In arthritis of the varus knee, a high tibial osteotomy (HTO) redistributes load from the diseased medial compartment to the unaffected lateral compartment.

We report the outcome of 36 patients (33 men and three women) with 42 varus, arthritic knees who underwent HTO and dynamic correction using a Garches external fixator until they felt that normal alignment had been restored. The mean age of the patients was 54.11 years (34 to 68). Normal alignment was achieved at a mean 5.5 weeks (3 to 10) post-operatively. Radiographs, gait analysis and visual analogue scores for pain were measured pre- and post-operatively, at one year and at medium-term follow-up (mean six years; 2 to 10). Failure was defined as conversion to knee arthroplasty.

Pre-operative gait analysis divided the 42 knees into two equal groups with high (17 patients) or low (19 patients) adductor moments. After correction, a statistically significant (p < 0.001, t-test,) change in adductor moment was achieved and maintained in both groups, with a rate of failure of three knees (7.1%), and 89% (95% confidence interval (CI) 84.9 to 94.7) survivorship at medium-term follow-up.

At final follow-up, after a mean of 15.9 years (12 to 20), there was a survivorship of 59% (95% CI 59.6 to 68.9) irrespective of adductor moment group, with a mean time to conversion to knee arthroplasty of 9.5 years (3 to 18; 95% confidence interval ± 2.5).

HTO remains a useful option in the medium-term for the treatment of medial compartment osteoarthritis of the knee but does not last in the long-term.

Cite this article: Bone Joint J 2016;98-B:601–7.

Introduction

Elective Orthopaedics has been targeted by the UK Department of Health as a maximum six-month waiting time for operations could not be met. The National Orthopaedic Project was initiated as a consequence and Independent Sector Treatment Centres (ISTCs) and well established private hospitals were utilised to treat NHS long wait patients.

Introduction

This study was to investigate the association of developmental dysplasia of the hip (DDH) and primary protrusion acetabuli (PPA) with Vitamin D receptor polymorphisms TaqI and FokI and oestrogen receptor polymorphisms Pvu II and XbaI.

Aim: To investigate and compare the effects of two types of LCS total knee arthroplasty on joint proprioception and range of motion.

Methods: 47 patients were randomised to receive either a LCS AP glide or Rotating platform prosthesis. Clinical scores (Oxford knee score, American knee society score, EuroQol), range of motion and proprioception were assessed prior to and at 3,6, and 12 months after the operation. Proprioception was assessed in terms of absolute error angle (mean difference between the target angle and the response angle). Knee angles were measured in degrees using an electromagnetic tracking device, Polhemus 3Space Fastrak that detected positions of sensors placed on the test limb. Student’s t-test was used to compare the mean of two groups (with a level of significance of p < 0.05).

Results: Both groups were comparable in terms of pre-operative range of motion, oxford knee score, American knee society score, EuroQol score and proprioception. There was statistically significant improvement in the Oxford knee score, AKSS and EuroQol score in both groups (p< 0.001), but there was no difference between the groups with respect to these parameters. There was improvement in the proprioception (reduction in absolute error angle) in both groups though this was not significant statistically (p> 0.05).

Conclusions: We did not find significant difference between AP glide and RP LCS knee arthroplasty in terms of improvement in proprioception and range of motion.

We performed a prospective, randomised trial to evaluate the outcome after surgery of displaced, unstable fractures of the distal radius. A total of 280 consecutive patients were enrolled in a prospective database and 88 identified who met the inclusion criteria for surgery. They were randomised to receive either bridging external fixation with supplementary Kirschner-wire fixation or volar-locked plating with screws. Both groups were similar in terms of age, gender, hand dominance, fracture pattern, socio-economic status and medical co-morbidities.

Although the patients treated by volar plating had a statistically significant early improvement in the range of movement of the wrist, this advantage diminished with time and in absolute terms the difference in range of movement was clinically unimportant. Radiologically, there were no clinically significant differences in the reductions, although more patients with AO/OTA (Orthopaedic Trauma Association) type C fractures were allocated to the external fixation group. The function at one year was similar in the two groups.

No clear advantage could be demonstrated with either treatment but fewer re-operations were required in the external fixation group.

Introduction: Elective Orthopaedics has been targeted by the department of health in the U.K. as a maximum six-month waiting time for operations could not be met. National Orthopaedic project was initiated as a consequence and Independent Sector Treatment Centres (ISTC) and well established private hospitals were utilised to treat NHS long wait patients.

Materials and Methods: We audited the primary total hip replacements performed in our hospital in 1998 and 2003 to compare the differences in the patient characteristics in particular age, length of stay and ASA grade.

Results: The number of hip replacements increased to 308 in year 2003 from 194 in year 1998. Whilst, the number of ASA I patients were the same, the ASA II. III, IV increased by 40%, 260%, 266% respectively. The average length of stay decreased from 14.3 to 11.9 days which was statistically significant, in spite of increased numbers of ASA II – IV patients.

Discussion: The NHS hospitals are treating increasing number of patients who have a higher anaesthetic risk and are likely to stay longer in the hospital in the post-operative period. The case mix for primary total hip replacements in large tertiary referral hospitals have changed due to altered patient flow due to cherry picking of NHS waiting lists by the ISTC. NHS hospitals should be appropriately remunerated for dealing with complex cases and for managing complications referred by ISTC hospitals. In fact, the National joint registry’s 2^nd annual report confirms that 40% of primary total hip replacements operated in ISTC’s were ASA I while only 25% of primary total hip replacements operated in NHS hospitals were ASA I. None of the ISTC’s performed complex primary THRs.

Aim: To present and highlight a remote complication following deep x-ray radiotherapy to Ilium.

Background: Radiotherapy is one the options to treat malignancy. Surrounding normal tissue can be affected by super-imposed infection, radiation-induced tumors, and other complications of radiation therapy. Timing of radiation changes varies in the different organs. Acute radiation pneumonitis is generally seen approximately 2 months after completion of radiotherapy, but radiation pericarditis not until 6–9 months after therapy. Radiation-induced sarcomas do not develop on average until 10–15 years after radiation therapy.

Case report: A 39-year old presented to an oral surgeon 29 years ago with a submandibular swelling that was gradually increasing in size. Excision biopsy revealed Follicular, Large cell, Non-Hogdkin’s Lymphoma. Lymphogram showed positive nodes in pelvic and para-aoric regions. She was treated with chemotherapy initially. She developed left SI joint pain 2 years later and was treated with radiotherapy. The lymphoma later became chemotherapy resistant and the patient was treated with whole body irradiation. She was in remission since 26 years. She started having discomfort in the left hip region far past 5 years and was reviewed. A recent MRI scan revealed avascular necrosis of the femoral head with little collapse. Changes in the ilium and muscle wasting around the left iliac wing were noted, which were consistent with post radiation osteonecrosis.

This lady noticed a recent change in the gait and examination revealed positive trendelenberg test and a lurching gait. Latest radiographs have shown a fracture of the left iliac crest. The patient did not request any surgical intervention and was reassured with explanation.

Conclusion: Post radiation osteonecrosis can cause complications as late as 26 years following deep x-ray radiotherapy.

Aim: To investigate and compare the effects of two types of LCS total knee arthroplasty AP glide {(posterior cruciate is retained and the mobile bearing allows anteroposterior and well as rotational movement) and RP (in which posterior cruciate is sacrificed and the mobile bearing allows only rotational movement)} on joint proprioception and range of motion.

Methods: 30 patients scheduled to undergo mobile bearing total knee arthroplasty were randomised to receive either a LCS AP glide or Rotating platform prosthesis. Clinical scores (Oxford knee score, American knee society score (AKSS), EuroQol), range of motion and proprioception were assessed prior to and at three and six months after the operation. Proprioception was assessed in terms of absolute error angle (mean difference between the target angle and the response angle). Student’s t-test was used to compare the mean of two groups (with a level of significance of p < 0.05).

Results: Both groups were comparable in terms of pre-operative range of motion, oxford knee score, American knee society score, EuroQol score and proprioception. At 6 months there was significant improvement in the Oxford knee score, AKSS and EuroQol score in both groups (p< 0.001), but no difference was noted between the two groups with respect to these parameters. There was improvement in the proprioception (reduction in absolute error angle) in both groups though this was not significant statistically (p> 0.05). The mean active non-weight-bearing range of motion improved in both groups {AP glide group, (p< 0.05) and RP group, (p> 0.05)}

Conclusions: We did not find significant difference between AP glide and RP LCS knee arthroplasty in terms of improvement in proprioception and range of motion.

Objective- To review the 10-year results of 269, cemented total hip arthroplasties performed using matte surface finish Harvard femoral stem that is almost similar to Charnley femoral stem.

Design- Retrospective cross sectional survivorship study.

Patients and Methods- We retrospectively reviewed the results of 269 cemented total hip arthroplasties performed using Harvard femoral stem in 257 patients (M:F, 93:164. Mean age 71.2 years) between 1990–1994. We also reviewed a group of 51 patients who had hip arthroplasty performed on the contralateral side using cemented Charnley femoral stem. Radiographs were reviewed to evaluate following parameters: type of osteoarthritis, cement mantle thickness, alignment of the components, presence of aseptic loosening and radiolucent lines. Kaplan-Meier survival analysis was performed to calculate the survival of Harvard and Charnley femoral stem using various end points. Cox proportional-hazard analysis was performed to evaluate the impact of various radiological parameters on the prosthesis survival.

Results- Out of the 248 eligible patients (260 hips), 6 patients (7 hips) were lost to follow up and 67 patients were dead at the time of the study. 36 hips (35 patients) underwent revision surgery for aseptic failure (Median duration: 60 months, range: 12–125 months) and 11 hips were revised for septic failure (Median duration: 24 months, range: 10–53 months) from the index procedure. Femoral component was revised in all patients whereas acetabular component was revised in 27 patients. 10 year survival for the femoral and acetabular components using aseptic loosening (with and without revision surgery) as an end point was 77.5% (71.5%-83.5%) and 91.1% (87.2%-95%) respectively. Cox regression analysis did not reveal statistically significant (p> 0.05) impact of various radiological parameters on survival rate.

The 10 year survival in the bilateral hip arthroplasty group for the Charnley femoral component (Median follow up 138 months) and Harvard femoral component (Median follow up 120 months) using aseptic loosening as an end point was 95.2% (92.4%-98%) and 77.2% (69.2%-85.2%) respectively.

Conclusion- Our results suggest that the matte surface finish femoral component has less satisfactory long-term survival rate compared to smooth surface femoral stem with similar geometry.

Objective- To evaluate three femoral cement pressurization techniques in a laboratory setting.

Design- Observational study using a plastic femur (sawbone) model.

Materials and Methods- 12 femoral bone models were cemented and pressurized using three different cement pressurization techniques (standard technique, pressuriser in situ technique, and thumb pressurisation technique). Four sets of observations were taken for each technique. Intramedullary pressure readings were obtained using proximal and distal pressure monitoring transducers. The peak pressure and the time for which the pressure was above a particular cut off level (5 KPa and 100 KPa) were compared.

Results- There were significant variations between the peak pressure and the duration for which the pressure was above 100 KPa. The pressuriser in situ technique yielded significantly (p< 0.001) higher peak pressure both proximally (397.5 ± 40.2 KPa) and distally (597.3 ± 102.4). The standard technique produced the optimum pressure of 100 KPa for significantly (p< 0.001) longer duration proximally and distally (66.8 ± 29.5 and 45.2 ± 15.5 seconds respectively) compared to the other two techniques (less than 5 and 17 seconds for thumb pressurisation technique and pressuriser in situ technique respectively, both proximally and distally). There were no significant statistical differences between the three methods for the time for which the cement pressure was higher than 5 KPa.

Conclusion- Although the pressuriser in situ technique produced highest peak pressure, the standard technique produced optimum pressure for longer duration. The standard technique seems to be adequate to achieve optimum pressurization during femoral cementing without increased risk of embolisation.

Introduction: Peri-acetabular rotational osteotomy is recognized as the non-arthroplastic treatment for Developmental Dysplasia of the Hip (DDH). This procedure has increased in popularity during the last decade. It aims to restore the acetabular cover over the femoral head and thus delay secondary osteoarthritic changes in the hip.

Materials and methods: We reviewed 16 patients who underwent peri-acetabular rotational surgery at our hospital. The indication for surgery was DDH in all cases. Reinert’s approach was used for surgical exposure. Two patients underwent a valgus femoral osteotomy at the same time. Mean age was 40 years (range 15–49). The mean follow-up was 46.5 months (range 4–108). The results of the surgery were assessed with radiological indices and a patient satisfaction survey. The radiological indices recorded were Wiberg’s angle, acetabular inclination angle, femoral head extrusion index and Tonnis osteoarthritis grading.

Results: The intervention failed to benefit two patients who subsequently required a total hip arthroplasty. Both patients had Tonnis grade 3 osteoarthritis. One patient developed a necrotic skin flap requiring skin grafting. The mean pre-operative Wiberg’s angle was 11 degrees (range −7 to 25) which was corrected to 35 degrees (range 17 to 58). Mean pre-operative acetabular index was 25 degrees (range 14 to 40) which was corrected to 11 degrees (range of 2 to 21). Mean pre-operative femoral head extrusion index was 37 degrees (range 18–50) which was reduced to 14 degrees (range 0–32). In all but the two patients in whom the surgery had failed, patients reported reduction in hip pain.

Conclusions: Peri-acetabular rotational osteotomy is a challenging but worthwhile procedure for young patients with DDH. The early results from the procedure are encouraging providing patient selection is appropriate. We would like to initiate a debate to identify the ideal patient for this procedure.

Residual pain after total hip due to a number of causes both local to and replacement may be distant from the hip. We describe pain related to the psoas muscle after total hip replacement in nine patients. All presented with characteristic symptoms. We describe the key features and management. Gratifying results were achieved with treatment. This diagnosis should be considered when assessing patients with pain after total hip replacement.

We compared the mechanical properties of carbon fibre composite bone plates with those of stainless steel and titanium. The composite plates have less stiffness with good fatigue properties. Tissue culture and small animal implantation confirmed the biocompatibility of the material. We also present a preliminary report on the use of the carbon fibre composite plates in 40 forearm fractures. All fractures united, 67% of them showing radiological remodelling within six months. There were no refractures or mechanical failures, but five fractures showed an unexpected reaction; this is discussed.

Shelf operations performed on 24 patients (27 hips) for late presentation of congenital hip dysplasia were evaluated. The mean age at operation was 14 years 9 months and the mean follow-up 16 years 8 months. Two-thirds of the hips had good clinical results at follow-up. Patients operated on under the age of 20 years and with little or no radiological evidence of degenerative joint changes had the highest likelihood of success. The shelf operation was found to provide good cover of the femoral head and, should failure occur, also provides adequate superior support for the seating of an acetabular prosthesis.

Three patients referred for rehabilitation of brachial plexus lesions and two referred with leg weakness associated with sciatica were found to have conversion paralysis. The diagnosis was made by demonstrating normal motor nerve conduction to the clinically weak muscles. The weakness was treated by intensive physical rehabilitation with complete and sustained recovery in all cases.