Object: To assess the benefit of prescribed Iron supplementation on the recovery of patient’s Haemoglobin level after elective joint replacement. Design: A Prospective, Randomised Trial was undertaken. All patients undergoing elective arthroplasty (Hip, Knee, and Revision Hip) at our unit were considered. Qualifying parameters included: a normal store of Iron (Fe) prior to surgery (based on the serum Ferrittin level) and normal markers of inflammation (serum C - reactive protein [CRP] and erythrocyte sedimentation rate [ESR]). Elevated CRP and ESR are known to be factors affecting the serum Ferrittin level. Method: 318 patients undergo joint replacement from May 2004 to Oct 2004 were considered for the study. 208 patients were excluded for the following reasons: 52 patients had low serum Ferrittin level or elevated ESR and CRP levels pre-operatively. 156 patients was normal post operative Haemoglobin (> 11 mg %). This left 110 patients with normal pre-operative inflammatory markers and Iron stores. This cohort formed the basis of the study and was randomised to either receiving prescribed Iron Supplementation (Oral Ferrous Sulphate) twice a day for 8 week or no supplementation. Randomisation was performed based on the month of surgery. Even numbered months received the intervention, odd numbered did not. Post-operatively all patients had serum Haemoglobin checked at intervals 2. nd. –7. th. day and 8 weeks. Results: There was no significant different in mean Haemoglobin level between treatment group i.e. 12.72 mg% (10.8–15.4) and controlled group 12.71 mg% (11–15.3) at 8 weeks follow up. Conclusion: The prescription of oral Iron in healthy postoperative joint replacement patients did not hasten the recovery of Haemoglobin level provided adequate tissue Iron stores were present. The use of Fe supplementation provides no benefit in these patients and our study confirms this. Iron supplementation therapy should be reserved for patients identified pre-operatively with either low Iron stores or elevated serum inflammatory markers

Background: Neck pain is a common problem accounting for up to 22% of the workload of physiotherapists. Many different approaches are used and the evidence for these is unclear. Purpose: To evaluate the effectiveness of a brief physiotherapy intervention (1–3 sessions) for patients with neck pain in the primary care setting, taking preferences into account. Method: A Randomised controlled trial (n=268) compared a brief physiotherapy intervention based on cognitive-behavioural principles with ‘usual’ physiotherapy. Patients from physiotherapy waiting lists aged 18 – 87 years with neck pain of musculoskeletal origin of more than 2 weeks duration were invited to participate. Their preferences for type of treatment were elicited independently of randomisation. The brief intervention aimed to facilitate problem-solving, encourage self-management and early return to normal function. Physiotherapists undertook a one-day training programme in communication skills and cognitive-behavioural approaches. In the ‘Usual’ physiotherapy intervention treatment was provided at the discretion of the individual physiotherapist. The main outcome measures were the Neck Pain Questionnaire, a specific measure of functional disability due to neck pain, the SF-36 a generic health-related quality of life measure, the Tampa Scale for Kinesophobia, a measure of fear- and-avoidance of movement and the use of healthcare services. Data was collected at baseline, at 3 months and at 12 months. Results: Patients randomised to the ‘Usual’ physiotherapy group were significantly improved compared with the Brief Intervention group, 12 months after randomisation. However, the differences were small and patients randomised to the Brief Intervention who preferred that arm of the study also improved to a similar degree. In contrast, patients who wanted ‘Usual’ physiotherapy but got the brief Intervention did not improve. Conclusions: The Brief intervention may be effective for patients who prefer the option of a one-off treatment of advice. It is also cheaper and should therefore be offered as an option.ot

Purposes of the study and background

Smaller studies indicate that yoga may be an effective treatment for chronic low back pain. We conducted a randomised trial to evaluate if yoga compared to usual care improves back function in patients with chronic or recurrent low back pain.

Introduction: The excellent results obtained with metal-polyethylene (M-P) bearing surfaces in total hip arthroplasty (THA) are still limited by the production of polyethylene wear debris, osteolysis and aseptic loosening. Because of its superior tribologic properties and biologically inert composition, alumina-alumina (AL-AL) bearing surfaces are proposed to improved survival of THA but previously reported early complications prevented widespread use of this material.

Aim: To compare the early results and complications with Ceraver M-P and AL-AL THA.

Methods: One hundred and thirty-eight Ceraver hybrid THAs in patients less than 70 years old were randomised to M-P or AL-AL bearing surfaces. We present the clinical and radiological results for patients followed-up from six to 48 months.

Results: No significant difference was found on W.O.M.A.C. and Merle D’ Aubigné Postel scores. No specific complication associated with alumina components like fracture or malpositioning of the acetabular insert were observed in this study. Documented complications were: infection 3 AL-AL / 0 M-P; dislocation 1 AL-AL / 4 M-P; and heterotopic ossification 47% AL-AL / 24% M-P. No aseptic loosening was observed.

Discussion and Conclusion: Ceraver AL-AL bearing surfaces gave early clinical and radiological results similar to M-P. Our results were in accordance with studies suggesting that AL-AL has the potential to become the bearing surfaces of choice in THA in the young patients.

The aim of this prospective randomized controlled trial was to compare patient reported and functional outcomes, complications and costs for displaced olecranon fractures managed with either tension band wire (TBW) or plate fixation. We performed a registered prospective randomized, single blind, single centre trial in 67 patients aged between 16–74 years with an acute isolated displaced fracture of the olecranon. Patients were randomised to either TBW (n=34) or plate fixation (n=33). The primary outcome measure was the Disability Arm Shoulder and Hand (DASH) score at one-year.

The baseline demographic and fracture characteristics of the two groups were overall comparable. The one-year follow-up was 85percnt;. There was a significant improvement in elbow function over the 12 months following injury in both groups (p<0.001). At one-year following surgery the DASH for the TBW group was not statistically different to the plate fixation group (12.8 vs 8.5; p=0.315). There was no significant difference between groups in terms of range of movement, Broberg and Morrey Score, Mayo Elbow Score or the DASH at all assessment points over the one-year following injury (all p≥0.05). Complication rates were significantly higher in the TBW group (63percnt;vs38percnt;; p=0.042), predominantly due to a significantly higher rate of symptomatic metalwork removal (50percnt;vs22percnt;; p=0.021).

In active patients with an isolated displaced fracture of the olecranon, no difference was found in the patient reported outcome between TBW and plate fixation at one year following surgery. The complication rate is higher following TBW fixation due to a high rate of symptomatic metalwork removal.

Introduction

A recent meta-analysis published in the British Medical Journal suggested an increased risk of infection, but none of the studies were large enough to reach statistical significance. A prospective, randomised trial was designed at our institution to investigate the wound healing and complications related to surgery following fracture neck of femur in the elderly.

Bearing surfaces in Total Hip Arthroplasty (THA) may affect implant longevity and hence patient outcomes. This randomised clinical trial (RCT) determined how ceramic-on-ceramic bearing (CERAMIC) THA affected joint-specific pain, function and stiffness, and prosthesis fixation/longevity over 10 postoperative years compared with ceramic-on-highly-crosslinked-polyethylene bearing (POLYETHYLENE) THA. This is a follow-up to previously reported five year outcomes.

Subjects aged less than 61 years were randomised to CERAMIC [n=48] or POLYETHYLENE [n=44] THA. Subjects were assessed using the Western Ontario McMaster Osteoarthritis Index (WOMAC) and the RAND 12-Item Health Survey (RAND-12) preoperatively, and at one, five and 10 years postoperatively. Plain radiographs were evaluated at 10 years for fixation and medical records were reviewed for revisions.

Of 92 subjects, six (7%) died within 10 years; 68 (79%) survivors provided radiographic and/or clinical follow-up at 10 years postoperatively. Improvements seen at five years in both the WOMAC and RAND-12 were retained at 10 years with no group differences (p>0.48). There were no failures/loss of fixation related to bearing surfaces/wear in either group. Over 10 years, three subjects in the POLYETHYLENE group had revisions that were related to recurrent dislocation; two revisions were performed within two years of surgery and one further subject underwent revision at 7 years postoperatively.

This is one of the first RCTs to examine 10 year outcomes between ceramic-on-ceramic and ceramic-on-highly-crosslinked-polyethylene bearing THA. Both bearing surfaces performed well out to 10 years in subjects who were less than 61 years at time of surgery.

A hip fracture may lead to anaemia after surgery due to blood loss from the fracture site and operative blood loss. The value of iron supplementation for this group of patients remains controversial. A randomised trial was undertaken for 300 patients who had a haemoglobin of less than 110g/l after surgery. Patients were randomised to take either ferrous sulphate, (200mg twice daily for four weeks) or had no iron therapy. Patients were followed up to one year after surgery.

The mean age of patients was 82 years. 19% were male. The mean difference between admission haemoglobin and the haemoglobin taken 6 weeks after discharge was 7.3g/l in the iron supplementation group and 8.3g/l in the group that did not receive iron supplementation (p value 0.5). There was also no statistically significant difference between groups for hospital stay (19 versus 21 days) or mortality. 18% of those allocated to iron therapy reported side effects from the medication.

This study indicates that routine oral iron supplementation for anaemia after hip fracture surgery is not appropriate.

Hip resurfacing has generally been used in younger patients with early osteoarthritis of the hip. There has been considerable recent interest in this over the past few years. We conducted a prospective randomised trial comparing 2 hip resurfacing implants, Durom and ASR looking at radiological and clinical outcomes.

Forty-nine patients (78% male) with hip osteoarthritis which met the criteria for hip resurfacing were randomised to receive either a Durom or ASR resurfacing implant. These patients have so far been followed up for a minimum of one year. The groups were comparable in age (p=0.124) and gender (p=0.675). The average age in the ASR group was 54.04 years and in the Durom group it was 51.25.

Radiological views were scrutinised immediately post op and at final follow up so far to look at cup inclination, stem-shaft angle, and acetabular osseointegration.

Clinical outcomes were compared using the Oxford hip scores, WOMAC scores and SF12 scores.

At minimum follow up of 1 year the mean post operative Oxford hip score was not significantly different between the Durom (45.32, SD 3.93) and ASR (43.44, SD 8.44). The mean post operative WOMAC score was also not significantly different between the Durom (52.56, SD 6.06) and ASR (49.63, SD 2.23). There was no difference between the groups with regards to signs of osseointegration from radiological assessment (p=0.368). There were 3 periprosthetic femoral neck fractures (5.7%) and one revision for pain.

We conclude from this trial that there is no difference in the clinical or radiological findings between the Durom and ASR implants.

Objective

To investigate, through a randomised, single blind, Quasi-experimental trial, whether immediate physiotherapy after lumbar micro-discectomy enables patients to become independently mobile more rapidly with no increase in risk of complications.

The two commonest types of hemiarthroplasty used for the treatment of a displaced intracapsular fracture are the uncemented Austin Moore Prosthesis and cemented Thompson hemiarthroplasty. To determine if any difference in outcome exists between these implants we undertook a prospective randomised controlled trial of 300 patients with a displaced intracapsular hip fractures.

All operations were performed or supervised by one orthopaedic surgeon and all by a standard anterolateral approach. Patients were followed by a nurse blinded in the type of prosthesis to assess residual pain and mobility.

The average age of the patients was 83 years and 23% were male. 73% came from their own home with the remainder from institutional care. There was no statistically significant difference in mortality between groups, with 34/151 having died at one year in the cemented group and 45/149 in the uncemented group. Pain scores (grade 1-6) were less for those treated by a cemented prosthesis (mean score 1.8 versus 2.4, p value <0.00001). Mobility change was also less for those treated with a cemented implant (p=0002). No difference was found in hospital stay. Operative complications are as listed. One case of non-fatal intraoperative cardiac arrest occurred in the cemented group.

In summary a cemented Thompson Hemiarthroplasty causes less pain and less deterioration in mobility compared to uncemented Austin Moore hemiarthroplasty, without any increase in complications. The continued use of an uncemented Austin Moore cannot be recommended.

Introduction: Primary total hip replacement remains one of the commonest orthopaedic procedures performed. It is yet to be clearly demonstrated whether use of a postoperative drain is of benefit in these procedures.

Methods: We carried out a prospective randomised study comparing the use of autologous reinfusion drains, closed suction drains or no drain to determine their influence on allogenic blood transfusion requirements, length of hospital stay and infection rates. Stratification was carried out for confounding factors.

Results: 153 patients were recruited into the study and randomised to one of the three closely matched groups. There was no significant difference between the mean intra-operative blood loss or post-operative haemaglo-bin levels between the 3 groups. 42% of the suction drain group required post-operative transfusion as compared to 17% of the reinfusion drain group and 12% of the group with no drains. This difference was highly significant (P=0.02) Mean time for the wound to become dry was 3 days, 3.9 days and 4 days in the no drain, re-transfusion drain and suction drain groups respectively. This difference was statistically significant (P=0.03). There was no statistically significant difference in the mean length of inpatient stay.

Discussion: This study demonstrates a significantly higher transfusion rate with closed suction drains compared to reinfusion drains or no drains. With the drive to reduce hospital stay our study supports the considered use of no drain or a reinfusion drain.

Methods

There were 106 men and 94 women (mean age 65 years; 22 - 85). 69 patients had inflammatory arthritis and 131 osteo-arthritis. 27 patients (13 B-P, 14 STAR) had a pre-operative varus/valgus deformity greater than or equal to 20 degrees. Mean follow-up was 48 months (36-72).

Aims: To show that the treatment of buckle fractures in children in a soft bandage, rather than a plaster cast, is an effective and safe method of treatment. Methods: In order to determine the difference between the two groups it was decided to compare the range of movement at three weeks. Power calculations were performed. This gave a required sample size of 23 for each group. The project was submitted for ethical approval in July 1999. Patients enter the trial after parents agree and sign the consent form. Allocation to either plaster or bandage is random and parents draw previously sealed envelopes themselves. Patients are seen each week and measurements taken of their range of movement. Results: Thirty seven patients have completed the study. 17 have been allocated to bandage the rest to cast. Those in bandage show an excellent range of movement at the þrst week with no reported problems on their questionnaires. One patient has transferred from bandage to plaster at the request of the parents. Conclusion: Results suggest a positive result for treatment in bandage with no reported adverse effects and, a highly desirable result for the patient. We would hope to suggest a change in treatment policy for such fractures.

An acute phase of periprosthetic bone loss occurs following total hip arthroplasty (THA). Periprosthetic bone loss undermines implant support, may contribute to its failure, and complicates revision surgery as allograft may be required to replace lost bone. We assessed the effect of a single 90mg dose of the bisphosphonate pamidronate on early periprosthetic bone mineral density (BMD), biochemical markers of bone turnover, and clinical outcome in 47 men and women undergoing hybrid THA in a randomised, double-blinded, placebo-controlled trial.

The mean (± 95% CI) differences in BMD (area under BMD change.time curve) between those receiving pamidronate and those receiving placebo was 0.91(± 0.51) g.weeks/cm² for the proximal femur (P=0.002), and 0.80 (±0.60) g.weeks/cm² for the pelvis (P=0.009). Patients in the pamidronate group had suppression of all biochemical markers of bone turnover compared to placebo (P< 0.05), except for urinary free deoxypyridinoline. Both treatment groups experienced similar improvement in Harris hip and SF-36 UK outcome scores. The frequency of adverse events was similar in each treatment group (placebo 7/24, pamidronate 8/23, P> 0.05).

Acute periprosthetic bone loss following THA is due to a transient increase in bone turnover. A single dose infusion of pamidronate in the early post-operative period significantly reduces this bone loss, and is well tolerated.

Aim: To determine whether there is a difference in outcome between reamed and unreamed tibial nails.

Method: We performed a prospective, randomised trial comparing the results of reamed versus unreamed titanium tibial nails. Perioperative oxygen saturation and FIo2 were measured in each patient. Time to union was compared using survival analysis.

Results: There were 60 patients with 60 tibial shaft fractures including 10 (17%) compound fractures and three patients with thoracic trauma. There were 32 reamed and 28 unreamed nails. Fifty-seven nails were statically locked (95%). The average nail diameter in the reamed group was 9.7mm, significantly larger than that in the unreamed group (9.2mm), (p=0.02). There were no significant differences in average oxygen saturation and FIo2 between reamed and unreamed nails during insertion, immediately postoperatively or during the first two postoperative days. Forty-eight (80%) patients were followed until the fracture healed. Two patients died and 10 (17%) were lost to follow up. The mean time to union was 13.5 weeks in the reamed group versus 16 weeks in the unreamed group. This was not significant (p=0.2). There were 10 (17%) complications including one delayed union in each group, both united following ‘dynamization’. There were three compartment syndromes treated with fasciotomies. No nails broke and there were no deep infections.

Conclusion: We have shown no difference in the effects on pulmonary function between the two groups, but unfortunately we had insufficient patients to assess the effect of thoracic trauma.

To determine if any notable differences between a cemented Thompson stem hemiarthroplasty and a cemented Exeter stem hemiarthroplasty (ETS), 200 patients with a displaced intracapsular fracture were randomised between the two prosthesis. Surviving patients were followed-up for one year by a nurse blinded to the treatment allocation. The mean age of patients was 84 years and 13% were male.

There were no differences between groups for the length of surgery, need for blood transfusion or hospital stay. Implant related complications were three minor operative fractures of the femur in each group. Two patients in the Thompson group had dislocation of the prosthesis requiring revision surgery and one further patient in the Thompson group had late acetabular wear requiring conversion to a total hip replacement. One further patient in the Thompson group had cement retained in the acetabulum. In total therefore only three patients, all in the Thompson group, which required revision surgery. Easy of surgery was assessed subjectively by the surgeon and reported to be easier for the ETS group (p=0.0002). During follow-up there was no significant difference in the degree of residual pain between groups.

Conclusions are that the cemented Exeter stem hemiarthroplasty has some advantages over the traditional cemented Thompson hemiarthroplasty.

Congenital talipes equinovarus (CTEV) is a complex three-dimensional deformity with an incidence of 1–3 per 1000 live births. The Ponseti method is widely accepted and practiced, giving reliably good long-term results. There are a number of studies showing the benefits of a physiotherapy led Ponseti service with outcomes similar to a consultant led service. We present the first prospective randomised series comparing a physiotherapy led Ponseti service with a standard orthopaedic surgeon led series.

16 infants with bilateral CTEV were randomised into two groups. Each infant had one foot treated by a physiotherapist and the other foot treated by an orthopaedic surgeon using the Ponseti technique. Both groups had a premanipulation Pirani score of 5.5. All patients were followed up for a minimum of 12 months and the results demonstrated no significant difference in the post-treatment Pirani scores (p=0.77) and no significant difference in the success rate the Ponseti technique (p=1.00).

This study is the first of its kind and demonstrates the value of a physiotherapy led Ponseti service in the management of CTEV. Although overall supervision by a paediatric orthopaedic surgeon is still necessary, this service will allow the surgeon to spend more time dealing with more complex problems.

Fractures of the proximal femur at the level of the lesser trochanter (reversed and transverse fracture lines, Evans classification type II, AO classification A3 fractures) are known to have an increased risk of fixation failure. 58 patients with such a fracture were randomised to have the fracture fixed with either an intramedullary nail (220 mm Targon PF nail) or a sliding hip screw (SHS). The mean age of the patients was 82 and 11% were male. All patients were followed up for one year by a research nurse blinded to the treatment groups.

Mean length of surgery was 50 minutes for the nail versus 52 minutes for the SHS. There were no differences between groups in the need for blood transfusion. Operative complications tended to be less for the nail group (1/27 versus 5/26). Mean hospital stay was 18 days for the nail group versus 29 days for those treated with the SHS. The only fracture healing complications were one case of cut-out in the SHS group and two cut-outs in the nail group, two of which required revision surgery. During follow-up those patients treated with the nail reported a tendency to lower pain scores than those treated with the SHS (p=0.04 at two months). This difference persisted even at one year from injury. Mortality and regain of mobility was similar between groups.

These results indicate that for these difficult fractures types both types of fixation produce comparable outcomes.