Objectives

Guidelines for the management of patients with metastatic bone disease (MBD) have been available to the orthopaedic community for more than a decade, with little improvement in service provision to this increasingly large patient group. Improvements in adjuvant and neo-adjuvant treatments have increased both the number and overall survival of patients living with MBD. As a consequence the incidence of complications of MBD presenting to surgeons has increased and is set to increase further. The British Orthopaedic Oncology Society (BOOS) are to publish more revised detailed guidelines on what represents ‘best practice’ in managing patients with MBD. This article is designed to coincide with and publicise new BOOS guidelines and once again champion the cause of patients with MBD.

We previously compared component alignment in total knee replacement using a computer-navigated technique with a conventional jig based method. Improved alignment was seen in the computer-navigated group (Beaver et al. JBJS 2004 (86B); 3: 372–7.). We also reported two-year results showing no difference in clinical outcome between the two groups (Beaver et al. JBJS 2007 (89B); 4: 477–80). We now report our five-year functional results comparing navigated and conventional total knee replacement. To our knowlege this represents the first Level 1 study comparing function in navigated and conventional total knee replacement at five years.

An original cohort of 71 patients undergoing Duracon (Stryker Orthopaedics, St. Leonards, Australia) total knee replacement without patellar resurfacing were prospectively randomised to undergo operation using computer navigation (Stryker Image Free Computer Navigation System (version 1.0; Stryker Orthopaedics))(n=35) or a jig-based method (n=36). The two groups were matched for age, gender, height, weight, BMI, ASA grade and pre-operative deformity. All operations were performed by a single surgeon. All patients underwent review in our Joint Replacement Assessment Clinic at 3, 6 and 12 months and at 2 and 5 years. Reviews were undertaken by senior physiotherapist blinded to participant status using validated outcome scoring tools (Knee Society Score, WOMAC Score and Short Form SF-36 Score). All patients underwent CT scanning of the implanted prosthesis as per Perth CT Knee Protocol to assess component alignment.

After 5 years 24 patients in the navigated group and 22 patients in the conventional group were available for review. At 5 years no statistically significant difference was seen in any of the aforementioned outcome scores when comparing navigated and conventional groups. No statistically significant difference was seen between 2- and 5-year results for either group.

Due to the relatively low numbers in each group these data were compared with retrospective cohorts of navigated (n=100) and conventional (n=70) Duracon total knee replacements performed outwith this study over the same 5-year period. WITHIN the retrospective cohorts no statistically significant differences were found when comparing any of the aforementioned outcome scores. In addition, when comparing parallel scores between prospective and retrospective groups again no statistically significant differences were identified.

At 5-years post-operatively the functional outcome between computer navigated and conventional total knee replacement appears to be no different despite the better alignment achieved using navigation.

We report our five-year functional results comparing navigated and conventional total knee replacement. To our knowlege this represents the first Level 1 study comparing function in navigated and conventional total knee replacement at five years.

An origianl cohort of 71 patients undergoing Duracon (Stryker Orthopaedics, St. Leonards, Australia) total knee replacement without patellar resurfacing were prospectively randomised to undergo operation using computer navigation (Stryker Image Free Computer Navigation System (version 1.0; Stryker Orthopaedics))(n=35) or a jig-based method (n=36). The two groups were matched for age, gender, height, weight, BMI, ASA grade abd pre-operative deformity. All operations were performed by a single surgeon. Reviews were undertaken by senior physiotherpist blinded to participant status using validated outcome scoring tools (Knee Society Score, WOMAC Score and Short Form SF-36 Score). All patients underwent CT scanning of the implanted prosthesis as per Perth CT Knee Protocol to assess component alignment.

After 5 years 24 patients in the navigated group and 22 patients in the conventional group were available for review. At 5 years no statistically significant difference was seen in any of the aforementioned outcome scores when comparing navigated and conventional groups. No statistically significant differencewas seen between 2- and 5-year results for either group.

Due to the relatively low numbers in each group these data were compared with retrospective cohorts of navigated (n=100) and conventional (n=70) Duracon total knee replacements performed outwith this study over the same 5-year period. WITHIN the retrospective cohorts no statistically significant differences were found when comparing any of the aforementioned outcome scores. In addition, when comparing parallel scores between prospective and retrospective groups again no statistically significant differences were identified.

At 5-years post-operatively the functional outcome between computer navigated and conventional total knee replacement appears to be no different despite the better alignment achieved using navigation.

In order to avoid complications of hip arthroplasty such as dislocation, impingement and eccentric liner wear accurate acetabular orientation is essential. The three-dimensional assessment of acetabular cup orientation using two-dimensional plain radiographs is inaccurate. The aim of this study was to develop a CT-based protocol to accurately measure postoperative acetabular cup inclination and anteversion establishing which bony reference points facilitate the most accurate estimation of these variables.

An all-polyethylene acetabular liner was implanted into a cadaveric acetabulum. A conventional pelvic CT scan was performed and reformatted images created in both functional and anterior pelvic planes. CT images were transferred to a Freedom-Plus Graphics software package enabling an identical, virtual, three dimensional model of the cadaveric pelvis to be created. Using a computer interface this model could be ‘palpated’, bony landmarks accurately identified and definitive acetabular cup orientation established. Using original CT scans, acetabular cup inclination and anteversion were measured on five occasions by eight radiographers using differing predetermined bony landmarks as reference points. The intra- and inter-observer variation in measurement of acetabular cup orientation using varying bony reference points was assessed in comparison to the previously elucidated definitive cup position. Statistical analysis using appropriate ANOVA models was performed in order to assess the significance of the results obtained.

Virtually derived definitive acetabular cup orientation was measured showing cup inclination and anteversion as 41.0 and 22.5 degrees respectively. Mean CT-based measurement of cup inclination and anteversion by eight radiographers were 43.1 and 20.8 degrees respectively. No statistically significant difference was found in intra- and inter-observer recorded results. No statistically significant differences were found when using different bony landmarks for the measurement of inclination and anteversion (p= 0.255 and 0.324 respectively).

CT assessment of acetabular component inclination and anteversion is accurate, reliable and reproducible when measured using differing bony landmarks as reference points. We recommend measuring acetabular inclination and anteversion from the inferior acetabular wall/teardrop and posterior ischium respectively. The Perth CT hip protocol is easily reproducible in the clinical setting both in the routine assessment of hip arthroplasty patients and as research tool. In our unit its initial application will be to validate commercially available hip navigation systems.

Aim: In order to avoid complications of hip arthroplasty such as dislocation, impingement and eccentric liner wear accurate acetabular orientation is essential. The three-dimensional assessment of acetabular cup orientation using two-dimensional plain radiographs is inaccurate. The aim of this study was to develop a CT-based protocol to accurately measure postoperative acetabular cup inclination and anteversion establishing which bony reference points facilitate the most accurate estimation of these variables.

Methods: An all-polyethylene acetabular liner was implanted into a cadaveric acetabulum. A conventional pelvic CT scan was performed and reformatted images created in both functional and anterior pelvic planes. CT images were transferred to a Freedom-Plus Graphics software package enabling an identical, virtual, three dimensional model of the cadaveric pelvis to be created. Using a computer interface this model could be ‘palpated’, bony landmarks accurately identified and definitive acetabular cup orientation established. Using original CT scans, acetabular cup inclination and anteversion were measured on five occasions by eight radiographers using differing predetermined bony landmarks as reference points. The intra- and inter-observer variation in measurement of acetabular cup orientation using varying bony reference points was assessed in comparison to the previously elucidated definitive cup position. Statistical analysis using appropriate ANOVA models was performed in order to assess the significance of the results obtained.

Results: Virtually derived definitive acetabular cup orientation was measured showing cup inclination and anteversion as 41.0 and 22.5 degrees respectively. Mean CT-based measurement of cup inclination and anteversion by eight radiographers were 43.1 and 20.8 degrees respectively. No statistically significant difference was found in intra- and inter-observer recorded results. No statistically significant differences were found when using different bony landmarks for the measurement of inclination and anteversion (p= 0.255 and 0.324 respectively).

Conclusions: CT assessment of acetabular component inclination and anteversion is accurate, reliable and reproducible when measured using differing bony landmarks as reference points. We recommend measuring acetabular inclination and anteversion from the inferior acetabular wall/teardrop and posterior ischium respectively. The Perth CT hip protocol is easily reproducible in the clinical setting both in the routine assessment of hip arthroplasty patients and as research tool. In our unit its initial application will be to validate commercially available hip navigation systems.

Introduction: We previously compared component alignment in total knee replacement using a computer-navigated technique with a conventional jig based method. Improved alignment was seen in the computer-navigated group (Beaver et al. JBJS 2004 (86B); 3: 372–7.). We also reported two-year results showing no difference in clinical outcome between the two groups (Beaver et al. JBJS 2007 (89B); 4: 477–80). We now report our five-year functional results comparing navigated and conventional total knee replacement. To our knowlege this represents the first Level 1 study comparing function in navigated and conventional total knee replacement at five years.

Methods: An original cohort of 71 patients undergoing Duracon (Stryker Orthopaedics, St. Leonards, Australia) total knee replacement without patellar resurfacing were prospectively randomised to undergo operation using computer navigation (Stryker Image Free Computer Navigation System (version 1.0; Stryker Orthopaedics))(n=35) or a jig-based method (n=36). The two groups were matched for age, gender, height, weight, BMI, ASA grade and pre-operative deformity. All operations were performed by a single surgeon. All patients underwent review in our Joint Replacement Assessment Clinic at 3, 6 and 12 months and at 2 and 5 years. Reviews were undertaken by senior physiotherpist blinded to participant status using validated outcome scoring tools (Knee Society Score, WOMAC Score and Short Form SF-36 Score). All patients underwent CT scanning of the implanted prosthesis as per Perth CT Knee Protocol to assess component alignment.

Results: After 5 years 24 patients in the navigated group and 22 patients in the conventional group were available for review. At 5 years no statistically significant difference was seen in any of the aforementioned outcome scores when comparing navigated and conventional groups. No statistically significant difference was seen between 2- and 5-year results for either group.

Due to the relatively low numbers in each group these data were compared with retrospective cohorts of navigated (n=100) and conventional (n=70) Duracon total knee replacements performed outwith this study over the same 5-year period. WITHIN the retrospective cohorts no statistically significant differences were found when comparing any of the aforementioned outcome scores. In addition, when comparing parallel scores between prospective and retrospective groups again no statistically significant differences were identified.

Conclusion: At 5-years post-operatively the functional outcome between computer navigated and conventional total knee replacement appears to be no different despite the better alignment achieved using navigation.

The aim of this study was to investigate genetic influences on the development and progression of tears of the rotator cuff. From a group of siblings of patients with a tear of the rotator cuff and of controls studied five years earlier, we determined the prevalence of tears of the rotator cuff with and without associated symptoms using ultrasound and the Oxford Shoulder Score.

In the five years since the previous assessment, three of 62 (4.8%) of the sibling group and one of the 68 (1.5%) controls had undergone shoulder surgery. These subjects were excluded from the follow-up.

Full-thickness tears were found in 39 of 62 (62.9%) siblings and in 15 of 68 (22.1%) controls (p = 0.0001). The relative risk of full-thickness tears in siblings as opposed to controls was 2.85 (95% confidence interval (CI) 1.75 to 4.64), compared to 2.42 (95% CI 1.77 to 3.31) five years earlier. Full-thickness tears associated with pain were found in 30 of 39 (76.9%) tears in the siblings and in eight of 15 (53.3%) tears in the controls (p = 0.045). The relative risk of pain associated with a full-thickness tear in the siblings as opposed to the controls was 1.44 (95% CI 2.04 to 8.28) (p = 0.045).

In the siblings group ten of 62 (16.1%) had progressed in terms of tear size or development compared to one of 68 (1.5%) in the control group which had increased in size.

Full-thickness rotator cuff tears in siblings are significantly more likely to progress over a period of five years than in a control population. This implies that genetic factors have a role, not only in the development but also in the progression of full-thickness tears of the rotator cuff.

Introduction: Optimal positioning of the femoral component in hip resurfacing is determined by accurate guidwire placement in the centre of the femoral neck. This can be a challenging procedure. The more extensile approach needed, patient size, the shape of the femoral head and the presences of osteophytes can all result in sub-optimal guidewire positioning and ultimately in varus insertion or femoral notching both of which have been shown to increase the risk of post-operative fracture, the commonest cause of implant failure. Various alignment guides are available but these are cumbersome and time consuming and their accuracy is highly operator dependent. Anecdotally, accuate guidewire insertion is regarded as the most challenging part of this procedure with heightened anxiety levels particularly when low down on the‘learning curve’.

Methods: We describe the technique, difficulties and learning curve experienced with the first ten navigated hip resurfacing procedures at our institution. Post-operative radiographs were obtained and randomly incorporated into a series of 40 post-operative resurfacing radiographs. Radiographic assessment was undertaken by a senior colleague with experience of over 600 resurfacing procedures (blinded to which cases utilised navigation) and classified as poor, satisfactory or good.

Results: The use of navigation in femoral resurfacing has a definite but short learning curve. It provides a means of achieving excellent alignment of the femoral component without any subjective increase in operation time. Anxiety levels associated with accurate guidewire positioning are greatly reduced. Navigation should offer benefits to all surgeons particularly those low down on the ‘learning curve’ for this procedure reducing the risk of femoral component malpositioning and early failure.

We describe three cases of fracture of the titanium JRI-Furlong hydroxyapatite-ceramic (HAC)-coated femoral component. We have examined previous case reports of failure of this stem and conclude that fracture may occur in two places, namely at the neck-shoulder junction and at the conical-distal cylindrical junction. These breakages are the result of fatigue in a metallurgically-proven normal femoral component. All the cases of failure of the femoral component have occurred in patients with a body mass index of more than 25 in whom a small component, either size 9 or 10, had been used.

In patients with a body mass index above normal size 9 components should be avoided and the femoral canal should be reamed sufficiently to accept a large femoral component to ensure that there is adequate metaphyseal fixation.

The purpose of this study was to investigate the role that genetics play in the aetiology and symptomatology of full thickness tears of the rotator cuff.

From a retrospective, cohort study of 205 patients diagnosed with full thickness rotator cuff tears, we determined, using ultrasound, the prevalence of full thickness tears in their 129 siblings. Using 150 spouses as controls, the relative risk of full thickness rotator cuff tear in siblings v controls was 2.42 (p< 0.0001, 95 % CI 1.77 to 3.31). The relative risk of symptomatic full thickness rotator cuff tear in siblings v controls was 4.65 (p< 0.0001, 95 % CI 2.42 to 8.63).

The significantly increased risk for tears in siblings implies that genetic factors play a major role in the development of full thickness tears of the rotator cuff.

The purpose of this study was to investigate the association of endocrine disease with calcific tendinitis and the effects that such disease has on its natural history.

A retrospective observational cohort study of 102 consecutive patients (125 shoulders) with calcific tendinitis is presented. Seventy-three (71.6 %) female, 29 (28.4 %) male. Compared with population prevalences, significant levels of endocrine disorders were found in our study cohort. Sixty-six patients (81 shoulders, 62 female (93.9 %), 4 male (6.1 %), mean age 50.3 years) with associated endocrine disease were compared with 36 patients (44 shoulders, 11 female (30.6 %), 25 male (69.4 %), mean age 52.4 years) without endocrine disease. The endocrine cohort were significantly younger than the non-endocrine cohort when symptoms started (mean 40.9 years and 46.9 years respectively, p=0.0026), had significantly longer natural histories (mean 79.7 months compared with 47.1 months, p=0.0015) and a significantly higher proportion underwent operative treatment (46.9 % compared with 22.7 %, p=0.0014).

Disorders of thyroid and oestrogen metabolism may contribute to calcific tendinitis aetiology. Classifying calcific tendinitis into Type I idiopathic and Type II secondary or endocrine-related aids prognosis and management.

From a retrospective, cohort study of 205 patients diagnosed with full-thickness tears of the rotator cuff, we determined, using ultrasound, the prevalence of such tears in their 129 siblings. Using 150 spouses as controls, the relative risk of full-thickness tears in siblings versus controls was 2.42 (95% CI 1.77 to 3.31). The relative risk of symptomatic full-thickness tears in siblings versus controls was 4.65 (95% CI 2.42 to 8.63).

The significantly increased risk for tears in siblings implies that genetic factors play a major role in the development of full-thickness tears of the rotator cuff.