Aims

Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees. Fractures, however, can occur in the residual limb, but they have rarely been reported. Approximately 2% to 3% of amputees with socket-mounted prostheses may fracture within five years. This is the first study which directly addresses the risks and management of periprosthetic osseointegration fractures in amputees.

The purpose of this study was to evaluate and to compare the mechanical stability of external fixation with and without ankle spanning fixation using a foot plate in an in-vitro model of periarticular distal tibia osteotomy/fracture.

Ten fresh frozen lower extremities (five pairs) with a simulated distal tibia osteotomy/fracture were stabilised with an Ilizarov hybrid fixator with and without a foot plate. All specimens were loaded using a servohydraulic load frame. Relative interfragmentary motions (vertical and horizontal translations, and rotation) were measured. Statistical analysis was performed as a paired t-test to compare the different frame constructs. A p<0.05 was considered indicative of a significant difference between fixator constructs.

The vertical displacement measured at the centre of the distal fragment under load with the foot plate was such that the bone fragments became closer together (-0.83±0.64 mm). Loading of specimens without the foot plate resulted in distraction of the distal fragment (2.57±0.97 mm). The difference was statistically significant (p<0.05). The horizontal displacement of distal fragment with (1.12±0.98 mm) was not significantly different from the motion without (1.19±1.23 mm) a foot plate and was in the anterior direction in both cases. Loading of the construct with the foot plate caused sagittal plane angulation of the fragments with the osteotomy/fracture gap opening anteriorly (-1.15±0.61 deg.). Loading of the construct without a foot plate resulted in sagittal plane angulation of fragments with the gap opening posteriorly (4.49±0.45 deg.). These motion differences were statistically significant (p<0.05). There was not a statistically significant difference between the order of testing the construct with a foot plate and the construct without it (p>0.05).

Fixators with ankle spanning using foot plates increase the mechanical stiffness of external fixation of periarticular distal tibia osteotomy/fracture.

Purpose: Frozen shoulder, an excruciatingly painful condition known medically as adhesive capsulitis, affects two million people in Britain. Diabetics and women aged 40–60 are particularly at risk. The current treatment for frozen shoulder includes painkillers, physiotherapy, or surgery. The above presents their own problems, including recurrence of symptoms, failure of therapy, and for surgery: recovery period, anaesthetic and surgical operative risks. In contrast, the therapy involving hydrodilatation injections into the shoulder takes just ten minutes and allows patients to go home immediately. Hydrodilatation had fallen out of favour as a means of treating frozen shoulders until the recent publications specifically the King’s Lynn study (Quraishi et al) in 2007. Our objective is to see if we can reproduce these results that the King’s Lynn study shows.

Method: Our study is a cohort study, prospectively evaluating the outcome of hydrodilatation as treatments for adhesive capsulitis. 24 patients were treated with hydrodilatation, and had Oxford scores done before injection; 2 months and 6 months after injection. The overall scores were recorded as was the range of movement.

Results: The overall scores for the study showed a significant improvement and increased ROM of patients’ shoulders.

Conclusion: We believe our study shows that hydrodilatation is an effective means of treating frozen shoulders. We believe our study demonstrates the need for hydrodilatation to be more widely practiced. Other therapy such as painkillers and physiotherapy has shown not to be effective, and surgery has its respective complications. Therefore hydrodilatation offers a minimally invasive, cheap, low risk alternative.

Purpose: The objectives of this project were to compare four commercially available hybrid external fixator systems under multiple loading conditions, and to compare each system to an idealized «rigid» frame to distinguish between motion allowed by the pins and wires and motion allowed by frame deformation.

Methods: A mechanical testing investigation was performed using fifteen fiberglass composite tibias (Pacific Research Laboratories, Vashon Island, WA, USA) with a 2 cm proximal metaphyseal gap osteotomy (simulating OTA classification 41-A3.3) to test four hybrid systems (Ace-Fischer, DePuyACE, Warsaw, IN; Hoffmann II, Stryker Howmedica Osteonics, Rutherford, NJ; Synthes Hybrid, Synthes USA, Paoli, PA; EBI DynaFix®, EBI, Parsippany, NJ) and a custom built «rigid» frame. Setting: A biomechanics laboratory using a servohydraulic load frame (MTS Bionix 858, Minneapolis, MN). Measurements were made of the motion produced when loads were applied to the proximal tibia through a custom load plate.

Results: The only significant difference between commercial systems was in axial loading where the Ace-Fischer allowed less motion than the other frames. In all cases the «rigid» reference frame allowed significantly less motion than the commercial systems. Approximately 50% of the motion comes from frame deformation and 50% from deformation of the pins and wires.

Conclusions/Significance: There are few differences between commercially available hybrid external fixation systems for treating unstable proximal tibia fractures. Approximately half of the motion at the fracture site is due to bending deformation in asymmetric frame designs, which leads to unwanted angular and shear displacements at the fracture site.

The management of bony lesions associated with glenohumeral instability has been open to debate. Invariably a significant period of time elapses between injury and surgery during which the bony fragment may atrophy and reduce both in size and in quality. Histomorphometric bone analyses were prospectively performed on the glenoid bone fragments harvested during the modified Latarjet operation. The main purpose of the study was to assess the viability of the bone. Biopsies were obtained from 21 patients that had given informed consent. Median age was 21 years (range 16–50). All were male patients. The most important sports identified were rugby (64%) and water sports (surfing, water polo, water skiing, surfing (21%)). Mean glenoid bone loss on CT scan was 17% (range 10–50%). Thirty-three percent had bone loss greater than 20%. Gross morphology of glenolabral fragments identified a single large fragment (11/21); dominant large fragment plus smaller fragments (7/21); multiple fragments (4/21). Single large fragments comprised 52% of the study. Mean volume and mass of bony fragments were 2.18 ml (range 1–3 ml) and 1.64 gms (range 0.43–2.8 g), respectively. Histology of the specimens revealed no bone in three of the 21 specimens. Bony necrosis was present in 8/18 (44%) of the specimens. From a histopathological point of view, reattachment of these devitalized bone fragments by screws or anchors may result in predictable operative failure and recurrent instability. We can therefore not support the practice of “repair” of bony Bankart lesions based on the above findings.

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.

Prior studies have compared the bacterial load observed in laminar flow operating theatres (LFOTs) and standard operating theatres (STOTs) by wound culture and air sampling during surgery. However many organisms responsible for low grade infection after THR are not readily identified on routine culture and may be detectable only by more sensitive techniques such as the poly-merase chain reaction (PCR). This study assessed the wound contamination rate during THRs and compared the results in STOT with that in LFOTs using PCR.

We recruited patients undergoing primary THR for osteoarthritis. Surgery was performed in either STOTs or LFOTs, using identical skin preparation solutions, surgical drapes and operating attire. Specimens of the deep tissue, taken at the beginning and end of surgery, were each immediately separated into two sterile containers, one sent for culture (aerobic, anaerobic and enriched meat broth) and the other frozen at minus 80 degrees Celsius for PCR at a later date.

In each theatre type, 40 specimens from 20 THRs were analysed by both PCR and culture. Using PCR, bacterial DNA was identified on 12 of 40 specimens (30%) from STOTs, of which 3 were taken at the start of surgery and 9 at the end of the surgery, giving a 45% wound contamination rate (9 of 20). Two specimens (5%), both taken at the end of surgery, were positive on enriched culture. In LFOTs, bacterial DNA was identified by PCR on 8 of 40 specimens (20%), of which 2 were taken at the start of surgery and 6 at the end of surgery, giving a 30% wound contamination rate (6 of 20). No specimens were positive on enriched culture.

Wound contamination of primary THR occurs frequently in both STOTs and LFOTs. Although STOTs showed evidence of more frequent wound contamination than LFOTs, with the numbers available, no significant difference was detected. These data remind us the importance of aseptic surgical technique as significant wound contamination can occur despite the use of ultra clean air operating theatres.

Treatment of OA of the shoulder in young and active patients remains a problem. Present treatment options are debridement, microfracturing, arthrodesis or shoulder replacement. We report the preliminary results of soft-tissue interposition arthroplasty with an acellular allograft skin-derived collagen matrix (Graft Jacket®, Wright Medical).

Between July and December 2003 five men and one woman with severe glenohumeral OA had a soft-tissue interposition arthroplasty of the shoulder. The mean age of the patients was 47 years (34 to 58). In four patients the procedure was done arthroscopically. The Graft Jacket® was sutured to the labrum with a minimum of five sutures. The mean postoperative follow-up was 6.2 months.

Four patients experienced notable pain relief after the operation. Preoperatively the mean visual analogue pain score was 7.2 and postoperatively it was 2.6. One patient had no improvement and elected to wait before having further treatment. One patient needed a hemi-arthroplasty. The range of motion improved in only one patient. The mean Constant score improved 14 points, from 45 to 59. There were no complications peroperatively or postoperatively.

While the long-term results are still unknown, soft-tissue interposition arthroplasty with the Graft Jacket® shows promising results.

External rotation of the shoulder is commonly measured in two ways, with the arm adducted or with the arm abducted to 90°. The measurement forms an important part of the assessment of shoulder function, but has been shown to be unreliable. Following the observation that, with the arm adducted, the range of external rotation alters according to the exact position of the arm in the sagittal plane, we conducted a study to quantify the effect on the range of external rotation of a small increment in forward flexion (15°).

With the arm first in a vertical position and then in 15° of forward flexion, external rotation was measured in 40 asymptomatic and 20 ‘frozen’ shoulders. With forward flexion, the range of external rotation decreased by a mean of 16.9° in the asymptomatic and 13.5° in the ‘frozen’ shoulders.

We postulate that some of the variation is a function of scapular positioning. With arm flexion, the scapula protracts, resulting in alteration in glenoid version. However, some difference is due also to alteration in soft tissue tension in the two arm positions.

The sagittal position of the arm affects the range of external rotation of the adducted shoulder. This variation in measurement may affect the scores of certain outcome measures.

Introduction and Aims: Distal biceps ruptures are an uncommon injury. They represent approximately three percent of all biceps ruptures. Intervention was popularised by Boyd and Anderson who described a two-incision technique. Improved outcome has been achieved with stronger fixation allowing early mobilisation.

Method: All patients who underwent operative fixation of distal biceps ruptures by the senior two authors were identified. All patients were clinically reviewed at a minimum of six months from surgery. Functional outcomes scores in the form of Patient Rated Elbow Evaluation (PREE) and DASH scores were assessed. The operative technique utilised the Endobutton (Smith and Nephew) and is a substantial modification of that published by Bain,G et al.

Results: Thirty-one patients were identified. All patients were male with an average age of 47 years. Average delay to surgery was 24 days. There were no postoperative complications and no repeat ruptures. Thirty patients have returned Patient Rated Elbow Evaluation (PREE) forms with an average score of eight. Cybex testing demonstrates good return of strength when compared to the uninjured side.

Conclusion: Fixation of distal biceps ruptures using this modified Endobutton technique is a safe and effective method.

Little has been written about the results of isolated acromioclavicular joint (ACJ) resection using the superior approach. We report the results of our large series.

Between June 1994 and October 2003, a single surgeon performed 155 isolated ACJ resections, using the direct superior approach. Exclusion criteria were previous ipsilateral shoulder surgery, simultaneous arthroscopic procedures and OA. We asked 90 of the patients (94 shoulders) to complete the Simple Shoulder Test questionnaire by telephone. The median age of the 72 males and 18 females was 38 years (16 to 62). The dominant shoulder was involved in 54 patients. There was a history of trauma in 44 patients, with 11 rugby injuries. The median follow-up period was 29 months (6 to 118).

One portal infection resolved with debridement and antibiotics. Five revision procedures were done, four open revision Mumfords and one subacromial decompression. The mean postoperative Simple Shoulder score was 11.5 (6 to 12). Patients rated outcome as excellent in 63 shoulders, good in 22, moderate in five and poor in four.

The technique provides consistently good or excellent results (90%) and allows rapid return to normal function. There was complete resolution of pain in 73 of the 94 shoulders. All rugby players returned to the same level of play.

The management of bony lesions associated with glenohumeral instability is the subject of debate. Invariably some time elapses between injury and surgery, during which atrophy may reduce both size and quality of the bone.

The main purpose of our study was to assess the viability of the bone. Histomorphometric bone analyses were prospectively performed on glenoid fragments harvested from 21 male patients during modified Latarjet operations. Their median age was 21 years (16 to 50). Rugby was the main sport of 64% and water sports (surfing, water polo, water skiing) of 21%.

The mean glenoid bone loss on CT scan was 17% (10% to 50%). In 33% of patients, bone loss exceeded 20%. Gross morphology of glenolabral fragments identified a single large fragment in 11 patients, a dominant large fragment with smaller fragments in seven, and multiple fragments in the remaining patients. The mean volume of bony fragments was 2.18 ml (1 to 3) and the mean mass was 1.64 gm (0.43 to 2.8). Histological examination revealed that there was no bone in three of the 21 specimens. Bony necrosis was present in eight of the 18 specimens that contained bone (44%).

Given the histopathological findings, attempts to reattach these devitalised bone fragments by screws or anchors may fail and lead to recurrent instability.

Calcific tendinitis of the shoulder is a common cause of shoulder pain and is usually treated conservatively initially. We evaluated the ultrasound-guided needling procedure for calcium deposits in the rotator cuff.

Between 2002 and 2003 eight men and 18 women (mean age 49 years) with calcific tendinitis of the shoulder were treated this way. The mean duration of symptoms was 29 months. Before the procedure, the skin and subacromial bursa were infiltrated with local anaesthetic. The calcium deposit was perforated and aspirated when possible. With saline, a lavage was done to wash out the calcium.

Eleven patients (42.3%) had marked improvement in pain and needed no further treatment. Four patients required a reneedling procedure, and four patients needed repeated subacromial injections during the absorption phase of the calcium. In six patients arthroscopic calcium removal was needed. The mean visual analogue pain score during the procedure was 2.63. There were no complications.

The ultrasound-guided needling procedure is an effective and well-tolerated method of treatment of calcific tendinitis of the shoulder and in 77% of our cases there was no need for surgical removal. Where there is incomplete dissolution, the procedure can be repeated.

Introduction: Although there is evidence that laminar flow operating theatres (LFOTs) can reduce the incidence of wound infection over standard operating theatres (STOTs) when no routine peri-operative antibiotics were used, the evidence for the use with concurrent parenteral antibiotics is less compelling. A number of prior studies have compared the bacterial load observed in LFOTs and STOTs by wound culture and air sampling during surgery. However many organisms responsible for low grade infection after THR are not readily identified on routine culture and may be detectable only by more sensitive techniques such as the polymerase chain reaction (PCR), a molecular biology test for the presence of bacterial DNA. The purpose of this study was to compare the wound contamination rate during THRs performed in STOT with that in LFOTs using PCR.

Method: Patients undergoing primary THR for osteoarthritis without a history of joint infection were recruited for the study. Surgery was performed in either STOTs or LFOTs, using identical skin preparation solutions, surgical drapes and operating attire. Specimens of the deep tissue, taken at the beginning and end of surgery, were each immediately separated into two sterile containers, one sent for culture (aerobic, anaerobic and enriched meat broth) and the other frozen at minus 80 degrees Celsius for PCR at a later date.

Results: In each theatre type, 40 specimens from 20 THRs were analysed by both PCR and culture (80 specimens and 40 THRs in total).

Using PCR, bacterial DNA was identified on 12 of 40 specimens (30%) from STOTs. Of these 12, three were taken at the start of surgery and nine at the end of the surgery, equivalent to a 45% wound contamination rate (9 of 20). Only two specimens (5%), both taken at the end of surgery, were positive on enriched culture.

In LFOTs, bacterial DNA was identified by PCR on eight of 40 specimens (20%). Of these eight, two were taken at the start of surgery and six at the end of surgery, equivalent to a 30% wound contamination rate (6 of 20). None of the specimens were positive on enriched culture.

Discussions: We concluded that wound contamination of primary THR occurs frequently in both STOTs and LFOTs. Although STOTs showed evidence of more frequent wound contamination than LFOTs, with the numbers available, no significant difference was detected. These data are important in that they confirm that continued vigilance to technique continue to be important as significant wound contamination can occur despite the use of ultra clean air operating theatres.

The research question was: can ex-vivo chondrocyte cultures be established in shoulder cartilage biopsies?

Arthroscopic or open biopsies were obtained, with informed consent and institution-approved review protocol, from patients undergoing total shoulder replacement or orthopaedic interventions for end-stage rotator cuff deficiency or arthropathy. Chondrocytes were isolated from eight biopsies and cells cultured over 4-weeks.

In the first week post-digestion, validation studies showed cell counts varying from 30 000 to 400 000 (mean 126 666) and viability ranging from 30% to 100% (mean 75.2%). No primary culture failures were observed. One of the eight had an unexplained lower cell count and viability. Viability exceeded 80% in six of the eight cultures (75%). Alcian Blue stains and flow cytometry (Facscan) confirmed stable cultures with matrix formation. Aggrecan studies are in progress.

The fact that ex-vivo chondrocyte cultures can be established in biopsied shoulder cartilage may prove encouraging for autologous chondrocyte transplant in selected patients meeting stringent inclusion criteria.

With widely reported co-existence of impingement syndrome and acromioclavicular joint (ACJ) disease, some surgeons recommend that ACJ resection be combined with subacromial decompression.

From 1998 to 2003, 201 patients with symptomatic ACJs were taken to theatre. Bursoscopy was performed on 129 males and 54 females, those patients who had previously undergone ipsilateral shoulder surgery or had sonographically-proven rotator cuff tears being excluded. The mean age was 41 years (16 to 72). The preoperative diagnosis was isolated ACJ disease in 136 patients and combined ACJ disease and impingement in 47. Bursoscopy revealed no abnormalities in 124 of the 136 patients in whom isolated ACJ disease was diagnosed. In two patients, minimal bursal fraying was noted but no decompression was performed. Significant ‘impingement lesions’ were seen in 10 patients, all of whom were over age 35 years.

Symptomatic ACJ disease coexisted with impingement (lesion or signs) in only 57 of 183 patients (31%) patients. With careful preoperative evaluation, unnecessary surgery is avoidable.

Aims: Identifying low-grade infection in failed total hip replacements (THR) is an important but often difficult task. Recently, there has been interest in the use of molecular biology techniques as potential sensitive tests for low-grade infection by identifying fragments of bacterial DNA within human tissue. Methods: We investigated the ability of a molecular biology technique known as the polymerase chain reaction (PCR) to identify low-grade infection during revision of THR considered to have failed from aseptic causes. We analysed 113 specimens of tissue and synovial fluid from 31 THR revised for aseptic loosening and compared them to 105 control specimens taken during 28 primary THR. All cases were performed in laminar flow theatres. No primary or revision specimen had positive microbiological cultures. No revision specimen had histological evidence suggestive of infection. Results: Using PCR, we identified bacterial DNA in 39 of 85 revision THR tissue specimens (46%) compared to 18 of 84 primary THR specimens (21.4%, p=0.001). Bacterial DNA was identified within the synovial fluid in three specimens taken from 28 revision THR (10.7%) and in two specimens taken from 21 primary THR (9.5%, p=0.36). As multiple specimens were sent per case, 16 of 31 revision THR (52%) and eight of 28 primary THR (29%) were considered to be infected (p=0.072). Conclusions: Our results suggest that many aseptically loose revision THR actually contain bacterial DNA within the peri-prosthetic tissue, but infrequently within the synovial fluid. With an overall specimen contamination rate of 19%, however, PCR has poor specificity for routine diagnostic use in revision THR.

Introduction: Aseptic loosening of THR has a multifactorial aetiology. Differentiating such cases from loosening due to low-grade infection can often be difficult. It is possible that at least some cases of ‘aseptic’ loosening may be related to unidentified bacterial infection. This study attempted to identify the frequency with which bacterial DNA could be observed in the periprosthetic membrane and synovial fluid of patients undergoing revision surgery for what was considered ‘aseptic’ loosening.

Methods: Specimens from 39 revision and 31 primary hip replacements were obtained. The latter were used as a control for environmental contamination. All revision THR cases were investigated pre-operatively for infection by CRP, ESR, WCC, Gallium Scan. Operative specimens were analysed by bacteriological culture as well as by PCR to identify the presence of the 16S bacterial ribosomal fraction. Results were analysed by Chi square test.

Results: By PCR, bacterial DNA was identified in 22 of 39 revision hip surgery specimens and 6 of 31 primary hip replacement specimens (p=0.002). By culture none of these specimens had any bacterial growth.

Conclusions: The increased frequency with which bacterial DNA has been identified in ‘aseptically’ loose revision THR is unlikely to be due solely to environmental contamination although this remains a concern. These results may have relevance for our interpretation and understanding of aseptic loosening as well for the diagnosis of prosthetic infection.