Introduction: In this study we have studied the range of motion within Dynesys treated discs and levels adjacent to flexible stabilisation. Dynesys was designed to offer physiological motion at the lumbar spine. An advantage which is superior to abolishing movements through spinal fusion. Methods: A cohort of 75 post-Dynesys patients had weight-bearing lateral lumbar spine x rays in flexion/extension positions. Evaluation was done through PACS™ digital software. Flexibility at individual disc level was measured as the differences between flexion/extension angles accurate to within 1°. Motion was evaluated at the index and immediate adjacent levels. Results: Patients with single level Dynesys had an average ROM of (3+/−4.7) at L5-S1 and (5.1+/−2.9) at the immediate adjacent level. Two levels Dynesys was associated with a ROM of 5+/−3.6 at L5-S1 & L4–5 and 3.5+/−1.8 at their immediate neighbour disc. Across three levels, Dynesys favoured a ROM of 5.3+/−2.5 at the operated sites and 1.6+/− 2 at the adjacent level. Discussion & Conclusion: This study is the first radiological research to confirm the flexibility of Dynesys. Controlled motion at the dynesys treated disc levels share to distribute global spinal movements. This will advantage the next disc segments and protects them from risk of developing “accelerated adjacent segment disease”

There is still want of evidence in the current literature of any significant improvement in clinical outcome when comparing computer-assisted total knee arthroplasty (CA-TKA) with conventional implantation. Analysis of alignment and of component orientation have shown both significant and non-significant differences between the two methods. Not much work has been reported on clinical evidence of stability of the joint. We compared computer-assisted and conventional surgery for TKA at 5.4 years follow-up for patients with varus osteoarthritic knees with deformity of more than 15∗. Our goal was to assess clinical outcome, stability and restoration of normal limb alignment. We used CT and Cine video X ray techniques to analysize our results in Computer navigated and conventional TKRs. A three dimentional CT scan of the whole extremity was performed and evaluation was done in three planes; saggital, coronal and transverse views. CT scan was done between 10 to 14 days postoperative. Mean deviations in the mechanical axis, femoral and tibial plateau angles, and in transverse view, the trans-epicondylar axis vs posterior condylar axis were measured. The prospective randomized study comprised of 98 patients with surgery done on knees, one side navigated and other side conventional. Mean deviation in the mechanical axis was 2.2∗ in conventional knees and 1.8∗ in navigated knees. In 5 % of cases retinacular release was needed and CT analysis showed TEA in deviation of more than 2 ∗ in these cases. We analysed intraoperative data (surgical time and intraoperative complications), postoperative complications, lower limb alignment, radiographic complication on X-ray imaging, and clinical outcome throughknee and function score, range of motion and joint stability. Our results showed that CAS had greater consistency and accuracy in implant placement and stability of joint in full extension and 90∗ flexion. In the coronal view, 93.3% in the CAS group had better outcomes compared with EM (73.4%). In the sagittal axis, 90.0% CAS also had better outcomes compared with EM (63.3%). Computer-navigated total knee arthroplasty helps increase accuracy and reduce “outliers” for implant placement

Introduction: Occult fractures of carpal bones are underestimed. To be treated succesfully fractures of the scaphoid must be identified at an early stage. A delay in detection may result in non union. We validated with 3 prospective studies a new tool using scintigraphy : The quantitative Xray bone scan (QRS). Material and Methods: A previous preliminary prospective study with 60 patients was performed and published to valid the QRS as a step in diagnosis of wrist occult bones fractures equal to RMI. This exam is a bone scan with 2 improvments. 1) A quantification of the fixation spot : If the spot is two times more important on the injuried wrist (than controlateral side) the fracture is sure. 2) If you combine plain Xrays of the the wrist with scintigraphy the fracture is automatically located. This previous report pointed that repeat set of scaphoid views, dynamic and static, Ct scan, proved unsuitable for screening occult fractures of the wrist. Result: Between november 97 and march 04, 667 patients were enrolled in a prospective continue study. 40% (260/667) of patients with an injury of the wrist with normal X ray sustained an occult fracture. QRS was performed at an average of 17,7 days after the injury and after clinical exam and repeat set of scaphoid view. Scaphoid fractures were most frequent. Fixation was most important if scintigraphy was performed between 11 and 20 days after the injury. Fixation did not depend on age, sex, volume of the bone, and delay (after 15 days). Discussion: As Dikson, Dias, Thompson, and Kuckla, repeat set of scaphoid view are unable to improve significativally the number of occult fractures of the wrist. RMI as reported by Kuckla can reduce the need for further imaging procedure. RMI and scintigraphy are both the best exam to diagnose surely an occult fracture of the wrist. But QRS does not over diagnose, as RMI, bones fracture’s. Conclusion: “Plaster cast and wait” is not the treatment for occult carpal bones fracture’s. The quantitative Xray bone scan is able to diagnose such fractures with short delay

Background

Using digital X-rays to plan a hip replacement can cause problems with sizing and templating the prosthesis. Using an AP view of both hips is desirable as this allows the use of the sometimes unaffected contralateral hip for templating.

Aim of the study: The aim of the study was to register and þnd out the longterm femoral bone response after insertion of femoral stem with or with-out cement. Materials and methods: Seventeen patients (7 men, 10 women) underwent cemented and 22 patients (14 men, 8 women) uncemented total hip arthroplasty (THA). The mean age in the cemented group was 69 (58–74) years and in the uncemented group 58 (46–68) years. Femoral bone mineral density (BMD) was measured using Lunar DPX or Lunar DPX-IQ densitometry according to zones by Gruen (ROI 1–7). BMD measurements were made preoperatively, and postoperatively over four to 14 days, and at 3, 6, 12, 24, and 36 months after THA. Postoperative BMD changes were calculated using the immediate postoperative BMD value as a reference, the change being expressed as a percent. Results: Peri-prosthetic BMD decreased signiþcantly almost in all ROIs during the þrst three months after both cemented (5–18%) and uncemented (3–14%) THA (p-values < 0.05 to p< 0.001). At the end of the þrst year the most remarkable decrease in BMD was found in the calcar (zone 7) in both groups (cemented 25%; uncemented 23%). Low preoperative bone loss predicted higher periprosthetic bone loss in both groups. From one to three year only small changes in periprosthetic BMD were detected after THA. Conclusions: The present study suggests that postoperative bone loss is equal after uncemented and cemented THA. The bone loss is most pronounced during the þrst six months after THA and mainly associated in proximal femoral bone. After the phase of acute bone loss, further loss is minimal after uncomplicated THA, reßecting merely the normal aging of bone. Patients with poor bone quality at baseline are at higher risk to lose bone around the prosthesis after THA.

Purpose

To evaluate Radiological changes in the lumbosacral spine after insertion of Wallis Ligament for Foraminal Stenosis.

To evaluate Radiological changes in the lumbosacral spine after insertion of Wallis Ligament for Foraminal Stenosis.

Thirty two Levels in Twenty Six patients were followed up with standardised radiographs after insertion of Wallis Ligaments for Foraminal Stenosis. Wallis ligaments as a top-off or those with prolapsed discs were not included. The Radiological parameters compared were Anterior and Posterior Disc height, Foraminal height and width, The inter-vertebral angle (IVA), Lumbar lordosis and Scoliosis if any. The presence of slips and their progression post-op was noted, as was bony lysis if any.

There were ten males with thirteen levels and sixteen females with nineteen levels in the study. Eighteen levels (56.25%) were L4/L5, ten (31.25%) were L5/S1 and 4 (12.5%)were L3/L4. The average age in the series was 59.6 years (Range 37 – 89 yrs). Average follow up was 9.5 months (Range 2 to 36). The Average increase in Anterior disc height was 1.89 mm (+/−1.39), the posterior disc height increased by an average 1.09 mm (+/−1.14). Foraminal height increased by an average 3.85 mm (+/− 2.72), while foraminal width increased by 2.14 mm (+/− 1.38). The IVA increased in 16 and reduced in 15 patients, with no change in 1. Lumbar Lordosis increased in 23 patients, with an average value of 2.3°. No patient exhibited progression in scoliosis and no lysis could be identified. There were three Grade I slips pre-op; none progressed.

Foraminal dimensions and Disc height were consistently improved after Wallis insertion. Changes in IVA and Lumbar lordosis were however variable. A longer follow up is suggested to look for sustained improvement and the presence of lysis.

Aims and objectives

Our aim was to evaluate the indications for patients undergoing magnetic resonance imaging (MRI) of the knee prior to referral to an orthopaedic specialist, and ascertain whether these scans altered initial management.

Neck of femur fractures are a common presentation and certain patients can be managed with a total hip replacement. To receive a total hip replacement the pelvic X-rays should be templated as per AO guidelines and a common way this is performed is by including a calibration marker on the X-ray. The aim of this study is to assess and improve upon the use of the calibration marker. Details of patients admitted with a neck of femur fracture from January 1st 2018 until December 31st 2018 were gathered and used to review each initial X-ray and determine if a calibration marker was included. 376 patients were admitted with a neck of femur fracture over the one year period. 36% of patients did not have a calibration marker on their initial pelvic X-ray and 11% did not have a chest X ray. 215 patients had an intracapsular fracture and 39 went on to have a total hip replacement. 12 patients were lacking a calibration marker on their original X ray and required a repeat X ray. After a poster was placed in the radiographer booth acting as a visual aid, the use of a calibration marker improved from 62% to 70%. Calibration markers are useful tools which can aid the pre-operative planning for hip replacement surgeries shortening operative time, increase precision and reduce prosthetic loosening, lowers the risk of peri-prosthetic fractures, reduce leg length discrepancy and ensure the required implants are available. If a marker is not included on the initial X-rays, and a patient has a neck of femur fracture which requires a joint replacement, they may have to have additional X-rays performed as was the case for 12 patients in this study. This process leads to possible delays in surgery, additional radiation and increased healthcare costs

Aims: Irradiated allograft bone may help to reduce the risk of transmission of infectious agents from donor to recipient. The purpose of this study was to establish the results of impaction bone grafting of acetabular defects with froze, irradiated allograft bone. Methods: All patients treated by a single surgeon with impaction bone grafting of acetabular defects at revision total hip replacement were reviewed retrospectively. All operations were performed during the period 1994–2000. The mean follow-up was 50 months (range 30–96 months). Case notes and X rays were reviewed and analysed. The Paprosky grade of acetabular defects was determined from the pre-operative X rays and the surgeonñs operation note. Post-operative X rays were reviewed to establish the extent and rate of new bone in-growth. Functional outcomes were determined by way of self-administered questionnaires. Results: Complete records and X rays were obtained for 33 patients who underwent revision hip arthroplasty with impaction bone grafting of the acetabulum using frozen, irradiated allograft bone. There were no complications associated with the bone grafts and no patient required a re-operation. Review of serial X rays conþrmed in-growth of host bone and the functional outcome was satisfactory. Overall 29 patients (88%) declared themselves satis-þed with the outcome of their operation and 32 patients (97%) improved functionally after the operation. Conclusions: These results indicate that satisfactory results can be achieved with impaction bone grafting using frozen, irradiated allograft bone. The use of irradiated bone graft can potentially reduce the risk of disease transmission from donor to recipient without compromising the surgical results

The aim is to investigate if there is a relation between patellar height and knee flexion angle. For this purpose we retrospectively evaluated the radiographs of 500 knees presented for a variety of reasons. We measure knee flexion angle using a computer-generated goniometer. Patellar height was determined using computer generated measurement for the selected ratios, namely, the Insall–Salvati (I/S), Caton–Deschamps (C/D) and Blackburne–Peel (B/P) indices and Modified I/S Ratio. A search of an NHS hospital database was made to identify the knee x rays for patients who were below the age of forty. A senior knee surgeon (DC) supervised three trainee trauma and orthopaedics doctors (HA, JM, ES) working on this research. Measurements were made on the Insall–Salvati (I/S), Caton–Deschamps (C/D) and Blackburne–Peel (B/P) indices and Modified I/S Ratio. The team leader then categorised the experimental measurement of patients’ knee flexion angle into three groups. This categorisation was according to the extent of knee flexion. The angles were specifically, 10.1 to 20, 20.1 to 30, and 30.1 to 40 degrees of knee flexion. Out of the five-hundred at the start of the investigation, four hundred and eighteen patients were excluded because they had had either an operation on the knee or traumatic fracture that was treated conservatively

Background. An improved understanding of intervertebral disc (IVD) structure and function is required for treatment development. Loading induces micro-fractures at the interface between the nucleus pulposus (NP) and the annulus fibrosus (AF), which is hypothesized to induce a cascade of cellular changes leading to degeneration. However, there is limited understanding of the structural relationship between the NP and AF at this interface and particularly response to load. Here, X-ray scattering is utilised to provide hierarchical morphometric information of collagen structure across the IVD, especially the interface region under load. Methodology. IVDs were imaged using the I22 SAXS/WAXS beamline at Diamond Light Source. Peaks associated with the D-banded structure of collagen fibrils were fitted to quantify their azimuthal distribution, as well the magnitude and direction of internal strains under static and applied strain (0–20%). Results. IVD tissue regions exhibited structural “AF-like” and “NP-like” fingerprints. Demonstrating high internal strains on collagen fibres particularly within the NP region of the disc. AF and NP regions showed distinct collagen orientation and internal strains with an apparent lack of bracing structure seen at the interface between the differential mechanical tissues. X-ray scattering under tensile strain provided structural information at high resolution, with clear differences observed between normal and degenerate discs under load. Conclusion. X ray scattering has been utilised to develop an improved understanding of collagen structure across the intervertebral disc which can be utilised to gain an increased understanding of load induced propagation of micro fissures and disc degeneration. Conflict of Interest: No conflict of interest. Funding: BioPro Network, UCL for funding this study through support from the MRC (MR/R025673/1)

Aim: Assessing Polyethylene wear is very important in following up patients after Total hip replacement (THR) and Livermore method (using callipers) is routinely used by clinicians in calculating this wear. Our aim was to assess if ‘Imagika’, a new computer software programme can accurately assess polyethylene wear(PE-wear). We also compared the computer software with the Livermore method in calculating wear. Method: We used 15 different THR X rays of patients who had an ABG total hip replacement done. X rays that were included for the calculations were taken at different time intervals following the operation. Wear was calculated on each X ray by 3 clinicians using both the methods, on 3 separate occasions. We compared the Livermore method and the computer software for consistency of measurements and also calculated the inter and intra observer variability for both. Results: There was a statistically significant difference (at the 5% level) between the measurements taken by the Imagika software and the Livermore method. F(1,88) = 5.38, p< 0.05. There was a statistically significant difference in the inter-observer measurements using the Livermore method. F(2,42) = 4.18, p< 0.05, but there was no significant inter-observer variation using the Imagika computer software. There was no statistically significant difference (at the 5%level) in the intra-observer variability of both groups. Conclusion: The Imagika computer software proved to be better than the Livermore method in calculating wear with regards to inter-observer bias. There was also a significant difference between measurements taken using both methods. We conclude that the computer software may be a more accurate tool in the assessment of PE-wear in the future

Introduction: A good cup positioning requires reliable anatomical landmarks expecially for navigation. The anterior pelvic plane (APP) seems to be a good reference for navigation because it is in relation with pelvic tilt which do affect the position of the cotyle and consequently the position of the cup. The value of this plane is not well known according to gender, age, weight… The aim of the study is to assess radiologically the APP in standing and supine position before and after total hip arthroplasty. MATERIALS AND Methods: 92 Patients (32 males, 60 females, mean age 65 years) underwent strict lateral X-rays in standing and supine standardized position. Uninterpretable or unsatisfying X rays were withdrawn. 45 patients underwent a standing X-ray, 24 a supine X-ray, 21 a supine and standing X ray. Statistical analysis used a Student t-test. Results: Non matched values showed a retroversion of the pelvis of 6.4° (+/− 6.9) in supine position, 0.3° (+/− 7.4) in standing position. Matches values showed an retroversion of the pelvic of 6.9° (+/− 5.3) in supine position, 0.3° (+/− 5.03) in standing position (significant difference). Extreme values varied from −15° to + 18° (3 patients showed no variation, 2 patients a retroversion from supine to standing position). There was no statistical difference between male and female but a statistical differences in females. Discussion: The APP is easily assessable by X rays in standing as in supine position. Bony landmarks of the plane are also assessable by navigation tools and to can be a good plane as reference. Several authors showed the repercussion of the pelvic tilt on the cotyle position. The difference between standing and supine position is about 6°. But for some patients the difference is may be of 20°and that could explain some impigment and instability. A cup well positioned in supine position may be not so good in standing position because of the pelvic tilt. Conclusion: The value of the APP is important to know before THA and seems to be a good plane as reference for navigation

Patients with osteoarthritis of the knee reviewed by the General practioners, are usually referred for further management to the orthopaedic surgeon. It was our observation that patients were usually referred with supine knee X-rays. This meant weight-bearing films were repeated at the clinic. Methods: We sent out questionnaires to GPs inquiring whether they asked for X-rays of the knee prior to patient referral and whether they asked for weight bearing films. We also reviewed the policy in one National Hospital Service trust and one teaching hospital with regards to GPs asking for weight bearing films. The time patients spent waiting at the X-rays department was noted. Finally we inquired about the cost of a knee X-ray. Results: A total number of 65 questionnaires were sent and the response was 44 i.e. 67%. 80% of the GPs asked for non weight bearing X-rays prior to referral. Only 5% asked for weight bearing films. The radiology departments of hospitals in one NHS trust and the teaching hospital did not accept weight bearing requests from GPs. The time taken for a patient to get an X ray in the department was at least 30 minutes and the cost of X rays of the knee was £51. With an average of two patients with osteoarthritis of the knee per clinic, the cumulative waiting time for repeated X-rays was 1 hr per clinic, 5 hrs per week and 240 hrs per year. With an average of two X rays per clinic the cumulative cost was £102 per clinic, £510 per week and £24480 per year. Discussion: Non weight bearing X-rays of the knee do not add any value in making or confirming a diagnosis of osteoarthritis yet they are costly both in terms of time and money. Weight bearing films were repeated for patients with these X-rays. The cumulative cost in terms of time can be better used to review other patients and therefore reduce the waiting time before surgeons can see referrals. The other issue is the cumulative cost which can be put to better use in the trust. The time wasted by the patients who have repeated X-rays was not considered, but is also of importance. Conclusion: Patients with osteoarthritis of the knee should have weight bearing films from the initial onset. This will save time for the patient and the surgeon and will save the hospital money

The best follow up strategy after hip replacement (THR) is unclear. There are conflicting demands to obtain early diagnosis of loosening, and to minimise clinic visits. It would be desirable to achieve follow up with a validated symptom questionnaire alone, but it is unclear how frequently THRs are asymptomatic during early loosening. This study examined the relationship between patient reported symptoms after THR using two measures (Oxford Hip Questionnaire (OHQ) and Visual Analogue Scale (VAS)), and the classification of the patients AP x ray of the hip as having definite loosening, possible loosening, or a sound implant. We examined data from 325 patients who had undergone a standard Charnley THR for osteoarthritis. Patients had a mean follow-up of 85 months (range 24–144). X rays were examined by a single Consultant Orthopaedic surgeon, and classified as satisfactory, possible loosening or definite loosening. As expected, the large majority of patients had a satisfactory appearance on x-ray at all-time points. 12 patients were classified as having definite loosening on the basis of the available x-rays. 8 of these were subsequently listed for revision surgery at review. 20 patients were noted to have evidence of possible loosening. Examination of the Oxford hip questionnaire and VAS data demonstrated a strong relationship between OHQ value and the VAS result for pain (r = 0.78, p < 0.001, Spearman rank correlation). Data were analysed separately (using ROC curves) to determine whether the OHQ or VAS was a satisfactory method of selecting patients who fell into “definite loosening” or “definite or possible loosening” groups. Neither OHQ or VAS were sensitive or specific for definite or possible loosening. We conclude that x rays are required for early detection of loosening, and that follow up by OHQ or VAS alone is insufficient for this purpose

Introduction. Magnetic resonance arthrogram (MRA) is the investigation of choice in young adults with symptoms of femero acetabular impingement. The aim of the study is to assess the accuracy of MRA when correlated with surgical findings on hip arthroscopy. Materials and Method. Between June 2007 and January 2014, 136 patients had MRA followed by subsequent arthroscopy at our institution. The radiology information system was used to gather MRA data. All scans were reported by a consultant radiologist with a specialist interest in musculoskeletal radiology. Patient records were reviewed to gather surgical data. Assessment was made of labral injury, Camshaft (CAM) or Pincer lesion and degeneration of the cartilage. Results. Mean age at MRA was 34.5 years with a 2.5:1 female to male ratio. For labral pathology sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 89, 100, 100 and 22% respectively. For CAM (62, 80, 79 and 64% respectively) and Pincer lesions (15, 84, 81 and 18% respectively). MRA was specific for picking up Grade 3/4 degenerate changes in the articular cartilage (92.2%) but was not as sensitive (60%), PPV 55 and NPV 94. Conclusion. These findings demonstrate that MRA is a sensitive and specific imaging modality for assessing the labrum and articular surface, but not as good for assessing CAM and Pincer lesions. This could be due to the static nature of the MRA or a lack of firm definition as to what constitutes a CAM or Pincer lesion leading to under reporting. This maybe better assessed with plane X ray or Computed tomography with 3 dimensional reconstruction. Further to this it would be interesting to combine the plane X ray and MRA finding and see if sensitivity and specificity was improved

Introduction and Objective. Malunion after trauma can lead to coronal plane malalignment in the lower limb. The mechanical hypothesis suggests that this alters the load distribution in the knee joint and that that this increased load may predispose to compartmental arthritis. This is generally accepted in the orthopaedic community and serves as the basis guiding deformity correction after malunion as well as congenital or insidious onset malalignment. Much of the literature surrounding the contribution of lower limb alignment to arthritis comes from cohort studies of incident osteoarthritis. There has been a causation dilemma perpetuated in a number of studies - suggesting malalignment does not contribute to, but is instead a consequence of, compartmental arthritis. In this investigation the relationship between compartmental (medial or lateral) arthritis and coronal plane malalignment (varus or valgus) in patients with post traumatic unilateral limb deformity was examined. This represents a specific niche cohort of patients in which worsened compartmental knee arthritis after extra-articular injury must rationally be attributed to malalignment. Materials and Methods. The picture archiving system was searched to identify all 1160 long leg x ray films available at a major metropolitan trauma center over a 12-year period. Images were screened for inclusion and exclusion criteria, namely patients >10 years after traumatic long bone fracture without contralateral injury or arthroplasty to give 39 cases. Alignment was measured according to established surgical standards on long leg films by 3 independent reviewers, and arthritis scores Osteoarthritis Research Society International (OARSI) and Kellegren-Lawrence (KL) were recorded independently for each compartment of both knees. Malalignment was defined conservatively as mechanical axis deviation outside of 0–20 mm medial from centre of the knee, to give 27 patients. Comparison of mean compartmental arthritis score was performed for patients with varus and valgus malalignment, using Analysis of Variance and linear regression. Results. In knees with varus malalignment there was a greater mean arthritis score in the medial compartment compared to the contralateral knee, with OARSI scores 5.69 vs 3.86 (0.32, 3.35 95% CI; p<0.05) and KL 2.92 vs 1.92 (0.38, 1.62; p<0.005). There was a similar trend in valgus knees for the lateral compartment OARSI 2.98 vs 1.84 (CI −0.16, 2.42; p=0.1) and KL 1.76 vs 1.31 (CI −0.12, 1.01; p=0.17), but the evidence was not conclusive. OARSI arthritis score was significantly associated with absolute MAD (0.7/10mm MAD, p<0.0005) and Time (0.6/decade, p=0.01) in a linear regression model. Conclusions. Malalignment in the coronal plane is correlated with worsened arthritis scores in the medial compartment for varus deformity and may similarly result in worsened lateral compartment arthritis in valgus knees. These findings support the mechanical hypothesis that arthritis may be related to altered stress distribution at the knee, larger studies may provide further conclusive evidence

Introduction. One of the important criteria of the success of TKR is achievement of the Flexion ROM. Various factors responsible to achieve flexion are technique, Implant and patient related. Creation of the Posterior condylar offset is one such important factor to achieve satisfactory flexion. Aim. To correlate post op femoral condylar offset to final flexion ROM at 1 yr. post op. Methods. This is a clinico-radiological study of the cases done prospectively between September 2011 and August 2012. Inclusion criteria:. All patients undergoing Bilateral TKRs and have agreed for the follow up at 1 yr. Exclusion criteria:. Patients who had previous bony surgery on lower end femur. Patients with previous fracture of lower end femur. All the patients had PS PFC Sigma (De Puy, Warsaw) components cemented. ROMs were measured at 6 weeks, 3 months, & 1 year post op. The last reading was taken as final flexion ROM as measured by a Physiotherapist with the help of a Goniometer. Results. We had 21 cases of Bilateral TKRs who satisfied our criteria. Pre and post op femoral condylar offset was measured in mm. on lateral x ray. Pre and post op flexion was measured. Results showed that variation in the posterior femoral offset by > 3mm in post op x ray was related to loss of flexion of an average 21 deg. (16 – 24 degrees). Greater the deflection from the normal offset, greater was the loss of flexion. These patients also showed lesser improvement in KSS functional score. Discussion. Flexion is one of the most important yardsticks for the measurement of success of TKR. This factor is more important more so in Asian population. Literature has shown that three important determinants for good flexion are…. Posterior Condylar Offset Restoration. Tibial slope restoration. Femoral Roll back in flexion. An increased offset permits greater flexion before impingement between the tibial insert and the femur. In our study we kept Tibial slope and Femoral Roll back constant by using the same prosthesis. The femoral condylar offset changed as per the size of the AP femoral cutting block. (Anterior referencing guide used). Overresection of the posterior condyles reduced the posterior femoral condylar offset and hence significant loss of post op flexion. The shorter posterior condyle of smaller femoral component can increase the potential for bone impingement proximal to the posterior condyles. In our study the opposite side replaced knee acted as a control. It is generally stated that after a TKR flexion can improve upto 1 year and hence was taken as final possible flexion. Conclusion. Keeping Tibial slope and Femoral roll back constant during the surgery, posterior condylar offset restoration within 3 mm of its original pre op offset was necessary to achieve satisfactory flexion at 1 year. Undersizing the femoral component to achieve more flexion is perhaps suboptimal. Appropriate AP femoral sizing is a must to restore the normal offset

Aims: Functional results of anterior cruciate ligament (ACL) is closely related to the anatomical position of the graft. Femoral or tibial miss placements are associated with increase laxity, decrease range of motion. Based on anatomical dissections we developed a triangle method able to be used as fluoroscopic intra-operative landmark to increase the reproductibility of the placements. Methods: A lateral X ray of normal knee is mandatory before the surgical procedure. During the ACL reconstruction using patellar tendon a pin is placed to determine the tibial tunnel, and a small screw is inserted at the femoral ACL location. Under imagine intensifier, a lateral X ray of the operated knee is realised. The picture is exported and analysed on a PC computer. The surgical placement is compared with the ACL center position according to the triangle method. 35 knees have been operated and compared with 35-paired knees operated with the same technique and operator. Results: The mean distance between the ACL center and the surgically chosen femoral position is 7.5 ± 1.9 mm for the standard surgery and 4.9 ± 1.3 mm for the fluoroscopy based surgical navigation. The Wilcoxon test for small-paired series indicates a statistical significance (p=0.001). The mean extra operative time is 15 ± 7mn. Conclusion: This technique is simple, easy and rather fast. It gives to the surgery a significative improvement for positioning the ACL graft on the femoral side. It has to be confirmed for larger and by long term clinical results

The authors report their preliminary experience with a minimum of one year follow –up of hydroxyapatite coating as the means of fixation of the femoral head in hip resurfacing. Between Dec 2003 and Dec 2004, of the 23 cases performed by the senior author,22 were available for follow up,15 were women (68.2%) and 7 were men (31.8). The femoral and acetabular components of the uncemented version of the CORMET 2000(Corin,Cire ncester,UK) were used. The surgical approach was the Hardinge approach in all cases. Patients were assessed pre-operatively for pain and function,using the Harris Hip Score. Post operatively they were assessed in clinic with x rays at 6 weeks,6 months and annually thereafter. X rays were evaluated for pre and post op neck shaft angle,giving an indication of varus or valgus placement of the head prosthesis. The lateral view was assessed to reveal anterior or posterior tilting of the prosthesis. Neck thinning was evaluated by measuring the ratio of the metal cup and bony neck diameters at the cup neck junction, recorded post op and at one year. None of the femoral implants were placed in varus. Only one case had inferior notching, which had remodelled at one year. In the lateral view none of the cups showed a displacement of more than ten degrees in the AP direction. There were no stem lucencies or signs of femoral implant migration in any of the cases. None of our cases showed neck thinning (change in ratio greater than 10%). Uncemented femoral implant in a metal on metal resurfacing hip replacement appears to perform well and shows no catastrophic problems at the short term one year follow up. Longer follow up studies are necessary

Introduction: Acute elbow trauma is commonly seen in the emergency department. The purpose of the present study was to evaluate in our emergency department the assessment of elbow trauma radiographs in children. Methods: 136 patients aged between 0 and 16 presented at our institution for an elbow trauma over a 6 months period. All the radiographs were digitalised and stored in a commercially available computerised X ray system. All the radiographs were reviewed at the daily clinical radiological conference by an orthopaedic surgeon and a radiologist. Results: There were 64 fractures, 2 dislocations, 37 radial head subluxations and 33 simple contusions. Of these, 15 (11 per cent) were considered to have been misinterpreted. There were 12 undisplaced fractures (5 supra-condylar fractures, 3 radial head fractures, one fracture of the lateral condyle, 3 fractures of the olecranon and 3 false-positive diagnoses of fractures. All patients were reviewed within a few days and were correctly reassessed and treated. Conclusions: Compared to other fractures, children’s elbow trauma are commonly misdiagnosed in the emergency department. In this short series, correct diagnosis was missed 15 times (11%) by various physicians working in the Emergency Department (trainees, emergency physicians). The senior specialists (orthopaedic surgeon and radiologist) used real time digital contrast enhancement, as well as magnification and soft tissue assessment with the digitizer to correctly analyse the missed diagnosis. X ray review by senior specialists at the daily clinical radiological conference is time consuming and sometimes difficult but appears to be clearly beneficial to patients ‘care

Aims:ACL revision surgery is a second-generation type of knee ligament surgery. The artificial ligaments, the imperfect mastering of arthoscopic assisted surgery and the absence of clinical and radiological analysis of peripheral laxities are among the main factors for failures. Methods:43 patients of a mean age of 29y were previously operated between 1 and 5 times.14 artificial ligaments, 23 patellar tendons and 4 hamstrings tendons failed as a first ACL reconstruction. The mean time between the first operation and the index revision was 44 months. In 6 cases an additional HTO was used. Different tendon grafts were used: quadriceps 11, patellar 19 and hamstrings 8. In 3 occasions an additional extra articular reefing was used. The patients were reviewed by one independent observer using KT 1000, Stress X rays, IKDC form (2000). The mean follow up is 35 months (11–123)Results:The IKDC score in pre operative time was 19 D, 21 C and 1B. At the review the score is 2A, 28 B, 9C, 2D. The functional IKDC form show 37.5% of remaining pain, 44% of stiffness sensation and 12.5% of instability. The mean functional improvement is 44%. The mean laxity improvement is 5.3mm for KT1000 and 4.5mm for stress X rays. Conclusions:Revision ACL surgery is not as good as primary surgery. The reconstruction is technically difficult and must be ‘à la carte’ in order to take in account several simultaneous problems: bone defect, cartilage abnormalities, skin and ligament insufficiencies

Background: Over many years our understanding of fracture patterns and management has evolved. One of the biggest steps was the adoption of the principles of fracture fixation as described by the Arbitsgemeinschaft fur Osteosynthesefragen (AO). The application of this philosophy has allowed us to optimise fracture management and improve outcome. In our unit we noted a number of complications resulting from suboptimal fracture fixations of ankles some of which required revision. It was decided to review fracture fixation of ankles in the unit to see whether the basic principles of fixation was being followed in our DGH. Aim: To evaluate whether the AO principles of fixation for ankle fractures are being followed in our local unit. Patients and Methods: 52 consecutive patients over a period of 1 year from August 2005 to August 2006 with bi malleolar and isolated medial malleolar ankle fractures, requiring surgery, had their case notes and pre operative x rays reviewed retrospectively looking at fracture patterns according to the AO and Weber classification. Post operative x rays where reviewed to see if the principles of facture fixation had been appropriately followed. Results: Of the 52 patients evaluated 26 were Weber type B fractures, 20 were type C and 6 were isolated medial malleolar fracture. Nine of the type B and three of type C (23% of the total number) underwent fixation not in accordance with AO principles. In every case the fibula fixation did not include a cortical lag screw. Discussion/Conclusions: Although none of the 12 described had to undergo revision, their management was far from optimum. By ensuring that operating surgeons have the appropriate training and experience in basic fracture fixation before being allowed to undertake such procedures, our unit hopes to show an improvement on these figures by the time this audit is repeated

Objective: We report an unusual presentation of telangiectatic osteosarcoma of distal femur in a preadolescent boy. Methods: A 9 year old boy fell down heavily while he was on holiday and fractured his distal femur. He was given above knee plaster locally and then transferred him to hospital where he lives normally. He developed increasing pain over next two weeks over fracture site (4 weeks after injury) and was reviewed in clinic. X ray of his femur showed permeative pattern of bone destruction with new bone formation. Subsequent biopsy of his lesion confirmed telangiectatic osteosarcoma. His subsequent MRI scan of thigh and CT scan of his chest showed pulmonary metastasis and dissemination of tumour to proximal femur. He never noticed any pain, discomfort or swelling before fracture and until four weeks after fracture apart from symptoms of fracture. Retrospective review of his x ray which was taken at the time of fracture demonstrated not very obvious osteolytic lesion in distal femur. Conclusion: Telangiectatic osteosarcoma is a rare subtype of osteosarcoma and represents nearly 2% of all osteosarcomas. The incidence peaks in early to mid-adolescence and is not commonly encountered in very young and preadolescent patients. Osteosarcoma usually presents with pain at night and precedes tumour by weeks or months. Some times there may be only a history of a tired feeling, a slight limp or a history of trauma. Our case did not have any symptoms at all until two weeks before the presentation. The fracture made the tumour extra compartmental and led to metastasis and poor prognosis. We should always aware of this possibility of rare presentation when we see a preadolescent patient with increasing pain following fracture

Introduction: The development of laboratory techniques in the last ten years has enabled the successful harvest, in vitro selection, culture and transplant of chondrocytes. The study proposes that transplantation of autologous chondrocytes prevents degeneration of the intervertebral disc following outer annular injury in an ovine model. Methods: Eight sheep were anaesthetised and five contiguous lumbar discs were exposed via a left-sided posterolateral approach. Four of the animals were given full thickness annular incisions in three alternate discs. No annular incisions were made in the other 4 sheep. Costal cartilage was harvested from the left twelfth rib of all animals. Tissue was cultured and the chondrocytes were labelled in vitro with CFSE for verification following transplantation. Six weeks later autologous cultured chondrocytes were injected into the lower two alternate discs of all animals, leaving the uppermost discs and those untouched in between as internal controls. Animals were sacrificed after three, six, twelve and twenty-four weeks. Results were based on X rays, histological, and immunocytochemical assessments. Results: Preliminary histological results up to three months showed viability of cultured chondrocytes and matrix production post transplantation. Serial X rays suggested that progressive disc degeneration was arrested in the treated discs. Discussion: In this pilot study we have shown that cultured autologous chondrocytes can remain viable long term in vivo. These preliminary results suggest that these transplanted chondrocytes have the ability to retard and possibly prevent disc degeneration following annular incision. Previous similar studies have reported the use of chondrocytes cultured from disc, whilst this study showed that chondrocytes from a source foreign to the disc can exert positive effects. The encouraging result from this pilot study needs to be further validated to realise its potential as a treatment for degenerative disc disease

Introduction: Preoperative use of tomodensitometry is a common practice when assessing fractures with intraarticular involvement, helping to determine the most appropriate surgical approach according to the lesions observed. To date, during the surgical procedure itself, radiographical or fluoroscopic controls still largely rely on two dimensions X rays. We assessed the possible benefits of intraoperative tridimensional reconstructions using mobile isocentric fluoroscopy (iso-C-3D) after one year of use. Material and Methods: All the procedures where intra-operative tridimensional fluoroscopy was used were assessed prospectively for one year. The type of osteosynthesis as well as specific modalities of installation and therapeutic measures driven from analysis of the images were analyzed. Results: During the first year of use, intraoperative tridimensional reconstruction had been carried out in 48 procedures in 47 patients. The region involved was calcaneus 13 times, thoracolumbar spine 12 times, acetabulum 11 times, tibial condyles 9 times, axis 2 times and pelvis one time. Installation was the same than usually performed in the cases of calcaneus and axis osteosynthesis. For the other localisations, obtention of good quality images was facilitated through the use of a carbon table for spine and osteosynthesis of the tibial condyles, and through the use of a carbon traction table for acetabular or pelvic fractures. Intraoperative tridimensional reconstruction allowed to check for freedom of the vertebral canal after reduction and osteosynthesis of the spine. in the cases of fracture of the calcaneus, reduction of one thalamic fragment was improved in one case and one intraarticular screw could be changed in another case. In the case of acetabular surgery, one screw stabilizing the posterior wall was found intraarticular on tridimensional reconstruction and could be changed before closure. Discussion: Intraoperative tridimensional reconstruction, during its first year of use, allowed to avoid 3 early reinterventions (for 2 calcaneus and one acetabulum). Accurate interpretation of standard plain X ray in these two localizations is difficult because of the spherical shape of the hip joint and because good quality imaging, especially the retrotibial view, is hardly obtained intraoperatively in fractures of the cacaneus. When using tridemensional reconstructions, acquisition of good quality images has to be anticipated during the installation of the patient, limiting any interfereces with metallic supports to a minimum. Conclusion: the results obtained over the first year of use of intraoperative tridimensional reconstructions with the ISO-C-3D encouraged the authors to generalize its use when performing osteosynthesis of the acetabulum or calcaneus as well as percutaneus osteosynthesis of articular fractures

Introduction:. One of the important criteria of the success of TKR is achievement of the Flexion ROM. Various factors responsible to achieve flexion are technique, Implant and patient related. Creation of the Posterior condylar offset is one of the important factors to achieve satisfactory flexion. Aim:. To correlate post op femoral condylar offset to final flexion ROM at 1 yr. post op. Methods:. This is a clinico-radiological study of the cases done prospectively between September 2011 and August 2012. Inclusion criteria:. All patients undergoing Bilateral TKRs and have agreed for the follow up at 1 yr. Exclusion criteria: . 1). Patients who had previous bony surgery on lower end femur. 2). Patients with previous fracture of lower end femur. All the patients had PS PFC Sigma (De Puy, Warsaw) components cemented. ROMs were measured at 6 weeks, 3 months, & 1 year post op. The last reading was taken as final flexion ROM as measured by an independent Physiotherapist with the help of a Goniometer. Results:. We had 21 cases of Bilateral TKRs who satisfied our criteria. Pre and post op femoral condylar offset was measured in mm. on lateral x ray. Pre and post op flexion was measured. Results showed that variation in the posterior femoral offset by > 3 mm in post op x ray was related to loss of flexion of an average 21 deg. (16–24 degrees). Greater the deflection from the normal offset, greater was the loss of flexion. These patients also showed lesser improvement in KSS functional sco. Discussion:. Flexion is one of the most important yardsticks for the measurement of success of TKR. This factor is more important more so in Asian population. Literature has shown that three important determinants for good flexion are…. . 1). Posterior Condylar Offset Restoration. 2). Tibial slope restoration. 3). Femoral Roll back in flexion. An increased offset permits greater flexion before impingement between the tibial insert and the femur. In our study we kept Tibial slope and Femoral Roll back constant by using the same prosthesis. The femoral condylar offset changed as per the size of the AP femoral cutting block. (Anterior referencing guide used). Overresection of the posterior condyles reduced the posterior femoral condylar offset and hence significant loss of post op flexion. The shorter posterior condyle of smaller-sized femoral component can increase the potential for bone impingement proximal to the posterior condyles. In our study the opposite side replaced knee acted as a control and hence eliminating patient bius. It is generally stated that after a TKR flexion can improve upto 1 year and hence that was taken as final possible flexion. Conclusion:. Keeping Tibial slope and Femoral roll back constant during the surgery, posterior condylar offset restoration within 3 mm of its original pre op offset was necessary to achieve satisfactory flexion at 1 year. Undersizing the femoral component to achieve more flexion is perhaps suboptimal. Appropriate AP femoral sizing is a must to restore the normal offset

Introduction: As the age for performing a primary knee replacement is gradually falling there is increase need and demand for revision total knee replacement and subsequent revisions thereafter. There are very few published studies showing the outcome of re revision knee replacement surgery. Aim: We aim to show functional outcome of 21 patients at 3 to 5 years after undergoing Re revision knee arthroplasty. Methods: We defined re revision as a procedure where there was exchange of either one or both Tibial and Femoral components using a modular revision system. We included all patients undergoing re revision knee replacement and had complete records & X rays . We excluded patients with incomplete records, those who could not be assessed due to medical infirmity or other reasons. We also excluded patients with 2 stage revision knee replacement for infection. This left us with 21 patients in our cohort operated between 1996–2002. The patients were scored pre operatively using Knee society score ( KSS) and Western Ontario and McMasters Osteoarthritis Index (WOMAC). Patients were assessed with same scoring system post operatively at 3 months, 1 year and annually there after. Post op x rays were reviewed by Knee society Radiological Evaluation. Results: 18 modular revision prosthesis ( Co ordinate ultra, DePuy) and 3 rotating hinge (S Rom) prosthesis were used. The mean follow up was 3.5 years range from 11 months to 5.7 years. The mean post operative KSS score improved to 83 from pre op 41. Final post operative WOMAC scores for pain 12.3, Stiffness 5.6, Function are 47.1. We had few minor complication not requiring further surgery. Overall in 15 patients (71.43%) had a statistically significant improvement at latest follow up. 4 patients (19%) had moderate improvement and 2 patients ( 8%) had no improvement in scores. Conclusion: We conclude that re revision knee arthroplasty provides satisfactory pain relief and knee stability. As 71% of our cohort improved significantly we continue to support the clinical use of this procedure

Objectives/Background: Long-term outcome in THR is multifactorial influenced. Malpositioning leads to complications as early loosening, leg length difference or dislocation of the artificial joint. A proven factor for early losening is a misplacment of the center of rotation or varusposition of the stem. A higher luxation risk results out of high inclination and anteversion angles an reduced soft tissue tension. Aim of this study was to prove the image free navigation software in the modular Navitrack-System to check the implant position based on anatomical intraoperative acquired data. Design/Methods: In 35 consecutive cases we implantet the ACA screwcup and the Optan anatomical stem with use of the Navitrack navigation System. The software calculates al relevant data out of intraopertive probed landmarks. Intraoperative the shifting of the center of rotation, the cup anteversion and inclination, the stem inclination and torsion and the leglength shift is shown in real time. Intraoperative data were compared with postoperative position measurement in plain X-rays and in 15 patients in postoperative CT scans. Results: In all cases navigated implantpositioning was possible. In 3 cases stem positioning was not possible cause of refference loosening. Mean inclination of the cup as shown in the Navigation System was 52 (range 45 – 58 ), mean anteversion was 11 (range -5 – 27). Mean postoperative inclination measured on postoperative X-Ray was 53,8 (range 49 – 60). The difference between the shown values from the CAS System to the postoperative X Ray for the inclination was 1,8 (range -9 – 6). The leg length difference on postoperative X-ray was in mean 3,1 mm, on screenshots 2,8 mm. The difference between screenshot and X ray was in mean 0,83 mm. Conclusions: This study shows, that with the CT free software for the Navitrack-System reliable cup and stem navigation is possible. Whenever the hip joint allows to probe a spherical segment in the femoral head or acetabulum navigated THR is possible without the need of intraoperative fluoroscopy or preoperative CT scan. For leg length control and cup Inclination the data are still promising. Further investigation is necessary for stem axis and cup anteversion according to the navigation based reference coordinate system. Whenever no geometric sphere existent, e.g. severe hip dysplasia, the system must be developed as a hybrid system with CT (NMR) based cup and image-less stem navigation

Introduction: An accepted treatment of lateral compartment osteoarthritis with valgus deformity is to correct the malalignment, and unload the affected compartment. Previous techniques have used large fixation plates to secure complete osteotomy sites. We present a prospective study using a novel incomplete opening wedge osteotomy, in treating lateral compartment osteoarthritis in active patients younger than 65. Methods: We assessed all patients (n=26) who underwent opening wedge femoral osteotomy with Puddu plate fixation over a 5 – year period by one surgeon (PRA). All patients had long leg X rays and arthroscopic evaluation; revealing either grade 3 and 4 osteoarthritis within the lateral compartment; 11 secondary to lateral menisectomy, 4 to complex trauma to the lateral tibial plateau, the others were diagnosed with primary osteoarthritis. Pre operative and post-operative Knee Society and Oxford Knee scores and long leg X rays were used to monitor subjective and functional improvement. Results: Patients had a mean age of 48, (mode 56); ASA of 1 (range 1–2); and BMI of 24 (range 20–26). Mean follow up time was 46.8 months (6–62 months). Results in table 1 show early benefits in post-operative pain and improved function scores, which were maintained to 42 months. All patients had radiological union by 3 months (2–8months). Plates were removed as a minor procedure in some patients at 8 months (6–18 months), and did not lead to loss of correction or conversion to total knee replacement within the study. Subjective and functional progress was observed by using the Oxford Knee Score and the Knee Society Score, early results showed an improvement from in the Oxford Knee score from 54.4 (+/−5.7) to 27.2 (+/−4.7)*, and the improvement was maintained at 12**, 30**, and 62** months (*P< 0.002; **P< 0.005). The same pattern was repeated with the knee society score where a pre opetrative score of 53.9 (+/−4.8) improved to 87.6 (+/−6.2) at 6 months and was 82.4(+/−8.7) at 62 months. No infections were recorded, or differences in pre and post-operative flexion were observed at 36 months (P< 0.005) in all patients. However, 3 patients required further manipulation to overcome post-operative stiffness. Plates were removed only for local discomfort, and follow up showed there was no loss of corrective angulation. Conclusion: These results suggest using the puddu plate is an alternative to unicompartmental or total knee arthroplasty in young active patients with lateral compartment osteoarthritis, without significant morbidity

This study investigates the use of porous biphasic ceramics as graft extenders in impaction grafting of the femur during revision hip surgery. Impaction grafting of the femur was performed in four groups of sheep. Group one received pure allograft, group two 50% allograft and 50% BoneSave, group three 50% allograft and 50% BoneSave type 2 and group four 10% allograft and 90% BoneSave as the graft material. Function was assessed using an index of pre- and post-operative peak vertical ground reaction force ratios. Changes in bone mineral density were measured by dual energy X ray absorptiometry (DEXA) scanning. Loosening and subsidence were assessed radiographically and by histological examination of the explanted specimens. There was no statistically significant difference between the four groups after 18 months of unrestricted functional loading for all outcome measures

Atrophic non-unions are usually attributed to impaired blood supply but the events that lead to atrophic non-union remain poorly understood. Recent studies. 1,. 2. have shown that vascularity is not reduced in established non-unions but these studies have not examined vascularity at an early stage. The aims of this study were to: 1) develop and validate a clinically relevant small animal model of atrophic non-union and 2) test the hypothesis that the vessel density of atrophic non-unions reaches that of normal healing bones but at a later time point. Twenty eight adult female Wistar rats underwent application of a novel circular frame external fixator to the right tibia under general anaesthesia. The fixator construct was standardised, with eight needles that were drilled through the skin into the proximal and distal metaphyses of the tibia. An osteotomy was performed with a 1mm burr under irrigation. The periosteum was removed on 14 of the 28 animals using a scalpel and the intramedullary canal was curetted. Both insults were performed proximally and distally for a distance equivalent to 1 diameter of the tibia. A 1mm gap was introduced at the osteotomy site and the wound was closed. Once the animal had recovered it was allowed unrestricted weight bearing. Anteroposterior X rays were performed every 2 weeks. Animals were killed at 1, 3, 8 and 16 weeks. Callus areas were measured from X rays using an image analysis system. The average callus area was calculated for each rat every 2 weeks as an indicator of callus production. Specimens were fixed, decalcified, embedded in paraffin wax and 6 ìm sections were stained with H& E. Vascularity was assessed immunohistochemically with monoclonal antibody against smooth muscle actin. The total number of blood vessels in the interfragmentary gap was counted. At 8 and 16 weeks post-osteotomy all animals where stripping and curetting had been performed went on to an atrophic non-union. All animals where this was not performed went on to unite successfully. Histological observations support these radiological findings. Significantly less callus formed in the non-unions than in those that united. There were significantly fewer vessels in the non-unions at week 1 compared to the controls but, by 8 weeks the blood vessel density in the established atrophic non-unions had reached the same level as the vessel density during normal healing. An atrophic non-union model that closely resembles the clinical situation has been developed and validated in rats. The results support the hypothesis that the number of vessels in atrophic non-unions reaches the same level as in those that unite but at a later time point. It is concluded that diminished vessel density within the first 3 weeks may prevent fractures from uniting

Objectives. Total hip arthroplasty (THA) is one of the most successful surgical procedures; several bearing technologies have been used, however none of these is optimal. Metal on polycarbonate-urethane (PCU) is a new bearing technology with several potential advantages: PCU is a hydrophilic soft pliable implant quite similar in elasticity to human cartilage, offers biostability, high resistance to hydrolysis, oxidation, and calcification, no biodegradation, low wear rate and high corrosion resistance and can be coupled with large metal heads (Tribofit Hip System, THS). The aim of this prospective study was to report the survivorship and the clinical and radiographic outcomes and the metal ions dosage of a group of patients operated with metal on PCU arthroplasty featuring large metal diameter heads, at 5 years from surgery. Study Design & Methods. 68 consecutive patients treated with the THS were included. The patients have been contacted by phone call and invited to return to our centre for clinical (Oxford Hip Score, OHS, and Harris Hip Score, HHS), radiographic exam and metal ion levels evaluation. All the patients were operated with uncemented stems. Results. The survival rate is 100% and no major complications were seen. The average preoperative OHS was 17 (6–34), at follow-up it was 44 (40–48). The average preoperative HHS was 48 (12–76), at follow-up it was 93 (84–100). On the x rays taken at follow-up, no signs of periprosthetic bone rarefaction and/or osteolysis were seen. No signs of PCU liner wear were visible. At follow up mean Co serum level was 0.52 ng/mL (<0.1–2.5, sd 0.5), mean Cr level was 0.27 ng/mL (0.1–2.2, sd 0.2). In this prospective study at a mean follow up of 5 years, all implants were well functioning, with no radiological signs of loosening and normal serum levels of cobalt and chrome. Although large diameter metal heads and metal sleeve were used no trunnionosis occurred. Conclusions. We believe that these positive outcomes are due the positive biomechanical characteristics of PCU. These results need to be confirmed at a longer follow up and in a more active younger patient population

Stems are a crucial part of implant stabilization in revision total knee arthroplasty. In most cases the metaphyseal bone is deficient, and stabilization in the diaphyseal cortical bone is necessary to keep the implant tightly fixed to bone and to prevent tilt and micromotion. While sleeves and cones can be effective in revision total joint arthroplasty, they are technically difficult and may lead to major bone loss in cases of loosening or infection, especially if the stem is cemented past the cone. A much more conservative method is to ream the diaphysis to the least depth possible to achieve tight circumferential fixation, and to apply porous augments to the undersurface of the tibial tray or inner surface of the femoral component to allow them to bottom out against the bone surface and apply compressive load. If a robust, strong taper, stem and component combination is used, rim contact on only one side is necessary to achieve rigid permanent fixation. Porous and non-porous stems are available. The non-porous stems should have a spline surface that engages the diaphyseal bone and achieves rigid initial fixation but does not provide long-term axillary support. In that way the porous rim-engaging surface can bear compressive load and finally unload the stem and taper junction. Correctly designed stems do not stress relieve unless they are porous-coated. In situations where metaphyseal bone is not available, porous-coated stems that link to hinge prostheses are a very important part of the armamentarium in complex revision arthroplasty. Use of stems requires experience and special technique. Slight underreaming and initial scratch fit are necessary techniques. This does not result in tight fixation every time because split of the cortex does occasionally occur. In most cases these splits do not need to be repaired, but when there is a question, an intra-operative x ray should be taken and the surgeon should be prepared to repair the fracture. Stems are an essential part of revision total knee arthroplasty. A tightly fit stem in the diaphysis is necessary for fixation when metaphyseal bone is deficient. No amount of cement pressed into the deficient metaphyseal bone will substitute for rigid stem fixation

Introduction. Literature describes pelvic rotation on lateral X rays from standing to sitting position. EOS full body lateral images provide additional information about the global posture. The projection of the vertical line from C7 (C7 VL) is used to evaluate the spine balance. C7 VL can also measure pelvic sagittal translation (PST) by its horizontal distance to the hip center (HC). This study evaluates the impact of a THA implantation on pelvic rotation and sagittal translation. Materials and Method. Lumbo-pelvic parameters of 120 patients have been retrospectively assessed pre and post- operatively on both standing and sitting acquisitions (primary unilateral THA without complication). PST is zero when C7VL goes through the center of the femoral heads and positive when C7VL is posterior to the hips' center (negative if anterior). Three subgroups were defined according to pelvic incidence (PI): low PI <45°, 45°<normal PI<65° or high PI>65°. Results. Pre-operatively PST standing was −0.9 cm (SD 4.5; [−15.1 to 7.2]) and PST sitting was 1.3cm (SD 3.3; [−7.7 to 11.8]). The overall mean change from standing to sitting was 2.2 cm ([−7.2 to 17.4]) (p<0.05). Post-operatively PST standing was 0.2 cm (SD 4.7; [−17 to 8.1]) and PST sitting was 1.4cm (SD 3.5; [−7.3 to 10.4]). The overall mean change from standing to sitting was 1.2 cm ([−14.2 to 22.4]) (p<0.05). In low PI group pre and post-operatively, PST increased significantly from standing to sitting (p<0.05; with HC going anterior to C7VL). When comparing pre and post operative changes, standing PST significantly increased (p=0.001). Pre to postoperative PST variation (sitting-standing) decreased significantly (p=0,01). In normal PI group pre-operatively, PST increased from standing to sitting (p=0.004). When comparing pre and postoperative changes, PST increased (p=0.006). Pre to postoperative PST variation (sitting-standing) decreased significantly (p=0,04). In high PI group pre and post operatively, PST increased from standing to sitting (p=0.034) while there are no significant changes from pre to post-operative status in standing and in sitting. Discussion. Anteroposterior pelvic tilt is not the only adaptation strategy for postural changes from standing to sitting positions. Anteroposterior pelvic translation (quantified by PST) is an important adaptation mechanism for postural changes. Comparison of pre and post-operative values of PST points out the importance of pelvic translation for low and standard PI patients after THA. The anteroposterior translation appears to change significantly in different functional positions pre and post operatively. This is an important variable to consider when assessing the patients' posture change or investigating the causes of the hip dislocation after total hip arthroplasty or spinal fusion. Conclusion. Pelvic translation must be considered as a significant mechanism of adaptation after THA. Further studies are needed to study the impact on subluxation or dislocation

Introduction. Ankle fractures are common injuries presenting to trauma departments and ankle open reduction and internal fixation (ORIF) is one of the first procedures targeted in early orthopaedic training. Failure to address the fracture pattern with the appropriate surgical technique and hardware may lead to early failure resulting in revision procedures or premature degenerative change. Patients undergoing revision ORIF are known to be at much greater risk of complications, and many of these secondary procedures may be preventable. Method. A retrospective analysis of all patients attending our unit for ankle ORIF over a two year period was undertaken. Patients were identified from our Bluespier database and a review of X rays was undertaken. All patients undergoing re-operation within eight weeks of the primary procedure were studied. The cause of primary failure was established and potential contributing patient and surgical factors were recorded. Results. 236 patients undergoing ankle ORIF were identified. 13 patients (5.5%) returned to theatre for a secondary procedure within eight weeks. Within this group, 7 (54%) patients returned for treatment of a neglected or under treated syndesmotic injury, 3 (23%) for complete failure of fixation, 2 (15%) with wound problems and 1 (8%) for medial malleoulus mal-reduction. Of the patient group, 5 (38%) were known type 2 diabetics. Consultants performed 2 (15%) of procedures, supervised registrars 5 (39%) and unsupervised registrars 6 (46%) operations. Conclusion. Errors are being made at all levels of training in applying basic principles such as restoring fibula length and screening the syndesmosis intra-operatively. Appropriate placement and selection of hardware is not always being deployed in osteopenic bone resulting in premature failure of fixation and fracture patterns are not being fully appreciated. Patients are undergoing preventable secondary procedures in the operative treatment of ankle fractures

In early secondary arthritis due to femoral dysplasia, varus osteotomy achieves a control of arthritis for two decades in 80 % of cases : it is therefore a very reliable conservative treatment. Moreover, in carefully selected cases of severe arthritis in young active patients, a valgus osteotomy can achieve pain relief for a decade in 70 % of cases. THE VARUS OSTEOTOMY is recommended when the arthritis is due to a coxa valga ≥ 140°. By reducing the inclination angle to 125° the abductors level of arm is optimized, and their contracture is decreased. Therefore, the osteotomy reduces the surface strains, but it does not improve the extent of articular surfaces. A – . INDICATIONS. 1) Four factors are mandatory to achieve long term improvement:. The arthritis must be the . consequence. of the dysplasia, with degenerative changes localized at the supero lateral part of the head and of the acetabulum. This can be confirmed by isotope scanning. If the arthritic changes are not localised the desease is rather a primary arthritis, or an inflammatory or a metabolic disease, which are not an indication for a biomecanical treatment. There must be a real . coxa valga. , evidenced by coxometry. Anteversion is mesured by CT scan, and the inclinaison is mesured on a X ray of the pelvis with the hips in internal rotation equal to the ante-version. If there is a shortened femoral neck (such as a post reduction osteonecrosis), the modification of the glutei lever of arm may not change significantly the articular strains, and therefore osteotomy is no indicated. The articular . congruency. must not be impaired by the reduced inclination angle. Pre operative X rays with the hips in an abduction equal to the planned varisation must not reveal any lateral narrowing of the joint space, which would mean incongruity, and lead to failure. The possibility of articular . healing. must be important : varus osteotomy is recommended before 45 years, and if the joint space remains ≥ 50 % of normal. 2) Therefore varus osteotomy is . not recommended. in a non symptomatic dysplasia (as some of them may not lead to arthritis), or if the symptoms are those of a labrum syndrom, with suddent pain, instead of a progressive and mechanical arthritic pain. if the dysplasia is only acetabular : then only the acetabulum has to be treated. if the anatomic abnormality is not an increase of the inclinaison (neck-shaft) angle, but a modification of the head-neck angle, which causes impigement with the labrum, and which is not improved by inter-tro-chanteric osteotomy. 3) The . assosciated dysplasia. have to be taken into consideration. If there is a femoral hyperanteversion there are two different conditions in the adult :. if the patient walks with internal rotation of knees (convergent strabismus of patella), realising a dynamic correction of hyperanteversion, the association an external rotation of the femur to the varisation is recommended. but if, despite hyperanteversion, walking is without abnormal rotations of the knees, this means that the optimum congruity of the hip is in that position. An ostotomy is no advocated as, instead of retroversing the femoral neck, it would rotate externally the femoral shaft. If there are both an acetabular and a femoral dysplasia, they both have to be treated :. if an augmentation is recommended for an anterolateral defect, the shelf osteoplasty can be performed in the same operation that the varus osteotomy. if a medialisation is necessary (Chiari), both osteotomies can be assosciated in one stage. but if a complex reorientation osteotomy is necessary (either periacetabular –Giacometti-,. or pelvic –Ganz-), it could be hazardous to perform a varus osteotomy at the same time. B – . SURGICAL TECHNIC. The importance of the varisation depends on that of the coxa valga. The final inclinaison angle must be 125°, as the lever of arm of the abductors is impaired for a lower angle. Moreover there is a post operative limping due to the ajustement of the glutei length, the duration of which is function of the varisation (one year per 10°). To reduce this limping, only the necessary varisation has to be made. The technic has several important points :. non union is avoided by non dissection of the medial metaphysis or removal of a wedge :. we use a subperiosteal osteotomy, leaving in contact the medial cortex, with a lateral opening, fixed by a nail plate as a tension band. This technique gives a minimum limb shortening (12 mm for 15° varisation). respect of the articulation and soft tissues. There is no arthrotomy as the nail plate is inserted on a guide pin. Later implantation of the THR will not be complicated by the previous osteotomy. precise, « automatic » correction, depends only on the nailplate angle. the resistance of the osteosynthesis allows immediate rehabilitation (this extra articular operation does not reduce ROM), and 10 to 20 kilos weight bearing. Full weight bearing is authorized at three months. C – . RESULTS. There are less thant 5 % mechanical complications. An antalgic effect is obtained within some weeks. In 80 % of cases, painlessness and absence of radiological deterioration for two decades is achieved, a THR becoming necessary in the third decade. In 20 % of cases, only a temporary effect is obtained, leading to a THR after 5 to 10 years. THE VALGUS OSTEOTOMY is at present used in only seldom cases of young patients with a severely damaged articulation, but who prefer an antalgic conservative surgery than a THR, because they wish to continue for a decade a strenuous activity not compatible with an arthroplasty. This can be made only when there are two large osteophytic drops of the acetabulum and of the femoral head, which can be put into contact by the valgisation, and facilitate healing of the superior lesions. In carefully selected cases, a relief of pain is achieved for a decade in 70 % of patients. IN CONCLUSIONS. The femoral varus osteotomy remains one of the most reliable conservative operations in osteoarthritis due to DDH. However to achieve these good results, a clear understanding of the indications and biomechanical demands of this operation is required. In seldom and selected cases of severe arthritis, a palliative valgus osteotomy can achieve a decade of pain relief

Amniotic membrane (AM) and amnion/chorion foetal membranes (ACM) are mainly composed of collagen & laminin layers and constitute relatively new materials to the dental market. They have proven effective for periodontal treatments such as Guided Tissue Regeneration (GTR) [1–3]. Based on our expertise in the field of lyophilisation & securisation of human bone allograft (Phoenix® process), we aimed to develop our own process applied to ACM and to control its in vivoefficacy in GTR indication. Human placentas were donated under informed consent. ACM were separated from placenta and processed with a proprietary AMTRIX (TBF) Process. Resulting product was called ACMTRIX. The effectiveness of ACMTRIX in GTR was evaluated using an in vivorat calvaria defect model as followed:. Empty defect (2 animals),. ACMTRIX apposed onto the defect (4 animals),. 3 Bone substitutes (allogenic – mineralized cortical bone powder (Phoenix®); demineralized cancellous bone powder mixed with hydroxyapatite and demineralized bone matrix (DBM) cancellous block) filled in the defect and covered by ACMTRIX (4 animals). One animal per study group was sacrificed after 8 weeks, all others after 8 weeks. Evaluations were performed by: macroscopic observations, X Ray micro-CT, and histological analysis. For all groups using ACMTRIX, no major sign of inflammation were observed macroscopically and histologically. Moreover, bone tissue was already mature from 8 weeks and bone filling was slight to moderate. The higher mean rate of mineralization was obtained for the group associating DBM cancellous block + ACMTRIX. Although a xenogenic material, ACMTRIX was very well integrated without significant inflammatory reaction compared to empty defect and fully integrated in subcutaneous area. The mineralization was superior with DBM cancellous block probably thanks to the stabilization of the material in the defect. Used alone, ACMTRIX has no osteogenic potential. In conclusion, ACMTRIX has the potential to function as barrier for GTR and the unique properties associated with this material can augment its potential as a matrix for periodontal regeneration

We have implanted 371 CLS acetabular components in our centre since 1989. Despite design changes in the component we report 4 cases of failure by fracture through the metal backing of the cup. Our aim is to highlight this uncommon mechanism of failure and advise that in cases of unexplained hip pain in those with CLS acetabular components X rays in at least 2 planes are performed

A series of 76 distal tibial pilon fractures treated with surgical fixation were retrospectively reviewed from case notes, plain radiographs and CT imaging. Patient demographics, injury and fracture patterns, methods and timing of fixation and clinical and radiological outcomes were assessed over a mean follow up period of 8.6 months (range 2–30). Definitive fixation was most commonly performed through an open technique (71 cases) with plate fixation. CT imaging was used to plan the most direct approach to access the fracture fragments. Single or double incision techniques were used to access the tibia, with fixation of the fibular performed when necessary. Superficial infection occurred in 5 cases (6.9%) and deep infection in 2 (2.8%). Aseptic wound breakdown occurred in 5 cases (6.9%). The rate of wound breakdown after three-incision technique was 37.5%. There were 10 cases of non-union (13.9%) and 8 of mal-union (10.5%). Post-traumatic arthritis was present on the most recent x ray in 17 cases (23.4%). Further surgery was required in 20 cases (27.8%), most commonly for metalwork related problems and also for treatment of non-union, post-traumatic arthritis and infection. This review gives comprehensive injury specific and surgical outcome data from one of the largest reported series of these complex and problematic injuries

Introduction. Tip apex distance (TAD) is reported as a predictor for cut outs of lag screws in the treatment of intertrochanteric fractures, and surgeons are adviced to strive for TAD within 20 mm. However the definition of neck axis and the limb position of lateral radiograph are not clearly described in the original literature. We propose the refined TAD by defining these factors. The objective of this study was to analyze the interobserver agreement of this refined TAD. Materials and Method. X rays of 130 cases of unstable trochanteric fractures were used for the analysis of the refined TAD. In the refined TAD, neck axis was defined as the line between the center of femoral head and midpoint of narrowest part of the femoral neck, and lateral radiograph was taken with hip flexion 90 degrees and abduction 45 degrees. The refined TAD was independently measured by 2 experienced (observer 1,2) and 2 inexperienced (observer 3,4) orthopaedic surgeons who were trained with the new method before the measurement. Intraclass correlation coefficient (ICC [2,4]) was calculated to assess the interobserver agreement. Result. The mean refined TADs were 18.2:18.4:18.2:18.2 for observer 1:2:3:4. There was a strong correlation among all four observers (ICC 0.998, (95% CI: 0.998, 0.999). Discussion. Regardless of the clinical experience of observers, the refined TAD is a reliable tool and can be used to develop new TAD recommendations for predicting failure of fixation

We reviewed 35 patients who underwent a medial unicondylar knee replacement, with an average follow up of 4 years (for functional assessment). All patents had a weight bearing AP and lateral X rays and were clinically assessed using Hospital for Special surgery score, Bristol Knee Score and SF 36 health assessment form. Five angles were measured on the x-rays to assess the alignment of the tibial and femoral alignment. There was a significant relation between the femoral component varus/valgus angle and three sub scores (fixed flexion contracture, maximum valgus/varus and range of movement) in Bristol Knee scores. The best functional out come correlated with femoral components of 4–8 degrees of valgus

Introduction: Distal radius locking plates are increasingly being used to treat distal radius fractures. The purpose of our study was to determine the medium term clinical and radiological outcome of comminuted, displaced fractures of the distal radius. We present our experience in using the Aculoc (Acumed) volar fixed angle plate to treat 100 consecutive fractures of the distal radius. Methods: All one hundred patients were prospectively (clinically and radiologically) assessed between 2003 –2007, with a minimum follow up of one year. Fractures were radiologically classified using the Frykman classification Clinical outcome was measured using the Mayo score, DASH questionnaire, SF36 and Range of Wrist Movement and pinch and grasp power. The post operative x rays were assessed for fracture union, alignment and displacement. Conclusion: Our study demonstrates that volar fixation of distal radius fractures, using a fixed angle, locking accumed plate provides satisfactory treatment for fractures of the distal radius. Angular stability of the implant provides mechanical stability and aids early rehabilitation which results in good functional outcomes

To measure for evidence of early subsidence of Accolade tapered uncemented femoral stems. To quantify any subsidence and to identify factors which may predispose to this. A retrospective audit of patients who have received Accolade stem total hip joint replacement in Hawkes Bay Hospital from October 2003 to October 2004. Post operative and follow up x rays (within one year of surgery) were reviewed and position of femoral component in the femur was measured and adjusted for magnification and angulation. Thirty-eight patients were identified. Patients age averaged 66 years old (44 – 82yo). Results show an mean subsidence of 2.8mm with a range of 0 – 13mm. There is evidence of early subsidence of Accolade femoral stems. In cases of large subsidence under sizing of the femoral component was identified as the most significant contributing factor

This is a prospective study analysing the accuracy of expected tunnel position (graft site) for anterior cruciate ligament reconstruction and to decide whether or not confirmation of the tunnel site using intraoperative imaging is required. 35 cases of anterior cruciate ligament reconstruction using bone patella bone tendon performed by three surgeons are studied. The surgeons use three different techniques. Immediately after the surgery, the surgeon marks the expected tunnel site (graft site) in a diagram (AP and LAT of femur and tibia) without seeing the x rays and a separate observer studies the actual position in the x-ray. Significance of the difference is studied using statistical tests. Best surgical outcome can be obtained using radiological confirmation of tunnel position intraoperatively with the guide wires

Reviewing our experience of scoliosis in children with a Cavopulmonary Shunt or Fontan circulation and the cardiovascular challenges that this presents. A notes and x ray review was performed. Special attention was paid to the changes in cardiovascular status whilst prone. The review was from first presentation to latest follow up. There were 6 patients who underwent 7 major procedures between 2001 and 2009. All had cardiac procedures in early life. Both definitive fusion and growing instrumentation was used. All procedures were successful. Growing instrumentation allowed earlier primary surgery before completion of the Fontan circulation. All have been subsequently lengthened in a lateral position. The mean follow up is 56 months. There was one death 40 months following last surgery, cause unrelated to spinal surgery. In the older patients with a completed Fontan significant blood loss was seen, due to the raised venous pressure required to run the Fontan, and occult hypotension seen as a climbing difference between Pulmonary Artery Wedge Pressure and Central Venous Pressure were common when prone. We recommend early intervention, using instrumentation without fusion to correct the deformity over time and allow intervention prior to completing the Fontan circulation. As haemodynamic instability increases with increasing time in the prone position, surgery should be expedited rapidly

A retrospective descriptive preliminary study on early experience using all pedicle screw correction. Pedicle screw fixation enables enhanced correction of spinal deformities. However, the technique is still in early development in our clinic. Tends of the scoliosis patient to come in late ages make maximum correction failed. A total 16 patients are subjected to pedicle screw fixation for spinal deformities were analyzed descriptively as an early follow-up in the last two-year. 14 patients are girl and 2 are boys. The age range between 12 to 18 year. 8 are Kings type II and 8 are Kings type III, 212 screws were inserted between Th3 – L2 (14-18 screws per-patient), all concave pedicles were inserted with screws but in convex side every two or three pedicles were inserted. The position of screws was analyzed using the post-operative plain X ray film. Before surgery the mean deformity measurement are 52.56° (range, 42-72°, correction achieved was 18° (range 10-34%, it was correlated to 68% achievement (range, 53-80%). All patients are happy with their image improvement. In total 212 screws inserted, 28 screws are malpositions (13.2%), but no clinical complication recorded. In this early experience using all pedicle screw scoliosis surgery, all patients are happy with the results although the correction only 53-80(. More patients are needed to improve this achievement

The lack of a universal, consistent protocol for the subjective, objective and radiographic evaluation of these injuries has hampered the comparison of results. Methods. 45 patients with complex fractures of the calcaneus were included in this prospective study, which was undertaken from July 2003 to December 2005. The fracture classification of Essex-Lopresti was used. We also observed the extent of secondary fracture lines extending from the primary shear line (on axial and external oblique plain radiographs) to establish comminution. The external oblique view for subtalar joint was performed with the patient supine, the knee at about 60 degree of flexion and the limb rotated externally 45 degree with a vertical X ray beam. All of these patients were managed by an external fixator using the principle of ligamentotaxis. Patients were evaluated by AOFAS. Results. We identified two broad patterns of secondary lines on plain X-rays:. with anterior secondary fracture lines and. with posterior secondary fracture lines. There were 20 cases of tongue type and 25 of joint depression type fracture pattern by the Essex-Lopresti classification. Forty two (93.4%) patients had fractures with posterior secondary fracture line and 3 (6.7%) patients had anterior secondary lines. The calcaneo-cuboid type of anterior secondary line pattern was present in 2 (4.5%) cases, and the plantar type in only 1 (2.5%) case. We observed posterior secondary line Type A pattern in 2 (4.5%) cases, depression / central depression type B in 20 (44.5%) cases, tongue shaped Type C pattern in 16 (36.5%) cases and Type D severely comminuted fracture line pattern in 4 (8.7%) cases. Conclusion. Comminution was significantly associated with prognosis and final outcome. Evaluation of secondary fracture lines corresponds with comminution of fractures of the calcaneus and the final outcome of these fractures. NO DISCLOSURES

Introduction. Stem cells have the capacity for self renewal and capability of differentiation into various cell lineages. Non union remains a clinically important problem in orthopaedic surgery. Method. We randomly assigned 45 patients into 3 groups. Test group: 15 patients in which mesenchymal stem cells prepared by conventional density-gradient centrifugation using ficoll-hypaque solution were injected (n=15), control A: 15 patients in which autogenous bone marrow aspirate were injected (n=15), control B: 15 patients in which neither the stem cell nor bone marrow injection given, symptomatically treated(n=15). Ultra sound and x rays were performed at follow up of 6, 12, 18, 24 weeks and comparison done. Results. Stem cell group: 12 patients out of 13 followed showed excellent results and 1 patient showed good result. Control A bone marrow injection group: 6/15 patients showed excellent results and 3 patients showed good results. Control B: only 2/15 patients showed excellent results. In fracture gap 4–5mm the stem cell group showed union in most of the patients. In control A and control B patients with same fracture gap failed to unite. Conclusion. In fracture situations, in which a manipulation or augmentation of natural healing mechanisms is needed to regenerate larger quantities of new bone Stem cells play a part. This technique of percutaneous stem cell injection provides a very safe, easy, non immunogenic, non invasive and reliable alternative to open bone grafting. This one-stage isolation procedure in comparison to the ex-vivo expansion of autologous cells from bone marrow/embryonic cells reduces the cost and infection rates related to the extra personal need and extended time required for the expansion. Summary. Stem cells have potential to enhance bone healing in non union of fractures

MISTKA resulted earlier recovery of ROM, muscle power and shorter incision. But bleeding after operation did not decrease compared with conventional TKA. We compared MISTKA results between several approach mini arthrotomy, mini midvastus and mini subvastus. There were no difference in these series. We thought extramedullary femoral guide may be less invasive than intramedullary femoral guide system. 34 cases were performed by minisubvastus approach. 17 cases were using intramedullary method. 17 cases were using extramedullary method. We compared JOA score, ROM, muscle power, blood examination, X ray, and operation time. Total protein(TP), albumin(alb), prealbumin(prealb), hemoglobin(Hb), total lymphocyte content(TLC) and CRP were examined. There was no difference in JOA score, ROM and recovery of muscle power. But there were statistically difference in prealbumine at 1 week after operation and TLC at 2 week after operation. Extramedullary group showed earlier recovery than intramedullary group. MIS TKA does not discuss about approach but also system of bone cut. Navigation system is very good method but it is very expensive and takes more time at operation. Extramedullary system we developed is simple and low technology method and useful for MISTKA

Introduction. Proper femoral reaming is a key factor for a successful outcome in cementless hip arthroplasty. Good quality reaming minimizes risks of intra-operative femoral fracture during reaming and prevents poor fitting of the implant which can lead to subsidance of the stem postoperativly. Determining the quality of reaming is largely a subjective skill and dependant on the surgeon's experience with no documented intraoprative method to assess it objectively. Method. We recorded and analysed the frequencies of sound signals recorded via a bone conduction microphone during reaming of the femoral canal in a series of 28 consecutive patients undergoing uncemented total hip replacement performed by same surgeon. Hammaring sound frequencies and intensity were analysed by mean of computer software. The relationship between the patterns of the recorded reaming sound frequencies compared with surgeon judgment of the reaming quality intraoparativly and post operative x rays. All patients were followed up clinically and radiologically for 2 years after surgery to determine the integrity of the fix and to evaluate the stability of the prosthesis. Results. There was a consistent pattern of frequency changes detected in all cases regardless of gender, age, bone density size of reamer etc. Our results showed that the resonances in the femur can be accurately recorded during canal reaming and proved that there is a definite increase in the amplitude of sound frequencies between 600 and 1000 Hz when the tension of the reamer moves from loose to tight during hammering. Adding all of the dB values between 600 to 1000 Hz for the loose tension sound and comparing this to the total for the tight tension sound showed an average of 449.6% increase. Our Analysis of the sound signals changes was comparable to the adequacy of the reaming postoperatively. Conclusion. There are identifiable audio frequency patterns changes associated with satisfactory reaming of the femoral canal. Our findings may pave the way for the development of a real-time intraoperative reaming audio analyser which can guide the surgeon to the optimal reaming tension

Introduction: Obtaining adequate images can be difficult in ring fixator patients during outpatient follow-up. Following a recent publication, we introduced the spirit level technique as an effective method to ensure better quality images for interpretation, reduce unnecessary x-ray exposure, and improve clinic efficiency. Method: A comparison was made of radiograph quality, patient inconvenience and x-ray exposure between standard X-ray techniques and those with a frame mounted spirit-level in all patients attending the senior author’s outpatient clinic for routine follow up following Ilizarov and Taylor-Spatial frames. Prospective data was collected using a paper proforma in frame clinic. Information was gathered on all patients sent for plain radiographs. Radiographers collected data regarding time taken in the X-ray Department and total number of radiographs taken to gain the images required. The senior author recorded if these images were satisfactory and if returned to the department for further imaging. The radiation dose was retrieved from the Radiology computer. The control group consisted of patients from clinics prior to implementation of the spirit-level device. Following a period of familiarization, data was collected from the study group using the spirit-level. Results: (Table deleted). Conclusion: The implementation of a simple frame mounted spirit-level as a guide for the radiographers in the outpatient clinic improves x ray quality, to assess healing, and significantly reduces the number of suboptimal images. The data does not support a significant impact on patient inconvenience

In this study we aimed to identify infection rates in arhroplasty patients which were operated bilaterally with single anesthesia and to discuss the reasons of infections in these patients. We evaluated 163 knees of 82 patients (Follow up: 12 to 60 months). Mean age was 66.8. Right knees were operated first followed by left knees. 16 of the patients had diabetes mellitus, 4 of them had rheumatoid arthritis, and 1 of them had systemic lupus erithmatosus. All patients were evaluated according to operation time, wound healing, laboratory findings, clinical presentation and X rays. We had 7 infections (6 deep, 1 superficial infection). When we evaluate operation times, no statistically significant difference was obtained between the infected knees and non infected knees (p=0,275). Two of the infected knees had urinary track infection and dental abscess after the opertaion. Five of seven infected knees were left sided. Six of the infected knees were treated with debridement irrigation and antibiotics successfully. But one had two staged revision. Bilaterally operated knee arthroplasty increases operation time significantly. This increase of operation time decreases the sterility of surgical field, and may increase infection rates. The increased infection rates in left sided knees may explain this. Postoperative dental and urinary tract infections may also increase infection rates. There is no correlation between infection and other systemic diseases like diabetes mellitus, systemic lupus erithematosus or rheumatoid arthritis

Aim: To validate the accuracy of the MobilityTotal Ankle Replacement alignment jig. Method: The early radiological alignment outcomes (angles ‘A, B, C’) of 35 Mobility ankle replacements were determined from weight bearing X rays. These radiological outcomes were compared with alignment outcomes for ‘Star’ total ankle replacement, as published by PLR Wood. (Total Ankle Replacement JBJS April 2003 85B, pg 334). Results: Indication: osteoarthritis 25, posttraumatic osteoarthritis 6, rheumatoid arthritis 4. 32/35 Angle A were within the published accepted range (850–950). 23/35 Angle B were within the published accepted range (800–900). 35/35 Angle C were within the published accepted range (200–400). No statistical difference between the distribution of angle A, B and C and the means for A, B and C for the published results. Discussion: Results for angle B are skewed toward the upper limit of the current accepted range (800–900). The author (MSS) attempts to reproduce this, to place the anterior margin of the tibial component on subchondral bone. A lower angle B positions the implant on metaphyseal bone with a risk of subsidence. Comparing Angle B with a modified acceptable range (850–950) 31/35 fell in the new range. Conclusion: Early radiological alignment for Mobility is reproducible and compares favourably with published data

Aims: The objectives of this study are to determine the feasibility of the endoscopic þxation of the anterior pelvis. Material and Methods: Twenty adult cadavers were studied. A þve hole plate was introduced and þxed by balloon and C02 dilatation of the space of Retzius. After plating, the cadavers were dissected to analyze plate and screw position, and presence of damage on the surrounding tissues related to the procedure. Results: Plate and screws were seen to be in good position in all cases. No damage to vital structures was identiþed. Case Report: 33 y/o male sustained an open book external rotation AO/OTA type 61-B3.1 pelvic fracture. EFAP was performed successfully. Postoperative x rays showed good reduction and implants position. Discussion and conclusion: Open approaches to the anterior pelvis are not free of complications. Endoscopy allows clear visualization of the space of Retzius and it is a valuable aid for pelvis fracture þxation. Extraperitoneal endoscopy of the anterior pelvis is a safe and commonly performed surgical procedure. This paper shows that plate and screws þxation of the symphysis pubis can also be performed using this minimally invasive approach

Aim: The purpose of this study is to evaluate the long term results of modified Elmslie-Trillat procedure. We have also reviewed the various modifications and its outcome seen in the literature to the original conventional Elmslie-Trillat procedure. Our modified surgical technique is described. Materials and Methods: The patients were evaluated functionally using Kujala and Fulkerson scoring system. Clinical examination was performed to look for patella apprehension, tracking of patella, crepitus and range of movement. X rays were done to look for degenerative changes. The primary end point in our study was evidence of recurrent instability and the secondary end point was functional scoring and evidence of degenerative changes. Results: Out of 38 patients and 42 knees available from our records from 1991 to 2005, 16 patients and 20 knees were available for functional and clinical review. The mean age at operation was 27 years. The average follow up was 9 years. 74% of the knees scored excellent to good with kujala and Fulkerson scoring. There was no episode of recurrent dislocation post-operatively in our series. Minimal degenerative changes were noted in 15% of knees. 37% of knees needed removal of screw. 58% of knee had some numbness around the scar. 80% of them returned back to original occupation. 60% of them went back to original sporting levels. All patients felt happy to recommend the operation. Conclusion: We conclude that our modified Elmslie-Trillat surgical procedure is very successful in eliminating recurrent patellar dislocation and instability. We present the literature available on the various modifications of Elmslie-Trillat procedure and its outcome

Introduction We report the clinical and radiographic outcome of a consecutive series of 138 hydroxyapatite coated total knee replacements with a mean follow up of 11 years (10–13 years). Method and Results These patients were entered into a prospective study. There were 74 females and 32 males. Indications for surgery were osteoarthritis in 131 knees, rheumatoid arthritis in 5 knees and pigmented villo-nodular synovitis in 2 knees. The mean age of the patient was 72.5 years at the time of surgery. All living patients (76 knees) were examined and X rayed. A current Hospital for Special Surgery knee score (mean 83 points) was obtained for comparison with the preoperative profile (mean 55 points).The knee status of deceased patients was known within the year of death. No patient was lost to follow up. Radiological evaluation, assessed according to the method described by the Knee Society, revealed no loosening in surviving patients, and there are no impending revisions. Seven prostheses have been revised, giving a cumulative survival rate of 93 percent at 13 years. Discussion. We believe this to be the longest follow up report available for an hydroxyapatite coated knee replacement, and the first using the Insall Burstein knee. Results can thus be compared with the identical prosthesis using cemented fixation. Further modifications would be likely to improve reliability

A case report of an 11 year old boy who underwent tibial osteotomy to prevent angulation of his right tibia. As a 7 year old, LH sufered a minor injury to his right tibia. A lump appeared at the same site. Soon the lump grew to be similar to “a second knee cap”. However, it only caused him pain when he traumatised it. He and his parents were disturbed by the lump, and the fact that it was creating an anterior-posterior bowing of his tibia. They sought medical advice. His original hospital carried out X rays that demonstrated the deformity and a cloud like lump at the tibial tuberosity. A bone scan confirmed a solitary osseous lesion. In July 2002 he was referred to the RNOH, where the decision was taken to resect the tibial tuberosity and undertake a corrective osteotomy. Post surgery in August 2002, LH was mobilised in a full cast for 9 weeks and graduated slowly from non to full weight bearing. Histology revealed a probable endchondroma, or unusual growth plate reaction. A year after the procedure LH is a symptom free, happy and active boy. Radiographs confirm normal angulation of his Tibia. In conclusion an osteotomy can be a very successful treatment for a childhood lesion that leads to progressive deformity

This is a retrospective study of patient out-come after spondylolytic repair using a Scott¦s or a Van Dam Procedure (tension band repair). We also looked at the use of plain static radiographs, and a reverse gantry computed tomography scanning in the assessment of healing of the spondylolytic defect. Tension band repair of spondylolysis has proved to be a useful procedure for refractory spondylolysis. However, there is no universally accepted method or determining fusion of the spondylolysis, and the definitive criteria for diagnosing a successful fusion remains controversial. The Oswestry Disability Index was measured in 2000 and in 2004. Plain static radiographs and computed tomography scans were performed on 14 patients one year after fixation of the spondylolysis. A radiologist and an independent orthopaedic surgeon assessed the presence of bridging trabecular bone in the scan and X rays. Results in 14 patients were rated as excellent and in 4 as good in year 2000 and results remained excellent to good in 16 of 17 patients followed up in year 2004. The fusion rate was 90%[18/20] on the plain radiographs. Fusion on the computed tomography scans was observed in 50% [7/14]. A high rate of good-excellent clinical results can be obtained following a Scott or Van Dam Procedure. Radiological fusion rate was higher than assessment with thin-section computed tomography scans. CT tomography studies clearly demonstrated the presence or absence of bridging bone, a property not easy to see in plain static radiographs. However, clinical significance of CT non-union is not clear

The authors report the use of a modified ‘Y-V’ medial capsular repair in association with Scarf osteotomy for Hallux valgus in 55 patients (62 feet) aged 18 to 61 years (mean 43 years) between July 2004 and July 2005. All patients were followed up for minimum 6 months by questionnaire, physical examination (American Orthopaedic Foot and Ankle Society score) and comparison of preoperative and post operative x rays. Using this technique none of the patients required an additional proximal phalangeal osteotomy (Akin Oste-otomy). At six months follow up American Orthopaedic Foot and Ankle Society score improved from 46 to 87. Intermetatarsal (IM) angle and the hallux valgus (HV) angle improved from 16 degree to 9 degree and from 31 degree to 16 degrees respectively (p less than 0.05). Of the sixty two procedures 59 did not develop any complications. Two had superficial infections which required oral antibiotics only. One partial loss of correction of hallux valgus occurred for which the patient refused a second operation. Seven cases had some residual pronation deformity of the big toe identified by the patients who felt the deformity was ‘about 50%’ compared to before the operation. Akins osteotomy achieves an apparent correction of hallux valgus without addressing subluxation of meta-tarso-phalangeal joint. Our technique reduces the meta-tarso-phalangeal joint and corrects the hallux valgus angle anatomically. We recommend the use of this modified ‘Y-V’ medial capsular repair to correct the hallux valgus angle and reduce the need for an additional procedure to augment the correction achieved during Scarf osteotomy for hallux valgus

CT- scan as an management tool is being used extensively in managing calcaneal fractures. We set out to see if a CT-scan makes any difference to the management plan as obtained by looking at the plain radiograph. We also looked at the correlation with the actual management. Methodology: This was a retrospective study involving 24 patients with fracture of the calcaneum. These patients had both a plain radiograph and a CT- scan to help decide on management. The actual management that each of these patients had was documented. Three consultants who were blinded to the actual management and names of the subjects were independently asked to grade the radiographs, as operative or non-operative. They were then similarly, asked to decide on operation or no-operation based on blinded CT- scans. The data obtained from the three observers were compared to the actual management and were subjected to statistical analysis. Results: As the data was categorical and matched, the Mcnemars test was used to test the association between the management plan obtained from the radiographs and the management plan obtained from the CT scans, for each consultant. They were also compared with the actual management. The statistical analysis showed that there was no statistically significant association between the management decision obtained from the radiographs and the CT san, for all three observers. Radiograph and CT scan based management decisions also did not correlate with the actual management. Conclusion: The CT scan should only be done when a definite decision is made to operate on a patient, based on plain radiographs. Calcaneal fractures which are decided not to operate, based on X rays, should not have a CT scan as a routine as it provides no valuable additional information

Introduction: In this study we report our experience with the clinical outcomes following Dynesys. Our objectives are to revalidate the most suitable indication(s) of Dyne-sys in patients with backpain. Method: A prospective cohort study on 374 consecutive patients who had Dynesys for backpain from September 2000 to-present. Average age of patients was 57 years and male to female ratio were (40%:60%). Preoperative assessment involved ODI, SF36, VAS for leg and backpain and the diagnosis was confirmed with physical examination, x rays, spinal probe and lumbar spine MRI. Regular follow up was arranged at 2 weeks, 3, 6 and 12 months then on annual intervals. In our cohort, clinical indications were:. • Degenerative Disc Disease (DDD). 271 patients. • Spondylolisthesis. 55 patients. • Adjacent segment disease (ASD). 30 patients. • Spinal canal stenosis. 18 patients. t-test was used for comparison between preoperative and postoperative scores and p-value was used to show the significance. Results: Overall outcome assessment revealed significant improvement in ODI, SF36 and VAS in comparison with preoperative status (p-value < 0.05). Improvement was greatest in DDD group and average for ASD. Patients with stenosis performed better when the procedure involved adjunct decompression. Similarly, results of decompression and fusion were better than Dynesys alone in patients with spondylolisthesis. Discussion and Conclusion:. Dynesys was successfully controlled symptoms of DDD in the intermediate term. Dynesys can be used as surgical treatment for symptomatic ASD. Dynesys alone in the treatment of spondylolysthesis resulted in a 45% re-operation rate, and we believe it should not be recommended as an indication. Dynesys alone is not recommended as a treatment for symptomatic spinal stenosis

Introduction. Open tibial fractures are associated with increased risk of complications, particularly a higher risk of infections and decreased functional outcome. Objectives. To evaluate the incidence of complications and the functional outcomes after managing open tibial fractures with circular fine-wire fixators. Methods. Retrospective review of 35 open tibial fractures treated with circular fine-wire fixators {Ilizarov and Taylor Spatial Frame (TSF)} in a teaching hospital. Patients were reviewed with x rays and clinical outcomes measured using Iowa Knee Score questionnaire, Olerud-Molander Ankle Scores (OMAS), Ankle Evaluation Score and Euroqol EQ-5D descriptive system (generic health questionnaire). Results. Ilizarov frame was used for 19 (56%) and TSF was used for 16 (44%) patients. Mean patient age was 47.1 years. 74% had high energy while 26% had low energy injury. 4 patients (12%) had grade I, 3 (9%) had grade II, 27 (79%) patients had grade III injury as per Gustilo & Anderson Classification. 14% patients had proximal, 17% had mid-shaft, 67% had distal tibial fractures respectively. Average time to union was 28.9 weeks. 12 (35%) had pin-track infection treated with antibiotics. Grade IIIB fractures healed in 29.6 weeks. 17 required soft tissue coverage and only two developed skin graft complications. There was no case of deep infection & mal-union and one patient had non-union. Patients had good satisfaction scores (EQ-5D descriptive system) following surgery (mean = 0.751). The mean Iowa Knee Evaluation score, OMAS and Ankle Evaluation score was 87.32, 73.48 and 74 respectively (maximum being 100). The ankle range of movement was similar in operated and contra lateral normal ankles. Conclusions. We report fewer complications with no incidence of deep infection rates and infection only limited to superficial tissues. Healing time is considerably reduced and there are high satisfaction rates with good functional outcomes

Consequent upon a retrospective audit of all acute tibial nail patients within GRI in 2010, it was agreed, due to variable follow-up, imaging and requirement for secondary intervention, a standardised protocol for management of acutely nailed tibial fractures within GRI was to be established. Subsequently, a Nurse Led Tibial Nail Clinic commenced in July 201. The majority of consultants (11 of 13) devolving follow up of these patients to a protocol based algorithm designed on evidence based principles and consensus expert opinion. Aims were to standardise/improve management of tibial nail patients in terms of patient education, weight bearing, imaging, follow-up intervals and also coordinate secondary intervention via a single consultant with an interest in limb reconstruction/non union. A secondary goal was to achieve measureable outcome data for this subgroup of patients. All patients underwent post operative radiographs prior to discharge, review in clinic at 10 days for wound assessment, 6 weeks for physiotherapy and 12 weeks where standard AP and lateral tibial radiographs were repeated. Patients are discharged at 12 weeks if the radiographs confirm bony healing on three cortices or more and fractures are clinically united. If not, repeat x rays are undertaken at 20 weeks. A parallel consultant led limb reconstruction clinic is available to review patients failing to demonstrate satisfactory progression to union with secondary intervention instigated thereafter as appropriate. Since commencement of the Nurse Led Tibial Nail Clinic, 60 patients have been treated with a tibial nail, 44 managed in the Tibial Nail Clinic. The mean number of radiographs has reduced from 6.4 to 3.1 per patient to discharge. Clinic visits are reduced from 6.4 to 3.9 per patient to discharge. Non compliance is low with 4.6% of patients failing to attend. Secondary interventions have been low (13%), confirming a relatively benign course of healing for most patients treated with an IM nail for acute tibial fractures. There has been one non union, no deep infections, two nail removals and one DVT. A protocol based specialist nurse led clinic is safe for patients, cost effective for the NHS and gives increased opportunity for measuring outcome and improving care in a previously heterogenously managed group of patients

At our institution significant number of patients were able to have full movement after TKA; however the concern is whether deep flexion after TKA will increase certain complications or whether it will cause early damage to the knee components. 384 Total knee replacements were performed from January 97 to January2002. Three deferent knee systems were used (IB2, NEXGEN and LPS Flex). Preoperative and post operative range of motion was document on lateral x-ray. Knee score was documented and data was processed at major university in Scotland. All surgeries were performed by a single surgeon. Patient was considered to have full flexion if he is able to flex the knee over 140 and able to kneel with the calf touching the thigh for at least one minute. Post operative x-ray was reviewed at 1 and 2 years.3D images were obtained on selected cases. 216 Cases had full flexion as per above definition and 168 cases failed to achieve full flexion. There was no significant deference in complication rate between patients who had full flexion and those who did not. The complication rates were similar to that reported in other series. X ray review did not show any component damage in the full the flexion group; however two phenomenons were documented in some patient who had full movement: dig in phenomenon and lateral femoral condyle spin off (confirmed on 3D images). Full flexion after TKA did not increase complication rates. The significance of dig in and spin off phenomenon needs further investigation

We undertook a comparative audit of 171 consecutive Hip and Knee Arthroplasties performed by an overseas team at an Independent Hospital (Group 1) between August 2005 and December 2005 and compared them to a corresponding number performed by all grades of surgeons at the local NHS Trust (Group 2). We examined patient selection criteria such as BMI and ASA grade and compared the early radiological outcome, complication rate, length of hospital stay and the patient satisfaction rate between the two groups. We found that patients in Group 1 had a lower average BMI (27.13) and a better ASA grade (95% grade 1 and 2) as compared to Group 2 (BMI - 29.69 and 80% ASA Grade 1 and 2). The average hospital stay was 6.1 days in Group 1 and 8 days in Group 2. Only 74% of the patients in Group 1 were completely satisfied with their treatment outcome as compared to 91% in Group 2. (Trent Arthroplasty Questionnaire). There were 7 early dislocations (9.1%) in Group 1 (76 THRs), two requiring revision, as compared to one in Group 2 (1.3%, 84 THRs). Three other patients from Group 1 (TKRs) required a revision procedure within the first year. There was an increased incidence of adverse features (mal-alignment and mal-positioning of components) on the post operative X rays of patients in Group 1 as compared to Group 2 leading to adverse clinical events. 11 patients (95TKRs) showed substantial femoral notching in Group 1 as compared to 3 in Group 2. This study shows that patients selected for surgery by the overseas team were the fitter of the two groups, but had a significantly higher complication rate and a much lower satisfaction rate. The study underlines the potential risks of commissioning work to overseas teams in order to reduce waiting times

Introduction: Recently, highly cross-linked polyethylene has been highlighted in THAs, which is thought to reduce wear. However, little is known about an accurate nature of cross-linked polyethylene particles and long term wear in vivo. One of the authors implanted all polyethylene cups irradiated by 100 Mrad in 1970’s. Recently, we performed two revisions with this cup. In the present study, we extracted polyethylene particles and analyzed them. Methods: Case1 was revised for a stem fracture and ace-tabular loosening at 25 years postoperatively and case2 for acetabular loosening at 27 years postoperatively. There was no osteolysis on X rays. We extracted polyethylene particles using a tiussue digestion and iamge analysis using computed iamge analyzer developed by Cambell. Results: Equivalent circle diameter (ECD) was 0.73mm, roundness was 0.69, aspect ratio (AR) was 1.4 and number of particles was 6.0x108/g wet tissue in case1. ECD was 0.57mm, roundness was 0.62, AR was 1.54 and number of particles was 5.8x108/g in case2. SEM showed that granule or globular shapes were abundant and fibril shapes were rare. Discussion and conclusion: Cross-linked polyethylene particles were less, a little smaller and much rounder in compared with our previous result of conventional polyethylene particles in peri-implant tissue after more than 25 years postoperatively in vivo

Despite the high success rates of Reverse Shoulder replacements, complications of instability & scapular notching are a concern. Factors reducing relative motion of implant to underlying bone which include lateral offset to centre of rotation, screw & central peg insertion angle and early osteo-integration are maximized in the Trabecular Metal Reverse total shoulder system. We present clinico-radiological outcomes over 72 months. Analysis of a single surgeon series of 140 Reverse total shoulder replacements in 135 patients was done. Mean age was 72(range 58– 87 yrs); 81 females: 54 males. Indications were Rotator cuff arthropathy {n= 88} (63%); Osteo-arthritis with dysfunctional cuff {n= 22}(15%); post-trauma{n=23} (15%); revision from hemiarthroplasty {n=3} (2.4%) and from surface replacement {n=4} (2.8%). All patients were assessed using pre-operative Constants and Oxford scores and clinical & radiographic reviews with standard X-Rays at 6 weeks, 3, 6,12 months and yearly thereafter. X rays included an AP view in 45 degrees of external rotation and modified axillary view. Inferior Scapular notching using the Nerot-Sirveaux grades and Peg Glenoid Rim Distance were looked into by a consultant musculoskeletal radiologist/ Orthopaedic surgeon/ Senior Fellow (post CCT) or a specialist Trainee (ST4 and above). Pain on the visual analogue scale decreased by 98% (9.1 to 0.8) (p<0.01). Constant score improved by 81.8% (12.4 to 68.1) (p<0.05), Oxford shoulder score by 76.7% (56 to 13) (p<0.05). 95.6% of Humeral stems had no radiolucent lines and 4.4% had < 2mm of lucency. Scapular notching was calculated using Sirveaux grades with Peg scapular base angle distance (PSBA) measurements on PACS with Siemens calibration (grade 1= 4 (2.8%); grade 2 =1; grade 3 =0; grade 4=0). 3.57% showed radiographic signs of scapular notching at 72 months. Range of Peg Glenoid Rim Distance was 1.66 to 2.31 cm. Power analysis showed 65 patients were needed to have an 80% power to detect relation of Peg Glenoid Rim Distance to Scapular notching. A likelihood ratio test from Logistic regression model to check correlation of Peg Glenoid Rim Distance to Scapular notching gave a p value of 0.0005. A likelihood ratio from Logistic regression gave a p value of 0.0004 for Infraglenoid Scapular spurs. Highest incidence of spurring was seen in Reverse Total Shoulder Replacements done for Trauma and lowest in patients who got the procedure for Osteoarthritis. Complications included two glenosphere revisions; two stitch abscesses and two Acromial fractures in patients who had a fall two years after the procedure. Improved surgical outcomes can be attributed to surgical technique and implant characteristics. Trabacular metal promotes early osteointegration which resists shearing action of Deltoid on Glenoid component. This allows early mobilisation. Deltoid split approach preserves integrity of Subscapularis and Acromial osteotomy and lateral clavicle excision improve exposure and prevent Acromion fracture. Positioning the Glenoid component inferiorly on the Glenoid decreases incidence of Scapular notching. Our mid-term validated outcomes are promising with only 3.57% Grade I/II radiographic signs of scapular notching. Long term studies (10 year follow ups) are necessary to confirm its efficacy

Summary. There is little consensus regarding the regime for treatment of tuberculosis of spine, although WHO has laid down guidelines couple of years back classifying spinal tuberculosis in Category 1. This study proves the efficacy of WHO regime in spinal tuberculosis by clinico-radiological evaluation. Introduction. The medical fraternity is divided over the duration of chemotherapy in cases spinal tuberculosis. WHO clearly recommend spinal tuberculosis under Category I, but not accepted by most clinicians. Patient and Methods. In this prospective study during the period between August 2005 and July 2012, a total of 76 cases were diagnosed and evaluated clinico-radiologically to test the efficacy of WHO protocol (2HRZE+4HR) in our hospital with a mean follow up of 50 months (30 – 80 months). Results. Spinal tuberculosis was seen in 56% of all osteoarticular tuberculosis. Maximum population was between 11–50 years, females were involved more than males (66%), and regional distribution was different in males (Lumbar) and females (Thoracic). Skip and multifocal lesions were seen in 13% (6 cases), more common in immune compromised cases. Pain was the most common symptom (95%) followed by constitutional symptoms. Radiographic changes were nonspecific, appear late and suggestive of tuberculosis in 53%case, MRI is very useful in diagnosing in 95% cases especially when X ray is contributory. ESR is useful tool for follow up of patients, elevated in 94%cases. Results were evaluated on clinical, hematological and radiological basis. Of the total 64cases (after dropouts, lost in follow up, mortality), 50 patients (78%) received treatment for 6 months and14 cases for more than 6months (P value<0.001). No MDR cases were present. In 50 patients fall in ESR at the end of 2 months was found to be statistically significant (P value<0.05) and hence were given a treatment for 6 months, the fall at the end of 6 months was highly significant (P value<0.001). In rest of the 14 cases the duration of treatment was given for more than 6 months as the trend of fall of ESR was not significant. MRI changes were assessed in the form of osteitis, osteitis with discitis, abscess formation and granulation tissue on initiation of treatment, completion of treatment and 6 months after completion of treatment. Conclusion and Discussion. The experience shows that spinal tuberculosis is common in a tertiary health care centre in India with diagnosis possible by combination of clinical evaluation and radiological evaluation. Statistical significance was found in clinical symptoms, ESR trends and MRI evaluation in cases receiving 6 months of chemotherapy. With this study, WHO short course chemotherapy was found to be effective in spinal tuberculosis, with no relapse over a period of 6 years

Purpose: To investigate the value of various clinical signs to identify occult hip fracture. Methodology: MRI register was searched to identify all patients who had MRI scan between July 2000–June 2006 for suspected occult hip fracture. 64 patients were identified. 33 patients had occult proximal femoral fractures. 27 patients had no fracture. Results: 19 patients with fracture were not independently mobile compared to 6 patients without fracture. 7 patients with fracture and 2 patients without fracture were able to weight bear. 13 patients with fracture and 10 patients without fracture had unrestricted straight leg raise ability. 7 patients with fracture and 16 patients without fracture had no pain on axial loading. Fisher exact and chi square analysis was performed; with Bonferroni correction for multiple comparisons (10 tests) p< 0.005 was deemed significant. Pain on axial loading of limb and pre-fracture patient mobility were associated with fracture (p< 0.005). Both factors had positive predictive value = 0.76 and post-test probability of disease given a negative test = .30. Predictive values remained the same when both factors were considered together. Discussion: These data indicate that although patients who were independently mobile before the fall and who do not have pain on axial compression of the limb are less likely to have a fracture, these signs alone or in combination will not exclude a fracture. It is essential to perform MRI scanning of patients with severe hip pain but normal x rays after fall as it does not seem possible to clinically exclude fracture

Malignant change in existing benign enchondroma of phalanx of hand to chondrosarcoma of hand is extremely rare. Books suggest that chondrosarcoma does not arise in small bones of hands and feet although in literature few cases have been reported but not described comprehensively. We report a rare case of chondrosarcoma in distal phalanx of ring finger in a 75- year old healthy female who had cystic lesion for past 25 years with recurrent fractures. Patient came to us with severe pain and tender, hard swelling of distal phalanx of left ring finger. X ray showed pronounced expansion of the terminal phalanx surrounded partially by a shell of bone, with focal spotty calcification with in the lesion. Because of sudden increase in size and pain of swelling, an amputation was performed at distal inter phalangeal joint. Histopathology showed grade II myxoid chondrosarcoma with pre-existing enchondroma. Wound healed nicely. Extensive investigation in form of CT chest and bone scan did not show any metastasis. Five year follow up did not show any local recurrence or distant metastasis. Clinical suspicion should be aroused in an older individual with a previously relatively quiescent lesion that becomes larger and painful. Usually course of the tumour is slow and metastasis to lungs is late. Treatment of choice is disarticulation a joint proximal to lesion. Prognosis is good if metastasis has not occurred. Once diagnosis is made, patient should be investigated to look for any possible metastasis and must be regularly followed up. A literature review and discussion of salient diagnostic and treatment issues is included

Prenatal androgen exposure has important organising effects on brain development and influences future behavioural patterns. Second to fourth digit ratio (2D:4D) is a marker for prenatal androgen exposure and as such is a sexually dimorphic trait. Smaller, more masculine second digit (index finger) to fourth digit (ring finger) ratio’s are associated with higher exposure to prenatal testosterone levels or greater sensitivity to androgens, or both. People with smaller finger ratios, a longer fourth finger than second finger, have been shown to be more successful in competitive sports, exhibit increased visuo-spatial ability, more fertile and are perceived as being more masculine and dominant by female observers. Smaller ratios have also been associated with an increased propensity to engage in aggressive behaviour. We examined the relationship between Boxer’s fractures, a traditional injury of aggression and finger length ratio. We reviewed 1123 patient records and/or hand x rays over a seven month time frame showing 123 fifth metacarpal (Boxer’s) fractures. We then measured, using recorded radiological data, the distance in millimetres from the base of the proximal phalanx to the tip of the distal phalanx for the second, third and fourth fingers. We also recorded sex, side of injury, site of injury and mode of injury. One hundred and twenty three Boxer’s fractures were found over a seven month time period, 110 male and 13 female; 67.27% were right sided. The average age was 27.6 yrs ±14.2. The average finger length ratio (proximal phalanx to distal phalanx) for males was 0.9 and for females was 0.94. Both ratios were smaller than the published normal digit ratio for the general population. Smaller second digit to fourth digit ratios are positively associated with persons presenting with fifth metacarpal fractures, thereby indicating increased aggressive tendancies independently of gender

Aim: The operative management of proximal humerus fractures is still viewed as an unsolved question. Surgical treatment aims at restoring anatomical elements to a condition stable enough, to allow early mobilization to avoid secondary displacement. The blood supply of the humeral head should not be damaged, so the risk of avascular necrosis will be minimal. This work offers a new surgical technique that dramatically reduces the need for dissection of soft tissues while using a new locked plate. Material and Method: This prospective study was carried out between August 2002 and March 2004. 47 fractures of the humerus proximal were operated on 47 patients aged 63 as an average. There were 9 four part fractures, 18 three part and 17 two part fractures. The two arms of this Y shaped plate embrace the humeral head. The anterior arm overbridges the biceps longus tendon and fixes the lesser tuberosity, with a locked screw in the head. The posterior arm fixes the greater tuberosity with an another locked screw. These two screws cross each other at nearly right angle thus giving optimal fixation in the head. Results: Fourty four patients (44 shoulders) were later re-examined with 10,3 months mean delay. Re-education was made immediate for 85% of the cases. The final evaluation was made with the functional Constant score and X ray control. The main complications were 3 algodystrophies, 1 hematoma, 4 failures of fixation, 2 nonunions and only one necrosis. Conclusion: This first clinical experience with this new implant is stimulating, since it provides a reliable fixation, even into the osteopenic bone

We wish to report the use of a modified ‘Y-V’ medial capsular repair in association with Chevron osteotomy fixed rigidly with Barouk screw for Hallux valgus in 45 patients (52 feet) aged 16 to 70 years (mean 47 years) between July 2004 and September 2005. All patients were retrospectively reviewed by questionnaire, physical examination (American Orthopaedic Foot and Ankle Society score) and comparison of preoperative and post operative x rays. Using this technique none of the patients required additional immobilization apart from wool and crepe bandage following surgery. All osteotomies healed without any problem. There was no deep infection reported in this series. There were two superficial infection treated with oral antibiotics. There is no recurrence of deformity so far. At an average of six months follow up American Orthopaedic Foot and Ankle Society score improved significantly. Intermetatarsal (IM) angle and the hallux valgus (HV) angles were also improved considerably. Stabilization of Chevron osteotomy with k wires, plaster of Paris is well known but these techniques have problems of infection and stiffness. Osteotomies carried out without any stabilization has high recurrence rate. Fixation of osteotomy with Barouk screw is a very simple procedure, which not only gives stability and compression to osteotomy but also reduces need for any plaster immobilization thus speed up rehabilitation. This also gives extra confidence to surgeon to allow patient for early weight bearing and mobilization. We also recommend the use of modified ‘Y-V’ medial capsular repair to correct the hallux valgus angle and reduce the meta tarso-phalangeal joint leading to reduction in possibility of recurrence

Goodfellow & Bullough (1968) first described the pattern of articular cartilage wear in the elbow. More recent post mortem studies have shown that advanced degenerative changes can develop in the radio-capitellar (lateral) compartment of elbow joints of elderly subjects in which the humeroulnar (medial) compartment remains remarkably well preserved. We have reviewed the findings in a consecutive series of 117 elbow arthroscopies performed on patients with elbow pain resistant to conservative treatments (age range 21–80 years: mean age 51 years). We documented established degenerative changes involving articular cartilage in 68 patients (59%). In this group we found that in 60 patients (88%) the degenerative changes were confined to the lateral compartment and contrasted with normal appearances of the articular cartilage of the medial compartment. The post mortem studies carried out on mainly elderly subjects demonstrated that the degree of degenerative change in the elbow is age dependant and involves predominantly the lateral compartment of the joint. Our study would support these observations, but indicates that symptomatic degenerative change occurs at a much earlier age than had previously been thought. We consider that lateral compartment degenerative change is a distinct clinical entity. It begins in relatively young patients in whom the x ray appearance may be normal or near normal and is often diagnosed as lateral epicondylitis. Our observations taken together with the reported post mortem studies indicate that primary osteoarthritis of the elbow begins in the lateral compartment of the joint and may remain confined to the lateral compartment throughout life. We believe that new treat ment strategies need to be developed specifically for patients with primary osteoarthritis as opposed to degenerative joint disease due to other causes

Introduction: Tantalum Monoblock Acetabular cup was designed to reduce backside wear and stimulate osseo-integration of cup with bone. The cup has peripheral fit to improve the initial stability and further stability and longevity depends on the osseointegration of cup with acetabulum. The revision cup was intended to give added stability with screws in case of defective rim or large acetabulum. The aim of this study is to assess the radiological outcome following tantalum monoblock revision cup in total hip replacement. Methods: Between 1999 and 2000, 32 Tantalum mono-block revision acetabular cups was used in 31 patients. Standard hip radiographs were performed during post op, at three months, six months and then annually. X rays were assessed for loosening in De Lee and Charnley zones and for migration of cup. Results: At a minimum follow-up of 2 years (range 2 to 5 years), 31 hips in 30 patients were assessed. The average age of the patient was 62.4 years (39–78 years). Three Brookers type 1 and one type 2 heterotrophic ossification was seen. There was a gap of 2–5mm in Zone 1(6 patients), 1–5mm in Zone 2 (8 Patients) and 5mm in Zone 3 of one patient. At final follow up, all the gaps were filled, except for one, where 5mm gap was persistent. There was no migration of cup or problems with screws. All the patients were satisfied with the operation. Conclusion: Short term radiological result following uncemented revision tantalum monoblock acetabular cup in total hip replacement is highly encouraging. However, similar results from other centres and long term follow up studies are necessary to confirm the efficacy of the revision cups

Background: Because of his tribologic properties Alumina on alumina bearing for THA is an attractive alternative to the the other traditional bearings surfaces and is used since about forty years, especially for young peoples. In order to resolve the problem caused by the rigidity of ceramic, the ceramic sandwich liner was introduced but some cases of ceramic fracture were reported. The purpose of this study was to quantify and analyse these specific failure. Methods: Between November 1999 and February 2008, a total of 353 CÉRASUL. ®. (Zimmer, Winterthour, Suisse) liner acetabular component with a 28 mm alumina head were implanted in 298 patients. The results were reviewed at a mean of 3,5 years postoperatively with 6 patients loss to follow-up. Clinical follow-up with the PMA score and plain radiographic evaluation were performed. Based on Xray analysis, ceramic sandwich liner fractures were counted and analyzed. Results: The mean PMA was 17,5 (10 to 18) at the final review. Kaplan-Meier survival curves were constructed for the outcomes of revision for any reasons and for ceramic liner fracture. Seven fractures (2%) of ceramic sandwich liner were found and occured at a mean of 4,3 years after surgery without trauma. Fractures (20%) were the third diagnosis leading to the liner revision after dislocation (43%) and sepsis (26%). Neither patient related factors nor X ray position of the implants could be isolated as risk factor of liner fracture. Discussion: Despite promising short term results in term of clinical and Xray analysis, ceramic sandwich liner is associated with a high rate of fracture. This complication have been already reported by other authors for different devices of the same concept ; instead of their conclusions, we were unabled to identify any risk factor of fracture. We hypothesised that repetitive impingement of the stem neck could be the first event of that disappointing complication. Due to this high rate of fracture we discontinued to implant ceramic sandwich liner for THA

In this work we mean explain our clinical experience about the use of a T.R.K. mobile meniscal bearing implanted during the 2000 and 2001 in our institute. The prostheses design allows the motion of the polietilenic component 5mm in the anteroposterior directions and 12.5 degrees in the internal and external rotation. In association with the shaping of the femural contact surfaces this design allows a huge upgrade of contact surfaces compared with other protheses already in use. We have evaluated 17 patients on short term follow up, patients operated in our division, four males and 13 females. The average ages are 68 ± 8. The indication was in all cases gonartrosis. The evaluation protocol includes:. § Pre and post operative x rays (after 60 days);. § Clinical evaluation of the range of motion;. § D.E.X.A. mineralometry;. § Stabilometric evaluation pre operative and after 6 months. The first results have pointed out the disappearing of pain in all the patients, an optimal recovering of the articular function with no loss of extension, a good prothesic osteointegration (even in an initial phase in our cases) and the stabilometric evaluation confirms a soon proprioceptivity recovering and the motion of the operated limb. After all this encouraging results we have decided to continue implanting this kind of protheses as we think that not only it warrants a better range of motion, but the utmost null polietilenic debris may allows a longer life to the implant as a consequence of the reduced stress rate

Introduction: Ankle fractures in the elderly is on the increase both in prevalence and severity. The major goal of treating displaced fractures in the elderly is rapid resumption of mobility. Review of literature showed better outcome was achieved by Open Reduction and Internal Fixation. Aim: to study the complication and reoperation rates following ankle fractures in the elderly population. Method: We studied the outcome following displaced ankle fractures in patients above the age of 55 admitted to Good hope hospital over the last þve years. The study was conducted on retrospective basis with a review of notes and x rays to assess the outcome. Result:The rate of complications and re-operation rate were studied. A total of 62 patients were identiþed with a mean age of 70. MUA and cast immobilisation was used in 13 patients, 3 patients treated with MUA and Percutenous K wire þxation and 41 patients were treated with Open reduction and internal þxation. One case in the MUA and cast immobilisastion group needed ORIF (7%). In the ORIF group, one case had to be re-operated to introduce a syndosmosis screw due to residual talar shift. The rate of complications in the ORIF group was 17%. Wound infection and delayed wound healing were the main complications. Based on the results of this audit, we believe that MUA and cast immobilisation supplemented with K wire þxation if necessary should be used as a þrst line of management in the elderly. Conclusion:The use of Open reduction and internal þxation should be reserved for þt and mobile patients with no circulation problems or osteopenia in order to avoid bone healing and wound complications

Introduction: We report a series of 10 cases from a cohort of 421 Dynesys procedures in which evidence of Accelerated Adjacent Disc Disease (AASDD). Spinal fusion for degenerative disc disease is known to have inconsistent outcomes. One concern is the possibility of AASDD as a result of the altered kinematics. The Dynamic Neutralisation System (Dynesys) appears to offer an advantage in that it restricts, rather than abolishes movement at the treated segment, and should thereby reduce the problem of AASDD, In the event of failure, it can in addition be removed, returning the spine to the former status quo. Various biomechanical studies confirmed flexibility of Dynesys. Method: Ten patients developed new and symptomatic disc disease within segments adjacent to Dynesys. The average age of patients was 49 year with range between 36–70 years. Average post Dynesys to secondary surgery for ASD was 24.7 months. Previous discography and MRI in all cases had shown no evidence of disc disease within these adjacent segements prior to Dynesys. All patients were evaluated preoperatively using Oswestry Disability Index, SF 36 and Visual Analogue Scores together with plain x ray imaging, MRI scanning and discography. Of this cohort Dynesys was indicated to treat single disc level in 7 and two levels in 3. Results: Incidence of AASDD associated with Dynesys was 2.1%. Further surgical intervention included:. Extension of Dynesys10. Dynesys combined with MIF2. Dynesys combined with PLIF2. There was no caudal ASD in our cohort. Discussion & Conclusions: Dyensys did not prevent the development of accelerated ASD. Evidence from Aylott cadaver studies suggests that Dynesys instrumentation alters the Kinematics of the adjacent segment and increases the excursion. It is unclear whether the small number of AASDD reported here is other than the natural progression of degenerative change. 95.7 cases did not progress

Aim: To determine the accuracy of the posterior-to-anterior (PA) 15 degrees caudad view of the clavicle to assess amount of shortening of clavicular fractures. Method: The first stage of the study involved taking x-rays of an adult skeleton, centred on the clavicle. The projections included the standard anterior-to-posterior (AP) 15 degrees cephalad view, and the PA 15 degrees caudad view. Additional images were taken in the 15 degrees caudad view with a series of oblique rotational views, and oblique images in the vertical plane. Metal markers were placed on the clavicle at 10mm intervals. The clavicular length and the interval between markers were measured on the x rays.The second stage of the study involved obtaining the PA 15 degrees caudad x-ray on 50 patients with clavicular fractures. The non injured clavicle was also x-rayed. The lengths of the non injured clavicle and the lengths of the fragments of the fractured clavicle were recorded. Results: The length of the clavicle of the skeleton in the AP standard image was 149mm. The length in the PA 15 degrees caudad image was 130mm, with a maximum of 4mm variation on the oblique views up to 30 degrees. The true length was 124mm.Forty-five fractures were diaphyseal, and five were outer third fractures. There was less than 5mm measured difference in the length of injured and non injured clavicle in 38 out of 45 patients with diaphyseal fractures (84%). Conclusions: The PA 15 degrees caudad clavicular x-ray provided a more accurate assessment of clavicular shortening than the standard AP view, and was well tolerated by the patients

The aim of this study was to assess the results of bone ingrowth into the glenoid component of one design of Total Shoulder Arthroplasty (TSA) in which hydroxyapatite (HA) coating of the glenoid baseplate was introduced since 1997. Glenoid loosening is one of the most important complications of both cemented and uncemented TSA. Between May 1993 and April 1997 over 140 uncemented, porous coated, metal backed glenoid component were used in our Unit. By 1997 it had become clear that a significant number of these glenoid components had developed mechanical loosening and some required revision. We therefore started using an HA coated glenoid component for our TSAs from April 1997. One hundred and seventy-four shoulder arthroplasty procedures were performed between April 1997 and October 1999 of which 37 were TSAs using the HA coated uncemented glenoid. The indications included osteoarthritis (22), rheumatoid arthritis (nine), revision TSA (three), avascular necrosis (two) and cuff arthropathy with cuff reconstruction (one). The minimum follow-up was 18 months. The X rays were evaluated using the MLS (Migration, Lucent lines, Screw problems) system, which had been developed and reported previously. This system of evaluation has been shown to be reproducible for assessment of glenoid fixation. There was one case in which the glenoid liner became displaced and had to be replaced. Our early results at a mean FU of approximately 2 years show an improved radiological fixation compared with those glenoids inserted without HA

Introduction: It is common practice to screen the hips of infant with a family history of DDH clinically and ultra-sonographically in selective screening programmes. The practice of regular radiographic follow-up of infants with a positive family history of Developmental Hip Dysplasia (DDH) is based on the widespread belief that Primary Acetabular Dysplasia is a genetic disorder that can occur in the absence of frank hip subluxation or dislocation. 1. It has been our practice to obtain a 6 – 12 month screening radiograph in such patients but this practice is not conclusively supported in the literature. Materials and Methods: We reviewed all such infants who had a normal clinical and ultrasound examination of the hips at the 6–8 week screening examination but who, because of the family history underwent further radiographic screening after a 6–12 month interval. The radiographs of all such infants (n=77) were analysed for any signs of late hip dysplasia. Results and Discussion: Sixty six infant had normal X rays at the 6–8 month assessment and were discharged. The remaining eleven patients had acetabular angles at the upper end of the normal range for age and were reviewed again with further radiographs at 12 months. At this stage ten patients were normal and were discharged. The remaining patient was reviewed again at 18 months and 24 months and finally proved to be normal and was discharged. The result of a postal survey has suggested that majority of BSCOS members do not get follow up x-ray done if the clinical and ultrasound scan is normal at screening visit. Conclusion: All of the seventy seven patients eventually developed normal radiographs and we question the need for radiographic follow up of infants with a family history of DDH but who have a normal clinical examination and ultrasound scan at 6–8 weeks

Introduction The biomechanical properties of biologic cages made of femoral ring allograft in providing immediate stability for lumbar fusion as compared to bovine xenograft, titanium and polyethylether ketone (PEEK) cages are unknown. Biomechanical comparisons were done of lumbar constructs to determine their adequacy in providing immediate stability for fusion mass and demonstrate the need for supplemental posterior fixation. Methods Fusion constructs were evaluated in 40 Merino sheep as lumbar spine models. Discectomy was performed on multisegmental specimens. Femoral ring allograft, bovine xenograft, titanium cage (Syncage) and Polyethylether ketone / PEEK cage (Plivios) were inserted. Dual X ray absorptiometry assessment of bone mineral content was performed .Testing was one for insertional torque and pullout strengths. Static testing consisted of flexion and extension 2Nm moment and100Nm compression load, bilateral axial rotation pure 5.5 Nm moment and lateral bending pure moments 1.1Nm moment and100Nm compression loads. Dynamic testing was done to detemine long term properties of the construct. Results Interbody cages performed equivalently to femoral ring allograft. Bovine xenograft had lower stability compared to the rest. Posterior supplemental transpedicular fixation achieved increased stability in flexion, extension & lateral bending. Reduced stability was observed in all contructs with cyclical loading. The stabilizing effects were affected by the disc space distraction and facet joints. The titanium cage had significantly greater median pullout force compared to the others. Discussion Femoral ring allograft is valid alternative to titanium and PEEK cages. It is able to provide adequate immediate stability. Supplemental posterior fixation resulted in further rigidity of the constructs

Hypothesis. The use of cartilage compensated virtual standing CT images for pre surgical planning improves the reliability of preoperative planning. Materials and Method. Sampling included in this study were > 62 years of age (mean age 58.17 yrs ±3.54 yrs, range 55–62) with symptomatic isolated medial osteoarthritis, genu varum (mean varus 5.6°±2.6 °, range 2.1°–8.6°), good range of motion (flexion > 90° and flexion contracture < 10°) and with minimal ligamentous instability. All subjects had obtained a pre-op CT scan, MRI scan and weight-bearing long bone x ray. Post-op CT and long standing x-rays were taken prior to hospital discharge. A virtual software suite (HTO-OP3D, Zapalign Inc, Seoul, Korea) was utilised to determine an optimal osteotomy site, hinge location and a gap necessary to achieve the targeted virtual passing point. Prerequisite to performing the necessary calculations a virtual standing pose for each patient specific bone models was created using the following steps. To transfer the pre surgical plan intra-operatively, a customised alignment jig was manufactured. Results. Analysing the data using three dimensional imagery the femorotibial angle was corrected from a mean varus 5.5° ±2.3 ° (range 2.1°–8.6°) to a mean valgus 4.1° ±1.1° (range 2.9°– 6.1°). There was no statistical difference [p = 0.514] between the virtual simulatedpre-op valgus vs actual post-op valgus results extrapolated from the post op CT data {−0.18° ±0.3° (range −0.7°–1.0°)}. Analysing the same parameters using two dimensional standard X-rays, the femorotibial angle was corrected from a mean varus 6.6° ±2.9 ° (range 3.4°–10.6°) to a mean valgus 3.9° ±1.2° (range 2.9°–6.1°) respectively showing no statistical difference in average change in alignment measured using both modalities [p = 0.13]. The mean opening gap calculated using the three dimensional imagery vs two dimensional were 8.2mm ±2.9mm (range 5mm – 12mm) and 13.3mm ±3.3mm (range 10.2mm – 17.6mm) respectively, the difference between these data sets being statistically different [p = 0.03059]. The post operative evaluation of the posterior slope showed no statistical difference [p = 0.371] between the native slope {11.6° ±3.7° (range 5.3°–15.0°)} vs the post operative tibial slope {11.6° ±3.6° (range 6.2°–16.1°)} respectively indicating that the patients slope was well preserved. Conclusion. The use of patient specific bone model images superimposed into a cartilage compensated full extension simulated weight bearing pose and used to calculate the femorotibial corrective alignment and opening gap produces predictable results that is not influenced by the condition of the patients soft tissue. Corrective angles and opening gap calculations using two dimensional weight bearing X-rays does not always relate to good surgical outcome, primarily due to the influence of laxity on the alignment in standing pose. Furthermore, a patient specific clamping type surgical guide is effective to implement the pre surgical and aid in maintaining the tibial slope

Background: Selective ultrasound screening of neonatal hips with risk factors has been undertaken in Lanarkshire from 2001. Referral reasons included family history, breech, clicky hip and instability. Patients are examined by an orthopaedic surgeon with a special interest and scanned by static Graf technique. Our experience with selective screening and its effect on late DDH is presented. Methods: All ultrasound screening data was collected prospectively and entered into a database. Late presenters were identified at the tertiary centre by case note and X ray review. Population data was obtained from the Scottish registry. Results: Between 2001–2005, there were 30,824 live-births. 405 babies (910 hips) were identified as being at risk. 5(1.2%) were identified as Graf III/IV. Three responded to splinting, 1 required closed reduction and 1 open reduction. 11 who had initially normal scans were noted to have abnormal acetabular index (> 30) at 6 months. 2 required open reduction, 1 closed reduction and the rest eventually normalised with follow up. True late presentation was identified (> 3 months) in 11 children. Mean age at diagnosis was 14.7m (4–29 mts). 7(64%) did not have any identifiable risk factors. 4 had risk factors, but had escaped screening. 8 underwent open and 3 closed reduction. 7 derotation osteotomies and 1 pelvic osteotomy were additionally performed. Discussion: The identifiable incidence of DDH in Lanarkshire is 0.87/1000. The incidence of true late presenting DDH in the same population was 0.35/1000. If all hips with risk factors had been successfully screened it would reduce to 0.22/1000. Selective screenings can minimise the incidence of late presenting DDH if rigorously implemented. Majority of late presenters do not have risk factors and are likely to escape detection with a selective screening programme. This suggests a different natural history in late presenting cases

Objective: The purpose of this communication was to evaluate the long-term outcome of patients with type II odontoid fractures treated with anterior screw fixation. Material and Methods: In our prospective clinical study 34 patients, 21 males and 13 females (with mean age 35.4 + 0.8 years) with type II odontoid fractures of traumatic etiology, underwent anterior cannulated screw fixation, during a period of 36 months. All patients had radiologicaly confirmed intact transverse ligament and a reducible odontoid fracture. All patients were immobilized in a Miami J cervical collar for 4 weeks postoperatively. Radiological examination of the cervical spine with plain X rays and cervical spine CT was performed at 6 weeks and two, six and 12 and 24 months postoperatively. Follow-up time ranged between 36 and 80 months (mean follow-up 54.3+ months). Results: 32 patients had an uneventful postoperative course, while one patient developed pulmonary atelectasis, which resolved without any significant sequelae and another one developed a superficial wound infection, which resolved without removing the implanted hardware. Radiographic evaluation showed satisfactory bony fusion and no evidence of abnormal movement at the fracture site in 31 patients (91.1%). In two patients (5.8%), the radiographic studies showed pseudo-arthrosis and instability while in one patient (2.9%) the implanted cannulated screw was broken but there was no instability shown. Conclusions: In our series anterior odontoid screw fixation constituted a safe therapeutic modality with high stability and low mechanical failure rates in short and long term follow-up period

Recently, highly cross-linked polyethylene has been highlighted in THAs which is thought to reduce wear. However, little is known about an accurate nature of cross-linked polyethylene particles and long term wear in vivo. One of the authors implanted all polyethylene cups irradiated by 100 Mrad in 1970s. Recently, we performed two revisions with this cup. In the present study, we extracted polyethylene particles and made direct wear measurements on retrieved cups. Case one was revised for a stem fracture and acetabular loosening at 25 years postoperatively and case two for acetabular loosening at 27 years postoperatively. There was no osteolysis on X rays. We extracted polyethylene particles using a tiussue digestion and image analysis developed by Cambell and measured wear of retrieved cups using casting and 3D scanner developed by us. Equivalent circle diameter (ECD) was 0.73 um, roundness was 0.69, aspect ratio (AR) was 1.4 and number of particles was 6.0 hundreds million/g wet tissue in case one. ECD was 0.57 um, roundness was 0.62, AR was 1.54 and number of particles was 5.8 hundreds million/g in case two. SEM showed that granule or globular shapes were abundant and fibril shapes were rare. Direct wear measurement showed concentric wear patterns were observed with very low linear wear (less than 0.03 mm). Cross-linked polyethylene particles were less, a little smaller and much rounder in compared with our previous result of conventional polyethylene in peri-implant tissue. No unidirectional and significant amount of wear was observed in retrieved cups even after over 25 years

Introduction: Loss of the meniscus frequently leads to progressive arthritic changes in the involved compartment. Replacement of the lost meniscus with a resorbable collagen scaffold has been proved to allow regeneration of meniscal tissue. MATERIAL AND Methods: Between June 2001 and September 2004, 42 patients, 38 male and 4 female, underwent arthroscopic placement of a collagen meniscus implant (CMI) to reconstruct the damaged medial meniscus. Their age ranged between 22 and 50 years. All patients had an associated ACL insufficiency, 39 secondary to acute ACL tear and 3 ACL graft failures. ACL reconstruction with hamstrings grafts (39) and ACL revision with allograft (3) was performed at the time of CMI implantation. The interval between ACL injury and surgery ranged between 3 weeks and 6 months. Ten patients also had a lateral meniscus tear. All patients were followed with clinical, weight-bearing radiographs, KT-1000 and magnetic resonance examinations for at least 18 months (range, 18– 84 months). The IKDC form was used to record and evaluate the Results:. Results: The length of the implanted CMI ranged between 3 and 5.5 cm and required 4 to 8 stiches. The IKDC subjective evaluation was normal in 18 patients, nearly normal in 18, abnormal in 5 and severely abnormal in 1. Range of motion was normal in 28 patients and nearly normal in 14. KT 1000 examination was normal in 32 patients, nearly normal in 7, abnormal in 1 and severely abnormal in 2. The X ray findings were normal in 28 patients, nearly normal in 6 and abnormal in 8. Complications included 2 saphenous nerve neuritis, 1 ACL graft tear with CMI implant breakage and 2 knee stiffness that required mobilization. 40 patients returned to work. The average time to resume work was 5.5 months. Conclusion: Simultaneous ACL reconstruction and collagen meniscal implantation is a viable and effective option in young active patients with ACL insufficiency and associated meniscal injuries

Background: The Calcaneus is the largest of the tarsal bones. 2% of all adult and 60 % of all tarsal fractures involve the Calcaneus. A true consensus regarding the management of these fractures still eludes orthopaedic surgeons. While operative treatment for displaced fractures has gained more acceptance in the last decade, surgical morbidity still remains high. Aim: A retrospective review of the early complications and radiological outcomes following open reduction and internal fixation of displaced calcaneal fractures in our unit over the last 15 months. Methods: A consecutive series of 33 patients who underwent surgical fixation of the Calcaneus was selected. Patient records, X rays and scans were reviewed. Mode and nature of injury, life style factors, surgical complications and Bohler’s angles were analysed. Results: 37 fractures in 33 patients underwent operative fixation. 81 % were male. Mean age at surgery was 37yrs (range19–59). 35 % were operated within 1 week of the injury and 13% after 2 weeks of injury. 43% were Sanders’ type III, 18% type II and 13% tuberosity avulsion fractures. 63% of patients had a reversed or zero Bohler’s angle. Mean post-op Bohler’s angle was 32 degrees. Overall complication rate was 32%, with a combined deep infection rate of 8%. All patients with infection were male, and 70% were smokers. 86% were above 40yrs of age (mean 47yrs). The deep infection rate for intra-articular fractures was 3% and for tuberosity avulsion fractures 40%. Majority of patients with wound complications had been operated within 7 days of injury. 4 patients had persisting pain requiring removal of metal work. Discussion: Our study highlights that there are significant risks associated with operative management of calcaneal fractures. Male patients over the age of 40yrs who are smokers seem to be at most risk of wound complications. Time to surgery or delay in surgery up to 2 weeks did not seem to have any adverse consequences. Complications increase with fracture complexity, and avulsion fractures have a high risk of wound breakdown. Near anatomical restoration of the articular surface is possible in most cases

Introduction: The possibility of occult hip fracture in older patients after a fall is a common problem. The value of various clinical signs to determine which patients require further investigation has not been reported. Methodology: MRI register was hand searched to identify all patients who had MRI scan between July 2000–June 2006 for suspected occult hip fracture. 64 patients were identified. 33 patients had occult proximal femoral fractures. 27 patients had no fracture. Results: More patients with fracture were living in their own home (20/26), were independent for daily living (20/26) and were not independently mobile(19/26) compared to patients without a fracture (14/22, 11/22 and 6/22 respectively). 7 patients with fracture and 2 patients without fracture were able to weight bear. 13 patients with fracture and 10 patients without fracture had unrestricted straight leg raise ability. 7 patients with fracture and 16 patients without fracture had no pain on axial loading. The value of individual tests was evaluated using Fisher exact and chi square analysis; with Bonferroni correction for multiple comparisons (10 tests) p< 0.005 was deemed significant. Pain on axial loading of the limb and pre-fracture patient mobility were both associated with the presence of a fracture (p< 0.005). Discussion: These data indicate that although patients who were independently mobile before the fall and who do not have pain on axial compression of the limb are less likely to have a fracture, these signs alone or in combination will not exclude a fracture. Other widely used signs (eg ability to straight leg raise) appear of little predictive value. On the basis of our data, we believe it is essential to have a policy of MRI scanning of patients with severe hip pain but normal x rays after a fall as it does not seem possible to clinically exclude a fracture

Abstract: resurfacing hip arthroplasty has shown promising early results in the treatment of hip arthrosis in younger patients as published from specialist centres in the United Kingdom. We are reporting early results and complications of Birmingham hip resurfacing arthroplasty (BHR) from a district general hospital. This is a retrospective study of 216 hips in 186 patients during January 1999 to December 2004. The study included review of notes and X rays and a questionnaire based assessment of hip function and activities using Oxford Hip Score (OHS) and Duke’s activity score (DAS). This study has got national ethical committee approval. The response rate for questionnaire was 76%. Average age was 53.3 years (range 20–72). Male: female ratio was 3:1. There were 152 unilateral and 32 bilateral cases. Majority of the cases had osteoarthritis in the hip. Average follow-up was 30.3 months (range 12–72). Average length of stay was 6 days (range 3–17). Average OHS and DAS were 15.8 and 51 respectively. 163 patients had OHS of less than 24. 113 patients had DAS of 58.2. Radiological assessment showed six cases of hetero-topic calcification. Lysis was noted at prosthesis-neck junction in two cases but patients were asymptomatic. The complications included superficial wound infection in 2, DVT in 6, neuroparaxia of sciatic and brachial plexus in one case each. There were six dislocations. There were nine revisions – seven following fracture neck of femur and two for aseptic loosening. The incidence of fracture neck of the femur was high in early part of the study suggesting technical improvement with experience. Overall failure was 4.1%, slightly higher than other published literature. The OHS and DAS were comparable to other published results. In conclusion the results of the BHR are encouraging and long-term prospective study is needed to find out the longevity of the implants and long-term results

Older fracture patients frequently ask whether their osteoporosis will affect fracture healing. There is only limited previous data about this. We investigated recovery after distal radial fracture, and compared it with BMD of the other distal radius and the lumbar spine (measured using quantitative CT). All 28 patients had sustained a dorsally displaced distal radial fracture which was deemed to require treatment by intrafocal wire fixation. All patients had acceptable correction of dorsal and radial angle at final x ray (3 months). Wrist function was measured using the Patient Rated Wrist Evaluation (PRWE – a validated outcome measure for use after distal radial fractures), grip strength,and range of motion. All measurements were made at 6, 12 and 26 weeks. BMD was measured in the opposite wrist and the lumbar spine using QCT at 6 weeks after fracture. There was no correlation between recovery of grip strength (% of contralateral grip strength) at 6,12,or 26 weeks with BMD at either site. Similarly, there was no correlation between BMD and either absolute PRWE scores at any time point or improvement in PRWE between time points. The strongest predictor of recovery of grip appeared to be the proportion of grip recovered at 6 weeks (correlation between% grip recovered at 6 weeks and 3 months r = 0.85; at 6 weeks and 6 months r= 0.56; both p < 0.001). This was not affected by age or variations in measured final dorsal or radial angles or length within this group. It was not affected by degree of preoperative fracture displacement. These data suggest that recovery of function after distal radial fractures is not influenced by osteoporosis. The data about the importance of initial recovery of grip suggest that factors other than bone position and bone healing may affect rate of functional recovery after distal radial fracture

Introduction: Frozen shoulder is a general term denoting all causes of motion loss in the shoulder. As the syndrome is very common, many patients do not undergo detailed imaging studies before treatment. Objectives: A series of 15 patients with primary neoplasms of the shoulder girdle mimicking frozen shoulder syndrome is presented. Results: There were 6 male and 9 female patients. The common presentation was pain and stiffness of the shoulder joint. Mean age at diagnosis was 46.63Yrs (range 23 “ 71 Yrs). 73% were less than 50 Yrs of age. Only 2 gave history of trauma. Most received local steroids and physiotherapy before diagnosis. There were 10(66.6%) proximal humeral lesions and 5(33.3%) scapular lesions. Humeral lesions included chondrosarcoma (2), Ewing’s (2), lymphoma (2), chondroma (2) and osteoblastoma (1). Scapular lesions included chondrosarcoma (3), lymphoma (1) and fibromatosis (1). Scapular tumors involved older individuals. The mean delay in diagnosis after onset of symptoms was 15.8 mts (range 2 weeks- 48 months). All patients had X rays and CT / MRI. Treatment included a combination of surgery, chemotherapy and radiation. 3 patients with humeral lesions died at a mean of 20.6 mts, and 3 patients with scapular lesions died at a mean of 4.3 mts after diagnosis. The common cause of death was pulmonary metastasis. Discussion: Many so called frozen shoulders are joints inhibited by pain rather than by true contracture. The commonest lesion to mimic a frozen shoulder is a slow growing low/middle grade chondrosarcoma. Young patients presenting with persistent pain or night pain must be examined for this possibility. Consideration should be given for further investigation before instituting treatment. Delay in diagnosis adversely affects survival. Surgeons are reminded that although rare, a tumor should be suspected when clinical presentations are unusual

Purpose. In 2010, the new clinical guideline of Osteoporosis Canada for the diagnosis of osteoporosis, clearly indicates that patients with high-risk of fracture are those that have already sustained a fracture (osteoporotic fracture). Until now, only 12% of the 3,400 fractures that we treat each year receive a treatment for osteoporosis. We are validating an evaluation protocol and a multidisciplinary systematic follow-up approach for osteoporosis. Patients are managed by a clinical nurse specialist. We are recruiting 543 patients with an osteoporotic fracture at Hal du Sacré-Coeur de Montréal. We aim to evaluate: 1) the incidence of a second osteoporotic fracture, 2) the initiation of a treatment and determine the compliance and adherence to treatment and 3) the evaluation of CTX-1 and Osteocalcin at Baseline, 6, 12,18 et 24 months (treatment efficacy) and 4) the functional outcome and quality of life post-fracture. Method. We've enrolled 153 subjects (men and women) over 40 years of age who were treated for an osteoporotic fracture at the orthopaedic clinic of Hal du Sacré-Coeur de Montréal. After starting a treatment protocol for osteoporosis, the subjects will be followed for a 24 months period at different time intervals. During these visits, they fill up functional outcome questionnaires, undergo physical exam, blood test, x rays and their compliance to treatment is evaluated. Results. Mean patients age was 65 y.o (+ 13). Two hundred seventeen patients were approached and 153 patients were enrolled (23 men and 130 women). Eleven patients refused to be part of the systematic follow up because they were satisfied with their family doctors osteoporosis management. Fifty-three were explained treatment and follow up and refused to participate. Thirteen patients (9%) dropped out after six months. One patient died. Twenty-one patients (13.7%) were already on bisphosphonates and 53 pts (34.6 %) had already sustained a fragility fracture. All patients were prescribed risedronate except three that were prescribed zoledronic acid or pamidronate for intolerance or contraindication to oral bisphosphonates. Up to now, we obtained 71% adherence and 91% persistence. After validation, 10% of the patients needed to be referred to a rheumatologist and 90% of the patients were managed by the clinical nurse specialist. Conclusion. Our multidisciplinary systematic follow up of osteoporotic fracture improved the osteoporosis treatment rate from 12 to 71 % in our orthopaedic surgery department. Clinical Nurse Specialists could represent the best approach to manage the underlying osteoporosis that leads to fragility fractures

Resurfacing total hip replacement using metal on metal bearings is increasing in popularity, but the outcomes are currently unclear. We report a series of 23 hips in 20 patients who underwent resurfacing total hip replacement over a period of 4 years. The mean age at surgery was 47 years (21–61). There were 8 females and 12 male patients. The mean follow up was 27 months (range 6 to 50 months). Before performing this study, our impression was that most outcomes were good but that there appeared to be more variability in pain relief than anticipated after conventional total hip replacement. Most were performed for primary osteoarthritis; other diagnoses included AVN, DDH and multiple epiphyseal dysplasia. Outcomes were measured examining x rays, survival of the implant and the Oxford hip questionnaire. There were no early revisions, but we are aware of one loose acetabular cup (in a patient with DDH) which is asymptomatic but which will probably require revision. There were no femoral neck fractures. The median score using the Oxford hip questionnaire was 15 (mean 23.5; range 12 to 41). These outcomes compare favourably with those reported at 6 months follow up after conventional total hip replacement by the Oxford group (OHQ median score 22; mean 24.3 (12 to 51)). We conclude that resurfacing metal on metal hip replacement gives comparable results to total hip replacement at early follow up. The age of the Oxford groups patients was considerably older than ours (75 years), and a comparative trial of resurfacing versus conventional hip replacements will be required to determine which gives better short and long term results in young patients. There may be more variability in pain relief after resurfacing THR than after conventional THR, but this will require a larger study to determine with confidence

This prospective study evaluates the outcome of a new metal -on-metal total hip replacement in a younger group of patients. Fifty-five primary all-metal total hip replacements (THR) were evaluated prospectively at a follow-up of 2.8–5.5 years. Patients were selected according to age and activity levels. The mean age was 58 years (41–69). 33 males and 22 females were included in the study. Surgery was carried out for osteoarthritis in 52 patients and for non-union fractured femoral neck, ankylosing spondilitis and post slipped upper femoral epiphysis in the three remaining patients. A single surgeon (the senior author) through the posterior approach carried out the surgery. All patients received the porous coated titanium shell with a Morse taper cobalt chrome liner and double wedge tapered polished cobalt chrome stem and modular head. Blood metal ion analysis was performed on a cohort of 24 patients using High Resolution Inductively Coupled Plasma Mass Spectrometry, sampling taken preoperatively and then repeated post operatively at 6 months, 1 year and then annually. Clinical results have been excellent. X rays show Harris A cementation in all femurs, with no component migration or radiolucencies being identified on follow-up radiographs. No prosthesis to-date has required revision. One patient has died and one is lost to follow up. The following non-device related complications were reported in the group, 2 (4%) superficial wound infections, 1 (2%) dislocation, 1 (2%) thrombosis, 1 (2%) IT band defect and 2 (4%) impingement. The dislocation was treated with a closed reduction. The impingement has resolved by one year in both patients. The results of the pre and postoperative blood metal ion analysis demonstrate some elevated levels, these levels being similar to those previously reported in the literature. The hybrid all-metal THR may represent a valuable alternative in the younger, high demand patient

In currently used expansive laminoplasty (ELAP) for cervical spondylotic myelopathy (CSM), persistent axial pain, restriction of neck motion and loss of cervical l ordosis have been the significance postoperative problems. To prevent them, the author has developed skip laminectomy in which ordinary laminectomy at appropriate levels is combined with partial laminectomy of the cephalad half of laminae with preservation of the muscular attachments at adjacent levels. Since December 98, the author performed this procedure on 55 patients with CSM who required multilevel posterior decompressions. Twenty-one of these cases with follow-up period longer than 8 months, with an average of 12 months, were observed. In skip laminectomy, a consecutive four-level decompression between C3/4 and C6/7 as an example is accomplished by removing alternate laminae (C4 and C6), the cephalad half of the C5 and C7 lamina and the ligamentum flava at those four levels. The laminae to be removed were selected after analysis of the pre- and postoperative radiological findings. Intraoperative blood loss averaged 34 grams. The operation time averaged 128 minutes. The patients were allowed to sit up or walk on the first postoperative day without neck support of any kind. An average recovery rate according to the Japanese Orthopaedic Association score was 63%. None of these patients complained of residual axial pain. The postoperative ranges of neck motion on lateral X rays averaged 87% of the preoperative ranges. The spinal curvature index, according to Ishihara’s method, was reduced in only one of the 21 cases. Postoperative atrophy of the deep extensor muscles measured on T2 weighed axial MRI was minimal. Skip laminectomy is less damaging to the posterior extensor muscles and its use reduces the postoperative problems commonly seen after ELAP

Introduction: Location on iliac bone account for 20% to 30% of sarcomas. Gold standard of local treatment is wide resection but till now few papers tried to evaluate the long term results of reconstructive procedures when chemotherapy and/or radiotherapy are used. Patients: 44 patients (25 males and 19 females aged 9 to 66 years) with bone sarcoma of innominate bone in Zone 1, 2 or 4 (without involvement of acetabulum) were treated and/or followed up by the same team in 23 years. Histology was: chondrosarcoma (28), Ewing (13), osteosarcoma (2), MH (1). Preoperative screening of patients included standard X rays, CT and bone technetium scan in all cases and MRI in 15 cases. Diagnosis was made by open biopsy except for 4 cases of chondrosarcoma for these preoperative screening was sufficient (and diagnosis confirmed by postoperative histological examination). Following limb salvage using reconstruction of pelvis was performed with methyl metacrylate without prosthesis Titanium screws were inserted in remaining bone before moulding of acrylic cement (2 to 3 packs of antibiotic loaded cement). Results: With a median follow-up of 15 years (minimal 2- maximal 22). 11 patients died from disease after local recurrence (6) and/or metastases (7). One disease free survivor has been lost for follow after 3 years,1 patient is alive with disease. The 31 others are disease free survivors. Prognostic value: in our patients the prognosis was directly correlated with the histological grading (low grade chondrosarcoma have a 85% DFS) and for high grade tumours with the efficacy of the chemotherapy protocol. For primary metastatic patients, when chemotherapy is suboptimal or margins contaminated, the prognosis is dismal. With our most effective protocols and free margins, metastatic lesions did not affect the disease free survival of our patients. Orthopaedic results: weight bearing was immediate in all cases. We observed 3 deep infections (2 compelled to make resection of the cement) and 2 late mobilisations of cement. In all other patients, the reconstructive procedure gave a good and stable functional result even in very long follow up. Conclusion: Acrylic reconstruction is an easy and reliable reconstructive procedure after en bloc resection of iliac bone for malignant tumours in zone 1, 2 or 4. It is more reliable than bone graft when chemotherapy or radiotherapy are necessary