Introduction and Objective

Ceramic on Ceramic bearings in Total Hip Arthroplasty (THA) afford a low friction coefficient, low wear rates and extreme hardness. Significant complications include hip squeak, ceramic fracture and poor polyethylene performance in revision procedures due to imbedding of abrasive microscopic ceramic fragments. We report on the results of this bearing at a minimum of 10 years.

Introduction and Objective

Malunion after trauma can lead to coronal plane malalignment in the lower limb. The mechanical hypothesis suggests that this alters the load distribution in the knee joint and that that this increased load may predispose to compartmental arthritis. This is generally accepted in the orthopaedic community and serves as the basis guiding deformity correction after malunion as well as congenital or insidious onset malalignment. Much of the literature surrounding the contribution of lower limb alignment to arthritis comes from cohort studies of incident osteoarthritis. There has been a causation dilemma perpetuated in a number of studies - suggesting malalignment does not contribute to, but is instead a consequence of, compartmental arthritis. In this investigation the relationship between compartmental (medial or lateral) arthritis and coronal plane malalignment (varus or valgus) in patients with post traumatic unilateral limb deformity was examined. This represents a specific niche cohort of patients in which worsened compartmental knee arthritis after extra-articular injury must rationally be attributed to malalignment.

Aims

The aticularis genu (AG) is the least substantial and deepest muscle of the anterior compartment of the thigh and of uncertain significance. The aim of the study was to describe the anatomy of AG in cadaveric specimens, to characterize the relevance of AG in pathological distal femur specimens, and to correlate the anatomy and pathology with preoperative magnetic resonance imaging (MRI) of AG.

To identify the validity of the Straight leg raise and crossed straight leg raise in the diagnosis of Lumbar disc prolapse.

Systematic review of the literature. The Medline database was used (1966-09) using the search terms Lumbar disc prolapse /disc herniation/straight leg raise /crossed straight leg raise.

80 papers were identified from the search after duplicates had been removed. Of these, 6 abstracts were read and the full papers of 5 reviewed. Four papers scored highly on the STARD criteria and were used in the final review. Two systematic reviews (Vroomen et al, 1999; Deville et al, 2000) and two diagnostic studies (Majessi et al,2000; Vroomen et al, 2002). The review by Vroomen in 1999 identified 37 papers. Trials were included that used CT myelography, MRI or surgical findings as the gold standard. Deville identified 15 studies with the gold standard being findings at surgery. The diagnostic trial by Majessi et al (2008) and Vroomen et al (2002) both used MRI as the gold standard. The Diagnostic odds ratio for SLR ranged from 2.3-8.8 and for CSLR from 4.4 to 11.2. The most valid clinical test in the diagnosis of Lumbar disc prolapse is

the crossed straight leg raise. The straight leg raise has not been shown to have high validity

Introduction: Several theories have been proposed to explain the therapeutic benefit of spinal manipulation (SM), one of which is the reflexogenic response, whereby there is thought to be a reflex reduction in pain, muscle hypertonicity and functional improvement.

Methods: 60 patients were randomised to receive a single high velocity low amplitude thrust or a sham manipulation, where a similar thrust was given to the subject, but applied non-specifically. After testing for reliability, physiological effects in a number of muscle groups was explored through assessment of pressure pain threshold (PPT) and muscle activity using algometry and surface electromyography (sEMG) respectively. The sEMG reflex response was recorded during the manipulation and a record of whether cavitation was achieved was recorded. PPT measurements were taken pre and post intervention over three experimental visits (each visit being a week apart).

Results: There were no statistically significant differences in the magnitude of the sEMG reflex response to a single SM compared to the sham. However at the third application a significantly larger sEMG reflex response was seen in the SM group compared to the sham manipulation, for multifidus (F=9.57, p=0.01) and gluteus maximus muscles (F=6.41, p=0.02). There were no associations between the size of the reflex response and any of the subject’s baseline characteristics or changes in pain at any time point.

Conclusion: It is unlikely SM influences pain and function via a muscular reflexogenic effect. It may be that the longitudinal change in the reflex response indicates a biomechanical change in one group.

Background: There is evidence that spinal manipulation (SM) has therapeutic benefit in the treatment of back pain. However, there is still poor understanding of the physiological mechanism by which it achieves its therapeutic benefit. In order to explore the mechanism of SM, this study explored it’s immediate anti-nociceptive effect, by measuring the pressure pain threshold (PPT) in spinal muscles pre and post SM, in subjects with low back pain.

Methods: A group of low back pain patients (n=60) were randomised into two groups, one received a SM to a dysfunctional segment in the lumbar spine. The second group received a sham procedure, where the patient was placed in a similar ‘wind up’ position, but the thrust applied non-specifically through the low back. Algometry measurements were taken over four spinal muscles (iliocostalis, multifidus, glutei and trapezius), before and after the manipulation or sham procedure.

Results: Paired t-tests for within group differences showed statistically significant differences for the SM group iliocostalis (p< 0.001) multifidus (p< 0.001) glutei (p< 0.001) and trapezius (p=0.20) with small to moderate effect size (0.60; 0.58; 0.36 & 0.20 respectively) small between group differences were also noted. There were no significant changes in PPT in any muscle in response to the sham procedure.

Conclusion: SM produced a statistically significant change in PPT with a small to medium effect size. No changes were observed in the sham and thus the active component of SM appears to be related to the specific manipulative thrust technique rather than to the general handling and positioning of the patient.

Introduction: A large number of patients with non-specific low back pain (NSLBP) are examined by physiotherapists. Physiotherapists ask their patient’s questions, as part of their clinical examination, however the reliability of the information elicited by these questions has never been examined.

Methods: Following a Focus group with a sample of physiotherapists (n=30), and subsequent Delphi technique questionnaire, a list of questions and tests for the clinical examination to NSLBP was developed. The clinical examination list was then tested for item inter-tester reliability with 100 NSLBP patients and 16 physiotherapists. Patients were assessed by both physiotherapists on one day. Data were analysed using kappa coefficients for nominal data and weighted kappas for ordinal data.

Results: The physiotherapists rated issues regarding the location and quality of pain with good levels of reliability, kappa values ranged from 0.49 to 0.64. Diurnal changes in pain and history of pain were also reliably ascertained (Kappa values ranging from 0.49 to 0.73), with symptoms other than pain demonstrating good reliability (values ranging from 0.50 to 0.77). Issues regarding the affect of psychosocial issues as barriers to recovery and the degree to which the patient’s pain was affecting their function were not as reliable (kappa values from 0.14 to 0.51)

Conclusions: It is clear that whilst the questions typically used in the clinical examination of NSLBP are reliable when addressing simple issues relating to the report of symptoms, more complex issues are less reliable and further work is required to improve the reliability of the information obtained.

Introduction: Algometry has been shown to be an effective way of quantifying pressure pain threshold (PPT), although it’s reliability in assessing spinal muscle pain (excluding trigger points) has not been robustly analysed.

Method: Intra-rater test re-test reliability PPT assessment by algometry over the belly of four pairs of spinal muscles, (iliocostalis, multifidus, gluteus maximus and trapezius) in a healthy sample (80 assessments) was analysed. Healthy subjects were tested twice (within 15mins) on three occasions (separated by a week); 240 sets of assessments revealed good within-session reliability (ICC> .91) and good between session reliability (ICC> .87), with a relatively small measurement error (approximately 3kg/cm²) and no systematic difference within session or between sessions.

Conclusion: In conclusion, PPT assessment by algometry is a reliable, both within and between sessions, measure of a subject’s pain. This study provides further validity to the use of this measure as a suitable, convenient method of monitoring treatment effects.

Introduction A reliable biomechanical diagnosis is necessary to justify the use of spinal manipulative treatment to correct it. Palpation is considered to be one of the most informative aspects of physical examination of patients with musculoskeletal pain and is the most commonly used method for the examination of the spine for joint dysfunction. Previous studies into reliability of palpation of joint dysfunction are confounded by the clinician having first to correctly identify the appropriate spinal segment, introducing a further measurement error. The purpose of this study was to examine the intra-observer reliability of identifying a manipulable lesion in the lumbar and thoracic spine.

Methods 12 asymptomatic subjects were examined by an experienced osteopath and the selected joint marked on two occasions using a ultra-violet marker rather than by naming the spinal level. The marks were recorded on acetates by a separate researcher and intra-rater reliability was assessed by measuring the agreement between the two markings. Using the palpation examination protocol resulted in an excellent level of intra-rater agreement in the lumbar spine ICC (1,1) .96 but poor reliability ICC (1,1) .70 in the thoracic spine.

Conclusion Intra-rater reliability for identifying a spinal segment exhibiting signs of segmental dysfunction was excellent in the lumbar spine, but poor in the thoracic spine. The examiner was experienced in the examining method for the lumbar spine, but less so in the thoracic spine, highlighting that experience improves palpatory agreement.

Introduction Non-specific low back pain (NSLBP) is an extremely heterogeneous condition with many attempts at sub-classification having been made over the years.

Background and Purpose of the Study This study developed UK physiotherapy, professional consensus on the items to be included in a list of important “discriminatory” examination features. These features will be subsequently tested in a large cluster analysis with a view to generating a valid sub-classification of NSLBP.

Material and Method Thirty UK Chartered Physiotherapists, representatives from Clinical Interest Groups, attended a focus group and subsequently undertook a Delphi consensus technique. Participants were purposively sampled from all clinical interest groups to represent as broad a clinical experience as possible. The focus group established the areas of the examination that were to be included in the Delphi process. The Delphi consensus process involved an initial round of statement generation. The physiotherapists were asked to list the examination items, from the history and physical examinations that they rated as important discriminators of different “types” of NSLBP. A content analysis was undertaken to establish common features within the statements and the examination features were then rated for inclusion in the list. A priori, consensus was considered to have been gained when > 80% of participants agreed on inclusion of an examination feature and following a third round of rating consensus was achieved.

Results Eighty examination items were included in the list by participants, following three rounds of the Delphi technique. Fifty items were from the history and thirty items from the physical examination. Items included were from the biomedical, psychological and social domains.

Conclusion This study provides valuable insight into the items of the clinical examination considered important in the discrimination of sub-groups of NSLBP by UK physiotherapists.

To define the natural history of bone loss around a femoral prosthesis, the bone mineral content and bone mineral density were measured for each femur in 28 patients with unilateral total hip arthroplasty, 18 age-matched controls, and seven patients with unilateral osteoarthritis. The areas measured were inside the lesser trochanter and 4.8 cm distal to it. The contralateral hip served as the control. Three years after arthroplasty there was 40% loss in average bone mineral content inside the lesser trochanter, and 28% loss in average bone mineral content 4.8 cm distally in the medial cortex. At seven to 14 years after operation, patients had lost 40% of bone proximally and 49% distally. The data suggest that this may progress in a proximal-to-distal fashion, and could account for a 50% decrease in bone mass seven to 14 years after surgery.