There has been a significant increase in waiting times for elective surgical procedures in orthopaedic surgery as a result of the coronavirus disease 2019 (COVID-19) pandemic. As per the hospital policy, patients awaiting elective surgery for more than 52 weeks were offered a consultant-led harm review.

The aim of this study was to objectively assess the impact of this service on the field of foot and ankle surgery.

The data from harm review clinics at a District General Hospital related to patients waiting to undergo elective foot and ankle procedures in the year 2021 (wait time of more than 52 weeks) were assessed. Clinical data points like change in diagnosis, need for further investigations, and patients being taken off the waiting list were reviewed. The effect of the waiting time on patients’ mental health and their perception of the service was assessed as well.

A total of 72 patients awaiting foot and ankle procedures for more than 52 weeks were assessed as a part of the harm review service. It was noted that 25% of patients found that their symptoms had worsened while 66.1% perceived them to be unchanged. Twelve patients (16.9%) were sent for updated investigations. Twenty-one patients (29.5%) were taken off the waiting lists for various reasons with the most common one being other pressing health concerns; 9% of patients affirmed that the wait for surgery had a significant negative impact on their mental health.

This study concludes that the harm review service is a useful programme as it helps guide changes in the diagnosis and clinical picture. The service is found to be valuable by most patients, and its impact on the service specialities and multiple centres could be further assessed to draw broad conclusions.

We report a consecutive series of 200 patients who underwent Dynesys flexible stabilisation in the management of intractable lower back pain.

Methods: Patients were only accepted for the study if exhaustive conservative management had failed. They underwent operation between September 2000 and March 2003. Patients were divided into two groups:

Group 1 - Cases where implantation was used as an adjunct to other procedures including decompression, discectomy, or posterior lumbar interbody fusion. (32 male, 36 female, Mean age 56years (range 31–85)).

Group 2 - Patients with back pain and/or sciatica in which no other procedure was used. (65 male 67 female, Mean age 58years (range 27–86))

All patients were profiled prospectively using the Oswestry Disability Index (ODI), SF36 and Visual Analogue Scale (VAS). Patients were reviewed post-operatively using the same measures at 3, 6 & 12 months, and yearly thereafter. Follow-up was 95% at 2 to 5 years.

Results: Group 1 – Mean ODI fell from 54 pre-op to 24 at four years

Group 2 – Mean ODI fell from 49 pre-op to 28 at four years

Similar trends were observed in both groups with a fall in VAS and improvement in SF36.

Discussion: Indications can only be defined following clinical outcome. Perceived indications were based on contemporary understanding of the biomechanical effects of the construct. Further investigation of these variables is clearly desirable. Screw failures (15%) have detracted from the overall success. The virtue of flexible stabilisation over fusion includes avoidance of domino effect, reversibility and possible healing of a painful segment. The key issue is whether it is as effective and this requires prospective randomised controlled investigation, both against fusion, and conservative management. We feel our results in this difficult group of patients are reasonable and continue to use it in our practice.

Introduction: Porous Tantalum has been used in a variety of clinical settings since 1997. The use of trabecular metal backed prostheses and augments in the revision hip scenario is attractive due to the higher propensity of bony ingrowth than traditional porous coatings, and also the high coefficient of friction with bone leads to excellent press fit.

We describe the early results of twenty trabecular metal backed acetabular components in the revision setting.

Methods: From 2004, 20 patients received trabecular metal backed acetabular components as a revision hip procedure. The average age of the patients was 69 (42–84) yrs at the time of surgery. 4 patients had trabecular metal shells with cemented liners, 16 patients had modular trabecular metal implants. Structural allograft was used in 2 cases, trabcular metal augment in 1. Revision was for aseptic loosening in 17 cases, infection in 3. Acetabular defects were graded according to Paprosky as 2A(10), 2B(1), 2C(1), 3A(6) and 3B(2).

Fixation was augmented in all cups with at least one screw.

Patients were evaluated with standard x-rays for osteolysis and migration, Harris hip score, SF 36 and Oxford hip score.

Results: Average follow up was 12 months (24–5). 100% follow up was achieved. There were no complications directly related to the acetabular surgery.

There were no revisions. There are no progressive radiolucencies or detectable migration in any of the cups. There were no dislocations.

Conclusion: These early results suggest that trabecular metal backed acetabular components may be confidently used in the setting of hip revision surgery and show promise for the more severe defects for which a reliably reproducible solution has yet to be proven.

Introduction: The failure rate of cemented hip replacements is about 1% per year, mainly due to aseptic loosening. PMMA acts as a grout, therefore high pressure is needed to ensure fixation. Various plug designs are used to increase pressure. No data is available on their ability to occlude the canal. Factors including canal size, canal shape and cement viscosity may affect performance. The two aims of this study are (I) to determine the effect of cement viscosity, canal shape and canal size on the ability of cement restrictors to withstand cementation pressures, and (II) to determine which of the currently commercially available designs of cement restrictor is able to withstand cementation pressures, regardless of values of other potentially influential factors.

Methods: Artificial femoral canals were drilled in oak blocks. Circular canals had diameters of 12 or 17.5 mm. Oval canals had short axes equal to the diameter of the circular canals and long axes 1.3 times longer. This ellipticity of 1.3 is average for human femoral canals. One of four types of cement plugs (Hardinge, DePuy, UK; Exeter, Stryker, UK; Amber Flex, Summit Medical, UK; and OptiPlug, Scandimed, Sweden) was inserted. A pressure transducer was fitted in the canal just proximal to the plug. Bone cement (Palacos LV-40 low viscosity or Palacos R-20 high viscosity, both Schering Plough, UK) was prepared in a mixing device for 1 min at 21°C, and inserted in the artificial canal after 4 minutes. A materials testing machine was used to generate pressure in the cement. Cement pressure and plug position were measured. All combinations of canal size and shape, plug design and cement viscosity were pre-selected according to a D-optimal experimental design which was optimised to perform a four-way ANOVA to analyse the four main factors plus the interactions between plugs and the other three factors. A total of 23 experiments was performed.

Results: Average cement pressures achieved differed between implants (OptiPlug 448±66 kPa, Hardinge 142±66, Exeter 705±66, Amber Flex 475±72; p=0.002, all mean±SEM). They also differed between canal sizes (12 mm 529±49, 18 mm 356±47; p=0.03), canal shapes (Round 631±45, Oval 254±51; p=0.004) and cement viscosity (High 535±54, Low 350±43; p=0.03). No significant interaction between factors was found.

Discussion and Conclusion: All plugs resisted lower pressures in large canals, oval canals or with low viscosity cement. When comparing plugs, these different circumstances should therefore be taken into account. Of the four tested, the Exeter plug performed best in all adverse circumstances. The OptiPlug and AmberFlex, which are both resorbable, had an intermediate performance. The Hardinge plug performed worse.

Introduction Dynesys flexible stabilisation was developed by Giles Dubois in 1992, and first used in 1994 (1). Our unit has undertaken 375 operations to date. We report a consecutive series of 200 patients who underwent Dynesys flexible stabilisation in the management of intractable lower back pain.

Methods Access to our spinal service is exclusively from a back assessment centre run by a triaging nurse practitioner who works closely with the senior author. Conservative treatment is arranged by the centre, and includes physiotherapy to the point of failure. Patients were only accepted for the study if exhaustive conservative management had failed. They underwent operation by the senior author between September 2000 and March 2003. Patients were divided into two groups: Group 1 – Cases where implantation was used as an adjunct to other procedures including decompression, discectomy, or posterior lumbar interbody fusion. (32 male, 36 female, Mean age 56years (range 31–85)) Group 2 – Patients with back pain and/or sciatica in which no other procedure was used. (65 male 67 female, Mean age 58years (range 27–86)) All patients were profiled prospectively using the Oswestry Disability Index (ODI), SF36 and Visual Analogue Scale (VAS). Patients were reviewed post-operatively using the same measures at 3, 6 and 12 months, and yearly thereafter. Follow-up was 95% at 2 to 5 years.

Results Group 1 – Mean ODI fell from 54 pre-op to 24 at four years. Mean SF36 improved from 43 pre-op to 56 at four years Group 2 – Mean ODI fell from 49 pre-op to 28 at four years. Mean SF36 improved from 40 pre-op to 62 at four years. Similar trends were observed in both groups at five years with these favourable scores tending back towards pre-operative levels. Screw failures, either loosening or fracture, occurred at a rate of 15% over the follow-up period.

Discussion Our results support the use of flexible stabilisation as an alternative to spinal fusion. There is currently no consensus on absolute indications for the procedure however. Such indications can only be defined following clinical outcome. Perceived indications were based on contemporary understanding of the biomechanical effects of the construct. Further investigation of these variables is clearly desirable. Screw failures (15%) have detracted from the overall success, although the relationship between such failures and poor outcomes is complex and difficult to elucidate at the current time. The virtue of flexible stabilisation over fusion includes avoidance of domino effect, reversibility and possible healing of a painful segment. The key issue is whether flexible stabilisation is as effective and this requires prospective randomised controlled investigation, both against fusion, and against conservative management. We feel our results in this difficult group of patients are reasonable and continue to use it in our practice.

We report a consecutive series of 352 patients with back pain treated by Dynesys flexible stabilisation between July 2000 and November 2004, to include perceived indications, surgical techniques and complications. A detailed analysis of the first 120 cases with minimum follow up of 2 years is included. Our unit has undertaken 352 operations to date, and this communication reports all cases. Follow up is to 48 months.

All patients were profiled prospectively using the Oswestry Disability Index, Euroquol, SF36, Pain analogue scale, Pain chart and modified Zung. The same measuring instruments were used at review for which follow up was 100%

The procedure involves paired bilateral pedicle screw instrumentation above and below the level of perceived pathology, with each screw pair connected by load relieving carbopolyurethane flexible spacers, in conjunction with a tension band polyethylene cord passed through the spacer. This construct is then held under tension with screws in the main pedicle screws.

All patients are profiled at entry to the hospital service using a proforma which includes the measures outlined above. Conservative treatment is arranged by the centre, and includes physiotherapy to the point of failure. All our cases have failed conservative treatment before enrolling for surgery.

There was significant improvement in symptoms for most of the patients in the series. However clear patterns emerged as to those cases in which Dynesys is contra-indicated.

This is the largest series of cases reviewed so far in the literature.

Modern cementation techniques in hip arthroplasty are enhanced by the use of a cement restrictor. Failure of cemented hip replacements is commonly caused by aseptic loosening. Cement plugs which occlude the medullary canal are widely used to increase cementation pressures. Many plug types with variable performance exist. Ideally, plug performance should be sufficient regardless of other factors. All plug designs are circular in cross section, yet the vast majority of human femora are of oval section, the average ellipticity for human femora being 1.3. This study aims to determine (I) the effect of cement viscosity, canal shape and canal size on plug performance and (II) which designs of cement restrictor are able to withstand cementation pressures, regardless of values of other potentially influential factors.

Methods: Artificial femoral canals were drilled in oak blocks. Canals had diameters of 12 or 17.5 mm and oval or circular cross section. Four synthetic plug types (Hardinge, Exeter, Summit and OptiPlug.) and a bone plug (human allograft, Sulzer instrumentation) were tested. The effect of canal diameter, canal shape and low or regular cement viscosity was assessed.

Results: Maximal pressures achieved varied significantly between plugs. (OptiPlug 448±66 kPa, Hardinge 142±66, Exeter 705±66, Amber Flex 475±72, Bone plug 502±97 kPa; p=0.002, all mean±SEM). Al plugs performed worse in canals of increased size and of elliptical canal cross section (12 mm 529±49, 18 mm 356±47; p=0.03), canal shapes (Round 631±45, Oval 254±51; p=0.004). Cement viscosity had no statistical effect.

Discussion: Elliptical canal cross section and increased canal diameter adversely affects performance of all plug designs. Of the five tested, the Exeter and bone plugs performed best in all adverse circumstances. The Opti-Plug and AmberFlex, which are both resorbable, had an intermediate performance. The Hardinge plug performed worse. These factors should be considered when selecting plug design.

Aim: The purpose of this study was to determine the long-term results of tibial tubercle osteotomy in a series of revision and difþcult primary total knee replacements. Method: A consecutive series of total knee replacements in which tibial tubercle osteotomy was performed were reviewed retrospectively. 18 revision knees and 5 primary knee replacements were identiþed. All of the operations performed were by the senior author. The technique was the same in all cases, involving 9cm osteotomy with screw þxation. In cases with marked restricted ßexion and patella baja, the tubercle was deliberately moved proximally to gain length in the extensor mechanism. In 3 revisions the index component had a porous in-growth stem. The osteotomy facilitated explantation. Results: All osteotomies had united by 8–12 weeks. Range of movement increased on average 45û in the revisions, and by 60û in the primaries. An active extensor lag in 4 cases (all deliberate proximalisations) post operatively which all recovered.5 patients underwent MUA for stiffness at 12 weeks. Conclusion: Tibial tubercle osteotomy allows predictable extensile exposure in primary and revision total knee replacement. It also allows lengthening of a contracted extensor mechanism. Union rate was excellent and complications low. It allows preservation of the quadriceps mechanism and a normal postoperative rehabilitation.