Impaction bone grafting for the reconstitution of bone stock in revision hip surgery has been used for nearly 30 years. Between 1995 and 2001 we used this technique in acetabular reconstruction, in combination with a cemented component, in 304 hips in 292 patients revised for aseptic loosening. The only additional supports used were stainless steel meshes placed against the medial wall or laterally around the acetabular rim to contain the graft. All Paprosky grades of defect were included. Clinical and radiographic outcomes were collected in surviving patients at a minimum of ten years after the index operation. Mean follow-up was 12.4 years (sd 1.5) (10.0 to 16.0). Kaplan–Meier survival with revision for aseptic loosening as the endpoint was 85.9% (95% CI 81.0 to 90.8) at 13.5 years. Clinical scores for pain relief remained satisfactory, and there was no difference in clinical scores between cups that appeared stable and those that appeared radiologically loose.

Cite this article: Bone Joint J 2014;96-B:188–94.

The threshold for decompression in acute compartment syndrome is quoted as a pressure difference between the compartment and diastolic blood pressure of less than 30mmHg. This study reports the findings of continuous compartment pressure monitoring in children who underwent tibial osteotomies.

In this prospective observational study, twenty seven children who underwent tibial osteotomies had anterior compartment pressures monitored using a transducer-tipped probe for a minimum of 72 hours following surgery. Pressure data were collected hourly together with evidence of clinical signs, symptoms and patterns of analgesic use. Patients were also reviewed for late sequelae of compartment syndrome.

One case of compartment syndrome were encountered. Pressure differences (diastolic BP - compartment pressure) were found to vary widely, with many children exceeding the threshold for decompression but without manifesting other signs of compartment syndrome. Fasciotomies were not performed in view of the conflicting evidence and subsequent review confirmed the absence of late sequelae. In these children, low diastolic blood pressures were a common but normal feature. The prevalence of compartment syndrome was 3.7% (1/27). The positive predictive value of using the adult threshold was 7.1%; the negative predictive value was 100%.

We conclude that the threshold for decompression as applied to adults is unsuitable for use in children inasmuch as a positive result would lead to a correct diagnosis in only 7.1% of children. A negative test is more useful in correctly excluding compartment syndrome in 100% of the children studied.

Introduction

Advances in the management of open tibial fractures have reduced the incidence of long-term complications of these injuries. However, a number of patients continue to suffer from sequelae such as infection, non-union and malunion. Many orthopaedic surgeons believe a below-knee amputation with a well-fitted prosthesis is a better alternative to limb reconstruction surgery. There are few studies that evaluate the long-term functional outcomes of amputees against patients who have undergone limb salvage procedures, and their results are conflicting. The hypothesis of this study is that patients who have undergone limb salvage have as good or better outcomes than those who have had below-knee amputations.

Aseptic loosening of the acetabular component continues to be the most common indication for revision of total hip replacements in younger patients. Early in the evolution of the cemented hip, arthroplasty surgeons switched from removal to retention of the acetabular subchondral bone plate, theorising that unfavourable mechanical forces were the cause of loosening at the bone-cement interface.

It is now known that the cause of aseptic loosening is probably biological rather than mechanical and removing the subchondral bone plate may enhance biological fixation of cement to bone. With this in mind, perhaps it is time to revive removal of the subchondral bone as a standard part of acetabular preparation.

The management of spasticity of children with cerebral palsy is often complex and challenging. Effective treatment requires a multidisciplinary approach involving paediatricians, orthotists, occupational therapists, physiotherapists and orthopaedic surgeons. Botulinum toxin A therapy in the lower limb has been shown to relieve spasticity and to improve the function in the short term. However, the use of Botulinum toxin A in the upper limb remains controversial, moreover only selected few orthopaedic surgeons have experience in managing it. The aim is to assess the functional improvement following an upper limb Botulinum toxin A injections to the upper limb and then to evaluate the patient’s and parents’ satisfaction after the procedure.

During 2007 a total of 36 spastic cerebral palsy patients underwent 47 episodes of Botulinum toxin A injections to the upper limb. There were 22 male and 14 female with an age range between 2 to 17 years (average age was 2 years). Following the surgery, all patients received a course of an intense exercise regime with the physiotherapist and occupational therapist. All patients were prospectively followed-up by the clinic with no loss to follow-up. We also assessed the functional movement of the patients as well as the patient’s and parents’ subjective evaluation of the procedure.

Overall, the range of movement of the upper limb has improved following the Botulinum toxin A injection. Most patients/parents were satisfied with the procedure and would consider further injection in the future. Botulinum toxin A injection to the upper limb is generally well received with good short term results. Many would consider further injections to sustain improve function.

Modern methods of deformity correction such as the Taylor Spatial Frame (TSF) allow correction of deformities to within tolerances of 1° and 0.5mm. Plain X-radiography using orthogonal views is the current standard for the assessment for the evaluation of angular limb deformities. CT has been used for the assessment of torsional and axial deformities but its use has not been described for the measurement of angular deformities. Furthermore, dedicated correction planning software (SpatialCad™) may allow more accurate deformity definition.

This study aims to evaluate the accuracy of CT and SpatialCad™ to measure angular deformities in vitro. A tibia sawbone was coated in radio-opaque paint. A TSF was mounted on it and an osteotomy made in the mid-diaphyseal region. Four deformities were created and imaged with plain radiography and CT. Four observers measured the deformities using paper and pencil, PACS and SpatialCad™ for plain radiographs and Spatial-Cad™ for the CT scout views. The variance of the mean response of observed differences between main treatment factors was measured using analysis of variance.

There was no significant difference in variability (precision) between observers or methods of measurement. However, measurements made with PACS and Spatial-Cad™ on plain radiographs, but not CT scout views, were also accurate.

There does not appear to be any evidence at present that the use of CT for measurement of angular limb deformity is justified over plain radiography. Spatial-Cad™ is designed to optimize deformity correction planning for use with TSF, but PACS appears to be adequate for use with other deformity correction systems.

Introduction: The management of spasticity of children with cerebral palsy is often complex and challenging. Effective treatment requires a multidisciplinary approach involving paediatricians, orthotists, occupational therapists, physiotherapists and orthopaedic surgeons. Botulinum toxin A therapy in the lower limb has been shown to relieve spasticity and to improve the function in the short term. However, the use of Botulinum toxin A in the upper limb remains controversial.

Aim: To assess any improvement following upper limb Botulinum toxin A injections and to evaluate patient’s and parents’ expectation and satisfaction of the procedure.

Method: During 2007 a total of 36 spastic cerebral palsy patients underwent 47 episodes of Botulinum toxin A injections to the upper limb. There were 22 male and 14 female with a mean age of 6 years old. A questionnaire was devised to assess the outpatient consultation, peri-operative care and the post-operative outcome. Subjective improvement and the patient’s and parents’ evaluation of the procedure were also recorded.

Results: Good to excellent results were achieved in most areas. Daily activities were improved by 52% with an average duration of 4 months. The majority of the patient achieved their expectation. Most patients/parents were satisfied with the procedure and would consider further injections.

Conclusions: Botulinum toxin A injection to the upper limb was generally well received with good short term results. Most would consider further injections.

Background and purposes of study The objective of this study is to report the preliminary clinical data from a stand-alone interbody fusion cage (Stabilis™) from two centres.

Methods and results This was a retrospective group comparative study. Anterior lumbar interbody fusion was performed using Brantigan (n=6) or Stabilis™ cages (n=19). Clinical assessment was performed using standardised questionnaires. Lumbar flexion/extension views were used to assess union and implant subsidence. There were no significant differences between the groups for ODI, VAZ, MZ and MSPQ pre-operatively. The Stabilis group showed an improvement in ODI (pre: 49.4; post: 39.3; p=0.024), VAS (pre: 76.1; post: 47.8; p< 0.01) and MZ (pre 32.9; post: 20.6; p< 0.01).

There was no statistical improvement in the Brantigan cage group. Despite clinical improvement, five patients in the Stabilis group failed to unite and six demonstrated subsidence of the implant. The relationship between non-union and subsidence was statistically significant (p = 0.017). Furthermore, the change in ODI between patients who united and those who did not was both statistically significant (p=0.03) and the difference in mean ODI between the two groups was considerable (21%).

Conclusions: Stand-alone cages show promise, involve a shorter operating time and less tissue trauma for the patient. This study has identified a high rate of non-union and implant subsidence. This did not appear to be clinically relevant.