Purpose

The traditional management of pediatric aneurysmal bone cysts involves the application of intralesional resection principles that are used to treat benign aggressive tumors in general. Alternatively, some are treated by injections of sclerosing agents. The risks of these approaches include growth arrest, additional bony destruction necessitating the restoration of structural integrity, and soft tissue necrosis. We wished to evaluate the effectiveness of treating aneurysmal bone cysts in children by percutaneous curettage as a means to avoid these risks.

Aim

To determine the effects of knee and ankle position on tendo Achilles (TA) gap distance in patients with acute rupture using ultrasound.

To investigate the effectiveness of surgical fusion for chronic low back pain (CLBP) compared to non-surgical intervention, databases were searched from 1966-2005. The meta-analysis was based on the mean difference in Oswestry Disability Index (ODI) change from baseline to follow-up. Four studies were eligible (634 patients). The pooled mean difference in ODI was 4.13 in favour of surgery (95% CI: -0.82-9.08; p=0.10; I2=44.4%). Surgery was associated with a 16% pooled rate of complication (95% CI: 12-20%, I2=0%).

The cumulative evidence does not support surgical fusion for CLBP due to the marginal improvement in ODI which is of minimal clinical importance.

We present our experience of forearm lengthening in children with various conditions performed by a single surgeon between 1995 and 2009. A total of 19 children with a mean age of 9.8 years (2.1 to 15.9) at the time of surgery had 22 forearm lengthenings using either an Ilizarov/spatial and Ilizarov circular frame or a monolateral external fixator. The patients were divided into two groups: group A, in whom the purpose of treatment was to restore the relationship between the radius and the ulna, and group B, in whom the objective was to gain forearm length. The mean follow-up after removal of the frame was 26 months (13 to 53).

There were ten patients (11 forearms) in group A with a mean radioulnar discrepancy of 2.4 cm (1.5 to 3.3) and nine patients (11 forearms) in group B. In group A, the mean lengthening achieved was 2.7 cm (1.0 to 5.5), with a lengthening index of 11.1 weeks/cm. Equalisation or overcorrection of the discrepancy was achieved in seven of 11 forearms, but lengthening was only partially successful at preventing subluxation or dislocation of the radial head. In group B, the mean lengthening achieved was 3.8 cm (1.9 to 6.8), with a lengthening index of 7.25 weeks/cm. Common complications in both groups were pin-site infection and poor regenerate formation.

Forearm lengthening by distraction osteogenesis is a worthwhile procedure in children that can improve cosmesis and function, particularly in patients with shortening of both radius and ulna.

Introduction: To report the 11-year follow-up of patients of contaminated femoral heads donated at primary total hip replacement from a cohort study published in 2004.

Methods: Of the 440 donors, 266 patients (61%) were still alive at a mean of 11.7 years post primary total hip replacement and 170 patients (64%) agreed to review. The patients had either a positive or negative culture from their donated femoral head at primary total hip replacement. The Oxford hip score, European Quality of Life (EuroQOL) questionnaire, rates of complication and revision surgery were used as outcome measures.

Results: At long-term follow-up, the Oxford hip score was not different between the positive (mean = 36, standard deviation = 12.3) and sterile (mean = 39, standard deviation = 10.9) groups (p = 0.40). The EuroQOL questionnaire was also not different between the positive and sterile groups. There was no statistically significant difference in the rate of complications (p = 0.93) and revision surgery (p = 0.11) of the age-matched patients whose femoral heads had a positive culture compared with those whose femoral heads were sterile.

Discussion: The results of this 11-year follow-up of contaminated donated femoral heads cohort study were similar to those at short-term follow-up. Culture results of donated femoral heads play no significant role in predicting failure of primary total hip replacement in the donor at long-term follow-up.

The aim of this study was to evaluate temporal trends in the prevalence of primary total hip and knee replacements (THR and TKR) throughout the Trent region from 1991 through 2004.

The Trent Regional Arthroplasty Study (TRAS) records details of primary THR and TKR prospectively. TRAS data in conjunction with age-gender population data from the National Office of Statistics was used to quantify the rates of primary THR and TKR as a function of age (45–55, 56–65, 66–75, 76–85 and greater than 85 years), gender and diagnosis (osteoarthritis, rheumatoid arthritis and trauma). Poisson regression analysis was used to evaluate the procedural rate over time in primary THR and TKR as a function of age, gender and diagnosis.

A total of 26,281 THR and 23,606 TKR were recorded during this period. The overall prevalence for primary THR did not change significantly over time (IRR = 1.0, 95% CI: 0.99 to 1.0, p = 0.875), whereas, the overall prevalence for primary TKR increased significantly by 2.5% during the fourteen year period (IRR = 1.025, 95% CI: 1.021 to 1.028, p < 0.001). Analysis showed that females had an increased incidence rate ratio (IRR) for both primary THR (IRR = 1.29, 95% CI: 1.26 to 1.33, p < 0.001) and TKR (IRR = 1.17, 95% CI: 1.14 to 1.20, p < 0.001). Patients aged 74–85 years had the largest IRR for both primary THR (IRR = 6.7, 95% CI: 6.4 to 7.0, p < 0.001) and TKR (IRR = 15.3, 95% CI: 14.4 to 16.3, p < 0.001).

The prevalence of primary TKR increased significantly over time whereas THR increased steadily in the Trent region between 1991 and 2004. These trends have important ramifications to the number of joint replacements expected to be performed in the future.

Aims: To investigate the effect of age and occupation on the outcome of carpal tunnel decompression.

Patients and Methods: A total of 271 patients undergoing primary carpal tunnel decompression by a single surgeon were studied. Patients with inflammatory joint disease, thyroid disease and diabetes mellitus were excluded. Outcome was assessed using the Levine-Katz carpal tunnel questionnaire at two weeks preoperatively and six months postoperatively. Cases were divided into six age groups (less than 40 years of age, 40 to 49, 50 to 59, 60 to 69, 70 to 79, and over 80 years of age) and 12 occupational groups according to the International Standard Classification of Occupations (ISCO-88). Statistical analysis was performed using one-way analysis of variance (ANOVA) and post ad-hoc analyses.

Results: Overall there was an improvement in total Levine scores in 269 (99.3%) patients (mean change 33.1, 95%CI: 31.5 to 34.7). This change was greatest in those over 80 years of age (mean 35.8, 95%CI: 29.0 to 42.6) and in those who were service or sales workers (mean 39.6, 95%CI: 34.9 to 44.2), and least in the 70–79 age group (mean 30.7, 95%CI 25.7 to 35.8) and craft and trade workers (mean 29.8, 95%CI: 21.8 to 37.9). Patients reported a greater improvement in symptoms (mean score change 21.4, 95%CI: 20.2 to 22.2), than function (mean 12, 95%CI: 11.1 to 12.7). We found no significant difference in the total, functional or symptomatic Levine score changes between the six age groups (p=0.05) and the 12 occupation groups (p=0.05) following carpal tunnel decompression.

Conclusion: Almost all patients improved after carpal tunnel decompression. However, we found no influence of age and occupation on the outcome of carpal tunnel decompression in our series of patients.

We report the 15 year follow-up of displaced intra-articular calcaneal fractures from a randomised controlled trial of conservative versus operative treatment. Of the initial study, 46 patients (82%) were still alive and 26 patients (57%) agreed to review.

The clinical outcomes were not different between operative versus conservative treatment. American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale: p = 0.11; Foot Function Index (FFI): p = 0.66; and calcaneal fracture score: p = 0.41. The radiological outcomes also were not different between both groups. Böhler’s angle: p = 0.07; height of calcaneum: p = 0.57; and grade of osteoarthritis of the subtalar joint: p = 0.54. There was no correlation between Böhler’s angle and the outcome measures in either group.

The results of this 15 year follow-up of displaced intra-articular calcaneal fracture randomised controlled trial demonstrate similar findings to those at one year follow-up.

Background: Chronic low back pain is the most common complaint of the working age population. Controversy exists regarding the benefit of surgical fusion of the spine for the treatment of chronic low back pain. We performed a meta-analysis of randomised controlled trials to investigate the effectiveness of surgical fusion for chronic low back pain compared to non-surgical intervention.

Methods: Several electronic databases (MEDLINE, EMBASE, CINAHL, Science Citation Index and Cochrane registry of clinical trials) were searched from 1966 to October 2005. Two authors independently extracted data on study characteristics and methodological quality and the number of patients with early complications from surgery. The random-effect meta-analysis comparison was based on the mean difference in Oswestry Disability Index (ODI) change from baseline to follow-up of patients undergoing surgical versus non-surgical treatment. Between-study heterogeneity was analyzed by means of I2.

Results: Four studies of 58 articles identified in the search were eligible with a total of 740 patients. One of the studies recruited patients with adult isthmic spondy-lolisthesis, whereas the other studies recruited patients with a history of chronic low back pain of at least 1 year duration. Surgical treatment involved posterolateral fusion with or without instrumentation or flexible stabilisation. Non-surgical treatment involved exercise programs with or without cognitive therapy. The follow-up period ranged from 1 to 2 years. The pooled mean difference in ODI between the surgical and non-surgical groups was statistically in favour of surgery (mean difference of ODI: 3.90; 95% confidence interval: 0.17–7.62; p=0.04; I2=21.4%). Surgical treatment was associated with a 13% pooled rate of early complication (95% confidence interval: 6–20%, I2=66.9%).

Conclusion: Surgical fusion for chronic low back pain favoured an improvement in the ODI compared to non-surgical intervention. This difference in ODI is of minimal clinical importance. Furthermore, surgery was associated with a significant risk of complications. Therefore, the cumulative evidence at present does not support routine surgical fusion for the treatment of chronic low back pain.

Aim: To evaluate the morbidity and mortality in the perioperative period of patients with aortic stenosis following fractures of the proximal femur.

Patients and Methods: A retrospective review was undertaken of medical notes of all patients (n=20) admitted to our trauma unit over an 18 month period with fractures of the proximal femur and concomitant aortic stenosis confirmed by transthoracic echocardiography. Assessment was made of perioperative factors thought to be important in influencing outcomes in such patients as highlighted in the 2001 Report of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) “Changing the way we operate”. These included previous history of angina or ischaemic heart disease, preoperative optimisation by an anaesthetist or physician, maximum pressure gradient across the aortic valve and ventricular ejection fraction on transthoracic echocardiography, seniority of anaesthetist and surgeon performing the procedure, intraoperative invasive monitoring, postoperative high dependency care and complications and outcomes.

Results: Prior to surgery three patients (15%) were seen by a physician and nine patients (45%) by an anaesthetist for medical optimisation. The mean maximum pressure gradient across the aortic valve on transthoracic echocardiography was 38.6 mmHg (range: 12 to 111 mmHg), and five patients (25%) were confirmed as having severe aortic stenosis. Anaesthesia was performed by consultant anaesthetists in 85% of cases with the remaining 15% carried out by trainees. No patients had intraoperative central venous pressure (CVP) monitoring, and only three of the 20 (15%) patients had intra-arterial blood pressure (IABP) monitoring. Only two patients spent one day in the High Dependency Unit postoperatively. The remainder of the patients were discharged back to the general ward where the mean length of stay was 28 days (range: 0 to 135). Postoperatively two patients (10%) developed arrhythmias, three (15%) experienced an episode of acute left ventricular failure and four (20%) developed hypotension. There were two deaths (10%).

Conclusion: It is evident that patients with proximal femoral fracture and concomitant aortic stenosis are still not benefiting from the recommendations of the NCEPOD report in the perioperative period. The authors suggest the introduction of a dedicated multidisciplinary team for the management of patients with proximal femoral fractures and concomitant aortic stenosis.

Our aim in this prospective radiological study was to determine whether the flexibility rate calculated from radiographs obtained during forced traction under general anaesthesia, was better than that of fulcrum-bending radiographs before corrective surgery in predicting the extent of the available correction in patients with idiopathic scoliosis. We evaluated 33 patients with a Cobb angle > 60° on a standing posteroanterior radiograph, who had been treated by posterior correction. Pre-operative standing fulcrum-bending radiographs and those with forced-traction under general anaesthesia were obtained. Post-operative standing radiographs were taken after surgical correction.

The mean forced-traction flexibility rate was 55% (sd 11.3) which was significantly higher than the mean fulcrum-bending flexibility rate of 32% (sd 16.1) (p < 0.001). We found no correlation between either the forced-traction or fulcrum-bending flexibility rates and the correction rate post-operatively (p = 0.24 and p = 0.44, respectively).

Radiographs obtained during forced traction under general anaesthesia were better at predicting the flexibility of the curve than fulcrum-bending radiographs in curves with a Cobb angle > 60° in the standing position and may identify those patients for whom supplementary anterior surgery can be avoided.

Aim: A meta-analysis of randomised controlled trials was performed to investigate the effectiveness of surgical fusion for chronic low back pain compared to non-surgical intervention.

Methods: Several electronic databases (MEDLINE, EMBASE, CINAHL and Science Citation Index) were searched from 1966 to October 2005. Two authors independently extracted data. The meta-analysis comparison was based on mean difference in Oswestry disability index (ODI) change from baseline to follow up of patients undergoing surgical versus non-surgical treatment.

Results: Four studies of 58 articles identified in the search were eligible with a total of 740 patients. One of the studies recruited patients with adult isthmic spondylolisthesis, whereas the other studies recruited patients with a history of chronic low back pain of at least 1 year duration. Surgical treatment involved pos-terolateral fusion with or without instrumentation and flexible stabilisation. Non-surgical treatment involved exercise programs with or without cognitive therapy. The follow-up period ranged from 1 to 2 years. The mean overall difference in ODI between the surgical and non-surgical groups was statistically in favour of surgery (mean difference of ODI: 3.90; 95% confidence interval: 0.17–7.62; p=0.04; I²=21.4%). Surgical treatment was associated with a 13% pooled rate of early complications (95% confidence interval: 6–20%).

Conclusion: Surgical fusion for chronic low back pain favoured an improvement in the ODI compared to non-surgical intervention; this difference in ODI is of minimal clinical importance. Furthermore, surgery is associated with a significant risk of complications. Therefore, the cumulative evidence at present does not support routine surgical fusion for the treatment of chronic low back pain.

Aim: The purpose of this study was to report the long-term follow-up (mean of 15 years) of patients with displaced intra-articular calcaneal fractures from a randomised controlled trial published in 1993.

Patients and Methods: 46 patients (82% of patients in the initial study group) were alive at a mean of 15 years post injury. The patients had been randomly allocated to either conservative or operative (Soeur and Remy technique) treatment in the original study. Clinical (AOFAS, FFI and calcaneal fracture score) and radiological (Böhler’s angle and calcaneum height) outcome measures were used. The grade of osteoarthritis was also assessed at long-term follow-up.

Results: 26 patients (57%) were reviewed and these patients served as the focus of the study (11 conservative and 15 operative). The clinical outcomes after conservative treatment were not found to be different from those after operative treatment, scores of the AOFAS were 78.5 and 70 respectively (p = 0.11); scores of the FFI were 24.4 and 26.9 respectively (p = 0.66) and calcaneal fracture scores were 70.1 and 63.5 respectively (p = 0.41). The radiological outcomes after conservative treatment were not found to be different from those after operative treatment, Böhler’s angles were 10° and 16° respectively (p = 0.07) and the height of the calcaneum were 37mm and 36mm respectively (p = 0.57). There was no difference in the grade of osteoarthritis between the groups.

Conclusion: The functional and radiological long-term outcomes after conservative treatment of displaced intra-articular calcaneal fractures were equivalent to those after operative treatment. The operative technique showed no benefit compared to conservative treatment at long-term follow-up. There was a trend for higher scores on clinical outcomes with conservative treatment

Background: Aseptic loosening of total joint arthroplasty is characterised by osteolysis caused by osteoclasts and macrophages. Osteolysis occurs by acidification and dissolution of hydroxyapatite crystals then proteolysis of the bone collagen matrix. N-Telopeptide (NTx) and deoxypyridinolone (DPD) represent highly specific markers for bone resorption.

Aim: To investigate whether urinary NTx and DPD generated in-vivo can be used as bone markers in a small animal model of wear debris induced osteolysis.

Materials and Methods: 41 and 38 urinary samples were collected from mice at autopsy four weeks following either the implantation of clinically relevant ceramic particles or sham surgery into their femora and assayed for NTx and DPD respectively. Bone markers were corrected for urinary creatinine.

Results: The mean urinary NTx concentration for mice that underwent the implantation of clinically relevant ceramic particles was 95.0 nM BCE/mM creatinine compared to 85.3 nM BCE/mM creatinine for mice who had sham surgery (p = 0.8, 95%CI: −29.0 to 30.7). The mean urinary DPD concentration for mice that underwent the implantation of clinically relevant ceramic particles was 5.3 nM DPD/mM creatinine compared to 4.0 nM DPD/ mM creatinine for mice who had sham surgery (p = 0.07, 95%CI: −2.8 to 1.4).

Conclusion: The absolute values of NTx and DPD increased in mice that underwent the implantation of clinically relevant ceramic particles compared to sham surgery even though this was not statistically significant. Extending the post operative interval might allow both NTx and DPD to be utilised as bone markers of osteolysis in our small animal model of aseptic loosening.

Background: The commonest cause of long term failure of total joint arthroplasty is aseptic loosening. As a result, many patients will require complex revision surgery that is not only technically challenging but associated with poorer results. Revisions procedures are also associated with higher morbidity and costs.

Aim: To quantify osteolysis in a small animal model of aseptic loosening. This model can then be utilised for screening therapeutic agents to inhibit aseptic loosening.

Materials and Methods: 7 time mated female mice were injected with radioactive calcium 45 on day 14 of gestation. The 52 offsprings were divided into 2 equal groups and subjected to either the implantation of clinically relevant ceramic particles or sham surgery into their femora. The non-operated femora were used as control. Animals were killed 4 weeks following surgery. Femora were retrieved, dissolved and radioactivity measured as outcome (CPM/mg = Counts Per Minute per milligram). A Linear mixed effects model was utilised to examine the difference in outcome between the 2 groups.

Results: The mean scintillation count for sham surgery was 388 CPM/mg compared to 449 CPM/mg in the control femora. The mean scintillation count for ceramic particles was 351 CPM/mg compared to 420 CPM/mg in the control femora. The mean effect on outcome of surgery with ceramic particles relative to sham surgery was estimated at 16.7 CPM/mg (95CI%: 0.9 to 32.5 CPM/mg; p = 0.025).

Conclusion: We have successfully shown that this model can quantify osteolysis. However, the difference detected between sham surgery and ceramic particles was biologically small displaying the inert properties of ceramic. Extending the post surgery interval might show a larger difference between sham surgery and ceramic particles and permit quantitative analysis of therapeutic agents to be screened to inhibit aseptic loosening.

Background Our hospital operates a consultant led rapid review process of X-rays and case notes of patients referred to fracture clinic from Accident & Emergency (A& E) and General Practitioners (GP) on a daily basis. This compares with other centres where patients are reviewed in outpatient fracture clinics soon after injury.

Aim Evaluate effectiveness of consultant led rapid review process compared to standard consultant fracture clinics.

Patients and Methods Prospective study of the rapid review process over 4 weeks of all patients referred to fracture clinic by A& E and GPs. Total number of patients referred per day, time taken to review these patients case notes and X-rays, number of recalls and reason for recall were documented. This was compared to consultant led fracture clinics, which included time taken to review patients.

Results 797 patients were processed through the rapid review over 4 weeks. 53 (6%) patients were recalled, 32 (4%) for a change of management and 21 (2.6%) because of lack of information. The mean number of patients referred per day was 28 taking a mean of 28 minutes; thus the mean time to review one patient was 1.0 minute. The mean number of patients recalled per day was 2. The mean time taken to review a patient in a standard fracture clinic was 11 minutes. Therefore, the total time that would have taken to review 28 patients in the standard fracture clinic would be 308 minutes.

Conclusion A consultant led rapid review process of all patients referred to fracture clinic is a very efficient process. Rapid review process saves clinic time and resources, minimises delays in clinical decision-making and saves the patient an unnecessary visit to the outpatient department.

Background Adhesive capsulitis of the shoulder is a painful condition that results in gradual loss of joint movement. Numerous treatment modalities have been utilised with variable benefits. Because of the risk of brachial plexus injury and fracture, manipulation under anaesthesia is considered with caution.

Aim To determine the rate of manipulation under anaesthesia (MUA) following primary distension arthrogram for adhesive capsulitis of the shoulder.

Patients and Methods The case notes of 40 patients (42 shoulders) between 1998 to 2004 at Glenfield Hospital, Leicester under the care of one consultant with adhesive capsulitis of the shoulder treated with distension arthrogram by using intra-articular injection of local anaesthetic, corticosteroid, contrast media and air were reviewed.

Results Capsular disruption into the subscapular bursa was demonstrated in all cases. 15 of 42 (36%) shoulders underwent MUA following distension arthrogram. The average period of pain prior to distension arthrogram for these patients was 42 weeks (range: 7–156). 35 of 40 (88%) patients were pain free following primary distension arthrogram.

One patient experienced a vasovagal episode during the distension arthrogram.

Conclusion Distension arthrogram can be used as a therapeutic procedure for achieving symptomatic pain relief in the early phase of adhesive capsulitis and decreasing the risk of MUA of the shoulder.

Implantation of allograft bone is an integral part of revision surgery of the hip. One major concern with its use is the risk of transmission of infective agents. There are a number of methods of processing allograft bone in order to reduce this risk. One method requires washing the tissue using pulsed irrigation immediately before implantation. We report the incidence of deep bacterial infection in 138 patients (144 revision hip arthroplasties) who had undergone implantation of allograft bone. The bone used was fresh-frozen, non-irradiated and pulse-washed with normal saline before implantation. The deep infection rate at a minimum follow-up of one year was 0.7%. This method of processing appears to be associated with a very low risk of allograft-related bacterial infection.

We determined the rate of contamination of donated femoral heads at primary hip arthroplasty within a single region between July 1992 and July 2001. We established the null hypothesis that culture results played no role in predicting early failure of the joint because of infection.

The rate of contamination was 9%. A positive culture, at the time of retrieval, was found in 367 of 4045 femoral heads. Coagulase-negative staphylococcus was isolated in 77% of the positive cases. At a minimum follow-up of one year, there was no statistically significant difference in the rate of complications or of revision of age-matched patients whose femoral heads had a positive culture compared with those whose femoral heads were sterile.

Our findings confirm that culture of the femoral head plays no part in determining future failure of joint replacement in the donor.

Background: Femoral heads donated at primary arthroplasty are screened microbiologically. Contaminated femoral heads are either discarded or irradiated in an effort to protect recipients from the risk of transmitted infection.

Aims:

Determine the contamination rate of donated femoral heads at primary arthroplasty within the Trent Region between July 1992 and July 2001.

Method: We reviewed the culture results of all femoral heads donated to the Leicester Bone Bank. All patients with a contaminated femoral head that were operated upon in the Leicestershire region were then compared to a control group of patients with no contamination of their femoral heads. The two groups of patients were then cross-referenced against the data in the Trent Arthroplasty Audit Group database. Hospital records of all patients who had a complication or re-operation were also reviewed to determine their outcome

Results: A contamination rate of 9% was present with 365 of 4043 femoral heads culturing positive at the time of retrieval. Coagulase negative Staphylococcus was isolated in 75% of the cases. At a minimum of one year follow up, there was no statistically significant difference in the complication or revision rate of age matched patients whose femoral heads cultured positive compared to those whose heads were sterile.

Conclusion: The allograft contamination rate is similar to other published series with coagulase negative staphylococcus being the most prevalent contaminant. The available evidence confirms what has been anecdotal in the past. Femoral head culture results play no role in determining future joint failure in the donor