Purpose: In slipped capital femoral epiphysis (SCFE) with increasing slip angle and increasing impingement, pain, stiffness, limping and degenerative change may follow. Currently there are no accepted guidelines to guide management in patients with stable SCFE. The main purpose of this study was to evaluate the proximal femoral geometry in stable SCFE using a postero-anterior radiograph of the hip in the extended position and to determine its use in predicting subsequent surgical management.

Methods: Over a 7 year period, we evaluated the proximal femoral geometry in a consecutive series of 31 adolescents with stable SCFE using the prone extension hip radiograph and statistically analysed the relationship between lateral slip angle (LSA), the morphology of the metaphyseal-epiphyseal (ME) junction, pain and hip range of motion.

Results: The mean age was 13.5 years and statistical analysis shows that ME anatomy is strongly related to LSA and pain. Linear regression analysis shows a strong significant relationship between LSA and hip range of movements.

Conclusions: The prone extension hip x-ray, is capable of accurately predicting the response to a flexion valgus intertrochanteric osteotomy and will clearly demonstrate the degrees of flexion and valgus required to restore the proximal femoral anatomy to allow a more functional range of motion by reducing impingement. The prone extension hip x-ray will also indicate when an additional cheilectomy may be required or alternatively define degrees of proximal femoral deformity which are beyond the scope of intertrochanteric osteotomy and in which a more radical correction at the epiphyseal-metaphyseal junction is required.

Significance: We found the prone extension hip radiograph useful in selecting those hips amenable to management by flexion valgus intertrochanteric osteotomy and other surgical Methods:

Introduction: Microfracture is found to be effective for isolated chondral defect of knee in young adults however controversy exists over the relevance of microfracture treatment in degenerative knee. The purpose of the study is to assess the outcome and patient satisfaction with the arthroscopic microfracture of osteoarthritic knee.

Materials: We collected the demographic details of the patient, weight, procedure and follow up details from June 2000 to Dec 2002. We reviewed the case notes retrospectively and assessed the patient satisfaction with Oxford knee score and Lysholm score.

Results: There were total of 194 patients but only 76 patients returned the questionnaire. The average patient age was 57 years (range: 27–87 years) with majority of the patients being male patients (43 patients). The average weight of the patient was 82 kg (44–119) and the mean duration of operation was 28 minutes. The patients were evaluated at an average follow-up of 51 months (range: 36–66 months). The average Lysholm score was 49 (4–100) with mean oxford score of 32.5(13–56).

21 patients required knee replacement at an average of 24 months (range: 6–48 months) from the initial microfracture. 17 out of 21 patients had kissing lesion and all showed grade 4 degenerative changes

Discussion: Age and weight does not appear to have any effect on microfracture treatment however more number of female patients seem to have more kissing lesion and poor result. With shorter duration of operation and proper explanation to patient give short term symptomatic relief before replacement surgery. It is worth considering this treatment for isolated grade 4 lesion or less than grade 4 degenerative chondral lesions in appropriately selected patients.

Background and Aim: Developmental dysplasia of the hips covers a wide spectrum of hips scenario ranging from mild subluxation to frank dislocation. Sonographic examination has been a widely accepted method of screening and monitoring treatment. Graf IIa+ hips are believed to indicate physiological immaturity with alpha angles appropriate for age and are expected to develop normally without any treatment. The aim of this study was to assess the final outcome of sonographically proven Graf IIa+ hips and to identify any factors which may influence the progression of dysplasia in this group of children.

Materials and methods: Over a six year period, 19,170 new born babies were assessed for DDH. 393 infants with high risk factors and clinical abnormality of the hips underwent ultrasound examination. The scans were performed and reported according to Graf Technique. Pavlik harness treatment was instituted as indicated. Seventy four hips in 44 children were classified as Graf IIa+. Patients who had the hips scans before four weeks and those with incomplete medical records were excluded. All children had regular follow-up with a pelvic x-ray. Acetabular Index (AI), Reimers Index (RI) and Centre edge (CE) angle was measured. All children were followed up until their hips were clinically or radiologically satisfactory. The results were analysed using SPSS software.

Results: Thirty six children with 60 Graf IIa+ hips were eligible for this study. There were 28 girls with 46 hips and eight boys with 14 hips (Girls: Boys = 3.5:1). 29 Left hip and 31 right hip were involved. At a mean follow up of 13 months (range 6 – 41months), the AI was normal in 62%, mildly dysplastic in 30% and severly dysplastic in 8% of the hips. The Reimers Index was normal in 73%, sub-optimal in 24% and subluxated in 3% of the hips. The CE angle was normal in 65%, mildly pathological in 23% and moderately pathological in 12% of the hips. Limitation of abduction after 48hrs of birth appeared to have a direct effect on the development of dysplasia (p=0.02)

Conclusion: From our study, we believe that hips with Graf IIa+ scans are not as benign as they were thought to be. When associated with limited abduction after 48 hours of birth, a high index of suspicion and a long term follow up may be prudent.

Background: Internal snapping often resolves with conservative treatment but persistent significant symptoms may require surgical treatment. Different approaches and treatments have been suggested in the literature with weakness of hip flexion, recurrence of symptoms and nerve injury following surgery. We describe a modified surgical approach for internal snapping of hip in adults with good results.

Methods: Patients who failed conservative treatment for internal snapping between September 02 to February 04 were included. All patients had x-rays of relevant hips; ultrasound and MRI were done when required to exclude other causes. Patients were operated in supine position. A skin crease incision was made just lateral to the ASIS. The psoas tendon was reached sub-periosteally along the internal iliac surface hooked into the wound and divided releasing its musculo-tendonous junction. The patients were allowed to mobilise as able in the postoperative period.

Results: There were 8 snapping hips (3 right, 3 left, 1 bilateral) in 7 patients (6 females, 1 male) with average age of 30 years (17–51 yrs). The mean follow was 11 months. The average duration of symptoms before operation was 4.5 years (range 2–10 years). Clicking was relieved in all patients. Two patients felt slight weakness of hip flexion. One patient had temporary neuropraxia of lateral cutaneous nerve of thigh.

Discussion: The diagnosis is made by ultrasound or examination for a palpable click. Surgical correction of snapping is considered after failure of conservative treatment. Different extra pelvic (medial and iliofemoral) and intrapelvic extraperitoneal approaches have been described with varying results. With our slightly modified intrapelvic and sub-periosteal approach through oblique inguinal incision in adults, psoas muscle release at musculo-tendonous junction seems safe and effective (all clicking resolved) method. This method could be used as an alternative surgical approach for treatment of internal snapping of hip in adults.

Introduction: Tantalum Monoblock Acetabular cup was designed to reduce backside wear and stimulate osseo-integration of cup with bone. The cup has peripheral fit to improve the initial stability and further stability and longevity depends on the osseointegration of cup with acetabulum. The revision cup was intended to give added stability with screws in case of defective rim or large acetabulum. The aim of this study is to assess the radiological outcome following tantalum monoblock revision cup in total hip replacement.

Methods: Between 1999 and 2000, 32 Tantalum mono-block revision acetabular cups was used in 31 patients. Standard hip radiographs were performed during post op, at three months, six months and then annually. X rays were assessed for loosening in De Lee and Charnley zones and for migration of cup.

Results: At a minimum follow-up of 2 years (range 2 to 5 years), 31 hips in 30 patients were assessed. The average age of the patient was 62.4 years (39–78 years). Three Brookers type 1 and one type 2 heterotrophic ossification was seen. There was a gap of 2–5mm in Zone 1(6 patients), 1–5mm in Zone 2 (8 Patients) and 5mm in Zone 3 of one patient. At final follow up, all the gaps were filled, except for one, where 5mm gap was persistent. There was no migration of cup or problems with screws. All the patients were satisfied with the operation.

Conclusion: Short term radiological result following uncemented revision tantalum monoblock acetabular cup in total hip replacement is highly encouraging. However, similar results from other centres and long term follow up studies are necessary to confirm the efficacy of the revision cups.

Aim: To analyze early clinical outcome and patients satisfaction following Oxford phase 3 Unicompartmental Knee arthroplasty at a mean follow up of 30 months from a single centre in the Trent arthroplasty register.

Methods: Between 1999 and 2002, 180 Oxford phase 3-unicompartmental knees were implanted in 173 patients. Average age at operation was 66 years. All patients were assessed pre and post-operatively using Oxford Knee questionnaire. At a mean follow up of 30 months (range 12–48 months); ninety knees in 83 patients were assessed using Oxford and EuroQol health questionnaire. Subjective patient’s satisfaction was also assessed.

Results: Seven knees out of 180 were revised early in the series giving a failure rate of 4%. Three patients had died due to unrelated causes. 90 knees were assessed at recent follow-up. The mean Oxford knee score improved from 48 preoperatively to 28 post-operatively. Subjectively 76% of the patients felt that the operation was successful and 74% were able to resume their leisure activities with out any pain.

Conclusion: This study shows that the short-term results following minimally invasive Oxford phase 3-unicompartmental knee implantation technique can yield satisfactory clinical and functional results. Using stringent selection criteria, Oxford phase 3-unicompartmental knee offers a good alternative to total knee arthroplasty.

The purpose of this prospective clinical study was to identify the true incidence, pattern, and location of the injury and nature of fracture following hand injuries in different paediatric age groups attending a hand unit. Three hundred and sixty children (237 boys and 123 girls) under 16 years of age who presented with hand injuries between 1st April 2000 and 30th September 2000 were included in the study. Bony injuries accounted for 65.5% (236 injuries), 33.3% (120 injuries) were soft tissue injuries. The projected annual incidence rate for skeletal injuries was 418/100,000 children/year. Incidence was low in toddlers (34/100,000), more than doubled in pre-school children (73/100,000) and steeply increased to around 20 fold after the 10th year (663/100,000). Girls had a higher incidence of hand injuries among toddlers and pre-school children. Crushing was the most common cause of hand injury (64%) and most injuries were sustained at home (45%). Toddlers sustained soft tissue injuries predominantly (86%) and older children sustained more bony injuries (77%). Sport was the cause of injures commonly in the older children. There was a higher incidence of fracture in little finger (52%) followed by the thumb (23%). The proximal phalanx was the most frequently fractured bone (67%) among the phalanges. Diaphyseal fractures (46%) were more common in the metacarpal and basal fractures (51%) were common in the phalanges. At discharge more than 80% of the patients felt that they were cured or significantly better. This paper highlights the changing pattern and the different varieties of hand injuries in different paediatric age groups.

Introduction and Aims: ‘External’ snapping hip, secondary to a tight thickened portion of the iliotibial band snapping over the greater trochanter is usually treated by Z-plasty. We report experience of managing painful paediatric snapping hips by a novel alternative, proximal TFL release.

Method: Patients referred between 1989–2002 with painful snapping hips to the paediatric orthopaedic unit were retrospectively reviewed. Diagnosis was made on the basis of history and physical examination. All the patients had a plain radiograph of the hip and other causes of an audible snap were excluded. Most cases had failed to improve with physiotherapy pre-operatively. Fifteen patients (21 hips) had proximal tensor fascia lata release. All the patients had regular follow-up and were assessed for recurrence and complications.

Results: There were two boys and thirteen girls. The mean age at the time of operation was 15 years and minimum post-operative follow-up was six months. Two hips required revision surgery. Eighty-one percent had a pain-free non-snapping hip at the time of discharge. The remainder were pain-free, with a reduced frequency of snapping.

Conclusion: For painful snapping hips when conservative methods have failed, proximal release can offer good results with low morbidity in a paediatric population.

Purpose: To audit the quality of the still images and documentation of arthroscopic surgery of the knee and to provide guidelines to optimize photographic records.

Methods and Results: The study was conducted in 4 parts

Questionnaire of surgeons views on photographic records: This showed that less than 50% of surgeons felt they could interpret their own photographs and only 25% felt other surgeons records were useful. 80% felt that single image photographs gave clearer information than 4 small images per sheet.

Conclusion: Poor picture labelling, inadequate pictures and documentation were found in the majority of the cases. New formulated guidelines led to an improvement in the accuracy and usefulness of recorded images.

This may lead to a reduction in the need for repeat arthroscopy when patients are referred for second opinions to specialist knee surgeons, thereby reducing costs and morbidity.

Aim: Prospective study to evaluate the results and the technique of 63 proximal femoral osteotomies in 39 cerebral palsy patients performed with the new Fixclipª biological internal þxator system. Methods: Thirty nine cerebral palsy patients with dislocated or painful subluxing hips, who underwent upper femoral osteotomy from 2 different centres in the last 7 years were included in the study. Results: The average age of patients at operation was 12.7 years (range 3 Ð 60 years). All the patients were followed up until union. Some had removal of the implant. Postoperative splintage was normally used when soft tissue procedures were performed along with femoral osteotomy. Three patients needed revision surgery for readjustment of the device and 2 patients had superþcial infections. All osteotomies healed by 12–16 weeks apart from one. There was no malunions, or avascular necrosis. One patient had a non-union that united after revision surgery. Conclusion: The Fixclips system is modular and easily adjustable. The system lies off the bone with minimal disturbance to the periosteal blood supply. Compared to other implants, Fixclips are biologically and mechanically very effective with low complications and well suited in cerebral palsy patients where rigid þxation can cause extensive loss of bone mass. This is the þrst study reporting the use of ÔFixclipsñ system for upper femoral osteotomy.

Aims: Prospective study to evaluate the radiological outcome of developmental dysplasia of the hips at 1 year, which were ultrasonographically abnormal at birth. Methods: Routine ultrasound screening for neonatal hip instability has been carried out in Coventry since June 1989. Of the 8007 babies born in Coventry during 1997,1998 and early 1999, 534(6.6%) babies were found to have early ultrasonographic abnormality. Inclusion criteria for our study were an early abnormal ultrasound examination in babies with no other risk factors. Pavlik harness treatment was started for babies with persistent abnormality. Results: 212 babies were available for follow up at 1year with X-ray for measurement. Study criteria matched 230 new born hips in 115 babies with average radiographic follow-up of 52 weeks (range 48Ð60weeks). Acetabular angle and the femoral head epiphysis were measured from the pelvic X-ray. The results were statistically analyzed and the F-value was calculated. Ultrasonic abnormality was common in female babies (83%: 17%) compared to male babies. The results in the severely abnormal group following treatment with Pavlik Harness were found to be the same as the mildly abnormal group. Conclusions: We hereby conclude that treatment of the severely abnormal group with Pavlik Harness has resulted in no statistically signiþcant radiological abnormality in the acetabular angle and the growth of the femoral head epiphysis at 1-year follow up.

Aims: Prospective study to evaluate the results of arthroscopic lateral release in patient’s with patella disorders, who failed conservative treatment. Patient’s symptoms, functional status, return to work and sports activity were assessed post-operatively. Methods: During 1997–1999, 52 arthoscopy and lateral release in 39 patients were reviewed by an independent observer. Questionnaires containing subjective pain evaluation, visual analogue pain scale (VAS), and disability at work and sports were used to assess pre and postoperatively. Results: 52 knees were evaluated at an average follow up of 30 months (range: 8–44 months). 37 (71%) of knees has Chondromalacia patella, 5 (10%) had anterior knee pain, 4(7.6%) knees had recurrent dislocation of patella and six (11.5%) knees had patellofemoral degenerative disease.39 (75%) of knees were pain free following surgery. The mean pain score improved from 7.7 pre-op to 3.4 post-op at follow up (P< 0.005). Seventy (70) percent had good to excellent results as per the Lysholm Knee score (P< 0.005). Subjectively 85% felt that the operation was worth while and 77% would have it again in similar circumstances. Two knees had mild superficial infection and 1(2%) patient had a DVT following the procedure. Conclusions: With appropriate patient selection and a good surgical technique arthroscopic lateral release proves to be a very good surgical procedure for patella disorders with minimal complication yielding good result with high patient satisfaction.

Aims: The new Fixclips are used with 0.8mm to 3.0mm diameter wires and screws to þx osteotomies and fractures. This study deals with the biomechanical properties of the þxclip system. Methods: The range of normally accepted screw tightness was established by using a torque screwdriver at surgery. The mechanical grip-strength over this torque range was measured using a Hounsþeld Tensometer in the laboratory. The þxation was simulated using Tufnol material and the effect of additional clips on the grip strength and the stability of the construct was assessed. Results: Pull out force depends on the wire size and varied linearly over the clinical range of screw torque (0.25 to 3Nm) with values from 50 N to 900 N. An additional clip increases the pull-out force upto 3000N and the adjusting the distance also affects the test results. The strength increased with the distance between the clips and a maximum was obtained at a distance of 4.5cms between the clips. Conclusions: The system is modular and is designed to lie slightly off the bone causing minimal damage to the underlying periosteum and hence less disturbance to blood supply. The system is cost effective, less time consuming and mechanically reliable and stable for the given clinical situations. It has signiþcant advantage over the existing methods of þxation especially in paediatric orthopaedic and trauma situations.

Aim: Many risk factors for DDH are well documented. This study was undertaken to investigate whether multiple pregnancy is a risk factor for developmental dysplasia of hips. Method: During a 10-year period from 1989 to 1998, 39826 newborn babies had their hips scanned. Of these, 1022 (2.6%) babies were non-singletons. Inclusion criteria for our study were all non-singletons, who had their hips scanned in the þrst week after birth. We analyzed the results of their hip scans and calculated the risk for developing DDH either alone or with other risk factor and other variables like the gender, mode of delivery, birthweight and the length of pregnancy. Results: Of the 1022 babies, 825 (80.7%) had their hips scanned in the þrst week. M: F: 49.6%: 50.4%. We had 397 sets of twins, 9 sets of triplets and 1 set of quadruplet. 78% of this group had a normal presentation. 21% (181) of these babies were breech. There was no family history associated with any of the multiple births. Ultrasound abnormality was seen in 30 hips (1.8%). 1 patient had Pavlik harness treatment for persistent ultrasound abnormality. No signiþcant correlation was seen in the gender or in the length of pregnancy. Conclusion: Though it is a general impression that the hips of the non-singletons are under high mechanical stress during pregnancy and would be expected to have a relatively high incidence of DDH, from our study it is evident that the risk is no greater than the normal singletons.

Aims: Prospective study to evaluate the radiological outcome of developmental dysplasia of the hips at 1 year in breech babies, whichwere ultrasonographically abnormal at birth. Methods: Routine ultrasound screening for neonatal hip instability has been carried out in Coventry since June 1989. Of the 16000 babies born in Coventry during 1995,1996,1997and1998, 759 (4.7%) were Breech born. Of these, 100(13%) babies had early ultrasonographic abnormality of the hips. Inclusion criteria for our study were an early abnormal ultrasound examination in breech babies with no other risk factors. Babies with family history of CDH were excluded. Pavlik harness treatment was started for babies with persistent abnormality. Results: Study criteria matched 56 new born hips in 46 breech babies with average radiographic follow-up of 52 weeks (range 48Ð60weeks). Acetabular angle and the femoral head epiphysis were measured from the pelvic X-ray. The results were statistically analyzed and the F-value was calculated. Ultrasonic abnormality was common in female babies (74%: 26%) compared to male babies. The results in the severely abnormal group following treatment with Pavlik Harness were found to be same as the mildly abnormal group. Conclusions: We hereby conclude that treatment of the severely abnormal group with Pavlik Harness has resulted in no statistically signiþcant radiological abnormality in the acetabular angle and the growth of the femoral head epiphysis at 1-year follow up in breech babies.

Aim: Assessment of the management of painful paediatric snapping hips by a novel alternative, ie. proximal TFL release.

Materials and Methods: A retrospective study was undertaken between 1989 – 2002, reviewing 15 patients (21 hips) who had had proximal tensor fascia lata release. Diagnosis was made on the basis of history and physical examination. All hips were X-rayed and other causes of an audible snap were excluded. Physiotherapy had been attempted in all cases and most had failed to improve pre-operatively. All cases were followed up for a minimum period of 6 months.

Results: There were 2 males and 13 females. The mean age of operation was 15 years. 2 hips required a revision procedure. 81% had a pain-free, non-snapping hip at the time of discharge. There was 1 case of numbness in the thigh secondary to damage to the lateral cutaneous nerve of the thigh. No cases had a long-term Trendelenberg limp.

Conclusion: It was felt that proximal release of the tensor fascia lata from the pelvis is a good operation for painful, snapping hips with an excellent result in 81%. This has a similar success rate to the Brignall & Stainsby procedure, ie. Z-plasty of the tensor fascialata.

To audit and assess the cost effectiveness and patient satisfaction of an orthopaedic pre-admission clinic.

A pre-admission clinic for patients undergoing elective orthopaedic surgery has been in use in our hospital for the past 3 years. We audited the activities of this clinic over a period of 1 year and also assessed the cost effectiveness and patient satisfaction over the study period. Over 1 year, 2391 patients were invited and 2167 (90. 63 %) attended the clinic.

Patients’ satisfaction was assessed using a multidimensional questionnaire which included information on time spent with patients by doctors and nurses and communication, facilities, patient involvement and overall quality of the clinic. Patient cancellation and deferring of surgery was also calculated. Cost of bed blocking due to cancellation following admission and cost of theatre time was also calculated.

During the 1 year period, the non-attendance rate was 9. 37 % (224 patients). The cancellation rate following admission was 3. 4% (75 patients). 270 patients (11. 3%) had their surgery postponed due to medical and social reasons. Of the 2167 patients, 1822 (84%) had their surgery performed as scheduled. Thirty percent of the patients were unaware that they would be seen by both doctors and nurses. All the patients were satisfied with time spent with them and the information given regarding the surgery. 90% of the attending patients rated the service as excellent to good. Based on average cost of one night stay and overnight bed blocking and theatre time, this clinic has saved over £200, 000 for the Trust. The pre-admission clinic for elective orthopaedic surgery is not only cost effective but also reduces the ward-based workload for the junior doctors.