At first-stage revision surgery for infection of total knee arthroplasties, antibiotic-impregnated cement spacers are frequently implanted. Two types of cement spacers are commonly used, “static” and “articulating” cement spacers. Advocates of cement spacers state that they deliver high doses of antibiotics locally, increase patient comfort, allow mobility and provide joint stability. They also minimize contracture of collateral ligaments, thereby facilitating re-implantation of a definitive prosthesis at a later stage. The use of these cement spacers, however, are not without significant complications, including patella tendon injuries.

We describe a series of three patients who sustained patella tendon injuries in infected total knee arthroplasties following the use of a static cement spacer at first-stage knee revision.

The patella tendon injuries resulted in significant compromise to wound healing and knee stability requiring multiple surgeries. The mid-term function was poor with an Oxford score at 24 months ranging from 12–20

Based on our experience, we advise caution in the use of static cement spacer blocks. If they are to be used, we recommend that they should be keyed in the bone to prevent patella tendon injuries.

Electronic PROMs have many potential uses in orthopaedic practice. The primary objective of this three-phase pilot study was to measure uptake using a web-based ePROM system following the introduction of two separate process improvements.

80 consecutive new elective orthopaedic patients in a single surgeon's practice were recruited. Group 1 (n=26) received a reminder letter, Group 2 (n=31) also received a SMS message via mobile or home telephone and Group 3 (n=23) also had access to Tablet Computer in clinic.

Overall 79% of patients had Internet access. 35% of Group 1, 55% of Group 2 and 74% of Group 3 recorded an ePROM score (p=0.02). There was no significant age difference between groups. In Group 3, 94% of patients listed for an operation completed an ePROM score (p=0.006).

Collecting PROM data effectively in everyday clinical practice is challenging. Electronic collection should improve healthcare delivery, but is in its infancy. This pilot study shows that the combination of SMS reminder and access to Tablet Computer within clinic setting enabled 94% of patients listed for an operation to complete a score on a clinical outcomes web-based system. Further process improvements, such as additional staff training and telephone call reminders, may further improve uptake.

Introduction: Adult acquired flatfoot is a common cause of foot pain. The majority of series describe surgery although important non-surgical series exist. This series of 166 patients gives an overview of the clinical spectrum of the condition and outcomes.

Materials and Methods: Data was collected prospectively on 166 consecutive patients with adult acquired flatfoot between 1995 and 2005. 104 patients were reviewed at a median of eight years (range 3–13). A standardised clinical examination, AOFAS hindfoot and visual analogue satisfaction scores were performed.

Results: There were 40 men (median age 56 years) and 126 women (median age 60 years). 68% had other musculoskeletal problems. Patients were Truro staged at presentation; Stage 1: 26 patients. Stage 2A: 84 patients. Stage 2B: 25 patients. Stage 2C: 23 patients. Stage 3: 6 patients. Stage 4: 2 patients.

Stage 1 patients were younger (p< 0.001). 133 patients had soft-tissue symptoms, but 33 had degenerative problems. Degenerative patients had a higher median age (p=0.0138) and stiffer deformities (p< 0.0001). Most patients (131, 78.9%) were managed conservatively. Surgery was commoner in the arthritic group (p=0.001).

Fifty-two conservatively treated feet were clinically reassessed. In 31 (59%) patients the Truro stage had not changed, 11 (21%) had improved and 10 (20%) had deteriorated. Twenty percent of patients treated with orthoses stopped using them after 18 to 24 months. In non-surgically treated patients, the median AOFAS score was 73/100 and satisfaction score 71/100. In surgically treated patients the median AOFAS score was 74/100 and satisfaction score 83/100.

Discussion: There is a young group of patients with adult acquired flatfoot, with soft tissue symptoms but no progressive deformity. There is a large group with a flexible deformity who can mostly be treated with orthoses, and an older group with stiffer, arthritic deformities who are more likely to need surgery.

Conclusion: Final outcomes and satisfaction were similar in surgically and non-surgically treated patients.

Purpose: Recently an orthopedic manufacturer has introduced a gender specific knee design implying that there is a substantial anatomical difference between the genders. If such concept is true then TKA prosthesis implanted in the female population over the last decades, by definition, must have suboptimal outcome when compared to the male patients. The purpose of this study was to examine the functional outcome, the incidence of complications, and the need for revision between the two genders receiving the same knee design.

Method: The study selected a matched group of 150 men and 250 women undergoing TKA at our instituion. The patients were matched for age, BMI, pre-op diagnosis, comorbidities, race, mode of fixation, and the type of implant. Other demographic, surgical, and medical factors between the two genders were similar. Both pre-op and post-op functional scores were compared between the two groups. Pre-op and post-op radiographic images were assessed for implant fit.

Results: There was a significant improvement in functional outcome as measured by Knee Society score, WOMAC, and SF-36 for all patients. The improvement in functional outcome was not different between the two groups. The incidence of complications, reoperations, and need for revision between the two genders was also not significantly different.

Conclusion: Total knee arthroplasty continues to be an effective surgical procedure. Both genders appear to enjoy relief of pain and improvement of function equally. Based on this retrospective study the use of non-gender specific knee prosthesis did not seem to result in suboptimal outcome in female patients. There appears to be little merit in introduction of gender specific knee designs when previous non-gender specific prosthesis appeared to function well in both genders.

Previous studies of adult acquired flatfoot have reported the results of treatment. No study has described the clinical characteristics of a consecutive series.

In a ten-year period we managed 166 patients with adult acquired flatfoot. Forty were male and 126 female The median age of the men was 56 years and of the women 60 years (p=0.149). Twenty-eight had bilateral problems and 78% had gastrocnemius/soleus tightness.

We used the Truro classification. There were 26 stage 1 patients, with a median age of 45 years. Eight were male and 18 female. Eight had features of enthesopathy but rheumatological investigations were negative. There were 84 stage 2 patients, with a median age of 61 years; 23 were male and 61 female. Twenty-five patients were stage 3, with a median age of 59 years; 5 were male and 20 female. 23 patients were in stage 4, with a median age of 67 years; 4 were male and 19 female. Six patients were stage 5, with a median age of 67.5 years; all were female. There were two patients in stage 6, aged 81 and 85 years, both female. The stage 1 patients were significantly younger than the others (p< 0.001); there were no other significant differences in ages or sex ratios.

Most patients had predominantly soft-tissue problems. However, we identified 33 whose problems related mainly to osteoarthritis. These patients had a higher median age (62.5 years versus 58 years, p=0.0138) and stiffer deformities (p< 0.0001).

Most patients (131, 78.9%) were managed solely with orthotics, shoe adaptations and physiotherapy. Thirty-five patients were offered surgery. Twenty-eight procedures were performed on 23 patients. Surgery was commoner in the arthritic group (15/33 offered surgery versus 20/133, p=0.001).

The purpose of the study is to assess changes in cortical activity in chronic low back pain patients with and without illness behaviour.

Introduction: It is well recognised that patients with chronic low back pain (CLBP) may have major psychological factors which affect their level of disability. Abnormal patterns of illness behaviour have been described ¹.

Methodology: 30 patients with CLBP of more than six months duration were recruited. Patients with radicular pain or previous surgery were excluded. Two groups were created dependant on the presence of Waddell signs. “Copers” (n=16) showed 0 or 1 Waddell signs. “Non-copers” (n=14) showed 4 or 5 Waddell signs.

After informed consent, all subjects underwent fMRI scanning. Experimental pain was induced by thermal stimulation of the right hand. Straight leg raising (SLR) was performed following visual clues indicating that a leg raise was either definitely, possibly or not going to occur. Finally, clinical LBP was simulated by direct vibrotactile stimulation of the lumbar spine to a VAS threshold of 7/10.

The individual fMRI scans were independently referenced to anatomical markers and corrected for motion. Inter group analysis was performed using cluster-corrected thresholds of p< 0.05.

Results: During experimental pain stimulation, Non-copers showed significantly increased cortical activity as compared to Copers. Similar findings were evident when SLR was anticipated. The areas of increased cortical activity were primarily regions known to be involved in affective pain interpretation suggesting heightened activity.

When clinical LBP was simulated, the outcome was strikingly different with the Copers showing increased cortical activity particularly in the dorsolateral prefron-tal cortex and regions associated with cognitive pain processing and inhibition of subcortical pain pathways.

Discussion: This study shows that in patients with CLBP and illness behaviour cortical pain processing is abnormal. The findings suggest that possibly the abnormal behaviour shown by such patients may be due to failure of cognitive inhibitory pain pathways. It is possible that these abnormalities might respond to either pharmacological or psychological treatment.

Primary care trusts (PCTs) are encouraged to create musculoskeletal services to improve access and reduce pressure on orthopaedic clinics. Previous reports have suggested problems can arise.

A PCT with a population of 100,000 launched a musculoskeletal service in July 2004. The foot and ankle component was in partnership with the local secondary care foot team. Treatment and referral guidelines were agreed. The PCT staff reviewed GP referrals to orthopaedic clinics. They could forward letters to the acute trust orthopaedic department or initially treat the patients in primary care.

We audited referrals from October-December 2004, allowing 3 months to establish the service and 6 months follow-up.

617 orthopaedic referrals were received, including 123 (19.9%) adult foot and ankle problems. 82 patients were treated initially in primary care: 54 by the podiatrist, 20 by the physiotherapist and 8 by the specialist GP. Commonest problems were metatarsalgia (12), hallux valgus (10), Achilles tendonopathy (9), plantar heel pain (9), generalised foot pain (8) and arthritis (6). The commonest intervention was attendance at a physiotherapy programme (26) followed by advice (22), usually about shoewear, insoles (14) and injections (8). Ten patients were referred to secondary care after initial treatment in the community, all in accordance with guidelines; four were listed for surgery. Four patients failed to attend and information was missing on six.

31 referrals were sent directly to secondary care, 29 of which were according to guidelines. 9 were offered surgery, 9 had other specialist care, 6 required services which could not be accessed directly by the PCT team and 3 failed to attend.

Primary and secondary care can work together successfully to deliver services for patients with foot and ankle problems, though waiting time remains a challenge.

As part of a 10 year follow-up study investigating the relationship between MRI-diagnosed disc disease and low back pain (LBP), a comparison of MRI image acquisition protocols was conducted. The aim was to establish whether the modern protocol produced improved diagnoses of lumbar disc disease. This is of significance when attempting to determine links between lumbar disc disease and LBP. The proposed hypothesis was that little difference in the pathology reported of MRI lumbar spines between the surface coil acquired images (Coil-MRI) and phased-array acquired images (Phased-MRI) would be found.

Methods: Local ethics committee approval was granted for this study. 31 male subjects (aged 35–71 years) were recruited and underwent two subsequent scans. For both Coil-MRI and Phased-MRI scans sagittal dual echo, T1, axial T1 and T2 images were acquired. A Consultant Radiologist blindly reviewed the 62 scans continuously and reported on the pathology. Disease pathology assessment consisted of disc degeneration, disc herniation (based on 5-grade classification systems), facet hypertrophy (FH) and nerve root compression (NRC).

Results: A wide range of pathology was reported at all disc levels, particularly with regard to disc degeneration and herniation. Kappa agreement statistics were computed for each pathological feature at all disc levels. Disc degeneration and herniation reports were statistically consistent for all disc levels (kappa range: 0.6–0.8, p< 0.05 for degeneration & 0.5–0.7, p< 0.05 for herniation). The results show that at the L4/L5 disc level, 1 in 10 discs were reported as ‘moderately degenerate’ (an increase of 1 grade) in Phased-MRI scans. At the same disc level, 1 in 6 discs were reported as ‘moderately herniated’ in Phased-MRI scans compared to ‘bulging’ in Coil-MRI scans, indicating that Phased-MRI coil scans may improve clarity in particular for herniation diagnosis. Pathology for FH and NRC were limited, with the majority of subjects (over 91% for FH and NRC irrespective of protocol) presenting with normal features.

Conclusion: The statistical results indicate that few differences in pathological diagnosis of lumbar disc disease occurred, however Phased-MRI appears to increase confidence in diagnosing more severe features at some disc levels.

Adult polytrauma patients are at high risk of developing acute lung injury. Fat embolism or traumatic pulmonary contusions are the usual causes and respiratory support is often indicated. Conventional treatment with intubation and positive pressure ventilation is sufficient for most patients with moderate lung injury. However, for patients with acute severe respiratory failure who remain hypoxic despite maximal pressure ventilation, the mortality rate exceeds 60%.

We have reviewed the use of extracorporeal membrane oxygenation (ECMO) in adult trauma patients with acute severe respiratory failure. ECMO was performed at a tertiary unit in an intensive care setting. Using an external oxygenation circuit the injured lungs were “rested” until pulmonary function recovered. With this method ventilation pressures could be reduced and ventilator-related pulmonary barotrauma was limited.

Between 1992 and 2000, 28 adult trauma patients were referred for ECMO. This group of patients were at the severe end of the ARDS spectrum with an average Murray Lung Injury score of 3.2. The most common injuries included long bone or pelvic fractures, and blunt chest trauma. Over 50% of patients with long bone fractures treated with ECMO had developed respiratory failure following internal fixation.

Overall survival was 71.4%. Statistical analysis demonstrated that outcome was not related to age, injury severity score, ECMO duration or the degree of lung injury as classified by the Murray scoring system. Mortality was usually a consequence of trauma-related sepsis or cardiogenic failure. Although the study group is small due to the relatively small number of referral, we believe that ECMO may confer a survival advantage. Since orthopaedic surgeons often play a pivotal role in the management of the patient with multiple injuries and are also increasingly involved in their intensive care therapy, we feel an awareness of this technique could offer benefit to a predominantly young healthy population.