The number of total knee arthroplasties continues to increase annually with over 90,000 total knee replacements performed in the United Kingdom in 2018. Multiple national bodies including the British Association for Surgery of the Knee (BASK) and the British Orthopaedic Association collaborated in July 2019 to produce best practice guidance for knee arthroplasty surgery. This study aims to review practice in a regional healthcare trust against these guidelines. Fifty total knee replacement operation notes were reviewed between January and February 2020 from 11 different consultant orthopaedic surgeons. Documents were assessed against 17 criteria recommended by the BASK guidance. Personnel names and grades were generally well documented. Tourniquet time and pressure were documented in over 98% of operation notes however, protection from spirit burns was not documented at all. Trialling and soft tissue balancing was well recorded in 100% and 96% of operation notes respectively. Areas lacking in documentation included methods utilised to optimise cementation technique and removal of cement debris. Protection of key knee structures was documented in only 56% of operation notes clearly. Prior to closure, final assessment of mechanism integrity, collateral ligament was not documented at all and final ROM after implantation of components was recorded 34% of the time. Subsequently authors have created a universal operation note template, uploaded onto the patient electronic notes, which prompts surgeons to complete documentation of the relevant criteria advocated by BASK. In conclusion, detailed and systematic documentation is vital to prevent adverse events and reduce the risk of litigation. By producing detailed operative templates this risk can be mitigated

Aims. Lumbar disc prolapse is a frequent indication for surgery. The few available long-term follow-up studies focus mainly on repeated surgery for recurrent disease. The aim of this study was to analyze all reasons for additional surgery for patients operated on for a primary lumbar disc prolapse. Methods. We retrieved data from the Swedish spine register about 3,291 patients who underwent primary surgery for a lumbar disc prolapse between January 2007 and December 2008. These patients were followed until December 2020 to record all additional lumbar spine operations and the reason for them. Results. In total, 681 of the 3,291 patients (21%) needed one or more additional operations. More than three additional operations was uncommon (2%; 15/906). Overall, 906 additional operations were identified during the time period, with a mean time to the first of these of 3.7 years (SD 3.6). The most common reason for an additional operation was recurrent disc prolapse (47%; 426/906), followed by spinal stenosis or degenerative spondylolisthesis (19%; 176/906), and segmental pain (16%; 145/906). The most common surgical procedures were revision discectomy (43%; 385/906) and instrumented fusion (22%; 200/906). Degenerative spinal conditions other than disc prolapse became a more common reason for additional surgery with increasing length of follow-up. Most patients achieved the minimally important change (MIC) for the patient-reported outcomes after the index surgery. After the third additional spinal operation, only 20% (5/25) achieved the MIC in terms of leg pain, and 29% (7/24) in terms of the EuroQol five-dimension index questionnaire visual analogue scale. Conclusion. More than one in five patients operated on for a lumbar disc prolapse underwent further surgery during the 13-year follow-up period. Recurrent disc prolapse was the most common reason for additional surgery, followed by spinal stenosis and segmental pain. This study shows that additional operations after primary disc surgery are needed more frequently than previously reported, and that the outcome profoundly deteriorates after the second additional operation. The findings from this study can be used in the shared decision-making process. Cite this article: Bone Joint J 2022;104-B(5):627–632

Aims. Repeated lumbar spine surgery has been associated with inferior clinical outcomes. This study aimed to examine and quantify the impact of this association in a national clinical register cohort. Methods. This is a population-based study from the Norwegian Registry for Spine surgery (NORspine). We included 26,723 consecutive cases operated for lumbar spinal stenosis or lumbar disc herniation from January 2007 to December 2018. The primary outcome was the Oswestry Disability Index (ODI), presented as the proportions reaching a patient-acceptable symptom state (PASS; defined as an ODI raw score ≤ 22) and ODI raw and change scores at 12-month follow-up. Secondary outcomes were the Global Perceived Effect scale, the numerical rating scale for pain, the EuroQoL five-dimensions health questionnaire, occurrence of perioperative complications and wound infections, and working capability. Binary logistic regression analysis was conducted to examine how the number of previous operations influenced the odds of not reaching a PASS. Results. The proportion reaching a PASS decreased from 66.0% (95% confidence interval (CI) 65.4 to 66.7) in cases with no previous operation to 22.0% (95% CI 15.2 to 30.3) in cases with four or more previous operations (p < 0.001). The odds of not reaching a PASS were 2.1 (95% CI 1.9 to 2.2) in cases with one previous operation, 2.6 (95% CI 2.3 to 3.0) in cases with two, 4.4 (95% CI 3.4 to 5.5) in cases with three, and 6.9 (95% CI 4.5 to 10.5) in cases with four or more previous operations. The ODI raw and change scores and the secondary outcomes showed similar trends. Conclusion. We found a dose-response relationship between increasing number of previous operations and inferior outcomes among patients operated for degenerative conditions in the lumbar spine. This information should be considered in the shared decision-making process prior to elective spine surgery. Cite this article: Bone Joint J 2023;105-B(4):422–430

The Royal College of Surgeons of England (RCS) Good Surgical Practice guidance identifies essential criteria for surgical operation note documentation. The current quality improvement project aims to identify if using pre-templated operation notes for documenting fractured neck of femur surgery results in improved documentation when compared to free hand orthopaedic operation notes. A total of fourteen categories were identified from the RCS guidance as required across all the operations identified in this study. All operations for the month of October 2021 were identified and the operation notes analysed. Pre-templated operation notes were compared to free hand operation notes. 97 cases were identified, of which 74 were free hand operation notes and 23 were pre-templated fractured neck of femur operation notes. All fourteen categories were completed in 13 (57%) of the templated operation notes vs 0 (0%) in the free hand operation notes (odds ratio 0.0052, 95% CI 0.0003 to 0.0945, p < 0.001). The median total number of completed categories was significantly higher in the templated op-note group compared to the free hand op-note group (templated median 14, range 12-14, vs. free hand median 11, range 9 to 13, p < 0.001). Logistic regression analysis of operation notes written by Registrars or Consultants identified Registrars as more likely to document the antibiotic prophylaxis given (p = 0.025). Use of pre-templated operation notes results in significantly improved documentation. Adoption of generic pre-templated operation notes to improve surgical documentation should be considered across all operations

Aim. To investigate the impact of waiting for surgical treatment for bone and joint infection (BJI) on patient self-reported quality of life (QoL). Method. Patients presenting to clinic between January 2019 and February 2020 completed the EuroQol EQ-5D-5L questionnaire. Patients were divided into three groups: surgery performed; on the waiting list for surgery; or decision for non-operative management. All patients were followed-up for 2 years. The EQ-index score was calculated and change from presentation to 1-year and 2-year follow-up was compared across the 3 groups. Mortality at final follow-up was measured in all groups. Results. 188 patients were included. Of these, 98 had an operation performed, 50 were on the waiting list for surgery but did not receive an operation and 40 were treated non-operatively. At presentation, all three groups had similar EQ-5D-5L index scores (surgery:0.412 SD0.351; waiting list:0.510 SD0.320; non-operative management: 0.467 SD0.354; p=0.269). There was a significant improvement in QoL in patients who underwent surgery when compared to their pre-operative state (mean increase of EQ-index score +0.241 in the first year (SD0.333, p<0.001) and +0.259 (SD0.294, p<0.001) in the second year. Patients on the waiting list for surgery had a small time-dependent decrease in EQ-index score at 1 year (−0.077, SD0.282, p=0.188) and 2 years (−0.140, SD0.359, p=0.401). Patients treated non-operatively had similar changes in EQ-index scores at 1 year (−0.052, SD0.309, p=0.561) and 2 years (−0.146, SD 0.234, p=0.221). Patients who had surgery had significantly better QoL at 2-years after treatment compared to other groups (mean EQ-index scores: surgery performed 0.671 vs. waiting list 0.431, p<0.001; surgery performed vs. non-operative management 0.348, p<0.001). Mortality in the operated group was 3.1%, which was similar to patients who were on the waiting list for surgery (6.5%, p=0.394) but lower than patients who were non-operatively managed (14.7%, p=0.014). Conclusions. The Covid-19 pandemic created long waiting times for some patients. Selecting patients with BJI who can safely wait for surgery is difficult. QoL for patients with BJI deteriorates over time if surgery is delayed or not performed. When patients decline surgery, they should be counselled that their QoL is likely to be impaired over time. The relationship between waiting time and mortality merits further study

Aims. This study explores data quality in operation type and fracture classification recorded as part of a large research study and a national audit with an independent review. Patients and Methods. At 17 centres, an expert surgeon reviewed a randomly selected subset of cases from their centre with regard to fracture classification using the AO system and type of operation performed. Agreement for these variables was then compared with the data collected during conduct of the World Hip Trauma Evaluation (WHiTE) cohort study. Both types of surgery and fracture classification were collapsed to identify the level of detail of reporting that achieved meaningful agreement. In the National Hip Fracture Database (NHFD), the types of operation and fracture classification were explored to identify the proportion of “highly improbable” combinations. Results. The records were reviewed for 903 cases. Agreement for the subtypes of extracapsular fracture was poor; most centres achieved no better than “fair” agreement. When the classification was collapsed to a single option for “extracapsular” fracture, only four centres failed to have at least “moderate” agreement. There was only “moderate” agreement for the subtypes of intracapsular fracture, which improved to “substantial” when collapsed to “intracapsular”. Subtrochanteric fracture types were well reported with “substantial” agreement. There was near “perfect” agreement for internal fixation procedures. “Perfect” or “substantial” agreement was achieved when the type of arthroplasty surgery was reported at the level of “hemiarthroplasty” and “total hip replacement”. When reviewing data submitted to the NHFD, a minimum of 5.2% of cases contained “highly improbable” procedures for the stated fracture classification. Conclusion. The complexity of collecting fracture classification data at a national scale compromises the accuracy with which detailed classification systems can be reported. Data around type of surgery performed show similar tendencies. Data capture, reporting, and interpretation in future studies must take this into account. Cite this article: Bone Joint J 2019;101-B:1292–1299

Aims. This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days. Methods. We analyzed data from 26,393 patients with trochanteric AO/OTA A1 and A2 fractures treated with IMNs (n = 9,095) or SHSs (n = 17,298) in the Norwegian Hip Fracture Register (January 2008 to December 2020). Exclusions were made for patients aged < 60 years, pathological fractures, pre-2008 operations, contralateral hip fractures, fractures other than trochanteric A1/A2, and treatments other than IMNs or SHSs. Kaplan-Meier and Cox regression analyses adjusted for type of fracture, age, sex, cognitive impairment, American Society of Anesthesiologists (ASA) grade, and time period were conducted, along with calculations for number needed to harm (NNH). Results. In unadjusted analyses, there was no significant difference between IMN and SHS patient survival at 30 days (91.8% vs 91.1%; p = 0.083) or 90 days (85.4% vs 84.5%; p = 0.065), but higher one-year survival for IMNs (74.5% vs 73.3%; p = 0.031) compared with SHSs. After adjustments, no significant difference in 30-day mortality was found (hazard rate ratio (HRR) 0.94 (95% confidence interval (CI) 0.86 to 1.02(; p = 0.146). IMNs exhibited higher mortality at 0 to 1 days (HRR 1.63 (95% CI 1.13 to 2.34); p = 0.009) compared with SHSs, with a NNH of 556, but lower mortality at 8 to 30 days (HRR 0.89 (95% CI 0.80 to 1.00); p = 0.043). No differences were observed in mortality at 2 to 7 days (HRR 0.94 (95% CI 0.79 to 1.11); p = 0.434), 90 days (HRR 0.95 (95% CI 0.89 to 1.02); p = 0.177), or 365 days (HRR 0.97 (95% CI 0.92 to 1.02); p = 0.192). Conclusion. This study found no difference in 30-day mortality between IMNs and SHSs. However, IMNs were associated with a higher mortality at 0 to 1 days and a marginally lower mortality at 8 to 30 days compared with SHSs. The observed differences in mortality were small and should probably not guide choice of treatment. Cite this article: Bone Joint J 2024;106-B(6):603–612

Introduction:. Unicompartmental knee arthroplasty (UKA) is becoming an increasingly popular option in single compartment osteoarthritis. As a result, diverse second operations including revisions to total knee arthroplasty (TKA) will also increase. The objective of this study is to investigate the distribution of causes of second operations after UKA. Methods:. We retrospectively reviewed 695 UKAs performed on 597 patients between January 2003 and December 2011. Except in one case, all UKAs were replaced at the medial compartment of the knee. The UKAs were performed on 559 (80.4%) women's knees and 136 (19.6%) men's knees. The mean age at the time of UKA was 61.5 years. The mobile-bearing designs were those that were predominantly implanted (n = 628 mobile, 90.2%; n = 67 fixed). The mean interval between UKA and second operation was 14.1 months. Results:. In our study, the burden of a second operation after the initial UKA was 7.3%, and the total number of second operations was 51 (n = 45 mobile, n = 6 fixed). The most common cause of a second operation after a mobile-bearing UKA was the dislocation of the meniscal bearing (34.8%), followed by component loosening (21.7%), the formation of a cement loose body (15.2%), unexplained pain (13%), infection (6.5%), periprosthetic fracture (4.3%), and others (4.4%). For the fixed-bearing UKA, the causes of a second operation were loosening (n = 2), unexplained pain (n = 2), and bearing wear (n = 1). The main causes of either a revision UKA or a conversion to TKA were multiform operations that included bricement, internal fixation for a periprosthetic fracture, isolated bearing changes, open debridement with bearing changes, or implant removal due to early infection. Conversions to TKA during the second operation were performed in 17 cases. Discussion and conclusion:. The most common cause of a second operation after a mobile-bearing UKA was the dislocation of the bearing, followed by component loosening and the formation of a cement loose body. After a fixed-bearing UKA, component loosening and unexplained pain were the most common. A cause-based approach to the primary and failed UKA may be helpful to minimize the possibility of a second operation and to give rise to a successful outcome of a revision TKA

Introduction: Since 2004 we chose the arthroscopic method of therapy by the retrocalcaneal bursitis and problems caused by prominence of heel Haglund type. Materials and Method: We operated 48 patients (52 heel bones) by arthroscopic method. We do this operation on ventral position with using 2 or 3 paraachilear incisions, we commonly check the progress of the operation using X-rays sciascopy. After operation we recommend light exercises of the movement of the ankle and 3 week walking on crutches with limited weight. Antitrombotic prophylaxis is standard. Results: We checked the results after 2–48 months after operating procedure. The patients were examined clinically and with the help of VAS (Visual Analogue Scale). The condition of all patients has improved, most of them were very satisfied with the operation. We have not noticed any disorders in healing operation wounds, 1 deep trombosis has been diagnosed by the sonography. We compared this arthroscopy method with open operating method. We have been using since the year 2004 both operating methods, but we have been trying to separate the indications for the arthroscopy and for the open approach, because we are the meaning, that the arthroscopy technique is not the best choice in all cases. We have recently set clear indications for both methods in our orthopaedic department. The progress of rehabilitation was noticeably faster than by the open method, postoperative swelling and pain were markedly less as well

1. The operation of spinal fusion combined with Harrington rod instrumentation is often accompanied by severe blood loss. Factors affecting the degree of blood loss are discussed with emphasis on the adverse effects of partial or complete obstruction of the inferior vena cava during operation. 2. A new scoliosis operating frame is described which is designed to encourage normal venous return during spinal fusion with the patient prone. In addition, it stabilises the patient during the procedure. 3. A standard anaesthetic technique and method of supporting the patient have been used in forty major corrective operations in thirty-eight consecutive cases of scoliosis in the past nine months. The measured blood loss at operation encountered in this series compares favourably with the quantities lost in a previously reported series of cases in which alternative methods of anaesthesia and of support for the patients were used. 4. All operations in both series were performed by the same surgeon (J. E. H.). Although further experience with the surgical technique has helped in reducing the blood loss in the later series, the same basic method of exposure and performance of the instrumentation and fusion has been used in all cases

Studies of operation notes have shown they can vary in quality and affect patient safety. This audit compares the quality of operation notes against standards set by the Royal College of Surgeons of England and the British Orthopaedic Association. Information from operation notes was collected prospectively over a two-week period. All operations performed were included and trainees from the region coordinated data collection in 9 hospitals. Data from 1091 operation notes was reviewed. A number of standards were nearly met including legibility (98.4%), the name of operating surgeon (99.3%) and operation title (99.1%). However a number of standards were not met and those with potential patient safety implications include availability on the ward (88.8%), documentation of type of anaesthetic used (78.6%), diagnosis (73.4%) and findings (80.1%). In addition, the postoperative instructions recorded the need for and type of postoperative antibiotics or venous thromboembolism prophylaxis in only 49.7% and 48.8% of cases respectively. The quality of operation notes studied across the region in this period was variable. Software programmes meant some hospitals had better results for date, time and patient identification details. Following this study, awareness of the standards combined with additional local measures may improve the quality of operation notes

Metal-on-metal (MoM) hip resurfacing was developed in the 1990s by surgeons in Birmingham, UK, as a surgical solution to the problem of osteoarthritis in younger, more active patients. Early results were promising and the procedure gained in popularity. However, adverse reports of soft-tissue reaction and failure started to appear from 2008 onwards. Surgeons may be asked to write medico-legal reports on the surgical aspects of an individual case for claimant lawyers or in defence for the NHSLA or indemnity insurers. The purpose of this article is to cover some of the aspects of the operation that may be considered in such medico-legal reports

Infection of the intervertebral space is a rare complication of operation on the disc (Ford and Key 1955). It occurred in five cases in a series of 650 operations for lumbar disc protrusion done by two of the authors of this paper--an incidence of 0-8%. Symptoms began between seven and twelve days after operation. After initial relief of the original sciatic pain, the patients developed severe back pain and muscle cramps in the legs. Straight-leg raising became much more limited than before operation. The erythrocyte sedimentation rate was raised in all cases. The diagnosis was confirmed by rescreening the Myodil, when an indentation was seen opposite the intervertebral space from which the disc had been excised. Early removal of infected material from the disc space resulted in complete relief of pain and cure of the infection

British military forces are heavily committed in Iraq and Afghanistan. Operation HERRICK, currently supported by a Role 2(Enhanced) medical facility at Camp Bastion, is predicted to continue for the next 10 years. There has been no large published series on surgical workload on Operation HERRICK. The aim of this study is to determine and plan future medical needs. A retrospective analysis of operating theatre records between 10th October 2006 and 31st Oct 2007 was performed. Data was collated on a monthly basis, to assess seasonal variation, and included patient demographics, operation type and time of operation. During the study period 968 cases required 1262 procedures. Thirty-four per cent were ISAF, 27% were Afghan soldiers, police or enemy forces and 39% were civilians, of which, 43% were children. Ninety-one per cent were secondary to battle injury and 50% were emergencies. The breakdown of procedures, by specialty, was 67% (841) were orthopaedic, 16% (199) general surgery, 8% (96) head and neck, 5% (55) burns surgery and a further 4% (50) were non-battle, non-emergency procedures. During the second half of the study period 655 cases were operated on compared to 313 in the preceding half (p< 0.05). Twenty-eight per cent of cases were performed between 6pm and 8am. Surgical workload remains consistently high throughout the study period, however there was significant seasonal variation with casualty rates being greater in the summer months, this may have bearing on the decision to deploy additional surgeons and trainees in the future

Introduction: Hypothesis:- Posterior lumbar interbody fusion (PLIF) produces improvement in the MOS Short Form 36 (SF36) scores comparable to that seen in total hip replacement. Current consensus holds the surgical treatment of lower back pain as less effective or predictable than interventions performed in most other orthopaedic subspecialties. Detailed clinical and economic outcome studies are vital to justify its use in routine practice. This prospective study presents medium to long-term clinical outcome scores for PLIF which are compared with those of an operation that might be considered a modern orthopaedic gold-standard: total hip arthroplasty. Methods: The authors present 100 consecutive PLIF operations performed by the senior author between 1997 and 2004. SF36, Oswestry Disability Index (ODI), Visual Analogue Scores (VAS) and walking distances were prospectively collected and analysed in the post-operative period. Results were compared to the SF36 healthy population norms and with the outcome scores of standard total hip replacement available in the literature. Results: The mean pre-operative ODI was 49. 12 months following surgery this improved to 22. All outcomes as measured by SF36 improved following surgery. The VAS for back pain improved from 8.5 pre-operatively to 3.21 post-operatively. Leg pain improved from 6.98 to 2.85. Improvements in the SF36 scores were similar to those seen in hip arthroplasty. Discussion: The hypothesis has been proven. The gains in function following spinal fusion are comparable with those seen in hip arthroplasty. In the authors’ opinion PLIF is an effective procedure in an appropriately selected patient population

1. In congenital absence of the fibula, the fibrous strip that replaces the bone, abnormal insertions of fibular muscles, and disturbances in the formation and growth of the tarsal bones all go to cause the valgus deformity of the foot and the complete or partial dislocation of the talo-tibial joint. 2. Conservative treatment is justified only for children less than a year old and then only as preparation for operation. 3. Between the second and seventh year of life operations upon the soft tissues are indicated, to eliminate the contractures occurring on the posterior and lateral sides, to restore the proper position of the foot in line with the axis of the tibia, and to restore the normal shape of the foot and muscular equilibrium. At the same time favourable conditions are created for operative reconstruction of the lateral malleolus. 4. Arthrodesis of the talo-tibial joint or reconstruction of the lateral malleolus by a bone graft with the aim of stabilising the foot in the axis of tibia is not advisable in the growing limb. 5. The results obtained in three cases described support the conclusion that the bifurcation operation recommended by Gruca produces a new lateral malleolus with an epiphysis that grows at the same rate as the remainder of the lower epiphysis of the tibia, does not affect the rate of growth of the tibial epiphysis, prevents the recurrence of the deformity, and preserves the mobility of the talo-tibial joint. 6. In early cases this reconstructive operation may be done at the same time as soft-tissue deformities are corrected and subluxation reduced. 7. It is probable that the bifurcation operation should be done on children aged between two and seven years in order to give the limb the best chance to develop normally

Dual mobility hip arthroplasty utilizes a freely rotating polyethylene liner to protect against dislocation. As liner motion has not been confirmed in vivo, we investigated the liner kinematics in vivo using dynamic radiostereometry.

16 patients with Anatomical Dual Mobility acetabular components were included. Markers were implanted in the liners using a drill guide. Static RSA recordings and patient reported outcome measures were obtained at post-op and 1-year follow-up. Dynamic RSA recordings were obtained at 1-year follow-up during a passive hip movement: abduction/external rotation, adduction/internal rotation (modified FABER-FADIR), to end-range and at 45° hip flexion. Liner- and neck movements were described as anteversion, inclination and rotation.

Liner movement during modified FABER-FADIR was detected in 12 of 16 patients. Median (range) absolute liner movements were: anteversion 10° (5–20), inclination 6° (2–12), and rotation 11° (5–48) relative to the cup. Median absolute changes in the resulting liner/neck angle (small articulation) was 28° (12–46) and liner/cup angle (larger articulation) was 6° (4–21). Static RSA showed changes in median (range) liner anteversion from 7° (-12–23) postoperatively to 10° (-3–16) at 1-year follow-up and inclination from 42 (35–66) postoperatively to 59 (46–80) at 1-year follow-up. Liner/neck contact was associated with high initial liner anteversion (p=0.01).

The polyethylene liner moves over time. One year after surgery the liner can move with or without liner/neck contact. The majority of movement is in the smaller articulation between head and liner.

The records of 110 cases of ulnar neuritis in 100 patients have been reviewed an average of 4.4 years after anterior transposition, or release of the aponeurosis. Seventy of the patients were reviewed personally. In over half the cases no precipitating cause was apparent. At operation the nerve was constricted by the flexor carpi ulnaris aponeurosis in fifty cases but in twenty-five no abnormal pathology was found. Recovery was greatest when operation was performed within three months of the onset of symptoms. In those cases where no abnormality was found, and those in which adhesions in the postcondylar groove involved the nerve, simple release was less effective than anterior transposition. It is therefore recommended that release be restricted to patients with a short history and with an obvious aponeurotic constriction unaccompanied by adhesions. Anterior transposition is the operation of choice where no abnormality is seen or where the nerve is dislocated, compressed or tethered proximal to the aponeurosis of flexor carpi ulnaris

A prospective trial has been carried out to determine the value of suction drainage in the operation of meniscectomy. One hundred operations were analysed, in half of which drains had been used. The use of the drain could not be shown to result in any sustained advantages. The demand for analgesics after the operation was reduced but not to a statistically significant level. The size of the early effusion was significantly reduced, but this benefit was lost when the knee was mobilised. The return of power to the quadriceps and of movement to the knee were not hastened. The average volume of fluid drained was 134 millilitres and it has been shown that forty-eight hours is a suitable time for removal of the drain. The use of suction drainage is not advocated for the uncomplicated operation of meniscectomy

All surgical operations have the potential for contamination, and the equipment used can harbour bacteria. We collected samples from 100 elective primary hip and knee arthroplasties. These showed rates of contamination of 11.4% for the sucker tips, 14.5% for light handles, 9.4% for skin blades and 3.2% for the inside blades used during surgery; 28.7% of gloves used for preparation were also contaminated. Of the samples taken from the collection bags used during hip arthroplasty, 20% grew bacteria, which represents a significant microbial reservoir. Also, 17% of theatre gowns were contaminated at the end of the operation. Contamination was found in 10% of the needles used during closure of the fascia. Overall, 76% of the organisms grown were coagulase-negative staphylococcus. A total of 63% of operations showed contamination in the field of operation. Some changes in practice are suggested. Follow-up for a minimum of two years revealed one deep infection but the organism was not identified as a contaminant. These data provide a baseline for studying the bacteriology of the surgery of revision arthroplasty

1. A realignment operation is described for the treatment of recurrent dislocation of the patella. 2. In twenty-three patients (twenty-seven knees) operation prevented further dislocation. The physical and functional condition of the knees two to twenty years after operation is described. 3. Patello-femoral osteoarthritis was not a clinical complication in any of these patients. This finding is discussed. 4. Genu recurvatum developed in four patients operated upon between the ages of ten and thirteen years. The cause of this deformity is discussed. It is concluded that the realignment operation should not be performed under the age of fourteen years. 5. In three patients operation failed to control the recurrent dislocation

Aim To assess the reliability of Stainsby’s operation for dislocated lesser toe metatarsophalangeal (MTP) joints. Method Seventy-four patients underwent this operation between 1998–2003. Sixty-nine patients (93%) were reviewed at mean follow up of 32 months (range 10–67) post-operatively. Forty-eight patients had rheumatoid arthritis, two had psoriatic arthropathy, 19 had other causes. Ninety-four feet were reviewed, 73 had had multiple lesser toe operations, 21 had single lesser toe operations, 52 feet had surgery to the hallux. Assessments were made of pre- and post-operative pain, shoe problems, callosities, alignment and function. Results Out of 94 feet, 89 (95%) had severe or moderate pain pre-operatively. Only 19 (20%) had significant pain at review. Pain under operated toes was relieved in 78 feet (83%). Tender plantar callosities were reduced from 76 feet pre-operatively (81%) to 31 feet (33%) at review, these mainly under un-operated metatarsal heads. Shoe problems were reduced from 89 feet (95%) pre-operatively to 61 feet (65%) at review. American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scores were increased from a mean of 19 pre-operatively to 52 at review. Residual valgus of big toe more than 25 degrees persisted in 33 feet (35%). Corrective osteotomy of 44 first metatarsals failed to prevent recurrent valgus in 16 feet (36%). Conclusions The Stainsby operation was effective in relieving pain and skin callosities from under dislocated lesser metatarsal heads, and in reducing shoe problems but we found that varus osteotomy was unreliable in correcting valgus of the big toe. This was probably due to stretching of the repaired medial ligament

1. The indications for open reduction in congenital dislocation of the hip are discussed. 2. The technique of the operation and the post-operative treatment are briefly described. 3. The results of the operation in fifty hips are presented. 4. The function and the radiographic appearances of the hip were usually good in the early years after open reduction, but there was a marked tendency to deterioration ten to thirteen years afterwards. 5. The indications for the shelf operation and for rotation osteotomy after open reduction are discussed

1. Patients subjected to the flexor-extensor transplant have been reviewed. The results in forty feet were assessed by direct questioning and examination, and the results of a further five operations were assessed from the records. 2. Worthwhile improvement was gained in a little over half the cases. The chances of success are greatest when the symptoms are mildest. 3. The operation appears to be inadequate in certain respects and it seems doubtful whether it has any advantage over the multiple arthrodesis (Lambrinudi) operation

The purpose of our study was to evaluate the necessity of blood transfusions in operations for neglected DDH. It is generally known that blood transfusion is necessary in neglected DDH operations. Because of transfusion complications, Erythropoetin and autologous blood donation are proposed for blood replacement. However, these two methods are expensive and not useful in children. We evaluated Hb-Hct levels in 48 children (52hips) operated on from 1992 to 1997. Mean age was 5.7 years (range 1.5 to14). Open reduction and pelvic osteotomy was performed in 40 hips, and open reduction, femoral shortening, and pelvic osteotomy in 12 hips. The authors performed all of the operations. We approached the surgical technique and haemostasis carefully by using a curved ostetom instead of a gigly saw and left the medial apophisis and periosteum intact until the roof surgery. Dissection of the posterior-superior part of the ischiadic notch was avoided, and without using a drain. Oral supplemental ferrum (5 mg/kg) was prescribed to all patients until the Hb value increased to 12mg/dl. There was close clinical status follow-up of the patients for ten days after surgery and Hb–Hct levels were recorded periodically. In the open reduction and modified Salter osteotomy group there were 4/40 hips respectively (10%). In the combined surgery group (open reduction, femoral shortening, pelvic osteotomy) there were 16 hips (33%) that required transfusion. We preferred packed red blood cell transfusion for blood substitution. Transfusions were made within one to five days. Mean loss of Hb was 4.7g/dl. Up to 7g/dl Hb level was well-tolerated by the patients. Digitalisation was required for one patient. There were no mortalities or infections in our patients up to the time of follow-up. The process requires experienced surgeons, a meticulous surgical technique, a shortened operation time by modification of the pelvic osteotomy, and without using a drain. This is one of the most effective and less expensive ways to perform an operation for neglected DDH with a minimal loss of blood

An operation for chronic prepatellar bursitis is described in which only the posterior wall of the bursa is excised, thus preserving, undamaged, healthy and normally sensitive skin. This procedure is easier and less traumatic than complete excision of the bursa and results in fewer complications. It is suggested that removal of tha anterior wall of the bursa results in unnecessary and harmful interference with the underlying skin. The operation described gives a good functional and structural result; leaving the anterior wall of the bursa does not predispose to recurrence

Aims. The aim of this study was to determine whether the rates of revision for metal-on-metal (MoM) total hip arthroplasties (THAs) with Pinnacle components varied according to the year of the initial operation, and compare these with the rates of revision for other designs of MoM THA. Patients and Methods. Data from the National Joint Registry for England and Wales included 36 mm MoM THAs with Pinnacle acetabular components which were undertaken between 2003 and 2012 with follow-up for at least five years (n = 10 776) and a control group of other MoM THAs (n = 13 817). The effect of the year of the primary operation on all-cause rates of revision was assessed using Cox regression and interrupted time-series analysis. Results. For MoM THAs involving Pinnacle components, those undertaken between 2007 and 2012 had higher rates of revision compared with those undertaken between 2004 and 2006 (hazard ratio (HR) 2.01; 95% confidence interval (CI) 1.57 to 2.57; p < 0.001). For THAs undertaken during and after 2007, the number of revisions per 1000 implant-years at risk significantly increased by 5.20 (95% CI 0.52 to 9.89; p = 0.033) compared with those undertaken before this time. In the control group, THAs undertaken between 2007 and 2012 also had higher rates of revision (HR 1.77; 95% CI 1.49 to 2.10; p < 0.001), with revisions per 1000 implant-years for those undertaken during and after 2007 significantly increasing by 6.13 (95% CI 1.42 to 10.83; p = 0.016). Conclusion. The five-year revision rates were significantly increased for all primary MoM THAs undertaken from 2007 onwards. Contrary to recent reports, this finding was not specific to those involving Pinnacle acetabular components and may be explained by increased surveillance and recent lowering of the threshold for revision. Cite this article: Bone Joint J 2018;100-B:33–41

We reviewed 26 patients with 34 shoulders treated by the inferior capsular shift operation for inferior and multidirectional instability. The mean follow-up was 8.3 years. In total, 12 shoulders showed voluntary subluxation. Eight operations used an anterior and posterior approach, 11 were by the posterior route, and 15 shoulders had an anterior approach. In 30 shoulders (85%) the outcome was satisfactory and 20 (59%) scored good or excellent results on the Rowe system. Instability had recurred in nine shoulders (26%) from three months to three years after the operation. Six of the 12 shoulders with voluntary subluxation (50%) had recurrence, as against three of the other 22 (14%), a statistically significant difference. The operation is therefore not indicated for voluntary subluxation. The 19 shoulders which had been assessed in 1987 at a mean of 3.5 years after surgery, were also reviewed in 1995 and found to have no significant changes in instability or Rowe score. This shows that the capsular shift appeared to have maintained its tension over an eight-year period. After the use of a posterior approach, 64% of the shoulders showed a posterolateral defect on radiographs of the humerus

Introduction: Increasing medicolegal pressures, as well as problems with continuity of care and trauma patients outlying on non-orthopaedic wards, led to a concern regarding the quality of operation notes, especially with regard to postoperative instructions. A computerised system was introduced to address these issues. Method: The quality of trauma operation notes was surveyed over a period of four weeks, before and after the introduction of the computerised system. Royal College of Surgeons guidelines, as well as additional orthopaedic criteria, were used as the expected standards. Results: Most criteria were met significantly more of the time after the introduction of the computer generated notes, including antibiotic prophylaxis, weightbearing status and outpatient appointment. Discussion: A computerised system is an effective and acceptable way of improving the standard of trauma operating notes. Users should be reminded to sign the resulting printed note until a full paperless record is in place

Failure of normal acetabular development is inevitable in congenital dislocation of the hip when it is unrecognised until late infancy or early childhood. Numerous stabilising procedures have been described, one of the first being the shelf operation or acetabuloplasty. This procedure fell into disrepute because the shelf was often located too high or was too small to prevent upward migration of the femoral head. The technique described emphasises the importance of resecting the thickened capsule and exposing the lateral margin of the acetabulum to allow a substantial portion of the outer cortex of the ilium to be turned down both laterally and anteriorly over the femoral head. Twenty cases of acetabuloplasty have been followed up for an average period of nine years. The results have been assessed from the point of view of function, relief of pain, and degree of support of the femoral head as demonstrated radiologically. The shelf operation is a simple and safe procedure, and provided it gives adequate support to the subluxated femoral head it will ensure a stable, mobile joint capable of standing up to reasonable use for many years. If deterioration should occur in later life, total hip replacement may be undertaken more easily than if the joint had been allowed to undergo progressive subluxation

1. Butler's operation for the correction of the dorsally adducted fifth toe is described. 2. It is a simple and safe operation not needing splints, and giving good reliable results. 3. The results of seventy operations performed over ten years are studied

A system is presented for the analysis of failure after spinal operations: 1) outright failure; 2) temporary relief; 3) failure in spondylolisthesis; and 4) infections. With this system it is possible to trace the causes of failure and to correct some of them. When they are used as a guide before operation, the recommendations made should help to prevent many failures

1 . Paralytic talipes calcaneus and calcaneo-cavus are difficult deformities to correct and keep corrected. Many operations have been devised for this purpose. 2. Emslie's operation is a simple procedure by which satisfactory correction can be obtained and maintained. It can be modified to suit individual cases without altering the basic principles of the procedure and is physiologically sound. 3. Illustrative cases are described

The trauma and the operation of femoral fractures provoke a double increase inflammatory reaction. We studied the CRP and how it is influenced form the time and the type of operation. 70 patients, without malignancy or infection, age 80 ± 7 years. The values of CRP were measured on admission, before operation and 48 hours postoperative. The patients were grouped:. Group 1: Operation at 1–3 day. Group 2: Operation at 4–6 day. Group 3: operation after 7 day. And in relation with type of operation. TGN 23, DHS 19, HEMIARTHROPLASTY 28. The CRP presents a double increase from the trauma to osteosynthesis and at 48 hours after operation. The first moderate increase is presented from the immediate to late osteosynthesis. The second increase is presented at group of late osteosynthesis and TGN> DHS> HEMIARTH. In conclusion the maximum postoperative inflammatory reaction at patients who sustained fractures of femoral neck is measured at 3d and at 6th postoperative day, while before the operation there weren’t any important and statistically differences of CRP values. In comparison with the type and the method of operation, the CRP presents differences between Hemiarthroplasty and (TGN-DHS)

The results of operation performed within the first six months of life upon seventy-seven resistant club feet are presented. The indications for and the rationale of early operation are discussed. Particular attention has been paid to the relationship between the age at operation and the outcome more than four years later; the results were greatly superior when operation was undertaken early. Two surgical techniques are compared, the postero-medial release proving better than a simple posterior release. The relationship between clinical and radiological assessment is discussed, and also the influence of the results reported upon future practice

The outcome of operations performed on 38 patients for rheumatoid disorders of the cervical spine were analysed 10 or more years later. The mean age of the patients at the time of operation was 56 years (35 to 77); 32 had seropositive disease. The mean duration of the disease was 17 years (four to 36). Twenty-seven patients had painful anterior atlanto-axial subluxation (AAS), nine had subaxial subluxation alone and two had severe cranial subluxation of the odontoid, one also with subaxial subluxation. One patient died from postoperative staphylococcal septicaemia and another 18 died during the follow-up period. Patients with coincident cardiac or other diseases, and those with cranial subluxation of the odontoid of more than 3 mm had an increased mortality. Neither the patients' age nor the magnitude of AAS correlated with mortality. Of the 37 patients with occipitocervical pain, 30 were relieved and all the six patients with tetraparesis were improved. Of the 24 Gallie fusions only 12 were solidly united; patients with long-term cortisone treatment were more likely to develop pseudarthrosis. There was no correlation between clinical outcome and radiological result. Four patients had further operations to treat subluxation which developed below the fused segments

The goal of the present study was to evaluate the results of a one-stage operation performed on dislocated hips in children with infantile cerebral palsy. Our data indicate that the one-stage operation is a quite useful method to treat hip dislocation in children with infantile cerebral palsy. Based on our experience we emphasize the use of an individual operation plan in every instance. In selected cases it seems to be justified to ignore an element of the method. We used the radiological findings for evaluation by comparing the geometric parameters in the affected hips before and after surgery. During the last ten years, 21 dislocated hips in 13 patients were operated on by the one-stage surgical technique used at the Department of Orthopaedic Surgery of University Medical School of Pécs. The technique consists of the following steps: open reduction, iliopsoas tendon transfer, and femoral varus derotational osteotomy with shortening, modified Tönnis acetabuloplasty, and open adductor tenotomy. Spastic diplegia occurred in eight children and hemiplegia in five. During this period, eight girls and five boys were operated, with 12 procedures on the right hip and 9 on the left. Mean age was 11.4 years. The average age of the children at the time of operations was 6.5 years. In eight hips of five children, all elements of the surgery were carried out in one sitting; in six hips of four children the surgery was performed without acetabuloplasty. In nine hips of seven children there was no need for open reduction, and in six hips of five children we used deep frozen allograft to perform acetabuloplasty. A varus derotational femoral osteotomy with shortening was a part of the surgical approach in all cases. We evaluated Hilgenreiner (H), Wieberg (CE) and collodiaphyseal (CCD) angle preoperatively and postoperatively. The average preoperative H angle decreased from 39.7 to 24 degrees postoperatively. The average preoperative CE angle increased from minus 18.6 to 31.9 degrees postoperatively. The minus means that all of the patients had dislocation in their hips. The average preoperative CCD angle decreased from 165.2 to 131.4 degrees postoperatively. The results were evaluated by the modified Severin classification based on age and anatomical changes of hips: 17 cases were evaluated as excellent, 2 as good, and 2 as acceptable. We did not see any complications such as avascular necrosis of the femoral head, absolute revalgisation (compared to the opposite side), subluxation, re-dislocation, or disturbed development of the acetabulum

We evaluated the long-term results of a modified Spitzy shelf operation for secondary osteoarthritis in 119 hips with a mean follow-up of 23.8 years. The mean age of the patients at the time of surgery was 25 years. Preoperative osteoarthritic change, the age at operation and shelf height were important factors in determining the outcome. Of the 61 hips in the pre-stage (three) and the initial stage (58) of osteoarthritis, 53 (87%) had good results, compared with only 30 (51%) of 58 hips with advanced osteoarthritis. Of the latter, 72% of those aged less than 25 years had good results compared with only 40% of patients aged over 25 years. The shelf height in the group with good results was significantly lower than in those with poor results. This operation is a safe procedure and indicated for acetabular dysplasia or subluxation of the hip with early osteoarthritic change in patients aged less than 25 years

A method of repair for anteromedial rotatory instability of the knee is described and the results of operations on 36 knees reviewed. Complete static correction occurred in 30 of these patients (84 per cent), three patients showed improvement (8 per cent) and three showed no improvement (8 per cent). Although the operation was not reliable as a correction for valgus instability, it did not increase this instability. This operation may be combined with other procedures to correct all instabilities or problems of the knee

Shelf operations performed on 24 patients (27 hips) for late presentation of congenital hip dysplasia were evaluated. The mean age at operation was 14 years 9 months and the mean follow-up 16 years 8 months. Two-thirds of the hips had good clinical results at follow-up. Patients operated on under the age of 20 years and with little or no radiological evidence of degenerative joint changes had the highest likelihood of success. The shelf operation was found to provide good cover of the femoral head and, should failure occur, also provides adequate superior support for the seating of an acetabular prosthesis

1. Fifty cases of recurrent dislocation of the shoulder are reported, operated upon by Bankart and his colleagues from 1925 to 1954. 2. This is the first detailed survey of his patients, some of whom we were unable to trace. 3. It has been confirmed that the operation is successful, and that a full range of movement can be regained after operation, though not in every case. 4. Two cases treated unsuccessfully are described and discussed

A new technique for repair of neglected posterior dislocation of the elbow is described, consisting of open reduction with tendon graft stabilisation to create a medial collateral and an intra-articular "cruciate" ligament. This allows flexion-extension exercises to start six days after operation. Eleven cases are reported in which the average range of movement improved from 38 degrees before operation to 105 degrees after a minimum follow-up of two years, with a mean valgus-varus instability of only 13 degrees. One patient had a postoperative infection but all the others were satisfied with the functional result

In a prospective study we attempted to define the role of lumbar discography in the investigation of patients with low back pain with or without non-dermatomal pain in the lower limb. The records of 195 patients were studied at least two years after a technically successful operation. Of 137 patients in whom discography had revealed disc disease and provoked symptoms, 89% derived significant and sustained clinical benefit from operation. Of 25 patients whose discs showed morphological abnormality but had no provocation of symptoms on discography only 52% had clinical success. These findings support the continued use of lumbar discography for the investigation of this particular group of patients

1. Operative treatment of scaphoid pseudarthrosis by the Matti-Russe method is a reliable procedure which in our series has given ninety-seven cases of bony union in a total of 100 operations. 2. We do not hesitate to advise operation for this condition as soon as it is discovered, except in cases with severe secondary osteoarthritis. Equally good results have been reported by Murray (1946) from a series of 100 cases treated with cortical grafts from the tibia (blind method) and by Agner (1963) from a series of twenty-four patients treated by Bentzon's operation (interposition of a pedicled soft-tissue flap). 3. In our opinion, Russe's open operation has great technical advantages over Murray's blind method. 4. We have no experience of Bentzon's operation, which seems attractive on account of its technical simplicity and as not more than two weeks' immobilisation in plaster after operation are needed. 5. It would be interesting to see Agner's results confirmed from other sources. It is true that many scaphoid pseudarthroses remain symptomless for years, as London (1961) has pointed out, but many of them sooner or later cause pain, and we do not agree with London's opinion that a few weeks of immobilisation will usually make the wrist painless. 6. Although severe osteoarthritis is very slow to develop in wrists with pseudarthrosis of the scaphoid bone it cannot be denied that these wrists are constantly threatened with suddenly developing pain and by progressive deterioration of function. 7. Therefore, early repair of pseudarthrosis of the scaphoid bone is advisable; it can be expected to save many wrists from progressive loss of function and from final development of severe degenerative change

We have treated 45 patients (47 ankles) for chronic lateral instability by a new reconstructive procedure. The operation includes lateral shift of the entire lateral capsule-ligament complex and proximal advancement of the talocalcaneal ligament and the inferior extensor retinaculum. We reviewed 39 patients (39 ankles) at a mean of 4.6 years (2 to 7) after operation. There were 29 men and 10 women with an average age of 27 years (19 to 43); 11 of them were competitive college-level athletes and 28 were recreational athletes. The functional rating was excellent in 26 patients, good in 8, fair in 3 and poor in 2. Thirty-six patients (92%) were satisfied with the result and 34 (9 of 11 college-level athletes and 25 of 28 recreational athletes) have been able to return to their preinjury level of sport. At the last review, there had been only three episodes of recurrent ankle instability, all in recreational athletes; none had required further surgery. The unsatisfactory results were associated with pre-existing degenerative changes in the ankle

Sixty-nine heels in 42 patients with prominence of the calcaneus sufficient to cause symptoms were operated upon after conservative treatment had failed. At review the overall results of operation were found to be poor

A modification of the Lapidus procedure to correct hallux valgus is described in which the length of the first metatarsal is maintained. One hundred and nineteen operations in 78 patients have been followed up for between two and 16 years. There were excellent or good results in 110 feet (92 per cent)

We describe the results after open reduction and internal fixation of 22 consecutive displaced fractures of the glenoid with a mean follow-up of ten years. A posterior approach was used in 16 patients and an anterior in six, the approach being chosen according to the Ideberg classification of the fractures. The fixation failed in two patients, one of whom required a further operation. There were two cases of deep infection. At follow-up the median Constant score was 94% (mean 79%, range 17 to 100). The score was less than 50% in four patients, including the two who became infected. A further two had an associated complete palsy of the brachial plexus

We have reviewed the results of the Sofield-Millar operation on 58 long bones in ten patients. If more than three osteotomies were undertaken the time to union of the bone was significantly prolonged (p< 0.001) with significant thinning of the bone (p< 0.02). We have used a modified technique in order to minimise surgical trauma and devascularisation of the bone. The rod is introduced under the control of an image-intensifier. Small surgical exposures are made only at the sites of corrective wedge osteotomies. The number of osteotomies is kept to the minimum

Patients suffering from generalised convulsions may dislocate their shoulders either anteriorly or posteriorly. Those with anterior dislocation are likely to have recurrent episodes because of secondary bony damage to the anterior rim of the glenoid and head of the humerus. In such patients there is high rate of failure of the standard soft-tissue stabilisation procedures. We have therefore devised a bone buttress operation in which autograft or allograft is secured to the deficient anterior glenoid and shaped to form an extension of its articular surface. We report our experience in 14 patients with grandmal epilepsy and recurrent anterior dislocation of the shoulder. After the bone buttress operation there were no further dislocations and all patients were satisfied despite a small restriction in their range of movement. We believe this to be the operation of choice for patients with this difficult problem