In 1823 J. White excised the head. In 1887 a German surgeon replaced the head with ivory. Interposition arthroplasties were common after WW1. Short-stemmed head replacing prosthesis were developed after WW2. Moores and Thompson designed a more stable intramedullary stem. Acetabular erosion was troublesome—and so replacing both surfaces started in the late 1950s using Teflon cup and metal femur. Unfortunately, these quickly became loose due to wear or sepsis. In 1960, Charnley used a polyethylene cup and stainless-steel femur and fixed both with dental cement. This ‘low friction arthroplast’ became a routine procedure after 1961. In the 1970s there were many ‘Charnley look-alike’ prosthesis with similar problems of poly-wear, granulomas and cysts causing bone loss, loosening, breakages and infection. Resurfacing with two thin shells was developed to reduce the foreign material, the bone resection and the cement used. Unfortunately, neck fractures, avascular necrosis and excessive wear of the poly shell were common. Despite operating theatres with laminar flow of sterile air, space suits and improved cementing techniques, the same problems occurred. To avoid poly and cement, Mittelmayer developed a ceramic screw cup, which did not require cement. Although some screws migrated, they did not wear. Because the un-cemented metal stem remained fixed solid to the femur, un-cemented metal cups and stems were developed. To avoid the poly-wear, ceramic liners became popular.

To provide the active patients with a stable joint that requires no restriction in physical activity, a large head in a large cup is desirable. Unfortunately, the large metal-on-metal resurfacing prosthesis produce metal wear ions and nanoparticles which can form hypersensitivities, cysts and pseudotumours. Computer assisted navigation to ensure correct positioning of the prosthetic components is obviously useful for surgeons that use incisions too small to see enough to be certain of the cups position. Presently, articular cartilage research is progressing rapidly and by 2020 most arthritic hip joints will be arthroscopically debrided and resurfaced by an injection of genetically engineered articular cartilage stem cells.

About 20% of orthopaedic surgery is foot and ankle. This area of orthopaedics has undergone huge changes in last few decades. Not that long ago we were still performing Keller's procedure for bunions and using a Charnley clamp for ankle fusions. It is becoming increasingly more difficult for the general orthopaedic surgeon to stay abreast of current surgical treatment.

Some of the newer foot and ankle surgical surgical techniques will be discussed. Ankle arthroplasty is undergoing a period of revival. This is a difficult procedure with results not as reliable as hip and knee arthroplasty and I would not recommend it to the occasional foot and ankle surgeon. Ankle arthroscopy is now a commonly performed procedure and with the right equipment is a procedure that is useful to the generalist.

Foot and ankle fusion are now performed with rigid internal fixation. The actual procedures are not difficult but it does require a reasonable amount of experience to obtain the correct position of the fusion. Bunion surgery is commonly done and can result in disappointment for all. The newer surgical options for the correction of hallux valgus will be discussed.

Initially, all surgeons in Australia were generalists and those with an interest in the anatomy of the hand performed hand surgery. Early hand surgeons, such as Benjamin Rank, excelled and Rank and Wakefield's Textbook of Hand Surgery was widely used throughout the world.

Eventually, groups of like-minded surgeons formed the Australian Hand Club in 1972, which subsequently became formalised as The Australian Hand Surgery Society (AHSS), in 2001.

A very high standard of hand surgery has been achieved in Australia, with most hand surgeons having trained in either plastic surgery or orthopaedic surgery, and then further trained in Fellowships in Europe or North America. Bernard O'Brien and John Hueston achieved international recognition in the field of microsurgery and Dupuytren's surgery. Wayne Morrison has been responsible for pioneering work in toe–to–hand transfer and basic research. Tim Herbert changed the way fractures of the scaphoid are managed throughout the world.

In 2007 the AHSS commenced a Travelling Fellowship Programme to facilitate an increased involvement in Australia in academic hand surgery and to foster contacts between hand surgeons of the future. At the present time, the AHSS is concentrating on education and training in order to raise the overall standard of management of hand surgery, particularly in relation to after hours' trauma. This is particularly necessary in rural and regional areas where hand surgery has traditionally been treated by occasional practitioners.

There is a risk that hand surgery falls between the two stools of plastic surgery and orthopaedic surgery and the AHSS wishes to further formalise training and education within the Royal Australasian College of Surgeons (RACS) as a single training stream in the future.

There are potential threats both within and without, with safe working hours a particular threat in relation to reducing both the quantity and quality of training. The future will almost certainly involve greater emphasis on biomaterials and prosthetic compounds, but trying to ensure a uniformly high standard of hand surgery management throughout the country will remain as a primary focus.

As the victor records his version of history, so I accept the privilege to discuss my version of a history of knee surgery.

I would like to share my experiences of the Australian Knee Society—the concept and founders, the characters, and the benefits to me as a regional specialist.

I have, of course, some favourite hobby horses and I will develop some of these involving clinical topics—arthroscopy, ligament arthroplasty and patella surgery—as part of a discussion of my personal journey to finding a balance and personal happiness, and an empathetic approach to orthopaedic practice.

The inquisitive and skeptical nature of humans drives research. Questions continue to be raised from a basic, applied and clinical perspective related to our areas of interest—be it molecular biology, biomaterials, biomechanics or clinical. The future of research will only be realised by understanding the past and the planning a pathway for the future. Translating advances in the laboratory to the patient are key to improving clinical outcomes. The future holds great promise, as long as we continue to challenge ourselves and ask those fundamental questions of ‘why’ and ‘how’ things happen.

Orthopaedic Outreach Fund is to a large extent the humanitarian face of Australian orthopaedic surgery. Outreach is a registered charitable organisation.

Outreach works closely with Australian Government aid projects, as administered by the College of Surgeons, including the Pacific Islands Projects, Ausaid to PNG and the Australia Timor-Leste Program of Assistance for Specialist Services (ATLASS). In addition, Outreach runs its own projects with a particular emphasis on education and capacity building in developing countries. Finally, Outreach ‘facilitates’ individual surgeon's personal projects, helping with fund raising and the organisation of team visits to host countries.

Outreach's work could not be possible without the support of the Australian Orthopaedic Association (AOA), Royal Australasian College of Surgeons (RACS), Rotary International and the Orthopaedic Industry. Last but not least, the pro-bono contribution from surgeons, anaesthetists, nurses and physiotherapists is the essential ingredient that makes it all happen—and there is much to do!

The childhood hip conditions of Developmental Dysplasia, Legg-Calve-Perthes Disease and Slipped Capital Femoral Epiphysis have a wide spectrum of anatomical outcomes following childhood treatment; ranging from morphologies, which result in normal hip function throughout life, to severely deranged morphologies, which result in pain and disability during childhood and adolescence. Some of these outcomes are as a result of well-intentioned interventions that result in catastrophic complications.

In 2003, after years of working with impingement complicating periacetabular osteotomies and building on the work of William Harris, Reinhold Ganz published his concepts of ‘cam’ and ‘pincer’ hip impingement, and how these anatomical morphologies resulted in hip arthritis in adulthood. These concepts of impingement were added to his previous published work on hip instability to provide a comprehensive theory describing how hip arthritis develops on the basis of anatomical abnormalities. Surgical techniques have been developed to address each of these morphological pathologies.

Ganz's concepts of hip impingement and instability may be applied to severe paediatric hip deformities to direct reconstructive joint preserving surgery to both the femur and the acetabulum. Ganz's surgical approaches have also been refined for use in paediatric hip surgery to allow radical reshaping salvage osteotomies to be performed on the developing femoral head with minimal risk of the devastating consequence of vascular Necrosis.

Thirty years ago, rotator cuff surgery was exceedingly uncommon and shoulder arthroplasty almost unknown. Surgery for shoulder instability was largely empirical, non-anatomical and frequently unsuccessful.

With the help of arthroscopy and MR scanning, a complex array of labral, ligament and tendon pathologies can now be recognised and treated, precisely and predictably. Anatomy-restoring arthroscopic techniques have largely replaced open stabilisation surgery. As life expectancy rises and citizens remain active into their seventh and eighth decades, the call for rotator cuff surgery has risen dramatically. Complex tendon transfers have expanded the indications for cuff surgery. Open repair has in part been supplanted by increasingly sophisticated arthroscopic techniques. The potential use of orthobiologics and stem cells promises further advances in the foreseeable future.

Following the successful development of humeral hemiarthroplasty, and later of total shoulder replacement, surgical techniques and clinical indications for arthroplasty are now well refined. Predictable outcomes have been further enhanced by the present generation of ‘anatomic’ prostheses. More recently, the ‘rediscovery’ and improvement of semi-constrained (reverse) prostheses has transformed the previously dismal outlook for sufferers of cuff arthropathy and similar conditions.

Many Australian Orthopaedic Association trainees undertake post-specialisation fellowships in shoulder surgery, both at home and abroad, and there is a steady flow of young overseas fellows through Australian shoulder units. The Shoulder and Elbow Society of Australia, founded in 1990 as a loose grouping of interested colleagues, now boasts over 70 active members. Australian surgeons and researchers are well represented in the prestigious Journal of Shoulder and Elbow Surgery and Australian shoulder surgery has come of age.

To date, the goals of spinal surgery have been easy to define: to ‘decompress’, to ‘realign’ and to ‘fuse’. More recent refinements have been directed towards two new goals: to ‘preserve’ and to ‘protect’.

Preservation of the enveloping soft tissues minimises bleeding and scarring, and reduces pain. This can be facilitated by minimal and alternate access surgery, using techniques such as percutaneous pedicle screw insertion, transpsoas and transsacral vertebral access and endoscopic scoliosis correction. Protection of the neural elements improves the safety of spinal surgery and allows the surgeon to perform more complex procedures. Methods have been developed to accurately guide the surgeon to the target structure or pathology while avoiding neural structures, and to monitor spinal cord and nerve function. Both approaches allow safer instrumentation and deformity correction.

In the past, protection of important structures has been achieved by wide exposures, sacrificing preservation of soft tissues. As this shortcoming has been recognised, techniques have been developed that have radically reduced wound size but often compromised vision and put neurovascular elements at risk. Refinements have attempted to balance these goals. At present, we have a variety of techniques available to us but were hare hampered by cost and complexity. The future will hopefully bring further improvements but perhaps new ideas and approaches that challenge our current concepts of invasive spinal surgery.

In 1788, a significant date for Australia, and also for Sir Percival Pott and us, as it was the year Sir Pott fractured his ankle. Wars, as well as individuals like Sir Pott, play a strong role in trauma technique advancement, exemplified by the Thomas splint and the Kuntscher nail. Over the 50 years of my clinical lifetime, a significant period of rapid advancement in knowledge and technology very fortunately occurred and with which I was involved in.

In the 1960s, the strong and long ingrained conservative influence of the British Orthopaedic school of trauma care was challenged by the equally long-established but more aggressive European school, in the form of the Swiss AO Foundation (Arbeitsgemeinschaft für Osteosynthesefragen). Australia was ‘a ham in the sandwich’. Which way to go? The pilgrimage to Davos produced some early converts. Phillip Segelov and I were among those and we returned three times to become educators and trainers for the AO Foundation.

We convened AO courses in Australia, with our St George-made colour videos (before the Swiss). In 1980 the St George Skills Laboratory was born and became the venue for ongoing technique education. This became known (by some, and not always as a compliment) as the ‘Phil and Bill show’. Almost all who underwent this early training, including Phil and Bill, experienced an initial phase of doubt and rejection. This was metallic madness. However, we had new teachers, new parents, and we learnt to respect them. Interesting and controversial days were to follow.

Unfortunately, a number of our very senior Australian colleagues clearly felt deeply confronted. They clinically rejected and in open meeting condemned these aggressive concepts. We were very concerned. This unfortunate circumstance subsided only slowly over time and in concert with the decline of their influence.

Interestingly, today, successful trauma unit bed administration and outcomes depend significantly on our use of these concepts and methods. We could not practice modern traumas care without them.

Prior to the 1970s, almost all bone sarcomas were treated by amputation.

The first distal femoral resection and reconstruction was performed in 1973 by Dr Kenneth C Francis at the Memorial Sloan-Kettering Cancer Centre in New York. Since that time, limb-sparing surgery for primary sarcoma has become the mainstay of sarcoma surgery throughout the world. Initially, the use of mega-prostheses of increasing complexity, involving all the major long bones and both pelvic and shoulder girdles, was popularised. In the early 1980s, wide use of massive allograft reconstructions became widespread in both Europe and in multiple centres in the USA and UK.

Since that time, increasing complexity in the design of prostheses has allowed for increasing functional reconstructions to occur, but the use of allograft has become less popular due to the development of late graft failures of patients survive past ten years.

Fracture rates approaching 50% at 10 years are reported, and thus, other forms of reconstruction are being sought. Techniques of leg lengthening, and bone docking procedures to replace segmental bone loss to tumour are now employed, but the use of biological vascularised reconstructions are becoming more common as patient survivorship increases with children surviving their disease.

The use of vascularised fibular graft, composite grafts and re-implantation of extra-corporeally irradiated bone segments are becoming more popular.

The improvement in survivorship brought about the use of chemotherapy is producing a population of patients with at least a 65% ten year survivorship, and as many of these patients are children, limb salvage procedures have to survive for many decades.

The use of growing prostheses for children have been available for some 25 years, first commencing in Stanmore, UK, with mechanical lengthening prostheses. Non-invasive electro-magnetic induction coil mechanisms are now available to produce leg lengthening, with out the need for open surgery.

Whilst many of these techniques have great success, the area of soft tissue attachment to metallic prostheses has not been solved, and reattachment of muscles is of great importance, of course, for return of function.

There are great problems in the shoulder joints where sacrifice of rotator cuff muscles is necessary in obtaining adequate disease clearance at the time of primary resection, and a stable shoulder construct, with good movement, has yet to emerge. Similar areas of great difficultly remain the peri-acetabular and sacro-iliac resections in the pelvis.

Perhaps the real future of the art of limb salvage will be in the reconstruction of failed major joint replacements where there is great loss of bone stock, and already massive tumour prostheses are providing a salvage pathway for failed standard joint replacement.

The final future for limb salvage, however, may not rest with increasing surgical complexity and innovation, but with the development of molecular biology and specific targeted treatments, according to the cytogenetics of a particular tumour.

We are on the threshold of yet another quantum change in the approach to cancer management; just as chemotherapy brought a tremendous change in the 1970s, molecular biology is the frontier to make much of the current limb salvage surgery that is performed redundant.

This fiducial role implies special duties imposed where one person (the fiduciary) must act in the best interest of the other (the beneficiary), even if it is in the fiduciary's detriment to do so.

While a doctor/patient relationship is not generally a fiduciary relationship, part of the relationship may involve a fiduciary role for the surgeon.

The fiduciary duties include:

Keeping a patient's medical information confidential.

While the doctor–patient relationship requires a duty of care, a fiduciary duty implies a duty of loyalty and honesty. As per using navigation techniques in hip and knee surgery, the surgeon can use the above fiducials (markers) to navigate his way through his fiduciary role in managing patients; whether it is disclosing emergent risks arising during treatment, with new products or during clinical trials.

Fiduciary roles are independent of informed consent, which occurs before the event, but mitigate a risk that occurs after the event. It is an inbuilt quality assurance mechanism in risk management.

With the protection of crocodile species in Far North Queensland it was proposed that an increase in crocodile related injuries could be expected. The aim of this paper was to prospectively follow any crocodile injuries admitted for treatment at the Cairns Base Hospital and to establish a treatment regime for these injuries.

A database was created in 2000 and patients admitted for treatment at the Cairns Base Hospital were followed prospectively. Prior to 2000 chart reviews were undertaken back to 1993. The injuries sustained, place of attack, wound infections and treatments were reviewed. Approval for this study was obtained from the ethics committee.

The majority of patients treated over that period of time were attacked in the wet season and occurred in the water or at the waters edge. All of the injuries were related to the extremities, except for a single case of multiple abdominal lacerations. All wounds were contaminated with positive swab cultures at the time of their initial debridement. Four of these wounds developed a deep infection. In the majority of wounds adequate debridement, temporary stabilisation, and subsequent definitive surgery and skin coverage (coupled with appropriate antibiotic coverage) related in fracture healing.

Avoidance of attack is the best form of defence. If exposed to crocodile wounds then surgical debridement, antibiotic coverage with keflin, gentamicin and metronidazole and delayed stabilsation will result in successful fracture and soft tissue healing.

Ankle sprains have been shown to be the most common sports related injury. Ankle sprain may be classified into low ankle sprain or high ankle sprain.

Low ankle sprain is a result of lateral ligament disruption. It accounts for approximately 25% of all sports related injuries. The ankle lateral ligament complex consists of three important structures, namely the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). The ATFL is the weakest and most easily injured of these ligaments. It is often described as a thickening of the anterolateral ankle capsule. The ATFL sits in a vertical alignment when the ankle is plantarflexed and thus is the main stabiliser against an inversion stress. T he CFL is extracapsular and spans both the tibiotalar and talocalcaneal joints. The CFL is vertical when the ankle is dorsiflexed. An isolated injury to the CFL is uncommon.

Early diagnosis, functional management and rehabilitation are the keys to preventing chronic ankle instability following a lateral ligament injury. Surgery does not play a major role in the management of acute ligament ruptures. Despite this up to 20% of patients will develop chronic instability and pain with activities of daily living and sport especially on uneven terrain. Anatomic reconstruction for this group of patients is associated with 90% good to excellent results. It is important that surgery is followed by functional rehabilitation. One of the aims of surgery in patients with recurrent instability is to prevent the development of ankle arthritis. It should be noted that the results of surgical reconstruction are less predictable in patients with greater than 10 year history of instability. Careful assessment of the patient with chronic instability is required to exclude other associated conditions such as cavovarus deformity or generalised ligamentous laxity as these conditions would need to be addressed in order to obtain a successful outcome.

High ankle sprain is the result of injury to the syndesmotic ligaments. The distal tibiofibular joint is comprised of the tibia and fibula, which are connected by anterior inferior tibiofibular ligament, interosseous ligament and the posterior inferior tibiofibular ligament (superficial and deep components). The mechanism of injury is external rotation and hyperdorsiflexion. High index of suspicion is required as syndesmotic injuries can occur in association of low ankle sprains. The clinical tests used in diagnosing syndesmotic injuries (external rotation, squeeze, fibular translation and cotton) do not have a high predictive value. It is important to exclude a high fibular fracture. Plain radiographs are required. If the radiograph is normal then MRI scan is highly accurate in detecting the syndesmotic disruption. Functional rehabilitation is required in patients with stable injuries. Syndesmotic injuries are often associated with a prolonged recovery time. Accurate reduction and operative stabilisation is associated with the best functional outcome in patients with an unstable syndesmotic injury. Stabilisation has traditionally been with screw fixation. Suture button syndesmosis fixation is an alternative. Early short-term reviews show this alternate technique has improved patient outcomes and faster rehabilitation without the need for implant removal.

In most cases the etiology of Hallux rigidus is unknown. The purpose of this presentation is to discuss the classification of hallux rigidus, as well as the treatment options for every stage.

Treatment suggestions should be individualised depending not only on the grade of the hallux rigidus, but also the patient's expectations. These include expectations regarding footwear, recreational activities and the potential of further surgeries depending upon the initial choice of treatment.

Emphasis will be placed on joint preserving options, including adding a Moberg osteotomy to proximal halangs to increase perceived dorsiflexion of the great toe.

Operative repair of tendo Achilles ruptures is associated with a lower re-rupture rate. A medial approach is made and the tendon ends debrided. The tendon is repaired with two non-absorbable core sutures and an absorbable perimeter suture, with care to avoid any lengthening of the musculotendinous unit. The tendon sheath is repaired, with a deep fascial releasing incision to allow apposition of the edges if necessary. In the case of insertional avulsions, the avulsed bony fragment is excised and the tendon repaired to bone with a 3.5 mm corkscrew anchor and non-absorbable suture.

A frontslab is applied with the ankle in gravitational equinus and worn for eight weeks with protected weight bearing. Sutures are removed at 10 to 14 days and active range of motion commenced. At eight weeks, weight bearing as tolerated is allowed with a heel raise and physiotherapy for calf strenghthening is commenced. Recovery of full strength will take one year.

Worldwide, total ankle replacement is being more frequently offered as an alternative to ankle fusion. Most reports in the literature come from single centres with surgery performed by ‘high volume’ foot and ankle surgeons. We describe the New Zealand experience with the Scandinavian Total Ankle Replacement (STAR).

Fifty-two STARs in 49 patients were implanted between September 1998 and May 2005. Eleven surgeons performed between one and thirteen of the operations. Of the 49 patients five were deceased and five refused to participate in the study. The average age at surgery was 64.9 years (range 46-80). There were 26 males and 13 females. The average follow up was 58.2 months. Of the 41 ankles available for review 11 had been revised or fused (27%) at an average of 42 months post surgery. Of the remaining 30 intact ankles recent radiographs were available on all ankles. Of the retained primary ankles, the mean Oxford ankle score was 25.6. This scale has a range from 12, for an asymptomatic ankle, to 60. The mean WOMAC score was 18.9, the SF-12 PH 42 and the SF-12 MH 54. The scores were substantially worse for the group who had been revised or arthrodesed. Perioperative x-ray findings demonstrated intraoperative malleolar fracture occurred in seven patients including one with a complete saw cut transection of the medial malleolus and one who had sustained fractures of both malleoli. The tibial component was undersised in five patients and the talus oversized in at least three patients.

Of the 11 revision cases, two were bearing exchanges only. Nine involved either a major revision procedure or tibiotalocalcaneal arthrodesis for subsidence of malaligned components usually in the presence of peri-implant fracture. Of the unrevised cases, the latest x-rays did not demonstrate any significant osteolysis or increased lucent lines. Five cases demonstrated subtle talar or tibial component subsidence when compared with earlier radiographs. Despite overall satisfactory outcomes in the majority of patients the perioperative complication rate and revision rate in infrequent users is concerning. There may be implant and instrumentation elements, which also contribute to these suboptimal outcomes.

Level of evidence IV, retrospective review.

Hallux valgus continues to frustrate foot and ankle surgeons the world over.

The condition is mostly clear in its aetiology but unclear in its pathogenesis. The key, as in all surgery, is decision making, patient selection and to have many surgical options available.

The key things to consider are: joint congruency, the presence of arthritis, the presence of metatarsus adductus, the intermetatarsal angle, the hallux valgus angle and the presence of interphalangeal deformity. I consider true hypermobility of the first ray and Achilles tendon tightness to be less important factors. Patient expectations are particularly important as most patients with hallux valgus are women who want to wear high-heeled shoes!

The most successful operations consist of a combination of soft tissue and bony procedures. The most common error in bunion surgery, in my opinion, is the use of a procedure with inadequate power to correct the deformity. When the joint is markedly arthritic and deformed an arthrodesis is the procedure of choice.

I will discuss the above points in the lecture.

Crossover second toe deformity is a multiplanar deformity derived from multiple etiologies with the common endpoint of metatarsophalangeal joint instability. The stability of the joint is compromised through laxity of the volar plate, secondary rupture of the lateral collateral ligament, and ultimately dorsal subluxation or dislocation of the metatarsophalangeal joint. The digital malalignment often includes a hammertoe deformity, but should not be confused with a routine clawtoe. Elimination of alternative diagnoses relies on precise palpation to negate Morton's neuroma, 2nd metatarsalgia, Freiberg's infraction, and 2nd metatarsal stress fracture. Radiographs assist in the diagnosis in not only eliminating the above mentioned differential diagnoses, but also in evaluating confounding anatomic variables such as hallux valgus, metatarsus primus varus, and metatarsal length.

These variables may necessitate additional osteotomies in conjunction with ligament reconstruction to minimise recurrence. Operative intervention has revealed long term failure of secondary ligament reconstruction, mandating tendon transfers such as the flexor-to-extensor and the extensor digitorum brevis to support the repair. We will explore these techniques and subsequent modifications to achieve patient satisfaction.

The first MTP Joint (MTPJ) is critical in normal gait. MTPJ replacements treat the articular surface as a hemisphere, as it appears radiographically. In reality the articular surface has two grooves to accommodate sesamoids and facilitate a better range of motion. We compare a standard hemispherical and a modified grooved implant. Six cadaver feet were implanted with Toefit 1st MTPJ replacements and sequentially four different metatarsal head implants. Two of the metatarsal heads had grooves. The intact joints were used as a baseline for comparison, with their measurements taken before implantation. Each construct had a standard dorsiflexion force applied (50N).

Flexion angle was measured on lateral radiographs. Contact pressure and area were measured with a pressure transducer (Tekscan I-Scan 6900 electronic pressure sensor).

The anatomical (grooved) implants showed higher flexion angles and lower contact pressures in each case although there were too few trials to reach statistical significance.

Results suggest a tendency towards better flexion and contact pressure characteristics in a more anatomical device. This may lead to better clinical outcomes for 1st MTPJ replacements.

Tarsometatarsal arthritis must be evaluated in conjunction with naviculocuneiform joint arthritis, as the two generally coexist. Primary osteoarthritis or systemic arthritis generally leads to uncomplicated non-deformity correction through arthrodesis.

Challenges in correction become more pronounced following Lisfranc injury, where deformity and ligament instability introduce malalignment that mandates osteotomies to correct deformity. Diagnosis hinges on both CT scan data and selective diagnostic injections under fluoroscopy. The surgeon must simultaneously consider minimising bone resection to lessen the impact of metatarsal shortening. In addition, the three columns of the foot must be respected with reference to midfoot arthrodesis rules, introducing challenges in operative reconstruction as the lateral column mandates preserved flexibility.

In addition, collapse at the midfoot often leads to a rigid pes planovalgus deformity, and the surgeon must consider when it is appropriate to add a medial slide calcaneal osteotomy and gastrocnemius recession.

Finally, naviculocuneiform joint arthrodesis, if required, introduces significant technical challenges in both alignment and fixation that will be addressed.

The surgical management of subtalar arthritis will be discussed including: clinical assessment, appropriate imaging and the range of surgical techniques, which may need to be utilised.

Hindfoot fusions are not new and can be a very valuable tool to address a variety of hindfoot problems. It is, however, not a procedure without significant issues. With the combination of a subtalar and talo-navicular fusion most of the ability to compensate for uneven terrain is lost, as is the ability to compensate for minor misalignments in the foot itself.

It is therefore extremely important to be diligent in planning and execution of a triple arthrodesis. Deformities should be corrected, but not over-corrected. It is seldom that in situ fusions of deformities are indicated. Stable internal fixation is recommended to avoid loss of correction in the healing period. Indications, surgical approach and rationale for treatment will be discussed.

The forefoot is affected less frequently than the hindfoot in rheumatoid patients but comes to surgical reconstruction more frequently.

The classical rheumatoid deformities of hallux valgus and clawed lesser toes are made more painful with destructive arthritis, plantar prominence of metatarsal heads and callus formation.

Rheumatoid forefoot reconstruction has not changed dramatically over the last three decades and has been reliably efficacious.

However subtle technique changes and implant improvements have helped to keep this operation reproducible and beneficial for rheumatoid patients.

Tibiotalocalcaneal arthrodeisis is performed for a variety of conditions, including advanced osteoarthritis, Charcot arthropathy, rheumatoid arthritis, post-traumatic arthrosis and foot deformities such as fixed equinovarus. There have been few published studies showing the results of such a procedure for limb salvage.

Over a period of 11 years between 1996 and 2007, 18 patients underwent calcaneotalotibial arthrodeisis using either cannulated screws or a retrograde intramedullary locking nail. Post-operative rehabilitation regimes were standardised. VAS, AOFAS ankle-hindfoot, SF-36 and patient satisfaction scores were obtained and analysed.

Eighteen patients (10 male and 8 female) with 19 ankles underwent tibiotalocalcaneal arthrodeisis at an average age of 52.3 (31.4 to 70.2 years). Seven patients had cavovarus deformity, six had osteoarthritis, three had Charcot's joint, two had failed previous fusions and one patient had a footdrop post-T12 tumour resection. Twelve right and seven left fusions were performed, with six cannulated screws and 13 retrograde nails. The mean time to complete fusion was 5.89 (3 to 11) months in 18 ankles (94.7%). There was one pseudoarthrosis (5.3%). Patients were followed up for an average of 35.6 (11 to 144) months. Four wound infections (21%) occurred post-operatively. Two patients died from unrelated caused whilst on follow-up.

Thriteen patients returned for follow-up scoring. VAS scores improved from 7.85 to 2.54 (p=0.00). AOFAS ankle-hindfoot scores improved from 30.50 to 63.62 (p=0.00). SF-36 scores also improved in several parameters. Physical function improved from 40.38 to 66.15 (p=0.02); physical role improved from 15.38 to 53.85 (p=0.03); Bodily pain improved from 36.69 to 62.23 (p=0.00); emotional role improved from 69.23 to 100 (p=0.04); and mental health improved from 62.77 to 0.15 (p=0.04). Eleven patients (84.6%) reported good to excellent satisfaction and expectation scores.

Hindfoot arthrodesis, via retrograde imtramedullary nailing or cannulated screw insertion, are effective techniques for treating complex foot deformities and often is the only alternative to amputation. Although a demanding procedure with high potential complications, they provide effective relief from pain, improves the quality of life, and has high patient satisfaction.

Deformity correction has become a more common intervention in an attempt to mitigate pain from an arthritic ankle while hopefully preventing progression of intraarticular disease.

Malunion takes the form of angulation, rotation, translation, and length discrepancy, all of which must be measured and addressed by the surgeon. Contact surface area within the ankle joint can decrease up to 40% with angular malalignment, with subsequent increase in contact pressures in the residual joint surface. As the apex of the deformity moves closer to the ankle joint, pressures increase further. There are no rules as to the magnitude of deformity that necessitates correction, but the literature suggests 15 degrees of varus alalignment, 10 degrees of valgus malalignment and 20 mm shift medial to the mechanical axis all should undergo correction.

This lecture will explore: assessment of deformity, methods of correction, and literature results on the impact deformity correction has on ankle arthritis. As a separate issue, we will also address fibula length and the impact that shortening has on creating ankle arthritis and flatfoot.

Total ankle arthroplasty is used as a treatment for end stage arthritis of the ankle.

Surgical techniques highlight risk of injury to anterior neurovascular structures. No literature highlights injury risk to the posterior neurovascular structures in ankle replacement surgery. Current literature consists of cadaveric study in relation posterior ankle arthroscopy.

A retrospective review was done of ankle MRI's, performed by the senior author in his practice. Studies were included in the study where there was no pathology of the posterior ankle present. Axial, coronal and sagital T1 weighted films were reviewed and measurements of the posterior neurovascular structures and tendons were made in relation to the posterior tibia and medial malleolus in relation to planned tibial and talar cutting planes.

A total of seventy-eight MRI's were included in the study (ages ranged from 22 to 78 years). There were 40 females and 38 males. At the level of the tibial cut the tibial nerve and artery were between two to six millimeters from the posterior surface of the tibia. The flexor hallucis longus (FHL) is located in the midline between the medial malleolus and fibula, closely related to the posterior tibial surface. The flexor digitorum longus (FDL) tendon is located in the posterior medial corner of the ankle. There is a window approx ten millimeters wide between where the neurovascular structures lie between the FDL and FHL tendons. At the level of the talus cut the tibial nerve and artery were between five to 11 mm from the posterior body of the talus.

A similar window is present at this level where the neurovascular structures lie between the FDL and FHL tendons.

The neurovascular structures of the ankle are potentially at risk during the tibial and talar bone resection. They are most at risk with the transverse cut of the tibia. This may be decreased by preventing direct pressure over these structures during bone resection.

There are many reasons for muscle imbalance around the foot and ankle but the most common is some form of neuromuscular disease. The etiology is obviously very important in the decision making of treatment options. One should be aware of the progression pattern of the disease or condition. The simplest imbalances to treat are those secondary to a static condition.

The initial goal is to determine what force couples are available, what can be used, is it an in phase, or out of phase muscle you want to transfer. Next is to determine if there are any contractures that will have to be addressed and equally important whether there are fixed skeletal deformities present. No tendon transfer will be able to overcome a fixed bony deformity, and those should be corrected prior to transferring muscles.

The treatment of osteochondral lesions in the ankle joint remains a challenging problem. While debridement and drilling or microfracture of the lesion reduce symptoms initially, long-term stability of the fibrous repair tissue is questionable. Osteochondral transplantation or mosaicplasty provide hyaline cartilage and repair the bony defect at the same time. However, an open arthrotomy with medial, lateral or anterior osteotomy is necessary to repair lesions of the talus. Lesions of the distal tibia cannot be reached. Matrix Associated Chondrocyte Implantation (MACI) has been shown to produce hyaline like cartilage repair tissue, and the implantation can be performed arthroscopically. Long term follow up studies (up to 10 years) in the knee demonstrate promising results.

The purpose of this study was to assess the efficacy of arthroscopic MACI for the treatment of osteochondral lesions in the ankle joint. We reviewed all patients (n=20) who had arthroscopic MACI treatment (n=22) between February 2006 and November 2008 clinically (Foot Function Index, AAOS Foot and Ankle Questionnaire, AOFAS-Hindfoot Score) and with MRI (3 Tesla Siemens MRI).

The clinical results and MRI findings up to three years after MACI were compared to pre-operative data. Possible correlations with the individual history and the nature, size or location of the lesion will be discussed. The surgical technique will be described. The results of the procedure are promising.

Arthroscopic ankle arthrodesis is an alternative to more traditional open techniques. Potential advantages include more rapid time to union, decreased complication rate, shorter hospital stay and more rapid rehabilitation. Advances in instrumentation and techniques have made the procedure more reproducible and easier to perform. The literature on the subject is reviewed including the indications and contraindications. The surgical technique is also presented along with the potential surgical pitfalls.

Identifying the core competencies of musculoskeletal medicine has been the basis for the development of the Australian Musculoskeletal Education Competencies (AMSEC) project. AMSEC aims to ensure Australian health professionals are suitably equipped through improved and appropriate education to address the increasing burden of both acute and chronic musculoskeletal disease. The AMSEC project has consisted of four distinct phases. The first two phases were consultative and highlighted concerns from medical educators, specialists and students that current curricula inadequately address the increasing scientific information base in MSK medicine and management. In phase three, Multidisciplinary Working Groups were established to detail competencies in MSK areas such as physical examination, red flag emergencies, basic and clinical science, patient education and self-management, procedural skills and rehabilitation and a web portal was developed. Phase four will see the core competencies completed, endorsed by the relevant professional colleges and integrated into Australian Medical School curricula.

By bringing together experts from different groups involved in musculoskeletal education, it has been possible to agree on the core competencies required of a graduating medical student and from these determine the required underlying basic knowledge, skills and attitudes. These competencies are based on actual needs determined from current disease impact studies and the experience of professionals working in the various areas of musculoskeletal related clinical practice. This multidisciplinary and multi-professional approach, which includes consumer groups, has allowed a broader and more complete perspective of requirements. Both improved horizontal and vertical integration are facilitated and more efficient implementation is possible. By linking these core competencies to specific anatomy and basic science knowledge requirements, justification of the need to address current deficits in these areas was achieved. A standardised evidenced based approach to physical examination was developed allowing a unified approach to the resourcing and teaching of this skill by orthopaedic surgeons, rheumatologists and others.

The ability to outline competency requirements vertically from medical student to resident, general practitioner and specialist is greatly facilitated by combining specialist educators with those of the universities and general practitioners. For the specialists, this approach yields excellent education leverage for very little additional effort.

AMSEC has undertaken significant inter and intra disciplinary consultations to identify and classify core MSK competencies at a basic, median and advanced level of specialisation across professions. This novel national integrated model to address education needs offers many benefits and could be translated into other areas of medicine.

Frequently, radiological data is transferred verbally between ED/GP/LMO to the Orthopaedic registrar. Given the different medical backgrounds and presentation skills there is often a limit to the verbal description of the radiographs. The aim of this study is to determine the feasibility and benefits of concurrently using picture messaging of X-rays to enhance communication between ED and Orthopaedic Registrars to optimise patient care. The X-rays of 40 patients referred to orthopaedics OPD or admitted from the ED were photographed and retrospectively reviewed on a mobile phone screen (240 × 320) by an orthopaedic registrar along with a printout of the patient history and verbal description of the x-ray as interpreted by the ED staff. No further information was provided to the registrar. A questionnaire was completed to subjectively and objectively evaluate the therapeutic benefit of the image review. Patient(tm)s management was compared to management plans after image review and differences were attributed to the visual inspection of the x-rays on the mobile phone.

Concurrent to the retrospective review, the ED is currently trialling this with a Sony-Erickson K750i. After hours orthopaedic cases are sent via MMS to the registrar prior to consultation. In the emergency department, 10% of patients who presented with a fracture were reviewed in person by an orthopaedics registrar and none were admitted straight from ED whilst two were admitted following review at the OPD. X-rays of 40 patients were reviewed in this study. Twenty-seven patients presented with a fracture and four with islocations.

When the clinical data was reviewed alongside images of x-rays by an orthopaedic registrar, a difference in management plans were observed in 25% of cases and 7.5% where surgical intervention would yield a better result. Twenty-six of the twenty-seven fractures and four dislocations were successfully visualised on the MMS. In 18 cases, picture messaging provided additional information compared to verbal report alone. The limiting factor in picture messaging was the resolution and size of the radiograph. Ease of operation and portability was found to be satisfactory by both ED and Orthopaedic staff. Equipping the ED with the phone has enhanced communication with the orthopaedics department and increased the potential for optimising patient care. This will be formally assessed through questionnaires after 12 months trial of the phone.

Picture messaging is an inexpensive way of utilising technical advancements to improve patient care. Consistent with current literature, the quality of images was not sufficient as a diagnostic tool but rather a screening tool. Picture messaging is valuable practically and educationally and enhances the consultation and teaching process whilst encompassing medical staff who have limited skills in radiological description.

As there is currently no evidenced-based and systematic way of prioritising people requiring JRS we aimed to develop a clinically relevant system to improve prioritisation of people who may require JRS. An important challenge in this area is to accurately assign a queue position and improve list management. To identify priority criteria areas eight workshops were held with surgeons and patients. Domains derived were pain, activity limitations, psychosocial wellbeing, economic impact and deterioration. Draft questions were developed and refined through structured interviews with patients and consultation with consultants. 38 items survived critical appraisal and were mailed to 600 patients. Eleven items survived clinimetric and statistical item reduction.

Validation then included co-administration with standardised questionnaires (960 patients), verification of patient MAPT scores through clinical interview, examination of concordance with surgeon global ratings and test-retest.

Ninety-six Victorian surgeons weighted items using Discrete Choice Experiments (DCEs). The DCE scaling generated a scale, which clearly ranked patients across the disease continuum. The MAPT differentiated people on or not on waiting lists (p<0.001), and was highly correlated with other questionnaires, e.g., unweighted-MAPT vs WOMAC (r=0.78), Oxford Hip/Knee (r=0.86/0.75), Quality of Life (r=0.78), Depression (r=0.64), Anxiety (r=0.60), p<0.001 for all. Test-retest was excellent (ICC=0.89, n=90). Cronbachs reliability was also high 0.85. The MAPT is now routinely administered across all Victorian hospitals undertaking arthroplasty where the response rate is generally above 90%. In the hands of clinicians the MAPT has been used to facilitate fast-tracking of patients with the greatest need, monitoring for deterioration in those waiting for surgery or having a trial of non-operative treatment and deferment of surgery for those that may benefit from further non-operative treatments.

The MAPT is short, easy to complete and clinically relevant. It is a specific measure of severity of hip/knee arthritis and assigns priority for surgery. It has excellent psychometric and clinimetric properties evidenced by concordance with standard disease-specific and generic scales and widespread use and endorsement across health services.

Literature suggests in senile IT fracture group with osteoporosis and comminution, the rates of complications are very high. Documented figures show 16% deaths in non-operative treatment and 16% (late) non-union IT fractures in non operative treatment. The post fixation re-operation rate is 23% after two to three years. High rate implant cutout, penetration and plate cutout leads to increased morbidity and mortality again. The aim of this study is to find out the results of primary prosthetic replacement in comminuted, osteoporotic intertrochanteric fractures in elderly patients.

Eight patients of the age group from 68 to 94 years (average 78.4) with four part fractures were operated primarily with bipolar hemiarthroplasty. They were operated by posterolateral approach and the hip joint was exposed through the fracture site itself. After pan release the proximal fragment was delivered and a modular locally manufactured cemented bipolar hemiarthroplasty was performed. Due care was taken to restore offset, limb length and soft tissue balancing. The patients were mobile early after two days with walker and they became independent within four weeks after operation. They were followed up from six months to 3.5 years (average 2.1 years). The functional and radiological evaluation was done.

There were five females and three males. The modified Charnley score improved from average 2.3 pre-operatively to an average of 5.2 with respect to pain, mobility and function. All the patients were happy and independent. One patient developed abductor lurch, but managed to carry out independently all her activities of daily living. One patient had a dislocation. This lady was very unco-operative and never helped in the rehabilitation programme. She lost to follow-up. Radiologically, there were no signs of loosening, progressive adiolucent lines, subsidence or osteolysis at the latest follow-up.

Primary prosthetic hemi-replacement in cases of osteoporotic four part fractures in elderly patients helps early restoration of function and thereby prevents complications.

S epidermidis and P aeruginosa are recognised major biofilm pathogens in medical device contamination and chronic wounds. Within biofilms, bacteria are enclosed in a polymeric matrix that cements them to each other and to the surface and protects them by increasing resistance to host immunity, antibiotics and biocides. Staph and pseudomonas spp biofilm were grown on glass coupons for 48 hours and the coupons randomly inserted into the wound model for 24 hours and subjected to TNP and the following:

No instillation

Betadine and saline instillations were for 30 minutes, while FHA was for three minutes, every eight, four and two hours per day. The biocides were at sub-lethal concentrations. The coupons were then extracted to avoid damaging the biofilms and effect of TNP was assessed by colony forming units and electron microscopy.

The results show that lower frequency of instillation did not have significant effect on bacterial load for both types of bacteria. Increase in frequency of instillations resulted in no growth of pseudomonas while increase in frequency of instillations resulted in a significant decrease in growth of staph spp.

Frequent flushing of the wound model resulted in a loss of biofilm bacteria for both Pseudomonas and Staph epi. The biocides combined with TNP were more effective in killing Pseudomonas compared with Staph epi.

Thromboprophylaxis for venous thromboembolism (VTE) after elective arthroplasty remains controversial. Previous surveys have shown considerable variation amongst orthopaedic surgeons, and the topic is still being debated. Chest physicians recently advocated that randomised data demonstrating a risk reduction with long- established thromboprophylaxis have been ignored by orthopaedic surgeons. We present the current thromboprophylaxis practice amongst AOA members performing elective hip and knee replacements and discuss its rationale.

All orthopaedic surgeons in the AOA were asked to complete a one page postal questionnaire asking for information regarding: whether they performed elective hip or knee arthroplasty, which methods of mechanical and/or chemical prophylaxis were routinely used, the time frame in ceasing thromboprophylaxis, the motive in using thromboprophylaxis, and whether thromboprophylaxis guidelines released by the AOA or RACS would be helpful in their orthopaedic practice.

Responses from the survery are currently being collected and analysed. These results will be ready for presentation at the AOA conference.

The results of the survey will be presented in addition to a discussion of the rationale behind current use of post-operative thromboprophylaxis for elective hip and knee arthroplasty and a need for clinical guidelines.

We report decreased clinical VTE rates following increased use of mechanical prophylaxis in elective kip and knee arthroplasty. Usage of intermittent pneumatic compression (IPC) increased due to the increased availability of pump machinery. Timing of IPC use also changed with IPC used intraoperatively on the unoperated limb and for a longer period postoperatively Clinical VTE rates are assessed for two years prior to the change in practice (1140 procedures) and two years afterwards (1285 procedures). There was no other change in practice (chemical thromboprophylaxis, anesthetic technique, use of compression stockings, usage of tourniquet or usage of cement) or in patient profile.

Overall clinical VTE rates during admission dropped from 2.98% to 0.62% (p<0.0001). This decrease was seen in both hips 1.77% to 0.2% (p=0.029) and knees 3.97% to 0.89% (p=0.0002). There was a decrease in both pulmonary emboli 1.14% to 0.16% (p=0.0043) and symptomatic DVT 1.84% TO 0.47% (p=0.0023). There was no change in the rate of post discharge VTE events recorded 1.07% (p=0.57), either for DVT or PE (P=0.74 for each).

We conclude that IPC with non-sequential calf compression is effective in reducing the rates of clinical in-hospital VTE after elective hip and knee arthroplasty.

Multimodal analgesia protocols for pain control following total joint arthroplasty can reduce post-operative pain, allow early mobilisation and early discharge from hospital.

This study analyses the achievement of functional milestones, patient satisfaction, length of stay and adverse outcomes using a multimodal analgesia protocol in total joint arthroplasty.

All patients planned for elective hip and knee arthroplasty in a NSW teaching hospital under one surgeon between July 2007 and January 2009 were included in this prospective study. Patients undergoing revision surgery, bilateral arthroplasty or total hip arthroplasty for fractures were excluded. Unless contraindicated, all patients followed the multimodal analgesia protocol based on the local infiltration analgesia technique described by Kerr and Kohan.

Femoral nerve block is a reliable and effective method of providing anaesthesia and analgesia in the peri-operative period but there remains a small but serious risk of neurological complication. We aimed to determine incidence and outcome of neurological complications following femoral nerve block in patients who had major knee surgery.

During the period January 2003 to August 2008, medical records of all patients undergoing knee surgery by Dr Myles Coolican and Dr David Parker, who had been administered femoral block for peri-operative analgesia, were evaluated.

Patients with a neurological complication were invited take part in the study. A detailed physical examination including sensory responses, motor response and reflexes in both limbs was performed by an independent orthopaedic surgeon. Subjective outcome and pain specific questionnaires as well as clinical measurements were also collected.

Out of 1393 patients administered with femoral nerve block anaesthesia during this period, 28 subjects (M:F= 5:23) were identified on the basis of persistent symptoms (more than three months) of femoral nerve dysfunction. All the patients had sensory dysfunction in the autonomous zone of femoral nerve sensory distribution. The incidence of neurological complications was 2.01%. One patient was deceased of unrelated causes and five patients declined to participate in the study. 14 patients out of the 22 have been examined so far. Nine cases had a one shot nerve block and five had continuous peripheral nerve block catheter. Areas of hypoesthesia/anaesthesia involving femoral nerve distribution occurred in 7 subjects and hyperaesthesia/paresthesia occurred in four. One subject had a combination of hypoesthesia and hyperesthesia in different areas of the femoral nerve distribution. Three subjects had bilateral symptoms following bilateral simultaneous nerve blocks. Dysesthesias in the affected dermatomes were found in seven cases and paresthesias were found in eight cases. Douleur Neuropathique en 4 questions (DN4) score of ï³ 4 was found in all the patients (average value: 5.55). The average scores for tingling, pins and needles and burning sensation (in a scale from 0 to 10) are 3.8, 3.1 and 2.9 respectively.

The incidence of persistent neurological complication after femoral nerve block in our series is much higher compared to the reported incidence in the contemporary literature (Auroy Y. et al. Major complications of regional anesthesia in France: Anesthesiology 2002; 97:1274 80). The symptoms significantly influence the quality of life in the affected cases and question the value of the femoral nerve block in knee surgery.

Patient controlled analgesia (PCA) is commonly used after TKR. Prolonged use of PCA may however have a negative impact on patients delaying their rehabilitation and therefore discharge. We aimed to evaluate the effect of the duration of PCA on the hospital length of stay (LOS) in patients who undergo TKR. We reviewed the casenotes of all patients who underwent a primary TKR in two South Australian teaching hospitals between 2006 and 2007. After excluding patients whose LOS was determined by placement issues and patients who developed intra-hospital post-operative complications, a number of 345 patients were included in this study. Data collected included: age, gender, ASA grade, regional blocks used, duration of postoperative PCA (< 24 hours, 24-48 hours, > 48 hours) and hospital LOS. Using SAS Version 9.2 statistical analysis software the data was analysed using univariate and multivariate Poisson regression models. Risk ratios, confidence intervals and P values were calculated.

Univariate regression models showed that there was a significant difference in length of stay between the three PCA groups (p < 0.0001). Post hoc tests revealed that the length of stay was longer in the 24 to 48 hours and > 48 hours groups compared to the < 24 hours group (p < 0.0001). There was also a significant difference in hospital LOS between males and females (p = 0.0049) with females expected to stay on average 9.7% longer (risk ratio = 1.097, 95% CI 1.028, 1.169). Patients in the ASA categories (1 and 2) recorded shorter lengths of stay than patients in the ASA categories (3 and 4) (p < 0.0001). Also patients treated at one hospital had longer LOS than the patients treated at the other hospital (risk ratio = 1.122, p = 0.0001). There was no evidence for a relationship between the patients' ages, and use or type of regional block used and the hospital LOS. Results from the multivariate regression models showed that each of the four variables found to influence LOS significantly, did so independent of the other variables. Therefore, duration of PCA, gender, ASA and hospital were all independent predictors of hospital LOS after primary TKR.

Longer administration of PCA, higher ASA grades and female gender are associated with longer hospital LOS after TKR. Reducing postoperative PCA, as well as improving ASA grading, could reduce LOS in these patients. A multimodal pain management strategy that shortens PCA use could reduce hospital LOS and costs after TKR.

There has been considerable activity in the past year as a result of the Justice Department Investigation into the medical device industry. There has been an over reaction by many which may negatively impact future research, development and reporting of clinical outcomes. This paper will review some of these activities. A review of professional standards and guidelines has been conducted looking at health care compliance issues as they related to commercial relationships, professional medical societies, individual surgeons, and health care workers with specific focus on disclosure.

Within any important issue, there are always aspects no one wishes to discuss: conflict of interest. Perception of a conflict of interest is often enough to bring about a review of activity.

Overreaction has occurred as a result of government intervention into the medical device industry. Continuing medical education, professional societies by-laws, clinical/surgical publications, medical/legal exposure, product research, development and industry marketing activities have all been impacted.

When professionals fail to provide a proper review process on standards and guidelines on ethical behavior they set themselves up for government oversight and restrictions on their behavior. Be informed and disclose. Know what, when and how to disclose. Protect yourself, no one else will.

Practice variation may occur when there is no standardised approach to specific clinical problems and there is a lack of scientific evidence for alternative treatments. Practice variation suggests that a segment of the patient population may be managed sub-optimally, and indicates a need for further research in order to establish stronger evidence-based practice guidelines. We surveyed Australian orthopaedic surgeons to examine practice variation in common orthopaedic presentations. In February 2009, members of the Australian Orthopaedic Association were emailed an online survey, which collected information regarding experience level (number of years as a consultant), sub-specialty interests, state where the surgeon works, on- call participation, as well as five common (anecdotally controversial) orthopaedic trauma cases with a number of management options. Surgeons were asked to choose their one most likely management choice from the list provided, which was either surgical or non-surgical in nature. A reminder was sent two weeks later. Exploratory regression was modeled to examine the predictors of choosing surgical management for each case and overall.

Of 760 surgeons, 358 (47%) provided responses. For undisplaced scaphoid fractures, respondents selected short-arm cast (53%), ORIF (22%), percutaneous screw (22%) and long-arm cast (3%). Less experienced (0 to 5 years) (p=0.006) and hand surgeons (p=0.008) were more likely to operate. For a displaced mid-shaft clavicle fracture, respondents selected non-operative (62%), plating (31%) and intramedullary fixation (7%). Shoulder surgeons were more likely to operate (p<0.001). For an undisplaced Weber B lateral malleolus fracture, respondents selected plaster cast or boot (59%), lateral plating (31%), posterior plating (9%) and no splinting (2%). For a displaced Colles fracture in an older patient, respondents selected plating (47%), Kirschner wires (28%), cast/splint (23%) and external fixation (1%). Less experienced (p<0.001) and hand surgeons (p=0.024) were more likely to operate. For a two-part neck of humerus fracture in an older patient, respondents selected non-operative (74%), locking plate (14%), and hemiarthroplasty (7%). Shoulder surgeons were more likely to operate (p<0.001). Accounting for all answers in multiple regression modeling, it was found that more experienced surgeons (>15 years) were 25% less likely to operate (p=0.001). Overall, there was no difference among sub-specialties, or whether a surgeon participated in an on-call roster.

Considerable practice variation exists among orthopaedic surgeons in the approach to common orthopaedic problems. Surgeons who identify with a sub-specialty are more likely to manage conditions in their area of interest operatively, and more experienced surgeons are less likely to recommend surgical management.

Long waiting times and a growing demand on services for joint replacement surgery (JRS) prompted the Victorian Department of Human Services to fund a University of Melbourne/Melbourne Health partnership to develop and implement an osteoarthritis (OA) hip and knee service delivery and prioritisation system for those who may require JRS.

The service delivery model consists of a multidisciplinary team providing, comprehensive early assessment, evidence-based interventions, including support for patient self-management, continuity of care processes, and prioritisation for both surgical assessment and JRS. Prioritisation occurs via clinical assessment and the Hip and Knee Multi-Attribute Prioritisation Tool (MAPT), a patient, clinician, or proxy-administered 11-item questionnaire, resulting in a 100-point scale ranking of need for surgery. The Hip and Knee MAPT was developed using intensive consultation with surgeons, state-of-the-art clinimetrics and with input from patients, hospital management groups. Ninety-six surgeons contributed to the developing the final scoring system.

Over 4000 patients per year are entering the system across 14 hospitals in Victoria. Under the supervision of the orthopaedics unit, musculoskeletal coordinator (MSC), typically an experienced physiotherapist or nurse, as part of the multidisciplinary team, undertakes early comprehensive assessment, referral and prioritisation of patients with hip or knee OA referred to orthopaedic outpatient clinics. In addition, the MSC coordinates the monitoring and management of patients on the orthopaedic surgery waiting list. The processes enable patients who are most needy (via higher MAPT score and clinical assessment) to be fast-tracked to orthopaedic surgery; conversely those patients with lower scores receive prompt conservative management.

Time to first assessment and waiting times to see a surgeon for many patients have reduced from 12+ months to weeks. Patients seen by surgeons are more likely to be ready for surgery and have had more comprehensive non-operative optimisation. Patients placed on the surgical waiting list receive quarterly reassessments and evidence of deterioration is used as a basis for fast-tracking to surgery.

The OWL system is a whole of system(tm) approach informed by patients needs and surgeons needs. Clinicians have developed confidence in the clinical relevance of the MAPT scores. Uptake of the OWL model of care has been very high because it facilitates better care and better patient outcomes.

Axial loading of the wrist results in carpal pronation, which loads the scapholunate ligament (SLL). ECRL and FCR are carpal supinators and ECU is a carpal pronator. In this study we aim to show differential activity in the ECRL and ECU as a protective mechanism for the SLL in simulated falls.

Eight healthy volunteers were recruited for a simulated fall situation. Surface EMG was used to record muscle activity in the six major muscles that control wrist movement (FCU, FCR, ECRL, ECU, APL, ECRB) in the right forearm. The forearm skin was prepared in a standard fashion and the electrodes placed following an established protocol. Recordings were made using zero wire (Noraxon) surface EMG equipment. The data was exported and analysed using MyoResearch XP. Recordings were rectified and mean value, peak value, area under the curve and frequency were compared. Recordings were divided into five time periods from rest to post-impact.

ECRL has the most predictable and consistent response to impact of the wrist on the ground. Immediately following impact there is inhibition of the extensors and no change in flexor activity. The next phase is characterised by a ‘spike’ in ECRL activity with a less marked increase in ECRB and minimal change in ECU activity. There is decrease activity in the flexors during the ECRL peak.

The pre-peak period lasts between 5 to 10 ms. The ECRL peak period lasts between 20 to 30 ms.

We have identified that ECRL is active post fall and this response takes less than 10 ms from the time of impact. The time response is in the order of a spinal proprioceptive reflex. We were unable to identify a stretch response in the flexors that could act to trigger the ECRL response.

Nurse practitioners have been widely used throughout Australia in private practice for many years. The work has been funded entirely by the orthopaedic surgeons themselves. The role has not been formally defined. The aim of this study was to demonstrate one aspect of the use of a nurse practitioner in gathering unbiased research information.

Using a software package, all carpal tunnel release patients by a single surgeon were identified. The patient names, phone numbers and date of surgery were isolated. A simple phone questionnaire was developed based on previous questionnaires in the literature regarding carpal tunnel surgery. The nurse practitioner was able to contact 30 of 50 patients by phone, despite the local population being transient. Patients were asked directly if their surgery had fixed their problem: 29/30 patients answered yes. However, only 25/30 had resolution of their pins and needles and 26/60 had resolution of their numbness. 26/30 had resumed their activities. 11/30 had undertaken formal hand therapy, 13/30 had informal exercises. 10/30 patients were insured with Workcover.

Self-audit is required as part of continuing education requirements, and is easily performed with the assistance of a nurse practitioner. Standardising questions is facilitated by the use of a nurse practitioner. Patients have significant difficulty understanding direct, formal questions, which is reflected in their variable answers. This study reiterates the success of carpal tunnel surgery and demonstrates a facet of the nurse practitioner role.

Standard imaging of complex intra-articular distal radius fractures consists of posterior-anterior, lateral and oblique x-rays. Recently the liberal use of CT scan in this area became widely accepted as an additional imaging tool in pre-operative evaluation. The aim of this study was to evaluate whether CT scanning of complex distal radius fractures changed the management of these fractures compared to plain films.

A series of 20 closed distal radius complex intra-articular fractures AO 12-C which had both plain PA, lateral and oblique films and CT scans were selected from our long bone trauma database. The plain films were blindly reviewed by five observers. A management plan was then formulated. Options provided were: closed manipulation, closed manipulation with percutaneous K wire fixation, open reduction and internal fixation, external fixature or bone graft/substitute. The same patients' CT scans (in randomised order) were blindly reviewed at the one week interval by the same clinicians with the same management options decided upon. Kappa statistic was used to measure the intra-individual agreement between x-ray and CT, as well as inter-individual agreement within each imagining modality.

The agreement between individual observer's management decisions, based on the x-rays and on the CT scan was poor; with an average Kappa score of 0.038 (range 0.006 to 0.19). A regression model with management as a graded 5 level variable ranging from least invasive to most invasive and imaging modality as the predictor gave an estimated coefficient of 0.163, (p=-0.267); this indicates a trend towards a slightly higher level of invasiveness when the management decision was based on the CT compared to the plain x-rays. The agreement on management decisions between the observers based on x-ray alone was higher than that based on CT alone (kapa=0.174 vs 0.03)

This study indicates a very poor level of agreement between decision-making, based on x-ray and on CT. Even within individual's ‘interindividual’ agreement appears higher with x-ray than CT. This study also raises the possibility that the use of CT scans increases the level of invasiveness in the surgical management of complex distal radius fractures.

Distal radial volar locking plating systems (DRVLP) are increasingly used for complex fractures of the distal radius. There have been limited studies on volar locking plating systems focusing on functional outcome and complications data. The aim of this study is to assess whether the surgeon can predict which fractures will have a good or poor outcome in terms of clinical, radiological and functional outcome assessment.

Patients who sustained a distal radial fracture managed with a radial volar locking plate were identified from hospital audit data systems. Data was collected on all patients from patient notes including radiographs performed pre- and post-operatively and functional scores using the Patient Rated Wrist Evaluation score (PRWE). The study was approved by the Barwon Health Research and Ethics Advisory Committee.

In total, there were 153 patients (105 female, 48 male) from all 11 surgeons in the unit. Patients ranged in age from 17 to 91 years, average age of 53.7 years at time of injury (IQR 41-70yr). A quarter had concomitant other injuries, and 60% had type C1-C3 fractures. Most of the patients (n = 147) had the AO Synthes DRVLP, six patients had other volar locking plate systems. Twenty-seven percent of patients (n = 42) had exogenous bone graft insertion for more unstable fracture patterns. The major complication rate was 12% (18/153) with 17 cases requiring further surgery. Post-operative radiographs demonstrated no increase in ulnar variance (median 0.0mm IQR 2.0 to1.0 mm) but an increase in radial inclination by 5 deg (IQR 0-12 deg), radial length by 3.5 mm (IQR 1.0-6.3 mm) and radial tilt by 17 deg (IQR 3-32 deg) (volar angulation) compared to pre-operative radiographs, which was statistically significant (all p<0.001). Ninety percent of patients returned a PRWE form with an average follow-up of 1.16 years (IQR 0.46-2.16yr). Median score for those aged less than 50 years was 14.00 (IQR 6.00-41.50) and did not differ from those greater than 50 years (median 16.00 IQR 4.50-36.00) (p = 1.00). PRWE score across groups categorised by classification of fracture showed large variance within each category and were not significantly different: Class A median 8.00 (IQR 3.50-26.25), Class B 13.00 (IQR 6.75-34.00) and Class C 17 (IQR 5.00-38.50) (p = 0.65).

The majority of patients were female and had a type C fracture. Post-operative x-rays displayed an increase in radial inclination, length and tilt, and restoration of radial antatomy. PRWE scores were not different across age groups or classification of the fracture. This demonstrates that predictable outcomes can be achieved with volar locking plates despite fracture complexity if attention is paid to anatomical restoration of the radius, and in more unstable patterns with void support using injectable graft. Quadratus can act as an effective barrier to prominent hardware and superficial infection. Supination range may be reduced by this approach due to a tight repair, though a palmar DRUJ capsule contracture may also be an explanation.

Increased use of locking volar plates for distal radius fractures led to a number of reports in literature of flexor tendon injuries from impingement and attrition against hardware. Repair of the pronator quadratus is critical in preventing tendon injury. We present a pronator quadratus sparing approach to the distal radius.

The senior author has used a pronator quadratus sparing lateral pillar approach for for the past five years. A lateral incision is used over the radial styloid. The first dorsal compartment is released and APL and EPB tendons retracted. The underlying brachio-radialis tendon and insertion fascia is split and the palmar portion elevated off the distal radius with the pronator quadratus as a single contiguous sheet. The distal edge of the pronator quadratus is elevated from the wrist capsule by sharp dissection. The radial artery is protected by the retracted tissue.

Repair of the brachio-radialis tendon and insertion fascia is much more robust than that of the pronator quadratus covering the entire plate. Since 2004, the senior author has used the pronator quadratus sparing approach for volar plating of the distal radius, in 183 cases.

At last follow-up there were no instances of flexor tendon injury, which was considered to be one of the outcome measures and end-points. There was no impingement in the first dorsal compartment, except in two cases of lateral pillar hardware impingement from additional lateral pillar plate fixation through the same approach. Nine cases had minor persistent superficial radial nerve parasthesia. One case had a superficial wound infection requiring drainage. The repaired pronator quadratus formed a barrier protecting the plate. The infection was aggressively treated and the plate left in situ for three months till fracture union. Cultures from the retrieved plate showed no organisms.

Another implant had two of the locking screws back out. The pronator quadratus fascia was tented with an underlying haematoma. The fascia however only showed minimum screw penetration and no flexor tendon injury. Average wrist dorsiflexion was 72 deg and palmar flexion 65 deg.

Average pronation was 81 deg and average supination 69 deg. Supination range was slow to recover in younger patients. One explanation could be the tight pronator quadratus repair. Average PRWE and DASH scores were 19.

The quadratus sparing approach to the volar distal radius is easy to perform and protects the flexor tendons at the wrist. Cases demonstrated that an intact pronator quadratus can act as an effective barrier to prominent hardware and superficial infection. Supination range may be reduced by this approach due to a tight repair, though a palmar DRUJ capsule contracture may also be an explanation.

The controversy of the management of this common fracture still remains and even the recent literature is not conclusive. Controversy is mainly because the need for either conservative or operative and what type of internal fixation mainly depends on many factors like age and patient factors, the type and convection of fracture and the bone quality.

In the wake of the problem, the present study was undertaken mainly focusing on the importance of newer locking plates compared to percutaneous pinning, external fixatures or a combination.

This study of 106 cases fairly outlines what treatment is suited for what type of fractures though the ideal treatment is yet to be determined.

Favourable long-term results have been reported with the standard Exeter cemented stem. We report our experience with a version for use in smaller femora, the Exeter 35.5 mm stem. Although, also a collarless polished taper, the stem is slimmer and 25 mm shorter than a standard stem.

Between August 1988 and August 2003, 192 primary hip arthroplasties were performed in 165 patients using the Exeter 35.5 mm stem. Clinical and operative data were collected prospectively. Clinical evaluation was by the Charnley, Harris and Oxford hip scores and radiographs were analysed post-operatively and at latest follow up.

The mean age at time of operation was 53 years (18 to 86), with 73 patients under the age of 50 years. The diagnosis was osteoarthritis in 91, hip dysplasia in 77, inflammatory arthritis in 18, septic arthritis of the hip in three, secondary to Perthes disease in two and avascular necrosis of the hip in one patient. The fate of every implant is known.

At a median follow-up of 8 years (5 to 19), survivorship with revision of the femoral stem for aseptic loosening as the endpoint was 100%. Fifteen cases (7.8%) underwent further surgery 11 for acetabular revision, one for stem fracture and three others.

Although, smaller than a standard Exeter Universal polished tapered cemented stem—with a shorter, slimmer taper—the performance of the Exeter 35.5 mm stem was equally good even in this young, diverse group of patients.

The triple taper polished cemented stem (C-stem, DePuy) was developed to promote calcar loading, and reduce proximal femoral bone resorption and aseptic loosening. We aimed to evaluate the changes in peri-prosthetic bone mineral density using Dual Energy X-ray Absorbtiometry (DEXA) after total hip arthroplasty (THA) using the C-stem prosthesis.

One hundred and three patients were recruited voluntarily through and single institution for THA. The prosthesis used was the triple-taper polished cemented C-Stem (De Puy, Warsaw, Indiana, USA). DEXA scans were performed pre- operatively, then at day for, three months, nine months, 18 months and 24 months post-operativley. Scans were analysed with specialised software (Lunar DPX) to measure bone mineral density (BMD) in all seven Gruen zones at each time interval. Changes in calcar BMD were also correlated with patient age, sex, surgical approach, pre-operative BMD and post-operative mobility to identify risk factors for periprosthetic bone resorption.

One hundred and three patients underwent 103 primary THA over a five-year period (98 osteoarthritis; 5 AVN). No femoral components were loose at the two year review and none were revised. The most marked bone resorption occured in Gruen zones 1 and 7, and was best preserved in zone 5. BMD decreased rapidly in all zones in the first three months post-operatively, after which the rate of decline slowed substantially. BMD was better preserved medially (zones 6 and 5) than laterally (zones 2 and 3) at 24 months. There was delayed recovery of BMD in all zones except zones 4 and 5.

High pre-operative T-scores (>2.0) in the spine, ipsilateral and contralateral femoral neck were associated with the higher post-operative BMD and less bone resorption at all time intervals in Gruen zone 7. Pre-operative osteopenia and osteoporosis were associated with low BMD and accelerated post-operative bone resorption in zone 7.

Patients whose mobility rendered them housebound had lower post-operative BMD, and accelerated post-operative BMD loss in zone 7 when compared to non-housebound patients. Females had a lower post-operative BMD and greater loss of BMD in zone 7. Patient age and surgical approach did not effect post-operative BMD or rate of bone resorption in zone 7.

The triple-taper femoral stem design did not show an increase in periprosthetic bone density at the proximal femur at two years post-operative. Calcar bone resorption is accelerated by low pre-operative BMD, poor post-operative mobility, and in females. Age and surgical approach do not have significant effects on calcar bone remodelling.

We aim to report the clinical and radiological outcome of consecutive primary hip arthroplasties using the JRI-Furlong HAC coated femoral and acetabular components.

We reviewed 586 consecutive cementless primary THA in 542 patients with a minimum 12-18 year follow-up, performed at one institution between 1986 and 1994. Twenty-eight (32 THA) were lost to follow-up. Clinical outcome was measured using Harris, Charnley and Oxford scores. Quality of life using EuroQol

EQ-5D. Radiographs were systematically analysed.

The mean age was 75.2 years. Dislocation occurred in 12 patients (three recurrent). Re operations were performed in 11 patients (1.9%). Four acetabular and one stem revisions were performed for aseptic loosening. Other re-operations were for infection (two), periprosthetic fractures (two), cup malposition (one), revision of worn liner (two). The mean Harris and Oxford scores were 89 (79–96) and 18.4 (12–32) respectively. The Charnley score was 5.7 for pain, 5.3 for movement and 5.4 for mobility. Acetabular radiolucencies were present in 54 hips (9.7%).

The mean linear polythene wear was 0.06 mm/year. Stable stem by bony ingrowth was identified in all hips excluding one femoral revision case. Mean stem subsidence was 2.2mm (0.30–3.4mm). Radiolucencies were present around 37 (6.6%) stems. EQ- 5D description scores and health thermometer scores were 0.81 (0.71–0.89) and 86 (64–95). With an end point of definite or probable loosening, survival at 12 years was 96.1% for acetabular and 98.3% for femoral components. Overall survival at 12 years with removal or repeat revision of either component for any reason as the end point was 97.2%.

The results of this study support the continued use of a fully coated prosthesis and documents the durability of the HAC coated components. In our clinical experience, the Furlong prosthesis revealed encouraging radiographic stability over a long-term period.

Over the past ten years we have seen a move to less invasive surgical approaches and simplification of OR procedures; hence, there has been a renewed interest in the use of rectangular wedge-taper design hip stems. I present a personal series of over five hundred Accolade (Stryker) stems with a high (6%) early failure rate.

Cases are drawn from a personal database. These patients presented with either pain or difficulty with stair-climbing. Several remain asymptomatic, but radiographs are early identical in all cases. Impressive radio-lucent and sclerotic lines are seen on the lateral radiograph in Gruen zones VIII and XIV at between three and six months, and later appear in Gruen I. Most occurred in type A or AA bone. These failures are interesting as they are due to rotational loosening, not axial subsidence. To date, 6 of 12 have been revised, all showing complete lack of ingrowth to proximal porous coating.

Rectangular wedge-taper design stems have enjoyed high success rates in several published series. However, the author believes that the use of this stem in Type A or AA bone leads to preferential distal (diaphyseal) taper engagement, which negates proximal (meta-diaphyseal) taper engagement, and predisposes the stem to rotational micromotion, failure of ingrowth, and subsequent loosening.

To our knowledge, this is the first paper to recognise this mode of failure. The authors strongly believe stems of this type should be used with caution in males with type A or AA bone.

Impaction bone grafting (IBG) of the acetabulum in cemented primary total hip replacement is a useful technique in the management of acetabular deficiencies. It has the capacity to restore anatomy and bone stock with good long-term outcome. We present 125 consecutive cases of IBG with a cemented polyethylene component. All patients who received full IBG of the acetabulum in primary cemented Exeter total hip replacements and who underwent surgery between August 1995 and August 2003 were identified. All operative and follow-up data was collected prospectively and no patients were lost to follow-up. All patients underwent pre-operative and regular post-operative hip scores with the Harris, Oxford and the modified Charnley scoring systems. Data on indication, surgical technique, socket position and migration and revision was reviewed at a mean follow-up of 7.6 (range 5 to13.4) years.

Between August 1995 and August 2003, 113 patients (85 females) with an average age of 67.8 (range 22.9–99.2) years underwent 125 primary Exeter cemented total hip replacements with IBG of acetabular defects. Acetabular defects were classified according to the AAOS classification as cavitatory in 62 hips and as segmental, requiring application of a rim mesh prior to IBG, in 63 hips. Life tables were constructed demonstrating 86.4% survival of the acetabular component at 13.4 years with revision for any reason as the endpoint and 89.3% survival with revision for aseptic loosening as the endpoint. Of the seven patients who underwent revision for aseptic loosening, all had pre-operative segmental acetabular defects requiring application of a rim mesh. No patient who underwent IBG for a cavitatory defect required revision surgery for aseptic loosening. Survival of the Exeter cemented femoral component was 100% at 13.4 years with revision for aseptic loosening as the endpoint. There were 11 radiographic failures of the acetabular component, which have not been revised at latest review. One of these is symptomatic but not fit for revision surgery, two were asymptomatic at time of death and eight are asymptomatic but under review.

This is the largest series of IBG in the acetabulum in cemented primary THR. Our results suggest that the medium term survival of this technique is good, particularly when used for cavitatory defects. Although there were radiographic failures, these are largely asymptomatic and may not require revision.

The Birmingham Hip Mid Head Resection (BMHR) was designed to accommodate patients with lower quality bone in the proximal half of the femoral head. It is a relatively new conservative hip implant with promising early results. Finite element modelling may provide an insight into mid-term results.

A cadaveric femur was CT scanned and 3D geometry of the intact femur constructed. The correctly sized BMHR implants (with and without visual stop) were positioned and these verified by a surgeon; hence constructing the post-operative models. Walking loads were applied and contact surfaces defined.

Stress analyses were performed using the finite element method and contact examined. Also, a strain-adaptive bone remodelling analysis was run using 45% gait hip loading data. Virtual DEXA images were computed and were analysed in seven regions of the bone surrounding the implants.

The BMHR was found to be mechanically stable with all surfaces indicating micromotion less than the critical 150 microns. Stress distribution was similar to the intact femur, with the exception of the head-neck region where some stress/strain shielding occurs. This is mirrored in the bone remodelling results, which show some bone resorption in this region. The visual stop, which is designed to ensure that the stem is not overdriven during implantation, did not affect the stress/strain results; only on a very local scale.

There is minimal data available in the literature regarding conservative hip implants and no data regarding the BMHR. This study is the first to look at the mechanical response of the bone to this implant.

Thermal damage to bone related to the exothermic polymerisation of bone cement (PMMA) remains a concern. A series of studies were conducted to examine PMMA bone interface during cemented arthroplasty.

In vitro and in vivo temperature distributions were performed in the laboratory and human and animal surgery. In vivo (10 patients) measurements of cement temperature during cementing of BHR femoral prosthesis using thermocouples. Intra-operative measurement of cement temperature in BHR in the presence of femoral head cysts was examined in patients. The BHR femoral heads were sectioned to assess cement mantle as well as position of thermocouples. An additional study was performed in sheep with PMMA implanted into cancellous defects. Thermocouples were used to monitor temperature in the cement as well as adjacent bone. Histology and CT was used to assess any thermal damage.

The exothermic reaction of PMMA during polymerization does indeed result in an increase in temperature at the interface with bone. The in vivo study recorded a maximum temperature of 49.12C for approximately three minutes in the cancellous bone underneath the BHR prosthesis. This exposure is probably not sufficient to cause significant injury to the femoral head. The maximum temperature of the cement on the surface of the bone was 54.12C, whereas the maximum recorded in the cement in the mixing bowl was 110.2C.

In the presence of artificial cysts within the bone, however, temperatures generated within the larger cysts, and even at the bone-cement interface of these cysts, reached levels greater than those previously shown to be harmful to bone. This occurred in one case even in the 1 cc cyst.

Routine histology revealed a fibrous layer at the cement bone interface in the sheep study. Fluorescent microscopy demonstrated bone label uptake adjacent to the defect site. Histology did not reveal thermal necrosis in the defects in terms of bony necrosis. CT data was used to measure the amount of PMMA placed into each defect. This analysis revealed a range of volumes that did not seem to influence the histology.

The heat of cement polymerisation in resurfacing as performed in our study is not sufficient to cause necrosis. This may reflect the ability of the body to rapidly conduct heat away by acting as a heat sink. The temperature-conducting properties of the metal prosthesis are also likely to be important.

Typical devices to limit leg length changes rely on a fixed point in the ileum and femur in order to measure leg length changes intraoperatively. The aim of this study is to determine the ideal position for placement of these devices and to identify potential sources of error.

Using saw bones the leg length device was attached at four different positions along the iliac crest extending from the ASIS to its midpoint. After marking the femur on the lateral edge of the Greater Trochanter, measurements were taken with gradually increasing leg length from each individual position on the ileum. This was also performed for different degrees of hip flexion.

It was determined that when the hip was in an extended position the degree of error was small for all positions along the iliac crest, with a tendency for an increase error the closer the pin is to the ASIS.

When the hip is flexed the error is increased with pin positions closer to the ASIS. With a lengthening of 10 mm, minimal leg length changes can be determined using the device. More than 20 mm resulted in significant change using the leg length device.

Ideal iliac crest pin position is towards the midpoint of the iliac crest, which will minimise the potential error. Measuring the leg length while the hip is in a neutral position will limit the error and increase the accuracy—thus avoiding unwanted lengthening.

Hip simulator studies on MOM bearings have historically involved ‘custom’ cetabular cups. I.e. having neither beaded layers nor biological coatings.

The aim of this study was to investigate wear using such MOM bearings and evaluate the potential wear and evaluate the potential for error in the gravimetric assessment.

Six x 38 mm HC Co-Cr bearings were supplied (Global and IO International Orthopaedics). The cups were received in ‘off-the-shelf’ condition with a cast Co-Cr beaded/HA-coated backing. To remove the HA-coating, the cups were pre-soaked in lemon juice for 4 days (articular surfaces shielded). Custom plastic fixtures were machined to fit the beaded contours of the cups. Test duration was 5Mc inorbital hip simulator (Shore-Western). MOM wear was estimated from serum ion contamination. Serum samples were digested and assessed using ICP/MS (Weck Labs Inc, CA).

The majority of the HA-coating was removed from the cups after four days of soaking inlemon juice after 21 days of soaking all cup weights appeared atable (within 1 mg). Reflected-light microscopy (RLM) showed no descernible signs of HA and the total weight loss due to HA remval averaged∼400mg.

During hip simulator there was no visual evidence of lost or broken beads, 3rd body abrasion etc (Sa<30nm). Both gravimetric and metal ion analysis showed consistent wear trends for all MOM cups. The MOM with the highest wear (predicted by ion analysis) demonstrated 1.2 mm (3)/Mc)OWR) at 5Mc. In comparsion, gravimetric analysis predicted an OWR of 1.3 mm (3)Mc for the same MOM, a difference of only 8%. Soaking beaded-HA cups in lemon juice and BCS proved effective in removing the coating.

The beaded cups remained stable in weight during the wear study and caused little discrepancy in gravimetric analysis (8%).

The method described did not lead to breaking of beads, elevated 3rd-body abrasion, cup damage or distorted wear scars.

With the advent of digital radiology, our institution has introduced digital templating for preoperative planning of total hip arthroplasty (THA). Prior studies of the accuracy of digital templating had contradictory results. This study compares the accuracy of digital and analog templating for THA. Ninety patients were recruited. Sixty-eight patients had analog pre-operative templating while 22 patients had digital templating. A retrospective review of medical records obtained the sizes of hip implants inserted during THA and patient demographics. The templated hip sizes were compared with the actual hip implants inserted. Accuracies of both templating methods were compared in four outcomes: prediction of acetabular cup size, prediction of femoral stem size, prediction of femoral offset and prediction of femoral neck length.

Digital templating was more accurate than analog templating in predicting acetabular cup size, femoral stem size and femoral offset. Analog templating was more accurate in predicting femoral neck length. However, only the comparison of femoral offset achieved statistical significance (p-value = 0.049).

After stratifying the data by BMI, digital templating was more accurate than analog templating in predicting acetabular cup and femoral stem sizes for patients with high BMI. For patients with BMI = 25-30, accuracy of digital templating was 100.0% for cup and 80.0% for stem while accuracy of analog templating was 74.1% for cup and 74.1% for stem. For patients with BMI > 30, accuracy of digital templating was 84.6% for cup and 69.2% for stem while that of analog templating was 75.0% for cup and 66.7% for stem.

Digital templating outperformed analog templating in all the outcomes except femoral neck length. In addition, digital templating was significantly more accurate in predicting femoral offset. This study showed that digital templating has the potential to reduce errors in pre-operative planning for THA.

THA continues to improve but complications still occur. Improper restoration of hip mechanics can lead to a number of clinical problems: increase in leg length, soft tissue laxity, weakness of the abductors, mechanical impingement, increase of wear and improper implant sizing can lead to thigh pain, subsidence and hip dislocation.

Six-hundred-and-fifty-five primary cementless THA were performed over the past twenty-four years by the senior author at two hospitals. Three different stems were used, two being modular and one being monoblock. A variety of cups head sizes and bearing material were used. All cups were implanted cementless. All surgeries were performed with the posterior approach. Sixty percent of patients were female forty percent males. Majority of cases were for OA.

Cup revisions have been the biggest problem to-date with excessive wear of the poly material. This is more than likely due to the first and second generation designs that had poor locking mechanics. Over the last four years since going to MOM technology cup revisions have not been seen. On the femoral side there have been no femoral lysis, five dislocations two treated closed and three open reductions treated with constrained sockets. Four stem revisions, all for late sepsis. There has been two recent aseptic loosening, and only one traumatic dislocation since going to large MOM heads.

One was one post-op with an ASR MOM cup that had spun out of position of function and the second a week later that was only six weeks post-op and came in for her first post-operative visit.

Routine use of intra-operative x-rays has resulted in +80% decision on fine-tuning of implant sizing by either increasing stem size and or femoral offset. Intra- operative x-rays provide valuable assistance and allow full advantage of the features and benefits of stem modularity reducing post-operative complications.

The advent of the Australian National Joint Replacement Registry has been an outstanding success in identifying prosthesis with higher than average failure rates, but it is principally a measure of revision rates for specific prostheses.

In order to consider the causes of failure it is necessary to start at the point where prostheses are able to enter the Australian market through the Therapeutic Goods administration, Australian Registered Therapeutic Goods list (ARTG) and consider each of the steps of the joint replacement procedure from that point to well beyond the operation date.

This ARTG listing process as it now exists is described and an explanation of how this process may need to be reformed if the occasionally very inadequate prosthesis is to be eliminated from the Australian market. Other matters that may be predictors of variable outcomes include hospital case volume, surgeon experience, patient selection and pre-operative planning.

Intra-operative factors that lead to failure, including from infection, will include surgical approaches, operative technique, instrumentation, wound care and theatre discipline.

Post operatively patient factors, particularly falls and osteoporosis, will influence long-term outcomes as will prosthesis performance.

Further concern has been the advocacy by some by what might be considered, fashionable orthopaedics, but the literature to date has demonstrated little benefit from endeavours such as minimal invasive surgery and two-incision hip replacement. Gender specific prostheses and navigation have yet to make their mark as a universally accepted method of performing joint replacement surgery and there may be some negative issues with these matters.

Hip arthroscopy is becoming more popular. A literature review demonstrated paucity of published papers reporting the outcome of hip arthroscopy in teenagers without developmental dysplasia of the hip. Our aim was to record the type of lesions found and report the outcome and level of satisfaction following hip arthroscopy in teenagers.

From 2002 to 2008, 96 hip arthroscopies were undertaken in 76 patients. Pre-operative and two-week, six-week and current post-operative assessments were performed using the modified Harris hip score (HHS) and the Non Arthritic Hip Score (NAHS). In addition, a satisfaction survey was completed at their most recent review.

Patients enrolled in the study were under the age of 20. Patients with a history of developmental dysplasia of the hip, Perthes disease and arthritis were excluded from the study. Patients had at least a six-month follow-up from their surgery.

Our study cohort comprised 53 males and 43 females with an average age of 17 years old (range 13 to 19 years). The average duration of follow up was 19 months (range 3 to 75 months). There were 41 left and 54 right-sided hip arthroscopies. There were five re-operations. The average duration of hip traction was 19 minutes (range 6 to 47 minutes).

We found pathology in all hips that underwent arthroscopy. We report a significant improvement in MHHS and NAHS at six weeks and current review (p-value <0.01). Sixty-two percent of patients had returned to sport at the previous level of competition, 32% of patients returned to sport at a lower level of competition and 5% patients did not return to sport. Overall, 84% of patients were satisfied following their hip arthroscopy and 91% would have the surgery again if they had to. There were five re-operations.

Our study has revealed a range of intra articular hip pathologies amenable to surgical treatment using hip arthroscopy. We have observed a significant improvement in hip scores; with up to 94% of patients returning to sport in the short term with high satisfaction levels. Long term follow up of this group is ongoing.

This study presents the results of 60 consecutive hip arthroscopic procedures for the treatment of Acetabulo-Femoral Impingement. The procedures were performed by a single surgeon over a period of 36 months. The learning curve and the evolution of the current technique along with the clinical outcomes are discussed Additionally two new clinical signs of AFI are described, along with the correlation of radiological and arthroscopic findings.

Sixty patients underwent hip arthroscopies. The procedures included labral debridement, labral repair, femoral and/or acetabular osteectomies. All patients underwent MRI examination and three-dimensional CT imaging to identify the impingement lesion. Follow up CT scanning was performed to assess the accuracy of the bony resection. Patients were reviewed at three months and subsequently at twelve monthly intervals. All patients participated in completing questionnaires.

Post-operatively Modified Harris Hip score improved from 54 to 70, Non-Arthritic hip score improved from 58 to 75, SF12 score improved from 35 to 40. Three patients required a second procedure for further bony resection. One patient underwent a THR within 12 months. Two female patients suffered minor vaginal abrasions.

Hip arthroscopy is a demanding procedure. Good clinical results are achieved only when the cause of impingement has been identified and treated.

FAI has been implicated in the progression of osteoarthritis (OA) and early detection may allow for treatment, which can slow or halt progression. FAI is a difficult condition to image and there is little objective evidence about imaging accuracy. We aim to measure the accuracy of five imaging modalities.

Three blinded observers retrospectively reviewed five different modalities from two age and sex matched groups: A patient group referred to the outpatient clinic with a clinical diagnosis of FAI and a control group who had had CT scans of the pelvis for suspected trauma, where the Pelvic scan had been reported as showing no injuries.

The imaging modalities were: Standard x-ray; Antero-Posterior, Lateral; Condition-specific x-ray projections; Dunn view, lateral internal rotation; Standard Computer Tomography (CT) multiplanar reconstruction (MPR); axial, sagittal and coronal; Condition-specific CT MPR; angled axial, angled coronal; 3D modelling; and surface rendered dynamic.

We found marked variations in the sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictiive Value (NPV) for each of the following imaging modalities: Standard X-ray; Sensitivity 51.9; Specificity; 57.1; PPV; 40; NPV; 68.3 Special X-rays; Sensitivity; 66.7; Specificity; 57.1; PPV; 46.1; NPV; 75.7. Standard CT MPR; Sensitivity; 40.7; Specificity; 75.5; PPV; 47.8; NPV; 69.8 Special CT MPR; Sensitivity; 48.1; Specificity; 57.1; PPV; 46.4; NPV; 70.8 Dynamic 3D CT models; Sensitivity; 55.6; Specificity; 69.3; PPV; 42.8; and NPV; 71.8.

The Dynamic 3D CT models (where the observer can manipulate the model in real time three dimension to control the perspective) proved to be the most accurate, closely followed by the special X-Ray views, which were also the most sensitive. The Standard CT MPRs were the most specific but had a low sensitivity.

This is the first study to measure sensitivity, specificity and PPV and NPV for these imaging modalities in FAI. We recommend the use of condition-specific X-Ray views as well as 3D CT Models for optimal imaging accuracy in this condition. Standard X-Ray views and CTs proved less useful.

Arthrotomy is considered the standard treatment for septic arthritis of the hip. This may be complicated by AVN or postoperative hip instability. Arthroscopic treatment of this condition is still not an established technique despite its minimally invasive nature and being associated with low morbidity.

A three portal arthroscopic technique was used for drainage, debridment and irrigation in 13 patients with septic coxarthrosis. Continuous intraarticular irrigation was not performed, nor was decompression drains used. All patients were treated with intravenous antibiotics for three weeks, followed with oral antibiotics for an additional minimum of three weeks. The patients were followed for 1-7 years.

Staphylococcus aureus was identified in four of the six patients. All patients had a rapid postoperative recovery. The mean Harris Hip Score at the last review was 97.5 points. All patients had a full range of motion of the affected hip. No complications occurred with this group of patients.

Three directional arthroscopic surgery combined with large volume irrigation is an effective treatment modality in cases of septic arthritis of the hip. It is less invasive than arthrotomy, and offers low post surgical morbidity.

This study describes a safe endoscopic technique for decompression of trochanteric bursa and presents the results of this procedure.

Fifteen patients who had failed non-operative treatment for trochanteric bursitis were treated by endoscopic lengthening of fascia lata (FL) and trochanteric bursectomy. Two patients had also failed open decompressions performed at another institution prior to their endoscopic surgery. All patients took part in questionnaires pre-operatively and at three months and twelve months. A two-portal endoscopic procedure was performed in all subjects. A Cruciate incision was made in the FL hence lengthening it in three dimensions. A trochanteric bursectomy was then performed using a mechanical shaver.

No patients were lost to follow up. At last review 14 patients rated their result as excellent and one patient had a fair result. There were no complications. The modified Harris hip score improved from 45 to 60, Non-arthritic hip score improved from 45 to 64 and SF12 score improved from 31 to 34.

Endoscopic lengthening of FL and trochanteric bursectomy is a safe and effective procedure in relieving the symptoms of persistent trochanteric bursitis.

Osteochondral fracture of the femoral head is an uncommon injury with a high potential for a poor functional outcome. Management is often challenging with limited options. We present two cases in which osteochondral fractures of the femoral head were treated with partial resurfacing using the HemiCAP System (Arthrosuface, Franklin MA, USA).

Perthes disease often leaves young adults with hip joint incongruency due to femoral head asphericity, (extra-articular extrusion and superior flattening). This causes femoro-acetabular impingement, a reduced range of movement and early degenerative change. We report a novel method for restoration of femoral head sphericity and femoro-acetabular congruency.

Two males (aged 21 and 22 years) presented with groin pain and severe hip stiffness after childhood Perthes disease. Imaging confirmed characteristic saddle shaped deformities of the femoral head, with cartilage loss overlying a central depression in the superior section of the head. A new method of treatment was proposed. Both cases were treated in the same manner.

A surgical dislocation was performed with a trochanteric flip osteotomy. The extra-articular bump was removed with osteotomes and a burr to reduce femoro- acetabular impingement. The sphericity of the femoral head was restored using a HemiCap partial re-surfacing (Arthrosurface, MA, USA). The radius of the implant was selected to match that of the acetabulum. Restoration of the height of the flattened portion of the weight-bearing surface of the femoral head reduces abnormal loading of the acetabular articular cartilage by improving congruency of the joint. Both patients recovered without incident and were mobilised with crutches, restricted to touch weight-bearing for six weeks to protect union of the trochanteric osteotomy.

At a minimum of three year follow-up both patients had sustained improved range of movement, pain and Oxford hip score. Repeated imaging shows no evidence of joint space narrowing or loosening at this stage.

We conclude that this novel treatment functions well in the short term. Further surveillance is on-going to confirm that this treatment results in improved long term durability of the natural hip joint after Perthes disease.

Large articulations are increasingly being used to reduce dislocation, the most common early complication following THR. However, potential benefits of large articulations in reducing dislocation have not been proven in a well-controlled clinical trial.

The aim of our randomised controlled trial was to compare the one-year incidence of dislocation between 36 and 28 mm metal on highly cross-linked polyethylene articulations.

Patients were excluded if they had a high risk of dislocation due to, for example, abnormal anatomy, neuromuscular disease, previous infection or dislocation. Eligible patients were stratified according to a number of other factors which may influence dislocation risk, including primary or revision THR and, if primary THR, by surgeon, age, diagnosis, sex and Charnley grade. Patients were randomised intra- operatively to either a 28 or 36 mm articulation. Dislocation incidence was determined using a hip instability questionnaire and a hospital visit questionnaire. A dislocation was diagnosed if there was radiological evidence and reduction by a doctor was required. Six-hundred-and-forty-four patients undergoing primary or revision THR were entered into the study.

Overall, the incidence of dislocation at one year following THR was 5.4% with a 28 mm articulation and 1.3% with a 36 mm articulation (p=.004). Incidence in primary THR patients was 4.4% with a 28 mm articulation, compared to 0.8% with a 36 mm articulation (p=.007). Incidence in revision THR patients was 12.2% and 4.9% with 28 and 36 mm articulations, respectively. For both primary and revision THR patients, sex distribution, age and BMI of patients who dislocated were similar to those of the total samples of primary or revision patients.

This large randomised study unequivocally shows for the first time that, compared to a 28 mm articulation, a 36 mm articulation in THR is efficacious in reducing the incidence of dislocation in the first year following THR.

The authors entered patients into a randomised trial to compare the results of the use of cemented and cementless acetabular prostheses between 1993 and 1995. The results of mid-term wear studies at average follow up of eight years were reported in the journal in 2004. We now present long-term results to show the eventual fate of the hip replacements under study.

The initial study group of 162 patients was randomly assigned to a modular titanium cup with a polyethylene liner or an all polyethylene cemented cup. All patients received a cemented stem with a 26 mm head and a standardised surgical technique. The polyethylene wear was estimated via head penetration measurement and the mid-term results showed a significantly higher wear rate in the cementless cups compared to the cemented cups (0.15mm/yr vs. 0.07mm/yr p<0.0001). The prediction was that this would lead to a higher rate of aseptic loosening in the cementless group.

Patients have now been re-examined at an average of 15 years with the main emphasis on prosthesis survival. Wear studies were also performed.

There were exclusions from the initial study because of death and reoperation for reasons other than aseptic loosening. The number of patients in this longer-term study had decreased as a result of death and loss to follow up. Revisions for aseptic loosening did not follow the path as suggested by the mid term wear studies. There were five cup revisions in the cemented group and one cup revision in the cementless group for aseptic loosening. No femoral stem was revised for aseptic loosening. Details of the long-term wear studies will be presented and osteolysis rates and extent documented.

Despite the statistically significant difference in wear rates at the mid term, an incorrect prediction of eventual loosening rates was made. The authors believe that there are many factors other than wear rates involved in longevity of fixation. We also believe there are many weaknesses in long term prospective, randomised trials in joint replacement and question whether they are, in fact, level 1 evidence in the age of evidence based medicine.

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.

Nationally, experimental estimated Indigenous life expectancy was 59 years for Indigenous males (compared with 77 for all males) and 65 years for Indigenous females (compared with 82 years for all females). This is a difference of around 17 years for both males and females (ABS 2004).

The Australian Government has embarked on numerous educational and health campaigns addressing the disease processes that lead to such a stark difference in life expectancy. The results of these campaigns are evident, as the population of Indigenous Australians over 60 years of age has risen from 9968 (Census 1986) to 25604 (Census 2008). As a result, we are now beginning to see orthopaedic degenerative disease states such as osteoarthritis. This increase in the number of Iindigenous Australians suffering from osteoarthritis will result in a greater number of hip and knee joint arthroplasty for osteoarthritis. Although the largest populations of Indigenous patients reside in urban areas, notably Sydney (census count 41,800), Brisbane (41,400) and Perth (21,300), the Torres Strait region of Queensland has 83% of the Indigenous population in remote Australia (Census 2008).

This is reflected in the number of hip and knee joint arthroplasties performed through the orthopaedic department at the Cairns Base Hospital on indigenous patients, from a total of seven in 2001 to a total of 22 in 2008.

Retrospective analysis was conducted of those patients failing to attend their full complement of post-operative follow-up in the first year post total hip and knee joint arthroplasty for the eight year period from 2001 to 2008 at the Cairns Base Hospital. Within this period a total of 99 hip and knee arthroplasties were performed on indigenous patients. Over 30% of indigenous patients failed to attend their full complement of post-operative follow up in the first year post hip and knee joint arthroplasty.

Due to the increasing life expectancy of the indigenous population, more are presenting with orthopaedic degenerative disease states that require joint arthroplasty. The higher number of co-morbidities such as type II diabetes mellitus and peripheral vascular disease makes post operative follow up of the indigenous patient essential to avoid complications. The lack of follow up will undoubtedly lead to an inability to appropriately monitor the indigenous patient's recovery and/or decrease in morbidity post total hip and knee joint arthroplasty. Patient centered follow-up must be given greater consideration in relation to the Australian indigenous population such as an increase in outreach services, the provision of orthopaedic follow up by the local health practitioners in the rural and remote setting, maintaining up to date contact details along with affording the indigenous patient greater access to transport so as to improve follow up.

Failed internal fixation of hip fracture is a problem with varied aetiology. This becomes more complex when associated with infection. Total hip arthroplasty (THA) remains the only option to restore hip biomechanics when there is partial/complete head destruction associated with it.

A retrospective review was performed for 22 consecutive patients of THA following failed infected internal fixation between Sept. 2001 and Nov. 2007. There were 11 dynamic hip screw failures for intertrochanteric fractures, six failed osteotomies following proximal femoral fractures and five failed screw fixations for transcervical fractures. The average age of the patients was 48.5 years and average follow up period was 3.5 years (16 months–7.5 years).

All the patients have undergone two stage revision surgeries.

The average Harris Hip Score improved from 35.5 to 82.8 at the latest follow up. None of the patients had recurrence of infection. One patient developed sciatic nerve palsy, recovered partially at one year following surgery. The results were comparable to primary arthroplasty in femoral neck fractures.

THA is a useful salvage procedure for failed infected internal fixation of hip fractures. Extreme care must be taken to avoid fracture and penetration of femoral shaft in such cases. Auto graft, allograft and special components like multihole cup, narrow stem should be available for reconstruction in difficult cases.

We have followed a consecutive series of revision hip arthroplasties, performed for severe femoral bone loss using anatomic specific proximal femoral allografts

Forty-nine revision hip arthroplasties, using anatomic specific proximal femoral allografts longer than five centimetres were followed for a mean of 10.4 years.

The mean preoperative HHS improved from 42.9 points to 76.9 points postoperatively. Six hips (12.2%) were further revised, four for non-union and aseptic failure of the implant (8.2%), one for infection (2%), and one for host step-cut fracture (2%). Junctional union was observed in 44 hips (90%). Three hips underwent re-attachment of the greater trochanter for trochanteric escape (6.1%). Asymptomatic non-union of the greater trochanter was noticed in three hips (6.1%). Moderate allograft resorption was observed in five hips (10.2%). Two fractures of the host step-cut occurred (4.1%). There were four dislocations (8.2%), two of them developed in conjunction with trochanteric escape. By definition of success as increase of HHS by 20 points or more, and no need for any subsequent re-operation related to the allograft and/or the implant, a 75.5% rate of success was found. Kaplan-Meier survivorship analysis predicted 73% rate of survival at 12 years, with the need for further revision of the allograft and/or implant as the end point.

We conclude that the good medium-term results with the use of large anatomic- specific femoral allografts justify their continued use in cases of revision hip arthroplasty with severe bone stock loss.

The purpose of this paper is to review the early results of Prostalac system under licence from Therapeutic Goods Administration for Professor Howie in the management of two stage exchange hip arthroplasty for infection (restricted to Royal Adelaide Hospital) and the addition of vancomycin and teicoplanin powder to tobramycin cement without additional tobramycin.

Thirteen patients were treated for an infected THR with the Prostalac system. Preoperative and intra-operative cultures were taken to identify the infective organisms. Vancomycin 3 gm was added to the Prostalac cement mantle per 40 gm packet of antibiotic bone cement containing tobramycin 1 gm. Teicoplanin 2.4 gm was used in one case where the patient had a known vancomycin allergy. Postoperatively patients underwent six weeks of IV antibiotics followed by four to six weeks of oral.

A short term successful clinical outcome was determined by implantation of a total hip prosthesis at the time of second stage operation and no reoperations resulting from recurrent infection and off antibiotics for â□¥ 6 months with normal clinical and CRP lab values.

Thirteen patients received the Prostalac system. No patient was lost to follow-up. Nine have progressed to second stage revision, eight of which had femoral impaction grafting. Two deaths occurred not attributed to the Prostalac system. Three superficial wound infections and two required washout and debridement. One Prostalac stem subsidence. There has been no recurrence of deep joint infection. Retention of the second stage prosthesis has been 100% at 17 months.

The PROSTALAC system with the addition of vancomycin or teicoplanin to the tobramycin antibiotic cement has encouraging short-term results for treatment of deep joint infection. Complication rate has been well within the range reported in literature. Successful early outcomes are encouraging with all patients in the Prostalac study having retained their permanent hip prosthesis following second stage surgery.

Removal of well-fixed cement at the time of revision THA for sepsis is time consuming and risks bone stock loss, femoral perforation or fracture. We report our experience of two-stage revision for infection in a series of cases in which we have retained well-fixed femoral cement.

All patients underwent two-stage revision for infection. At the first stage the prostheses and acetabular cement were removed but when the femoral cement mantle demonstrated good osseo-integration it was left in-situ. Following Girdlestone excision arthroplasty (GEA), patients received local antibiotics delivered by cement spacers, as well as systemic antibiotics. At the second stage the existing cement mantle was reamed, washed and dried and then a femoral component was cemented into the old mantle.

Sixteen patients (M:F 5:11) had at least three years follow-up (mean 80 months – range 43 to 91). One patient died of an unrelated cause at 53 months. Recurrence of infection was not suspected in this case. The mean time to first stage revision was 57 months (3 to 155). The mean time between first and second stages was nine months (1 to 35). Organisms were identified in 14 (87.5%) cases (5 Staphylococcus Aureas, 4 Group B Streptococcus, 2 Coagulase negative Staphylococcus, 2 Enterococcus Faecalis, 1 Escheria Coli). At second stage, five (31.2%) acetabulae were uncemented and 11 (68.8%) were cemented. There were two complications; one patient dislocated 41 days post-operatively and a second patient required an acetabular revision at 44 days for failure of fixation. No evidence of infection was found at re-revision. One patient (1/16, 7%) has been re-revised for recurrent infection. Currently no other patients are suspected of having a recurrence of infection (93%).

Retention of a well-fixed femoral cement mantle during two-stage revision for infection and subsequent cement-in-cement reconstruction appears safe with a success rate of 93%. Advantages include a shorter operating time, reduced loss of bone stock, improved component fixation and a technically easier second stage procedure.

We carried out a protocol driven study of 30 consecutive patients who had an infected hip arthroplasty and were treated with two stage uncemented revision hip surgery. There were 23 males (average age 65 years) and 50% of the patients were obese.

Radical debridement of hip was performed to achieve control of infection at first stage surgery. Twenty patients grew one organism and 10 patients had multiple organisms grown. The predominant organism was Staphylococcus epidermidis. Eight patients had MRSA/MRSE. All patients were treated with antibiotics for at least three months. The mean time to reimplantation was 4.7 months. In 15 patients, allograft was used for reconstruction in the second stage. All patients were followed up clinically and radiologically and mean follow up was 4.2 years. No patient was lost to follow up.

Rate of eradication of deep infection was 100%. Two patients required re-debridement for stitch abscesses which healed without sequeale. Only two patients (6%) had poor result as assessed by Harris Hip score, Merled Aubigne score and SF12 score. Sixty-seven percent of patients had good to excellent result and 27% had fair outcome. The poor results correlated to the old age and other significant co-morbidities in these patients. One patient died due to unrelated cause after eight years of surgery. Radiographically, all but one implant were well fixed at review. One patient had a radiolucent line around the acetabulum and was radiologically and clinically loose. There is no clinical or haematological evidence of infection. Twelve patients had heterotopic ossification and four patients had trochanteric non-union but no pain. One patient developed sciatic nerve palsy and one patient had recurrent dislocation.

This medium term review has revealed that a satisfactory outcome of a difficult problem can be achieved by using a standardised treatment protocol and uncemented implants.

We present our mid-term results with the use of structural allografts in cases of revision of failed THA due to infection.

Eighteen patients with a deep infection at the site of a THA were treated with a two-stage revision, which included reconstruction with massive allografts. All the allografts were frozen and sterilised by gamma-irradiation. The mean age at the time of the revision was 65.9 years. A cement spacer containing 1 g of Gentamicin was used during the interval period. Parenteral antibiotics were administrated for a period of three to four weeks. Oral antibiotics were given for an average of 18 weeks. The patients were followed for a mean of 8.9 years (5.4–14.2).

Definite deep wound infection developed in one patient (5.6%), who underwent resection arthroplasty. An additional patient underwent re-revision of an acetabular component for mechanical loosening. The mean HHS improved from 34.2 points preoperatively to 70.7 points at the last review. Sixteen of the patients (88.9%) had a successful outcome. Kaplan-Meier survivorship analysis predicted 80.95% rate of survival at 14 years.

Radiographicly, all allografts were found to be united to host bone. There were no signs of definite loosening of any of the implants. The complications include one fracture and two postoperative recurrent dislocations.

The use of massive allografts in a two-stage reconstruction for infected THA gives satisfactory results and should be considered in cases complicated with severe bone stock loss, where standard revision techniques are not an option.

High tibial osteotomy (HTO) is an established treatment for medial compartment osteoarthritis of the knee; the aim being to achieve a somewhat valgus coronal alignment, thereby unloading the affected medial compartment. This study investigated knee kinematics and kinetics before and after HTO and compared them with matched control data.

A three dimensional motion analysis system and two force platforms were used to collect kinematic and kinetic data from eight patients with medial compartment knee osteoarthritis during walking preoperatively and 12 months following HTO (opening wedge). Nine control participants of similar age and the same sex were tested using the same protocol. Sagittal and coronal knee angles and moments were measured on both the operated and non-operated knees and compared between the two time points and between HTO participants and controls. In addition, preoperative and postoperative radiographic coronal plane alignments were compared in the HTO participants.

The point at which the mechanical axis passed through the knee joint was corrected from a preoperative mean of 10% tibial width from the medial tibial margin to 56% postoperatively. Stride length and walking speed both improved to essentially normal levels (1.57 m and 1.5 m/s) ostoperatively. In the coronal plane the mean peak adduction angle during stance reduced from 14.3° to 5.2° (control: 6.8°). Mean maximum adduction moments were similarly reduced to levels less than in control participants, in keeping with the aim of the surgical procedure: peak adduction moment 1: pre 3.8, post 2.7, control 3.6 peak adduction moment 2: pre 2.5, post 1.7 and control 2.6.

In the sagittal plane, both mean maximum flexion and extension during stance increased postoperatively—extension to greater than in control participants and flexion to almost control levels. The maximum external knee flexor moment during stance also increased to near normal postoperatively.

High tibial osteotomy appears to achieve the intended biomechanical effects in the coronal plane (reduced loading of the medial compartment during stance). At the same time there were improvements in sagittal plane kinematics and kinetics which may reflect a reduction in pain. The net effect was to reduce quadriceps demand.

Osteotomies are performed in patients with lower limb malalignment, usually associated with osteoarthritis of the knee or instability. The surgery realigns the mechanical axis of the leg by either an opening or closing wedge procedure with the goal of decreasing symptoms, improving function, and delaying the progression of osteoarthritis.

The 103 patients that had undergone osteotomy surgery were studied prospectively, and data was analysed one year post surgery. We examined subjective outcomes, patient history and surgical variables using backwards stepwise multiple regression models to determine whether there were any associations between these.

Subjective outcomes from a total of 103 osteotomy patients at one year post surgery were compared to patient history and surgical variables. All categories of KOOS and WOMAC scores were improved after surgery.

The multivariate models showed that variables significantly influencing the outcomes were pre-operative flexion, pre-operative weight, the size of the HTO plate used and tourniquet time.

Greater pre-operative flexion; lower weight; larger plate used, indicating larger corrections; and lower tourniquet times were shown to result in improved scores. Not all variables influenced all categories of the scores. While flexion and pre-operative weight influenced across the categories of both scores, plate size influenced KOOS pain and symptoms and tourniquet time influenced KOOS sport and quality of life.

Knee flexion and body weight were the most influential variables when considering KOOS and WOMAC outcome scores as a measure of success. The size of the correction may have influenced the pain and symptom scores because patients with greater malalignment may have initially had worse symptoms and their perception of their current function and pain is affected by their previous levels of pain and function. Osteotomy results in improved function and pain scores and our results indicate that there are several variables which significantly influence patient outcomes and may be of greater importance than other variables.

Tranexamic acid is a potent antifibrinolytic which has shown efficacy in reducing blood loss in total knee arthroplasty when administered intravenously. We performed a randomised controlled trial of oral tranexamic acid in total knee arthroplasty in order to assess the blood sparing effect of this preparation.

We investigated the effects of oral tranexamic acid on blood loss in 50 patients (25 treatment arm and 25 placebo) undergoing unilateral total knee replacement in a two year period starting January 2007. The treatment arm received 1500 mg of encapsulated oral tranexamic acid TDS pre-operatively, with the third dose occurring within two hours of surgery, and a fourth dose six hours post surgery. The control arm received an identically encapsulated non-active formulation at the same dosing intervals. Baseline pre-operative haemoglobin and heamatocrit measures were collected. Outcome measures were post-operative haemoglobin and haematocrit taken 12 to 24 hours post operatively and total blood loss in wound drains at 24 hours.

Results showed a non-clinically significant trend towards decreased blood loss and transfusion rates in the treatment arm when compared to placebo. No significant adverse events occurred in relation to the use of oral Tranexamic acid in this study. The perioperative use of oral tranexamic acid in conjuntion with elective total knee arthroplasty appears safe; however, its efficacy as a blood sparing medication is less than that which has been recorded with intravenous dosing. The study supports further consideration of the availability of intravenous tranexamic acid for decreasing blood loss in orthopaedic arthroplasty.

Recent emphasis in total knee arthroplasty has been on accelerated rehabilitation and recovery. Minimally invasive and quadriceps sparing techniques have been developed to expediate return to normal function. The aim of this study was to evaluate the effect of the tourniquet on post-operative pain and quadriceps function in total knee arthroplasty.

This study involved a randomised, blinded, prospective trial of 20 patients undergoing total knee arthroplasty by a single surgeon. All patients received a general anaesthetic, identical prosthesis and post-operative protocol. Patients were randomly allocated to one of two group: (a) tourniquet group or (b) no tourniquet group. A standard surgical tourniquet was applied to all patients but only inflated in the tourniquet group.

Outcomes included Oxford knee scores, post-operative pain scores, post-operative drainage and transfusion requirements, thigh and knee circumference measurements, range of motion, and surface EMG measurements at intervals of two weeks, six weeks, six months and twelve months.

The study included 16 male and four female patients with 11 right and nine left knees. There was no significant difference pre-operatively between groups in age, degree of deformity or range of motion.

There was no significant difference detected between Oxford knee scores up to twelve months, days to discharge, post-operative drainage and range of motion. However, the pain scores were significantly higher in the tourniquet group. Surface EMG as a measurement of quadriceps activation showed a significant difference between the groups and between time points. The no tourniquet group can support more energy in their quads muscle than the tourniquet group

The use of a tourniquet in total knee arthroplasty has no effect on overall knee function at twelve months as measured by the Oxford knee score and range of motion; however tourniquet use results in higher initial pain scores and reduction in quadriceps function as measured by surface EMG.

The advantages of unicompartmental knee arthroplasty (UKA) include its bone preserving nature, lower relative cost and superior functional results. Some temporary pain has been reported clinically following this procedure. Could this be related to bone remodeling? A validated bone remodeling algorithm may have the answers…

A 3D geometry of an intact human cadaveric tibia was generated using CT images. An all poly unicompartmental implant geometry was positioned in an inlay and onlay configuration on the tibia and the post-operative models created. An adaptive bone remodeling algorithm was used with finite element modeling to predict the bone remodeling behavior surrounding the implant in both scenarios. Virtual DEXA images were generated from the model and bone mineral density (BMD) was measured in regions of interest in the AP and ML planes. BMD results were compared to clinical results.

The bone remodelling algorithm predicted BMD growth in the proximal anterior regions of the tibia, with an inward tendency for both inlay and onlay models. Looking in the AP plane, a maximum of up to 7% BMD growth was predicted and in the ML plane this was as high as 16%. Minimal BMD loss was observed, which suggests minimal disturbance to the natural bone growth following UKA.

Positron emission tomography (PET) scans showed active hot spots in the antero- medial regions of the tibia. These results were consistent with the finite element modeling results.

Bone remodeling behavior was found to be sensitive to sizing and positioning of the implant.

The adaptive bone remodeling algorithm predicted minimal BMD loss and some BMD growth in the anterior region of the tibia following UKA. This is consistent with patient complaint and PET scans.

Joint load correlates with knee OA incidence, symptoms, radiographic, morphologic and biological changes. Available load modifying therapies are clinically effective but have drawbacks. The KineSpringTM (Moximed Inc), an investigational device, is designed to reduce compartment loads while avoiding the limitations of current treatments. We compare load reductions of braces, HTO and KineSpringTM.

Literature review and experimental data provide compartment load changes for clinically effective knee braces and HTO. Simulated gait testing was completed on four cadaver knees with early-stage OA. Gait was simulated using a cadaver-based kinematic test system that applies motion and loading patterns dynamically to cadaver specimens. Medial and lateral compartment femoro-tibial pressures were measured throughout testing using thin film dynamic pressure sensors (Tekscan, Inc.) placed inframeniscally. Three conditions were tested: no treatment, applied valgus moments to simulate a valgus moment brace, and implanted KineSpring.

Sufficient clinical data exists to support the development of new and novel load modifying therapies for knee OA. Joint load reductions provided by HTO and valgus moment braces provide insight into clinically effective load reduction ranges. Opening wedge HTOs of 5° and 10° are reported to reduce average medial compartment load by 55 N (12 lbs) and 286 N (64 lbs), respectively1. Valgus braces were reported to reduce medial compartment loads an average of 97-280 N (22-63 lbs). From this data we propose a clinically effective load reduction range of 55 to 286N is a valid indicator of the likely clinical success for medial knee load reduction treatments.

Gait simulation was successfully completed in all specimens in all test configurations. The valgus moment brace reduced medial compartment load by 58 ±20 N but did not reach statistical significance. The Kinespring reduced medial compartment load by 129±64 N in comparison to the untreated case, a statistically significant reduction. Neither the KineSpring nor the valgus moment brace caused significant changes in the lateral compartment during stance.

All treatments reduced medial compartment loads. KineSpringTM reduces loads in what we determined to be the clinically effective range. Additional studies and clinical investigations are warranted to determine the ultimate effectiveness of this implant system.

Several attempts have been made to treat medial compartment OA of the knee with mobile spacers. All have met with dismal failure.

This presentation explores the history of attempts to treat OA in the younger knee with mobile spacers and explains why they were all doomed to fail.

Sources of information for this presentation include the published peer reviewed literature, publically available documents, and an insiders view of some of the failed attempts to solve the problem of medial compartment OA with mobile spacers.

All attempts to treat medial compartment OA of the knee with mobile spacers have failed. The unispacer has been a failure with a 60% revision rate at three years. The ABS intercushion had a 100% revision rate at one year and in many cases caused permanent damage to the host knees. The Salucartilage spacer was implanted in one patient only and failed within 48 hours.

Mobile spacers do not work, are never likely to work, and are not indicated for the treatment of medial compartment osteoarthritis of the knee.

A key determinant of long-term implant survival following primary TKA is post- operative alignment of the limb and components. The aim of this study was to compare the accuracy of the Vector-Vision CT-free navigation system versus conventional hand-guided TKA by comparing post-operative alignment.

In a retrospective study 51 sets of post-operative radiographs were analysed, 33 computer-guided and 18 hand-guided. A specific protocol for the measurement of post-operative TKA radiographs was outlined and a novel Trigonometric Method (TM) of angle measurement was compared with the traditional Goniometer Method (GM) of measurement.

The standardised protocol was applied to all 51 sets of radiographs. In total, six angles were measured on each radiograph by two independent observers and compared between the computer-guided and hand-guided groups.

A protocol for the measurement of post-operative TKA radiographs was delineated with step-by-step instructions. The TM of angle measurement had a precision of 1.06° compared with 1.5° using the GM. The standard deviation of the TM was significantly smaller than the GM (p=0.033) and the intra-class correlation coefficient (ICC) of the TM was 0.94 versus 0.90 for the GM.

For the Mechanical Axis (MA), 91% of patients in the computer-guided group attained a MA within 180±3o compared with only 78% in the hand-guided group. T he absolute median raw deviation from 180° was 0.8 in the navigated group and 1.9° in the hand-guided group (p=0.029). Thus, the navigated group was associated with significantly less variability about the neutral 180°. For the other five angle measurements, a higher percentage of patients attained a more neutral alignment with computer-guided TKA; however, these did not reach statistical significance

The computer-assisted group demonstrated significantly more neutral alignment following TKA, and this may in turn lead to reduced TKA failure rates and improved implant longevity. In addition, a new TM of angle measurement was found to be more superior in terms of precision in comparison to the traditional method.

We designed this study to determine the clinical evidence to support use of the five degree tibial extra-medullary cutting block over the zero degree cutting block.

We identified three groups of patients from the databases and clinical notes at St Michaels Hospital, Toronto. Group one were primary total knees performed using the five degree cutting block, group two were primary total knees performed using the zero degree cutting block and the third group were computer navigated primary total knees. Patients in all three groups were age and sex matched. The senior author advocating use of the five degree block aimed to obtain a five degree posterior slope. The senior author who advocated the use of computer navigation, or the traditional zero degree cutting block, aimed to obtain a three degree posterior slope. All operations were performed by residents or clinical fellows, under the supervision of the senior authors. Patient radiographs were assessed to obtain the optimal direct lateral view obtained and they were saved on a database. Two independent blinded researchers assessed the posterior slope using Siemens Magicweb Software Version VA42C_0206. Two methods were used and the results averaged. The average posterior slope for the navigated total knee replacements was 0.1 degrees (−2 to 4). The average posterior slope for the five degree cutting block was 5.2 degrees (−2 to 16). The average posterior slope for the zero degree block was 3.79 degrees (−2 to 13). Computer navigated knee arthroplasty patients had significantly less variation in outlier measurements compared to the traditionally jigged arthroplasty patients. They were however, less accurate. The five degree cutting block tended to provide a more consistent posterior slope angle, but both the five degree and zero degree cutting blocks had variability in outliers. Computer Navigated Total Knee replacement provides a more consistent and reproducible tibial cut with less variability in alignment than extra-medullary jigs. The traditional five degree cutting block tended to provide a more reliable five degree posterior slope than the zero degree block, but was still subject to outliers.

Accurate implant alignment, prolonged operative times, array pin site infection and intra-operative fracture risk with computer assisted knee arthroplasty is well documented. This study compares the accuracy and cost-effectiveness of the pre- operative MRI based Signature custom made guides (Biomet) to intra-operative computer navigation (BrainLab Knee Unlimited).

Twenty patients from a single surgeon's orthopaedic waiting list awaiting primary knee arthroplasty were identified. Patients were contacted and consented for the study and their suitability for MRI examination assessed. An MRI scan of the hip, knee and ankle was performed of the operative side following a set scanning protocol. Following MRI, patient specific femoral and tibial positioning cutting guides were manufactured. Patients then underwent arthroplasty and intra-operative computer navigation was used to measure the accuracy of the custom made, patient specific cutting guides. A cost analysis of the signature system compared with computer navigation was made.

Our provisional results show that the accuracy of the pre-operative MRI patient specific femoral and tibial positioning guides was comparable to computer navigation.

Pre-operative, patient specific implant positioning cutting guides were as accurate as computer navigation from analysis of our preliminary results. The potential advantages of the MRI based system are accurate pre-operative planning, reduced operating times and avoidance of pin site sepsis. However, further larger studies are required to examine this technique.

The standard approach for kinematic analysis of knee joints has been roentgen stereophotogrammetry (RSA). This approach requires implanting tantalum beads during surgery so pre- and post-surgery comparisons have not been conducted. CT- fluoroscopy registration is a non-invasive alternative but has had accuracy and speed limitations. Our new algorithm addresses these limitations.

Our approach to the problem of registering CT data to single-plane fluoroscopy was to generate a digitally reconstructed radiograph (DRR) from the CT data and then filter this to produce an edge-enhanced image, which was then registered with an edge-enhanced version of the fluoroscopy frame. The algorithm includes a new multi-modal similarity measure and a novel technique for the calculation of the required gradients.

Three lower limb specimens were implanted with 1 mm tantalum beads to act as fiducial markers. Fluoroscopy data was captured for a knee flexion and femur and tibia CT data was registered to the fluoroscopy images.

A previous version of our algorithm (developed in 2008) showed good accuracy for in-plane translations and rotations of the knee bones. However, this algorithm did not have the ability to accurately determine out-of-plane translations. This lack of accuracy for out-of-plane translations has also been the major limitation of other single-plane 2D-3D registration algorithms. Fregly et. al. and Dennis et. al. reported standard deviations for this measurement of 5.6 and 3.03 mm respectively. The latest version of our algorithm achieves error standard deviations for out-of-plane translations of 0.65 mm. The algorithm includes a new similarity measure, which calculates the sum of the conditional variances (SCV) of the joint probability distributions of the images to be registered. This new similarity measure determines the true 3D position of the bones for a wider range of initial disparities and is also faster than the cross-cumulative residual entropy (CCRE) measure used in the 2008 version. For a set of initial 3D positions ranging from ± 5 pixels and ± 5 degrees the proposed approach successfully determined the correct 3D position for 96% of cases–whilst the approach using CCRE was successful for only 49% of cases. The algorithm also required 60% less iterations than the previous CCRE approach.

The new registration algorithm developed for the project provides a level of accuracy that is superior to other similar techniques. This new level of accuracy opens the way for a non-invasive mechanism for sophisticated kinematic analysis of knee joints. This will enable prospective, longitudinal and controlled studies of reconstruction surgery.

Increasingly, high flexion components have been touted by the industrial manufacturers of them as the implants of choice for routine total knee replacement (TKR). An acceptable flexion arc is obtainable in most patients through various intra-operative techniques; however, the importance of obtaining high flexion—which we define as greater than 120 degrees—is unclear.

In our pilot study, a review was undertaken involving 60 of the senior authors patients who attained greater than 120 degrees of flexion after receiving an implant said to be high flexion based on the presence of both a rotating platform as well as a conforming cam-and-post third condylar space.

Despite the achievement of both high flexion and impressive patient satisfaction, no functional benefits were observed—an observation that is supported in the current literature. We will explore possible reasons for this discord and note that most patients did not express the desire to regularly perform high flexion activities such as kneeling, squatting and stooping on a daily basis. Our results and evaluation of the literature lead us to question the importance placed upon the achievement of the maximum possible post-operative flexion arc as well as the importance placed in the ability to perform high flexion activities.

This, in turn, calls into question the validity of many of the currently accepted outcomes measures used to post-operatively evaluate total knee replacements.

Increased knee flexion is seen as a primary goal in achieving a better functional outcome following TKR. However, the relationship between passive knee flexion and biomechanical outcome remains unclear. The aim of this study was to compare kinematic outcomes in TKR patients and controls during high flexion activities.

A three dimensional motion analysis system and two force platforms were used to collect kinematic and kinetic data from 40 patients who had undergone total knee replacement at least 12 months previously and 40 controls who were matched to the patients for age and gender. Participants completed the following activities six times: standing from a seated position, squatting, and lunging with each leg leading. Peak knee flexion angles and moments were compared between groups using t-tests and the correlations between passive knee flexion and functional knee flexion were calculated using ‘Pearson's r’.

For both squatting and lunging, peak knee flexion in the TKR group was significantly less than in the control group. There was no difference between the two groups for the sit to stand activity as peak flexion for this activity was primarily determined by the chair height.

Squat: control 124, TKR 91 (p<0.001) Lunge - op. forward: control 100, TKR 81 (p<0.001) Lunge - op. trail: control 106, TKR 84 (p<0.001) Sit to stand: control 87, TKR 85 (p=0.5)

Although there were significant correlations between functional and passive knee flexion in the TKR group for the squatting and lunging activities, the patients used only approximately 70 to 75% of their available flexion during these activities. As anticipated, there was only a weak correlation between passive and functional flexion for the sit to stand activity.

Percentage of passive flexion used: squat: 77%, lunge - op. forward: 68%, lunge - op. trail: 70% Sit to stand: 71%, Correlations: squat: 0.50, lunge - op. forward: 0.57, lunge - op. trail: 0.50, Sit to stand: 0.27

Normal sagittal knee kinematics during high flexion activities was not restored following TKR. Patients did not or were unable to use their available range of flexion to achieve a normal kinematic pattern. The cause of this important functional deficit remains to be established but may be amenable to targeted rehabilitation.

This paper reports the clinical outcomes and survivorship of a prospective series of Advantim cementless TKR performed at the RAH between 1993 and 2005. There were 210 knees in 176 patients. All procedures were performed or supervised by a single surgeon.

All patients were followed up at regular intervals, up to 15 years later, with Knee Society Cinical Rating System and X-Rays. No patients were lost to follow-up. The knee rating improved from a median of 47 to 90. The median range of motion was 0–100. At 11 years the survivorship of the tibial component was 95.5% and femur was 93.7%. There were two major revisions and three minor revisions for polyethelene exchange. There was no deep sepsis. There was no knee stiffness requiring arhrolysis or manipulation. No screw osteolysis observed. Advantim was the best perfoming TKR in the AOA registry in 2008 with 0.3 revisions per 100 observed component years.

The aim of this study was to compare the outcome of cemented TKR using either oxidized zirconium (oxinium) or cobalt chrome (CoCr) femoral components in patients undergoing simultaneous bilateral TKR. Patients involved in the study received one of each prosthesis, thereby acting as their own control. The hypothesis was that there would be no difference in the clinical and radiographic outcome between the two prosthetic materials.

Forty consecutive patients who were undergoing bilateral Genesis ll TKR consented to participate in the study. Patients were assessed preoperatively, at five days, six weeks and one, two and five years, postoperatively. The outcome measures included the KOOS, Knee Society Score, BOA Patient Satisfaction Scale, and radiographs at six weeks and one, two and five years. In two patients polyethlylene exchange was performed at 56 months from surgery during patellofemoral resurfacing. The four retrieved polyethylene liners were studied for wear with the aid of a stereo zoom microscope and an environmental scanning electron microscope (ESEM). Both the patients and the all examiners were blinded as to the prosthesis type throughout the study.

Forty patients (80 knees) were included in the study. At five years, three patients were deceased and two had developed senile dementia. No patients were lost to follow up. At five years from surgery the CoCr knee was preferred by 41% of patients compared to 13% who preferred the Oxinium knee (p=0.009). There was no significant difference in range of motion between the two prosthesis at five days, six weeks or one, two and five years. There were also no significant differences between the two prostheses in any of the other variables assessed. The four retrieved polyethylene inserts showed similar patterns of wear in terms of both wear types and patterns under examination with both the stereo zoom and scanning electron microscope with no clear differences between CoCr and Oxinium bearing against the polyethlylene. There was no difference in the grade or incidence of radiographic lucencies between the two prosthesis at five years.

At five years after surgery the only significant difference between the Genesis II Oxinium prosthesis and the CoCr prosthesis was a subjective preference for the CoCr prosthesis by a higher proportion of patients. There were no unexpected complications associated with the use the Oxinium femoral implants. In the four retrieved polyethylene liners, no significant differences were identified between the two prosthesis materials in terms of detectable wear type and patterns. Continued follow up of this cohort is planned to establish whether Oxinium femoral implants have an improved survivorship compared to CoCr femoral component in total knee replacement to warrant the additional cost.

Mobile bearings in knee arthroplasty carry the theoretical advantage of lower wearing prostheses. However, dislocating mobile bearings can be a significant issue in mobile bearing knee replacement arthroplasty. Our aim is to report our design alterations to the insert to address bearing spinout.

A total of 598 RBK mobile bearing total knee arthroplasties were performed by the senior author over a 10–year period. The standard bearing was subjected to three design changes to address spinout and increase flexion range. The first alteration involved a deeper dish with a higher anterior lip. Subsequently, a reduced footprint insert (RFI) was created. The final modification was a shaved off posterior rim to allow for greater flexion (high flex).

An overall bearing dislocation rate of 1.0% (6 out of 595) was obtained. Of these 595 knees, 132 were of the initial insert design, 194 were deep-dished inserts, 71 inserts were RFI, and 198 were high flex. There were four (3%) dislocations with the initial insert design and two (1%) dislocations in the final implant version. In our series the dislocated bearings have in all but one required revision to higher constrained prostheses. The mechanism of dislocation is speculated to be instability in flexion, leading to posterior loading of the insert and spinning out of the bearing. Most of the bearing subluxations have been medial but one was observed intra operatively to be a lateral extrusion. With respect to the two dislocations in the final implant design, one dislocation was attributed to a technical error of under sizing the insert. At revision surgery he was also found to have a disrupted MCL, which was repaired. He has had no further issues after the insert was upsized

. The cause of spin out in the second patient was speculated to be obesity and a diminished pre- operative range of movement. She required a revision to a higher constrained prosthesis.

Insert spinout has a multifactorial aetiology. The occurrence of spinout can be minimised by a combination of good surgical technique, such as balanced flexion and extension gaps and design modifications to the insert as we have instituted.

Sensitive and accurate measures of osteolysis around TKR are needed to enhance clinical management and assist in planning revision surgery. Therefore, our aim was to examine, in a cadaver model of osteolysis around TKR, the sensitivity of detection and the accuracy of measuring osteolysis using Xray, CT and MRI.

Fifty-four simulated osteolytic lesions were created around six cadaver knees implanted with either a cemented or cementless TKR. Twenty-four lesions were created in the femur and thirty in the tibia ranging in size from 0.7 cm3 to 14 cm3. Standard anteroposterior and lateral fluoroscopically guided radiographs, CT and MRI scans with metal reduction protocols were taken of the knees prior to the creation of lesions and at every stage as the lesion sizes were enlarged. The location, number and size of the lesions from images obtained by each method were recorded.

The sensitivity of osteolytic lesion detection was 44% for plain radiographs, 92% for CT and 94% for MRI. On plain radiographs, 54% of lesions in the femur and 37% of lesions in the tibia were detected. None of the six posterior lesions created in the tibia were detected on the AP radiographs; however, three of these six lesions were detected on the lateral radiographs. CT was able to detect lesions of all sizes, except for four lesions in the posterior tibia (mean volume of 1.2 cm3, range 1.06–1.47 cm3). Likewise, MRI was very sensitive in detecting lesions of all sizes, with the exception of three lesions, two of which were in the femur and one was in the medial condyle of the tibia (mean volume of 1.9 cm3, range 1.09–3.14 cm3). Notably, all six posterior tibial lesions, which could not be detected using AP radiographs, were detected by MRI.

This study demonstrates the high sensitivity of both CT and MRI (which uses no ionising radiation) to detect simulated knee osteolysis and can therefore be used to detect and monitor progression of osteolysis around TKR. The study also shows the limitations of plain radiographs to assess osteolysis.

Osteolysis commonly causes total knee replacement (TKR) failure, often associated with asymptomatic large defects. Detection and size estimation of lytic defects is important for the indications and planning of revision surgery. Our study compares the utility of fluoroscopic-guided plain X-rays and computed topography (CT) in osteolysis detection and volume appreciation.

Three cadaveric specimens were imaged at baseline and following the creation of reamed defects (small, medium and large approximately = 1, 5 & 10 cm3 volume respectively) in the tibia and femur with TKR component implantation at each timepoint. Imaging was with fluoroscopic-guided plain X-rays (Anteroposterior & Lateral [APL], Paired Oblique [OBL]) as well as rapid-acquisition spiral Computed Topography [CT] with a beam-hardening artefact removal algorithm.

Three arthroplasty surgeons estimated the size of the lesion, if present, and confidence (none=0, fair=1, excellent=2) in their assessment on randomly presented images. Each surgeon performed two assessments of each image one month apart.

The accuracy of detecting lesions was determined using the area under the receiver-operating curve (AU-ROC) obtained from a logistic regression with adjustment for assessment sequence, observer, knee and bone. Volume appreciation and assessor confidence were determined using Kappa and the mean average of confidence scores respectively.

The AU-ROC using combinations of either APL/OBL/CT (0.83) or OBL/CT (0.83) resulted in superior detection of lesions (p<0.05) compared to APL (0.75) or OBL alone (0.77). Correct volume appreciation was highest with APL/OBL/CT (kappa=0.52), followed by APL/OBL (0.51) and was superior (p<0.05) to APL (0.29) or CT alone (0.31). Small and medium defects were more often missed than large with all modalities (20.3 vs. 39.7 %). Femoral defects were missed more often than tibial defects (40% vs. 28.7%) and small lesions missed more with CT (50%) versus APL (48%) and Oblique (40%). CT missed 19% of large sized defects, attributed mostly to femoral (29.1%) rather than tibial defects (8.3%)

Greater confidence was derived from use of CT (1.29) and APL (1.19) [Interquartile range (IQR) 1,2] when compared to OBL (.98, IQR 1,1) [p<.01]. Also, there was greater confidence regarding judgement of tibial defects (1.25, IQR 1,2) compared with femoral defects (1.05, IQR 1,1) [p<.01].

Combining all imaging modalities was synergistic and the most sensitive and specific means of defect detection and volume appreciation. CT provided more confidence, superior detection and volume appreciation when used in combination with APL/OBL versus APL/OBL alone. There is also additional value when APL is combined with OBL.

The management of shoulder instability has changed a great deal in the last five years due to a better understanding of the biomechanics of the shoulder and the use of arthroscopic surgery.

It is essential to understand the anatomy of the labrum and bony structures of the shoulder joint, as well as the contribution of these structures as well as the Rotator Cuff to stability in the different positions of the arm. The history and examination still remains the most important diagnostic tool and a thorough history and examination cannot be over-emphasised.

MR Arthrography is the investigation of choice in confirming the diagnosis of instability while a CT scan may be required if there is significant bony damage.

The most controversial topic is that of the first time dislocator. If there is a significant labral tear then the options of an arthroscopic labral repair or external rotation brace need to be considered. In the absence of a labral tear then physiotherapy is the treatment of choice.

For recurrent dislocators, the results of arthroscopic labral repairs with capsular plication techniques are approaching those of the gold standard open stabilisation. If, however, there is significant bony damage to the glenoid or humeral head then a bone block procedure may be the treatment of choice.

Rotator Cuff tears need to be excluded in older patients with instability and often in such cases an arthroscopic procedure to deal with the Rotator Cuff and Labrum can be done simultaneously.

Trauma is often involved in the history given at presentation but the main underlying problem in patients with Rotator Cuff tearing is degenerative change.

There has been a transition in techniques for repair of tendon tears from majority open repairs in the 1970–80s to minideltoid repairs in the 1980–90s. In the last 10–15 years there has been a strong drive to evolve the repair to an all arthroscopic technique.

With this evolution has come new equipment, implants and steep learning curves for surgeons at significant increase in cost to the health system with no clear improvement in long term outcome.

The ability to obtain repair of a degenerate tendon to bone remains the challenge and poses a difficult problem for all orthopaedic surgeons.

Fractures of the clavicle remain common in clinical practice. The main changes that have occurred in the last five years are in the indications for surgical intervention. The traditional indications remain. For example, complex cases such as compound fractures, those in which the skin is threatened, fractures of the clavicle associated with a floating shoulder, fractures of the clavicle associated with vascular injury and unstable lateral clavicle fractures.

Fractures of the middle 1/3 of the clavicle with displacement of greater than 2 cm have been identified as having a poorer outcome based on patient related factors. In adults these fractures are now recommended for surgical stabilisation.

A number of surgical techniques have been described including internal fixation with plates and intramedullary pins. It is the author's preference to use plate fixation as it provides stable fixation of the clavicle including rotational control. Although there are some authors that do recommend pin fixation, insertion of these pins can be technically demanding and there is a risk of displacement of undisplaced fragments. The intramedullary pins do not provide rotational control of the fracture.

When performing internal fixation of clavicle fractures it is important to be aware of the risk of major neurovascular compromise. In the second quarter (from the medial edge of the clavicle) the major neurovascular structures are at risk and care is required to ensure that drills and screws do not penetrate the inferior cortex of the clavicle and violate these neurovascular structures.

Adolescents with fractures of the clavicle are often managed without surgical intervention even if there is significant displacement. However, further work is required to identify the natural history of this group.

Non-union of the clavicle is a relatively uncommon event. For those patients who have a persistent symptomatic non-union, surgical stabilisation and bone grafting is recommended.

The causes of a stiff elbow are numerous including: post-traumatic elbow, burns, head injury, osteoarthritis, inflammatory joint disease and congenital.

Types of stiffness include: loss of elbow flexion, loss of elbow extension and loss of forearm rotation. All three have different prognoses in terms of the timing of surgery and the likelihood of restoration of function.

Contractures can be classified into extrinsic and intrinsic (all intrinsic develop some extrinsic component). Functional impairment can be assessed medicolegally; however, in clinical practice the patient puts an individual value on the arc of motion. Objectively most functions can be undertaken with an arc of 30 to 130 degrees.

The commonest cause of a Post-traumatic Stiff elbow is a radial head fracture or a complex fracture dislocation. Risk factors for stiffness include length of immobilisation, associated fracture with dislocation, intra-articular derangement, delayed surgical treatment, associated head injury, heterotopic ossification. Early restoration of bony columns and joint stability to allow early mobilisation reduces incidence of joint stiffness. Heterotopic ossification (HO) is common in fracture dislocation of the elbow. Neural Axis trauma alone causes HO in elbows in 5%. However, combined neural trauma and elbow trauma the incidence is 89%. Stiffness due to thermal injury is usually related to the degree rather than the site. The majority of patients have greater than 20% total body area involved.

Extrinsic contractures are usually managed with a sequential release of soft tissues commencing with a capsular excision (retaining LCL/MCL), posterior bundle of the MCL +/− ulna nerve decompression (if there is loss of flexion to 100 degrees). This reliably achieved via a posterior incision, a lateral column exposure +/− ulna nerve mobilisation. A medial column exposure is a viable alternative. Arthroscopic capsular release although associated with a quicker easier rehabilitation is associated with increased neural injury. Timing of release is specific to the type of contracture, i.e. flexion contractures after approx. six months, extension contractures ASAP but after four months, loss of forearm rotation less 6 to 24 months.

The use of Hinged Elbow Fixators is increasing. The indications include reconstructions that require protection whilst allowing early movement, persistent instability or recurrent/late instability or interposition arthroplasty.

Post-operative rehabilitation requires good analgesia, joint stability and early movement. The role of CPM is often helpful but still being evaluated.

Simon Schama, the eminent British historian, Cambridge scholar and lecturer, Oxford Fellow, History Professor at Harvard and Columbia University, and author of the acclaimed BBC series ‘History of Britain’, made the following observation of Edward 1st (also known as the Hammer of the Scots): “However the subjugation of Wales was far more subtle than the surgical application of brute force. Edward had the chilling, uncanny modern knowledge that to break your enemy, you must first strip him of his cultural identity.”

The National Registration and Accreditation Scheme (NRAS) is part of a programme designed to remove the Australian Medical Profession from its central role in the delivery of Australian health care.

The Australian medical profession, by action or inaction, will determine the success or failure of this agenda. My aim is simply to provide some researched observations for critical analysis.

My central tenet is that the Australian medical profession has been a remarkable force for good. Anything that would weaken its confidence and ability to deliver world-class medical treatment needs to be opposed in the interests of the welfare of all Australians, particularly the most vulnerable.

Orthopaedic International Medical Graduates (IMGs) have provided an invaluable service and source of workforce relief mainly in rural and outback Australia. Queensland has relied more heavily than any other state on overseas trained doctors to provide general practitioners and specialists around the state, particularly in areas deemed ‘an area of need’ (AON). The AON designation was seen to be a way of easy recruitment but is a two-edged sword for both the state government and for the IMG.

While overseas trained doctors may be more compliant with administrators' wishes than what locally trained doctors might be, they have not necessarily passed a local medical examination or even sat a medical examination in English before coming to Australia.

Meticulous and drawn out medical qualification checks, health and security checks are carried out which can take a long time to perform and could frustrate the end user who is often dependent on that doctor arriving by a certain date to cover a call roster and maintain a continuum of care for a specific district. The many and varied steps have been changing over the past few years and so this presentation is meant to clear up some of the misunderstandings that exist for the various parties involved. This would include some guidelines to the IMG and to the recipient hospital or practice recruiting that IMG, outlining some of the traps and pitfalls for all to consider.

State government administrators also need to show leadership when advertising, interviewing and employing IMGs, as this may have implications for all of us into the next decade. A frank look at our present and future workforce needs by the whole Orthopaedic community is necessary. The challenges and solutions of how Orthopaedic Surgery will be provided both publically and privately into the future is resting with us now.

The suggestion of a meniscal tear produces a pavlovian response in the orthopaedic surgeon. However, meniscal signal anomalies and associated changes become common with age in symptom free knees. T he issue for the IME requested to assess workers with painful knees is to determine if the MRI changes represent a painful injury and if the treatment planned (usually arthroscopy) may, in fact, be harmful.

MRI signal changes are assessed on the likelihood they predict for unstable meniscal tears. Some patterns of meniscal tears are benign. Associated changes such as baker's cyst and ligament thickening are also common but are poor predictors of symptomatic tears. Preclinical osteoarthritis has a high incidence of associated meniscal change and arthroscopic menisectomy may accelerate osteoarthritis progression.

Clinical tests have variable specificity and sensitivity but in combination with an understanding of the patterns of MRI signal can be combined to predict which meniscal tears would benefit from arthroscopic surgery, which injuries would do as well with non-operative treatment and which patterns predict deterioration after surgery.

As the views of the IME are often contrary to the surgeon, a comprehensive bibliography is provided for any who need to argue their case. As the topic is information and image dense, a CD ROM will be distributed.

Australia is a foundation member of the Asia Pacific Orthopaedic Association—thus, recognising our geographical position in the most rapidly advancing region in the world.

It is a serious mistake to think of Asia as ‘third world’. Research, education and surgical techniques are at the forefront of modern technology. Australia has to be a part of this ‘learn and teach’ movement.

We have much to gain through exchange and travelling fellowships; paediatric, spinal, trauma and arthroplasty fellowships are available. The Orthopaedic Sports Medicine Travelling Fellowship is co-ordinated with corresponding organisations in Europe, North America and South America and previous travelling fellows become part of the influential Magellan Society.

APOA has many sections (knee, hip, hand, spine, trauma, infection, sports medicine and paediatrics), with each having regular Congresses. Join APOA and attend the Triennial Congress in Taipei November 2010 and be impressed at the level of research.

Australian Doctors for Africa was formed in 2005 to provide some focus on the orthopaedic needs of the east coast of Africa.

With the support of the college and the AOA, and in response to requests for assistance, the size and scope of the organisation has increased.

ADFA has four active projects based primarily around the provision of orthopaedic services and teaching, along with the supply of medical, surgical and hospital equipment. Each location has different needs and is the subject of a different three-year development partnership.

In Addis Ababa, Ethiopia the programme is mainly teaching the trainee orthopaedic surgeons, coordinating the visits of volunteers from other organisations and providing hospital equipment. A container of hospital beds, crutches, wheelchairs and splints have just arrived. An orthopaedic team led by Dr Tony Jeffries visited for two weeks in September 2009 to teach the operative management of forearm fractures, improve the sterile technique in the operating theatres and deliver and install an intramedullary nailing set.

In Hargeisa Somaliand, ADFA is involved with the Faculty of Medicine of the University of Western Australia to develop a curriculum with School of Medicine and provide medical staff for clinical teaching.

In Bosaso, Puntland, Northern Somalia, we, together with Rotary, are assisting with the construction of new theatre wards and furnishing with hospital beds and equipment. Here, the orthopaedic service is consulting and operating rather than teaching.

In Madagascar we have been building up the talipes screening and plaster treatment service, providing container loads of medical and surgical equipment and conducting bi-annual orthopaedic operating visits. The next visit is in November 2009 with orthopaedics, gastroenterology and urology specialists from ADFA.

Re-positioning osteotomy in the treatment of un-united fracture neck of femur in young patients improves the biomechanical pre-conditions to promote bone union of the Pseudarthrosis. This operative procedure is the method of choice for Pseudarthrosis of the neck of the femur with a viable femoral head. It is also the method of choice in children and in adolescents even if there is avascular necrosis of the femoral head.

The operative technique permits exacts planning, stable osteosynthesis both of the un-united fracture of the neck of the femur as well as the osteotomy and allows early mobilisation. In this series of 56 cases, only six (10%) had collapse of the femoral head due to avascular necrosis, six (10%) patients had severe pain in the hip and nine (16%) patients had severe restriction of hip movement. The overall success of the operation in this series was 84%.

Five medical visits (soon to be six) and three countries since 2005.

Do we make a difference? Is it money well spent? Ausaid, Outreach or PIP?

Good for the soul—ours or theirs?

A brief story/journey based on my personal experiences and journeys to the Pacific Islands.

R Appleyard, Murray Maxwell Biomechanics Lab, Royal North Shore Hospital, Sydney

The fundamental mechanisms that underlie tendon breakdown are ill understood. There is an emerging hypothesis that altered mechanical strain modulates the metabolism and/or phenotype of tenocytes, disrupting the balance of matrix synthesis and degradation, and that rupture then occurs through an abnormal tendon matrix. The critically regulated genes have not yet been determined. We have developed sheep model in sheep where both stress-deprived and over-stressed areas can be examined in the one tendon, to evaluate the pathological and molecular changes over time. We have also used ‘wild type’ and genetically modified mice to determine the role of specific enzymes and proteoglycans in tendon degeneration. Stress-deprived and over-stressed regions showed classical changes of increased cellularity and vascularity, rounded tenocytes and interfascicular matrix infiltration. These structural changes resolved for up to one year after injury. Resolution was more rapid in over-stressed regions. Irrespective of the initiating stress, proteoglycan staining and chondroid metaplasia increased in tendon with time. There were distinct molecular and temporal differences between regions, which are reviewed here. While tendon degeneration has traditionally been regarded as a single field of change, our studies show that at a molecular level, the injured tendon may be regarded as a number of distinct regions—overloaded and underloaded, adjacent to bone or adjacent to muscle. Each region manifests distinct molecular changes, driven by relevant gene expression.

While collagen metabolism in pathological tendon has received much attention, accumulation of proteoglycan is also consistently induced by altered mechanical loading. We suggest that ADAMTS enzymes, which cleave aggrecan, versican and small proteoglycans, may play a significant role in tendon homeostasis and pathology. Regulating proteoglycan turnover may represent a novel target for treating tendon degeneration. We have initiated studies using mesenchymal stem cells (MSC), not to directly augment healing but to modify the molecular pathology in tendon resulting from altered loading. Preliminary data indicates that injection of MSC into an acute tendon defect significantly abrogates the increase in expression of aggrecan and collagen degrading metalloproteinases in the adjacent over-stressed tendon. This may decrease the resultant degeneration. The effects of MSC in treating tendon degeneration are reviewed here, as are the possible benefits of radiofrequency microtenotomy.

A radiation sterilisation dose (RSD) of 25 kGy is commonly recommended for sterilisation of allograft bone. However, the mechanical and biological performance of allograft bone is gamma dose-dependent. Therefore, this study aimed to apply Method 1 – ISO 11137–2: 2006 to establish a low RSD for frozen bone allografts. Two groups of allograft bones were used: 110 femoral heads (FH) and 130 structural and morselized bones (SMB).

The method included the following stages: bioburden determination using 10 FHs and 30 SMBs; verification dose selection using table six in the ISO standard and bioburden; the verification dose was used to irradiate 100 samples from each group; then irradiated bone segments were tested for sterility. The criterion for accepting the RSD as valid is that there must be no more than two non-sterile samples out of 100. The radiation sterilisation dose is then established based on table five, ISO 11137– 2: 2006.

The bioburden of both types of frozen allograft was zero. The verification dose chosen was 1.3 kGy. Two hundred bone segments were irradiated at 1.3 kGy. The average delivery gamma dose was 1.23 kGy (with minimum dose of 1.05 kGy maximum dose of 1.41kGy), which is acceptable according to the ISO standard. Sterility tests achieved 100% sterility. Accordingly, 11 kGy was established as a valid RSD for those frozen bone allografts. A reduction in the RSD from 25 kGy to 11 kGy will significantly improve bone allograft mechanical and biological performance because our data show that this dose level improves the mechanical toughness and osteoclast activity of the allograft by more than 10 and 100 percent, respectively, compared with bone allografts irradiated at 25 kGy.

A low RSD of 11 kGy was established for allograft bones manufactured at Queensland Bone Bank by applying dose validation method 1 (ISO 11137.2-2006) that is internationally accepted.

The biological properties of morselised bone allograft treated with either a supercritical fluid process or low-dose (15 kGy) gamma irradiation were compared using radiological, histological and immunohistological techniques. The aims were to investigate any differences in the biological properties of supercritical fluid treated allograft and low-dose gamma irradiated allograft in-vivo.

Rabbit allograft were cleaned of all soft tissue, cartilage and processed into ‘corticancellous crunch’ using a Noviomagus Bone Mill. Pooled samples were either gamma irradiated (15 kGy) or treated by NovaSterilis using super critical carbon dioxide. A well-reported tibial defect model in ten rabbits was used to examine the in vivo response of the different treatments at two and four weeks following surgery (n=5 per time point). Radiographic (x-ray, CT and micro CT), histology and immunohistochemistry was used to assess the in vivo response.

Radiographic results revealed an initial response to the gamma-irradiated samples compared to SCF. Histology confirmed this reaction to be inflammatory in nature at two weeks that continued at four weeks for the gamma irradiated samples. In contrast, the SCF treated sample demonstrated new bone formation while the inflammatory reaction was muted compared to the gamma irradiated samples. Four week x-rays and histology confirmed new bone formation in both groups while the lack of significant inflammatory response in the SCF group was noted.

Allograft sterilisation techniques do not result in the same initial response when evaluated in vivo. Removal of lipids and cellular debris following SCF treatment may influence the in vivo response. While both techniques can provide a sterile product, the in vivo response requires further investigation.

It is not known if the radiation sterilisation dose (RSD) of 25 kGy affects mechanical properties and biocompability of allograft bone by alteration of collagen triple helix or cross-links. Our aim was to investigate the mechanical and biological performance, cross-links and degraded collagen content of irradiated bone allografts.

Human femoral shafts were sectioned into cortical bone beams (40 × 4 × 2 mm) and irradiated at 0, 5, 10, 15, 20, and 25 kGy for three-point bending tests. Corresponding cortical bone slices were used for in vitro determination of macrophage activation, osteoblast proliferation and attachment, and osteoclast formation and fusion. Subsequently, irradiated cortical bone samples were hydrolised for determination of pyridinoline (PYD), deoxypyridinoline (DPD), and pentosidine (PEN) by high performance liquid chromatography (HPLC) and collagen degradation by the alpha chymotrypsin (ï_jCT) method.

Irradiation up to 25 kGy did not affect the elastic properties of cortical bone, but the modulus of toughness was decreased from 87% to 74% of controls when the gamma dose increased from 15 to 25 kGy. Macrophages activation, the proliferation and attachment of osteoblasts on irradiated bone was not affected. Osteoclast formation and fusion were less than 40% of controls when cultured on bone irradiated at 25 kGy, and 80% at 15 kGy. Increasing radiation dose did not significantly alter the content of PYR, DPD or PEN but increased the content of denatured collagen.

Cortical allografts fragility increases at doses above 15 kGy. Decreased osteoclast viability at these doses suggests a reduction in the capacity for bone remodelling. These changes were not correlated with alterations in collagen cross-links but in degradation to the collagen secondary structure as evidenced by increased content of denatured collagen.

Cortical bone is a complex composite material composed of an inorganic mineral phase and organic matrix of type I collagen and various non-collagenous proteins. The hierarchical organisation of bone results in a transversely isotropic material with the mechanical properties in the long-axis (z) being superior to the radial and circumferential axes which are equivalent. This directional dependence of bone has been well reported, whilst the mechanisms/anisotropy are more difficult to study. This study examined the anistropic nature of cortical bone and the influence of different sterilisation procedures.

Ninety cortical bone cubes were prepared using established techniques (Walsh and Guzelsu) and randomly allocated to three treatments; control, 15 KGy, Super Critical Fluid (SCF) (n=30 per group). The ultrasonic moduli was examined using longitudinal sound waves at 5 MHz using a pulse receive technique. Unconfined compression was performed non-destructively in longitudinal (z), circumferential (ï±) and radial orientations (r). Samples were tested to failure in the z axis. A two-way analysis of variance (treatment and time) followed by a Games Howell post hoc test and covariate analysis was performed using SPSS for Windows.

Data from this study revealed some interesting and intriguing results with respect to the effects of gamma irradiation and dense gas technology on the properties of cortical bone and load transmission. A statistical decrease in the compressive stiffness and strength was noted with 15 KGy of whilst SCF treatment did not alter the properties in the r or ï orientations. Similar results were found with respect to the ultrasonic moduli (data not shown). The pilot data confirmed the adverse effects of bone in compression following gamma irradiation as we found in our recently presented ORS work. However, the study in compression demonstrated that the directional dependence that makes cortical bone a transversely isotropic material is removed following gamma irradiation with SCF did not appear to have this effect.

The effects of gamma irradiation on the mechanical performance of allografts in the long bone axis may play a role in their in vivo performance. The removal of the anisotropy following gamma irradiation provides insight into the relationship(s) between the mineral and organic constituents, which requires further study.

Millions of medical devices made of synthetic or modified natural materials all trigger a similar reaction—the foreign body reaction. Biocompatibility, for materials that pass routine cytoxicity assays, is largely associated with a mild foreign body reaction. I.e. a thin, avacular, collagenous, non-adherent foreign body capsule. The implant is incorporated into a dead-zone of acellular scar. The contemporary tissue engineering paradigm would suggest that synthetic polymers and scaffolds lacking cellular, biomolecule or biomimetic elements will give this same fibrotic, avascular healing reaction.

In this talk, a synthetic biomaterial will be described that readily integrates into tissue and may stimulate spontaneous reconstruction of tissue. The material is fabricated by a process called sphere-templating and it can be made from many synthetic polymers including hydrogels, silicones and polyurethanes. All pores are identical in size and interconnected. Studies from our group have shown optimal healing (as suggested by extensive vascularity and minimal fibrosis) for spherical pores of 30–40 m size. The integrative healing noted is independent of biomaterial. Similar results are observed with sphere-templated silicone rubber and pHEMA hydrogel. In addition, surface chemical modification of the hydrogel with carbonyl diimidazole, or immobilisation on the hydrogel of collagen I or laminin did not change the healing response.

Also, good healing results have been seen upon implantation in skin (subcutaneous, percutaneous), heart muscle, sclera, skeletal muscle, bone and vaginal wall. We consistently find the pore spaces heavily populated by monocytic cells that stain for macrophage cell surface markers. However, at long implantation times (16 or more weeks), the ability to stain for macrophage surface markers decreases. It could be possible that these cells populating the implants are differentiating into other tissues. Thus, such materials may represent a path to cell-free tissue engineering. Others have seen similar healing results, via completely different materials strategies, generally involving biological molecules. The in vivo results from our group and related results from other groups suggest we are on the cusp of a revolution in healing, biomaterials integration and tissue reconstruction. Also, the boundaries between biomaterials and tissue engineering continue to blur.

Developing biomaterials for bone regeneration that are highly bioactive, resorbable and mechanically strong remains a challenge. Zreiqat's lab recently developed novel scaffolds through the controlled substitution of strontium (Sr) and zinc (Zn) into calcium silicate, to form Sr-Hardystonite and Hardystonite, respectively and investigated their in vivo biocompatibility and osteoconductivity

We synthesized 3D scaffolds of Sr-Hardystonite, Hardystonite and compared them to the clinically used tricalcium phosphate (micro-TCP) (6 × 6 × 6 mm) using a polyurethane foam template to produce a porous scaffold. The scaffolds were surgically implanted in the proximal tibial metaphysis of each tibia of Female Wistar rats. Animals were sacrificed at three weeks and six weeks post-implantation and bone formation and scaffold resorption were assessed by microcomputed tomography (micro-CT) histomorphometry and histology. Histological staining on undecalcified sections included Toluidine blue, tartrate-resistant acid phosphatase (TRAP) and alkaline phosphatase (ALP).

The bone formation rate and mineral apposition rate will be determined by analysing the extent and separation of fluorescent markers by fluorescent microscopy micro-CT results revealed higher resorbability of the developed scaffolds (Sr-Hardystonite and Hardystonite) which was more pronounced with the Sr-Hardystonite. Toluidine blue staining revealed that the developed ceramics were well tolerated with no signs of rejection, necrosis, or infection. At three weeks post implantation, apparent bone formation was evident both at the periphery and within the pores of the all the scaffolds tested. Bone filled in the pores of the Sr- Hardystonite and Hardystonite scaffolds and was in close contact with the ceramic. In contrast, the control scaffolds showed more limited bone ingrowth and a cellular layer separating the ceramic scaffolds from the bone. By six weeks the Hardystonite and Sr Hardystonite scaffolds were integrated with the bone with most pores filled with new bone. The control scaffold showed new bone formation in the plane of the cortical bone but little new bone where the scaffold entered the marrow space. Sr Hardystonite showed the greatest resorbability with replacement of the ceramic material by bone.

We have developed novel engineered scaffolds (Sr-Hardystonite) for bone tissue regeneration. The developed scaffolds resorbed faster than the clinically used micro- TCP with greater amount of bone formation replacing the resorbed scaffold.

Osteocytes (OCY) are the end stage differentiation cells of the osteoblast lineage, and are incorporated in the bone matrix during bone formation. In doing so, OCY control the mineralisation of osteoid. OCY form a dense inter-connected network of cell bodies and cell processes throughout the mineralised matrix of bone.

OCY viability depends on interstitial fluid flow along the OCY canaliculi, driven by pulsatile blood flow and loading of the skeleton. Maintenance of the density and viability of OCY are essential for bone health because OCY perform many important functions in bone. Firstly, OCY appear to initiate bone repair of bone microdamage. Secondly, OCY are almost certainly the cells, which initiate new bone formation in response to increased loading of bone. Thirdly, OCY are able to regulate the amount of new bone formation in bone remodelling cycles, at least in part by the production of a molecule called sclerostin (SCL).

Mutations in the SCL gene, or deletion of the SCL gene in transgenic mice, are associated with particularly dense, fracture resistant bones. This information has led to development of anti-SCL antibodies as a potential anabolic therapy for bones. Bone loss in ovariectomised aged rats was shown recently to be reversed by treatment with neutralising SCL antibodies. There is also some data to suggest that these antibodies may promote fracture healing. Reduced OCY viability and/or density have been reported in association with osteoporotic fracture. OCY viability seems to be dependent on skeletal loading, adequate skeletal blood flow and estrogen in females. OCY viability is adversely affected by hypoxia, unloading of the skeleton and pharmacobiology, such as chronic exposure to glucocorticoids. Both micro and macro-fractures result in disruption of the OCY network, as do procedures such as drilling and cutting of bone.

Because of the important roles of OCY in bone, new approaches to bone health may require the identification of agents to protect these cells from harmful influences in disease and ageing.

A Ruys, School of Aerospace, Mechanical and Mechatronic Engineering, University of Sydney, Sydney

The effects of bone anabolics can be maximised by systemic co-treatment with an anti-catabolic. Local treatment may reduce the total drug required and produce superior outcomes, although high dose local bisphosphonate has been reported to impair bone formation. We have explored local co-delivery of anabolic/anti- catabolic bone drugs at different doses.

We manufactured biodegradable poly-D,L-lactic acid (PDLLA) polymer pellets containing 25g BMP-7 as an anabolic with or without 0.002mg-2mg Pamidronate (PAM) as an anti-catabolic. Polymer pellets were surgically implanted into the hind limb muscle of female C57BL6 mice. Animals were sacrificed at three weeks post- implantation and bone formation was assessed by radiography, microcomputed tomography (microCT) and histology. Histological staining on five Âm paraffin sections included haematoxylin/eosin, alcian blue/picrosirius red, and tartrate- resistant acid phosphatase (TRAP).

Radiographic and microCT data confirmed that 0.02mg and 0.2mg local PAM doses significantly augmented BMP-7 induced bone formation. In contrast, 2mg local PAM dramatically reduced the amount of bone present. This dose was comparable to that used by Choi et al who also reported impaired bone formation in a skull defect model.2 three-dimensional microCT and histological analyses of the ectopic bone and surrounding muscle showed a cortical shell covering the polymer pellet, which had not completely resorbed.

Histological analysis at the pellet/bone interface showed tissue granulation and no inflammation, suggesting a high biocompatibility of the PDLLA polymer. The presence of bisphosphonate also decreased the amount of fatty marrow tissue seen within between the cortical shell and the unresorbed polymer.

For the first time we can demonstrate synergy with local BMP/bisphosphonate. This study confirms that high local PAM doses can have negative effects, indicating a need to avoid overdosing. The lack of implant degradation suggests a need to optimise polymer degradation for bone tissue engineering application.

Bone morphogenetic proteins (BMPs) are able to induce osteogenic differentiation in many cells, including muscle cells. However, the actual contribution of muscle cells to bone formation and repair is unclear. Our objective was to examine the capacity of myogenic cells to contribute to BMP-induced ectopic bone formation and fracture repair.

Osteogenic gene expression was measured by quantitative PCR in osteoprogenitors, myoblasts, and fibroblasts following BMP-2 treatment. The MyoD-Cre x ROSA26R and MyoD-Cre x Z/AP mouse strains were used to track the fate of MyoD+ cells in vivo. In these double-transgenic mice, MyoD+ progenitors undergo a permanent recombination event to induce reporter gene expression. Ectopic bone was produced by the intramuscular implantation of BMP-7. Closed tibial fractures and open tibial fractures with periosteal stripping were also performed. Cellular contribution was tracked at one, two and three week time points by histological staining.

Osteoprogenitors and myoblasts exhibited comparable expression of early and late bone markers; in contrast bone marker expression was considerably less in fibroblasts. The sensitivity of cells to BMP-2 correlated with the expression of BMP receptor-1a (Bmpr1a). Pilot experiments using the MyoD-Cre x Rosa26R mice identified a contribution by MyoD expressing cells in BMP-induced ectopic bone formation. However, false positive LacZ staining in osteoclasts led us to seek alternative systems such as the MyoD-cre x Z/AP mice that have negligible background staining. Initially, a minor contribution from MyoD expressing cells was noted in the ectopic bones in the MyoD-cre x Z/AP mice, but without false positive osteoclast staining. Soft tissue trauma usually precedes the formation of ectopic bone. Hence, to mimic the clinical condition more precisely, physical injury to the muscle was performed. Traumatising the muscle two days prior to BMP-7 implantation: (1) induced MyoD expression in quiescent satellite cells; (2) increased ectopic bone formation; and (3) greatly enhanced the number of MyoD positive cells in the ectopic bone. In open tibial fractures the majority of the initial callus was MyoD+ indicating a significant contribution by myogenic cells. In contrast, closed fractures with the periosteum intact had a negligible myogenic contribution.

Myoblasts but not fibroblasts were highly responsive to BMP stimulation and this was associated with BMP receptor expression. Our transgenic mouse models demonstrate for the first time that muscle progenitors can significantly contribute to ectopic bone formation and fracture repair. This may have translational applications for clinical orthopaedic therapies.

The treatment of fracture accompanied with bone defect remains a challenge in skeletal surgery. For bone defect, we have to give a material to support healing process. Some material is allograft given at second to sixth weeks to avoid osteoclastic activity. We try to give primary allograft and to prevent osteoclastic activity we use risedronat. Risedronate (Actonel(r)) is one of bisphosphonate group that decrease the turnover of the bone by activating apoptosis of osteoclast and increasing osteoblast activity. The aim of this paper is to evaluate radiologically and histologically result for the effect of the bone healing process for a fracture associated with bone defect which treated by a combination of fresh frozen allograft and risedronate (Actonel(r)).

The design is an experimental study, Post Test Only Control Group Design, using adult male white rats spraque-dawley. Right open tibial osteotomies to create bone defect are performed surgically and put Kirschner wire as intramedularry fixation. Rats are divided into four groups, with six samples in each group. Group one with bone defect in 2 mm, group two with bone defect 2 mm and put fresh frozen allograft, group three with bone defect 2 mm and put fresh frozen allograft and given Actonel(r) 350g a week for two first week, and group four with bone defect 2 mm and put fresh frozen allograft and given Actonel(r) 350g a week for six week. Six weeks after implantation, the animals were sacrificed, and the tibia were evaluated by radiological and histological studies.

Radiologically, there are significant different of relative bone healing result between ungiven risedronat group (group one and two) and given risedronat group (group three and four) (Kolmogorof smirnov test). Histological results by one way anova shows varians test was p = 0,168 (p > 0,05). Anova test was p = 0,000 (p < 0,05), post hoc Turkey HSD there was not significant different between group one and group two p = 0,969, between group one dan group four p = 0,634 (p > 0,05), between group two dan group four p = 0,634 (p > 0,05); a significant different between group one and group three p = p = 0,000 (p<0,05) between group two and group three p = 0,01 (p < 0,05), and group three and group four p=0,004 (p < 0,05)

Risedronate (Actonel(r)) influence the healing process of two mm bone defect radiologically. By histologically, two first weeks given of risedronate at group three have a better result than groups one, two and four.

Excellent reconstruction of bone will be described induced by a synthetic biomaterial without a calcium phosphate mineral phase or growth factors, and with a pore size of 35 m. The material is fabricated by a process called sphere-templating and it can be made from many synthetic materials including hydrogels, silicones, polyurethanes and glasses. All pores are identical in size and interconnected. Studies from our group have shown optimal healing in soft tissue (as suggested by extensive vascularity and minimal fibrosis) for spherical pores of 30–40 m size. Sphere-templated hydrogel implants in bone were performed using the following procedure: Under appropriate anesthesia, 18–24month old NZW rabbits underwent medial parapatellar arthrotomy, with exposure of the medial femoral condyle. A 3.5 mm end-cutting drill, locked in a rigid armature, was used to create a host graft site at the center of the articular cartilage lesion, with depth of cut matched to the sphere-templated construct thickness of 2 mm. Animals were sacrificed at one day, 28 days, and 12 weeks. After sacrifice, the femora were isolated and the condyles dissected. Condyles were fixed in 4% paraformaldehyde at 4°C for 48 hrs, decalcified in Immunocal for 14 days at 4°C and paraffin embedded. Specimens were sectioned to a thickness and stained with Safranin- O/Fast Green, hematoxylin/eosin or Masson's trichrome. Prior to decalcification, selected samples were evaluated by micro-CT utilising a Skyscan 1076 microCT low dose in-vivo X-ray scanner, slice imaging and 3D image reconstruction. Both histologically, and with micro-CT imaging, excellent tissue and mineral reconstruction was observed in the sphere templated material. The contralateral control, drilled but without implant, showed essentially no reconstruction.

Since the classical paradigm for bone reconstruction requires either autologous bone, cadaver bone, or calcium phosphate scaffolds with pores >150 microns, the healing observed here suggests new avenues for bone regeneration.

The quality of bone in the skeleton depends on the amount of bone, geometry, microarchitecture and material properties, and the molecular and cellular regulation of bone turnover and repair. This study aimed to identify material and structural factors that alter in fragility hip fracture patients treated with antiresorption therapies (FxAr) compared to fragility hip fracture patients not on treatment (Fx).

Bone from the intertrochanteric site, femoral head (FH: FxAr = 5, Fx = 8), compression screw cores and box chisel were obtained from patients undergoing hemi-arthroplasty surgery, FxAr (6f, 2m, mean 79 and range [64–89] years), and Fx (7f, 1m, age 85 [75–93] years). Control bone was obtained at autopsy (9f, 4m, 77 [65–88] years). Treated patients were on various bisphosphonates. Samples were resin-embedded, for quantitative backscattered electron imaging of the degree of mineralisation and assessment of bone architecture. Trabecular bone volume fraction (BV/TV) and architectural parameters were not significantly different between FxAr and Fx groups.

Both groups showed normal distributions of weight (wt) % Ca; however, the FxAr was less mineralised than the Fx and the control group (mean wt % Ca: FxAr = 24.3%, Fx = 24.8%, Control = 24.9%). When comparing the FH specimens only, we found that BV/TV in the FxAr was greater than the Fx group (18% vs 15%). All other parameters were not significantly different. In addition, the mineralisation was greater in the FxAr group compared to the Fx group (25.5 % vs 25.0%) but was not significantly different.

Collectively, these data suggest the effect on bone of antiresorptives may be different for patients on antiresorptive treatment that do not subsequently fracture. Assessment of bone material property data together with other bone quality measures may hold the key to better understanding of antiresorptive treatment efficacy.

Biomechanical stimuli have fundamental roles in the maintenance and remodeling of ligaments including collagen gene expressions. Mechanical stretching signals are mainly transduced by cell adhesion molecules such as integrins. However, the relationships between stress-induced collagen expressions and integrin-mediated cellular behaviors are still unclear in anterior cruciate ligament cells.

Human ACL cells were harvested from ligament samples donated by patients who underwent total knee arthroplasties with informed consents. Interface cells were isolated from the 5-mm-end of ACL. Midsubstance cells were cultured from the middle part of ACL. The cells were seeded onto stretch chambers (2Ä−2 cm, 50,000 cells/chamber) and uni-axial cyclic mechanical stretch (0.5 Hz, 7%) was applied for 2 h using a ST140. RNA samples were reverse-transcripted and quantitative real-time RT-PCR analysis were performed. To inhibit the function of integrin alphaVbeta3 subunit or alpha5 in stretching experiments, anti-human integrin alphaVbeta3 and alpha5 functional blocking antibodies (alphaVbeta3: 20 mg/ml, alpha5: 4 mg/ml) were used. To investigate the cellular attachments responding to mechanical stretch, we observed the distribution of integrins and stress fibers in both ACL cells.

The shape of midsubstance cells showed spindle and fibroblastic cellular morphologies. On the other hand, the interface cells displayed chondroblastic appearances such as small and triangular morphologies. The expressions of COL1A1, COL2A1, and COL3A1 genes were detected in the tissue RNAs of interface zones. However, these expressions were decreased in cultured interface cells. In midsubstance cells, the expression of COL1A1 gene was equally detected in both tissues and cultured cells. COL3A1 gene expression was maintained in cultured midsubstance cells. These results indicated that the phenotypes of both ACL cells were changed by cultured conditions, especially in the interface cells. After mechanical stretch, the COL1A1 expression of midsubstance and interface cells were stimulated up to 6 and 14-fold levels of each non-stretched control, respectively. The COL3A1 expressions were also enhanced up to 1.8-fold level of controls by stretching treatment in both cells. Integrin alphaVbeta3 was shifted to the peripheral edge of cells by stretching treatment. In addition, mechanical stretch changed the integrin alphaVbeta3-dependent stress fiber formation in both ACL cells. The functional blocking of integrin alphaVbeta3 inhibited stretch-activated COL1A1 and COL3A1 expressions. However, the functional blocking of integrin alpha5 did not suppress the stretch-induced COL1A1 and COL3A1 expressions in both ACL cells.

Cultured interface cells loose their phenotypes in collagen gene expressions.

However, mechanical stretch reproduces the expression of COL1A1 and COL3A1 genes in cultured ACL cells. The present study demonstrated that stretch-activated collagen gene expressions depend on the integrin alphaVbeta3-mediated cellular adhesions.

Squeaking ceramics bearing surfaces have been recently recognised as a problem in total hip arthroplasty. The position of the acetabular cup has been alluded to as a potential cause of the squeaking, along with particular combinations of primary stems and acetabular cups. This study has used the finite element method to investigate the propensity of a new large diameter preassembled ceramic acetabular cup to squeaking due to malpositioning.

A verified three-dimensional FE model of a cadaveric human pelvis was developed which had been CT scanned, and the geometry reconstructed; this was to be used to determine the behaviour of large diameter acetabular cup system with a thin delta ceramic liner in the acetabulum. The model was generated using ABAQUS CAE pre-processing software. The bone model incorporated both the geometry and the materials properties of the bone throughout based on the CT scan. Finite element analysis and bone material assignment was performed using ABAQUS software and a FORTRAN user subroutine. The loading applied simulated edge loading for rising from a chair, heel-strike, toe off and stumbling.

All results of the analysis were used to determine if the liner separated from the shell and if the liner was toggling out of the shell. The results were also examined to see if there was a propensity for the liner to demobilise and vibrate causing a squeaking sound under the prescribed loading regime.

This study indicates that there is a reduction in contact area between the ceramic liner and titanium shell if a patient happens to trip or stumble. However, since the contact between the liner and the shell is not completely lost the propensity for it to squeak is highly unlikely.

Autologous cell therapy using stem cells and progenitor cells is considered to be a popular approach in regenerative medicine for the repair and regeneration of tissue and organs. In orthopaedic practice, autologous cell therapy has become a major focus, particularly, as a feasible treatment for tendon injury.

Tendons are dense connective tissue that bridge bone to muscle and transmit forces between muscle and bone to maintain mechanical movement. Tendons are poorly vascularised and have very little capacity to self-regenerate. Degeneration of tendon is often caused by injury. The pathogenesis of tendon injury, commonly known as tendinosis, is not an inflammatory condition but is secondary to degenerative changes, including disruption of the collagen matrix, calcification, vascularisation and adipogenesis. The aetiology of tendinosis is considered to be multifactorial and the pathogenesis is still unclear. Intrinsic factors such as a lack of blood and nutrition supply and extrinsic factors such as acute trauma and overuse injury caused by repetitive strain, have been implicated as contributors to the pathogenesis of tendinosis. More recent studies suggest that programmed tendon cell death (tenocyte apoptosis) may play a major role in the development of tendinosis. Such cellular abnormalities may influence the capacity of tendon to maintain its integrity.

Traditional treatments such as anti-inflammatory drugs, steroid injections and physiotherapy are aimed at symptom relief and do not address the underlying pathological changes of degeneration. Here, we propose that autologous cell therapy may be an innovative and promising treatment for tendon injury. We will present evidence that suggest that autologous tendon cell therapy may be feasible to repair and regenerate tendon.

We will also present data summarising the preclinical evaluation of autologous tendon cell therapy in animal models and the safety and tolerability of autologous tendon cell therapy in humans in studies, which are currently conducted at the Centre for Orthopaedic Research at the University of Western Australia.

Subchondral drillings for articular cartilage defects usually result in fibrocartilage repair, which is inferior biomechanically compared to hyaline cartilage. We postulate that intra-articular injections with autologous marrow-derived stem cells (MSC) and hyaluronic acid (HA) can improve the quality of repair cartilage.

We tested this hypothesis in a goat model by creating an articular cartilage defect in the stifle joint and conducted subchondral drillings. The animals were divided into three groups: Group A (control) no injections, Group B (HA) weekly injection of 1 ml sodium hyaluronate for three weeks, Group C (HA+MSC) similar to Group B but with 2 mls autologous MSC in addition to HA. MSC were obtained by bone marrow aspiration, centrifuged, and divided into aliquots, which were cryopreserved. Fifteen animals were equally divided between the groups and sacrificed at 24 weeks after surgery where the joint was harvested and examined macroscopically and histologically.

Of the 15 animals, two had died in Group A and one was excluded from Group C due to an infection. In Group A, repair constituted mainly of scar tissue, while in Group B, there was less scar tissue, with small amounts of proteoglycan and collagen II at the osteochondral junction. In contrast, repair cartilage from Group C animals demonstrated almost complete coverage of the defect with evidence of hyaline cartilage regeneration. Histology as assessed by Gill scoring was significantly better in Group C with one-way ANOVA giving an F-statistic of 10.611 with a p-value of 0.004, which was highly significant.

Post-operative intra-articular injections of autologous MSC in combination with HA following subchondral drillings into chondral defects resulted in better cartilage repair.

It is generally accepted that children treated for congenital pseudarthrosis of the tibia (CPT) should be followed-up until skeletal maturity, before drawing conclusions about the efficacy of treatment. We undertook this study in order to evaluate the long-term results of treatment of CPT by excision of the pseudarthrosis, intramedullary rodding and onlay cortical bone grafting.

Among a total of 46 children with CPT treated by a single surgeon during a 20-year period, 38 had been treated by this technique and 11 of these children have reached skeletal maturity. These eleven cases (nine boys and two girls) formed the basis for this study.

The mean age at presentation was 3.1 years (range 0.4–7 years); the mean age at index surgery was 3.2 years (range 0.7–7 years). The mean age at follow-up was 18.4 years (range 16–21.6 years) with a mean interval between surgery and final follow-up of 15.2 years (range 12.8–17.4 years).

In all 11 children bone graft was harvested from the contralateral tibial diaphysis. Rods passed from the heel were used in nine children and in two Sheffield telescopic rods were passed from the ankle into the tibia. The fibula was divided in three children to ensure that the tibial fragments were in good contact before placing the graft astride them; the fibula was not touched in the remaining eight instances. To ensure that the intramedullary rod supported the pseudarthrosis site till skeletal maturity, revision rodding was performed as needed when the tip of the rod receded into the distal third. A thermoplastic clamshell orthosis was used till skeletal maturity.

At final follow-up the union at the pseudarthrosis site was deemed to be ‘sound’ only if two independent observers concurred that there was definite bony continuity of the cortices on both the anteroposterior and lateral radiographs. Deformities of the tibia and ankle and ranges of motion of the knee, ankle and subtalar joints were noted. The limb lengths were measured with scanograms. The morbidity at the bone graft donor site was recorded. The function of the ankle was assessed by applying the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hind foot Score.

Primary union of the tibial pseudarthrosis was achieved in nine of 11 cases with a mean time to union of 6.1 months. Secondary union was achieved in the remaining two cases following further intervention. At final follow-up sound union of the tibial pseudarthrosis was noted in all eleven patients but persistent pseudarthrosis of the fibula was present in 10 of 11 cases. The lateral malleolus was proximally situated in six cases.

Ten of eleven children underwent a total of 21 secondary operations on an average of 2.6 years (range 0.5–5.1 years) after initial union was achieved. Six re-fractures were encountered in five patients at a mean of 6.1 years after index surgery. All the re-fractures united following the single episode of intervention. The overall mean shortening at final follow-up was 2.6 cm. At final follow-up, five patients had ankle valgus greater than 10 degrees. All the 11 patients walked without pain. Only two patients had significant motion at the ankle. Despite the ankle stiffness in the remaining children the AOFAS ankle-hindfoot scores ranged between 70 and 98 (mean 83.3).

Our long-term results are comparable to the results of other studies in terms of the rate of union, the re-fracture rate, limb length discrepancy, residual deformity and the frequency of surgery.

Supracondylar fractures of the humerus (SCH) are one of the most common orthopaedic injuries in childhood. Numerous studies worldwide demonstrate that play equipment is a common mechanism of injury for SCH. Our study aimed to identify the prevalence of play equipment related SCH in a large population in Western Sydney.

We conducted a retrospective analysis of 856 infants who suffered a SCH between 2001–2007 and were treated at The Children's Hospital at Westmead. We obtained data on patient demographics, mechanism of injury, severity of SCH (Gartland classification), and management of SCH (open reduction vs closed reduction vs. non operative management).

Of the total 856 patients, 739 provided useful information for analysis. In 696 of these patients the mechanism of injury could be determined according to the patients information provided in the medical record. The mechanisms of injury were as follows: trampoline 72 (10.3%), monkey bars 58 (8.3%), slides 26 (3.7%), other playground equipment 84 (12.0%), home furniture 157 (22.6%), bikes 39 (5.6%), non-equipment related fall 260 (37.3%). Of the patient demographics, there was a significant correlation between the age groups (0–3, 4–7, 8+ years) and severity of SCH (Ï24 = 18.36, p=0.001). Fifty-two percent of Gartland type three fractures occurred in the age group of 4–7 years.

The study demonstrates that playground equipment represents a major mechanism of injury of SCH in children. In particular trampoline related SCH and to a lesser degree monkey bar related SCH, represent an area in which primary preventative strategies should be targeted.

Sixty-two children with unilateral Perthes disease who underwent trochanteric epiphyseodesis combined with varus osteotomy of the femur during the active stage of the disease, (mean age at surgery: 8.4 years) and twenty controls were followed up untill skeletal maturity.

The following measurements were taken on radiographs taken at skeletal maturity: the articulo-trochanteric distance (ATD), the center-trochanteric distance (CTD), the length of the abductor lever arm, the neck-shaft angle, the radius of the femoral head and the Reimer's migration index of normal and affected hips. The shape of the femoral head was assessed according to the criteria of Mose. The range of hip motion, the strength of hip abduction and limb lengths were measured and the Trendelenburg sign was elicited.

The mean values of ATD and CTD were greater and the frequency of a positive Trendelenburg sign was less in children who had undergone trochanteric epiphyseodesis in 60% of operated children. The procedure was not effective in 30% and there was over-correction in in 10% of children. Logistic regression analysis showed that the size of the femoral head and the age at surgery were variables that significantly influenced the effectiveness of trochanteric growth arrest.

At skeletal maturity, the mean shortening of the affected limb in operated children was 0.44 cm (SD 0.68 cm), while that of non-operated children was 0.86 cm (SD 0.78 cm) (p: 0.023). The range of motion of the hip was excellent and there were no significant differences in the range of motion between children with optimal correction, under-correction and over-correction.

A probability curve plotted on the basis of the of a logistic regression model suggests that effective trochanteric arrest may be achieved in a high proportion of children operated at, or before, 8.5 years of age, and in half the children operated between the age of 8.5 years and 10 years.

This single centre study was a prospective analysis from 2000 to 2008, aiming to explore and characterise the incidence and management of orthopaedic injuries sustained from motorcycle-related accidents in children under 16 years of age in Far North Queensland. In addition, it aimed to recognise factors contributing to crash occurrence, injury pattern and severity.

Prospective survey data has been collected for the past eight years looking at various aspects of non-fatal motorcycle injuries in children up to the age of 16 years who present to Cairns Base Hospital. The study incorporated a simple 12-point questionnaire that was completed upon the child's first presentation to the hospital in either an in- or out-patient clinical setting. The aspects addressed by the survey included: number of accidents, use of safety gear, experience level, injury and management, and cause of the accident. Little research has been conducted on characterising the nature and occurrence of off-road motorcycle accidents in children and adolescents.

A total of 238 children were admitted to Cairns Base Hospital with injuries related to motorcycle accidents. The results of 210 children who sustained orthopaedic injuries are presented. Motorcycle accidents involving children were responsible for over 340 presentations to the Emergency department and for a total of more than 500 hospital bed-days upon admission.

The majority of accidents occurred off-road with over 40% on public property. An average of 11% of riders was female.

This study gives evidence that off-road motorcycle accidents in children are the result of inexperience, utilise a significant proportion of our orthopaedic resources, and that programs and policies directed at reducing the number of injuries from off-road motorcycle riding need implementation.

Slipped Capital Femoral Epiphysis (SCFE) is a common paediatric disorder with documented racial predilection. No data exists regarding the Australian indigenous and Australian non-indigenous populations. This study provides a comprehensive demographic and epidemiologic analysis of SCFE in South Australia, with emphasis on establishing associations between increasing obesity and incidence.

A demographic review of all cases of SCFE managed in South Australian public hospitals between 1988 and 2007 was performed. Clinical presentation, surgical management and complication profile information was collected. Given that obesity is implicated in the biomechanical causation of SCFE due to increased shearing forces, particular emphasis was placed on gathering weight, race, gender and age data. A profile of the incidence and nature of SCFE was generated. Comparisons were then drawn between this profile and existing epidemiologic percentile data of weight, age and gender in South Australia.

A rising prevalence of obesity in South Australia corresponded with a rising incidence of SCFE. However, this relationship was not linear as the incidence of SCFE has doubled in the last 20 years and the average weight of SCFE patients has increased markedly.

The indigenous population was found to have higher rates of obesity than the non- indigenous population in South Australia. The indigenous population also has a relative risk of developing a SCFE of over three times the non-indigenous population.

The overall rate of complications in South Australian public hospitals was low, with avascular necrosis being recognised in our profile.

The rise in incidence of SCFE in South Australia; especially noticeable in the indigenous population is associated with an increasing prevalence of obesity. The considerable morbidity associated with SCFE was confirmed in our analysis and further highlights the importance of public health initiatives to tackle obesity in our community.

Untill recently, major reduction defects of the tibia were treated by amputation and prosthetic fitting. However, Wada et al (1) and Weber (2) recently reported impressive results of limb reconstruction in children with tibial aplasia. If an attempt is being made to reconstruct the leg and foot, a clear understanding of the nature of anomalies is necessary.

A retrospective study of case records and radiographs of children with congenital anomalies of the tibia seen at our centre was undertaken to determine the patterns of associated anomalies in the leg and foot. In addition, five amputated specimens of the leg and foot from children with complete tibial aplasia were dissected.

A wide spectrum of congenital anomalies of the tibia was seen and this included complete aplasia, partial aplasia, hypoplasia, dyplastic trapezoidal tibia and congenital bowing.

Complete and partial aplasia was seen either with or without duplication of the formed skeletal elements. The patterns of duplication that were seen included fibular dimelia, pre-axial mirror polydactyly, duplication of the calcaneum, cuboid and lateral cuneiforms. Trapezoidal dysplastic tibia was associated with duplication of the talus and pre-axial mirror polydactyly.

Dissection of the amputated specimens of complete tibial aplasia revealed aplasia of some muscles, aberratant tendinous structures, abnormal insertion of muscles and absence of the plantar arterial arch.

An understanding the nature of these associated anomalies in children with tibial aplasia and dyplasia will help the surgeon to decide the strategies for reconstruction of the limb if that is the desired option.

At the other end of the spectrum of congenital anomalies of the tibia is posteromedial bowing which was considered an innocuous condition that required little or no treatment. A review of 20 cases of posteromedial bowing demonstrated that there are number of problems related to the leg, ankle and foot that may require surgical intervention.

In 2000, Reinhold Ganz developed a surgical technique for treating slipped capital femoral epiphysis using his surgical hip dislocation approach to facilitate anatomical reconstruction of the slipped epiphysis—reportedly, without risk of avascular necrosis. This technique is now being adopted cautiously in paediatric orthopaedic centres internationally.

The technique will be described and early results presented. Complications and their treatments will also be discussed.

Early experience suggests morbidity following the procedure is not insignificant and until more corroborating safety data is available, the author suggests this technically demanding surgery should only be offered to children whose significant deformity would otherwise result in childhood disability.

The foot and ankle are very commonly affected in various paralytic conditions. Paralysis of different muscles acting on the foot results in characteristic gait aberrations. The gait abnormalities are a result of one or more of the consequences of paralysis including: loss of function, muscle imbalance, deformity and instability of joints.

The aims of treatment of the paralysed foot and ankle are to: make the foot plantigrade, restore active dorsiflexion during the swing phase of gait (if this is not possible then prevent the foot from ‘dropping’ into plantar flexion during swing), ensure that the ankle and subtalar joints are stable throughout the stance phase of gait, facilitate a powerful push-off at the terminal part of the stance phase (if this is not possible, at least prevent a calcaneal hitch in terminal stance).

The specific aims of treatment in each patient depend on the pattern and the severity of paralysis that is present and hence the aims are likely to vary. In order to determine what treatment options are available in a particular patient, it is imperative that a careful clinical assessment of the foot is done. Based on the clinical assessment, these questions need to be answered before planning treatment: What are the muscles that are paralysed What is the power of each muscle that is functioning? Is there muscle imbalance at the ankle, subtalar or midtarsal joints that has either already produced a deformity or has the potential to produce a deformity in future? Are there any muscles of grade V power that can be spared for a tendon transfer without producing a fresh imbalance or instability

To facilitate responses to these questions, the muscle power of each muscle can be charted on a template that facilitates graphic representation of the muscle balance around the axes of the ankle and subtalar joints. This assessment clarifies whether a tendon transfer is a feasible option. If a tendon transfer is considered feasible, then the following questions also need to be answered: Is there a fixed, static deformity that needs to be corrected prior to a tendon transfer? If a tendon transfer was performed, would the child be capable of comprehending and cooperating with the post-operative muscle re-education programme?

The decision-making process will be outlined and the use of the template in choosing the tendon transfer and deciding the site of anchorage of the transferred tendon will be explained. With suitable examples the choice of tendon transfers in different patterns of paralysis would be illustrated.

Many of the questionnaire based scoring systems (i.e. Rowe score) require some form of clinical assessment. These clinical components can be very difficult to perform on a large scale particularly when a patient lives a long distance from clinic. We have attempted to counter this problem by asking the patient to asses their own range of motion. The aim of this study was to test the agreement between patient and clinician measured shoulder external rotation range using a photo based self-assessment tool.

Fifty-one professional and semi-professional rugby players were recruited to assess shoulder external rotation range. Each player was presented with a photo based shoulder external rotation range self-assessment tool, which featured four photos of progressive shoulder external rotation in 2 positions, 900 abduction (150, 300, 450 & 600 of external rotation) and 00 abduction (700, 800, 900 & 1000 of external rotation). The players were asked to perform active external rotation in these two positions and mark the image which best matched their maximal external rotation. The player was then independently assessed using the same tool, by a clinician.

The difference between the player's and the clinician's assessment was analysed using a weighted Kappa test. The Kappa for the shoulder external rotation in 900 abduction was 0.75 and 0.71 for left and right respectively, and 0.57 and 0.55 for shoulder external rotation in 00 abduction. Thus, the strength of agreement between the player's and clinician's assessment of shoulder external rotation is good in 900 abduction and moderate in 00 abduction.

These results demonstrate that the photo-based shoulder external rotation range self-assessment tool is a very useful addition to researchers' and clinicians' toolkits and may be most useful when a patient lives a great distance from/or is unable to attend a clinic.

Clinical examination for shoulder conditions is not perfect. For that reason MRI tends to be accepted as the ‘gold standard’ and operative decisions may be based more on the MRI than the clinical findings. This has led to inappropriate treatment including unnecessary operations.

MRI's are not perfect either. Normal variations and abnormalities in asymptomatic people must be considered.

Clinical examination by a combination of tests can make MRI unnecessary or determine whether MRI abnormalities are relevant. This paper concentrates on rotator cuff tears.

The transosseous equivalent/Suture Bridge or TOE/SB repair has received much attention in recent years as more shoulder surgeons transition to all arthroscopic rotator cuff repairs. The purpose of this study was to compare the biomechanical behaviour of several variants of the Suture Bridge repair performed by the authors.

Four different Suture Bridge constructs were performed six times on 24 sheep infraspinatus tendon humerus constructs. The first group was a standard Suture Bridge with two medial mattress stitches with knots (KSSB4). The second group had four medial mattress stitches with knots and was called KDSB8. The third group had two medial mattress stitches without knots and was called USBFT4. These first three repairs used two medial 5.5 mm Bio-Corkscrew FT Anchors and two lateral 3.5 mm PushLock Anchors (Arthrex). The fourth repair had two medial mattress stitches without knots and used all Pushlocks and was called USBP4.

The repairs were then analysed for failure force, cyclic creep and stiffnessafter. Cycling was performed from 10 to 100 N at 1 Hz for 500 cycles. Following cyclic testing a single cycle pull to failure at 33 mm/sec was performed. The constructs were also observed for failure mechanism and gap formation using digital video recording.

The KDSB8 repair with a mean failure force of 456.9N was significantly stronger than the USBP4 repair at 299.7N (P=0.023), the KSSB4 repair at 295.4N (P=0.019) and lastly the USBFT4 repair at 284.0N (P=0.011). There was no statistical difference between the measured failure force for the two mattress stitch KSSB4 repair with knots and the knotless two mattress stitch repairs USBFT4 and USBP4. There was not a statistical difference between any of the repairs for measured stiffness and cyclic creep. However, the KDSB8 repair showed no discernable gap formation or movement at the footprint during cyclic testing. The KSSB4, USBFT4 and USBP4 repairs demonstrated bursal sided gap formation in the range of 1 to 3 mm.

Based on the results of this study the transosseous equivalent/Suture Bridge repair with four stitches tied in the medial row and maximal lateral suture strand utilization (KDSB8 TOE/SB) is the strongest. The KDSB8 also appeared to show less bursal sided gap formation and greater footprint stability than the other Suture Bridge constructs tested.

This study looks at the dynamic tendon-to-bone contact properties of rotator cuff (RC) repairs—comparing single row repairs (SRR) with double row transosseous- equivalent (TOE) repairs. It was postulated that relaxation during, and movement following, the repair would significantly compromise contact properties and therefore, the ability of the tendon healing.

Simulated tears were created in the supraspinatus tendon of six cadaveric human shoulders. A SRR was then performed using the OPUS System, creating two horizontal mattress sutures. An I-Scan electronic pressure-sensor (Tekscan, Boston, MA) was placed between the supraspinatus tendon and bone. The arm was then rested for 300secs (relaxation) before being passively moved twice through a range-of-motion (0-90 degrees abduction, 0-45 external and 0-45 internal rotation) and finally returned to neutral. The contact properties were recorded throughout each movement. The procedure was then repeated using two TOE techniques: parallel sutures (TOE-P) and a cross over suture pattern (TOE-C).

While peak pressures during the repair were higher in the two TOE repairs, all three methods demonstrated relaxation over 300s such that there was no significant diference in contact pressures at the end of this time. TOE parallel and cross-over repairs demonstrated no significant change in mean TTB contact pressure, force and area during abduction, external rotation and return to neutral, when compared to the 300sec relaxation state. TOE-C demonstrated a higher contact force on internal rotation (+53%). The SRR demonstrated a significant drop in contact force on abduction (−63%), and return to neutral (−43%) and a trend on external rotation (−34%). SRR exhibited no change on internal rotation.

There have been very few biomechanical studies with which observe RC repair contact properties dynamically. Relaxation of the repair can be partially reversed. Significant decrease in contact area with SRR during movement occurred, compared to the TOE repairs, which remains unaltered. This is an important consideration when determining postoperative rehabilitation.

The diagnosis and treatment of disorders of the long head of the biceps tendon remains controversial. There is uncertainty as to the role of the long head of biceps and it can be difficult to determine whether the patient's pathology is coming from the biceps or other adjacent structures. In addition, the appropriate type of treatment remains controversial.

We retrospectively reviewed the files of the senior author's experience in over 4000 arthroscopic shoulder procedures. We examined cases involving isolated biceps pathology, excluding those patients with rotator cuff tears and labral pathology, involving 92 biceps tenotomies and 103 biceps tenodeses.

Our analysis supports the benefit of clinical examination over all types of radiological investigations. The benefits and technique of biceps tenodesis is described including surgical technique. Irritation by PLA interference screw is examined. A paradigm is put forward to help in diagnosis and management of these lesions.

Long head of biceps pathology is a significant cause of shoulder pain in association with other shoulder problems and in isolation. Biceps tenodesis and tenotomy is an efficacious way of dealing with this pathology.

Isolated rupture of short head of biceps is a rare injury. There have been no published reports of rupture at the musculotendinous junction. We report two cases of complete rupture of the musculotendinous junction of the short head of biceps in young males both occurring during water skiing.

Two males sustained water skiing injuries where the handle was forced against the flexor region of the arm. Whilst trying to adduct and flex the extended arm, they both sustained complete musculotendinous ruptured of their short head of biceps.

Both underwent pre-operative magnetic resonance imaging and one underwent isokinetic strength testing of elbow flexion and supination.

Surgical repair was performed using absorbable sutures. One patient had the short head muscle belly flipped distally to lie in a subcutaneous plane in front of the elbow.

Post-operative management included cast immobilisation for three weeks then gentle range of motion exercises. Both patients recovered their full range of motion in the arm. There were no complications. Post-operative strength testing was performed and will be presented.

This is a unique series of complete musculotendinous rupture of the short head of biceps. The mechanism of injury was resisted adduction and flexion against the towrope handle with the arm in extension.

These ruptures occurred in high impact high velocity accidents. Surgical repair lead to an excellent outcome.

There are a multitude of studies internationally that have considered the rates of redislocation of shoulders, where, after first time anterior dislocation, initial management has consisted of an internal rotation sling immobiliser or no immobility. The majority of these have indicated poor results. This is in comparison with recurrence rates of dislocation, post shoulder stabilisation (arthroscopic or open), after first time anterior dislocation, which have demonstrated excellent results.

The question remains, is there a non-operative alternative that will give similarly good results for these patients.

A selection criteria was set up for use of the external rotation brace for first time anterior dislocators. Thirty-five patients were used that fit the criteria and were able to be followed over time. A physiotherapy program was initiated at the two-week stage in combination with clinic reviews. We encouraged use of the brace for six weeks in total, with removal only for hygiene purposes. At two years, post first time anterior dislocation, patients were reviewed clinically and a quick DASH score performed. Any recurrence of dislocation was recorded and an MRI was also undertaken to show residual injury.

The compliance with the brace and physiotherapy program were excellent, with only one reported redislocation, during this period, in the 31 patients that were followed up. The majority of patients were functioning at predislocation levels at review and no one had required surgical intervention for instability. Quick-Dash results were also very good, with a vast majority scoring less than 2/100 level of disability.

Michael Robinson has been a Consultant Orthopaedic Surgeon and Senior Lecturer in the Department of Orthopaedics and Traumatology in Edinburgh, Scotland, United Kingdom for 10 years. His special interests include the treatment of proximal humeral and clavicle fractures, and shoulder instability.

Primary traumatic anterior dislocations of the glenohumeral joint in young adults are common injuries, which are associated with persistent deficits of shoulder function and a high risk of recurrent instability. Although several risk factors have been implicated, a younger age at the time of the primary dislocation, and male gender, are the factors that have been most consistently associated with a higher risk of recurrence.

Recent studies have suggested that primary arthroscopic repair of the anteroinferior detachment of the glenoid labrum (Bankart repair) may reduce the risk of subsequent recurrent instability and improve function, when compared with non-operative treatment. However, the unblinded or single-blind design of these studies fails to eliminate the potential for error due to observer or subject bias, and the therapeutic effects of the Bankart repair cannot be distinguished from those of the arthroscopic examination and washout alone. The latter may reduce the rate of subsequent instability, by promoting healing of the labral detachment, or by altering the patient's subsequent level of physical activity and compliance with rehabilitation protocols.

A clinical trial conducted recently in our Institution assessed the efficacy of a primary arthroscopic stabilisation after a first-time dislcoation, whilst controlling for the therapeutic effects of the arthroscopic examination and washout alone. We aimed to specifically test the null hypothesis, that an arthroscopic Bankart repair (ABR) would not produce an improvement in the rate of recurrent instability, functional outcome, range of movement, levels of patient satisfaction or total cost of treatment, when compared with an arthroscopic examination and washout (AWO) alone. The results of this study will be presented, together with an overview of the advantages and disadvantages of primary arthroscopic stabilisation.

None of the authors have received any payment or consideration from any source for the conduct of this study.

Shoulder istability is an increasing problem in the natonal rugby league. Arthroscopic stabilisation has become an acceptable form of treatment for this instability. This study details the results of surgery to 32 elite contact athletes from one NRL club— the North Queensland Cowboys

Thirty-two cases of shoulder stabilisation have been performed on the players from the North Queensland Cowboys since 2003. A case series presentation of these procedures and follow up shall be detailed.

Thirty-two cases of instability surgery have been performed on North Queensland Elite Rugby League players. Five procedures were open, two bilateral and five for posterior instability. Two recurrences have been seen in the arthroscopically reconstructed group. The first developed a HAGL at his subsequent instability episode and required open repair.

The second case was a player with significant ligament instability he eventually underwent bilateral open reconstruction.

Arthroscipic stabilisation is an acceptable option for elite rugby league players; recurrence rates are low, range of motion loses are reduced and earlier return to play occurs, when compared to open stabilisation.

Michael Robinson has been a Consultant Orthopaedic Surgeon and Senior Lecturer in the Department of Orthopaedics and Traumatology in Edinburgh, Scotland, United Kingdom for 10 years. His special interests include the treatment of proximal humeral and clavicle fractures, and shoulder instability.

The majority of proximal humerus fractures can be managed non-operatively with surgery reserved for approximately 10–20% of patients. The choice of surgical treatment is usually between a humeral head head-conserving fracture reduction and internal fixation and humeral head sacrifice hemiarthroplasty. Current indications for primary hemiarthroplasty include a displaced four-part fracture (with or without associated dislocation of the humeral head) and a head-splitting fracture (with involvement of >40% of the articular surface), due to the high associated risk of avascular necrosis. However, the indications for internal fixation of proximal humerus fractures have expanded over the last decade, and many fractures which have previously been considered unsalvageable and treated either non-operatively or with hemiarthroplasty are now deemed reconstructable. This is partially as a result of improved appreciation of sub-groups of fractures which have a better prognosis from head-salvage, the possibility that subsequent development of osteonecrosis may be relatively asymptomatic and the realisation that functional results after hemiarthroplasty are often sub-optimal.

The purpose of this talk is to discuss the current concepts in fracture classification and the indications for operative treatment for these fractures. The novel surgical approaches, techniques and implants which have renewed interest in their treatment are also highlighted.

None of the authors have received any payment or consideration from any source for the conduct of this study.

Successful ORIF of proximal humeral fractures requires a careful assessment of the patient factors (age/osteoporosis/functional expectations), accurate identification the fracture segments (head/shaft/tuberosities) and accessory factors which are of vascular and surgical relevance (length of posteromedial metaphyseal head extension, integrity of medial soft tissue hinge, head split segments, tuberosity/head segments impacted to-gether or distracted apart).

Fixation of the fracture can be achieved by a number of techniques because of the multiple factors that often apply—numerous techniques are usually required of the surgeon.

The principles of fixation require accurate restoration of the head and tuberosity orientation, fixation of the metaphyseal segments (tuberosities) results in a stable circular platform on which the head segment rests. Thus, the fixation of choice acts as a load sharing device not a load bearing device. This fixation is often augmented with tension band and circlage suture fixation. These concepts are especially applicable to the osteoporotic patient.

The order of fixation requires that the medial hinge not be disrupted. If it is disrupted in the younger patient it requires fixation first. All tuberosity segments are tagged with ethibond sutures. The head and the largest tuberosity segment are reduced and held with k-wire or canulated scews, avoiding the central medullary canal entry point. If the head tuberosity segment is unstable in relation to the shaft, the fixation implant of choice (plate/intramedullary) is chosen and the head/tuberosity complex is reduced to the shaft. Depending on the fracture segments and the degree of comminution this may require compression of distraction.

Post-op the patient is immobilised in external rotation to balance the cuff forces. If very rigid fixation is achieved then early mobilisation is undertaken to minimise the adhesions due to opening of the subdeltoid space. If fixation is tenuous movement is commenced a 3–4 weeks.

AVN of the humeral head with good tuberosity head architecure can be salvaged. The diagnosis of AVN is determned at three months with a MRI and consideration given to Zolidronate therapy. Post-traumatic stiffness with good architecture can be salvaged with an arthroscopic capsular release.

Michael Robinson has been a Consultant Orthopaedic Surgeon and Senior Lecturer in the Department of Orthopaedics and Traumatology in Edinburgh, Scotland, United Kingdom for 10 years. His special interests include the treatment of proximal humeral and clavicle fractures, and shoulder instability.

The traditional view that the vast majority clavicle fractures heal with non- operative treatment with consistently good functional outcomes is no longer valid. Recent studies have identified a higher rate of nonunion and specific defects of shoulder function in sub-groups of patients with these injuries. These fractures should therefore be viewed as a spectrum of injuries with diverse functional outcomes, each requiring careful assessment and individualised treatment. This talk provides an overview of the current knowledge regarding their epidemiology, classification, clinical assessment and treatment in adults. The following key points will be highlighted:

Undisplaced fractures of both the diaphysis and the lateral end of the clavicle have a high rate of union and good functional outcomes after non-operative treatment.

None of the authors have received any payment or consideration from any source for the conduct of this study.

We present a series of 18 consecutive cases of primary reverse total shoulder arthroplasty for irreparable proximal humerus fractures in patients over 70. Failure of tuberosity union and poor cuff function leads to unsatisfactory results in over half the patients with hemiarthroplasty. Reverse total shoulder arthroplasty does not depend upon a functional rotator cuff and requires little formal rehabilitation.

Patients over 70 with irreparable proximal humerus fractures treated with a reverse total shoulder arthroplasty were included in this study. Only primary arthroplasties were included. Reverse arthroplasties for failed hemiarthroplasties were excluded.

All arthroplasties were performed using either a deltoid split direct lateral (superior) approach or the antero-lateral MacKenzie approach. The SMR reverse total shoulder prothesis was implanted in all cases using a press-fit glenoid base plate and glenosphere, and press-fit or cemented humerus stem. Tuberosity repair was attempted in 10 cases. The supraspinatus was excised from the greater tuberosity.

Patients were allowed self-mobilisation after two weeks in a sling. Patients were recruited and followed up per ethics approved protocol.

Outcome measures used were range of motion, dislocation and revision rates radiological signs of loosening and glenoid notching, DASH and Constant scores. Results were compared to another series of cases of reverse shoulder arthroplasty for sequelae of trauma and failed hemiarthroplasties, as well as a series of primary hemiarthroplasties.

At an average follow-up of 30 months (minimum 12 months) all patients were satisfied with their results. Average forward elevation was 132 deg. and abduction 108 deg. There was not deterioration of movement at 12 or 24 months. No patient had ongoing pain. The average constant score was 62.

There was no evidence of humeral stem loosening apart from one case of early subsidence in a press fit stem. Eleven cases showed glenoid notching, four Nerot grade 1, six Nerot grade 2 and one Nerot grade 3. All notching had stabilised after 12 months. There were no cases of dislocation. No case needed revision, or awaits revision. All cases were pain-free at last review.

Overall results for this group of primary reverse arthroplasties for fractures was much better than for reverse arthroplasties for sequelae of trauma. The results were also better than for primary hemiarthroplasties. Irreparable three and four part fractures of the proximal humerus pose management challenges in the elderly. The reverse total shoulder arthroplasty is very attractive option for elderly patients with irreparable proximal humerus fractures. They require little rehabilitation and can give reproducibly good functional results, which do not deteriorate with time.

This study reviews the early results of Distal Humeral Hemiarthroplasty(DHH) for distal humeral fracture and proposed a treatment algorithm incorporating the use of this technique in the overall management of distal humeral fractures.

DHH was performed on 30 patients (mean 65 years; 29-91) for unreconstructable fractures of the distal humerus or salvage of failed internal fixation. A triceps on approach was used in six and an olecranon osteotomy in 24. A Sorbie Questor prosthesis (Wright Medical Technology) was used in 14 patients and a Latitude (Tornier) in 16. Clinical review at a mean of 25 months (3–88) included the American Shoulder and Elbow Surgeons elbow outcomes instrument (ASES), Mayo Elbow Performance Index (MEPI) and radiological assessment.

At follow up of 28 patients mean flexion deformity was 25 degrees, flexion 128 degrees, range of pronosupination 165 degrees, mean ASES 83, MEPI 77 and satisfaction 8/10. Acute cases scored better than salvage cases. Re- operation was required in 16 patients (53%); two revisions to a linked prosthesis for periprosthetic fracture and aseptic loosening at 53 and 16 months, 12 metalwork removals and four ulnar nerve procedures. Posterolateral rotatory instability was present in one elbow, four had laxity and mild pain on loading (two with prosthesis or pin loosening), four had laxity associated with column fractures (two symptomatic) and 10 had asymptomatic mild laxity only. The triceps on approach had worse instability and clinical scores. Uncomplicated union occurred in all olecranon osteotomies and 86% of column fractures. One elbow had an incomplete cement mantle and seven had lucencies >1 mm; one was loose but acceptable. Five prostheses were in slight varus. Two elbows had early degenerative changes and 15 developed a medial spur on the trochlea.

This is the largest reported experience of DHH. Early results of DHH show good outcomes after complex distal humeral fractures, despite a technically demanding procedure. Better results are obtained for treatment in the acute setting and with use of an olecranon osteotomy. As a result of this experience anatomical and clinical pre-requisites and advise on technique are outlined. An algorithm for use of DHH in relation to total elbow arthroplasty and ORIF for the treatment of complex intra-articular distal humeral fractures with or without column fractures is proposed.

Despite the publication of numerous studies, controversy regarding the non- operative treatment of type II dens fractures remains. The halo-thoracic vest (HTV) and cervical collar are the most commonly used devices. We sought to compare the outcomes of patients managed with these devices in terms of non-union risk factors and associated complication rates.

This study was a retrospective review of adult patients with type II dens fractures treated non-operatively at a level one trauma centre between 2001 and 2007. The patients were identified using a hospital trauma database. Each patient included in the study had a minimum follow up of six months. Patient medical records and imaging studies were reviewed. Union was defined as stable fibrous union or bony union, measured at three months. A p-value of < 0.05 was considered statistically significant.

Sixty-seven patients were included. Thirty-five patients were treated using a HTV and 32 with a collar. Non-union was found to be associated with increased time in HTV or collar (p = 0.011) and with a mechanism of injury involving a low fall (p = 0.008). In addition, the proportion of patients with stable union at three months was 60% for the HVT group versus 35% for the cervical collar group (p = 0.10). There were trends to support an increased risk of non-union with a patient age of greater than or equal to 65 years at the time of presentation (p = 0.13) as well as with a fracture displacement of greater than or equal to 2 mm at time of presentation (p = 0.17). Clinically significant complications of the HTV were of greater prevalence than those experienced by collar patients. Sixty percent of HTV patients suffered one or more complications compared with 6% of collar patients.

We were unable to demonstrate any clear advantage or disadvantage of either device. Further investigation of mortality would be beneficial, particularly in the patient group injured with a mechanism involving a low fall (which tends to include more elderly patients).

Posterolateral spinal fusion using autograft in adult rabbits has been reported by many groups using the Boden model. Age in general has an adverse effect on skeletal healing; although, its role in posterolateral fusion is not well understood. This study examined the influence of animal age on spinal fusion using a standard model and experimental endpoints. We hypothesised that fusion quality and quantity would be less with increasing age.

A single level posterolateral fusion between the fifth and sixth lumbar segments were performed in six-month and two-year-old New Zealand white rabbits (n=6 per group) using morcelized iliac crest autograft. All animals were sacrificed at 12 weeks following surgery. Posteroanterior Faxitron radiographs and CT scans were taken and DICOM data was analysed (MIMICS Version 12, Materialise, Belgium). Axial, sagittal, coronal and three-dimensional models were created to visualise the fusion masses. Bone mineral density (BMD) of the fusion mass was measured using a Lunar DPXL Dexa machine. An MTS Bionix testing machine was then used to assess peak load and stiffness. Sagittal and coronal plane histology was evaluated in a blinded fashion using H&E, Tetrachrome and Pentachrome stains. Assessment included overall bony response on and between the transverse processes. Radiographs and CT confirmed a more robust healing response in younger animals. Radiographic union rates decreased from 83% to 50% in the aged animals. A neo- cortex surrounding the fusion mass was observed in the younger group but absent in the aged animals. Fusion mass BMD and that of the vertebral body was decreased in the older animals (P<0.05). Tensile mechanical data revealed a 30% reduction in peak load (P=0.024) and 34% reduction in stiffness (P=0.073) in the two-year-old animals compared with the six-month-old animals. Histological evaluation demonstrated a reduction in overall biological activity in the two-year-old animals. This reduction in activity was observed in the more challenging intertransverse space as well as adjacent to the transverse processes and vertebral bodies at the decortication sites. Numerous sites of new bone formation was present in the middle of the fusion mass in the six-month-old animals while the bone graft in the two-year- old animals were less viable.

Skeletal healing is complex and mediated by both local and systemic factors. This study demonstrated that ageing leads to an impaired and delayed skeletal repair.

Where autograft is utilised, diminished graft osteoinductivity and reduced levels of growth factors and nutritional supply in the surrounding milieu explains our observations. The aged rabbit posterolateral spinal fusion model has not been previously described but would be a useful to evaluate new treatment modalities in a more challenging host environment.

Single level posterolateral spinal fusion in rabbits is the accepted preclinical model for evaluating bone graft substitutes or treatments to enhance/augment healing. This study aimed to improve preclinical testing by developing a multi-level unilateral fusion model that could be used as a screening tool prior to larger scale preclinical experiments.

A four level unilateral posterolateral fusion was performed in nine animals. The materials were randomly allocated and placed between the decorticated surfaces of the transverse processes and vertebral bodies. Animals were euthanised at three, six and 12 weeks. The materials were (1) 25 kGy y-irradiated rabbit allograft chips (RAC), (2) SCF RAC, (3) 60% tri-calcium phosphate, 40% hydroxyapatite formagraft (BiOstetic) (4) Autograft (1.5 cc morsellised to 1-2.5 mm granules). The autograft was harvested from the iliac crest using the L5-L6 incision. Endpoints included x-ray, CT, micro CT and histology.

The animals tolerated the surgery well. Radiographic data provided a useful method to differentiate between groups. Micro CT however was extremely valuable demonstrating new bone formation as early as three weeks across the groups. Gamma irradiated samples demonstrated an initial inflammatory reaction while the autograft, SCF allograft and synthetic TCP did not show this response. As expected, time was an important factor demonstrating the maturity in the fusions. These materials responded in a similar fashion in this model as observed in a single level fusion.

A unilateral multi-level fusion can be performed in rabbits to provide a useful screening for different materials. Gamma irradiated allograft has an initial inflammatory reaction that may be related to the presence of residual cellular material whereas SCF and synthetic materials do not.

Atlanto-axial subluxation (AAS) presents with marked frequency among patients with instability in rheumatoid arthritis (RA) patients. This study investigated the morphology of the atlanto-occipital joint (AOJ) in AAS patients due to RA using computed tomography, and examined the relationship between its morphology and other radiographic results

Twenty-six consecutive patients with AAS due to RA treated by surgery were reviewed. In all patients, the AOJ was morphologically evaluated using sagittal reconstruction view on computed tomography before surgery. Moreover, the ADI value was investigated at the neutral position, and atlanto-axial angle (AAA) at the neutral and maximal flexion position in preoperative lateral cradiographs. The morphology of the AOJ was classified into three types as follows: a normal type which showed a maintenance of the joint space, a narrow type which showed a disappearance of the joint space and a fused type which showed the fusion of the AOJ.

The pre-operative CT image of the AOJ demonstrated a normal type bilaterally in six cases (Group A). In 15 cases (Group B), CT image demonstrated narrowing on at least one side of the AOJ. In five cases (Group C), CT images demonstrated fusion on at least one side of the AOJ. The average ADI value at the flexion position was 10.7 mm in Group A, 11.7 mm in Group B, and 12.6 mm in Group C. There was no significant difference among those groups. The average ADI value at the neutral position before surgery was 2.8 mm in Group A, 5.9 mm in Group B, and 10.4 mm in Group C. There was no significant difference between Group A and B, and Group B and C; however, there was a significant difference between Group A and C (p < 0.004). The average AAA value was 25.3 degrees in Group A, 19.3 degrees in Group B and 3.4 degrees in Group C. There was no significant difference between Group A and B; however, there was a significant difference between Group A and C (p < 0.002), and Group B and C (p < 0.007).

This study showed that fusion or ankylosis of the AOJ induced an enlargement of the ADI and anterior inclination of the atlas in the neutral position—despite the fact that normal findings of AOJ showed a slight displacement of the atlas to axis in RA patients showing AAS involvement.

The use of cervical pedicle screws as anchors in posterior reconstruction surgery has not been widely accepted due to the neurological or vascular injury. We thus sought to investigate the accuracy of free-handed pedicle screw placement in the cervical and upper thoracic spine at the early stage of clinical application.

Eight patients (five males and three females) were included in this study. Mean age was 63 years (31 to 78 years). There were three patients with rheumatoid arthritis, three with cervical fracture-dislocation, and two with spinal metastasis. Twenty-four pedicle screws (3.5 mm diameter: Vertex, Medtronic Sofamordanek) were placed into the pedicle from C2 to T2 level by free-handed technique2). Grade of breaching of pedicle cortex was divided into four groups (Grade 0–3). In addition, screw axis angle (SAA) were calculated from the horizontal and sagittal CT images and compared with pedicle transverse angle (PTA). Furthermore, perioperative complications were also examined.

Our free-handed pedicle screw placement with carving technique is as follows: A longitudinal gutter was created at the lamina-lateral mass junction and then transverse gutter perpendicular to the longitudinal gutter was made at the lateral notch of lateral mass. The entry point of the pedicle screw was on the midline of lateral mass. Medial pedicle cortex through the ventral lamina was identified using the probes to create the hole within the pedicle. The hole was tapped and the screw was gently introduced into the pedicle to ensure the sagittal trajectory using fluoroscopy. In the transverse direction, 22 out of 24 screws (92%) were entirely contained within the pedicle (Grade 0). In contrast, only teo screws (8%) produced breaches less than half the screw diameter (Grade 1). In the sagittal direction, all screws were within the pedicle (Grade 0). Screw trajectories were not consistent with anatomical pedicle axis angle; the mean SAA were smaller than the mean PTA at all levels. The pedicle diameter ranged from 3.9 to 9.2 mm. The mean value gradually increased toward the caudal level. There were no neurological and vascular complications related to screw placement.

Existing techniques of posterior multi-point C1/2 stabilisation are technically demanding and can be hazardous. The coauthors have recently reported successful atlantoaxial fusion using a novel C1/2 stabilisation technique employing C1 multi-axial posterior arch screws (MA-PAS) in a clinical series of three patients where anatomical anomalies precluded established techniques.

The technically less demanding nature of this new technique, and possible wider application in patients with normal anatomy, led the authors to investigate its biomechanical stability compared to other established techniques.

Twenty-four human fresh-frozen cadaveric spines were harvested C0-C5. Motion was restricted to between C0 and C4. Each spine was non-destructively tested in flexion/extension, lateral bending and axial rotation, firstly in the intact state and then after Type 2 odontoid fracture destabilisation and insertion of Magerl-Gallie, Unicortical Harms, Bicortical Harms or MA-PAS instrumentation. ROM between C1 and C2 was monitored using two digital cameras. Results for each technique were compared statistically compared using ANOVA.

The C1-C2 joint of the intact spines demonstrated high flexibility in flexion/extension (16.5deg). After instrumentation all specimens showed significantly reduced ROM in flexion/extension (Magerl-Gallie FE = 4.2deg, Unicort Harms FE = 7.2deg, Bicort Harms FE = 4.4deg). Lateral bend ROM of instrumented specimens (Magerl-Gallie LB =3.8deg, Unicort Harms LB = 3.8deg, Bicort Harms LB =2.3 deg) was, however, similar or slightly greater than intact (2.7 deg) . MA-PAS showed similar ROM in flexion/extension (4.2 deg) as the Magerl-Gallie and Harms techniques but was slightly higher in lateral bend (5.3 deg).

The MA-PAS technique was shown to have similar biomechanical stability to the Magerl-Gallie and Harms techniques. Given the demonstrated biomechanical stability of the MA-PAS technique, it may be a suitable alternative to the existing technically demanding, and possibly more hazardous, multi-point fixation techniques in patients with normal, as well as anomalous, C1/2 segmental anatomy.

Cahill et. al. published a large review of the use of BMP in spinal fusions. They reviewed the nationwide inpatient database, which represents approximately 25% of use U.S. Community Hospitals from the years 2002 to 2006. This included over 300,000 fusion type procedures. They noted increased complications with the use of anterior cervical procedures specifically increased complications with increased dysphasia and wound complications.

Due to these concerns, the Food and Drug Administration released last year a public health notification about the potential life threatening complications related to the use of BMP in anterior cervical spine fusions. Joseph & Rampersaud noticed a 20% incidence of heterotopic ossification in patients undergoing this procedure versus only 8% for patients who had undergone fusions without BMP.

Wong et. al. published a report on five cases of neurologic injury that relate to the use of BMP and the formation of heterotopic bone. Again, the suggestion of a barrier or closure defect was brought up and this may help minimise the risks; however, further work is noted. Multiple authors have noted a phenomenon of osteolysis occurring around graft fusion sites for the use of BMP. McCullen et. al. evaluated that 32 levels in 26 patients who had undergone a TLIF procedure. It is unclear the carcinogenic and tetraogenic effects of the use of BMP in the spine and also, the effects of repeat exposures on BMP has yet to be addressed. Finally, the long term cost and benefits of the use of BMP on the health care system has yet to be fully addressed.

So in conclusion, BMP2 is effective in producing fusions especially in challenging environments, deformity, smoking and infection. However, the complications continue to be a concern especially with regards to interbody fusions as well as in the cervical spine.

Decision-making regarding operative versus non-operative treatment of patients with thoracolumbar burst fractures in the absence of neurological deficits is controversial, and evidence from trials is sparse. We present a systematic review and meta-analysis of randomised trials comparing operative treatment to non-operative treatment in the management of thoracolumbar burst fractures.

With the assistance of a medical librarian, an electronic search of Medline Embase and Cochrane Central Register of Controlled trials was performed. Trials were included if they: were randomided, had radiologically confirmed thoracolumbar (T10-L3) burst fractures, had no neurological deficit, compared operative and non-operative management (regardless of modality used), and had participants aged 18 and over. We examined the following outcomes: pain, using a visual analogue scale (VAS), where 0=no pain and 100=worst pain; function, using the validated Roland Morris Disability Questionnaire (RMDQ); and Kyphosis (measured in degrees). Two randomised trials including 79 patients (41 operative vs. 38 non-operative) were identified. Both trials had similar quality, patient characteristics, outcome measures, rates of follow up, and times of follow up (mean=47 months). Individual patient data meta-analysis (a powerful method of meta-analysis) was performed, since data was made available by the authors. There were no between-group differences in sex, level of fracture, mechanism of injury, follow up rates or baseline pain, kyphosis and RMDQ scores, but there was a borderline difference in age (mean 44 years in operative group vs. 39 in non-operative group, p=0.046).

At final follow up, there were no between group differences in VAS pain (25 in operative group vs. 22 non-operative, p=0.63), RMDQ scores (6.1 in operative group vs. 5.8 non-operative, p=0.85), or change in RMDQ scores from baseline (4.8 in operative group vs. 5.3 non-operative, p=0.70). But both kyphosis at final follow up (11 degrees vs. 16 degrees, p=0.009) and reduction in kyphosis from baseline (1.8 degrees vs. -3.3 degrees, p=0.003) were better in the operative group.

Operative management of thoracolumbar burst fractures appears to improve kyphosis, but does not improve pain or function.

The simple dictum of the late Prof. Alf Nachemson was that ‘surgery should very rarely, if ever, be performed in adult scoliotic patients for lumbar curves when pain is the most serious problem’. Today, the complexity of intercurrent neural symptoms, the advancing age of the population and the increasing demands and expectations of modern living require a somewhat more flexible approach to this increasingly common problem.

Treatment of adult deformity has improved along with our understanding of the radiological features of the condition most likely to be associated with disabling pain and also with our appreciation of the adverse significance of patient co-morbidity. In those patients where conservative measures have failed and where an acceptable quality of life has been lost, surgical management may be undertaken, but must address all the symptomatic aspects of the deformity in one episode of care.

Primary objectives include the restoration of satisfactory sagittal plane correction using the minimum number of operated levels whilst providing adequate spinal stability. Meticulous preoperative planning from a clinical and radiological perspective maximises the possibility of a satisfactory outcome and in this regard patient expectation is of prime importance. The questions of operative approach and levels of fixation are ever present and recent advances in our understanding of distal end fixation are worthy of consideration.

Finally, exemplary cases and our series of 23 patients undergoing surgical treatment of adult scoliosis will be presented. Mean coronal curve correction by anteroposterior approach was 60.4% and by posterior only approach 40.3%.

Patient satisfaction was 77.8% by combined approach and 58.9% by posterior only approach. The rate of reoperation was 66.7% for posterior surgery alone and 11.1% for combined approach corrections.

Primary spinal cord injury is followed by secondary, biochemical, immunological, cellular changes in the injured cord

A review article written by Brian Kwon looking critically at the use of hypothermia for SCI. It shows that it is neuroprotective in some settings (i.e. cardiac arrest). However, there are 25 animal studies with mixed results and only eight human SCI studies. Importantly, they are all case series of local, not systemic hypothermia. And the last one published was in 1984.

Rho is a critical molecule in SCI. Rho ultimately inhibits axonal growth cone proliferation. Stopping RHO therefore will promote the growth cone. There are two drugs that ultimately targets rho. These are anti nogo antibodies and cethrin both of which ultimately inhibit rho.

President Obama lifted the ban on federal funding of stem cell research. This was a monumental occasion and was right around the time that the FDA approved the first trial of hESC for SCI.

The FDA trial of Geron is with Thoracic ASIA A SCI patients with transplantation of ESC directly into the cord at 7 to 14 days after injury. Geron has provided evidence to the FDA that there is no teratoma formation with transplantation of a human ESC to a rat or mouse. However, we do not know what will happen in a human to human transplant.

In conclusion, use of steroids in setting of SCI is diminishing. There is no clinical evidence to support use of systemic hypothermia. Current clinical trials of pharmacologic therapy include Minocycline and RILUTEK(r) (riluzole) for neuroprotection, Anti-Nogo Antibodies and Cethrin(r) for axonal growth by ultimately inhibiting Rho. There is only one small study supporting safety, not efficacy of OEC transplantation.

Subchondral drillings for articular cartilage repair give functional improvement that peaks at 24 months after surgery. We postulate that intra-articular injections with autologous peripheral blood stem cells (PBSC) and hyaluronic acid (HA) following subchondral drillings can improve the repair process.

Thirty-four patients with full thickness chondral defects of the knee joint underwent subchondral drillings. The operated knees were then placed on continuous passive motion for a period of two hours per day for four weeks, with partial weight-bearing for the first six weeks. PBSC were harvested by apheresis and divided into aliquots which were cryopreserved. One week after surgery, weekly intra-articular injections of 2.5 mLs PBSC mixed with 2 mLs of sodium hyaluronate were given for five weeks after surgery. Patients were followed up for an average of 11 months (range 6–20) and assessed using serial MRI scans. Second look arthroscopy and chondral biopsies were obtained in five patients. International Knee Documentation Committee (IKDC) scores were compared with previous microfractures results from the Mithoefer cohort study using linear interpolation to generate time-based predicted values. The difference was compared using a two-tailed, one-sample T-test against a value of zero.

Serial MRI scans showed healing of subchondral bone and evidence of cartilage regeneration that was confirmed on arthroscopy with good integration into surrounding cartilage with no delamination. Biopsy specimens showed attributes typical of hyaline cartilage with good cellular morphology, abundant proteoglycans and Type II collagen. No oedema or degenerative changes were seen. The IKDC data was on average 12.8 points (95% CI 6.5-19.1) higher than the Mithoefer group with p=0.0002.

Intra-articular injections of PBSC and HA following subchondral drillings resulted in good repair tissue based on MRI, arthroscopic, and histological criteria, with IKDC scores superior to standard microfracture surgery.

To assess the clinical outcomes of patients undergoing ACI in the patellofemoral joint.

Over recent years chondrocyte implantation (MACI) has become a recognised procedure. This paper presents the results of two players in the national rugby league competition who play first grade football and have undergone the procedure.

Professional sports medical care can be difficult. Demands from players, the public and coaches are beyond our normal requirements as surgeons. Faced with two high-profile players with career ending focal grade 4 chondral lessions and not responding to our normal treatment methods, I performed chondrocyte implantation (MACI) to deal with this. Both players have responded well to treatment and returned to first grade football

The two players in question had focal grade 4 chondral lesions. They had not responded to treatment and had recurrent effusions restricting their ability to play. Player A required a revision acl reconstruction as he was to be away from the game for a year. I treated his chondral lesion with MACI. His effusion settled and he returned to play with no further delays other than those expected from the acl surgery.

Encouraged by this result, I performed the second procedure on a very high- profile player who had recurrent pain and effusion and had been treated with arthroscopies with little improvement.

Faced with retirement, he opted for the procedure and returned to first grade the following season.

After meniscetomy there is an increased risk of tibiofemoral arthritis. In recent times there has been an increased emphasis on preservation of healthy meniscal tissue. When this cannot be achieved some patients may benefit from allograft transplantation. This aims to restore meniscal function and so limit pain and the development of arthritis. This is an evolving area with controversy surrounding patient selection, tissue harvesting and sterilisation, longterm outcome and overall efficacy.

Twenty-eight patients have undergone 30 meniscal transplants beginning in 2001. All transplants have been performed by the senior author. The mean age at surgery was 37.7 years (range 20–51), there were 16 males and 12 females. At the time of the index operation nine patients underwent additional procedures on the same knee. All patients are scored using recognised knee scoring systems including the Oxford, IKDC and Lysholm scores. All patients are being followed up regularly with clinical assessment and repeat scores.

To date the average follow up is 34.3 months (range 6–84). There have been 12 patients requiring further arthroscopy (three with complete meniscal transplant failure). The average increases in Lysholm, Oxford and IKDC scores were 10.7, 7.6 and 8.6 respectively.

Lack of donors is the current limitation to performing transplants in Brisbane. 61 patients are currently awaiting suitable menisci and in the last 12 months there have been only three donors. A national registry may address this issue but raises problems related to uniform retrieval, storage, sizing and availability. Early results are encouraging with the majority of patients experiencing pain relief and improvement of function over time.

The purpose of this study is to investigate the incidence of patients with isolated bundle ACL tear (either isolated posterolateral or anteromedial bundle) during arthroscopy, and its correlation with physical exam. The relevant surgical technique to reconstruct the ligament is discussed.

Between September 2006 and March 2009, patients with ACL injuries who received double- bundle ACL reconstruction were reviewed retrospectively. A specialist fellow performed a physical exam before and after anaesthesia. Intraop status of the ACL tear was assessed with correlation of the physical findings. Patients with isolated bundle tear would receive anatomical reconstruction of the torn bundle with preservation of the intact bundle.

Double-bundle hamstrings reconstruction would be performed to those with complete tear. Medical notes of 159 patients were reviewed. There were 118 patients (74%) with complete ACL tear, 36 (23%) with isolated AM tear, and 5 (3%) with PL tear.

For patients with complete ACL tear, 94% and 100% had positive Lachman, 50% and 87% had positive pivot shift, before and after anaesthesia. For patients with isolated AM tear, 100% had positive Lachman, 36% and 19% had positive pivot shift, before and after anaesthesia.

For patients with isolated PL tear, 100% had positive Lachman, 20% and 80% had positive pivot shift, before and after anaesthesia.

With better understanding of ACL, patients with isolated-bundle tear can preserve their intact bundle during reconstruction. However, in this study we find that physical exam correlates poorly with the arthroscopic findings.

Further imaging (e.g. MRI) may be helpful to differentiate patients from isolated- bundle tear to complete tear.

Previous research has shown that tunnel placement is critical in ACL reconstruction. The ultimate position of both the femoral and tibial tunnel determines knee kinematics and overall function of the knee post surgery. As with all techniques there is a definite learning curve for the arthroscopic technique. However, the effect of the learning curve on tunnel placement has been studied sparsely. The purpose of this project therefore is to investigate the effect of the learning curve on tunnel placement.

Postoperative radiographs of the first 200 anterior cruciate reconstructions with bone-tendon-bone patella tendon of a single orthopaedic surgeon performed during the first four years of independent practice were analysed for tunnel placement. Radiographs were digitalised and imported into a CAD program.

Tunnel placement both femoral and tibial antero-posterior and sagittal was assessed using Sommer's criteria. A rating scale was developed to assess overall placement. A total of 100 points indicated perfect placement. A maximum of 30 points each were allocated for sagittal femoral and tibial placement and a maximum of 20 points each were allocated for coronal placement.

Tunnel placement scores improved from 66 for the first 25 procedures to 87 for the last 25 procedures. Sagittal femoral placement (zone 1–4 with zone 1 being the preferred zone of placement) improved from an average of 1.44 to 1.08. Sagittal tibial placement (45% from anterior border of tibia) did not change significantly and remained between 42.82 t0 44.76%. Coronal femoral placement (between 10:00–11:00 o'clock for the right knee and 1:00–2:00 for the left knee) ranged from 10.45–11.15 and 12:45-1:15 o'clock respectively. This finding may be related to the transtibial tibial technique used to place the femoral tunnel. Coronal tibial placement (45% from medial tibial border) ranged from 45-46.58%.

Correct placement of the femoral and tibial bone tunnels is important for a successful reconstruction of the anterior cruciate ligament (ACL). This study demonstrated a definitive learning curve and steady improvement of tunnel placement. Whilst there was no significant improvement in sagittal placement, overall placement improved significantly.

Tibial and femoral bone tunnel widening (TW) has been observed following anterior cruciate ligament (ACL) reconstruction. We developed a χ12 mm cannulated cancellous screw (Intercondylar Ligament Screw, ICLS) for femoral fixation to reduce TW.

The purpose of this study is to introduce our surgical method and its results. We employed an original ICLS system developed to reduce the needed distance between the tibial and femoral-fixation points (distance between fixation points, DbF) in ACL reconstruction. Five-strand (sometimes four or six-strand) hamstring grafts are connected to the ICLS. Tibial fixation is achieved with a Ligament Tension Screw, which had been developed by Murase et al. rom 2001 to 2008, 169 knees underwent ACL reconstruction at our hospitals using our ICLS system. TW was evaluated by radiographs at least three months postoperatively. An enlargement of more than 2 mm was considered TW. The following was also evaluated: range of motion, the limb symmetry index (LSI, injured leg divided by uninjured and multiplied by 100), value of knee extension power in OKC, anterior knee laxity, Lysholm score, and DbF. The average length of DbF was 38.1 mm (n=132). Only 6.7% (n=104) of cases showed more than 2 mm of TW. Mean LSI was 83.3%(n=77) four months postoperatively. The mean Lysholm score was 96.2(n=68) at three months after ACL reconstruction. The mean side-to-side difference in anterior tibial translation, measured with use of a KT-2000 or Knee Lax, was 1.60 mmï1/4N=57ï1/4‰.

We were able to reduce TW after ACL reconstruction using our ICLS system with good results.

The results of PLLA screws for ACL reconstruction have demonstrated no significant clinical differences when compared to metallic screws up to two years. However, studies examining PLLA-HA screws are lacking, as are medium term outcomes of bioresorbable screws. This study aims to compare the clinical outcome of ACL reconstruction with a PLLA-HA to a titanium screw, and to assess the extent of resorption of the PLLA-HA screw at two and five years after ACL reconstruction.

Forty patients were randomised to receive either a PLLA-HA or titanium RCI interference screw for ACL reconstruction. Both examiners and patients were blinded to screw type. Patients were prospectively reviewed at 24 and 60 months after surgery with full IKDC assessment, Instrumented Ligament Testing, Lysholm knee score. MRI scans were performed at two and five years following surgery.

Five years after surgery, one patient with a titanium screw had an ACL graft rupture and had undergone revision surgery. Of the remaining 39 patients, 38 (97%) were reviewed at five years. There was no significant difference between the two groups in the volume of the tibial (p=0.89) or femoral (p=0.22) tunnels at five years. Significant screw resorbtion at five years was seen in 77% on the tibial side and 88% on the femoral side in the PLLA group. Good ossification was evident on five year MRI in 94% of the tibial screws and 56% of the femoral screws. In the PLLA-HA group peri tunnel bone marrow oedema was present in 35% of patients on the tibial side and 53% of patients on the femoral side at five years. There was no peri-tunnel bone marrow oedema evident in the titanium group. Peri-graft ganglion cyst was evident on MRI scan on the tibial side in 24% of patients from the PLLA-HA group and 18% of the titanium group (p=0.67). There was no significant difference between the PLLA-HA group and the titanium group on any of the other clinical parameters including IKDC subjective knee score (mean 93), symptoms, range of motion, instrumented ligament laxity (mean 1.8 mm) or overall IKDC grade (90% normal or nearly normal).

ACL reconstruction with PLLA-HA bioabsorbable screws affords comparable clinical and subjective results to titanium screws at five years after surgery. Significant progression of PLLA HA screw resorption occurs between two and five years, with over 75% of screws demonstrating some resorption by five years. However, complete resorption was only evident in a small number of patients. ACL reconstruction with a PLLA HA screw has excellent clinical outcomes and progressive screw resorption and ossification is evident at five years.