Blast and ballistic weapons used on the battlefield cause devastating injuries rarely seen outside armed conflict. These extremely high-energy injuries predominantly affect the limbs and are usually heavily contaminated with soil, foliage, clothing and even tissue from other casualties. Once life-threatening haemorrhage has been addressed, the military surgeon’s priority is to control infection.

Combining historical knowledge from previous conflicts with more recent experience has resulted in a systematic approach to these injuries. Urgent debridement of necrotic and severely contaminated tissue, irrigation and local and systemic antibiotics are the basis of management. These principles have resulted in successful healing of previously unsurvivable wounds. Healthy tissue must be retained for future reconstruction, vulnerable but viable tissue protected to allow survival and avascular tissue removed with all contamination.

While recent technological and scientific advances have offered some advantages, they must be judged in the context of a hard-won historical knowledge of these wounds. This approach is applicable to comparable civilian injury patterns. One of the few potential benefits of war is the associated improvement in our understanding of treating the severely injured; for this positive effect to be realised these experiences must be shared.

To date, all surgical techniques used for reconstruction of the pelvic ring following supra-acetabular tumour resection produce high complication rates. We evaluated the clinical, oncological and functional outcomes of a cohort of 35 patients (15 men and 20 women), including 21 Ewing’s sarcomas, six chondrosarcomas, three sarcomas not otherwise specified, one osteosarcoma, two osseous malignant fibrous histiocytomas, one synovial cell sarcoma and one metastasis. The mean age of the patients was 31 years (8 to 79) and the latest follow-up was carried out at a mean of 46 months (1.9 to 139.5) post-operatively.

We undertook a functional reconstruction of the pelvic ring using polyaxial screws and titanium rods. In 31 patients (89%) the construct was encased in antibiotic-impregnated polymethylmethacrylate. Preservation of the extremities was possible for all patients. The survival rate at three years was 93.9% (95% confidence interval (CI) 77.9 to 98.4), at five years it was 82.4% (95% CI 57.6 to 93.4). For the 21 patients with Ewing’s sarcoma it was 95.2% (95% CI 70.7 to 99.3) and 81.5% (95% CI 52.0 to 93.8), respectively. Wound healing problems were observed in eight patients, deep infection in five and clinically asymptomatic breakage of the screws in six. The five-year implant survival was 93.3% (95% CI 57.8 to 95.7). Patients were mobilised at a mean of 3.5 weeks (1 to 7) post-operatively. A post-operative neurological defect occurred in 12 patients. The mean Musculoskeletal Tumor Society score at last available follow-up was 21.2 (10 to 27).

This reconstruction technique is characterised by simple and oncologically appropriate applicability, achieving high primary stability that allows early mobilisation, good functional results and relatively low complication rates.

Cite this article: Bone Joint J 2013;95-B:1410–16.

We measured the tension in the interosseous membrane in six cadaveric forearms using an in vitro forearm testing system with the native radial head, after excision of the radial head and after metallic radial head replacement. The tension almost doubled after excision of the radial head during simulated rotation of the forearm (p = 0.007). There was no significant difference in tension in the interosseous membrane between the native and radial head replacement states (p = 0.09). Maximal tension occurred in neutral rotation with both the native and the replaced radial head, but in pronation if the radial head was excised. Under an increasing axial load and with the forearm in a fixed position, the rate of increase in tension in the interosseous membrane was greater when the radial head was excised than for the native radial head or replacement states (p = 0.02). As there was no difference in tension between the native and radial head replacement states, a radial head replacement should provide a normal healing environment for the interosseous membrane after injury or following its reconstruction. Load sharing between the radius and ulna becomes normal after radial head Replacement. As excision of the radial head significantly increased the tension in the interosseous membrane it may potentially lead to its attritional failure over time.

Cite this article: Bone Joint J 2013;95-B:1383–7.

We evaluated results at one year after surgical correction of internal rotation deformities in the shoulders of 270 patients with obstetric brachial plexus palsy. The mean age at surgery was 6.2 years (0.6 to 35). Two techniques were used: open subscapularis elongation and latissimus dorsi to infraspinatus transfer. In addition, open relocation was performed or attempted in all patients with subluxed or dislocated joints. A mixed effects model approach was used to evaluate the effects of surgery on internal and external rotation, abduction, flexion and Mallet score. Independent factors included operative status (pre- or post-operative), gender, age, the condition of the joint, and whether or not transfer was performed. The overall mean improvement in external rotation following surgery was 84.6° (95% confidence interval (CI) 80.2 to 89.1) and the mean Mallet score improved by 4.0 (95% CI 3.7 to 4.2). There was a mean decrease in internal rotation of between 27.6° and 34.4° in the relocated joint groups and 8.6° (95% CI 5.2 to 12.0) in the normal joint group. Abduction and flexion were unchanged following surgery. Adding a latissimus dorsi transfer did not result in greater improvement in the mean external rotation compared with elongation of the subscapularis alone.

Cite this article: Bone Joint J 2013;95-B:1432–8.

The October 2013 Children’s orthopaedics Roundup³⁶⁰ looks at: Half a century of Pavlik treatment; Step away from the child!: trends in fracture management; Posterolateral rotatory elbow instability in children; Osteochondral lesions undiagnosed in patellar dislocations; Oral bisphosphonates in osteogenesis imperfecta; Crossed or parallel pins in supracondylar fractures?; Not too late nor too early: getting epiphysiodesis right; Fixation of supramalleolar osteotomies.

The October 2013 Foot & Ankle Roundup³⁶⁰ looks at: Operative treatment of calcaneal fractures advantageous in the long term?; Varus ankles and arthroplasty; Reducing autograft complications in foot and ankle surgery; The biomechanics of ECP in plantar fasciitis; Minimally invasive first ray surgery; Alcohol: better drunk than injected?; Is it different in the foot?; It’s all about the temperature

Fractures of the proximal femur are one of the greatest challenges facing the medical community, constituting a heavy socioeconomic burden worldwide. Controversy exists regarding the optimal treatment for patients with unstable trochanteric proximal femoral fractures. The recognised treatment alternatives are extramedullary fixation usually with a sliding hip screw and intramedullary fixation with a cephalomedullary nail. Current evidence suggests that best results and lowest complication rates occur using a sliding hip screw. Complications in these difficult fractures are relatively common regardless of type of treatment. We believe that a novel device, the X-Bolt dynamic plating system, may offer superior fixation over a sliding hip screw with lower reoperation risk and better function. We therefore propose to investigate the clinical effectiveness of the X-bolt dynamic plating system compared with standard sliding hip screw fixation within the framework of a the larger WHiTE (Warwick Hip Trauma Evaluation) Comprehensive Cohort Study.

Cite this article: Bone Joint Res 2013;2:206–9.

Objectives

The most prevalent disorders of the shoulder are related to the muscles of rotator cuff. In order to develop a mechanical method for the evaluation of the rotator cuff muscles, we created a database of isometric force generation by the rotator cuff muscles in normal adult population. We hypothesised the existence of variations according to age, gender and dominancy of limb.

The outcome of high tibial osteotomy (HTO) deteriorates with time, and additional procedures may be required. The aim of this study was to compare the clinical and radiological outcomes between unicompartmental knee replacement (UKR) and total knee replacement (TKR) after HTO as well as after primary UKR. A total of 63 patients (63 knees) were studied retrospectively and divided into three groups: UKR after HTO (group A; n = 22), TKR after HTO (group B; n = 18) and primary UKR (group C; n = 22). The Oxford knee score (OKS), Knee Society score (KSS), hip–knee–ankle angles, mechanical axis and patellar height were evaluated pre- and post-operatively. At a mean of 64 months (19 to 180) post-operatively the mean OKS was 43.8 (33 to 49), 43.3 (30 to 48) and 42.5 (29 to 48) for groups A, B and C, respectively (p = 0.73). The mean KSS knee score was 88.8 (54 to 100), 88.11 (51 to 100) and 85.3 (45 to 100) for groups A, B and C, respectively (p = 0.65), and the mean KSS function score was 85.0 (50 to 100) in group A, 85.8 (20 to 100) in group B and 79.3 (50 to 100) in group C (p = 0.48). Radiologically the results were comparable for all groups except for patellar height, with a higher incidence of patella infra following a previous HTO (p = 0.02).

Cite this article: Bone Joint J 2013;95-B:1348–53.

Orientation of the acetabular component influences wear, range of movement and the incidence of dislocation after total hip replacement (THR). During surgery, such orientation is often referenced to the anterior pelvic plane (APP), but APP inclination relative to the coronal plane (pelvic tilt) varies substantially between individuals. In contrast, the change in pelvic tilt from supine to standing (dPT) is small for nearly all individuals. Therefore, in THR performed with the patient supine and the patient’s coronal plane parallel to the operating table, we propose that freehand placement of the acetabular component placement is reliable and reflects standing (functional) cup position. We examined this hypothesis in 56 hips in 56 patients (19 men) with a mean age of 61 years (29 to 80) using three-dimensional CT pelvic reconstructions and standing lateral pelvic radiographs. We found a low variability of acetabular component placement, with 46 implants (82%) placed within a combined range of 30° to 50° inclination and 5° to 25° anteversion. Changing from the supine to the standing position (analysed in 47 patients) was associated with an anteversion change < 10° in 45 patients (96%). dPT was < 10° in 41 patients (87%). In conclusion, supine THR appears to provide reliable freehand acetabular component placement. In most patients a small reclination of the pelvis going from supine to standing causes a small increase in anteversion of the acetabular component.

Cite this article: Bone Joint J 2013;95-B:1326–31.

A retrospective study was conducted to investigate the changes in metal ion levels in a consecutive series of Birmingham Hip Resurfacings (BHRs) at a minimum ten-year follow-up. We reviewed 250 BHRs implanted in 232 patients between 1998 and 2001. Implant survival, clinical outcome (Harris hip score), radiographs and serum chromium (Cr) and cobalt (Co) ion levels were assessed.

Of 232 patients, 18 were dead (five bilateral BHRs), 15 lost to follow-up and ten had been revised. The remaining 202 BHRs in 190 patients (136 men and 54 women; mean age at surgery 50.5 years (17 to 76)) were evaluated at a minimum follow-up of ten years (mean 10.8 years (10 to 13.6)). The overall implant survival at 13.2 years was 92.4% (95% confidence interval 90.8 to 94.0). The mean Harris hip score was 97.7 (median 100; 65 to 100). Median and mean ion levels were low for unilateral resurfacings (Cr: median 1.3 µg/l, mean 1.95 µg/l (< 0.5 to 16.2); Co: median 1.0 µg/l, mean 1.62 µg/l (< 0.5 to 17.3)) and bilateral resurfacings (Cr: median 3.2 µg/l, mean 3.46 µg/l (< 0.5 to 10.0); Co: median 2.3 µg/l, mean 2.66 µg/l (< 0.5 to 9.5)). In 80 unilateral BHRs with sequential ion measurements, Cr and Co levels were found to decrease significantly (p < 0.001) from the initial assessment at a median of six years (4 to 8) to the last assessment at a median of 11 years (9 to 13), with a mean reduction of 1.24 µg/l for Cr and 0.88 µg/l for Co. Three female patients had a > 2.5 µg/l increase of Co ions, associated with head sizes ≤ 50 mm, clinical symptoms and osteolysis. Overall, there was no significant difference in change of ion levels between genders (Cr, p = 0.845; Co, p = 0.310) or component sizes (Cr, p = 0.505; Co, p = 0.370). Higher acetabular component inclination angles correlated with greater change in ion levels (Cr, p = 0.013; Co, p = 0.002). Patients with increased ion levels had lower Harris hip scores (p = 0.038).

In conclusion, in well-functioning BHRs the metal ion levels decreased significantly at ten years. An increase > 2.5 µg/l was associated with poor function.

Cite this article: Bone Joint J 2013;95-B:1332–8.

The aim of this study was to define the incidence of venous thromboembolism (VTE) and risk factors for the development of deep-vein thrombosis (DVT) after the resection of a musculoskeletal tumour. A total of 94 patients who underwent resection of a musculoskeletal tumour between January 2003 and December 2005 were prospectively studied. There were 42 men and 52 women with a mean age of 54.4 years (18 to 86). All patients wore intermittent pneumatic compression devices and graduated compression stockings. Ultrasound examination of the lower limbs was conducted to screen for DVT between the fifth and ninth post-operative days.

DVT was detected in 21 patients (22%). Of these, two were symptomatic (2%). One patient (1%) had a fatal pulmonary embolism. Patients aged ≥ 70 years had an increased risk of DVT (p = 0.004).

The overall incidence of DVT (both symptomatic and asymptomatic) after resection of a musculoskeletal tumour with mechanical prophylaxis was high. It seems that both mechanical and anticoagulant prophylaxis is needed to prevent VTE in patients who have undergone the resection of a musculoskeletal tumour.

Cite this article: Bone Joint J 2013;95-B:1280–4.

In developmental dysplasia of the hip (DDH), a bone defect is often observed superior to the acetabulum after the reconstruction at the level of the true acetabulum during total hip replacement (THR). However, the essential amount of uncemented acetabular component coverage required for a satisfactory outcome remains controversial. The purpose of this study was to assess the stability and function of acetabular components with a lack of coverage > 30% (31% to 50%). A total of 760 DDH patients underwent THR with acetabular reconstruction at the level of the true floor. Lack of coverage above the acetabular component of > 30% occurred in 56 patients. Intra-operatively, autogenous morcellised bone grafts were used to fill the uncovered portion. Other than two screws inserted through the acetabular shell, no additional structural supports were used in these hips. In all, four patients were lost to follow-up. Therefore, 52 patients (52 hips, 41 women and 11 men) with a mean age of 60.1 years (42 to 78) were available for this study at a mean of 4.8 years (3 to 7). There were no instances of prosthesis revision or marked loosening during the follow-up. The Harris hip score improved from a mean of 40.7 points (sd 12.2) pre-operatively to 91.1 (sd 5.0) at the last follow-up. Radiological analysis with medical imaging software allowed us to calculate the extent of the uncoverage in terms of the uncovered arc of the implant as viewed on the anteroposterior pelvic radiograph. From this we propose that up to 17 mm of lateral undercoverage in the presence of a stable initial implantation in the presence of bone autografting, with an inclination angle of the acetabular component between 40° and 55°, is acceptable. This represents undercoverage of ≤ 50%.

Cite this article: Bone Joint J 2013;95-B:1178–83.

While an increasing amount of arthroplasty articles report comorbidity measures, none have been validated for outcomes. In this study, we compared commonly used International Classification of Diseases-based comorbidity measures with re-operation rates after total hip replacement (THR). Scores used included the Charlson, the Royal College of Surgeons Charlson, and the Elixhauser comorbidity score. We identified a nationwide cohort of 134 423 THRs from the Swedish Hip Arthroplasty Register. Re-operations were registered post-operatively for up to 12 years. The hazard ratio was estimated by Cox’s proportional hazards regression, and we used C-statistics to assess each measure’s ability to predict re-operation. Confounding variables were age, gender, type of implant fixation, hospital category, hospital implant volume and year of surgery.

In the first two years only the Elixhauser score showed any significant relationship with increased risk of re-operation, with increased scores for both one to two and three or more comorbidities. However, the predictive C-statistic in this period for the Elixhauser score was poor (0.52). None of the measures proved to be of any value between two and 12 years. They might be of value in large cohort or registry studies, but not for the individual patient.

Cite this article: Bone Joint J 2013;95-B:1184–91.

As it remains unproven that hypermobility of the first tarsometatarsal joint (TMTJ-1) is a significant factor in hallux valgus deformity, the necessity for including arthrodesis of TMTJ-1 as part of a surgical correction of a hallux valgus is questionable. In order to evaluate the role of this arthrodesis on the long-term outcome of hallux valgus surgery, a prospective, blinded, randomised study with long-term follow-up was performed, comparing the Lapidus procedure (which includes such an arthrodesis) with a simple Hohmann distal closing wedge metatarsal osteotomy. The study cohort comprised 101 feet in 87 patients: 50 feet were treated with a Hohmann procedure and 51 with a Lapidus procedure. Hypermobility of TMTJ-1 was assessed pre-operatively by clinical examination. After a mean of 9.25 years (7.25 to 11.42), 91 feet in 77 patients were available for follow-up. There was no difference in clinical or radiological outcome between the two procedures. Also, there was no difference in outcome between the two procedures in the subgroup clinically assessed as hypermobile. This study does not support the theory that a hallux valgus deformity in a patient with a clinically assessed hypermobile TMTJ-1 joint requires fusion of the first tarso-metatarsal joint.

Cite this article: Bone Joint J 2013;95-B:1222–6.

Some surgeons are reluctant to perform a reverse total shoulder arthroplasty (RTSA) on both shoulders because of concerns regarding difficulty with activities of daily living post-operatively as a result of limited rotation of the shoulders. Nevertheless, we hypothesised that outcomes and patient satisfaction following bilateral RTSA would be comparable to those following unilateral RTSA. A single-surgeon RTSA registry was reviewed for patients who underwent bilateral staged RTSA with a minimum follow-up of two years. A unilateral RTSA matched control was selected for each shoulder in those patients undergoing bilateral procedures. The Constant–Murley score (CMS), American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Values (SSV), visual analogue scale (VAS) for pain, range of movement and strength were measured pre- and post-operatively. The mean CMS, ASES, SSV, VAS scores, strength and active forward elevation were significantly improved (all p < 0.01) following each operation in those undergoing bilateral procedures. The mean active external rotation (p = 0.63 and p = 0.19) and internal rotation (p = 0.77 and p = 0.24) were not significantly improved. The improvement in the mean ASES score after the first RTSA was greater than the improvement in its control group (p = 0.0039). The improvement in the mean CMS, ASES scores and active forward elevation was significantly less after the second RTSA than in its control group (p = 0.0244, p = 0.0183, and p = 0.0280, respectively). Pain relief and function significantly improved after each RTSA in those undergoing a bilateral procedure.

Bilateral RTSA is thus a reasonable form of treatment for patients with severe bilateral rotator cuff deficiency, although inferior results may be seen after the second procedure compared with the first.

Cite this article: Bone Joint J 2013;95-B:1232–8.

The variation in surgical performance, both between centres and individual surgeons, has recently been of significant political, media and public interest. Within the United Kingdom, a government agenda to increase accountability amongst surgeons has led to the online publication of ‘surgeon-level’ data. Surgeons, journalists and the public need to understand these data if they are to be useful in driving up standards of surgical care. This Editorial describes the use of Funnel Plots, which are the common means by which such data are presented, and discusses how the plots are generated.

Cite this article: Bone Joint J 2013;95-B:1156–7.

The FRCS (Tr & Orth) examination has three components: MCQs, Vivas and Clinical Examination. The Vivas are further divided into four sections comprising Basic Science, Adult Pathology, Hands and Children’s Orthopaedics and Trauma. The Clinical Examination section is divided into Upper and Lower limb cases. The aim of this section in the Journal is to focus specifically on the trainees preparing for the exam and to cater to all the sections of the exam. The vision is to complete the cycle of all relevant exam topics (as per the syllabus) in four years.

Supracondylar humeral fractures are common in children, but there are no classification systems or radiological parameters that predict the likelihood of having to perform an open reduction. In a retrospective case–control study we evaluated the use of the medial spike angle and fracture tip–skin distance to predict the mode of reduction (closed or open) and the operating time in fractures with posterolateral displacement. A total of 21 patients (4.35%) with a small medial spike angle (< 45°) were identified from a total of 494 patients, and 42 patients with a medial spike angle of > 45° were randomly selected as controls. The medial spike group had significantly smaller fracture tip–skin distances (p < 0.001), longer operating times (p = 0.004) and more complications (p = 0.033) than the control group. There was no significant difference in the mode of reduction and a composite outcome measure. After adjustments for age and gender, only fracture tip–skin distance remained significantly associated with the operating time (β = -0.724, p = 0.042) and composite outcome (OR 0.863 (95% confidence interval 0.746 to 0.998); p = 0.048).

Paediatric orthopaedic surgeons should have a lower threshold for open reduction when treating patients with a small medial spike angle and a small fracture tip–skin distance.

Cite this article: Bone Joint J 2013;95-B:1290–4.

Patients with acetabular dysplasia commonly undergo peri-acetabular osteotomy after skeletal maturity to reduce the risk of the late development of osteoarthritis. Several studies have suggested that deformity of the femoral head influences the long-term outcome. We radiologically examined 224 hips in 112 patients with acetabular dysplasia and early-stage osteoarthritis. There were 103 women and nine men with a mean age of 37.6 years (18 to 49). A total of 201 hips were placed in the acetabular dysplasia group and 23 in a normal group. The centre–edge angle and acetabular head index were significantly smaller (both p < 0.001), and the acetabular angle, acetabular roof angle and roundness index were significantly greater in the acetabular dysplasia group than those in the normal group (all p < 0.001). There were significant correlations between the roundness index and other parameters. Femoral head shape may be influenced by the severity of the acetabular dysplasia.

Cite this article: Bone Joint J 2013;95-B:1192–6.

We describe the outcome of tibial diaphyseal fractures in the elderly (≥ 65 years of age). We prospectively followed 233 fractures in 225 elderly patients over a minimum ten-year period. Demographic and descriptive data were acquired from a prospective trauma database. Mortality status was obtained from the General Register Office database for Scotland. Diaphyseal fractures of the tibia in the elderly occurred predominantly in women (73%) and after a fall (61%). During the study period the incidence of these fractures decreased, nearly halving in number. The 120-day and one-year unadjusted mortality rates were 17% and 27%, respectively, and were significantly greater in patients with an open fracture (p < 0.001). The overall standardised mortality ratio (SMR) was significantly increased (SMR 4.4, p < 0.001) relative to the population at risk, and was greatest for elderly women (SMR 8.1, p < 0.001). These frailer patients had more severe injuries, with an increased rate of open fractures (30%), and suffered a greater rate of nonunion (10%).

Tibial diaphyseal fractures in the elderly are most common in women after a fall, are more likely to be open than in the rest of the population, and are associated with a high incidence of nonunion and mortality.

Cite this article: Bone Joint J 2013;95-B:1255–62.

We hypothesised that cells obtained via a Reamer–Irrigator–Aspirator (RIA) system retain substantial osteogenic potential and are at least equivalent to graft harvested from the iliac crest. Graft was harvested using the RIA in 25 patients (mean age 37.6 years (18 to 68)) and from the iliac crest in 21 patients (mean age 44.6 years (24 to 78)), after which ≥ 1 g of bony particulate graft material was processed from each. Initial cell viability was assessed using Trypan blue exclusion, and initial fluorescence-activated cell sorting (FACS) analysis for cell lineage was performed. After culturing the cells, repeat FACS analysis for cell lineage was performed and enzyme-linked immunosorbent assay (ELISA) for osteocalcin, and Alizarin red staining to determine osteogenic potential. Cells obtained via RIA or from the iliac crest were viable and matured into mesenchymal stem cells, as shown by staining for the specific mesenchymal antigens CD90 and CD105. For samples from both RIA and the iliac crest there was a statistically significant increase in bone production (both p < 0.001), as demonstrated by osteocalcin production after induction.

Medullary autograft cells harvested using RIA are viable and osteogenic. Cell viability and osteogenic potential were similar between bone grafts obtained from both the RIA system and the iliac crest.

Cite this article: Bone Joint J 2013;95-B:1269–74.

Fracture repair occurs by two broad mechanisms: direct healing, and indirect healing with callus formation. The effects of bisphosphonates on fracture repair have been assessed only in models of indirect fracture healing.

A rodent model of rigid compression plate fixation of a standardised tibial osteotomy was used. Ten skeletally mature Sprague–Dawley rats received daily subcutaneous injections of 1 µg/kg ibandronate (IBAN) and ten control rats received saline (control). Three weeks later a tibial osteotomy was rigidly fixed with compression plating. Six weeks later the animals were killed. Fracture repair was assessed with mechanical testing, radiographs and histology.

The mean stress at failure in a four-point bending test was significantly lower in the IBAN group compared with controls (8.69 Nmm^-2 (sd 7.63) vs 24.65 Nmm^-2 (sd 6.15); p = 0.017). On contact radiographs of the extricated tibiae the mean bone density assessment at the osteotomy site was lower in the IBAN group than in controls (3.7 mmAl (sd 0.75) vs 4.6 mmAl (sd 0.57); p = 0.01). In addition, histological analysis revealed progression to fracture union in the controls but impaired fracture healing in the IBAN group, with predominantly cartilage-like and undifferentiated mesenchymal tissue (p = 0.007).

Bisphosphonate treatment in a therapeutic dose, as used for risk reduction in fragility fractures, had an inhibitory effect on direct fracture healing. We propose that bisphosphonate therapy not be commenced until after the fracture has united if the fracture has been rigidly fixed and is undergoing direct osteonal healing.

Cite this article: Bone Joint J 2013;95-B:1263–8.

Mobile-bearing (MB) total knee replacement (TKR) was introduced to reduce the risk of aseptic loosening and wear of polyethylene inserts. However, no consistent clinical advantages of mobile- over fixed-bearing (FB) TKR have been found. In this study we evaluated whether mobile bearings have an advantage over fixed bearings with regard to revision rates and clinical outcome scores. Furthermore, we determined which modifying variables affected the outcome.

A systematic search of the literature was conducted to collect clinical trials comparing MB and FB in primary TKR. The primary outcomes were revision rates for any reason, aseptic loosening and wear. Secondary outcomes included range of movement, Knee Society score (KSS), Oxford knee score (OKS), Short-Form 12 (SF-12) score and radiological parameters. Meta-regression techniques were used to explore factors modifying the observed effect.

Our search yielded 1827 publications, of which 41 studies met our inclusion criteria, comprising over 6000 TKRs. Meta-analyses showed no clinically relevant differences in terms of revision rates, clinical outcome scores or patient-reported outcome measures between MB and FB TKRs. It appears that theoretical assumptions of superiority of MB over FB TKR are not borne out in clinical practice.

Cite this article: Bone Joint J 2013;95-B:1209–16.

Although it has been suggested that the outcome after revision of a unicondylar knee replacement (UKR) to total knee replacement (TKR) is better when the mechanism of failure is understood, a comparative study on this subject has not been undertaken.

A total of 30 patients (30 knees) who underwent revision of their unsatisfactory UKR to TKR were included in the study: 15 patients with unexplained pain comprised group A and 15 patients with a defined cause for pain formed group B. The Oxford knee score (OKS), visual analogue scale for pain (VAS) and patient satisfaction were assessed before revision and at one year after revision, and compared between the groups.

The mean OKS improved from 19 (10 to 30) to 25 (11 to 41) in group A and from 23 (11 to 45) to 38 (20 to 48) in group B. The mean VAS improved from 7.7 (5 to 10) to 5.4 (1 to 8) in group A and from 7.4 (2 to 9) to 1.7 (0 to 8) in group B. There was a statistically significant difference between the mean improvements in each group for both OKS (p = 0.022) and VAS (p = 0.002). Subgroup analysis in group A, performed in order to define a patient factor that predicts outcome of revision surgery in patients with unexplained pain, showed no pre-operative differences between both subgroups.

These results may be used to inform patients about what to expect from revision surgery, highlighting that revision of UKR to TKR for unexplained pain generally results in a less favourable outcome than revision for a known cause of pain.

Cite this article: Bone Joint J 2013;95-B:1204–8.

We hypothesised that adjuvant intermittent pneumatic compression (IPC) beneath a plaster cast would reduce the risk of deep-vein thrombosis (DVT) during post-operative immobilisation of the lower limb. Of 87 patients with acute tendo Achillis (TA) rupture, 26 were prospectively randomised post-operatively after open TA repair. The treatment group (n = 14) received two weeks of IPC of the foot for at least six hours daily under a plaster cast. The control group (n = 12) had no additional treatment. At two weeks post-operatively all patients received an orthosis until follow-up at six weeks. At two and six weeks the incidence of DVT was assessed using colour duplex sonography by two ultrasonographers blinded to the treatment. Two patients withdrew from the study due to inability to tolerate IPC treatment.

An interim analysis demonstrated a high incidence of DVT in both the IPC group (9 of 12, 75%) and the controls (6 of 12, 50%) (p = 0.18). No significant differences in incidence were detected at two (p = 0.33) or six weeks (p = 0.08) post-operatively. Malfunction of the IPC leading to a second plaster cast was found to correlate with an increased DVT risk at two weeks (φ = 0.71; p = 0.019), leading to a premature abandonment of the study.

We cannot recommend adjuvant treatment with foot IPC under a plaster cast for outpatient DVT prevention during post-operative immobilisation, owing to a high incidence of DVT related to malfunctioning of this type of IPC application.

Cite this article: Bone Joint J 2013;95-B:1227–31.

We investigated the relationship between spinopelvic parameters and disc degeneration in young adult patients with spondylolytic spondylolisthesis. A total of 229 men with a mean age of 21 years (18 to 26) with spondylolytic spondylolisthesis were identified. All radiological measurements, including pelvic incidence, sacral slope, pelvic tilt, lumbar lordosis, sacral inclination, lumbosacral angle (LSA), and sacrofemoral distance, were calculated from standing lateral lumbosacral radiographs. The degree of intervertebral disc degeneration was classified using a modified Pfirrmann scale. We analysed the spinopelvic parameters according to disc level, degree of slip and disc degeneration.

There were significant positive correlations between the degree of slip and pelvic incidence (p = 0.009), sacral slope (p = 0.003) and lumbar lordosis (p = 0.010). The degree of slip and the LSA were correlated with disc degeneration (p < 0.001 and p = 0.003, respectively). There was also a significant difference between the degree of slip (p < 0.001) and LSA (p = 0.006) according to the segmental level of disc degeneration.

Cite this article: Bone Joint J 2013;95-B:1239–43.

The purpose of this study was to identify changing trends in the pattern of distribution of the type and demographics of fractures of the hip in the elderly between 2001 and 2010. A retrospective cross-sectional comparison was conducted between 179 fractures of the hip treated in 2001, 357 treated in 2006 and 454 treated in 2010. Patients aged < 60 years and those with pathological and peri-prosthetic fractures were excluded. Fractures were classified as stable extracapsular, unstable extracapsular or intracapsular fractures.

The mean age of the 179 patients (132 women (73.7%)) treated in 2001 was 80.8 years (60 to 96), 81.8 years (61 to 101) in the 357 patients (251 women (70.3%)) treated in 2006 and 82.0 years (61 to 102) in the 454 patients (321 women (70.1%)) treated in 2010 (p = 0.17). There was no difference in the gender distribution between the three study years (p = 0.68).

The main finding was a steep rise in the proportion of unstable peritrochanteric fractures. The proportion of unstable extracapsular fractures was 32% (n = 57) in 2001, 35% (n = 125) in 2006 and 45% (n = 204) in 2010 (p < 0.001). This increase was not significant in patients aged between 60 and 69 years (p = 0.84), marginally significant in those aged between 70 and 79 years (p = 0.04) and very significant in those aged > 80 years (p < 0.001). The proportion of intracapsular fractures did not change (p = 0.94).

At present, we face not only an increasing number of fractures of the hip, but more demanding and complex fractures in older patients than a decade ago. This study does not provide an explanation for this change.

Cite this article: Bone Joint J 2013;95-B:1250–4.

A soft-tissue defect over an infected total knee replacement (TKR) presents a difficult technical problem that can be treated with a gastrocnemius flap, which is rotated over the defect during the first-stage of a revision procedure. This facilitates wound healing and the safe introduction of a prosthesis at the second stage. We describe the outcome at a mean follow-up of 4.5 years (1 to 10) in 24 patients with an infected TKR who underwent this procedure. A total of 22 (92%) eventually obtained a satisfactory result. The mean Knee Society score improved from 53 pre-operatively to 103 at the latest follow-up (p < 0.001). The mean Western Ontario and McMaster Universities osteoarthritis index and Short-Form 12 score also improved significantly (p < 0.001).

This form of treatment can be used reliably and safely to treat many of these complex cases where control of infection, retention of the components and acceptable functional recovery are the primary goals.

Cite this article: Bone Joint J 2013;95-B:1217–21.

We report the long-term survival and functional outcome of the Birmingham Hip Resurfacing (BHR) in patients aged < 50 years at operation, and explore the factors affecting survival. Between 1997 and 2006, a total of 447 BHRs were implanted in 393 patients (mean age 41.5 years (14.9 to 49.9)) by one designing surgeon. The mean follow-up was 10.1 years (5.2 to 14.7), with no loss to follow-up. In all, 16 hips (3.6%) in 15 patients were revised, giving an overall cumulative survival of 96.3% (95% confidence interval (CI) 93.7 to 98.3) at ten years and 94.1% (95% CI 84.9 to 97.3) at 14 years. Using aseptic revision as the endpoint, the survival for men with primary osteoarthritis (n = 195) was 100% (95% CI 100 to 100) at both ten years and 14 years, and in women with primary osteoarthritis (n = 109) it was 96.1% (95% CI 90.1 to 99.9) at ten years and 91.2% (95% CI 68.6 to 98.7) at 14 years. Female gender (p = 0.047) and decreasing femoral head size (p = 0.044) were significantly associated with an increased risk of revision. The median Oxford hip score (OHS, modified as a percentage with 100% indicating worst outcome) at last follow-up was 4.2% (46 of 48; interquartile range (IQR) 0% to 24%) and the median University of California, Los Angeles (UCLA) score was 6.0 (IQR 5 to 8). Men had significantly better OHS (p = 0.02) and UCLA scores (p = 0.01) than women. The BHR provides excellent survival and functional results in men into the second decade, with good results achieved in appropriately selected women.

Cite this article: Bone Joint J 2013;95-B:1172–7.

We performed a CT-based computer simulation study to determine how the relationship between any inbuilt posterior slope in the proximal tibial osteotomy and cutting jig rotational orientation errors affect tibial component alignment in total knee replacement. Four different posterior slopes (3°, 5°, 7° and 10°), each with a rotational error of 5°, 10°, 15°, 20°, 25° or 30°, were simulated. Tibial cutting block malalignment of 20° of external rotation can produce varus malalignment of 2.4° and 3.5° with a 7° and a 10° sloped cutting jig, respectively. Care must be taken in orientating the cutting jig in the sagittal plane when making a posterior sloped proximal tibial osteotomy in total knee replacement.

Cite this article: Bone Joint J 2013;95-B:1201–3.

We investigated the spinopelvic morphology and global sagittal balance of patients with a degenerative retrolisthesis or anterolisthesis. A total of 269 consecutive patients with a degenerative spondylolisthesis were included in this study. There were 95 men and 174 women with a mean age of 64.3 years (sd 10.5; 40 to 88). A total of 106 patients had a pure retrolisthesis (R group), 130 had a pure anterolisthesis (A group), and 33 had both (R+A group).

A backward slip was found in the upper lumbar levels (mostly L2 or L3) with an almost equal gender distribution in both the R and R+A groups. The pelvic incidence and sacral slope of the R group were significantly lower than those of the A (both p < 0.001) and R+A groups (both p < 0.001). The lumbar lordosis of the R+A group was significantly greater than that of the R (p = 0.025) and A groups (p = 0.014). The C7 plumb line of the R group was located more posteriorly than that of the A group (p = 0.023), but was no different from than that of the R+A group (p = 0.422). The location of C7 plumb line did not differ between the three groups (p = 0.068). The spinosacral angle of the R group was significantly smaller than that of the A group (p < 0.001) and R+A group (p < 0.001).

Our findings imply that there are two types of degenerative retrolisthesis: one occurs primarily as a result of degeneration in patients with low pelvic incidence, and the other occurs secondarily as a compensatory mechanism in patients with an anterolisthesis and high pelvic incidence.

Cite this article: Bone Joint J 2013;95-B:1244–9.

Coronal plane fractures of the posterior femoral condyle, also known as Hoffa fractures, are rare. Lateral fractures are three times more common than medial fractures, although the reason for this is not clear. The exact mechanism of injury is likely to be a vertical shear force on the posterior femoral condyle with varying degrees of knee flexion. These fractures are commonly associated with high-energy trauma and are a diagnostic and surgical challenge. Hoffa fractures are often associated with inter- or supracondylar distal femoral fractures and CT scans are useful in delineating the coronal shear component, which can easily be missed. There are few recommendations in the literature regarding the surgical approach and methods of fixation that may be used for this injury. Non-operative treatment has been associated with poor outcomes. The goals of treatment are anatomical reduction of the articular surface with rigid, stable fixation to allow early mobilisation in order to restore function. A surgical approach that allows access to the posterior aspect of the femoral condyle is described and the use of postero-anterior lag screws with or without an additional buttress plate for fixation of these difficult fractures.

Cite this article: Bone Joint J 2013;95-B:1165–71.

Objectives

The goals of this study were: 1) to determine if high-fat diet (HFD) feeding in female mice would negatively impact biomechanical and histologic consequences on the Achilles tendon and quadriceps muscle; and 2) to investigate whether exercise and branched-chain amino acid (BCAA) supplementation would affect these parameters or attenuate any negative consequences resulting from HFD consumption.

Objectives

We aimed to determine the effect of surgical approach on the histology of the femoral head following resurfacing of the hip.

The treatment of osteochondral lesions and osteoarthritis remains an ongoing clinical challenge in orthopaedics. This review examines the current research in the fields of cartilage regeneration, osteochondral defect treatment, and biological joint resurfacing, and reports on the results of clinical and pre-clinical studies. We also report on novel treatment strategies and discuss their potential promise or pitfalls. Current focus involves the use of a scaffold providing mechanical support with the addition of chondrocytes or mesenchymal stem cells (MSCs), or the use of cell homing to differentiate the organism’s own endogenous cell sources into cartilage. This method is usually performed with scaffolds that have been coated with a chemotactic agent or with structures that support the sustained release of growth factors or other chondroinductive agents. We also discuss unique methods and designs for cell homing and scaffold production, and improvements in biological joint resurfacing. There have been a number of exciting new studies and techniques developed that aim to repair or restore osteochondral lesions and to treat larger defects or the entire articular surface. The concept of a biological total joint replacement appears to have much potential.

Cite this article: Bone Joint Res 2013;2:193–9.

Lateral epicondylitis, or ’tennis elbow’, is a common condition that usually affects patients between 35 and 55 years of age. It is generally self-limiting, but in some patients it may continue to cause persistent symptoms, which can be refractory to treatment. This review discusses the mechanism of disease, symptoms and signs, investigations, current management protocols and potential new treatments.

Cite this article: Bone Joint J 2013;95-B:1158–64.

The aim of this study was to assess a specific protocol for the treatment of patients with a parosteal osteosarcoma of the distal femur with limb salvage involving hemicortical resection and reconstruction using recycled pasteurised autograft and internal fixation. Between January 2000 and January 2010, 13 patients with a mean age of 26.5 years (17 to 39) underwent this procedure. All the tumours were staged according to Enneking’s criteria: there were eight stage IA tumours and five stage IB tumours. The mean follow-up was 101.6 months (58 to 142), and mean post-operative Musculoskeletal Tumour Society functional score was 88.6% (80% to 100%) at the final follow-up. All the patients had achieved bony union; the mean time to union was 11.2 months (6 to 18). Local recurrence occurred in one patient 27 months post-operatively. No patient had a pulmonary metastasis.

A hemicortical procedure for the treatment of a parosteal osteosarcoma is safe and effective. Precise pre-operative planning using MRI is essential in order to define the margins of resection. Although it is a technically demanding procedure, gratifying results make it worthwhile for selected patients.

Cite this article: Bone Joint J 2013;95-B:1275–9.

Fractures of the forearm (radius or ulna or both) in children have traditionally been immobilised in plaster of Paris (POP) but synthetic cast materials are becoming more popular. There have been no randomised studies comparing the efficacy of these two materials. The aim of this study was to investigate which cast material is superior for the management of these fractures. We undertook a single-centre prospective randomised trial involving 199 patients with acute fractures of the forearm requiring general anaesthesia for reduction. Patients were randomised by sealed envelope into either a POP or synthetic group and then underwent routine closed reduction and immobilisation in a cast. The patients were reviewed at one and six weeks. A satisfaction questionnaire was completed following the removal of the cast. All clinical complications were recorded and the cast indices were calculated. There was an increase in complications in the POP group. These complications included soft areas of POP requiring revision and loss of reduction with some requiring re-manipulation. There was an increased mean padding index in the fractures that lost reduction. Synthetic casts were preferred by the patients.

This study indicates that the clinical outcomes and patient satisfaction are superior using synthetic casts with no reduction in safety.

Cite this article: Bone Joint J 2013;95-B:1285–9.

A total of 187 patients with primary osteoarthritis (OA) of the knee undergoing total knee replacement (TKR) were randomly divided into two groups, one of which underwent synovectomy. The patients and assessors were blinded to the randomisation both before and after surgery. The duration of surgery, hospitalisation period, concealed bleeding, drainage volume, blood transfusion rate and range of movement of the knee at three days after the operation were analysed. Patients were followed up at four weeks and 12 months after their operation, and a visual analogue score (VAS) for pain, Knee Society score (KSS) and a patellar ballottement test were compared between the groups.

The mean amount of concealed bleeding was higher in the synovectomy group compared with the control group (1.24 l (0.08 to 3.28) vs 1.03 l (0.16 to 2.94); p = 0.042), as was the mean drainage volume (0.90 l (0.35 to 1.81) vs 0.81 (0.25 to 1.65); p = 0.030). The mean operating time was also higher in the synovectomy group compared with the controls (1.50 hours (1.34 to 1.75) vs 1.41 hours (1.21 to 1.79); p = 0.006). There were no significant differences in blood transfusion rate (p = 0.882), hospital stay (p = 0.805) or range of movement of the knee (p = 0.413) between the two groups. At four weeks and 12 months post-operatively there were no statistically significant differences in any of the measured parameters. We concluded that synovectomy confers no clinical advantages in TKR for primary OA while subjecting patients to higher levels of bleeding and longer operating times.

Cite this article: Bone Joint J 2013;95-B:1197–200.

Objectives

We aimed to examine the characteristics of deep venous flow in the leg in a cast and the effects of a wearable neuromuscular stimulator (geko; FirstKind Ltd) and also to explore the participants’ tolerance of the stimulator.

Limited forefoot amputation in diabetic patients with osteomyelitis is frequently required. We retrospectively reviewed diabetic patients with osteomyelitis, an unhealed ulcer and blood pressure in the toe of > 45 mmHg who underwent limited amputation of the foot with primary wound closure. Between 2006 and 2012, 74 consecutive patients with a mean age of 67 years (29 to 93), and a median follow-up of 31 months, were included. All the wounds healed primarily at a median of 37 days (13 to 210; mean 48). At a median of 6 months (1.5 to 18; mean 353 days), 23 patients (31%) suffered a further ulceration. Of these, 12 patients (16% of the total) required a further amputation.

We conclude that primary wound closure following limited amputation of the foot in patients with diabetes is a safe and effective technique when associated with appropriate antibiotic treatment.

Cite this article: Bone Joint J 2013;95-B:1083–7.

The purpose of this study was to undertake a meta-analysis to determine whether there is lower polyethylene wear and longer survival when using mobile-bearing implants in total knee replacement when compared with fixed-bearing implants. Of 975 papers identified, 34 trials were eligible for data extraction and meta-analysis comprising 4754 patients (6861 knees). We found no statistically significant differences between the two designs in terms of the incidence of radiolucent lines, osteolysis, aseptic loosening or survival. There is thus currently no evidence to suggest that the use of mobile-bearing designs reduce polyethylene wear and prolong survival after total knee replacement.

Cite this article: Bone Joint J 2013;95-B:1057–63.

Metal artefact reduction (MAR) MRI is now widely considered to be the standard for imaging metal-on-metal (MoM) hip implants. The Medicines and Healthcare Products Regulatory Agency (MHRA) has recommended cross-sectional imaging for all patients with symptomatic MoM bearings. This paper describes the natural history of MoM disease in a 28 mm MoM total hip replacement (THR) using MAR MRI. Inclusion criteria were patients with MoM THRs who had not been revised and had at least two serial MAR MRI scans. All examinations were reported by an experienced observer and classified as A (normal), B (infection) or C1–C3 (mild, moderate, severe MoM-related abnormalities). Between 2002 and 2011 a total of 239 MRIs were performed on 80 patients (two to four scans per THR); 63 initial MRIs (61%) were normal. On subsequent MRIs, six initially normal scans (9.5%) showed progression to a disease state; 15 (15%) of 103 THRs with sequential scans demonstrated worsening disease on subsequent imaging.

Most patients with a MoM THR who do not undergo early revision have normal MRI scans. Late progression (from normal to abnormal, or from mild to more severe MoM disease) is not common and takes place over several years.

Cite this article: Bone Joint J 2013;95-B:1035–9.

We evaluated the risk of late relapse and further outcome in patients with soft-tissue sarcomas who were alive and event-free more than five years after initial treatment. From our database we identified 1912 patients with these pathologies treated between 1980 and 2006. Of these 1912 patients, 603 were alive and event-free more than five years after initial treatment and we retrospectively reviewed them. The mean age of this group was 48 years (4 to 94) and 340 were men. The mean follow-up was 106 months (60 to 336). Of the original cohort, 582 (97%) were alive at final follow-up. The disease-specific survival was 96.4% (95% confidence interval (CI) 94.4 to 98.3) at ten years and 92.9% (95% CI 89 to 96.8) at 15 years. The rate of late relapse was 6.3% (38 of 603). The ten- and 15-year event-free rates were 93.2% (95% CI 90.8 to 95.7) and 86.1% (95% CI 80.2 to 92.1), respectively. Multivariate analysis showed that tumour size and tumour grade remained independent predictors of events. In spite of further treatment, 19 of the 38 patients died of sarcoma. The three- and five-year survival rates after the late relapse were 56.2% (95% CI 39.5 to 73.3) and 43.2% (95% CI 24.7 to 61.7), respectively, with a median survival time of 46 months. Patients with soft-tissue sarcoma, especially if large, require long-term follow-up, especially as they have moderate potential to have their disease controlled.

Cite this article: Bone Joint J 2013;95-B:1139–43.

It has been suggested that extracorporeal shockwave therapy is a safe and effective treatment for pain relief from recalcitrant plantar fasciopathy (PF). However, the changes in gait and associated biomechanical parameters have not been well characterised. We recruited 12 female patients with recalcitrant PF who had a mean age of 59 years (50 to 70) and mean body mass index of 25 kg/m² (22 to 30). The patients reported a mean duration of symptoms of 9.3 months (6 to 15). Shockwave therapy consisting of 1500 impulses (energy flux density 0.26 mJ/mm²) was applied for three sessions, each three weeks apart. A pain visual analogue scale (VAS) rating, plantar pressure assessment and motion analysis were carried out before and nine weeks after first shock wave therapy. It was demonstrated that patients increased their walking velocity and cadence as well indicating a decrease in pain after shockwave therapy. In the symptomatic foot, the peak contact pressure over the forefoot increased and the contact area over the digits decreased. The total foot impulse also decreased as did stance duration. The duration the centre of pressure remained in the hindfoot increased in the symptomatic foot after shockwave therapy. The differences in centre of pressure trajectory at baseline decreased at final follow-up. In conclusion, shockwave therapy not only decreased the pain VAS rating but also improved the gait parameters of the symptomatic foot in PF patients.

Cite this article: Bone Joint J 2013;95-B:1088–93.

The August 2013 Foot & Ankle Roundup³⁶⁰ looks at: mobility, ankles and fractures; hindfoot nailing: not such a bad option after all?; little treatment benefit for blood injection in tendonitis; fixed bearing ankles successful in the short term; hindfoot motion following STAR ankle replacement; minimally invasive calcaneal fracture fixation?; pes planus in adolescents; and subluxing peroneals and groove deepening

The significance of weight in the indications for unicompartmental knee replacement (UKR) is unclear. Our hypothesis was that weight does not affect the long-term rate of survival of UKRs.

We undertook a retrospective study of 212 UKRs at a mean follow-up of 12 years (7 to 22). The patients were distributed according to body mass index (BMI; < vs ≥ 30 kg/m²) and weight (< vs ≥ 82 kg). Kaplan-Meier survivorship analysis was performed and ten-year survival rates were compared between the sub-groups. Multimodal regression analysis determined the impact of the various theoretical contraindications on the long-term rate of survival of UKR.

The ten-year rates of survival were similar in the two weight subgroups (≥ 82 kg: 93.5% (95% confidence interval (CI) 66.5 to 96.3); < 82 kg: 92.5% (95% CI 82.5 to 94.1)) and also in the two BMI subgroups (≥ 30 kg/m²: 92% (95% CI 82.5 to 95.3); < 30 kg/m²: 94% (95% CI 78.4 to 95.9)). Multimodal regression analysis revealed that weight plays a part in reducing the risk of revision with a relative risk of 0.387, although this did not reach statistical significance (p = 0.662). The results relating weight and BMI to the clinical outcome were not statistically significant. Thus, this study confirms that weight does not influence the long-term rate of survival of UKR.

Cite this article: Bone Joint J 2013;95-B:1064–8.

Objectives

To quantify and compare peri-acetabular bone mineral density (BMD) between a monoblock acetabular component using a metal-on-metal (MoM) bearing and a modular titanium shell with a polyethylene (PE) insert. The secondary outcome was to measure patient-reported clinical function.

We prospectively assessed the efficacy of a ceramic-on-metal (CoM) hip bearing with uncemented acetabular and femoral components in which cobalt­–chrome acetabular liners and alumina ceramic heads were used.

The cohort comprised 94 total hip replacements (THRs) in 83 patients (38 women and 45 men) with a mean age of 58 years (42 to 70). Minimum follow-up was two years. All patients had pre- and post-operative assessment using the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), Oxford hip score and Short-Form 12 scores. All showed a statistically significant improvement from three months post-operatively onwards (all p < 0.001).

After two years whole blood metal ion levels were measured and chromosomal analysis was performed. The levels of all metal ions were elevated except vanadium. Levels of chromium, cobalt, molybdenum and titanium were significantly higher in patients who underwent bilateral THR compared with those undergoing unilateral THR (p < 0.001). Chromosomal analysis demonstrated both structural and aneuploidy mutations. There were significantly more breaks and losses than in the normal population (p < 0.001). There was no significant difference in chromosomal aberration between those undergoing unilateral and bilateral procedures (all analyses p ≥ 0.62).

The use of a CoM THR is effective clinically in the short-term, with no concerns, but the significance of high metal ion levels and chromosomal aberrations in the long-term remains unclear.

Cite this article: Bone Joint J 2013;95-B:1040–44.

In a retrospective study we compared 32 HINTEGRA total ankle replacements (TARs) and 35 Mobility TARs performed between July 2005 and May 2010, with a minimum follow-up of two years. The mean follow-up for the HINTEGRA group was 53 months (24 to 76) and for the Mobility group was 34 months (24 to 45). All procedures were performed by a single surgeon.

There was no significant difference between the two groups with regard to the mean AOFAS score, visual analogue score for pain or range of movement of the ankle at the latest follow-up. Most radiological measurements did not differ significantly between the two groups. However, the most common grade of heterotopic ossification (HO) was grade 3 in the HINTEGRA group (10 of 13 TARs, 76.9%) and grade 2 in the Mobility group (four of seven TARs, 57.1%) (p = 0.025). Although HO was more frequent in the HINTEGRA group (40.6%) than in the Mobility group (20.0%), this was not statistically significant (p = 0.065).The difference in peri-operative complications between the two groups was not significant, but intra-operative medial malleolar fractures occurred in four (11.4%) in the Mobility group; four (12.5%) in the HINTEGRA group and one TAR (2.9%) in the Mobility group failed (p = 0.185).

Cite this article: Bone Joint J 2013;95-B:1075–82.

The August 2013 Research Roundup³⁶⁰ looks at: passive smoking and bone substitutes; platelet-rich plasma and osteogenesis; plantar fasciitis and platelet-rich plasma: a match made in heaven?; MRSA decolonisation decreases infection rates; gums, bisphosphonates and orthopaedics; PRAISE and partner violence; blunt impact and post-traumatic OA; and IDEAL research and implants

The indications for reverse shoulder arthroplasty (RSA) continue to be expanded. Associated impairment of the deltoid muscle has been considered a contraindication to its use, as function of the RSA depends on the deltoid and impairment of the deltoid may increase the risk of dislocation. The aim of this retrospective study was to determine the functional outcome and risk of dislocation following the use of an RSA in patients with impaired deltoid function. Between 1999 and 2010, 49 patients (49 shoulders) with impairment of the deltoid underwent RSA and were reviewed at a mean of 38 months (12 to 142) post-operatively. There were nine post-operative complications (18%), including two dislocations. The mean forward elevation improved from 50° (sd 38; 0° to 150°) pre-operatively to 121° (sd 40; 0° to 170°) at final follow-up (p < 0.001). The mean Constant score improved from 24 (sd 12; 2 to 51) to 58 (sd 17; 16 to 83) (p < 0.001). The mean Single Assessment Numeric Evaluation score was 71 (sd 17; 10 to 95) and the rate of patient satisfaction was 98% (48 of 49) at final follow-up.

These results suggest that pre-operative deltoid impairment, in certain circumstances, is not an absolute contraindication to RSA. This form of treatment can yield reliable improvement in function without excessive risk of post-operative dislocation.

Cite this article: Bone Joint J 2013;95-B:1106–13.

We evaluated the outcome of 41 consecutive Charnley low-friction arthroplasties (LFAs) performed by a single surgeon in 28 patients aged ≤ 35 years at operation between 23 and 36 years previously. There were 20 women and eight men with a mean age of 32 years (23 to 35) at surgery. Two patients (three hips) were lost to follow-up at 12 and 17 years post-operatively, respectively, and one patient (one hip) died at 13 years post-operatively. These patients were excluded from the final evaluation. The survival rate of the acetabular components was 92.7% (95% confidence interval (CI) 88.7 to 96.7) at ten years, 67.1% (95% CI 59.75 to 74.45) at 20 years and 53.2% (95% CI 45.3 to 61.1) at 25 years. For the femoral component the survival was 95.1% (95% CI 91.8 to 98.5) at ten years, 77.1% (95% CI 73.9 to 80.3) at 20 years and 68.2% (95% CI 60.7 to 75.8) at 25 years. The results indicate that the Charnley LFA remains a reasonable choice in the treatment of young patients and can serve for comparison with newer techniques and implants.

Cite this article: Bone Joint J 2013;95-B:1052–6.

The August 2013 Hip & Pelvis Roundup³⁶⁰ looks at: are we getting it right first time?; tantalum augments in revision hip surgery; lower wear in dual mobility?; changing faces changes outcomes; synovial fluid aspiration in MOM hips; taper disease: the new epidemic of hip surgery; the super-obese and THR; and whether well fixed stems can remain in infected hips

The August 2013 Shoulder & Elbow Roundup³⁶⁰ looks at: the sternoclavicular joint revisited; surgical simulators: more than just a fancy idea?; arthroscopic tennis elbow release; costly clavicle stabilisation; a better treatment for tennis elbow?; shock news: surgeons and radiologists agree; overhead athletes and SLAP repair; and total shoulder arthroplasty more effective than hemiarthroplasty

Objectives

The development of tibiofemoral angle in children has shown ethnic variations. However this data is unavailable for our population.

Arthroscopy has become a routine surgical procedure, used as a diagnostic and therapeutic tool for the treatment of joint problems. This article discusses its origins and looks at how it is currently used.

We welcome letters to the Editor concerning articles that have recently been published. Such letters will be subject to the usual stages of selection and editing; where appropriate the authors of the original article will be offered the opportunity to reply.

The belief that an intervertebral disc must degenerate before it can herniate has clinical and medicolegal significance, but lacks scientific validity. We hypothesised that tissue changes in herniated discs differ from those in discs that degenerate without herniation. Tissues were obtained at surgery from 21 herniated discs and 11 non-herniated discs of similar degeneration as assessed by the Pfirrmann grade. Thin sections were graded histologically, and certain features were quantified using immunofluorescence combined with confocal microscopy and image analysis. Herniated and degenerated tissues were compared separately for each tissue type: nucleus, inner annulus and outer annulus.

Herniated tissues showed significantly greater proteoglycan loss (outer annulus), neovascularisation (annulus), innervation (annulus), cellularity/inflammation (annulus) and expression of matrix-degrading enzymes (inner annulus) than degenerated discs. No significant differences were seen in the nucleus tissue from herniated and degenerated discs. Degenerative changes start in the nucleus, so it seems unlikely that advanced degeneration caused herniation in 21 of these 32 discs. On the contrary, specific changes in the annulus can be interpreted as the consequences of herniation, when disruption allows local swelling, proteoglycan loss, and the ingrowth of blood vessels, nerves and inflammatory cells.

In conclusion, it should not be assumed that degenerative changes always precede disc herniation.

Cite this article: Bone Joint J 2013;95-B:1127–33.

The purpose of this study was twofold: first, to determine whether the five-year results of hip resurfacing arthroplasty (HRA) in Canada justified the continued use of HRA; and second, to identify whether greater refinement of patient selection was warranted.

This was a retrospective cohort study that involved a review of 2773 HRAs performed between January 2001 and December 2008 at 11 Canadian centres. Cox’s proportional hazards models were used to analyse the predictors of failure of HRA. Kaplan–Meier survival analysis was performed to predict the cumulative survival rate at five years. The factors analysed included age, gender, body mass index, pre-operative hip pathology, surgeon’s experience, surgical approach, implant sizes and implant types. The most common modes of failure were also analysed.

The 2773 HRAs were undertaken in 2450 patients: 2127 in men and 646 in women. The mean age at operation was 50.5 years (sd 8.72; 18 to 82) and mean follow-up was 3.4 years (sd 2.1; 2.0 to 10.1). At the last follow-up a total of 101 HRAs (3.6%) required revision. Using revision for all causes of failure as the endpoint, Kaplan–Meier survival analysis showed a cumulative survival of 96.4% (95% confidence interval (CI) 96.1 to 96.9) at five years. With regard to gender, the five-year overall survival was 97.4% in men (95% CI 97.1 to 97.7) and 93.6% in women (95% CI 92.6 to 94.6). Female gender, smaller femoral components, specific implant types and a diagnosis of childhood hip problems were associated with higher rates of failure. The most common cause of failure was fracture of the femoral neck, followed by loosening of the femoral component.

The failure rates of HRA at five years justify the ongoing use of this technique in men. Female gender is an independent predictor of failure, and a higher failure rate at five years in women leads the authors to recommend this technique only in exceptional circumstances for women.

Cite this article: Bone Joint J 2013;95-B:1044–50.

This study evaluates the long-term survival of spinal implants after surgical site infection (SSI) and the risk factors associated with treatment failure.

A Kaplan-Meier survival analysis was carried out on 43 patients who had undergone a posterior spinal fusion with instrumentation between January 2006 and December 2008, and who consecutively developed an acute deep surgical site infection. All were appropriately treated by surgical debridement with a tailored antibiotic program based on culture results for a minimum of eight weeks.

A ‘terminal event’ or failure of treatment was defined as implant removal or death related to the SSI. The mean follow-up was 26 months (1.03 to 50.9). A total of ten patients (23.3%) had a terminal event. The rate of survival after the first debridement was 90.7% (95% confidence interval (CI) 82.95 to 98.24) at six months, 85.4% (95% CI 74.64 to 96.18) at one year, and 73.2% (95% CI 58.70 to 87.78) at two, three and four years. Four of nine patients required re-instrumentation after implant removal, and two of the four had a recurrent infection at the surgical site. There was one recurrence after implant removal without re-instrumentation.

Multivariate analysis revealed a significant risk of treatment failure in patients who developed sepsis (hazard ratio (HR) 12.5 (95% confidence interval (CI) 2.6 to 59.9); p < 0.001) or who had > three fused segments (HR 4.5 (95% CI 1.25 to 24.05); p = 0.03). Implant survival is seriously compromised even after properly treated surgical site infection, but progressively decreases over the first 24 months.

Cite this article: Bone Joint J 2013;95-B:1121–6.

The glenopolar angle assesses the rotational alignment of the glenoid and may provide prognostic information and aid the management of scapula fractures. We have analysed the effect of the anteroposterior (AP) shoulder radiograph rotational offset on the glenopolar angle in a laboratory setting and used this to assess the accuracy of shoulder imaging employed in routine clinical practice. Fluoroscopic imaging was performed on 25 non-paired scapulae tagged with 2 mm steel spheres to determine the orientation of true AP views. The glenopolar angle was measured on all the bony specimens rotated at 10° increments. The mean glenopolar angle measured on the bone specimens in rotations between 0° and 20° and thereafter was found to be significantly different (p < 0.001). We also obtained the AP radiographs of the uninjured shoulder of 30 patients treated for fractures at our centre and found that none fitted the criteria of a true AP shoulder radiograph. The mean angular offset from the true AP view was 38° (10° to 65°) for this cohort. Radiological AP shoulder views may not fully project the normal anatomy of the scapular body and the measured glenopolar angle. The absence of a true AP view may compromise the clinical management of a scapular fracture.

Cite this article: Bone Joint J 2013;95-B:1114–20.

Penetration of the dorsal screw when treating distal radius fractures with volar locking plates is an avoidable complication that causes lesions of the extensor tendon in between 2% and 6% of patients. We examined axial fluoroscopic views of the distal end of the radius to observe small amounts of dorsal screw penetration, and determined the ideal angle of inclination of the x-ray beam to the forearm when making this radiological view.

Six volar locking plates were inserted at the wrists of cadavers. The actual screw length was measured under direct vision through a dorsal approach to the distal radius. Axial radiographs were performed for different angles of inclination of the forearm at the elbow.

Comparing axial radiological measurements and real screw length, a statistically significant correlation could be demonstrated at an angle of inclination between 5° and 20°. The ideal angle of inclination required to minimise the risk of implanting over-long screws in a dorsal horizon radiological view is 15°.

Cite this article: Bone Joint J 2013;95-B:1101–5.

The August 2013 Children’s orthopaedics Roundup³⁶⁰ looks at: a multilevel approach to equinus gait; whether screening leads to needless intervention; salvage of subcapital slipped epiphysis; growing prostheses for children’s oncology; flexible nailing revisited; ultrasound and the pink pulseless hand; and slipping forearm fractures.

Following the recall of modular neck hip stems in July 2012, research into femoral modularity will intensify over the next few years. This review aims to provide surgeons with an up-to-date summary of the clinically relevant evidence. The development of femoral modularity, and a classification system, is described. The theoretical rationale for modularity is summarised and the clinical outcomes are explored. The review also examines the clinically relevant problems reported following the use of femoral stems with a modular neck.

Joint replacement registries in the United Kingdom and Australia have provided data on the failure rates of modular devices but cannot identify the mechanism of failure. This information is needed to determine whether modular neck femoral stems will be used in the future, and how we should monitor patients who already have them implanted.

Cite this article: Bone Joint J 2013;95-B:1011–21.

Things have not been quiet in the Cochrane Collaboration in the four months since the last 'Cochrane Corner', with the publication of six new or updated reviews summarised here, all conducted with the bulletproof Collaboration's methodology representing the pinnacle of evidence relevant to orthopaedic surgeons.

Although the importance of lateral femoral wall integrity is increasingly being recognised in the treatment of intertrochanteric fracture, little attention has been put on the development of a secondary post-operative fracture of the lateral wall. Patients with post-operative fractures of the lateral wall were reported to have high rates of re-operation and complication. To date, no predictors of post-operative lateral wall fracture have been reported. In this study, we investigated the reliability of lateral wall thickness as a predictor of lateral wall fracture after dynamic hip screw (DHS) implantation.

A total of 208 patients with AO/OTA 31-A1 and -A2 classified intertrochanteric fractures who received internal fixation with a DHS between January 2003 and May 2012 were reviewed. There were 103 men and 150 women with a mean age at operation of 78 years (33 to 94). The mean follow-up was 23 months (6 to 83). The right side was affected in 97 patients and the left side in 111. Clinical information including age, gender, side, fracture classification, tip–apex distance, follow-up time, lateral wall thickness and outcome were recorded and used in the statistical analysis.

Fracture classification and lateral wall thickness significantly contributed to post-operative lateral wall fracture (both p < 0.001). The lateral wall thickness threshold value for risk of developing a secondary lateral wall fracture was found to be 20.5 mm.

To our knowledge, this is the first study to investigate the risk factors of post-operative lateral wall fracture in intertrochanteric fracture. We found that lateral wall thickness was a reliable predictor of post-operative lateral wall fracture and conclude that intertrochanteric fractures with a lateral wall thickness < 20.5 mm should not be treated with DHS alone.

Cite this article: Bone Joint J 2013;95-B:1134–8.

We report the results of revision total knee replacement (TKR) in 26 patients with major metaphyseal osteolytic defects using 29 trabecular metal cones in conjunction with a rotating hinged total knee prosthesis. The osteolytic defects were types II and III (A or B) according to the Anderson Orthopaedic Research Institute (AORI) classification. The mean age of the patients was 72 years (62 to 84) and there were 15 men and 11 women. In this series patients had undergone a mean of 2.34 previous total knee arthroplasties. The main objective was to restore anatomy along with stability and function of the knee joint to allow immediate full weight-bearing and active knee movement. Outcomes were measured using Knee Society scores, Oxford knee scores, range of movement of the knee and serial radiographs. Patients were followed for a mean of 36 months (24 to 49). The mean Oxford knee clinical scores improved from 12.83 (10 to 15) to 35.20 (32 to 38) (p < 0.001) and mean American Knee Society scores improved from 33.24 (13 to 36) to 81.12 (78 to 86) (p < 0.001). No radiolucent lines suggestive of loosening were seen around the trabecular metal cones, and by one year all the radiographs showed good osteo-integration. There was no evidence of any collapse or implant migration. Our early results confirm the findings of others that trabecular metal cones offer a useful way of managing severe bone loss in revision TKR.

Cite this article: Bone Joint J 2013;95-B:1069–74.

Congenital pseudarthrosis of the tibia (CPT) is a rare but well recognised condition. Obtaining union of the pseudarthrosis in these children is often difficult and may require several surgical procedures. The treatment has changed significantly since the review by Hardinge in 1972, but controversies continue as to the best form of surgical treatment. This paper reviews these controversies.

Cite this article: Bone Joint J 2013;95-B:1027–34.

The August 2013 Trauma Roundup³⁶⁰ looks at: reverse oblique fractures do better with a cephalomedullary device; locking screws confer no advantage in tibial plateau fractures; it’s all about the radius of curvature; radius of curvature revisited; radial head replacement in complex elbow reconstruction; stem cells in early fracture haematoma; heterotrophic ossification in forearms; and Boston in perspective.

The June 2013 Knee Roundup³⁶⁰ looks at: iodine washout: chondrotoxic or antiseptic?; stem tip pain following revision knee replacements; metalwork removal prior to TKR; astroturf and ACL rupture; Robert Jones dressings; if thicker gloves safer; and the long leg radiograph: is it still the gold standard?

Peri-prosthetic osteolysis and subsequent aseptic loosening is the most common reason for revising total hip replacements. Wear particles originating from the prosthetic components interact with multiple cell types in the peri-prosthetic region resulting in an inflammatory process that ultimately leads to peri-prosthetic bone loss. These cells include macrophages, osteoclasts, osteoblasts and fibroblasts. The majority of research in peri-prosthetic osteolysis has concentrated on the role played by osteoclasts and macrophages. The purpose of this review is to assess the role of the osteoblast in peri-prosthetic osteolysis.

In peri-prosthetic osteolysis, wear particles may affect osteoblasts and contribute to the osteolytic process by two mechanisms. First, particles and metallic ions have been shown to inhibit the osteoblast in terms of its ability to secrete mineralised bone matrix, by reducing calcium deposition, alkaline phosphatase activity and its ability to proliferate. Secondly, particles and metallic ions have been shown to stimulate osteoblasts to produce pro inflammatory mediators in vitro. In vivo, these mediators have the potential to attract pro-inflammatory cells to the peri-prosthetic area and stimulate osteoclasts to absorb bone. Further research is needed to fully define the role of the osteoblast in peri-prosthetic osteolysis and to explore its potential role as a therapeutic target in this condition.

Cite this article: Bone Joint J 2013;95-B:1021–5.

The August 2013 Wrist & Hand Roundup³⁶⁰ looks at: random group therapy is no good at treating OA of the hand; salvaging failed CMCJ arthroplasty; scaphocapitate arthrodesis for instability in manual workers; Brunelli tenodesis and scapholunate instability; night splints for Dupytren’s revisited; the smallest IM nail?; early diagnosis of CRPS?; and endoscopic carpal tunnel release?

The August 2013 Spine Roundup³⁶⁰ looks at: SPECT CT and facet joints; a difficult conversation: scoliosis and complications; time for a paradigm shift? complications under the microscope; minor trauma and cervical injury: a predictable phenomenon?; more costly all round: incentivising more complex operations?; minimally invasive surgery = minimal scarring; and symptomatic lumbar spine stenosis.

In Canada, Dupuytren's contracture is managed with partial fasciectomy or percutaneous needle aponeurotomy (PNA). Injectable collagenase will soon be available. The optimal management of Dupuytren’s contracture is controversial and trade-offs exist between the different methods. Using a cost-utility analysis approach, our aim was to identify the most cost-effective form of treatment for managing Dupuytren’s contracture it and the threshold at which collagenase is cost-effective. We developed an expected-value decision analysis model for Dupuytren’s contracture affecting a single finger, comparing the cost-effectiveness of fasciectomy, aponeurotomy and collagenase from a societal perspective. Cost-effectiveness, one-way sensitivity and variability analyses were performed using standard thresholds for cost effective treatment ($50 000 to $100 000/QALY gained). Percutaneous needle aponeurotomy was the preferred strategy for managing contractures affecting a single finger. The cost-effectiveness of primary aponeurotomy improved when repeated to treat recurrence. Fasciectomy was not cost-effective. Collagenase was cost-effective relative to and preferred over aponeurotomy at $875 and $470 per course of treatment, respectively.

In summary, our model supports the trend towards non-surgical interventions for managing Dupuytren’s contracture affecting a single finger. Injectable collagenase will only be feasible in our publicly funded healthcare system if it costs significantly less than current United States pricing.

Cite this article: Bone Joint J 2013;95-B:1094–1100.

Objectives

One commonly used rat fracture model for bone and mineral research is a closed mid-shaft femur fracture as described by Bonnarens in 1984. Initially, this model was believed to create very reproducible fractures. However, there have been frequent reports of comminution and varying rates of complication. Given the importance of precise anticipation of those characteristics in laboratory research, we aimed to precisely estimate the rate of comminution, its importance and its effect on the amount of soft callus created. Furthermore, we aimed to precisely report the rate of complications such as death and infection.

Mesenchymal stem-cell based therapies have been proposed as novel treatments for intervertebral disc degeneration, a prevalent and disabling condition associated with back pain. The development of these treatment strategies, however, has been hindered by the incomplete understanding of the human nucleus pulposus phenotype and by an inaccurate interpretation and translation of animal to human research. This review summarises recent work characterising the nucleus pulposus phenotype in different animal models and in humans and integrates their findings with the anatomical and physiological differences between these species. Understanding this phenotype is paramount to guarantee that implanted cells restore the native functions of the intervertebral disc.

Cite this article: Bone Joint Res 2013;2:169–78.

Objectives

To determine the morbidity and mortality outcomes of patients presenting with a fractured neck of femur in an Australian context. Peri-operative variables related to unfavourable outcomes were identified to allow planning of intervention strategies for improving peri-operative care.

The FRCS (Tr & Orth) examination has three components: MCQs, Vivas and Clinical Examination. The Vivas are further divided into four sections comprising Basic Science, Adult Pathology, Hands and Children’s Orthopaedics and Trauma. The Clinical Examination section is divided into Upper and Lower limb cases. The aim of this section in the Journal is to focus specifically on the trainees preparing for the exam and to cater to all the sections of the exam. The vision is to complete the cycle of all relevant exam topics (as per the syllabus) in four years.

We investigated the clinical outcome of internal fixation for pathological fracture of the femur after primary excision of a soft-tissue sarcoma that had been treated with adjuvant radiotherapy.

A review of our database identified 22 radiation-induced fractures of the femur in 22 patients (seven men, 15 women). We noted the mechanism of injury, fracture pattern and any complications after internal fixation, including nonunion, hardware failure, secondary fracture or deep infection.

The mean age of the patients at primary excision of the tumour was 58.3 years (39 to 86). The mean time from primary excision to fracture was 73.2 months (2 to 195). The mean follow-up after fracture fixation was 65.9 months (12 to 205). Complications occurred in 19 patients (86%). Nonunion developed in 18 patients (82%), of whom 11 had a radiological nonunion at 12 months, five a nonunion and hardware failure and two an infected nonunion. One patient developed a second radiation-associated fracture of the femur after internal fixation and union of the initial fracture. A total of 13 patients (59%) underwent 24 revision operations.

Internal fixation of a pathological fracture of the femur after radiotherapy for a soft-tissue sarcoma has an extremely high rate of complication and requires specialist attention.

Cite this article: Bone Joint J 2013;95-B:1144–8.

The August 2013 Oncology Roundup³⁶⁰ looks at: spinal osteosarcoma: all hope is not lost; intralesional curettage for low-grade chondrosarcoma?; isolated limb perfusion is a salvage option; worryingly high infection rates in patients with endoprostheses; how bad is endoprosthetic infection?; operatively treated metastatic disease; and cementoplasty gives immediate pain relief

In Neer type II (Robinson type 3B) fractures of the distal clavicle the medial fragment is detached from the coracoclavicular ligaments and displaced upwards, whereas the lateral fragment, which is usually small, maintains its position. Several fixation techniques have been suggested to treat this fracture. The aim of this study was to assess the outcome of patients with type II distal clavicle fractures treated with coracoclavicular suture fixation using three loops of Ethibond. This prospective study included 14 patients with Neer type II fractures treated with open reduction and coracoclavicular fixation. Ethibond sutures were passed under the coracoid and around the clavicle (UCAC loop) without making any drill holes in the proximal or distal fragments. There were 11 men and three women with a mean age of 34.57 years (29 to 41). Patients were followed for a mean of 24.64 months (14 to 31) and evaluated radiologically and clinically using the Constant score. Fracture union was obtained in 13 patients at a mean of 18.23 weeks (13 to 23) and the mean Constant score was 96.07 (91 to 100). One patient developed an asymptomatic fibrous nonunion at one year. This study suggests that open reduction and internal fixation of unstable distal clavicle fractures using UCAC loops can provide rigid fixation and lead to bony union. This technique avoids using metal hardware, preserves the acromioclavicular joint and provides adequate stability with excellent results.

Cite this article: Bone Joint J 2013;95-B:983–7.

We report on the long-term results of 163 bicruciate-retaining Hermes 2C total knee replacements in 130 patients at a mean follow-up of 22.4 years (20.3 to 23.5). Even when the anterior cruciate ligament had a partially degenerative appearance it was preserved as long as the knee had a normal anterior drawer and Lachman’s test pre-operatively. The description and surgical technique of this minimally constrained prosthesis were published in 1983 and the ten-year clinical results in 1999.

A total of 12% of the knees (20 of 163) in this study were revised because of wear of the polyethylene tibial insert. Excellent stability was achieved and the incidence of aseptic component loosening was 4.3% (seven of 163). The survival rate using revision for any reason as the endpoint was 82% (95% confidence interval 76.2 to 88.0).

Although this series included a relatively small number of replacements, it demonstrated that the anterior cruciate ligament, even when partially degenerated at the time of TKR, remained functional and provided adequate stability at a long-term follow-up.

Cite this article: Bone Joint J 2013;95-B:917–22.

In a time of limited resources, the debate continues over which types of hip prosthesis are clinically superior and more cost-effective. Orthopaedic surgeons increasingly need robust economic evidence to understand the full value of the operation, and to aid decision making on the ‘package’ of procedures that are available and to justify their practice beyond traditional clinical preference.

In this paper we explore the current economic debate about the merits of cemented and cementless total hip replacement, an issue that continues to divide the orthopaedic community.

Cite this article: Bone Joint J 2013;95-B:874–6.

Medial patellofemoral ligament (MPFL) reconstruction is used to treat patellar instability and recurrent patellar dislocation. Anatomical studies have found the MPFL to be a double-bundle structure. We carried out a meta-analysis of studies reporting outcomes of patellofemoral reconstruction using hamstring tendon autograft in a double-bundle configuration and patellar fixation via mediolateral patellar tunnels.

A literature search was undertaken with no language restriction in various databases from their year of inception to July 2012. The primary outcome examined was the post-operative Kujala score. We identified 320 MPFL reconstructions in nine relevant articles. The combined mean post-operative Kujala score was 92.02 (standard error (se) 1.4, p = 0.001) using a fixed effects model and 89.45 (se 37.9, p = 0.02) using random effect modelling. The reported rate of complications with MPFL reconstruction was 12.5% (40 of 320) with stiffness of the knee being the most common. High-quality evidence in assessing double-bundle MPFL reconstruction is lacking. The current literature consists of a mixture of prospective and retrospective case series. High-quality randomised trials evaluating this procedure are still awaited.

Cite this article: Bone Joint J 2013;95-B:900–5.

We report the results at a mean of 24.3 years (20 to 32) of 61 previously reported consecutive total hip replacements carried out on 44 patients with severe congenital hip disease, performed with reconstruction of the acetabulum with an impaction grafting technique known as cotyloplasty. The mean age of the patients at operation was 46.7 years (23 to 68) and all were women. The patients were followed post-operatively for a mean of 24.3 years (20 to 32), using the Merle d’Aubigné and Postel scoring system as modified by Charnley, and with serial radiographs. At the time of the latest follow-up, 28 acetabular components had been revised because of aseptic loosening at a mean of 15.9 years (6 to 26), and one at 40 days after surgery because of repeated dislocations. The overall survival rate for aseptic failure of the acetabular component at ten years was 93.1% (95% confidence interval (CI) 86.5 to 96.7) when 53 hips were at risk, and at 23 years was 56.1% (95% CI 49.4 to 62.8), when 22 hips remained at risk. These long-term results are considered satisfactory for the reconstruction of an acetabulum presenting with inadequate bone stock and circumferential segmental defects.

Cite this article: Bone Joint J 2013;95-B:887–92.

We have designed a prospective study to evaluate the usefulness of prolonged incubation of cultures from sonicated orthopaedic implants. During the study period 124 implants from 113 patients were processed (22 osteosynthetic implants, 46 hip prostheses, 54 knee prostheses, and two shoulder prostheses). Of these, 70 patients had clinical infection; 32 had received antibiotics at least seven days before removal of the implant. A total of 54 patients had sonicated samples that produced positive cultures (including four patients without infection). All of them were positive in the first seven days of incubation. No differences were found regarding previous antibiotic treatment when analysing colony counts or days of incubation in the case of a positive result. In our experience, extending incubation of the samples to 14 days does not add more positive results for sonicated orthopaedic implants (hip and knee prosthesis and osteosynthesis implants) compared with a conventional seven-day incubation period.

Cite this article: Bone Joint J 2013;95-B:1001–6.

Whether to combine spinal decompression with fusion in patients with symptomatic lumbar spinal stenosis remains controversial. We performed a cohort study to determine the effect of the addition of fusion in terms of patient satisfaction after decompressive spinal surgery in patients with and without a degenerative spondylolisthesis.

The National Swedish Register for Spine Surgery (Swespine) was used for the study. Data were obtained for all patients in the register who underwent surgery for stenosis on one or two adjacent lumbar levels. A total of 5390 patients fulfilled the inclusion criteria and completed a two-year follow-up. Using multivariable models the results of 4259 patients who underwent decompression alone were compared with those of 1131 who underwent decompression and fusion. The consequence of having an associated spondylolisthesis in the operated segments pre-operatively was also considered.

At two years there was no significant difference in patient satisfaction between the two treatment groups for any of the outcome measures, regardless of the presence of a pre-operative spondylolisthesis. Moreover, the proportion of patients who required subsequent further lumbar surgery was also similar in the two groups.

In this large cohort the addition of fusion to decompression was not associated with an improved outcome.

Cite this article: Bone Joint J 2013;95-B:960–5.

Objectives

Our study aimed to examine if a mobile-bearing total knee replacement (TKR) offered an advantage over fixed-bearing designs with respect to rates of secondary resurfacing of the patella in knees in which it was initially left unresurfaced.

Aims

We performed a systematic review of the literature to determine whether earlier surgical repair of acute rotator cuff tear (ARCT) leads to superior post-operative clinical outcomes.

Dysphagia is a common complication of anterior surgery of the cervical spine. The incidence of post-operative dysphagia may be as high as 71% within the first two weeks after surgery, but gradually decreases during the following months. However, 12% to 14% of patients may have some persistent dysphagia one year after the procedure. It has been shown that female gender, advanced age, multilevel surgery, longer operating time and severe pre-operative neck pain may be risk factors. Although the aetiology remains unclear and is probably multifactorial, proposed causes include oesophageal retraction, prominence of the cervical plate and prevertebral swelling. Recently, pre-operative tracheal traction exercises and the use of retropharyngeal steroids have been proposed as methods of reducing post-operative dysphagia.

We performed a systematic review to assess the incidence, aetiology, risk factors, methods of assessment and management of dysphagia following anterior cervical spinal surgery.

Cite this article: Bone Joint J 2013;95-B:868–73.