The surgical management of musculoskeletal tumours is a challenging problem, particularly in pelvic and diaphyseal tumour resection where accurate determination of bony transection points is extremely important to optimise oncologic, functional and reconstructive options. The use of computer assisted navigation in these cases could improve surgical precision.

We resected musculoskeletal tumours in fifteen patients using commercially available computer navigation software (Orthomap 3D). Of the eight pelvic tumours, three underwent biological reconstruction with extra corporeal irradiation; three endoprosthetic replacement (EPR) and two required no bony reconstruction. Four diaphyseal tumours had biological reconstruction. Two patients with proximal femoral sarcoma underwent extra-articular resection and EPR. One soft tissue sarcoma of the adductor compartment involving the femur was resected with EPR.

Histological examination of the resected specimens revealed tumour free margins in all cases. Post-operative radiographs and CT show resection and reconstruction as planned in all cases. Several learning points were identified related to juvenile bony anatomy and intra-operative registration.

The use of computer navigation in musculoskeletal oncology allows integration of local anatomy and tumour extent to identify resection margins accurately. Furthermore, it can aid in reconstruction following tumour resection. Our experience thus far has been encouraging.

We report the short term follow up of nineteen consecutive PFC sigma unicompartmental knee replacements carried out in our institution with minimum one year follow up. The PFC Sigma medial unicompartmental knee replacement is a fixed bearing, cemented unicompartmenal knee replacement. There are currently no published reports of follow up for the PFC Sigma medial unicompartmental knee replacement.

Nineteen patients (nineteen knees) underwent PFC sigma medial unicompartmental knee arthroplasty. The pre-operative diagnosis was osteoarthritis in eighteen patients and osteonecrosis in one patient. There were ten males and nine females with a mean age of sixty four years. All patients had clinical and radiological review at one year. All operations were carried out by the two senior authors (BPR and BL).

The mean length of admission was 2.7 days (Range 2–5). There have been no infective or thromboembolic complications to date. The mean oxford scores improved from 41 (Range 26–52) pre-operatively to 18 (15–27) at one year follow-up. The mean range of motion improved from 115 degrees of flexion preoperatively to 125 degrees. All radiographs were satisfactory at one year follow up with no evidence of loosening.

We report the promising early results of a new medial unicompartmental knee replacement with at least one year follow up. No early complications or infections were identified in our cohort of patients.

Current knowledge regarding upper limb myotomes is based on historic papers. Recent advances in magnetic resonance imaging (MRI) and surgical exploration with intraoperative nerve stimulation now allow accurate identification of nerve root injuries in the brachial plexus. The aim of this study is to identify the myotome values of the upper limb associated with defined supraclvicular brachial plexus injuries.

57 patients with partial supraclavicular brachial plexus injuries were identified from the Scottish brachial plexus database. The average age was 28 years and most injuries secondary to motor cycle accidents or stabbings. The operative and MRI findings for each patient were checked to establish the root injuries and the muscle powers of the upper limb documented.

The main patterns of injuries identified involved (C5,6), (C5,6,7), (C5,6,7,8) and (C8, T1). C5, 6 injuries were associated with loss of shoulder abduction, external rotation and elbow flexion. In 30% of the 16 cases showed some biceps action from the C7 root. C5,6,7 injuries showed a similar pattern of weakness with the additional loss of flexor carpi radialis and weakness but not total paralysis of triceps in 85% of cases. C5,6,7,8 injuries were characterised by loss of pectoralis major, lattisimus dorsi, triceps, wrist extension, finger extension and as well as weakness of the ulnar intrinsic muscles. We identified weakness of the flexor digitorum profundus to the ulnar sided digits in 83% of cases. T1 has a major input to innervation of flexors of the radial digits and thumb, as well as intrinsics.

This is the largest study of myotome values in patients with surgically or radiologically confirmed injuries in the literature and presents information for general orthopaedic surgeons dealing with trauma patients for the differentiation of different patterns of brachial plexus injuries. In addition we have identified new anatomical relationships not previously described in upper limb myotomes.

Obtaining accurate bone cuts based on mechanical axes and ligament balancing, are necessary for a successful total knee procedure. The Orthosensor Tibial Trial displays on a GUI the magnitude and location of the lateral and medial contact forces at surgery. The goal of this study was to develop the algorithms to inform the surgeon which bone cuts or soft tissue releases were necessary to achieve balancing, from an initial unbalanced state.

A rig was designed for lower body specimens mounted on a standard operating table. Surgical Tests were then defined: Sag Test, leg supported at the foot; Dynamic Heel Push test, flexing to 120 degrees with the foot sliding along a rail; Varus-Valgus test; AP Drawer test; Internal-External Rotation test. The bone cuts were made using a Navigation system, to match the Triathlon PCL retaining knee. To determine the initial thickness of the tibial trial, the Sag Test was performed to reach 0 deg flexion. The Heel Push Test was then performed to check the AP position of the lateral and medial contacts, from which the rotational position of the tibial tray was determined. Pins were used to reproduce this position during the experiments.

Surgical Variables were then defined, which would influence the balancing: LCL Stiffness, MCL Stiffness, Distal Femoral Cut Level, Tibial Sagittal Slope, Tibial Varus or Valgus, and AP Femoral Component Length. Balancing was defined as equal lateral and medial forces due to soft tissue tensions throughout the flexion range, equal varus and valgus stiffnesses, and no contacts closer than 10mm to component edges. All of the above tests were then performed sequentially, and the changes in the contact force readings were considered as a signature of that Surgical Variable.

In an actual surgical case, having obtained readings from the Surgical Tests, the data will be compared with the signatures of the Surgical Variables. This will then identify the Variable which needed correction. The Surgical Tests will be repeated and the readings should be closer to balanced. Further correction of another Variable is carried out if necessary. In early clinical cases, it was found that this method allowed for identification of how to reach a balanced state, and achieved soft tissue balancing in a quantitative way.

The number of revision knee arthroplasties performed is projected to rise dramatically in the coming years. Primary knee arthroplasties are also being performed in younger patients increasing the likelihood of multiple revision procedures. Reconstruction can be challenging with bone stock deficiencies and ligament incompetence. The aim of this study was to present our results of revision total knee arthroplasty using metaphyseal sleeve components to aid reconstruction.

Sixty seven patients underwent revision total knee arthroplasty between September 2005 and November 2010 using metaphyseal sleeves. There were thirty one male and thirty six female patients. The indication for revision was aseptic loosening in thirty nine, sepsis in fifteen, malalignment in eight and instability in five patients. Thirty four patients had tibial sleeves, thirty patients had both tibial and femoral sleeves and three patients had femoral sleeves during revision.

The patients were followed up for a mean of 32 months (Range 12–60) with outcome data collected prospectively. The mean revised oxford knee scores for the patients improved from 15 (Range 2 to 29) preoperatively to 33 (Range 20 to 45) postoperatively. Mean arc of flexion following revision was 87 degrees (Range 55 to 120). Seventy six percent of patients were satisfied or very satisfied with the result of the revision surgery. There have been no radiographic complications specific to the sleeves and no re-operations. There has been one recurrence of infection in a patient revised for sepsis. This has been managed with suppressive antibiotics due to patient co-morbidities.

Metaphyseal sleeves are an effective adjunct in revision knee arthroplasty. We have had good results with their use. To our knowledge no larger series has been presented or published.

To collate and present epidemiological data collected by Scottish National Brachial Injury Service over the past decade.

The Brachial Plexus Injury Service is based at the Victoria Infirmary, Glasgow and has been a designated National Service since 2004. It provides an integrated multidisciplinary service for traumatic brachial plexus injury and plexus tumours. The Service maintains an active archive recording details of all clinical referrals and procedures conducted by the Service over the past decade. The data presented here was derived from analysis of this database and information contained in the National Brachial Plexus Injury Service Annual Report 2010/11 & 2011/12.

Data shows that there has been a steady rate in the number of referrals to the Service, particularly since 2004, with an average of 50 cases referred per annum. Of these, approximately 25% required formal surgical exploration for traumatic injury and a further 10% required surgery for brachial plexus tumour removal. The vast majority of referred cases are treated non-operatively, with appropriate support from specialist physiotherapy and occupational therapy. Referrals to the Service appear well distributed from around Scotland. However, data from 2011 shows that Greater Glasgow & Clyde is the greatest individual source of referrals and subsequent hospital admissions for surgical treatment. The commonest mechanism of brachial plexus injury appears to be secondary to falls and motorcycle RTA. Using the Disabilities of the Arm, Shoulder and Hand (DASH) Score, improved functional outcomes have been demonstrated consistently in patients who have undergone surgery for brachial plexus injuries within the Service.

Over the past decade, the Brachial Plexus Injury Service has had a steady patient referral record from across the Scotland, particularly Glasgow. Data indicates that there is an on-going clinical need for provision of the service with improved outcomes and reduced functional disability in patients treated by the service. It is envisaged that data from the Service will also act as a useful planning model for the provision of UK national services in the future.

Aim

The Pelvic Support Osteotomy (PSO) or Ilizarov Hip Reconstruction(IHR) is well described for the treatment of septic sequelae of infancy. The purpose of this study was to clinically, functionally and radiographically assess our short-term results of this procedure.

The Pelvic Support Osteotomy (PSO) or Ilizarov Hip Reconstruction(IHR) is well described for the treatment of septic sequelae of infancy. The purpose of this study was to clinically, functionally and radiographically assess our short-term results of this procedure.

25 patients (16 boys, 9 girls) who had undergone a IHR using the Ilizarov/TSF construct over a period of 10 years for a variety of pathologies were reviewed. The mean age at surgery was 15 years 4 months. The pre-operative diagnoses were SCFE(10), hip sepsis (6), DDH (6) and Perthes (3). All had significant leg length discrepancies, 16 had a painful stiff hip, 6 had a painful mobile hip and 3 had a painless unstable hip. At surgery, a mean measured proximal valgus angle of 51° and a mean extension angle of 15° was achieved. Distal femoral lengthening averaged 4.2 cm and distal varus correction was a mean of 8°. The mean fixator time was 173 days.

At a mean of 2 years and 7 months follow-up the lower-extremity length discrepancy had improved from a mean of 5.6 cm apparent shortening to 2.3 cm. Trendelenberg sign was eliminated in 18/25 cases. Improvements in range of hip movements and gait parameters were observed. Stance time asymmetry, step length asymmetry, pelvic dip and trunk lurch improved significantly. One patient had conversion to a total hip replacement after 7 years, 4 patients required re-do PSO due to remodelling of the proximal osteotomies, two had heterotopic ossification and two had significant knee stiffness due to lack of compliance.

The early results of IHR are encouraging to equalise limb lengths, negate trendelenburg gait, provide a mobile hip with a reasonable axis and the possibility of conversion to THR in the future if needed. Complications need to be anticipated and the effects of remodelling and maintaining adequate knee range of motion must be emphasised.

Background

The surgical management of musculoskeletal tumours is a challenging problem, particularly in pelvic and diaphyseal tumour resection where accurate determination of bony transection points is extremely important to optimise oncologic, functional and reconstructive options. The use of computer assisted navigation in these cases could improve surgical precision.

Purpose

Tenodesis of the long head of biceps is an established technique for management of biceps pathology including tears, instability, and chronic tendinosis intractable to non-operative management. Very few studies have reported on clinical outcomes of all-arthroscopic, non-interference, biceps tenodesis techniques. The purpose of this study is to evaluate the functional and quality of life outcomes of patients treated with an all-arthroscopic biceps tenodesis with a suture anchor.

Introduction

Bony tumours of the foot account for approximately 3% of all osseous tumours. However, literature regarding os calcis and talar tumours comprises individual case reports, short case series or literature reviews with no recent large series.

Arthordesis of small joints of the foot is a commonly performed procedure in orthopaedics. A variety of fixation devices have been used for this purpose. Nickel-Titanium Memory compression staples for arthrodesis have been used in our institute since June 2003. We report the results of the procedure over a period of 7years involving 252 feet in 232 consecutive patients who underwent arthrodesis or an osteotomy fixation using compression staples. The patients were evaluated to determine the period of immobilization in cast and the time to radiographic joint fusion.

The emphasis of this study was to validate the safety of the implant for fusion of small joints of the foot, as well as to determine whether there is a demonstrable trend in time to fusion and period of immobilization required.

The average time to fusion was 7.2 weeks, the average period of immobilisation was 6.5 weeks. Successful union was achieved in 98% cases. We report the follow up results, finer technical aspects of the procedure and pitfalls to avoid whilst performing the fusions.

Introduction

In an ageing population the incidence of patients sustaining a neck of femur fracture is likely to rise. Whilst the neck of femur fracture is thought to be a pre-terminal event in many patients, there is little literature following this common fracture beyond 1 year. With improving healthcare and increasing survival rate, it is likely that a proportion of patients live to have subsequent fractures. However little is known about if these occur and what the epidemiology of these fractures are.

Purpose

Controversy exists regarding the optimal technique for arthroscopic rotator cuff repair. The purpose of this multicentre randomized double-blind controlled study was to compare the functional outcomes and healing rates of double-row suture techniques with single row repair.

The purpose of this study was to determine if the use of a new 4 Dimensional CT scan aids the clinician in defining the size and area of the scapular bone to be removed arthroscopically in patients with Snapping Scapular Syndrome.

From January 2009 – January 2011 nine consecutive patients with Snapping Scapular Syndrome were included. In six patients, (mean age 21±5 years, range 15–27) conservative treatment failed. These patients were positioned prone and demonstrated their snapping motion during the 7 seconds duration of the scan. The 4D CT machine scans 16 cm volumes in 0.3 seconds. It also scans motion, allowing a 3D reconstruction of the scapulothoracic joint, its’ movements and the dynamic area of impingement of the scapula on the surrounding structures. This scan has already improved arthroscopic removal of the supero-medial angle of the scapula.

The scan showed in one case not only snapping of the superior medial angle of the scapula on the 2nd rib, but also extra bone impinging on the 3rd rib. Another case showed no real impingement but movement of the 2nd and 3rd rib by a tethering structure and a third case demonstrated impingement of the lateral third of the clavicle on the 2nd rib.

The images provided by this new 4D CT scan offer greater pre-operative insight on the pathology in each individual patient with Snapping Scapular Syndrome. Therefore, we feel that it is a valuable addition to the assessment and treatment of these patients.

Purpose

Controversy exists regarding the optimal technique of subscapularis mobilization during shoulder arthroplasty. The purpose of this multicentre randomized double-blind study was to compare the functional outcomes and healing rates of the lesser tuberosity osteotomy (LTO) to the subscapularis tenotomy (ST).

Introduction

Total knee arthroplasty is an established and successful operation. In up to 10% of patients who undergo total knee arthroplasty continue to complain of pain [1]. Recently computerised tomography (CT) has been used to assess the rotational profile of both the tibial and femoral components in painful total knee arthroplasty.

Purpose

An open superior capsular shift is a well-established technique for the management of patients with multidirectional shoulder laxity and the absence of a Bankart lesion. Few studies have reported on functional and quality of life outcomes using arthroscopic technique for shoulder stabilization using superior capsular shift in patients with no Bankart lesion. The purpose of this study was to assess the functional and quality of life outcome scores following shoulder stabilization with a selective arthroscopic superior capsular shift with suture anchors, for treatment of multidirectional laxity and the absence of a Bankart lesion.

The purpose of this study was to determine the motion pattern of the Acromio-Clavicular (AC) joint in a normal shoulder with the use of the new 4 Dimensional CT scan.

From April 2010 till January 2011 fourteen healthy volunteers (4 female, 10 male)(mean age 42±11 years) with no previous history of shoulder complaints participated in this study. The 4D CT machine scans motion, allowing a 3D reconstruction of the shoulder joint and its movements. Patients were positioned supine with their arm elevated 90° in the sagittal plane. During the 7 seconds duration of the scan they adducted their arm at that level and then elevated their arm upwards resisted by the gantry for 4 seconds, in this way simulating the clinical Bell-van Riet test for AC pathology.

In the transverse plane the mean AC joint space measured in the neutral position is 1.8±0.5 mm. While adducting the arm the AC joint narrows 0.0±0.4 mm (with a positive value being narrowing and a negative value widening). On resisted elevation the joint space is narrowed 0.2±0.6 mm. The mean antero-posterior (AP) translation in this same plane is 0.2±2.2 mm on adduction (with a positive value being posterior translation of the clavicle and a negative value anterior translation) and 0.4±2.9 mm on resisted elevation.

The new 4D CT scan demonstrates that the AC joint in a normal shoulder mainly translates in an AP direction, rather than being narrowed or widened, when the arm is adducted (with or without resisted active elevation).

Introduction

Bony tumours of foot account for approximately 3% of osseous tumours. However, literature regarding calcaneal tumours comprises individual case reports, short case series or literature reviews, with last large case series in 1973. Literature on bony tumours of the talus is limited to case reports only.