In arthritis of the varus knee, a high tibial osteotomy (HTO) redistributes load from the diseased medial compartment to the unaffected lateral compartment.

We report the outcome of 36 patients (33 men and three women) with 42 varus, arthritic knees who underwent HTO and dynamic correction using a Garches external fixator until they felt that normal alignment had been restored. The mean age of the patients was 54.11 years (34 to 68). Normal alignment was achieved at a mean 5.5 weeks (3 to 10) post-operatively. Radiographs, gait analysis and visual analogue scores for pain were measured pre- and post-operatively, at one year and at medium-term follow-up (mean six years; 2 to 10). Failure was defined as conversion to knee arthroplasty.

Pre-operative gait analysis divided the 42 knees into two equal groups with high (17 patients) or low (19 patients) adductor moments. After correction, a statistically significant (p < 0.001, t-test,) change in adductor moment was achieved and maintained in both groups, with a rate of failure of three knees (7.1%), and 89% (95% confidence interval (CI) 84.9 to 94.7) survivorship at medium-term follow-up.

At final follow-up, after a mean of 15.9 years (12 to 20), there was a survivorship of 59% (95% CI 59.6 to 68.9) irrespective of adductor moment group, with a mean time to conversion to knee arthroplasty of 9.5 years (3 to 18; 95% confidence interval ± 2.5).

HTO remains a useful option in the medium-term for the treatment of medial compartment osteoarthritis of the knee but does not last in the long-term.

Cite this article: Bone Joint J 2016;98-B:601–7.

Objectives

The PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial has recently demonstrated that surgery is non-superior to non-operative treatment in the management of displaced proximal humeral fractures. The objective of this study was to assess current surgical practice in the context of the PROFHER trial in terms of patient demographics, injury characteristics and the nature of the surgical treatment.

Purpose and Background:

The spread of upright MRi scanning is a relatively new development in the UK. However, there is a lack of information about whether weight bearing scans confer any additional useful information for low back conditions.

Perthes disease is a childhood disorder often resulting in femoral head deformity. Categorical/dichotomous outcomes of deformity are typical clinically, however quantitative, continuous measures, such as Sphericity Deviation Score (SDS), are critical for studying interventions. SDS uses radiographs in two planes to quantify femoral head deformity. Limitations of SDS may include non-orthogonal planes and lost details due to projections. We applied this method in 3D, with specific objectives to: 1. Develop SDS-like sphericity measures from 3D data 2. Obtain 2D and 3D sphericity for normal and Perthes hips 3. Compare slice-based (3D) and projection-based (2D) sphericity CT images of 16 normal (8 subjects) and 5 Perthes hips (4 subjects) were segmented to create 3D hip models. Ethics board approval was obtained for this study. SDS consists of roundness error (RE) in two planes and ellipsoid deformation (ED) between planes. We implemented a modified SDS which was applied to (a) orthogonal projections simulating radiographs (sagittal/coronal; 2D-mSDS), and (b) largest radii slices (sagittal/coronal; 3D-mSDS). Mean 2D-mSDS was higher for Perthes (27.2 (SD 11.4)) than normal (11.9 (SD 4.1)). Mean 3D-mSDS showed similar trends, but was higher than 2D (Perthes 33.6 (SD 5.3), normals 17.0 (SD 3.1)). Unlike 2D-mSDS, 3D-mSDS showed no overlap between groups. For Perthes hips, 2D-mSDS was consistent with SDS. For normal hips, 2D-mSDS was higher than expected (similar to Stulberg II). Projection-based (2D) measures may produce lower mSDS due to spatial averaging. Slice-based (3D) measures may better distinguish between normal and Perthes shapes, which may better differentiate effectiveness of treatments.

The Oxford Hip Score (OHS), the Harris Hip Score (HHS) and WOMAC are examples of patient reported outcome measures (PROMs) have well documented ceiling effects, with many patients clustered close to full marks following arthroplasty. Any arthroplasty that offers superior function would therefore fail to be detectable using these metrics. Two recent well conducted randomised clinical trials made exactly this error, by using OHS and WOMAC to detect a differences in outcome between hip resurfacing and hip arthroplasty despite published data already showing in single arm studies that these two procedures score close to full marks using both PROMS.

We had observed that patients with hip resurfacing arthroplasty (HRA) were able to walk faster and with more normal stride length than patients with well performing hip replacements, but that these objective differences in gait were not captured by PROMs. In an attempt to capture these differences, we developed a patient centred outcome measure (PCOM) using a method developed by Philip Noble's group. This allows patients to select the functions that matter to them personally against which the success of their own operation will be measured.

Our null hypothesis was that this PCOM would be no more successful than the OHS in discriminating between types of hip arthroplasty.

22 patients with a well performing Hip Resurfacing Arthroplasty were identified. These were closely matched by age, sex, BMI, height, preop diagnosis with 22 patients with a well performing conventional THA. Both were compared with healthy controls using the novel PCOM and in a gait lab.

Introduction

Bone loss in the distal femur and proximal tibia is frequently encountered with both complex primary and revision knee replacement surgery. Metaphyseal sleeves provide a good option for enhanced fixation in managing such defects on both the tibia and femur. We present our results in 48 patients (50 knees) with a minimum 12 month follow up (range 12 to 45).

At first-stage revision surgery for infection of total knee arthroplasties, antibiotic-impregnated cement spacers are frequently implanted. Two types of cement spacers are commonly used, “static” and “articulating” cement spacers. Advocates of cement spacers state that they deliver high doses of antibiotics locally, increase patient comfort, allow mobility and provide joint stability. They also minimize contracture of collateral ligaments, thereby facilitating re-implantation of a definitive prosthesis at a later stage. The use of these cement spacers, however, are not without significant complications, including patella tendon injuries.

We describe a series of three patients who sustained patella tendon injuries in infected total knee arthroplasties following the use of a static cement spacer at first-stage knee revision.

The patella tendon injuries resulted in significant compromise to wound healing and knee stability requiring multiple surgeries. The mid-term function was poor with an Oxford score at 24 months ranging from 12–20

Based on our experience, we advise caution in the use of static cement spacer blocks. If they are to be used, we recommend that they should be keyed in the bone to prevent patella tendon injuries.

Background

Management of failed total ankle replacements (TAR) remains a difficult challenge. Ankle arthrodesis, revision TAR, debridement and amputation are all utilized as surgical options. The purpose of the study was to review a series of failed TAR surgically managed in our tertiary referral centre.

Honey has been used as a topical antiseptic for at least 5,000 years. SurgiHoney is a CE licensed sterile product, which has been proven to be non-toxic and effective when used topically in the treatment of chronically infected wounds. The key difference from other medical grade honey is the broad spectrum antimicrobial characteristics with activity against Gram +ve, Gram –ve and multi-resistant organisms. Its novel role against the bacterial bioburden and biofilm associated with periprosthetic infections around total knee arthroplasties (TKA's) is therefore considered.

SurgiHoney was used as an implant coating immediately prior to wound closure after implantation of salvage endoprosthesis for multiply revised, infected TKA's undergoing staged reconstruction.

We report a consecutive series of multi-revised, infected revision TKA's where SurgiHoney was used as an active antimicrobial coating. We discuss its intra-operative application and early clinical outcomes.

The use of Surgihoney as a novel anti-microbial is established in the management of complex wound infections. This is the first reported use of SurgiHoney as a deep, implant coating in the salvage of prosthetic joint infection.

To compare the costs of treatment and income received for treating patients with tibial osteomyelitis, comparing limb salvage with amputation.

We derived direct hospital costs of care for ten consecutive patients treated with limb salvage procedures and five consecutive patients who underwent amputation, for tibial osteomyelitis. We recorded all factors which affect the cost of treatment. Financial data from the Patient-Level Information and Costing System (PLICS) allowed calculation of hospital costs and income received from payment under the UK National Tariff. Hospital payment is based on primary diagnosis, operation code, length of stay, patient co-morbidities and supplements for custom implants or external fixators.

Our primary outcome measure was net income/loss for each in-patient episode.

The mean age of patients undergoing limb salvage was 55 years (range 34–83 years) whereas for amputation this was 61 years (range 51–83 years). Both groups were similar in Cierny and Mader Staging, requirement for soft-tissue reconstruction, anaesthetic technique, diagnostics, drug administration and antibiotic therapy.

In the limb salvage group, there were two infected non-unions requiring Ilizarov method and five free flaps. Mean hospital stay was 15 days (10–27). Mean direct cost of care was €16,718 and mean income was €9,105, resulting in an average net loss of €7,613 per patient. Patients undergoing segmental resection with Ilizarov bifocal reconstruction and those with the longest length of stay generated the greatest net loss.

In the amputation group, there were 3 above knee and 2 below knee amputations for failed previous treatment of osteomyelitis or infected non-union. Mean hospital stay was 13 days (8–17). Mean direct cost of care was €18,441 and mean income was €15,707, resulting in an average net loss of €2,734 per patient. Length of stay was directly proportional to net loss.

The UK National Tariff structure does not provide sufficient funding for treatment of osteomyelitis of the tibia by either reconstruction or amputation. Average income for a patient admitted for limb salvage is €6,602 less than that for amputation even though the surgery is frequently more technically demanding (often requiring complex bone reconstruction and free tissue transfer) and the length of hospital stay is longer.

Although both are significantly loss-making, the net loss for limb salvage is more than double that for amputation. This makes treatment of tibial osteomyelitis in the UK National Health Service unsustainable in the long term.

Cephalasporin antibiotics have been commonly used for prophylaxis against surgical site infection. To prevent Clostridium difficile, the preferential use of agents such as flucloxacillin and gentamicin has been recommended. The aim of this study was to investigate the bone penetration of these antibiotics during hip and knee arthroplasty, and their efficacy against Staphylococcus aureus and S. epidermidis.

Bone samples were collected from 21 patients undergoing total knee arthroplasty (TKA) and 18 patients undergoing total hip replacement (THA). The concentration of both antibiotics was analysed using high performance liquid chromatography. Penetration was expressed as a percentage of venous blood concentration. The efficacy against common infecting organisms was measured using the epidemiological cut-off value for resistance (ECOFF).

The bone penetration of gentamicin was higher than flucloxacillin. The concentration of both antibiotics was higher in the acetabulum than the femoral head or neck (p=0.007 flucloxacillin; p=0.021 gentamicin). Flucloxacillin concentrations were effective against S. aureus and S. epidermis in all THAs and 20 (95%) TKAs. Gentamicin concentrations were effective against S.epidermis in all bone samples. Gentamicin was effective against S. aureus in 11 (89%) femoral samples. Effective concentrations of gentamicin against S. aureus were only achieved in 4 (19%) femoral and 6 (29%) tibial samples in TKA.

Flucloxacillin and gentamicin was found to effectively penetrate bone during arthroplasty. Gentamicin was effective against S. epidermidis in both THA and TKA, while it was found to be less effective against S. aureus during TKA. Bone penetration of both antibiotics was less in TKA than THA.

Joint degeneration may make a total knee arthroplasty (TKA) a requirement for pain relief and function. However, the presence of ipsilateral limb osteomyelitis (OM) makes surgical management extremely challenging.

We report the experience of a high volume revision knee surgeon managing ipsilateral limb multi resistant OM and the outcome of subsequent TKA.

Four consecutive patients were identified who had either ipsilateral femoral or tibial chronic osteomyelitis treated prior to undergoing TKA. Surgery to eradicate the osteomyelitis involved a Lautenbach compartmental debridement, and where necessary, healing by secondary intention. The decision to proceed to a TKA was based on history, clinical examination and radiological findings of advanced osteoarthritic change.

The patients had a mean age of 50 years. They had a background of multi-organism OM and underwent single-stage TKAs at an average of 63 months following eradication of the underlying OM.

Three patients did well but had complications associated with poor skin and soft tissues, and abnormal bone anatomy. One patient developed an infection and following a re-revision had an arthrodesis.

The results for the four cases are summarised in Table 1.

We have highlighted that patients with ipsilateral limb multi resistant OM are a difficult cohort to manage.

A common step to revision surgery for infected total knee replacement (TKR) is a thorough debridement. Whilst surgical and mechanical debridement are established as the gold standard, we investigate a novel adjuvant chemical debridement using an Acetic Acid (AA) soak that seeks to create a hostile environment for organisms, further degradation of biofilm and death of the bacteria.

We report the first orthopaedic in vivo series using AA soak as an intra-operative chemical debridement agent for treating infected TKR's. We also investigate the in vitro efficacy of AA against bacteria isolated from infected TKR's.

A prospective single surgeon consecutive series of patients with infected TKR were treated according to a standard debridement protocol. Patients in the series received sequential debridement of surgical, mechanical and finally chemical debridement with a 10 minute 3% AA soak.

In parallel, we isolated, cultured and identified bacteria from infected TKR's and assessed the in vitro efficacy of AA. Susceptibility testing was performed with AA solutions of different concentrations as well as with a control of a gentamicin sulphate disc. The effect of AA on the pH of tryptone soya was also monitored in an attempt to understand its potential mechanism of action.

Physiological responses during the AA soak were unremarkable. Intraoperatively, there were no tachycardic or arrythmic responses, any increase in respiratory rate or changes in blood pressure. This was also the case when the tourniquet was released. In addition, during the post-operative period no increase in analgesic requirements or wound complications was noted. Wound and soft tissue healing was excellent and there have not been any early recurrent infections at mean of 18 months follow up.

In vitro, zones of inhibition were formed on less than 40% of the organisms, demonstrating that AA was not directly bactericidal against the majority of the clinical isolates. However, when cultured in a bacterial suspension, AA completely inhibited the growth of the isolates at concentrations as low as 0.19%v/v.

This study has shown that the use of 3% AA soak, as part of a debridement protocol, is safe. Whilst the exact mechanism of action of acetic acid is yet to be determined, we have demonstrated that concentrations as low as 0.19%v/v in solution in vitro is sufficient to completely inhibit bacterial growth from infected TKR's.

Introduction

Cross linked polyethylene (XLPE) has gained popularity as a bearing surface of choice for younger patients despite only medium term results being available for wear rates. Concern remains regarding the long-term stability and durability of these materials. In order to address these issues we present the longest radiological and clinical follow-up of XLPE.

Introduction

The number of total hip replacements taking place across the UK continues to grow. In an ageing population, with people living longer and placing greater strain on their prostheses, the number of peri-prosthetic femoral fractures is increasing. We studied the economic impact this has on a large university teaching hospital.

Introduction

Severe osteolysis of the femur secondary to aseptic loosening in hip arthroplasty, remains a difficult revision scenario. Multiple techniques have been developed to aid the surgeon, including restoration of bone stock with impaction bone grafting or strut allografts, various distal fixation prostheses and mega-prostheses. Cemented femoral components, with integration of the cement into the cavitations, has largely fallen out of favour. We examined the long-term outcomes with this technique.

Obtaining primary wound healing in Total Joint Arthroplasty (TJA) is essential to a good result. Wound healing problems can occur and the consequences can be devastating to the patient and to the surgeon. Determination of the host healing capacity can be useful in predicting complications. Cierney and Mader classified patients as Type A: no healing compromises and Type B: systemic or local healing compromises factors present. Local factors include traumatic arthritis with multiple previous incisions, extensive scarring, lymphedema, poor vascular perfusion, and excessive local adipose deposition. Systemic compromising factors include diabetes, rheumatic diseases, renal or liver disease, immunocompromise, steroids, smoking, and poor nutrition. In high risk situations the surgeon should encourage positive patient choices such as smoking cessation and nutritional supplementation to elevate the total lymphocyte count and total albumin.

Careful planning of incisions, particularly in patients with scarring or multiple previous operations, is productive. Around the knee the vascular viability is better in the medial flap. Thusly, use the most lateral previous incision, do minimal undermining, and handle tissue meticulously. We do all potentially complicated TKAs without tourniquet to enhance blood flow and tissue viability. The use of peri-operative anticoagulation will increase wound problems.

If wound drainage or healing problems do occur immediate action is required. Deep sepsis can be ruled out with a joint aspiration and cell count [less than 2500], differential [less than 60% polys], and negative culture and sensitivity. All hematomas should be evacuated and necrosis or dehiscence should be managed by debridement to obtain a live wound.

The major benefit of TKA with tourniquet is operating in a bloodless field. A possible secondary benefit is a better cement bone interface for fixation.

The disadvantages of tourniquet use for TKA include multiple risk factors both local and systemic: Nerve damage; Altered hemodynamics with limb exsanguinations (15–20% increase in circulatory volume) and reactive hyperemia with tourniquet release (10% increase in limb size increasing soft tissue tension and secondary pain); Delay in recovery of muscle function; Increased risk of DVT with direct trauma to vessel walls and increased levels of thrombin-antithrombin complexes; A 5.3× greater risk for large venous emboli propagation and transesophageal echogenic particles; Vascular injury with higher risk in atherosclerotic, calcified arteries; Increase in wound healing disturbances.

Our initial experience with TKA without tourniquet was in high risk patients with previous DVT or PE, multiple scarring, or compromised cardiovascular status. We have used this method on all patients for the last eight years. The protocol includes regional anesthesia, incision and approach made with 90-degree knee flexion, meticulous hemostasis, jet lavage and filtered carbon dioxide delivered to dry and prepare bone beds for cementation, application of topical tranexamic acid and routine closure. We have encountered no differences in blood loss or transfusion rates, less post-operative pain, faster straight leg raise and knee flexion gains, and fewer wound healing disturbances. We recommend TKA sans tourniquet. Let it bleed!

Introduction

The exact mechanisms leading to tendinopathies and tendon ruptures remain poorly understood while their occurrence is clearly associated with exercise. Overloading is thought to be a major factor contributing to the development of tendon pathologies. However, as animal studies have shown, heavy loading alone won't cause tendinopathies. It has been speculated, that malfunctioning adaptation or healing processes might be involved, triggering tendon tissue degeneration. By analysing the expression of the entirety of degrading enzymes (degradome) in pathological and non-pathological, strained and non-strained tendon tissue, the aim of this study was to identify common or opposite patterns in gene regulation. This approach may generate new targets for future studies.

There has been a lot of focus on the value of anatomic tunnel placement in ACL reconstruction, and the relative merits of single and double bundle grafts. Multiple cadaveric and animal studies have compared the effects of tunnel placement and graft type on knee biomechanics. 45 patients who underwent ACL reconstruction were included into our study. Femoral tunnel position was analysed by two independent doctors using the radiographic quadrant method as described by Bernard et al., and the mean values calculated. Forty-one of these patients completed a KOOS questionnaire. The mean ratio ‘a’ was 26.57% and mean ratio ‘b’ was 30.04% as compared to 24.8% (+/− 2.2%) and 28.5% (+/− 2.5%) respectively quoted by Bernard et.al, as the ideal tunnel position. Only twenty-three of these femoral tunnels were in the anatomic range. Analysis of forty-one KOOS surveys (23 anatomic, 18 non-anatomic) revealed no significant difference in total score or subscales between the anatomic and non-anatomic groups (p= >0.05). Our study suggests that the ideal tunnel position, as described by Bernard et.al. may not be ideal and fixed.

Introduction

Tendinopathies are debilitating and painful conditions. They are believed to result from repetitive overuse, which can create micro-damage that accumulates over time, and initiates a catabolic cell response. The aetiology of tendinopathy remains poorly understood, therefore the ideal treatment remains unclear. However, current data support the use of eccentric exercise as an effective treatment. In a previous study, we have shown that eccentric loading generates perturbations in the tendon at 10Hz, which is not present during other less effective loading regimes. Consequently, we hypothesis that 10Hz loading initiates an increased anabolic response in tenocytes, that can promote tendon repair.

Introduction

Achilles tendinopathy (AT) is a highly prevalent injury in athletes and non-athletes with an unknown aetiology. Genetic risk factors have been a recent focus of investigation. The aim of this systematic review was to determine which loci have been linked with mid-portion AT and could potentially be used as biomarkers in tendinopathy risk models or as preventative or therapeutic targets.

Periprosthetic femoral fracture (PFF) is a potentially devastating complication after total hip arthroplasty, with historically high rates of complication and failure because of the technical challenges of surgery, as well as the prevalence of advanced age and comorbidity in the patients at risk.

This study describes the short-term outcome after revision arthroplasty using a modular, titanium, tapered, conical stem for PFF in a series of 38 fractures in 37 patients.

The mean age of the cohort was 77 years (47 to 96). A total of 27 patients had an American Society of Anesthesiologists grade of at least 3. At a mean follow-up of 35 months (4 to 66) the mean Oxford Hip Score (OHS) was 35 (15 to 48) and comorbidity was significantly associated with a poorer OHS. All fractures united and no stem needed to be revised. Three hips in three patients required further surgery for infection, recurrent PFF and recurrent dislocation and three other patients required closed manipulation for a single dislocation. One stem subsided more than 5 mm but then stabilised and required no further intervention.

In this series, a modular, tapered, conical stem provided a versatile reconstruction solution with a low rate of complications.

Cite this article: Bone Joint J 2015;97-B:1031–7.

A femoral fracture in an adolescent is a significant injury. It is generally agreed that operative fixation is the treatment of choice and rigid intramedullary nailing is a surgical treatment option. We present on experience of treating adolescent femoral fractures using a lateral entry intramedullary nail.

We reviewed 15 femoral fractures in 13 children who we treated in our unit between 2011 and 2014. Two patients had bilateral fractures (non-simultaneous). Data collected included patient demographics, mechanism of injury, type of fracture, associated injuries, size of nail, time to unite and complications.

The mean age of the patients at time of surgery was 12 years (range 10–15). There were 7 male and 6 female. 10 fractures were caused by a fall whilst 5 were due to road traffic collisions (RTC). 8 fractures involved the middle third, 2 of theses were open fractures and were caused by a RTC. The remaining 7 involved the proximal third of the femur. The mean time to radiological union was 3.4 months (range 2.5–5) in 14 fractures. One patient had a delayed union that required bone grafting and united fully at 7.5 months post injury. The only other complications were a broken proximal locking screw in one patient and an undisplaced femoral neck fracture in another patient. These complications did not compromise the outcome. No patients had infection or developed avascular necroses at the latest follow up.

Intramedullary nailing of adolescent femoral fractures using the lateral entry point is safe and effective

The purpose of the study was to investigate the incidence of surgical site infection following elective paediatric orthopaedic surgery.

A pro forma adopted from a pilot study was filled out preoperatively for each elective operation performed during the study period. Each patient was then followed up for six weeks postoperatively to record any SSI that developed. Data collected included patient demographics, type of operation, grade of Surgeon, type of procedure, wound length, skin preparations, use of tourniquet, any antibiotic prophylaxis and length of operation.

This study collated data on 334 operations with 410 procedural sites over a six month period. Infection were recorded in 19 sites equivalent to a SSI rate of 4.63%. None of the patients developed long-term complications.

The mean age of the participants in the study was 11 years (range 0.5 to 17 years), 57% were males and 43% were females.

The infection were detected between 1 and 38 days after surgery. The outcome was not compromised in any of the patients as none of them required long-term treatment. Statistical analysis was undertaken.

The study proves that the surgical site infection after elective paediatric orthopaedic surgery is low and serve as a bases for consenting patients for surgery.

Background:

Lower limb reconstruction is performed in trauma centres where uplifted tariffs support the treatment of severely injured patients. Calculation of Healthcare Resource Groups (HRG4) codes is affected by the accuracy of clinical coding, determining the financial viability of this service in a district general hospital (DGH).

Successful treatment of periprosthetic joint infection involves surgical intervention and identification of infecting organisms to enable targeted antibiotic therapy. Current guidelines recommend intra-operative culture sampling to include at least 4 tissue samples and for each sample to be taken with a separate instrument.

We aimed to review current revision arthroplasty practice for Greater Glasgow, specifically comparing intra-operative sampling technique for infected revision cases with these guidelines.

We reviewed the clinical notes of all patients undergoing lower limb revision arthroplasty procedures in Greater Glasgow Hospitals (WIG, GRI, SGH) from July 2013 to August 2014. Demographics of all cases were collected. For revision procedures performed for infection we recorded details of intraoperative samples taken (number, type and sampling technique) and time for samples to reach the laboratory. Results of microbiology cultures were reviewed.

Two hundred and fifty five revision arthroplasty procedures (152 hips, 103 knees) were performed in the 12 month study period. Of these 57 (22%) were infected cases (28 hips, 29 knees). These cases were treated by 14 arthroplasty surgeons with a median number of 3 infected cases managed per surgeon (range 1–11). 58% of cases had the recommended number of tissue samples taken. The median number of microbiology samples collected was 4 (range 1–14). Most procedures (91%) had no documentation of whether separate instruments were used for sampling. Number of tissue samples taken (≥4, p=0.01), time to lab (<24 hours, p=0.03) were significantly associated with positive culture results.

In Greater Glasgow, a large number of surgeons manage infected arthroplasty cases with variability in intra-operative sampling techniques. Sample collection adheres to guideline recommendations in 58% cases. Adhering to guideline standards increases the likelihood of positive tissue cultures. Implementation of a standardised approach to intra-operative sampling for infected cases may improve patient management.

Functional restoration of patella kinematics is an essential component of TKA, whether the patella is replaced or not. This goal is accomplished by a multifactorial approach: establish proper component position and alignment, especially rotation; avoid IR of the femoral and ER of the tibial components; maintain correct joint line position; achieve symmetrical soft tissue balance.

Most modern TKA designs have an anatomic trochlear groove shape to enable midline tracking. Patella implants are better designed as well with three equilateral lugs for fixation and either dome or anatomic shape. The apex of the patella component should be aligned with the apex of the patella raphe which is more medial than lateral. This method leaves an island of exposed lateral patella facet which is managed with the “lateral slat technique” to be described. It is essentially an intraosseous lateral release. The early mobilization of modern TKA patients demands watertight closure to prevent soft tissue attenuation and late tracking issues.

When confronted with a patient with a laterally dislocated patella, implementation of the “lateral slat technique” should be done at the approach to obtain midline tracking. Such patients require a median parapatellar (MPP) approach and may need distal-lateral vastus medialis advancement (Insall Procedure).

Adherence to the principles iterated herein will produce a happy patient with good patello-femoral kinematics and function.

The major benefit of TKA with tourniquet is operating in a bloodless field. A possible secondary benefit is a better cement bone interface for fixation.

The disadvantages of tourniquet use for TKA include multiple risk factors both local and systemic - Nerve damage; Altered hemodynamics with limb exsanguinations (15‐20% increase in circulatory volume) and reactive hyperemia with tourniquet release (10% increase in limb size increasing soft tissue tension and secondary pain); Delay in recovery of muscle function; Increased risk of DVT with direct trauma to vessel walls and increased levels of thrombin-antithrombin complexes; A 5.3x greater risk for large venous emboli propagation and transesophageal echogenic particles; Vascular injury with higher risk in atherosclerotic, calcified arteries; Increase in wound healing disturbances.

Our initial experience with TKA without tourniquet was in high risk patients with previous DVT or PE, multiple scarring, or compromised cardiovascular status. We have used this method on all patients for the last eight years. The protocol includes regional anesthesia, incision and approach made with 90-degree knee flexion, meticulous hemostasis, jet lavage and filtered carbon dioxide delivered to dry and prepare bone beds for cementation, application of topical tranexamic acid and routine closure. We have encountered no differences in blood loss or transfusion rates, less postoperative pain, faster straight leg raise and knee flexion gains, and fewer wound healing disturbances. We recommend TKA sans tourniquet. Let it bleed!

Purpose and Background

Back pain impinges upon all aspects of life, has a reported UK lifetime prevalence as high as 84% and considering approximately a third of our lives are spent asleep the paucity of research into the effect a mattress has on back pain and sleep is surprising. Mood changes, effecting an increase in pain perception, due to sleep loss may also lead to a downward spiral of increasing back pain and greater sleep loss. A controllable factor in this spiral, affecting both aspects, is the mattress but to the authors' knowledge none currently available on the market have any robust, published research to objectively support any claims made and at best being ‘endorsed’ by experts. This may lead to possible misinterpretation of efficacy and leave professionals at a loss with what to advise when questioned.

Revision knee arthroplasty presents a number of challenges, not least of which is obtaining solid primary fixation of implants into host bone. Three anatomical zones exist within both femur and tibia which can be used to support revision implants. These consist of the joint surface or epiphysis, the metaphysis and the diaphysis. The methods by which fixation in each zone can be obtained are discussed. The authors suggest that solid fixation should be obtained in at least two of the three zones and emphasise the importance of pre-operative planning and implant selection.

Cite this article: Bone Joint J 2015;97-B:147–9.

Stoppa approach has recently been adapted for pelvic surgery as it allows direct intra-pelvic reduction and fixation of the quadrilateral plate and anterior column. We report our early experience, indications and complications with this exposure introduced in 2010 in our tertiary unit.

A Retrospective review of all Stoppa approaches in pelvic-acetabular fixations was performed from a prospectively maintained database.

Of the 25 patients, mean age 40 years (range 15–76), who underwent pelvic-acetabular fixation using Stoppa approach, 21 patients had mean follow up of 7.3 months (1–48 months). All except 24% of patients had one or more additional systemic injury some requiring additional surgery. There were 6 acetabular fractures, 13 pelvic ring injuries and 6 combined fractures. Mean injury-surgery interval was 9 days (range 3–20). 8 patients had an isolated Stoppa approach whilst the remaining others also had an additional approach. Mean surgical time was 239 minutes. Anatomical reduction was achieved in 96% (24/25) cases. There was 1 minor intra-operative vascular injury, repaired immediately successfully, and no late wound infections, or other visceral complications. One patient reported new onset sensory numbness which resolved after the first review. Two patients reported erectile dysfunction thought to be caused by the initial injury. One patient had asymptomatic plate loosening. None required revision surgery.

Despite the obvious learning curve, we found this approach safe and it did not compromise accuracy of reduction in well selected patients, but early surgery within 10–14 days is recommended to aid optimal reduction.

Introduction:

The Best Practice Tariff (BPT) for hip fractures was introduced in April 2010 to promote a number of quality markers, including surgery within 36 hours. We conducted an audit to see whether the introduction of the BPT has had an inadvertent adverse effect on delay to fixation of unstable ankle fractures.

Introduction:

In 2009 the Smart Toe implant was introduced as an option for lesser toe fusion in our department. The Smart Toe is an intramedullary device made from Nitinol, an alloy that can change shape with a change of temperature, expanding within the intramedullary canals of the proximal and middle phalanx to achieve fixation. The advantages of the Smart Toe are that patients are spared 6 weeks with K-wires protruding from their toes and there is no need for wire removal. We conducted a retrospective review of radiographic and clinical outcomes to assess the performance of this implant.

Aims

Femoroacetabular Junction Impingement (FAI) describes abnormalities in the shape of the femoral head–neck junction, or abnormalities in the orientation of the acetabulum. In the short term, FAI can give rise to pain and disability, and in the long-term it significantly increases the risk of developing osteoarthritis. The Femoroacetabular Impingement Trial (FAIT) aims to determine whether operative or non-operative intervention is more effective at improving symptoms and preventing the development and progression of osteoarthritis.

Patellofemoral complications are common after total knee replacement (TKR). Leaving the patellar unsurfaced after TKR may lead to complications such as anterior knee pain, and re-operation to surface it. Complications after patellar resurfacing include patellar fracture, aseptic loosening, patellar instability, polyethylene wear, patellar clunk and osteonecrosis. Historically, patellar complications account for one of the larger proportions of causes of failure in TKR, however, with contemporary implant designs, complication rates have decreased. Most remaining failures relate to patellofemoral tracking. Understanding the causes of patellofemoral maltracking is essential to prevent these complications as well as manage them when they occur.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):84–6.

The K2M MESA Rail is a new implant with a unique beam-like design which provides increased rigidity compared with a standard circular rod of equivalent diameter potentially allowing greater control and maintenance of correction. The aim of this study was to review our early experience of this implant.

We retrospectively reviewed the case notes and radiographs of all consecutive cases of spinal deformity correction in which at least one rail was used. All radiological measurements were made according to the Scoliosis Research Society definitions.

Since June 2012 thirty-three cases of spinal deformity correction were performed using the K2M Rail system. One case was excluded as there were no pre-operative radiographs. Median age was 15 years; there were 23 females. There were 26 scoliosis cases of which two had associated Chiari malformation, three were neuromuscular, and the remainder were adolescent idiopathic cases. Six patients had kyphotic deformity secondary to Scheuermann's disease. Mean length of follow-up was 16 months. In the scoliosis cases the mean pre-operative Cobb angle of the major curve was 58.6° with a mean correction of 35.6°. The mean post-operative thoracic kyphosis was 21.1°. The median number of levels included in the correction was 13. Bilateral rails were used in four cases, the remainder had one rail on the concave side and a contralateral rod. No patients required an anterior release or staged surgery. All kyphosis cases had posterior apical corrective osteotomies. The mean pre-operative thoracic kyphosis was 75.5° with a mean correction of 31°. The median number of levels included in the correction was 11. Four patients had bilateral rails. No patients required anterior release. Complications: two patients had prominent hardware. One patient had a malpositioned screw causing nerve root irritation, which was removed. There were three superficial infections, which settled with antibiotics. There were no cases of implant breakage, screw pull-out, or loss of correction.

The K2M MESA Rail is a powerful new implant design which helps to achieve and maintain satisfactory correction of complex spinal deformity, and is particularly strong at correcting kyphotic deformity. It also enables restoration of normal thoracic kyphosis, particularly in idiopathic thoracic curves, which tend to be lordosing. This may prevent thoracic flat back and potential long-term sequelae. Early results show that the system is as safe and effective as other posterior deformity correction implants on the market, however, it requires further prospective follow-up to ascertain its outcomes in the long-term.

Unicompartmental knee arthroplasty (UKA) has been gaining popularity in recent years due to its perceived benefits over total knee arthroplasty (TKA), such as greater bone preservation, reduced operating-room time, better post-operative range of motion and improved gait. However there have been failures associated with UKA caused by misalignment of the implants that have lead to revisions. To improve the implant alignment a robotic guidance system called the RIO Robotic Arm has been developed by MAKO Surgical Corp (Ft. Lauderdale, FL), which is designed to give improved accuracy compared to traditional UKA using cutting jigs and other manual instrumentation.

The University of Strathclyde in association with Glasgow Royal Infirmary has undertaken the first independent RCT trial of the MAKO system against the Oxford unicompartmental knee arthroplasty – a conventional UKA used in the UK. Motion analysis was used in order to obtain a quantitative assessment of their movement. The results from a total of 51 patients (23 MAKO, 28 Oxford) that underwent a one year post-operative biomechanical assessment were investigated.

Motion analysis showed that during level walking the MAKO group achieved a higher knee excursion during the highest flexion portion of the weight bearing stage of the gait cycle (foot-strike to mid-stance) compared to the Oxford group (18.6° and 15.8° respectively). This difference was statistically significant (p-value = 0.03). Other knee excursion values that were compared were from mid-stance to terminal stance, and overall knee flexion. No statistically significant differences were seen in either of these measurements. A subsequent comparison of both MAKO and Oxford groups with a matched normal cohort (50 patients), demonstrated that there wasn't a statistically significant difference between the MAKO group and the normal knees during mean knee excursion from foot-strike to mid-stance (18.6° and 19.5° respectively, p-value 0.36). However the Oxford group, with a lower knee excursion was found to be significantly different to our normal control group (15.8° and 19.5° respectively, p-value < 0.001).

This suggests that the robotic-assisted knees behaved more similarly to normal gait during this phase of the gait cycle than those of the conventional group. While significant differences in gait were found between the Oxford and MAKO groups, further work is required to determine if this results in improved knee function that is perceptible to the patient.

Summary Statement

This study provides preliminary evidence that people with knee osteoarthritis have greater asymmetry in joint loading than healthy controls. Altered loading of the contralateral limb may signify increased risk of injury to other lower limb joints in knee osteoarthritis.

Summary

This study shows a significant reduction in knee adduction moment in patients with medial compartment osteoarthritis, in both the symptomatic and asymptomatic knees. Long-term follow-up studies are required to confirm the effect of treating the asymptomatic side on disease progression.

Summary

The dGEMRIC index correlates more strongly with the pattern of radiographic joint space narrowing in hip osteoarthritis at five year follow-up than morphological measurements of the proximal femur. It therefore offers potential to refine predictive models of hip osteoarthritis progression.

Summary

162 patient cohort with serial Metal Artefact Reduction Sequence MRI scans. Patients with normal initial scans can be followed up at 1 year. Those with abnormal scans should be followed up at a shorter interval of 6 months.

Summary Statement

We have shown that integrin mRNA expression is regulated by the application of mechanical load. This indicates that mechanical loading may modify cell sensitivity to perceive further load through increased interaction with the ECM.

Infection after total knee arthroplasty poses formidable challenges to the surgeon. Once an infection is diagnosed, the identification of the organism and its sensitivity to antibiotics is essential. The host's healing capacity is vital. Optimisation of modifiable comorbidities, supplemental nutrition and cessation of smoking can improve wound healing. Surgical goals include debridement of necrotic tissue and elimination of the dead space. Intravenous antibiotics and a two-stage protocol are the standard of care. At our institution, the first stage is performed with an implant and antibiotic-cement composite. This articulating spacer maintains limb length and tissue compliance. The patient can maintain a functional status between stages. Definitive reconstruction is more readily accomplished with this method in contrast to the static spacer approach. The clinical efficacy of this protocol has been well documented in the literature.

The major benefit of TKA with tourniquet is operating in a bloodless field. A possible secondary benefit is a better cement bone interface for fixation.

The disadvantages of tourniquet use for TKA include multiple risk factors both local and systemic.

Nerve damage

Our initial experience with TKA without tourniquet was in high risk patients with previous DVT or PE, multiple scarring, or compromised cardiovascular status. We have used this method on all patients for the last eight years. The protocol includes regional anesthesia, incision and approach made with 90-degree knee flexion, meticulous hemostasis, jet lavage and filtered carbon dioxide delivered to dry and prepare bone beds for cementation, application of topical tranexamic acid and routine closure. We have encountered no differences in blood loss or transfusion rates, less post-op pain, faster straight leg raise and knee flexion gains, and fewer wound healing disturbances. We recommend TKA sans tourniquet. Let it bleed!

Arthroscopic intervention for early symptoms of arthrosis of the knee was a well-established procedure until Moseley cited his study showing no difference in outcomes when compared to “sham” surgery. Now there is no opportunity for reimbursement with arthroscopic debridement unless mechanical internal derangement can be documented. There are, however, several specific lesions of arthrosis which respond well to arthroscopic intervention and are reimbursed by third party payers.

Arthroscopic three compartment microfracture with non-weight bearing and passive motion for eight weeks post- op has significantly relieved symptoms. Second look biopsies have confirmed type II hyaline cartilage and increased joint interval. Proper patient selection is paramount and guidelines will be discussed.

Isolated severe patellofemoral arthrosis with patella subluxation responds to arthroscopic patella lateral facetectomy. Jones has reported significant pain relief up to two years with this excellent option for a difficult patient problem. The technique and results will be presented in detail.

Loss of terminal extension in the arthritic knee can accelerate deterioration and force earlier decision for TKA. Parson's third tubercle is an osteophyte that forms just anterior to the ACL insertion on the tibia and is the frequent cause of extension loss. Arthroscopic resection of the tubercle results in increased extension and diminishes the stress concentration assuring better longevity for the native knee. The diagnostic characteristics, resection techniques and results of the Dallas series will be presented.

Functional restoration of patella kinematics is an essential component of TKA, whether the patella is replaced or not. This goal is accomplished by a multifactorial approach: establish proper component position and alignment, especially rotation, avoid IR of the femoral and ER of the tibial components, maintain correct joint line position, and achieve symmetrical soft tissue balance

Most modern TKA designs have an anatomic trochlear groove shape to enable midline tracking. Patella implants are better designed as well with three equilateral lugs for fixation and either dome or anatomic shape. The apex of the patella component should be aligned with the apex of the patella raphe which is more medial than lateral. This method leaves an island of exposed lateral patella facet which is managed with the “lateral slat technique” to be described. It is essentially an intraosseous lateral release. The early mobilisation of modern TKA patients demands watertight closure to prevent soft tissue attenuation and late tracking issues.

When confronted with a patient with a laterally dislocated patella, implementation of the “lateral slat technique” should be done at the approach to obtain midline tracking. Such patients require a median parapatellar (MPP) approach and may need distal-lateral vastus medialis advancement (Insall Procedure).

Adherence to the principles iterated herein will produce a happy patient with good patello-femoral kinematics and function.

The number of primary Total Knee Arthroplasty (TKA) and primary Total Hip Arthroplasty (THA) procedures carried out in England and Wales is increasing annually. The British Orthopaedic Association guidelines for follow up currently differ for patients with TKA and THA. In THA the BOA recommends that Orthopaedic Data Evaluation Panel (ODEP) 10A rated implants should be followed up in the first year, once at seven years and three yearly thereafter. The BOA guidelines for TKA minimum requirement is radiographs at 5 years and each five years thereafter. Few studies have investigated if early follow up affects patient management following total hip and knee arthroplasty

We carried out a retrospective review of all revision procedures carried out in our institution between April 2010 to April 2013. The medical notes and radiographs for each patient were examined to determine the operative indications and patients symptoms. 92 knee revisions and 143 hip revisions were identified. Additionally we retrospectively reviewed the outcome of 300 one year routine arthroplasty follow up appointments.

The mean time of hip revision was 8.5years (range 0 to 27years) and 5.6years (range 0 to 20years) for knee revisions. The commonest cause for revision was aseptic loosening associated with pain in 49 (53%) of knee revision patients and 89 (63%) of hip revisions. Infection accounted for 26 (28%) knee revisions and 16 (12%) hip revisions. Only 1% of hip and knee revisions was carried out in asymptomatic patients with aseptic loosening.

We did not identify any cases were a patients management was altered at the routine arthroplasty review clinic and none were referred on for further surgical treatment. The findings of our study suggest there is no evidence for a routine one year arthroplasty review and revisions were carried out in asymptomatic patients in 1% of patients.

Aim:

To determine the efficacy and safety of the Magec system in early onset scoliosis (EOS).