Pigmented villonodular synovitis is a monoarticular proliferative process most commonly involving the synovium of the knee joint. There is considerable debate with regards to diagnosis and effective treatment.

We present our experience of managing PVNS of the knee joint over a 12 year period. Twenty-eight patients were reviewed. MRI was used to establish recurrence in symptomatic patients rather than routine screening and to identify posterior disease prior to surgery.

Eight patients had localised disease and were all treated with open synovectomy and excision of the lesion, with no evidence of recurrence. Twenty patients had diffuse disease, eight treated arthroscopically and twelve with open total synovectomy. Nineteen patients (95%) had recurrence on MRI, however, only five (25%) had evidence of clinical recurrence.

There were no significant complications following arthroscopic synovectomy. Open synovectomy, in contrast, was associated with three wound infections and two thrombo-embolisms. Three patients had Complex regional pain syndrome.

We believe diffuse disease should be treated with arthroscopic synovectomy which is associated with minimal morbidity and can be repeated to maintain disease control. Radiotherapy is helpful in very aggressive cases. TKR was used when there was associated articular erosion.

Purpose: The purpose of our work was to assess sutures, suturing techniques, and suture anchors used in rotator cuff surgery in order to explore weak parts in our repair.

Material and Methods: Ten types of sutures, four types of suturing techniques and eight types of sutures anchors commonly used in shoulder surgery were tested. Vicryl, Ticron, Dexon, PDS, Panacryl, Ethibond, Durabraid, Fiberwire, HiFi and Orthocord sutures were tested. Simple, mattress, massive cuff tear (MCT) technique and modified Mason Allen.

(MMA) suturing technique in ex-vivo ovine healthy rotator cuff were tested. Four metallic and four bioabsorbable anchors: Arthrex, Smith+Nephew, Linvatec, Mitek and bio respectively were tested. Their pull-out strength and failure mode was determined in ex-vivo ovine humeral heads. Materials Testing Machine and attached load cell run with Emperor Software (MEC-MESIN, UK) was used for the tests with application of tensile load(60mm/min). Load and displacement were recorded at a sampling rate of 100 Hz and breaking load and stiffness were recorded.

Results: The suture mean breaking strength (N) was: Vicryl 89.0, Ticron 70.9, Dexon 111.7, PDS 92.9, Panacryl 52.9, Ethibond 64.5, Durabraid 72.6, Fiber-wire 127.2, HiFi 163.0 and Orthocord 141.8. The mean suture stiffness (N/mm) was: Vicryl 3.4, Ticron 3.0, Dexon 2.4, PDS 1.2, Panacryl 0.7, Ethibond 2.5, Durabraid 3.1, Fiberwire 9.7, HiFi 11.1, and Orthocord 6.9. The technique’s mean breaking strength (N) was: simple 54.1, mattress 102.8, MCT 194.0, MMA 227.7 and their mean stiffness (N/mm) was: simple 10.4, mattress 13.1, MCT 26.0 and MMA 18.9. The anchors had mean pull-out strength (N): Arthrex 534.0 and Smith & Nephew 574.0, Linvatec 707.2N, Mitek 736.4N and Arthrex Bio 257.4, Linvatec Bio 305.2, Mitek Bio 359.6, S& N Bio 330.6. Often either in metallic (10/20) or in bioabsorbable anchors (11/20) the eyelet fails first.

Conclusion: Modern non absorbable sutures (HiFi Orthocord Fiberwire) have higher breaking strength and stiffness than absorbable ones (p< 0.05). MCT suturing technique, arthroscopically applicable, and MMA technique, which is most commonly used in open surgery have no great differences in strength and stiffness (p=0.046 and p=0.352 respectively). Both of them have higher strength and stiffness than simple and mattress technique (p< 0.05). Metallic anchors have a higher pull-out strength than bioabsorbable ones (p< 0.05) and the eyelet is a weak point in both.

Multiple ligament deficiency in knees is usually the aftermath of high velocity trauma and leads to complex multidirectional instability, that can in turn greatly compromise the patient’s functional level if left untreated. The aim of this study is to evaluate the mid- and long-term functional outcome of patients who underwent complex reconstruction for multiple ligament deficiency.

Twenty-nine patients (21 male and 8 female) with an average age of 35.54 years (range 17–60) underwent arthroscopic or arthroscopically assisted multiple ligament reconstruction at an average of 2.1 years following their initial knee injury. Thirteen of them sustained a multiple ligament injury following an RTA, 11 during sports and 5 following a fall from a height.

They were followed for a period of 13 to 108 months (average: 45.8) and functionally evaluated according to Clancy’s criteria. The functional outcome was excellent in five patients (17.2%), good in ten (34.5%), fair in twelve (41.4%), while two reconstructions resulted in a failure (6.9%). Eleven patients returned to sporting activities and all but three returned to work, although sometimes in lighter duties.

Arthroscopic multiple ligament reconstruction is a complex and technically demanding procedure that should be carried out in specialised units. Although it rarely results in a “normal” knee, it offers in most cases a stable as well as functional knee.

Aim The aim of this study was to identify the presentation, management and outcomes this rare disease using the large series of patients treated at our unit

Material and Methods We reviewed the medical records and x-rays of all the patients who were referred – treated for PVNS around the knee joint between 1990 and 2002

Results 42 patients totally were treated or had second opinion for PVNS disease. 37 have been analysed in detail.

Their mean age was 33 years old and 11 patients were below 17 years of age. There was a predilection for females with 22 (59.5%) out of 37 patients.

There was average 3.3 years period of time with swelling/knee symptoms before diagnosis .

The MRI scan was the cornerstone for the patient’s assessment. It has proved useful in recurrent disease and posterior ”Bakers cyst” disease.

2 of the patients had been managed with arthroscopic synovectomy alone, 10 patients have undergone simultaneous arthroscopic synovectomy combined with open excision of any “Bakers cyst” disease.

10 had “open synovectomy”. 3 patients have had radiotherapy .3 patients have had TKR Complications included 3 superficial wound infections, 1 DVT, 1 PE, 1 stress fracture after radical bone curettage, common temporary/refractory stiffness (needing physio/ MUAs). Recurrence was high and managed with repeat arthroscopic synovectomy.

Conclusion PVNS is a rare disorder with typical mono-articular involvement affecting most commonly the knee joint. MRI and biopsy is the gold standard for the establishment of diagnosis and often needs a combined approach with arthroscopic and open posterior cyst excision. Radiotherapy is helpful in aggressive cases. TKR is suggested when there is associated articular erosion. The patient should be warned about the long course of treatment and often multiple procedures because of high recurrence rates.

Aims: Periprosthetic osteolysis, generally ascribed to cup polyethylene debris is the most common reason for revision THR. We carried out a radiological – retrieval study in 63 patients undergoing revision THR in order to explore potential correlation between osteolysis and wear in the cup. Material and Methods: 43 intact polyethylene liners were retrieved following revision THR because aseptic loosening. Radiological osteolysis was assessed from the De Lee and Gruen zones. The linear wear depth in the cups was measured using the shadowgraph technique and the volumetric wear was assessed using the Hashimoto formula. Statistical analysis was performed using the SPSS® software package. Results: There was a statistically significant inverse correlation between Volumetric Wear Rate (VWR)-Total Femoral Osteolysis (TFO) (p=0.024), VWR -Total Osteolysis TO (p=0.003), Volumetric Wear (VW) – TFO (p=0.015), and a trend between VW – TO (p=0.087). This shows that increased levels of osteolysis appear to be associated with lower VWR. Conclusions: Overall these results demonstrate an overall inverse relationship between long term wear of the polyethylene and periprosthetic osteolysis in pre-revision patients. Restriction in the mobility-activity could be a reason for that.

Aims: The reliability of accurately determining wear in polyethylene cups using plain x-rays has been questioned by many authors. In order to explore the accuracy of wear assessment radiologically, we carried out a radiological-retrieval study in 63 patients undergoing revision THR.

Methods:We retrieved 45 intact polyethylene liners from patients after revision THR. The Linear Wear Depth (LWD) in the cups was assessed radiologically measuring the femoral head eccentricity on the plain non-weight bearing x-ray films. The LWD was assessed in the laboratory using the shadowgraph technique. Statistical analysis was performed using the SPSS® software package.

Results: Themean radiological eccentricity of the femoral head was 2.09±2.17 mm (ranging from 0 to 9.50) and the mean LWD 3.52±1.85 mm (ranging from 0.50 to 9.29). The results of Wilcoxon sign ranks test indicated that this 1.43mm-difference is statistically significant (p< 0.001). The measured wear on the plain x-rays was 40,6% less than the true linear wear measured on the retrieved cup.

Conclusions: It is obvious that the radiological eccentricity of the femoral head underestimates the Linear Wear Depth (“true wear”) quite substantially. That difference could be less if the x-rays had been taken weight bearing.

Aims: It is well established that implant characteristics influence the Volumetric Wear Rate (VWR) of the polyethylene cup at the Total Hip Replacement (THR). In order to explore these, a retrieval study in 63 patients having revision THR was carried out. Methods: 45 intact THR components were retrieved from patients after revision THR. The polyethylene VWR was assessed in the laboratory using the shadowgraph technique. Implant features such as femoral head size, stem/cup modularity and liner thickness were recorded. Statistical analysis to identify potential correlations with the VWR was performed. Results: 22 mm diameter femoral heads produced significantly lower VWR values than 28 mm (p=0.006) and 32 mm (p< 0.001), however, there was no significant difference between the 28mm and 32mm (p=0.375) heads. There was no statistically significant difference between the mean VWR in the metal-backed and the all-polyethylene cups with the first 25% higher than the second. However, the femoral stems with a modular head generated a VWR about 3.5 times higher than the solid monoblock femoral components (p< 0.001). Polyethylene thickness didn’t influence statistically significantly the VWR (p=0.135). Conclusions: Modular implants with large femoral head size significantly influence the polyethylene wear rate. However, in this study, the liner thickness did not influence the wear rate, although it is recognised that there is probably a critical thickness below which wear is accelerated.

Aims: To present our experience from the diagnosis and treatment of axillary vein thrombosis in seven cases. Methods: We reviewed the medical records and x-rays of all the patients who were admitted and treated for axillary vein thrombosis (AVT) in the Orthopaedic and Vascular Surgery Departments of our hospital between 1995 and 2001. Results: We reviewed seven patients (þve males and two females, mean age 52.3 years old) presented in our hospital with AVT. Two of these cases occurred following musculoskeletal injuries (extrinsic trauma), three after central line insertion for oncological treatment (intrinsic trauma), one was related to the oral contraceptive pill (thrombophilic tendency) and one case was effort related (Paget-Schroetter syndrome). Clinically there was plethoria, arm swelling and persistent superþcial veins which were aggravated with activity and dependency. Venography or Duplex scan was used to establish the diagnosis. Causing factors and associated morbidity were assessed and treated. All of the cases of vein thrombosis responded well to conservative treatment (heparin/low molecular weight heparin for three months). None of the cases developed pulmonary embolism and we had no mortality. Conclusions: This study demonstrates that the innocent appearance of upper limb swelling should raise the index of suspicion of a potential underlying vascular lesion. Although quite rare, missed AVT may cause associated morbidity but very rarely mortality.

Aims: Although there have been theoretical expectations of increased polyethylene wear rate with the time a THR is in situ, wear rate is reported to slow down. We performed this study aiming to identify the relationship between wear rate and time of service for the prosthesis. Material and Methods: 45 intact polyethylene liners were retrieved from patients undergoing revision THR. The LWD was measured in the laboratory using the shadowgraph technique. Dividing LWD with time the prosthesis was in place allowed assessment of the Linear Wear Rate (LWR). A correlation between LWR and time of service was explored. Statistical analysis was performed using the SPSS® software package. Results: Linear Wear Rate (LWR) was not stable with time. There was a significant inverse correlation (p< 0.001) between the time that the prosthesis was in place and LWR. This relationship was stronger for the first 6 years of the THR service (p=0.005), while LWR does not change significantly after the 6th year of prosthesis implantation (p=0.060). Conclusions: The LWR is higher in the beginning either as result of the initial higher creep or because of initial lower conformity of the femoral head within the acetabular cup. As conformity increases, the LWR reduces to a more stable value.

Rotator cuff pathology is common in orthopaedic patients. However, there are still debates about the best way of treating those patients. We present the clinical experience from our Unit.

We present 85 patients who had arthroscopic or arthroscopically assisted shoulder surgery for full thickness rotator cuff tears between 1994 and 2001. Their medical records and radiological investigations were reviewed, and the management as well as the outcome of their treatment were recorded. The aim was to review those patients and determine if optimum assessment and management was implemented to them.

There were 47 male and 38 female patients with average age 58.8 years and weight 79.9 kg, 32 of the patients reported trauma prior to their symptoms. 63 patients had MRI scan and they had average 2.6 years of symptoms and 2.4 steroid injections before their operative management. 27 patients had arthroscopic and 58 mini open rotator cuff repair. From those with recorded pain management 32 patients had interscalene block and 21 infiltration with local anaesthetic. Their average hospital stay was 1.4 and 1.8 days for the arthroscopic and mini open repairs respectively. In 69 (77.7%) patients the result was considered overall satisfactory; 8 (9.4%) patients had temporary shoulder stiffness and/or pain, which were treated conservatively with steroid injections and physiotherapy. 11 (12.9%) of the patients required reoperation, 5 from which required cuff resuturing and 4 manipulations under anaesthetic for postoperative stiffness. 3 patients (3.5%) had other than shoulder complications including CVA, chest infection, and CTS.

Rotator cuff surgery remains a challenge where often the working surgical plan is altered intraoperatively and tissue quality is of major importance for the final outcome. Arthroscopy has reduced patient’s hospital stay and rehabilitation time. However, a not durable repair, or postoperative stiffness can be a potential risk complicating the surgical result.

In this study it is demonstrated that treatment of patients with rotator cuff disease is still a challenge, time in hospital is reduced with arthroscopic management, but the overall risk for reoperation/MUA either for not durable previous repair or postoperative stiffness was still quite high (12.9%).

Rotator cuff or long head of biceps tendon tears are common in patients with degenerative shoulder rotator cuff disease. Most often they are investigated with an MRI scan. Diagnosis prior to surgery is useful for the appropriate surgical planning.

We present 63 consecutive patients who had arthroscopic shoulder surgery and prior to that had MRI investigation between 1994 and 2001. Their medical records were reviewed; arthroscopic operative findings as well as the report of the MRI scan were recorded and compared retrospectively. The aim of our study was to assess the accuracy of MRI findings comparing the arthroscopic ones regarding rotator cuff and biceps tendon pathology.

There were 63 patients with mean age 58 years. All of these had MRI scan investigation and the waiting time prior to surgery was 10 months. It was found that there were 6 false (−)ve, 1 false (+)ve and two cases with full thickness cuff tears which were reported as probable tears. Further to that, there were 11 frayed biceps tendons, 8 partially ruptured, 3 subluxed, 4 complete ruptures and 1 SLAP lesion. All biceps lesions were not commented in the MRI scan reports.

MRI scan is very sensitive detecting soft tissue pathology in shoulder investigation. However, even on that basis, rotator cuff and in particular biceps tendon pathology can be missed. The shoulder arthroscopy is the best method to accurately diagnose those lesions. However, it should be noted that often the surgeon has got to alter to working surgical plan in order to address the problem intraoperatively.

In this study it is demonstrated the MRI scan often misses rotator cuff or long head of biceps tendon pathology. The most sensitive method for the diagnosis of it is the shoulder arthroscopy, which address its treatment in the same time.

The long-term biological effects of wear debris are unknown. We have investigated whether there is any evidence of cumulative mutagenic damage in peripheral blood lymphocytes of patients undergoing revision arthroplasty of predominantly metal-on-plastic total hip replacements compared with those at primary arthroplasty.

There was a threefold increase in aneuploidy and a twofold increase in chromosomal translocations which could not be explained by the confounding variables of smoking, gender, age and diagnostic radiographs. In the patients with TiVaAl prostheses there was a fivefold increase in aneuploidy but no increase in chromosomal translocations. By contrast, in patients with cobalt-chrome prostheses there was a 2.5-fold increase in aneuploidy and a 3.5-fold increase in chromosomal translocations. In six patients with stainless-steel prostheses there was no increase in either aneuploidy or chromosomal translocations.

Our results suggest that future epidemiological studies of the putative long-term risks of joint replacement should take into account the type of alloy used in the prosthesis.