Orientation of the native acetabular plane as defined by the transverse acetabular ligament (TAL) and the posterior labrum was measured intra-operatively using computer-assisted navigation in 39 hips. In order to assess the influence of alignment on impingement, the range of movement was calculated for that defined by the TAL and the posterior labrum and compared with a standard acetabular component position (abduction 45°/anteversion 15°).

With respect to the registration of the plane defined by the TAL and the posterior labrum, there was moderate interobserver agreement (r = 0.64, p < 0.001) and intra-observer reproducibility (r = 0.73, p < 0.001). The mean acetabular component orientation achieved was abduction of 41° (32° to 51°) and anteversion of 18° (−1° to 36°). With respect to the Lewinnek safe zone (abduction 40° ±10°, anteversion 15° ±10°), 35 of the 39 acetabular components were within this zone. However, there was no improvement in the range of movement (p = 0.94) and no significant difference in impingement (p = 0.085).

Alignment of the acetabular component with the TAL and the posterior labrum might reduce the variability of acetabular component placement in total hip replacement. However, there is only a moderate interobserver agreement and intra-observer reliability in the alignment of the acetabular component using the TAL and the posterior labrum. No reduction in impingement was found when the acetabular component was aligned with the TAL and the posterior labrum, compared with a standard acetabular component position.

The efficacy of circumpatellar electrocautery in reducing the incidence of post-operative anterior knee pain is unknown. We conducted a single-centre, outcome-assessor and patient-blinded, parallel-group, randomised, controlled trial to compare circumpatellar electrocautery with no electrocautery in total knee replacement in the absence of patellar resurfacing. Patients requiring knee replacement for primary osteoarthritis were randomly assigned circumpatellar electrocautery (intervention group) or no electrocautery (control group). The primary outcome measure was the incidence of anterior knee pain. A secondary measure was the standardised clinical and patient-reported outcomes determined by the American Knee Society scores and the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index. A total of 131 knees received circumpatellar electrocautery and 131 had no electrocautery.

The overall incidence of anterior knee pain at follow-up at one year was 26% (20% to 31%), with 19% (12% to 26%) in the intervention group and 32% (24% to 40%) in the control group (p = 0.02). The relative risk reduction from electrocautery was 40% (9% to 61%) and the number needed to treat was 7.7 (4.3 to 41.4). The intervention group had a better mean total WOMAC score at follow-up at one year compared with the control group (16.3 (0 to 77.7) versus 21.6 (0 to 76.7), p = 0.04). The mean post-operative American Knee Society knee scores and function scores were similar in the intervention and control groups (knee score: 92.4 (55 to 100) versus 90.4 (51 to 100), respectively (p = 0.14); function score: 86.5 (15 to 100) versus 84.5 (30 to 100), respectively (p = 0.49)).

Our study suggests that in the absence of patellar resurfacing electrocautery around the margin of the patella improves the outcome of total knee replacement.

We report the results of intramedullary leg lengthening conducted between 2002 and 2009 using the Intramedullary Skeletal Kinetic Distractor in 69 unilateral lengthenings involving 58 femora and 11 tibiae. We identified difficulties that occurred during the treatment and assessed whether they were specifically due to the implant or independent of it. Paley’s classification for evaluating problems, obstacles and complications with external fixators was adopted, and implant-specific difficulties were continuously noted. There were seven failures requiring premature removal of the device, in four due to nail breakage and three for other reasons, and five unsuccessful outcomes after completion of the lengthening. In all, 116 difficulties were noted in 45 patients, with only 24 having problem-free courses. In addition to the difficulties arising from the use of external fixators, there were almost the same number again of implant-specific difficulties.

Nevertheless, successful femoral lengthening was achieved in 52 of the 58 patients (90%). However, successful tibial lengthening was only achieved in five of 11 patients (45%).

We report the case of a 22-year-old woman who underwent plate and screw fixation for a traumatic left acetabular fracture and fixation with cancellous screws for an associated femoral neck fracture. Two months later, the internal fixation became infected and was removed. This resulted in a painful high dislocation of the hip. We solved the problem with continuous soft-tissue distraction using a fully implantable motorised distraction nail in order to reduce the proximal femur prior to total hip arthroplasty. To our knowledge, this is the first time that reduction of a high dislocation of the hip has been performed using such a system.

We present a patient who underwent delayed sub-periosteal hemipelvectomy for control of infection and to enable soft-tissue cover after trauma. At four months after amputation, clinical examination and radiographs demonstrated almost complete re-ossification of the hemipelvis. This has allowed the patient to regain sitting balance and to use a walking prosthesis designed for patients following disarticulation of the hip. After 14 months from injury, no perineal hernia has developed, and no dysfunction of pelvic organs is attributable to heterotopic bone formation or adhesions.

The patient’s mobility with a prosthesis is similar to that expected of a through-hip amputee.

Over recent years hip arthroscopic surgery has evolved into one of the most rapidly expanding fields in orthopaedic surgery. Complications are largely transient and incidences between 0.5% and 6.4% have been reported. However, major complications can and do occur. This article analyses the reported complications and makes recommendations based on the literature review and personal experience on how to minimise them.

It has been suggested that a supramalleolar osteotomy can return the load distribution in the ankle joint to normal. However, due to the lack of biomechanical data, this supposition remains empirical. The purpose of this biomechanical study was to determine the effect of simulated supramalleolar varus and valgus alignment on the tibiotalar joint pressure, in order to investigate its relationship to the development of osteoarthritis. We also wished to establish the rationale behind corrective osteotomy of the distal tibia.

We studied 17 cadaveric lower legs and quantified the changes in pressure and force transfer across the tibiotalar joint for various degrees of varus and valgus deformity in the supramalleolar area. We assumed that a supramalleolar osteotomy which created a varus deformity of the ankle would result in medial overload of the tibiotalar joint. Similarly, we thought that creating a supramalleolar valgus deformity would cause a shift in contact towards the lateral side of the tibiotalar joint. The opposite was observed. The restricting role of the fibula was revealed by carrying out an osteotomy directly above the syndesmosis. In end-stage ankle osteoarthritis with either a valgus or varus deformity, the role of the fibula should be appreciated and its effect addressed where appropriate.

Twenty patients underwent simultaneous bilateral medial unicompartmental knee arthroplasty. Pre-operative hip-knee-ankle alignment and valgus stress radiographs were used to plan the desired post-operative alignment of the limb in accordance with established principles for unicompartmental arthroplasty. In each patient the planned alignment was the same for both knees. Overall, the mean planned post-operative alignment was to 2.3° of varus (0° to 5°).

The side and starting order of surgery were randomised, using conventional instrumentation for one knee and computer-assisted surgery for the opposite side.

The mean variation between the pre-operative plan and the achieved correction in the navigated and the non-navigated limb was 0.9° (sd 1.1; 0° to 4°) and 2.8° (sd 1.4; 1° to 7°), respectively. Using the Wilcoxon signed rank test, we found the difference in variation statistically significant (p < 0.001).

Assessment of lower limb alignment in the non-navigated group revealed that 12 (60%) were within ± 2° of the pre-operative plan, compared to 17 (87%) of the navigated cases.

Computer-assisted surgery significantly improves the post-operative alignment of medial unicompartmental knee arthroplasty compared to conventional techniques in patients undergoing bilateral simultaneous arthroplasty. Improved alignment after arthroplasty is associated with better function and increased longevity.

We investigated factors that were thought to be associated with an increased incidence of squeaking of ceramic-on-ceramic total hip replacements. Between June 1997 and December 2008 the three senior authors implanted 2406 primary total hip replacements with a ceramic-on-ceramic bearing surface. The mean follow-up was 10.6 years. The diagnosis was primary osteoarthritis in each case, and no patient had undergone previous surgery to the hip. We identified 74 squeaking hips (73 patients) giving an incidence of 3.1% at a mean follow-up of 9.5 years (4.1 to 13.3).

Taller, heavier and younger patients were significantly more likely to have hips that squeaked. Squeaking hips had a significantly higher range of post-operative internal (p = 0.001) and external rotation (p = 0.003) compared with silent hips. Patients with squeaking hips had significantly higher activity levels (p = 0.009). A squeaking hip was not associated with a significant difference in patient satisfaction (p = 0.24) or Harris hip score (p = 0.34). Four implant position factors enabled good prediction of squeaking. These were high acetabular component inclination, high femoral offset, lateralisation of the hip centre and either high or low acetabular component anteversion.

This is the largest study to date to examine patient factors and implant position factors that predispose to squeaking of a ceramic-on-ceramic hip. The results suggest that factors which increase the mechanical forces across the hip joint and factors which increase the risk of neck-to-rim impingement, and therefore edge-loading, are those that predispose to squeaking.

We studied 24 children (40 feet) to demonstrate that a physiotherapist-delivered Ponseti service is as successful as a medically-led programme in obtaining correction of an idiopathic congenital talipes equinovarus deformity. The median Pirani score at the start of treatment was 5.5 (mean 4.75; 2 to 6). A Pirani score of ≥5 predicted the need for tenotomy (p < 0.01). Of the 40 feet studied, 39 (97.5%) achieved correction of deformity. The remaining foot required surgical correction. A total of 25 (62.5%) of the feet underwent an Achilles tenotomy, which was performed by a surgeon in the physiotherapy clinic. There was full compliance with the foot abduction orthoses in 36 (90%) feet. Continuity of care was assured, as one practitioner was responsible for all patient contact. This was rated highly by the patient satisfaction survey.

We believe that the Ponseti technique is suitable for use by non-medical personnel, but a holistic approach and good continuity of care are essential to the success of the programme.

We analysed the long-term clinical and radiological results of 63 uncemented Low Contact Stress total knee replacements in 47 patients with rheumatoid arthritis. At a mean follow-up of 12.9 years (10 to 16), 36 patients (49 knees) were still alive; three patients (five knees) were lost to follow-up. Revision was necessary in three knees (4.8%) and the rate of infection was 3.2%. The mean clinical and functional Knee Society scores were 90 (30 to 98) and 59 (25 to 90), respectively, at final follow-up and the mean active range of movement was 104° (55° to 120°). The survival rate was 94% at 16 years but 85.5% of patients lost to follow-up were considered as failures. Radiological evidence of impending failure was noted in one knee.

The aim of this study was to determine the comorbid risk factors for failure in young patients who undergo fixation of a displaced fracture of the femoral neck. We identified from a prospective database all such patients ≤ 60 years of age treated with reduction and internal fixation. The main outcome measures were union, failure of fixation, nonunion and the development of avascular necrosis.

There were 122 patients in the study. Union occurred in 83 patients (68%) at a mean follow-up of 58 months (18 to 155). Complications occurred in 39 patients (32%) at a mean of 11 months (0.5 to 39). The rate of nonunion was 7.4% (n = 9) and of avascular necrosis was 11.5% (n = 14). Failures were more common in patients over 40 years of age (p = 0.03). Univariate analysis identified that delay in time to fixation (> 24 hours), alcohol excess and pre-existing renal, liver or respiratory disease were all predictive of failure (all p < 0.05). Of these, alcohol excess, renal disease and respiratory disease were most predictive of failure on multivariate analysis.

Younger patients with fractures of the femoral neck should be carefully evaluated for comorbidities that increase the risk of failure after reduction and fixation. In patients with a history of alcohol abuse, renal or respiratory disease, arthroplasty should be considered as an alternative treatment.

This study validates the short-form WOMAC function scale for assessment of conservative treatment of osteoarthritis of the knee. Data were collected before treatment and six and nine months later, from 100 patients with osteoarthritis of the knee to determine the validity, internal consistency, test-retest reliability, floor and ceiling effects, and responsiveness of the short-form WOMAC function scale. The scale showed high correlation with the traditional WOMAC and other measures. The internal consistency was good (Cronbach α: 0.88 to 0.95) and an excellent test-retest reliability was found (Lin’s concordance correlation coefficient (ρ_c): 0.85 to 0.94). The responsiveness was adequate and comparable to that of the traditional WOMAC (standardised response mean 0.56 to 0.44 and effect size 0.64 to 0.57) and appeared not to be significantly affected by floor or ceiling effects (0% and 7%, respectively).

The short-form WOMAC function scale is a valid, reliable and responsive alternative to the traditional WOMAC in the evaluation of patients with osteoarthritis of the knee managed conservatively. It is simple to use in daily practice and is therefore less of a burden for patients in clinical trials.

Polished, tapered stems are now widely used for cemented total hip replacement and many such designs have been introduced. However, a change in stem geometry may have a profound influence on stability. Stems with a wide, rectangular proximal section may be more stable than those which are narrower proximally. We examined the influence of proximal geometry on stability by comparing the two-year migration of the Exeter stem with a more recent design, the CPS-Plus, which has a wider shoulder and a more rectangular cross-section. The hypothesis was that these design features would increase rotational stability.

Both stems subsided approximately 1 mm relative to the femur during the first two years after implantation. The Exeter stem was found to rotate into valgus (mean 0.2°, sd 0.42°) and internally rotate (mean 1.28°, sd 0.99°). The CPS-Plus showed no significant valgus rotation (mean 0.2°, sd 0.42°) or internal rotation (mean −0.03°, sd 0.75°). A wider, more rectangular cross-section improves rotational stability and may have a better long-term outcome.

We present the results of the surgical correction of lower-limb deformities caused by metabolic bone disease. Our series consisted of 17 patients with a diagnosis of hypophosphataemic rickets and two with renal osteodystrophy; their mean age was 25.6 years (14 to 57). In all, 43 lower-limb segments (27 femora and 16 tibiae) were osteotomised and the deformity corrected using a monolateral external fixator. The segment was then stabilised with locked intramedullary nailing. In addition, six femora in three patients were subsequently lengthened by distraction osteogenesis. The mean follow-up was 60 months (18 to 120). The frontal alignment parameters (the mechanical axis deviation, the lateral distal femoral angle and the medial proximal tibial angle) and the sagittal alignment parameters (the posterior distal femoral angle and the posterior proximal tibial angle) improved post-operatively. The external fixator was removed either at the end of surgery or at the end of the lengthening period, allowing for early mobilisation and weight-bearing. We encountered five problems and four obstacles in the programme of treatment.

The use of intramedullary nails prevented recurrence of deformity and refracture.

We reviewed the clinical outcome of arthroscopic femoral osteochondroplasty for cam femoroacetabular impingement performed between August 2005 and March 2009 in a series of 40 patients over 60 years of age. The group comprised 26 men and 14 women with a mean age of 65 years (60 to 82). The mean follow-up was 30 months (12 to 54).

The mean modified Harris hip score improved by 19.2 points (95% confidence interval 13.6 to 24.9; p < 0.001) while the mean non-arthritic hip score improved by 15.0 points (95% confidence interval 10.9 to 19.1, p < 0.001). Seven patients underwent total hip replacement after a mean interval of 12 months (6 to 24 months) at a mean age of 63 years (60 to 70). The overall level of satisfaction was high with most patients indicating that they would undergo similar surgery in the future to the contralateral hip, if indicated. No serious complications occurred.

Arthroscopic femoral osteochondroplasty performed in selected patients over 60 years of age, who have hip pain and mechanical symptoms resulting from cam femoroacetabular impingement, is beneficial with a minimal risk of complications at a mean follow-up of 30 months.

Bicruciate-stabilised total knee replacement (TKR) aims to restore normal kinematics by replicating the function of both cruciate ligaments. We performed a prospective, randomised controlled trial in which bicruciate- and posterior-stabilised TKRs were implanted in 13 and 15 osteo-arthritic knees, respectively. The mean age of the bicruciate-stabilised group was 63.9 years (sd 10.00) and that of the posterior-stabilised group 63.2 years (sd 6.7). A control group comprised 14 normal subjects with a mean age of 67.9 years (sd 7.9). The patellar tendon angle (PTA) was measured one week pre-operatively and at seven weeks post-operatively during knee extension, flexion and step-up exercises.

At near full extension during step-up, the bicruciate-stabilised TKR produced a higher mean PTA than the posterior-stabilised TKR, indicating that the bicruciate design at least partially restored the kinematic role of the anterior cruciate ligament. The bicruciate-stabilised TKR largely restored the pre-operative kinematics, whereas the posterior-stabilised TKR resulted in a consistently lower PTA at all activities. The PTA in the pre-operative knees was higher than in the control group during the step-up and at near full knee extension. Overall, both groups generated a more normal PTA than that seen in previous studies in high knee flexion. This suggested that both designs of TKR were more effective at replicating the kinematic role of the posterior cruciate ligament than those used in previous studies.

We examined prospectively collected data from 6782 consecutive hip fractures and identified 327 fractures in 315 women aged ≤65 years. We report on their demographic characteristics, treatment and outcome and compare them with a cohort of 4810 hip fractures in 4542 women aged > 65 years.

The first significant increase in age-related incidence of hip fracture was at 45, rather than 50, which is when screening by the osteoporosis service starts in most health areas. Hip fractures in younger women are sustained by a population at risk as a result of underlying disease. Mortality of younger women with hip fracture was 46 times the background mortality of the female population. Smoking had a strong influence on the relative risk of ‘early’ (≤ 65 years of age) fracture.

Lag screw fixation was the most common method of operative treatment. General complication rates were low, as were re-operation rates for cemented prostheses. Kaplan-Meier implant survivorship of displaced intracapsular fractures treated by reduction and lag screw fixation was 71% (95% confidence interval 56 to 81) at five years. The best form of treatment remains controversial.

We examined the reliability of radiological findings in predicting segmental instability in 112 patients (56 men, 56 women) with a mean age of 66.5 years (27 to 84) who had degenerative disease of the lumbar spine. They underwent intra-operative biomechanical evaluation using a new measurement system. Biomechanical instability was defined as a segment with a neutral zone > 2 mm/N. Risk factor analysis to predict instability was performed on radiographs (range of segmental movement, disc height), MRI (Thompson grade, Modic type), and on the axial CT appearance of the facet (type, opening, vacuum and the presence of osteophytes, subchondral erosion, cysts and sclerosis) using multivariate logistic regression analysis with a forward stepwise procedure. The facet type was classified as sagittally orientated, coronally orientated, anisotropic or wrapped.

Stepwise multivariate regression analysis revealed that facet opening was the strongest predictor for instability (odds ratio 5.022, p = 0.009) followed by spondylolisthesis, MRI grade and subchondral sclerosis. Forward stepwise multivariate logistic regression indicated that spondylolisthesis, MRI grade, facet opening and subchondral sclerosis of the facet were risk factors. Symptoms evaluated by the Short-Form 36 and visual analogue scale showed that patients with an unstable segment were in significantly more pain than those without. Furthermore, the surgical procedures determined using the intra-operative measurement system were effective, suggesting that segmental instability influences the symptoms of lumbar degenerative disease.

In our study, the aims were to describe the changes in the appearance of the lumbar spine on MRI in elite fast bowlers during a follow-up period of one year, and to determine whether these could be used to predict the presence of a stress fracture of the posterior elements. We recruited 28 elite fast bowlers with a mean age of 19 years (16 to 24) who were training and playing competitively at the start of the study. They underwent baseline MRI (season 1) and further scanning (season 2) after one year to assess the appearance of the lumbar intervertebral discs and posterior bony elements. The incidence of low back pain and the amount of playing and training time lost were also recorded.

In total, 15 of the 28 participants (53.6%) showed signs of acute bone stress on either the season 1 or season 2 MR scans and there was a strong correlation between these findings and the later development of a stress fracture (p < 0.001). The prevalence of intervertebral disc degeneration was relatively low. There was no relationship between disc degeneration on the season 1 MR scans and subsequent stress fracture. Regular lumbar MR scans of asymptomatic elite fast bowlers may be of value in detecting early changes of bone stress and may allow prompt intervention aimed at preventing a stress fracture and avoiding prolonged absence from cricket.