Hip resurfacing is a bone-conserving procedure with respect to proximal femoral resection, but there is debate in the literature as to whether the same holds true for the acetabulum. We have investigated whether the Birmingham hip resurfacing conserves acetabular bone.

Between 1998 and 2005, 500 Birmingham hip resurfacings were performed by two surgeons. Between 1996 and 2005 they undertook 700 primary hip replacements, with an uncemented acetabular component. These patients formed the clinical material to compare acetabular component sizing. The Birmingham hip resurfacing group comprised 350 hips in men and 150 hips in women. The uncemented total hip replacement group comprised 236 hips in men and 464 hips in women. Age- and gender-matched analysis of a cohort of patients for the sizes of the acetabular components required for the two types of replacement was also undertaken. Additionally, an analysis of the sizes of the components used by each surgeon was performed.

For age-matched women, the mean outside diameter of the Birmingham hip resurfacing acetabular components was 2.03 mm less than that of the acetabular components in the uncemented total hip replacements (p < 0.0001). In similarly matched men there was no significant difference (p = 0.77). A significant difference was also found between the size of acetabular components used by the two surgeons for Birmingham hip resurfacing for both men (p = 0.0015) and women (p = 0.001). In contrast, no significant difference was found between the size of acetabular components used by the two surgeons for uncemented total hip replacement in either men or women (p = 0.06 and p = 0.14, respectively). This suggests that variations in acetabular preparation also influence acetabular component size in hip resurfacing.

Despite extensive experience with prosthetic replacement for the reconstruction of limbs following juxta-articular resection of tumours, there are few reports of prosthetic replacement of the distal radius. We present two cases of massive bone defects of the distal radius in which alumina ceramic prosthetic replacements were used. We evaluated the patients more than ten years after the procedure. Both patients had degenerative changes to the wrist. This, however, was not associated with pain or decreased function, and both had returned to their previous occupation after surgery.

When a patient has a massive defect of the distal radius, reconstruction using a ceramic prosthesis is a reasonable alternative to using autograft. This method of treatment results in little pain, a moderate range of movement and satisfactory function.

The epidemiological data and intra-operative findings from 260 consecutive arthroscopically-diagnosed acetabular labral tears seen over a ten-year period were analysed. Radiographs of 128 of these patients were assessed for dysplasia using established radiological parameters. Patients with acetabular dysplasia were then compared against those without in order to identify any differences in gender, age, the side of the tear, the pattern of the tear, the number of quadrants involved, the quadrant preference and the prevalence of intra-articular comorbidity. Dysplasia was found in 46% (59 of 128) of the hips. No significant differences existed between the dysplastic and non-dysplastic subgroups as regards gender distribution, the side of the lesion, the number of quadrants involved or the distribution of tears among the quadrants. However, tears associated with dysplasia were diagnosed in an older age group, had a different pattern and were associated with a much higher prevalence of osteoarthritis.

We have investigated the oncological outcome of 63 patients with soft-tissue sarcomas of the hand managed at three major centres in the United Kingdom. There were 44 males and 19 females with a mean age of 45 years (11 to 92). The three most common diagnoses were synovial sarcoma, clear cell sarcoma and epithelioid sarcoma. Local excision was carried out in 45 patients (71%) and amputation in 18 (29%). All those treated by amputation had a wide margin of excision but this was only achieved in 58% of those treated by local excision. The risk of local recurrence was 6% in those treated by amputation compared with 42% for those who underwent attempted limb salvage. An inadequate margin of excision resulted in a 12 times greater risk of local recurrence when compared with those in whom a wide margin of excision had been achieved. We were unable to demonstrate any role for radiotherapy in decreasing the risk of local recurrence when there was an inadequate margin of excision. Patients with an inadequate margin of excision had a much higher risk of both local recurrence and metastasis than those with wide margins. The overall survival rate at five years was 87% and was related to the grade and size of the tumour and to the surgical margin.

We have shown that a clear margin of excision is essential to achieve local control of a soft-tissue sarcoma in the hand and that failure to achieve this results in a high risk of both local recurrence and metastastic disease.

A consecutive series of 23 patients (25 ankles) with osteoarthritis of the ankle and severe varus or valgus deformity were treated by open arthrodesis using compression screws. Primary union was achieved in 24 ankles one required further surgery to obtain a solid fusion. The high level of satisfaction in this group of patients reinforces the view that open arthrodesis, as opposed to ankle replacement or arthroscopic arthrodesis, continues to be the treatment of choice when there is severe varus or valgus deformity associated with the arthritis.

We identified ten patients who underwent arthroscopic revision of anterior shoulder stabilisation between 1999 and 2005. Their results were compared with 15 patients, matched for age and gender, who had a primary arthroscopic stabilisation during the same period.

At a mean follow-up of 37 and 36 months, respectively, the scores for pain and shoulder function improved significantly between the pre-operative and follow-up visits in both groups (p = 0.002), with no significant difference between them (p = 0.4). The UCLA and Rowe shoulder scores improved significantly (p = 0.004 and p = 0.002, respectively), with no statistically significant differences between groups (p = 0.6). Kaplan-Meier analysis for time to recurrent instability showed no differences between the groups (p = 0.2).

These results suggest that arthroscopic revision anterior shoulder stabilisation is as reliable as primary arthroscopic stabilisation for patients who have had previous open surgery for recurrent anterior instability.

The dysplasia cup, which was devised as an adjunct to the Birmingham Hip Resurfacing system, has a hydroxyapatite-coated porous surface and two supplementary neutralisation screws to provide stable primary fixation, permit early weight-bearing, and allow incorporation of morcellised autograft without the need for structural bone grafting.

A total of 110 consecutive dysplasia resurfacing arthroplasties in 103 patients (55 men and 48 women) performed between 1997 and 2000 was reviewed with a minimum follow-up of six years. The mean age at operation was 47.2 years (21 to 62) and 104 hips (94%) were Crowe grade II or III.

During the mean follow-up of 7.8 years (6 to 9.6), three hips (2.7%) were converted to a total hip replacement at a mean of 3.9 years (2 months to 8.1 years), giving a cumulative survival of 95.2% at nine years (95% confidence interval 89 to 100). The revisions were due to a fracture of the femoral neck, a collapse of the femoral head and a deep infection. There was no aseptic loosening or osteolysis of the acetabular component associated with either of the revisions performed for failure of the femoral component. No patient is awaiting a revision.

The median Oxford hip score in 98 patients with surviving hips at the final review was 13 and the 10th and the 90th percentiles were 12 and 23, respectively.

In order to determine the potential for an internervous safe zone, 20 hips from human cadavers were dissected to map out the precise pattern of innervation of the hip capsule. The results were illustrated in the form of a clock face. The reference point for measurement was the inferior acetabular notch, representing six o’clock. Capsular branches from between five and seven nerves contributed to each hip joint, and were found to innervate the capsule in a relatively constant pattern. An internervous safe zone was identified anterosuperiorly in an arc of 45° between the positions of one o’clock and half past two.

Our study shows that there is an internervous zone that could be safely used in a capsule-retaining anterior, anterolateral or lateral approach to the hip, or during portal placement in hip arthroscopy.

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

We have compared four computer-assisted methods to measure penetration of the femoral head into the acetabular component in total hip replacement. These were the Martell Hip Analysis suite 7.14, Rogan HyperOrtho, Rogan View Pro-X and Roman v1.70. The images used for the investigation comprised 24 anteroposterior digital radiographs and 24 conventional acetate radiographs which were scanned to provide digital images. These radiographs were acquired from 24 patients with an uncemented total hip replacement with a follow-up of approximately eight years (mean 8.1; 6.3 to 9.1). Each image was measured twice by two blinded observers. The mean annual rates of penetration of the femoral head measured in the eight-year single image analysis were: Martell, 0.24 (SD 0.19); HyperOrtho, 0.12 (SD 0.08); View Pro-X, 0.12 (SD 0.06); Roman, 0.12 (SD 0.07). In paired analysis of the six-month and eight-year radiographs: Martell, 0.35 (SD 0.22); HyperOrtho, 0.15 (SD 0.13); View Pro-X, 0.11 (SD 0.06); Roman, 0.11 (SD 0.07). The intra- and inter-observer variability for the paired analysis was best for View Pro-X and Roman software, with intraclass correlations of 0.97, 0.87 and 0.96, 0.87, respectively, and worst for HyperOrtho and Martell, with intraclass correlations of 0.46, 0.13 and 0.33, 0.39, respectively.

The Roman method proved the most precise and the most easy to use in clinical practice and the software is available free of charge. The Martell method showed the lowest precision, indicating a problem with its edge detection algorithm on digital images.

We performed a prospective, randomised trial to evaluate the outcome after surgery of displaced, unstable fractures of the distal radius. A total of 280 consecutive patients were enrolled in a prospective database and 88 identified who met the inclusion criteria for surgery. They were randomised to receive either bridging external fixation with supplementary Kirschner-wire fixation or volar-locked plating with screws. Both groups were similar in terms of age, gender, hand dominance, fracture pattern, socio-economic status and medical co-morbidities.

Although the patients treated by volar plating had a statistically significant early improvement in the range of movement of the wrist, this advantage diminished with time and in absolute terms the difference in range of movement was clinically unimportant. Radiologically, there were no clinically significant differences in the reductions, although more patients with AO/OTA (Orthopaedic Trauma Association) type C fractures were allocated to the external fixation group. The function at one year was similar in the two groups.

No clear advantage could be demonstrated with either treatment but fewer re-operations were required in the external fixation group.

Achieving deep flexion after total knee replacement remains a challenge. In this study we compared the soft-tissue tension and tibiofemoral force in a mobile-bearing posterior cruciate ligament-sacrificing total knee replacement, using equal flexion and extension gaps, and with the gaps increased by 2 mm each. The tests were conducted during passive movement in five cadaver knees, and measurements of strain were made simultaneously in the collateral ligaments. The tibiofemoral force was measured using a customised mini-force plate in the tibial tray. Measurements of collateral ligament strain were not very sensitive to changes in the gap ratio, but tibiofemoral force measurements were. Tibiofemoral force was decreased by a mean of 40% (sd 10.7) after 90° of knee flexion when the flexion gap was increased by 2 mm. Increasing the extension gap by 2 mm affected the force only in full extension. Because increasing the range of flexion after total knee replacement beyond 110° is a widely-held goal, small increases in the flexion gap warrant further investigation.

We compared the outcome of peri-operative humeral condylar fractures in patients undergoing a Coonrad-Morrey semiconstrained total elbow replacement with that of patients with rheumatoid arthritis undergoing the same procedure without fractures. In a consecutive series of 40 elbows in 33 patients, 13 elbows had a fracture in either condyle peri-operatively, and 27 elbows were intact. The fractured condyle was either fixed internally or excised. We found no statistical difference in the patients’ background, such as age, length of follow-up, immobilisation period, Larsen’s radiological grade, or Steinbrocker’s stage and functional class. There was also no statistical difference between the groups in relation to the Mayo Elbow Performance Score, muscle strength, range of movement, or radiolucency around the implants at a mean of 4.8 years (1.1 to 8.0) follow-up.

We conclude that fractured condyles can be successfully treated with either internal fixation or excision, and cause no harmful effect.

We report a case of sciatic nerve palsy following total hip replacement which has lead to a novel hypothesis to account for this complication.

We compared the orientation of the acetabular component obtained by a conventional manual technique with that using five different navigation systems.

Three surgeons carried out five implantations of an acetabular component with each navigation system, as well as manually, using an anatomical model. The orientation of the acetabular component, including inclination and anteversion, and its position was determined using a co-ordinate measuring machine.

The variation of the orientation of the acetabular component was higher in the conventional group compared with the navigated group. One experienced surgeon took significantly less time for the procedure. However, his placement of the component was no better than that of the less experienced surgeons. Significantly better inclination and anteversion (p < 0.001 for both) were obtained using navigation. These parameters were not significantly different between the surgeons when using the conventional technique (p = 0.966).

The use of computer navigation helps a surgeon to orientate the acetabular component with less variation regarding inclination and anteversion.

Ensuring the accuracy of the intra-operative orientation of the acetabular component during a total hip replacement can be difficult. In this paper we introduce a reproducible technique using the transverse acetabular ligament to determine the anteversion of the acetabular component. We have found that this ligament can be identified in virtually every hip undergoing primary surgery. We describe an intra-operative grading system for the appearance of the ligament. This technique has been used in 1000 consecutive cases. During a minimum follow-up of eight months the dislocation rate was 0.6%. This confirms our hypothesis that the transverse acetabular ligament can be used to determine the position of the acetabular component. The method has been used in both conventional and minimally-invasive approaches.