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

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

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

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

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

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

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

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

Aim

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

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

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

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

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

Background

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

Purpose

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

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

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

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

Introduction

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

Introduction

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

Purpose

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

Purpose

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

Introduction

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

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

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

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

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

Purpose

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

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

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

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

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

Total knee arthroplasty (TKA) is an established and successful operation. However patient satisfaction rates vary from 81 to 89% 1,2,3. Pain following TKA is a significant factor in patient dissatisfaction 1. Many causes for pain following total knee arthroplasty have been identified 4 but rates of unexplained pain vary from 4 to 13.1% 5,6. Recently computerised tomography (CT) has been used to assess the rotational profile of both the tibial and femoral components in painful TKA

We reviewed 57 patients with an unexplained painful following TKA and compared these to a matched control group of 60 patients with TKA. Datum gathered from case notes and radiographs using a prospective database to identify patients. The CT information recorded was limb alignment, tibial component rotation, and femoral component rotation and combined rotation.

The two matched cohorts of patients had similar demographics. A significant difference in tibial, femoral and combined component rotation was identified between the groups. The following mean rotations were identified for the painful and control groups respectively. Tibial rotation was 3.46 degrees internal rotation (IR) compared to 2.50 degrees external rotation (ER)(p=0.001). Femoral rotation was 2.30 IR compared to 0.36 ER(p=0.02). Combined rotation was 7.08 IR compared to 2.85 ER(p=0.001).

This is the largest study presently in the literature. We have identified significant internal rotation in a patient cohort with unexplained painful TKA when compared to a matched control group. Internal rotation of the tibial component, femoral component and combined rotation was identified as a factor in unexplained pain following TKA.

Introduction

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

Bony tumours of the foot account for approximately 3% of all osseous tumours. However, literature regarding os calcis tumours comprises individual case reports, short case series or literature reviews, with the last large case series in 1973.

We retrospectively reviewed the medical notes and imaging for all patients with calcaneal tumours recorded in the Scottish Bone Tumour Registry since the 1940's. Demographics, presentation, investigation, histology, management and outcome were reviewed.

38 calcaneal tumours were identified. Male to female ratio 2:1, mean age at presentation 30 with heel pain and swelling, average length of symptoms 9 months. 4 cases present with pathological fracture. 24 tumours benign including 6 unicameral bone cysts, 3 chondroblastoma, 3 PVNS with calcaneal erosion, and a wide variety of individual lesions. 13 malignant tumours comprising 6 osteosarcoma, 5 chondrosarcoma and 2 Ewings sarcoma. 1 metastatic carcinoma.

Tumours of the calcaneus frequently are delayed in diagnosis due to their rarity and lack of clinician familiarity. They are more common in men and have a 1 in 3 risk of malignancy, covering a wide variety of lesions. Outcome is dependent on early diagnosis, timely surgery and most importantly neo-adjuvant chemotherapy. Diagnosis is often made on plain radiograph but MRI is the gold standard.

We present the largest case series of calcaneal tumours, from our experience with the Scottish Bone Tumour Registry. Despite their rarity clinicians should maintain a high index of suspicion as accurate and timely diagnosis is important to management and outcome.

Total knee arthroplasty is an established and successful operation. In up to 13% of patients who undergo total knee arthroplasty continue to complain of pain. Recently computerised tomography (CT) has been used to assess the rotational profile of both the tibial and femoral components in painful total knee arthroplasty.

We reviewed 56 painful total knee replacements and compared these to 56 matched patients with pain free total knee replacements. Patients with infection, aseptic loosening, revision arthroplasties and gross coronal malalignment were excluded. Datum gathered from case notes and radiographs using a prospective orthopaedic database to identify patients. The age, sex, preoperative and postoperative Oxford scores, visual analogue scores and treatments recorded. The CT information recorded was limb alignment, tibial component rotation, femoral component rotation and combined rotation.

The two cohorts of patients had similar demographics. The mean limb alignments were 1.7 degrees varus and 0.01 degrees valgus in the painful and control groups respectively. A significant difference in tibial component rotation was identified between the groups with 3.2 degrees of internal rotation in the painful group compared to 0.5 degrees of external rotation in the control group (p=0.001). A significant difference in femoral component rotation was identified between the groups with 3.8 degrees of internal rotation in the painful group compared to 1.1 degrees of external rotation in the control group (p=0.001). A significant difference in the combined component rotation was identified between the groups with 6.8 degrees of internal rotation in the painful group compared to 1.7 degrees of external rotation in the control group (p=0.001).

We have identified significant internal rotation in a patient cohort with painful total knee arthroplasty when compared to a control group with internal rotation of the tibial component, femoral component and combined rotation. This is the largest comparison series currently in the literature.

Primary bone tumours of the talus are rare. Currently the existing literature is limited to a single case series and case reports or cases described in series of foot tumours. Information regarding the patient's demographics and tumour types is therefore limited.

The aim of this study was to investigate these questions and also suggest a management protocol for suspected primary bone tumours of the talus. We retrospectively reviewed the Scottish Bone Tumour Register from January 1954 to May 2010 and included all primary bone tumours of the talus. We identified only twenty three bone tumours over fifty six years highlighting the rarity of these tumours. There were twenty benign and three malignant tumours with a mean age of twenty eight years. A delay in presentation was common with a mean time from onset of symptoms to diagnosis of ten months. Tumour types identified were consistent with previous literature. We identified cases of desmoplastic fibroma and intraosseous lipodystrophy described for the first time.

We suggest an investigatory and treatment protocol for patients with a suspected primary bone tumour of the talus. This is the largest series of primary bone tumours of the talus in the literature.

Aim

To investigate the effect of intraoperative wound irrigation with povidone-iodine on surgical site infection.

Posterolateral spinal fusion using autograft in adult rabbits has been reported by many groups using the Boden model. Age in general has an adverse effect on skeletal healing; although, its role in posterolateral fusion is not well understood. This study examined the influence of animal age on spinal fusion using a standard model and experimental endpoints. We hypothesised that fusion quality and quantity would be less with increasing age.

A single level posterolateral fusion between the fifth and sixth lumbar segments were performed in six-month and two-year-old New Zealand white rabbits (n=6 per group) using morcelized iliac crest autograft. All animals were sacrificed at 12 weeks following surgery. Posteroanterior Faxitron radiographs and CT scans were taken and DICOM data was analysed (MIMICS Version 12, Materialise, Belgium). Axial, sagittal, coronal and three-dimensional models were created to visualise the fusion masses. Bone mineral density (BMD) of the fusion mass was measured using a Lunar DPXL Dexa machine. An MTS Bionix testing machine was then used to assess peak load and stiffness. Sagittal and coronal plane histology was evaluated in a blinded fashion using H&E, Tetrachrome and Pentachrome stains. Assessment included overall bony response on and between the transverse processes. Radiographs and CT confirmed a more robust healing response in younger animals. Radiographic union rates decreased from 83% to 50% in the aged animals. A neo- cortex surrounding the fusion mass was observed in the younger group but absent in the aged animals. Fusion mass BMD and that of the vertebral body was decreased in the older animals (P<0.05). Tensile mechanical data revealed a 30% reduction in peak load (P=0.024) and 34% reduction in stiffness (P=0.073) in the two-year-old animals compared with the six-month-old animals. Histological evaluation demonstrated a reduction in overall biological activity in the two-year-old animals. This reduction in activity was observed in the more challenging intertransverse space as well as adjacent to the transverse processes and vertebral bodies at the decortication sites. Numerous sites of new bone formation was present in the middle of the fusion mass in the six-month-old animals while the bone graft in the two-year- old animals were less viable.

Skeletal healing is complex and mediated by both local and systemic factors. This study demonstrated that ageing leads to an impaired and delayed skeletal repair.

Where autograft is utilised, diminished graft osteoinductivity and reduced levels of growth factors and nutritional supply in the surrounding milieu explains our observations. The aged rabbit posterolateral spinal fusion model has not been previously described but would be a useful to evaluate new treatment modalities in a more challenging host environment.

PURPOSE OF THE STUDY

To assess if prolonged use of Bisphosphonates in Osteogenesis Imperfecta alters the pattern of femoral fractures.

Osteogenesis Imperfecta (OI) has been treated with Bisphosphonates for many years with some clear clinical benefits. In adult cohorts there are reports of a new pattern of atraumatic subtrochanteric fractures seen with Bisphosphonate treatment.

Forearm fractures are a common paediatric injury. This study was aimed to describe the epidemiological of paediatric forearm fractures in the urban population of Glasgow.

We reviewed of all the forearm fracture treated by the orthopaedic service in Yorkhill Children's Hospital in 2008. Datum gathered from case notes and radiographs using the prospective orthopaedic database to identify patients with forearm fractures. The age, sex, side and type of fracture, the timing and mechanism of the injury and treatment were documented for the 436 fractures. Census data were used to derive absolute age-specific incidences.

Distinction was made between torus and other types of fractures. Torus fractures require no specific orthopaedic treatment and were segregated out. For the remaining 314 fractures, the age and sex distribution, seasonal variation of fractures and treatments for each type of fracture were examined. The incidence of forearm fractures in our population is 411 fractures per 100,000 population per year. An increased number of fractures occurred during the months of May and August. A fall from less than one metre was the commonest mechanism of injury, sporting injuries were the second commonest with football the most common sport associated.

This study identifies some features which are in good agreement with studies from elsewhere in Britain, such as incidence and seasonality. However, there are also interesting differences – such as the Glasgow peak incidence for forearm fractures being at age 8, with a marked decline by 12 years. Furthermore, our findings have been extended to consideration of type of intervention, and likelihood of successful treatment.

Purpose: Impending and pathologic fractures of the humerus, usually due to metastatic disease, are associated with significant pain, morbidity, loss of function, and diminished quality of life. Several methods of stabilization have been described. Here we report the outcome of fixation using intramedullary poly methyl methacrylate (bone cement) and non-locking plates.

Method: A retrospective review was undertaken which included all patients treated at a tertiary musculoskeletal oncology referral center from February, 1989 to October, 2009. Patients who underwent surgical management of an impending or pathologic fracture of the humerus were included. All patients were treated using the following technique: Vascular tumors were embolized pre-operatively. Following gross tumor removal through curettage, antibiotic bone cement was placed into the humeral canal and bone defect. If there was a fracture, the bone ends were held in place as the cement cured. The humerus was stabilized using non-locking plates fixed with screws inserted through the bone and hardened bone/cement composite. Ideally, plates spanned the osseous defect by at least 2 cortical diameters and often the entire length of the bone.

Results: Clinical records were available for 67 patients who underwent the above procedure. There were 44 males and 23 females with an average age of 62.2 years. In 76% of patients there was a pathologic fracture at presentation, while in 24% it was impending. The most common histology was myeloma (21%), followed by renal (20%) and lung adenocarcinoma (20%). Forty-nine patients (73%) had one plate, 16 (24%) had two plates, one patient had three plates, and one had four plates. Complications occurred in 14 (21%) cases, and eight (12%) required reoperation of the humerus. The most common cause for reoperation was disease progression (six of eight). There were two nerve palsies, one deep infection, and one hardware failure. Interestingly, the single hardware failure occurred in a patient whose pain relief and functional status improved to the point that he fractured his construct while hammering with the affected arm in a home improvement project.

Conclusion: Intralesional tumor resection and stabilization of impending and pathologic fractures of the humerus with the described technique has several attributes. Most importantly, it provides immediate, absolute rigidity of the upper extremity and enables early pain relief and return of function without the need for osseous union. Radiation has no negative effects on the construct. The patient’s local disease burden is reduced, thus helping to alleviate tumor-related pain and slow local disease progression. Finally, this technique is user-friendly and cost-effective as it does not require any special equipment or devices that are not available to community orthopaedic surgeons. This technique provides a durable option for the treatment of impending and pathologic humerus fractures.

Purpose: Most displaced olecranon fractures can be treated with ORIF. However with severe comminution or bone loss, excision of the fragments and repair of the triceps to the ulna is recommended. The triceps can be reattached to either the anterior or posterior aspect of the ulna. The purpose of this in-vitro study was to determine the effect of triceps repair technique on elbow laxity and extension strength in the setting of olecranon deficiency.

Method: Eight unpreserved cadaveric arms were used (age 75 ± 11 years). Surface models were generated from CT images and sequential olecranon resections in 25% increments were performed using real-time navigation. Muscle tendons (biceps, brachialis, brachioradialis and triceps) were sutured to actuators of an elbow motion simulator, which produced active extension. A tracking system recorded kinematics in the varus and valgus positions. A triceps advancement was performed using either an anterior or posterior repair to the remaining olecranon in random order. Triceps extension strength was measured in the dependent position with the elbow flexed 90° using a force transducer located at the distal ulnar styloid, while triceps tension was increased from 25–200 N. Outcome variables included maximum varus-valgus elbow laxity and triceps extension strength. Two-way repeated measures ANOVAs were performed for laxity comparing resection level and repair method. Three-way repeated measures ANOVAs were performed for triceps extension strength comparing triceps tension, resection level and repair method. Significance was set at p < 0.05.

Results: Progressive olecranon resection increased elbow laxity (p < 0.001). Although the posterior repair produced slightly greater laxity for all but the 50% resection, this difference was not significant (p = 0.2). The posterior repair provided greater extension strength than the anterior repair at all applied triceps tensions and for all olecranon resections (p = 0.01). The initial 0% resection reduced extension strength for both repairs (p < 0.01), however, there was no effect of progressive olecranon resections (p = 0.09).

Conclusion: There was no significant difference in laxity between the anterior and posterior repairs. Thus even for large olecranon resections, the technique of triceps repair does not have significant influence on joint stability. Extension strength was not reduced by progressive olecranon resections, perhaps due to wrapping of the triceps tendon around the trochlea putting it in-line with the ulna and giving it a constant moment arm. Triceps extension strength was higher for the posterior repair. This is likely due to the greater distance and hence moment arm of the posterior repair to the joint rotation center. Conversely, the anterior repair brings the triceps insertion closer to the joint center, reducing the moment arm. Since there was no significant difference in laxity between the repairs, the authors favour the posterior repair due to its significantly higher triceps extension strength.

Background: Activity advice and prescription are commonly used in the management of low back pain (LBP). However, no research has assessed whether objective measurements of physical activity predict outcome, recovery and course of LBP.

Methods: One hundred and one patients with acute LBP were recruited into a longitudinal cohort study. Each participant completed the Roland Morris Disability Questionnaire (RMDQ), Visual Analogue Scale and a “simple” activity question, detailing whether they had resumed full “normal” activities (Y/N), at baseline (T0) and 3 months (T1); Baecke Physical Activity Questionnaire, Fear-Avoidance Beliefs Questionnaire and the 12-item General Health Questionnaire at T0. Physical activity was measured for 7 days at T0 and T1 with an RT3 accelerometer and the seven day physical activity recall questionnaire (7d-PAR).

Results: The only significant predictor of RMDQ change was RMDQ score at T0 (p < .0001). Physical activity change did not predict RMDQ change in both univariate (p = 0.82) and multivariate analysis (p = 0.84). Paired t-tests found a significant change in RMDQ (p < .0001) and return to full “normal” activities (p < .0001) from T0 to T1, but no significant change in activity levels measured with the RT3 (p = 0.56) or the 7d-PAR (p = 0.43). RMDQ change (OR 1.72, p = 0.01) and RMDQ at T1 (OR 0.65, p = 0.04) predicted return to full “normal” activities at T1.

Conclusions: These results question the role of physical activity in LBP recovery and the assumption that activity levels change as LBP symptoms resolve.

Conflicts of Interest: None

Sources of Funding: This research was supported by a University of Otago Establishment Grant

Purpose: The purpose of this study was to determine the effect of serial olecranon resections on elbow stability.

Method: Eight fresh, previously frozen cadaveric arms underwent CT scanning. The specimens were mounted in an in-vitro motion simulator, and kinematic data was obtained using an electromagnetic tracking system. Simulated active and passive flexion was produced with servo-motors and pneumatic pistons attached to specific muscles. Flexion was studied in the dependent, horizontal, varus, and valgus positions. Custom computer navigation software was utilized to guide serial resection of the olecranon in 12.5% increments. A triceps advancement repair was performed following each resection.

Results: Serial olecranon resections resulted in a significant increase in valgus-varus (V-V) laxity for both passive (p< 0.001) and active (p=0.04) flexion. For passive motion this increase reached statistical significance following the 12.5% resection. This corresponded to an increase in V-V laxity of 1.4 ± 0.1o and a total laxity of 7.5 ± 1.0o. For active flexion this increase reached significance following the 62.5% resection. This corresponded to an increase in V-V laxity of 5.6 ± 1.1o and a total laxity of 11.2 ± 1.5. There was no significant effect of sequential olecranon excision on elbow kinematics or stability with the elbow in the vertical or horizontal positions. The elbows became grossly unstable after resection of greater than 75% of the olecranon.

Conclusion: A progressive increase in the varus-valgus laxity of the elbow was seen with sequential excision of the olecranon. Laxity of the elbow was increased with excision of 75% of the olecranon, likely due to the loss of the bony congruity and attachment site of the posterior band of the medial collateral ligament. Gross instability resulted when 87.5% or greater was removed, likely due to damage to the anterior band of the medial collateral ligament as it inserts on the sublime tubercle of the ulna. Rehabilitation of the elbow with the arm in the dependant position should be considered following excision of the olecranon; varus and valgus orientations should be avoided. The contribution of the olecranon to elbow stability may be even more important in patients with associated ligament injuries or fractures of the elbow.

Introduction: Open tibial fractures presenting to the 3 Northern Ireland trauma hospitals with over 36 months (2003–2006) were considered regarding the BAO/BAPS guidelines, which recommended joint orthopaedic/plastic management with definitive tissue coverage within 5 days.

Methods: Details of Gustillo-Anderson classification, method and timing of surgery, and complications were identified retrospectively from a regional database and patient notes.

Results: Of 111 patients with 115 fractures, 28 were Gustillo-Anderson grade 1, 21 were grade 2, 28 were grade 3a, 35 were grade 3b, and 3 were grade 3c. Grade 1 fractures were chiefly treated by IM nailing or cast. Most grade 2 and 3 injuries received IM nailing or external frames and primary closure within 5 days. Most grade 3b fractures were treated with external frames and tissue coverage after day 5, 46% having documented plastics referrals, and 20% receiving flaps All grade 3c fractures required amputation. Complications occurred in 42% of patients, mainly soft tissue infections (19%) and delayed union (10%) or non-union (12%). Only 42% of grade 3 injuries had documented referrals to plastics. Only 26% of patients were treated initially at the regional plastics unit (with orthpaedics on-site) but only 11% of patients required transfer for plastics input (chiefly for flaps).

Conclusions: Complications were common despite most patients meeting the guidelines regarding time to definitive surgery. With increasing Gustillo-Anderson grade the number of procedures increased and method of management changed for orthopaedic and plastics procedures. Many patients with Gustillo 3 injuries had no recorded referral to plastics.

We prospectively reviewed patients who had undergone a Revision Total Knee Replacement (TKR) to a mobile-bearing arthroplasty. We wanted to assess functional outcome and survival, and to determine whether the perceived advantages of a mobile-bearing arthroplasty could be expanded to the revision situation.

We divided the patients into two groups. Group 1 consisted of 40 patients who were revised to a rotating platform, with or without stems and augments, and group 2 consisted of 41 patients revised to a varus-valgus constrained mobile-bearing device that still allowed rotation of the bearing. All were assessed with Knee Society Knee Scores, WOMAC, and New Jersey Knee Scores and standard radiographs by an independent examiner.

Group 1 had an average age of 71 years at revision and a follow-up of 5–9 years. Seventy-six percent had excellent or good results with 89% survival at 9 years. Group 2 had an average age of 71 years at revision and a follow-up of 2–5 years. The patient satisfaction score was 8/10 and the normality score was 6.8/10. There was only one case of instability in both groups in a patient with a patellar fracture.

A mobile-bearing TKR can be used in the revision situation with acceptable clinical results and patient outcome without compromising the stability or survivorship in the short-term. It has proved to be a “patellar-friendly” procedure with reduced re-operation for patellar complications; however longer-term studies are required to determine whether the rates of polyethylene wear are reduced by the use of a more congruent articulation.

Purpose: The functional consequences of femoral nerve resection during soft tissue sarcoma management are not well described. Sciatic nerve resection with a sarcoma, once considered an indication for amputation, is now commonly performed during limb salvage. We compared the functional outcomes of femoral and sciatic nerve resections in patients undergoing wide resection of soft-tissue sarcomas.

Method: The prospectively collected database from a tertiary referral center for sarcomas was retrospectively reviewed to identify patients with resection of the femoral or sciatic nerve performed during wide excision of a soft tissue sarcoma. Patient demographics, treatment, complications and functional outcomes were collected.

Results: Ten patients with femoral nerve resections were identified, all women, aged 47 to 78, with large soft tissue sarcomas of varied subtypes. All patients received adjuvant radiotherapy, most pre-operatively. Six patients developed fractures with long-term follow-up, only two of which were in the prior radiation field. Musculoskeletal Tumor Society (MSTS) 1987 scores demonstrated one excellent, 4 good, and 5 fair results. MSTS 1993 scores averaged 71.4 ± 17.2 percent and Toronto Extremity Salvage Scores (TESS) averaged 61.7 ± 21.8. There were no significant differences between the functional scores for patients with femoral or sciatic nerve resections (P=1.0).

Conclusion: Femoral nerve resection appears more morbid than anticipated. The falls to which patients were prone, even years after surgery, subject them to ongoing long-term risks for fractures and other injuries. Nerve-specific functional outcomes should be considered when counseling patients prior possible resection of the femoral nerve for involvement by a soft tissue sarcoma.

Purpose: Few functional outcomes of total femoral endoprosthetic replacement (TFEPR) using contemporary modular systems are available. We compared functional results between TFEPR patients receiving fixed- and rotating-hinge knee componentry following oncologic resections.

Method: Eighteen TFEPR patients were identified from a prospectively gathered sarcoma database. Six were secondary procedures and 12 primary. Four patients had metastatic carcinoma, 8 osteosarcoma, 4 non-osteogenic spindle cell sarcomas of bone, 1 Ewing’s sarcoma, and 1 femur-invading soft-tissue sarcoma. All reconstructions used modular implants from a single company. Proximally, all were bipolar hip hemiarthoplasties, 12 including abductor reattachment. Distally, 8 had fixed- and 10 had rotating-hinge knee componentry. Toronto Extremity Salvage Score (TESS), and both Musculoskeletal Tumor Society Scores (MSTS) were compared between fixed- and rotating-hinge groups using the Mann-Whitney test.

Results: Complications included 1 hip dislocation, 1 femoral malrotation, and wound problems requiring 3 debridements and 1 amputation. One metastatic carcinoma patient developed local relapse. Follow-up averaged 4 years (range 1 month to 14 years). At latest follow-up, 10 patients had died of disease. Eight remained alive, 6 disease-free, 2 with distant disease. Among patients surviving 6 months, 6 used no assistive devices, 5 used a single cane, and 4 were wheelchair bound, each at least partly due to distant disease progression. TESS averaged 74.5±17.4, MSTS1987 25.2±4.4; and MSTS1993 58.6±22.9 among the 12 patients for whom functional results were available from latest follow-up. No statistically significant differences or even trends were detected between fixed-hinge and rotating-hinge patients (lowest p = 0.755), but both instability problems were in the rotating-hinge group.

Conclusion: While both rotating- and fixed-hinge TFEPR reconstructions may function well, consideration should be given to fixed-hinge knee reconstruction when massive myectomies or poorer conditioning make hip and knee stability a primary concern in the short-term.

Introduction: The aim of this study was to assess the outcomes of patients with recurrent antero-inferior gle-nohumeral instability with associated antero-inferior glenoid bone loss treated with a specific open stabilisation technique, using intra-substance coracoid bone grafting. It is hypothesised that this method of reconstruction produces low recurrence of instability as well potential for patients to return to high-risk sport.

Methods: 30 shoulders with recurrent anterior dislocation and glenoid bone loss were stabilised with open capsular and labral repair and intra-substance coracoid bone grafting. Motion and stability were assessed by Rowe Stability Score (RSS) with follow-up over 2 years in all cases. American Shoulder and Elbow Score (ASES) and Oxford Stability Scoring (OSS) were also recorded at follow-up. Intention to and actual return to sporting level was assessed. Union of the graft was confirmed by CT scan.

Results: For all 30 shoulders at a mean follow-up time of 2 years 11 months (range 2–5 years) the RSS improved from a mean of 32 to 78.5 post-op. 1 redislocation occurred whilst continuing high-risk sport after 2 years. ASES index at 2 years had a mean of 91.8 whilst the OSS was 18.5. Pre-operatively, 24 patients participated in high-risk sport. 20 intended to return to high-risk sport post operatively. 18 achieved this return without restriction. CT scans were available on 25 shoulders at a mean of 4.5 months after surgery. 1 showed slight resorption of the graft, union was confirmed in 23.

Conclusion: This small sample shows an overall acceptable clinical and radiological outcome at a minimum of 2-year follow-up. These results support the current literature advocating open stabilisation and bone grafting of the glenoid where loss is evident, particularly in the young contact athlete with recurrent instability and high expectations of success.

Arthrodesis of small joints of the feet has been used for a variety of conditions. Described initially for treatment of congenital or paralytic foot deformities, arthrodesis has now been widely accepted as treatment for a range of foot disorders from inflammatory and post traumatic arthritis to acquired flat foot. A variety of fixation devices have been used to achieve compression at the Arthrodesis site.

The aim of our study is to evaluate the use of Memory compression staples in small joint fusions of the feet. The staples are made of a nickel-titanium alloy which exhibits a phenomenon called “Marmen” effect. When kept at ice-cold temperature (0–5°C), the alloy becomes plastically deformed, but, regains its original shape at body temperature. The emphasis of this study is to validate the safety of the implant for fusion of small joints of feet, as well as to determine whether the higher cost of the implant is justified by a demonstrable trend in time to fusion and period of immobilization required.

Between June 2003 and June 2008, a total of 148 feet (276 joints) had Arthrodesis using memory compression staples.

Data was collected retrospectively and clinical and radiological outcomes were assessed.

The average period of immobilization in cast was 6.8 weeks (range, 6–12). The average time to fusion was 8 weeks (range, 6–16).

The use of memory staples provides an accurate, reproducible and predictable method of achieving arthrodesis in small joints of the feet. The time to fusion is less, thereby reducing the recovery time after surgery.

Aim: To evaluate the accuracy of ultrasound to locate the gastrocnemius musculotendinous junction (GMTJ) prior to surgery. There is no clear clinical method to precisely localise this junction, either in the paediatric or adult populations.

Method: Twenty calves in 12 paediatric patients with a diagnosis of spastic gastrocnemius muscle (GM) contracture underwent ultrasound examination prior to slide lengthening (Strayer). Surgeons did the ultrasound examination after only a short introduction to the method, using a portable ultrasound machine (Sonosite 180 PLUS) with a linear (5–10 MHz frequency range) transducer.

Only the GMTJ of medial head was located as it usually has a lower attachment and is thicker. The soleus muscle has short multipennate fibres running obliquely between aponeuroses overlying its anterior and posterior surfaces. GM has long parallel fibres and merges distally with the posterior aponeurosis of the soleus muscle. The GMTJ has a unique conical appearance on ultrasound. Pre operative skin markings were compared with the location of GMTJ during surgery.

Results: All ultrasound-guided locations of GMTJ were found to be accurate within 5mm at time of surgery.

Conclusions: This study indicates that ultrasound of the calf muscles by a surgeon prior to surgery is an accurate and reliable way of centering the incision over the GMTJ. The distinct morphological structure of the soleus muscle and overlying GM heads means that even surgeons with little ultrasound experience can perform the examination.

Introduction: Forearm fractures are the most common long bone fracture in the paediatric population. Associated neurological injury is a well recognized complication of these injuries yet is generally considered to beuncommon. This study sought to evaluate the incidence of neurological impairment in children referred for manipulation by the orthopaedics team in this tertiary referral hospital.

Materials & Methods: A retrospective chart analysis was performed of the first 100 children to be referred for orthopaedic assessment. This represented 43% of the total number of children presenting to the emergency department in this time period. Inclusion criteria involved a fracture of any segment of the radius and/or ulna on radiological examination. Exclusion criteria included concomitant ipsilateral upper limb fracture, and compartment syndrome.

Results: A total of 96 cases met the inclusion criteria. The cohort had a mean age of 8.04. Males were more likely to be injured as was the left forearm. The distal metaphysis was the segment most likely to be fractured and compound injuries were uncommon. The incidence of associated neurological impairment was 15.6%. The median nerve was most commonly injured, comprising 60% of nerve injuries. Distal physeal fractures were the most common fracture pattern to be associated with neurological impairment, with a rate of 37%.

Conclusions: Forearm fractures requiring manipulation in the paediatric population are commonly associated with nerve injuries, with distal physeal fractures having a particularly strong correlation. Clinicians require a high index of suspicion for nerve injury when evaluating forearm fractures to avoid underdiagnosis. Failure to recognize neurological injury at the time of initial assessment has the potential to delay time to reduction due to the injury being misclassified as non-urgent. This delay has the potential to cause a prolonged or failed recovery of nerve function.

Purpose: To review the oncologic outcomes following treatment of soft tissue sarcomas in the foot and ankle, and to determine the results of limb salvage surgery in this anatomically constrained area with often expected close pathologic margins.

Method: One hundred twenty-nine patients with soft tissue sarcomas of the foot were treated at our institution since 1986. Average age at presentations was 55 years old. Females and males were equally represented. Most common diagnosis was MFH in 31 patients, followed by leiomyosarcoma in 16 patients, synovial sarcoma in 13, and clear cell sarcoma in 6, the remainder being other soft tissue sarcomas. Most of sarcomas were intermediate or high grade. Our follow-up averaged 58 months.

Results: Limb salvage surgery was possible in 97 patients. Of those, negative margin excision was achieved in 75 patients, 18 patients had micro-positive margins, and 4 had grossly positive margins. Fifty-three patients in the limb salvage group required free tissue transfer for coverage. Of 97 limb salvage patients, 82 received radiation therapy, 5 patients received chemotherapy. Local recurrence occurred in 24 patients. Two of these were amenable to re-excision, the remaining required amputation. Thirty-two patents developed systemic disease. Average disease-free survival for patients with recurrent disease was 23 months. At last follow-up, 78 patients were alive with no evidence of disease and 24 were alive with disease. Seventeen patients died of disease, and the remainder of other causes.

Conclusion: In the setting of soft tissue sarcoma in foot and ankle, amputation rate is higher than in other anatomic areas. However, limb salvage surgery can be achieved with good oncological outcomes despite often unavoidable close margins. Soft tissue reconstructive procedures aid in achieving good surgical results while radiation therapy aids local control. Given these results, limb salvage in soft tissue tumors of foot and ankle should be the goal.

The benefit of open stabilization for recurrent shoulder instability is well known, however there have been recent reports of postoperative dysfunction of the subscapularis tendon following open shoulder surgery (Habermeyer et al, Scheibel et al). We present our findings in patients who have undergone an open anterior stabilization using a subscapularis split approach.

We reviewed 48 patients (49 shoulders), who were treated by the senior author (SB) from 2003–2005. They all underwent an open anterior stabilization of shoulder through a deltopectoral approach, with a subscapularis split technique, without any lateral tendon detachment. The minimum follow-up was 2 years, with average 34 months. Thirty-eight shoulders underwent an isolated anterior stabilization (1 bilateral) and 11 patients had additional procedures (8 bone grafts, 1 SLAP repair, 1 cuff repair, 1 anterior and posterior repair). There were 41 male and 7 female patients, and the mean age was 23.9 years (range 15–47 years). All patients were involved in sports and 45 had presented with recurrent dislocations. Patients were followed up using the Oxford instability score and the Rowe score questionnaires. All had a clinical examination for range of movement, stability, subscapularis muscle function, or signs of dysfunction. All had a MRI to assess the quality of the subscapularis muscle and tendon.

Mean postoperative Oxford instability score was 22.5 and the Rowe score was 69.38. Two patients had redislocated following re-injury. There was no evidence clinically of subscapularis dysfunction and the muscle and tendon were normal on all MRI scans. External rotation was reduced by a mean of 15.6 degrees. There was no significant loss of flexion or abduction. 81% of patients returned to their previous level of sport.

With a subscapularis split technique for anterior shoulder stabilization there is no significant postoperative dysfunction or damage to the subscapularis muscle, and most patients return to their previous level of sport.

Biologic resurfacing of the glenoid combined with surface replacement hemiarthroplasty for relatively young patients suffering from advanced glenohumeral arthritis has the advantages of both humeral head and glenoid bone preservation. The longer term results of this procedure are reported.

Twenty two shoulders in 21 patients had a surface replacement hemiarthroplasty with resurfacing of the glenoid with the anterior capsule. At follow up one had died, and another was not contactable. The prosthesis was removed in one for deep infection, and the fourth patient had undergone revision to a total shoulder arthroplasty for ongoing pain. Therefore, 17 patients with 18 operated shoulders were available for clinical assessment. The average age of the patients was 54.8 years (35–78) at the time of surgery.

The average length of follow-up was 4.8 years (2–10.6). The average Constant Score was 71.4 points (41–95), and the sex- and age-adjusted Constant Score was 83.9%. The mean ASES score was 74.4 points (35–100). The average arc of forward flexion was 130 degrees (100–160), and external rotation was 39 degrees (20–60). On a VAS scale of 0 to 10, the average pain score at rest was 0.5 (0–3), while pain with activity was 2.4 (0–6). Sixteen of the 17 patients (94%) had a satisfactory result, and would have the operation again. Eight of the 17 patients (47%) were able to return to their previous sporting activities. Radiographic follow-up demonstrated there were 2 mild and 2 moderate cases of superior subluxation of the humeral head. There was no subsidence or signs of loosening of any humeral prosthesis. The average glenohumeral joint space was 0.13mm (0–2). Glenoid erosion was none in one case, mild in 6 cases, moderate in 6 cases, and severe in 3 shoulders.

Although the results of this procedure compare favourably with other series, the extent of glenoid erosion is concerning. A more robust tissue for interposition may give better results

Objectives: To investigate whether components of MSTS-87 (Pain, ROM, Strength, Stability, Deformity, Acceptance and Function) correlate with function as measured by TESS following endoprosthetic replacement (EPR) for patients with bone sarcoma.

Methods: 255 patients with extremity bone sarcoma treated by resection & EPR were identified from a prospective database. From this group we investigated 111 patients with primary bone sarcoma with > 2 years follow up, evaluated by both MSTS-87 & TESS, no local recurrence, metastasis or major complication for at least 2 years prior to the follow-up. Upper extremity patients were excluded due to small numbers. We examined the influence of patient demographics and tumour characteristics on functional outcome scores. Correlation between MSTS-87 & TESS was performed using linear regression analysis.

Results: Age, gender, tumour size, anatomical site, chemotherapy treatment and presence of pathological fracture did not significantly correlate with TESS. Linear regression analysis of MSTS-87 individual criteria and total score revealed that only pain, ROM and function helped explain the TESS score (p < 0.05) while strength, stability, deformity & acceptance had no significant effect on overall functional outcome.

Conclusions: Of the seven MSTS-87 variables, only pain, ROM and function significantly correlate with overall functional outcome as measured by TESS following EPR for bone sarcoma. This suggests that patients with decreased strength, stability, deformity and acceptance as defined by MSTS-87 scores, may still adapt well with good overall functional outcomes.

A technical goal in total knee arthroplasty is the production of a neutral coronal plane mechanical axis. Errors may produce large mechanical axis deviations precipitating early implant failure. This study sought to test if measured distal femoral resection produced more accurate and consistent coronal alignment than arbitrarily set distal femoral resection.

Data from a cohort of 255 consecutive unselected primary total knee arthroplasties undertaken by the senior author (PM) was collected prospectively and independently assessed. In the first 167 cases distal femoral resection was arbitrarily set to 5 degrees of valgus. In the remaining 88 cases the distal femoral resection angle was determined on a preoperative long leg standing AP radiograph. Postoperative coronal alignment was measured on long leg standing AP radiograph in all cases.

The measured distal femoral valgus angle was between 4 and 7 degrees. An equal number measured either 5 or 6 degrees and accounted for 85% of the total number. Statistically insignificant improvements in mean axis and standard deviation were observed in the measured group: mean axis deviation −0.31 vs −0.51: p=0.17 (independent samples t test) and standard deviation 0.91 vs 1.09: p=0.055 (Levene test).

Acceptable coronal alignment in total knee arthroplasty can reliably be obtained with conventional instrumentation. Improvement in standard deviation with measured distal femoral valgus angle approaches statistical significance.

Bone allograft use in trauma and orthopaedic surgery is limited by the potential for cross infection due to inadequate acceptable decontamination methods. Current methods for allograft decontamination either put the recipient at risk of potentially pathogenic organisms or markedly reduce the mechanical strength and biological properties of bone. This study developed a technique of sterilization of donor bone which also maintains its mechanical properties.

Whole mature rat femurs were studied, as analogous to strut allograft. Bones were inoculated by vortexing in a solution of pathogens likely to cause cross infection in the human bone graft situation. Inoculated bones were subjected to supercritical carbon dioxide at 250 bar pressure at 35 degrees celsius for different experimental time periods until a set of conditions for sterilization was achieved. Decontamination was assessed by vortexing the treated bone in culture broth and plating this on suitable culture medium for 24 hours. The broth was also subcultured. Controls were untreated-, gamma irradiated- and dehydrated bone. Mechanical testing of the bones by precision three-point bending to failure was performed and the dimensions and cross-section digitally assessed so values could be expressed in terms of stress.

Mechanical testing revealed bone treated with supercritical carbon dioxide was consistently significantly stronger than that subjected to gamma irradiation and bones having no treatment (due to the minor dehydrating effect of the carbon dioxide). Terminal sterilization of bone is achieved using supercritical carbon dioxide and this method maintains the mechanical properties.

The new technique greatly enhances potential for bone allograft in orthopaedic surgery.

Deterioration in knee joint proprioception has been postulated to occur following injury, resulting in further instability due to disruption of receptors and feedback mechanisms. Surgical reconstruction techniques may also influence post-operative proprioceptive ability (PA). We hypothesised that anterior cruciate ligament (ACL) reconstruction techniques which disrupt the knee capsule would result in a decrease in PA.

Following ethical approval, a total of 48 subjects (mean age: 28.1 ± 10.5, 34 male, 14 female) undergoing ACL reconstruction surgery were included in the study. Fifteen subjects underwent “open” capsule ACL surgery and patellar tendon graft, whereas 33 subjects had “closed” capsule surgery with a hamstring tendon graft. Knee proprioception was measured on a custom-designed test apparatus incorporating electromagnetic position sensors (Polhemus Fastrack) located on femoral and tibial landmarks to accurately track knee angle during flexion-extension (no load). Leg flexion-extension under partial weight-bearing (5kg) was also evaluated. Pre-operative PA was assessed bilaterally, and then again on operated joints at three, six and twelve months post-op. Proprioceptive ability was measured as the cumulative absolute error in knee angle (°) between five repeat measurements and a target angle.

We observed no significant difference in PA between injured and contralateral knees prior to ACL reconstruction. Post-operatively, no significant difference in PA was observed between “open” versus “closed” ACL techniques, irrespective of loading conditions. While trends indicated that PA during knee extension (no load) and leg flexion (partial weight-bearing) improved over the 12 months compared to pre-operative values in closed ACL surgery, these were not significantly different to open ACL results.

The proportion of subjects whose PA improved in at least two out of the three post-op evaluations was also similar (approx 50%) across all groups, irrespective of joint loading. The only difference was PA during leg flexion under partial weight bearing, where 27% of open ACL surgery patients showed improvement in two or more follow-up tests, as opposed to 58% of closed ACL surgery patients.

We present a method to determine pre- and postoperative PA during knee flexion/extension under no load as well as under partial weight-bearing. We saw no significant difference in PA of the knee under no-load versus load. We also saw no significant difference in postoperative PA following open capsule, patellar tendon graft versus closed capsule, hamstring tendon graft ACL reconstruction technique after 1 year follow-up.

Distraction osteogenesis (DO) is useful for bone lengthening and deformity correction. Unfortunately, this often requires prolonged use of an external fixator with concomitant morbidities. This study investigates whether low-magnitude, high-intensity vibrations (Dynamic Motion Therapy, DMT) can accelerate maturation of regenerate bone in DO, thus reducing the duration of external fixation. 28 NZ White Rabbits underwent a right mid-tibial osteotomy with application of an Orthofix M-103 fixator (Orthofix, Busselengo, Italy). Distraction commenced on day 3 at 0.5 mm every 12 hours for 12 days. All animals were sacrificed on day 45. Animals were randomly assigned into 4 groups:

control group;

DMT was applied with the Juvent platform (Juvent, Somerset, NJ) for 10 minutes/day. X-ray and CT scans were taken prior to mechanical testing. All specimens were processed for histology. X-rays and CT scans showed evidence of cortical remodelling and re-establishment of the medullary canal in animals treated with DMT (groups 2, 3 and 4). This was most pronounced in animals treated during the distraction and consolidation phases (group 4). Regenerate bone in the control group (group 1) was more disorganised, with a delayed union evident in 1 animal. Group 1 achieved peak torque and stiffness values of 70% and 50% of the contralateral (unoperated) tibia respectively. No significant difference was seen in peak torque and stiffness between groups 2, 3, and 4, however each was significantly higher than group 1 (P< 0.05). H& E staining revealed less porosity in the newly formed cortical bone and a more defined medullary canal in animals treated with DMT than in the control group. Low-magnitude, high-intensity vibrations appear to accelerate cortical remodelling and reestablishment of a medullary canal. Regenerate bone in animals treated with DMT was also mechanically superior. The timing of DMT therapy did not appear to be important. Further studies are required to determine the optimal timing and duration of DMT therapy.

Infrapatellar Contracture Syndrome describes a postoperative complication characterised by a vertical migration of the patella due to Patella Tendon (PT) shortening and/or PT adhesion (PTA) formation. We investigated how removal of the central one-third of the PT influences both PT length (LP) and in vitro knee kinematics in 18 sheep divided into 3, 6, 12 and 24 week groups. At time of sacrifice the pelvis-lower extremities complexes were left in a supine position until rigor mortis set in. Limbs were CT-scanned (0.5mm) whilst frozen and LP measured (ProEngineer, PTC, MA). Specimens were fixed into a loading frame with 50N applied to the rectus femoris and knee kinematics obtained (Polhemus, VT). Bones and associated registration block portions of the receiver assemblies were CT-scanned (0.5mm), reconstructed, and imported into ProEngineer where coordinate systems were created in accordance with the Joint Coordinate System (JCS). Registration was accomplished by aligning models of the receiver assemblies with the reconstructed surfaces. Post-processing and statistical analysis (ANOVA) was performed using Matlab (MathWorks, MA) and data referenced to the contralateral controls.

No significant changes in LP were observed. The mean PT length ratio (LP/LC) in the 3 week group was 1.0028±0.004 (mean±SD). In the 6 week group this ratio had increased to 1.0282±0.0246, returning to 1.005±0.0035 at 12 weeks and back to 1.0159±0.0217 at 24 weeks. No PTA’s were observed. A significant proximal shift of the patella reflecting the increase in LP was observed which correlated well with a retardation of patellar flexion (r = 0.880, p< 0.001). A significant decrease in medial patellar tilt was also observed but was not coupled with changes in tibial rotation. Proximal and lateral tibial shifts were also detected.

The results of this study seem to suggest that the changes in knee kinematics and LP induced by removal of the central one-third of the PT do not recover 24 weeks post-operatively.

Introduction: Systematic reviews have found that sitting at work is not associated with LBP, although the biomechanical evidence does offer plausible causative mechanisms. Indeed, exposure to lumbar postures has been assessed using imprecise tools that have limited epidemiological investigations. The aim of this study was to use new technology to measure the seated lumbar postures of sedentary (call centre) workers, and survey their current and future symptoms in order to determine associations with LBP.

Methods: A fibre-optic goniometer (FOG) system was attached to the lumbar spine and hip of 181 sedentary call centre workers at the start of their working shift. The lumbar FOG provides a continuous measure of sagittal lumbar curvature (lumbar position and movement), whilst the hip FOG enables quantification of sitting time. Baseline and 6-month follow-up questionnaires were used to collected symptom data, and logistic regression was used to determine associations between postural and symptom (yes/no) data.

Results: Workers spent a mean proportion of 83% of work-time sitting, with 17% sitting for more than 90 minutes without a break. Current LBP (symptoms lasting more than 24hrs) was associated with a kyphotic (mean lumbar angle> 180°) sitting posture (yes/no) (OR 2.1, 1.1–4.1), although movement (mean standard deviation and angular velocity °sec-1) in sitting was not. Sitting relatively static (AV< 4.26° yes/no) (OR 3.30, 1.06–10.25), using a small amount of range (SD< 10.2° yes/no) (OR 3.79, 1.2–11.7), and adopting a kyphotic posture (yes/no) (OR 2.75, 1.02–7.3) all significantly increased the risk of future LBP.

Discussion: Sitting postures at work are associated with current LBP and are statistically significant risks for recurrence. These results highlight the potential for ergonomic interventions to reduce current symptoms and the risk of future episodes. The findings from this study are novel, and the FOG system should now be used in larger investigations of sedentary risk factors for LBP.

Radiation induced pathologic fractures present a difficult problem for musculoskeletal oncologists. The purpose of this study was to determine the outcomes of management of radiation-induced pathologic fractures in a group of patients who had previously undergone combined management of extremity soft tissue sarcoma.

A review of our retrospective database was undertaken. From 1986 to present, thirty-two patients with soft tissue sarcomas were found to have radiation induced pathologic fractures. The records of these patients were reviewed for patient demographics, tumour size and anatomic site, presence of periosteal stripping at time of surgery, radiation dose, time to fracture, fracture treatment and fracture outcome.

There were twenty-three females and nine males with a mean age of sixty-three (range thirty-six to eighty-nine) years. Fractures occurred at a mean of forty-five months after resection of the sarcoma (range three to one hundred and fifty months). Anatomic distribution of fractures were : proximal femur(twelve), femoral diaphysis (eight), distal femur (two) tibia (five), acetabulum (two), metatarsal (two) and patella (one). Periosteal stripping was performed in half of the patients. Twenty-three patients had received high dose radiation (6600Gy). Seven fractures were managed conservatively while twenty-five were treated surgically. Only eleven of the thirty-two fractures united. Six patients underwent amputation, three for local recurrence and three for non-union of their fracture. Eight patients ultimately underwent arthroplasty, while seven patients have persistent non-unions. In the proximal femur, only three out of twelve fractures healed while six patients eventually underwent arthroplasty and three continue to have non-unions. Of eight femoral diaphyseal fractures, only one united. Patients who eventually underwent prosthetic replacement had good function and pain relief.

Radiation induced pathologic fractures are a difficult clinical problem. In particular patients with fractures in the proximal femur often undergo multiple attempts at fixation before definitive management with resection and endoprosthetic replacement. Fractures of the femoral diaphysis rarely heal despite aggressive surgical management. Primary arthroplasty may be considered in some patients as an alternative to fixation in radiation-induced pathologic fractures of the femur in order to avoid long term morbidity and repeated operations.

The purpose of this study was to evaluate the impact of dalteparin use on transfusion rates and blood loss in patients undergoing primary total joint arthroplasty at our center.

We prospectively studied the transfusion patterns of 1642 patients who underwent primary total hip or knee arthroplasty between January 2004 and December 2005 by five arthroplasty surgeons. The influence of daltaperin use, release of tourniquet in total knee arthroplasty, and the turnover of house staff were analyzed using SPSS V14.0 statistical software.

We identified seven hundred and three total hip and nine hundred and thirty-nine knee arthroplasty patients. The mean haemoglobin drop was statistically significant between 2004 and 2005 (p< 0.001). This was seen in both hip (p=0.014) and knee (p< 0.001) patients. Subgroup analysis of total knee arthroplasty revealed a significant difference in haemoglobin drop between surgeons who released the tourniquet prior to closure compared to release at the end of the case (p=0.005). In addition, there were significant monthly differences that corresponded with the turnover of house staff (p=0.039). Overall, no statistically significant increase in allogeneic transfusion rates was observed between years, months, and individual surgeons.

The use of dalteparin was found to be associated with a significantly increased haemoglobin drop in primary total joint replacement when compared to warfarin. However, the use of dalteparin was not associated with an increase in allogeneic transfusions at our center. The results also suggest that there may be an advantage to releasing the tourniquet and achieving hemostasis prior to closure in knee arthroplasty. Finally, the results emphasise the importance of educating new house staff on methods to reduce intra-operative blood loss and transfusion rates.

Background: Many sedentary workers will experience low back pain (LBP) whilst sitting, and some will believe that work caused their symptoms. They also report that their symptoms can be aggravated or relieved by work. Little is known about sedentary workers’ beliefs about the causes of back pain or symptom modifying factors (SMFs), and this study sought to determine their influence on absence.

Methods: 600 call centre workers completed validated questionnaires concerning beliefs about work-related causes of LBP in sedentary work and SMFs. Three constructs for work-related causes of LBP (physical demands; work environment; work organisation), and three groups of SMFs (physical aggravating; movement relieving; and postural relieving factors) were measured. A 6-month follow-up survey identified workers who did and did not take absence due to LBP. Logistic regression was used to predict future absence.

Results: Results indicated that, on their own, beliefs about the work environment (OR 1.2, 95% CI 1.1–1.4), and work organisation (OR 1.2, 95% CI 1.0–1.3) were significant risks for future absence (P< 0.001). Physical aggravating factors also represented a significant risk (OR 1.3, 95% CI 1.1–1.4, P< 0.001). Perceived physical demands and relieving factors were not significant (P> 0.05). The multivariable model showed that physical aggravating factors accounted for 16% of the variance (OR 1.3, 95% CI 1.1–1.4).

Conclusions: Beliefs about the work environment/organisation and physical aggravating factors are significant risks for future absence, although when considered together, physical aggravating factors dominate. These results highlight the potential for ergonomic interventions to reduce symptom-aggravating aspects of work to reduce absence.

Introduction: This study examined the cohort of patients selectively screened over a 5 year period with ultrasonography according to our risk factors (positive Ortolani or Barlow manoeuvre, breech presentation, first degree affected relative and talipes equinovarus) for developmental hip dysplasia (DDH). The aims were to evaluate the success of those managed in a Pavlik harness and identify predictive factors for those that failed treatment.

Methods: 1181 patients were selectively screened between 1999 and 2004. Of those, 128 patients (189 hips) were identified as having hip instability. Failure was defined as inability to achieve or maintain hip reduction in a Pavlik harness. A proforma was designed to document patients’ risk factors and ultrasound findings at time of initial dynamic ultrasound scan where the senior radiographer and treating consultant were present. Each hip was classified according to Graf type. Acetabular indices were recorded prior to discharge.

Results: All 128 patients with hip instability were managed in a Pavlik harness. This was abandoned for surgical treatment in 9 patients (10 hips) giving a failure rate of 5.3 % (0.17 per 1000 live births). All those successfully managed had an acetabular index of less than 30 degrees at follow up (6 – 48 months). 7 hips in the series were classified as Graf type IV, of these, 6 went on to fail management in a Pavlik harness. 67% of those that failed were also breech presentation compared to 22% of those managed successfully. There were no complications associated with management in a Pavlik harness. 16 patients born within our region presented after 12 weeks of age with DDH resulting in a late presentation rate of 0.3 per 1000 live births.

Discussion: Our overall rate of selective screening is 14 per 1000 live births with a subsequent treatment rate of 2.3 per 1000 is comparable with other centres. Our rate of failure for DDH in a Pavlik harness 0.17 per 1000 live births is an improvement on any previously published results. Irreducible hips, Graf type IV hips and breech presentation correlated with a high likelihood of treatment failure.