Aims

We aimed to evaluate the temperature around the nerve root during drilling of the lamina and to determine whether irrigation during drilling can reduce the chance of nerve root injury.

Two protocols for the operative technique and care of the pin-site with external fixation were compared prospectively. There was a total of 120 patients with 46 in group A and 74 in group B. Infection was defined as an episode of pain or inflammation at a pin site, accompanied by a discharge which was either positive on bacterial culture or responded to a course of antibiotics. Patients in group B had a lower proportion of infected pin sites (p = 0.003) and the time to the first episode of infection was longer (p < 0.001). The risk of pin-site infection is lower if attention is paid to avoiding thermal injury and local formation of haematoma during surgery and if after-care includes the use of an alcoholic antiseptic and occlusive pressure dressings

Twenty patients were examined by standard radiography and roentgen stereophotogrammetric analysis (RSA) during a two-year period after total hip arthroplasty. Eleven of the acetabular components migrated cranially and three femoral components migrated distally. This migration was most rapid during the first four months after operation. Our findings support the possibility that mechanical loosening is initiated by thermal injury during polymerisation of the cement; the less frequent migration of the metallic femoral component compared with the polyethylene acetabular component may be because the metal acts as a heat sink. Standard radiographs were inadequate for assessment of early mechanical loosening, whereas RSA could reveal migration within four months of the arthroplasty

Fatigue fractures which originate at stress-concentrating voids located at the implant-cement interface are a potential cause of septic loosening of cemented femoral components. Heating of the component to 44°C is known to reduce the porosity of the cement-prosthesis interface. The temperature of the cement-bone interface was recorded intra-operatively as 32.3°C. A simulated femoral model was devised to study the effect of heating of the component on the implant-cement interface. Heating of the implant and vacuum mixing have a synergistic effect on the porosity of the implant-cement interface, and heating also reverses the gradients of microhardness in the mantle. Heating of the implant also reduces porosity at the interface depending on the temperature. A minimum difference in temperature between the implant and the bone of 3°C was required to produce this effect. The optimal difference was 7°C, representing a balance between maximal reduction of porosity and an increased risk of thermal injury. Using contemporary cementing techniques, heating the implant to 40°C is recommended to produce an optimum effect

We studied the various drill bits available for engineering purposes, and compared them with standard orthopaedic drill bits, using continuous temperature recording at 0.5 mm, 1.0 mm and 1.5 mm from the edge of a 2.5 mm hole as it was drilled in fresh cadaver human tibia. We found that some commercially available drill bits performed better than their orthopaedic equivalents, producing significantly less thermal injury to the surrounding bone and halving the force required for cortical penetration. Our work suggests that the optimal bit for orthopaedic purposes should have a split point and a quick helix. Theoretical knowledge of cutting technology predicts that the addition of a parabolic flute will further reduce thermal damage. Further work is being done on other drill sizes used in orthopaedic practice and on new custom-designed bits

Hallux valgus (HV) presents as a common forefoot deformity that causes problems with pain, mobility, footwear, and quality of life. The most common open correction used in the UK is the Scarf and Akin osteotomy, which has good clinical and radiological outcomes and high levels of patient satisfaction when used to treat a varying degrees of deformity. However, there are concerns regarding recurrence rates and long-term outcomes. Minimally invasive or percutaneous surgery (MIS) has gained popularity, offering the potential for similar clinical and radiological outcomes with reduced postoperative pain and smaller scars. Despite this, MIS techniques vary widely, hindering comparison and standardization. This review evaluates the evidence for both open Scarf and Akin osteotomy and newer-generation MIS techniques. Fourth-generation MIS emphasizes multiplanar rotational deformity correction through stable fixation. While MIS techniques show promise, their evidence mainly comprises single-surgeon case series. Comparative studies between open and MIS techniques suggest similar clinical and radiological outcomes, although MIS may offer advantages in scar length and less early postoperative pain. MIS may afford superior correction in severe deformity and lower recurrence rates due to correcting the bony deformity rather than soft-tissue correction. Recurrence remains a challenge in HV surgery, necessitating long-term follow-up and standardized outcome measures for assessment. Any comparison between the techniques requires comparative studies. Surgeons must weigh the advantages and risks of both open and MIS approaches in collaboration with patients to determine the most suitable treatment.

Cite this article: Bone Joint J 2025;107-B(1):10–18.

Aims

This exploratory randomized controlled trial (RCT) aimed to determine the splint-related outcomes when using the novel biodegradable wood-composite splint (Woodcast) compared to standard synthetic fibreglass (Dynacast) for the immobilization of undisplaced upper limb fractures in children.

Aims

The Fassier Duval (FD) rod is a third-generation telescopic implant for children with osteogenesis imperfecta (OI). Threaded fixation enables proximal insertion without opening the knee or ankle joint. We have reviewed our combined two-centre experience with this implant.

Aims

The aims of this study were to validate the outcome of total elbow arthroplasty (TEA) in patients with rheumatoid arthritis (RA), and to identify factors that affect the outcome.

Aims

The aim of this study was to determine whether chilled irrigation saline decreases the incidence of clinical upper limb palsy (ULP; a reduction of one grade or more on manual muscle testing; MMT), based on the idea that ULP results from thermal damage to the nerve roots by heat generated by friction during bone drilling.

This animal study compares different methods of performing an osteotomy, including using an Erbium-doped Yttrium Aluminum Garnet laser, histologically, radiologically and biomechanically. A total of 24 New Zealand rabbits were divided into four groups (Group I: multihole-drilling; Group II: Gigli saw; Group III: electrical saw blade and Group IV: laser). A proximal transverse diaphyseal osteotomy was performed on the right tibias of the rabbits after the application of a circular external fixator. The rabbits were killed six weeks after the procedure, the operated tibias were resected and radiographs taken.

The specimens were tested biomechanically using three-point bending forces, and four tibias from each group were examined histologically. Outcome parameters were the biomechanical stability of the tibias as assessed by the failure to load and radiographic and histological examination of the osteotomy site.

The osteotomies healed in all specimens both radiographically and histologically. The differences in the mean radiographic (p = 0.568) and histological (p = 0.71) scores, and in the mean failure loads (p = 0.180) were not statistically significant between the groups.

Different methods of performing an osteotomy give similar quality of union. The laser osteotomy, which is not widely used in orthopaedics is an alternative to the current methods.

Cite this article: Bone Joint J 2015;97-B:1628–33.

Using the transverse processes of fresh porcine lumbar spines as an experimental model we evaluated the heat generated by a rotating burr of a high-speed drill in cutting the bone. The temperature at the drilled site reached 174°C with a diamond burr and 77°C with a steel burr. With water irrigation at a flow rate of 540 ml/hr an effective reduction in the temperature was achieved whereas irrigation with water at 180 ml/hr was much less effective. There was a significant negative correlation between the thickness of the residual bone and the temperature measured at its undersurface adjacent to the drilling site (p < 0.001).

Our data suggest that tissues neighbouring the drilled bone, especially nerve roots, can be damaged by the heat generated from the tip of a high-speed drill. Nerve-root palsy, one of the most common complications of cervical spinal surgery, may be caused by thermal damage to nerve roots arising in this manner.

Osteoid osteoma is treated primarily by radiofrequency (RF) ablation. However, there is little information about the distribution of heat in bone during the procedure and its safety. We constructed a model of osteoid osteoma to assess the distribution of heat in bone and to define the margins of safety for ablation. Cavities were drilled in cadaver bovine bones and filled with a liver homogenate to simulate the tumour matrix. Temperature-sensing probes were placed in the bone in a radial fashion away from the cavities. RF ablation was performed 107 times in tumours < 10 mm in diameter (72 of which were in cortical bone, 35 in cancellous bone), and 41 times in cortical bone with models > 10 mm in diameter. Significantly higher temperatures were found in cancellous bone than in cortical bone (p <  0.05). For lesions up to 10 mm in diameter, in both bone types, the temperature varied directly with the size of the tumour (p < 0.05), and inversely with the distance from it. Tumours of > 10 mm in diameter showed a trend similar to those of smaller lesions. No temperature rise was seen beyond 12 mm from the edge of a cortical tumour of any size. Formulae were developed to predict the expected temperature in the bone during ablation.

Cite this article: Bone Joint J 2014; 96-B:677–83

We report our early experience with the use of a new prosthesis, the Modular Hemipelvic Prosthesis II, for reconstruction of the hemipelvis after resection of a primary malignant peri-acetabular tumour involving the sacroiliac joint.

We retrospectively reviewed the outcome of 17 patients who had undergone resection of a pelvic tumour and reconstruction with this prosthesis between July 2002 and July 2010.

One patient had a type I+II+III+IV resection (ilium + peri-acetabulum + pubis/ischium + sacrum) and 16 had a type I+II+IV resection (ilium + acetabulum + sacrum). The outcome was assessed at a mean follow-up of 33 months (15 to 59). One patient was alive with disease, 11 were alive without disease and five had died of disease. The overall five-year survival rate was 62.4%. Six patients had a local recurrence. The mean Musculoskeletal Tumour Society score was 58% (33 to 77). Deep infection occurred in two patients, problems with wound healing in five and dislocation in one.

For patients with a primary malignant peri-acetabular sarcoma involving the sacroiliac joint, we believe that this new prosthesis is a viable option for reconstruction of the bony defect left following resection of the tumour. It results in a satisfactory functional outcome with an acceptable rate of complications.

Cite this article: Bone Joint J 2014;96-B:399–405.

The purpose of this study was to establish whether exploration and neurolysis is an effective method of treating neuropathic pain in patients with a sciatic nerve palsy after total hip replacement (THR). A total of 56 patients who had undergone this surgery at our hospital between September 1999 and September 2010 were retrospectively identified. There were 42 women and 14 men with a mean age at exploration of 61.2 years (28 to 80). The sciatic nerve palsy had been sustained by 46 of the patients during a primary THR, five during a revision THR and five patients during hip resurfacing. The mean pre-operative visual analogue scale (VAS) pain score was 7.59 (2 to 10), the mean post-operative VAS was 3.77 (0 to 10), with a resulting mean improvement of 3.82 (0 to 10). The pre- and post-neurolysis VAS scores were significantly different (p < 0.001). Based on the findings of our study, we recommend this form of surgery over conservative management in patients with neuropathic pain associated with a sciatic nerve palsy after THR.

Cite this article: Bone Joint J 2013;95-B:20–2.

Recent reports have suggested an increase in the number of anterior cruciate ligament (ACL) injuries in children, although their true incidence is unknown.

The prognosis of the ACL-deficient knee in young active individuals is poor because of secondary meniscal tears, persistent instability and early-onset osteoarthritis. The aim of surgical reconstruction is to provide stability while avoiding physeal injury. Techniques of reconstruction include transphyseal, extraphyseal or partial physeal sparing procedures.

In this paper we review the management of ACL tears in skeletally immature patients.

Cite this article: Bone Joint J 2013;95-B:1562–9.

We present the histological findings of bone retrieved from beneath the femoral components of failed metal-on-metal hip resurfacing arthroplasties. Of a total of 377 patients who underwent resurfacing arthroplasty, 13 required revision; for fracture of the femoral neck in eight, loosening of a component in three and for other reasons in two. None of these cases had shown histological evidence of osteonecrosis in the femoral bone at the time of the initial implantation.

Bone from the remnant of the femoral head showed changes of osteonecrosis in all but one case at revision. In two cases of fracture which occurred within a week of implantation, the changes were compatible with early necrosis of the edge of the fracture. In the remaining six fractures, there were changes of established osteonecrosis. In all but one of the non-fracture cases, patchy osteonecrosis was seen.

We conclude that histological evidence of osteonecrosis is a common finding in failed resurfaced hips. Given that osteonecrosis is extensive in resurfaced femoral heads which fail by fracture, it is likely to play a role in the causation of these fractures.

Eighteen hip fusions were converted to total hip replacements. A constrained acetabular liner was used in three hips. Mean follow up was five years (two to 15). Two (11%) hips failed, requiring revision surgery and two patients (11%) had injury to the peroneal nerve. Heterotopic ossification developed in seven (39%) hips, in one case resulting in joint ankylosis. No hips dislocated.

Conversion of hip fusion to hip replacement carries an increased risk of heterotopic ossification and neurological injury. We advise prophylaxis against heterotropic ossification. When there is concern about hip stability we suggest that the use of a constrained acetabular liner is considered. Despite the potential for complications, this procedure had a high success rate and was effective in restoring hip function.

Giant cell tumours (GCTs) of the small bones of the hands and feet are rare. Small case series have been published but there is no consensus about ideal treatment. We performed a systematic review, initially screening 775 titles, and included 12 papers comprising 91 patients with GCT of the small bones of the hands and feet. The rate of recurrence across these publications was found to be 72% (18 of 25) in those treated with isolated curettage, 13% (2 of 15) in those treated with curettage plus adjuvants, 15% (6 of 41) in those treated by resection and 10% (1 of 10) in those treated by amputation.

We then retrospectively analysed 30 patients treated for GCT of the small bones of the hands and feet between 1987 and 2010 in five specialised centres. The primary treatment was curettage in six, curettage with adjuvants (phenol or liquid nitrogen with or without polymethylmethacrylate (PMMA)) in 18 and resection in six. We evaluated the rate of complications and recurrence as well as the factors that influenced their functional outcome.

At a mean follow-up of 7.9 years (2 to 26) the rate of recurrence was 50% (n = 3) in those patients treated with isolated curettage, 22% (n = 4) in those treated with curettage plus adjuvants and 17% (n = 1) in those treated with resection (p = 0.404). The only complication was pain in one patient, which resolved after surgical removal of remnants of PMMA. We could not identify any individual factors associated with a higher rate of complications or recurrence. The mean post-operative Musculoskeletal Tumor Society scores were slightly higher after intra-lesional treatment including isolated curettage and curettage plus adjuvants (29 (20 to 30)) compared with resection (25 (15 to 30)) (p = 0.091). Repeated curettage with adjuvants eventually resulted in the cure for all patients and is therefore a reasonable treatment for both primary and recurrent GCT of the small bones of the hands and feet.

Cite this article: Bone Joint J 2013;95-B:838–45.

A 60-year-old man developed severe neuropathic pain and foot-drop in his left leg following resurfacing arthroplasty of the left hip. The pain was refractory to all analgesics for 16 months. At exploration, a PDS suture was found passing through the sciatic nerve at several points over 6 cm and terminating in a large knot. After release of the suture and neurolysis there was dramatic and rapid improvement of the neuropathic pain and of motor function.

This case represents the human equivalent of previously described nerve ligation in an animal model of neuropathic pain. It emphasises that when neuropathic pain is present after an operation, the nerve related to the symptoms must be inspected, and that removal of a suture or irritant may lead to relief of pain, even after many months.