In a prospective observational study we compared the two-year outcome of lumbar fusion by a simple technique using translaminar screws (n = 57) with a more extensive method using transforaminal lumbar interbody fusion and pedicular screw fixation (n = 63) in consecutive patients with degenerative disease of the lumbar spine. Outcome was assessed using the validated multidimensional Core Outcome Measures Index. Blood loss and operating time were significantly lower in the translaminar screw group (p < 0.01). The complication rates were similar in each group (2% to 4%). In all, 91% of the patients returned their questionnaire at two-years. The groups did not differ in Core Outcome Measures Index score reduction, 3.6 (sd 2.5) (translaminar screws) vs 4.0 (sd 2.8) (transforaminal lumbar interbody fusion) (p = 0.39); ‘good’ global outcomes, 78% (translaminar screws) vs 78% (transforaminal lumbar interbody fusion) (p = 0.99) or satisfaction with treatment, 82% (translaminar screws) vs 86% (transforaminal lumbar interbody fusion) (p = 0.52).

The two fusion techniques differed markedly in their extent and the cost of the implants, but were associated with almost identical patient-orientated outcomes.

Extensive three-point stabilisation is not always required to achieve satisfactory patient-orientated results at two years.

The presence of pseudotumours, which are soft-tissue masses relating to the hip, after metal-on-metal hip resurfacing arthroplasty has been associated with elevated levels of metal ions in serum, suggesting that pseudotumours occur when there is increased wear. We aimed to quantify the wear in vivo of implants revised for pseudotumours (eight) and of a control group of implants (22) revised for other reasons of failure.

We found that the implant group with pseudotumours had a significantly higher rate of median linear wear of the femoral component at 8.1 μm/year (2.75 to 25.4) than the 1.79 μm/year (0.82 to 4.15; p = 0.002) of the non-pseudotumour group. For the acetabular component a significantly higher rate of median linear wear of 7.36 μm/year (1.61 to 24.9) was observed in the pseudotumour group compared with 1.28 μm/year (0.81 to 3.33, p = 0.001) in the other group. Wear of the acetabular component in the pseudotumour group always involved the edge of the implant, indicating that edge-loading had occurred.

Our findings are the first direct evidence that pseudotumour is associated with increased wear at the metal-on-metal articulation. Furthermore, edge-loading with the loss of fluid-film lubrication may be an important mechanism of generation of wear in patients with a pseudotumour.

We undertook a randomised controlled trial to compare the outcomes of skin adhesive and staples for skin closure in total hip replacement. The primary outcome was the cosmetic appearance of the scar at three months using a surgeon-rated visual analogue scale. In all, 90 patients were randomised to skin closure using either skin adhesive (n = 45) or staples (n = 45). Data on demographics, surgical details, infection and oozing were collected during the in-patient stay. Further data on complications, patient satisfaction and evaluation of cosmesis were collected at three-month follow-up, and a photograph of the scar was taken. An orthopaedic and a plastic surgeon independently evaluated the cosmetic appearance of the scars from the photographs. No significant difference was found between groups in the cosmetic appearance of scars at three months (p = 0.172), the occurrence of complications (p = 0.3), or patient satisfaction (p = 0.42). Staples were quicker and easier to use than skin adhesive and also less expensive. Skin adhesive and surgical staples are both effective skin closure methods in total hip replacement.

Balancing service provision and surgical training is a challenging issue that affects all healthcare systems. A multicentre prospective study of 1501 total hip replacements was undertaken to investigate whether there is an association between surgical outcome and the grade of the operating surgeon, and whether there is any difference in outcome if surgeons’ assistants assist with the operation, rather than orthopaedic trainees. The primary outcome measure was the change in the Oxford hip score (OHS) at five years. Secondary outcomes included the rate of revision and dislocation, operating time, and length of hospital stay.

There was no significant difference in ΔOHS or complication rates between operations undertaken by trainers and trainees, or those at which surgeons’ assistants and trainees were the assistant. However, there was a significant difference in the duration of surgery, with a mean reduction of 28 minutes in those in which a surgeons’ assistant was the assistant.

This study provides evidence that total hip replacements can be performed safely and effectively by appropriately trained surgeons in training, and that there are potential benefits of using surgeons’ assistants in orthopaedic surgery.

Advanced osteoarthritis of the wrist or the distal articulation of the lunate with the capitate has traditionally been treated surgically by arthrodesis. In order to maintain movement, we performed proximal row carpectomy with capsular interposition arthroplasty as an alternative to arthrodesis in eight patients with advanced arthritis and retrospectively reviewed their clinical and radiographic outcomes after a mean follow-up of 41 months (13 to 53). The visual analogue scale (VAS) for pain at its worst and at rest, and the patient-rated wrist evaluation score improved significantly after surgery, whereas ranges of movement and grip strength were maintained at the pre-operative levels. Progression of arthritis in the radiocapitate joint was observed in three patients, but their outcomes were not significantly different from those without progression of arthritis.

Proximal row carpectomy with capsular interposition arthroplasty is a reasonable option for the treatment of patients with advanced arthritis of the wrist.

In a prospective randomised study we compared the results of arthroscopic subacromial bursectomy alone with debridement of the subacromial bursa followed by acromioplasty. A total of 57 patients with a mean age of 47 years (31 to 60) suffering from primary subacromial impingement without a rupture of the rotator cuff who had failed previous conservative treatment were entered into the trial. The type of acromion was classified according to Bigliani. Patients were assessed at follow-up using the Constant score, the simple shoulder test and visual analogue scores for pain and functional impairment. One patient was lost to follow-up.

At a mean follow-up of 2.5 years (1 to 5) both bursectomy and acromioplasty gave good clinical results. No statistically significant differences were found between the two treatments. The type of acromion and severity of symptoms had a greater influence on the clinical outcome than the type of treatment. As a result, we believe that primary subacromial impingement syndrome is largely an intrinsic degenerative condition rather than an extrinsic mechanical disorder.

We have reviewed the rate of revision of fully cemented, hybrid and uncemented primary total hip replacements (THRs) registered in the New Zealand Joint Registry between 1999 and December 2006 to determine whether there was any statistically significant difference in the early survival and reason for revision in these different types of fixation. The percentage rate of revision was calculated per 100 component years and compared with the reason for revision, the type of fixation and the age of the patients.

Of the 42 665 primary THRs registered, 920 (2.16%) underwent revision requiring change of at least one component. Fully-cemented THRs had a lower rate of revision when considering all causes for failure (p < 0.001), but below the age of 65 years uncemented THRs had a lower rate (p < 0.01). The rate of revision of the acetabular component for aseptic loosening was less in the uncemented and hybrid groups compared with that in the fully cemented group (p < 0.001), and the rate of revision of cemented and uncemented femoral components was similar, except in patients over 75 years of age in whom revision of cemented femoral components was significantly less frequent (p < 0.02). Revision for infection was more common in patients aged below 65 years and in cemented and hybrid THRs compared with cementless THRs (p < 0.001). Dislocation was the most common cause of revision for all types of fixation and was more frequent in both uncemented acetabular groups (p < 0.001). The experience of the surgeon did not affect the findings.

Although cemented THR had the lowest rate of revision for all causes in the short term (90 days), uncemented THR had the lowest rate of aseptic loosening in patients under 65 years of age and had rates comparable with international rates of aseptic loosening in those over 65 years.

Articular cartilage repair remains a challenge to surgeons and basic scientists. The field of tissue engineering allows the simultaneous use of material scaffolds, cells and signalling molecules to attempt to modulate the regenerative tissue. This review summarises the research that has been undertaken to date using this approach, with a particular emphasis on those techniques that have been introduced into clinical practice, via in vitro and preclinical studies.

Valgus high tibial osteotomy for osteoarthritis of the medial compartment of the knee can be performed using medial opening- and lateral closing-wedge techniques. The latter have been thought to offer greater initial stability.

We measured and compared the stability of opening- and closing-wedge osteotomies fixed by TomoFix plates using radiostereometry in a series of 42 patients in a prospective, randomised clinical trial.

There were no differences between the opening- and closing-wedge groups in the time to regain knee function and full weight-bearing. Pain and knee function were significantly improved in both groups without any differences between them. All the osteotomies united within one year. Radiostereometry showed no clinically relevant movement of bone or differences between either group.

Medial opening-wedge high tibial osteotomy secured by a TomoFix plate offers equal stability to a lateral closing-wedge technique. Both give excellent initial stability and provide significantly improved knee function and reduction in pain, although the opening-wedge technique was more likely to produce the intended correction.

There is a trend towards the use of double-bundle techniques for the reconstruction of the anterior cruciate ligament. This has not been substantiated scientifically. The functional outcome of these techniques is equivalent to that of single-bundle methods. The main advantage of a double-bundle rather than a single-bundle reconstruction should be a better rotational stability, but the validity and accuracy of systems for the measurement of rotational stability have not been confirmed.

Despite the enthusiasm of surgeons for the double-bundle technique, reconstruction with a single-bundle should remain the standard method for managing deficiency of the anterior cruciate ligament until strong evidence in favour of the use of the double-bundle method is available.

We retrospectively reviewed 21 patients (22 shoulders) who presented with deep infection after surgery to the shoulder, 17 having previously undergone hemiarthroplasty and five open repair of the rotator cuff. Nine shoulders had undergone previous surgical attempts to eradicate their infection. The diagnosis of infection was based on a combination of clinical suspicion (16 shoulders), positive frozen sections (> 5 polymorphonuclear leukocytes per high-power field) at the time of revision (15 shoulders), positive intra-operative cultures (18 shoulders) or the pre-operative radiological appearances. The patients were treated by an extensive debridement, intravenous antibiotics, and conversion to a reverse shoulder prosthesis in either a single- (10 shoulders) or a two-stage (12 shoulders) procedure.

At a mean follow-up of 43 months (25 to 66) there was no evidence of recurrent infection. All outcome measures showed statistically significant improvements. Mean abduction improved from 36.1° (sd 27.8) pre-operatively to 75.7° (sd 36.0) (p < 0.0001), the mean forward flexion from 43.1° (sd 33.5) to 79.5° (sd 43.2) (p = 0.0003), and mean external rotation from 10.2° (sd 18.7) to 25.4° (sd 23.5) (p = 0.0037). There was no statistically significant difference in any outcome between the single-stage and the two-stage group.

We compared a group of 46 somatised patients with a control group of 41 non-somatised patients who had undergone elective surgery to the lumbar spine in an attempt to identify pre-operative factors which could predict the outcome. In a prospective single-centre study, the Distress and Risk Assessment method consisting of a modified somatic perception questionnaire and modified Zung depression index was used pre-operatively to identify somatised patients. The type and number of consultations were correlated with functional indicators of outcome, such as the Oswestry disability index and a visual analogue score for pain in the leg after follow-up for six and 12 months.

Similar improvements in the Oswestry disability index were found in the somatised and non-somatised groups. Somatised patients who had a good outcome on the Oswestry disability index had an increased number of orthopaedic consultations (50 of 83 patients (60%) vs 29 of 73 patients (39.7%); p = 0.16) and waited less time for their surgery (5.5 months) (sd 5.26) vs 10.1 months (sd 6.29); p = 0.026). No other identifiable factors were found. A shorter wait for surgery appeared to predict a good outcome. Early review by a spinal surgeon and a reduced waiting time to surgery appear to be of particular benefit to somatised patients.

We report the clinical and radiological results of a two- to three-year prospective randomised study which was designed to compare a minimally-invasive technique with a standard technique in total knee replacement and was undertaken between January 2004 and May 2007. The mini-midvastus approach was used on 50 patients (group A) and a standard approach on 50 patients (group B). The mean follow-up in both groups was 23 months (24 to 35).

The functional outcome was better in group A up to nine months after operation, as shown by statistically significant differences in the mean function score, mean total score and the mean Oxford knee score (all, p = 0.05). Patients in group A had statistically significant greater early flexion (p = 0.04) and reached their greatest mean knee flexion of 126.5° (95° to 135°) 21 days after operation. However, at final follow-up there was no significant difference in the mean maximum flexion between the groups (p = 0.08). Technical errors were identified in six patients from group A (12%) on radiological evaluation.

Based on these results, the authors currently use minimally-invasive techniques in total knee replacement in selected cases only.

We wished to determine whether simultaneous bilateral sequential total knee replacement (TKR) carried increased rates of mortality and complications compared with unilateral TKR in low- and high-risk patients.

Our study included 2385 patients who had undergone bilateral sequential TKR under one anaesthetic and 719 who had unilateral TKR. There were no significant pre-operative differences between the groups in terms of age, gender, height, weight, body mass index, diagnosis, comorbidity and duration of follow-up, which was a mean of 10.2 years (5 to 14) in the bilateral and 10.4 years (5 to 14) in the unilateral group.

The peri-operative mortality rate (eight patients, 0.3%) of patients who had bilateral sequential TKR was similar to that (five patients, 0.7%) of those undergoing unilateral TKR. In bilateral cases the peri-operative mortality rate (three patients, 0.4%) of patients at high risk was similar to that (five patients, 0.3%) of patients at low risk as it was also in unilateral cases (two patients, 1.0% vs three patients, 0.6%). There was no significant difference (p = 0.735) in either the overall number of major complications between bilateral and unilateral cases or between low- (p = 0.57) and high-risk (p = 0.61) patients. Also, the overall number of minor complications was not significantly different between the bilateral and unilateral group (p = 0.143).

Simultaneous bilateral sequential TKR can be offered to patients at low and high risk and has an expected rate of complications similar to that of unilateral TKR.

We report the long-term survival of a prospective randomised consecutive series of 501 primary knee replacements using the press-fit condylar posterior cruciate ligament-retaining prosthesis. Patients received either cemented (219 patients, 277 implants) or cementless (177 patients, 224 implants) fixation. Altogether, 44 of 501 knees (8.8%) underwent revision surgery (24 cemented vs 20 cementless). For cemented knees the 15-year survival rate was 80.7% (95% confidence interval (CI) 71.5 to 87.4) and for cementless knees it was 75.3% (95% CI 63.5 to 84.3). There was no significant difference between the two groups (cemented vs cementless; hazard ratio (HR) 0.83, 95% CI 0.45 to 1.52, p = 0.55). When comparing the covariates there was no significant difference in the rates of survival between the side of operation (HR 0.58, p = 0.07), age (HR 0.97, p = 0.10) and diagnosis (HR 1.25 p = 0.72). However, there was a significant gender difference, with males having a higher failure rate with cemented fixation (HR 2.48, p = 0.004). Females had a similar failure rate in both groups.

This single-surgeon series, with no loss to follow-up, provides reliable data of the revision rates of one of the most commonly-used total knee replacements. The survival of the press-fit condylar total knee replacement remained good at 15 years, irrespective of the method of fixation.

Narrowing of the femoral neck after resurfacing arthroplasty of the hip has been described previously in both cemented and uncemented hip resurfacing. The natural history of narrowing of the femoral neck is unknown. We retrospectively measured the diameter of the femoral neck in a series of 163 Birmingham hip resurfacings in 163 patients up to a maximum of six years after operation to determine the extent and progression of narrowing.

There were 105 men and 58 women with a mean age of 52 years (18 to 82). At a mean follow-up of five years, the mean Harris hip score was 94.8 (47 to 100) and the mean flexion of the hip 112.5° (80° to 160°). There was some narrowing of the femoral neck in 77% (125) of the patients reviewed, and in 27.6% (45) the narrowing exceeded 10% of the diameter of the neck. A multiple logistic regression analysis showed a significant association (chi-squared test (derived from logistic regression) p = 0.01) of narrowing with female gender and a valgus femoral neck/shaft angle. There was no significant association between the range of movement, position or size of the component or radiological lucent lines and narrowing of the neck (chi-squared test; p = 0.10 (flexion), p = 0.08 (size of femoral component), p = 0.09 (size of acetabular component), p = 0.71 (femoral component angulation), p = 0.99 (lucent lines)). There was no significant difference between the diameter of the neck at a mean of three years (2.5 to 3.5) and that at five years (4.5 to 5.5), indicating that any change in the diameter of the neck had stabilised by three years (sign rank test, p = 0.60).

We conclude that narrowing of the femoral neck which is found with the Birmingham hip resurfacing arthroplasty is in most cases associated with no adverse clinical or radiological outcome up to a maximum of six years after the initial operation.

Between 1985 and 2000, 120 patients underwent arthroscopic management for primary synovial chondromatosis of the hip. We report the outcome of 111 patients with a mean follow-up of 78.6 months (12 to 196). More than one arthroscopy was required in 23 patients (20.7%), and 42 patients (37.8%) went on to require open surgery. Outcomes were evaluated in greater detail in 69 patients (62.2%) treated with arthroscopy alone, of whom 51 (45.9%) required no further treatment and 18 (16.2%) required further arthroscopies. Of the 111 patients, 63 (56.7%) had excellent or good outcomes. At the most recent follow-up, 22 patients (19.8%) had undergone total hip replacement.

Hip arthroscopy proved beneficial for patients diagnosed with primary synovial chondromatosis of the hip, providing good or excellent outcomes in more than half the cases.

The majority of patients with osteoarthritis present to orthopaedic surgeons seeking relief of pain and associated restoration of function. Although our understanding of the physiology of pain has improved greatly over the last 25 years there remain a number of unexplained pain-related observations in patients with osteoarthritis. The understanding of pain in osteoarthritis, its modulation and treatment is central to orthopaedic clinical practice and in this annotation we explore some of the current concepts applicable. We also introduce the concept of the ‘phantom joint’ as a cause for persistent pain after joint replacement.

The Oxford hip and knee scores have been extensively used since they were first described in 1996 and 1998. During this time, they have been modified and used for many different purposes. This paper describes how they should be used and seeks to clarify areas of confusion.