Introduction

The advent of double bundle ACL (Anterior Cruciate Ligament) reconstruction had been hailed as potentially allowing for more anatomically and physiologically functioning graft, however until recently there had been little evidence of enhanced functional outcomes.

The aim of this study is to explore whether the dimensions of hamstring two strand single bundle grafts, are predictive of the combined four strand single bundle graft that results from combining the single bundle grafts, as well as the impact of double bundle grafts upon the available healing and attachment area within the bony tunnels.

Introduction

We discuss the use of the SMILES (Stanmore Modular Individualised Lower Extremity System) in salvage revision knee surgery and review the medium-long term results of 42 cases.

Introduction: Malignant tumours of the fibula are rare and can be difficult to treat. We discuss the management and outcome of 52 patients who presented with malignant tumours of the fibula over a 15-year period between 1983 and 1998.

Methods: Data was collected prospectively and reviewed from the Bone Tumour database, medical records and by clinical review. Consecutive patients were studied and survival was calculated using the Kaplan-Meier curve.

Patients: The tumour type was Osteosarcoma (23 patients), Ewing’s sarcoma (16), Chondrosarcoma (11 – of which 10 low grade) and Malignant Fibrous Histiocytoma (2). We concentrate on the two most common frankly malignant groups: Osteosarcoma and Ewing’s. The male:female ratio of patients with Osteosarcoma was 11:12 and with Ewing’s Sarcoma was 11:5. Mean age for Osteosarcoma was 21.5 years and for Ewing’s Sarcoma was 14.2. The most common site of tumour was in the proximal fibula in both Osteosarcoma (19 / 23) and Ewing’s Sarcoma (10 / 16). The stage of disease at presentation was IIa or IIb in the majority of patients, with seven patients presenting with metastases.

Management: The current investigative procedures are Radiographs, Magnetic Resonance Imaging, Radioisotope Bone Scans, Computerised Tomography of the chest and needle biopsy whereas in the past CT of the lesion and open biopsy were common. Chemotherapy was administered as per protocol at the time of diagnosis and radiotherapy was given in selected cases. Surgery was performed on all but 3 patients, who were unfit and died. This consisted of local en bloc resection in 86.3% and above knee amputation in 6.8%.

Outcome: Whereas all the diaphyseal and distal lesions were completely excised, 9 out of 26 proximal lesions had a marginal excision, 4 of which had open biopsies. The common peroneal nerve was sacrificed in 50% of cases and this had no link to survival. The overall 5-year survival was 33% for Osteosarcoma and 40% for Ewing’s Sarcoma, with proximal lesions doing much worse than diaphyseal and distal lesions. Patients who had marginal excisions all died within 2.5 years.

Introduction: Over the past decade metal-on-metal bearings in the form of hip resurfacings have been increasing in popularity and with it, an associated interest in the potential side effects of elevated serum metal ion levels.

Method: We prospectively measured the cobalt and chromium serum levels of 20 patients over a two-year period following Birmingham hip resurfacing. Cobalt was measured with inductively coupled plasma mass spectrometry and chromium using graphite furnace atomic absorption spectrometry.

Results: For serum cobalt there was an initial increase, to a peak at six months then a gradual decline. A similar pattern was observed for chromium, although the peak occurred slightly later at nine months.

Conclusion: One-off single measurements of metallic ion levels is of minimal clinical use, when the actual pattern of ion elevation and fall is not known. This study allows us to expect a peak at certain times following a hip resurfacing and a gradual decline thereafter.

Introduction and Aims: Hip resurfacing has undergone a resurgence of interest in the past five years, requiring surgeons to learn new principles and new operative techniques. For experienced surgeons, the learning curve is more transparent than in their earlier careers.

Method: We have reviewed the first 100 hip resurfacings performed by two experienced surgeons. Results of the first 20 and second 20 were compared for a difference, then the first 30 and second 30 and finally the first 50 and second 50. We evaluated accuracy of pre-operative planning to final sizing, pre-operative neck shaft angle and post-operative prosthesis angle, revision rates, complication rates, equipment problems, placement of the acetabular component.

Results: On comparing the first 50 procedures performed with the second 50 performed, there was a significant difference (p< 0.001) in positioning of the femoral prosthesis, notching of the femoral neck, seating of the femoral and acetabular component position and seating. When comparing the first 20 and second 20 procedures no significant difference was noted.

Conclusion: We note there is a definite learning curve associated with the hip resurfacing procedure and it was longer than we estimated.

Introduction: Hip resurfacing has undergone a resurgence of interest in the past five years. With it, the awareness of femoral neck fractures associated with this prosthesis has grown. We report the first national review of femoral neck fractures over a four-year period.

Method: All surgeons using the Birmingham hip resurfacing in Australia were contacted and asked to supply details of any femoral neck fractures they had experienced. Routine co-morbidities and demographics were collated.

Results: Fifty fractures have occurred in the time period. The fracture rate was twice as high in women than men and this was statistically significant (p< 0.001). Mean time to fracture was 15 weeks and was slightly longer in women than men. Technical difficulties included notching of the femoral neck, varus placement of the femoral prosthesis, poor exposure due to obesity and poor impaction of the femoral component.

Conclusions: The national fracture rate associated with the Birmingham hip resurfacing is 1.46%.

Between April 1999 and April 2004, 3497 Birmingham hips were inserted by 89 surgeons. Fracture of the neck of the femur occurred in 50 patients, an incidence of 1.46%. Complete data were available for 45 patients in whom the incidence was 1.91% for women and 0.98% for men. The relative risk of fracture for women vs men was 1.94961 and this was statistically significant (p < 0.01).

The mean time to fracture was 15.4 weeks. In women the fractures occurred at a mean of 18.5 weeks and were more likely to have been preceded by a pro-dromal phase of pain and limping. In men the mean time to fracture was 13.5 weeks.

Significant varus placement of the femoral component, intra-operative notching of the femoral neck and technical problems were common factors in 85% of cases.

Introduction: Over the past decade metal on metal bearings in the form of hip resurfacings have been increasing in popularity and with it an associated interest in the potential side effets of elevated serum metal ion levels.

Methods: We prospectively measured the cobalt and chromium serum levels of 20 patients over a 2 year period following Birmingham hip resurfacing. Cobalt was measured with inductively coupled plasma mass spectrometry and chromium using graphite furnace atomic absorption spectrometry.

Results: For serum cobalt there was an initial increase to a peak at 6 months then a gradual decline. A similar pattern was observed for chromium, although the peak occurred slightly later at 9 months.

Conclusions: One off single measurements of metallic ion levels are of minimal clinical use, when the actual pattern of ion elevation and fall is not known. This study allows us to expect a peak at certain times following a hip resurfacing and a gradual decline thereafter.

We describe our early experience with the implantation of the first consecutive 231 primary Birmingham Hip resurfacings. At a mean follow up of 33 months, survivorship was 99.14 %, with revision in one patient for a loose acetabular component and one unrelated death.

Mean Harris Hip score improved from a mean of 62.54 ( Range : 8–92) to 97.74. (Range: 61 – 100) Mean flexion improved from a mean of 91.52°, ( Range : 25° –140°) to a mean 110.41°. ( Range : 80° – 145°)

1 patient presented at 6 weeks post resurfacing with pain and no history of trauma. An undisplaced fracture of the superior femoral neck was seen, which healed with a period of non-weight bearing.

96.94% of patients rated their prosthesis as good / excellent, the remainder rated it good/fair.

220 consecutive hip resurfacing procedures were reviewed at a minimum of two years follow up to assess the incidence of heterotopic ossification and its effect on function and clinical outcome. We also reviewed the pre-operative diagnosis, gender and previous surgery. The overall percentage of heterotopic ossification was 58.63%. The incidence of Brooker 1 was 37.27%, Brooker 2 was 13.18% and Brooker 3 was 8.18%.

Male osteoarthritics had the highest incidence of heterotopic bone formation. Three males underwent excision of heterotopic bone, two for pain and stiffness and one for decreased range of movement.

Both antero-posterior and lateral radiographs were reviewed for evidence of heterotopic bone formation. 12.7% had no evidence of heterotopic bone formation on one view but clearly had on the second view.

Overall we found no evidence that heterotopic bone formation affected the clinical or functional outcome of the hip resurfacing at a mean of 3 years follow up.

Introduction: Hip resurfacing has undergone a resurgence of interest in the past 5 years. This has required the acquistion of new surgical principles and techniques. Allowing us to study the learning curve associated with acquiring these skills.

Methods: The first 50 hip resurfacings and the second hip resurfacings performed by two consultant surgeons were compared for femoral fit, pre-operative femoral neck shaft angle, post-operative prosthesis angle, acetabular cup abduction angle, seating of the acetabular component, post-operative complications and revision rates.

Results: There was a statistically significant improvement in the alignment of acetabular components, seating of the acetbaular component and fewer problems associated with the acetabular introducer in the second cohort. There was more consistent placement of the femoral prosthesis in the neck,less notching and less variation in position in the second cohort.

Conclusions: There is a definite leaning curve associated with hip resurfacing and it was longer than expected.

This study addresses four questions:

Does laminar flow exist in our operating theatres?

Do perioperative warming blankets affect laminar flow?

Do perioperative warming blankets cause displacement of particles into a wound perioperatively?

Do conventional theatres have adequate airflow?

It has been widely recognised that laminar flow theatres decrease colony forming units in operating theatres and thus decrease the risk of infection in arthroplasty surgery. It is also accepted that perioperative warming blankets improve patient haemodynamic stability and may reduce the risk of wound infection.

However, there has been great debate as to whether these perioperative warming blankets cause disruption of laminar flow and excess displacement of dust into a wound, and thus increase the risk of infection of total joint arthroplasty surgery. Using digital video imaging and airflow measurement techniques as used in formula 1 racing design, this independent study reveals that the Bair Hugger system has no effect on laminar flow or paticle displacement. It also shows that factors out of the surgeon’s control disrupt laminar flow and that general theatre design may be inherently flawed. This would seriously affect the risk of infection.

Purpose: To review the orthopaedic manifestations and document the results of surgical intervention. Material and Methods: A review of all 22 children currently attending a specialist scleroderma clinic was performed. Disease extent was measured in terms of percentage body surface area (BSA) affected and all orthopaedic abnormalities were documented. The outcome of surgical intervention was evaluated.

Results: All children presented by the age of 12 and all but 2 had developed joint contractures of either the lower or upper limbs affecting function within 2yrs of diagnosis. Overall, lower limbs were more commonly affected than upper. Abdominal scleroderma led to a scoliosis in 75% of cases. The mean BSA affected was 35% (range 5-65%) with contractures more related to site of disease rather than extent. Pain was associated with lower limb contractures and loss of function with hand contractures. Limb length discrepancy (LLD) was common with a mean of 3cms (range 2-6.5cms). 8 children have had surgery. 7 developed wound healing problems. 50% of operations failed to correct the deformity and in a further 25% relapse has occurred. In the remaining 2 cases a good result was achieved. In addition, one epiphysiodesis has been performed and 3 are planned.

Conclusions: This is the largest known review of children with linear scleroderma. Joint contractures are common but poorly managed by conservative methods alone. Surgical intervention is difficult but early defini-tive treatment is recommended with subsequent aggressive splinting during growth whilst the disease is active. LLD must be corrected.

100 pre-operative and post-operative knee and function scores were analysed to assess whether a low pre-operative score was related to a poorer outcome, ie, are we operating too late? A two tailed student “t” test was performed showing that a pre-operative “function “ score of less than 30, resulted in a lower post-operative “function” score and the difference was statistically significant. These patients also showed the greatest improvement in scores and were the most satisfied with surgery. However, a low pre-operative “knee” score could not be related to a low post-operative “knee” score. Patients who had either a “knee” or “function” score of greater than 60 made no statistically significant improvement in either score. In conclusion, the pre-operative “knee” score is not a reliable indicator for when to perform surgery. However, the “pre-operative “ function score should be given more credence, along with clinical judgement, as it would appear that operating too late adversely affects the functional outcome of total knee arthroplasty.

65 patients over the age of 80 years, who underwent a total knee arthroplasty between 1989 and 1994, were retrospectively reviewed, by means of questionnaire, phone call, clinical and radiological examination.Notes were reviewed for pre-existing medical conditions, pre-operative and post-operative Knee Society “Knee” and “Function” scores. They were then compared with 65 randomly selected patients in a different age group, 70 years and under.56 octogenarians were alive at 5 years and 50 available for full review.

Elderly patients had more pre-existing medical conditions, with hypertension a ubiquitous diagnosis, required a longer in patient stay and more social services input before discharge, than the younger age groups. All patients in the elderly group suffered from osteoarthritis, unlike the younger age groups. Valgus deformity of the knees was only seen in the younger cohort. Previous surgery was more common in the octogenarians, with more octogenarians having undergone a tibial osteotomy and more youngsters undergoing arthroscopy. A reflection of changing surgical practice.

“Knee” Scores were not significantly different between the age groups. However, the “function “ scores pre-operatively, were significantly lower in the over 80s and they made a more significant post-operative gain. Post-operatively, elderly male patients were more likely to go into retention post-operatively, than female patients and males in the younger age group.

None of the prostheses had required revision in the elderly age group and only 5 patients had died since the surgery. None of the deaths were related to the surgery.

We recommend pre-operative catheterisation of octogenarian patients, especially those with a history of prostatism. There would appear to be from this review no indication for denying elderly patients an arthroplasty on the basis of age.