Studies have shown that 10–30% patients do not achieve optimal function outcomes after total hip replacement (THR). High quality randomised controlled trials (RCTs) evaluating the clinical and cost-effectiveness of techniques to improve functional outcomes after THR are lacking. We performed this study to evaluate the feasibility of a RCT comparing patient-reported functional outcomes after hybrid or fully cemented THR (ISRCTN11097021).

Patients were recruited from two centres and randomised to receive either a fully cemented or hybrid THR. Data collection included Patient Reported Outcome Measures (PROMs), non-serious adverse events of special interest (AESI), serious adverse device effects (SADE) and NHS resource use. Qualitative interviews were undertaken to understand a) patient experiences of study processes and their reasons for taking part or not, and b) to understand surgeons’ perceptions of the study, factors affecting willingness to participate, and barriers to implementation of the future RCT findings.

The target of 40 patients were successfully recruited for the feasibility RCT; the ratio of successful recruitment to eligible patients was 0.61 across both sites. Treatment crossovers occurred in four patients, all related to bone quality. Four patients were withdrawn due to not undergoing surgery within the study window because of the pandemic. Follow-up was 100% and PROMs were completed by all patients at all time points. The feasibility of conducting a within-trial cost-utility analysis was demonstrated. Interviews were conducted with 27 patients and 16 surgeons. Patients and surgeons generally found the study procedures acceptable and workable. Some declined participation because they did not want treatment allocated at random, or because blinding was off-putting. Surgeons’ perceptions of equipoise varied, and implementation of findings from the future RCT would need to recognise the ‘craft’ nature of surgery and the issue of training.

We conclude that a full RCT with economic analysis will be both feasible and practicable, although mechanisms to safely implement potential changes to practice because of RCT findings may need consideration by the wider arthroplasty community.

The purpose of this study was to determine whether there have been changes in the complexity of femoral fragility fractures presenting to our Dunedin Orthopaedic Department, New Zealand, over a period of ten years.

Patients over the age of 60 presenting with femoral fragility fractures to Dunedin Hospital in 2009 −10 (335 fractures) were compared with respect to demographic data, incidence rates, fracture classification and treatment details to the period 2018-19 (311 fractures). Pathological and high velocity fractures were excluded.

The gender proportion and average age (83.1 vs 83.0 years) was unchanged. The overall incidence of femoral fractures in people over 60 years in our region fell by 27% (p<0.001). Intracapsular fractures (31 B1 and B2) fell by 29% (p=0.03) and stable trochanteric fractures by 56% (p<0.001). The incidence of unstable trochanteric fractures (31A2 and 31A3) increased by 84.5% from 3.5 to 6.4/10,000 over 60 years (p = 0.04). The proportion of trochanteric fractures treated with an intramedullary (IM) nail increased from 8% to 37% (p <0.001). Fewer intracapsular fractures were treated by internal fixation (p<0.001) and the rate of acute total hip joint replacements increased from 13 to 21% (p=0.07). The incidence of femoral shaft fractures did not change significantly with periprosthetic fractures comprising 70% in both cohorts.

While there has been little difference in the numbers there has been a decrease in the incidence of femoral fragility fractures likely due to the increasing use of bisphosphonates. However, the incidence of unstable trochanteric fractures is increasing. This has led to the increased use of IM nails which are increasingly used for stable fractures as well.

The increasing complexity of femoral fragility fractures is likely to have an impact on implant use, theatre time and cost.

Purpose

To perform an Interrater reliability study determining the agreement between an Orthopaedic team and a Radiology team on the MRI features of prolapsed uncontained cervical discs in Flexion-Distraction injuries of the cervical spine. This leads us to determine how many patients demonstrated evidence of a ‘dangerous’ disc: an uncontained disc herniating posteriorly that may be drawn into the spinal canal during closed reduction.

Systemic capillary leak syndrome, or the Clarkson syndrome, is an extremely rare condition in which increased capillary permeability results in a massive shift of fluid into the extravascular space. This is followed rapidly by hypotensive shock, haemoconcentration, and, potentially, substantial oedema of the limbs resulting in an acute compartment syndrome. It is important for orthopaedic surgeons to be aware of this syndrome as our medical colleagues, who initially care for these patients, are less familiar with the diagnosis and the need for emergency management of the associated compartment syndrome should it develop. There have been fewer than 100 cases of this entity reported.

This case report is the first to describe the subsequent development of a compartment syndrome in all four limbs. Clinical vigilance and continuous monitoring of intracompartmental pressure is necessary in these patients in order to help reduce limb-threatening complications.

Introduction: The aetiology of dystrophic disc calcification in adult humans is unknown but a well-described clinical disorder with hydroxyapatite as the single mineral phase. Comparable but age-related pathology in the sheep could serve as a model for the human disorder. The objective of this study was to investigate the mineral phase, its mechanisms of formation/association with degeneration in a naturally-occurring animal model of disc calcification.

Methods: Adult sheep lumbar intervertebral discs (n=134) from animals aged 6 (n=4), 8 (n=12) and 11 years (n=2) were evaluated using radiography, morphology, scanning and transmission electron microscopy, energy dispersive X-ray spectroscopy, X-ray powder diffraction, histology, immunohistology and proteoglycan analysis.

Results: Half of the 6 yr, 84% of the 8 yr and 86% of the 11 yr old discs had calcific deposits. These were not well delineated by plain radiography. They were either:

punctate deposits in the outer annulus,

Their maximal incidence was in the lower lumbar discs (L4/5-L6/7) with no calcification seen in the lumbosacral or lower thoracic discs. All deposits were hydroxyapatite with large crystallite sizes (800–1300 angstrom) compared to cortical bone (300–600 angstrom). No type X-collagen, osteopontin or osteonectin, were detected in calcific deposits although positive staining for bone sialoprotein was evident. Calcified discs had less proteoglycan of smaller hydrodynamic size than non-calcified discs.

Discussion: Disc calcification in ageing sheep is due to hydroxyapatite deposition. The variable but large crystal size, lack of protein markers indicate that this does not occur by an ordered endochondral ossification-like process. The decrease in disc proteoglycan content and size suggests an association between calcification and disc degeneration in ageing sheep. There are notable dissimilarities between hydroxyapatite deposition disorder in humans and sheep. No mechanistic explanation can be offered for the different spinal distributions, thoracic and upper lumbar in the former and lumbar in the latter; hydroxyapatite deposition disorder has occasionally been seen in the lumbar spines of four year old sheep during the course of other studies but not at an earlier age. Diffferences in spinal biomechanics may be implicated but hydroxyapatite deposition does not primarily affect the most or least mobile discs in either species. Neither can an explanation be offered for the apparent immunity of the ovine lumbosacral disc to calcification. However, it is known that proteoglycan turnover is faster at this spinal level than at more proximal lumbar discs. While we have been unable to elucidate the mechanism of hydroxyapatite deposition disorder in sheep, clearly it is different from that in normal osteogenesis. We contend this animal provides a useful, naturally-occurring model for investigation of the aetiology and pathogenesis of human hydroxyapatite deposition disorder, notwithstanding obvious differences between sheep and man.

Introduction: The Merino sheep breed has been used extensively for intervertebral disc research but it has not previously been documented that the breed displays a mild form of chondrodystrophy with disproportionate dwarfism. The ovine Merino intervertebral disc is similar to human and chondrodystrophic canine discs in structure, absence of notochordal cells in the adult structure, response to trauma, display of an age-dependant loss of proteoglycans and degenerative spinal pathology including Schmorl’s nodes. In contrast, non-chondrodystrophic breeds have a gelatinous nucleus pulposus, notochordal cells which may persist into adulthood and a low incidence of spinal disorders of discal origin thus are unsuitable as models of the human intervertebral disc.

Methods: Haematoxylin and Eosin, Toluidine blue stained and aggrecan and versican immunolocalised sections were examined by bright field and Nomarsky differential interference contrast microscopy.

Results: The ovine merino intervertebral disc undergoes an age-dependant chondroid transformation of the central nucleus pulposus with the appearance of cell nests of chondrocytic morphology within a hyaline cartilage-like matrix rich in aggrecan and type II collagen but deficient in versican and type I collagen. In contrast, the adjacent nucleus pulposus is a fibrocartilage rich in types I and II collagen, versican and aggrecan; the constituent cells are readily distinguished from the aforementioned cell clusters. The ovine femoral epiphyseal growth plate displays dysplastic changes with relatively short columns of flattened, columnar chondrocytes in the pre-hypertrophic region and a disorganised integration of the hypertrophic cells into metaphyseal endochondral bone in the distal growth plate.

Conclusions: These observations warrant the classification of the Australian merino as a chondrodystrophic breed. The Merino is a useful comparative animal model for the human intervertebral disc.

High complication rates and technical difficulties of intramedullary fixation in children with osteogenesis imperfecta have prompted the modification of existing rod systems. The Sheffield telescoping intramedullary rod system was introduced to reduce the complications. It has a T-piece which is permanently fixed to prevent its separation and is expanded to reduce the migration. This study analyses the outcome of this rod system over a 12-year period in two specialist centres.

Sixty rods were inserted in the lower limbs of 19 children with osteogenesis imperfecta. All children had multiple fractures of the bones before rod insertion. 39 rods were inserted into the femur, of which 3 were exchange and 4 revision procedures. 21 rods were inserted in the tibia. Eight children had intramedullary rodding of all the four lower limb long bones. The outcome was measured in terms of mobility status, incidence of refractures and rod-related complications.

Our series demonstrates that there is significant reduction in refractures and improvement in the mobility status in children with osteogenesis imperfecta following intramedullary fixation. The frequent complication of T-piece separation and the need for reoperation has been overcome with the Sheffield modification of rod design. But the extracortical and metaphyseal migration of the rod continues to be a problem and further improvement in the design is desirable.

Introduction Sequestered disc fragments in the achondroplastic dwarf are rare. They should be removed by an anterior approach because:

access to remove the fragment posteriorly is severely compromised by the condition.

Method The case is of a 30 year old achondroplastic dwarf with spontaneous sudden onset of myelopathy over three myotomes. An MRI scan revealed an L1-2 large disc herniation compressing the thecal sac in an already small canal.

Results The spinal decompression resulted in recovery from the paresis without creating the instability associated with a wide posterior exposure.

Discussion The thoraco-abdominal approach involves incision along the line of the rib two levels above the most proximal vertebral body to be visualized. The external oblique and internal oblique are incised in the line of the rib. The diaphragm is taken down from the costal cartilage to the crus posteriorly allowing access to the upper lumbar spine. The segmental vessels are identified and subperiosteal dissection carried out. The disc is excised and the adjacent posterolateral vertebral body extending toward the segmental vessels. The neural elements are decompressed and the spine is stabilized using the rib strut as graft in the space created by the vertebral resection with morselized graft into the intervertebral disc space.

Calcification of a thoracic intervertebral disc (IVD) with prolapse and root syndromes/spinal cord compression in humans are well-documented entities. The mineral phases have been identified. Similar pathology occurs very rarely in children. It is also seen in dogs, especially the short-legged, chondrodystrophoid (CD) breeds, which are prone to disc degeneration, and in older sheep. The latter exhibit some morphological CD features.

This study is based on radiological/histological/electron microscopic/x-ray diffraction studies of human operative specimens and post-mortem adult animal tissues

The transitional zone (TZ), the interface between the nucleus pulposus and the annulus fibrosus, is the area of the IVD most sensitive in children and adults to the events which lead to dystrophic calcification. The TZ is the “growth plate” of the IVD and the site of maximal proteoglycan and protein synthesis. Giant hydroxyapatite crystallites are the dominant mineral phase in the human (children and adults) and canine pathology. Nucleation occurs in degraded matrix.

The new observation of the type and distribution of calcification in the elderly ovine IVD suggests this animal is a suitable model for further research into the enigmatic phenomenon of so-called dystrophic IVD calcification.

Introduction The aim of this study was to assess trends in the circumstances of spinal cord injury in all codes of football played in Australia in 1997 to 2002, and to combine and contrast these findings with those of identical studies done covering earlier years (1960 to 1996).

Methods A retrospective review of all spinal cord injuries occurring in all codes of football 1997 to 2002, combining and contrasting the results with identical studies done covering the years 1960 to 1985 and 1986 to 1996. Every football player with a documented spinal cord injury admitted to one of the spinal cord injury units across Australia was included. Data was recorded by way of record and radiograph review, and patient interview.

Results Fifty-four footballers were admitted to the spinal injury units over the period. The average yearly frequency of injuries over the study period was higher than the period 1986 to 1996, and similar to the period 1977 to 1985. The annual incidence of injury was lower in every sport except soccer, although data still remains to be collected from Victoria which may affect the incidence pertaining to Australian Rules. Rugby League had the biggest decrease in incidence. Most notable was the absence of any scrum injuries in league, down from nine (24% of all league injuries) in the prior study. Scrums sustained at engagement remained a prevalent cause of injury in Union. They by far predominated over those in collapsed scrums, reversing the trend towards the latter noted in the prior study. One-third of scrum injuries were in adult front-rowers who had played between one and four games in the front-row in their careers. The incidence of schoolboy injuries overall decreased substantially. The tackle accounted for all League and 40% of Union injuries. Over 75% of known tackle injuries on the ball carrier involved two or more tacklers at once. A much smaller percentage of patients remain wheelchair dependent (30%) than in the last study, and nearly 15% returned to near normality.

Conclusions Spinal cord injuries remain a significant concern in football, particularly the rugby codes. While the incidence overall may have slightly decreased, attention is needed to enforcing scrummaging laws, particularly in adult rugby, and focusing on the gang tackle as a cause of increased injuries in League and Union. An adequate compensation scheme and a national registry also need realisation.

Recent years have seen a decided swing from the longstanding inpatient model of rehabilitation to an outpatient model for all branches of medicine in Australia. This swing has been largely cost-driven and is unlikely to change. This paper reports on the development of a paediatric spinal outreach team (ORT) in NSW. The ORT was formed in 1993 and consists of a nurse, physiotherapist, occupational therapist and a social worker. It functions in close collaboration with the two children’s hospitals in Sydney. Approximately 10–11 new cases of paraplegia/quadriplegia occur in children/adolescents (up to 18 years of age) in NSW each year. Their therapeutic needs change with growth, development and maturation. Families in regional NSW have special requirements and website information services (distance education) will play an important role for them in the future. Integration with an organisation which provides ancillary services is essential for a comprehensive, statewide program.

It is suggested that a comparable service would play an equally important role in other states. Case studies to demonstrate savings to be made with this type of service need to be done to secure recurrent government funding.

High complication rates and technical difficulties of intramedullary fixation in children with osteogenesis imperfecta has prompted the modification of existing rod systems. The Sheffield telescoping intramedullary road has T-piece which is permanently fixed and is expanded to reduce metaphyseal migration. This study analyses the outcome of this rod system over an 11 year period in two tertiary referral hospitals.

60 rods were inserted in the lower limbs of 19 children with osteogenesis imperfecta. All children had multiple fractures of the bones before rod insertion. 39 rods were inserted into femur, of which 3 were exchange and 4 revision procedures. 21 rods were inserted into tibia. Eight children had intramedullary rodding of both femur and tibia bilaterally. The outcome was measured in terms of incidence of refractures, mobility status, functional improvement and rod related complications.

Our series demonstrates that there is significant reduction in refractures and improvement in the functional status of children with osteogenesis imperfecta following intramedullary fixation. The frequent complication of T-piece separation and the need for re-operation has been overcome with Sheffield modification of rod design. But the incidence of the rod, particularly at the proximal end of femur remains high and further improvement in the design is desirable.

A review of 77 patients with traumatic central cord syndrome revealed that atypical variations are more common than the existing literature suggests and that these may be seen in a wide variety of acute injuries to the cervical spine. In general the outcome is good; a favourable prognosis on admission is suggested by good hand function, hyperpathia, Lhermitte's sign and normal perianal sensation. The study has highlighted the value of regular muscle charting and has cast doubt on previous neuroanatomical assumptions about the syndrome.

A case is reported of fracture of the pedicles of the axis vertebra in an infant. Non-operative management in a Minerva cast resulted in union and full recovery without complications.

Distraction fractures of the upper lumbar spine are most often associated with the wearing of seat-belts. Twenty patients with this spinal fracture were reviewed and half of them had intra-abdominal injuries. Eight patients required an exploratory laparotomy. Three distinct patterns of distraction fractures have been identified. Open reduction, local spinal fusion and Harrington instrumentation are recommended for unstable fractures and for those with neurological involvement. Four cases of non-union are included ln the series. Legislation for the compulsory wearing of seat-belts should encompass improvements in design and stricter criteria for installation.

Acute myelopathy is a rare complication of Scheuermann's disease. Three patients are reported where spinal cord compression occurred at the apex of a kyphos. All were male, aged 14, 18 and 20 years, and each had a profound neurological defect associated with a short, sharp kyphos in the low thoracic region. Each patient underwent anterior decompression and all made an almost full recovery. It is deduced that factors which may influence the onset of cord compression include the angle of kyphosis, the number of segments involved, the rate of change of the angle, local anatomical variations, trauma, and possible secondary impairment of the vasculature of the cord.

Twenty-three adults with fractures of the odontoid process are reviewed. Te possible reasons for the high rate of non-union in reported series are considered: these include the type of fracture, its displacement, the presence of a gap at the fracture site, imperfect reduction and inadequate immobilisation. Type 2 fractures (at the base of the odontoid process) are the commonest and also the most liable to nonunion. In their treatment, reduction is important; as seen in the lateral radiograph at least two-thirds of the fracture surfaces should be in contact. Skull traction is not advised and halo-cast fixation is the treatment of choice; with this method 87.5 per cent of recent odontoid fractures united.

One hundred and twenty-seven cases of intervertebral disc calcification in children, including 11 previously unreported cases, have been analysed. A distinction is made between symptomatic and asymptomatic patients, whose age, sex and spinal distributions of the calcifications have been shown to differ. Radiologically detectable protrusions and later resorption of the calcifications are common events in symptomatic children, but are unrecorded in asymptomatic children. The spinal distribution of paediatric calcifications is quite different to that of adult and canine calcifications of the nucleus pulposus.

Aneurysmal bone cysts are uncommon lesions, especially in the spine. Seventy-eight cases have been previously documented in the English literature and an additional fourteen cases are now reported. There is a definite predilection for the lumbar region and the neural arch is the part of the vertebra most commonly affected. It is recommended that treatment should consist of total excision or when this is not possible, curettage. Radiotherapy should be reserved for those few cases where operation is inadvisable.