Introduction: Acetabular cup inclination is associated with higher wear in both UHMWPE and ceramic-on-ceramic hips. It has also emerged recently as a critical factor in the success of hip resurfacing. A direct correlation between socket inclination and serum metal ion levels has been demonstrated and concerns remain regarding edge loading and hypersensitivity. Resurfacing socket designs vary and manufacturers do not recommend specific inclination angles for their products. The aim of this study was to investigate the effect of cup geometry on the effective inclination for a variety of different designs of resurfacing socket.

Methods: The internal geometry of every available size of Birmingham Hip Resurfacing(BHR-Smith & Nephew), ASR(DePuy) and MITCH TRH(Stryker) socket was measured using X-ray templates. This data was used to calculate the difference between the apparent inclination and the true inclination for all sockets.

Results: BHR and MITCH TRH cups have lateralised internal geometries in that the centre of the internal surface is lateralised by 3.5mm in the case of the BHR and varies from 2 to 3.8mm in the MITCH TRH system. The ASR is concentric but the bearing surface is less than a hemisphere and there is also an internal groove which further reduces the bearing surface. The difference between apparent and true inclination was greatest in the ASR socket (13o–18 o) followed by the BHR (7o–10o) and then the MITCH TRH (6o–8o). This difference increased with decreasing socket size in both the BHR and ASR but was more or less constant in the MITCH TRH.

Conclusion: These results show that a socket measured at 45o of inclination may have a true inclination of up to 63o. This has important implications for surgeons who should have full knowledge of the design geometry of the socket being implanted and adjust the inclination angle accordingly.

Introduction: Total hip replacement (THR) in young patients is a controversial subject due to high failure rates reported in the literature. The purpose of this study was to show our short term results of primary total hip replacement in patients younger than 30 years of age.

Methods: Patients who underwent THR prior to the age of 30 years between 1998 and 2007 were identified and records of all patients were reviewed together with the radiographs till the last follow up.

Results: Forty three THRs were performed on 36 patients with an average age of 24.4 years (range, 17–30) and an average follow up period of 47 months (range, 7–109 months). There were 5 cases of Juvenile chronic arthritis, 2 Rheumatoid arthritis, 11 DDH, 2 septic arthritis, 1 pseudoachondroplasia, 4 Perthes disease, 2 seronegative arthitides, 2 SUFE and 7 AVN [alcohol, leukaemia, fracture, SLE (2), mannosidosis, idiopathic].

Thirty cemented THRs and 13 hybrid THRs were performed through trochanteric osteotomy approach (23), posterior approach (17), Hardinge approach (2) and anterior approach (1). In the cemented group there were 3 cases of superficial wound discharges, 1 recurrent dislocation, 1 complete femoral nerve palsy, 2 cases of neuropraxia and 1 case with persistent hip pain but no cases of infection. In the hybrid group there was one case of partial femoral nerve palsy. None of the patients has undergone any revision surgery till the latest follow up. Radiologically only one case showed aseptic loosening in both femoral and acetabular components, which is not revised as the patient is asymptomatic.

Discussion: THR is an elegant procedure and should be certainly considered in young patients suffering with disabling arthritic conditions affecting the hip joint. Our results show that THR - both cemented and hybrid types - is a successful and durable treatment.

Introduction: The clinical results of the modular Charnley Elite total hip system have been the subject of some interest in recent years. Some studies have shown significant subsidence and rotational instability in stems when used with low-viscosity cement. These unstable stems have been shown to fail early. The purpose of this study is to demonstrate our conflicting clinical results.

Materials and Methods: 616 modular Charnley Elite total hip arthroplasties were inserted between 1995 and 2002 at Wrightington Hospital, which is a tertiary referral centre and centre of excellence for joint replacement in United Kingdom. Both Consultants and trainees performed operations and a variety of surgical approaches were used. Normal viscosity bone cement was used in all patients. All patients were followed up prospectively.

Results: At mean follow-up of 8 years (range 5–12), 471 hips were available for review. 87 patients had died and 12 were lost to follow-up. 2.7% (13 cases) of femoral components and 2.9% (14 cases) of acetabular components had been revised for aseptic loosening. 10 hips (2.1%) underwent revision for deep infection and 2 (0.04%) for recurrent dislocation. The overall survival with aseptic loosening as an end point was 97% and for revision for any reason was 94.5%.

Conclusion: Our results show acceptable clinical survivor-ship for this implant when used with standard viscosity cement. This contrasts with the lower survivorship rates published by other centres. Our result should reassure patients and surgeons alike that this prosthesis can be associated with acceptable results in the medium term.

Leg length discrepancy (LLD) following total hip arthroplasty (THA) is a well-known and documented phenomenon. LLD can pose a substantial problem for both the patient and the surgeon. Patient dissatisfaction with LLD after THA is the most common reason for litigation against orthopaedic surgeons. Failure to restore limb length may lead to an unstable hip, whereas over-lengthening may cause low back pain, sciatic nerve palsy and early mechanical loosening.

Several intra operative techniques both invasive and non invasive have been reported in the literature to over-come LLD during THA. The accuracy of all the methods that measure from pins anchored into pelvis to point on the greater trochanter may be affected by the inherent variability of the leg position when measurements are made. Bending or dislodging the pins and using of calliper devices can be cumbersome during the THA surgery and can compromise the measurements.

Hence we describe a simple, safe and reliable intra operative technique to overcome LLD by using a stout braided suture material tied to the stout Judd pin used to retract the soft tissues in posterior approach. Utilising the routine incision for the posterior approach to the hip, this technique can be easily carried out in primary THA surgery as compared to other techniques used to avoid LLD, which require further incision, and specialised equipment which are time consuming, cumbersome and may not be very secure. This technique of using a suture mark over the Judd pin is simple, inexpensive and easily adaptable.

Introduction: The Birmingham Hip Resurfacing(BHR) has shown encouraging early to medium term results. It has tended to be used in patients wishing to achieve high functional activity. However there is little data available to support this notion. The purpose of the study was to report the functional levels of patients following BHR.

Methods: Since February 2000, 313 patients have undergone resurfacing by the senior author. Two hundred and sixty four patients with a minimum 12 month follow-up were assessed for functional activity using the modified UCLA activity score. Patients were asked to score their activity level during the pre-symptomatic period as well as pre-operatively and during follow-up.

Results: The mean age at surgery was 55.7 years. The mean follow-up period was 46.72 months. The revision rate for any reason was 3.8%. The mean pre-symptomatic, pre-operative, one year post-operative and final follow-up UCLA scores were 7.9, 3.7, 6.6 and 7.0 respectively. At one year 89% (235 patients) had improved by at least one activity grade from pre-operative levels and 35% (93 Patients) achieved functional scores the same as, or better than their pre-symptomatic levels. This increased to 45% at final follow-up. Of the 242 patients previously involved in moderate activity(UCLA> =5), 31% regained this activity level at one year, rising to 40% at last follow-up. Only 19% of the 180 patients participating in very active/impact sports(UCLA> =8) obtained these levels at one year, rising to 30% at last follow-up.

Conclusion: This is the first assessment of function after BHR comparing pre-symptomatic scores with those obtained during follow-up. Functional scores continue to improve beyond one year in all groups. Significant numbers of patients can achieve functional levels at least as good as before they developed symptoms from their hip, however, the proportion of patients achieving this goal reduces with increasing pre-symptomatic activity.

Introduction: Hip Resurfacing has increased in popularity, particularly in young, active patients. However, concerns remain regarding metal ion levels, hypersensitivity leading to aseptic lymphocytic-vasculitis-associated lesions(ALVAL) and AVN. The purpose of this study was to document our experience of revising resurfacing arthroplasty for ALVAL.

Methods: All patients undergoing conversion of hip resurfacing to total hip replacement at our institution were reviewed. The notes were reviewed for the reason for revision, the make of the implant, time interval between primary procedure and revision and final diagnosis. Radiographs were reviewed to assess for implant alignment, signs of loosening, neck thinning and AVN.

Results: Out of the 34 patients who had revision surgery 13 were revised for suspected ALVAL, with mean age of 58.8 years at a mean 42.9 months following primary surgery. Of the 13 resurfacings revisions 11 were Birmingham resurfacing and 1 each of Cormet and ASR resurfacing. Groin pain was the presenting complaint in all patients, 5 patients developed their symptoms immediately postoperatively whilst 8 developed symptoms at mean 28.25 months. Haematological investigations were non-diagnostic. Radiographs were normal in 4 patients, whilst 4 demonstrated a loose cup. Thinning of femoral neck and vertical cup alignment were present in 2 patients each while 1 patient had both vertical cup and thinning of femoral neck. All revisions were achieved with primary implants and all patients had immediate pain relief after surgery. Implants and tissue were sent for laboratory analysis. 3 patients had a confirmed histological diagnosis of ALVAL, the remaining cases had identical operative findings and are presumed ALVAL.

Discussion: ALVAL accounts for nearly 1/3 of all our revisions for failed resurfacing arthroplasty. Unexplained pain in patients with resurfacing arthroplasty should be considered for a diagnosis of ALVAL and investigated appropriately. Symptoms tend to resolve reliably following conversion to total hip arthroplasty.

Introduction: Revision arthroplasty using the impaction grafting technique is an increasingly popular technique. The lost bone stock is replaced rather than substituted with ever increasing amounts of metal. There have been many advances in the understanding of this technique in recent years. It has recently been shown that washing of the graft improves the biomechanical strength, bony ingrowth and biocompatibility of morsellised allograft bone. The aim of this study was to identify the most efficacious method of washing morsellised allograft in the operating room.

Methods: Fresh frozen femoral heads identified for research purposes were randomly divided into four groups. Group A was washed using a serial dilution technique at 37°C, group B serial dilution at 60 °C, group C pulsed lavage wash at 37°C and group D pulsed lavage wash at 60 °C. Three-gram samples of each femoral head were taken prior to washing. The heads were then washed according to the grouping. The unwashed and washed morsellised bone was then assessed for the presence of protein, haemoglobin, DNA and lipid using spectrophotometric analysis techniques. The removal of these marrow components from the femoral heads in each group was assessed as a proportion of the original content.

Results: All washing techniques removed a large proportion of the marrow load of the femoral heads. The most efficacious technique was washing by serial dilution (removal rate 67.5–87.4%). Washing by pulsed lavage removed less marrow (28.4–80.9%). Protein showed the highest removal rate (80.9–86.4%) and haemoglobin the lowest (28.4–67.5%). Removal of lipid was most affected by temperature with a larger proportion removed at 60°C as compared to 37°C.

Conclusion: We conclude that the most efficient method of washing morsellised allograft bone for impaction grafting is by serial dilution with fluid at 60°C. This information should improve the results of impaction grafting, as it is known that cleaner bone results in improved biomechanical stability, enhanced biological compatibility and accelerated bony ingrowth.

Introduction: Freezing and storage of fresh frozen femoral heads destined for use in revision hip arthroplasty is thought to result in graft cell death. Washing of the graft following the morsellisation process also removes a large proportion of the marrow content of the allograft. However, the immunological load of the impaction allografting process remains unknown. The aim of this study was to investigate the immune response by observing any changes in peripheral blood lymphocyte subsets in response to allografted bone used in revision hip replacement

Methods: 87 patients were entered into this prospective study and grouped according to whether impaction allograft was used or not. Venous blood samples were collected pre-operatively and at set time intervals up to one year post-operatively. Using flow cytometry, analysis of venous blood allowed counts of the following cells: Helper T-lymphocytes, cytotoxic T-lymphocytes, memory T-lymphocytes, naïve T-lymphocytes, Natural Killer cells and B-lymphocytes.

Results: All patients had a successful outcome at one year. 50 patients with radiologically defined host-graft union were compared with 37 patients who did not receive allograft. Pre-operatively, a significant difference (p=0.03) was found between the groups of patients with respect to Natural Killer cells but other subsets showed no significant difference. Post-operatively the significant difference between Natural Killer cells resolved. T-helper lymphocytes, cytotoxic lymphocytes, memory T-lymphocytes and naïve T-lymphocytes in both groups showed decreases in values immediately post surgery, recovering to normal values within 6 weeks post-surgery. The allograft group showed significant increases from baseline in cytotoxic T-lymphocytes at 6 months (p< 0.01) and memory T-lymphocytes one year postoperatively (p=0.04). B-lymphocyte numbers did not alter significantly from baseline.

Conclusion: Cytotoxic T-lymphocytes recognise HLA-class I molecules which are present on all nucleated cells and have been implicated in having a role in osteoclast regulation. Memory T-lymphocytes are produced after a naïve T-lymphocyte is exposed to an antigen. The observed increases of these subsets were not observed in the non-grafting group suggesting the allografted bone had elicited an immunological response. At 12 months all grafts appeared radiologically stable and the immunological response may have been beneficial to the outcome.

Impaction grafting with morsellised allograft is becoming the treatment of choice for revision arthroplasty, especially in the younger patient. The optimum treatment of the graft prior to impaction has not been determined. Some groups wash the graft prior to impaction and others do not. Washing of graft has been shown to enhance bone ingrowth in an animal model, however the reasons for this remain unclear. The aim of this study was to identify any underlying cellular cytotoxicty of fresh frozen allograft bone before and after washing.

Paired samples of washed and unwashed morcellised FFH allograft were taken during revision hip arthroplasties. Washing was performed by 4 consecutive rinses in 300ml warmed saline, the bone being filtered between each exchange of saline. Contact cytotoxicity assays involved culture of cell lines in direct contact with bone samples. Quantitative cytotoxicity assays utilised culture media conditioned with the bone samples and subsequent assessment of cell metabolism and viability using both dimethylthiazol (MTT) and neutral red (NR) assays. Assays were performed with human osteoblastic (MG63) and fibroblastic (HSF) cell lines.

Nine pairs of samples were analysed. Contact assays demonstrated a clear zone of cellular inhibition around the unwashed bone samples. Quantitative assays were performed in triplicate for each cell type and both MTT and NR assays giving 108 paired assay results. 88.9% of pairs (92/108) showed cytotoxicity in the unwashed sample. No washed samples demonstrated cytotoxicity. When grouped by assay and cell type, analysis of means showed statistically significant differences between washed and unwashed samples in MG63-NR (p=0.0025), HSF-NR (p=0.0004) and MG63-MTT (p=0.008). The difference observed in the HSF-MTT assays did not reach statistical significance (p=0.06).

Unwashed FFH allograft can be cytotoxic to human osteoblastic and fibroblastic cell lines in vitro. This suggests that allograft should be washed prior to impaction in order to optimise the biological compatibility.

Introduction: The long term success of impaction grafting depends on the remodelling process during incorporation. This project was designed to characterise any differences in the biochemical markers of bone turnover following revision hip arthroplasty performed with or without impaction grafting.

Methods: 87 patients undergoing revision hip arthroplasty were entered into this prospective study and grouped according to whether impaction allograft was used or not. Biochemical markers of bone turnover were assessed pre-operatively and post-operatively on day 2, day 9, week 6, 6 months and 1 year. Osteocalcin, pro-collagen type-I N-terminal propeptide and bone specific alkaline phosphatase were measured as bone formation markers. C-telopeptide, pyridinoline and deoxypyridinoline were measured as bone resorption markers.

Results: All patients had a successful radiological and clinical outcome at one year. 50 patients with radiologically defined host-graft union were compared with 37 patients who did not receive allograft. Markers of bone formation tended to rise by day 9 but the rise in osteocalcin was delayed in the graft group and was significantly lower at 6 months in comparison to the non-graft group (p=0.002). Alkaline phosphatase levels remained significantly elevated at one year in the graft group (p=0.027) whilst levels in the non-graft group had normalised. Markers of bone resorption also rise in both groups but with no significant differences between the groups.

Discussion: Following impaction grafting, new bone formation may be delayed in comparison to revisions performed without graft. The pattern of markers of bone resorption did not differ significantly between the groups suggesting that there is no large scale resorption of the impacted allograft in these cases.

These results provide a biochemical insight into the bone formation and bone resorption processes during allograft incorporation.

Movement of the limb during computer aided arthroplasty may cause soft tissue impingement on the reference marker(RM) and consequently alter the spatial relationship between RM and bone with resulting inaccuracies in navigation. The purpose of this study was to investigate the effect of different degrees of soft tissue dissection on the stability of reference markers during limb movement.

The stability of both one- and two-pin RM systems inserted using three different levels of soft-tissue dissection was analysed in relation to a super-stable RM in fresh cadaver lower limbs. The spatial relationship of the two RMs was analysed using the VectorVision® system (BrainLAB, Germany) during multiple repetitions of four predefined limb movements. All tests were done with RMs inserted in both the distal-anterior femur and distal-lateral femur.

Analysis of movements of the test RM in relation to the super-stable RM showed that rotations of less than 0.15o and translations of less than 0.4mm occurred in most test combinations. The combination that showed the greatest instability was when a stab incision was used to insert a pin in the distal/lateral femur (translation 0.73mm+/− 0.05, rotation 0.25o+/− 0.05)(p< 0.001). This instability occurred in both single and double pin RMs(p=0.21).

RM pins can be placed in the anterior distal femur through simple stab incisions without resulting in significant soft tissue impingement during limb movement. If pins are placed in the lateral distal femur through stab incisions, impingement may occur from the fascia lata. Release of the fascia lata 1cm either side of the pin prevents significant impingement. Wide skin incision is unnecessary in any location.

Fresh frozen femoral head (FFH) allograft is commonly used in impaction grafting for revision hip arthroplasty and long term success has been demonstrated by some groups. The optimum treatment of the graft prior to impaction has not yet been determined. Some groups wash the graft prior to impaction and others do not. Washing of the graft has been shown to improve bone ingrowth in a bone chamber animal model however the reasons for this remain unclear. The aim of this study was to identify any underlying cellular cytotoxicty of fresh frozen allograft bone before and after washing.

Samples of morcellised FFH allograft were taken during revision hip arthroplasties prior to impaction grafting. Paired samples, taken before and after washing were taken from each case. Washing was performed by 4 consecutive washes in 300ml warmed saline, the bone being filtered between each exchange of saline. Cytotox-icity was assessed for all samples using both contact and extract assays. Contact assays involved culture of cell lines in direct contact with bone samples. Extract assays utilised culture media conditioned with bone samples and subsequent quantitative assessment of cell metabolism and viability using both dimethylthiazol (MTT) and neutral red (NR) assays. All assays were performed using both human osteoblastic (MG63) and fibroblastic (HSF) cell lines.

Nine pairs of samples were analysed for cytotoxicity using both cell lines. Contact assays demonstrated a clear zone of cellular inhibition around the unwashed bone samples. Extract assays were performed in triplicate for each cell type and both MTT and NR assays giving 108 paired assay results. 88.9% of pairs (92/108) showed cytotoxicity in the unwashed sample. No washed samples demonstrated cytotoxicity. When grouped by assay and cell type, analysis of means showed statistically significant differences between washed and unwashed samples in MG63-NR (p=0.0025), HSF-NR (p=0.0004) and MG63-MTT (p=0.008). The difference observed in the HSF-MTT assays did not reach statistical signifi-cance (p=0.06).

In conclusion, we have shown that unwashed FFH allograft can be cytotoxic to human osteoblastic and fibroblastic cell lines in vitro. This suggests that allograft should be washed prior to impaction in order to optimise the biological compatibility.

Introduction: The long term success of impaction grafting depends on the remodelling process during incorporation. This project was devised to characterise any differences in the biochemical markers of bone turnover following revision hip arthroplasty performed with or without impaction grafting.

Methods: 87 patients were entered into this prospective study and grouped according to whether impaction allograft was used or not. Biochemical markers of bone turnover were assessed pre-operatively and post-operatively on day 2, day 9, week 6, 6 months and 1 year. Osteocalcin, procollagen type-I N-terminal propeptide and bone specific alkaline phosphatase were measured as bone formation markers. C-telopeptide, pyridinoline and deoxypyridinoline were measured as bone resorption markers.

Results: All patients had a successful outcome at one year. 50 patients with radiologically defined host-graft union were compared with 37 patients who did not receive an allograft. Markers of bone formation tended to rise by day 9 but the rise in osteocalcin was delayed in the graft group and was significantly lower at 6 months in comparison to the non-graft group (p=0.002). Alkaline phosphatase levels remained significantly elevated at one year in the graft group (p=0.027) whilst levels in the non-graft group had normalised. Markers of bone resorption also rise in both groups but with no significant differences between the groups.

Discussion: Following impaction grafting, new bone formation may be delayed in comparison to revisions performed without graft. The pattern of markers of bone resorption did not differ significantly between the groups suggesting that there is no large scale resorption of the impacted allograft in these cases.

These results provide a biochemical insight into the bone formation and bone resorption processes during allograft incorporation.

Bone morphogenic proteins (BMPs) are members of the transforming growth factor beta (TGF-beta) family and play a central role in bone formation. These morpho-gens are known to be present in bone matrix however the characteristics of their release during the grafting process has not previously been defined. The aim of this study was to determine the release BMP-7 (osteogenic protein; OP-1) from cancellous allograft that occurs during impaction grafting for revision hip arthroplasty.

Forty, 10mm cubes of cancellous bone were accurately cut from the central region of 7 fresh frozen femoral heads. The cubes were centrifuged and washed to remove the marrow contents. The cubes were then individually washed and the fluid assayed for BMP-7 activity using a commercially available enzyme linked immuno-sorbent assay kit (Raybiotech Inc.). The cubes were then divided into 4 groups with samples from each femoral head in each group. Each group was subjected to strain of either 20%, 40%, 60% or 80% using a material testing machine. The cubes were then individually washed again and the wash fluid analysed for BMP-7 activity.

BMP-7 activity was found to be present in all groups. Release of BMP-7 was found to increase with increasing strain. At 80% strain the mean concentration of BMP-7 released (830 pg/g) was 58% greater than that released at 60% strain (527 pg/g), 150% greater than the concentration at 40% strain (333 pg/g) and 476% greater than at 20% strain (144 pg/g). The differences between release at 80% and 40% strain and between 80% and 20% strain were statistically significant (p=0.036, p=0.002).

Activity of BMP-7 in fresh frozen cancellous allograft bone has not previously been demonstrated. This study shows that the freezing and storage of femoral heads allows some maintenance of biological activity. Furthermore we have shown that BMP-7 may be released in proportion to the strain applied to the bone. This confirms that the process of impaction of bone morsels during revision hip arthroplasty may release BMPs that could aid in the incorporation and remodelling of the allograft.

Introduction This prospective study was carried out to assess the outcome of manipulation of the shoulder with interscalene block as a treatment for adhesive capsulitis of the shoulder.

Materials and Methods 31 patients underwent manipulation under general anaesthesia and interscalene block followed by intra-articular glenohumeral injection of steroid and local anaesthetic. Physiotherapy was started on the day of surgery. Shoulder function was assessed with range of movement, Constant score and DASH score (Disability of the Arm, Shoulder and Hand) by specialist upper limb physiotherapists, pre-operatively, and post-operatively at 6 weeks, 3, 6 and 12 months.

Results The DASH score improved from a mean of 60.1 pre-operatively to a mean of 24.1 at final follow up. Constant scores improved from a mean of 34.4 pre-operatively to 65.8. The mean improvement in Constant scores was 31.5 points. Pre-operative range of movement (expressed as a percentage of the total ROM of the unaffected side) was 51.5%. The mean post-operative ROM was 85.4%. External rotation improved from 41.7% of the unaffected side preoperatively to 77.7% at final review. Abduction improved from 47.4% to 85.4% and forward flexion improved from 59.1% to 90%. No patients required further manipulation.

Discussion All outcome measures improved following treatment. These improvements were sustained at 12 months follow-up. In particular external rotation, which was the most restricted movement preoperatively, was seen to improve and this improvement was maintained throughout follow-up.

Conclusion We conclude that manipulation of the shoulder under interscalene block and general anaesthetic for adhesive capsulitis results in a sustained improvement in function and movement.

Aim: This prospective study was carried out to assess the outcome of manipulation of the shoulder as a treatment for adhesive capsulitis of the shoulder.

Method: 31 patients were followed prospectively for twelve months after shoulder manipulation for adhesive capsulitis. All patients underwent manipulation under general anaesthetic and scalene block followed by intra-artificial gleno-humeral injection of steroid and local anaesthetic. Postoperative physiotherapy was started on the day of surgery. Shoulder function was assessed with range of movement, Constant and Murley score and DASH score (Disability of the Arm, Shoulder and Hand by specialist upper limb physiotherapists, pre-operatively, and post – operatively at 6 weeks, 3, 6, and 12 months.

Results: The DASH score improved from a mean of 60.1 (range 27–98) pre-operatively to a mean of 24.1 (range 5–83) at final follow up. Constant scores improved from a mean of 34.4 (range 16–51) pre-operatively to 65.8 (range 35–88). The mean improvement in Constant scores was 31.5 points.

Pre-operative range of movement (expressed as a percentage of the total ROM of the unaffected side) was 51.5 % (range 23.8–67.2). The mean postoperative ROM was 85.4% (range 56.2 – 99.3). External rotation improved from 41.7% (range 23.5 – 81.5) of the unaffected side preoperatively to 77.7% (range 44.1 – 105.3) at final review. Abduction improved from 47.4 % (range 23.3 – 70.6) to 85.4% (range 49.7 – 100) and forward flexion improved from 59.1% (range 33.5 – 73.9) to 90o (range 64.3 – 100.6). No patients required further manipulation.

Conclusion: All outcome measure improved following treatment. These improvements were sustained at 12-month follow up. In particular, external rotation which was the most restricted movement pre-operatively was seen to improve and this improvement was maintained throughout follow-up. We conclude that manipulation of the shoulder under inter-scalene block and general anaesthetic for adhesive capsulitis results in a sustained improvement in function and movement.

Aims: To assess the effectiveness of intra-articular facet joint injections in controlling disability in patients with low back pain. Methods: 100 consecutive patients admitted in our day case unit for facet joint injections were included in the study. Fluoroscopically controlled intra-articular facet joint block with injection of a local anaesthetic and corticosteroid suspension was performed after clinical and radiological assessment. Disability due to back pain was assessed by determining a revised Oswestry Low Back Pain Disability Index (Oswestry Score). The patients completed a questionnaire immediately prior to treatment, two weeks following injection and three months following injection. Results: Facet joint injections were performed for intervertebral disc prolapse (66%), spondylolysthesis (13%), spinal stenosis (10%), spondylosis (7%), and sacro-iliac joint pain (4%). The mean Oswestry Score prior to injection was 40.6% (95% conþdence interval 4.4), at two weeks following injection was 26.6% (95% conþdence interval 4.9) and at three months following injection was 21.5% (95% conþdence interval 4.8). 78% of the patients found the facet joint injections useful at 2 weeks following treatment and this þgure was maintained (79%) at 3 months after injection. No complications were reported following treatment. Conclusions: We have found intra-articular facet joint block for the treatment of low back pain a valid therapeutic option, acceptable by the patients and with negligible risks.