Gluteal Tendinopathy is a poorly understood condition that predominantly affects post-menopausal women. It causes lateral hip pain, worse when lying on the affected side or when walking up a hill or stairs. It has been labelled ˜Greater Trochanteric Pain Syndrome” a name that recognises the lack of understanding of the condition.

Surgical reconstruction of the gluteal cuff is well established and has been undertaken numerous times over the last 16 years by the senior author (AJL). However, the quality of collagen in the tendons can be very poor and this leads to compromised results. We present the results of gluteal cuff reconstruction combined with augmentation using a bioinductive implant.

14 patients (11 female, 3 male; mean age 74.2 ± 6.3 years) with significant symptoms secondary to gluteal tendinopathy that had failed conservative treatment (ultrasound guided injection and structured physiotherapy) underwent surgical reconstruction by the senior author using an open approach. In all cases the iliotibial band was lengthened and the trochanteric bursa excised. The gluteal cuff was reattached using Healicoil anchors (3–5×4.75mm anchors; single anchors but double row repair) and then augmented using a Regeneten patch. Patients were mobilised fully weight bearing post-operatively but were asked to use crutches until they were no longer limping. All had structured post-surgery rehabilitation courtesy of trained physiotherapists.

There were no post-operative complications and all patients reported an improvement in pain levels (Visual Analogue Scale 7.8 pre-op; 2.6 post-op) and functional levels (UCLA Activity Score 3.5 pre-op; 7.1 post-op) at 6 months post surgery.

Surgery for gluteal tendinopathy produces good outcomes and the use of Regeneten as an augment for poor quality collagen is seemingly a safe, helpful addition. Further comparative studies would help clarify this.

Introduction

Knee arthroscopy can be used for ligamentous repair, reconstruction and to reduce burden of infection. Understanding and feeling confident with knee arthroscopy is therefore a highly important skillset for the orthopaedic surgeon. However, with limited training or experience, furthered by reduced practical education due to COVID-19, this skill can be under-developed amongst trainee surgeons.

Abstract

Aims

United Classification System (UCS) B2 and B3 periprosthetic fractures in total hip arthroplasties (THAs) have been commonly managed with modular tapered stems. No study has evaluated the use of monoblock fluted tapered titanium stems for this indication. This study aimed to evaluate the effects of a monoblock stems on implant survivorship, postoperative outcomes, radiological outcomes, and osseointegration following treatment of THA UCS B2 and B3 periprosthetic fractures.

Prosthetic joint infections (PJI) are one of the most devastating complications of joint replacement surgery. They are associated with significant patient morbidity and carry a significant economic cost to treat. The management of PJI varies from antibiotic suppression, debridement, antibiotics, and implant retention (DAIR) procedures through to single/multiple stage revision procedures. Concerns have been raised recently in relation to the rising number of revision arthroplasty procedures that are being undertaken in relation to infection. This database aims to collect data on all PJIs that have been managed in the Australian Capital Territory (ACT) region. This will allow us to investigate the microbial trends, outcomes of surgical intervention and patient outcomes within our local population.

This database will incorporate diagnostic, demographic, microbiological and treatment information in relation to local PJI cases. The data will be collated from the local infectious diseases database, hospital medical records, and where available the Australian Orthopaedic Association National Joint Replacement Registry Data.

The first 100 cases of PJI were assessed. 76% were defined as being acute. 56% of the patients received antibiotics prior to their diagnosis however only 3% were culture negative. 89% were monomicrobial and 11% polymicrobial. The intended management strategy was a DAIR in 38% of patients and a 2-stage revision in 12% of cases. The intended management strategy was successful in 46% of the patients.

The ACT is uniquely placed to analyze and create a local PJI database. This will allow us to guide further treatment and local guidelines in terms of management of these complex patients.

Staphylococcus aureus is the most frequently isolated organism in periprosthetic joint infections. The mechanism by which synovial fluid (SF) kills bacteria has not yet been elucidated, and a better understanding of its antibacterial characteristics is needed. We sought to analyze the antimicrobial properties of exogenous copper in human SF against S. aureus.

SF samples were collected from patients undergoing total elective knee or hip arthroplasty. Different S. aureus strains previously found to be sensitive and resistant, UAMS-1 and USA300 WT, respectively, were used. We performed in-vitro growth and viability assays to determine the capability of S. aureus to survive in SF with the addition of 10µM of copper. We determined the minimum bactericidal concentration of copper (MBC-Cu) and evaluated the sensitivity to killing, comparing WT and CopAZB-deficient USA300 strains.

UAMS-1 evidenced a greater sensitivity to SF when compared to USA300 WT, at 12 (p=0.001) and 24 hours (p=0.027). UAMS-1 significantly died at 24 hours (p=0.017), and USA300 WT survived at 24 hours. UAMS-1 was more susceptible to the addition of copper at 4 (p=0.001), 12 (p=0.005) and 24-hours (p=0.006). We confirmed a high sensitivity to killing with the addition of exogenous copper on both strains at 4 (p=0.011), 12 (p=0.011), and 24 hours (p=0.011). Both WT and CopAZB-deficient USA300 strains significantly died in SF, evidencing a MBC-Cu of 50µM against USA300 WT (p=0.011).

SF has antimicrobial properties against S. aureus, and UAMS-1 was more sensitive than USA300 WT. The addition of 10µM of copper was highly toxic for both strains, confirming its bactericidal effect. We evidenced CopAZB-proteins involvement in copper effluxion by demonstrating the high sensitivity of the mutant strain to lower copper concentrations. Thus, we propose CopAZB-proteins as potential targets and the use of exogenous copper as possible treatment alternatives against S. aureus.

There is a need for non-radiographic, objective outcome measures for children with Adolescent Idiopathic Scoliosis (AIS). Standing balance and stability is altered in children with AIS. The Margin of Stability (MoS) has been used to compare gait stability in clinical populations. Our objective was to compare the MoS in anterior-posterior (MoS_AP) and mediolateral (MoS_ML) directions in girls with AIS to Controls.

Girls with AIS and healthy girls walked at three speeds on an instrumented treadmill wearing retroreflective markers, surrounded by motion capture cameras. The MoS_AP/ML was calculated at left and right heel strike. Data was processed in Visual 3D. A two-way ANOVA was used to compare MoS_AP/ML between group, speed and the interaction between group and speed. Pearson's correlation coefficient was used to compare the MoS to Cobb angle. Statistical significance was accepted when p > 0.05.

A priori power analysis suggested 12 participants per group. Three Cases and four Controls were recruited. Girls with AIS all had right-sided main thoracic curves (Lenke type 1a, 61.3° ± 10.0°). MoS_AP was significantly bigger for Cases compared to Controls on the left (p=0.038) and right foot (p=0.041). There was no significant difference between Cases and Controls for MoS_ML, but there was a visual trend for a smaller MoS_ML in Cases. There was no significant difference for speed or the interaction between group and speed for MoS_AP or MoS_ML. In Cases, MoS_AP increased with increasing Cobb angle on the left (r²=0.687, p=0.054) and right (r²=0.634, p=0.067) and MoS_ML decreased with increasing Cobb angle on the left (r²=-0.912, p=0.002). Further subjects are being recruited.

Girls with Lenke type 1a AIS are more stable in the AP direction and less stable in the ML direction than Controls during treadmill walking. AP stability increases and ML stability decreases with increasing Cobb angle. This research suggests that the MoS could be used as an outcome measure for children with AIS. Continued work is required to increase the power of this study. Further work could consider these changes during walking overground, measuring an MoS or MoS-like measure using a wearable device, and in different curve types.

Success treating AIS with bracing is related to time worn and scoliosis severity. Temperature monitoring can help patients comply with their orthotic prescription. Routinely collected temperature data from the start of first brace treatment was reviewed for 14 patients. All were female with an average age of 12.4 years (range 10.3–14.6) and average 49o Cobb angle (30–64).

Our current service recommendation is brace wear for 20 hours a day. Patients complied with this prescription 38.0% of the time, with four patients averaging this or more. Average brace wear was 16.3 hours per day (3.5–22.2).

There were 13 patients who had completed brace treatment. The majority had surgery (7/13; 54%) or were considering surgery (1/13; 8%). There were 5 who did not wish surgery at discharge (5/13; 38%); 1 achieved a 40o Cobb angle, with 4 larger (53o;53o;54o;68o). The Bracing in AIS Trial (BrAIST) study measured “success” as less than a 50o Cobb angle, so using this metric our cohort has had a single “success”.

Temperature monitors allowed an analysis of when patients were achieving their brace wear. When comparing daywear (8am-8pm) to nightwear (8pm-8am), patients wore their brace an average of 7.6 hours a day (2.5–11.2) and 8.7 hours a night (0.4–11.5).

We conclude the minority of our patients comply with our current 20 hour orthotic prescription. The “success” of brace treatment is lower than comparison studies despite higher average compliance but starting with a larger scoliosis. Brace wear is achieved during both the day and night.

Aims

This study investigates the effects of intra-articular injection of adipose-derived mesenchymal stem cells (AdMSCs) and platelet-rich plasma (PRP) on lameness, pain, and quality of life in osteoarthritic canine patients.

Anterior cruciate ligament (ACL)-retaining total knee arthroplasty (TKA) has been associated with more physiologic motion patterns, more normal knee kinematics, and higher patient preference than ACL-sacrificing implant designs. However, it remains unclear how many osteoarthritic patients can be expected to have an intact ACL at the time of surgery in order to undergo ACL-retaining TKA. A systematic literature review was performed in November 2018 using the PubMed and EMBASE databases. Papers written in English, with more than 10 adult patients relevant to the research question were included, whereas cadaveric, revision, animal and simulation studies and conference abstracts were excluded. Data on ACL retention during intraoperative assessment or MRI scans were extracted and analysed using proportional meta-analyses. Twenty-six eligible publications (4167 knees) were included: 20 using intraoperative assessment, 4 using MRI, and 2 using both. Intraoperative assessment of the ACL during TKA showed that the ligament was present in 78% (95% confidence interval [CI]: 72–84%) and intact in 55% (95% CI: 45–65%) of the patients examined. MRI scans revealed higher percentages of ACL presence and intactness than intraoperative assessment, with 91% (95% CI: 79–96%) of the ACL being present and 68% (95% CI: 28–92%) intact. Fewer studies reported on MRI results compared to studies reporting on the intraoperative status of the ACL. In conclusion, intraoperative assessment suggests that over half of the osteoarthritic patients have an intact ACL at the time of TKA surgery, some of whom may qualify for bicruciate-retaining arthroplasty.

For any figures or tables, please contact authors directly.

Introduction

Renal impairment following major surgery is a formidable complication. There is recent evidence suggesting increasing risk of progression to chronic kidney disease and mortality after transient renal impairment. We aimed to evaluate the impact of pre-operative comorbidities on long-term outcomes of renal-function following hip arthroplasty.

Introduction

The purpose of this study was to compare pre-operative acetabular cup parameters using this novel dynamic imaging sequence to the Lewinnek safe zone

Adductor canal blocks offer an alternative to femoral nerve block for postoperative pain relief in knee arthroplasty. They may reduce the risk of quadriceps weakness, allowing earlier mobilisation of patients postoperatively. However, little is known about the effect of a tourniquet on the distribution of local anaesthetic in the limb.

Ultrasound-guided adductor canal blocks were performed on both thighs of five human cadavers. Left and right thighs of each cadaver were randomised to tourniquet or no tourniquet for one hour. Iohexol radio-opaque contrast (Omnipaque 350) was substituted for the local anaesthetic for X-Ray imaging. All limbs underwent periodic flexion and extension during this hour to simulate positioning during surgery. The cadavers were refrozen. Fiducial markers were inserted into the frozen tissue. X-rays were obtained in 4 planes (AP, lateral 45° oblique/medial oblique, lateral). University Research Ethics Approval was obtained and cadavers were all pre-consented for research, imaging and photography according to the Anatomy Act (1984).

Analysis of radiographs showed contrast distribution in all thighs to be predominantly on the medial aspect of the thighs. The contrast margins were entire and well circumscribed, strongly suggesting it was largely contained within the aponeurosis of the adductor canal. Tourniquets appeared to push the contrast into a narrower and more distal spread along the length of the thigh compared to a more diffuse spread for those without. Proximal spread towards the femoral triangle was reduced in limbs without tourniquets.

The results suggest that contrast material may remain within the adductor canal structures during adductor canal blocks. Tourniquets may cause greater distribution of contrast proximally and distally in the thigh, but this does not appear to be clinically significant. Further studies might include radio-stereo photometric analysis using the fiducial markers in the limbs and in vivo studies to show the effect of haemodynamics on distribution.

Aims

The mainstay of surgical correction of hallux valgus is first metatarsal osteotomy, either proximally or distally. We present a technique of combining a distal chevron osteotomy with a proximal opening wedge osteotomy, for the correction of moderate to severe hallux valgus.

Purpose and Background

Traditional physiotherapy methods utilised in the management of NSCLBP have small effects on pain and disability and this is reflected by data previously collected by the host physiotherapy service. O'Sullivan has validated a novel classification system and matching treatment strategy known as Classification Based–Cognitive Functional Therapy (CB-CFT) for people with NSCLBP. Briefly, CB-CFT is a behavioural and functional management approach to NSCLBP. A recent RCT employing CB-CFT has demonstrated superior outcomes in comparison to traditional physiotherapy methods advocated by clinical practice guidelines. It was unknown if CB-CFT improved outcomes for people with NSCLBP attending an NHS physiotherapy service, therefore an evaluation of practice was proposed.

Introduction:

NICE guidelines state that every patient should be assessed for their VTE risk on admission to hospital. The aim of this study was to determine whether currently recommended risk assessment tools (Nygaard, Caprini, NICE and Plymouth) can correctly identify the patients at risk.

Single shot interscalene blocks are an effective analgesic for arthroscopic shoulder surgery. However, patients receiving these blocks are often found to be in significant pain when the block wears off, usually in the late evening or early hours of the morning. Overnight admission is currently routine in our unit, to ensure adequate analgesia can be administered during this period. Recent studies have suggested that adding dexamethasone to the local anaesthetic agent can prolong the duration of the block. We carried out a prospective study to assess whether addition of dexamethasone to brachial plexus blocks could reduce patient's post-operative analgesic demands and allow safe discharge on the same day after surgery.

Twenty-six patients undergoing arthroscopic shoulder surgery during a morning theatre list, had ultrasound guided brachial plexus blocks using a mixture of 0.25% bupivacaine 20–30ml with 2–3mg of dexamethasone. All were admitted to the ward afterwards for analgesia and physiotherapy. Pain numerical rating scores (0–10) were recorded at rest in recovery one hour postoperatively by the attending anaesthetist and on active movement of the shoulder joint 24 hours after surgery by the attending physiotherapist. A standardised analgesia regime was prescribed with regular and as required medication, including as required strong opiates.

Mean pain scores in recovery were 0.31 and on the morning after surgery were 2.38. Sixteen out of 26 required no further analgesia, with only 3 out of the 10 who did requiring opiates.

The use of dexamethasone provides adequate analgesia for a prolonged period for most patients after brachial plexus block for shoulder surgery and does not result in a significant analgesic requirement when the block wears off. This may provide support for avoiding overnight admission in selected patients after arthroscopic shoulder surgery.

Intervention is rare following minimally displaced radial head fractures or positive elbow ‘fat pad’ signs. A pilot study (n=20) found no patient required active treatment after discharge following their first fracture clinic visit. We therefore initiated routine discharge from A&E with an advice sheet, and an ‘open-door policy’ if patients failed to progress.

51 patients were managed by A&E according to this protocol over a six-month period. A standardised assessment of symptoms, satisfaction and functional limitation was completed for 24 patients by phone; average time to follow-up 4.2 months (range 2–9 months). Fourteen (58.4%) reported no pain. The 10 patients (41.6%) with on-going pain reported a median visual analogue score (VAS 0–10) of 0.7 (0–4) at rest, 0.25 (0–4) at night, 3.0 (0–10) carrying heavy objects and 2.75 (0–10) during repetitive movement. 4 of 24 (16.7%) reported minor functional impairment. 3 of 24 (12.5%) patients requested orthopaedic review, but all were satisfied with outcome, seeking reassurance and discharged without any intervention. 3 of 24 (12.5%) were unhappy with their progress, but all had suffered from chronic pain or psychological conditions predating their injury. When offered further review, none of these patients accepted.

22 (91%) were satisfied with their treatment and 23 (95.8%) returned to work and hobbies. This data suggests routine discharge from A&E with advice does not compromise care, as no intervention is usually required beyond advice. These findings have obvious positive clinical and financial implications in streamlining clinical workload.

Lateral malleolar plating is associated with complication rates of up to 30%. The fibular nail is an alternative fixation technique, requiring a minimal incision and tissue dissection, with the potential to reduce the incidence of complications. We reviewed our results of 105 unstable ankle fractures fixed with the Acumed fibular nail between 2002 and 2010. The mean age was 65 years and 72% of patients had significant systemic medical comorbidities.

A number of different locking screw configurations were assessed over the study period. A proximal blocking screw resulted in satisfactory stability in 93%, single locking screws in 86%, but nailing without locking in only 66%, leading to the development of our current technique. Of the twenty-one patients treated with this technique there have been no significant complications, and only two superficial wound infections. Good fracture reduction was achieved in all of these patients. The mean physical component SF12, Olerud and Molander and Foot and Ankle Outcome scores were 46, 65 and 83 respectively.

The outcomes of unstable ankle fractures managed with the fibular nail are encouraging, with good radiographic and functional outcomes and minimal complications. This technique should be considered in the management of debilitated patients with unstable ankle fractures.

Techniques for fixation of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce complications.

We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities.

Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and AAOS Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion.

Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture.

Background

Doubt has been cast over the accuracy of dermatome charts. This study investigated a large group of patients with known lumbar nerve root compression (NRC), and identified whether their radicular pain corresponded with the predicted distribution on a dermatome chart.

Six week old male Sprague-Dawley rats were administered intravenous clozapine, quetiapine, haloperidol or vehicle once daily for a period of 42 days with access to only high fat diet and their weight was monitored regularly. At the end of the study the rats were killed and the tibiae excised and bone mineral density (BMD) measured with dual X-ray absorptiometry and bone architecture assessed with micro-computed tomography (micro-CT) and associated software. Results were subjected to one-way ANOVA and post hoc Dunnetts multiple comparison test.

All treatment groups were compared to control. There were no significant differences in body weight between the different groups at completion of the study. Clozapine treated animals alone showed a significant reduction in bone mineral density (p<0.05) however no differences were seen with haloperidol and quetiapine. Both haloperidol and quetiapine, but not clozapine, treatment showed a significant reduction in the bone to tissue volume ratio (BV/TV) by approximately 23% (p<0.05) and an increase in trabecular number (TbN) by approximately 21% (p<0.05). Trabecular bone architecture parameters for haloperidol and quetiapine, but not clozapine, showed more rod like and disconnected structure as reflected in the increases in structure model index (SMI) of around 15% (p<0.05) and trabecular pattern factor (TbPf) by 22% (p<0.05).

This data demonstrates that in rats receiving a high fat diet, haloperidol and quetiapine have an adverse effect on bone micro-architecture without significant change in whole body bone mineral density.

Clozapine did not affect bony architecture in a significant manner as reported in our earlier study, though bone mineral density was reduced. Reasons for the different effect of clozapine in this study are still uncertain but may be related to the significant weight loss seen at the end point of the previous study. Causes for osteoporosis and increased fracture risk in schizophrenia may include smoking history, malnutrition, limited sun exposure and compliance.

Long term administration of both typical and atypical anti-psychotics may have a negative effect on bone and is a further factor that can influence this risk. An awareness of this relationship is useful in the orthopaedic management of schizophrenic patients.

Techniques for fixation of fractures of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce the incidence of complications.

We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities. Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and American Academy of Orthopaedic Surgeons Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion.

Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture.

The reinfusion of perioperative cell salvage is one method employed to reduce exposure to donor blood. Data on the safety of this process, however, are scant. Notably, the effect of intraoperative, washed cell salvage reinfusion on prothrombotic markers has not been demonstrated. The risk of postoperative venous thromboembolism following major orthopaedic operations is not insignificant. The study objective was to assess the effect of cell salvage reinfusion on coagulation and platelet activation.

Twenty-one patients undergoing elective primary hip operations were recruited. Nine patients received washed cell salvage intraoperatively, and were compared with 12 patients undergoing similar surgery that did not. Two patients in the cell salvage group also received postoperative, unwashed cell salvage. Blood samples were collected pre-operatively, immediately post-operatively, and one day post-operatively for assays of platelet activation markers, P-selectin expression and fibrinogen binding by flow cytometry in diluted whole blood; coagulation activation marker, thrombin-antithrombin complex (TAT); D-dimer by ELISA, thrombin generation by chromogenic assay, and full blood count. Samples of cell salvage material were also analysed for prothrombotic markers.

There were no significant differences between the groups preoperatively. Postoperatively haemoglobin levels did not differ significantly between the cell salvage group and controls. Postoperative TAT and D-dimer were significantly higher in the cell salvage group compared with controls (p<0.05). One day postoperatively, there were significantly higher platelet P-selectin expression (p=0.006) and platelet fibrinogen binding (p=0.004) in the cell salvage group compared with controls. The white cell count (WCC) was also significantly higher (p=0.04). In the intraoperative washed cell salvage material, and in postoperative cell salvage, the platelet count was low, but significant proportions of platelets were activated, and levels of D-dimer were elevated compared with venous blood. The postoperative salvage material also contained high levels of TAT.

The results from this pilot study show the induction of a prothrombotic state following reinfusion of intraoperative, washed cell salvage in recipients undergoing primary elective hip operations. An inflammatory response to reinfusion is also indicated by the raised WCC. Further investigation into the safety of cell salvage is indicated.

TKA (Total Knee Arthroplasty) is a successful operation. Soft tissue problems with TKA are difficult to treat. Flap surgery is successful in treating this problem and salvaging the prostheses. We present results of flap surgery for complicated TKAs over a ten year period, performed by a single surgeon.

Between 1996 and 2005, 31 patients (32 knees) underwent flap surgeries for TKAs. Four of these procedures were done prophylactically in patients with previous knee surgeries. Gastrocnemius, medial fasciocutaneous and anterior compartment flaps were used either solely or in combination based on the size of the defect. The data was collected retrospectively from case-notes and correspondence from the treating orthopaedic surgeons. All the knees included in the study had a minimum follow up of 6 months.

The patients were aged between 50 and 94 years. Indication for primary TKA was osteoarthritis in 26 patients and rheumatoid arthritis in 5. The index orthopaedic surgery was a primary knee arthroplasty in 14 and revision in 13. The average duration between the TKA and flap surgery was 11 weeks (range 1 – 52). Gastrocnemius was the most commonly used local flap (17 cases). Anterior compartment flap was used in 5 cases and in the rest combination of flaps was used. Coagulase -ve Staph. aureus was the most commonly isolated organism from the perioperative wound swabs. Successful soft tissue cover was achieved in 29 of 32 knees (92%). Overall, TKA was salvaged in 23 of 32 knees (72%) and 3 knees (9.7%) underwent arthrodesis. Three (9.7%) patients had above knee amputation, two of these had post op MRSA infection. We could not use a functional knee scoring system due to inadequate information available.

We conclude local flap surgery is a viable and successful procedure for providing soft tissue cover for complicated TKAs with good results.

Shoulder pain represents a significant burden of disease in the general population, yet there is a lack of evidence about the effectiveness of routinely used interventions. Current management of ‘painful arc’ of the shoulder in Primary Care is not evidence-based.

Over a six-month period patients with ‘painful arc’ of less than six months duration were recruited via their GPs. Eligible patients were consented to enter the trial and were then randomised, by sealed envelopes, to one of four arms of the study: control (normal analgesia and/or non-steroidal anti-inflammatory medication), a specified and repeatable Exercise and Manual Therapy Package (EMTP), a course of up to three subacromial steroid injections or both the EMTP and the steroid injections. The interventions and clinic follow-ups were over an 18-week period. A final postal questionnaire was sent out at one year. The progress of the patients was monitored using the Oxford Shoulder Score (OSS) and the SF36 general health questionnaire.

Seventy-nine GPs referred 186 patients, of whom 112 were randomised (Control=27, EMTP=29, Injections=28, Both=28). 64 patients were female and 48 male. The mean age was 54.5 years (range 23-88 years). Ninety patients completed the trial (Control=20, EMTP=22, Injections=26, Both=22). Sixty-two returned the follow-up questionnaire.

By paired sample t-tests, no significant differences were found between the OSS scores or SF-36 (physical health total) at the beginning and end of the intervention period, or at one year, in any group. There were no differences in changes in scores between groups. Two patients in the injection group went on to surgery, along with one each in the control and EMTP groups.

We have found no significant differences in outcome between steroid injections, a physiotherapy package, both treatments, or symptomatic treatment in our group of patients presenting with symptoms of painful arc of the shoulder.

Patients with spinal cord injuries have been seen to have increased healing of attendant fractures. This for the main has been a clinical observation with laboratory work confined to rats. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear.

This paper evaluates two groups with spinal column fractures – those with neurological compromise (n=10) and those without (n=15), and compares them with a control group with isolated long bone fractures (n=12). Serum was taken from these patients at five specific time intervals post injury (1 day, 5 days, 10 days, 42 days (6 weeks) and 84 days (12 weeks)). These samples were then analysed for levels of Transforming Growth Factor-Beta (TGF-β using the ELISA technique. This cytokine has been shown to stimulate bone formation after both topical and systemic administration.

Results show TGF-β levels of 142.79+/-29.51 ng/ml in the neurology group at 84 days post injury. This is higher than any of the other time points within this group (p=0.009 vs. all other time points, ANOVA). Furthermore, this level is also higher than the levels recorded in the no neurology (103.51+/-36.81 ng/ml) and long bone (102.28=/-47.58 ng/ml) groups at 84 days post-injury (p=0.009 and p=0.04 respectively, ANOVA).

In conclusion, the results of this work, carried out for the first time in humans, offers strong evidence of the causative role of TGF-β in the increased bone turnover and attendant complications seen in patients with acute spinal cord injuries.

Introduction

Previous work(1) has suggested that Spectral Colour Mapping (SCM) may have potential as an objective measurement tool for analysing Electromyography (EMG) data from spinal muscles, but the production and analysis of these maps is a complex undertaking. It would be beneficial for a system to create these maps and be useable with a minimum of training.

Background: Psychosocial factors are well-known contributors to the suffering and disability associated with common musculoskeletal problems. How to identify salient obstacles to recovery or return to work, and how to manage them effectively remains difficult. This project interpreted the evidence base and presented it as solution-focused guidance for everyday practical use by the key players (clinicians, employers, funders, case managers, etc) to help people remain active and working.

Methods and Results: Two methods were used to identify evidence and practical advice, and synthesize this into use-able statements:

existing reviews;

An extended conceptual development of a ‘flags framework’, based on the earlier approach of Yellow Flags, was used to prepare an easily understood and pragmatic approach. The framework integrates obstacles related to the person (yellow flags), the workplace (blue flags) and the context (black flags). A full-colour 32-page document suitable for distribution as both print and electronic media was developed. This contains a clear explanation of how to identify psychosocial flags, how to develop a plan to address them effectively, and how to take action to overcome the obstacles. Poster-style summaries for clinicians, the workplace, and the individual are included, and are available for download. International consultation was used to ensure system-independent applicability and language.

Conclusion: The new document provides practical guidance on identifying and managing psychosocial issues relevant to common musculoskeletal problems based on the latest evidence and conceptual approaches.

Conflict of Interest: none

Sources of Funding: Society for Back Pain Research, Faculty of Occupational Medicine, BackCare, Transport for London, Royal Mail, HCML, TSO

Background: Low back pain (LBP) can affect work ability. Retention of employment relies on appropriate management by employer and employee, and the healthcare that the employee may access. Healthcare in the UK has historically not been work-focused. The UK government has directed the NHS to play a greater role in enabling people with health conditions to remain in work.

Purpose: The aim of this study was to explore patients’ experiences of healthcare interventions regarding the management of work problems due to LBP.

Method: Individual semi-structured interviews were conducted with twenty-five LBP patients who had been referred for multidisciplinary back pain rehabilitation. All were in employment and concerned about their ability to work with LBP.

Findings: Although the participants had received a range of healthcare interventions, these had failed to alleviate their concerns about working with LBP. There was little evidence of work-related advice or interventions provided by any of the clinicians treating the participants. In a number of cases, patients had remained at work despite the recommendations they had received. Clinicians depended on the patient as an information channel rather than creating opportunities for ‘stakeholder’ dialogue and joint problem-solving.

Conclusions: Healthcare professionals need to improve their ability to explain the nature of persistent and recurrent LBP and to explore their patients’ concerns about working with pain. They should take more active steps to address those concerns, e.g. by communicating directly with employers where necessary, by advising patients how to address actual or perceived negative attitudes at work, and how to access modifications if required.

Conflicts of Interest: None

Source of Funding: Arthritis Research Campaign

The ideal acetabular component is characterised by reliable, long-term fixation with physiological loading of bone and a low rate of wear. Trabecular metal is a porous construct of tantalum which promotes bony ingrowth, has a modulus of elasticity similar to that of cancellous bone, and should be an excellent material for fixation.

Between 2004 and 2006, 55 patients were randomised to receive either a cemented polyethylene or a monobloc trabecular metal acetabular component with a polyethylene articular surface. We measured the peri-prosthetic bone density around the acetabular components for up to two years using dual-energy x-ray absorptiometry.

We found evidence that the cemented acetabular component loaded the acetabular bone centromedially whereas the trabecular metal monobloc loaded the lateral rim and behaved like a hemispherical rigid metal component with regard to loading of the acetabular bone. We suspect that this was due to the peripheral titanium rim used for the mechanism of insertion.

The purpose of this prospective study was to determine the predictive factors and hence optimal management of closed uncomplicated proximal radial fractures. We examined all patients presenting to our unit over an 18-month period with isolated closed proximal radial fractures. 237 consecutive patients were included. Demographic data, physical examination, radiographs, treatment and complications were recorded. Patients were reviewed at 2, 6, 12, 26 and 52 weeks post injury. Outcome was determined via functional assessment and Mayo Elbow Score (MES). Data were analysed using SPSS.

There were 156 (66%) radial head fractures and 81 (34%) radial neck fractures. 225 (95%) patients were treated non-operatively in a collar and cuff for one week followed by physiotherapy. 12 (5%) patients required primary surgical intervention due to either a mechanical block to forearm rotation (n=4) or a significant degree of radiographic comminution and/or displacement (n=8). Of the 201 patients who attended follow-up, 183 (91%) patients achieved excellent or good functional results measured on the MES. 155 (78%) patients achieved this by six weeks, with an average flexion arc of 125 degrees. Of the 12 patients treated operatively, the average MES at six weeks was fair (60). Regression analysis showed that increasing age, the AO-OTA fracture classification (B2.3, C2.3), radiographic displacement and operative treatment were significant predictors of a fair or poor outcome at six weeks.

The majority of isolated proximal radial fractures can be treated non-operatively with early mobilization, achieving excellent or good results within 6 weeks. Age, fracture classification, radiographic displacement and treatment choice are important factors that determine speed of recovery.

Introduction: The Rhys-Davies exsanguinator is a commonly used tool for exsanguinating upper or lower limbs in orthopaedic surgery. The use of same exsanguinators on a repetitive basis can cause cross contamination. This study was aimed at looking at the contamination of the Rhys-Davies exsanguinators in our hospital and comparing the results after cleaning it with a disinfectant wipe.

Materials and Methods: We used two standard methods to measure the contamination levels of the Rhys-Davies exsanguinators. In first method, we used rapid microbial ATP bioluminescence assay to detect contamination before and after cleaning of these exsanguinators. We did this test at four specified sites (outer top, outer bottom, inside top and inside bottom) after clearly marking them. Our second method was taking samples and using standard agar plates from the 24 sites of these 6 Rhys-Davies exsanguinators. We repeated the assay as well the swabs from all the sites, after cleaning these exsanguinators with Sani Cloth 70 Alcohol Wipes. We incubated these samples at 37 deg cel for 48 hours and kept them in enrichment cultures for 7 days.

Results: All sampled Rhys-Davies exsanguinators were heavily contaminated as revealed by both the methods. On bioluminescence assay, in some exsanguinators the count was 100 times more than normal (acceptable value is 30). Similarly all exsanguinators were colonised with bacterial count varying from 8 to > 350. Coagulase negative staphylococcus was the most commonly grown organism from the exsanguinators. After cleaning these tourniquets with Sani Cloth Wipes, there was 95% reduction in bioluminescence assay and 99% reduction in contamination from colony growth point of view, which is statistically significant (P=0.02).

Conclusion: Nine percent of hospital in-patients are believed to acquire an infection after their admission to hospital. Different organisms can raise different levels of concerns. Coagulase negative Staphylococcus from a skin swab is normal but it can be a major source for surgical site infections. The presence of any number of such organisms around a surgical site can be worrying. The presence of a single colony of other pathogenic organisms such as MRSA, Coliforms or Pseudomonas can be alarming if found on these devices. This study suggests that mechanical decontamination by cleaning with sani cloth wipes, then leaving it to dry completely for 15 minutes might reduce the level of contamination of these devices. Use of rapid R-mATP assay has added strength to our study as it requires only 5 min to complete, including sampling. This screening method can be used randomly to check whether protocols are being properly followed, regarding decontamination of such devices.

Introduction: Subtle deformity of the hip joint may cause osteoarthritis. In femoroacetabular impingement (FAI), cam deformities damage acetabular cartilage. Whether surgical removal of cam lesions halts progression is unknown. Sensitive, non-invasive assays of chondral damage are required to evaluate early treatment efficacy.

Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) permits inference of glycosaminoglycan (GAG) distribution. We aimed to determine whether hips with cam deformities have altered GAG content, using dGEMRIC.

Methods: Subjects were recruited from a prospective cohort study. All were clinically and radiographically assessed. Hips with a normal joint space width (> 2.5mm) were eligible for dGEMRIC. 32 Hips (18 male, 14 female, mean age 51.7 years, none of whom had been investigated for hip pain) with (n=21) and without (n=11) cam deformities were scanned.

2 regions of interest (ROI) were studied:

acetabular cartilage from 12 to 3 O’Clock (T1-Index-acet).

The average of all pixels within the given ROI defined the T1-index.

For each hip, the ratio of the GAG content T1-Index-acet/T1-Indextotal was calculated. Mean T1-Indexto-tal and T1-Indexacet/T1-Indextotal were compared.

Results: T1-Indextotal were similar (689ms v 700ms, p=0.79) but T1-Indexacet/T1-Indextotal was lower in cam hips (0.93 v 1.01, p=0.017), indicating localised depletion of GAG content. Cam hips with positive clinical signs had lower T1-Indextotal than cam hips without (629ms v 717ms, p=0.055), and non-cam hips (629ms v 722ms, p=0.049).

Discussion: Cam hips have lower GAG content of their anterosuperior acetabular cartilage. dGEMRIC identified more generalised disease in cases with positive clinical findings. Ratios of GAG content for specific ROIs enable mapping of chondral damage. This may aid understanding of early disease mechanisms, track progression, and facilitate assessment of the efficacy of surgical procedures.

Introduction: The ideal acetabular component has low wear, permanent fixation and physiological bone loading. Recently trabecular metal has been promoted as reproducing the modulus of trabecular bone with a cementless fixation. The aim of this trial was to see if a monobloc trabecular backed polyethylene acetabular component loaded the pelvis physiologically as a cemented polyethylene component.

Method: Between 2004 and 2006 54 patients were ran-domised to a cemented polyethylene acetabular component versus a monobloc trabecular backed polyethylene acetabular component. The primary outcome measurement was bone density in peri-prosthetic acetabular regions of interest measured preoperatively and post operatively at 6 weeks and 1 year. Secondary outcomes measured were radiographic and functional outcomes (HHS and Oxford score).

Results: Radiographically 8 patients in the trabecular group had a significant gap in zone II which resolved in 6 by 1 year. The cemented group had 3 patients with a radiolucent line (zone 1) at 1 year. HHS and OXFORD scores improved with no significant difference between the groups. Both groups had significant loss of bone density in the ilium and ischium. The trabecular group produced a significant increase in bone density in the superolateral region. The cemented group produced increased bone density in the superomedial region.

Discussions and Conclusions: There is a significant reduction in BMD for both groups in the upper pelvis and ischium in keeping with finite element modelling predictions. The press-fit group relative to the cemented group resulted in decreased BMD in the superomedial peri-prosthetic region. The trabecular monobloc cup therefore behaves more like a rigid cementless shell despite the properties of trabecular metal.

Purpose: To determine if early MRI diagnosis in the acutely injured knee affects management, use of resources and patient satisfaction compared to conventional management with physiotherapy.

Methods: Patients referred to fracture clinic with acute knee injury in whom a specific clinical diagnosis could not be made were randomised to one of two groups. The MRI group had a scan within 2 weeks and were then reassessed in clinic with management according to the results. The control group received physiotherapy and then reassessed. Patients were assessed in clinic on presentation, at 2 weeks and then by a telephone questionnaire at 3 months. Electronic medical records were also reviewed.

Results: 48 patients were recruited in total: 23 in the MRI group (78.2% male, 21.8% female) and 25 in the control group (68% male, 32% female). The mean age was similar in the two groups (29 years (range 18–61) vs. 30 years (18–50)). The MRI group had significantly less physiotherapy appointments (5 ± 3.42 vs. 2.52 ±1.93, p=0.003) on average until definitive treatment but not outpatient appointments (2.72 ± 1.1 vs. 2.43 ±0.66, p=0.27). Median time to surgery was less in the MRI group (138 (31–199) vs.180 days (33–826) vs.) but not statistically significant (p=0.19). A similar number of patients returned to work in both groups (82.6% vs. 76%) but the MRI group had less time off work (15.82 ±22.26 vs. 20.56 ±25.38 days, p=0.48) and statistically better satisfaction scores (2 ±2.68 vs. 3.5 ±2.75, p=0.048) than the control group.

Conclusion: We have shown that early MRI in acute knee injury can provide early diagnosis of internal derangement and therefore allow targeted treatment. These patients had significantly less physiotherapy appointments and less time off work which may offset the cost of the MRI. Moreover these patients were significantly more satisfied with the service.

We carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by open reduction and internal fixation in 45 patients by a single surgeon between 1993 and 2001. The fractures were evaluated before operation by plain radiographs and a CT scan using Sanders’ classification. Osteosynthesis involved a lateral approach and the use of the AO calcaneal plate. The mean follow-up was for ten years (7 to 15). Clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS), the Creighton-Nebraska Score, the Kerr, Prothero, Atkins Score and the SF-36 Health Questionnaire. The radiological evaluation consisted of lateral and axial views of the os calcis. Arthritic changes in the subtalar joint were assessed with an internal oblique view and were graded using the Morrey and Wiedeman scale.

There were 18 excellent (38.3%), 17 good (36.2%), three fair (6.3%) and nine poor (19.2%) results. Five patients had a superficial wound infection and five others eventually had a subtalar arthrodesis because of continuing pain. Restoration of Böhler’s angle was associated with a better outcome. The degree of arthritic change in the subtalar joint did not correlate with the outcome scores or Sanders’ classification. Prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum in order to restore the shape of the hindfoot and Böhler’s angle.

Purpose: Bone grafting of subchondral voids during ORIF of tibial plateau fractures is commonly performed. The efficacy of various graft materials to resist post-operative articular displacement and stimulate bone regeneration in the grafted zone, remains largely unstudied. Studies in animals with a new composite material have shown that this composite material leads to greater bone formation and stronger bone versus autograft at 13 and 26 weeks. This study was designed to determine whether this material helps resist articular fragment displacement and leads to stronger bone regeneration and better functional outcome in the treatment of tibial plateau fractures.

Methods: Thirty four patients with unilateral tibial plateau fractures (OTA 41A-B), were enrolled in a prospective multicenter single cohort study. The treatment protocol included ORIF and defect augmentation with a composite bone graft substitute (PRODENSE®, Wright Medical Technology). Reduction and bone formation was evaluated and followed with both plain radiographs and CT scans obtained immediately postop and at 12 and 24 weeks. Functional outcome was assessed using the SMFA scores. CT analysis was performed by an independent musculoskeletal radiologist who quantified maintenance of reduction of the articular surface and bone density within the grafted area.

Results: Eighteen of the 34 enrolled patients were eligible for follow-up at 24 weeks (sixteen were not yet eligible for the 24 week time point). Mean change in articular reduction was 0.75mm, Density measures in the region of the initial subchondral void decreased from a mean of 1400 Hounsfield units at baseline (immediately post-op) to 600 at 24 weeks, suggesting bone regeneration and normal remodeling. Short form Musculoskeletal Function Assessment activity scores improved from 55.15 (SD=42.8) at baseline to 20.92 (SD=18.09) at 24 weeks. Complications include 1 DVT, 3 infections and 1 cellulitis, all of which resolved. There was an additional infection that required revision of the ORIF.

Conclusions and Significance: Serial CT evaluations revealed maintenance of post-operative reduction with displacement of less than 1mm. Bone density, in the region of the grafted area was near normal and confirms that the composite graft material promotes strong bone regeneration. Functional outcomes improved with time from surgery and approached that of uninjured cohorts.

Purpose and Background: Physiotherapeutic management of lumbar disorders often incorporates specific manual therapy techniques of which McKenzie’s lumbar extension exercises (EIL) and segmental rotational grade V manipulation are popular options. The use of proxy measures of sympathetic nervous system (SNS) activity (skin conductance) is a recognised method of ascertaining neurophysiological responses to physiotherapy treatment but have yet to be used to assess magnitude of response to lumbar techniques. This preliminary study aimed to investigate the neurophysiological effects of these two treatment techniques.

Methodology: A quasi-experimental, independent group’s design was utilised, with random allocation of 50 normal, healthy participants (25 per group) into a manipulation group or an EIL group. Non-invasive neurophysiological measurements of skin conductance were taken as a proxy-measure of sympathetic nervous system (SNS) activity in the lower limbs before, during and after the administration of the techniques. Results were calculated using Area Under the Curve readings and converted into percentage change calculations for the intervention and the post-intervention periods.

Results: Both treatments increased SNS activity during the intervention period, 76% for the manipulation group (p=0.0005) and 35% for EIL group (p=0.0005) with the manipulative technique having significantly greater effect (p=0.012). Further analysis of the manipulation group found no difference between the ‘opening’ and the ‘closing’ side of the technique (p=0.76).

Conclusion: Preliminary evidence now exists supporting the neurophysiological effects of two lumbar techniques and that manipulation has a greater magnitude of effect over the EIL technique. Future research, on a low back pain patient population, is proposed and projected sample size calculations computed.

Introduction: There is controversy regarding the effectiveness of PRC for bone healing. A possible explanation is the different bone graft substitutes (BGSs) used with PRC. Here we investigated the effect of combining different BGSs with PRC on hBMSCs differentiation and growth factor release from the BGS/PRC composites.

Method: hBMSCs, DBM and allograft were prepared from femoral heads donated by patients undergoing total hip replacement. Growth factor release (TGF-â, VEGF, PDGF-AB, BMP-2) was measured by ELISA. The effect of PRC on hBMSC differentiation was determined by ALP activity and mineralisation. PRC was produced using the CAPTION device (S& N) from 10 healthy volunteers.

Results: Combining PRC with BGSs increased hBMSC proliferation (p< 0.05) and decreased ALP activity (p< 0.05) compared to DBM or â-TCP (GenOS, S& N) alone, but had no effect on allograft following 3 and 5 days treatment. After 21 days PRC enhanced mineralisation compared to all BGSs alone (16%–56%). Compared to PRC alone addition of DBM and allograft increased proliferation (p< 0.05), decreased ALP activity (p< 0.005) and decreased mineralisation (p< 0.005). TGF-â, VEGF and BMP-2 release from PRC was unaffected when combined with DBM but PDGF-AB release was reduced by 50%.

Conclusions: Combining PRC with the majority of BGSs enhanced cell proliferation and decreased osteoblastic differentiation at early time points but increased total mineralisation compared to the BGSs alone. However, compared to PRC alone combining DBM or allograft with PRC reduced mineralisation. One potential explanation for the effects of combining PRC with DBM is altered growth factor release profiles compared to the components alone.

Patients with spinal cord injuries have been seen to have increased healing of attendant fractures. While the benefits are obvious, this excessive bone growth also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear.

This paper evaluates two groups with spinal column fractures – those with neurological compromise (n=10) and those without (n=15), and compares them with a control group with isolated long bone fractures (n=12). Serum was taken from these patients at five specific time intervals post injury (1 day, 5 days, 10 days, 42 days (6 weeks) and 84 days(12 weeks)). These samples were then analysed for levels of Transforming Growth Factor-Beta (TGF-.) using the ELISA technique. This cytokine has been shown to stimulate bone formation after both topical and systemic administration.

Results show TGF-.; levels of 142.79±29.51 ng/ml in the neurology group at 84 days post injury. This is higher than any of the other time points within this group (.0.009 vs. all other time points, ANOVA). Furthermore, this level is also higher than the levels recorded in the no neurology (103.51±36.81 ng/ml) and long bone (102.28±47.58 ng/ml) groups at 84 days post injury (p=0.009 and p=0.04 respectively, ANOVA).

In conclusion, the results of this work, carried out for the first time in humans, offers strong evidence of the causative role of TGF-.; in the increased bone turnover and attendant complications seen in patients with acute spinal cord injuries.

Despite tendencies for Claims against medical practitioners around Australia to fall, litigation continues to be a burden on individual practitioners and the system.

Unlike Claims frequency, Claims costs are not falling and indemnity insurance remains a significant practice cost.

Data is presented to illustrate some trends in litigation and illustrative cases are also presented to outline some of the difficulties in defending Claims.

Particular emphasis on the degree of difficulty is made in respect of Epidural Abscess.

Leptin is a major hormonal product of the adipocyte which regulates appetite and reproductive function through its hypothalamic receptors. It has now become clear that leptin receptors are much more widely distributed than just the hypothalamus, and the skeleton has emerged as an important site of action of leptin.

The signalling form of the leptin receptor has been found in several cell types including human osteoblasts, rat osteoblasts and human chondrocytes. In vitro we have shown leptin to an anabolic factor, stimulating osteoblast proliferation and inhibiting osteoclastogenesis. Leptin increases bone mass and reduces bone fragility when administered peripherally but has an indirect inhibitory effect on bone mass via the hypothalamus when administered directly into the central nervous system.

Data from animal models where there is an absence of either leptin production (ob/ob) or its receptor (db/db) have been contradictory. In this study we compared the bone phenotype of leptin receptor-deficient (db/db) and wild-type (WT) mice. Micro-CT analysis was done on proximal tibiae using a Skyscan 1172 scanner. Db/db mice had significantly reduced trabecular bone volume, trabecular thickness and trabecular number and a higher degree of trabecular separation. Cortical bone was also significantly lower in db/db animals in volume, cross-sectional thickness and perimeter.

These results demonstrate that in the absence of leptin signalling there is reduced bone mass indicating that leptin indeed acts in vivo as a bone anabolic factor, mimicking the in vitro results.

Adiponectin, a hormone secreted by adipocytes, regulates energy homeostasis and glucose and lipid metabolism. Plasma levels of adiponectin are negatively correlated with body fat mass. Adiponectin inhibits the formation and activity of osteoclasts and increases the proliferation and differentiation of osteoblasts in vitro. The aim of our study was to determine the bone phenotype of adiponectin knockout mice.

Male adiponectin-deficient (Ad-KO) and wild-type (WT) C57BL/6J mice were sacrificed at 8, 14 and 22 weeks of age. Body weights did not differ between Ad-KO and WT mice. We scanned the left proximal tibia using micro-CT at 5μm resolution and analysed bone microarchitecture by 3D analysis.

We found significant increases in trabecular bone volume (BV/TV) (15.9±1.63 vs. 12.2±0.72%, p=0.02) and trabecular number (3.20±0.18mm-1 vs. 2.32±0.12mm-1, p=0.0009) in 14-week old Ad-KO mice compared to controls. Similar differences between WT and Ad-KO were present in 8 and 22-week old animals but these did not reach statistical significance. Trabecular thickness was significantly greater (0.053±0.001mm vs. 0.048±0.002mm, p=0.04) in 22-week old Ad-KO mice compared to WT.

Ad-KO mice have increased number and volume of trabeculae at 14 weeks of age indicating that the net effect of adiponectin on bone accrual in vivo is inhibitory. These effects are age-dependent. Our data concur with the observations from epidemiological studies in humans that adiponectin negatively correlates with both fat mass and bone mass. Therefore, adiponectin may be a contributor to the link between fat and bone mass.

The current standard of care in Calgary, Alberta for management of a ruptured Achilles tendon is surgical repair, typically performed following admission to hospital. The primary objective of this study was to compare the costs of hospital treatment and complications associated with the surgical repair of Achilles tendon ruptures between two groups of patients: Group One = patients enrolled in the randomised clinical trial (RCT) Multicentre Achilles Tendon Treatment Study (MATTS), Group Two = all other non-study patients.

This observational cohort study analyzed all patients surgically treated for Achilles tendon ruptures at Calgary area hospitals over a three-year period (October 2002–September 2005). Inclusion criteria: age eighteen to seventy years, acute rupture.

A total of two hundred and eighty-two patients met the inclusion criteria; thirty-three patients were included in Group One, two hundred and forty-nine patients in Group Two. In Group One, twenty-seven patients (82%) were treated as outpatients, five patients (15%) were ADOP-24hr, and one patient (3%) was admitted. In Group Two, twenty-seven patients (11%) were treated as outpatients, ninety-five patients (38%) were ADOP-24hr, and one hundred and twenty-seven patients (51%) were admitted. The total costs for patients treated as outpatients and requiring overnight stays in Group One were $18,408 and $7,419, respectively. In Group Two, the total cost for outpatients was $18,071 compared to $379,496 for non-study patients requiring overnight stay. If all overnight patients in each group were treated as outpatients, the total savings would be $235,545. There were no serious complications in Group One. In Group Two, complications included two cases of pulmonary embolus, and one case of compartment syndrome requiring readmission. All complications resolved.

Surgical treatment of Achilles tendon rupture can be performed safely and at less cost on an outpatient basis. Participation in this RCT has allowed us to recommend a change in the standard of care in Calgary.

Intramedullary Nailing is now accepted as the standard treatment for most femoral diaphyseal fractures. Most intramedullary nails are designed for proximal and distal locking with screws. We describe our experience with the Brooker Wills femoral nail. This nail is unique as distal fixation is achieved with as transverse fixator deployed through slots in the nail, a concept first enunciated by deCamargo in 1952. The fins of the fixator pierce the distal cortex when deployed thereby conferring rotational stability. The entire nail (including the proximal and distal fixation devices) can be inserted through a single proximal incision in the skin.

We treated 17 patients with femoral shaft fractures using this system. 93% of the patients were males. Motor vehicle accidents accounted for 80 % of the fractures. Most fractures involved the middle third of the femur (54%), followed by distal third (33%) and proximal third (13%). 67 % of the fractures showed Winquist and Hansen Grade 3 or 4 comminution.

All the nailings were performed in the supine position. Static locking was done in 16 cases. Post operative weight bearing was individualized with 86% of the patients bearing full weight before the end of 16 weeks. The average time to full weight bearing was 14 weeks.

The mean time to union was 17.1 weeks, with proximal, middle and distal third fractures showing average healing times of 19, 15.6 and 18.8 weeks respectively. All the fractures united. There was one case of delayed union. Intra-operative complications included–inability to deploy the distal fixator in one case and unwinding of the reamer in another case. There was one case of superficial infection where a patient developed a sinus over the metallic fin of the distal fixation device, which had penetrated the cortex. This healed after the distal fixation device was removed. There was one case of proximal nail migration, but the fracture went onto union with some limb shortening.

Results were evaluated using the scoring system devised by Sanders etal (1991). The functional criteria in their scoring system include- knee flexion, presence of pain, femur deformity, walking distance, stair climbing and pre injury functional status. We achieved excellent results in 53% of patients, good- 27%, fair–13 % and poor-7%.

We feel that the main advantage of the Brooker Wills Nail is the ease of distal locking. This saves time and also leads to lower level of radiation exposure, as the image intensifier is sparingly used for distal locking. In fact, this nail is an attractive option in centres which lack an image intensifier. We achieved good results with this nailing system and feel that it is an acceptable alternative to other nailing systems with conventional locking systems with screws.

Introduction and aims: Soft tissue defects after total knee arthroplasty (TKA) are difficult problems to treat. Flap surgery has been successful in salvaging the prostheses. We present results of flap surgery for exposed TKAs over a 10 year period performed by single surgeon.

Material and Methods: Between 1996 and 2005, 31 patients (32 knees) underwent flap surgeries for TKAs. Four of these procedures were done prophylactically in patients with previous knee surgeries. Gastrocnemius, medial fasciocutaneous and anterior compartment flaps were used either solely or in combination based on the size of the defect. The data was collected retrospectively from case-notes and correspondence from the treating orthopaedic surgeons.

Results: The patients were aged between 50 and 94 years. Indication for primary TKA was osteoarthritis in 25 patients and rheumatoid arthritis in 5. Coagulase negative Staph. aureus was the most commonly isolated organism. In patients using steroids, 4 of 6 (71.4%) knees had good or satisfactory outcome compared to 22 of 24 (91.7%) knees in patients not on steroids. Smoking did not influence the outcome of flap surgery . The average duration between the TKA and flap surgery was 11 weeks (range 1 – 52). Successful soft tissue cover was achieved in 30 of 32 knees (94%). Overall, TKA was salvaged in 20 of 28 knees (71.4%) knees, 3 knees (9.7%) underwent arthrodesis and above knee amputation was performed in 4 (12.4%). The information gathered from case notes and orthopaedic surgeons was insufficient to use a knee score for evaluating the functional outcome of the procedure.

Conclusion: Local flap surgery for providing soft tissue cover for exposed TKA is a viable and successful procedure with good results.

The aim of this randomised, controlled trial is to compare subacromial steroid injections, physiotherapy and both interventions with a control treatment in early painful arc of the shoulder.

Over a six-month period patients with “painful arc”, of less than six months duration, were recruited via their GPs. Eligible patients were consented to enter the trial and were then randomised, by sealed envelopes, to one of four arms of the study: control (normal analgesia and/or non-steroidal anti-inflammatory medication), a specified and repeatable Exercise and Manual Therapy Package (EMTP), a course of up to three subacromial steroid injections or both the EMTP and the steroid injections. The interventions and clinic follow-ups were over an 18-week period. A final postal questionnaire was sent out at one year. The progress of the patients was monitored using the Oxford Shoulder Score (OSS) and the SF36 general health questionnaire.

Seventy-nine GPs referred 186 patients, of whom 112 were randomised (Control=27, EMTP=29, Injections=28, Both=28). 64 patients were female and 48 male. The mean age was 54.5 years (range 23–88 years). Ninety patients completed the trial (Control=20, EMTP=22, Injections=26, Both=22). Sixty-two returned the follow-up questionnaire. By paired sample t-tests, no significant differences were found between the OSS scores or SF-36 (physical health total) at the beginning and end of the intervention period, or at one year. Two patients in the injection group went on to surgery, along with one each in the control and EMTP groups.

We have found no significant differences in outcome between steroid injections, a physiotherapy package, both treatments, or symptomatic treatment in our group of patients presenting with symptoms of painful arc of the shoulder.

Background: Each year, 7% of the adult population consult their General Practitioner (GP) with low back pain (LBP). Approximately half of these patients still experience disabling pain after three months. Evidence suggests a biopsychosocial approach may be effective at reducing long-term pain and disability. This study aimed to evaluate, for persistent disabling LBP, the effectiveness of an exercise, education and cognitive behavioural therapy intervention compared to usual GP care plus educational material, and to investigate the effect of patient preference.

Method: Design: randomised controlled trial. Patients, aged 18–65yrs, consulting their GP with LBP were recruited. After 3 months those still reporting disabling LBP (≥20mm on 100mm pain visual analogue scale (VAS) and ≥5 Roland and Morris Disability Questionnaire (RMDQ) points) were randomised, having first established preference, to 2 groups. VAS and RMDQ were assessed at 0, 6, and 12-months post-intervention.

Results: 234 patients were randomised; 116 to the intervention. The intervention showed small non-significant effects at reducing pain (3.6mm) and disability (0.6points RMDQ) over one year. Preference showed significant interaction with treatment effect at one-year; patients had better outcomes if they received their preferred treatment.

Conclusion: The above intervention program produces only a modest effect in reducing LBP and disability over a one-year period. These results add to accumulating evidence that interventions for LBP produce, at best, only moderate benefits. The challenge for future research is to evaluate interventions tailored for specific LBP sub-populations. These results suggest that if patients receive treatment which they believe is beneficial their outcome can be optimised.

Introduction: Shoulder pain represents a significant burden of disease in the general population, yet there is a lack of evidence about the effectiveness of routinely used interventions such as corticosteroid injection and physiotherapy.

Methods: Over a six-month period patients with “painful arc” of less than six months duration were recruited via their GPs.

Eligible patients randomised to one of four arms of the study: control (normal analgesia and/or non-steroidal anti-inflammatory medication), a specified and repeatable Exercise and Manual Therapy Package (EMTP), a course of up to three subacromial steroid injections or both the EMTP and the steroid injections. Follow-up was for 18 weeks, with postal questionnaire at one year.

The primary outcome measure was the Oxford Shoulder Score (OSS).

Results: 186 patients were referred, 112 were randomised. Mean age was 54.5 years. Ninety patients completed the trial. Sixty-two returned the follow-up questionnaire.

By analysis of covariance, no significant differences were found between the OSS scores or SF-36 (physical health total) at the beginning and end of the trial, or at one year. Two patients in the injection group went on to surgery, along with one each in the control and EMTP groups. No significant differences were found between treatment groups.

Conclusion: We have found no significant differences in outcome between steroid injections, physiotherapy, both treatments, and symptomatic treatment in a group of patients with early painful arc of the shoulder. Further, larger studies may be needed to find small differences in outcome between these treatments.

We undertook a prospective randomised controlled trial to investigate the efficacy of autologous retransfusion drains in reducing the need for allogenic blood requirement after unilateral total knee replacement. We also monitored the incidence of post-operative complications. There were 86 patients in the control group, receiving standard care with a vacuum drain, and 92 who received an autologous drain and were retransfused postoperatively. Following serial haemoglobin measurements at 24, 48 and 72 hours, we found no difference in the need for allogenic blood between the two groups (control group 15.1%, retransfusion group 13% (p = 0.439)). The incidence of post-operative complications, such as wound infection, deep-vein thrombosis and chest infection, was also comparable between the groups. There were no adverse reactions associated with the retransfusion of autologous blood.

Based on this study, the cost-effectiveness and continued use of autologous drains in total knee replacement should be questioned.

We studied 33 third generation, alumina ceramic-on-ceramic bearings retrieved from cementless total hip replacements after more than six months in situ. Wear volume was measured with a Roundtest machine, and acetabular orientation from the anteroposterior pelvic radiograph. The overall median early wear rate was 0.1 mm³/yr for the femoral heads, and 0.04 mm³/yr for the acetabular liners. We then excluded hips where the components had migrated. In this stable subgroup of 22 bearings, those with an acetabular anteversion of < 15° (seven femoral heads) had a median femoral head wear rate of 1.2 mm³/yr, compared with 0 mm³/yr for those with an anteversion of ≥15° (15 femoral heads, p < 0.001). Even under edge loading, wear volumes with ceramic-on-ceramic bearings are small in comparison to other bearing materials. Low acetabular anteversion is associated with greater wear.

The mechanism by which cells die is important in an immune response and its resolution. The role of apoptosis in sepsis and trauma, and its regulation by cytokines is unclear. During the systemic inflammatory response, rates of human neutrophil apoptosis are decreased. Peritoneal macrophage apoptosis has been induced by nitric oxide and Lipopolysaccharide (LPS) in vitro but this has not as yet been demonstrated in vivo.

We examined the induction and effects of macrophage apoptosis in a model of trauma and sepsis.

One hundred female CD-I mice were randomised into four groups: Control, Septic model, challenged with intraperitoneal LPS (1.Img/200ul/mouse), Traumatic model, received hind limb amputation (HLA) and a Combined trauma/septic model. After 24 hrs mice were sacrificed and peritoneal macrophages were assessed for apoptosis by morphology and DNA fragmentation by flow cytometry and DNA gel electrophoresis

Peritoneal lavage from septic models had a decreased percentage of macrophages in comparison to control and trauma groups. The septic model also had a significantly increased incidence of apoptosis in comparison to control and trauma levels. There was no significant difference between control and traumatic groups.

These findings demonstrate that in a murine model of sepsis, lipopolysaccharide induces macrophages apoptosis. Modulation of this immune response may have important roles in the management of trauma patients.

We compared peri-prosthetic bone mineral density between identical cemented and cementless LCS rotating platform total knee arthroplasties. Two matched cohorts had dual energy x-ray absorptiometry scans two years post-operatively using a modified validated densitometric analysis protocol, to assess peri-prosthetic bone mineral density. The knee that was not operated on was also scanned to enable the calculation of a relative bone mineral density difference. Oxford Knee and American Knee Society scores were comparable in the two cohorts.

Statistical analysis revealed no significant difference in absolute, or relative peri-prosthetic bone mineral density with respect to the method of fixation. However, the femoral peri-prosthetic bone mineral density and relative bone mineral density difference were significantly decreased, irrespective of the method of fixation, particularly in the anterior distal portion of the femur, with a mean reduction in relative bone mineral density difference of 27%.

There was no difference in clinical outcome between the cemented and cementless LCS total knee arthroplasty. However, both produce stress-shielding around the femoral implants. This leads us to question the use of more expensive cementless total knee components.

Aseptic loosening is the single most important long-term complication of total joint arthroplasty. Wear debris induced inflammation stimulates osteoclastic resorption of bone. Cellular mechanisms involved in osteoblast viability in PWD induced inflammation is poorly understood.

Wear induced inflammation increases osteoblast necrosis and susceptibility to death by apoptosis. PMMA cement has a detrimental effect on osteoblast resistance to apoptosis, and that this is via an receptor mediated pathway. Osteoblast cell cultures (Human and MG63) were grown with and without PMMA cement and assessed for apoptosis and necrosis. TNF-α or Fas antibody simulated inflammation. Viability and apoptosis with PI exclusion, flow cytometry and western blotting assessed response.

Cement induced osteoblast necrosis up to 1 hour. This effect was negated after 24 hours. Culture of osteob1asts on cement had no direct effect on spontaneous apoptosis but susceptibility to inflammation was increased.

Polymerised cement has no direct effect on osteoblast cell death. Effects are mediated by inhibiting expression of anti-apoptotic protein (Bcl-2), and increasing susceptibility to inflammatory. Osteoblast resistance to death may represent a novel and important factor in aseptic loosening. The role of gene therapy is explored.

Injuries to the spinal cord may be associated with increased healing of fractures. This can be of benefit, but excessive bone growth can also cause considerable adverse effects.

We evaluated two groups of patients with fractures of the spinal column, those with neurological compromise (n = 10) and those without (n = 15), and also a control group with an isolated fracture of a long bone (n = 12). The level of transforming growth factor-beta (TGF-β), was measured at five time points after injury (days 1, 5, 10, 42 and 84).

The peak level of 142.79 ng/ml was found at day 84 in the neurology group (p < 0.001 vs other time points). The other groups peaked at day 42 and had a decrease at day 84 after injury (p ≤ 0.001).

Our findings suggest that TGF-β may have a role in the increased bone turnover and attendant complications seen in patients with acute injuries to the spinal cord.

Increased bone turnover and fracture healing is associated with acute spinal cord injuries. Experimental work to date has been confined to animal models. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi.

This paper evaluates two groups of patients with spinal column fractures – those with neurological compromise and those without, and compares them with a control group with isolated long bone fractures. Serum was taken from these patients at 10 days post injury and was analysed for the known osteogenic cytokines Insulin-like Growth Factor-1 (IGF-1) and Transforming Growth Factor-b1 (TGF-b1) as well as being added to an osteoblast cell culture line to analyse cell proliferation.

The results for the IGF-1 show a higher level in the neurology group compared to the no neurology group (p=0.038). In the TGF-B1 assay, the neurology group has a lower level than the other two groups (p< 0.0001 and p=0.002 respectively). However, when this group is subdivided into patients with complete and incomplete neurology, it can be seen that the levels of the complete group are elevated, although not significantly so (p=0.228).

All three groups stimulated markedly increased osteoblast cell proliferation versus a control group (p=0.086, p=0.005 and p=0.002 respectively). However, the neurology group is significantly lower than the other two groups (p=0.007 and p=0.001 respectively). Furthermore the complete group causes a lower proliferation rate than the incomplete group (p=0.539).

In conclusion, at 10 days post injury when the acute inflammatory reaction is subsiding and new bone is being laid down, patients with acute spinal cord injuries have increased bone turnover. This increase is being indirectly mediated by IGF-1, and more elevated levels with more severe neurological compromise suggest a contributory role of TGF-b1. Direct stimulation of osteoblasts does not appear to have any role to play in this accelerated bone healing.

Patients with spinal cord injuries have been seen to have increased healing of attendant fractures. This for the main has been a clinical observation with laboratory work confined to rats. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear.

This paper evaluates two groups with spinal column fractures – those with neurological compromise (n=10) and those without (n=11), and compares them with a control group with isolated long bone fractures (n=10). Serum was taken from these patients at five specific time intervals post injury (1 day, 5 days, 10 days, 42 days (6 weeks) and 84 days(12 weeks)). These samples were then analysed for levels of Transforming Growth Factor-Beta (TGF-b) using the ELISA technique. This cytokine has been shown to stimulate bone formation after both topical and systemic administration.

Results show TGF-b levels of 142.79+/−29.51 ng/ml in the neurology group at 84 days post injury. This is higher than any of the other time points within this group (p< 0.001 vs. day 1, day 5 and day 10 and p=0.005 vs. 42 days, ANOVA univariate analysis). Furthermore, this level is also higher than the levels recorded in the no neurology (103.51+/−36.81 ng/ml) and long bone (102.28=/−47.58 ng/ml) groups at 84 days post injury (p=0.011 and p=0.021 respectively, ANOVA univariate analysis). There was statistically significant difference in TGF-b levels seen between the clinically more severely injured patients i.e. complete neurological deficit and the less severely injured patients i.e. incomplete neurological deficit.

In conclusion, the results of this work, carried out for the first time in humans, offers strong evidence of the causative role of TGF-b in the increased bone turnover and attendant complications seen in patients with acute spinal cord injuries.

Introduction: Historically, it has been accepted that the pain associated with arthritis of the hip is usually located in the groin, anterior and lateral thigh with occasional radiation to the anterior knee. Patients complaining of thigh pain that extends below the knee are often considered to have a degenerative lumbar spine as the cause for their lower limb symptoms and total hip replacement (THR) may not be offered.

Following review of data regarding the preoperative distribution of pain in 2000 patients attending for hip replacement, it was noted that 40% of these patients had complained of pain at or below the knee.

We proposed to prospectively investigate the severity and location of pain in patients attending for THR and assessed how this distribution of pain altered following surgery. We also proposed to examine the distribution of radiological wear preoperatively and assess if there is any relationship between localisation of pain, and the severity or distribution of the radiological wear pattern.

Methods: 200 consecutive patients undergoing primary THR completed a questionnaire regarding the location and severity of their pain. Pain was localised to one or more of nine areas extending from low back to the foot. The localisation of pain was quantified as to severity using a visual analogue score. Questionnaires were completed both 4 weeks preoperatively and subsequently at a 3-month review clinic.

All patients underwent a standardised preoperative AP and Lateral x-ray. The AP film was divided into three areas, and the lateral film was divided into 5 areas. Each zone was assessed as to the severity of wear pattern and graded from 1–3 (no change in joint space, decreased joint space, femoral or acetabular destruction).

Results: The 200 patients complained of pain in a total of 980 areas preoperatively and 105 areas postoperative. 70% of the patients had complete relief of all pain at 3 months. The most common area of pain identified by patients was to the anterior aspect of the knee (82%), followed by pain at the greater trochanter and groin. 55% patients complained of pain extending to below the knee, mostly over the anterolateral aspect of the leg. Only 7% of these patients continued to complain of any below knee pain postoperatively, and all of these patients still had some relief of their below knee pain at review.

With regard to the frequencies and severity of x-ray changes, zone-1 (34%) was most commonly severely damaged with femoral and/or acetabular destruction in the AP film, with the anterior and anterolateral areas being most commonly affected areas in the lateral film (20% and 19% respectively).

When the distributions and severities of x-ray changes were correlated with the distribution of pain localised pre and postoperatively we were unable to show any association between the degree of radiological wear in any one zone and the locatin of pain identified by the patient. In fact, there was a normal distribution to the severity of radiological damage between each of the zones and localisation of pain in any of the 9 areas.

Conclusions: A significant number of patients who require hip arthroplasty have pain extending below the knee. This pain is frequently relieved following THR. The commonest area of sever hip joint wear with loss of femoral or acetabular bone is antero-superiorly. It is important to recognise this during surgery, such that action can be taken to ensure appropriate reaming such that subsequent correct tissue tension and leg lengths are achieved. We are unable to show any relationship between area of pain and area of radiological degeneration. We believe that patients who complain of pain in their back, buttock or thigh, which extends below the knee, can still benefit from total hip replacement. Patients who attend complaining of low back pain with radiation of pain down their leg should have their hips as well as their lumbar spine examined and imaged. Careful consideration should be taken before labelling the paid as being referred from degenerative back disease.

Patients with spinal cord injuries have been seen to have increased healing of attendant fractures. This for the main has been a clinical observation with laboratory work confined to rats. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear.

This paper evaluates two groups with spinal column fractures – those with neurological compromise (n=10) and those without (n=11), and compares them with a control group with isolated long bone fractures (n=10). Serum was taken from these patients at five specific time intervals post injury (1 day, 5 days, 10 days, 42 days (6 weeks) and 84 days (12 weeks)). These samples were then analysed for levels of Transforming Growth Factor-Beta (TGF-ß) using the ELISA technique. This cytokine has been shown to stimulate bone formation after both topical and systemic administration.

Results show TGF-ß levels of 142.79+/−29.51 ng/ml in the neurology group at 84 days post injury. This is higher than any of the other time points within this group (p< 0.001 vs day 1, day 5 and day 10 and p=0.005 vs 42 days, ANOVA univariate analysis). Furthermore, this level is also higher than the levels recorded in the non neurology (103.51+/−36.81 ng/ml) and long bone (102.28=/−47.58 ng/ml) groups at 84 days post injury (p=0.011 and p=0.021 respectively, ANOVA univariate analysis). There was statistically significant difference in TGF-ß levels seen between the clinically more severely injured patients, ie complete neurological deficit and the less severely injured patients, ie incomplete neurological deficit.

In conclusion, the results of this work, carried out for the first time in humans, offers strong evidence of the causative role of TGF-ß in the increased bone turnover and attendant complications seen in patients with acute spinal cord injuries.

Study Design: The effects of heat on porcine intertvertebral disc were studied experimentally.

Objective: To assess the effects of in-vitro heating of porcine nucleus pulposus on expression of inducible heat shock protein 70 and subsequent modification of biochemical responses to an inflammatory insult in the heated intervertebral disc tissue.

Subjects: Lumbar spines were harvested from six pigs. The nucleus pulposus was dissected from each intervertebral disc, divided into control (37°C) and heat shocked (42°C) groups then cultured in medium for one hour. All samples were then cultured at 37 C for a further two hours. After three hours tissue and supernatant were harvested from one third of the samples and the expression of inducible heat shock protein 70 (HSP70) was quantified via Western immunoblotting and enzyme linked immuno-sorbent assay (ELISA). The remaining samples were cultured either in normal medium or altered (pro-inflammatory) medium containing 5ug/ml bacterial lipopolysaccharide (LPS). At 24 hours the supernatant from these samples was analysed for both interleukin-8 (IL-8) and prostaglandin E2 (PGE2) secretion using ELISA.

Outcome Measures: Western immunoblotting and enzyme linked immuno-sorbent assay (ELISA) for heat shock protein 70. ELISA for interleukin-8 (IL-8) and prostaglandin E2 (PGE2).

Results: HSP70 expression was significantly increased in the heat shocked specimens. IL-8 and PGE2 secretion were significantly increased in nucleus pulposus exposed to LPS at both temperatures. The concentrations of IL-8 and PGE2 secreted in the heat shocked samples were significantly less than controls, particularly after exposure to LPS (p< 0.05, paired students t test).

Conclusions: In vitro heating of porcine nucleus pulposus causes overexpression of HSP70. This heat shock effect can alter aspects of the biochemical response of the intervertebral disc tissue to an inflammatory insult. Intradiscal electrothermal therapy (IDET) may, in theory, reduce discogenic pain at temperatures as low as 42°C by generating similar heat-induced changes in the nuclear biochemistry of degenerate intervertebral discs.

Purpose of the study: To investigate whether video analysis, in addition to self-reported paper audit, could elucidate expected differences in the content of two interventions.

Background: We have completed a randomised clinical trial comparing two types of physiotherapy for subacute low back pain (“hands on” physiotherapy versus a pain management programme). An essential component in conducting clinical trials is to audit the interventions to check for compliance with the protocol. We use two approached:

self complete proforma

Methods: i) Treatment content was recorded on a proforma by the physiotherapists after each session.

ii) A check-list of treatment modalities was constructed from this proforma. Twelve sessions were recorded on video (one new and one review patient for each therapist). The recordings were rated by 3 blinded, independent observers using the checklist. These were compared with the self-report audit forms relating to the same physiotherapy session.

Results: Analysis of the videos showed good levels of agreement (67%) between the 3 observers. Agreement between the video content and paper audit was also good (84%, _ = 0.59). The complete paper audit revealed clear differences between the treatment arms. Patients undergoing the “handson” treatment received manual therapy, whereas patients in the pain management group had specific issues addressed in the course of the consultation.

Conclusions: Feasible, reliable methods of confirming the content of interventions delivered in pragmatic trials are difficult to achieve. Self report paper audits are simple but rely upon the honesty and accuracy of the completer, and may not pick up subtle differences in approach. Video recording is time consuming, may be threatening to the treating practitioner and patient, and is difficult to analyse. A compromise approach involving sample video recordings along with paper self complete audit was able to validate the content of the treatments delivered.

Introduction: The Resurfacing Hip System offers an attractive option for the treatment of arthritis in the young and active patients with gratifying outcome. Currently available Metal-on-Metal Resurfacing Hip Systems in the UK include Cormet 2000 (Corin Medical), the Birmingham Hip (Midland Medical Technologies) and Conserve Plus (Wright Cremascoli) (5). The Cormet 2000 implant design utilises the hybrid principle with an uncemented acetabular and a cemented femoral component. Achieving full seating of the acetabular component in shallow or anatomically deficient sockets can sometimes be technically difficult. On occasion, structural tricortical autografts or allografts are required to obtain a satisfactory positioning of the acetabular component. We describe a simple technique to aid fixation of the uncemented acetabular component in patients with shallow or deficient sockets.

Technical tip: The Cormet acetabular cup is equatorially expanded, resulting in improved stress distribution to the acetabulum. The acetabular component is available as pegless and pegged cup. Both Cormet cups, there are two sets of anti-rotation splines. The original Cormet cup design incorporated two sets of three anti-rotation splines; two long splines with one small spline above. These two sets of fins engage the ischium and pubis snugly. The cup is then firmly impacted in place using the cup introducer.

In shallow or deficient sockets, we describe a simple technique by 180° rotation of the Cormet 2000 metal-on-metal resurfacing pegged acetabular prosthesis. This works by utilising ischio-pubic splines for superolateral socket engagement. We have used this technique in three patients with successful outcome avoiding the need of structural graft augmentation. In one patient, this technique was supplemented with cadaveric allograft.

Conclusion: Rotating the acetabular component 180° in shallow or deficient sockets should be considered as one of the viable option with or without structural augmentation. This works satisfactorily by utilising the ischio-pubic splines for superolateral socket engagement.

Introduction: The incidence of aseptic osteonecrosis is 1.09% to 10.1% following the combination chemotherapy and high dose corticosteroid therapy of acute lymphoblastic leukaemic patients. The treatment of younger patients with advanced avascular necrosis remains controversial. No definite evidence is available yet on the effect of disseminated metal ions on the body. The clinical consequence of systemic absorption of metal degradation products in the causation of leukaemia remains contentious. We describe a 21 year old case with avascular necrosis of the hip joint due to T-Cell Acute Lymphoblastic Leukaemia treated with Metal-on-Metal surface hip arthroplasty with an excellent outcome at 5 year follow-up.

Case report: A 21 year old man presented with painful right hip for a period of four years. The past medical history was significant for T-Cell Acute Lymphoblastic Leukaemia which was treated with high dose corticosteroids and combination chemotherapy. He was diagnosed with avascular necrosis of the right hip and was offered hip replacement. He underwent a metal-on-metal surface hip replacement. The uncemented dual coated 54mm cup and cemented 48mm femoral head (Cormet 2000, Corin Medical) were implanted. Now at 5 years follow up since the surface hip replacement he has an excellent result. His haematological indices remain normal and he remains in remission.

Conclusion: Avascular necrosis of the femoral head is a well-known but rare complication of chemotherapy for leukaemia with a reported incidence ranging from 1 to 10 per cent. Metal-on-metal hip resurfacing arthroplasty is a potentially viable option for younger patients with aseptic osteonecrosis secondary to combination chemotherapy and high dose corticosteroid therapy used in the management of acute lymphoblastic leukaemias. Contrary to the general belief, we found no relapse in the leukaemia with use of metal-on-metal surface hip prosthesis till five years of follow-up.

Background: Evidence-based occupational health guidelines recommend that some form of case-management approach, involving getting ‘all players onside’, should be implemented for control of absence due to back pain; this approach has not been formally tested in the UK.

Methods/Results: A quasi-experimental controlled trial was conducted at selected sites of a large pharmaceutical company in the UK. The experimental intervention, delivered by occupational health nurses working to a guidelines-based protocol, was implemented at two manufacturing sites (n=1,435). Three matched sites acted as controls, delivering management as usual (n=1,483). Absence data were collected for both experimental and control sites for the two years prior to, and the two years during, the intervention period.

The intended early contact (within first week) of workers absent with musculoskeletal disorders only occurred at one experimental site; the control sites had no procedure for early contact. Absence rates improved over the four years at the intervention sites compared with the control sites: a decrease of 2.0 v an increase of 0.9 days/1000 working hours. The median return-to-work time for early intervention compared with controls was 4 days v 5 days (P=NS). Considering return-to-work time irrespective of whether the intervention was delivered early or late, the median durations were also 4 days v 5 days (P< 0.05). When looking at work retention over 12 months, the median duration of subsequent absence for early intervention was 5 days compared with 11 days for controls (P=NS). For the larger number of workers receiving a late intervention, the median duration of subsequent absence was median 4 days v 11 days for controls (P< 0.05).

Conclusion: The data consistently favoured a reduction in absence at the experimental sites, but organisational obstacles (black flags) precluded statistically significant results for early intervention. Implementation of certain guidelines principles (a supportive network with ‘all players onside’) can be effective for reducing absence.

Introduction: Metal-on-metal hip resurfacing arthroplasty is recommended for younger patients with advanced hip disease who are likely to outlive a conventional primary total hip arthroplasty and wish to be reasonably active. Intraoperative or immediate postoperative femoral neck fracture is a well described technical complication as a result of notching and stress shielding of the femoral head. We report two cases of femoral neck fracture incurred eight to fifteen months following the index operation.

Case 1: A 47 year old lady was admitted after sustaining a fall. Radiograph confirmed left femoral neck fracture with resurfacing prosthesis in situ. She underwent metal-on-metal surface hip replacement 15 months ago for advanced osteoarthritis. The periprosthetic fracture was treated by revising the femoral component, using Eurocone cormet modular endo head 44mm size. At one year follow up, she was able to mobilise unassisted and had a good range of movements.

Case 2: A 52 year old gentleman presented with a painful right hip. While walking in the supermarket, he suddenly felt a click in the right hip. Radiograph confirmed right femoral neck fracture with resurfacing prosthesis in place. The metal-on-metal surface hip replacement was performed 8 months previously for advanced avascular necrosis. His medical history was significant for epilepsy. The Femoral component was revised, using Eurocone cormet modular endo head 52mm. He made a satisfactory progress at 18 months follow up since his periprosthetic fracture.

Conclusion: We recommend that patient selection should be given prime importance before embarking on metal on metal surface hip replacement. The surgeons’ factors are meticulous technique in preventing neck notching and femoral head fixation in varus angulation. Revising femoral component, using large head and leaving resurfaced cups in place should be considered as mode of treatment. Large multicentric trials are needed to evaluate the exact incidence of periprosthetic fractures in metal on metal hip resurfacing

Aims: The aim of this study was to investigate the ability of control and degenerate human nucleus pulposis to respond to an exogenous proinßammatory stimulus. Methods: Disc material from patients undergoing surgery for scoliosis, sciatica and low back pain was cultured under basal and lipopolysaccharride (LPS) stimulated conditions using a serumless technique. Levels of IL-1β, TNFα, LTB4, GM-CSF, IL-6, IL-8, MCP-1, PGE2, bFGF and TGFβ-1 in the media were estimated using commercially available enzyme linked immunoabsorbent assay kits. Results: Neither basal nor LPS stimulated control nucleus pulposis (NP) produced detectable levels of IL-1β, TNFα, LTB4 or GM-CSF. LPS induced a significant increase in scoliotic disc IL-8 production, p< .02. LPS induced signiþcant increases in degenerate disc IL-6, IL-8 and PGE2 production, p< .01, p< .001 and p< .005 respectively. LPS signiþcantly increased degenerate disc IL-6, IL-8 and PGE2 production compared to LPS stimulated scoliotic disc, p< .05, p< .02 and p< .003 respectively. Conclusions: Human nucleus pulposus can react to a pro-inßammatory stimulus by secreting IL-6, IL-8 and PGE2, suggesting that the NP may actively participate in the genesis of chemical radiculitis and dis-cogenic back pain.

Background: The influence of psychosocial factors on absence rates is incompletely understood; much research has been cross-sectional, involving a limited range of psychosocial variables. This paper reports a large prospective study of the relationship between psychosocial factors and absence rates due to low back pain across a multi-site UK pharmaceutical company.

Methods/Results: Baseline data were collected from 4,637 workers, and absence data over the ensuing 15 months were obtained from company records. In addition to demographic and historical variables, a wide range of psychosocial variables was included with a focus on occupational psychosocial factors, termed ‘blue flags’. Validated questionnaires were used to quantify job satisfaction, social support, attribution of cause, control over work, and organisation of work, with psychological distress as a ’yellow flag’. 176 workers took absence due to back pain during follow-up.

Previously defined cut-off scores were used to categorise hypothesised risk; scores beyond the cut-off point were considered detrimental, and the ‘flag’ was considered to be ‘flying’. Odds ratios (OR) were calculated to explore the association between the flags and taking sick leave; a statistically significant association was found with ORs between 1.5 and 2.9. The cut-off scores were then used to compare the length of absence between workers who had zero flags flying and those who had one or more flags flying. Absence over the ensuing 15 months was significantly longer for those people who had one or more flags flying (mean 10.6 days compared with 6.1 days, P< 0.05). There was a trend for longer absence with more flags flying.

Conclusion: This prospective study confirms the influence of blue, as well as yellow, psychosocial flags on both the taking of sick leave and the subsequent length of absence. This supports their hypothesised role as obstacles to recovery that might be suitable targets for occupational health interventions.

Recently there has been considerable interest in the role of inflammatory mediator production by herniated degenerate discs. Modic has described MR endplate changes which have an inflammatory appearance and have been linked with discogenic back pain. To date there has been no biomechanical investigation of discs with associated Modic changes.

The aim of this study is to determine if degenerate discs with associated Modic changes have higher levels of pro-inflammatory mediator production than those without Modic changes.

Intervertebral disc tissue was obtained from 52 patients undergoing spinal surgery for sciatica [40] and discogram proven discogenic low back pain [12]. The tissue was cultured and the medium analysed for interleukin-6, interleukin-8 and prostaglandin E2 using an enzyme linked immunoabsorbetn assay method. Preoperative MR images of the patients were examined by a double blinded radiologist to determine the Modic status of the cultured disc level.

Forty percent of patients undergoing surgery for discogenic low back pain had a Modic 1 change compared to only 12.5% of patients undergoing surgery for sciatica [p< .05] There was a statistically significant difference between levels of IL-6, IL-8 and PGE2 production by both the Modic1 [M1] and Modic2 [M2] groups compared to the Modic negative [NEG] group. IL-6:NEGvM1 p< .001, NEG v M2 p< .05, IL-8: NEG v M1 p< .01, NEG v M2 p> .05, PGE2: NEG v M1 p< 01, NEG v M2 p< .05.

Modic changes have been associated with positive provocative discography by a number of authors. Pain generation requires the presence of nerves and hyperalgsia inducing mediators. Both IL-8 and PGE2 are known to induce hyperalgesia. The fact that Modic changes are associated with high levels of production of these mediators supports their role as an objective marker of discogenic low back pain.

Introduction: Increased levels of IL-6 and IL-8 have been found in intervertebral disc (IVD) tissue from patients undergoing fusion for discogenic low back pain. The stimuli that induce these mediators in degenerate discs remain unknown. Impaired diffusion of nutrients and wastes to and from the nucleus pulposus (NP) is believed to be an important factor in the degenerative process. The oxygen tension and pH in the NP of degenerating discs are significantly decreased.

Aims: The aims of this study were to (1) demonstrate the ability of porcine NP to respond to a proinflamma-tory stimulus (lipopolysaccharride) in vitro, (2) investigate the effects of pH, pO₂ and glucose concentration on NP proinflammatory mediator secretion and (3) determine if methylprednisolone or indomethacin can block NP proinflammatory mediator secretion.

Methods: IVDs were harvested from 6-month old pigs and dissected under sterile conditions in the laboratory. 200mg samples of NP were cultured under optimal conditions (control), in a 1% O₂ environment, at pH6 and in culture medium without glucose for 72 hours. Blocking experiments were performed by culturing LPS-stimulated samples with either methylprednisolone or indomethacin for 24 hours. IL-6 and IL-8 levels were estimated by ELISA.

Results: Time and dose-response curves were generated for each experiment (results not shown). Results for the optimum dose and at 72 hours incubation were note.

Data = mean ± standard deviation. Statistical analysis was by students t test. A significant result between control and stimulated groups is indicated by: * p=0.024m, † p=0.0007 or ‡ p=0.012.

Methylprednisolone (2mg/ml) caused a significant (p=0.044) 30-fold reduction in IL-6 production and a significant (p=0.00004) 500-fold reduction in IL-8 levels as compared with nucleus pulposus cultured with 5 μg/ml LPS alone for 24 hours.

Addition of 500 μM indomethacin significantly (p=0.04) decreased IL-6 production by a factor of 120 and IL-8 levels by a factor of 50 (p=0.00004).

Necrotic cell death, as measured by lactate dehydrogenase (LDH) concentration, was not significant in any of the experiments.

The role of nucleus pulposus (NP) biology in the genesis of sciatica is being increasingly investigated.

The aim of this study was to examine the ability of control and degenerate human nucleus pulposus to respond to an exogenous pro-inflammatory stimulus.

Control disc material was obtained from surgical procedures for scoliosis and degenerate disc tissue from surgical procedures for sciatica and low back pain. Disc specimens were cultured using a serumless technique under basal and lipopolysaccharride (LPS) stimulated conditions and the media harvested, aliquoted and stored at –80°C for subsequent analysis. Levels of IL-1β,TNFα, LTB4, GM-CSF, IL-6, IL-8, MCP-1, PGE2, bFGF and TGFβ-1 in the media were estimated using commercially available enzyme linked immunoabsorbent assay kits.

Neither basal nor LPS stimulated control or degenerate NP produced detectable levels of IL-1β, TNFα, LTB4 or GM-CSF. Control disc IL-8 secretion increased significantly with LPS stimulation, p< .018. Degenerate disc IL-6, IL-8 and PGE2 production increased significantly with LPS stimulation, p< .01, p< .001 and p< .005 respectively. LPS stimulated degenerate NP secreted significantly more IL-6, IL-8 and PGE2 than LPS stimulated control NP, p < 0.05, 0.02 and 0.003 respectively.

LPS induces an increase in both control and degenerate NP mediator production demonstrating the ability of human NP to react to a noxious stimulus by producing pro-inflammatory mediators. The difference in levels of basal and LPS stimulated mediator production between control and degenerate discs show that as a disc degenerates it increases both its level of inflammatory mediator production and its ability to react to a pro-inflammatory stimulus. The increased sensitivity of degenerating human NP to noxious stimuli and increased ability to respond with inflammatory mediator production support the role of NP as an active participant in the genesis of lumbar radiculopathy and discogenic back pain.

This basic science study attempts to explain why patients with spinal cord injuries have been seen to display increased healing of attendant fractures.

For the main part, this has been a clinical observation with laboratory work confined to rats. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear.

This paper evaluates two group with spinal column fractures – those with neurological compromise (n=10) and those without (n=11), and compares them with a control group with isolated long bone fractures (n=10). Serum was taken from these patients at five specific time intervals post injury (24hrs, 120hrs, 10 days, 6 weeks and 12 weeks). The time period most closely related to the end of the acute inflammatory reaction and the laying down of callus was the 10-day post injury time period.

Serum samples taken at this time period were analysed for IGF-1 and TGF-ß levels, both known to initiate osteoblastic activity, using ELISA kits. They were also exposed to an osteoblast cell culture line and cell proliferation was measured.

Results show that the group with neurology has increased levels of IGF-1 compared to the other groups (p< 0.14, p< 0.18 respectively, Student’s t-test) but had lower TGF-ß (p< 0.05, p< 0.006) and osteoblast proliferation levels (p< 0.002, p< 0.0001). When the neurology group is subdivided into complete (n=5) and incomplete (n=5), it was shown that the complete group had higher levels of both IGF-1 and TGF-ß. This trend is reversed in the osteoblast proliferation assay.

This work, for the first time in human subjects, identifies a factor which may be regulating this complication of acute spinal cord injuries, namely IGF-1. Furthermore, the observed trend in the two cytokines seen in the complete neurology group may suggest a role for TGF-ß. However, the results do show that a direct mediation of this unwanted side effect of spinal cord injuries is unlikely as seen in the proliferation assay. Further work remains to be done to fully understand the complexities of the excessive bone growth recognised in this patient group.

Degenerate disc disease is a major cause of low back pain, yet its aetiology is still poorly understood. The intervertebral disc is the largest avascular structure in the body. Cells of the nucleus pulposus, therefore, rely on diffusion of oxygen & nutrients down concentration gradients from peripheral vessels in the cartilage end-plates. Thus, there is a low oxygen tension and cellular respiration is largely anaerobic.

The purpose of this study was to examine the effects of inflammation, hypoxia and acidosis on degeneration and pro-inflammatory mediator production in virgin porcine nucleus pulposus cultures.

Intervertebral discs were harvested from normal 6-month old agricultural pigs slaughtered for other purposes. Nucleus pulposus was contained within the annulus until further dissection under sterile conditions in the laboratory was performed. Nucleus pulposus was harvested, diced and divided into 200mg samples. Samples were incubated under optimal conditions.

Discs were cultured in 5μg/ml E. coli lipopolysaccharide, in a hypoxic environment or at low pH. IL-6, IL-8 and LDH assays were performed by ELISA, in accordance with manufacturer’s instructions.

Time and dose-response curves were generated for each experiment (results not shown). Results at 72 hours incubation are tabulated below:

These results confirm that nucleus pulposus is a biochemically active tissue capable of producing pro-inflammatory mediators in response to environmental stresses. IL-6 and IL-8 are both involved in the inflammatory cascade, causing chemotaxis of neutrophils and macrophages to the area. IL-8 itself causes hyperalgesia. Acidotic and inflammatory conditions, but not hypoxia, stimulated cytokine release. This may indicate a protective reduction in cellular activity in reduced oxygen environments. Necrosis, as measured by LDH production, was negligible.

Total knee arthroplasty has evolved considerably over the last thirty years. Early implant design achieved the short-term goals of pain relief and mobility, however loosening and polyethylene wear associated with over constraint was problematic. The Low Contact Stress total knee arthroplasty was developed in an attempt to address the problems of loosening and polyethylene wear. The highly congruent interface between the femoral component and the mobile insert minimises stress within the polyethylene and reduces the potential of wear and damage. Furthermore, the mobile bearing phenomenon minimises both torsional and shear stresses at the component bone interface. In our unit the impact of choice is the LCS rotating platform prosthesis, which is inserted with cruciate-sacrifice.

We reviewed 219 patients (272 knees) with an average follow-up of 6 years (5–8 years). In almost all cases the components were inserted with cement fixation. The patella was primarily resurfaced in 20 patients (21 knees). All operations were performed or supervised by the senior author. Female to male ratio was 2:1. Average age at surgery was 68 years (40–86) with osteoarthritis being the commonest primary diagnosis (89%). Postoperative range of motion ranges from 30–130° (average 103°). Average Oxford Knee, American Knee Society Score and Patellar Score was 19 (12–53), 160 (42–199) and 25 (4–30) respectively. Six patients (1.7%) required MUA at six weeks. Two patients (0.6%) required secondary patellar resurfacing. Three patients (0.8%) had revision of their components for persistent pain. At operation all components were noted to be well fixed. Spinout of the rotating platform occurred in one patient (0.3%). This was treated by exchange of the insert.

In conclusion, our early results of the LCS rotating platform prosthesis are encouraging with no cases of component loosening to date. This supports the continued use of the implant.

Introduction: Historically, it has been accepted that pain associated with arthritis of the hip is usually located in the groin and thigh with radiation to the anterior knee. However pain below the knee, and into the foot was not believed to be associated with arthritis of the hip. Patients complaining of thigh pain that extends below the knee are often considered to have a degenerative lumbar spine as the cause for their lower limb symptoms, and hip arthroplasty may not be offered. We examined the severity and location of pain in patients attending for arthroplasty and assessed how this altered following surgery.

Methods: 200 consecutive patients undergoing primary total hip arthroplasty completed a questionnaire regarding the location and severity of pain in the leg and also an Oxford hip score to assess functionality. These were completed approximately 4 weeks preoperatively and again at a 3-month review clinic.

Results: 57% (114/200) of patients complained of pain below their knee preoperatively. Only 9% (10/114) of these patients continued to complain of pain postoperatively, and of these patients their mean pain score decreased by 44% (9 to 5). Only 1% (2/200) of all patients complained solely of pain in the knee or more distally, and both of these had complete relief of pain 3 months postoperatively.

Conclusion: A significant number of patients with degenerative hip disease have pain below the knee. Patients who complain of pain in their back, buttock or thigh, which extends below the knee, may still benefit from total hip replacement. Careful consideration should be taken before labelling the pain as being referred from degenerative back disease.

Dupuytren’s contracture is characterised by abnormal fibroblast proliferation and extracellular matrix deposition in the palmar fascia. Fibroblast proliferation and matrix deposition in connective tissues are regulated by cytokines. A number of cytokines including transforming growth factor beta (TGFβ), basic fibroblast growth factor (bFGF), platelet derived growth factor (PDGF) and epidermal growth factor (EGF) are known to have potent anabolic effects on connective tissue. The aim of this study was to investigate the role played by anabolic cytokines in the pathogenesis of Dupuytren’s disease.

Twelve specimens of Dupuytren’s contracture and six control specimens of palmar fascia obtained from patients undergoing carpal tunnel release were cultured using a serumless method under standard conditions for 72 h. Levels of TGFβ-1, bFGF, PDGF and EGF in the medium were estimated using an enzyme linked immunoabsorbent assay technique.

Neither Dupuytren’s tissue nor control palmar fascia produced any EGF. The mean (±S.D.)levels of bFGF, PDGF and TGFβ-1 produced by cultured palmar fascia were: 1270 ± 832, 74 ± 24, < 7, and for Dupuytren’s tissue were 722 ± 237, 139 ± 76.6, 645 ± 332, respectively. The levels of PDGF and TGFβ-1 were significantly higher in Dupuytren’s tissue.

PDGF is produced in increased amounts by Dupuytren’s tissue. This may contribute to the fibroblast proliferation and increased ECM deposition observed in this condition. TGFβ-1 is not produced by normal palmar fascia but is produced in large amounts by Dupuytren’s tissue. The major physiologic role of TGFβ-1 is to stimulate formation of fibrous tissue. It plays a major role in wound healing and also in pathological conditions where fibrosis is a prominent feature. Inappropriate production of TGFβ-1 in the palmar fascia in Dupuytren’s disease may play a central role in initiating and stimulating the abnormal fibroblast proliferation and collagen synthesis seen in this condition.

The pathophysiology of discogenic low back pain is poorly understood. The morphological changes occurring in disc degeneration are well documented but unhelpful in determining if a particular degenerate disc will be painful or not.

Herniated intervertebral disc tisssue has been shown to produce a number of pro-inflammatory mediators and cytokines. No similar studies have to date been done utilising disc material from patients with discogenic low back pain.

The aim of this study was to compare levels of production of interleukin-6 (IL-6), interleukin-8 (IL-8) and Prostaglandin E2 (PGE2) in disc tissue from patients undergoing discectomy for sciatica with that from patients undergoing fusion for discogenic low back pain.

Tissue from 50 patients undergoing discectomy for sciatica and 20 patients undergoing fusion for discogenic low back pain was cultured and the medium harvested for subsequent analysis using an enzyme linked immunoabsorbent assay method. Statistical analysis of the results was performed using the Mann-Whitney test.

Disc specimens from both experimental groups produced measurable levels of all three mediators. Mean production of IL-6, IL-8 and PGE2 in the sciatica group was 26.2±75.7, 247±573 and 2255±3974 respectively. Mean production of IL-6, IL-8 and PGE2 in the low back pain group was 92±154, 776±987 and 3221±3350 respectively (data = mean production pg/ml ± 1 standard deviation).

There was a statistically significant difference between the levels of IL-6 and IL-8 production in the sciatica and low back pain groups (p< 0.006 and p< 0.003 respectively).

The high levels of pro-inflammatory mediator production found in disc tissue from patients undergoing fusion for discogenic LBP may indicate that nucleus pulposis pro-inflammatory mediator production is a major factor in the genesis of a painful lumbar disc. This could explain why some degenerate discs cause LBP while other morphologically similar discs do not.

Rapidly progressive cases of primary idiopathic hip osteoarthrosis are well known and recognised. The prevalence reported in the literature varies from 4–18%. Three types have been identified- type 1 (rapid), type 2 (moderate) and type 3 (delayed) depending on the duration of chondrolysis and the subsequent rate of bone loss per year.

We reviewed the charts of all patients deemed to be RPO type 1 who had underwent hip arthroplasty under the care of the senior author (DEB) over a two-year period in an attempt to identify risk factors, which may have contributed to the rapid progression of their disease. All patients were treated using a custom femoral stem and a spiked Duraloc cementless socket following careful preparation of the acetabulum.

We identified 34 patients (40 hips) with type 1 rapidly progressive osteoarthrosis. Over the same time period 991 patients had underwent primary total hip arthroplasty, giving a prevalence of 4%. Of the 34 patients, 29 were female of average age 70.6 years (range, 51–83 years). All of the bilateral cases (6 patients) were female. Body mass index (BMI) for the female group ranged from 20.6 to 41.1Kg/m² (average, 28.2kg/m²) whilst that for the males was on average 25.8Kg/m² (range, 23.4–29.7Kg/m²).

Preoperative erythrocyte sedimentation rate (ESR) was 18mm/hr on average for the female group (range, 2–65mm/hr) and ranged from 3–52mm/hr (average, 20mm/hr) for the male patients. The preoperative Oxford Hip Score averaged 51 points for the female group and 48 points for the male group.

A detailed review of occupational history did not reveal any common occupational hazard. The majority of patients were non-smokers and denied any regular alcohol intake. Twenty-two patients (65%) had a history of hypertension. Twenty-seven patients (79%) had a history of non-steroidal anti-inflammatory use (most common preparation-diclofenac). Twenty-four patients (71%) resided in a rural area.

When compared to a cohort of patients undergoing primary total hip arthroplasty over the same time period, the only statistically significant risk factor identified was female gender.

We conclude, that patients who develop rapidly progressive osteoarthrosis of the hip are difficult to identify due to the absence of specific clinical features. We also outline our experience in the management of these technically challenging cases.

Objective: To determine the factor structure of the Coping Strategies Questionnaire (CSQ)¹ in chronic low back pain patients (CLBP) presenting for physiotherapy.

Subjects: CLBP patients presenting for their first assessment at an outpatient physiotherapy department were used (N = 105; 60% male; M age = 41 yrs; SD ± 10).

Design: A factor analysis, using varimax rotation, was performed on patients’ responses to the CSQ. Factors emerging with eigenvalues of ≥1 were considered. A coping strategy was included in a factor if it correlated with the factor at a level greater than 0.6.

Results: Three factors accounted for 70% of the variance in questionnaire responses. Factor 1, labeled Adaptive Coping, accounted for 35% of the variance and comprised the subscales for reinterpreting pain sensations, ignoring pain sensations, and coping self-statements. Factor 2, labeled Maladaptive Coping, accounted for 23% of the variance and comprised the subscales for diverting attention, catastrophizing, praying or hoping, and behavioural coping styles. The final factor, labeled Efficacy of Pain Management, accounted for 12% of the variance and comprised the two single-item scales. Adaptive Coping was positively correlated with Maladaptive Coping (r = 0.37, P < 0.01). Efficacy of Pain Management was positively correlated with Adaptive Coping (r = 0.28, P < 0.01). A non-significant negative correlation was found between Maladaptive Coping and Efficacy of Pain Management (r = −0.03, P > 0.05).

Conclusion: Three underlying factors, labelled Adaptive Coping, Maladaptive Coping, and Efficacy of Pain Management accounted for 70% of the variance in questionnaire responses.

Background: Prospective population studies demonstrate that poor paraspinal muscle endurance increases the risk of developing first-time LBP and many CLBP studies also document excessive paraspinal muscle fatigability. The question arises as to whether this could have predisposed to chronic symptoms, through impaired spinal instability, especially in light of the wide inter-individual variation observed in the constitutionally determined paraspinal muscle fibre-type composition, which governs contractile performance.

Objective: To determine whether CLBP-associated excessive paraspinal fatigue results from a paucity in the type I fibre content.

Design: Control comparison using male subjects.

Subjects: Thirty-five CLBP patients with Von-Korff Chronic Pain Scores of ≤ III (high level of residual function, despite pain, to negate effects of disuse atrophy), and 32 controls of similar age.

Outcome measures: Fatigue-induced median frequency (MF) declines in the surface EMG signal, monitored bilaterally at L4 level during Biering-Sorensen- and 60%MVC- isometric fatigue tests. Percutaneous para-spinal muscle biopsies permitted histomorphometric comparisons.

Results: Between-group differences were assessed using independent t-tests (p < 0.05). There were no differences for MF decline during the Biering-Sorensen -0.37(0.16) vs. -0.36(0.12), and the 60% MVC test −0.42(0.31) vs −0.51(0.29), and in the percentage number of type I fibres, 63.6% vs 64.3%, or percentage area occupied by type I fibres, 69.4% vs 67.2%, in the paraspinal muscles for patients and controls respectively (p> 0.05).

Conclusion: Impaired CLBP-associated endurance is not the result of a constitutionally ‘adverse’ fibre-type composition.

Patients with spinal cord injuries have been seen to have increased healing of attendant fractures. This for the main has been a clinical observation with laboratory work confined to rats. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear.

This paper evaluates two groups with spinal column fractures – those with neurological compromise (n=10) and those without (n=11), and compares them with a control group with isolated long bone fractures (n=10). Serum was taken from these patients at five specific time intervals post injury (24hrs, 120hrs, 10 days, 6 weeks and 12 weeks). The time period most closely related to the end of the acute inflammatory reaction and the laying down of callus was the 10-day post injury time period.

Serum samples taken at this time period were analysed for IGF-1 and TGF-β levels, both known to initiate osteoblastic activity, using ELISA kits. They were also exposed to an osteoblast cell culture line and cell proliferation was measured.

Results show that the group with neurology has increased levels of IGF-1 compared to the other groups (p< 0.14, p< 0.18 respectively, Student’s t-test) but had lower TGF- (p< 0.05, p< 0.006) and osteoblast proliferation levels (p< 0.002, p< 0.001), despite having a significantly higher cell proliferation than a control group (p< 0.0001). When the neurology group is subdivided into complete (n=5) and incomplete (n=5), it was shown that the complete group had higher levels of both IGF-1 and TGF-. This trend is reversed in the osteoblast proliferation assay.

This work, for the first time in human subjects, identifies a factor which may be regulating this complication of acute spinal cord injuries, namely IGF-1. Furthermore, the observed trend in the two cytokines seen in the complete neurology group may suggest a role for TGF-β. However, the results do show that a direct mediation of this unwanted side effect of spinal cord injuries is unlikely as seen in the proliferation assay. Further work remains to be done to fully understand the complexities of the excessive bone growth recognised in this patient group.

Objective: To determine the extent to which coping strategies mediate chronic low back pain (CLBP) disability in patients presenting for physiotherapy.

Subjects: CLBP patients presenting for their first assessment at an outpatient physiotherapy department were used (N = 90; 60% male; M age = 41 yrs; SD ± 10).

Design: The mediating role of coping strategies was investigated after controlling for the influence of recorded demographics, healthcare variables and pain. Hierarchical multiple regression was employed with disability¹ as the dependent variable. Independent variables were entered in three separate steps. Demographics (sex, age and socioeconomic status) were entered in Step one. Healthcare and Pain variables (leg pain, previous surgery, history of back pain and current pain intensity [VAS]) were entered in Step two. Three coping dimensions (Adaptive Coping, Maladaptive Coping and Efficacy of Pain Management), derived from a factor analysis of the Coping Strategies Questionnaire², were entered in the final Step.

Results: Demographics accounted for 14% of the variance in disability [F (3, 86) = 4.81, P =. 004]. Healthcare and Pain variables accounted for an additional 17% of the variance [F (4, 82) = 5.11, P =. 001]. The three coping dimensions accounted for a further 6% of the variance [F (3, 79) = 2.71, P =. 05]. The model accounted for 38% of the variance in disability [F (10, 79) = 4.81, P =. 000].

Conclusion: Coping did mediate levels of CLBP disability. Moreover, disability is influenced more by Adaptive (Standardised β = −. 26, P =. 02) and Maladaptive (Standardised β =. 27, P =. 02) coping strategies than Efficacy of Pain Management (Standardised β =. 07, P > . 05).

Objective: To implement an early occupational intervention which tackles the psychosocial factors (yellow and blue flags) that influence recovery from occupational back pain.

Design: An early, psychosocial, occupational health nurse-led intervention using a basic ‘counselling’ technique that reinforces evidence-based messages and advice, along with availability of modified work.

Subjects: 206 workers from a sample of Glaxosmithkline sites who took absence due to back pain.

Outcome measures: Duration of presenting absence.

Results: The target for contacting the worker was achieved at Site 1 (mean 3 days), but not Site 2 (mean 12 days). Results showed that late contact of absent workers (> 1 week) was significantly associated with both longer presenting absence and fewer recipients of the psychosocial intervention, compared with early contact. Preliminary results show that the psychosocial intervention (irrespective of early or late contact) reduces the length of presenting absence by half.

Conclusions: The lack of early contact at Site 2 was due to local sickness absence management differences. This study reveals a third class of obstacles to recovery – organisational policies (black flags) – that can negate the effect of occupational rehabilitation programs.

Objective: To assess the psychometric properties of the Tampa Scale for Kinesiophobia (TSK)¹.

Subjects: Eighty-four chronic low back pain (CLBP) patients presenting for their first assessment at an outpatient physiotherapy department were used (57% female; M age = 45 yrs; SD ± 10 yrs).

Design: Eighty-four patients completed the TSK. Internal consistency, item-total correlations, distribution of scores on each item, three-day test-retest reliability and responsiveness were then calculated. To determine responsiveness, patients were categorised into two groups, namely meaningful change in pain-related fear (Group 1) and non-meaningful change in pain-related fear (Group 2). Patients were categorised based on their response to a thirteen-point global rating scale (GRS). Standardised Response Means (SRMs)² were computed for each group.

Results: Internal consistency was excellent (Cronbach α = 0.82). With the exception of items 8 and 16 all item-total correlations exceeded the level of 0.20. Scores were normally distributed for most items, however, items 4, 12 and 14 were positively skewed (Z-scores > 1.96). Test-retest coefficients were high (ICC = 0.91). SRMs were −0.96 and −0.44 for Groups 1 and 2, respectively, thus indicating good discriminatory power. An adapted version of the TSK (MTSK-12), constructed from the twelve most psychometrically robust items, had comparable reliability and validity (Cronbach α = 0.82; ICC = 0.91; SRM [Group 1] = 0.89; SRM [Group 2] = 0.39).

Conclusion: Overall the TSK has excellent psychometric properties. The MTSK-12 is a valid and reliable measure of pain-related fear and warrants further investigation.

Study design: Cross-sectional questionnaire-based workforce survey together with collection of retrospective data on work absence.

Objectives: To determine if psychosocial ‘blue flags’ are related to back pain and/or sickness absence due to back pain.

Summary of background: The original description of the psychosocial ‘yellow flags’ for back pain chronicity included a mixture of individual psychological parameters and parameters related to perceptions about work and the workplace. It has recently been suggested that these latter parameters should be considered separate and distinct from the individual parameters , and can be termed ‘blue flags’. To date, however, there has been no attempt to explore the specific relationship between the blue and yellow flags or their relative relationship to symptoms and disability.

Methods: The workforce of a large multi-site company was invited to complete a booklet of questionnaires, which included the standard Nordic instrument for obtaining back pain data, and specific instruments to obtain data on ‘yellow’ and ‘blue’ psychosocial flags. The blue flags included psychosocial aspects of work, attribution and elements from the demand/control model, with psychological distress used as a yellow flag comparator. Of the 7,500 workers, 60% responded. Sickness absence records identified workers who had taken absence for back pain. The exploration of the data involved determining statistically significant relationships between psychosocial scores and both back pain history and absence. Appropriate statistical procedures were then used to establish cut-off points for the psychosocial variables. Odds ratios were calculated for two particular outcome variables: self-reported back pain in the previous 12 months and recorded absence over the same period.

Results: Cut-off points were established for each variable, along with the odds ratio (OR) that this score or a score above or below (depending on the scale direction) is associated with reports of back pain or absence. The ORs for psychological distress were 1.9 and 2.4 respectively for LBP and absence in the last 12 months. The ORs for the blue flag variables varied from 1.1 to 1.5 for LBP and from 1.8 to 3.2 for absence.

Conclusions: The psychosocial blue flags reported here are statistically significantly related both to reported back pain and absence. The effect size is less than that for distress in respect of back pain, but variously higher and lower for absence. Whilst prospective studies are needed to determine cause/effect, the results offer tentative support for the suggestion that blue flags should be addressed in clinical interventions.

Aseptic loosening has become the single most important long-term complication of total joint replacements. The pathophysiology of this loosening is multifactorial in origin ranging from mechanical wear, poor surgical technique, thermal damage and the inflammatory response to particulate wear debris. Cytokines are released in response to macrophage activation by particulate wear debris (PWD), the resultant inflammatory cascade stimulates osteoclastic resorption of bone. The failure of remodelling and repair mechanisms may be as a result of Osteonecrosis from cement (PMMA).

Hypothesis: That PMMA increases Osteoblast susceptibility to necrosis and apoptosis following inflammatory challenge.

Materials and Methods: Osteoblast cell cultures were grown on PMMA cement plates and assessed for apoptosis and necrosis by PI exclusion staining, morphological changes on light and electron microscopy and flow cytometry.

Results: PMMA induced osteonecrosis is highest at 1 hour (34.45) in comparison to control levels (4.55). There is no significant change in Apoptosis at 24 hours. Culture of the Osteoblasts on cement and delayed stimulation with TNF-α causes increased Apoptosis and Necrosis.

Conclusion: PMMA cement causes Osteoblast necrosis in the early stages of polymerisation, after 24 hours there is little increase in apoptosis/necrosis. However Osteoblasts that grow in contact with cement are more susceptible to apoptosis and necrosis following TNFα challenge. This may prove to be an important step in the pathogenesis of Aseptic loosening.

Aseptic loosening is currently the leading cause of failure of total hip arthroplasty. The aetiology of periprosthetic bone resorption is currently under intense investigation. Wear particles are produced from the articulating surface of the femoral and acetabular components. These particles gain access to the bone-cement interface where they are phagocytosed by macrophages. Particle stimulated macrophages differentiate into bone resorping osteoclasts. This leads to periprosthetic bone resorption and subsequent implant loosening.

Nuclear factor kappa B (NFκB) is a transcription factor known to be activated by pathogenic stimuli in a variety of cells. The activation of NFkB would appear to be the primary event in the activation of particle stimulated macrophages in the periprosthetic membrane. NFκB subsequently causes a cascade of events leading to the release of bone resorbing cytokines, namely interleukin-6 (IL-6) and tumour necrosis factor α (TNFα).

The aim of our study was to ascertain if bone resorption could be prevented in vitro by the addition of PDTC, an NFkB inhibitor to particle stimulated macrophages.

Human monocytes were isolated and cultured from healthy volunteers. The monocyte/macrophage cell line was differentiated into osteoclasts by the addition of alumina particles and allowed to adhere onto bone slices. The NFkB inhibitor, PDTC, has added to the cultured osteoclasts. Bone resorption was analysed by counting the number of resorption pits in each bone slice.

The addition of PDTC to stimulated macrophages reduced the number of resorption pits by greater than 40% compared to control.

This is a unique and promising finding that may offer a future therapeutic strategy for the prevention of periprosthetic bone resorption and therefore aseptic loosening in total hip arthoplasty.

Dupuytren’s disease is a benign fibroproliferative disease of unknown aetiology. It is often familial and commonly affects Northern European Caucasian men, but genetic studies have yet to identify the relevant genes.

Transforming growth factor beta one (TGF-β1) is a multifunctional cytokine which plays a central role in wound healing and fibrosis. It stimulates the proliferation of fibroblasts and the deposition of extracellular matrix. Previous studies have implicated TGF-β1 in Dupuytren’s disease, suggesting that it may represent a candidate susceptibility gene for this condition.

We have investigated the association of four common single nucleotide polymorphisms in TGF-β1 with the risk of developing Dupuytren’s disease. A polymerase chain reaction-restriction fragment length polymorphism method was used for genotyping TGF-β1 polymorphisms. DNA samples from 135 patients with Dupuytren’s disease and 200 control subjects were examined.

There was no statistically significant difference in TGF-β1 genotype or allele frequency distributions between the patients and controls for the codons 10, 25, −509 and −800 polymorphisms.

Our observations suggest that common TGF-β1 polymorphisms are not associated with a risk of developing Dupuytren’s disease. These data should be interpreted with caution since the lack of association was shown in only one series of patients with only known, common polymorphisms of TGF-β1. To our knowledge, this is the first report of a case-control association study in Dupuytren’s disease using single nucleotide polymorphisms in TGF-β1.

Traditional biomedical/ergonomic occupational interventions to reduce work loss show limited success. Attention is now focussing on tackling the psychosocial factors that influence occupational back pain.

A workforce survey of Glaxo Smith Kline (reported to the Society last year) established that clinical and occupational psychosocial factors (yellow & blue flags) act independently and may represent obstacles to recovery. Consequently, a nurse-led intervention was devised. Occupational nurses at two manufacturing sites were trained to identify both clinical and occupational psychosocial factors, and address them using a basic ‘counselling’ technique that reinforces evidence-based messages and advice, along with availability of modified work. The program should ideally be implemented within the first days of absence, with ‘case-management’ by the nurse for a further 4 weeks. Control sites simply offer ‘usual management’. Outcomes at 12-month follow-up are rates for work loss/work retention.

The target for contacting the worker (3 days) was achieved at one site, but not the other (mean 12 days), thus exerting a differential delay in delivering the intervention. The lack of early identification at the second site was due to local reporting/recording mechanisms. This study reveals a third class of obstacles to recovery – black flags – company policies/procedures that can impede occupational rehabilitation programs.

Herniated intervertebral disc tissue has been shown to produce a number of proinflammatory mediators and cytokines, but there have been no similar studies using discs from patients with discogenic low back pain.

We have compared the levels of production of interleukin-6 (IL-6), interleukin-8 (IL-8) and prostaglandin E₂ (PGE₂) in disc tissue from patients undergoing discectomy for sciatica (63) with that from patients undergoing fusion for discogenic low back pain (20) using an enzyme-linked immunoabsorbent assay.

There was a statistically significant difference between levels of production of IL-6 and IL-8 in the sciatica and low back pain groups (p < 0.006 and p < 0.003, respectively).

The high levels of proinflammatory mediator found in disc tissue from patients undergoing fusion suggest that production of proinflammatory mediators within the nucleus pulposus may be a major factor in the genesis of a painful lumbar disc.

A bipolar spacer was inserted for severe arthritic destruction of the shoulder in 14 patients, and followed up for a mean of 5.9 years. In one patient the operation failed because of infection. Two others required revision for loss of low-friction properties which caused loosening of the humeral component.

At the end of the follow-up all the patients showed improvement. The Hospital for Special Surgery pain score had increased from 5.3 to 18.9 and the movement score from 7.5 to 20.1.

We dissected 105 cadaveric shoulders to study the origin of the tendon of the long head of biceps, and examined histologically the interrelationship between the tendon, the supraglenoid tubercle and the superior labrum of the glenoid. In all specimens approximately 50% of the biceps tendon arose directly from the superior glenoid labrum with the remainder attached to the supraglenoid tubercle. The main labral origin was from the posterior labrum in more than half of the specimens, and in a quarter this was the only labral attachment. On the basis of the biceps attachment to the anterior or posterior labrum, we distinguished four types of origin. These normal anatomical variations are significant for arthroscopic diagnosis and may help to explain the various patterns of injury seen in partial or complete detachment of the tendon, the labrum or both.

The long-term functional result of exposed total knee arthroplasty, treated by flap cover, is presented and the results compared with those of a randomly selected control group. The wound was successfully covered and the prosthesis was preserved in 76% of cases, but the final functional score was not as good as in those with primary wound healing.

Augmentation of the acetabular component of total hip replacements is a method of increasing stability and preventing recurrent dislocation. We report a series of mechanical experiments designed to evaluate the turning moments and angles required to dislocate standard, long posterior wall and two different augmented prostheses.

Thirty-three patients with impingement syndrome of the rotator cuff were studied before and at operation. It was shown that the rotator cuff lengthens and twists during elevation of the arm. Elevation is achieved by early glenohumeral abduction and continuous flexion and external rotation. The range of free rotation at the glenohumeral joint diminishes progressively during elevation. Rotator cuff impingement occurs towards the end of the early glenohumeral abduction. Excision arthroplasty of the acromioclavicular joint and anterior acromioplasty is highly effective for impingement under the acromion, but only moderately effective where impingement is under the acromioclavicular joint.

Major ruptures of the rotator cuff were repaired in 89 patients over a six-year period, using an approach through the split deltoid muscle and the bed of the excised outer centimetre of the clavicle. Review of these patients showed that poor results were associated with larger cuff defects, with more pre-operative steroid injections and with pre-operative weakness of the deltoid muscle. A randomised prospective study showed that repair followed by splinting in abduction gave no better results than repair followed by resting the arm at the side. Excision of the coraco-acromial ligament was associated with worse results than leaving its divided halves in situ. Follow-up showed that the results continued to improve for two years after operation; their quality was maintained in patients less than 60 years old, but in those over 60 there was deterioration with time.

Non-operative management has frequently been adopted for closed injuries of the infraclavicular brachial plexus and its branches in the belief that spontaneous recovery is likely to occur, and surgical exploration is performed only if recovery has not occurred in the expected time. This paper correlates the clinical and electrophysiological features with the operative findings in six patients with such injuries. The axillary nerve was ruptured in all six patients, the musculocutaneous nerve in two and the radial nerve in two. When the muscles supplied by a branch of the plexus were denervated, the differentiation between rupture of that branch and a lesion in continuity could only be made by surgical exploration, which should be performed as soon as other injuries permit.