We retrospectively reviewed 89 consecutive patients (45 men and 44 women) with a mean age at the time of injury of 58 years (18 to 97) who had undergone external fixation after sustaining a unilateral fracture of the distal humerus. Our objectives were to determine the incidence of heterotopic ossification (HO); identify risk factors associated with the development of HO; and characterise the location, severity and resultant functional impairment attributable to the presence of HO. . HO was identified in 37 elbows (42%), mostly around the humerus and along the course of the medial collateral ligament. HO was hazy immature in five elbows (13.5%), mature discrete in 20 (54%), extensive mature in 10 (27%), and complete bone bridges were present in two elbows (5.5%). Mild functional impairment occurred in eight patients, moderate in 27 and severe in two. HO was associated with less extension (p = 0.032) and less overall flexion-to-extension movement (p = 0.022); the flexion-to-extension arc was < 100º in 21 elbows (57%) with HO compared with 18 elbows (35%) without HO (p = 0.03). HO was removed surgically in seven elbows. . The development of HO was significantly associated with sustaining a head injury (p = 0.015), delayed internal fixation (p = 0.027), the method of fracture fixation (p = 0.039) and the use of bone graft or substitute (p = 0.02).HO continues to be a substantial complication after internal fixation for distal humerus fractures. Cite this article: Bone Joint J 2014;96-B:1681–7

Aims. Heterotopic ossification (HO) is a common complication after elbow trauma and can cause severe upper limb disability. Although multiple prognostic factors have been reported to be associated with the development of post-traumatic HO, no model has yet been able to combine these predictors more succinctly to convey prognostic information and medical measures to patients. Therefore, this study aimed to identify prognostic factors leading to the formation of HO after surgery for elbow trauma, and to establish and validate a nomogram to predict the probability of HO formation in such particular injuries. Methods. This multicentre case-control study comprised 200 patients with post-traumatic elbow HO and 229 patients who had elbow trauma but without HO formation between July 2019 and December 2020. Features possibly associated with HO formation were obtained. The least absolute shrinkage and selection operator regression model was used to optimize feature selection. Multivariable logistic regression analysis was applied to build the new nomogram: the Shanghai post-Traumatic Elbow Heterotopic Ossification Prediction model (STEHOP). STEHOP was validated by concordance index (C-index) and calibration plot. Internal validation was conducted using bootstrapping validation. Results. Male sex, obesity, open wound, dislocations, late definitive surgical treatment, and lack of use of non-steroidal anti-inflammatory drugs were identified as adverse predictors and incorporated to construct the STEHOP model. It displayed good discrimination with a C-index of 0.80 (95% confidence interval 0.75 to 0.84). A high C-index value of 0.77 could still be reached in the internal validation. The calibration plot showed good agreement between nomogram prediction and observed outcomes. Conclusion. The newly developed STEHOP model is a valid and convenient instrument to predict HO formation after surgery for elbow trauma. It could assist clinicians in counselling patients regarding treatment expectations and therapeutic choices. Cite this article: Bone Joint J 2022;104-B(8):963–971

Aims. Heterotopic ossification (HO) is a potentially devastating complication of the surgical treatment of a proximal humeral fracture. The literature on the rate and risk factors for the development of HO under these circumstances is lacking. The aim of this study was to determine the incidence and risk factors for the development of HO in these patients. Methods. A retrospective analysis of 170 patients who underwent operative treatment for a proximal humeral fracture between 2005 and 2016, in a single institution, was undertaken. The mean follow-up was 18.2 months (1.5 to 140). The presence of HO was identified on follow-up radiographs. Results. The incidence of HO was 15% (n = 26). Our multivariate model revealed that male sex (odds ratio (OR) 3.57, 95% confidence interval (CI) 1.30 to 9.80 compared to female) and dislocation as the initial injury (OR 5.01, 95% CI 1.31 to 19.22) were significantly associated with the formation of HO (p < 0.05) while no significant associations were seen for the age of the patient, the characteristics of the injury, or the type of operative treatment. Conclusion. This retrospective radiological study is the first to investigate the association between the method of surgical treatment for a proximal humeral fracture and the formation of HO postoperatively. We found that male sex and dislocation as the initial injury were risk factors for HO formation, whereas the method of surgical treatment, the age of the patient, and the pattern of the fracture were not predictive of HO formation. While additional studies are needed, these findings can help to identify those at an increased risk for HO formation under these circumstances. Cite this article: Bone Joint J 2020;102-B(4):539–544

Aims. In patients with a failed radial head arthroplasty (RHA), simple removal of the implant is an option. However, there is little information in the literature about the outcome of this procedure. The aim of this study was to review the mid-term clinical and radiological results, and the rate of complications and removal of the implant, in patients whose initial RHA was undertaken acutely for trauma involving the elbow. Methods. A total of 11 patients in whom removal of a RHA without reimplantation was undertaken as a revision procedure were reviewed at a mean follow-up of 8.4 years (6 to 11). The range of motion (ROM) and stability of the elbow were recorded. Pain was assessed using a visual analogue scale (VAS). The functional outcome was assessed using the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score (OES), and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). Radiological examination included the assessment of heterotopic ossification (HO), implant loosening, capitellar erosion, overlengthening, and osteoarthritis. Complications and the rate of further surgery were also recorded. Results. The indications for removal of the implant were stiffness in five patients, aseptic loosening in five, and pain attributed to the RHA in three. The mean time interval between RHA for trauma to removal was ten months (7 to 21). Preoperatively, three patients had overlengthening of the implant, three had capitellar erosion, six had HO, and four had radiological evidence of loosening. At the final follow-up, the mean the flexion-extension arc improved significantly by 38.2° (95% CI 20 to 59; p = 0.002) and the mean arc of prono-supination improved significantly by 20° (95% CI 0 to 72.5; p = 0.035). The mean pain VAS score improved significantly by 3.5 (95% CI 2 to 5.5; p = 0.004). The mean MEPS improved significantly by 27.5 (95% CI 17.5 to 42.5; p = 0.002). The mean OES improved significantly by 9 (95% CI 2.5 to 14; p = 0.012), and the mean DASH score improved significantly by 23.5 (95% CI 7.5 to 31.6; p = 0.012). Ten patients (91%) had HO and osteoarthritis. Two patients underwent further surgery due to stiffness and pain, respectively. Conclusion. Simple removal of the implant at revision surgery following a failed RHA introduced following trauma provides satisfactory mid-term results with an acceptable risk of complications. Osteoarthritis, instability, and radioulnar impingement were not problems in this series. Cite this article: Bone Joint J 2024;106-B(11):1327–1332

Aims. Heterotopic ossification (HO) occurs after arthroplasty, especially total hip arthroplasty. In this study we describe the incidence, evolution, morphology and clinical consequences of HO following reverse shoulder arthroplasty. Patients and Methods. This is a single-centre retrospective study of 132 consecutive patients who received a Delta III or Delta Xtend reverse total shoulder arthroplasty between 2006 and 2013 for the treatment of cuff tear arthropathy. There were 96 women and 36 men. Their mean age at the time of surgery was 69 years (49 to 89) and the mean follow-up was 36 months (12 to 84). The incidence, evolution, morphology and clinical consequences of HO using the Constant-Murley score (CS) were analysed. A modified Brooker classification of HO of the hip was used. Results. HO was seen in 39 patients (29.5%). A total of 31 of these patients (81.6%) began to develop HO by three months post-operatively. According to the Hamada classification, 11 patients had grade 1a, eight had grade 1b, six had grade 1c and 14 had grade 2 HO. The HO evolved over a mean of 8.3 months (3 to 21). Patients with HO had a lower mean CS at three (p = 0.017), six (p < 0.001) and 12 months (p < 0.001) post-operatively. HO was not associated with notching (p = 0.675). Conclusion. HO after reverse shoulder arthroplasty is a non-progressive condition without long-term clinical consequences. Only grade 2 HO is clinically relevant with a negative effect on the function of the shoulder during its development. Cite this article: Bone Joint J 2016;98-B:1215–21

Aims. The aim of this study was to assess the efficacy of non-selective and selective non-steroidal anti-inflammatory drugs (NSAIDs) in preventing heterotopic ossification (HO) after total hip arthroplasty (THA). Methods. A thorough and systematic literature search was conducted and 29 studies were found that met inclusion criteria. Data were extracted and statistical analysis was carried out generating forest plots. Results. Non-selective NSAIDs showed a significant decrease in the odds for forming HO after THA (odds ratio (OR) -1.35, confidence interval (CI) -1.83 to -0.86) when compared with placebo. Selective NSAIDs also showed a significant decrease in the odds for forming HO after THA when compared with placebo (OR -1.58, CI -2.41 to -0.75). When comparing non-selective NSAIDs with selective NSAIDs, there was no significant change in the odds for forming HO after THA (OR 0.22, CI -0.36 to 0.79). Conclusion. Our meta-analyses of all available data suggest that both non-selective and selective NSAIDs are effective HO prophylaxis and can be used routinely after THA for pain control as well as prevention of HO. Indomethacin may serve as the benchmark among non-selective NSAIDs and celecoxib among selective NSAIDs. There was no difference in the incidence of HO between non-selective and selective NSAIDs, allowing physicians to choose either based on the clinical scenario and patient-specific factors. Cite this article: Bone Joint J 2018;100-B:915–22

Aims. We aimed to assess the influence of ethnicity on the incidence of heterotopic ossification (HO) after total hip arthroplasty (THA). . Patients and Methods. We studied the six-month post-operative anteroposterior radiographs of 1449 consecutive primary THAs (1324 patients) and retrospectively graded them for the presence of HO, using the Brooker Classification. . Results. Based on multivariate analysis, African-American ethnicity was an independent risk factor for HO formation following THA with an adjusted odds ratio (OR) of 2.6 (95% confidence interval (CI) 1.3 to 5.2, p = 0.007) for severe HO and 1.9 (95% CI 1.3 to 2.7, p < 0.001) for any grade of HO. . Conclusion. Given the increased risk of HO formation, particularly high grade HO, and the potentially poorer outcomes associated with HO, it is important to consider using prophylaxis against HO in patients of African-American ethnicity undergoing THA. Take home message: African Americans are at an increased risk for developing heterotopic ossification and thus may benefit from HO prophylaxis. . Cite this article: Bone Joint J 2016;98-B:761–6

Aim. The primary aim of this retrospective study was to identify the incidence of heterotopic ossification (HO) following elective and trauma elbow arthroplasty. The secondary aim was to determine clinical outcomes with respect to the formation of heterotopic ossification. Patients and Methods. A total of 55 total elbow arthroplasties (TEAs) (52 patients) performed between June 2007 and December 2015 were eligible for inclusion in the study (29 TEAs for primary elective arthroplasty and 26 TEAs for trauma). At review, 15 patients (17 total elbow arthroplasties) had died from unrelated causes. There were 14 men and 38 women with a mean age of 70 years (42 to 90). The median clinical follow-up was 3.6 years (1.2 to 6) and the median radiological follow-up was 3.1 years (0.5 to 7.5). Results. The overall incidence of HO was 84% (46/55). This was higher in the trauma group (96%, 25/26) compared with the elective arthroplasty group (72%, 21/29) (p = 0.027, Fisher’s exact test). Patients in the trauma group had HO of higher Brooker class. The presence of HO did not significantly affect elbow range of movement within the trauma or elective groups (elective arthroplasty, Mann–Whitney U test, p = 0.070; trauma arthroplasty, p = 0.370, Mann–Whitney U test). Conclusion. HO after total elbow arthroplasty is seen more commonly than previously reported. We have reported a significantly higher rate of HO in TEAs performed for trauma than those performed electively. Cite this article: Bone Joint J 2018;100-B:767–71

Early total hip replacement (THR) for acetabular fractures offers accelerated rehabilitation, but a high risk of heterotopic ossification (HO) has been reported. The purpose of this study was to evaluate the incidence of HO, its associated risk factors and functional impact. A total of 40 patients with acetabular fractures treated with a THR weres retrospectively reviewed. The incidence and severity of HO were evaluated using the modified Brooker classification, and the functional outcome assessed. The overall incidence of HO was 38% (n = 15), with nine severe grade III cases. Patients who underwent surgery early after injury had a fourfold increased chance of developing HO. The mean blood loss and operating time were more than twice that of those whose surgery was delayed (p = 0.002 and p < 0.001, respectively). In those undergoing early THR, the incidence of grade III HO was eight times higher than in those in whom THR was delayed (p = 0.01). Only three of the seven patients with severe HO showed good or excellent Harris hip scores compared with eight of nine with class 0, I or II HO (p = 0.049). Associated musculoskeletal injuries, high-energy trauma and head injuries were associated with the development of grade III HO. The incidence of HO was significantly higher in patients with a displaced acetabular fracture undergoing THR early compared with those undergoing THR later and this had an adverse effect on the functional outcome. Cite this article: Bone Joint J 2013;95-B:95–100

Currently, there is no animal model in which to evaluate the underlying physiological processes leading to the heterotopic ossification (HO) which forms in most combat-related and blast wounds. We sought to reproduce the ossification that forms under these circumstances in a rat by emulating patterns of injury seen in patients with severe injuries resulting from blasts. We investigated whether exposure to blast overpressure increased the prevalence of HO after transfemoral amputation performed within the zone of injury. We exposed rats to a blast overpressure alone (BOP-CTL), crush injury and femoral fracture followed by amputation through the zone of injury (AMP-CTL) or a combination of these (BOP-AMP). The presence of HO was evaluated using radiographs, micro-CT and histology. HO developed in none of nine BOP-CTL, six of nine AMP-CTL, and in all 20 BOP-AMP rats. Exposure to blast overpressure increased the prevalence of HO. This model may thus be used to elucidate cellular and molecular pathways of HO, the effect of varying intensities of blast overpressure, and to evaluate new means of prophylaxis and treatment of heterotopic ossification. Cite this article: Bone Joint J 2015;97-B:572–6

In this paper we propose a new classification of neurogenic peri-articular heterotopic ossification (HO) of the hip based on three-dimensional (3D) CT, with the aim of improving pre-operative planning for its excision. . A total of 55 patients (73 hips) with clinically significant HO after either traumatic brain or spinal cord injury were assessed by 3D-CT scanning, and the results compared with the intra-operative findings. At operation, the gross pathological anatomy of the HO as identified by 3D-CT imaging was confirmed as affecting the peri-articular hip muscles to a greater or lesser extent. We identified seven patterns of involvement: four basic (anterior, medial, posterior and lateral) and three mixed (anteromedial, posterolateral and circumferential). Excellent intra- and inter-observer agreement, with kappa values > 0.8, confirmed the reproducibility of the classification system. We describe the different surgical approaches used to excise the HO which were guided by the 3D-CT findings. Resection was always successful. . 3D-CT imaging, complemented in some cases by angiography, allows the surgeon to define the 3D anatomy of the HO accurately and to plan its surgical excision with precision. Cite this article: Bone Joint J 2015; 97-B:899–904

Heterotopic ossification (HO) of the hip after injury to the central nervous system can lead to joint ankylosis. Surgery is usually delayed to avoid recurrence, even if the functional status is affected. We report a consecutive series of patients with HO of the hip after injury to the central nervous system who required surgery in a single, specialised tertiary referral unit. As was usual practice, they all underwent CT to determine the location of the HO and to evaluate the density of the femoral head and articular surface. The outcome of surgery was correlated with the pre-, peri- and post-operative findings. In all, 183 hips (143 patients) were included of which 70 were ankylosed. A total of 25 peri-operative fractures of the femoral neck occurred, all of which arose in patients with ankylosed hips and were associated with intra-articular lesions in 18 and severe osteopenia of the femoral head in seven. All the intra-articular lesions were predicted by CT and strongly associated with post-operative complications. The loss of the range of movement before ankylosis is a more important factor than the maturity of the HO in deciding the timing of surgery. Early surgical intervention minimises the development of intra-articular pathology, osteoporosis and the resultant complications without increasing the risk of recurrence of HO

Aims. Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants. Methods. A total of 39 hip fusion conversions to THA were undertaken in 38 patients by a single surgeon employing a consistent surgical technique and uncemented implants. Parameters assessed included Harris Hip Score (HHS) for function, range of motion (ROM), leg length discrepancy (LLD), satisfaction, and use of walking aid. Radiographs were reviewed for loosening, subsidence, and heterotopic ossification (HO). Postoperative complications and implant survival were assessed. Results. At mean 12.2 years (2 to 24) follow-up, HHS improved from mean 34.2 (20.8 to 60.5) to 75 (53.6 to 94.0; p < 0.001). Mean postoperative ROM was flexion 77° (50° to 95°), abduction 30° (10° to 40°), adduction 20° (5° to 25°), internal rotation 18° (2° to 30°), and external rotation 17° (5° to 30°). LLD improved from mean -3.36 cm (0 to 8) to postoperative mean -1.14 cm (0 to 4; p < 0.001). Postoperatively, 26 patients (68.4%) required the use of a walking aid. Complications included one (2.5%) dislocation, two (5.1%) partial sciatic nerve injuries, one (2.5%) deep periprosthetic joint infection, two instances of (5.1%) acetabular component aseptic loosening, two (5.1%) periprosthetic fractures, and ten instances of HO (40%), of which three (7.7%) were functionally limiting and required excision. Kaplan-Meier Survival was 97.1% (95% confidence interval (CI) 91.4% to 100%) at ten years and 88.2% (95% CI 70.96 to 100) at 15 years with implant revision for aseptic loosening as endpoint and 81.7% (95% CI 70.9% to 98.0%) at ten years and 74.2% (95% CI 55.6 to 92.8) at 15 years follow-up with implant revision for all cause failure as endpoint. Conclusion. The use of an optimal and consistent surgical technique and cementless implants can result in significant functional improvement, low complication rates, long-term implant survival, and high patient satisfaction following conversion of hip fusion to THA. The possibility of requiring a walking aid should be discussed with the patient before surgery. Cite this article: Bone Joint J 2021;103-B(7 Supple B):129–134

Aims. Whether to perform hybrid surgery (HS) in contrast to anterior cervical discectomy and fusion (ACDF) when treating patients with multilevel cervical disc degeneration remains a controversial subject. To resolve this we have undertaken a meta-analysis comparing the outcomes from HS with ACDF in this condition. Methods. Seven databases were searched for studies of HS and ACDF from inception of the study to 1 September 2019. Both random-effects and fixed-effects models were used to evaluate the overall effect of the C2-C7 range of motion (ROM), ROM of superior/inferior adjacent levels, adjacent segment degeneration (ASD), heterotopic ossification (HO), complications, neck disability index (NDI) score, visual analogue scale (VAS) score, Japanese Orthopaedic Association (JOA) score, Odom’s criteria, blood loss, and operating and hospitalization time. To obtain more credible results contour-enhanced funnel plots, Egger’s and Begg’s tests, meta-regression, and sensitivity analyses were performed. Results. In total, 17 studies involving 861 patients were included in the analysis. HS was found to be superior to ACDF in maintaining C2-C7 ROM and ROM of superior/inferior adjacent levels, but HS did not reduce the incidence of associated level ASD. Also, HS did not cause a higher rate of HO than ACDF. The frequency of complications was similar between the two techniques. HS failed to achieve more favourable outcomes than ACDF using the NDI, VAS, JOA, and Odom’s scores. HS did not show any more advantages in operating or hospitalization time but did show reduction in blood loss. Conclusion. Although HS maintained cervical kinetics, it failed to reduce the incidence of ASD. This finding differs from previous reports. Moreover, patients did not show more benefits from HS with respect to symptom improvement, prevention of complications, and clinical outcomes. Cite this article: Bone Joint J 2020;102-B(8):981–996

Aims

The optimal bearing surface design for medial unicompartmental knee arthroplasty (UKA) remains controversial. The aim of this study was to compare outcomes of fixed-bearing (FB) and mobile-bearing (MB) UKAs from a single high-volume institution.

Aims. The classical longitudinal incision used for the direct anterior approach (DAA) to the hip does not follow the tension lines of the skin and can lead to impaired wound healing and poor cosmesis. The purpose of this retrospective study was to determine the satisfaction with the scar, and functional and radiographic outcomes comparing the classic longitudinal incision with a modified skin crease ‘bikini’ when the DAA is used for total hip arthroplasty (THA). Patients and Methods. A total of 964 patients (51% female; 59% longitudinal, 41% ‘bikini’) completed a follow-up questionnaire between two and four years postoperatively, including the Oxford Hip Score (OHS), the University of North Carolina ‘4P’ scar scale (UNC4P) and two items for assessing the aesthetic appearance of the scar and symptoms of numbness. The positioning of the components, rates of heterotopic ossification (HO) and rates of revision were assessed. Results. The mean OHS was similar in both groups (p = 0.41). The mean UNC4P total score was slightly better (p = 0.01) and the proportion of patients who were very satisfied with the cosmetic aspects of the scar was higher in the ‘bikini’ group (p < 0.001). The proportion of patients reporting numbness in the scar was higher in the longitudinal group (14.5% vs 7.5%, respectively, p < 0.001). The abduction angle of the acetabular component, the position of the stem and rates of HO did not differ between the groups. There were no differences in the revision rates of both groups, being 2.3% in the longitudinal and 1.5% in the ‘bikini’ group (p = 0.911). Conclusion. We found that a short oblique ‘bikini’ skin crease incision is safe when used for the DAA at THA, without compromising the positioning of the components or increasing the rate of lateral femoral cutaneous nerve dysaesthesia. Although it leads to a superior scar satisfaction, as it is less extensile, it should be used after having gained experience with the classic longitudinal incision. Cite this article: Bone Joint J 2018;100-B:853–61

We have studied prospectively the effect of indomethacin on the development of heterotopic ossification (HO) after the internal fixation of acetabular fractures. After operation 107 patients randomly received either a six-week course of indomethacin or no treatment against HO. Plain radiographs of 101 patients at a mean of 7.9 months after surgery showed HO in 47.4% of the 57 patients who received indomethacin and in 56.8% of the 44 who did not. This difference was not statistically significant. Heterotopic ossification of Brooker class II or more was seen in four patients (7%) with prophylaxis and in one without (p = 0.51). Measurements of the volume of HO on 3-D CT reconstructions showed a median value of 1.5 cm. 3. in patients with indomethacin and 4.0 cm. 3. in those without (p = 0.28). When only the 57 patients in whom the operation was carried out through either a Kocher-Langenbeck or an extended iliofemoral approach were included the indomethacin group showed a median volume of 1.7 cm. 3. compared with 3.6 cm. 3. On plain radiographs Brooker class II or above was seen in 9.4% of the patients receiving indomethacin and in 4.8% of those who did not. Indomethacin was therefore not effective in preventing ectopic bone formation after surgery for acetabular fractures. There was a significant association of male gender with volume of HO using a non-parametric analysis of variance

We have carried out a prospective, randomised study of prophylaxis for heterotopic ossification (HO) comparing indomethacin for 7 and 14 days, acetylsalicylic acid, and fractional (4 × 3 Gy) or single exposure of 5 or 7 Gy irradiation after operation. We initially had 723 patients (733 hip replacements), but after withdrawals there were 685 hips of which 18.4% developed HO; 14% were grade I, 2.9% grade II and 1.5% grade III of the Brooker classification. We compared the results between these groups with those of a matched control series and found that indomethacin, 2 × 50 mg for 7 and 14 days, and postoperative irradiation of 4 × 3 Gy or 1 × 7 Gy, significantly reduced the development of HO compared with the control group. Patients in the acetylsalicylic acid group and those with a single irradiation of 5 Gy after operation developed significantly more ossification than those in the indomethacin and other irradiation groups. We suggest the use of 2 × 50 mg of indomethacin with mucoprotection for seven days as prophylaxis against HO after total hip replacement for all patients. A single irradiation of 7 Gy is recommended for patients who have developed HO after previous operations or to whom administration of indomethacin is contraindicated

We report a prospective, randomised, blinded clinical comparison of the use of indomethacin or radiation therapy for the prevention of heterotopic ossification (HO) in 75 adults who had open reduction and internal fixation of acetabular fractures through either a Kocher-Langenbeck, a combined ilioinguinal and Kocher-Langenbeck, or an extended iliofemoral approach. Indomethacin, 25 mg, was given three times daily for six weeks. Radiation with 800 cGy was delivered within three days of operation. Plain radiographs were reviewed and given Brooker classification scores by three independent observers who were unaware of the method of prophylaxis. One patient died from unrelated causes and two were lost to follow-up, leaving 72, 33 in the radiation group and 39 in the indomethacin group, available for evaluation at a mean of 12 months (6 to 48). There was no significant difference in the two groups in terms of age, gender, injury severity score, estimated blood loss, delay to surgery, head injury, presence of femoral head dislocation, or operating time, and no complications due to either method of treatment. The final extent of HO was already present by six weeks in all patients who were followed up. Three patients in the radiation group and five who received indomethacin developed HO of Brooker grade III. Two patients in the indomethacin group developed Brooker IV changes; both had failed to receive proper doses of the drug. Cochran-Armitage analysis showed no significant difference between the two treatment groups as regards the formation of HO. Indomethacin and single-dose radiation therapy are both safe and effective for the prevention of HO after operation for acetabular fractures. Radiation therapy is, however, approximately 200 times more expensive than indomethacin therapy at our institution and has other risks

Aims

The purpose of this study is to examine six types of bearing surfaces implanted at a single institution over three decades to determine whether the reasons for revision vary among the groups and how long it takes to identify differences in survival.

Aims

The aim of this study was to evaluate the outcome of complex radial head fractures at mid-term follow-up, and determine whether open reduction and internal fixation (ORIF) or radial head arthroplasty (RHA) should be recommended for surgical treatment.

Aims

The aim of this study was to identify the risk factors for adverse events following the surgical correction of cervical spinal deformities in adults.

Indomethacin is commonly administered for the prophylaxis of heterotopic ossification (HO) after the surgical treatment of acetabular fractures. Non-steroidal anti-inflammatory drugs such as indomethacin, have been associated with delayed healing of fractures and mechanically weaker callus. Our aim was to determine if patients with an acetabular fracture, who received indomethacin for prophylaxis against HO, were at risk of delayed healing or nonunion of any associated fractures of long bones. We reviewed 282 patients who had had open reduction and internal fixation of an acetabular fracture. Patients at risk of HO were randomised to receive either radiation therapy (XRT) or indomethacin. Of these patients, 112 had sustained at least one concomitant fracture of a long bone; 36 needed no prophylaxis, 38 received focal radiation and 38 received indomethacin. Fifteen patients developed 16 nonunions. When comparing patients who received indomethacin with those who did not, a significant difference was noted in the rate of nonunion (26% v 7%; p = 0.004). Patients with concurrent fractures of the acetabulum and long bones who receive indomethacin have a significantly greater risk of nonunion of the fractures of the long bones when compared with those who receive XRT or no prophylaxis

Aims

It has been hypothesized that a unicompartmental knee arthroplasty (UKA) is more likely to be revised than a total knee arthroplasty (TKA) because conversion surgery to a primary TKA is a less complicated procedure. The purpose of this study was to determine if there is a lower threshold for revising a UKA compared with TKA based on Oxford Knee Scores (OKSs) and range of movement (ROM) at the time of revision.

Aims

A conventional arthroscopic capsuloligamentous repair is a reliable surgical solution in most patients with scapholunate instability. However, this repair does not seem to be sufficient for more advanced injuries. The aim of this study was to evaluate the functional results of a wide arthroscopic dorsal capsuloligamentous repair (WADCLR) in the management of severe scapholunate instability.

Aims

The aim of this study was to develop and internally validate a prognostic nomogram to predict the probability of gaining a functional range of motion (ROM ≥ 120°) after open arthrolysis of the elbow in patients with post-traumatic stiffness of the elbow.

1. Using the incidence of hip fracture as an indication of senile osteoporosis, the occurrence of this disease is found to vary greatly in different racial groups. The highest reported incidence is in Sweden, followed by Britain, Hong Kong Chinese, Singapore Chinese and South African Bantu, in that order. Likewise, the sex incidence varies, women outnumbering men in Sweden and Britain, men exceeding women in Singapore; an equal sex incidence is found in Hong Kong.

2. In all races and in both sexes the incidence is more closely related to age than any other factor, a progressive increase being noted after forty-five. Ageing is clearly the dominant etiological factor, but this does not explain the different racial incidence. These differences cannot be attributed to hormonal state or to the dietary intake of calcium, but do accord in general with the living standards of the different countries and the degree of physical activity undertaken by the different populations and sexes.

3. Hereditary factors may play a part, but further geographical study of the incidence of senile osteoporosis is necessary before the relative importance of inheritance and environment can be assessed.

Aims

This study aims to report the outcomes in the treatment of unstable proximal third scaphoid nonunions with arthroscopic curettage, non-vascularized bone grafting, and percutaneous fixation.

Aims

Head-taper corrosion is a cause of failure in total hip arthroplasty (THA). Recent reports have described an increasing number of V40 taper failures with adverse local tissue reaction (ALTR). However, the real incidence of V40 taper damage and its cause remain unknown. The aim of this study was to evaluate the long-term incidence of ALTR in a consecutive series of THAs using a V40 taper and identify potentially related factors.

Aims

Arthroplasty is being increasingly used for the management of distal humeral fractures (DHFs) in elderly patients. Arthroplasty options include total elbow arthroplasty (TEA) and hemiarthroplasty (HA); both have unique complications and there is not yet a consensus on which implant is superior. This systematic review asked: in patients aged over 65 years with unreconstructable DHFs, what differences are there in outcomes, as measured by patient-reported outcome measures (PROMs), range of motion (ROM), and complications, between distal humeral HA and TEA?

We have used dual-energy X-ray absorptiometry to measure bone mineral density (BMD) in patients with ankylosing spondylitis comparing 41 healthy control subjects and 33 patients with either mild or advanced ankylosing spondylitis. A Norland XR-28 bone densitometer was used to measure the BMD of the lumbar spine and that of the head, trunk, arms, femoral neck, Ward's triangle, legs, pelvis, and total body. Mild ankylosing spondylitis was defined as that showing no or incipient syndesmophytes between L1 and L5 vertebrae: we studied 16 men of mean age 37 years and six women of mean age 37 years. Advanced ankylosing spondylitis, in 11 men of mean age 42 years, showed a bamboo spine with bridging syndesmophytes across all disc spaces between L1 and L5. The mean BMD of the lumbar spine was significantly different in the patients and control subjects of the same sex (0.01 < p < 0.05, analysis of variance), being significantly reduced compared with control subjects in mild disease (0.001 < p < 0.01, t-test) and significantly increased in advanced disease over control subjects (0.01 < p < 0.05; t-test) and over patients with mild disease (0.001 < p < 0.01; t-test). The relevance of these findings to the aetiology and pathogenesis of spinal deformities and other complications in ankylosing spondylitis is discussed.

The development of the iliolumbar ligament and its anatomy and histology were studied in cadavers from the newborn to the ninth decade. The structure was entirely muscular in the newborn and became ligamentous only from the second decade, being formed by metaplasia from fibres of the quadratus lumborum muscle. By the third decade, the definitive ligament was well formed; degenerative changes were noted in older specimens. The iliolumbar ligament may have an important role in maintaining lumbosacral stability in patients with lumbar disc degeneration, degenerative spondylolisthesis and pelvic obliquity secondary to neuromuscular scoliosis.

1. Transplantations of autografts and of Kiel bone to the iliac bone and to muscle tissue were performed in rabbits. Through labelling with two tetracycline compounds which have different fluorescent colours in ultraviolet light, bone formation between the labelling periods could be followed.

2. It was shown that bone formation between the fifth and the tenth day after transplantation to bone took place in about 50 per cent of the fresh autografts. Storage of the transplants in saline for one hour before replacement had little adverse effect, whereas exposure to air for one hour seemed to reduce the osteogenic effect of the grafts. Bone formation was not observed in grafts of Kiel bone during this period.

3. The fact that new bone formation in fresh autografts could be demonstrated even during the first four days after transplantation to bone indicates that osteogenic cells from the fresh autografts continue their activity under favourable conditions. This is supported by microradiographic and histological evidence.

4. The amount of callus which developed in close contact with the grafts during the first ten days after transplantation to bone was more pronounced both in fresh autografts and in autografts kept in saline than in autografts exposed to air for one hour. Callus developing at a later stage showed no significant difference between the various grafts, including those of Kiel bone.

5. In fresh autografts transplanted to muscle tissue callus formation could be demonstrated in most cases by the tenth day, indicating either survival of osteoblasts or the transformation of more primitive cells from the graft or from the host bone into osteogenic cells. No bone formation was observed when Kiel bone was embedded in muscle tissue.

In a retrospective study we compared 32 HINTEGRA total ankle replacements (TARs) and 35 Mobility TARs performed between July 2005 and May 2010, with a minimum follow-up of two years. The mean follow-up for the HINTEGRA group was 53 months (24 to 76) and for the Mobility group was 34 months (24 to 45). All procedures were performed by a single surgeon. There was no significant difference between the two groups with regard to the mean AOFAS score, visual analogue score for pain or range of movement of the ankle at the latest follow-up. Most radiological measurements did not differ significantly between the two groups. However, the most common grade of heterotopic ossification (HO) was grade 3 in the HINTEGRA group (10 of 13 TARs, 76.9%) and grade 2 in the Mobility group (four of seven TARs, 57.1%) (p = 0.025). Although HO was more frequent in the HINTEGRA group (40.6%) than in the Mobility group (20.0%), this was not statistically significant (p = 0.065).The difference in peri-operative complications between the two groups was not significant, but intra-operative medial malleolar fractures occurred in four (11.4%) in the Mobility group; four (12.5%) in the HINTEGRA group and one TAR (2.9%) in the Mobility group failed (p = 0.185). Cite this article: Bone Joint J 2013;95-B:1075–82

Aims

Acute distal biceps tendon repair reduces fatigue-related pain and minimizes loss of supination of the forearm and strength of flexion of the elbow. We report the short- and long-term outcome following repair using fixation with a cortical button techqniue.

Aims

Existing literature indicates that inferiorly inclined glenoid baseplates following reverse total shoulder arthroplasty (RSA) produce better outcomes compared to superiorly inclined baseplates. We aim to compare clinical outcomes for RSAs with superiorly and neutrally/inferiorly inclined lateralized glenospheres.

Aims

To evaluate the outcomes of terrible triad injuries (TTIs) in mid-term follow-up and determine whether surgical treatment of the radial head influences clinical and radiological outcomes.

Endoscopic carpal tunnel release has the advantage over open release of reduced tissue trauma and postoperative morbidity. Limited open carpal tunnel release has also been shown to have comparable results, but is easier to perform and is safer. We have compared the results of both techniques in a prospective, randomised trial. Thirty patients with bilateral carpal tunnel syndrome had simultaneous bilateral release. The technique of release was randomly allocated to either two-portal endoscopic release (ECTR) or limited open release using the Strickland instrumentation (LOCTR).

The results showed that the outcome was similar at follow-up of one year using both techniques. However, the LOCTR group had significantly less tenderness of the scar at the second and fourth postoperative week (p < 0.01). There was also less thenar and hypothenar (pillar) pain after LOCTR. Subjective evaluation showed a preference for LOCTR.

Composites of chondrocytes and polymerised fibrin were supplemented with insulin-like growth factor-I (IGF-I) during the arthroscopic repair of full-thickness cartilage defects in a model of extensive loss of cartilage in horses. Repairs facilitated with IGF-I and chondrocyte-fibrin composites, or control defects treated with chondrocyte-fibrin composites alone, were compared before death by the clinical appearance and repeated analysis of synovial fluid, and at termination eight months after surgery by tissue morphology, collagen typing, and biochemical assays. The structure of cartilage was evaluated histologically by Toluidine Blue reaction and collagen type-I and type-II in situ hybridisation and immunohistochemistry. Repair tissue was biochemically evaluated by DNA assay, proteoglycan quantitation and characterisation, assessment of collagen by reverse-phase high-performance liquid chromatography, and collagen typing using cyanogen bromide digestion and peptide separation by polyacrylamide gel electrophoresis.

The results at eight months showed that the addition of IGF-I to chondrocyte grafts enhanced chondrogenesis in cartilage defects, including incorporation into surrounding cartilage. Gross filling of defects was improved, and the tissue contained a higher proportion of cells producing type-II collagen. Measurements of collagen type II showed improved levels in IGF-I-treated defects, supporting in situ hybridisation and immunohistochemical assessments of the defects. IGF-I improves the repair capabilities of chondrocyte-fibrin grafts in large full-thickness repair models.

Aims

Use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased in recent years due to proposed benefits, including a lower risk of dislocation and improved early functional recovery. This study investigates the dislocation rate in a non-selective, consecutive cohort undergoing THA via the DAA without any exclusion or bias in patient selection based on habitus, deformity, age, sex, or fixation method.

Aims

The aim of this systematic review and meta-analysis is to evaluate differences in functional outcomes and complications between single- (SI) and double-incision (DI) techniques for the treatment of distal biceps tendon rupture.

Between January 1992 and December 1998, we treated 24 patients with necrotising fasciitis of a limb. There were 15 men and nine women with a mean age of 59.8 years (5 to 86). The infection was usually confused with cellulitis. Exquisite pain and early systemic toxicity were the most consistent clinical features. Diabetes mellitus and hepatic cirrhosis were the most commonly associated medical diseases. One third of the patients died. Those with involvement of the limbs above the knee or elbow on admission had a significantly higher rate of mortality than those with distal lesions (Fisher’s exact test, p = 0.027). There was no correlation between mortality and advanced age (Student’s t-test, p = 0.22) or between amputation and survival (Fisher’s exact test, p = 0.39).

We reviewed 40 extensive destructive vertebral lesions in 35 patients with established ankylosing spondylitis. Of these, 31 had presented with localised pain while three had a neurological deficit. The radiographs suggested ununited fractures through either ankylosed discs (37) or vertebral bodies (3). Corresponding fractures were seen in the posterior column in 34 cases. Sixteen patients with 18 lesions underwent anterior spinal fusion, and pseudarthrosis was consistently proven by histopathology. Two pseudarthroses healed in conservatively treated patients. Thirteen of the operated patients were followed for an average of 7 years 7 months. There were two cases of non-union and one required an additional posterior fusion; in the remainder fusion was sound.

Aims

The purpose was to evaluate early clinical, patient-reported, and radiological outcomes of the scapholunate ligament 360° tenodesis (SL 360) technique for treatment of scapholunate (SL) instability.

Components from 73 failed knee replacements (TKRs) consisting of rotating-platform, mobile-bearing and fixed-bearing implants were examined to assess the patterns of wear. The patterns were divided into low-grade (burnishing, abrasion and cold flow) and high-grade (scratching, pitting/metal embedding and delamination) to assess the severity of the wear of polyethylene.

The rotating-platform group had a higher incidence of low-grade wear on the upper surface compared with the fixed-bearing group. By contrast, high-grade wear comprising scratching, pitting and third-body embedding was seen on the lower surface. Linear regression analysis showed a significant correlation of the wear scores between the upper and lower surfaces of the tibial insert (R² = 0.29, p = 0.04) for the rotating-platform group, but no significant correlation was found for the fixed-bearing counterpart.

This suggests that high-grade wear patterns on the upper surface are reduced with the rotating-platform design. However, the incidence of burnishing, pitting/third-body embedding and scratching wear patterns on the lower surface was higher compared with that in the fixed-bearing knee.

Aims

Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort.

Aims

The aim of this study was to evaluate the outcome of Monteggia-like lesions at midterm follow-up and to determine whether the surgical treatment of the radial head influences the clinical and radiological results.

One of the most controversial issues in total knee replacement is whether or not to resurface the patella. In order to determine the effects of different designs of femoral component on the conformity of the patellofemoral joint, five different knee prostheses were investigated. These were Low Contact Stress, the Miller-Galante II, the NexGen, the Porous-Coated Anatomic, and the Total Condylar prostheses. Three-dimensional models of the prostheses and a native patella were developed and assessed by computer. The conformity of the curvature of the five different prosthetic femoral components to their corresponding patellar implants and to the native patella at different angles of flexion was assessed by measuring the angles of intersection of tangential lines.

The Total Condylar prosthesis had the lowest conformity with the native patella (mean 8.58°; 0.14° to 29.9°) and with its own patellar component (mean 11.36°; 0.55° to 39.19°). In the other four prostheses, the conformity was better (mean 2.25°; 0.02° to 10.52°) when articulated with the corresponding patellar component. The Porous-Coated Anatomic femoral component showed better conformity (mean 6.51°; 0.07° to 9.89°) than the Miller-Galante II prosthesis (mean 11.20°; 5.80° to 16.72°) when tested with the native patella. Although the Nexgen prosthesis had less conformity with the native patella at a low angle of flexion, this improved at mid (mean 3.57°; 1.40° to 4.56°) or high angles of flexion (mean 4.54°; 0.91° to 9.39°), respectively. The Low Contact Stress femoral component had the best conformity with the native patella (mean 2.39°; 0.04° to 4.56°). There was no significant difference (p > 0.208) between the conformity when tested with the native patella or its own patellar component at any angle of flexion.

The geometry of the anterior flange of a femoral component affects the conformity of the patellofemoral joint when articulating with the native patella. A more anatomical design of femoral component is preferable if the surgeon decides not to resurface the patella at the time of operation.

Aims

The aim of this study was to analyze the results of two radiocapitellar prostheses in a large case series followed prospectively, with medium-term follow-up.