Aims

CERAMENT|G is an absorbable gentamicin-loaded biocomposite used as an on-site vehicle of antimicrobials for the treatment of chronic osteomyelitis. The purpose of the present study was to investigate the sole effect of CERAMENT|G, i.e. without additional systemic antimicrobial therapy, in relation to a limited or extensive debridement of osteomyelitis lesions in a porcine model.

We describe a technique of soft-tissue reconstruction which is effective for the treatment of chronic lunotriquetral instability. Part of extensor carpi ulnaris is harvested with its distal attachment preserved. It is passed through two drill holes in the triquetrum and sutured to itself. This stabilises the ulnar side of the wrist. We have reviewed 46 patients who underwent this procedure for post-traumatic lunotriquetral instability with clinical signs suggestive of ulnar-sided carpal instability. Standard radiographs were normal. All patients had pre-operative arthroscopy of the wrist at which dynamic lunotriquetral instability was demonstrated. A clinical rating system for the wrist by the Mayo clinic was used to measure the outcome. In 19 patients the result was excellent, in ten good, in 11 satisfactory and in six poor. On questioning, 40 (87%) patients said that surgery had substantially improved the condition and that they would recommend the operation. However, six (13%) were unhappy with the outcome and would not undergo the procedure again for a similar problem. There were six complications, five of which related to pisotriquetral problems. The mean follow-up was 39.1 months (6 to 100). We believe that tenodesis of extensor carpi ulnaris is a very satisfactory procedure for isolated, chronic post-traumatic lunotriquetral instability in selected patients. In those with associated pathology, the symptoms were improved, but the results were less predictable

1. A series of 705 fractures of the tibia is reviewed, 674 of which were treated conservatively. 2. The factors most conducive to delayed or non-union are initial displacement, comminution, associated soft-tissue wound and infection. The extent to which these are combined in any fracture determines its "personality" and its inherent propensity for union. 3. Eight fracture types are differentiated based on the above "personality rating." The incidence of delayed union or non-union varies from 9 per cent in the most favourable type to 39 per cent in the least favourable. Infection raises the incidence to 60 per cent. Comparative statistics which fail to recognise these differences can be entirely misleading. 4. Continuous traction does not retard union. 5. The results of conservative treatment are analysed with regard to union, deformity, stiff joints and contractures and the conclusion is reached that no case has yet been made out for internal fixation as the method of choice in the treatment of this fracture

We have compared the density of nerve fibres in the synovium in club foot with that of specimens obtained from the synovium of the hip at operations for developmental dysplasia. The study focused on the sensory neuropeptides substance P; calcitonin gene-related peptide; protein gene product 9.5, a general marker for mature peripheral nerve fibres; and growth associated protein 43, a neuronal marker for new or regenerating nerve fibres. In order to establish whether there might be any inherent difference we analysed the density of calcitonin gene-related peptide-positive nerve fibres in the hip and ankle joints in young rats. Semi-quantitative analysis showed a significant reduction in the number of sensory and mature nerve fibres in the synovium in club foot compared with the control hips. Calcitonin gene-related peptide (CGRP) positive fibres were reduced by 28%, substance P-positive fibres by 36% and protein gene product 9.5-positive fibres by 52% in club foot. The growth associated protein 43-positive fibres also seemed to be less in six samples of club foot. No difference in the density of CGRP-positive nerve fibres was observed in the synovium between ankle and hip joints in rats. The lack of sensory input may be responsible for the fibrosis and soft-tissue contractures associated with idiopathic club foot

In this review, we discuss the evidence for patients returning to sport after hip arthroplasty. This includes the choices regarding level of sporting activity and revision or complications, the type of implant, fixation and techniques of implantation, and how these choices relate to health economics. It is apparent that despite its success over six decades, hip arthroplasty has now evolved to accommodate and support ever-increasing patient demands and may therefore face new challenges.

Cite this article: Bone Joint J 2020;102-B(6):661–663.

From 1990 to 1994 we undertook arthroscopy of the ankle on 34 consecutive patients with residual complaints following fracture. Two groups were compared prospectively. Group I comprised 18 patients with complaints which could be attributed clinically to anterior bony or soft-tissue impingement. In group II the complaints of the 16 patients were more diffuse and despite extensive investigation the definitive diagnosis was not clear before arthroscopy. At the time of the fracture, some osteophytes were already present in 41% of the patients. These were related to previous supination trauma and participation in soccer. Arthroscopic treatment consisted of removal of the anteriorly located osteophytes and/or scar tissue. After two years, group I showed a significantly better score for patient satisfaction (p = 0.02). There were good or excellent results in group I in 76% and group II in 43%. Patients with residual complaints after an ankle fracture and clinical signs of anterior impingement may benefit from arthroscopic surgery. The place for diagnostic ankle arthroscopy is limited

We retrospectively reviewed 56 patients (71 hips) treated by total replacement for severe disability after pelvic irradiation. Symptoms were associated with various radiological lesions due to irradiation, including atraumatic femoral-neck fracture, osteonecrosis of the femoral head or of the acetabulum, and radiation osteitis of the whole pelvis. From 1970 to 1982 we used standard cemented components in 49 hips and had a high rate of acetabular loosening (52%) at a mean follow-up of 69 months. This was probably due to the mechanical insufficiency of irradiated periacetabular bone. From 1983 to 1990 we routinely used acetabular reinforcement rings. The rate of aseptic acetabular loosening in 22 hips at a mean follow-up of 40 months was 19%, but there were two septic loosenings emphasising the risk of infection in these patients. When total replacement is required for an irradiated hip, we recommend reinforcement of the acetabulum using a metallic ring, but there is still an increased risk of infection and in difficult cases such as severe acetabular destruction or soft-tissue or vascular injuries, a Girdlestone procedure may be indicated

The PROSTALAC functional spacer is made of antibiotic-loaded acrylic cement but has a small metal-on-polythene articular surface. We have used it as an interim spacer in two-stage exchange arthroplasty for infected total knee replacement. PROSTALAC allows continuous rehabilitation between stages as it maintains good alignment and stability of the knee and a reasonable range of movement. It also helps to maintain the soft-tissue planes, which facilitates the second-stage procedure. We reviewed 45 consecutive patients, treated over a period of nine years. The mean follow-up was for 48 months (20 to 112). At final review, there was no evidence of infection in 41 patients (91%); only one had a recurrent infection with the same organism. There was improvement in the Hospital for Special Surgery knee score between stages and at final review. The range of movement was maintained between stages. Complications were primarily related to the extensor mechanism and stability of the knee between stages. Both of these problems decreased with refinement of the design of the implant. The rate of cure of the infection in our patients was similar to that using other methods. Movement of the knee does not appear to hinder control of infection

Aims

The consensus is that bipolar hemiarthroplasty (BHA) in allograft-prosthesis composite (APC) reconstruction of the proximal femur following primary tumour resection provides more stability than total hip arthroplasty (THA). However, no comparative study has been performed. In this study, we have compared the outcome and complication rates of these two methods.

Nineteen chondrosarcomas are reported arising in proximal phalanges or metacarpal bones of the hand mainly in elderly patients, predominantly women. The usual clinical presentation was of a progressively painful large tumour, often arising in a dormant lesion near the metacarpo-phalangeal joint. Radiologically most showed some bone expansion with a poorly defined area of destruction and a considerable soft-tissue swelling. Histologically, malignancy was usually obvious, but confusion might arise from the inclusion of bland areas of chondromatous tissue that probably represented the original lesion. Four tumours, initially curetted and grafted, recurred locally and necessitated amputation of the digit or ray. Amputation was the primary treatment for fourteen other tumours and was curative except in one patient who eventually needed amputation through the forearm for a large second recurrence. One tumour was satisfactorily controlled by excision of the affected phalanx. None of these nineteen tumours is known to have metastasised. Correct treatment implies a carefully considered balance between conservation of function and complete removal of all tumour tissue

The authors wished to determine the late results of the Hauser operation, with special reference to the development of osteoarthritis. Predisposing factors associated with recurrent dislocation of the patella were also investigated. Thirty-five patients with forty-our surgically treated knees attended for review, ten to twenty-fve (aerage sixteen) years after operation. Two patients had subsequently undergone excision of the patella. Ten patients gave a family history of recurrent dislocation of the patella and seven patients showed generalised joint laxity. Pain was present in eight knees before operation and was present in thirty-three knees (75 per cent) at the time of review. Patellar crepitus was present in thirty-seven out of forty-two knees (88 per cent) at review. Osteoarthritis was present in thirty out of forty-two knees (70 per cent). The incidence increases with time since operation and the present age of the patient. It is concluded that the Hauser operation prevents further dislocation but does not prevent the development of osteoarthritis. It is possible that a simple soft-tissue operation which effectively prevents dislocation might achieve the same results

1. A study of fifty patients with dislocations of the lunate bone or perilunar dislocations has been made. The period of observation was adequate in thirty-eight. 2. The injuries generally occur in young or middle-aged men after unusually severe trauma. 3. Associated injuries are frequent, and the most common of these is damage to the median nerve. 4. In one-third of the cases the nature of the lesion was not initially diagnosed or the initial treatment was inadequate. 5. A dislocated lunate bone may be replaced even at a late stage and even if the displacement is severe so long as there is some soft-tissue attachment. The anterior approach may safely be used for the replacement. 6. The lunate bone may be removed without involving the necessity for arthrodesis of the wrist. 7. Open reduction should be employed for trans-scaphoid dislocations whenever exact realignment and good fixation cannot be achieved by closed methods. 8. Excision of the proximal row of the carpus gives the possibility of salvage of a reasonable degree of function, and may be preferable to arthrodesis or removal of only part of the proximal row

We report the results of a prospective randomised trial which assessed the role of the posterior cruciate ligament (PCL) following total knee replacement (Genesis I; Smith and Nephew, Memphis, Tennessee). Over a four-year period, 211 patients underwent total knee replacement by the senior author (TJW). They were randomised at surgery to have the PCL either retained, excised or substituted with a posterior stabilised insert. If it was not possible to retain the ligament due to soft-tissue imbalance, it was released from its tibial insertion until suitable tension was obtained. This created a fourth group, those who were intended preoperatively to have the ligament retained, but in whom it was partially released as a result of findings at the time of surgery. All patients were evaluated using the Knee Society rating system (adapted from Insall). A total of 188 patients (212 knees) was available for follow-up at a mean of 3.5 years after surgery. Preoperatively, there was a varus deformity in 191 knees (90%) and a valgus deformity in 21 (10%). There were no statistical differences in the knee or function scores or the range of movement between the excised, retained and substituted groups. There were, however, significantly worse knee and function scores in the group in whom the PCL was released (p = 0.002)

We reviewed 50 capitellocondylar elbow replacements performed by the lateral approach in 42 rheumatoid patients, at a median follow-up of three years. There were two major and 17 minor complications; 18 were early and one was late. Eight elbows required reoperation: soft-tissue surgery was performed in seven and prosthesis removal in one because of a deep infection. There were few problems of instability, but one patient sustained a traumatic dislocation which was stabilised after ligament reconstruction. Wound healing was delayed in two of five elbows which had been immobilised postoperatively for only five days, but healing was rapid in 45 elbows immobilised for 12 days. There was transient ulnar-nerve palsy postoperatively in 11 patients, with permanent palsy in three. All elbows were painfree or only slightly painful at follow-up; 49 were stable and 43 had a range of motion sufficient for activities of daily living. Radiological loosening of the humeral component was suspected in one asymptomatic elbow. The lateral approach is recommended for use with the capitellocondylar type of prosthesis in rheumatoid elbows with reasonably well-preserved bone stock

Aims

The mobile bearing Oxford unicompartmental knee arthroplasty (OUKA) is recommended to be performed with the leg in the hanging leg (HL) position, and the thigh placed in a stirrup. This comparative cadaveric study assesses implant positioning and intraoperative kinematics of OUKA implanted either in the HL position or in the supine leg (SL) position.

Aims

To evaluate graft healing of decellularized porcine superflexor tendon (pSFT) xenograft in an ovine anterior cruciate ligament (ACL) reconstruction model using two femoral fixation devices. Also, to determine if pSFT allows functional recovery of gait as compared with the preoperative measurements.

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We aimed to examine the long-term mechanical survivorship, describe the modes of all-cause failure, and identify risk factors for mechanical failure of all-polyethylene tibial components in endoprosthetic reconstruction.

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Metaphyseal fixation during revision total knee arthroplasty (TKA) is important, but potentially difficult when using historical designs of cone. Material and manufacturing innovations have improved the size and shape of the cones which are available, and simplified the required bone preparation. In a large series, we assessed the implant survivorship, radiological results, and clinical outcomes of new porous 3D-printed titanium metaphyseal cones featuring a reamer-based system.

Aims

To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP).

Aims

Iliac wing (Type I) and iliosacral (Type I/IV) pelvic resections for a primary bone tumour create a large segmental defect in the pelvic ring. The management of this defect is controversial as the surgeon may choose to reconstruct it or not. When no reconstruction is undertaken, the residual ilium collapses back onto the remaining sacrum forming an iliosacral pseudarthrosis. The aim of this study was to evaluate the long-term oncological outcome, complications, and functional outcome after pelvic resection without reconstruction.