Introduction. Comparative studies examining Fixed-Bearing (FB) and Mobile-Bearing (MB) Total Ankle Replacement (TAR) designs have demonstrated similar results and successful long-term outcomes for both. To date there has been no study directly comparing FB and MB designs of the same prosthesis. We present the first prospective randomised trial comparing patient satisfaction, functional outcomes and radiographic results of the Salto Talaris Fixed-Bearing and the Salto Mobile-Bearing Total Ankle Replacement in the treatment of end-stage ankle arthritis. Methods. A total of 108 adult patients with end-stage ankle arthritis were enrolled in the study between November 2014 and October 2021 with similar demographic comparison. Prospective patient-reported outcomes and standardised weightbearing ankle radiographs were performed preoperatively, at 6 weeks, 6 months and 12 months post-operatively, followed by yearly intervals. All surgeries were performed by a single non-design orthopaedic foot and ankle specialist with experience in over 200 Salto and Salto Talaris TAR prior to the study. Radiographs were examined independently by two clinicians. Complete patient data and radiographs were available for 103 patients with an average follow up of 2 years. Results. Both groups demonstrated statistically significant improvement from preoperative evaluation to most recent follow up with no statistically significant difference between the two groups in all outcome measures. Radiographic incidence of subchondral cyst formation was 8.9% and 38.2% for FB and MB, respectively. Talar subsidence occurred in 2.2% and 5.5% of FB and MB, respectively. Discussion. Our study demonstrates a higher than previously reported rate of cyst formation in the MB TAR and comparatively higher talar subsidence in the MB TAR vs FB however this did not correlate with clinical outcome measures which were favourable for both groups. Conclusion. Fixed-Bearing and Mobile-Bearing Total Ankle Replacement demonstrate comparable favourable

There are many operations for hallux valgus and hallux rigidus, but Keller's operation remains one of the most popular, particularly for the older patient. A prospective trial was carried out to compare the results of Keller's operation modified by Kirschner-wire distraction with those of the standard operation. The results suggest that there is no advantage in using temporary Kirschner-wire distraction; indeed, degenerative changes in the interphalangeal joint and a subjectively worse result may result from its use

Although drains date back to the Hippocratic era, their routine use remains controversial in total hip arthroplasty. The literature suggests that they can provide a retrograde route for infection as well as decreasing the organism count required to develop an infection. The use of drains has not decreased the size of wound haematomas at day five on ultrasound or the incidence of massive wound haematomas. Neither have they been shown to significantly decrease wound infections. This consecutive prospective randomised study was designed to evaluate what role drains have in the management of patients undergoing hip arthroplasty. A total of 577 patients undergoing unilateral or bilateral hip arthroplasty were evaluated in a randomised prospective trial of drain versus no drain, between September 1997 and December 2000. All patients had a standardised pre, inter and post operative regime and were independently assessed using the Harris hip score and SF36 pre-operatively, at discharge and at six months post surgery. The superficial and deep infection rate of 6. 4% and 0. 4% was seen in those drained and 7. 1% and 0. 7% in the non-drained group. Only one patient sustained a clinical haematoma that did not requiring drainage or transfusion in the non-drain group. The transfusion rate in those drained was 33. 0% compared to 26. 4% in those not drained. There was no statistical advantage in using a drain P> 0. 05 regarding these variables or in the length of stay, SF36 or Harris hip scores at pre-op and six months. Using a drain did significantly increase the likelihood of requiring a transfusion P< 0. 05. In conclusion drains provide no statistical advantage whilst represent an additional cost and expose hip arthroplasty patients to an unacceptable risk of infection and transfusion

Fifty patients with adolescent idiopathic scoliosis treated by posterior fusion and Harrington instrumentation augmented by a Cotrel bar or by sublaminal Luque wires were studied in a prospective trial to ascertain the need for postoperative bracing. Twenty-five patients wore a plaster brace postoperatively for six months, while 25 were managed without a brace. The mean loss of correction from the first standing postoperative radiograph to one obtained two years later was 7 degrees in the braced group, and 6.3 degrees in the unbraced group, the difference not being statistically significant. We conclude that postoperative bracing is unnecessary after augmented Harrington instrumentation

The results of a prospective controlled trial of early mobilisation of Colles' fractures in the elderly are presented. Early mobilisation produced less pain and a stronger grip. It did not lead to any greater loss of reduction of the fracture. However, there was no significant improvement in the final range of movement of the wrist. Immobilisation of the wrist for six weeks in plaster is extremely inconvenient for the elderly living alone and the patients greatly appreciated the reduction of this period of time to a minimum

The optimum design for the femoral component for cementless Total Hip Replacement is not known. We conducted an ethically approved, randomised and prospective trial to compare two radically different designs of fully hydroxyapatite (HA) coated femoral stems. We compared the original JRI Furlong stem with the Wright Anca fit stem which is more anatomical in design. The paper discusses the merits and disadvantages of these two stems. The same acetabular component was used in both samples. The only variable was the stem shape. All patients placed on the senior author's waiting list for primary THR were asked if they would enter the trial. There were no restrictions for selection to the sample. Patients were then randomised for one of the two stems. All surgery was performed by or under the direct supervision of the senior author. The periprosthetic and perioperative fracture rates for the two stems were found to be significantly different at three years into the study and the trial was stopped. 337 patients had been entered into the trial, 211 females and 126 males. 191 patients had the JRI furlong hip implanted (57%) and 146 are in the Anca sample (43%). The number of perioperative fractures in the Furlong group was 13 (6.8%)and in the Anca sample 22 (15.1%). This is statistically significant. The possible reasons for this difference are discussed. Anatomical fit cementless stems require a more careful technique to avoid fracture during implantation and the shorter stemmed Anca hip proved less stable in the presence of a fracture necessitating further surgical intervention. It is still not certain whether the anatomical shape has long term advantages that may outweigh this initial disadvantage and the cohort of patients continues to be followed up

The optimum design for the femoral component for cementless Total Hip Replacement is not known. We conducted an ethically approved, randomized and prospective trial to compare two radically different designs of fully hydroxyapatite(HA) coated femoral stems. We compared the original JRI Furlong stem with the Wright Anca fit stem which is more anatomical in design. The paper discusses the merits and disadvantages of these two stems. The same acetabular component was used in both samples. The only variable was the stem shape. All patients placed on the senior authors’ waiting list for primary THR were asked if they would enter the trial. There were no restrictions for selection to the sample. Patients were then randomised for one of the two stems. The surgery was undertaken by one surgeon, in one centre, in matched patients and using the same well-tried CSF acetabular cup and bearings. 335 patients had been entered into the trial, 228 females and 126 males. 191 patients had the JRI furlong hip implanted (57%) and 146 are in the Anca sample (43%). The number of perioperative fractures in the Furlong group was 13(6.8%)and in the Anca sample 22 (15.3%). The periprosthetic and perioperative fracture rates for the two stems were found to be significantly different at three years into the study and the trial was stopped. The possible reasons for this difference are discussed

In a randomised prospective trial 98 elderly women with trochanteric fractures of the femur were treated with either a 135 degrees Jewett nail-plate or a 135 degrees Dynamic hip screw. The results at six weeks, three months and six months were statistically analysed. There were no significant differences in the two groups with regard to pain, length of hospital stay, morbidity or mortality. Although operative difficulties and open reduction were more common with the Dynamic hip screw, at the end of six months more patients in this group were mobile and there was significant radiological evidence of better compression without loss of fixation

To assess if highly cross-linked polyethylene is associated with less linear wear than ultra high molecular weight polyethylene in vivo. To assess whether alteration in biomechanical characteristics of the reconstructed hip influence’s wear patterns. A randomised prospective trial comparing conventional polyethylene with highly cross-linked polyethylene in an acetabular component was designed. Identical cemented stems were used in all cases, with a metal head. The polyethylene thickness was controlled. The trial design required 124 cases to be entered to give the study sufficient power to determine any difference in wear rates. Polyware Auto was used to assess 2D wear rate and volume. This paper presents the preliminary results of the early patients entered into the study and looks at both 2D wear or creep at 18 months post operatively, and seeks to establish any relationships between 2D movement and biomechanical characteristics of the reconstructed hip. There was no significant difference in the 2D wear (or creep) between the two types of polyethylene at 18 months. There was no correlation between femoral offset, cup offset, or centre of rotation offset and 2D wear (or creep). This preliminary data shows no difference in the early wear rate of the two types of polyethylene. This is in contrast to an in vitro wear simulator study that has shown more creep in highly cross-linked polyethylene. The significance of this observation is unclear. We hope to demonstrate that as the trial progresses any difference in the performance of the two types of polyethylene should be evident

We performed a prospective randomised trial on matched groups of patients with displaced tibial shaft fractures to compare conservative treatment with closed intramedullary nailing. The results showed conclusively that intramedullary nailing gave more rapid union with less malunion and shortening. Nailed patients had less time off work with a more predictable and rapid return to full function. We therefore consider that closed intramedullary nailing is the most efficient treatment for displaced fractures of the tibial shaft

The optimum design for the femoral component for cementless Total Hip Replacement is not known. We conducted an ethically approved, randomized and prospective trial to compare two radically different designs of fully hydroxyapatite (HA) coated femoral stems. We compared the original JRI Furlong stem with the Wright Anca fit stem which is more anatomical in design. The paper discusses the merits and disadvantages of these two stems. The same acetabular component was used in both samples. The only variable was the stem shape. All patients placed on the senior authors’ waiting list for primary THR were asked if they would enter the trial. There were no restrictions for selection to the sample. Patients were then randomised for one of the two stems. All surgery was performed by or under the direct supervision of the senior author in one center. The surgical approach to the hip, Hardinge antero lateral, was the same in all cases. In all cases the same well-tried JRI CSF acetabular cup and bearings were used. Patients were x-rayed post operatively and reviewed and x-rayed at six weeks and then yearly. 360 patients had been entered into the trial, 219 females and 141 males. 203 patients had the JRI furlong hip implanted (56%) and 157 were in the Anca sample (44%). The periprosthetic and perioperative fracture rates for the two stems were found to be significantly different at three years into the study and the trial was stopped. The number of perioperative fractures in the Furlong group was 17(8.4%)and in the Anca sample 24 (15.3%). This is statistically significant. The possible reasons for this difference are discussed. Anatomical fit and wedge shaped cementless stems require a more careful technique to avoid fracture during implantation and the shorter stemmed Anca hip proved less stable in the presence of a fracture necessitating further surgical intervention. It is still not certain whether the anatomical shape has long term advantages that may outweigh this initial disadvantage and the cohort of patients continue to be followed up

We designed a prospective randomised trial to compare traditional conservative management with reaming, closed intramedullary nailing. Our aims were to compare early functional and the rehabilitation period between and of the two groups. The trial had strict criteria for entry: Group A) All patients were skeletally mature, Group B) All fractures were at least 50% displaced or angulated at least 10° in any direction, Group C) All patients had a displaced fracture of the tibial shaft more than 5 cm away from either knee or ankle and with no other significant injury, Group D) Only grade I compound fractures were admitted; grade II and III compound fractures were excluded. Group A was treated by manipulation of the fracture and the application of a long-leg plaster cast. Group B had closed intramedullary nailing of the fracture, with either dynamic or static locking as indicated. A total of 79 patients entered the trial: 37 in Group A and 42 in Group B. The criteria for fracture union was pain-free, unaided walking. There were two cases of non-union in Group A and none in Group B. Mean time to union was significantly shorter in Group B, as was the mean delay before return to work. There was significantly more angular deformity and shortening in Group A. Two patients in Group B had been nailed in significant external rotation (8 degrees). Movement at the knee, ankle and hindfoot was regained in the final control. Group B spent longer in hospital than group A. Group A had no cases of infection or wound problems. There was failure of conservative treatment in five of the 37 patients. These patients required late operation. Group B had one case of deep infection. In one case the distal locking screw was broken but no problem was encountered during follow-up. Autogenous bone grafting was performed in one case with non-union. We have concluded that displaced fractures of the tibial shaft are better and more efficiently treated by closed intramedullary nailing. This method has an acceptable complication rate when compared with conservative treatment

We designed a prospective randomised trial to compare traditional conservative management with reaming, closed intramedullary nailing. Our aims were to compare early functional and the rehabilitation period between and of the two groups. The trial had strict criteria for entry: Group A) All patients were skeletally mature, Group B) All fractures were at least 50% displaced or angulated at least 10° in any direction, Group C) All patients had a displaced fracture of the tibial shaft more than 5 cm away from either knee or ankle and with no other significant injury, Group D) Only grade I compound fractures were admitted; grade II and III compound fractures were excluded. Group A was treated by manipulation of the fracture and the application of a long-leg plaster cast. Group B had closed intramedullary nailing of the fracture, with either dynamic or static locking as indicated. A total of 79 patients entered the trial: 37 in Group A and 42 in Group B. The criteria for fracture union was pain-free, unaided walking. There were two cases of non-union in Group A and none in Group B. Mean time to union was significantly shorter in Group B, as was the mean delay before return to work. There was significantly more angular deformity and shortening in Group A. Two patients in Group B had been nailed in significant external rotation (8 degrees). Movement at the knee, ankle and hindfoot was regained in the final control. Group B spent longer in hospital than group A. Group A had no cases of infection or wound problems. There was failure of conservative treatment in five of the 37 patients. These patients required late operation. Group B had one case of deep infection. In one case the distal locking screw was broken but no problem was encountered during follow-up. Autogenous bone grafting was performed in one case with non-union. We have concluded that displaced fractures of the tibial shaft are better and more efficiently treated by closed intramedullary nailing. This method has an acceptable complication rate when compared with conservative treatment

The present IRB approved study evaluates the early results of 100 TKAs using CT-based Patient-Specific Instrumentation (PSI) (MyKnee®, Medacta International, SA, Castel San Pietro, Switzerland). For this technique, a CT scan of the lower extremity is obtained, and from these images, the knee is reconstructed 3-dimensionally. Surgical and implant-size planning are performed according to surgeon preference, with the goal to create a neutral mechanical axis. Once planned and approved, the blocks are made [Fig. 1].

Outcomes measured for the present study include surgical factors such as Tourniquet Time (TT) as a measure of surgical efficiency, the actual intraoperative bony resection thicknesses to be compared to the planned resections from the CT scan, and complication data. Furthermore, pre- and post-operative long standing alignment and Knee Society Scores (KSS) were obtained.

During surgery, the PSI cutting block is registered on the femur first and secured with smooth pins. No osteophytes are removed as the blocks use the positive topography of the osteophytes for registration. The distal femoral resection is performed directly through the block. An appropriate sized 4-in-1 block is placed and the remaining resections are performed. The tibial resection block is registered and resection performed. Final bone preparation, patella resurfacing, and trialing is performed as is standard to all surgical techniques.

There were 50 Left and 50 Right TKA's performed in 61 females and 39 males. All patients had diagnosis of osteoarthritis. The average BMI was 31.1 and average age was 64.5 (range 41–90). 79 patients had pre-operative varus deformities with Hip Knee Angle (HKA) average of 174.7° (range 167°–179.5°). 19 patients had pre-operative valgus deformities averaging 184.4° (range 180.5°–190°). Three patients were neutral.

Average TT was 31.2 minutes (range 21–51 minutes). With regard to the bony resections, the actual vs. planned resections for the distal medial femoral resection was 8.7 mm vs. 8.9 mm respectively. Further actual vs. planned femoral resections include distal lateral 7.2 vs. 6.7 mm; posterior medial 8.3 vs. 8.9 mm; and posterior lateral 6.2 vs. 6.8 mm. The actual vs. planned tibial resections recorded include medial 6.4 vs. 6.3 mm and lateral 8.3 vs. 8.2. The planned vs. actual bony cuts are strongly correlated, and highly predictive for all 6 measured cuts (p=<.001) [Fig. 3]. No intraoperative complications occurred.

Average KSS improved from 45.9 to 81.4, and KSS Function Score improved from 57.7 to 73.5 at 6 weeks postoperative visit. There were no thromboembolic complications. Two patients had a post-operative infection requiring surgical intervention.

Post-operative alignment was 179.36° (range 175°–186°) for all patients. Alignment was neutral, within 3° in 95.9% of patients. There were only 4 outliers with maximal post-operative angulation of 6° [Fig. 2].

In conclusion, these early results demonstrate efficacy of CT-based PSI for TKA. The surgery can be performed efficiently, accurately, and safely. Furthermore, excellent short term clinical and radiographic results can be achieved.

The present IRB approved study evaluates the early results of 100 TKAs using CT-based Patient-Specific Instrumentation (PSI) (MyKnee®, Medacta International, SA, Castel San Pietro, Switzerland). For this technique, a CT scan of the lower extremity is obtained, and from these images, the knee is reconstructed 3-dimensionally. Surgical and implant-size planning are performed according to surgeon preference, with the goal to create a neutral mechanical axis. Once planned and approved, the blocks are made.

Outcomes measured for the present study include surgical factors such as Tourniquet Time (TT) as a measure of surgical efficiency, the actual intraoperative bony resection thicknesses to be compared to the planned resections from the CT scan, and complication data. Furthermore, pre- and post-operative long standing alignment and Knee Society Scores (KSS) were obtained.

During surgery, the PSI cutting block is registered on the femur first and secured with smooth pins. No osteophytes are removed as the blocks use the positive topography of the osteophytes for registration. The distal femoral resection is performed directly through the block. An appropriate sized 4-in-1 block is placed and the remaining resections are performed. The tibial resection block is registered and resection performed. Final bone preparation, patella resurfacing, and trialing is performed as is standard to all surgical techniques.

There were 50 Left and 50 Right TKA's performed in 61 females and 39 males. All patients had diagnosis of osteoarthritis. The average BMI was 31.1 and average age was 64.5 (range 41–90). 79 patients had pre-operative varus deformities with Hip Knee Angle (HKA) average of 174.7° (range 167°–179.5°). 19 patients had pre-operative valgus deformities averaging 184.4° (range 180.5°–190°). Three patients were neutral.

Average TT was 31.2 minutes (range 21–51 minutes). With regard to the bony resections, the actual vs. planned resections for the distal medial femoral resection was 8.7 mm vs. 8.9 mm respectively. Further actual vs. planned femoral resections include distal lateral 7.2 vs. 6.7 mm; posterior medial 8.3 vs. 8.9 mm; and posterior lateral 6.2 vs. 6.8 mm. The actual vs. planned tibial resections recorded include medial 6.4 vs. 6.3 mm and lateral 8.3 vs. 8.2. The planned vs. actual bony cuts are strongly correlated, and highly predictive for all 6 measured cuts (p=<.001). No intraoperative complications occurred.

Average KSS improved from 45.9 to 81.4, and KSS Function Score improved from 57.7 to 73.5 at 6 weeks postoperative visit. There were no thromboembolic complications. Two patients had a post-operative infection requiring surgical intervention.

Post-operative alignment was 179.36° (range 175°–186°) for all patients. Alignment was neutral, within 3° in 95.9% of patients. There were only 4 outliers with maximal post-operative angulation of 6°.

In conclusion, these early results demonstrate efficacy of CT-based PSI for TKA. The surgery can be performed efficiently, accurately, and safely. Furthermore, excellent short term clinical and radiographic results can be achieved.

In a survey of 6000 children between 9 and 10 years of age, 122 were found to have unilateral or bilateral hallux valgus. These children were randomly assigned to no treatment or to the use of a foot orthosis. About three years later 93 again had radiography. The metatarsophalangeal joint angle had increased in both groups but more so in the treated group. During the study, hallux valgus developed in the unaffected feet of children with unilateral deformity, despite the use of the orthosis.

Immobilisation of the thumb is widely believed to be important in the management of fractures of the carpal scaphoid. To assess the need for this, we randomly allocated 392 fresh fractures for treatment by either a forearm gauntlet (Colles') cast, leaving the thumb free, or by a conventional 'scaphoid' plaster incorporating the thumb as far as its interphalangeal joint. In the 292 fractures which were followed for six months, the incidence of nonunion was independent of the type of cast used.

Hip fracture in the elderly is associated with significant morbidity and mortality. Significant intra-operative blood loss and the subsequent need for transfusion significantly contribute to patient morbidity. Making a surgical incision with diathermy reduces wound related blood loss, by coagulating small vessels as tissue is incised, however no study to date has looked at the use of diathermy in making surgical incisions around the hip. In addition, the increasing prevalence of blood borne infections makes the exclusion of sharps from the operative field an attractive option. The aim of this study was to compare diathermy incision with traditional wound opening using a scalpel to incise all layers. 50 patient undergoing hemiarthroplasty for fractured neck of femur were recruited prospectively. Patients on warfarin were excluded from the study while those on aspirin were not. After informed consent was obtained patients were randomized to scalpel or diathermy incision by coin toss.

In the diathermy group the dermis was incised with the scalpel and all further layers with the diathermy, while in both groups diathermy as used for haemostasis. All patients received prophylactic antibiotics at induction and for 24 hours post-op. Wounds were closed in a standard fashion using absorbable sutures for closing fascia and fat layers and surgical staples for skin. Intra-operative parameters measured included: 1) Time to open wound – defined as time taken to open wound from skin incision to complete opening of the fascia lata and achieve haemostasis. 2) Wound length and depth. 3) Wound related blood loss – swabs used while creating and closing the wound were weighed separately. 4) Total operative blood loss. Post-operatively all wound related complications were recorded. Statistical analysis was performed using the un-paired Student t-test parametric data.

Both groups were similar in relation to age, sex and pre-operative aspirin use. Intra-operatively neither wound sizes nor time taken to create the wound were statistically significantly different. In the scalpel group wound related blood loss represented over 30% of the total operative blood loss as compared with only 18.5% in the diathermy group. Post-operatively there were no wound infections or dehiscences in either group, however 4 patients in the scalpel group developed significant wound ooze that responded to conservative treatment. There were no significant wound problems in the diathermy incision group.

This prospective study has shown that the use of diathermy incision for hip hemiarthroplasty significantly reduces wound related blood loss and the incidence of post-operative wound ooze. We conclude that the routine use of diathermy to make incisions around the hip is effective in reducing wound related bleeding without adverse effects on wound healing or infection rate.

A series of 42 ankle fractures have been randomised into two groups respectively undergoing either open reduction and internal fixation or manipulative reduction and plaster. Their progress after removal of all external splintage has been followed using simple gait analysis techniques. There appears to be no difference in the outcome of treatment of the two groups in the early recovery period (up to 20 weeks).