Aims

The purpose of this study was to compare the clinical and radiographic outcomes of total ankle arthroplasty (TAA) in patients with pre-operatively moderate and severe arthritic varus ankles to those achieved for patients with neutral ankles.

Aims

Anatomical atlases document classical safe corridors for the placement of transosseous fine wires through the calcaneum during circular frame external fixation. During this process, the posterior tibial neurovascular bundle (PTNVB) is placed at risk, though this has not been previously quantified. We describe a cadaveric study to investigate a safe technique for posterolateral to anteromedial fine wire insertion through the body of the calcaneum.

Aims

The aims of this study were to determine the proportion of patients with outlier varus or valgus alignment in kinematically aligned total knee arthroplasty (TKA), whether those with outlier varus or valgus alignment have higher forces in the medial or lateral compartments of the knee than those with in-range alignment and whether measurements of the alignment of the limb, knee and components predict compartment forces.

We compared the strength of fixation of a biodegradable screw with that of two metal screws in a bone-patellar-tendon-bone (BPTB) graft in the bovine knee. We used 33 fresh BPTB specimens with a circular tibial bone plug of 9 mm in diameter which were anchored in a tibial metaphyseal bone tunnel with either an interference screw (n = 11), an AO cancellous screw (n = 11) or a fibrillated, self-reinforced biodegradable poly-L-lactide screw (n = 11). The mean force to failure (+/- SD) in the three groups was 1358 +/- 348 N, 1081 +/- 331 N and 1211 +/- 362 N, respectively. There was no significant difference in the groups with regard to the linear load or the elastic moduli of the fixation. We conclude that the biodegradable screw is as good as either of the two metal screws in the fixation of a BPTB graft in the bovine knee and can be recommended for ACL reconstruction using this type of graft

Between 1994 and 1997 we used the Ilizarov apparatus to treat 12 recurrent arthrogrypotic club feet in nine patients with a mean age of 5.3 years (3.2 to 7). After a mean of three weeks (two to seven) for correction of the deformity and 1.5 weeks (one to four) for stabilisation in the apparatus, immobilisation in a cast was carried out for a mean of 14 weeks (7 to 24). The mean follow-up period was 35 months (27 to 57). Before operation there were one grade-II (moderate), eight grade-III (severe) and three grade-IV (very severe) club feet, according to the rating system of Dimeglio et al. After operation, all the club feet except one were grade I (benign) with a painless, plantigrade platform. Radiological assessment and functional evaluation confirmed significant improvement. Two complications occurred in one patient, namely, epiphysiolysis of the distal tibia and recurrence of the foot deformity. These results suggest that our proposed modification of the Ilizarov technique is effective in the management of recurrent arthrogrypotic club foot in young children

Aims

Meniscal allograft transplantation is undertaken to improve pain and function in patients with a symptomatic meniscal deficient knee compartment. While case series have shown improvements in patient reported outcome measures (PROMs), its efficacy has not been rigorously evaluated. This study aimed to compare PROMs in patients having meniscal transplantation with those having personalized physiotherapy at 12 months.

Early implants for total knee replacement were fixed to bone with cement. No firm scientific reason has been given for the introduction of cementless knee replacement and the long-term survivorship of such implants has not shown any advantage over cemented forms. In a randomised, prospective study we have compared cemented and uncemented total knee replacement and report the results of 139 prostheses at five years. Outcome was assessed both clinically by independent examination using the Nottingham knee score and radiologically using the Knee Society scoring system. Independent statistical analysis of the data showed no significant difference between cemented and cementless fixation for pain, mobility or movement. There was no difference in the radiological alignment at five years, but there was a notable disparity in the radiolucent line score. With cemented fixation there was a significantly greater number of radiolucent lines on anteroposterior radiographs of the tibia and lateral radiographs of the femur. At five years, our clinical results would not support the use of the more expensive cementless fixation whereas the radiological results are of unknown significance. Longer follow-up will determine any changes in the results and conclusions

We carried out weight-bearing video radiological studies on 40 patients with a total knee arthroplasty (TKA), to determine the presence and magnitude of femoral condylar lift-off. Half (20) had posterior-cruciate-retaining (PCR) and half (20) posterior-cruciate-substituting (PS) prostheses. The selected patients had successful arthroplasties with no pain or instability. Each carried out successive weight-bearing knee bends to maximum flexion, and the radiological video tapes were analysed using an interactive model-fitting technique. Femoral lift-off was seen at some increment of knee flexion in 75% of patients (PCR TKA 70%; PS TKA 80%). The mean values for lift-off were 1.2 mm with a PCR TKA and 1.4 mm with a PS TKA. Lift-off occurred mostly laterally with the PCR TKA, and both medially and laterally with the PS TKA. Separation between the femoral condyles and the articular surface of the tibia was recorded at 0°, 30°, 60° and 90° of flexion. Femoral condylar lift-off may contribute to eccentric polyethylene wear, particularly in designs of TKA which have flatter condyles. Coronal conformity is an important consideration in the design of a TKA

Forty failed hinged arthroplasties of the knee were revised by the insertion of another hinged implant. In 14 cases the prosthesis used at the revision operation was similar to the primary implant; in 26, a hinge with an elongated femoral stem was used, usually replacing part of the femoral shaft. In seven of these knees an elongated tibial stem was also required, though the tibial shaft was replaced in only two of them. There were many complications. Fracture of the femur at the tip of the femoral stem was the most frequent. Sixteen first revisions failed and were revised a second time; 12 required replacement of the distal femoral shaft and three required replacement of the proximal tibia. The incidence of complications in knees requiring a second revision was even higher. Four required a third revision after an average interval of three years. Failure of a hinged prosthesis results in bone loss mainly in the femur. Revision of a failed hinged prosthesis with another of the same design is unlikely to be successful and may cause fracture of the femur

We have developed a new drug delivery system using porous apatite-wollastonite glass ceramic (A-W GC) to treat osteomyelitis. A-W GC (porosity, 70% and 20% to 30%), or porous hydroxyapatite (HA) blocks (porosity 35% to 48%) used as controls, were soaked in mixtures of two antibiotics, isepamicin sulphate (ISP) and cefmetazole (CMZ) under high vacuum. We evaluated the release concentrations of the antibiotics from the blocks. The bactericidal concentration of ISP from A-W GC was maintained for more than 42 days, but that from HA decreased to below the detection limit after 28 days. The concentrations of CMZ from both materials were lower than those of ISP. An in vivo study using rabbit femora showed that an osseous concentration of ISP was maintained at eight weeks after implantation. Osteoconduction of the A-W GC block was good. Four patients with infected hip arthroplasties and one with osteomyelitis of the tibia have been treated with the new delivery system with excellent results

An account is given of 38 patients with complicated tibial fractures who were treated by the Portsmouth method of external fixation. Twenty-one patients had multiple injuries and 30 had compound fractures of the tibia. Eighteen fractures wounds were infected, 17 cases required bone grafts and 13 had skin grafts. Thirty-four fractures united in an average time of six months; three patients underwent below-knee amputations; one with neurofibromatosis remains ununited. Those treated primarily by external fixation did better than those in whom external fixation was used after failure of another method. Most fresh fractures united with external callus; and the significance of this in relation to the rigidity of fixation is discussed. The method is easy to use, effective and economical. Improvements to permit adjustment of position and testing for union are suggested. We advise the use of this method of external fixation as the primary treatment for complicated tibial fractures where there is a significant risk of infection or non-union

Objectives

Malalignment of the tibial component could influence the long-term survival of a total knee arthroplasty (TKA). The object of this study was to investigate the biomechanical effect of varus and valgus malalignment on the tibial component under stance-phase gait cycle loading conditions.

Aims

To evaluate the effect of a single early high-dose vitamin D supplement on fracture union in patients with hypovitaminosis D and a long bone fracture.

Experience with thirty-eight Asian children and adolescents who presented with either stiffness of the knee, genu recurvatum, habitual dislocation of the patella or congenital lateral dislocation of the patella showed that all those disorders were manifestations of contracture of the extensor mechanism, which fell into two groups according to the components involved. In Group I the main components affected were in the midline of the limb, namely rectus femoris and vastus intermedius; these patients presented with varying degrees of stiffness of the knee, or worse, with genu recurvatum. In Group II the main components involved were lateral to the midline of the limb, namely vastus lateralis and the ilio-tibial band; these patients presented with habitual dislocation of the patella, or worse, congenital lateral dislocation of the patella. In both groups untreated patients developed secondary adaptive changes such as subluxation of the tibia or marked genu valgum which made operative procedures more formidable and less effective. Release of the contracture should therefore be performed as early as possible

1. A three-year survey of avascular necrosis of bone has been carried out in a community of some 400 professional divers for shell-fish who had used no modern technique of decompression. 2. Of 301 divers radiographed, 152 (50·5 per cent) had bone lesions. 3. The incidence of bone necrosis increased in proportion to the length of diving experience, being highest in men with over ten years, experience. 4. The incidence was also higher in men who usually dived deeper than thirty metres. 5. There was a high incidence in men with a history of the bends but no significant relationship between the sites of the bends and those of the lesions. 6. Bone lesions were more frequently multiple than solitary. 7. The upper end of the humerus was significantly more affected than the upper end of the femur or tibia, but not significantly more than the lower end of the femur. 8. At the upper ends of the humerus and femur the lesions were more frequently unilateral than bilateral

1. Fifteen patients who had had osteomyelitis of the lower femur or upper tibia during infancy have been studied. The cases of four patients showing particular features of the disease are presented in detail and the remainder are summarised. 2. It is suggested that damage to the epiphysis may be due to an abscess, or to ischaemia following occlusion of the blood supply. In the latter instance the prognosis may be better. 3. In the early stages the radiographic appearances may be deceptive, suggesting that damage to the epiphysis is irreparable. 4. Significant recovery of the epiphysis may occur in some patients after a delay of several years. This, together with the often good function which is preserved at the joint, should deter the surgeon from early destructive operation on the limb. 5. Deformity, which was present to some extent in all cases, appeared early and was not well controlled by conservative treatment. Operations were performed in twelve patients. 6. Shortening of the limb occurred in all patients and in some it was severe

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

1. Cancellous bone cubes from calf and man were deproteinised with hydrogen peroxide and with ethylenediamine. 2. Long bones were removed aseptically from sheep, stored in the bone bank and used for cancellous homografts. 3. Holes were drilled in the upper part of the tibia or ulna or in the lower part of the femur of sheep. Some were left empty; others were filled with plugs of the deproteinised heterogenous bone, with autografts, or with homografts. 4. Histological appearances were studied after seventeen and thirty-six days. 5. At seventeen days repair was more advanced in the plugged holes; the biological result was better with the ethylenediamine-treated than with the peroxide-treated material. After thirty-six days repair was at an advanced stage. As much new bone had been deposited on the trabeculae of the deproteinised heterografts as on those of the homografts. 6. There was no evidence of metaplastic bone formation; new bone seemed to form from endosteal osteoblasts. 7. Certain clinical implications are briefly discussed

Objectives

Posterior condylar offset (PCO) and posterior tibial slope (PTS) are critical factors in total knee arthroplasty (TKA). A computational simulation was performed to evaluate the biomechanical effect of PCO and PTS on cruciate retaining TKA.