Purpose: The aim of our study was to establish the pattern of knee skin temperature following uncomplicated TKA.

Methods and Materials: It was a prospective study that was carried out between 2001 and 2004. A pocket digital surface thermometer was used. A preliminary study established the site and time of temperature measurement.. Patients with an increased risk of infection and those with a contralateral knee pathology or a previous surgery were excluded. Forty-eight patients fulfilled the inclusion criteria and consented to participate; the skin temperature of operated and contralateral knees was measured preoperatively and daily during the first six weeks postoperatively. Measurements were also taken at 3, 6, 12 and 24 months following surgery. During the course of the study, patients developing complications of the operated knee or any pathology of the contralateral knee were excluded.

Results: Thirty-two patients completed the main study. Following surgery, systemic and both knees temperatures increased. Whereas systemic and contralateral knee temperature settled within one week, the operated knee temperature took a longer time. The difference in temperature between the two knees had a mean value of +2.9^oC at 7 days. This mean value decreased to +1.6^oC at 6 weeks, +1.3^oC at 3 months, +0.9^oC at 6 months +0.3°C at 12 months and +0.04°C at 24 months.

Conclusion: Following uncomplicated TKA, the operated knee skin temperature increases compared to the contra-lateral knee. This increase diminishes slowly over several months; however, it remains statistically significant up to 6 months.

We identified patients with a poor outcome by examining cases where nerve conduction studies had been repeated after surgery. 168 patients were identified in whom two sets of tests had been performed. 28 were excluded as either they had no pre-operative studies or had insufficient clinical information. Our study group was 140 patients (174 hands) in whom NCS had been performed before and after surgery, with adequate clinical information. Information on the clinical outcome was obtained from postal questionnaires and from hospital records. A proportion of the hands in which two tests had been performed turned out to have been retested because of presentation with symptoms in the other hand, after a satisfactory outcome from surgery on the first side. This accounted for 44 of the 174 hands, and these were used as control group. 130 hands in 92 patients were identified as having a poor outcome from surgery. Of these, 39 underwent a further operation; two went on to a third procedure. Logistic Regression Analysis was used to analyze the data (Stastica).

There was a trend for the poor results to be more common in the elderly, but age was not a statistically significant factor, (p< 0.36). The good results were found mainly in grades 2 to 5 and this was statistically significant, (p< 0.01). A poorer outcome was seen grouped in grades 0, 1, 2 and 6 and this was statistically significant. (p< 0.01). The NCS have been validated, are reproducible and cost about £15 per study. In the group with good outcome, the grade of severity of NCS improved or remained unchanged in the majority. Of the 39 re-explorations, 17 were found to have incomplete division of the ligament. Of these, 10 showed clinical improvement after re-operation. Of the 22 with no evidence of incomplete division, 7 were improved, 10 had persistent symptoms and 5 were worse after revision surgery.

We believe that pre-operative NCS are helpful for two reasons: Firstly, they provide as a baseline for comparison if the patient has unsatisfactory result following decompression. Secondly, we have shown that they are of prognostic value.

The pathogenesis of osteolysis in failed total hip arthroplasty is not fully understood. The purpose of this study is to identify CD4+CD25+ Regulatory T cells in periprosthetic tissues in failed total hip replacements secondary to osteolysis. Intra-operative tissue samples and peripheral blood were collected from patients undergoing revision total hip arthroplasty surgery. Regulatory T cells were present in the tissues, and significantly increased in the peripheral blood in patients with failed total hips compared to normal controls. Further characterization of these regulatory T cells are warranted as they may play a role in osteolysis in loose total hip replacements.

Osteolysis remains the most common complication following total joint arthroplasty. To date, no authors have investigated the role of CD4+CD25+ regulatory T cells (T_REG) participating in the osteolytic pathogenesis. The purpose of this study is to quantitate the presence of T_REG cells in periprosthetic tissues in failed total hip replacements secondary to osteolysis.

Fifteen consecutive patients booked for revision total hip arthroplasty secondary to osteolysis were included. Tissue samples were collected: peripheral blood (PB), synovial fluid (SF), synovial tissue (ST), and interface tissue (IT) between the failed component and the bone defect. Total lymphocytes were isolated and analyzed using fluorescent-tagged antibody cell sorting (FACS) for the presence of T_REG cells. Frozen sections of ST and IT were analyzed with immunohistochemistry for T_REG cells.

T_REG cells were significantly upregulated (p< 0.01) in the PB (68%) of revision hip patients compared to normal controls PB (44%). In the synovial tissue (ST) and interface tissue (IT), 57% of the lymphocytes isolated were TREG cells. The presence of T_REG cells in the ST and IT were confirmed with immunohistochemistry.

T_REG cells are upregulated in the peripheral blood of patients with failed total hips secondary to osteolysis. The TREG cells are also present in the synovial tissue and interface tissue.

Evidence for involvement of regulatory T cells contribute to our understanding of this complex biologic response to artificial wear particles.

Functional studies of these T_REG cells are warranted as they are upregulated in patients with loose total hip replacements.

Twenty-two patients who underwent thirty-four Kellers’ excision arthroplasty were followed up at an average of thirty-five months. They were assessed using AFAOS, satisfaction and radiological evaluation. The average hallux score was eighty- five (fifty-two to one hundred) while the average lesser toe score was ninety- two (seventy-five to one hundred). The average pain score was thirty- six (twenty to forty) for the hallux and thirty-eight for the lesser toes (twenty to forty). 23/34(68%) had good to excellent, 6/34 (18%) had fair and 5/34(14%) had poor results. The great toe was moderately short, but most patients do not seem to mind this. 91% patients were satisfied with the results.

We undertook a retrospective study of Kellers’ excision arthroplasty done over the last seven years to assess the medium term results.

Twenty-two patients who underwent thirty- four Kellers’ excision arthroplasty were followed up at an average of thirty-five months. They were followed up using the AFAOS, patient satisfaction and radiological evaluation. The average age at the time of surgery was 67.4 years. There were seventeen females (twenty-five feet) and five males (nine feet). All patients underwent bunionectomy along with excision of proximal third of the proximal phalanx. Of these twenty underwent K wire stablization of the hallux following excision.

The average hallux score was eighty- five (range sixty-two to one hundred) while the average lesser toe score was ninety- two (range seventy-five to one hundred). The average pain score was thirty- six (range twenty to forty) for the hallux and thirty-eight for the lesser toes (twenty to forty). 23/34 (68%) had good to excellent, 6/34 (18%) had fair and 5/34(14%) had poor results. The average correction of the hallux valgus was 9o. The average IMT was 25o preoperatively and 18o postoperatively. The average shortening was 7 mm. Complications included two cases of transfer metatarsalgia and two cases of clawing of the lesser toes. One patient developed abscess which settled after incision and drainage. Thirty-one out of thirty-four patients were satis-fied with the final outcome and thirty out of thirty-four patients would have the operation on the other feet.

The great toe is moderately short, but most patients do not seem to mind this. 91% patients were satisfied with the results.

T cells have been implicated in the pathogenesis of osteolysis. The goal of this study was to compare the ratios of CD4+ T cell populations in total hip arthroplasty (THA) patients with and without osteolysis. We found no significant differences in the frequency of peripheral blood CD4+CD25+ regulatory and effector T cells, serum IL-10 and TGF-β concentrations, and immuno-suppressive ability of regulatory T cells from patients with osteoarthritis prior to THA, and THA patients with and without radiographic evidence of osteolysis.

CD4+ T cells are critical in regulating immune-mediated conditions. This study compared the frequency of CD4+ T cell subpopulations in the peripheral blood of patients with and without osteolysis following total hip arthroplasty (THA).

Numbers of CD4+CD25hi regulatory T cells, CD4+CD25moderate effector T cells, and CD4+CD25+ T cells in the peripheral blood of thirty patients with osteoarthritis prior to primary THA, thirty patients with asymptomatic THAs and no radiographic evidence of osteolysis, nineteen patients with asymptomatic THAs with radiographic evidence of early osteolysis (not requiring revision surgery) and nine patients scheduled for revision THA for osteolysis were determined by flow cytometry. Serum IL-10 and TGF-β levels were measured using ELISA kits. Results were compared by t-test and rank sum test. CD4+ CD25hi regulatory T cells and CD4+ CD25neg T cells were isolated from blood using a MACS cell isolation kit, co-cultured for three days, and T cell proliferation determined by [3H]-thy-midine uptake.

The frequency of CD4+CD25hi regulatory T cells, CD4+CD25moderate effector T cells, and CD4+CD25+ T cells were similar in each study group. Regulatory T cells from patients with and without osteolysis had a normal functional ability to inhibit CD4+ T cell proliferation. Serum levels of the regulatory T cell-derived cytokines IL-10 and TGF-β were also comparable between groups.

Our data suggests that CD4+ T cell immune responses are normal in THA regardless of the level of osteolysis, in contrast to previous studies that have implicated T cell hypersensitivity in the pathogenesis of osteolysis surrounding THA.

We undertook the current study to analyze the factors involved with failed previous stabilization surgery for patients with anterior or anteroinferior glenohumeral instability. Between 1997 and 2003 we treated seventy-four patients with traumatic unidirectional instability. The average age was thirty-two and the average follow up was fifty-eight months. There were sixteen females and fifty-eight males. All patients underwent a primary diagnostic arthroscopy followed by arthroscopic stabilization in forty-seven and open stabilization in twenty-seven cases. Ten had a recurrence of instability. Of these two had significant trauma. Of the remaining, six were in the arthroscopic group and two in the open procedure group.

Analyze the factors involved with failed previous stabilization surgery for patients with anterior or anteroinferior glenohumeral instability.

Between 1997 and 2003 we treated seventy-four patients with traumatic unidirectional instability. The average age was thirty-two years (range nineteen to forty-seven). There were sixteen females and fifty-eight males. The average follow up was fifty-eight months (range seven to eighty-three). All patients underwent a primary diagnostic arthroscopy followed by arthroscopic stabilization in forty-seven and open stabilization in twenty-seven cases. The arthroscopic procedure involved two Suretac II labral reattachment and capsular shrinkage using electrocautery. The open procedure involved a Bristow/Latarjet procedure using a delto-pectoral approach and reattachment of coracoid process using a single malleolar screw.

Ten patients had a recurrence of instability. Of these two had significant trauma, one each group. Of the remaining eight, six were in the arthroscopic group and two in the open procedure group. In the arthroscopic recurrence group, three had a large Hill Sach’s lesion and one a large Bankart Lesion. In the open procedure group, both had a large Hill Sach’s and Bankart’s lesion. This gave a recurrence rate of 12.7% in the arthroscopic group and 7.4% in the open group.

A large Hill-Sach lesion > 2mm is a contra-indication to arthroscopic repair and the optimum stabilisation procedure is an open repair (Bristow/Laterjet). Without a significant Hill-Sach’s lesion an arthroscopic Suretac II labral re-attachment is an effective way of achieving stability. Those who have a large Hill-Sach and significant Bankart’s lesion may need a combination of Bankart’s repair plus an extra-articular procedure like a Bristow/Laterjet procedure.

Aims: The aims of this study were to evaluate the biomechanical properties and mode of failure of 4 methods of fixation used for hamstring tendon ACL grafts. The fixation methods investigated included titanium round headed cannulated interference (RCI) screws, bioabsorbable RCI screws, Endobuttons and Bollard fixation. It has been previously shown that a 2 strand tailored equine tendon-Soffix graft has equivalent biomechanical properties to a 4 strand human hamstring tendon-Soffix graft [1,2], therefore this model was used for the graft in the study.

Materials and Method: 32 stifle joints were obtained from skeletally mature pigs, the soft tissues were removed and the ACL and PCL were sacrificed. Tibial tunnel preparation was standardised using the Mayday Rhino horn jig to accurately position a guide wire. An 8 mm cannulated reamer was then used over the guide wire to create the final tibial tunnel. A back radiusing device was then placed into the tibial tunnel to chamfer the posterior margin of the tunnel exit to prevent abrasion and fretting of the graft. A 2 strand equine tendon-Soffix graft was then introduced into the tibial tunnel and secured with one of the four fixation methods. The proximal part of the graft was attached to the cross head of the materials testing machine using the Soffix. Five of each method of fixation were tested mechanically to failure and three of each method were cyclically loaded for 1000 cycles between 5 to 150 N, followed by 2000 cycles at 50 to 450 N.

Results: The mean ultimate tensile loads (UTL) were: titanium RCI screw = 444 N, bioabsorbable RCI screw = 668 N, Endobutton = 999 N and Bollard = 1153 N. The mode of failure for all RCI screws involved tendon slippage past the screw. Two Endobutton failures were encountered and one Bollard pull out occurred. Under cyclic loading conditions the titanium and bioabsorbable RCI screws failed rapidly after several hundred 5 to 150 N cycles due to tendon graft damage and progressive slippage. Both the Bollards and Endobuttons survived 1500 cycles at 50 to 450 N, with less tendon slippage occurring.

Conclusion: Titanium and bioabsorbable RCI screws provide poor initial fixation of tendon grafts used for ACL reconstruction, having significantly lower UTL’s than both Endobutton and Bollard fixation. Under cyclic loading titanium and bioabsorbable RCI screws fail rapidly due to progressive tendon slippage, whereas Bollards and Endobuttons survive cyclic loading. Both Bollard fixation and Endobuttons provide sufficiently high UTL’s and survive cyclic loading to allow early postoperative mobilisation and rehabilitation. Caution must be used in the early postoperative period when using interference screws to secure a hamstring tendon graft because progressive tendon slippage may result in excessive graft elongation and early clinical failure.

Aim: To identify the variables associated with poor radiological outcome in the distal radius fractures stabilized with K wires.

Materials & Methods: All the patients who underwent K wire fixation of distal radius fracture in last 3 years were included in this retrospective study. AO Classification was used to classify the fracture. Immediate post fixation radiographs and radiographs taken just prior to removal of K wires (5–6 weeks) were analyzed to study three radiological parameters (dorsal tilt, radial tilt, ulnar variance). Changes in these parameters were recorded. Results were graded as excellent, good, fair and poor according to the Stewart classification. The results were analyzed against variables like age, sex, AO classification, associated ulnar fracture, number of k wires used, delay in fixation and duration of fixation. Statistical tests were performed to find out variables associated with the poor radiological outcome.

Results: 113 distal radius fractures were analyzed in total. Average age of patients was 56.2 years (standard deviation-19.9) with male to female ratio of 1:2.1. Average loss of radial tilt was 4.12 deg, loss of dorsal tilt was 8.07 deg and change in the ulnar variance was 3.12 mm. We found excellent results in 23.9 %, good result in 56.6%, fair results in 15 % and poor results in 4.4 % of patients.

Age more than 65 years (p value 0.006), comminuted distal radius fracture [A3 or C3 in AO classification] (p value 0.049) and associated ulnar fracture (p value 0.013) were the variables found to have statistically significant correlation with poor radiological outcome.

Conclusion: Age more than 65, comminuted distal radius fracture and associated ulnar fracture are the variables associated with poor stability of K wire fixation in distal radius fracture. Alternative mode of stabilization should be considered to improve the stability of the fracture fixation in these patients.

Introduction and Aims: This study was undertaken to assess the long-term results of treatment of clubfoot by modified Turco’s Procedure.

Method: Thirty patients with 50 feet were treated by serial casting and postero-medial release for clubfeet, by modified Turco’s procedure. Eighteen patients with 33 clubfeet were available for the final follow-up. They were followed up for an average of 13.8 years, range of 10–16 years. There were two females and 16 males. All patients underwent serial plaster correction after birth until undergoing surgical correction. All procedures were carried out by the senior surgeon, using the same technique.

All patients were operated between the ages of 6–9 months. A modified Turco’s technique was used. A longer incision extending to the lateral border of tendo-achilles was used. The abductor hallucis was completely excised. No K wire was used for holding the correction. All children were left in plaster till they started walking. A modified splint and correction shoes were used in the post-operative period. There were no wound problems in any cases, either at the time of wound closure or later on.

Results: Patients were followed with clinical and radiological examinations. Three (9%) cases each had recurrence of heel varus and forefoot adduction. Three cases had some cavus deformity, while four cases had flat foot. All patients were noted to have calf muscle wasting. The results were assessed using Ponsetti’s score. The average Ponsetti score was 87.2 (range 49–98). Two feet out of 33 had recurrence of all the deformities. There were 27 good to excellent results. The most common problem was terminal restriction of dorsiflexion, but most of the patients were happy with the results. We believe that our treatment is safe and simple, giving satisfactory results in more than 80% and with minimal complications. The results are maintained over a long follow-up period.

Conclusion: We think that this modified approach helped reduce recurrence of one of the common deformities.

Introduction: Metal-on-metal hip resurfacing arthroplasty is one option for young and active patients with advanced hip disease. Intraoperative or immediate postoperative femoral neck fractures complicating a metal-on-metal hip resurfacing is a well described complication as a result of neck notching and stress shielding of the femoral head. The literature contains very little evidences on the conservative mode of treatment for peri-prosthetic fractures following the index operation with a favourable and an unfavourable outcome. We report a case of femoral neck fracture incurred three months after metal-on-metal hip resurfacing resulting in a varus malunion.

Case report: A 55 year old lady underwent metal-on-metal surface hip replacement for advanced osteoarthritis of the left hip. The implants used were Cormet 2000 uncemented 50mm dual coated cup and cemented 44mm femoral head. Intraoperative bone quality was good and no technical difficulties were encountered. She was admitted three months later with a painful left hip after sustaining a fall. The radiograph confirmed left periprosthetic femoral neck fracture with resurfacing prosthesis in situ. She was scheduled for elective revision surgery of the femoral component. The patient elected to go home with the intention of getting readmitted. Initially lost to follow-up, she self referred after 30 months of her fracture with shortening and persistent painful limp. The clinical examination revealed 1.5 cm of true limb shortening with restricted terminal range of abduction and rotational movements. The radiographs revealed a varus malunited fracture with proximal migration of greater trochanter. The acetabular component was well fixed in situ. She is awaiting revision surgery by conversion to conventional total hip arthroplasty.

Conclusion: We report the first case of a malunited femoral neck fracture following metal-on-metal hip resurfacing operation. Femoral neck fractures can heal in these cases but poor compliance and resultant failure to closely observe the patient may have contributed to such an unfavourable outcome. These complications may be prevented by increased compliance and communication with the patients. At the same time, the hospital management and professional staff should be aware of such potential problems to prevent their recurrence.

Aim of presentation: We present a case of patellar metastasis from lung carcinoma resulting in pathological fracture.

Material and methods: A 66 years old man with a clinical diagnosis of carcinoma of lung presented with complaints of severe pain in his right knee after a minor injury. Radiograph revealed undisplaced fracture of patella through a lytic area. A fine needle biopsy was done which showed infiltration of bone by non-small cell carcinoma consistent with origin in lung. Patient was treated conservatively in a splint and received local radiotherapy for pain relief. The fracture healed clinically and radiologically in six weeks time inspite of increase in the size of tumour on x-rays.

Conclusion: Patella is a rare site of metastasis. Mercury et al reviewed the literature from 1900 to 2000 and reported about 15 cases of patellar metastasis from lung carcinoma. Pathological fractures are even rare. This case is presented as a rare case of pathological fracture of patella.

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

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

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

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

Aims: The aims of this study were to evaluate the biomechanical properties and mode of failure of four methods of fixation of hamstring anterior cruciate ligament (ACL) grafts. A 2-strand equine extensor tendon graft model was used because a previous study has shown it to have equivalent biomechanical properties to that of 4-strand human semitendinosus and gracilis tendon grafts. Method: Twenty stifle joints were obtained from 10 skeletally mature pigs, the soft tissues were removed and the ACL and PCL were sacrificed. Tibial tunnel preparation was standardised using the Mayday rhino horn jig to accurately position a guide wire over which an 8mm tunnel was drilled. A 2-strand equine tendon graft was then introduced into the tibial tunnel and secured with either a titanium round headed cannulated interference (RCI) screw, a bioabsorbable RCI screw, an Endobutton or an expansile Bollard. Five of each method of fixation were tested mechanically to ultimate failure and under cyclical loading. Results: The mean ultimate tensile loads (UTL) were: titanium RCI screw = 444 N, bioabsorbable RCI screw = 668 N, Endobutton = 999 N and Bollard = 1153 N. Under cyclic loading conditions the titanium and bioabsorbable RCI screws rapidly failed after several hundred 5 to 150 N cycles due to tendon damage and slippage. Both the Bollards and Endobuttons survived 1500 cycles at 50-450N, with less tendon slippage. Conclusion: Titanium and bioabsorbale RCI screws provide poor initial fixation of tendon grafts and fail rapidly under cyclic loading. Both Bollards and Endobuttons provide sufficiently high UTL’s and survive cyclic loading to allow early postoperative rehabilitation.

All supracondylar humeral fractures managed with closed or open reduction and pin fixation at the Hospital for Sick Children between 1995 and 2002 were retrospectively reviewed. Time from injury to treatment, post reduction complications and need for open reduction were recorded. Fractures treated ≥ 8 hours from injury were considered in the early treatment group while > 8 hours were considered in the late treatment group. Fractures presenting with a cold hand (four patients) were taken to the operating room as quickly as possible and were excluded from the study.

There were 431 patients with a Gartland grade 3 and 141 patients with a Gartland grade 2b. The time from injury to surgery ranged from 2 hours to 13 days. The average time to reduction was 12 hours for grade 3 injuries and 21 hours for grade 2b injuries. None of the patients had an initial closed reduction in the emergency department. The early treatment group consisted of 230 patients with two compartment syndromes, six ulnar-, one superficial radial-, one median- and one radial nerve palsy, one septic arthritis, one pin site infection, six open reductions and one re-manipulation was required for loss of reduction. The late treatment group consisted of 342 patients with six ulnar-, three median-, one radial nerve palsy and one lateral cutaneous nerve of the forearm palsy, three pin site infections, five open reductions and re-manipulation was required in one patient. All nerve palsies recovered post-operatively.

Conclusion: There was no significant difference in the proportion of complications between the early and late treatment group, but the most severe complication, the development of a compartment syndrome was only seen in the early group. Delayed treatment of supracondylar humeral fractures seems to be safe in a large number of patients, and in fact, most of our patients were treated more than eight hours from the injury. Early operation of fractures not associated with a neurovascular compromise also does not seem to reduce the complication rate. Nevertheless the decision when to operate needs to be decided for each patient individually.