Between 1990 and 1998 we saw 21 children with primary subacute haematogenous osteomyelitis. Pain, swelling and a limp had been present for two to 12 weeks with little functional impairment. Laboratory tests were non-contributory. The lesions were classified radiologically into metaphyseal, diaphyseal, epiphyseal and vertebral. There were 24 sites involved, with most (20) being in the tibia; 17 lesions were in the diaphysis, five in the metaphysis and two in the epiphysis. The diagnosis was confirmed histologically in all cases. Staphylococcus aureus was cultured in six patients. Healing occurred in all patients after treatment with antibiotics for six weeks and radiological improvement was seen after three to six months. Subacute osteomyelitis develops as a result of increased host resistance and decreased bacterial virulence. The radiological features can mimic various benign or malignant bone tumours and non-pyogenic infections. Histological confirmation is necessary to avoid a delay in diagnosis

Over a 16-year period, 135 custom-made distal femoral prostheses, based on a fully constrained Stanmore-type knee replacement, were used in the treatment of primary malignant or aggressive benign tumours. Survivorship analysis showed a cumulative success rate of 72% at five years and 64% at seven years. Intact prostheses in 91% of the surviving patients gave good or excellent functional results. Deep infection was the major complication, occurring in 6.8% of cases; clinical aseptic loosening occurred in 6.0%. Revision surgery was carried out for loosening and infection, and the early results are encouraging. We conclude that prosthetic replacement of the distal femur can meet the objectives of limb salvage surgery

We used survival analysis to evaluate 113 consecutive semiconstrained total elbow arthroplasties (TEAs) in 95 patients at a maximum follow-up of 99 months. Our criteria for failure were mechanical malfunction, revision for any reason, and deep infection. The primary diagnosis was inflammatory arthritis in 86 elbows, post-traumatic arthritis in 6, supracondylar nonunion or fracture in 12, osteoarthritis in 2 and other causes in 3. Seven failures were due to deep infection, and five of these had a primary diagnosis of inflammatory arthritis. Eight failures were revised or had revision recommended for aseptic loosening, and six of these were in patients with post-traumatic arthritis or supracondylar nonunion. The cumulative survival for TEAs performed for post-traumatic arthritis, fractures or supracondylar nonunion was 73% at three years and 53% at five years, significantly worse than the cumulative three- and five-year survivals of 92% and 90%, respectively, for patients with inflammatory arthritis. TEA with a semiconstrained prosthesis appears to have a satisfactory survival in selected patients with arthritic disorders. The incidence of deep infection was reduced by improvements in surgical technique and postoperative management, and the routine use of antibiotic-impregnated cement. The incidence of aseptic loosening was low, except in patients with supracondylar nonunion or post-traumatic arthritis

Needle biopsy is an established technique for the histological diagnosis of bone tumours, usually guided by fluoroscopy or CT. Surface lesions and aggressive tumours which have extended through the cortex are also amenable to imaging with ultrasound (US). We have assessed the diagnostic accuracy of US-guided Trucut needle biopsy in a consecutive series of patients referred to a Bone Tumour Unit with suspected primary bone tumours. Of 144 patients (83 men, 61 women; mean age 34.7 years) referred over a period of two years, 63 were considered suitable for US-guided biopsy. This was based on the presence of a relatively large extraosseous component, seen typically in osteosarcoma and malignant round-cell tumours. The results of needle biopsy were compared with those of surgical biopsy. The diagnostic accuracy was 98.4%, with only a single failed biopsy. Thus, in a selected group of patients, US is a very reliable technique of guidance for percutaneous needle biopsy of bone tumours

We compared inflammation in the knee after total knee replacement (TKR) for primary osteoarthritis between two groups of patients undergoing joint replacement with and without synovectomy. A total of 67 patients who underwent unilateral TKR were randomly divided into group I, TKR without synovectomy, and group II, TKR with synovectomy. Clinical outcomes, serial serum inflammatory markers (including interleukin-6 (IL-6), CRP and ESR) and the difference in temperature of the skin of the knee, compared with the contralateral side, were sequentially evaluated until 26 weeks after surgery. Pre-operatively, there were no statistically different clinical parameters between groups I and II. At the 26-week follow-up, both groups had a similarly significantly improved American Knee Society clinical score (p < 0.001) and functional score (p < 0.001) with no differences between the groups. Similar changes in serial inflammatory markers were found in both groups, including mean peak levels of IL-6 (189 pg/ml (. sd. 53.4) versus 201 pg/ml (. sd. 49.4) for groups I and II, respectively) and CRP (91 mg/L (. sd. 24.1) versus 88 mg/L (. sd. 23.4), respectively) on the first post-operative day, returning to pre-operative values at two and six weeks, respectively. The mean peak level of ESR for the respective two groups was 46 mm/hr versus 48 mm/hr at two weeks, which had still not returned to its pre-operative mean value at 26 weeks. The elevation in the skin temperature appeared to mirror the peak elevation of the ESR, with a range of 2.5° C to 4.5° C with some reduction at 26 weeks but still exceeding the pre-operative value. We concluded that synovectomy at the time of TKR does not provide any benefit to the clinical outcome or shorten the duration of the inflammatory response after surgery

We report the results of medial physeal stapling in 16 knees with primary genu valgum and 27 with secondary genu valgum. In the primary group, stapling was undertaken at a mean chronological age of 12 years in girls and 13 years in boys. The medial femoral physis was stapled in ten knees and the medial femoral and tibial physes in six knees. At skeletal maturity, all patients had excellent or good leg alignment. Secondary genu valgum is due to skeletal dysplasia, haematological or endocrine disorders, or to juvenile chronic arthritis. Stapling was at a mean chronological age of 11 years in girls and 14 years in boys. The medial femoral physis was stapled in 13 knees, the medial tibial physis in three and both in 11 knees. At skeletal maturity, 85% had excellent or good leg alignment, and correction had occurred within one year. Two of the poor results were due to staple extrusion from osteoporotic bone, and two to overcorrection. Rebound growth was minimal and unpredictable after the removal of staples. Medial physeal stapling is a suitable method of treatment for both primary and secondary genu valgum in late childhood and in adolescence. At least one year of knee growth is required to achieve correction, and care is needed to avoid overcorrection of the secondary genu valgum

The management of traumatic dislocation of the knee in 40 patients (41 knees) with a mean age of 26.3 years is described. They were treated by primary repair and reconstruction with autologous grafting of the anterior (ACL) and posterior cruciate ligaments (PCL) and repair injuries to the collateral ligament and soft-tissue. The ACL and PCL were reconstructed using the patellar tendon and the gracilis and semitendinosus tendons, respectively. Early mobilisation using a continuous-passive-movement machine and active exercises was started on the second day after operation. At a mean follow-up of 39 months no patient reported ‘giving way’ and all except one had good range of movement. Of the 41 knees, 21 were rated as excellent, 15 good, four fair and one poor. Early reconstruction of the cruciate ligaments and primary repair of the collateral ligaments followed by an aggressive rehabilitation programme are recommended for these young, active patients

Since bone morphogenetic proteins (BMPs) are highly homologous, we investigated the hypothesis that recombinant BMP-4 of the genome of Xenopus laevis (rxBMP-4) may influence the proliferation or differentiation of human primary osteoblast-like cells (HPOC), as occurs with recombinant human BMP (rhBMP-2). HPOC were incubated in the presence of either rxBMP-4, rhBMP-2 or basic fibroblast growth factor (rh-bFGF). The last two were used as positive controls and are known to induce differentiation or proliferation of HPOC, respectively. rxBMP-4 (50 ng/ml and 100 ng/ml) induced a differentiation of HPOC to almost the same extent as rhBMP-2, whereas the addition of rh-bFGF, applied in the same concentration, failed to have any influence on cell differentiation. rh-bFGF however, provoked an increase in cell proliferation of up to 150% when compared with non-stimulated HPOC, while rhBMP-2 and rxBMP-4 had no such effect. Our results indicate an equipotent effect of rhBMP-2 and rxBMP-4 obtained from Xenopus laevis on the differentiation and proliferation of human primary osteoblast-like cells

We studied 4253 patients undergoing primary joint replacement between November 2002 and November 2007, of whom 4060 received aspirin only as chemical prophylaxis; 46 were mistakenly given low molecular weight heparin initially, which was stopped and changed to aspirin; 136 received no chemoprophylaxis and 11 patients received warfarin because of a previous history of pulmonary embolism. We identified the rate of clinical thromboembolism before and after discharge, and the mortality from pulmonary embolism at 90 days. The overall death rate was 0.31% (13 of 4253) and the rate of fatal pulmonary embolism was 0.07% (3 of 4253). Our data suggest that fatal pulmonary embolism is not common following elective primary joint replacement, and with modern surgical practice elective hip and knee replacement should no longer be considered high-risk procedures

Computerised arthrotomography was performed on 33 patients four to six weeks after acute primary anterior dislocation of the shoulder. Seventeen patients were under, and 16 over 50 years of age. Damage to the anterior glenoidal labrum was seen in all the younger patients and in 75% of the older ones. A large redundant capsular pouch, seen in the older patients, was present in 35% of the younger ones, and a posterior humeral head defect was seen in 82% of the younger patients and only 50% of the older. Associated fractures were more common in the older patients, and a tear of the rotator cuff was demonstrated in 63% of the older patients and in none of the younger ones

Compression testing of cadaver specimens showed that excision of the radial head allowed proximal radial displacement. The insertion of a metallic radial head restored normal mechanics, while a silicone rubber implant did not. We reviewed 31 of 36 comminuted fractures of the radial head, 21 associated with dislocation or ulnar fracture, which had been treated by primary replacement with a Vitallium prosthesis. At a mean follow-up of 4.5 years, there was reliable restoration of stability and prevention of proximal radial migration. There had been no dislocations or prosthetic failures, but two implants had been removed for loosening. The prosthesis is recommended for use as a spacer to stabilise the elbow after severe injuries while the soft tissues heal

The pathogenesis of slipped upper femoral epiphysis is unknown but the condition has been linked with various endocrine disorders. Nine patients with slipped epiphyses in association with primary juvenile hypothyroidism are presented. In all patients, slipping occurred or symptoms developed in the affected hip before the hypothyroidism was diagnosed. A generalised pathology was suggested by the absence of trauma (8 patients), by bilateral slipping (6 patients), and by obesity and short stature in all patients. All cases had delayed skeletal maturation and characteristic metaphysial changes were seen on their radiographs. The clinical diagnosis of juvenile hypothyroidism can be difficult but it merits consideration in patients who have a slipped upper femoral epiphysis in association with short stature, obesity, delay in skeletal maturity, or any one of these

We have studied 105 patients with 107 acute, primary, dislocations of the glenohumeral joint seen between January 1, 1991 and July 1, 1994. The mean time of follow-up was 71 months (46 to 91). In 34% the injury occurred during a sports activity and in 28% at home. The bias toward sport was even greater in patients less than 40 years of age, and in men. In patients older than 40 years of age, and in women, the dislocation occurred more often at home. The overall probability of recurrence within four years was 26%. Age was the most significant prognostic factor in recurrence which took place in 64% of patients less than 20 years of age and in 6% of those older than 40 years. Statistically, there was no difference between the rates of recurrence in patients who were active in sport and those who were not. The mean Rowe score for the whole group was 87 (15 to 100). Associated fractures were found in 20 patients (19%) and nerve injuries in 22 (21%). None of those in whom a fracture of the greater tuberosity was seen subsequently suffered a recurrent dislocation. At follow-up we found that 36 patients (34%) had not returned to their former employment but in only 2% was this owing to the injured shoulder

Segmental resection of malignant bone disease in the femoral diaphysis with subsequent limb reconstruction is a major undertaking. This is a retrospective review of 23 patients who had undergone limb salvage by endoprosthetic replacement of the femoral diaphysis for a primary bone tumour between 1989 and 2005. There were 16 males and seven females, with a mean age of 41.3 years (10 to 68). The mean overall follow-up was for 97 months (3 to 240), and 120 months (42 to 240) for the living patients. The cumulative patient survival was 77% (95% confidence interval 63% to 95%) at ten years. Survival of the implant, with failure of the endoprosthesis as an endpoint, was 85% at five years and 68% (95% confidence interval 42% to 92%) at ten years. The revision rate was 22% and the overall rate of re-operation was 26%. Complications included deep infection (4%), breakage of the prosthesis (8%), periprosthetic fracture (4%), aseptic loosening (4%), local recurrence (4%) and metastases (17%). The 16 patients who retained their diaphyseal endoprosthesis had a mean Musculoskeletal Tumour Society score of 87% (67% to 93%). They were all able to comfortably perform most activities of daily living. Femoral diaphyseal endoprosthetic replacement is a viable option for reconstruction following segmental resection of malignant bone disease. It allows immediate weight-bearing, is associated with a good long-term functional outcome, has an acceptable complication and revision rate and, most importantly, does not appear to compromise patient survival

1. An analysis has been made of the clinical features and investigations in ninety-five cases of primary intraspinal tumours. 2. Loss of muscle power was the commonest symptom, and was often ignored until late in the course of the disease. 3. Two-thirds of the patients had no pain in the spinal region, although five of these had either extensive growths or radiographical evidence of bone erosion by tumour. 4. One-third of the patients had urinary symptoms, and two of them had acute retention initially attributed to prostatic obstruction. 5. In eighteen cases posture and gait were abnormal. The case histories of five of these patients are recorded, and they emphasise the importance of recognising lumbar spasm and hamstring tightness in young patients as signs of a cauda equina neoplasm. 6. All patients had some detectable sensory, motor, or reflex changes, and these were mostly bilateral. 7. Radiography, and cerebrospinal fluid manometry and analysis, were helpful in establishing the diagnosis. 8. Hysteria should not be diagnosed until all efforts have been made to prove otherwise

We reviewed 249 consecutive Charnley primary low-friction arthroplasties in 191 patients performed by one surgeon using a transtrochanteric approach at a minimum follow-up of ten years. Of these, 37 hips in 32 patients showed osteolysis and were compared with 41 hips in 37 matched patients with no osteolysis. We assessed in each case the wear rate, stability of the prosthesis, acetabular angle, socket angle, thickness of the acetabular and femoral cement mantle, canal flare index, femoral score, stem alignment, implant:canal ratio and stem:canal ratio. We found that a high rate of wear, component instability and osteolysis were associated. Osteolysis was three times more common in men than in women. Factors which reduced osteolysis were cement mantles of 6 mm at the acetabulum and of 3 mm in all zones of the femur, a stem:canal ratio of 60% to 70% and an implant:canal ratio of over 99%. The overall incidence of osteolysis was 14.9% but when these technical criteria were met, the incidence was 5.2%. This suggests that careful technique can dramatically reduce the risk of this complication

Sixty-five knees were subjected to a kinematic analysis using the instant-centre technique in order to determine the effect of deficiency of the anterior cruciate ligament on the biomechanics of active movement in the knee. The instant-centre pathway in acute ruptures of the anterior cruciate ligament was found to have a specific abnormality. This corresponded with a positive pivot-shift sign, but was present even when that sign was not clinically detectable. Primary repair using a transosseous wire suture did not usually abolish the biomechanical abnormality. The data provide a possible explanation for the doubtful prognosis of primary repair of this ligament and encourage clinical and biomechanical evaluation of alternative procedures such as primary augmented repair

Between 1990 and 1996 we performed 20 consecutive ulnohumeral arthroplasties for primary osteoarthritis of the elbow. The outcome was assessed using the Disabilities of Arm, Shoulder and Hand Score (DASH) and the Mayo Elbow Performance Score (MEPS) at a mean follow-up of 75 months (58 to 132). There were excellent or good results in 17 elbows (85%) using the DASH score and in 13 (65%) with the MEPS (correlation coefficient 0.79). The mean fixed flexion deformity had improved by 10° and the range of flexion by a mean of 20°. In 16 elbows (80%) the benefits of surgery had been maintained, and of 16 patients working at the time of operation, 12 (75%) had returned to the same job. There was no correlation between radiological recurrence of degenerative changes and the amount of fixed flexion deformity, the flexion arc, or the elbow scores

Aims

The number of revision total knee arthroplasties (TKA) that are performed is expected to increase. However, previous reports of the causes of failure after TKA are limited in that they report the causes at specific institutions, which are often dependent on referral patterns. Our aim was to report the most common indications for re-operations and revisions in a large series of posterior-stabilised TKAs undertaken at a single institution, excluding referrals from elsewhere, which may bias the causes of failure.

Primary subacute haematogenous osteomyelitis (PSHO) of the small bones of the foot is a rare and infrequently considered cause of a limp in children. We describe 11 patients with PSHO, of whom nine were under three years of age, who had a limp with few symptoms. The talus was involved in 36%. Bone scans were positive in all patients and led to localisation of the lesion in two. The radiological features included soft-tissue swelling, an osteolytic lesion in the talus and the calcaneus and a sclerotic appearance of the cuboid and the navicular bones. All patients except one were cured with antibiotics