Aims

To identify unanswered questions about the prevention, diagnosis, treatment, and rehabilitation and delivery of care of first-time soft-tissue knee injuries (ligament injuries, patella dislocations, meniscal injuries, and articular cartilage) in children (aged 12 years and older) and adults.

Data was collected for patients referred to the orthopaedic department at Forth Valley Royal Hospital with metatarsalgia who subsequently received an ultrasound. Patients found to have a Morton's neuroma were divided into groups based on its size.

A total of 90 patients received an ultrasound scan and neuroma was confirmed in 58 with an alternative diagnosis found in 32 patients and a total of 42 were included in the final analysis.

All 14 patients with neuroma < 6mm reported resolution of symptoms. 4 (28.5%) underwent surgical excision as first line, 1 (7%) received a single corticosteroid injection and 9 (64%) were treated with metatarsal bars.

There were 27 patients with neuroma > 6mm; 8 (29.6%) underwent surgical excision as first line treatment, 5 (18.5%) received metatarsal bars and 14 (51.9%) received injections. 7 (25.9%) patients reported resolution of symptoms after 1 injection, 1 (3.7%) patient required 2 injections and 1 (3.7%) patient required 3 injections to achieve resolution. 5 (18.5%) patients required surgical excision following ongoing symptoms despite non-surgical treatment. 9 (33.3%) reported resolution of symptoms following injection. 5 (18.5%) reported resolution of symptoms following use of metatarsal bars.

A total of 71% of patients with a neuroma measuring < 6mm reported full resolution of symptoms with non-surgical treatment. For patients with neuroma >6mm, 64.3% had resolution of symptoms with injections alone and 18.5% required surgical excision despite injection.

In conclusion, there is a benefit to offering non-surgical treatment as first line in patients with a neuroma regardless of size.

Introduction

The knee is the most commonly injured joint in sporting accidents, leading to substantial disability, time off work and morbidity (1). Treatment and assessment vary around the UK (2), whilst there remains a limited number of high-quality randomised controlled trials assessing first time, acute soft tissue knee injuries (3,4). As the clinical and financial burden rises (5), vital answers are required to improve prevention, diagnosis, treatment, rehabilitation, and delivery of care. In association with the James Lind Alliance, this BASK, BOSTAA and BOA supported prioritising exercise was undertaken over a year.

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Delirium is associated with adverse outcomes following hip fracture, but the prevalence and significance of delirium for the prognosis and ongoing rehabilitation needs of patients admitted from home is less well studied. Here, we analyzed relationships between delirium in patients admitted from home with 1) mortality; 2) total length of hospital stay; 3) need for post-acute inpatient rehabilitation; and 4) hospital readmission within 180 days.

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Introduction and Objective

Objectives: To determine the effectiveness of LIA compared to ACB in providing pain relief and reducing opiates usage in hamstring graft ACL reconstructions.

We performed a systematic review to compare outcomes of cemented versus uncemented trapezio-metacarpal joint (TMCJ) replacement for treatment of base-of-thumb arthritis.

We assessed improvements in pain and function, range of movement (ROM), strength, complications and need for revision surgery. A thorough literature search was performed. A total of 481 studies were identified from the literature search (179 Medline, 253 Embase, 27 CINAHL, 22 Cochrane). Of 43 relevant titles 28 were selected for full-text review after assessment of the abstracts. Duplicate studies were removed. 18 studies met inclusion criteria on full-text review. All studies were of level IV evidence. There were no randomised controlled trials or meta-analyses. The studies were critically appraised using a validated scoring system.

Most studies reported good outcomes for pain and strength, and functional outcome was comparable for both groups. ROM was generally improved for both prosthetic types, however statistical calculation was lacking in many studies. Trapezial component loosening was the main problem for both cemented and uncemented prostheses, however radiological loosening did not necessarily correlate with implant failure.

This systematic review has found that both cemented and uncemented replacements generally give good outcomes for the treatment of TMCJ arthritis, however young, male, patients with manual occupations and with disease in the dominant hand and patients with poor trapezial bone stock appear to be at higher risk for implant failure due to cup loosening. We recommend the construction of a joint registry to record implantation and revision rates.

Treatments of Chronic Acromioclavicular joint dislocation are controversial. Many procedures have been described in the past for the management of them. Treatment modalities have changed with increasing understanding of the nature of the problem, patient expectations and the biomechanics of the joint

Treatments of Chronic Acromioclavicular joint dislocation are controversial. Many procedures have been described in the past for the management of them. Treatment modalities have changed with increasing understanding of the nature of the problem, patient expectations and the biomechanics of the joint

To assess the functional outcome of the chronic AC joint dislocations treated by modified Weaver-Dunn procedure combined with Acromioclavicular joint augmentation.

We treated 54 patients with chronic AC joint dislocation by modified Weaver-Dunn procedure with additional AC joint augmentation. We used tight rope system in 20 patients, Mersilene tape in 22 patients and no 5 Ethibond in 12 patients.

This Study was done between Jan 2003 to Jan2012. Mean follow up was 20 months, mean age of the patients was 35, and male to female distribution was 48:6. We assessed them clinically and radio logically during their follow up. All patients were back to their occupation. 80% are back to their pre injury sporting activity level. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 10.2 points. One patient had a failure of augmentation device.

Our study shows that chronic symptomatic AC joint dislocations, (Rockwood types III to V,) Managed with modified modified Weaver-Dunn procedure with augmentation are showing good short term results. Significant improvement in the patient satisfaction, early return to work and radiological appearance

Background

Both-bone diaphyseal forearm fractures constitute up to 5.4% of all fractures in children under 16 years of age in the United Kingdom. Most can be managed with closed reduction and cast immobilisation. Surgical fixation options include flexible intramedullary nailing and plating. However, the optimal method is controversial.

Introduction

Indications for the use of external fixation include damage control orthopaedics, definitive fracture treatment, deformity correction and leg lengthening. Despite many advances in the development of external fixation techniques, pin-tract infection and loosening are still significant complications. They are the most commonly occurring complications during limb lengthening using external fixation, with some studies reporting an incidence of up to 80%.

Purpose

We conducted a prospective study to investigate the role of the LARS ligament system to reconstruct the posterior cruciate ligament and the postero-lateral corner of the knee.

We present a prospective single surgeon case series to evaluate early clinical and functional outcomes of postero-lateral corner and posterior cruciate ligament reconstruction in the knee using the LARS (ligament Augmentation and Reconstruction System) artificial ligament. 23 patients with multi-ligament knee injuries or isolated PCL injuries were treated with a mean follow up of 8 months (range: 2-37 months). Outcomes were assessed using the modified International Knee Documentation Committee score, and a modified Tegner- Lysholm score. 2 patients had acute reconstructive surgery within 7 days of injury, 5 patients within 3 months (semi-acute) and 16 were chronic cases that were operated on after three months from the date of injury.

The LARS ligament reconstruction achieved a significant improvement between preoperative and postoperative assessment in relation to knee stability, function and patient satisfaction. The sooner the patients were treated the greater the improvements in functional scores were noted. Most patients achieved a full functional range of movement within six months. We had 2 complications, one superficial wound infection and one stiff knee requiring a manipulation. To date we have had no LARS ligament failures.

In the short term the LARS functions well, with high clinical patient satisfaction, no signs of progressive laxity, synovitis or failure. We found no significant difference in functional score post reconstruction between the isolated PCL reconstructions and the multi ligament reconstructions. Our results show no early signs of the problems associated with synthetic grafts used in the past. Such grafts appear to be an attractive alternative to the use of autografts and allografts.

Peripheral nerve injuries (PNI) occur in 10% of combat casualties. In the immediate field-hospital setting, an insensate limb can affect the surgeon's assessment of limb viability and in the long-term PNI remain a source of considerable morbidity. Therefore the aims of this study are to document the recovery of combat PNI, as well as report on the effect of current medical management in improving functional outcome. In this study, we present the largest series of combat related PNI in Coalition troops since World War II.

From May 2007 – May 2010, 100 consecutive patients (261 nerve injuries) were prospectively reviewed in a specialist PNI clinic. The functional recovery of each PNI was determined using the MRC grading classification (good, fair and poor). In addition, the incidence of neuropathic pain, the results of nerve grafting procedures, the return of plantar sensation, and the patients' current military occupational grading was recorded.

At mean follow up 26.7 months, 175(65%) of nerve injuries had a good recovery, 57(21%) had a fair recovery and 39(14%) had a poor functional recovery. Neuropathic pain was noted in 33 patients, with Causalgia present in 5 cases. In 27(83%) patients, pain was resolved by medication, neurolysis or nerve grafting. In 35 cases, nerve repair was attempted at median 6 days from injury. Of these 62%(22) gained a good or fair recovery with 37%(13) having a poor functional result. Forty-two patients (47 limbs) initially presented with an insensate foot. At final follow up (mean 25.4 months), 89%(42 limbs) had a return of protective plantar sensation. Overall, 9 patients were able to return to full military duty (P2), with 45 deemed unfit for military service (P0 or P8).

This study demonstrates that the majority of combat PNI will show some functional recovery. Adherence to the principles of war surgery to ensure that the wound is clear of infection and associated vascular and skeletal injuries are promptly treated will provide the optimal environment for nerve recovery. Although neuropathic pain affects a significant proportion of casualties, pharmacological and surgical intervention can alleviate the majority of symptoms. Finally, the presence of an insensate limb at initial surgery, should not be used as a marker of limb viability. The key to recovery of the PNI patient lies in a multi-disciplinary approach. Essential to this is regular surgical review to assess progress and to initiate prompt surgical intervention when needed. This approach allows early determination of prognosis, which is of huge value to the rehabilitating patient psychologically, and to the whole rehabilitation team.

The outcomes of 261 nerve injuries in 100 patients were graded good in 173 cases (66%), fair in 70 (26.8%) and poor in 18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)). The initial grades for the 42 sutures and graft were 11 good, 14 fair and 17 poor. After subsequent revision repairs in seven, neurolyses in 11 and free vascularised fasciocutaneous flaps in 11, the final grades were 15 good, 18 fair and nine poor. Pain was relieved in 30 of 36 patients by nerve repair, revision of repair or neurolysis, and flaps when indicated. The difference in outcome between penetrating missile wounds and those caused by explosions was not statistically significant; in the latter group the onset of recovery from focal conduction block was delayed (mean 4.7 months (2.5 to 10.2) vs 3.8 months (0.6 to 6); p = 0.0001). A total of 42 patients (47 lower limbs) presented with an insensate foot. By final review (mean 27.4 months (20 to 36)) plantar sensation was good in 26 limbs (55%), fair in 16 (34%) and poor in five (11%). Nine patients returned to full military duties, 18 to restricted duties, 30 to sedentary work, and 43 were discharged from military service. Effective rehabilitation must be early, integrated and vigorous. The responsible surgeons must be firmly embedded in the process, at times exerting leadership.

We describe 261 peripheral nerve injuries sustained in war by 100 consecutive service men and women injured in Iraq and Afghanistan. Their mean age was 26.5 years (18.1 to 42.6), the median interval between injury and first review was 4.2 months (mean 8.4 months (0.36 to 48.49)) and median follow-up was 28.4 months (mean 20.5 months (1.3 to 64.2)). The nerve lesions were predominantly focal prolonged conduction block/neurapraxia in 116 (45%), axonotmesis in 92 (35%) and neurotmesis in 53 (20%) and were evenly distributed between the upper and the lower limbs. Explosions accounted for 164 (63%): 213 (82%) nerve injuries were associated with open wounds. Two or more main nerves were injured in 70 patients. The ulnar, common peroneal and tibial nerves were most commonly injured. In 69 patients there was a vascular injury, fracture, or both at the level of the nerve lesion. Major tissue loss was present in 50 patients: amputation of at least one limb was needed in 18. A total of 36 patients continued in severe neuropathic pain.

This paper outlines the methods used in the assessment of these injuries and provides information about the depth and distribution of the nerve lesions, their associated injuries and neuropathic pain syndromes.

The aim of this study was to evaluate the effect of a single per operative injection of sodium hyaluronate (HA, Viscoseal^_¯) into the knee following arthroscopy.

This was a prospective, randomised controlled study. Knee arthroscopy patients were randomised into two groups: one receiving bupivicaine and the other sodium hyaluronate. Pre and post operative VAS scores for pain and Western Ontario and MacMaster Universities (WOMAC) scores for knee function were obtained. Forty eight patients of a single surgeon were randomised into two groups of 24. Both groups were similar as regards to age, sex, etc. Three patients withdrew from the study after randomisation. There was significant drop in pain scores for the Viscoseal¯ group compared to Bupivicaine group particularly between three-six weeks period (p< 0.05) and a significant improvement in WOMAC scores in the study group compared to control at 3 and 6 weeks (p=0.01). Viscosupplementation after arthroscopic knee surgery offers significantly improved function and pain relief over the medium term period (three-six weeks).

The aim of this study was to determine current practice in anterior cruciate ligament reconstruction amongst BASK members. This was an internet-based survey where members were invited to complete a questionnaire on ACL reconstruction.

Of the 365 BASK surgeons performing ACL reconstruction, 241 completed the questionnaire (response rate 66%). 147(61%) of surgeons used both hamstring and patellar tendon grafts, 71(29%) used only hamstrings and 21(9%) used patellar tendon only. All surgeons used ipsilateral autograft.

157 (65%) used the transtibial technique for femoral tunnel placement with 80(33%) using the anteromedial portal technique. Of those using the anteromedial portal, the most common femoral fixation devices were the Endobutton (34%) and RCI screw (34%). Interference screw fixation (81%) was the most common tibial fixation in the same group of surgeons with the RCI screw being the most common (63%). 19% (45/241) of surgeons were performing double bundle ACL reconstructions in select cases.

Hamstring femoral fixation was with a suspension device in 79% and interference screw in 18%. Of those using a suspension device the Endobutton was most common (48%) followed by Transfix (26%) and Rigidfix (19%). Tibial fixation was most commonly achieved by interference screw (57%) followed by Intrafix (30%).

With patellar tendon graft the most popular femoral fixation was with an interference screw (66%) followed by suspension (34%). All surgeons used interference screw for tibial fixation.

90% of surgeons (217) allow immediate full weight-bearing as tolerated irrespective of fixation type with 8% delaying full weight bearing between 1 and 3 weeks. The results show the wide spread of variation in practice of ACL reconstruction. With recent renewed interest in a more anatomic placement of tunnels, the use of the anteromedial portal may continue to increase. With such a wide variation in techniques, grafts and fixation implants used, a register may help assess outcomes.

Introduction: There is an ever-increasing clinical need for the regeneration and replacement of tissue to replace soft tissue lost due to trauma, disease and cosmetic surgery. A potential alternative to the current treatment modalities is the use of tissue engineering applications using mesenchymal stem cells that have been identified in many tissues including the fat pad. In this study, stem cells isolated from the fat pad were characterised and their differentiation potential assessed.

Materials and Methods: The infrapatellar fat pad was obtained from total knee replacement for osteoarthritis. Cells were isolated, expanded and stained for a number of stem cell markers. For adipogenic differentiation, cells were cultured in adipogenic inducing medium (10ug/ml insulin, 1uM dexamthasone, 100uM indomethacin and 500uM 3-isobutyl-1-methyl xanthine). Gene expression analyses and Oil red O staining was performed to assess adipogenesis.

Results: Cells at passage 2 stained strongly for CD13, CD29, CD44, CD90 and CD105 (mesenchymal stem cell markers). The cells stained sparsely for 3G5 (peri-cyte marker). On gene expression analyses, the cells cultured under adipogenic conditions had almost a 1,000 fold increase in expression of peroxisome proliferator-activated receptor gamma-2 (PPAR gamma-2) and 1,000,000 fold increase in expression of lipoprotein lipase (LPL). Oil red O staining revealed triglyceride accumulation within typical adipogenic morphology, confirming the adipogenic nature of the observed vacuoles, and showed failure of staining in control cells.

Discussion: Fat pad derived stem cells expressed a cell surface epitope profile of mesenchymal stem cells, and exhibited the potential to undergo adipogenic differentiation. Our results show that the human fat pad is a viable potential autogeneic source for mesenchymal stem cells capable of adipogenic differentiation as well as previously documented ostegenic and chondrogenic differentiation. This cell source has potential use in tissue engineering applications.

Introduction: Preoperative planning plays an important role in any surgical procedure and total hip replacement (THR) is no exception. Templating of radiographs allows preoperative assessment of the correct size of implant to be used, lowers the risk of periprosthetic fracture, helps restore femoral offset and leg length, facilitates the optimisation of alignment and ensures the correct implants sizes are available.

With the wide scale use of Picture Archiving and Communication Systems (PACS) in the National Health Service (NHS), the potential exists for faster and more accurate templating of THRs.

Aim: In performing this study, we assessed whether there is adequate provision of the current NHS PACS to allow optimal digital templating for THRs. We also made comparison between the availability and overall ease of conventional versus digital templating.

Methods: Data was collected using a telephone questionnaire requesting information from the on-call orthopaedic Specialist Registrar (SpR) in 28 Greater London and surrounding area NHS Hospitals. Data on the availability of PACS and the ability to template using hard-copy or digital templating was collected and analysed.

Results: PACS were used in all 28 (100%) hospitals that were contacted. None performed conventional templating regularly and only 8 (28.6%) admitted to occasional templating. The predominant reason for this was difficulty in obtaining hard copies of x-rays in 12 (42.9%) hospitals, as well as lack of availability acetate templates, with 13 (46.4%) claiming that this was the case.

Digital templating software was available in 14 (50%) hospitals. Despite this, none of them performed digital templating regularly. In the 50% that did have digital templating, this was not routinely done for the following reasons:

only 3 (10.7%) allowed easy access to the software to the SpRs

Discussion: Digital PACS systems have made great improvement in the access of radiographs in the NHS. With regards to orthopaedic practice, however, we have shown that the benefit of digital templating is being overlooked within the NHS.

A 60-year-old man developed severe neuropathic pain and foot-drop in his left leg following resurfacing arthroplasty of the left hip. The pain was refractory to all analgesics for 16 months. At exploration, a PDS suture was found passing through the sciatic nerve at several points over 6 cm and terminating in a large knot. After release of the suture and neurolysis there was dramatic and rapid improvement of the neuropathic pain and of motor function.

This case represents the human equivalent of previously described nerve ligation in an animal model of neuropathic pain. It emphasises that when neuropathic pain is present after an operation, the nerve related to the symptoms must be inspected, and that removal of a suture or irritant may lead to relief of pain, even after many months.

We aim to create a set of reference data of commonly used scoring systems in the normal population, and to compare these results with published postoperative scores for commonly performed knee operations. This was a questionnaire-based study and a total of 744 questionnaires were sent out, of which 494 replies were received. Six scoring systems were addressed: Lysholm and Oxford Knee Scores, Tegner and UCLA activity scales and Visual Analogue Scales (VAS) for both pain and function. Data was collected into groups based on age (20–29, 30–39, 40–49, 50–59, 60–69, 70–79, 80–89 years). The reference data obtained was then compared to published postoperative scores for knee arthroplasty and ACL reconstruction, to assess whether these patients did indeed return to “normal”.

The mean scores for sequential age groups (described above) were as follows: Oxford Knee Score – 13, 13, 14, 14, 17, 15, 17; Lysholm Knee Score – 96, 95, 92, 89, 89, 89, 79; Tegener Activity Scale – 6, 5, 5, 4, 4, 3, 3; UCLA Activity Scale – 8, 7, 7, 7, 6, 6, 5; VAS pain – 5, 8, 10, 9, 14, 12, 20; VAS function 96, 95, 90, 90, 86, 84, 84. Symptom based scoring systems (Oxford Knee Score, Lysholm) were independent of age whereas activity scores (Tegner, UCLA) decreased with age. There was no significant difference detected between scores in different sexes in the same age group. Compared to published scores in an age-matched population following TKR, the data obtained showed that patients do not return to normal scores following arthroplasty. Following ACL reconstructive surgery, activity scores were higher than compared to the data obtained from our population.

Data generated from this study can be used as reference data and can play an important role in interpreting post-intervention scores following knee surgery.

Paradoxical cerebral embolism is seen in 50–60% of patients following hip and knee arthroplasty surgery. It is responsible for post-operative symptoms like confusion and cerebral ischemic episodes. Embolism is less common with the use of uncemented implants. No study has looked into incidence of cerebral emboli in hip resurfacing.

We undertook a prospective randomised study to look at the incidence of cranial emboli in hip resurfacing. Patients were randomized to receive either uncemented or cemented femoral component. An arm of the study included evaluation of the effects of femoral venting by randomising patients to ‘venting’ or ‘no venting’ of proximal femur intra-operatively. The operations were performed by a single surgeon using a uniform surgical technique. Transcranial Doppler device was used to quantify the occurrence and distribution of cerebral microemboli. Emboli counts were recorded continuously and were correlated any major procedural event.

Eight patients (5 vented, 3 unvented) underwent cemented resurfacing and 7 patients (4 vented, 3 unvented) had cementless resurfacing. There was no difference between the two groups for age, gender, weight, or ASA status. Peri-operatively both groups were similar for vital observations (heart rate, temperature, blood pressure), haemoglobin change, mini – mental score at day 1 and 2, and oxygen saturation at day 1 and 3.

The mean number of significant emboli in the cemented group was 8.1 and in the cementless group was 1.7 (significant, p=0.009). Venting did not influence rate of emboli however, venting was independently associated with significantly higher drainage (mean 604mls compared to 335mls without venting, p=0.018). There was no significant difference in post-operative haemoglobin or number of units transfused.

Cranial emboli occur commonly after hip resurfacing. Their incidence is significantly reduced by the use of uncemented femoral component, however venting of proximal femur doesnot appear to make any difference.

Purpose of the study: What is the effect on the length of a procedure and the number of procedures performed on the list when a trainee is involved? What percentage of cases had trainee involvement for orthopaedic surgery?

Methods: Data was taken from two different sources, firstly, the ORMIS theatre system and patient operation notes. These were used to determine the length of six different types of orthopaedic procedures and the level of the main surgeon. The second source used was a consultant’s logbook comprising 227 primary total knee replacements between 2004 and 2008.

Results: The data collected via the ORMIS system produced trends suggesting trainees took longer to perform procedures than consultants. The data from the consultant logbook statistically proved this. List times appeared unaffected by trainee presence. In Orthopaedic surgeries, 92% times trainees were present during the procedure and out of this 17% cases were performed by trainees. For total knee replacements done by trainees the procedure took significantly longer surgical time than consultant performed procedures (p = 0.0337).

Among these cases, 71% were performed by senior trainees. The consultant’s log book data also suggested the similar trends. Statistically, trainee performed with consultant scrubbed versus consultant performed (P = < 0.0001), trainee performed with consultant in theatre versus consultant performed(P = 0.0318) and trainee performed with consultant scrubbed versus trainee performed with consultant in theatre (P = 0.002)

Discussion & Conclusion: To train the surgeon adds to the length of procedures and this is currently not accounted for, in the finance received to perform the operation by the hospital.

To counter this, training hospitals should be given financial incentives to train in surgery, or procedures performed by trainees should be priced differently to account for the time lost by training.

Purpose: Our aim of this study was to find out the abstract to publication ratio (APR) in peer-reviewed indexed journals of abstracts presented at BASK annual meetings. We also wanted to identify the publishing journals and to look at the amount of time taken for publication.

Methods: We obtained permission from BASK executive committee and retrieved all presentations (podium & poster) over six year period (2000–2005). An extensive PubMed database search was performed to determine whether or not the abstract had been published as a full paper up to the beginning of Nov 2008.

Results: A total of 294 abstracts identified, 114 of them were published as 101 full-text articles in 21 different journals. ‘The Knee’ Journal was the most popular destination with 47 publications (41.2%) followed by JBJS (British) with 28 publications (24.5%). The overall abstract to publication ratio (APR) at BASK annual meetings was 38.77%. The mean duration between presentations to publication was 3.96 yrs (range 0 to 7.2 yrs, median 3.4 yrs).

Conclusion: On bench marking the APR ratio at BASK presentations, it is comparable with those of BOA (33.1%), other BOA affiliated societies (26–50%) and medical specialties (32–66%). Abstract to publication ratio (APR) is considered as a measure of the quality of scientific meetings and our results indicates the higher credentials of BASK meetings. It is very difficult to exactly determine the reason for abstracts failing to indexed publications; it is arguable that some of these projects did not meet the scientific scrutiny of the peer-review process required for full publication. We recommend authors to submit the full manuscript of paper after acceptance of their abstracts for the BASK meeting as done in AAOS meeting in order to encourage them to complete their manuscript before presentation.

Delayed rather than early reconstruction of the anterior cruciate ligament is the current recommended treatment for injury to this ligament since it is thought to give a better functional outcome. We randomised 105 consecutive patients with injury associated with chondral lesions no more severe than grades 1 and 2 and/or meniscal tears which only required trimming, to early (< two weeks) or delayed (> four to six weeks) reconstruction of the anterior cruciate ligament using a quadrupled hamstring graft. All operations were performed by a single surgeon and a standard rehabilitation regime was followed in both groups. The outcomes were assessed using the Lysholm score, the Tegner score and measurement of the range of movement. Stability was assessed by clinical tests and measurements taken with the KT-1000 arthrometer, with all testing performed by a blinded uninvolved experienced observer. A total of six patients were lost to follow-up, with 48 patients assigned to the delayed group and 51 to the early group. None was a competitive athlete. The mean interval between injury and the surgery was seven days (2 to 14) in the early group and 32 days (29 to 42) in the delayed group. The mean follow-up was 32 months (26 to 36).

The results did not show a statistically significant difference for the Lysholm score (p = 0.86), Tegner activity score (p = 0.913) or the range of movement (p = 1). Similarly, no distinction could be made for stability testing by clinical examination (p = 0.56) and measurements with the KT-1000 arthrometer (p = 0.93).

Reconstruction of the anterior cruciate ligament gave a similar clinical and functional outcome whether performed early (< two weeks) or late at four to six weeks after injury.

There is an ever-increasing clinical need for the regeneration and replacement of tissue to replace soft tissue lost due to trauma, disease and cosmetic surgery. A potential alternative to the current treatment modalities is the use of tissue engineering applications using mesenchymal stem cells that have been identified in many tissue including the infrapatellar fat pad. In this study, stem cells isolated from the infrapatellar fat pad were characterised to ascertain their origin, and allowed to undergo adipogenic differentiation to confirm multilineage differentiation potential.

The infrapatellar fat pad was obtained from total knee replacement for osteoarthritis. Cells were isolated and expanded in monolayer culture. Cells at passage 2 stained strongly for CD13, CD29, CD44, CD90 and CD105 (mesenchymal stem cell markers). The cells stained poorly for LNGFR and STRO1 (markers for freshly isolated bone marrow derived stem cells), and sparsely for 3G5 (pericyte marker). Staining for CD34 (haematopoetic marker) and CD56 (neural and myogenic lineage marker) was negative. {BR}For adipogenic differentiation, cells were cultured in adipogenic inducing medium consisting of basic medium with 10ug/ml insulin, 1uM dexamthasone, 100uM indomethacin and 500uM 3-isobutyl-1-methyl xanthine. By day 16, many cells had lipid vacuoles occupying most of the cytoplasm. On gene expression analyses, the cells cultured under adipogenic conditions had almost a 1,000 fold increase in expression of peroxisome proliferator-activated receptor gamma-2 (PPAR gamma-2) and 1,000,000 fold increase in expression of lipoprotein lipase (LPL). Oil red O staining confirmed the adipogenic nature of the observed vacuoles and showed failure of staining in control cells.

Our results show that the human infrapatellar fat pad is a viable potential autogeneic source for mesenchymal stem cells capable of adipogenic differentiation as well as previously documented ostegenic and chondrogenic differentiation. This cell source has potential use in tissue engineering applications.

AIM: To create a set of reference data of commonly used scoring systems in the normal population, and to compare these results with published postoperative scores for commonly performed knee operations.

METHODS: This was a questionnaire-based study and a total of 657 questionnaires were sent out, of which 407 replies were received. A further 159 were excluded due to ongoing knee problems or previous knee surgery. Six scoring systems were addressed: Lysholm and Oxford Knee Scores, Tegner and UCLA activity scales and Visual Analogue Scales (VAS) for both pain and function. Data was collected into groups based on age (20–29, 30–39, 40–49, 50–59, 60–69, 70–79, 80–89 years). The reference data obtained was then compared to published postoperative scores for knee arthroplasty and ACL reconstruction, to assess whether these patients did indeed return to “normal”.

RESULTS: The mean scores for sequential age groups (described above) were as follows: Oxford Knee Score – 13, 14, 14, 14, 17, 15, 19; Lysholm Knee Score – 95, 92, 92, 90, 88, 90, 79; Tegener Activity Scale – 5, 5, 5, 4, 4, 3, 3; UCLA Activity Scale – 9, 7, 7, 7, 6, 6, 5; VAS pain – 2, 9, 9, 9, 14, 12, 20; VAS function 97, 94, 92, 90, 86, 86, 83. Symptom based scoring systems (Oxford Knee Score, Lysholm) were independent of age. Activity scores (Tegner, UCLA) showed a statistically significant decrease with age. There was no significant difference detected between scores in different sexes in the same age group. Compared to published scores in an age-matched population following TKR, the data obtained showed that patients do not return to normal scores following arthroplasty. Following ACL reconstructive surgery, activity scores were higher than compared to the data obtained from our population.

CONCLUSIONS: Data generated from this study can be used as reference data and can play an important role in interpreting post-intervention scores following knee surgery.

There is an ever-increasing clinical need for the regeneration and replacement of tissue to replace soft tissue lost due to trauma, disease and cosmetic surgery. A potential alternative to the current treatment modalities is the use of tissue engineering applications using mesenchymal stem cells that have been identified in many tissue including the infrapatellar fat pad. In this study, stem cells isolated from the infrapatellar fat pad were characterised to ascertain their origin, and allowed to undergo adipogenic differentiation to confirm multilineage differentiation potential.

The infrapatellar fat pad was obtained from total knee replacement for osteoarthritis. Cells were isolated and expanded in monolayer culture. Cells at passage 2 stained strongly for CD13, CD29, CD44, CD90 and CD105 (mesenchymal stem cell markers). The cells stained poorly for LNGFR and STRO1 (markers for freshly isolated bone marrow derived stem cells), and sparsely for 3G5 (pericyte marker). Staining for CD34 (haematopoetic marker) and CD56 (neural and myogenic lineage marker) was negative.

For adipogenic differentiation, cells were cultured in adipogenic inducing medium consisting of basic medium with 10ug/ml insulin, 1uM dexamthasone, 100uM indomethacin and 500uM 3-isobutyl-1-methyl xanthine. By day 16, many cells had lipid vacuoles occupying most of the cytoplasm. On gene expression analyses, the cells cultured under adipogenic conditions had almost a 1,000 fold increase in expression of peroxisome proliferator-activated receptor gamma-2 (PPAR gamma-2) and 1,000,000 fold increase in expression of lipoprotein lipase (LPL). Oil red O staining confirmed the adipogenic nature of the observed vacuoles and showed failure of staining in control cells.

Our results show that the human infrapatellar fat pad is a viable potential autogeneic source for mesenchymal stem cells capable of adipogenic differentiation as well as previously documented ostegenic and chondrogenic differentiation. This cell source has potential use in tissue engineering applications.

Injuries to the spinal cord are rarely isolated problems. Multiple trauma patients with spinal injuries can face significant long-term disability. In this retrospective, descriptive study we investigated the relationship between the level of spinal trauma and the injuries associated with this. We aimed to define the populations at risk and highlight trends identified.

METHODS: Analysis of 1500 trauma patients admitted to the Royal London Hospital by the Helicopter Emergency Medical Service (HEMS) over 6 years was undertaken. 265 patients of these patients had spinal cord injuries (SCI). Data was obtained from the HEMS trauma registry, patient records and interviews with patients.

RESULTS: 265 patients sustained SCI (mean age: 38 25% female). The most common mechanisms of injury were motor vehicle accidents (46%) and falls (29%) Attempted suicide was a common cause of SCI in our study group (mean age 32. M:F ratio 2:1) The most common associated injuries were limb and head trauma. C-spine injuries were the most common spinal injury and were associated with the highest mortality rates (37%). C-injuries presented with a bimodal age distribution, 84% had head trauma and 30% had significant chest injuries. In patients who sustained thoracic spinal injuries 71% had severe chest injuries and 34% had head injuries. The most common associated injury in lumbar spine trauma was injuries to the limbs or pelvis (68%). Injuries to the lumbar spine occurred more frequently in the 20–40 year old age groups.

Discussion: Mortality rate in our study was 26%. Mortality rates were highest in patients with cervical spine injuries (37%). The causes of mortality were from suicide attempts, falls and RTA. The mortality rates in these groups were 20%, 22% and 32% respectfully. Our review highlights significantly higher mortality in the over 60-age group. Our population had high numbers of suicide attempts. We highlight suicide attempts as a significant aetiology for SCI. All the deaths in the suicide group were as a result of jumping from high buildings. In patients over 60, c-spine injuries are by far the common level of SCI. Subdural haematomas occurred in almost 10% of patients with c- spine injuries. Any injury to the cervical spine should therefore prompt investigation for intracranial trauma. The GCS should be closely monitored and a low threshold for performing a CT scan is advisable. Thoracic spine injuries are strongly associated with severe chest injuries. Lumbar spine and sacral injuries are strongly associated with severe pelvic and lower limb injuries. Understanding the demographics and etiology is essential to allow effective planning for spinal services. Appreciating the injuries associated with SCI should ensure better care for patients, by recognizing problems earlier and using a multidisciplinary approach to optimize treatment and reduce morbidity and mortality.

Background: The cause of intervertebral disc degeneration (IVDD) is multifactorial. One proposed mechanism is that IVDD originates in the nucleus pulposus (NP) and progresses radially to the annulus fibrosis (AF). Failure of current treatment modalities in preventing and treating IVDD and thereby low back pain have led to a growing interest in tissue-engineered solutions where a biological repair is induced. By preventing the abnormality at the NP it may be possible to halt further progression of IVDD. Injection of NP cells into an early degenerative IVD, where the AF is still intact, may retard the degenerative process and is presently under investigation. Using a 3-dimensional scaffold that could be successfully introduced into the NP cavity through minimally invasive techniques would prevent the loss of chondrocytic phenotype of the cells and be an improvement over the existing technique by which cells are directly injected into the NP cavity.

Methods:

CaSO4 and CaCO3 3% alginate hydrogels were injected into the NP cavity of a bovine tail. After 90 minutes the tail was dissected to reveal the gel.

Results:

Injectable alginate suspensions formed solid viscoelastic gels, filling the exact shape of the NP cavity.

Discussion: This study demonstrates that slowly polymerising CaCO3 and CaSO4 alginate gels are injectable and capable of sustaining NP cells in-vitro. Cells remain viable, maintain their phenotype, proliferate and produce ECM during the culture period. CaCO3 alginate gel provides a 3-dimensional matrix more favourable to NP cellular activity than the CaSO4 alginate gel. Synvisc® has a chondro-stimulatory effect on NP cells in-vitro. These effects are similar to those observed previously with hyaluronic acid, in that it binds to cell surface CD44 receptors, thereby affecting essential cellular functions and cytoskeleton structure. Synvisc® however has an advantage in that it is highly viscous and can reside longer within an alginate construct thereby having a sustained long-term stimulatory effect. This study demonstrates a successful tissue-engineered approach for replacing the NP and, subject to further studies, may be used for retarding mild-to-moderate IVDD, alleviating lower back pain and restoring a functional NP through a minimally invasive technique.

Scoliosis and hip subluxation/dislocation are common and often coexistent problems encountered in patients with cerebral palsy (CP). The underlying mechanism may be related to muscle imbalance. Surgical correction may become necessary in severe symptomatic cases. The effect of surgical correction of one deformity on the other is not well understood.

We retrospectively reviewed a series of 17 patients with total body cerebral palsy with diagnoses of both scoliosis and hip subluxation who had undergone either surgical correction of their scoliosis (9 patients) or a hip reconstruction to correct hip deformity (8 patients). In all patients, the degree of progression of both deformities was measured, radiographically, using the Cobb angle for the spine and the percentage migration index for hip centre of rotation at intervals before and at least 18 months post surgery.

All patients who underwent scoliosis correction had a progressive increase in the percentage of hip migration at a rate greater than that prior to scoliosis surgery. Similarly, patients who underwent a hip reconstruction procedure demonstrated a more rapid increase in their spine Cobb angles post surgery.

There may be a relationship between hip subluxation/dislocation and scoliosis in CP patients. Surgery for either scoliosis or hip dysplasia may in the presence of both conditions lead to a significant and rapid worsening of the other. The possible negative implications on the overall functional outcome of the surgical procedure warrants careful consideration to both hip and the spine before and after surgical correction of either deformity. In selected cases there may be an indication for one procedure to follow soon after the other.

Study Purpose: The cause of intervertebral disc degeneration (IVDD) is multifactorial. One proposed mechanism is that IVDD originates in the nucleus pulposus (NP) and progresses radially to the annulus fibrosis (AF). Failure of current treatment modalities in preventing and treating IVDD and thereby low back pain have led to a growing interest in tissue-engineered solutions where a biological repair is induced. By preventing the abnormality at the NP it may be possible to halt further progression of IVDD. Injection of NP cells into an early degenerative IVD, where the AF is still intact, may retard the degenerative process and is presently under investigation. Using a three-dimensional scaffold that could be successfully introduced into the NP cavity through minimally invasive techniques would prevent the loss of chondrocytic phenotype of the cells and be an improvement over the existing technique by which cells are directly injected into the NP cavity.

Methods: (1) CaSO4 and CaCO3 alginates were injected into the NP cavity of a bovine tail. After 90 minutes the tail was dissected to reveal the gel. (2) NP cells released from pooled bovine NP tissue were dispersed into the CaSO4 and CaCO3 alginate gels (10x106 cells.mL-1) with and without Synvisc® and cultured for 21 days.

Results: (1) Injectable alginate suspensions formed solid viscoelastic gels, filling the exact shape of the NP cavity. (2) NP DNA and ECM synthesis was significantly greater in the CaCO3 alginate gel than in the CaSO4 alginate gel (p< 0.05). (3) Synvisc® significantly increased sulphated GAG (p< 0.01) and collagen (p< 0.05) production. These effects were supported histologically and immunohistologically where cells in the CaCO3 and Synvisc® gels stained more intensely for proteoglycan and collagen type II.

Conclusions: Both CaCO3 alginate gel and CaSO4 alginate gel are injectable and are capable of sustaining NP cells in-vitro. Cells remain viable, maintain their phenotype, proliferate and produce ECM during the culture period. The CaCO3 alginate gel provides a three-dimensional matrix more favourable to NP cellular activity than the CaSO4 alginate gel. Synvisc® behaves as a chondro-stimulant significantly enhancing NP cell metabolic activity. This study demonstrates a successful tissue-engineered approach for replacing the NP and, subject to further studies, may be used for retarding mild-to-moderate IVDD, alleviating lower back pain and restoring a functional NP through a minimally invasive technique.

Bovine and human articular chondrocytes were seeded in 2% alginate constructs and cultured for up to 19 days in a rotating-wall-vessel (RWV) and under static conditions. Culture within the RWV enhanced DNA levels for bovine chondrocyte-seeded constructs when compared with static conditions but did not produce enhancement for human cells. There was a significant enhancement of glycosaminoglycans and hydroxyproline synthesis for both bovine and human chondrocytes. In all cases, histological analysis revealed enhanced Safranin-O staining in the peripheral regions of the constructs compared with the central region. There was an overall increase in staining intensity after culture within the RWV compared with static conditions. Type-II collagen was produced by both bovine and human chondrocytes in the peripheral and central regions of the constructs and the staining intensity was enhanced by culture within the RWV. A capsule of flattened cells containing type-I collagen developed around the constructs maintained under static conditions when seeded with either bovine or human chondrocytes, but not when cultured within the RWV bioreactor.

Aim: Rehospitalisation following surgery is widely regarded as an important outcome measure. In this study we identified causes of readmission following surgery, in proximal hip fracture patients.

Method: A total of 267 patients underwent surgery for proximal hip fractures in one year (2001–2002) at our institution. Notes of these patients were reviewed to look for readmissions within three months.

Results: A total of 43 (16.1%) patients died during initial hospital admission episode. Of the remaining 224 patients, 46 (20.5%) patients had an emergency unplanned readmission back to the hospital, within 3 months of discharge. 9 admissions (19.5% of readmissions, 4.01% of discharged patients) were due to operative site complications. 8 patients (17.3% of readmissions, 3.5% of discharged patients) were referred back for suspected thromboembolic events. 29 admissions (63.04% of readmissions, 12.9% of discharged patients) were due to other medical problems. Of these 18 medical problems could be attributed to preceding hip fracture. 15 patients died during this 2nd admission episode. 10 of these patients could have their ‘cause of death’ attributable to previous hip fracture, though this was not mentioned in their death certificates. A total of 8 patients had died in community in the 3 months following discharge giving a total mortality of 24.7% (66/267 patients) within 3 months.

Conclusions: Hip fracture is underreported as a cause of prolonged morbidity and mortality. A high percentage of these patients were readmitted adding to resource crunch. An understanding of the causes of readmission would help to decrease this workload.

Aim: To determine effect of single post-operative injection of Sodium Hyaluronate (Viscoseal) on the pain and joint function, following arthroscopic knee surgery.

Method: Study design: A randomized, prospective, controlled, double blinded trial after ethical approval. Study procedure: Consenting patients (age group 18–60 years) undergoing arthroscopic knee surgery were randomized to either study group or control group, after the completion of their operation. Control group had 10 mls of 0.5% Bupivacaine injected in the joint after the procedure, while study group had 10 mls of Viscoseal (Sodium Hyaluronate preparation devoid of animal protein) injected in the joint. Patients were given questionnaires to assess their pain and function at various times (Preoperatively; 2 hour following surgery; Day 1, Day 7, 3 week and 6 week following surgery). Primary efficacy parameters used were Pain visual analogue scores at rest, on movement and on weight bearing. Secondary efficacy parameters used included WOMAC questionnaire, SF-12 general health questionnaire and use of rescue medication. Patients were evaluated clinically at 6 weeks by a blinded physiotherapist.

Results: 48 patients (Average age-41 years, 20 female, 28 male) undergoing knee arthroscopy were randomized (24 patients each). The hyaluronate group exhibited markedly lesser degrees of immediate post-operative pain and swelling; reduced need for analgesics, and a significantly larger drop in WOMAC scores than the bupivacaine group (p< 0.05). SF-12 scores and delayed pain VAS score improved by a comparable amount. In particular, those undergoing partial meniscectomy exhibited greater benefits with hyaluronate. No complications were recorded in either of the groups.

Conclusion: Sodium hyaluronate (Viscoseal) injections could be safely used following arthroscopic knee surgery, to facilitate patient’s recovery.

Study Design: Experimental study to assess tissue engineered solutions to disc degeneration.

Objectives: To investigate the use of a novel biodegradable hydrogel which is capable of minimally invasive introduction into an intervertebral disc (IVD) and support of cultured nucleus pulposus (NP) cells for the purpose of developing a tissue-engineered solution to retard progression of IVD degeneration. There were 3 objectives: (1) To introduce a slowly polymerising alginate hydrogel into the NP cavity of a bovine vertebral disc model. (2) To demonstrate the viability and metabolic activity of cultured NP cells in the hydrogel in vitro. (3) To determine the effect of Synvisc (hylan G-F 20) on NP cell proliferation and extracellular matrix (ECM) production.

Summary of Background Data: The cause of intervertebral disc degeneration (IVDD) is multifactorial. One proposed mechanism is that IVDD originates in the NP and progresses radially to the annulus fibrosis (AF). There is a growing interest in tissue-engineered solutions where a biological repair is induced. By preventing the abnormality at the NP it may be possible to halt progression of IVDD. Injection of NP cells into an early degenerative IVD, where the AF is still intact, may retard the degenerative process.

Subjects/Methods: CaSO₄ and CaCO₃ alginates were injected into the NP cavity of a bovine tail. After 90 minutes the tail was dissected to reveal the gel. NP cells released from pooled bovine NP tissue were dispersed into the CaSO₄ and CaCO₃ alginate gels (10x10⁶ cells.mL⁻¹) with and without Synvisc and cultured for 21 days.

Results: Injectable alginate suspensions formed solid viscoelastic gels, filling the exact shape of the NP cavity. NP DNA and ECM synthesis was significantly greater in the CaCO₃ alginate gel than in the CaSO₄ alginate gel (p< 0.05). Synvisc significantly increased sulphated GAG (p< 0.01) and collagen (p< 0.05) production. These effects were supported histologically and immunohistologically where cells in the CaCO₃ and Synvisc gels stained more intensely for proteoglycan and collagen type II.

Conclusions: Both CaCO₃ alginate gel and CaSO₄ alginate gel are injectable and are capable of sustaining NP cells in-vitro. Cells remain viable, maintain their phenotype, proliferate and produce ECM during the culture period. The CaCO₃ alginate gel provides a three-dimensional matrix more favourable to NP cellular activity than the CaSO₄ alginate gel. Synvisc behaves as a chondro-stimulant significantly enhancing NP cell metabolic activity.

Introduction Surgical treatment of metatarsalgia remains controversial, with many different techniques described. Recently the Weil osteotomy is gaining in popularity because of its relatively simple technique and excellent union rates, however, it is well known that the procedure does lead to stiffness in the metatarsophalangeal (MTP) joint with a reduction in plantarflexion. The aim of this study was to evaluate the outcome of the Weil osteotomy from a radiological and patient-based perspective.

Method This was a retrospective review of 42 patients (110 Weil osteotomies), with mean follow up of 24.8 months (range 6–48). Clinical examination and X-ray assessment were performed at follow-up, along with completion of patient questionnaires, American Orthopaedic Foot and Ankle Society (AOFAS) Score and Lesser Metatarsal Scores (LMTS). Additional parameters including arc of motion of each metatarsal, metatarsal shortening, non-union, redislocation and requirement for further surgery were also recorded.

Results Results showed that the average arc of motion for the second metatarsal was 61.1 degrees, the third metatarsal 59.6 degrees, and the fourth metatarsal 69.8 degrees. In all cases there was a significant reduction in plantarflexion at the MTP joint, with the average combined plantar flexion of less than 5 degrees. The average shortening was 7.2 mm, and there were no cases of redislocation or non-union. Analysis of the scoring systems showed that with AOFAS there were 88% excellent/ good results and with LMTS there were 83% excellent/ good results. No patients had residual metatarsalgia and plantar callosities disappeared in almost all patients, with 91% of patients reporting excellent/good satisfaction.

Conclusion Formal scoring systems and patient satisfaction scores showed that dorsiflexion contractures post-operatively were not of concern to the patients. The study suggests that the Weil osteotomy remains a safe, reliable and predictable operation with excellent results, and may be of value in the treatment of resistant metatarsalgia.

The purpose of this study was to examine the effects of hyaluronic acid supplementation on chondrocyte metabolism in vitro. The clinical benefits of intra-articular hyaluronic acid injections are thought to occur through improved joint lubrication. Recent findings have shown that exogenous hyaluronic acid is incorporated into articular cartilage where it may have a direct biological effect on chondrocytes through CD44 receptors.

Bovine articular chondrocytes were isolated and seeded into alginate constructs. These were cultured in medium containing hyaluronic acid at varying concentrations. Samples were assayed for biochemical and histological changes.

There was a dose-dependent response to the exposure of hyaluronic acid to bovine articular chondrocytes in vitro. Low concentrations of hyaluronic acid (0.1 mg/mL and 1 mg/mL) significantly increase DNA, sulphated glycosaminoglycan and hydroxyproline synthesis. Immunohistology confirmed the maintenance of cell phenotype with increased matrix deposition of chondroitin-6-sulphate and collagen type II. These findings confirm a stimulatory effect of hyaluronic acid on chondrocyte metabolism.

A 78 year old lady attended casualty with complaints of low back pain and calf pain following a fall. Radiographs of lumbar spine did not reveal any bony injury. Clinically deep vein thrombosis (DVT) of the calf could not be excluded. Hence, venogram was performed that confirmed the diagnosis of below knee DVT. Patient was then discharged. Patient attended casualty 2 months later with complaints of sudden increase in back pain and difficulty in mictuirition. Radiographs of lumbar spine revealed a collapse of L1 vertebra. Routine blood tests were all normal except for raised International Normalised Ratio (INR), 3.5. Patient developed parapaeresis within three days. Coagulation status was controlled but no obvious primary source could be identified. After discussion with Neurosurgeons, urgent Computerised Tomography (CT) guided biopsy was arranged which was performed one week after presentation. Histopathological examination of the specimens revealed only fibrous tissue and blood. At 3 weeks after presentation patient started recovering rapidly though there was some amount of residual power loss in the lower limbs. Patient did not regain bladder control. A repeat CT guided biopsy at 6 weeks, again revealed only fibrous tissue.

This case is presented to discuss the rarer etiologies that can present as a metastatic spinal cord compression.

Aim: To study the management and survival outcome of patients with metastatic long bone deposits referred to a general orthopaedic unit at a district general hospital.

Methods and materials: 43 patients with pathological or impending long bone fractures were identified between 1998 and 2001. Details of primary tumor, bony metastatic involvement and management were recorded. Additional data was collected regarding prophylactic versus therapeutic treatment, oncological input, time to death and Mirel’s score, where relevant.

Results: The most common areas of long bone metastases were found to be proximal femur 29/43 (67%) and humeral shaft 11/43 (26%). Proximal femoral lesions included subcapital, intertrochanteric and subtrochanteric lesions. Operative stabilisation was carried out in 27/43 (63%), and involved intramedullary fixation (10/27; 37%), extramedullary fixation (15/27; 56%), and arthroplasty (2/27; 7%). Of the initial 43 patients, 14 (33%) presented with impending fractures, with Mirel’s scores ranging from 7 to 11 (average 9).

The duration of pre-existing pain in the in the fracture group varied from 3 days to 6 months (average 55 days). None of these patients received oncological input during this time period. Of these 15 patients, 12 subsequently required surgery.

Patient survival times in the operated group averaged 3 months (2 days to 9 months) – with the exception of one patient who survived for 36 months. This compared equally with survival times for the unoperated group.

Only 2/43 patients received preoperative oncology input. In the postoperative group (27 patients), 16 (59%) received radiotherapy. Of the remaining 11 patients, 9 (33%) did not receive radiotherapy due to significant postoperative complications and died within 8 weeks.

Discussion: The main aims of surgery in patients with metastatic bony disease are pain relief, and preservation of stability and function. In view of the low life expectancy, preoperative oncology input is important in determining patient longevity and in deciding if surgery is beneficial. All patients should be considered for postoperative radiotherapy once the wound has healed. This multi disciplinary approach can be difficult to achieve in the setting of a district general hospital where oncology services are limited.

We studied 27 patients with low back pain and unilateral L5 or S1 spinal nerve root pain. Significant radiological changes were restricted to the symptomatic root level, when compared with controls. Low back and leg pain were graded on a visual analogue scale. Dermatomal quantitative sensory tests revealed significant elevations of warm, cool and touch perception thresholds in the affected dermatome, compared with controls. These elevations correlated with root pain (warm v L5 root pain; r = 0.88, p < 0.0001), but not with back pain. Low back pain correlated with restriction of anteroposterior spinal flexion (p = 0.02), but not with leg pain.

A subset of 16 patients underwent decompressive surgery with improvement of pain scores, sensory thresholds and spinal mobility. A further 14 patients with back pain, multilevel nerve root symptoms and radiological changes were also studied. The only correlation found was of low back pain with spinal movement (p < 0.002). We conclude that, in patients with single level disease, dermatomal sensory threshold elevation and restriction of spinal movement are independent correlates of sciatica and low back pain.

We describe seven cases of permanent neurological damage following interscalene block used in post-operative analgesia after operations at the shoulder. MRI, Nerve Conduction Studies and Quantitative assessments of function confirmed that in all there was infarction of the anterior spinal cord, resulting in a spinothalamic and corticospinal tract defect especially at segments C7, C8 and T1. We think that these lesions were caused by injury to radicular arteries. Domisse has demonstrated the anatomy of the radicular vessels joining the anterior spinal artery to supply the anterior two thirds of the cord. They are branches of the vertebral, ascending cervical and deep cervical arteries which pass through the inter-vertebral foramina with the C7, C8 and T1 roots predominantly. Chakravorty has shown that radicular vessels contribute to the blood supply of the lower cervical cord. Injury to them can cause ischaemia, leading to Anterior Spinal Artery Syndrome. We suggest tamponade of the radicular vessels by infusion of fluid under pressure deep to the prevertebral fascia as the main mechanism but neurotoxicity and vasospasm can be other possible explanations.

In a second group there was an additional interference with the vertebral artery presenting with transient bulbar and cranial nerve symptoms. We had 2 patients with such combined lesions. Complications of interscalene blocks are well documented but most are reversible and transient. In our cases the damage has been permanent and disabling. The innervation of the gleno-humeral joint is largely through the 4th, 5th and 6th cervical nerves and we suggest more appropriate placing of the blockade should be adapted and use of this technique for post-operative analgesia should be abandoned.

Study Design: To examine the innervation of the lumbar spine from patients with lower back pain, and spinal nerve roots from patients with traumatic brachial plexus injuries.

Objectives: To demonstrate the presence of nerve fibres in lumbar spine structures and spinal nerve roots, and determine whether they express the sensory neuronespecific sodium channels SNS/PN3 and NaN/SNS2.

Summary of background data: The anatomical and molecular basis of low back pain and sciatica is poorly understood. Previous studies have demonstrated sensory nerves in facet joint capsule and prolapsed intervertebral disc, but not in ligamentum flavum. The voltagegated sodium channels SNS/PN3 and NaN/SNS2 are expressed by sensory neurones which mediate pain, but their presence in the lumbar spine is unknown.

Methods: Tissue samples (ligamentum flavum n=32; facet joint capsule n=20; intervertebral disc n=15; spinal roots n=8) were immunostained with specific antibodies to protein gene product (PGP) 9.5, a pan-neuronal marker, SNS/PN3 and NaN/SNS2.

Results: PGP 9.5-immunoreactive nerve fibres were detected in 72% of ligamentum flavum and 70% of facet joint capsule but only 20% of intervertebral disc specimens. SNS/PN3-and NaN/SNS2-positive fibres were detected in 28% and 3% of ligamentum flavum and 25% and 15% of facet joint capsule specimens respectively. Numerous SNS/PN3 and NaN/SNS2-positive fibres were found in the acutely injured spinal roots, and some were still present in dorsal roots in the chronic state.

Conclusions: SNS/PN3 and NaN/SNS2-immunoreactivity is present in a subset of nerve fibres in lumbar spine structures, including ligamentum flavum and injured spinal roots. This is the first time that sensory nerve fibres have been demonstrated in the ligamentum flavum, and this raises the possibility that, contrary to the conclusions of previous studies, this unique ligament may be capable of nociception. Selective SNS/PN3 and NaN/ SNS2 blocking agents may provide new effective therapy for back pain and sciatica, with fewer side effects. Other novel ion channels are being studied in these tissues.

Contracture of the iliotibial band leading to flexion and abduction deformity at the hip is common in residual paralysis after polio. Ober’s test has been used to detect this, but it is unreliable and cannot determine the degree of contracture.

We describe a new test which quantifies this contracture and can be used for comparative purposes.

We performed intercostal nerve transfer in 19 patients to relieve pain from preganglionic injury to the brachial plexus. The procedure was successful in 16 patients at a mean of 28.6 months (12 to 68) after the injury.

We have determined the quality-adjusted-life-years and cost of such in several types of hip fracture and various treatment options. Operative treatment proved more cost-effective than other methods for displaced subcapital fractures and for extracapsular fractures. For undisplaced subcapital fractures conservative treatment was almost as cost-effective as surgery.