The current standard of care in Calgary, Alberta for management of a ruptured Achilles tendon is surgical repair, typically performed following admission to hospital. The primary objective of this study was to compare the costs of hospital treatment and complications associated with the surgical repair of Achilles tendon ruptures between two groups of patients: Group One = patients enrolled in the randomised clinical trial (RCT) Multicentre Achilles Tendon Treatment Study (MATTS), Group Two = all other non-study patients.

This observational cohort study analyzed all patients surgically treated for Achilles tendon ruptures at Calgary area hospitals over a three-year period (October 2002–September 2005). Inclusion criteria: age eighteen to seventy years, acute rupture.

A total of two hundred and eighty-two patients met the inclusion criteria; thirty-three patients were included in Group One, two hundred and forty-nine patients in Group Two. In Group One, twenty-seven patients (82%) were treated as outpatients, five patients (15%) were ADOP-24hr, and one patient (3%) was admitted. In Group Two, twenty-seven patients (11%) were treated as outpatients, ninety-five patients (38%) were ADOP-24hr, and one hundred and twenty-seven patients (51%) were admitted. The total costs for patients treated as outpatients and requiring overnight stays in Group One were $18,408 and $7,419, respectively. In Group Two, the total cost for outpatients was $18,071 compared to $379,496 for non-study patients requiring overnight stay. If all overnight patients in each group were treated as outpatients, the total savings would be $235,545. There were no serious complications in Group One. In Group Two, complications included two cases of pulmonary embolus, and one case of compartment syndrome requiring readmission. All complications resolved.

Surgical treatment of Achilles tendon rupture can be performed safely and at less cost on an outpatient basis. Participation in this RCT has allowed us to recommend a change in the standard of care in Calgary.

Intramedullary Nailing is now accepted as the standard treatment for most femoral diaphyseal fractures. Most intramedullary nails are designed for proximal and distal locking with screws. We describe our experience with the Brooker Wills femoral nail. This nail is unique as distal fixation is achieved with as transverse fixator deployed through slots in the nail, a concept first enunciated by deCamargo in 1952. The fins of the fixator pierce the distal cortex when deployed thereby conferring rotational stability. The entire nail (including the proximal and distal fixation devices) can be inserted through a single proximal incision in the skin.

We treated 17 patients with femoral shaft fractures using this system. 93% of the patients were males. Motor vehicle accidents accounted for 80 % of the fractures. Most fractures involved the middle third of the femur (54%), followed by distal third (33%) and proximal third (13%). 67 % of the fractures showed Winquist and Hansen Grade 3 or 4 comminution.

All the nailings were performed in the supine position. Static locking was done in 16 cases. Post operative weight bearing was individualized with 86% of the patients bearing full weight before the end of 16 weeks. The average time to full weight bearing was 14 weeks.

The mean time to union was 17.1 weeks, with proximal, middle and distal third fractures showing average healing times of 19, 15.6 and 18.8 weeks respectively. All the fractures united. There was one case of delayed union. Intra-operative complications included–inability to deploy the distal fixator in one case and unwinding of the reamer in another case. There was one case of superficial infection where a patient developed a sinus over the metallic fin of the distal fixation device, which had penetrated the cortex. This healed after the distal fixation device was removed. There was one case of proximal nail migration, but the fracture went onto union with some limb shortening.

Results were evaluated using the scoring system devised by Sanders etal (1991). The functional criteria in their scoring system include- knee flexion, presence of pain, femur deformity, walking distance, stair climbing and pre injury functional status. We achieved excellent results in 53% of patients, good- 27%, fair–13 % and poor-7%.

We feel that the main advantage of the Brooker Wills Nail is the ease of distal locking. This saves time and also leads to lower level of radiation exposure, as the image intensifier is sparingly used for distal locking. In fact, this nail is an attractive option in centres which lack an image intensifier. We achieved good results with this nailing system and feel that it is an acceptable alternative to other nailing systems with conventional locking systems with screws.

Introduction and aims: Soft tissue defects after total knee arthroplasty (TKA) are difficult problems to treat. Flap surgery has been successful in salvaging the prostheses. We present results of flap surgery for exposed TKAs over a 10 year period performed by single surgeon.

Material and Methods: Between 1996 and 2005, 31 patients (32 knees) underwent flap surgeries for TKAs. Four of these procedures were done prophylactically in patients with previous knee surgeries. Gastrocnemius, medial fasciocutaneous and anterior compartment flaps were used either solely or in combination based on the size of the defect. The data was collected retrospectively from case-notes and correspondence from the treating orthopaedic surgeons.

Results: The patients were aged between 50 and 94 years. Indication for primary TKA was osteoarthritis in 25 patients and rheumatoid arthritis in 5. Coagulase negative Staph. aureus was the most commonly isolated organism. In patients using steroids, 4 of 6 (71.4%) knees had good or satisfactory outcome compared to 22 of 24 (91.7%) knees in patients not on steroids. Smoking did not influence the outcome of flap surgery . The average duration between the TKA and flap surgery was 11 weeks (range 1 – 52). Successful soft tissue cover was achieved in 30 of 32 knees (94%). Overall, TKA was salvaged in 20 of 28 knees (71.4%) knees, 3 knees (9.7%) underwent arthrodesis and above knee amputation was performed in 4 (12.4%). The information gathered from case notes and orthopaedic surgeons was insufficient to use a knee score for evaluating the functional outcome of the procedure.

Conclusion: Local flap surgery for providing soft tissue cover for exposed TKA is a viable and successful procedure with good results.

The aim of this randomised, controlled trial is to compare subacromial steroid injections, physiotherapy and both interventions with a control treatment in early painful arc of the shoulder.

Over a six-month period patients with “painful arc”, of less than six months duration, were recruited via their GPs. Eligible patients were consented to enter the trial and were then randomised, by sealed envelopes, to one of four arms of the study: control (normal analgesia and/or non-steroidal anti-inflammatory medication), a specified and repeatable Exercise and Manual Therapy Package (EMTP), a course of up to three subacromial steroid injections or both the EMTP and the steroid injections. The interventions and clinic follow-ups were over an 18-week period. A final postal questionnaire was sent out at one year. The progress of the patients was monitored using the Oxford Shoulder Score (OSS) and the SF36 general health questionnaire.

Seventy-nine GPs referred 186 patients, of whom 112 were randomised (Control=27, EMTP=29, Injections=28, Both=28). 64 patients were female and 48 male. The mean age was 54.5 years (range 23–88 years). Ninety patients completed the trial (Control=20, EMTP=22, Injections=26, Both=22). Sixty-two returned the follow-up questionnaire. By paired sample t-tests, no significant differences were found between the OSS scores or SF-36 (physical health total) at the beginning and end of the intervention period, or at one year. Two patients in the injection group went on to surgery, along with one each in the control and EMTP groups.

We have found no significant differences in outcome between steroid injections, a physiotherapy package, both treatments, or symptomatic treatment in our group of patients presenting with symptoms of painful arc of the shoulder.

Background: Each year, 7% of the adult population consult their General Practitioner (GP) with low back pain (LBP). Approximately half of these patients still experience disabling pain after three months. Evidence suggests a biopsychosocial approach may be effective at reducing long-term pain and disability. This study aimed to evaluate, for persistent disabling LBP, the effectiveness of an exercise, education and cognitive behavioural therapy intervention compared to usual GP care plus educational material, and to investigate the effect of patient preference.

Method: Design: randomised controlled trial. Patients, aged 18–65yrs, consulting their GP with LBP were recruited. After 3 months those still reporting disabling LBP (≥20mm on 100mm pain visual analogue scale (VAS) and ≥5 Roland and Morris Disability Questionnaire (RMDQ) points) were randomised, having first established preference, to 2 groups. VAS and RMDQ were assessed at 0, 6, and 12-months post-intervention.

Results: 234 patients were randomised; 116 to the intervention. The intervention showed small non-significant effects at reducing pain (3.6mm) and disability (0.6points RMDQ) over one year. Preference showed significant interaction with treatment effect at one-year; patients had better outcomes if they received their preferred treatment.

Conclusion: The above intervention program produces only a modest effect in reducing LBP and disability over a one-year period. These results add to accumulating evidence that interventions for LBP produce, at best, only moderate benefits. The challenge for future research is to evaluate interventions tailored for specific LBP sub-populations. These results suggest that if patients receive treatment which they believe is beneficial their outcome can be optimised.

Introduction: Shoulder pain represents a significant burden of disease in the general population, yet there is a lack of evidence about the effectiveness of routinely used interventions such as corticosteroid injection and physiotherapy.

Methods: Over a six-month period patients with “painful arc” of less than six months duration were recruited via their GPs.

Eligible patients randomised to one of four arms of the study: control (normal analgesia and/or non-steroidal anti-inflammatory medication), a specified and repeatable Exercise and Manual Therapy Package (EMTP), a course of up to three subacromial steroid injections or both the EMTP and the steroid injections. Follow-up was for 18 weeks, with postal questionnaire at one year.

The primary outcome measure was the Oxford Shoulder Score (OSS).

Results: 186 patients were referred, 112 were randomised. Mean age was 54.5 years. Ninety patients completed the trial. Sixty-two returned the follow-up questionnaire.

By analysis of covariance, no significant differences were found between the OSS scores or SF-36 (physical health total) at the beginning and end of the trial, or at one year. Two patients in the injection group went on to surgery, along with one each in the control and EMTP groups. No significant differences were found between treatment groups.

Conclusion: We have found no significant differences in outcome between steroid injections, physiotherapy, both treatments, and symptomatic treatment in a group of patients with early painful arc of the shoulder. Further, larger studies may be needed to find small differences in outcome between these treatments.

The mechanism by which cells die is important in an immune response and its resolution. The role of apoptosis in sepsis and trauma, and its regulation by cytokines is unclear. During the systemic inflammatory response, rates of human neutrophil apoptosis are decreased. Peritoneal macrophage apoptosis has been induced by nitric oxide and Lipopolysaccharide (LPS) in vitro but this has not as yet been demonstrated in vivo.

We examined the induction and effects of macrophage apoptosis in a model of trauma and sepsis.

One hundred female CD-I mice were randomised into four groups: Control, Septic model, challenged with intraperitoneal LPS (1.Img/200ul/mouse), Traumatic model, received hind limb amputation (HLA) and a Combined trauma/septic model. After 24 hrs mice were sacrificed and peritoneal macrophages were assessed for apoptosis by morphology and DNA fragmentation by flow cytometry and DNA gel electrophoresis

Peritoneal lavage from septic models had a decreased percentage of macrophages in comparison to control and trauma groups. The septic model also had a significantly increased incidence of apoptosis in comparison to control and trauma levels. There was no significant difference between control and traumatic groups.

These findings demonstrate that in a murine model of sepsis, lipopolysaccharide induces macrophages apoptosis. Modulation of this immune response may have important roles in the management of trauma patients.

Aseptic loosening is the single most important long-term complication of total joint arthroplasty. Wear debris induced inflammation stimulates osteoclastic resorption of bone. Cellular mechanisms involved in osteoblast viability in PWD induced inflammation is poorly understood.

Wear induced inflammation increases osteoblast necrosis and susceptibility to death by apoptosis. PMMA cement has a detrimental effect on osteoblast resistance to apoptosis, and that this is via an receptor mediated pathway. Osteoblast cell cultures (Human and MG63) were grown with and without PMMA cement and assessed for apoptosis and necrosis. TNF-α or Fas antibody simulated inflammation. Viability and apoptosis with PI exclusion, flow cytometry and western blotting assessed response.

Cement induced osteoblast necrosis up to 1 hour. This effect was negated after 24 hours. Culture of osteob1asts on cement had no direct effect on spontaneous apoptosis but susceptibility to inflammation was increased.

Polymerised cement has no direct effect on osteoblast cell death. Effects are mediated by inhibiting expression of anti-apoptotic protein (Bcl-2), and increasing susceptibility to inflammatory. Osteoblast resistance to death may represent a novel and important factor in aseptic loosening. The role of gene therapy is explored.

Increased bone turnover and fracture healing is associated with acute spinal cord injuries. Experimental work to date has been confined to animal models. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi.

This paper evaluates two groups of patients with spinal column fractures – those with neurological compromise and those without, and compares them with a control group with isolated long bone fractures. Serum was taken from these patients at 10 days post injury and was analysed for the known osteogenic cytokines Insulin-like Growth Factor-1 (IGF-1) and Transforming Growth Factor-b1 (TGF-b1) as well as being added to an osteoblast cell culture line to analyse cell proliferation.

The results for the IGF-1 show a higher level in the neurology group compared to the no neurology group (p=0.038). In the TGF-B1 assay, the neurology group has a lower level than the other two groups (p< 0.0001 and p=0.002 respectively). However, when this group is subdivided into patients with complete and incomplete neurology, it can be seen that the levels of the complete group are elevated, although not significantly so (p=0.228).

All three groups stimulated markedly increased osteoblast cell proliferation versus a control group (p=0.086, p=0.005 and p=0.002 respectively). However, the neurology group is significantly lower than the other two groups (p=0.007 and p=0.001 respectively). Furthermore the complete group causes a lower proliferation rate than the incomplete group (p=0.539).

In conclusion, at 10 days post injury when the acute inflammatory reaction is subsiding and new bone is being laid down, patients with acute spinal cord injuries have increased bone turnover. This increase is being indirectly mediated by IGF-1, and more elevated levels with more severe neurological compromise suggest a contributory role of TGF-b1. Direct stimulation of osteoblasts does not appear to have any role to play in this accelerated bone healing.

Patients with spinal cord injuries have been seen to have increased healing of attendant fractures. This for the main has been a clinical observation with laboratory work confined to rats. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear.

This paper evaluates two groups with spinal column fractures – those with neurological compromise (n=10) and those without (n=11), and compares them with a control group with isolated long bone fractures (n=10). Serum was taken from these patients at five specific time intervals post injury (1 day, 5 days, 10 days, 42 days (6 weeks) and 84 days(12 weeks)). These samples were then analysed for levels of Transforming Growth Factor-Beta (TGF-b) using the ELISA technique. This cytokine has been shown to stimulate bone formation after both topical and systemic administration.

Results show TGF-b levels of 142.79+/−29.51 ng/ml in the neurology group at 84 days post injury. This is higher than any of the other time points within this group (p< 0.001 vs. day 1, day 5 and day 10 and p=0.005 vs. 42 days, ANOVA univariate analysis). Furthermore, this level is also higher than the levels recorded in the no neurology (103.51+/−36.81 ng/ml) and long bone (102.28=/−47.58 ng/ml) groups at 84 days post injury (p=0.011 and p=0.021 respectively, ANOVA univariate analysis). There was statistically significant difference in TGF-b levels seen between the clinically more severely injured patients i.e. complete neurological deficit and the less severely injured patients i.e. incomplete neurological deficit.

In conclusion, the results of this work, carried out for the first time in humans, offers strong evidence of the causative role of TGF-b in the increased bone turnover and attendant complications seen in patients with acute spinal cord injuries.

Introduction: Historically, it has been accepted that the pain associated with arthritis of the hip is usually located in the groin, anterior and lateral thigh with occasional radiation to the anterior knee. Patients complaining of thigh pain that extends below the knee are often considered to have a degenerative lumbar spine as the cause for their lower limb symptoms and total hip replacement (THR) may not be offered.

Following review of data regarding the preoperative distribution of pain in 2000 patients attending for hip replacement, it was noted that 40% of these patients had complained of pain at or below the knee.

We proposed to prospectively investigate the severity and location of pain in patients attending for THR and assessed how this distribution of pain altered following surgery. We also proposed to examine the distribution of radiological wear preoperatively and assess if there is any relationship between localisation of pain, and the severity or distribution of the radiological wear pattern.

Methods: 200 consecutive patients undergoing primary THR completed a questionnaire regarding the location and severity of their pain. Pain was localised to one or more of nine areas extending from low back to the foot. The localisation of pain was quantified as to severity using a visual analogue score. Questionnaires were completed both 4 weeks preoperatively and subsequently at a 3-month review clinic.

All patients underwent a standardised preoperative AP and Lateral x-ray. The AP film was divided into three areas, and the lateral film was divided into 5 areas. Each zone was assessed as to the severity of wear pattern and graded from 1–3 (no change in joint space, decreased joint space, femoral or acetabular destruction).

Results: The 200 patients complained of pain in a total of 980 areas preoperatively and 105 areas postoperative. 70% of the patients had complete relief of all pain at 3 months. The most common area of pain identified by patients was to the anterior aspect of the knee (82%), followed by pain at the greater trochanter and groin. 55% patients complained of pain extending to below the knee, mostly over the anterolateral aspect of the leg. Only 7% of these patients continued to complain of any below knee pain postoperatively, and all of these patients still had some relief of their below knee pain at review.

With regard to the frequencies and severity of x-ray changes, zone-1 (34%) was most commonly severely damaged with femoral and/or acetabular destruction in the AP film, with the anterior and anterolateral areas being most commonly affected areas in the lateral film (20% and 19% respectively).

When the distributions and severities of x-ray changes were correlated with the distribution of pain localised pre and postoperatively we were unable to show any association between the degree of radiological wear in any one zone and the locatin of pain identified by the patient. In fact, there was a normal distribution to the severity of radiological damage between each of the zones and localisation of pain in any of the 9 areas.

Conclusions: A significant number of patients who require hip arthroplasty have pain extending below the knee. This pain is frequently relieved following THR. The commonest area of sever hip joint wear with loss of femoral or acetabular bone is antero-superiorly. It is important to recognise this during surgery, such that action can be taken to ensure appropriate reaming such that subsequent correct tissue tension and leg lengths are achieved. We are unable to show any relationship between area of pain and area of radiological degeneration. We believe that patients who complain of pain in their back, buttock or thigh, which extends below the knee, can still benefit from total hip replacement. Patients who attend complaining of low back pain with radiation of pain down their leg should have their hips as well as their lumbar spine examined and imaged. Careful consideration should be taken before labelling the paid as being referred from degenerative back disease.

Patients with spinal cord injuries have been seen to have increased healing of attendant fractures. This for the main has been a clinical observation with laboratory work confined to rats. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear.

This paper evaluates two groups with spinal column fractures – those with neurological compromise (n=10) and those without (n=11), and compares them with a control group with isolated long bone fractures (n=10). Serum was taken from these patients at five specific time intervals post injury (1 day, 5 days, 10 days, 42 days (6 weeks) and 84 days (12 weeks)). These samples were then analysed for levels of Transforming Growth Factor-Beta (TGF-ß) using the ELISA technique. This cytokine has been shown to stimulate bone formation after both topical and systemic administration.

Results show TGF-ß levels of 142.79+/−29.51 ng/ml in the neurology group at 84 days post injury. This is higher than any of the other time points within this group (p< 0.001 vs day 1, day 5 and day 10 and p=0.005 vs 42 days, ANOVA univariate analysis). Furthermore, this level is also higher than the levels recorded in the non neurology (103.51+/−36.81 ng/ml) and long bone (102.28=/−47.58 ng/ml) groups at 84 days post injury (p=0.011 and p=0.021 respectively, ANOVA univariate analysis). There was statistically significant difference in TGF-ß levels seen between the clinically more severely injured patients, ie complete neurological deficit and the less severely injured patients, ie incomplete neurological deficit.

In conclusion, the results of this work, carried out for the first time in humans, offers strong evidence of the causative role of TGF-ß in the increased bone turnover and attendant complications seen in patients with acute spinal cord injuries.

Study Design: The effects of heat on porcine intertvertebral disc were studied experimentally.

Objective: To assess the effects of in-vitro heating of porcine nucleus pulposus on expression of inducible heat shock protein 70 and subsequent modification of biochemical responses to an inflammatory insult in the heated intervertebral disc tissue.

Subjects: Lumbar spines were harvested from six pigs. The nucleus pulposus was dissected from each intervertebral disc, divided into control (37°C) and heat shocked (42°C) groups then cultured in medium for one hour. All samples were then cultured at 37 C for a further two hours. After three hours tissue and supernatant were harvested from one third of the samples and the expression of inducible heat shock protein 70 (HSP70) was quantified via Western immunoblotting and enzyme linked immuno-sorbent assay (ELISA). The remaining samples were cultured either in normal medium or altered (pro-inflammatory) medium containing 5ug/ml bacterial lipopolysaccharide (LPS). At 24 hours the supernatant from these samples was analysed for both interleukin-8 (IL-8) and prostaglandin E2 (PGE2) secretion using ELISA.

Outcome Measures: Western immunoblotting and enzyme linked immuno-sorbent assay (ELISA) for heat shock protein 70. ELISA for interleukin-8 (IL-8) and prostaglandin E2 (PGE2).

Results: HSP70 expression was significantly increased in the heat shocked specimens. IL-8 and PGE2 secretion were significantly increased in nucleus pulposus exposed to LPS at both temperatures. The concentrations of IL-8 and PGE2 secreted in the heat shocked samples were significantly less than controls, particularly after exposure to LPS (p< 0.05, paired students t test).

Conclusions: In vitro heating of porcine nucleus pulposus causes overexpression of HSP70. This heat shock effect can alter aspects of the biochemical response of the intervertebral disc tissue to an inflammatory insult. Intradiscal electrothermal therapy (IDET) may, in theory, reduce discogenic pain at temperatures as low as 42°C by generating similar heat-induced changes in the nuclear biochemistry of degenerate intervertebral discs.

Purpose of the study: To investigate whether video analysis, in addition to self-reported paper audit, could elucidate expected differences in the content of two interventions.

Background: We have completed a randomised clinical trial comparing two types of physiotherapy for subacute low back pain (“hands on” physiotherapy versus a pain management programme). An essential component in conducting clinical trials is to audit the interventions to check for compliance with the protocol. We use two approached:

self complete proforma

Methods: i) Treatment content was recorded on a proforma by the physiotherapists after each session.

ii) A check-list of treatment modalities was constructed from this proforma. Twelve sessions were recorded on video (one new and one review patient for each therapist). The recordings were rated by 3 blinded, independent observers using the checklist. These were compared with the self-report audit forms relating to the same physiotherapy session.

Results: Analysis of the videos showed good levels of agreement (67%) between the 3 observers. Agreement between the video content and paper audit was also good (84%, _ = 0.59). The complete paper audit revealed clear differences between the treatment arms. Patients undergoing the “handson” treatment received manual therapy, whereas patients in the pain management group had specific issues addressed in the course of the consultation.

Conclusions: Feasible, reliable methods of confirming the content of interventions delivered in pragmatic trials are difficult to achieve. Self report paper audits are simple but rely upon the honesty and accuracy of the completer, and may not pick up subtle differences in approach. Video recording is time consuming, may be threatening to the treating practitioner and patient, and is difficult to analyse. A compromise approach involving sample video recordings along with paper self complete audit was able to validate the content of the treatments delivered.

Introduction: The Resurfacing Hip System offers an attractive option for the treatment of arthritis in the young and active patients with gratifying outcome. Currently available Metal-on-Metal Resurfacing Hip Systems in the UK include Cormet 2000 (Corin Medical), the Birmingham Hip (Midland Medical Technologies) and Conserve Plus (Wright Cremascoli) (5). The Cormet 2000 implant design utilises the hybrid principle with an uncemented acetabular and a cemented femoral component. Achieving full seating of the acetabular component in shallow or anatomically deficient sockets can sometimes be technically difficult. On occasion, structural tricortical autografts or allografts are required to obtain a satisfactory positioning of the acetabular component. We describe a simple technique to aid fixation of the uncemented acetabular component in patients with shallow or deficient sockets.

Technical tip: The Cormet acetabular cup is equatorially expanded, resulting in improved stress distribution to the acetabulum. The acetabular component is available as pegless and pegged cup. Both Cormet cups, there are two sets of anti-rotation splines. The original Cormet cup design incorporated two sets of three anti-rotation splines; two long splines with one small spline above. These two sets of fins engage the ischium and pubis snugly. The cup is then firmly impacted in place using the cup introducer.

In shallow or deficient sockets, we describe a simple technique by 180° rotation of the Cormet 2000 metal-on-metal resurfacing pegged acetabular prosthesis. This works by utilising ischio-pubic splines for superolateral socket engagement. We have used this technique in three patients with successful outcome avoiding the need of structural graft augmentation. In one patient, this technique was supplemented with cadaveric allograft.

Conclusion: Rotating the acetabular component 180° in shallow or deficient sockets should be considered as one of the viable option with or without structural augmentation. This works satisfactorily by utilising the ischio-pubic splines for superolateral socket engagement.

Introduction: The incidence of aseptic osteonecrosis is 1.09% to 10.1% following the combination chemotherapy and high dose corticosteroid therapy of acute lymphoblastic leukaemic patients. The treatment of younger patients with advanced avascular necrosis remains controversial. No definite evidence is available yet on the effect of disseminated metal ions on the body. The clinical consequence of systemic absorption of metal degradation products in the causation of leukaemia remains contentious. We describe a 21 year old case with avascular necrosis of the hip joint due to T-Cell Acute Lymphoblastic Leukaemia treated with Metal-on-Metal surface hip arthroplasty with an excellent outcome at 5 year follow-up.

Case report: A 21 year old man presented with painful right hip for a period of four years. The past medical history was significant for T-Cell Acute Lymphoblastic Leukaemia which was treated with high dose corticosteroids and combination chemotherapy. He was diagnosed with avascular necrosis of the right hip and was offered hip replacement. He underwent a metal-on-metal surface hip replacement. The uncemented dual coated 54mm cup and cemented 48mm femoral head (Cormet 2000, Corin Medical) were implanted. Now at 5 years follow up since the surface hip replacement he has an excellent result. His haematological indices remain normal and he remains in remission.

Conclusion: Avascular necrosis of the femoral head is a well-known but rare complication of chemotherapy for leukaemia with a reported incidence ranging from 1 to 10 per cent. Metal-on-metal hip resurfacing arthroplasty is a potentially viable option for younger patients with aseptic osteonecrosis secondary to combination chemotherapy and high dose corticosteroid therapy used in the management of acute lymphoblastic leukaemias. Contrary to the general belief, we found no relapse in the leukaemia with use of metal-on-metal surface hip prosthesis till five years of follow-up.

Background: Evidence-based occupational health guidelines recommend that some form of case-management approach, involving getting ‘all players onside’, should be implemented for control of absence due to back pain; this approach has not been formally tested in the UK.

Methods/Results: A quasi-experimental controlled trial was conducted at selected sites of a large pharmaceutical company in the UK. The experimental intervention, delivered by occupational health nurses working to a guidelines-based protocol, was implemented at two manufacturing sites (n=1,435). Three matched sites acted as controls, delivering management as usual (n=1,483). Absence data were collected for both experimental and control sites for the two years prior to, and the two years during, the intervention period.

The intended early contact (within first week) of workers absent with musculoskeletal disorders only occurred at one experimental site; the control sites had no procedure for early contact. Absence rates improved over the four years at the intervention sites compared with the control sites: a decrease of 2.0 v an increase of 0.9 days/1000 working hours. The median return-to-work time for early intervention compared with controls was 4 days v 5 days (P=NS). Considering return-to-work time irrespective of whether the intervention was delivered early or late, the median durations were also 4 days v 5 days (P< 0.05). When looking at work retention over 12 months, the median duration of subsequent absence for early intervention was 5 days compared with 11 days for controls (P=NS). For the larger number of workers receiving a late intervention, the median duration of subsequent absence was median 4 days v 11 days for controls (P< 0.05).

Conclusion: The data consistently favoured a reduction in absence at the experimental sites, but organisational obstacles (black flags) precluded statistically significant results for early intervention. Implementation of certain guidelines principles (a supportive network with ‘all players onside’) can be effective for reducing absence.

Introduction: Metal-on-metal hip resurfacing arthroplasty is recommended for younger patients with advanced hip disease who are likely to outlive a conventional primary total hip arthroplasty and wish to be reasonably active. Intraoperative or immediate postoperative femoral neck fracture is a well described technical complication as a result of notching and stress shielding of the femoral head. We report two cases of femoral neck fracture incurred eight to fifteen months following the index operation.

Case 1: A 47 year old lady was admitted after sustaining a fall. Radiograph confirmed left femoral neck fracture with resurfacing prosthesis in situ. She underwent metal-on-metal surface hip replacement 15 months ago for advanced osteoarthritis. The periprosthetic fracture was treated by revising the femoral component, using Eurocone cormet modular endo head 44mm size. At one year follow up, she was able to mobilise unassisted and had a good range of movements.

Case 2: A 52 year old gentleman presented with a painful right hip. While walking in the supermarket, he suddenly felt a click in the right hip. Radiograph confirmed right femoral neck fracture with resurfacing prosthesis in place. The metal-on-metal surface hip replacement was performed 8 months previously for advanced avascular necrosis. His medical history was significant for epilepsy. The Femoral component was revised, using Eurocone cormet modular endo head 52mm. He made a satisfactory progress at 18 months follow up since his periprosthetic fracture.

Conclusion: We recommend that patient selection should be given prime importance before embarking on metal on metal surface hip replacement. The surgeons’ factors are meticulous technique in preventing neck notching and femoral head fixation in varus angulation. Revising femoral component, using large head and leaving resurfaced cups in place should be considered as mode of treatment. Large multicentric trials are needed to evaluate the exact incidence of periprosthetic fractures in metal on metal hip resurfacing

Aims: The aim of this study was to investigate the ability of control and degenerate human nucleus pulposis to respond to an exogenous proinßammatory stimulus. Methods: Disc material from patients undergoing surgery for scoliosis, sciatica and low back pain was cultured under basal and lipopolysaccharride (LPS) stimulated conditions using a serumless technique. Levels of IL-1β, TNFα, LTB4, GM-CSF, IL-6, IL-8, MCP-1, PGE2, bFGF and TGFβ-1 in the media were estimated using commercially available enzyme linked immunoabsorbent assay kits. Results: Neither basal nor LPS stimulated control nucleus pulposis (NP) produced detectable levels of IL-1β, TNFα, LTB4 or GM-CSF. LPS induced a significant increase in scoliotic disc IL-8 production, p< .02. LPS induced signiþcant increases in degenerate disc IL-6, IL-8 and PGE2 production, p< .01, p< .001 and p< .005 respectively. LPS signiþcantly increased degenerate disc IL-6, IL-8 and PGE2 production compared to LPS stimulated scoliotic disc, p< .05, p< .02 and p< .003 respectively. Conclusions: Human nucleus pulposus can react to a pro-inßammatory stimulus by secreting IL-6, IL-8 and PGE2, suggesting that the NP may actively participate in the genesis of chemical radiculitis and dis-cogenic back pain.

Background: The influence of psychosocial factors on absence rates is incompletely understood; much research has been cross-sectional, involving a limited range of psychosocial variables. This paper reports a large prospective study of the relationship between psychosocial factors and absence rates due to low back pain across a multi-site UK pharmaceutical company.

Methods/Results: Baseline data were collected from 4,637 workers, and absence data over the ensuing 15 months were obtained from company records. In addition to demographic and historical variables, a wide range of psychosocial variables was included with a focus on occupational psychosocial factors, termed ‘blue flags’. Validated questionnaires were used to quantify job satisfaction, social support, attribution of cause, control over work, and organisation of work, with psychological distress as a ’yellow flag’. 176 workers took absence due to back pain during follow-up.

Previously defined cut-off scores were used to categorise hypothesised risk; scores beyond the cut-off point were considered detrimental, and the ‘flag’ was considered to be ‘flying’. Odds ratios (OR) were calculated to explore the association between the flags and taking sick leave; a statistically significant association was found with ORs between 1.5 and 2.9. The cut-off scores were then used to compare the length of absence between workers who had zero flags flying and those who had one or more flags flying. Absence over the ensuing 15 months was significantly longer for those people who had one or more flags flying (mean 10.6 days compared with 6.1 days, P< 0.05). There was a trend for longer absence with more flags flying.

Conclusion: This prospective study confirms the influence of blue, as well as yellow, psychosocial flags on both the taking of sick leave and the subsequent length of absence. This supports their hypothesised role as obstacles to recovery that might be suitable targets for occupational health interventions.