Abstract: With the current shift in recommended practice towards being evidence based, we wished to see if Orthopaedic surgeons are using the current evidence with regards to the use of drains in knee arthroplasty.

Method: A questionnaire was faxed to all UK members of BASK to ascertain their current practice regarding the use of drains in knee arthroplasty and the rationale for their drain policy.

Results: The BASK members handbook identified 231 UK members and a questionnaire was faxed to them. 160 replies were received, of which 8 were excluded from analysis as they were either retired or non-surgeons. This gave a 68.2% response rate (1 52 results out of 223).

Drain usage:

Primary TKR: Always 136(89.5%); Sometimes 13(8.5%), Never 3(2.0%).

Revision TKR: Always 141(94.6%); Sometimes 3 (2.0%); Never 5(3.4%); Not applicable 3.

Unicompartmental: Always 66(57.9%); Sometimes 28(24.6%); Never 20(17.5%); Not applicable 3.1.

Hours drain removed at:

< 24 hours 77(50.7%); 24–48 hours 64(42.1%);

> 48 hours 4(2.6%); No answer 7(4.6%).

Rationale for drain use:

Prevent wound haematoma/haemarthrosis 74; personal reasons 27; to allow retransfusion 20; evidence based 12; despite evidence 5.

29.6% of the responders are currently using cell salvage drains, and a further 7.9% are keen to start using cell salvage drains when the circumstances in their hospitals change to allow them to do so.

Conclusion: The results of our questionnaire have shown that for primary TKR 89.5% always use a drain. With regard to the duration of drainage, 42.1 % of the respondents removed their drains at between 24 and 48 hours. The commonest reason given for the use of drains in total knee arthroplasty was to prevent haematorna or haemarthrosis development. However the published literature does not support these practices and beliefs. Only 12 people said that their practice was evidence based. We therefore have to conclude that the majority of practising members of BASK do not practice evidence based medicine with regard to the use of drains in knee arthroplasty.

We describe the development and validation of a scoring system for auditing orthopaedic surgery. It is a minor modification of the POSSUM scoring system widely used in general surgery. The orthopaedic POSSUM system which we have developed gives predictions for mortality and morbidity which correlate well with the observed rates in a sample of 2326 orthopaedic operations over a period of 12 months.

In a prospective, randomised controlled trial, 68 children who had a completely displaced metaphyseal fracture of the distal radius were treated either by manipulation (MUA) and application of an above-elbow cast alone or by the additional insertion of a percutaneous Kirschner (K-) wire. Full radiological follow-up to union was obtained in 65 children and 56 returned for clinical evaluation three months after injury.

Maintenance of reduction was significantly better in the K-wire group and fewer follow-up radiographs were required. There was no significant difference in the clinical outcome measured three months after injury. Seven of 33 patients in the MUA group had to undergo a second procedure because of an unacceptable position compared with none of the 35 in the K-wire group (chi-squared test, p < 0.01). One patient in the K-wire group required exploration for recovery of a migrated wire.

We conclude that the use of a percutaneous K-wire to augment the reduction of the fracture in children who have a completely displaced metaphyseal fracture of the distal radius is a safe and reliable way of maintaining alignment of the fracture.

A continuous ambulatory activity monitor allows objective measurement of the amount and intensity of physical activity. We examined the reliability and validity of this device in the assessment of seven aspects of function over a period of 24 hours in 20 patients who had undergone limb salvage or amputation for a tumour in the leg.

The test-retest reliability was determined by undertaking identical assessments on two separate days. The measurements were compared with other indicators of functional status and quality of life in order to determine the validity of the monitor.

Its reliability was satisfactory, with intraclass correlation coefficients ranging from 0.65 to 0.91. Significant correlations were seen between the ‘time spent walking’ and the Musculoskeletal Tumor Society rating scales and the Rand-36 physical functioning score. There was also a significant association between the ‘movement intensity during walking’ and the Musculoskeletal Tumor Society score. The satisfactory reliability and validity of the monitor shows considerable promise for its use as a device for measuring physical activity objectively in patients after surgery for limb-salvage or an amputation.

Extensive osteolysis adjacent to implants is often associated with wear particles of prosthetic material. We have investigated if RANKL, also known as osteoprotegerin ligand, osteoclast differentiation factor or TRANCE, and its natural inhibitor, osteoprotegerin (OPG), may be important in controlling this bone loss.

Cells isolated from periprosthetic tissues containing wear particles expressed mRNA encoding for the pro-osteoclastogenic molecules, RANKL, its receptor RANK, monocyte colony-stimulating factor (M-CSF), interleukin (IL)-1β, tumour necrosis factor (TNF)α, IL-6, and soluble IL-6 receptor, as well as OPG. Osteoclasts formed from cells isolated from periprosthetic tissues in the presence and absence of human osteoblastic cells. When osteoclasts formed in the absence of osteoblastic cells, markedly higher levels of RANKL mRNA relative to OPG mRNA were expressed. Particles of prosthetic materials also stimulated human monocytes to express osteoclastogenic molecules in vitro.

Our results suggest that ingestion of prosthetic wear particles by macrophages results in expression of osteoclast-differentiating molecules and the stimulation of macrophage differentiation into osteoclasts.

We have studied the characteristics of bone ingrowth of a new porous tantalum biomaterial in a simple transcortical canine model using cylindrical implants 5 × 10 mm in size. The material was 75% to 80% porous by volume and had a repeating arrangement of slender interconnecting struts which formed a regular array of dodecahedron-shaped pores. We performed histological studies on two types of material, one with a smaller pore size averaging 430 μm at 4, 16 and 52 weeks and the other with a larger pore size averaging 650 μm at 2, 3, 4, 16 and 52 weeks. Mechanical push-out tests at 4 and 16 weeks were used to assess the shear strength of the bone-implant interface on implants of the smaller pore size.

The extent of filling of the pores of the tantalum material with new bone increased from 13% at two weeks to between 42% and 53% at four weeks. By 16 and 52 weeks the average extent of bone ingrowth ranged from 63% to 80%. The tissue response to the small and large pore sizes was similar, with regions of contact between bone and implant increasing with time and with evidence of Haversian remodelling within the pores at later periods. Mechanical tests at four weeks indicated a minimum shear fixation strength of 18.5 MPa, substantially higher than has been obtained with other porous materials with less volumetric porosity.

This porous tantalum biomaterial has desirable characteristics for bone ingrowth; further studies are warranted to ascertain its potential for clinical reconstructive orthopaedics.

We tested the hypothesis that children who sustain a supracondylar fracture have a greater range of elbow hyperextension than those with a fracture of the distal radius.

Three observers made 358 measurements in 183 children (114 boys and 69 girls). There were 119 fractures of the distal radius and 64 supracondylar fractures.

Initially, the group with a supracondylar fracture appeared to have extension 1.7° greater than that of the group with fracture of the distal radius. On average, there was a maximum variation of 3° between observers. After allowing for age, gender and observer, there was no significant difference between the groups. Our study had greater than 80% power to detect a difference in hyperextension of 2° at the 5% level with the above observer variability.

When age and gender are taken into account, any variation in the amount of hyperextension at the elbow is not sufficient to explain the occurrence of a supracondylar fracture.

We analysed the cellular immune response in ten transplantations of different massive bone allografts, of which five had a poor clinical outcome. Cytotoxic T lymphocytes (CTL) and T helper lymphocytes (TH) against mismatched donor antigens were found in all patients. More importantly, CTL with a high affinity for donor antigens were found in five cases. High-affinity CTL need no CD8 molecule to stabilise the antigen binding and are strongly associated with rejection of heart and corneal transplants. Even after removal of most of the bone-marrow cells, we found high-affinity CTL and high TH frequencies. This T-cell response could be detected over a period of years.

We conclude that frozen bone allografts can induce high-affinity donor-specific CTL. The present assay allows qualification and quantification of the levels of CTL and TH in the blood. This approach may be helpful in studying the effect of the immune response on the outcome of the graft.

We have treated 16 patients with recurrent complex elbow instability using a hinged external fixator. All patients had instability, dislocation or subluxation of the ulnohumeral joint. The injuries were open in eight patients and were associated with 20 other fractures and five peripheral nerve injuries. Two patients had received initial treatment from us; 14 had previously had a mean of 2.1 unsuccessful surgical procedures (1 to 6). The fixator was applied at a mean of 4.8 weeks (0 to 9) after the injury and remained on the elbow for a mean of 8.5 weeks (6 to 11). After treatment we found the mean range of flexion-extension to be 105° (65 to 140). At a final follow-up of 23 months (14 to 40), the mean Morrey score was 84 (49 to 96): this translated into one poor, three fair, ten good and two excellent results.

Complications included one fractured humeral pin, one temporary palsy of the radial nerve, one recurrent instability, one wound infection, one severe pin-track infection and one patient with reflex sympathetic dystrophy. Although technically demanding, the use of the fixator is an important advance in the management of recurrent complex elbow instability after failure of conventional treatment.

We report a prospective study of the incidence of fractures in the adult population of Edinburgh, related to age and gender. Over a two-year period, 15 293 adults, 7428 males and 7865 females, sustained a fracture, and 5208 (34.0%) required admission.

Between 15 and 49 years of age, males were 2.9 times more likely to sustain a fracture than females (95% CI 2.7 to 3.1). Over the age of 60 years, females were 2.3 times more likely to sustain a fracture than males (95% CI 2.1 to 2.4). There were three main peaks of fracture distribution: the first was in young adult males, the second was in elderly patients of both genders, mainly in metaphyseal bone such as the proximal femur, although diaphyseal fractures also showed an increase in incidence. The third increase in the incidence of fractures, especially of the wrist, was seen to start at 40 years of age in women.

Our study has also shown that ‘osteoporotic’ fractures became evident in women earlier than expected, and that they were not entirely a postmenopausal phenomenon.

We studied the reliability of the Singh classification of trabecular bone structure in the proximal femur as a measure of osteoporosis, using kappa statistics. Radiographs of fractures of the femoral neck or trochanteric region in 80 consecutive patients were assessed by six observers. The interobserver variation was large; only three of 72 radiographs were given the same classification by all six observers and the kappa values ranged from 0.15 to 0.54. The intraobserver variation showed substantial strength of agreement; kappa values ranged from 0.63 to 0.88.

In 77 patients dual-energy X-ray absorptiometry was used to measure bone mineral density. The results were compared with those of the Singh classification: we found no correlation.

1. Five cases of Salmonella osteomyelitis in infants without red-cell sickling are reported.

2. All these cases occurred in children under eighteen months of age and within a period of five months of time, suggesting a seasonal incidence.

3. Only one strain of Salmonella was isolated–Salmonella typhimurium.

4. There was complete healing in four of the cases.

5. In one case there was destruction and complete absorption ofthe upper humeral epiphysis.

1. An account of fifty-four patients suffering from ainhum is presented, and the clinical and pathological findings are discussed.

2. Etiology is considered, and a plan of treatment proposed.

3. Ainhum in Ibadan is a disease of all ages and both sexes.

4. Most patients have considerable pain.

5. It is due to a non-inflammatory change in the basal layer of the epidermis.

6. Surgical treatment has gratifying results.

The effect of cortisone on the repair of simple muscle injury was studied in rabbits. The histological findings in the crushed muscle are described for a period up to twenty-one days after injury.

Cortisone defers the onset of muscle regeneration, and retards its progress, but it does not change the course of the repair process or alter its eventual outcome under the conditions of the experiment.

This apparent refractoriness of repair of muscle, as compared with that of other connective tissues, is discussed.