 steps and postoperative 64.7 ± 8.4 seconds; 63.5 ± 4.2 steps.

Significant improvement following surgery (p = 0.0018 and p = 5.87 x 10⁻⁶ respectively) and improvement maintained for at least two years after surgery.

Discussion and Conclusions:

The test is reproducible and reliable with good sensitivity and specificity.

Demineralised homologous bone-matrix implant was used to bridge a large circumferential osteoperiosteal gap in the diaphysis of the ulna of rabbits. Periodic observations of the graft were made clinically, radiologically, histologically and by tetracycline fluorescence up to forty-two weeks. By the twelfth week after operation 81 per cent of the animals revealed bone formation in the implant and complete bridging of the gap. The new bone was laid on the surface and in the substance of the matrix, suggesting that the inductive principle was acting locally. The bone, once formed, remodelled to the texture of a mature tubular bone and did not undergo absorption during a long follow-up period. Demineralise bone-matrix proved to be a highly osteoinductive and readily osteoconductive material. The graft did not evoke any appreciable local foreign-body or immunogenic reaction. The high degree of success in bridging massive bone defects justifies further serious studies and hopes for a useful substitute for massive autologous bone grafts.

1. The skeletal changes in endemic fluorosis are described from an area of the Punjab where the fluorine content of water and soil is very high.

2. A detailed description of a fluorotic skeleton is given, with its various anthropometric measurements.

3. The vertebral changes demonstrated the pathogenesis of the neurological complications observed in this condition.