We compared the results of 146 patients who received an anatomic modular knee fixed-bearing total knee replacement (TKR) in one knee and a low contact stress rotating platform mobile-bearing TKR in the other. There were 138 women and eight men with a mean age of 69.8 years (42 to 80). The mean follow-up was 13.2 years (11.0 to 14.5). The patients were assessed clinically and radiologically using the rating systems of the Hospital for Special Surgery and the Knee Society at three months, six months, one year, and annually thereafter.

The assessment scores of both rating systems pre-operatively and at the final review did not show any statistically significant differences between the two designs of implant. In the anatomic modular knee group, one knee was revised because of aseptic loosening of the tibial component and one because of infection. In addition, three knees were revised because of wear of the polyethylene tibial bearing. In the low contact stress group, two knees were revised because of instability requiring exchange of the polyethylene insert and one because of infection.

The radiological analysis found no statistical difference in the incidence of radiolucent lines at the final review (Student’s t-test, p = 0.08), most of which occurred at tibial zone 1. The Kaplan-Meier survivorship for aseptic loosening of the anatomic modular knee and the low contact stress implants at 14.5 years was 99% and 100%, respectively, with a 95% confidence interval of 94% to 100% for both designs.

We found no evidence of the superiority of one design over the other at long-term follow-up.

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.

We have treated 14 patients (15 fractures) with nonunion of an intra-articular fracture of the body of the calcaneum. The mean follow-up was six years (2 to 8.5). A total of 14 fractures (93%) had initially been treated operatively with 12 (86%) having non-anatomical reductions. Four feet (27%) had concomitant osteomyelitis. Of the nonunions, 14 (93%) went on to eventual union after an average of two reconstructive procedures. All underwent bone grafting of the nonunion. The eventual outcome was a subtalar arthrodesis in ten (67%) cases, a triple arthrodesis in four (27%) and a nonunion in one (6%). Three patients had a wound dehiscence; all required a local rotation flap. The mean American Orthopaedic Foot and Ankle Society score at latest follow-up was 69, and the mean Visual analogue scale was 3. Of those who were initially employed, 82% (9 of 11) eventually returned to work. We present an algorithm for the treatment of calcaneal nonunion, and conclude that despite a relatively high rate of complication, this complex surgery has a high union rate and a good functional outcome.

There have been several reports of good survivorship and excellent function at ten years with fixed-bearing unicompartmental knee replacement. However, little is known about survival beyond ten years.

From the Bristol database of over 4000 knee replacements, we identified 203 St Georg Sled unicompartmental knee replacements (174 patients) which had already survived ten years. The mean age of the patients at surgery was 67.1 years (35.7 to 85) with 67 (38.5%) being under 65 years at the time of surgery. They were reviewed at a mean of 14.8 years (10 to 29.4) from surgery to determine survivorship and function. There were 99 knees followed up for 15 years, 21 for 20 years and four for 25 years. The remainder failed, were withdrawn, or the patient had died.

In 58 patients (69 knees) the implant was in situ at the time of death. Revision was undertaken in 16 knees (7.9%) at a mean of 13 years (10.2 to 21.6) after operation. In seven knees (3.4%) this was for progression of arthritis, in three (1.5%) for wear of polyethylene, in four (2%) for tibial loosening, in two (1%) for fracture of the femoral component and in two (1%) for infection. Two knees (1%) were revised for more than one reason.

The mean Bristol knee score of the surviving knees fell from 86 (34 to 100) to 79 (42 to 100) during the second decade. Survivorship to 20 years was 85.9% (95% CI 82.9% to 88.9%) and at 25 years was 80% (95% CI 70.2% to 89.8%). Satisfactory survival of a fixed-bearing unicompartmental knee replacement can be achieved into the second decade and beyond.

A retrospective analysis was performed of eight patients with an open triradiate cartilage, who underwent resection for osteosarcoma and reconstruction of the proximal femur with a hemiarthroplasty, in order to identify changes of acetabular development. An analysis of the centre-edge angle, teardrop-to-medial prosthesis distance, superior joint space, teardrop-to-superior prosthesis distance, degree of lateral translation, and arthritic changes, was performed on serial radiographs. The median age at the time of the initial surgery was 11 years (5 to 14).

All patients developed progressive superior and lateral migration of the prosthetic femoral head. Following hemiarthroplasty in the immature acetabulum, the normal deepening and enlargement of the acetabulum is arrested. The degree of superior and lateral migration of the prosthetic head depends on the age at diagnosis and the length of follow-up.

Talipes equinovarus is one of the more common congenital abnormalities affecting the lower limb and can be challenging to manage. This review provides a comprehensive update on idiopathic congenital talipes equinovarus with emphasis on the initial treatment. Current management is moving away from operative towards a more conservative treatment using the Ponseti regime. The long-term results of surgical correction and the recent results of conservative treatment will be discussed.

We compared the results ten years after an inverted V-shaped high tibial osteotomy with those of a historical series of conventional closing-wedge osteotomies. The closing-wedge series consisted of 56 knees in 51 patients with a mean follow-up of 11 years (10 to 15). The inverted V-shaped osteotomy was evaluated in 48 knees in 43 patients at a mean follow-up of 14 years (10 to 19). All the patients were scored using the Japanese Orthopaedic Association rating scale for osteoarthritis of the knee and radiological assessment.

The pre-operative grade of osteoarthritis was similar in both groups. Post-operatively, the knee function score was graded as satisfactory in 63% (35) of the closing-wedge group but in 89% (43) of the inverted V-shaped osteotomy group. Post-operative radiological examination showed that delayed union and loss of correction occurred more often after a closing-wedge osteotomy than after an inverted V-shaped procedure.

Our study suggests that the inverted V-shaped osteotomy may offer more dependable long-term results than traditional closing-wedge osteotomy.

We have developed a CT-based navigation system using infrared light-emitting diode markers and an optical camera. We used this system to perform cementless total hip replacement using a ceramic-on-ceramic bearing couple in 53 patients (60 hips) between 1998 and 2001. We reviewed 52 patients (59 hips) at a mean of six years (5 to 8) postoperatively. The mid-term results of total hip replacement using navigation were compared with those of 91 patients (111 hips) who underwent this procedure using the same implants, during the same period, without navigation. There were no significant differences in age, gender, diagnosis, height, weight, body mass index, or pre-operative clinical score between the two groups. The operation time was significantly longer where navigation was used, but there was no significant difference in blood loss or navigation-related complications. With navigation, the acetabular components were placed within the safe zone defined by Lewinnek, while without, 31 of the 111 components were placed outside this zone. There was no significant difference in the Merle d’Aubigne and Postel hip score at the final follow-up. However, hips treated without navigation had a higher rate of dislocation. Revision was performed in two cases undertaken without navigation, one for aseptic acetabular loosening and one for fracture of a ceramic liner, both of which showed evidence of neck impingement on the liner. A further five cases undertaken without navigation showed erosion of the posterior aspect of the neck of the femoral component on the lateral radiographs. These seven impingement-related mechanical problems correlated with malorientation of the acetabular component. There were no such mechanical problems in the navigated group.

We conclude that CT-based navigation increased the precision of orientation of the acetabular component and control of limb length in total hip replacement, without navigation-related complications. It also reduced the rate of dislocation and mechanical problems related to impingement.

We have evaluated the clinical outcomes of simple excision, ulnar lengthening and the Sauvé-Kapandji procedure in the treatment of deformities of the forearm in patients with multiple hereditary osteochondromas. The medical records of 29 patients (33 forearms) were reviewed; 22 patients (22 forearms) underwent simple excision (four with ulnar lengthening) and seven the Sauvé-Kapandji procedure.

Simple excision increased the mean supination of the forearm from 63.2° to 75.0° (p = 0.049). Ulnar lengthening did not significantly affect the clinical outcome. The Sauvé-Kapandji technique improved the mean pronation from 33.6° to 55.0° (p = 0.047) and supination from 70.0° to 81.4° (p = 0.045). Simple excision may improve the range of movement of the forearm but will not halt the progression of disease, particularly in younger patients. No discernable clinical or radiological improvement was noted with ulnar lengthening. The Sauvé-Kapandji procedure combined with simple excision of osteochondromas can improve stability of the wrist, movement of the forearm and the radiological appearance.

We present a series of 48 patients with infected total knee replacements managed by the use of articulating cement spacers and short-term parenteral antibiotic therapy in the postoperative period. All patients had microbiological and/or histological confirmation of infection at the first stage of their revision. They all underwent re-implantation and had a mean follow-up of 48.5 months (26 to 85).

Infection was successfully eradicated in 42 of the 48 patients (88%). Six had persistent infection which led to recurrence of symptoms and further surgery was successful in eliminating infection in four patients. These rates of success are similar to those of other comparable series. We conclude that protracted courses of intravenous antibiotic treatment may not be necessary in the management of the infected total knee replacement.

In addition, we analysed the microbiological, histological and serological results obtained at the time of re-implantation of the definitive prosthesis, but could not identify a single test which alone would accurately predict a successful outcome.

We report the use of the reverse shoulder prosthesis in the revision of a failed shoulder hemiarthroplasty in 19 shoulders in 18 patients (7 men, 11 women) with severe pain and loss of function. The primary procedure had been undertaken for glenohumeral arthritis associated with severe rotator cuff deficiency.

Statistically significant improvements were seen in pain and functional outcome. After a mean follow-up of 44 months (24 to 89), mean forward flexion improved by 26.4° and mean abduction improved by 35°. There were six prosthesis-related complications in six shoulders (32%), five of which had severe bone loss of the glenoid, proximal humerus or both. Three shoulders (16%) had non-prosthesis related complications.

The use of the reverse shoulder prosthesis provides improvement in pain and function for patients with failure of a hemiarthroplasty for glenohumeral arthritis and rotator cuff deficiency. However, high rates of complications were associated with glenoid and proximal humeral bone loss.

Between September 2004 and December 2005 we carried out a prospective study of all cases of sepsis of the hip in childhood at a South African regional hospital with a large local population, and which also took referrals from nine rural hospitals. The clinical, radiological, ultrasound and bacteriological features were assessed. All the hips were drained by arthrotomy and the diagnosis was confirmed microbiologically and histologically. Hips with tuberculosis were excluded. The children were reviewed in a dedicated clinic at a mean follow-up of 8.1 months (3 to 18).

There were 40 hips with sepsis in 38 patients. Two patients were lost to follow-up. Nine (24%) had multi-focal sepsis. Overall, 13 hips (34%) had a full and uncomplicated clinical and radiological recovery and 25 (66%) had complications. All patients treated by arthrotomy and appropriate antibiotics within five days of the onset of symptoms had an uncomplicated recovery. Initial misdiagnosis was associated with a delay to arthrotomy. However, ‘deprivation’, consultation with a traditional healer, maternal educational attainment and distance to a primary health-care facility were not associated with delay to arthrotomy. The early correct diagnosis of this condition, common in the developing world, remains a significant factor in improving the clinical outcome.

We report an independent prospective review of the first 230 Birmingham hip resurfacings in 212 patients at a mean follow-up of five years (4 to 6).

Two patients, one with a loose acetabular component and the other with suspected avascular necrosis of the femoral head, underwent revision. There were two deaths from unrelated causes and one patient was lost to follow-up. The survivorship with the worst-case scenario was 97.8% (95% confidence interval 95.8 to 99.5). The mean Harris hip score improved significantly (paired t-test, p < 0.05) from 62.54 (8 to 92) pre-operatively to 97.7 (61 to 100) at a mean of three years (2.1 to 4.3), then deteriorated slightly to a mean of 95.2 (47 to 100) at a mean of five years. The mean flexion improved from 91.5° (25° to 140°) to 110.4° (80° to 145°) at a mean of three years with no further improvement at five years (111.2°; 70° to 160°).

On radiological review at five years, one patient had a progressive lucent line around the acetabular component and six had progressive lucent lines around the femoral component. A total of 18 femoral components (8%) had migrated into varus and those with lucent lines present migrated a mean of 3.8° (1.02° to 6.54°) more than the rest. Superolateral notching of the femoral neck and reactive sclerosis at the tip of the peg of the femoral component were associated with the presence of lucent lines (chi-squared test, p < 0.05), but not with migration of the femoral component, and are of unknown significance.

Our results with the Birmingham hip resurfacing continue to be satisfactory at a mean follow-up of five years.

Our aim was to evaluate the efficacy of a two-level reconstruction technique using subchondral miniscrews for the stabilisation of comminuted posterior-wall marginal acetabular fragments before applying lag screws and a buttress plate to the main overlying posterior fragment. Between 1995 and 2003, 29 consecutive patients with acute comminuted displaced posterior-wall fractures of the acetabulum were treated operatively using this technique.

The quality of reduction measured from three standard plain radiographs was graded as anatomical in all 29 hips. The clinical outcome at a mean follow-up of 35 months (24 to 90) was considered to be excellent in five patients (17%), very good in 16 (55%), good in six (21%) and poor in two (7%). The use of the two-level reconstruction technique appears to provide stable fixation and is associated with favourable results in terms of the incidence of post-traumatic osteoarthritis and the clinical outcome. However, poor results may occur in patients over the age of 55 years.

The appearance of the ‘grand-piano sign’ on the anterior resected surface of the femur has been considered to be a marker for correct femoral rotational alignment during total knee replacement. Our study was undertaken to assess quantitatively the morphological patterns on the resected surface after anterior femoral resection with various angles of external rotation, using a computer-simulation technique. A total of 50 right distal femora with varus osteoarthritis in 50 Korean patients were scanned using computerised tomography. Computer image software was used to simulate the anterior femoral cut, which was applied at an external rotation of 0°, 3° and 6° relative to the posterior condylar axis, and parallel to the surgical and clinical epicondylar axes in each case. The morphological patterns on the resected surface were quantified and classified as the ‘grand-piano sign’, ‘the boot sign’ and the ‘butterfly sign’. The surgeon can use the analogy of these quantified sign patterns to ensure that a correct rotational alignment has been obtained intra-operatively.

Little is known about the increase in length of tendons in postnatal life or of their response to limb lengthening procedures. A study was carried out in ten young and nine adult rabbits in which the tibia was lengthened by 20% at two rates 0.8 mm/day and 1.6 mm/day.

The tendon of the flexor digitorum longus (FDL) muscle showed a significant increase in length in response to lengthening of the tibia. The young rabbits exhibited a significantly higher increase in length in the FDL tendon compared with the adults. There was no difference in the amount of lengthening of the FDL tendon at the different rates. Of the increase in length which occurred, 77% was in the proximal half of the tendon.

This investigation demonstrated that tendons have the ability to lengthen during limb distraction. This occurred to a greater extent in the young who showed a higher proliferative response, suggesting that there may be less need for formal tendon lengthening in young children.

This study assessed the frequency of acute injury to the spinal cord in Irish Rugby over a period of ten years, between 1995 and 2004. There were 12 such injuries; 11 were cervical and one was thoracic. Ten occurred in adults and two in schoolboys. All were males playing Rugby Union and the mean age at injury was 21.6 years (16 to 36). The most common mechanism of injury was hyperflexion of the cervical spine and the players injured most frequently were playing at full back, hooker or on the wing. Most injuries were sustained during the tackle phase of play. Six players felt their injury was preventable. Eight are permanently disabled as a result of their injury.

We studied 33 third generation, alumina ceramic-on-ceramic bearings retrieved from cementless total hip replacements after more than six months in situ. Wear volume was measured with a Roundtest machine, and acetabular orientation from the anteroposterior pelvic radiograph. The overall median early wear rate was 0.1 mm³/yr for the femoral heads, and 0.04 mm³/yr for the acetabular liners. We then excluded hips where the components had migrated. In this stable subgroup of 22 bearings, those with an acetabular anteversion of < 15° (seven femoral heads) had a median femoral head wear rate of 1.2 mm³/yr, compared with 0 mm³/yr for those with an anteversion of ≥15° (15 femoral heads, p < 0.001). Even under edge loading, wear volumes with ceramic-on-ceramic bearings are small in comparison to other bearing materials. Low acetabular anteversion is associated with greater wear.

The treatment of osteochondral lesions of the talus has evolved with the development of improved imaging and arthroscopic techniques. However, the outcome of treatment for large cystic type-V lesions is poor, using conventional grafting, debridement or microfracture techniques.

This retrospective study examined the outcomes of 50 patients with a cystic talar defect who were treated with arthroscopically harvested, cored osteochondral graft taken from the ipsilateral knee.

Of the 50 patients, 45 (90%) had a mean good to excellent score of 80.3 (52 to 90) in the Karlsson-Peterson Ankle Score, at a mean follow-up of 36 months (24 to 83). A malleolar osteotomy for exposure was needed in 26 patients and there were no malleolar mal- or nonunions. One patient had symptoms at the donor site three months after surgery; these resolved after arthroscopic release of scar tissue.

This technique is demanding with or without a malleolar osteotomy, but if properly performed has a high likelihood of success.