Hallux rigidus is a common condition involving the first Metatarsophalyngeal (MTP) joint. Total joint arthroplasty is an acceptable modality of treatment. A number of different prosthesis have been used. Our study aims to evaluate the outcome of uncemented ceramic on ceramic (MOJE) prosthesis, in the treatment of painful hallux rigidus.

Between March 2000 and June 2005, 38 patients (53 feet) with painful hallux rigidus were treated with uncemented ceramic on ceramic (MOJE) prosthesis. There were 30 female and 8 male patients. The hallux meta-tarsophalangeal-interphalangeal scoring scale, by the American Orthopaedic Foot and Ankle Society, was used to assess these patients, pre-operatively and at follow up. A total score of 100 is possible in a patient with no pain, full range of MTP joint movement and good alignment.

The average follow up was for 34 months (range 12–68 months). Three revisions were carried out in three patients, 2 for deep infection, and 2 for persisting pain. Five patients showed radiological signs of osteolysis but had no symptoms. There was one late subluxation after 32 months. One patient developed a superficial infection, which was treated successfully.

The average AOFAS score pre-operatively was 45, compared to 91 post-operatively (p< 0.05). 23 patients (36 feet) classed the outcome as excellent to good. Ten of the patients subjectively described the out come of the procedure as excellent.

The preop range of movement (combined dorsiflex-ion and plantarflexion) was improved from a mean of 22 degrees to 68 degrees postoperatively.

The ceramic/ceramic (MOJE) total arthroplasty gave excellent results in 77% of patients. The early outcome is encouraging. We ewcommend continued use of this prosthesis for painful hallux rigidus.

Opinions is divided among surgeons whether to operatively fix displaced calcaneal fractures in elderly patients and heavy smokers. In a long term follow-up of operatively treated calcaneal fractures, we considered several factors that could affect outcomes and complication rates.

Method: 59 calcaneal fractures in 54 patients that underwent operative fixation for displaced intra-articular fractures from April 1995 to January 2006 were reviewed. There were 18 Tongue type and 41 Joint depression fractures on X-rays. Of 38 available CT scans, 25 were Sanders Type II and 13 were Types III and IV fractures.

Average interval to surgery was 6 days. Postoperative mobilisation regime was passive range of motion immediately following surgery with non weight bearing for 6 weeks. Weight bearing was started at 6–8 weeks. On follow-up, patients were assessed with clinical and radiological exam, completed Short Form-36 (SF-36), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot scale and Visual Analogue Scale (VAS) scores.

Results: The duration of follow-up was between 6 months to 11.2 years (6.4 years). The pre and post operative Bohler angles were 8° ± 11° and 29° ± 6° respectively. There was significant limitation of subtalar movement on the operated side irrespective of the presence of arthritis. The average AOFAS, SF-36 and VAS scores were 79, 58 and 3 respectively. Good results were associated with age < 50 years, ASA grade I, pre-op Bohler angle of < 5° and Sanders < IIC. 89% of patients returned to their previous level of activity after an average of 6.5 months.

Smoking was not associated with early or late complication rates and did not affect outcome.

Conclusions: We think that advanced age and smoking are not contraindications for operative fixation of displaced calcaneal fractures.

Opinions differ among surgeons whether to operatively fix displaced calcaneal fractures in smokers. In a long term follow-up of operatively treated calcaneal fractures, we considered several factors that could affecting outcomes and complications.

Method: 59 calcaneal fractures in 54 patients that underwent operative fixation for displaced intra-articular fractures from April 1995 to January 2006 were reviewed. There were 18 Tongue type and 41 Joint depression fractures on X-rays. Of 38 available CT scans, 25 were Sanders Type II and 13 were Types III and IV fractures.

Average interval to surgery was 6 days. Postoperative mobilisation regime was passive range of motion immediately following surgery with non weight bearing for 6 weeks. Weight bearing was started at 6–8 weeks. On follow-up, patients were assessed with clinical and radiological exam, completed Short Form-36 (SF-36), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot scale and Visual Analogue Scale (VAS) scores.

Results: The duration of follow-up was between 6 months to 11.2 years (6.4 years). The pre and post operative Bohler angles were 8° ± 11° and 29° ± 6° respectively. There was significant limitation of subtalar movement on the operated side irrespective of the presence of arthritis. The average AOFAS, SF-36 and VAS scores were 79, 58 and 3 respectively. Good results were associated with age < 50 years, ASA grade I, pre-op Bohler angle of < 5° and Sanders < IIC. 89% of patients returned to their previous level of activity after an average of 6.5 months.

Smoking was not associated with early or late complication rates and did not affect outcome.

Conclusions: We think that smoking is not a contraindication for operative fixation of displaced calcaneal fractures.

Introduction: The Trent arthroplasty register reported that results of Hip arthroplasty in general setup were less than that reported from specialist centres by 5%. This independent prospective study tests the hypothesis that results of Birmingham Hip Resurfacing arthroplasty from specialist centres would not accurately represent the outcome of hip resurfacing when performed in general setup.

Material and Methods: All patients were prospectively followed for at least five years at Oswestry Hip outcome centre. The surgeons carrying out the operation prospectively provided surgical details and thereafter patients were followed using Oswestry hip questionnaire (OSHIP) at fixed intervals. Survival was assessed by Kaplan-Meier method. The results were compared to the published results of BHR from specialist centers

Results: There were 679 patients, and 58 surgeons in the study. Mean age at operation was 51 years and mean follow up was 5.63 years. The predominant preoperative diagnosis was osteoarthritis. The mean OSHIP score was 89.5. There were 29 (4.2%) failures mostly due to fracture neck of femur (62%); all of them were revised to conventional THR. The Kaplan-Meier survival at seven years is 95.354%.

Discussion: Compared to the published results, there were 2 to 19 times high failure rate which is significantly higher (p=0.001) than the published studies. Hence we prove our hypothesis, as the results of BHR from specialist centres do not accurately reflect on the outcome in general setup. The discrepancy in the results that we have identified would help to identify the weak areas in the general setup, where most of the patients get benefited from BHR arthroplasty.

Introduction: The wear particles produced from the metal-on-metal hip prosthesis causes measurable rise of metal ion levels in the patient’s body fluids. Wear of the bearing is directly related to its use. The goal of this study is to test two hypotheses. Firstly, that exercise causes increased wear particles in vivo which can cause immediate measurable rise in the serum metal ion levels. Secondly, that this rise in metal ion level is different for different types of bearings.

Material and Methods: Eighteen participants were allocated to four different groups i.e. Birmingham Hip Resurfacing prosthesis group, Cormet 2000 resurfacing prosthesis group, Thrust plate prosthesis group (28mm metasul articulation) and group four with out any metal work. Blood samples were taken immediately before, immediately after and one hour after exercise. Plasma cobalt and chromium was determined using Inductively-Coupled-Plasma-Mass-Spectrometry and Dynamic-reaction-cell respectively with detection limit of 2nmol/l each.

Results: The four patient groups were comparable. A significant increase (p< 0.005) in serum cobalt and chromium of 13% and 11% respectively, was noticed after the exercise. Rise of cobalt levels in patients with a resurfacing MOM was 8.5 times (BHR group) and 6.5 times (Cormet group) larger than in those with a Metasul (p=0.021 and p=0.047). Neither rise of metal levels nor baseline levels correlated with any other factor (p> 0.27).

Discussion: Physiologic exercise causes immediate detectable rise in the serum metal ion levels. The increase is predominantly related to the size of the bearing surface. Exercise-related-cobalt-rise could be used to assess the tribology of the different metal on metal designs in vivo for future research

The Trent arthroplasty register reported that results of Hip arthroplasty in general setup were less than that reported from specialist centres by 5%. This independent prospective study tests the hypothesis that results of Birmingham Hip Resurfacing (BHR) arthroplasty from pioneering centres would not accurately represent the outcome of hip resurfacing when performed in general setup.

All patients were prospectively followed for at least five years at Oswestry Hip outcome centre. The surgeons carrying out the operation prospectively provided surgical details and thereafter patients were followed using Oswestry hip questionnaire (OSHIP) at fixed intervals. Survival was assessed by Kaplan-Meier method. Results were compared to the published results of BHR from specialist centres.

There were 679 patients, and 58 surgeons in the study. Mean age at operation was 51 years and mean follow up was 5.63 years. The predominant preopera-tive diagnosis was Osteoarthritis. Mean OSHIP score was 89.5. There were 29 (4.2%) failures mostly due to fracture neck of femur (34%). Out of 14 failures in the first year, 9 (64%) were due to fracture neck of femur. The Kaplan-Meier survival up to eight years is 95.354% in the current study.

Compared to the published results, there were 2 to 19 times high failure rate which is significantly higher (p=0.001) than the published studies. Most of the early failures were due to fracture neck of femur in the first year. Hence we prove our hypothesis, as the results of BHR from specialist centres do not accurately reflect on the outcome in general setup. The discrepancy in the results is mostly due to fracture neck of femur in the early postoperative time. The results of this study will enhance awareness of the early trend in failures. Appropriate patient selection and meticulous surgical technique will help avoid this complication in the general setup, where most of the patients get benefited from BHR arthroplasty.

We present a unique prospective study which estimates the median sustained stage related improvement in pain and hand function predicting symptomatic relief period with high accuracy with a single steroid injection.

Patients were grouped into stages, I to IV according to the Eaton and Glickel radiological criteria. The steroid injection contained 40mg triamcelone and 1% lido-caine. The response was assessed by DASH and a visual analogue score before and at six-week interval. We used the Kaplan-Meier method to estimate median length of sustained improvement by grade of disease, with 95% confidence interval. All the patients were injected by an upperlimb physiotherapist (DD). Post injection review was carried out by an independent observer(MK).

Forty patients were studied: 33 females and 7 males. The age ranged from 53 to 81 years, (mean 65years). No patient was lost to follow-up. Mean duration of symptoms were 36 months. Six patients has stage I disease(15%), eighteen patients had stage II disease (45%), ten patients had stage III disease (25%) and six patients has stage IV disease (15%). Pain score ranged from 4 to 9 on visual analogue score. Reduction in pain visual analogue score was noticed in all but 3 patients. With the exception of Grade III patients, DASH scores decreased significantly at 6 weeks (Grade I 14.9, Grade II 19.3, Grade III 6.2 and Grade IV 10.0.). With the exception of Grade IV patients, pain scores decreased significantly at 6 weeks. In Grade II patients, over half had sustained symptomatic relief at 6 months. So on average, we can expect grade I patients to sustain symptomatic relief for an average of 17 weeks. The true average is likely to be between 13 and 21 weeks. For grade II patients, most will still have improved at 6 months. Grade III and IV patients have an identical prognosis of 4 weeks, though the true prognosis may be between 2 and 6 weeks.

In conclusion it is possible to predict the period of symptomatic improvement in each of the four disease stages. This allows the treating clinician to discuss the outcome of treatment with reasonable accuracy.

In-vitro studies have shown that wear rates of the metal on metal (MOM) bearing hip prostheses decline once the bearing runs-in and the bearing subsequently enters a steady state wear phase. Baseline cobalt levels are thus expected to decline with time in patients. Several clinical studies have not found such a decline. Baseline cobalt levels are hence limited in their capacity to provide information on the wear performance of the bearing couple. We have demonstrated in a previous study that exercise causes a rise in plasma metal ion levels in patients with MOM bearing hip replacement. Would the exercise related cobalt rise be more sensitive to detect change in wear behaviour of the bearing couple? We tested the alternate hypothesis that exercise related rise in the plasma cobalt levels will correlate inversely with the duration of MOM implantation.

Sixteen patients with three different well functioning MOM bearing hip replacement [two types of resurfacing (BHR, Cormet) and Metasul] were included into the study. Patients were divided in to two groups based on time since implantation, an early group of mean 18 months and a late group of mean 57 months. Plasma levels of cobalt were measured before (baseline) and after 1 hour of maximal exercise (peak). The difference between baseline and peak for each patient provided the exercise related cobalt rise. A significant increase in plasma cobalt levels of 13% was noticed after the exercise (p < 0.005). Baseline Cobalt levels in the late group (53nmol/l) were higher than early group (44nmol/l) but the difference was not significant (p=0.45). However, the mean exercise related Cobalt rise levels was lower in late group (3.5nmol/l) than the early group (6.5nmol/l). This lower rise in cobalt level in the late group precisely reflects on the steady state wear as seen in in-vitro tests.

Baseline cobalt levels are limited in determining the in-vivo performance of the bearing couple. Exercise related rise in cobalt levels can differentiate the running in and steady state wear phases of metal on metal bearings and is thus a more accurate tool of assessing in-vivo wear performance of the bearing couple.

Aim: To review the effectiveness of ipsilateral þbular transfer with its vascular pedicle mobilised in bridging defects in the tibial shaft. Method & Results: This operation was performed in 8 patients with segmental tibial defect following injury. We reviewed these cases with a minimal follow up of 2.5 years. All the tibial defects were the result of severe open fractures (Gustilo Grade III) and either bone loss or infected non-union, and ranged in size from 1 to 12 cm. The patients had an average of seven procedures and a delay of 33 months before þbular transfer. The procedure was successful in achieving fracture union in all cases, with an average time to union of 15 months (range, 5–33 months). Shortening of up to 3 cm and some residual ankle stiffness was found but all patients were ambulating bearing full weight and six had returned to their previous occupation by their þnal follow up. Only one patient had signiþcant pain affecting function. Conclusion: This is a successful and relatively simple method of reconstructing segmental tibial defects with relatively avascular beds, and avoids the problems of tibial transport and of microvascular anastomoses.