We have compared three different methods of treating symptomatic non-traumatic tears of the supraspinatus tendon in patients above 55 years of age. A total of 180 shoulders (173 patients) with supraspinatus tendon tears were randomly allocated into one of three groups (each of 60 shoulders); physiotherapy (group 1), acromioplasty and physiotherapy (group 2) and rotator cuff repair, acromioplasty and physiotherapy (group 3). The Constant score was assessed and followed up by an independent observer pre-operatively and at three, six and twelve months after the intervention.

Of these, 167 shoulders were available for assessment at one year (follow-up rate of 92.8%). There were 55 shoulders in group 1 (24 in males and 31 in females, mean age 65 years (55 to 79)), 57 in group 2 (29 male and 28 female, mean age 65 years (55 to 79)) and 55 shoulders in group 3 (26 male and 29 female, mean age 65 years (55 to 81)). There were no between-group differences in the Constant score at final follow-up: 74.1 (sd 14.2), 77.2 (sd 13.0) and 77.9 (sd 12.1) in groups 1, 2 and 3, respectively (p = 0.34). The mean change in the Constant score was 17.0, 17.5, and 19.8, respectively (p = 0.34). These results suggest that at one-year follow-up, operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this condition.

Cite this article: Bone Joint J 2014;96-B:75–81.

Objectives

To report the five-year results of a randomised controlled trial examining the effectiveness of arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome.

Objectives

To conduct a pilot randomised controlled trial to evaluate the feasibility of conducting a larger trial to evaluate the difference in Victorian Institute of Sports Assessment-Achilles (VISA-A) scores at six months between patients with Achilles tendinopathy treated with a platelet-rich plasma (PRP) injection compared with an eccentric loading programme.

Aims

Oxidised zirconium was introduced as a material for femoral components in total knee arthroplasty (TKA) as an attempt to reduce polyethylene wear. However, the long-term survival of this component is not known.

There is conflicting evidence about the benefit of using corticosteroid in periarticular injections for pain relief after total knee arthroplasty (TKA). We carried out a double-blinded, randomised controlled trial to assess the efficacy of using corticosteroid in a periarticular injection to control pain after TKA.

A total of 77 patients, 67 women and ten men, with a mean age of 74 years (47 to 88) who were about to undergo unilateral TKA were randomly assigned to have a periarticular injection with or without corticosteroid. The primary outcome was post-operative pain at rest during the first 24 hours after surgery, measured every two hours using a visual analogue pain scale score. The cumulative pain score was quantified using the area under the curve.

The corticosteroid group had a significantly lower cumulative pain score than the no-corticosteroid group during the first 24 hours after surgery (mean area under the curve 139, 0 to 560, and 264, 0 to 1460; p = 0.024). The rate of complications, including surgical site infection, was not significantly different between the two groups up to one year post-operatively.

The addition of corticosteroid to the periarticular injection significantly decreased early post-operative pain. Further studies are needed to confirm the safety of corticosteroid in periarticular injection.

Take home message: The use of corticosteroid in periarticular injection offered better pain relief during the initial 24 hours after TKA.

Cite this article: Bone Joint J 2016;98-B:194–200.

Aims

The aims of this study were to estimate the cost of surgical treatment of fractures of the proximal humerus using a micro-costing methodology, contrast this cost with the national reimbursement tariff and establish the major determinants of cost.

Most published randomised controlled trials which compare the rates of wear of conventional and cross-linked (XL) polyethylene (PE) in total hip arthroplasty (THA) have described their use with a cementless acetabular component.

We conducted a prospective randomised study to assess the rates of penetration of two distinct types of PE in otherwise identical cemented all-PE acetabular components.

A total of 100 consecutive patients for THA were randomised to receive an acetabular component which had been either highly XL then remelted or moderately XL then annealed.

After a minimum of eight years follow-up, 38 hips in the XL group and 30 hips in the annealed group had complete data (mean follow-up of 9.1 years (7.6 to 10.7) and 8.7 years (7.2 to 10.2), respectively). In the XL group, the steady state rate of penetration from one year onwards was -0.0002 mm/year (sd 0.108): in the annealed group it was 0.1382 mm/year (sd 0.129) (Mann–Whitney U test, p < 0.001). No complication specific to either material was recorded.

These results show that the yearly linear rate of femoral head penetration can be significantly reduced by using a highly XLPE cemented acetabular component.

Cite this article: Bone Joint J 2015;97-B:1458–62.

Hip displacement, defined in this study as a migration percentage (MP) of more than 40%, is a common, debilitating complication of cerebral palsy (CP). In this prospective study we analysed the risk of developing hip displacement within five years of the first pelvic radiograph.

All children with CP in southern and western Sweden are invited to register in the hip surveillance programme CPUP. Inclusion criteria for the two groups in this study were children from the CPUP database born between 1994 and 2009 with Gross Motor Function Classification System (GMFCS) III to V. Group 1 included children who developed hip displacement, group 2 included children who did not develop hip displacement over a minimum follow-up of five years. A total of 145 children were included with a mean age at their initial pelvic radiograph of 3.5 years (0.6 to 9.7).

The odds ratio for hip displacement was calculated for GMFCS-level, age and initial MP and head-shaft angle. A risk score was constructed with these variables using multiple logistic regression analysis. The predictive ability of the risk score was evaluated using the area under the receiver operating characteristics curve (AUC).

All variables had a significant effect on the risk of a MP > 40%. The discriminatory accuracy of the CPUP hip score is high (AUC = 0.87), indicating a high ability to differentiate between high- and low-risk individuals for hip displacement. The CPUP hip score may be useful in deciding on further follow-up and treatment in children with CP.

Cite this article: Bone Joint J 2015;97-B:1441–4.

Aims

A pragmatic multicentre randomised controlled trial (PROFHER) was conducted in United Kingdom National Health Service (NHS) hospitals to evaluate the clinical effectiveness and cost effectiveness of surgery compared with non-surgical treatment for displaced fractures of the proximal humerus involving the surgical neck in adults.

Tibial nonunion represents a spectrum of conditions which are challenging to treat, and optimal management remains unclear despite its high rate of incidence. We present 44 consecutive patients with 46 stiff tibial nonunions, treated with hexapod external fixators and distraction to achieve union and gradual deformity correction. There were 31 men and 13 women with a mean age of 35 years (18 to 68) and a mean follow-up of 12 months (6 to 40). No tibial osteotomies or bone graft procedures were performed. Bony union was achieved after the initial surgery in 41 (89.1%) tibias. Four persistent nonunions united after repeat treatment with closed hexapod distraction, resulting in bony union in 45 (97.8%) patients. The mean time to union was 23 weeks (11 to 49). Leg-length was restored to within 1 cm of the contralateral side in all tibias. Mechanical alignment was restored to within 5° of normal in 42 (91.3%) tibias. Closed distraction of stiff tibial nonunions can predictably lead to union without further surgery or bone graft. In addition to generating the required distraction to achieve union, hexapod circular external fixators can accurately correct concurrent deformities and limb-length discrepancies.

Cite this article: Bone Joint J 2015;97-B:1417–22.

We have previously reported the short-term radiological results of a randomised controlled trial comparing kinematically aligned total knee replacement (TKR) and mechanically aligned TKR, along with early pain and function scores. In this study we report the two-year clinical results from this trial. A total of 88 patients (88 knees) were randomly allocated to undergo either kinematically aligned TKR using patient-specific guides, or mechanically aligned TKR using conventional instruments. They were analysed on an intention-to-treat basis. The patients and the clinical evaluator were blinded to the method of alignment.

At a minimum of two years, all outcomes were better for the kinematically aligned group, as determined by the mean Oxford knee score (40 (15 to 48) versus 33 (13 to 48); p = 0.005), the mean Western Ontario McMaster Universities Arthritis index (WOMAC) (15 (0 to 63) versus 26 (0 to 73); p = 0.005), mean combined Knee Society score (160 (93 to 200) versus 137 (64 to 200); p= 0.005) and mean flexion of 121° (100 to 150) versus 113° (80 to 130) (p = 0.002). The odds ratio of having a pain-free knee at two years with the kinematically aligned technique (Oxford and WOMAC pain scores) was 3.2 (p = 0.020) and 4.9 (p = 0.001), respectively, compared with the mechanically aligned technique. Patients in the kinematically aligned group walked a mean of 50 feet further in hospital prior to discharge compared with the mechanically aligned group (p = 0.044).

In this study, the use of a kinematic alignment technique performed with patient-specific guides provided better pain relief and restored better function and range of movement than the mechanical alignment technique performed with conventional instruments.

Cite this article: Bone Joint J 2014;96-B:907–13.

We report our experience of performing an elbow hemiarthroplasty in the treatment of comminuted distal humeral fractures in the elderly patients.

A cohort of 42 patients (three men and 39 women, mean age 72; 56 to 84) were reviewed at a mean of 34.3 months (24 to 61) after surgery. Functional outcome was measured with the Mayo Elbow Performance Score (MEPS) and range of movement. The disabilities of the arm, shoulder and hand questionnaire (DASH) was used as a patient rated evaluation. Complications and ulnar nerve function were recorded. Plain radiographs were obtained to assess prosthetic loosening, olecranon wear and heterotopic bone formation.

The mean extension deficit was 23.5° (0° to 60°) and mean flexion was 126.8° (90° to 145°) giving a mean arc of 105.5° (60° to 145°). The mean MEPS was 90 (50 to 100) and a mean DASH score of 20 (0 to 63). Four patients had additional surgery for limited range of movement and one for partial instability. One elbow was revised due to loosening, two patients had sensory ulnar nerve symptoms, and radiographic signs of mild olecranon wear was noted in five patients.

Elbow hemiarthroplasty for comminuted intra-articular distal humeral fractures produces reliable medium-term results with functional outcome and complication rates, comparable with open reduction and internal fixation and total elbow arthroplasty.

Cite this article: Bone Joint J 2015;97-B:1377–84.

This pilot study reports the clinical outcomes of a combination of partial subscapularis tendon transfer and small-head hemiarthroplasty in patients with rotatator cuff arthropathy. A total of 30 patients (30 shoulders; eight men and 22 women) with a mean age of 74 years (55 to 84) were assessed at a mean follow-up of 31 months (24 to 60). The inclusion criteria were painful cuff tear arthropathy with normal deltoid function and a non-degenerative subscapularis muscle and tendon and a preserved teres minor.

Outcome was assessed using the University of California Los Angeles score, the Japanese Orthopaedic Association score, and the Oxford Shoulder Score. Radiographic measurements included the centre of rotation distance and the length of the deltoid.

All clinical scores were significantly improved post-operatively. The active flexion and external rotation improved significantly at the most recent follow-up (p < 0.035). Although the mean centre of rotation distance changed significantly (p < 0.001), the mean length of the deltoid did not change significantly from the pre-operative value (p = 0.29). The change in the length of the deltoid with < 100° flexion was significantly less than that with > 100° (p < 0.001).

Progressive erosion of the glenoid was seen in four patients. No patient required revision or further surgery.

A combination of partial subscapularis tendon transfer and small-head hemiarthroplasty effectively restored function and relieved pain in patients with rotator cuff arthropathy.

Cite this article: 2015;97-B:1090–5.

This prospective study reports the 15-year survival and ten-year functional outcome of a consecutive series of 1000 minimally invasive Phase 3 Oxford medial UKAs (818 patients, 393 men, 48%, 425 women, 52%, mean age 66 years; 32 to 88). These were implanted by two surgeons involved with the design of the prosthesis to treat anteromedial osteoarthritis and spontaneous osteonecrosis of the knee, which are recommended indications. Patients were prospectively identified and followed up independently for a mean of 10.3 years (5.3 to 16.6).

At ten years, the mean Oxford Knee Score was 40 (standard deviation (sd) 9; 2 to 48): 79% of knees (349) had an excellent or good outcome. There were 52 implant-related re-operations at a mean of 5.5 years (0.2 to 14.7). The most common reasons for re-operation were arthritis in the lateral compartment (2.5%, 25 knees), bearing dislocation (0.7%, seven knees) and unexplained pain (0.7%, seven knees). When all implant-related re-operations were considered as failures, the ten-year rate of survival was 94% (95% confidence interval (CI) 92 to 96) and the 15-year survival rate 91% (CI 83 to 98). When failure of the implant was the endpoint the 15-year survival was 99% (CI 96 to 100).

This is the only large series of minimally invasive UKAs with 15-year survival data. The results support the continued use of minimally invasive UKA for the recommended indications.

Cite this article: Bone Joint J 2015;97-B:1493–99.

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.

This study compared the clinical outcomes following mini-open rotator cuff repair (MORCR) between early mobilisation and usual care, involving initial immobilisation. In total, 189 patients with radiologically-confirmed full-thickness rotator cuff tears underwent MORCR and were randomised to either early mobilisation (n = 97) or standard rehabilitation (n = 92) groups. Patients were assessed at six weeks and three, six, 12 and 24 months post-operatively. Six-week range of movement comparisons demonstrated significantly increased abduction (p = 0.002) and scapular plane elevation (p = 0.006) in the early mobilisation group, an effect which was not detectable at three months (p > 0.51) or afterwards. At 24 months post-operatively, patients who performed pain-free, early active mobilisation for activities of daily living showed no difference in clinical outcomes from patients immobilised for six weeks following MORCR. We suggest that the choice of rehabilitation regime following MORCR may be left to the discretion of the patient and the treating surgeon.

Cite this article: Bone Joint J 2015;97-B:1257–63.

Failed internal fixation of a fracture of the proximal humerus produces many challenges with limited surgical options. The aim of this study was to evaluate the clinical outcomes after the use of a reverse shoulder arthroplasty under these circumstances. Between 2007 and 2012, 19 patients (15 women and four men, mean age 66 years; 52 to 82) with failed internal fixation after a proximal humeral fracture, underwent implant removal and reverse shoulder arthroplasty (RSA). The mean follow-up was 36 months (25 to 60). The mean American Shoulder and Elbow Score improved from 27.8 to 50.1 (p = 0.019). The mean Simple Shoulder Test score improved from 0.7 to 3.2 (p = 0.020), and the mean visual analogue scale for pain improved from 6.8 to 4.3 (p = 0.012). Mean forward flexion improved from 58.7° to 101.1° (p < 0.001), mean abduction from 58.7° to 89.1° (p = 0.012), mean external rotation from 10.7° to 23.1° (p = 0.043) and mean internal rotation from buttocks to L4 (p = 0.034). A major complication was recorded in five patients (26%) (one intra-operative fracture, loosening of the humeral component in two and two peri-prosthetic fractures). A total of 15 patients (79%) rated their outcome as excellent or good, one (5%) as satisfactory, and three (16%) as unsatisfactory.

An improvement in outcomes and pain can be expected when performing a RSA as a salvage procedure after failed internal fixation of a fracture of the proximal humerus. Patients should be cautioned about the possibility for major complications following this technically demanding procedure.

Cite this article: Bone Joint J 2015;97-B:967–72.

A total of 80 patients with an acute rupture of tendo Achillis were randomised to operative repair using an open technique (39 patients) or non-operative treatment in a cast (41 patients). Patients were followed up for one year. Outcome measures included clinical complications, range of movement of the ankle, the Short Musculoskeletal Function Assessment (SMFA), and muscle function dynamometry evaluating dorsiflexion and plantar flexion of the ankle. The primary outcome measure was muscle dynamometry.

Re-rupture occurred in two of 37 patients (5%) in the operative group and four of 39 (10%) in the non-operative group, which was not statistically significant (p = 0.68). There was a slightly greater range of plantar flexion and dorsiflexion of the ankle in the operative group at three months which was not statistically significant, but at four and six months the range of dorsiflexion was better in the non-operative group, although this did not reach statistically significance either. After 12 weeks the peak torque difference of plantar flexion compared with the normal side was less in the operative than the non-operative group (47% vs 61%, respectively, p < 0.005). The difference declined to 26% and 30% at 26 weeks and 20% and 25% at 52 weeks, respectively. The difference in dorsiflexion peak torque from the normal side was less than 10% by 26 weeks in both groups, with no significant differences. The mean SMFA scores were significantly better in the operative group than the non-operative group at three months (15 vs 20, respectively, p < 0.03). No significant differences were observed after this, and at one year the scores were similar in both groups.

We were unable to show a convincing functional benefit from surgery for patients with an acute rupture of the tendo Achillis compared with conservative treatment in plaster.

There is no consensus on the benefit of arthroscopically assisted reduction of the articular surface combined with fixation using a volar locking plate for the treatment of intra-articular distal radial fractures. In this study we compared the functional and radiographic outcomes of fluoroscopically and arthroscopically guided reduction of these fractures.

Between February 2009 and May 2013, 74 patients with unilateral unstable intra-articular distal radial fractures were randomised equally into the two groups for treatment. The mean age of these 74 patients was 64 years (24 to 92). We compared functional outcomes including active range of movement of the wrist, grip strength and Disabilities of the Arm, Shoulder, and Hand scores at six and 48 weeks; and radiographic outcomes that included gap, step, radial inclination, volar angulation and ulnar variance.

There were no significant differences between the techniques with regard to functional outcomes or radiographic parameters. The mean gap and step in the fluoroscopic and arthroscopic groups were comparable at 0.9 mm (standard deviation (sd) 0.7) and 0.7 mm (sd 0.7) and 0.6 mm (sd 0.6) and 0.4 mm (sd 0.5), respectively; p = 0.18 and p = 0.35).

Arthroscopic reduction conferred no advantage over conventional fluoroscopic guidance in achieving anatomical reduction of intra-articular distal radial fractures when using a volar locking plate.

Cite this article: Bone Joint J 2015; 97-B:957–62.