Aims

The importance of accurate identification and reporting of surgical site infection (SSI) is well recognised but poorly defined. Public Health England (PHE) mandated collection of orthopaedic SSI data in 2004. Data submission is required in one of four categories (hip prosthesis, knee prosthesis, repair of neck of femur, reduction of long bone fracture) for one quarter per year. Trusts are encouraged to carry out post-discharge surveillance but this is not mandatory. Recent papers in the orthopaedic literature have highlighted the importance of SSI surveillance and the heterogeneity of surveillance methods. However, details of current orthopaedic SSI surveillance practice has not been described or quantified.

We reviewed 40 patients treated surgically for lumbar stenosis at an average time of 8.6 years after operation. In 32, total laminectomy had been performed and in eight bilateral laminotomy, both at one or more levels. Of the 16 patients with degenerative spondylolisthesis, ten had had a concomitant spinal fusion. Patients were assigned to one of four groups according to the amount of bone regrowth: group 0 had no regrowth and groups I, II, and III, had mild, moderate or marked regrowth, respectively. Only 12% of the patients showed no bone regrowth; 48% were assigned to group I, 28% to group II and 12% to group III. Imaging studies showed varying degrees of recurrent stenosis in patients with moderate or marked bone regrowth. All patients with degenerative spondylolisthesis showed bone regrowth, which was more severe in those who had not had a fusion. The clinical results were satisfactory in most of the patients with mild or no bone regrowth and significantly less good in those with moderate or marked regrowth. In the group with degenerative spondylolisthesis, the proportion of satisfactory results was significantly higher in patients who had had spinal fusion. The long-term results of surgery for lumbar stenosis depend both upon the amount of bone regrowth and the degree of postoperative vertebral stability

Traumatic tenosynovitis of the wrist extensors is a common and disabling condition associated with overuse. It has been found to be associated with hypertrophy of the bellies of abductor pollicis longus and extensor pollicis brevis where they overlie the radial extensor tendons in the forearm, compressing these tendons and their enveloping paratenons against the deep structures beneath. Simple surgical decompression of the sheath of these overlying muscles has been found to give quick relief of symptoms and to allow a more rapid return to strenuous work than the conservative treatments usually employed

We examined biopsy specimens obtained during surgery on 115 patients with complete rotator cuff rupture. The vascularised connective tissue covering the area of rupture and the proliferating cells in the fragmented tendons reflected more of the features of repair than of degeneration and necrosis. The main source of this fibrovascular tissue was the wall of the subacromial bursa. These features clearly indicated a vigorous reparative response which might play an important role in tendon reconstitution and remodelling. We therefore suggest that extensive debridement along with subtotal bursectomy, commonly practised during surgical repair of rotator cuff rupture, should be avoided. Although strong suture margins are essential for good operative results, debridement should be judicious and preserve as much as possible of the bursa and the associated fibrovascular tissue

We have retrospectively reviewed the clinical and radiological results in 204 consecutive adult patients who had surgical correction of 70 late post-traumatic pelvic nonunions and 134 malalignments. The deformed pelvises were subdivided into united (true), unstable, ununited, and partially stable malalignments with heterotopic bone. The principal complaints were of pain, pelvic instability, sitting imbalance, and apparent limb-length discrepancy. After surgery, 195 patients (96%) achieved a primary union and 144 (71%) had slight, intermittent or no pelvic pain, while pelvic instability was entirely eliminated. Overall, 131 patients (64.2%) were extremely satisfied, 58 (28.4%) were satisfied and 15 (7.4%) were unsatisfied. After reconstruction of the malaligned pelvises, 67 results (50%) were anatomical, 47 (35%) were satisfactory and 20 (15%) were unsatisfactory. For a pelvic nonunion with local osteopenia and malalignment, stabilisation of all three pelvic columns is recommended. True pelvic (united) malunions were the most satisfactorily realigned and had the fewest complications. Ununited and unstable malalignments, especially those with heterotopic bone, had the poorest corrections and the most neurological complications. A therapeutic alternative, by the local resection of a symptomatic bony prominence, and fixation in situ of a posterior pelvic nonunion, gives highly effective symptomatic relief with fewer complications. Despite this, many patients had persistent low back pain

The clinical and radiological state of the hips of a group of children with cerebral palsy treated without operation is compared with that in a group treated by operation to correct adduction and flexion deformity and to obtain balanced action in the hip muscles. In the first group, 11 per cent of hips were dislocated, 28 per cent subluxated, 46 per cent dysplastic and 15 per cent normal. In the second group no hip was dislocated, 13 per cent were subluxated, 35 per cent dysplastic and 52 per cent normal. Surgical intervention is indicated clinically for a range of abduction diminishing to less than 45 degrees and–on radiological criteria–for early dysplastic changes, especially a break in Shenton's line, irrespective of the patient's age, severity of involvement or neurological maturity. Prevention of subluxation or dislocation improves function and diminishes the liability to develop a painful hip in adolescence or early adult life

At The Hospital for Sick Children in Toronto, 21 undescended scapulae were corrected by the Woodward procedure in 20 patients over the past 18 years. The average age at operation was six years six months. The average follow-up period after operation was 8 years 9 months. Fifteen patients were girls and five were boys. All the patients had other associated abnormalities. Only one patient had a concomitant clavicular osteotomy. The average increase in glenohumeral abduction was 37 degrees. The average scapular lowering was two centimetres. Excellent or good cosmetic results were obtained in 80 per cent of patients. Ninety-three per cent of patients expressed satisfaction with the operative results. Complications were few. The Woodward procedure is a safe and relatively straightforward surgical means to effect a good cosmetic and functional improvement in a patient with a congenital undescended scapula. We do not recommend clavicular osteotomy as a routine, but it may be added to gain more correction with less risk of neurovascular compression

A staged method of surgical management for congenital talipes equinovarus is described. The hindfoot was corrected and rebalanced early in 125 feet, and in 66 feet a second-stage medial forefoot correction was performed in the second, third or fourth year. The hindfoot relapsed in 19% and the forefoot in 9%; these feet were treated by further soft-tissue surgery. No bony operation was necessary. Assessment before and after operation allows comparison with other series

Tibial grafts in rabbits were studied using a microscopic technique in vivo that made it possible to photograph the "graft to be" at the donor site and then subsequently to observe the same graft repeatedly at the host site. With this method the effects on the graft tissues of varying degrees of surgical trauma have been tested. The period of follow-up ranged between 14 and 300 days. The grafts removed with minimal trauma showed a more rapid rapid of revascularisation. In this group the first vessels appeared on average seven days after grafting, whereas they took 15 days in the grafts which were more severely traumatised. Bone remodelling started when the vascular density resembled the more pattern and this occurred earlier and much more rapidly in the minimally injured grafts. It correlated with the presence of surviving cells, as shown by histochemical tests, and a causal relationship is suggested. It is concluded that control of trauma is important not only in the preparation of the host bed but also in procurement of the graft. Suggestions are given on techniques to minimise the surgical trauma

A review is presented of 41 patients with traumatic tetraplegia on whom reconstructive surgery of the upper limb was carried out. Twelve patients were followed up for more than 10 years after operation and the average period overall was seven and a half years. Tendon transfers were made with the aim of providing extension of the elbow or restoring a useful grasp or a combination of both. The assessment was carried out on four main aspects: the function of the elbow, the function of the hand, the ability to carry out the activities of daily living and the effect of the surgical reconstruction on the personal and social achievement of the patient

We examined soft tissue biopsies from 26 patients with symptomatic nerve root fibrosis and arachnoiditis after a previous laminectomy. Dense fibrous connective tissue was found about the nerve roots and in 14 cases (55%) fibrillar foreign material was seen within it. This material had the histochemical characteristics of cotton fibres from swabs and neurosurgical patties. In two other cases nerve root fibrosis was associated with residual radiopaque lipid thought to derive from earlier myelography. Our findings suggest that risks may be associated with the introduction of foreign material into the vertebral canal, and that microscopic fragments of surgical swabs and patties may have a role in the pathogenesis of postoperative periradicular fibrosis

Heterotopic ossification (HO) of the hip after injury to the central nervous system can lead to joint ankylosis. Surgery is usually delayed to avoid recurrence, even if the functional status is affected. We report a consecutive series of patients with HO of the hip after injury to the central nervous system who required surgery in a single, specialised tertiary referral unit. As was usual practice, they all underwent CT to determine the location of the HO and to evaluate the density of the femoral head and articular surface. The outcome of surgery was correlated with the pre-, peri- and post-operative findings. In all, 183 hips (143 patients) were included of which 70 were ankylosed. A total of 25 peri-operative fractures of the femoral neck occurred, all of which arose in patients with ankylosed hips and were associated with intra-articular lesions in 18 and severe osteopenia of the femoral head in seven. All the intra-articular lesions were predicted by CT and strongly associated with post-operative complications. The loss of the range of movement before ankylosis is a more important factor than the maturity of the HO in deciding the timing of surgery. Early surgical intervention minimises the development of intra-articular pathology, osteoporosis and the resultant complications without increasing the risk of recurrence of HO

Aims

The aims of this study were to estimate the cost of surgical treatment of fractures of the proximal humerus using a micro-costing methodology, contrast this cost with the national reimbursement tariff and establish the major determinants of cost.

Death during the first year after hip fracture may be influenced by the type of hospital in which patients are treated as well as the time spent awaiting surgery. We studied 57 315 hip fracture patients who were admitted to hospital in Ontario, Canada. Patients treated in teaching hospitals had a decreased risk of in-hospital mortality (odds ratio (OR) 0.89; 95% confidence interval (CI) 0.83 to 0.97) compared with those treated in urban community institutions. There was a trend toward increased mortality in rural rather than urban community hospitals. In-hospital mortality increased as the surgical delay increased (OR 1.13; 95% CI 1.10 to 1.16) for a one-day delay and higher (OR 1.60; 95% CI 1.42 to 1.80) for delays of more than two days. This relationship was strongest for patients younger than 70 years of age and with no comorbidities but was independent of hospital status. Similar relationships were seen at three months and one year after surgery. This suggests that any delay to surgery for non-medical reasons is detrimental to a patient’s outcome

Aim

Mesenchymal stem cells (MSCs) have several properties that may support their use as an early treatment option for osteoarthritis (OA). This study investigated the role of multiple injections of allogeneic bone marrow-derived stem cells (BMSCs) to alleviate the progression of osteoarthritic changes in the various structures of the mature rabbit knee in an anterior cruciate ligament (ACL)-deficient OA model.

Aims

The aims of this study were to determine the cumulative ten-year survivorship of hips treated for acetabular fractures using surgical hip dislocation and to identify factors predictive of an unfavourable outcome.

Between 1985 and 1998, 12 331 patients were included in the general neonatal ultrasound hip screening programme for developmental dysplasia of the hip (DDH). Patients who needed treatment (604) were compared with a second group of 73 unscreened children treated conservatively and surgically for DDH. The incidence of Graf sonographic hip types IIc to IV varied throughout the observation period. Femoral and pelvic osteotomies were almost entirely restricted to the unscreened group of patients. The six to ten per year recorded in the period 1985 to 1990 declined subsequently to three or less per year. The yearly admissions to hospital fell noticeably after six years of screening. Late presentations of DDH were reduced to three or less per year from 1990 to 1994, none between 1995 and 1998 and one or two per year from 2000. We conclude that general neonatal sonographic hip screening can reduce significantly surgical procedures, hospitalisation and late presentation of DDH

We reviewed the outcome in 24 children with bilateral spastic cerebral palsy aged seven years or younger for whom surgery was recommended between 1999 and 2005 following gait analysis. A total of 13 children (operative group) had surgery and the remaining 11 (control group) did not, for family or administrative reasons. The operative group had at least two post-operative gait analyses at yearly intervals, with eight children having a third and six children a fourth. The control group had a second analysis after a mean interval of 1.5 years (95% confidence interval 1.1 to 1.9). In the operative group, the Gillette gait index, the ranges of movement in the lower limb joint and knee extension in stance improved following surgery, and this was maintained overall at the second post-operative analysis. The minimum knee flexion in stance in the control group increased between analyses. These results suggest that surgical intervention in selected children can result in improvements in gait and function in the short to medium term compared with non-operative management

A comprehensive review of the literature relating to the pathology and management of the diabetic foot is presented. This should provide a guide for the treatment of ulcers, Charcot neuro-arthropathy and fractures involving the foot and ankle in diabetic patients.