The aim of this study was to examine the progression of osteolytic lesions following liner exchange surgery and relate this to the size of the lesion prior to surgery, and whether the defect underwent curettage and bone grafting during surgery.

Six patients with well-fixed Harris-Galante-1 acetabular components underwent liner exchange surgery for excessive polyethylene wear and osteolysis. The mean interval from primary arthroplasty to revision was 14 years (range 11–17 years). All patients underwent a CT scan pre-operatively to identify the location and size of the osteolytic lesions and during surgery, accessible lesions were curetted and bone grafted. One patient had recurrent dislocations and the acetabular component was revised one year following liner exchange surgery. The remaining five patients had CT scans taken at a mean of five months (range 3–5 months) and 5 years (range 3.4–8.2 years) following surgery. Osteolytic lesion volume with or without bone grafting was measured.

Of the 19 osteolytic lesions detected pre-operatively, the first post-operative CT scan showed that four lesions were fully bone-grafted, ten lesions were partially bone-grafted and five lesions had no bone grafting during surgery. At a minimum of three years following surgery, all fully bone-grafted lesions remained full of bone- graft. Of the ten partially bone-grafted lesions, the osteolytic non-grafted zone decreased in volume in five lesions and five lesions remained unchanged. Of the five osteolytic lesions with no bone grafting, one lesion increased in volume, one lesion decreased in volume and three lesions remained unchanged. No new lesions were detected in any of the hips.

These preliminary results suggest that liner exchange surgery is effective in treating periacetabular osteolysis. Although bone grafting appears to aid in restoring bone stock, it is not essential in halting the progression of osteolysis, which likely results from the ongoing production of polyethylene particles in the joint.

This study aimed to compare the early clinical results and stem subsidence between three consecutive series of revision hip replacement cases with femoral impaction bone grafting to evaluate the effects of developments in technique. In the original series 1 (n=23), bone graft was irradiated at 25kG. I n series 2 (n=12) non-irradiated double washed graft and long stems were used as required.

In series 3 (n=21) modular tamps were used. Sensitive radiographic analysis techniques, EBRA and RSA, were used to measure stem subsidence. Major stem re-revision was required in five hips in series one, one hip in series two and no hips in series three. Two periprosthetic fractures occurred in series one. There was a statistically significant reduction in stem subsidence at the cement-bone interface at 12 months between series one and series two and three (p<0.05). In series three there was negligible stem subsidence at the cement-bone interface.

Technique developments in femoral impaction grafting, including the use of modular tamps designed to simply the procedure, yields excellent early clinical and radiographic results. Using RSA, we have shown that the fixation of the stems in bone is comparable to that achieved in primary hip replacement.

Introduction: In the past, surgeons have found impaction bone grafting technically difficult leading to its limited use. This paper reviews the long term results and developments in instrumentation and techniques aimed at simplifying femoral impaction grafting at revision hip replacement. The expanded indications for this procedure are reviewed and recent results of stem fixation using radiostereometric analysis (RSA) are reported.

Methods: The impaction bone grafting procedure, using a cemented collarless polished double taper stem, has been used in 66 hips (median patient age 63yrs) since 1993. The technique has undergone numerous developments. Modular tamps have been used in the last 29 hips and in the last seven hips, a pneumatic mechanical vibration device has been used in place of manual impaction. Stem subsidence at both the prosthesis-cement and cement-graft/bone interfaces was measured, more recently using radiostereometric analysis.

Results: There was a high early incidence of failure in the initial cases but there have been no further revisions for mechanical failure at up to 15 years. Technique developments have resulted in dramatic improvements in stem fixation achieved. In the modular tamp cases, the mean stem subsidence at the cement-bone interface at 12 months was 0.07mm (0 to 0.7mm) at 12 months. The stem subsidence in the hips where the mechanical vibration device was used was 0.05mm (0 to 0.06mm). Femoral impaction grafting offers special advantages in younger patients include standard femoral stem revision and at the second stage of two stage revision for infection.

Discussion and Conclusion: A stable cement-bone interface is achieved using advanced techniques of femoral impaction grafting that includes the use of modular impaction instruments. Early results of mechanical vibration impaction are encouraging. Femoral impaction grafting restores bone and new techniques simplify the femoral revision procedure.

Aim: To investigate the magnitude of revenue lost by the Department of Trauma and Orthopaedics at Ports-mouth Hospitals NHS Trust in 2007 as a result of providing outpatient viscosupplementation joint injections.

Methods: Data was collated on all outpatient intra-articular hyaluronic acid viscosupplementation performed by our department in 2007. Information on existing HRG tariffs for orthopaedic outpatient attendances as well as clinical coding of joint injections by our department was also gathered.

Results: The 2007/2008 tariffs for orthopaedic outpatient first and follow-up appointments were £147 and £73 respectively for adults, and £157 and £85 respectively for children (under 17 years of age). No additional mandatory tariff currently exists for joint injections performed in the outpatient setting. During our study period, the cost of a dose of viscosuplementation (Hyaluronic acid 60mg/ 3 ml) varied between £213 and £248. A total of 812 doses of viscosupplementation were administered to outpatients by our department resulting in pharmaceutical costs of £175,126. Only 751 cases of outpatient appointment with joint injection (all types) were recorded and coded by the department.

Conclusions:

As long as no mandatory DoH tariff exists for out-patient joint injections, outpatient viscosupplementation remains an expensive service for trusts to provide and may warrant rationalisation.

Introduction: A recent clinical study has suggested that topical GTN may improve the outcome of non-insertional Achilles tendinopathy. The mechanism for this improvement is obscure but is thought to be due to modulation of local nitric oxide (NO) levels. The purpose of this study was to assess the clinical and histological results of topical GTN for non-insertional Achilles tendonitis.

Methods: 40 patients with non-insertional Achilles tendonitis underwent standard non¬operative therapy. 20 patients also used topical GTN daily. AOFAS, AOS visual analogue scores and SF36 forms were completed pre-treatment and 3 months later. Patients who failed conservative treatment and underwent surgery had histological examination of the Achilles tendon and histochemical analysis for isomers of NOS (eNOS and iNOS) as a marker of NO production.

Results: There was an overall improvement in symptoms in both groups but no significant difference in the improvement between them – there was no additional benefit in using GTN patches. 4 patients also had to stop using patches within 3 weeks because of headaches.

Histological examination did not show any difference in collagen synthesis or remodelling between the 2 groups and there was no evidence of stimulated wound fibroblasts in the GTN group. There was no difference between the groups in the expression of eNOS or iNOS.

Conclusion: This study fails to demonstrate any improvement in symptoms when using GTN patches. There is no histological evidence that GTN promotes degenerate tendon to stimulate wound fibroblasts and increase collagen synthesis and remodelling. GTN patches do not appear to modulate the expression of NOS enzymes in diseased Achilles tendon. The use of GTN patches in the treatment of non-insertional Achilles tendonitis remains questionable and the role of NO as a mediator of inflammatory response remains elusive.

Introduction: A recent clinical study has suggested that topical GTN may improve the outcome of non-insertional Achilles tendinopathy. The mechanism for this improvement is obscure but is thought to be due to modulation of local nitric oxide (NO) levels. The purpose of this study was to assess the clinical and histological results of topical GTN for non-insertional Achilles tendonitis.

Methods: 40 patients with non-insertional Achilles tendonitis underwent standard non-operative therapy. 20 patients also used topical GTN daily. AOFAS, AOS visual analogue scores and SF36 forms were completed pre-treatment and 3 months later.

Patients who failed conservative treatment and underwent surgery had histological examination of achilles tendon and histochemical analysis for isomers of NOS (eNOS and iNOS) as a marker of NO production.

Results: There was an overall improvement in symptoms in both groups but no significant difference in the improvement bewtween them – there was no additional benefit in using GTN patches. 4 patients also had to stop using patches within 3 weeks because of headaches.

Histological examination did not show any difference in collagen synthesis or remodelling between the 2 groups and there was no evidence of stimulated wound fibroblasts in the GTN group. There was no difference between the groups in the expression of eNOS or iNOS.

Conclusion: This study fails to demonstrate any improvement in symptoms when using GTN patches. There is no histological evidence that GTN promotes degenerate tendon to stimulate wound fibroblasts and increase collagen synthesis and remodelling. GTN patches do not appear to modulate the expression of NOS enzymes in diseased Achilles tendon. The use of GTN patches in the treatment of non-insertional Achilles tendonitis remains questionable and the role of NO as a mediator of inflammatory response remains elusive.

Introduction: Understanding the forces across the human lower extremity joint is of considerable interest to the clinician. In the past, telemetric hip implants have been used to determine the forces across the hip joint, but the forces at the knee joint remain unvalidated. Recently, video fluoroscopy has been utilized to accurately determine the in vivo kinematics of human joints during various activities. The objective of this study was to predict muscle and joint forces from a mathematical model utilizing fluoroscopy as the input motion data.

Methods: Initially, two subjects (one with a total knee and a second with a total hip arthroplasty) were asked to perform normal gait and a deep knee bend while under fluoroscopic surveillance. A fully automated computer model-fitting algorithm was employed to convert the two dimensional (2D) fluoroscopic videos to 3D, and the in vivo motion of the implanted joint was determined. The kinematic data then served as input to a mathematical model in which the relative motions of the segments and the interaction forces between the foot and the ground were also treated as input data. The predicted forces for the implanted joint, quadriceps muscles and patellar ligament were plotted with respect to time, percent gait cycle and knee flexion angle.

Results: The resultant force at the implanted knee joint ranged from 2.0 to 3.5 times body weight (BS) during gait, depending on walking speed and walking motion. A forward leaning pattern resulted in significantly higher knee joint forces. During a deep knee bend, the knee joint forces could rise as high as 3.5 BW. The resultant forces at the implanted hip joint ranged from 2.0 to 4.0 BW, depending on the activity (greater during deep knee bend), walking speed, walking motion and the incidence of hip separation. The patellofemoral forces were minimal during walking (< 0.5 BW), but increased significantly with greater knee flexion to a maximum of 3.5 BW. The quadriceps muscle and patellar ligament forces were similar during gait (1.0 BW), but the quadriceps force was 40% greater in deep knee flexion.

Discussion: The present study has determined that the predicted hip joint forces are similar to telemetrically derived joint forces at the hip joint. Both knee, hip and muscle forces were greater in deep flexion compared to gait. A sensitivity analysis determined that the model is extremely sensitive to patellar ligament and patella motion. Altering the kinematics of the patella and patellar ligament could increase the knee joint forces by 1.0 BW.

Background: The necessity for radiographic follow up of infants with hip clicks and normal ultrasound is not clear.

Materials and methods: Infants referred to a paediatric hip clinic whose sole risk factor for DDH was a soft tissue hip click who had a normal ultrasound scan on initial assessment were identified. A follow up six month AP pelvis radiograph was assessed and acetabular index(A.I), position of femoral ossific nucleus and Shen-ton’s line measured. Infants with rotated pelvis Xrays were excluded. Inter-observer variability for acetabular index was measured and dysplasia defined according to Tonnis.

Results: 171 infants (193 clicking hips) met the criteria for inclusion. 48 male and 109 female with unilateral clicks (57 right, 64 left) and 36 bilateral clicks. 10 were excluded due to rotation of the AP pelvis Xray. Inter-observer error for A.I. was 4°. All A.I. were within normal ranges. Shenton’s line was unbroken and all hips were located.

Conclusion: In this study infants with soft tissue hip clicks and a normal ultrasound scan on initial assessment had a normal Xray at six months.

Background

Studies have investigated driver reaction time (DRT) following hip replacement, knee replacement and arthroscopy. This study tests the null hypothesis that there is no difference in DRT between patients after right ankle fracture and healthy controls.

Methods

Patients with right ankle fractures were recruited and DRT was measured using a simulator (time taken to achieve a brake pressure of 100 Newtons after a visual stimulus).

Inclusion criteria: drivers aged 17–70 years with right ankle fractures. Patients were tested when first out of plaster (T0), two, four and six weeks subsequently. DRT was compared to controls matched for age, sex and driving experience (paired T test). The percentage reaching a “safe” DRT (0.7 seconds) was determined.

Results

There were 25 patients: 18 conservatively and seven operatively treated fractures. The age range of patients was 19 to 69yrs (mean 41.4yrs), and of controls: 19 to 68yrs (mean 41.8yrs). Conservative group DRT was significantly slower than controls at T0 (p< 0.001) but not thereafter. Operative group DRT was significantly slower than controls at T0 (p< 0.003) and two weeks (p< 0.005) but not thereafter

Conclusion

Following right ankle fracture and removal of cast, DRT is initially prolonged. This study suggests a return to normality within two weeks after conservatively treated fractures and four weeks after operatively treated fractures.

Aim of Study: To evaluate the efficacy of pulsed radio-frequency ablation to the suprascapular nerve in patients with chronic shoulder pain secondary to cuff tear arthropathy.

Methods: Twelve patients with chronic shoulder pain secondary to cuff tear arthropathy were recruited following ethics approval. Mean age 68 yrs (60–83 yrs). The suprascapular notch was identified under image intensifier and the suprascapular nerve lesioned with pulsed radiofrequency ablation for 120 seconds. Patients were assessed with the Oxford and Constant Shoulder scores, Visual Analogue pain score and sleep score pre, 3 and 6 months post procedure. Statistical analysis was undertaken using the Friedman test (non parametric analysis of variance).

Results: Ten patients had an improvement in the visual analogue pain score and Constant score, 11 in the Oxford score and all an improvement in sleep pattern.

Conclusions: Shoulder pain was reduced in 10 out 12 patients up to 6 months post procedure. This procedure may be a useful adjunct in elderly patients with painful cuff tear arthropathy who are not suitable for surgery.