Aims

The aims of this study were: firstly, to investigate the influence of the thickness of cartilage at the sigmoid notch on the inclination of the distal radioulnar joint (DRUJ), and secondly, to compare the sensitivity and specificity of MRI with plain radiographs for the assessment of the inclination of the articular surface of the DRUJ in the coronal plane.

Plain radiography has traditionally been used to investigate and monitor patients with adolescent idiopathic scoliosis. The X-ray allows a calculation of the Cobb angle which measures the degree of lateral curvature in the coronal plane. ISIS2 is a surface topography system which has evolved from ISIS, but with much higher precision and speed. It measures the three dimensional shape of the back using structured light and digital photography. This system has the benefit of not requiring any radiation. Lateral asymmetry is the ISIS clinical parameter estimating the curve of the spine in the coronal plane. The aim of this study was to compare this parameter to the Cobb angle measured on plain X-ray.

Twelve patients with idiopathic adolescent scoliosis underwent both a standing AP spine X-ray and an ISIS2 scan on multiple occasions. Both scan and X-ray were done within one month of each other. No patient underwent surgery during the study period. The Cobb angle and the degree of lateral asymmetry were calculated.

Twelve patients mean age 12.5 years (range 10-16) were investigated using both ISIS2 and X-ray. They had a mean 2.3 (1-5) combined investigations allowing for 30 comparisons. The correlation between the two measurements was r =0.63 (p=0.0002). The Cobb angle measured on ISIS2 was less than that measured by radiograph in 27 out of 30 comparisons. The mean difference between the measurements was mean 6.4° with a standard deviation of 8.2° and 95% confidence interval of 3.3° to 9.4°.

In adolescent idiopathic scoliosis, curve severity and rib hump severity are related but measure different aspects of spinal deformity. As expected, these relate closely but not precisely. ISIS2 offers the promise of monitoring scoliosis precisely, without adverse effects from radiation. The small numbers in this series focus on the group of patients with mild to moderate curves at risk of progression. In this group, ISIS2 was able to identify curve stability or progression, without exposing the subjects to radiation.

Purpose: to determine the effect of physiotherapy following arthroscopic subacromial decompression (ASD) for impingement syndrome

Methods: 50 patient undergoing ASD with or without excision of the distal clavicle (EDC) were randomized to have physiotherapy (physio group), or mobilize as tolerated and self exercise (no physio group). Patients in the physio group had an average of 7.4 sessions of physiotherapy under the guidance of a physiotherapist. Exercises included scapula stabilizer, passive, active-assisted, active and strengthening exercises developed at the Nuffield Orthopaedic Centre in Oxford. Patients in the no physio group were encouraged to mobilize their shoulders as tolerated and were given a leaflet with shoulder exercises. Patients were followed-up by postal Oxford shoulder questionnaires at 6 weeks, 3 months 6 months and 1 year. Time to return to work was used as secondary outcome measure.

Results: Our data showed that there was a significant difference between the average Oxford shoulder scores of the two groups at 6 weeks with the no physio group doing better (physio group: 34.3 vs. no physio group: 27.4, p=0.01) No difference was found between the two groups at 3 months, 6 months and 1 year in any of the outcome measures.

Conclusion: Patients not having formal physiotherapy seemed to have done better in the first 6 weeks after surgery with physio patients catching up later resulting in no difference in the final outcome between the groups. New therapy protocols should be developed to see if outcomes can be improved, but physiotherapy may not be necessary after ASD at all.

The aim of this study was to find evidence of tissue hypoxia and apoptosis (programmed cell death) have on a human model of rotator cuff failure.

We studied twenty seven patients with no tear mild impingment (3), no tear moderate impingment (3), no tear severe impingment (3), partial tear (3), small tear (3), moderate tear (3), large tear (3), massive tear (3) and control (3) who were undergoing shoulder arthroscopy, subacromial decompression and potential rotator cuff repair. A supraspinatus tendon biopsy was taken during debridement/repair on all cases (ethics number C01.071). Control tendon was obtained from the subscapularis tendon of patients undergoing stabilization surgery.

Biopsies were analysed using two immunocytological techniques. A monoclonal antibody against BNIP-3 (a pro-apoptotic marker of hypoxia) and TUNEL (an apoptotic marker). An immunofluorescent nuclear counterstain DAPI (4 6-Diamidino-2-phenylindole dihy-drochloride) was used to stain all cells. Positive cells and total cell number were then counted in 10 high powered fields per section.

The results showed a significant increase in BNIP-3 expression in the cuff tears compared with intact tendons. This increase was least in the massive tears. Apoptosis increases from mild impingement to massive cuff tears (mean 7.3% to 21%)

The aim of this study was to understand the role tissue hypoxia and apoptosis have on a human model of rotator cuff failure. We studied twenty seven patients with no tear mild impingment (3), no tear moderate impingment (3), no tear severe impingment (3), partial tear (3), small tear (3), moderate tear (3), large tear (3), massive tear (3) and control (3). A supraspinatus tendon biopsy was taken during debridement/repair in all cases (ethics no. C01.071). Control tendon was obtained from the subscapularis tendon of patients undergoing stabilization surgery. Biopsies were analysed using two immunocytological techniques. A monoclonal antibody against BNIP-III (a marker of hypoxia) and TUNEL (Terminal deoxynucleotidyl Transferase Biotin-dUTP Nick End Labeling – an apoptotic detection process). An immunoflorescent counterstain DAPI (4′,6-diamidino-2-phenylindol) was used to stain all cells. Positive cells and total cell number were then counted in 10 high powered fields. The results showed a significant increase in BNIP-III expression in the cuff tears compared with intact tendons. This increase was least in the massive tears. Apoptosis increases from mild impingment to massive cuff tears (mean 7.3% to 21%) In conclusion, as tear size increases, the viability of the tendon reduces with increasing hypoxia and apoptosis.

To assess the referral system, clinical notes and radiographs of patients presenting with metastatic disease of long bones in a regional oncology unit.

Thirty questionnaires were sent to oncologists asking about reasons for referral to orthopaedics and use of scoring system to assess risk of pathological fracture.

Ninety three percent of oncologists did not use a reliable scoring system to assess risk of pathological fracture. The majority referred in respect to pain on mobilising and the presence of a lytic lesion. Sixty percent felt an improvement in communication between the departments was required.

The notes and radiographs were reviewed of thirty-seven patients presenting with femoral metastatic lesions to the oncology department.

Sixteen patients had a Mirels score of greater than eight. Four patients were referred for an Orthopaedic opinion. All patients underwent prophylactic fixation. Twelve patients with a score of greater than eight were not referred. Seven of theses patients suffered a pathological fracture within three months.

Five patients had a Mirels score of 8. One patient had prophylactic fixation. No fractures occurred.

Sixteen patients had a Mirels score of less than 8. None of these patients were referred for an orthopaedic opinion. None of these patients had a pathological fracture within three months.

In conclusion, we presently do not offer a multidisciplinary approach to metastatic disease affecting the appendicular skeleton.

The majority of patients’ who score eight or above in the Mirels scoring system are at risk of fracture and do require prophylactic surgery.

In keeping with the BOA guidelines, “Metastatic Bone Disease: A Guide to Good Practice”, we would recommend that the introduction of a multidisciplinary approach and the use of a recognised scoring system is essential to improve patient care.

The aim of this study was to observe the macroscopic and microscopic appearance of the Coracoacromial ligament and Subacromial bursa during Subacromial decompression and correlate it with the outcome at 3 months. Twenty patients with Subacromial Impingement without Rotator Cuff tear and five patients with large/massive irreparable Rotator Cuff tears who underwent a Subacromial Decompression. Patients with other shoulder pathology were excluded. Patients completed an Oxford Shoulder Score pre-operatively and their injection history was noted. At operation the shape of the acromion was noted. The macroscopic appearance of the CA ligament and the Subacromial bursa was classified as normal, mild/moderate and severe. Biopsies of the Subacromial bursa and CA ligament were taken and were analysed using histological and contempory immunocytochemical techniques. A histological analysis was performed using Mayer’s Haemotoxylin and Eosin, Toluidine Blue and Congo Red. Sections were stained with primary antibodies against PCNA (Proliferating cell nuclear antigen), Mast Cell Tryptase, CD3 (T-cell), CD20 (B cell), CD 34 (QBEnd 10), CD45 (Leucocyte Common Antigen), CD68 and D2–40 (Lymphatic Endothelial Marker). Post operatively the patients completed an Oxford Shoulder Score at 3 months. All the patients demonstrated an improvement in their Oxford Shoulder Score. The histological analysis demonstrated thickening of the synovial membrane and increased vascularity within the bursa and ligament. Increased numbers of inflammatory cells were present within the ligament and bursa of patients with impingement compared with massive rotator cuff tears. There was a relationship between outcome and the appearance of the bursa and ligament.

Antero-medial osteoarthritis of the knee displays a well recognised pattern of cartilage damage on the medial tibial plateau. Anteriorly there is a full thickness cartilage defect, with transition to a partial thickness defect, becoming full thickness in the posterior third of the plateau. The retained posterior cartilage is macroscopically normal, but no previous study has assessed its histo-logical features. This study characterises the histological changes, to examine if antero-medial OA of the knee represents a model of progressive osteoarthritic cartilage damage.

Five unicompartmental resection specimens of patients with idiopathic single compartment antero-medial osteoarthritis were assessed. The samples were stained with H& E and Saffinin-O stains and reviewed using the Mankin system, an established method for scoring osteoarthritic changes in cartilage (range 0 [normal] to 14 [grossly osteoarthritic]) Digital images of the histology were reviewed by two observers to exclude inter and intra observer error. Each specimen was assessed at 4 interval points (A,B,C,D) along the A-P axis starting from the most posterior aspect of the exposed bone to the area of macroscopically normal cartilage. Three repeat measurements were taken from the macroscopically normal region (D1,D2,D3). The scores were compared to historical age matched controls of non-osteoarthritic cartilage, where a Mankin grade of < 3 suggests normal cartilage.

From anterior to posterior the H& E staining showed a consistent decrease in structural integrity and cellularity of the cartilage, matched by a qualitative decrease in GAG content (Saffinin-O staining). Mean Mankin scores showed a progressive decrease in score; A = 14.0 (95% CI 0), B = 5.8 (95%CI 2.4), C = 4.4 (95%CI 2.5), D = 1.0 (95%CI 0.9) {p=0.04 ANOVA}. Repeated measurements at the macroscopically normal area showed the Mankin grade was maintained; D1= 1.0 (95%CI 0.9), D2 = 0.6 (95%CI 0.5), D3 = 0.6 (95%CI 0.6).

The results show that the retained posterior cartilage in antero-medial arthritis has a consistently normal Mankin grade. We suggest the defect represents a model of progressive cartilage damage from near normal (posterior) to the grossly osteoarthritic state (anterior).

To assess the referral system and the clinical notes and radiographs of patients presenting with metastatic disease of long bones.

All oncology consultants and registrars received a questionnaire regarding referral to the orthopaedic department for metastatic disease of the appendicular skeleton.

Ninety three percent of oncologists did not use a reliable scoring system to assess risk of pathological fracture. The majority of oncologists referred with regards to degree of cortical erosion and increased pain on weight-bearing. Sixty percent felt an improvement in communication between the departments was required.

The notes and radiographs were reviewed of twentyfive patients presenting with femoral metastatic lesions to the oncology department.

Mirels scoring system was then applied to each patient to assess the risk of the possibility of a pathological fracture.

Ten patients had a Mirels score of greater than eight. Three patients were referred for an Orthopaedic opinion regarding prophylactic fixation. Two patients had no fracture of the femur after three months. Five patients had a pathological fracture within three months, resulting in an emergency admission for surgery.

Three patients had a Mirels score of 8. One patient suffered a pathological fracture.

Twelve patients had a Mirels score of less than 8. None of these patients were referred for an Orthopaedic opinion. None of these patients had a pathological fracture within three months.

In conclusion, we presently do not offer a multidisciplinary approach to metastatic disease affecting the appendicular skeleton.

The majority of patients’ who score eight or above in the Mirels scoring system are at risk of fracture and do require prophylactic surgery.

In keeping with the BOA guidelines, “Metastatic Bone Disease: A Guide to Good Practice”, we would recommend the introduction of a multidisciplinary approach and the use of a recognised scoring system to improve patient care.

Introduction: A major complication associated with external fixation is pin tract infection¹. This can occur in as many as 17–57%² of cases and in severe cases leads to premature removal of the fixator. An antimicrobial coated (AMC) sleeve has been designed to be placed over external fixation pin and wires that delivers an antibiotic, gentamicin, directly into the pin tract. The function of the sleeve is to inhibit bacterial colonisation of the pins and wires, the first step in the development of a clinical infection. This study reports the in vitro testing carried out to establish the effectiveness of the AMC sleeve.

Methods: The prevalence of gentamicin susceptibility amongst bacteria typically associated with pin tract infections was determined by comparing minimum inhibitory concentrations (MIC) of clinical isolates from the SENTRY Antimicrobial Surveillance Programme (1997–2002) to the NCCLS susceptibility breakpoint of < 4 μg/ml. The amount of gentamicin released over time from AMC sleeves into phosphate buffered saline (PBS) was measured using a microbiological zone of inhibition assay against S. epidermidis (NCTC 8853). Three 5 cm long sleeves, fitted over 6 mm diameter pins, were agitated in 5 ml of PBS eluant at 37°C. The eluant was replaced and tested at 2, 24, 48, 72 hours, then weekly until 26 weeks. Concentrations of gentamicin in the pin tract were calculated from these values using an estimated pin-tract volume. The ability of the sleeves to kill bacteria was measured by inoculating single 5 cm long, 5 mm diameter sleeves on pins with 1.5 ml of bacterial suspensions containing approx. 1 x 10⁸ cfu/ml. Surviving numbers of bacteria were counted after contact with the sleeves for 0.5, 1, 2 & 4 hours at 37°C. Effectiveness against clinical isolates of E. coli, S. aureus, S. epidermidis & Ps. aeruginosa was measured.

Results: The SENTRY database showed that of the 1456 individual surgical wound isolates gathered and evaluated, 1210 (83.1%) were found to be susceptible to gentamicin. Estimated concentrations of gentamicin in the pin tract reached 43.3 μg/ml at the end of the first week and exceeded the susceptibility threshold of 4 μg/ml over the next 19 weeks. The sleeves were able to reduce inoculum cell numbers of all organisms tested by 5 logs (99.9999% reduction) in ≤4h.

Discussion and Conclusion: Surveillance data confirms that gentamicin provides high level efficacy against pathogens commonly associated with pin tract infections. The AMC sleeves release gentamicin directly into the pin tract at concentrations above the susceptibility threshold for most clinically-encountered bacteria. These sleeves are also able to reduce significantly bacterial cell numbers when directly in contact with them. Therefore, this study demonstrates that the sleeves will inhibit bacterial colonisation of external fixation pins and emphasises their contribution to reducing the effects of pin tract infection.