Aim: In 1990 the Christchurch Hospital Sarcoma Clinic established management guidelines for patients with suspected sarcomas, recommending referral prior to investigation, biopsy and excision. The aim of this study was to determine whether these guidelines are being followed.

Method: A review of the case notes of all sarcomas referred to the Sarcoma Clinic between 1990 and 1999 was performed.

Results: There were 53 referrals, 34 (22%) from orthopaedic surgeons, 56 (37%) from general surgeons, 16 (10%) from general practice and 47 (31%) from other specialties. Only 83 (54%) of the referrals had followed the guidelines. Twenty-five (74%) of the orthopaedic referrals, 19 (34%) of the general surgical, 10 (63%) of the general practice and 29 (62%) of the other specialties had followed the guidelines. Seventy (46%) of the referrals had failed to follow the guidelines. Thirty-four (49%) of these had undergone excision inadequate for sarcoma prior to referral, of which eight had been re-excised. Twenty-four patients had not been staged prior to excision despite having a positive fine needle aspiration (FNA) in four cases. Eighteen patients (26%) had FNA or biopsy prior to imaging or referral.

Conclusion: Forty-six percent of sarcoma patients had not been treated according to the recommended guidelines. Forty-nine percent of these had inadequate primary sarcoma excision and this may have compromised their outcome. Orthopaedic surgeons had the best record for following the guidelines at 74% of referrals but this could be further improved. Doctors and especially surgeons need to be more aware of the principle of early referral of patients with suspected sarcomas.

A patient’s response to knee assessment questionnaires is often subjective and linked to age and cultural expectations.

In New Zealand 150 people, split into three groups of ages 20 to 40 years, 40 to 60 years and over 60 years, were given three commonly used knee assessment questionnaires. All were examined objectively to determine that their knees were normal. Scores in these groups were compared to similar groups of Canadian subjects and the results analysed.

The results show significant differences in expectations between the age groups. Older people were reluctant to score maximum points for their normal knees. The Hospital for Special Surgery’s knee score gave the lowest results, followed by the Knee Society score. In the over-60-year group there was a significant difference between scores in New Zealand and Canada, with Canadians tending to score higher in all scores.

These findings have implications when it comes to comparing results of total knee arthroplasty in different countries and age groups. This study has been expanded to include other countries in an attempt to find a mathematical formula that will make future comparisons more relevant.

Since its introduction in Christchurch in 1989, the mobile bearing LCS prosthesis has been used in over 3 500 total knee arthroplasty (TKA) procedures. The prosthesis is unique in that it has a mobile articulation not only at the tibiofemoral joint but also at the patellofemoral joint. The tibiofemoral articulation may be posterior cruciate retaining (meniscal bearings - MB) or sacrificing (rotating platform - RP).

Clinical and radiological assessment of 569 patients over three to nine years shows no significant difference between MB and RP groups with respect to Knee Society and New Jersey knees or the WOMAC functional score. In 93% of patients results were good or excellent. There were more early complications among MB patients, with five MB dislocations. However, four of these dislocations occurred in the early years this prosthesis and may reflect surgical inexperience. Clinical evidence of posterior cruciate laxity was present in 15% of the MB group, but there was no significant difference between knee scores of this group, the rest of the MB group, or the RP group.

When resurfaced patellae were compared to knees that were not resurfaced, there was no significant difference. Patellae with more than 4 mm of lateral subluxation were identified, but their knee scores were not significantly different.

The early to medium-term results of our continuing study of the LCS mobile bearing prosthesis are at least comparable to those of studies of fixed bearing prostheses. We continue to use this implant with confidence, but await long-term results.

We compared function in two groups of high demand patients who had undergone total knee arthroplasty (TKA), one group using a posterior cruciate sacrificing (PCS) prosthesis and the other a posterior cruciate retaining (PCR) prosthesis of similar design.

Patients were eligible for the study if surgery had been performed more than two years ago and they were under 65 years of age and had no coexisting morbidity that markedly decreased their physical activities. One surgeon operated on 28 patients in group A (20 TKAs), routinely retaining the posterior cruciate ligament (PCL). A second surgery operated on 19 patients in group B (25 TKAs) and routinely sacrificed the PCL. A mobile bearing prosthesis of similar design was used in each group. Patients were independently selected and assessed using a questionnaire specifically developed to assess higher levels of activity not usually assessed by other knee scores. Patients in the two groups were matched in terms of age, range of motion and follow-up

The gross activity score was 3.36 in group A and 3.12 in group B. The combined walking, running and stair-climbing score was in group A (7.68) than in group B (6.64). Patients in group B had decreased anterior knee pain and perceived their TKA closer to a normal knee (2.00 compared to 2.32).

We conclude that retaining the PCL in TKA results in better patient function without obvious complications.

We performed a prospective randomised trial on matched groups of patients with displaced tibial shaft fractures to compare conservative treatment with closed intramedullary nailing. The results showed conclusively that intramedullary nailing gave more rapid union with less malunion and shortening. Nailed patients had less time off work with a more predictable and rapid return to full function. We therefore consider that closed intramedullary nailing is the most efficient treatment for displaced fractures of the tibial shaft.

Fifty consecutive comminuted fractures of the femoral shaft were treated by closed unlocked intramedullary nailing. Twelve unstable fractures also had cast-bracing. There were no cases of infection or non-union, and satisfactory results were achieved in 38 fractures (76%). More severe comminution led to a higher incidence of unsatisfactory results, but malrotation deformity was seen more often in less comminuted fractures and appeared to be due to poor operative reduction. Shortening in severe comminution was the main complication and was not controlled by supplementary cast-bracing. Closed unlocked intramedullary nailing is effective for lesser grades of comminution, but fractures with no cortical continuity at reduction should be treated with a locking nail.

A new method of demonstrating sagittal laxity in the anterior cruciate-deficient knee is described. Seventy such knees were compared to 70 normal knees. Sagittal laxity was recorded as the average displacement of the medial and lateral femoral condyles. This displacement index was significantly different between the two groups of knees (P less than 0.0001). A range for normal and abnormal knees is discussed. Quantitative assessment of the degree of sagittal laxity by clinical evaluation is shown to be unreliable. Only the pivot-shift test demonstrated any significant correlation with the amount of sagittal displacement (P less than 0.05).

Blood flow in intact tendons in dogs was measured using 57Co-labelled microspheres and compared with the simultaneous clearance of a diffusible radionuclide, 85Sr, by the same tendons. Clearance was significantly greater than flow in all tendons, indicating that diffusion from surrounding tissues may be important in the nutrition of normal tendons.

Two cases of congenital pseudarthrosis of the ulna due to neurofibromatosis are reported. Similar radiographic changes in the ulna were found, with distortion of the capitulum and part of the trochlea and bowing of the radius. In one patient the head of the radius was dislocated and in the other it dislocated readily during pronation. A possible mechanism to explain the findings was suggested. On the basis of these and a review of the literature it is recommended that the main aim of treatment should be maintenance of the normal relative lengths of the radius and ulna by early excision of the pseudarthrosis to remove the restraining effect of the abnormal ulna. This will allow normal development of the lower end of the humerus and radius and prevent dislocation of the radial head.

The incidence of congenital dislocation of the hip in 156 children with infantile idiopathic scoliosis was 6.4 per cent, approximately 10 times its frequency in the general population. In both of these deformities there was a predominance of girls (eight girls: two boys). In unilateral dislocation of the hip the convexity of the thoracic scoliosis was on the same side as the dislocation. Eight out of the 10 children with both deformities also had plagiocephaly.