We examined the outcomes and levels of patient satisfaction in 202 consecutive cases of ultrasound-guided supraclavicular brachial plexus block (SBPB) in upper limb surgery performed between September 2007 and March 2010.

All blocks were performed by orthopaedic surgeons using ultrasound visualisation with a high-frequency linear probe. The probe was placed in the coronal–oblique plane in the supraclavicular fossa, and the puncture was ‘in-plane’ from lateral to medial. Most of the blocks were performed with 0.75% ropivacaine/1% lidocaine (1:1), with or without adrenaline in 1:200 000 dilution. In 201 patients (99.5%) the brachial plexus block permitted surgery without conversion to general anaesthesia. The mean procedure time for block was 3.9 min (2 to 12), the mean waiting time for surgery was 34.1 min (10 to 64), the mean surgical time was 75.2 min (6 to 232), and the mean duration of post-anaesthetic analgesia was 437 min (171 to 992). A total of 20 patients (10%) developed a transient Horner’s syndrome. No nerve injury, pneumothorax, arterial puncture or systemic anaesthetic toxicity were recorded. Most patients (96.7%) were satisfied with ultrasound-guided SBPB. This study demonstrates the efficacy and safety of ultrasound-guided SBPB for orthopaedic surgery on the upper limb.

Cite this article: Bone Joint J 2014;96-B:795–9.

Introduction: Preoperative planning is an important part of the total knee arthroplasty(TKA) surgical procedure.

In joint arthroplasty, the use of a templating system has been recommended and it is routinely used with most designs. The aim of this study was to compare the accuracy of preoperative templating in TKA between conventional two-dimensional (2D) and computed tomography (CT)-based 3D procedures in order to confirm the necessity of using 3D evaluations for preoperative planning.

Method: One-hundred consecutive primary TKAs performed during the period between December 2005 and May 2009 were analyzed. The mean age of the patients was 73.3 years (range, 33 to 90 years). Preoperative templating was performed for each TKA using both conventional 2D radiographs (both anteroposterior and lateral views) which were analyzed by a single senior surgeon. Preoperative CT scans of the knee were performed and a CT-based 3D image model (superimposing the computer aided design model of the implant) was generated using KneeCAS (KneeCAS: Knee Computer-Assisted System) and then was analyzed by a radiology technologist without any knowledge of the 2D procedure. Based on the operation notes, we determined which size implant had been inserted at the time of surgery and used this as the gold standard. The accuracy and reliability were assessed for all measurements of the two different templating procedures (2D and CT-based 3D procedures)

The Chi-square test for independence for paired observations was used to analyze the accuracy. The weighted kappa test was used to analyze reliability.

Results: 56% of the 2D procedures were found to be an exact match. This increased to 98% for the template sizes within one size above or below that used and 2% were two sizes or more adrift. Otherwise, 59% of the CT-based 3D procedures were an exact match; 98% were within one size and 2% were two sizes or more adrift. The CT-based 3D procedure was slightly more accurate than the 2D procedure. However, the difference was not statistically significant (p = 0.67). The weighted kappa coefficient of the 2D procedure was 0.49 (which indicates a moderate agreement), while that of the CT-based 3D procedure was 0.49 (which indicates a moderate agreement). The results of the weighted kappa coefficients were not statistically significant (p = 0.65).

Conclusion: Computer-assisted surgery systems are used often for preoperative planning in TKA. However, our results do not support the superiority of 3D preoperative templating to 2D conventional evaluation in predicting implant size. Thus, 3D templating may not be necessary for preoperative planning in TKA.

We prospectively examined the physical and imaging findings, including MRI, of 23 patients with spontaneous osteonecrosis of the knee after obtaining informed consent to acquire tissue specimens at surgery. There were four men and 19 women, with a mean age of 67.5 years (58 to 77). Plain radiographs were designated as stages 1, 2, 3 or 4 according to the classification of Koshino. Five knees were classified as stage 1, five as stage 2, seven as stage 3 and six as stage 4. The histological specimens were stained with haematoxylin and eosin and tetrachrome.

In the early stages of the condition, a subchondral fracture was noted in the absence of any features of osteonecrosis, whereas in advanced stages, osteonecrotic lesions were confined to the area distal to the site of the fracture which showed impaired healing. In such cases, formation of cartilage and fibrous tissue, occurred indicating delayed or nonunion. These findings strongly suggest that the histopathology at each stage of spontaneous osteonecrosis is characterised by different types of repair reaction for subchondral fractures.

Human bone-marrow mesenchymal stem cells have an important role in the repair of musculoskeletal tissues by migrating from the bone marrow into the injured site and undergoing differentiation. We investigated the use of autologous human serum as a substitute for fetal bovine serum in the ex vivo expansion medium to avoid the transmission of dangerous transfectants during clinical reconstruction procedures.

Autologous human serum was as effective in stimulating growth of bone-marrow stem cells as fetal bovine serum. Furthermore, medium supplemented with autologous human serum was more effective in promoting motility than medium with fetal bovine serum in all cases. Addition of B-fibroblast growth factor to medium with human serum stimulated growth, but not motility. Our results suggest that autologous human serum may provide sufficient ex vivo expansion of human bone-marrow mesenchymal stem cells possessing multidifferentiation potential and may be better than fetal bovine serum in preserving high motility.

We have analysed retrospectively the relationship between the axial parameters of alignment of the lower limb and the recurrence of varus deformity after high tibial osteotomy. We studied 29 patients (37 knees) with a mean age at surgery of 66 years. The mean follow-up was for 7.4 years (5 to 10.5). Recurrence of varus deformity was defined as an increase in the femorotibial angle of 3° or more, compared with that obtained six months after the operation. There were four patients (four knees) with recurrence of varus deformity. They had a greater varus inclination of the distal femur than those without varus recurrence.

An association between varus inclination of the distal femur and horizontal obliquity of the joint surface was observed. Excessive obliquity prevents the shift of weight-bearing to the lateral compartment, and may cause a recurrence of varus deformity after high tibial osteotomy.

We studied 37 patients with varus osteoarthritis of the knee to determine the influence of the bone mineral density (BMD) on the varus deformity. There were 15 men (21 knees) and 22 women (38 knees). The mean age of the men was 69 years and of the women 68 years. BMD was measured in the L1–L4 spinal region using dual X-ray absorptiometry.

In the women a low level of BMD was associated with varus deformity originating at the proximal tibia, but a high level was predominantly linked with deformity originating in the joint space. Similar findings were obtained in the men.

Our results suggest that a low BMD predisposes to trabecular microfractures and consequently increased stress on the articular cartilage. A low BMD does not preclude osteoarthritic change in the knee.