We report the results of limb salvage for non-metastatic osteosarcoma of the distal tibia using resection arthrodesis, autogenous fibular graft and fixation by an Ilizarov external fixator. In six patients with primary osteosarcoma of the distal tibia who refused amputation, treatment with wide en bloc resection and tibiotalar arthrodesis was undertaken. The defect was reconstructed using non-vascularised free autogenous fibular strut graft in three patients and a vascularised pedicular fibular graft in three, all supplemented with iliac cancellous graft at the graft-host junction. An Ilizarov external fixator was used for stabilisation of the reconstruction. In five patients sound fusion occurred at a mean of 13.2 months (8 to 20) with no evidence of local recurrence or deep infection at final follow-up. The mean post-operative functional score was 70% (63% to 73%) according to the Musculoskeletal Tumour Society scoring system. All five patients showed graft hypertrophy. Union of the graft was faster in cases reconstructed by vascularised fibular grafts. One patient who had a poor response to pre-operative chemotherapy developed local tumour recurrence at one year post-operatively and required subsequent amputation

Aims

The primary aim of this study was to assess whether patient satisfaction one year after total knee arthroplasty (TKA) changed with longer follow-up. The secondary aims were to identify predictors of satisfaction at one year, persistence of patient dissatisfaction, and late onset dissatisfaction in patients that were originally satisfied at one year.

Fractures of the distal third of the humerus may be complicated by complete lesions of the radial nerve which may be entrapped or compressed by bone fragments. Indirect reduction and internal fixation may result in a permanent nerve lesion. We describe the treatment of these lesions by insertion of a bridge plate using the minimally-invasive percutaneous technique. Six patients were operated on and showed complete functional recovery. Healing of the fractures occurred at a mean of 2.7 months (2 to 3) and complete neurological recovery by a mean of 2.3 months (1 to 5). In one patient infection occurred which resolved after removal of the implant

The Acclaim total elbow replacement is a modular system which allows implantation in both unlinked and linked modes. The results of the use of this implant in primary total elbow replacement in 36 patients, operated on between July 2000 and August 2002, are presented at a mean follow-up of 36 months (24 to 49). Only one patient did not have good relief of pain, but all had improved movement and function. No implant showed clinical or radiological loosening, although one had a lucent area in three of seven humeral zones. The short-term results of the Acclaim total elbow replacement are encouraging. However, 11 patients (30.5%) suffered an intra-operative fracture of the humeral condyle. This did not affect the outcome, or the requirement for further surgery, except in one case where the fracture failed to unite. This problem has hopefully been addressed by redesigning the humeral resection guide. Other complications included three cases of ulnar neuropathy (8.3%) and one of deep infection (2.8%)

We have evaluated the use of a synthetic porous ceramic (Triosite) as a substitute for bone graft in posterior spinal fusion for idiopathic scoliosis. In a prospective, randomised study 341 patients at five hospitals in the UK and France were randomly allocated either to autograft from the iliac crest or rib segments (171) or to receive Triosite blocks (170). All patients were assessed after operation and at 3, 6, 12 and 18 months. The two groups were similar with regard to all demographic and baseline variables, but the 184 treated in France (54%) had Cotrel-Dubouset instrumentation and the 157 treated in the UK usually had Harrington-Luque implants. In the Triosite group the average Cobb angle of the upper curve was 56°, corrected to 24° (57%). At 18 months, the average was 26° (3% loss). In the autograft group the average preoperative upper curve of 53° was corrected to 21° (60%). At 18 months the mean curve was 25° (8% loss). Pain levels after operation were similar in the two groups, being mild in most cases. In the Triosite group only three patients had problems of wound healing, but in the autograft group, 14 patients had delayed healing, infection or haematoma in the spinal wound. In addition, 15 autograft patients had pain at the donor site at three months. Seven had infections, two had haematoma and four had delayed healing. The haematological and serum biochemistry results showed no abnormal trends and no significant differences between the groups. There were no adverse events related to the graft material and no evidence of allergenicity. Our results suggest that Triosite synthetic porous ceramic is a safe and effective substitute for autograft in these patients. Histological findings on biopsy indicate that Triosite provides a favourable scaffolding for the formation of new bone and is gradually incorporated into the fusion mass

We reviewed the clinical and radiological results of 131 patients who underwent acetabular revision for aseptic loosening with impacted bone allograft and a cemented acetabular component. The mean follow-up was 51.7 months (24 to 156). The mean post-operative Merle D’Aubigné and Postel scores were 5.7 points (4 to 6) for pain, 5.2 (3 to 6) for gait and 4.5 (2 to 6) for mobility. Radiological evaluation revealed migration greater than 5 mm in four acetabular components. Radiological failure matched clinical failure. Asymptomatic radiolucent lines were observed in 31 of 426 areas assessed (7%). Further revision was required in six patients (4.5%), this was due to infection in three and mechanical failure in three. The survival rate for the reconstruction was 95.8% (95% confidence interval 92.3 to 99.1) overall, and 98%, excluding revision due to sepsis. Our study, from an independent centre, has reproduced the results of the originators of the method

1. The results have been reported of total hip replacement by a low-friction technique using high-density polyethylene for the acetabular component in 379 primary interventions, performed between November 1962 and December 1965 and followed for between four and seven years. 2. Apart from failures due to infection, the rate of which in the era under review was 3·8 per cent, late failures from mechanical causes were unusual after total hip replacement by this technique. When the socket was cemented in position, which is now routine, the late mechanical failure from all causes was only 1·3 per cent in 210 cases. 3. As regards the quality of the results and their maintenance over the years, the results were so good (Table X) that it was unnecessary to distinguish an intermediate class of "improvement" between success and failure. 4. As regards relief of pain and ability to walk, the average final rating, on a scale numbered 1 to 6, was 5·9 for both, indicating 90 per cent of patients in Grade 6 (excellent) and only 10 per cent in Grade 5 (good). 5. The average recovery of movement was not as spectacular and was influenced considerably by the pre-operative range, but in all cases that range was improved on. Even starting with the stiffest of hips about one patient in four regained a right angle of flexion movement. There was no tendency to lose movement with the passage of time. 6. As regards late infection (2·2 per cent out of a total of 3·8 per cent), the various findings tend to exonerate cement as a cause. 7. The mechanical details of the technique became stabilised in the period 1959 to 1962 in the Teflon era, and with the exception of improved methods of reattachment of the greater trochanter, they are identical with our current practice in 1971

The outcome at ten years of 100 Freeman hip stems (Finsbury Orthopaedics, Leatherhead, United Kingdom) retaining the neck with a proximal hydroxyapatite coating in a series of 52 men (six bilateral) and 40 women (two bilateral), has been described previously. None required revision for aseptic loosening. We have extended the follow-up to 20 years with a minimum of 17 years. The mean age of the patients at total hip replacement was 58.9 years (19 to 84). Six patients were lost to follow-up, but were included up to their last clinical review. A total of 22 patients (22 hips) had died, all from causes unrelated to their surgery. There have been 43 re-operations for failure of the acetabular component. However, in 38 of these the stem was not revised since it remained stable and there was no associated osteolysis. Two of the revisions were for damage to the trunnion after fracture of a modular ceramic head, and in another two, removal of the femoral component was because of the preference of the surgeon. In all cases the femoral component was well fixed, but could be extracted at the time of acetabular revision. In one case both components were revised for deep infection. There has been one case of aseptic loosening of the stem which occurred at 14 years. This stem had migrated distally by 7.6 mm in ten years and 8.4 mm at the time of revision at which stage it was found to be rotationally loose. With hindsight this component had been undersized at implantation. The survivorship for the stem at 17 years with aseptic loosening as the endpoint was 98.6% (95% confidence interval 95.9 to 100) when 62 hips were at risk. All remaining stems had a satisfactory clinical and radiological outcome. The Freeman proximally hydroxyapatite-coated femoral component is therefore a dependable implant and its continued use can be recommended

We treated 34 patients with recurrent dislocation of the hip with a constrained acetabular component. Roentgen stereophotogrammetric analysis was performed to assess migration of the prosthesis. The mean clinical follow-up was 3.0 years (2.2 to 4.8) and the radiological follow-up was 2.7 years (2.0 to 4.8). At the latest review six patients had died and none was lost to follow-up. There were four acetabular revisions, three for aseptic loosening and one for deep infection. Another acetabular component was radiologically loose with progressive radiolucent lines in all Gruen zones and was awaiting revision. The overall rate of aseptic loosening was 11.8% (4 of 34). Roentgen stereophotogrammetric analysis in the non-revised components confirmed migration of up to 1.06 mm of translation and 2.32° of rotation at 24 months. There was one case of dislocation and dissociation of the component in the same patient. Of the 34 patients, 33 (97.1%) had no further episodes of dislocation. The constrained acetabular component reported in our study was effective in all but one patient with instability of the hip, but the rate of aseptic loosening was higher than has been reported previously and requires further investigation

Aims

The outcome of total knee arthroplasty (TKA) is not always satisfactory. The purpose of this study was to identify satisfaction and biomechanical features characterising the gait of patients who had undergone TKA with either an anatomical single radius design or a medial pivot design. We hypothesised that the latter would provide superior function.

Aims

To address the natural history of severe post-tuberculous (TB) kyphosis, with focus upon the long-term neurological outcome, occurrence of restrictive lung disease, and the effect on life expectancy.

Aims

To determine the outcomes following revision surgery of metal-on-metal hip arthroplasties (MoMHA) performed for adverse reactions to metal debris (ARMD), and to identify factors predictive of re-revision.

Pathological fractures due to metastasis with destruction of the acetabulum and central dislocation of the hip present a difficult surgical challenge. We describe a series using a single technique in which a stable and long-lasting reconstruction was obtained using standard primary hip replacement implants augmented by strong, fully-threaded steel rods with cement and steel mesh, where required. Between 1997 and 2006, 19 patients with a mean age of 66 years (48 to 83) were treated using a modified Harrington technique. Acetabular destruction was graded as Harrington class II in six cases and class III in 13. Reconstruction was achieved using three 6.5 mm rods inserted through a separate incision in the iliac crest followed by augmentation with cement and a conventional cemented Charnley or Exeter primary hip replacement. There were no peri-operative deaths. At the final follow-up (mean 25 months (5 to 110)) one rod had fractured and one construct required revision. Of the 18 patients who did not require revision, 13 had died. The mean time to death was 16 months (5 to 55). The mean follow-up of the five survivors was 31 months (18 to 47). There were no cases of dislocation, deep infection or injury to a nerve, the blood vessels or the bladder

Aims

This 501-patient, multi-centre, randomised controlled trial sought to establish the effect of low-intensity, pulsed, ultrasound (LIPUS) on tibial shaft fractures managed with intramedullary nailing. We conducted an economic evaluation as part of this trial.