This prospective study compares the outcome of 157 hydroxyapatite (HA)-coated tibial components with 164 cemented components in the ROCC Rotating Platform total knee replacement in 291 patients. The mean follow-up was 7.6 years (5.2 to 11). There were two revisions for loosening: one for an HA-coated and one for a cemented tibial component. Radiological evaluation demonstrated no radiolucent lines with the HA-coated femoral components. A total of three HA-coated tibial components exhibited radiolucent lines at three months post-operatively and these disappeared after three further months of protected weight-bearing. With HA-coated components the operating time was shorter (p <  0.006) and the radiological assessment of the tibial interface was more stable (p < 0.01). Using revision for aseptic loosening of the tibial component as the end point, the survival rates at nine years was identical for both groups at 99.1%.

Our results suggest that HA-coated components perform at least as well as the same design with cemented components and compare favourably with those of series describing cemented or porous-coated knee replacements, suggesting that fixation of both components with hydroxyapatite is a reliable option in primary total knee replacement.

Charcot osteoarthropathy of the foot is a chronic and progressive disease of bone and joint associated with a risk of amputation. The main problems encountered in this process are osteopenia, fragmentation of the bones of the foot and ankle, joint subluxation or even dislocation, ulceration of the skin and the development of deep sepsis. We report our experience of a series of 20 patients with Charcot osteoarthropathy of the foot and ankle treated with an Ilizarov external fixator. The mean age of the group was 30 years (21 to 50). Diabetes mellitus was the underlying cause in 18 patients. Five had chronic ulcers involving the foot and ankle. Each patient had an open lengthening of the tendo Achillis with excision of all necrotic and loose bone from the ankle, subtalar and midtarsal joints when needed. The resulting defect was packed with corticocancellous bone graft harvested from the iliac crest and an Ilizarov external fixator was applied. Arthrodesis was achieved after a mean of 18 weeks (15 to 20), with healing of the skin ulcers. Pin track infection was not uncommon, but no frame had to be removed before the arthrodesis was sound.

Every patient was able to resume wearing regular shoes after a mean of 26.5 weeks (20 to 45).

In posterior stabilised total knee replacement (TKR) a larger femoral component is sometimes selected to manage the increased flexion gap caused by resection of the posterior cruciate ligament. However, concerns remain regarding the adverse effect of the increased anteroposterior dimensions of the femoral component on the patellofemoral (PF) joint. Meanwhile, the gender-specific femoral component has a narrower and thinner anterior flange and is expected to reduce the PF contact force. PF contact forces were measured at 90°, 120°, 130° and 140° of flexion using the NexGen Legacy Posterior Stabilized (LPS)-Flex Fixed Bearing Knee system using Standard, Upsized and Gender femoral components during TKR. Increasing the size of the femoral component significantly increased mean PF forces at 120°, 130° and 140° of flexion (p = 0.005, p < 0.001 and p < 0.001, respectively). No difference was found in contact force between the Gender and the Standard components. Among the patients who had overhang of the Standard component, mean contact forces with the Gender component were slightly lower than those of the Standard component, but no statistical difference was found at 90°, 120°, 130° or 140° of flexion (p = 0.689, 0.615, 0.253 and 0.248, respectively).

Upsized femoral components would increase PF forces in deep knee flexion. Gender-specific implants would not reduce PF forces.

A new anterior intrapelvic approach for the surgical management of displaced acetabular fractures involving predominantly the anterior column and the quadrilateral plate is described. In order to establish five ‘windows’ for instrumentation, the extraperitoneal space is entered along the lateral border of the rectus abdominis muscle. This is the so-called ‘Pararectus’ approach. The feasibility of safe dissection and optimal instrumentation of the pelvis was assessed in five cadavers (ten hemipelves) before implementation in a series of 20 patients with a mean age of 59 years (17 to 90), of whom 17 were male. The clinical evaluation was undertaken between December 2009 and December 2010. The quality of reduction was assessed with post-operative CT scans and the occurrence of intra-operative complications was noted. In cadavers, sufficient extraperitoneal access and safe instrumentation of the pelvis were accomplished. In the patients, there was a statistically significant improvement in the reduction of the fracture (pre- versus post-operative: mean step-off 3.3 mm (sd 2.6) vs 0.1 mm (sd 0.3), p < 0.001; and mean gap 11.5 mm (sd 6.5) vs 0.8 mm (sd 1.3), p < 0.001). Lesions to the peritoneum were noted in two patients and minor vascular damage was noted in a further two patients. Multi-directional screw placement and various plate configurations were feasible in cadavers without significant retraction of soft tissues.

In the treatment of acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach allowed anatomical restoration with minimal morbidity related to the surgical access.

We report the results of using a combination of fixator-assisted nailing with lengthening over an intramedullary nail in patients with tibial deformity and shortening. Between 1997 and 2007, 13 tibiae in nine patients with a mean age of 25.4 years (17 to 34) were treated with a unilateral external fixator for acute correction of deformity, followed by lengthening over an intramedullary nail with a circular external fixator applied at the same operating session. At the end of the distraction period locking screws were inserted through the intramedullary nail and the external fixator was removed.

The mean amount of lengthening was 5.9 cm (2 to 8). The mean time of external fixation was 90 days (38 to 265). The mean external fixation index was 15.8 days/cm (8.9 to 33.1) and the mean bone healing index was 38 days/cm (30 to 60).

One patient developed an equinus deformity which responded to stretching and bracing. Another developed a drop foot due to a compartment syndrome, which was treated by fasciotomy. It recovered in three months. Two patients required bone grafting for poor callus formation.

We conclude that the combination of fixator-assisted nailing with lengthening over an intramedullary nail can reduce the overall external fixation time and prevent fractures and deformity of the regenerated bone.

We report the use of a free vascularised iliac bone graft in the treatment of 21 patients (19 men and 2 women) with an avascular nonunion of the scaphoid in which conventional bone grafting had previously failed. The mean age of the patients was 32 years (23 to 46) and the dominant wrist was affected in 14. The mean interval from fracture to the vascularised bone grafting was 39 months (9 to 62). Pre-operative MRI showed no contrast enhancement in the proximal fragment in any patient. Fracture union was assessed radiologically or with CT scans if the radiological appearances were inconclusive.

At a mean follow-up of 5.6 years (2 to 11) union was obtained in 16 patients. The remaining five patients with a persistent nonunion continued to experience pain, reduced grip strength and limited range of wrist movement. In the successfully treated patients the grip strength and range of movement did not recover to match the uninjured side.

Prevention of progressive carpal collapse, the absence of donor site morbidity, good subjective results and pain relief, justifies this procedure in the treatment of recalcitrant nonunion of the scaphoid.

We reviewed 87 patients who underwent revision reconstruction of the anterior cruciate ligament. The incidence of meniscal tears and degenerative change was assessed and related to the interval between failure of the primary graft and revision reconstruction. Patients were divided into two groups: early revision surgery within six months of graft failure, and delayed revision. Degenerative change was scored using the French Society of Arthroscopy system.

There was a significantly higher incidence of articular cartilage degeneration in the delayed group (Mann-Whitney U-test, 53.2% vs 24%, p < 0.01). No patient in the early group had advanced degenerative change, compared to 9.2% of patients in the delayed group. There was no significant difference (Mann-Whitney U-test, p = 0.3) in the incidence of meniscal tears between the two groups.

We conclude that revision reconstruction should be carried out within six months of primary graft failure, in order to minimise the risk of degenerative change.

Lengthening of the humerus is now an established technique. We compared the complications of humeral lengthening with those of femoral lengthening and investigated whether or not the callus formation in the humerus proceeds at a higher rate than that in the femur. A total of 24 humeral and 24 femoral lengthenings were performed on 12 patients with achondroplasia. We measured the pixel value ratio (PVR) of the lengthened area on radiographs and each radiograph was analysed for the shape, type and density of the callus. The quality of life (QOL) of the patients after humeral lengthening was compared with that prior to surgery. The complication rate per segment of humerus and femur was 0.87% and 1.37%, respectively. In the humerus the PVR was significantly higher than that of the femur. Lower limbs were associated with an increased incidence of concave, lateral and central callus shapes. Humeral lengthening had a lower complication rate than lower-limb lengthening, and QOL increased significantly after humeral lengthening. Callus formation in the humerus during the distraction period proceeded at a significantly higher rate than that in the femur.

These findings indicate that humeral lengthening has an important role in the management of patients with achondroplasia.

Given the growing prevalence of obesity around the world and its association with osteoarthritis of the knee, orthopaedic surgeons need to be familiar with the management of the obese patient with degenerative knee pain. The precise mechanism by which obesity leads to osteoarthritis remains unknown, but is likely to be due to a combination of mechanical, humoral and genetic factors.

Weight loss has clear medical benefits for the obese patient and seems to be a logical way of relieving joint pain associated with degenerative arthritis. There are a variety of ways in which this may be done including diet and exercise, and treatment with drugs and bariatric surgery. Whether substantial weight loss can delay or even reverse the symptoms associated with osteoarthritis remains to be seen.

Surgery for osteoarthritis in the obese patient can be technically more challenging and carries a risk of additional complications. Substantial weight loss before undertaking total knee replacement is advisable. More prospective studies that evaluate the effect of significant weight loss on the evolution of symptomatic osteoarthritis of the knee are needed so that orthopaedic surgeons can treat this patient group appropriately.

We reviewed seven children with torticollis due to refractory atlanto-axial rotatory fixation who were treated in a halo vest. Pre-operative three-dimensional CT and sagittal CT imaging showed deformity of the superior articular process of C2 in all patients. The mean duration of halo vest treatment was 67 days (46 to 91). The mean follow-up was 34 months (8 to 73); at the latest review six patients demonstrated remodelling of the deformed articular process. The other child, who had a more severe deformity, required C1-2 fusion.

We suggest that patients with atlanto-axial rotatory fixation who do not respond to conservative treatment and who have deformity of the superior articular process of C2 should undergo manipulative reduction and halo-vest fixation for two to three months to induce remodelling of the deformed superior articular process before C1-2 fusion is considered.

The results of further soft-tissue release of 79 feet in 60 children with recurrent idiopathic congenital talipes equinovarus were evaluated. The mean age of the children at the time of re-operation was 5.8 years (15 months to 14.5 years). Soft-tissue release was performed in all 79 feet and combined with distal calcaneal excision in 52 feet. The mean follow-up was 12 years (4 to 32). At the latest follow-up the result was excellent or good in 61 feet (77%) according to the Ghanem and Seringe scoring system. The results was considered as fair in 14 feet (18%), all of whom had functional problems and eight had anatomical abnormalities. Four feet (5%) were graded as poor on both functional and anatomical grounds.

The results were independent of the age at which revision was undertaken.

We attempted to characterise the biological quality and regenerative potential of chondrocytes in osteochondritis dissecans (OCD). Dissected fragments from ten patients with OCD of the knee (mean age 27.8 years (16 to 49)) were harvested at arthroscopy. A sample of cartilage from the intercondylar notch was taken from the same joint and from the notch of ten patients with a traumatic cartilage defect (mean age 31.6 years (19 to 52)). Chondrocytes were extracted and subsequently cultured. Collagen types 1, 2, and 10 mRNA were quantified by polymerase chain reaction. Compared with the notch chondrocytes, cells from the dissecate expressed similar levels of collagen types 1 and 2 mRNA. The level of collagen type 10 message was 50 times lower after cell culture, indicating a loss of hypertrophic cells or genes. The high viability, retained capacity to differentiate and metabolic activity of the extracted cells suggests preservation of the intrinsic repair capability of these dissecates. Molecular analysis indicated a phenotypic modulation of the expanded dissecate chondrocytes towards a normal phenotype. Our findings suggest that cartilage taken from the dissecate can be reasonably used as a cell source for chondrocyte implantation procedures.

We describe the results of surgical treatment in a prospective study of 183 consecutive cases of subluxation (101) and dislocation (82) of the shoulder secondary to obstetric brachial plexus palsy between 1995 and 2000. Neurological recovery was rated ‘good’ or ‘useful’ in all children, whose lesions fell into groups 1, 2 or 3 of the Narakas classification. The mean age at operation was 47 months (3 to 204). The mean follow-up was 40 months (24 to 124).

The mean gain in function was 3.6 levels (9.4 to 13) using the Mallet score and 2 (2.1 to 4.1) on the Gilbert score. The mean active global range of shoulder movement was increased by 73°; the mean range of active lateral rotation by 58° and that of supination of the forearm by 51°. Active medial rotation was decreased by a mean of 10°. There were 20 failures. The functional outcome is related to the severity of the neurological lesion, the duration of the dislocation and onset of deformity.

The aim of this study was to determine whether the foundation programme for junior doctors, implemented across the United Kingdom in 2005, provides adequate training in musculoskeletal medicine. We recruited 112 doctors on completion of their foundation programme and assessed them using the Freedman and Bernstein musculoskeletal examination tool. Only 8.9% passed the assessment. Those with exposure to orthopaedics, with a career interest in orthopaedics, and who felt that they had gained adequate exposure to musculoskeletal medicine obtained significantly higher scores. Those interested in general practice as a career obtained significantly lower scores. Only 15% had any exposure to orthopaedics during the foundation programme and only 13% felt they had adequate exposure to musculoskeletal medicine. The foundation programme currently provides inadequate training in musculoskeletal medicine. The quality and quantity of exposure to musculoskeletal medicine during the foundation programme must be improved.

There is no simple method available to identify patients who will develop recurrent instability after an arthroscopic Bankart procedure and who would be better served by an open operation.

We carried out a prospective case-control study of 131 consecutive unselected patients with recurrent anterior shoulder instability who underwent this procedure using suture anchors. At follow-up after a mean of 31.2 months (24 to 52) 19 (14.5%) had recurrent instability. The following risk factors were identified: patient age under 20 years at the time of surgery; involvement in competitive or contact sports or those involving forced overhead activity; shoulder hyperlaxity; a Hill-Sachs lesion present on an anteroposterior radiograph of the shoulder in external rotation and/or loss of the sclerotic inferior glenoid contour.

These factors were integrated in a 10-point pre-operative instability severity index score and tested retrospectively on the same population. Patients with a score over 6 points had an unacceptable recurrence risk of 70% (p < 0.001). On this basis we believe that an arthroscopic Bankart repair is contraindicated in these patients, to whom we now suggest a Bristow-Latarjet procedure instead.

Since the Oxford knee was first used unicompartmentally in 1982, a small number of bearings have fractured. Of 14 retrieved bearings, we examined ten samples with known durations in situ (four Phase 1, four Phase 2 and two Phase 3). Evidence of impingement and associated abnormally high wear (> 0.05 mm per year) as well as oxidation was observed in all bearings. In four samples the fracture was associated with the posterior radio-opaque wire. Fracture surfaces indicated fatigue failure, and scanning electron microscopy suggested that the crack initiated in the thinnest region. The estimated incidence of fracture was 3.20% for Phase 1, 0.74% for Phase 2, 0.35% for Phase 3, and 0% for Phase 3 without the posterior marker wire. The important aetiological factors for bearing fracture are impingement leading to high wear, oxidation, and the posterior marker wire. With improved surgical technique, impingement and high wear should be prevented and modern polyethylene may reduce the oxidation risk. A posterior marker wire is no longer used in the polyethylene meniscus. Therefore, the rate of fracture, which is now very low, should be reduced to a negligible level.

We assessed the reliability, accuracy and variability of closed-wedge high tibial osteotomy (HTO) using computer-assisted surgery compared to the conventional technique. A total of 50 closed-wedge HTO procedures were performed using the navigation system, and compared with 50 HTOs that had been performed with the conventional technique. In the navigation group, the mean mechanical axis prior to osteotomy was varus 8.2°, and the mean mechanical axis following fixation was valgus 3.6°. On the radiographs the mean pre-operative mechanical axis was varus 7.3°, and the mean post-operative mechanical axis was valgus 2.1°. There was a positive correlation between the measured data taken under navigation and by radiographs (r > 0.3, p < 0.05). The mean correction angle was significantly more accurate in the navigation group (p < 0.002). The variability of the correction was significantly lower in the navigation group (2.3° vs 3.7°, p = 0,012). We conclude that navigation provides reliable real-time intra-operative information, may increase accuracy, and improves the precision of a closed-wedge HTO.

The Essex-Lopresti injury is rare. It consists of fracture of the head of the radius, rupture of the interosseous membrane and disruption of the distal radioulnar joint. The injury is often missed because attention is directed towards the fracture of the head of the radius. We present a series of 12 patients with a mean age of 44.9 years (26 to 54), 11 of whom were treated surgically at a mean of 4.6 months (1 to 16) after injury and the other after 18 years. They were followed up for a mean of 29.2 months (2 to 69). Ten patients had additional injuries to the forearm or wrist, which made diagnosis more difficult. Replacement of the head of the radius was carried out in ten patients and the Sauve-Kapandji procedure in three. Patients were assessed using standard outcome scores. The mean post-operative Disabilities of the Arm, Shoulder and Hand score was 55 (37 to 83), the mean Morrey Elbow Performance score was 72.2 (39 to 92) and the mean Mayo wrist score was 61.3 (35 to 80). The mean grip strength was 68.5% (39.6% to 91.3%) of the unaffected wrist.

Most of the patients (10 of 12) were satisfied with their operation and in 11 the pain was relieved. When treating the chronic Essex-Lopresti injury, we recommend accurate realignment of the radius and ulna and replacement of the head of the radius. If this fails a Sauve-Kapandji procedure to arthrodese the distal radioulnar joint should be undertaken to stabilise the forearm while maintaining mobility.