1. A series of 142 fractures of the trochanteric region treated by fixation with Vitallium nail-plates of the original McLaughlin pattern is described. The hospital mortality was 9 per cent. Disruption of the nail-plate junction occurred in 8 per cent of cases. This confirms McLaughlin and Garcia's (1955) view that this pattern of nail-plate should no longer be used. 2. Despite this, satisfactory functional results were achieved in 78 per cent of the survivors. 3. The new Model V McLaughlin nail-plate is described, and the stresses in nail-plates are considered. On theoretical grounds and laboratory tests the weakness at the nail-plate junction has been eliminated in the new model, and the strength of the appliance as a whole compares favourably with other types of nail-plate. Full clinical trial is therefore justified, and seventy-one patients have so far been operated on, with satisfactory early results. 4. Marked stiffness of the hip joint greatly increases angulatory and rotational stresses on the nail-plate, and a high incidence of disruption is to be expected in these cases

Aims

The aim of this study was to investigate whether clinical and radiological outcomes after intramedullary nailing of displaced fractures of the fifth metacarpal neck using a single thick Kirschner wire (K-wire) are noninferior to those of technically more demanding fixation with two thinner dual wires.

Antibiotics are often administrated prophylactically in spinal procedures to reduce the risk of infection of the disc space. It is still not known which antibiotics are able to penetrate the intervertebral disc effectively. In a prospective, randomised, double-blind clinical study, we examined the penetration of the intervertebral discs of two commonly used antibiotics, cefuroxime and gentamicin. The patients, randomised into two groups, received either 1.5 g of cefuroxime or 5 mg/kg of gentamicin prophylactically two hours before their intervertebral discs were removed. A specimen of blood, from which serum antibiotic levels were determined, was obtained at the time of discectomy. Therapeutic levels of antibiotic were detectable in the intervertebral discs of the ten patients who received gentamicin. Only two of the ten patients (20%) who received cefuroxime had a quantifiable level of antibiotic in their discs although therapeutic serum levels of cefuroxime were found in all ten patients. Our results show that cefuroxime does not diffuse into human intervertebral discs as readily as gentamicin. It is possible that the charge due to ionisable groups on the antibiotics can influence the penetration of the antibiotics. We therefore recommend the use of gentamicin in a single prophylactic dose for all spinal procedures in order to reduce the risk of discitis

We have undertaken a randomized clinical trial comparing two methods of reconstruction of the anterior cruciate ligament in patients with chronic instability. We used an ipsilateral bone-patellar-tendon-bone autograft in 27 patients and the Ligament Advancement Reinforcement System (LARS) artificial ligament in 26. Assessment before and at two, six, 12 and 24 months after surgery, included the history, physical examination, a modified International Knee Documentation Committee (IKDC) score, the Tegner score, the Knee Injury and Osteoarthritis Outcome Score (KOOS) and instrumented laxity testing. There were no cases of reactive synovitis or of infection of the knee, and there was no difference regarding the failure rate between the two groups. The IKDC showed no significant differences between the two groups at any stage of the follow-up. The KOOS evaluation showed consistently better results in all subscales for the LARS group during the first year of follow-up. After 24 months these differences were no longer evident. Instrument-tested laxity was greater in the LARS group at all stages of follow-up, but the differences were not significant at 24 months. Our findings suggest that at follow-up at 24 months the LARS ligament seems to be a satisfactory treatment option, especially when an early return to high levels of activity is demanded

We undertook a prospective controlled clinical trial of 109 patients to determine whether postoperative blood salvage in patients undergoing total hip or knee arthroplasty decreased the need for transfusion with banked blood. The average amount of blood collected in our series was 493 ml, most of which was collected in the first four postoperative hours. In patients undergoing bilateral total knee arthroplasty, there was a 54% reduction in banked blood utilisation. None of our patients developed adverse effects from the reinfused material. The cost of collecting and processing wound drainage using the Haemolite cell washer was $175 per patient, regardless of the volume processed, compared to $125 for a unit of banked blood. By reducing the requirement for homologous transfusion, blood salvage diminishes the risks of transmission of HIV and hepatitis viruses. In those cases where the equivalent of two units of blood are reinfused, blood salvage saves money. However, due to the small amounts of blood collected in unilateral hip or knee arthroplasty, we do not recommend its routine application in these cases

Autologous chondrocyte implantation (ACI) and mosaicplasty are both claimed to be successful for the repair of defects of the articular cartilage of the knee but there has been no comparative study of the two methods. A total of 100 patients with a mean age of 31.3 years (16 to 49) and with a symptomatic lesion of the articular cartilage in the knee which was suitable for cartilage repair was randomised to undergo either ACI or mosaicplasty; 58 patients had ACI and 42 mosaicplasty. Most lesions were post-traumatic and the mean size of the defect was 4.66 cm. 2. The mean duration of symptoms was 7.2 years and the mean number of previous operations, excluding arthroscopy, was 1.5. The mean follow-up was 19 months (12 to 26). Functional assessment using the modified Cincinatti and Stanmore scores and objective clinical assessment showed that 88% had excellent or good results after ACI compared with 69% after mosaicplasty. Arthroscopy at one year demonstrated excellent or good repairs in 82% after ACI and in 34% after mosaicplasty. All five patellar mosaicplasties failed. Our prospective, randomised, clinical trial has shown significant superiority of ACI over mosaicplasty for the repair of articular defects in the knee. The results for ACI are comparable with those in other studies, but those for mosaicplasty suggest that its continued use is of dubious value

Ceramic bearings have several desirable properties, such as resistance to wear, hardness, and biocompatibility, that favour it as an articulating surface in hip arthroplasty. However, ceramic fracture remains a concern. We have reviewed the contemporary literature, addressing the factors that can influence the incidence of ceramic bearing surface fracture.

Cite this article: Bone Joint J 2019;101-B:897–901.

Objectives

The long head of the biceps (LHB) is often resected in shoulder surgery and could therefore serve as a cell source for tissue engineering approaches in the shoulder. However, whether it represents a suitable cell source for regenerative approaches, both in the inflamed and non-inflamed states, remains unclear. In the present study, inflamed and native human LHBs were comparatively characterized for features of regeneration.

Aims

The aim of this study was to evaluate blood metal ion levels, leucocyte profiles, and serum cytokines in patients with a total hip arthroplasty (THA) involving modular dual-mobility components.

Previous clinical studies have studied tibiofibular torsion by measuring the angular difference between a proximal (often bicondylar) plane and a distal bimalleolar plane. We measured the angular difference between the proximal and distal posterior tibial planes as defined by ultrasound scans. We found no significant torsional difference between the right and left tibiae of 87 normal children, nor between their different age groups. The mean external torsion of 58 legs with congenital talipes equinovarus was 18 degrees; significantly less than the mean 40 degrees in the normal children and 27 degrees in the clinically normal legs of the 22 patients with unilateral congenital talipes equinovarus. We did not confirm the previously reported increase in external torsion with increasing age. The relative internal tibial torsion we have demonstrated in patients with congenital talipes equinovarus must be differentiated from the posterior displacement of the distal fibula observed by others and which may result from manipulative treatment. The relative internal tibial torsion we found in the clinically normal legs of children with congenital talipes equinovarus is further evidence that in this condition the pathology is not confined to the clinically affected foot

We made a clinical study of polyethylene wear in 240 hips of 187 patients having primary total hip arthroplasties from 1989 to 1990, using uncemented Osteonics components, with a head size of 26 mm. We excluded cups with anteversion of over 20° and measured linear wear by a new method using a digitiser and special software of our design. Follow-up was from two to five years (mean 4.3). The mean age at operation was 50.3 years, with more men than women (1.4:1). The mean linear wear per year was 0.15 mm; this did not increase with the longevity of the prosthesis (p = 0.54). In 59 hips showing evidence of osteolysis, the mean linear wear rate was significantly higher at 0.23 mm/year (p < 0.001). The mean linear wear rate also correlated significantly with age at the time of operation (p = 0.008), but we found no significant correlations with body-weight, gender, aetiology of the disease, thickness of polyethylene, or cup position. Our new method of measurement is time-saving and reproducible. The results confirm the greater rate of linear wear of polyethylene in patients showing osteolysis and in those who are younger

We have developed criteria to determine the appropriate indications for lumbar laminectomy, using the standard procedure developed at the RAND corporation and the University of California at Los Angeles (RAND-UCLA). A panel of five surgeons and four physicians individually assessed 1000 hypothetical cases of sciatica, back pain only, symptoms of spinal stenosis, spondylolisthesis, miscellaneous indications or the need for repeat laminectomy. For the first round each member of the panel used a scale ranging from 1 (extremely inappropriate) to 9 (extremely appropriate). After discussion and condensation of the results into three categories laminectomy was considered appropriate in 11% of the 1000 theoretical scenarios, equivocal in 26% and inappropriate in 63%. There was some variation between the six categories of malalignment, but full agreement in 64% of the hypothetical cases. We applied these criteria retrospectively to the records of 196 patients who had had surgical treatment for herniated discs in one Swiss University hospital. We found that 48% of the operations were for appropriate indications, 29% for equivocal reasons and that 23% were inappropriate. The RAND-UCLA method is a feasible, useful and coherent approach to the study of the indications for laminectomy and related procedures, providing a number of important insights. Our conclusions now require validation by carefully designed prospective clinical trials, such as those which are used for new medical techniques

Aims

The aim of this study was to determine the risk of local recurrence and survival in patients with osteosarcoma based on the proximity of the tumour to the major vessels.

Aims

The primary aim of this study was to establish the cost-effectiveness of the early fixation of displaced midshaft clavicle fractures.

The final results up to 15 years are reported of clinical trials of the management of tuberculosis of the spine in Korea and Hong Kong. In Korea, 350 patients with active spinal tuberculosis were randomised to ambulatory chemotherapy or bed rest in hospital (in Masan) or a plaster-of-Paris jacket for nine months (in Pusan). Patients in both centres were also randomised to either PAS plus isoniazid for 18 months or to the same drugs plus streptomycin for the first three months. In Hong Kong, all 150 patients were treated with the three-drug regime and randomised to either radical excision of the spinal lesion with bone graft or open debridement. On average, the disease was more extensive in Korea, but at 15 years (or 13 or 14 years in a proportion of the patients in Korea) the great majority of patients in both countries achieved a favourable status, no evidence of CNS involvement, no radiological evidence of disease, no sinus or clinically evident abscess, and no restriction of normal physical activity. Most patients had already achieved a favourable status much earlier. The earlier results of these trials are confirmed by the long-term follow-up with no late relapse or late-onset paraplegia. The results of chemotherapy on an outpatient basis were not improved by bed rest or a plaster jacket and the only advantage of the radical operation was less late deformity compared with debridement. A second series of studies has shown that short-course regimes based on isoniazid and rifampicin are as effective as the 18-month regimes: ambulatory chemotherapy with these regimes should now be the main management of uncomplicated spinal tuberculosis

A study is presented of the aetiology and results of treatment in a group of 125 proven osteosarcomas present in children under fifteen years of age. These cases have been collected from the records of one English and six European treatment centres. There is a slight male preponderance, but the striking aetiological feature is the very high proportion of tumours of the long bones of the limbs (96 per cent). The two and a half and five year disease-free survival rates were respectively 15 and 12 per cent, with a further 9 per cent still living, but under observation for less than two and a half years. Evidence of metastasis after two and a half years is very unusual, but no child with a tumour of an axial or girdle bone lived this length of time. Although the differences in the results of the different methods of treatment employed are not statistically valid, the largest number of long survivors had been treated by early amputation, which method also provided the lowest rate of local tumour recurrences. Reasons are discussed which indicate that prompt ablation is the treatment of choice, perhaps with certain advantages in the light of recent advances in adjuvant treatment. The past situation in connection with childhood osteosarcoma certainly provides strong support for immediate carefully designed clinical trials of the new adjuvant methods cited

1 . An operation for strengthening the lateral abdominal muscles in children after poliomyelitis is described. It consists of transposition of the proximal part of the gluteus maximus, the tensor fasciae latae and the ilio-tibial band ("the pelvic deltoid" of Henry) to a chosen rib. 2. The results of this operation in eight consecutive cases of paralytic scoliosis, pelvic obliquity and thoraco-pelvic instability are assessed. 3. A "strong" motor allows the child to lift the pelvis against gravity, whereas with a "weak" motor the child is unable to do so efficiently. However, even a "weak" musculotendinous tendinous unit helps invariably in restoring the thoraco-pelvic stability, just as a weak "hamstring-into-patella" transplant stabilises the knee. 4. Those motors (gluteus maximus with or without tensor fasciae latae) that contract vigorously and move the free end of the ilio-tibial band for at least three centimetres on direct faradic stimulation with a bipolar electrode during the operation become ultimately strong and most efficient. 5. The unreliability of the clinical test of tensor fasciae latae in small children is discussed, and the advantage of using the gluteus maximus as the motor for the musculo-tendinous unit is emphasised. 6. Using the proximal half (or less) of the gluteus maximus for strengthening the lateral abdominal muscles does not seem to affect appreciably the strength of hip extension. This phenomenon may be explained with reasonable probability by the existence of a twofold insertion of that muscle

We report the findings from independent prospective clinical and laboratory-based joint-simulator studies of the performance of ceramic femoral heads of 22.225 mm diameter in cross-linked polyethylene (XLP) acetabular cups. We found remarkable qualitative and quantitative agreement between the clinical and simulator results for the wear characteristics with time, and confirmed that ceramic femoral heads penetrate the XLP cups at only about half the rate of otherwise comparable metal heads. In the clinical study, 19 hips in 17 patients were followed for an average of 77 months. In the hip-joint simulator a similar prosthesis was tested for 7.3 million cycles. Both clinical and simulator results showed relatively high rates of penetration over the first 18 months or 1.5 million cycles, followed by a very much lower wear thereafter. Once an initial bedding-in of 0.2 mm to 0.4 mm had taken place the subsequent rates of penetration were very small. The initial clinical wear during bedding-in averaged 0.29 mm/year; subsequent progression was an order of magnitude lower at about 0.022 mm/year, lower than the 0.07 mm/year in metal-to-UHMWP Charnley LFAs. Our results show the excellent tribological features of alumina-ceramic-to-XLP implants, and also confirm the value of well-designed joint simulators for the evaluation of total joint replacements

Proponents of the biological theory of aseptic loosening have in recent years tended to concentrate on the production and distribution of particulate ultra-high-molecular-weight polyethylene (UHMWPE) debris around the potential joint space. However, mechanical loading of cemented implants with the differing elastic moduli of metal stems, polymethylmethacrylate (PMMA) cement and bone can result in relative micromotion, implying the potential for production of metal and PMMA particles from the stem-cement interface by fretting wear. In order to investigate the production and biological reactivity of debris from this interface, PMMA and metal particulate debris was produced by sliding wear of PMMA pins containing barium sulphate and zirconium dioxide against a Vaquasheened stainless steel counterface. This debris was characterised by SEM, energy-dispersive analysis by X-ray (EDAX) and image analysis, then added to cell cultures of a human monocytic cell line, U937, and stimulation of pro-osteolytic cytokines measured by ELISA. Large quantities of PMMA cement debris were generated by the sliding wear of PMMA pins against Vaquasheened stainless steel plates in the method developed for this study. Both cements stimulated the release of pro-osteolytic TNFα from the U937 monocytic cell line, in a dose-dependent fashion. There was a trend towards greater TNFα release with Palacos cement than CMW cement at the same dose. Palacos particles also caused significant release of IL-6, another pro-osteolytic cytokine, while CMW did not. The particulate cement debris produced did not stimulate the release of GM-CSF or IL1β from the U937 cells. These results may explain the cytokine pathway responsible for bone resorption caused by particulate PMMA debris. Radio-opaque additives are of value in surgical practice and clinical studies to quantify the relevance of these in vitro findings are required before the use of cement containing radio-opacifier is constrained

Objectives

Prosthetic joint infection (PJI) is the most common cause of arthroplasty failure. However, infection is often difficult to detect by conventional bacterial cultures, for which false-negative rates are 23% to 35%. In contrast, 16S rRNA metagenomics has been shown to quantitatively detect unculturable, unsuspected, and unviable pathogens. In this study, we investigated the use of 16S rRNA metagenomics for detection of bacterial pathogens in synovial fluid (SF) from patients with hip or knee PJI.