Introduction. Comparative studies examining Fixed-Bearing (FB) and Mobile-Bearing (MB) Total Ankle Replacement (TAR) designs have demonstrated similar results and successful long-term outcomes for both. To date there has been no study directly comparing FB and MB designs of the same prosthesis. We present the first prospective randomised trial comparing patient satisfaction, functional outcomes and radiographic results of the Salto Talaris Fixed-Bearing and the Salto Mobile-Bearing Total Ankle Replacement in the treatment of end-stage ankle arthritis. Methods. A total of 108 adult patients with end-stage ankle arthritis were enrolled in the study between November 2014 and October 2021 with similar demographic comparison. Prospective patient-reported outcomes and standardised weightbearing ankle radiographs were performed preoperatively, at 6 weeks, 6 months and 12 months post-operatively, followed by yearly intervals. All surgeries were performed by a single non-design orthopaedic foot and ankle specialist with experience in over 200 Salto and Salto Talaris TAR prior to the study. Radiographs were examined independently by two clinicians. Complete patient data and radiographs were available for 103 patients with an average follow up of 2 years. Results. Both groups demonstrated statistically significant improvement from preoperative evaluation to most recent follow up with no statistically significant difference between the two groups in all outcome measures. Radiographic incidence of subchondral cyst formation was 8.9% and 38.2% for FB and MB, respectively. Talar subsidence occurred in 2.2% and 5.5% of FB and MB, respectively. Discussion. Our study demonstrates a higher than previously reported rate of cyst formation in the MB TAR and comparatively higher talar subsidence in the MB TAR vs FB however this did not correlate with clinical outcome measures which were favourable for both groups. Conclusion. Fixed-Bearing and Mobile-Bearing Total Ankle Replacement demonstrate comparable favourable

Although drains date back to the Hippocratic era, their routine use remains controversial in total hip arthroplasty. The literature suggests that they can provide a retrograde route for infection as well as decreasing the organism count required to develop an infection. The use of drains has not decreased the size of wound haematomas at day five on ultrasound or the incidence of massive wound haematomas. Neither have they been shown to significantly decrease wound infections. This consecutive prospective randomised study was designed to evaluate what role drains have in the management of patients undergoing hip arthroplasty. A total of 577 patients undergoing unilateral or bilateral hip arthroplasty were evaluated in a randomised prospective trial of drain versus no drain, between September 1997 and December 2000. All patients had a standardised pre, inter and post operative regime and were independently assessed using the Harris hip score and SF36 pre-operatively, at discharge and at six months post surgery. The superficial and deep infection rate of 6. 4% and 0. 4% was seen in those drained and 7. 1% and 0. 7% in the non-drained group. Only one patient sustained a clinical haematoma that did not requiring drainage or transfusion in the non-drain group. The transfusion rate in those drained was 33. 0% compared to 26. 4% in those not drained. There was no statistical advantage in using a drain P> 0. 05 regarding these variables or in the length of stay, SF36 or Harris hip scores at pre-op and six months. Using a drain did significantly increase the likelihood of requiring a transfusion P< 0. 05. In conclusion drains provide no statistical advantage whilst represent an additional cost and expose hip arthroplasty patients to an unacceptable risk of infection and transfusion

The optimum design for the femoral component for cementless Total Hip Replacement is not known. We conducted an ethically approved, randomised and prospective trial to compare two radically different designs of fully hydroxyapatite (HA) coated femoral stems. We compared the original JRI Furlong stem with the Wright Anca fit stem which is more anatomical in design. The paper discusses the merits and disadvantages of these two stems. The same acetabular component was used in both samples. The only variable was the stem shape. All patients placed on the senior author's waiting list for primary THR were asked if they would enter the trial. There were no restrictions for selection to the sample. Patients were then randomised for one of the two stems. All surgery was performed by or under the direct supervision of the senior author. The periprosthetic and perioperative fracture rates for the two stems were found to be significantly different at three years into the study and the trial was stopped. 337 patients had been entered into the trial, 211 females and 126 males. 191 patients had the JRI furlong hip implanted (57%) and 146 are in the Anca sample (43%). The number of perioperative fractures in the Furlong group was 13 (6.8%)and in the Anca sample 22 (15.1%). This is statistically significant. The possible reasons for this difference are discussed. Anatomical fit cementless stems require a more careful technique to avoid fracture during implantation and the shorter stemmed Anca hip proved less stable in the presence of a fracture necessitating further surgical intervention. It is still not certain whether the anatomical shape has long term advantages that may outweigh this initial disadvantage and the cohort of patients continues to be followed up

The optimum design for the femoral component for cementless Total Hip Replacement is not known. We conducted an ethically approved, randomized and prospective trial to compare two radically different designs of fully hydroxyapatite(HA) coated femoral stems. We compared the original JRI Furlong stem with the Wright Anca fit stem which is more anatomical in design. The paper discusses the merits and disadvantages of these two stems. The same acetabular component was used in both samples. The only variable was the stem shape. All patients placed on the senior authors’ waiting list for primary THR were asked if they would enter the trial. There were no restrictions for selection to the sample. Patients were then randomised for one of the two stems. The surgery was undertaken by one surgeon, in one centre, in matched patients and using the same well-tried CSF acetabular cup and bearings. 335 patients had been entered into the trial, 228 females and 126 males. 191 patients had the JRI furlong hip implanted (57%) and 146 are in the Anca sample (43%). The number of perioperative fractures in the Furlong group was 13(6.8%)and in the Anca sample 22 (15.3%). The periprosthetic and perioperative fracture rates for the two stems were found to be significantly different at three years into the study and the trial was stopped. The possible reasons for this difference are discussed

To assess if highly cross-linked polyethylene is associated with less linear wear than ultra high molecular weight polyethylene in vivo. To assess whether alteration in biomechanical characteristics of the reconstructed hip influence’s wear patterns. A randomised prospective trial comparing conventional polyethylene with highly cross-linked polyethylene in an acetabular component was designed. Identical cemented stems were used in all cases, with a metal head. The polyethylene thickness was controlled. The trial design required 124 cases to be entered to give the study sufficient power to determine any difference in wear rates. Polyware Auto was used to assess 2D wear rate and volume. This paper presents the preliminary results of the early patients entered into the study and looks at both 2D wear or creep at 18 months post operatively, and seeks to establish any relationships between 2D movement and biomechanical characteristics of the reconstructed hip. There was no significant difference in the 2D wear (or creep) between the two types of polyethylene at 18 months. There was no correlation between femoral offset, cup offset, or centre of rotation offset and 2D wear (or creep). This preliminary data shows no difference in the early wear rate of the two types of polyethylene. This is in contrast to an in vitro wear simulator study that has shown more creep in highly cross-linked polyethylene. The significance of this observation is unclear. We hope to demonstrate that as the trial progresses any difference in the performance of the two types of polyethylene should be evident

The optimum design for the femoral component for cementless Total Hip Replacement is not known. We conducted an ethically approved, randomized and prospective trial to compare two radically different designs of fully hydroxyapatite (HA) coated femoral stems. We compared the original JRI Furlong stem with the Wright Anca fit stem which is more anatomical in design. The paper discusses the merits and disadvantages of these two stems. The same acetabular component was used in both samples. The only variable was the stem shape. All patients placed on the senior authors’ waiting list for primary THR were asked if they would enter the trial. There were no restrictions for selection to the sample. Patients were then randomised for one of the two stems. All surgery was performed by or under the direct supervision of the senior author in one center. The surgical approach to the hip, Hardinge antero lateral, was the same in all cases. In all cases the same well-tried JRI CSF acetabular cup and bearings were used. Patients were x-rayed post operatively and reviewed and x-rayed at six weeks and then yearly. 360 patients had been entered into the trial, 219 females and 141 males. 203 patients had the JRI furlong hip implanted (56%) and 157 were in the Anca sample (44%). The periprosthetic and perioperative fracture rates for the two stems were found to be significantly different at three years into the study and the trial was stopped. The number of perioperative fractures in the Furlong group was 17(8.4%)and in the Anca sample 24 (15.3%). This is statistically significant. The possible reasons for this difference are discussed. Anatomical fit and wedge shaped cementless stems require a more careful technique to avoid fracture during implantation and the shorter stemmed Anca hip proved less stable in the presence of a fracture necessitating further surgical intervention. It is still not certain whether the anatomical shape has long term advantages that may outweigh this initial disadvantage and the cohort of patients continue to be followed up

We designed a prospective randomised trial to compare traditional conservative management with reaming, closed intramedullary nailing. Our aims were to compare early functional and the rehabilitation period between and of the two groups. The trial had strict criteria for entry: Group A) All patients were skeletally mature, Group B) All fractures were at least 50% displaced or angulated at least 10° in any direction, Group C) All patients had a displaced fracture of the tibial shaft more than 5 cm away from either knee or ankle and with no other significant injury, Group D) Only grade I compound fractures were admitted; grade II and III compound fractures were excluded. Group A was treated by manipulation of the fracture and the application of a long-leg plaster cast. Group B had closed intramedullary nailing of the fracture, with either dynamic or static locking as indicated. A total of 79 patients entered the trial: 37 in Group A and 42 in Group B. The criteria for fracture union was pain-free, unaided walking. There were two cases of non-union in Group A and none in Group B. Mean time to union was significantly shorter in Group B, as was the mean delay before return to work. There was significantly more angular deformity and shortening in Group A. Two patients in Group B had been nailed in significant external rotation (8 degrees). Movement at the knee, ankle and hindfoot was regained in the final control. Group B spent longer in hospital than group A. Group A had no cases of infection or wound problems. There was failure of conservative treatment in five of the 37 patients. These patients required late operation. Group B had one case of deep infection. In one case the distal locking screw was broken but no problem was encountered during follow-up. Autogenous bone grafting was performed in one case with non-union. We have concluded that displaced fractures of the tibial shaft are better and more efficiently treated by closed intramedullary nailing. This method has an acceptable complication rate when compared with conservative treatment

We designed a prospective randomised trial to compare traditional conservative management with reaming, closed intramedullary nailing. Our aims were to compare early functional and the rehabilitation period between and of the two groups. The trial had strict criteria for entry: Group A) All patients were skeletally mature, Group B) All fractures were at least 50% displaced or angulated at least 10° in any direction, Group C) All patients had a displaced fracture of the tibial shaft more than 5 cm away from either knee or ankle and with no other significant injury, Group D) Only grade I compound fractures were admitted; grade II and III compound fractures were excluded. Group A was treated by manipulation of the fracture and the application of a long-leg plaster cast. Group B had closed intramedullary nailing of the fracture, with either dynamic or static locking as indicated. A total of 79 patients entered the trial: 37 in Group A and 42 in Group B. The criteria for fracture union was pain-free, unaided walking. There were two cases of non-union in Group A and none in Group B. Mean time to union was significantly shorter in Group B, as was the mean delay before return to work. There was significantly more angular deformity and shortening in Group A. Two patients in Group B had been nailed in significant external rotation (8 degrees). Movement at the knee, ankle and hindfoot was regained in the final control. Group B spent longer in hospital than group A. Group A had no cases of infection or wound problems. There was failure of conservative treatment in five of the 37 patients. These patients required late operation. Group B had one case of deep infection. In one case the distal locking screw was broken but no problem was encountered during follow-up. Autogenous bone grafting was performed in one case with non-union. We have concluded that displaced fractures of the tibial shaft are better and more efficiently treated by closed intramedullary nailing. This method has an acceptable complication rate when compared with conservative treatment

The present IRB approved study evaluates the early results of 100 TKAs using CT-based Patient-Specific Instrumentation (PSI) (MyKnee®, Medacta International, SA, Castel San Pietro, Switzerland). For this technique, a CT scan of the lower extremity is obtained, and from these images, the knee is reconstructed 3-dimensionally. Surgical and implant-size planning are performed according to surgeon preference, with the goal to create a neutral mechanical axis. Once planned and approved, the blocks are made [Fig. 1].

Outcomes measured for the present study include surgical factors such as Tourniquet Time (TT) as a measure of surgical efficiency, the actual intraoperative bony resection thicknesses to be compared to the planned resections from the CT scan, and complication data. Furthermore, pre- and post-operative long standing alignment and Knee Society Scores (KSS) were obtained.

During surgery, the PSI cutting block is registered on the femur first and secured with smooth pins. No osteophytes are removed as the blocks use the positive topography of the osteophytes for registration. The distal femoral resection is performed directly through the block. An appropriate sized 4-in-1 block is placed and the remaining resections are performed. The tibial resection block is registered and resection performed. Final bone preparation, patella resurfacing, and trialing is performed as is standard to all surgical techniques.

There were 50 Left and 50 Right TKA's performed in 61 females and 39 males. All patients had diagnosis of osteoarthritis. The average BMI was 31.1 and average age was 64.5 (range 41–90). 79 patients had pre-operative varus deformities with Hip Knee Angle (HKA) average of 174.7° (range 167°–179.5°). 19 patients had pre-operative valgus deformities averaging 184.4° (range 180.5°–190°). Three patients were neutral.

Average TT was 31.2 minutes (range 21–51 minutes). With regard to the bony resections, the actual vs. planned resections for the distal medial femoral resection was 8.7 mm vs. 8.9 mm respectively. Further actual vs. planned femoral resections include distal lateral 7.2 vs. 6.7 mm; posterior medial 8.3 vs. 8.9 mm; and posterior lateral 6.2 vs. 6.8 mm. The actual vs. planned tibial resections recorded include medial 6.4 vs. 6.3 mm and lateral 8.3 vs. 8.2. The planned vs. actual bony cuts are strongly correlated, and highly predictive for all 6 measured cuts (p=<.001) [Fig. 3]. No intraoperative complications occurred.

Average KSS improved from 45.9 to 81.4, and KSS Function Score improved from 57.7 to 73.5 at 6 weeks postoperative visit. There were no thromboembolic complications. Two patients had a post-operative infection requiring surgical intervention.

Post-operative alignment was 179.36° (range 175°–186°) for all patients. Alignment was neutral, within 3° in 95.9% of patients. There were only 4 outliers with maximal post-operative angulation of 6° [Fig. 2].

In conclusion, these early results demonstrate efficacy of CT-based PSI for TKA. The surgery can be performed efficiently, accurately, and safely. Furthermore, excellent short term clinical and radiographic results can be achieved.

The present IRB approved study evaluates the early results of 100 TKAs using CT-based Patient-Specific Instrumentation (PSI) (MyKnee®, Medacta International, SA, Castel San Pietro, Switzerland). For this technique, a CT scan of the lower extremity is obtained, and from these images, the knee is reconstructed 3-dimensionally. Surgical and implant-size planning are performed according to surgeon preference, with the goal to create a neutral mechanical axis. Once planned and approved, the blocks are made.

Outcomes measured for the present study include surgical factors such as Tourniquet Time (TT) as a measure of surgical efficiency, the actual intraoperative bony resection thicknesses to be compared to the planned resections from the CT scan, and complication data. Furthermore, pre- and post-operative long standing alignment and Knee Society Scores (KSS) were obtained.

During surgery, the PSI cutting block is registered on the femur first and secured with smooth pins. No osteophytes are removed as the blocks use the positive topography of the osteophytes for registration. The distal femoral resection is performed directly through the block. An appropriate sized 4-in-1 block is placed and the remaining resections are performed. The tibial resection block is registered and resection performed. Final bone preparation, patella resurfacing, and trialing is performed as is standard to all surgical techniques.

There were 50 Left and 50 Right TKA's performed in 61 females and 39 males. All patients had diagnosis of osteoarthritis. The average BMI was 31.1 and average age was 64.5 (range 41–90). 79 patients had pre-operative varus deformities with Hip Knee Angle (HKA) average of 174.7° (range 167°–179.5°). 19 patients had pre-operative valgus deformities averaging 184.4° (range 180.5°–190°). Three patients were neutral.

Average TT was 31.2 minutes (range 21–51 minutes). With regard to the bony resections, the actual vs. planned resections for the distal medial femoral resection was 8.7 mm vs. 8.9 mm respectively. Further actual vs. planned femoral resections include distal lateral 7.2 vs. 6.7 mm; posterior medial 8.3 vs. 8.9 mm; and posterior lateral 6.2 vs. 6.8 mm. The actual vs. planned tibial resections recorded include medial 6.4 vs. 6.3 mm and lateral 8.3 vs. 8.2. The planned vs. actual bony cuts are strongly correlated, and highly predictive for all 6 measured cuts (p=<.001). No intraoperative complications occurred.

Average KSS improved from 45.9 to 81.4, and KSS Function Score improved from 57.7 to 73.5 at 6 weeks postoperative visit. There were no thromboembolic complications. Two patients had a post-operative infection requiring surgical intervention.

Post-operative alignment was 179.36° (range 175°–186°) for all patients. Alignment was neutral, within 3° in 95.9% of patients. There were only 4 outliers with maximal post-operative angulation of 6°.

In conclusion, these early results demonstrate efficacy of CT-based PSI for TKA. The surgery can be performed efficiently, accurately, and safely. Furthermore, excellent short term clinical and radiographic results can be achieved.

Hip fracture in the elderly is associated with significant morbidity and mortality. Significant intra-operative blood loss and the subsequent need for transfusion significantly contribute to patient morbidity. Making a surgical incision with diathermy reduces wound related blood loss, by coagulating small vessels as tissue is incised, however no study to date has looked at the use of diathermy in making surgical incisions around the hip. In addition, the increasing prevalence of blood borne infections makes the exclusion of sharps from the operative field an attractive option. The aim of this study was to compare diathermy incision with traditional wound opening using a scalpel to incise all layers. 50 patient undergoing hemiarthroplasty for fractured neck of femur were recruited prospectively. Patients on warfarin were excluded from the study while those on aspirin were not. After informed consent was obtained patients were randomized to scalpel or diathermy incision by coin toss.

In the diathermy group the dermis was incised with the scalpel and all further layers with the diathermy, while in both groups diathermy as used for haemostasis. All patients received prophylactic antibiotics at induction and for 24 hours post-op. Wounds were closed in a standard fashion using absorbable sutures for closing fascia and fat layers and surgical staples for skin. Intra-operative parameters measured included: 1) Time to open wound – defined as time taken to open wound from skin incision to complete opening of the fascia lata and achieve haemostasis. 2) Wound length and depth. 3) Wound related blood loss – swabs used while creating and closing the wound were weighed separately. 4) Total operative blood loss. Post-operatively all wound related complications were recorded. Statistical analysis was performed using the un-paired Student t-test parametric data.

Both groups were similar in relation to age, sex and pre-operative aspirin use. Intra-operatively neither wound sizes nor time taken to create the wound were statistically significantly different. In the scalpel group wound related blood loss represented over 30% of the total operative blood loss as compared with only 18.5% in the diathermy group. Post-operatively there were no wound infections or dehiscences in either group, however 4 patients in the scalpel group developed significant wound ooze that responded to conservative treatment. There were no significant wound problems in the diathermy incision group.

This prospective study has shown that the use of diathermy incision for hip hemiarthroplasty significantly reduces wound related blood loss and the incidence of post-operative wound ooze. We conclude that the routine use of diathermy to make incisions around the hip is effective in reducing wound related bleeding without adverse effects on wound healing or infection rate.

Objectives: To show that the treatment of buckle fracture in children in a soft bandage, rather than a plaster cast, is an effective and safe method of treatment, with an earlier return to normal function.

Methods: In order to determine the difference between the two groups it was decided to compare the range of movement at three weeks. Power calculations were performed using the minimum difference for a two-sample t-test method and assuming a non-central distribution. The calculation was performed on Minitab release version 12.1 Assuming a required difference of 5 degrees and a standard deviation of 5 degrees also with a required power of 0.9(90%) this gave a required sample size of 23 for each group i.e a total of 46 patients. Guidelines for the parents, consent forms, doctor and nurse protocols, a guidance poster for the A& E, treatment profiles for each patient and a questionnaire for parents were written. The project was submitted for ethical approval in July 1999 and granted at the end of that month. Patients enter the trial after parents agree and sign the consent form. Allocation to either plaster or bandage is random and parents draw previously sealed envelopes themselves. Those allocated to bandage are seen each week and measurements taken of their range of movement.

Results: Thirty seven patients have completed the study. 17 have been allocated to bandage the rest to cast. Those in bandage show an excellent range of movement at the first week with no reported problems on their questionnaires. One patient has transferred from bandage to plaster at the request of the parents. Problems encountered have been compliance of those in bandage to return for follow up after two weeks and, ensuring all patients enter the trial and attend the right clinic.

Conclusion: Results suggest a positive result for treatment in bandage with no reported adverse effects and, a highly desirable result for the patient. We would hope to suggest a change in treatment policy for such fractures.

To determine whether resection of osteophyte at TKR improves movement, 139 TKRs were performed on knees with pre-operative posterior osteophyte. Randomisation was to have either resection of distal femoral osteophyte guided by a custom made ruler or no resection. After preparation of the femoral bone cuts the ruler measuring 19 mm was placed just proximal to the posterior chamfer cut. The proximal end of this ruler marked the bone to be resected and this was performed using an osteotome at 45 degrees. Knees randomised to no resection had no further femoral bony cuts. Three months after implantation the patients had range of motion assessed.

One hundred and fourteen suitable knees were assessed, with 59 knees (57 patients) in the resection group and 55 knees (54 patients) in the no resection group. Full extension was more likely in the resection group (62%) than the group without resection (41%)(p=0.08). Flexion to at least 110 degrees was, however, less in the resection group (37%) than the no resection group (54%) (p=0.09).

Our study failed to show a statistically significant difference if the bony osteophyte is removed. There were however sharp trends, with statistically a one in ten chance these results would be different if the trial was repeated. Although there is no indication as to the cause of improved extension this could be explained by the release of the posterior capsular structures allowing full extension. The reduction in flexion is harder to explain and this may be due to increase in perioperative trauma and resultant swelling, possibly with fibrosis. Range of movement, particularly flexion, is known to improve up to 1 year post-operatively and assessment of these groups at that stage would be beneficial.

This single-centre prospective randomised trial aimed to assess the superiority of operative fixation compared with non-operative management for adults with an isolated, closed humeral shaft fracture. 70 patients were randomly allocated to either open reduction and internal fixation (51%, n=36/70) or functional bracing (49%, n=34/70). 7 patients did not receive their assigned treatment (operative n=5/32, non-operative n=2/32); results were analysed based upon intention-to-treat. The primary outcome measure was the DASH score at 3 months. Secondary outcomes included treatment complications, union/nonunion, shoulder/elbow range of motion, pain and health-related quality of life (HRQoL). At 3 months, 66 patients (94%) were available for follow-up; the mean DASH favoured surgery (operative 24.5, non-operative 39.4; p=0.006) and the difference (14.9 points) exceeded the MCID. Surgery was also associated with a superior DASH at 6wks (operative 38.4, non-operative 53.1; p=0.005) but not at 6 months or 1yr. Brace-related dermatitis affected 7 patients (operative 3%, non-operative 18%; OR 7.8, p=0.049) but there were no differences in other complications. 8 patients (11%) developed a nonunion (operative 6%, non-operative 18%; OR 3.8, p=0.140). Surgery was associated with superior early shoulder/elbow range of motion, and pain, EuroQol and SF-12 Mental Component Summary scores. There were no other differences in outcomes between groups. Surgery confers early advantages over bracing, in terms of upper limb function, shoulder/elbow range of motion, pain and HRQoL. However, these benefits should be considered in the context of potential operative risks and the absence of any difference in patient-reported outcomes at 1yr

Introduction: Acetabular loosening can limit long-term success of total hip replacement. There are at least 62 different prosthesis designs available in the UK, many of which have no long term results. Revision surgery is expensive, challenging and potentially dangerous. There is still currently debate about the best method of acetabular fixation, in particular, regarding the use of press fit devices in elderly osteoporotic bone. Our study aims to test the null hypothesis that there is no significant difference in outcome between cemented and non-cemented acetabular fixation in this group of patients.

Methods: Patients over 72 years of age were prospectively randomised to receive either a cemented Exeter cup or a HA coated press fit cementless cup. Both groups received a cemented Exeter stem. The patients were assessed pre-operatively and reviewed at 6 weeks, 6 months and yearly in a research clinic, by an independent observer. Outcome measures were the Merle D’Aubignon Postel, Oxford Hip and Visual analogue pain scores. The implants were also assessed radiographically and all complications were recorded.

Results: To date 151 patients have been recruited into the trial. 2 year data is available for 69 patients. There were no differences in satisfaction, pain or hip scores between the groups.

There have been no major surgical complications. In particular, there have been no failures of acetabular fixation, dislocations or deep infections.

Discussion: There have been no failures in either group. Although there is insufficient data at this stage to reject our null hypothesis, there is no early evidence for concern in using cementless cups in elderly patients.

Objectives

Effective analgesia after total knee arthroplasty (TKA) improves patient satisfaction, mobility and expedites discharge. This study assessed whether continuous femoral nerve infusion (CFNI) was superior to a single-shot femoral nerve block in primary TKA surgery completed under subarachnoid blockade including morphine.

Purpose: To compare the early results and complications associated with two different minimally invasive surgical techniques, the mini-posterior and G3 approaches.

Method: The senior author prospectively allocated successive patients into either posterior or G3 groups for all primary total hip replacements from April 2005 to July 2006.

Results: Of 173 hips, 116 hips were introduced via a mini-posterior approach, 57 via a G3. There were no significant differences in composition of the two groups in average age, gender, length of hospital stay, or early functional outcome. The posterior group patients were generally heavier, but OR time was significantly less than in the G3 group, as were blood transfusion rates. Technical issues were noted in 25% of cases, including calcar and periprosthetic fracture (9), malposition of the acetabular and femoral components (6), and leg length discrepancies (28). There was one death and one infection. There were 3 dislocations, from both groups, deemed to be more a function of improper component implantation, rather than of the surgical approach. Of 4 with neurologic symptoms, one patient from each group experienced anterior thigh numbness with activity; in the G3 group there was a lateral femoral cutaneous nerve deficit, and a severe sciatic nerve deficit. There were 7 (4%) patients who required additional surgery, 5 for periprosthetic fracture or implant malposition. Two re-operations were attributed to being likely specific to the surgical approach and its limited visualization, both G3s with femoral component malposition. Technically it was appreciated that there was a fine line between a too tight femoral component (heightened fracture risk) and one too loose (heightened subsidence risk). The strengths of this study are that it reflects the experience of one career arthroplasty surgeon performing a consecutive, nearly randomized to two MIS approaches, consecutive case series of primary total hip arthroplasties, using the same fiber-metal acetabulum and tapered fiber-metal HA coated femur prostheses in all cases.

Conclusion: The G3 approach is technically difficult, with a long “learning curve”. This difficulty was acutely accentuated in larger patients. The mini-posterior incision was relatively easy, even in the larger patient, and became the preferred approach for the more challenging case.

The study was established to assess the long-term results and differences between autogenous and synthetic anterior cruciate ligament (ACL) reconstruction.

We randomised 50 patients into 2 groups: 26 (52%) underwent reconstruction with middle third patellar tendon graft (PTG) harvested using the ‘Graftologer’ (Neoligaments) and 24 (48%) underwent reconstruction with the Leeds-Keio ligament (LK).

Subjective knee function was assessed using the Lysholm score, Tegner activity score, IKDC grading, and clinical assessment of anterior knee pain. Laxity was tested clinically, including anterior draw at 20° (Lachman), pivot shift, and arthrometric measurements using the Stryker laxometer.

At five years we have noted no significant difference in Lysholm scoring and Pivot shift between the LK group and patellar tendon group. But there was a significant difference in Tegner activity level and IKDC activity scores with PTG faring better at five years. There is no significance difference in anterior knee symptoms between the groups.

Conclusion: Due to the success of PTG/Hamstring in routine primary ACL reconstruction there does not seem to be a role for artificial ligaments. However, if we just look at functional outcome and patient satisfaction, LK patients seem to be doing as well as PTG at five years. So, there may be a place for the Leeds Keio graft where autologous tissue is unavailable.

The study was established to assess the long-term results and differences between autogenous and synthetic anterior cruciate ligament (ACL) reconstruction.

We randomised 50 patients into 2 groups: 26 (52%) underwent reconstruction with middle third patellar tendon graft (PTG) harvested using the ‘ Graftologer ‘ (Neoligaments), and 24 (48%) underwent reconstruction with the Leeds-Keio ligament (LK).

Subjective knee function was assessed using the Lysholm score, Tegner activity score, IKDC grading, and clinical assessment of anterior knee pain. Laxity was tested clinically, including anterior draw at 20° (Lachman), pivot shift, and arthrometric measurements using the Stryker laxometer.

At five years we have noted a slight reduction in Lysholm scoring in the LK group, as well as reduced Tegner activity level. Pivot shift and laxity were significantly greater in the LK group.

Compared with earlier results, which showed little subjective difference between the groups, the autogenous PTG group show more sustainable long-term results than the synthetic (LK) group. There is no significant difference in anterior knee symptoms between the groups.

We wished to determine the most accurate and reliable technique for insertion of tibial prostheses, with tibial resection guided by either intramedullary (IM) or extramedullary (EM) alignment jigs.

135 consecutive AGC cemented total knee replacements in 126 patients in a single unit were performed by, or directly supervised by, four consultant surgeons. Ethical approval and patient consent was obtained. Intramedullary alignment was used for the femoral cuts and patients were randomised at the time of operation to have either IM or EM guides for resection of the proximal tibia, cut with a zero degree posterior slope in both. The protocol only entered patients into the trial if their knees were suitable for use with both IM and EM tibial alignment although, in the event, no patients were excluded. Long leg radiographs (standing hip to ankle) were taken by a standardised method three months after the surgery. A blinded assessor, unaware of the alignment method used, evaluated acceptable films and measured tibial component alignment. The proportion of tibial prostheses aligned within two degrees of 90 was the endpoint of the study.

Of the 135 knees 100 suitable x-rays were assessed. Correct tibial alignment was more likely in the IM group (85%) than the EM group (65%), p=0. 019. Though mean alignment was similar, variation (standard deviation) was less in the IM group (2. 0 vv 2. 2).

In the AGC knee, intramedullary alignment guides are superior to extramedullary guides for alignment of the tibial prosthesis. We recommend the routine use of intramedullary tibial alignment.