A literature review of bone graft substitutes for spinal fusion was undertaken from peer reviewed journals to form a basis for guidelines on their clinical use.

A PubMed search of peer reviewed journals between Jan 1960 and Dec 2009 for clinical trials of bone graft substitutes in spinal fusion was performed. Emphasis was placed on RCTs. Small and duplicated RCTs were excluded. If no RCTs were available the next best clinical evidence was assessed. Data were extracted for fusion rates and complications.

Of 929 potential spinal fusion studies, 7 RCTs met the inclusion criteria for BMP-2, 3 for BMP-7, 2 for Tricalcium Phosphate and 1 for Tricalcium Phosphate/Hydroxyapatite (TCP/HA). No clinical RCTs were found for Demineralised Bone Matrix (DBM), Calcium Sulphate or Calcium Silicate. There is strong evidence that BMP-2 with TCP/HA achieves similar or higher spinal fusion rates than autograft alone. BMP-7 achieved similar results to autograft. 3 RCTs support the use of TCP or TCP/HA and autograft as a graft extender with similar results to autograft alone. The best clinical evidence to support the use of DBMs are case control studies. The osteoinductive potential of DBM appears to be very low however. There are no clinical studies to support the use of Calcium Silicate.

The current literature supports the use of BMP-2 with HA/TCP as a graft substitute. TCP or HA/TCP with Autograft is supported as a graft extender. There is not enough clinical evidence to support other bone graft substitutes.

This study did not require ethics approval and no financial support was received.

It is established good practice that hip and knee replacements should have regular follow-up and for the past seven years at the North Hampshire Hospital a local joint register has been used for this purpose and we compare this with results of the Swedish and UK national and the Trent Regional registries.

Since March 1999, all primary and revision hip and knee arthroplasties performed at North Hampshire Hospital, Basingstoke have been prospectively recorded onto a database set up by one of the senior authors (JMB). Data from patients entered in the first five years of the register were analysed. All patients have at least one year clinical and radiological review then a minimum of yearly postal follow-up. 3266 operations (1524 hips and 1742 knees) were performed under the care of 13 consultants. Osteoarthritis was the most common primary diagnosis in over 75% of hips and knees. Our revision burden was 7.5% (10.2% hips and 3.5% knees). As of 31/12/2006 6.2% of patients had died and 5.5% were lost to follow-up.

Revision rates were 1.5% and 1.4% for primary total hip and knee replacements respectively.

Our data analysis of revisions and patello-femoral replacements has allowed us to change our practice following local audit which is ongoing. Oxford scores at 2 years had improved from a mean of 19 and 21 pre-operatively to 40 and 39 for primary hips and knees respectively. Our costs are estimated at approximately £35 per patient for their lifetime on the register.

Compared to other registries:

Our dataset is more complete and comprehensive

It is established good practice that joint replacements should have regular follow-up and for the past seven years at the North Hampshire Hospital a local joint register has been used for this purpose and we compare this with results of the Swedish and UK national registries.

Since March 1999, all primary and revision knee arthroplasties performed at North Hampshire Hospital, Basingstoke have been prospectively recorded onto a database set up by one of the senior authors (JMB). Data from patients entered in the first six years of the register were analysed. All patients have at least one year clinical and radiological review then a minimum of yearly postal follow-up.

As of 31/12/2006, 2854 knee replacement procedures had been performed under the care of 13 consultants. OA was the most common diagnosis in over 75% of knees. 5.2% of patients had died and 4.6% were lost to follow-up. Our revision burden was 3.5% and we had a revision rate of 1.4% for primary total knee replacements. Audit of data for revisions and patello-femoral replacements has enabled us to change our practices. Mean length of stay was 7.2 days for primary total knee arthroplasty versus 4.0 days for unicompartmental knee arthroplasty and 5.4 days for patellofemoral replacement and mean flexion at discharge was 88.4, 93.7 and 88.7 degrees respectively. WOMAC and Oxford scores at 2 years had improved from a mean of 52 and 21 pre-operatively to 74 and 39 respectively for primary total knee arthroplasty. Our costs are estimated at approximately £35 per patient for their lifetime on the register.

Compared to other registries:

Our dataset is more complete and comprehensive

Magnification of anteroposterior radiographs of the pelvis is variable. To improve the accuracy of templating, reliable and radiographer-friendly methods of scaling are necessary. We assessed two methods of scaling digital radiographs of the pelvis: placing a coin of known diameter in the plane of interest between the patient’s thighs, and using a caliper to measure the bony width of the pelvis. A total of 39 patients who had recently undergone hemiarthroplasty of the hip or total hip replacement were enrolled in the study. The accuracy of the methods was assessed by comparing the actual diameter of the head of the prosthesis with the measured on-screen value. The coin method was within a mean of 1.12% (0% to 2.38%) of the actual measurement, the caliper group within 6.99% (0% to 16.67%). The coin method was significantly more accurate (p < 0.001). It was also reliable and radiographer friendly. We recommend it as the method of choice for scaling radiographs of the pelvis before hip surgery.

Increasingly hospitals are moving away from hard copy xrays to digital films. These offer advantages in terms of cost, film availability and decreased radiation dosage but concerns have been raised about the accuracy of these images for preoperative templating.

We reviewed the pre and post operative films in 20 patients with subcapital fractured necks of femur. Each film was reviewed by 3 different observers on 3 separate occasions. The sizes of the femoral head and the hemi-arthroplasty were measured using the PACS digital system. These were then compared with the known size of the implant.

A total of 360 measurements were taken. Intra and inter observer errors were low with intra class correlations of in excess of 0.98 and 0.99 respectively. The average magnification on the pre-op film was 117.6% (t=18.96, p< 0.0001) and on the post-op film 121.5% (t=22.18, p< 0.0001) with a range of 109.3% to 128.2%. The overall magnification was 119.6%.

We conclude that measurements made on PACS have a high repeatability and reproducibility but that PACS has a significant and wide variation in magnification errors. PACS should therefore not be used for templating until a way of standardising magnification has been found.

Introduction: To review the medium term outcome of staged surgery for treating recalcitrant idiopathic talipes equinovarus.

Methods: Between 1988 and 1995, we studied 91 club feet from a series of 120 recalcitrant feet in 86 patients requiring surgical treatment. The initial results have been reported previously and this cohort has been subsequently followed up for between 7 and 15years. The mean age at initial operation was 8.9 months. Surgery consisted of an initial plantar medial release followed two weeks later by a posterolateral release. This strategy was used specifically to address the problems of wound healing associated with single-stage surgery and to ascertain the rate of relapse after a two-stage procedure. The feet were classified preoperatively and prospectively into four grades according to the system suggested by Dimeglio et al. Reported relapse at last review was 0.0% in grade 2, 20.4% in grade 3 and 65.4% in grade 4 feet. The rate of overall relapse was 30.8%. At 7 to 15 year review an additional 9.1% in grade 2, 7.4% in grade 3, 11.5% in grade 4 had relapsed. Overall a further 8.8% had relapsed and were treated with further surgery. Functional outcome of the group remains good with 95.6% overall finding no restrictions to activities.

Conclusion: This review confirms that the strategy of staged surgery is supported in the medium term when considering rates of relapse and functional outcome.