This study was performed to determine whether pure cancellous bone graft and Kirschner (K-) wire fixation were sufficient to achieve bony union and restore alignment in scaphoid nonunion. A total of 65 patients who underwent cancellous bone graft and K-wire fixation were included in this study. The series included 61 men and four women with a mean age of 34 years (15 to 72) and mean delay to surgery of 28.7 months (3 to 240). The patients were divided into an unstable group (A) and stable group (B) depending on the pre-operative radiographs. Unstable nonunion was defined as a lateral intrascaphoid angle > 45°, or a radiolunate angle > 10°. There were 34 cases in group A and 31 cases in group B. Bony union was achieved in 30 patients (88.2%) in group A, and in 26 (83.9%) in group B (p = 0.439). Comparison of the post-operative radiographs between the two groups showed no significant differences in lateral intrascaphoid angle (p = 0.657) and scaphoid length (p = 0.670) and height (p = 0.193). The radiolunate angle was significantly different (p = 0.020) but the mean value in both groups was < 10°. Comparison of the dorsiflexion and palmar flexion of movement of the wrist and the mean Mayo wrist score at the final clinical visit in each group showed no significant difference (p = 0.190, p = 0.587 and p = 0.265, respectively). Cancellous bone graft and K-wire fixation were effective in the treatment of stable and unstable scaphoid nonunion.

Cite this article: Bone Joint J 2013;95-B:809–14.

The Gamma nail is frequently used in unstable peri-trochanteric hip fractures. We hypothesised that mechanical failure of the Gamma nail was associated with inadequate proximal three-point fixation. We identified a consecutive series of 299 Gamma nails implanted in 299 patients over a five-year period, 223 of whom fulfilled our inclusion criteria for investigation. The series included 61 men and 162 women with a mean age of 81 years (20 to 101). Their fractures were classified according to the Modified Evans’ classification and the quality of fracture reduction was graded. The technical adequacy of three points of proximal fixation was recorded from intra-operative fluoroscopic images, and technical inadequacy for each point was defined. All patients were followed to final follow-up and mechanical failures were identified. A multivariate statistical analysis was performed, adjusting for confounders. A total of 16 failures (7.2%) were identified. The position of the lag screw relative to the lateral cortex was the most important point of proximal fixation, and when inadequate the failure rate was 25.8% (eight of 31: odds ratio 7.5 (95% confidence interval 2.5 to 22.7), p < 0.001).

Mechanical failure of the Gamma nail in peri-trochanteric femoral fractures is rare (< 1%) when three-point proximal fixation is achieved. However, when proximal fixation is inadequate, failure rates increase. The strongest predictor of failure is positioning the lateral end of the lag screw short of the lateral cortex. Adherence to simple technical points minimises the risk of fixation failure in this vulnerable patient group.

Cite this article: Bone Joint J 2013;95-B:825–30.

Whereas a general trend in the management of obstetric brachial plexus injuries has been nerve reconstruction in patients without spontaneous recovery of biceps function by three to six months of age, many recent studies suggest this may be unnecessary. In this study, the severity of glenohumeral dysplasia and shoulder function and strength in two groups of matched patients with a C5-6 lesion at a mean age of seven years (2.7 to 13.3) were investigated. One group (23 patients) underwent nerve reconstruction and secondary operations, and the other (52 patients) underwent only secondary operations for similar initial clinical presentations. In the patients with nerve reconstruction shoulder function did not improve and they developed more severe shoulder deformities (posterior subluxation, glenoid version and scapular elevation) and required a mean of 2.4 times as many operations as patients without nerve reconstruction.

This study suggests that less invasive management, addressing the muscle and bone complications, is a more effective approach. Nerve reconstruction should be reserved for those less common cases where the C5 and C6 nerve roots will not recover.

The purpose of this study was to examine the complications and outcomes of total hip replacement (THR) in super-obese patients (body mass index (BMI) > 50 kg/m²) compared with class I obese (BMI 30 to 34.9 kg/m²) and normal-weight patients (BMI 18.5 to 24.9 kg/m²), as defined by the World Health Organization.

A total of 39 THRs were performed in 30 super-obese patients with a mean age of 53 years (31 to 72), who were followed for a mean of 4.2 years (2.0 to 11.7). This group was matched with two cohorts of normal-weight and class I obese patients, each comprising 39 THRs in 39 patients. Statistical analysis was performed to determine differences among these groups with respect to complications and satisfaction based on the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index, the Harris hip score (HHS) and the Short-Form (SF)-12 questionnaire.

Super-obese patients experienced significantly longer hospital stays and higher rates of major complications and readmissions than normal-weight and class I obese patients. Although super-obese patients demonstrated reduced pre-operative and post-operative satisfaction scores, there was no significant difference in improvement, or change in the score, with respect to HHS or the WOMAC osteoarthritis index.

Super-obese patients obtain similar satisfaction outcomes as class I obese and normal-weight patients with respect to improvement in their scores. However, they experience a significant increase in length of hospital stay and major complication and readmission rates.

Cite this article: Bone Joint J 2013;95-B:758–63.

This prospective cohort study aimed to investigate the relationship between developmental dysplasia of the hip and mode of delivery in 571 consecutive breech infants using a modified Graf’s static morphological method to grade the severity of dysplasia.

In this group, 262 infants were born by planned Caesarian section, 223 by emergency section and 86 vaginally. Taking all grades of hip dysplasia into account (Graf types II, III and IV), there was no statistical difference in the incidence of dysplasia between the groups (elective section 8.4%, emergency section 8.1% and vaginal delivery 7.0%). However, when cases with Graf type II dysplasia, which may represent physiological immaturity, were excluded, the rate of type III and IV hips, which we consider to be clinically relevant, increased in the vaginally delivered group (4.7%) compared with the elective section group (1.1%), with a relative risk of approximately 1:4 (95% confidence interval 1.03 to 15.91). No difference was observed between the emergency and elective section groups, or between the emergency section and vaginally delivered groups.

This study supports previous published work, with the added value that the diagnoses were all confirmed by ultrasound.

Lyme disease is a vector-borne multisystem inflammatory disease caused by the spirochete Borrelia burgdorferi sensu lato. This disease is frequently seen in North America and to a lesser degree in Europe. However, its presence in England is uncommon and we present a case in which the patient developed a palsy of the common peroneal nerve

We examined the association of graft type with the risk of early revision of primary anterior cruciate ligament reconstruction (ACLR) in a community-based sample. A retrospective analysis of a cohort of 9817 ACLRs recorded in an ACLR Registry was performed. Patients were included if they underwent primary ACLR with bone–patellar tendon–bone autograft, hamstring tendon autograft or allograft tissue. Aseptic failure was the main endpoint of the study. After adjusting for age, gender, ethnicity, and body mass index, allografts had a 3.02 times (95% confidence interval (CI) 1.93 to 4.72) higher risk of aseptic revision than bone–patellar tendon–bone autografts (p < 0.001). Hamstring tendon autografts had a 1.82 times (95% CI 1.10 to 3.00) higher risk of revision compared with bone–patellar tendon–bone autografts (p = 0.019). For each year increase in age, the risk of revision decreased by 7% (95% CI 5 to 9). In gender-specific analyses a 2.26 times (95% CI 1.15 to 4.44) increased risk of hamstring tendon autograft revision in females was observed compared with bone–patellar tendon–bone autograft. We conclude that allograft tissue, hamstring tendon autografts, and younger age may all increase the risk of early revision surgery after ACLR.

Cite this article: Bone Joint J 2013;95-B:623–8.

Slipped capital femoral epiphysis (SCFE) is relatively common in adolescents and results in a complex deformity of the hip that can lead to femoroacetabular impingement (FAI). FAI may be symptomatic and lead to the premature development of osteoarthritis (OA) of the hip. Current techniques for managing the deformity include arthroscopic femoral neck osteochondroplasty, an arthroscopically assisted limited anterior approach to the hip, surgical dislocation, and proximal femoral osteotomy. Although not a routine procedure to treat FAI secondary to SCFE deformity, peri-acetabular osteotomy has been successfully used to treat FAI caused by acetabular over-coverage. These procedures should be considered for patients with symptoms due to a deformity of the hip secondary to SCFE.

Cite this article: Bone Joint J 2013;95-B:445–51.

Focal femoral inlay resurfacing has been developed for the treatment of full-thickness chondral defects of the knee. This technique involves implanting a defect-sized metallic or ceramic cap that is anchored to the subchondral bone through a screw or pin. The use of these experimental caps has been advocated in middle-aged patients who have failed non-operative methods or biological repair techniques and are deemed unsuitable for conventional arthroplasty because of their age. This paper outlines the implant design, surgical technique and biomechanical principles underlying their use. Outcomes following implantation in both animal and human studies are also reviewed.

Cite this article: Bone Joint J 2013;95-B:301–4.

We report a systematic review and meta-analysis of published randomised and quasi-randomised trials evaluating the efficacy of pre-operative skin antisepsis and cleansing techniques in reducing foot and ankle skin flora. The post-preparation culture number (Post-PCN) was the primary outcome. The data were evaluated using a modified version of the Cochrane Collaboration’s tool. We identified eight trials (560 participants, 716 feet) that met the inclusion criteria. There was a significant difference in the proportions of Post-PCN between hallux nailfold (HNF) and toe web spaces (TWS) sites: 0.47 vs 0.22, respectively (95% confidence interval (CI) 0.182937 to 0.304097; p < 0.0001).

Meta-analyses showed that alcoholic chlorhexidine had better efficacy than alcoholic povidone-iodine (PI) at HNF sites (risk difference 0.19 (95% CI 0.08 to 0.30); p = 0.0005); a two-step intervention using PI scrub and paint (S& P) followed by alcohol showed significantly better efficacy over PI (S& P) alone at TWS sites (risk difference 0.13 (95% CI 0.02 to 0.24); p = 0.0169); and a two-step intervention using chlorhexidine scrub followed by alcohol showed significantly better efficacy over PI (S& P) alone at the combined (HNF with TWS) sites (risk difference 0.27 (95% CI 0.13 to 0.40); p < 0.0001). No significant difference was found between cleansing techniques.

Cite this article: Bone Joint J 2013;95-B:498–503.

Between June 2005 and March 2008, 14 patients with a Campanacci grade-3 giant-cell tumour of the distal radius were treated by en bloc resection and reconstruction by ulnar translocation with arthrodesis of the wrist. The mean length of radius resected was 7.9 cm (5.5 to 15). All the patients were followed to bony union and 12 were available at a mean follow-up of 26 months (10 to 49).

The mean time to union was four months (3 to 7) at the ulnocarpal junction and five months (3 to 8) at the ulnoradial junction. All except one patient had an excellent range of pronation and supination. The remaining patient developed a radio-ulnar synostosis. The mean Musculoskeletal Tumor Society score was 26 (87%, range 20 to 28). Three patients had a soft-tissue recurrence, but with no bony involvement. They underwent a further excision and are currently well and free from disease.

Ulnar translocation provides a local vascularised bone graft to reconstruct the defect left after excision of the distal radius for giant cell tumour. It avoids the need for a microvascular procedure while retaining rotation of the forearm and good function of the hand.

The February 2013 Children’s orthopaedics Roundup³⁶⁰ looks at: ABC treated with suction and curettage; peri-acetabular osteotomy; cast index; Perthes’ disease associated with accidental injury; brachial plexus birth palsy; MRI assessment of DDH; total meniscectomy; and paediatric septic arthritis.

This study was performed to review the safety and outcome of total shoulder replacements in patients who are ≥ 80 years of age. A total of 50 total shoulder replacements in 44 patients at a mean age of 82 years (80 to 89) were studied. Their health and shoulder status, the operation and post-operative course were analysed, including pain, movement, patient satisfaction, medical and surgical complications, radiographs, the need for revision surgery, and implant and patient survival. A total of 27 patients had an ASA classification of III or IV and medical abnormalities were common. Of the 13 shoulders with bony deficiency of the glenoid, nine required grafting. The duration of hospital stay was prolonged and blood transfusions were common. There were no peri-operative deaths. The mean follow-up was for 5.5 years (2 to 12). Pain was significantly reduced (p < 0.001) and movement improved in active elevation and both external and internal rotation (p < 0.001). Using the Neer scale for assessing outcome, 40 (80%) shoulders had an excellent or satisfactory result. There were medical or surgical complications in 17 cases. Four shoulders developed radiological evidence of loosened glenoid components, and three of these had a poor outcome. Three other shoulders required revision, two for instability. By the time of this review 39 of the patients had died from unrelated causes at a mean of 7.5 years (0.8 to 16.4) after surgery.

Total shoulder replacement is a relatively effective treatment in this elderly group of patients. However, there is a requirement for more intense patient care in the peri-operative period, and non-fatal medical or surgical complications are common. Most of these elderly patients will have a comfortable functional shoulder for the rest of their lives.

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

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

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

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

This annotation considers the place of extra-articular reconstruction in the treatment of anterior cruciate ligament (ACL) deficiency. Extra-articular reconstruction has been employed over the last century to address ACL deficiency. However, the technique has not gained favour, primarily due to residual instability and the subsequent development of degenerative changes in the lateral compartment of the knee. Thus intra-articular reconstruction has become the technique of choice. However, intra-articular reconstruction does not restore normal knee kinematics. Some authors have recommended extra-articular reconstruction in conjunction with an intra-articular technique.

The anatomy and biomechanics of the anterolateral structures of the knee remain largely undetermined. Further studies to establish the structure and function of the anterolateral structures may lead to more anatomical extra-articular reconstruction techniques that supplement intra-articular reconstruction. This might reduce residual pivot shift after an intra-articular reconstruction and thus improve the post-operative kinematics of the knee.

Despite advances in contemporary hip and knee arthroplasty, blood loss continues to be an issue. Though blood transfusion has long been used to treat post-operative anemia, the associated risks are well established. The objective of this article is to present two practical and effective approaches to minimising blood loss and transfusion rates in hip and knee arthroplasty: the use of antifibrinolytic medications such as tranexamic acid and the adoption of more conservative transfusion indications.

Modern athletes are constantly susceptible to performance-threatening injury as they push their bodies to greater limits and endure higher physical stresses. Loss of performance and training time can adversely and permanently affect a sportsperson’s career. Now more than ever with advancing medical technology the answer may lie in biologic therapy. We have been using peripheral blood stem cells (PBSC) clinically and have been able to demonstrate that stem cells differentiate into target cells to enable regenerative repair. The potential of this technique as a regenerative agent can be seen in three broad applications: 1) articular cartilage, 2) bone and 3) soft tissue. This article highlights the successful cases, among many, in all three of these applications.

Arthroscopy of the knee is one of the most commonly performed orthopaedic procedures worldwide. Large-volume outcome data have not previously been available for English NHS patients. Prospectively collected admissions data, routinely collected on every English NHS patient, were analysed to determine the rates of complications within 30 days (including re-operation and re-admission), 90-day symptomatic venous thromboembolism and all-cause mortality. There were 301 701 operations performed between 2005 and 2010 – an annual incidence of 9.9 per 10 000 English population. Of these, 16 552 (6%) underwent ligament reconstruction and 106 793 (35%) underwent meniscal surgery. The 30-day re-admission rate was 0.64% (1662) and 30-day wound complication rate was 0.26% (677). The overall 30-day re-operation rate was 0.40% (1033) and the 90-day pulmonary embolism rate was 0.08% (230), of which six patients died. 90-day mortality was 0.02% (47). Age < 40 years, male gender and ligament reconstruction were significantly associated with an increased rate of 30-day re-admission and unplanned re-operation. In addition, a significant increase in 30-day admission rates were seen with Charlson comorbidity scores of 1 (p = 0.037) and ≥ 2 (p <  0.001) compared with scores of 0, and medium volume units compared with high volume units (p < 0.001).

Complications following arthroscopy of the knee are rare. It is a safe procedure, which in the majority of cases is performed as day case surgery. These data can be used for quality benchmarking, in terms of consent, consultant re-validation and individual unit performance.

The February 2013 Knee Roundup³⁶⁰ looks at: mobile-bearing TKRs; arthroscopic ACL reconstruction; the use of chondrocytes for osteochondral defects; ACL reconstruction and the return to pivoting sports; ACLs and the MOON study; the benefit of knee navigation; and trabecular metal.

Neurogenic heterotopic ossification (NHO) is a disorder of aberrant bone formation affecting one in five patients sustaining a spinal cord injury or traumatic brain injury. Ectopic bone forms around joints in characteristic patterns, causing pain and limiting movement especially around the hip and elbow. Clinical sequelae of neurogenic heterotopic ossification include urinary tract infection, pressure injuries, pneumonia and poor hygiene, making early diagnosis and treatment clinically compelling. However, diagnosis remains difficult with more investigation needed. Our pathophysiological understanding stems from mechanisms of basic bone formation enhanced by evidence of systemic influences from circulating humor factors and perhaps neurological ones. This increasing understanding guides our implementation of current prophylaxis and treatment including the use of non-steroidal anti-inflammatory drugs, bisphosphonates, radiation therapy and surgery and, importantly, should direct future, more effective ones.