Antegrade intramedullary nailing of fractures of the shaft of the humerus is reported to cause impairment of the shoulder joint. We have reviewed 33 patients with such fractures to assess how many had injuries to the ipsilateral shoulder. All had an MR scan of the shoulder within 11 days of injury. The unaffected shoulder was also scanned as a control. There was evidence of abnormality in 21 of the shoulders (63.6%) on the injured side; ten had bursitis of the subacromial space, five evidence of a partial tear of the rotator cuff, one a complete rupture of the supraspinatus tendon, four inflammatory changes in the acromioclavicular joint and one a fracture of the coracoid process. These injuries may contribute to pain and dysfunction of the shoulder following treatment, and their presence indicates that antegrade nailing is only partly, if at all, responsible for these symptoms.

We reviewed the outcome of arthroscopic stabilisation of anterior glenohumeral instability in young adults using the transglenoid suture technique. A questionnaire was sent to 455 consecutive patients who had undergone this procedure between 1992 and 2000. Of these, 312 patients (68.5%) with 313 affected shoulders and a mean age of 20 years (18 to 28) responded.

Outcome was determined by the number of re-dislocations or, in patients who had not re-dislocated, by the disease-specific quality of life as measured by the Western Ontario Shoulder Instability index. During a mean follow-up of 6.4 years (1 to 14), 177 patients (56%) sustained a re-dislocation, including 70 who required a further operation. In 136 patients (44%) who reported neither re-dislocation nor re-operation, the index scores were good (median 90.4%; 28.9% to 100%). No significant peri- or pre-operative predictors of re-dislocation or re-operation were found.

We found a high rate of re-dislocation after transglenoid suture repair in young, physically active patients.

The aim of this study was to perform a cost–utility analysis of total hip (THR) and knee replacement (TKR). Arthritis is a disabling condition that leads to long-term deterioration in quality of life. Total joint replacement, despite being one of the greatest advances in medicine of the modern era, has recently come under scrutiny. The National Health Service (NHS) has competing demands, and resource allocation is challenging in times of economic restraint. Patients who underwent THR (n = 348) or TKR (n = 323) between January and July 2010 in one Scottish region were entered into a prospective arthroplasty database. A health–utility score was derived from the EuroQol (EQ-5D) score pre-operatively and at one year, and was combined with individual life expectancy to derive the quality-adjusted life years (QALYs) gained. Two-way analysis of variance was used to compare QALYs gained between procedures, while controlling for baseline differences. The number of QALYs gained was higher after THR than after TKR (6.5 vs 4.0 years, p < 0.001). The cost per QALY for THR was £1372 compared with £2101 for TKR. The predictors of an increase in QALYs gained were poorer health before surgery (p < 0.001) and younger age (p < 0.001). General health (EQ-5D VAS) showed greater improvement after THR than after TKR (p < 0.001). This study provides up-to-date cost-effectiveness data for total joint replacement. THR and TKR are extremely effective both clinically and in terms of cost effectiveness, with costs that compare favourably to those of other medical interventions.

Cite this article: Bone Joint J 2013;95-B:115–21.

The June 2012 Spine Roundup³⁶⁰ looks at: back pain; spinal fusion for tuberculosis; anatomical course of the recurrent laryngeal nerve; groin pain with normal imaging; the herniated intervertebral disc; obesity’s effect on the spine; the medicolegal risks of cauda equina syndrome; and intravenous lidocaine use and failed back surgery syndrome.

We performed a biomechanical study to compare the augmentation of isolated fractured vertebral bodies using two different bone tamps. Compression fractures were created in 21 vertebral bodies harvested from red deer after determining their initial strength and stiffness, which was then assessed after standardised bipedicular vertebral augmentation using a balloon or an expandable polymer bone tamp.

The median strength and stiffness of the balloon bone tamp group was 6.71 kN (sd 2.71) and 1.885 kN/mm (sd 0.340), respectively, versus 7.36 kN (sd 3.43) and 1.882 kN/mm (sd 0.868) in the polymer bone tamp group. The strength and stiffness tended to be greater in the polymer bone tamp group than in the balloon bone tamp group, but this difference was not statistically significant (strength p > 0.8, and stiffness p = 0.4).

This prospective multicentre study was undertaken to determine segmental movement, disc height and sagittal alignment after total disc replacement (TDR) in the lumbosacral spine and to assess the correlation of biomechanical properties to clinical outcomes.

A total of 173 patients with degenerative disc disease and low back pain for more than one year were randomised to receive either TDR or multidisciplinary rehabilitation (MDR). Segmental movement in the sagittal plane and disc height were measured using distortion compensated roentgen analysis (DCRA) comparing radiographs in active flexion and extension. Correlation analysis between the range of movement or disc height and patient-reported outcomes was performed in both groups. After two years, no significant change in movement in the sagittal plane was found in segments with TDR or between the two treatment groups. It remained the same or increased slightly in untreated segments in the TDR group and in this group there was a significant increase in disc height in the operated segments. There was no correlation between segmental movement or disc height and patient-reported outcomes in either group.

In this study, insertion of an intervertebral disc prosthesis TDR did not increase movement in the sagittal plane and segmental movement did not correlate with patient-reported outcomes. This suggests that in the lumbar spine the movement preserving properties of TDR are not major determinants of clinical outcomes.

Cite this article: Bone Joint J 2013;95-B:81–9.

We investigated the clinical and radiological outcome after unilateral fracture of the lateral process of the talus in 23 snowboarders with a mean follow-up of 3.5 years (12 to 76 months). In this consecutive cohort study both operative and non-operative cases were considered.

The mean American Orthopaedic Foot and Ankle Society hindfoot score was 94 (82 to 100). The non-operative group of seven with a minimally-displaced fracture scored higher (98 points) than the operative group of 16 with displaced or unstable fractures (93 points). In 88% of operative cases, significant concomitant hindfoot injuries were found at operation. All but eight (35%) patients (six operative and two non-operative) regained their pre-injury level of sporting activity. Subtalar osteoarthritis was present in nine (45%) of the 20 patients available for radiological review, including one late-diagnosed non-operative case and eight operative cases with associated injuries or fracture comminution.

The outcome after fracture of the lateral process of the talus in snowboarders is favourable provided an early diagnosis is made and adequate treatment, which is related to the degree of displacement and associated injuries, is undertaken.

The technical advances in arthroscopic surgery of the hip, including the improved ability to manage the capsule and gain extensile exposure, have been paralleled by a growth in the number of conditions that can be addressed. This expanding list includes symptomatic labral tears, chondral lesions, injuries of the ligamentum teres, femoroacetabular impingement (FAI), capsular laxity and instability, and various extra-articular disorders, including snapping hip syndromes. With a careful diagnostic evaluation and technical execution of well-indicated procedures, arthroscopic surgery of the hip can achieve successful clinical outcomes, with predictable improvements in function and pre-injury levels of physical activity for many patients.

This paper reviews the current position in relation to the use of arthroscopy in the treatment of disorders of the hip.

Cite this article: Bone Joint J 2013;95-B:10–19.

Chronic patellofemoral instability can be a disabling condition. Management of patients with this condition has improved owing to our increased knowledge of the functional anatomy of the patellofemoral joint. Accurate assessment of the underlying pathology in the unstable joint enables the formulation of appropriate treatment. The surgical technique employed in patients for whom non-operative management has failed should address the diagnosed abnormality. We have reviewed the literature on the stabilising features of the patellofemoral joint, the recommended investigations and the appropriate forms of treatment.

We present the case of a 15-year-old boy with symptoms due to Klippel–Feil syndrome. Radiographs and CT scans demonstrated basilar impression, occipitalisation of C1 and fusion of C2/C3. MRI showed ventral compression of the medullocervical junction. Skull traction was undertaken pre-operatively to determine whether the basilar impression could be safely reduced. During traction, the C3/C4 junction migrated 12 mm caudally and spasticity resolved. Peri-operative skull-femoral traction enabled posterior occipitocervical fixation without decompression. Following surgery, cervical alignment was restored and spasticity remained absent. One year after surgery he was not limited in his activities. The surgical strategy for patients with basilar impression and congenital anomalies remains controversial. The anterior approach with decompression is often recommended for patients with ventral compression of the medullocervical region, but such procedures are technically demanding and carry a significant risk of complications. Our surgical strategy was an alternative solution. Prior to a posterior cervical fixation, without decompression, skull traction was used to confirm that the deformity was reducible and effective in resolving associated myelopathy.

This brief annotation summarises the particular contributions made by the annual Edinburgh International Trauma Symposium in various areas of research into aspects of orthopaedic trauma and the management of acutely injured patients, during the 25 years since its establishment.

The purpose of this study was to evaluate the long-term functional and radiological outcomes of arthroscopic removal of unstable osteochondral lesions with subchondral drilling in the lateral femoral condyle. We reviewed the outcome of 23 patients (28 knees) with stage III or IV osteochondritis dissecans lesions of the lateral femoral condyle at a mean follow-up of 14 years (10 to 19). The functional clinical outcomes were assessed using the Lysholm score, which improved from a mean of 38.1 (sd 3.5) pre-operatively to a mean of 87.3 (sd 5.4) at the most recent review (p = 0.034), and the Tegner activity score, which improved from a pre-operative median of 2 (0 to 3) to a median of 5 (3 to 7) at final follow-up (p = 0.021). The radiological degenerative changes were evaluated according to Tapper and Hoover’s classification and when compared with the pre-operative findings, one knee had grade 1, 22 knees had grade 2 and five knees had grade 3 degenerative changes. The overall outcomes were assessed using Hughston’s rating scale, where 19 knees were rated as good, four as fair and five as poor.

We found radiological evidence of degenerative changes in the third or fourth decade of life at a mean of 14 years after arthroscopic excision of the loose body and subchondral drilling for an unstable osteochondral lesion of the lateral femoral condyle. Clinical and functional results were more satisfactory.

We studied the epidemiology of 401 fractures of the shaft of the humerus in 397 patients aged 16 years or older. The incidence was 14.5 per 100 000 per year with a gradually increasing age-specific incidence from the fifth decade, reaching almost 60 per 100 000 per year in the ninth decade. Most were closed fractures in elderly patients which had been sustained as the result of a simple fall. The age distribution in women was characterised by a peak in the eighth decade while that in men was more even. Simple fractures were by far the most common and most were located in the middle or proximal shaft. The incidence of palsy of the radial nerve was 8% and fractures in the middle and distal shaft were most likely to be responsible. Only 2% of the fractures were open and 8% were pathological. These figures are representative of a population with a low incidence of high-energy and penetrating trauma, which probably reflects the situation in most European countries.

We obtained pre-operative and six-month post-operative Oxford hip (OHS) and knee scores (OKS) for 1523 patients who underwent total hip replacement and 1784 patients who underwent total knee replacement. They all also completed a six-month satisfaction question.

Scatter plots showed no relationship between pre-operative Oxford scores and six-month satisfaction scores. Spearman’s rank correlation coefficients were -0.04 (95% confidence interval (CI) -0.09 to 0.01) between OHS and satisfaction and 0.04 (95% CI -0.01 to 0.08) between OKS and satisfaction. A receiver operating characteristic (ROC) curve analysis was used to identify a cut-off point for the pre-operative OHS/OKS that identifies whether or not a patient is satisfied with surgery. We obtained an area under the ROC curve of 0.51 (95% CI 0.45 to 0.56) for hip replacement and 0.56 (95% CI 0.51 to 0.60) for knee replacement, indicating that pre-operative Oxford scores have no predictive accuracy in distinguishing satisfied from dissatisfied patients.

In the NHS widespread attempts are being made to use patient-reported outcome measures (PROMs) data for the purpose of prioritising patients for surgery. Oxford hip and knee scores have no predictive accuracy in relation to post-operative patient satisfaction. This evidence does not support their current use in prioritising access to care.

We studied the prevalence of severe crouch gait over a 15-year period in a defined population of children with spastic diplegia and Gross Motor Function Classification System levels II and III, to determine if there had been a decrease following changes to the management of equinus gait. These changes were replacing observational with three-dimensional gait analysis, replacing single level with multilevel surgery, and replacing gastrocsoleus lengthening with gastrocnemius recession. Of 464 children and adolescents with spastic diplegia who underwent three-dimensional gait analysis, 27 had severe crouch gait. Seventeen of these had been managed by isolated lengthening of the gastrocsoleus. Following changes in the management of equinus gait, the prevalence of severe crouch gait decreased from 25% and stabilised at a significantly lower rate, fluctuating between 0% and 4% annually (p < 0.001).

We conclude that severe crouch gait in this population was precipitated by isolated lengthening of the gastrocsoleus. These findings may be relevant to other surgical populations, as severe crouch gait may be a useful way to monitor the quality of the surgical management of abnormal gait in children with cerebral palsy and spastic diplegia.

A displaced fracture of the scaphoid is one in which the fragments have moved from their anatomical position or there is movement between them when stressed by physiological loads. Displacement is seen in about 20% of fractures of the waist of the scaphoid, as shown by translation, a gap, angulation or rotation. A CT scan in the true longitudinal axis of the scaphoid demonstrates the shape of the bone and displacement of the fracture more accurately than do plain radiographs. Displaced fractures can be treated in a plaster cast, accepting the risk of malunion and nonunion. Surgically the displacement can be reduced, checked radiologically, arthroscopically or visually, and stabilised with headless screws or wires. However, rates of union and deformity are unknown. Mild malunion is well tolerated, but the long-term outcome of a displaced fracture that healed in malalignment has not been established.

This paper summarises aspects of the assessment, treatment and outcome of displaced fractures of the waist of the scaphoid.

Free vascularised fibular grafting has been reported to be successful for adult patients with osteonecrosis of the femoral head (ONFH). However, its benefit in teenage patients with post-traumatic ONFH has not been determined. We evaluated the effectiveness of free vascularised fibular grafting in the treatment of this condition in children and adolescents. We retrospectively analysed 28 hips in 28 patients in whom an osteonecrotic femoral head had been treated with free vascularised fibular grafting between 2002 and 2008. Their mean age was 16.3 years (13 to 19). The stage of the disease at time of surgery, and results of treatment including pre- and post-operative Harris hip scores, were studied. We defined clinical failure as conversion to total hip replacement. All patients were followed up for a mean of four years (2 to 7). The mean Harris hip score improved from 60.4 (37 to 84) pre-operatively to 94.2 (87 to 100) at final follow-up. At the latest follow-up we found improved or unchanged radiographs in all four initially stage II hips and in 23 of 24 stage III or IV hips. Only one hip (stage V) deteriorated. No patient underwent total hip replacement.

Free vascularised fibular grafting is indicated for the treatment of post-traumatic ONFH in teenage patients.

Pathological fractures of the humerus are associated with pain, morbidity, loss of function and a diminished quality of life. We report our experience of stabilising these fractures using polymethylmethacrylate and non-locking plates. We undertook a retrospective review over 20 years of patients treated at a tertiary musculoskeletal oncology centre. Those who had undergone surgery for an impending or completed pathological humeral fracture with a diagnosis of metastatic disease or myeloma were identified from our database. There were 63 patients (43 men, 20 women) in the series with a mean age of 63 years (39 to 87).

All had undergone intralesional curettage of the tumour followed by fixation with intramedullary polymethylmethacrylate and plating. Complications occurred in 14 patients (22.2%) and seven (11.1%) required re-operation. At the latest follow-up, 47 patients (74.6%) were deceased and 16 (25.4%) were living with a mean follow-up of 75 months (1 to 184). A total of 54 (86%) patients had no or mild pain and 50 (80%) required no or minimal assistance with activities of daily living. Of the 16 living patients none had pain and all could perform activities of daily living without assistance.

Intralesional resection of the tumour, filling of the cavity with cement, and plate stabilisation of the pathological fracture gives immediate rigidity and allows an early return of function without the need for bony union. The patient’s local disease burden is reduced, which may alleviate tumour-related pain and slow the progression of the disease. The cemented-plate technique provides a reliable option for the treatment of pathological fractures of the humerus.

Given the growing prevalence of obesity around the world and its association with osteoarthritis of the knee, orthopaedic surgeons need to be familiar with the management of the obese patient with degenerative knee pain. The precise mechanism by which obesity leads to osteoarthritis remains unknown, but is likely to be due to a combination of mechanical, humoral and genetic factors.

Weight loss has clear medical benefits for the obese patient and seems to be a logical way of relieving joint pain associated with degenerative arthritis. There are a variety of ways in which this may be done including diet and exercise, and treatment with drugs and bariatric surgery. Whether substantial weight loss can delay or even reverse the symptoms associated with osteoarthritis remains to be seen.

Surgery for osteoarthritis in the obese patient can be technically more challenging and carries a risk of additional complications. Substantial weight loss before undertaking total knee replacement is advisable. More prospective studies that evaluate the effect of significant weight loss on the evolution of symptomatic osteoarthritis of the knee are needed so that orthopaedic surgeons can treat this patient group appropriately.