We have reviewed 22 patients at a mean of 30 years (28 to 31) after a whiplash injury. A complete recovery had been made in ten (45.5%) while one continued to describe severe symptoms. Persistent disability was associated with psychological distress but both improved in the period between 15 and 30 years after injury. After 30 years, ten patients (45.5%) were more disabled by knee than by neck pain.

This review discusses the causes, outcome and prevention of whiplash injury, which costs the economy of the United Kingdom approximately £3.64 billion per annum. Most cases occur as the result of rear-end vehicle collisions at speeds of less than 14 mph. Patients present with neck pain and stiffness, occipital headache, thoracolumbar back pain and upper-limb pain and paraesthesia. Over 66% make a full recovery and 2% are permanently disabled. The outcome can be predicted in 70% after three months.

Of 586 employed patients with a whiplash injury 40 (7%) did not return to work. The risk was increased by three times in heavy manual workers, two and a half times in patients with prior psychological symptoms and doubled for each increase of grade of disability. The length of time off work doubled in patients with a psychological history and trebled for each increase in grade of disability. The self-employed were half as likely to take time off work, but recovered significantly more slowly than employees.

We studied 50 consecutive patients presenting at an accident department after rear-end vehicle collisions and recorded symptoms and psychological test scores within one week of injury, at three months and at two years. The range of neck movement was noted at three months.

Within one week of injury, psychological test scores were normal in 82% of the group but became abnormal in 81% of the patients with intrusive or disabling symptoms at over three months (p < 0.001) and remained abnormal in 69% at two years. The clinical outcome after two years could be predicted at three months with 76% accuracy by neck stiffness, 74% by psychological score and 82% by a combination of these variables.

The severity of symptoms after a whiplash injury is related both to the physical restriction of neck movement and to psychological disorder. The latter becomes established within three months of the injury.

In previous randomised clinical trials of thromboprophylaxis after total hip replacement, low-molecular-weight heparin has been given for an arbitrary 7 to 14 days. The risk factors are mainly perioperative and it is possible that a shorter course may be adequate. We assessed the safety and effectiveness of a three-day course. We assessed 156 primary THR patients after randomisation to either a control group or to receive enoxaparin at 12 hours preoperatively and 12 and 36 hours postoperatively. Thrombosis was diagnosed by routine venography. Haemorrhagic side-effects were assessed by measurement of blood loss, and soft-tissue side-effects by descriptive scores for wound discharge and bruising of the leg. The prevalence of calf thrombosis was 15.4% in the enoxaparin group and 32.1% in the control group (p = 0.01); the prevalence of proximal thrombosis was 15.4% and 17.9% respectively (not significant). There was no difference in haemorrhagic side-effects or wound discharge, but there was more bruising in the enoxaparin group.

We studied 1162 consecutive total hip replacements (THR) to establish the incidence of fatal pulmonary embolism (PE), clinical non-fatal PE and deep-vein thrombosis (DVT) in the six months after surgery. Chemical thromboprophylaxis had not been routinely used. We used a validated questionnaire supplemented by post-mortem records and a review of the clinical notes. Follow-up was 100%. The death rate from PE was 0.34% (95% CI 0.09 to 0.88), with one fatal PE after discharge 40 days after operation. The clinical PE rate confirmed by imaging was 1.20% (CI 0.65 to 2.02), with 0.7% of patients readmitted. The venographically-confirmed clinical DVT rate was 1.89% (CI 1.11 to 2.76), with 1.13% readmitted. The total thromboembolic morbidity was 3.4% (95% CI 2.5% to 4.7%); prophylaxis to reduce this would be justifiable if the complications of such prophylaxis did not produce an alternative morbidity. The fatal PE rate after THR without routine chemical prophylaxis was low; a very large randomised clinical trial would be required to demonstrate directly whether any prophylactic measure could reduce this. There is a large discrepancy between the high DVT rate reported in clinical trials using universal screening venography and the symptomatic DVT rate shown in this study. We found insufficient evidence to recommend continuing thromboprophylaxis after discharge from hospital.

We examined ten femoral veins with duplex ultrasound during total hip replacement to demonstrate the operative manoeuvres which cause venous obstruction and to assess prophylactic measures which may overcome it. Exposure of the acetabulum by distraction of the femur with a hook was less likely to occlude flow than retraction with bone levers. Adequate exposure of the femoral shaft by adduction, flexion and either internal or external rotation caused cessation of flow in all cases. In four cases an A-V Impulse System foot pump was activated during periods of stasis. In each case it overcame the obstruction and produced peak velocities which were twice that of the resting state. In five cases, towards the end of the procedure, debris was seen travelling proximally through the femoral vein.

We modelled a 'clean' surgical wound lightly contaminated with airborne bacteria, using agar, ovine muscle and ovine adipose tissue. This was used to assess the effect on bacteria of ultraviolet C light (UVC) 1200 mu W/cm2, hydrogen peroxide 3%, povidone-iodine 1% and 10%, chlorhexidine 0.05%, pulsed jet lavage with UVC and syringe and needle lavage with chlorhexidine 0.05%. All the agents were effective on agar, but mixing with blood or plasma neutralised hydrogen peroxide and povidone-iodine 1%. All the agents were less effective on tissue specimens than on agar, but were more effective on adipose tissue than on muscle. All the antiseptics except chlorhexidine were less effective when blood or plasma was added to muscle specimens before disinfection. UVC after pulsed jet lavage had an additive effect. Syringe and needle lavage with chlorhexidine 0.05% was the most effective method tested; it reduced colony counts by 99.8% and warrants clinical investigation.

We studied the effects of nine techniques of bone surface preparation on cement penetration and shear strength at the cement-bone interface in a standard model of bovine cancellous bone. In unprepared bone the mean penetration was 0.2 mm and the mean shear strength of the interface was 1.9 MPa, less than that of the underlying bone. Brushing with surface irrigation gave mean penetrations of 0.6 to 1.4 mm and mean shear strengths of 1.5 to 9.9 MPa. In 50% of specimens the interface was weaker than the underlying bone. The use of pressurised lavage resulted in mean penetrations of 4.8 to 7.9 mm and mean shear strengths of 26.5 to 36.1 MPa, which were greater than those of the cancellous bone in all specimens. Pressurised lavage was equally effective alone or in combination with brushing, and its efficacy was not altered by using pulsed or continuous jets, or by changing the temperature of the solution from 21 degrees C to 37 degrees C.

We reviewed 43 patients who had sustained soft-tissue injuries of the neck after a mean 10.8 years. Of these, only 12% had recovered completely. Residual symptoms were intrusive in 28% and severe in 12%. Pain in the neck and lower back was the commonest complaint and older patients had a worse prognosis. After two years, symptoms did not alter with further passage of time.

Bleeding from cancellous bone causes lamination within bone cement and at its prosthetic interfaces, and weakens the fixation of joint replacements. We examined the effects of anaesthesia and blood pressure on bleeding in human cancellous bone, and investigated the local response to freezing saline, 1:200,000 adrenaline and hydrogen peroxide. Spinal anaesthesia reduced cancellous bleeding by an average of 44%, local freezing saline by 24%. Saline at room temperature, adrenaline solution and hydrogen peroxide each reduced it by 14%. The effects of spinal anaesthesia and of freezing saline were additive: used together they reduced bleeding by 56%. The reduction of blood contamination of cement and its interfaces should contribute to better prosthetic fixation.

We have reviewed 107 patients of 80 years or over who underwent primary total hip replacement. They had many more complications than younger patients. Thus, acute dislocation occurred in 15%, and became chronic in 9%; there were femoral shaft fractures in 4.6% and these, with shaft perforation gave universally poor results. Nevertheless, 75% of patients had a satisfactory outcome, with worthwhile relief of pain. It would seem sensible to warn elderly patients and their relatives of the increased risks in this age group.

In a prospective study, 60 patients with acute acromioclavicular dislocation were randomly allocated to treatment with a broad arm sling or to reduction and fixation with a coracoclavicular screw. Of these 54 were followed for four years. Conservatively-treated patients regained movement significantly more quickly and fully, returned to work and sport earlier and had fewer unsatisfactory results than those having early operation. For severe dislocations, with acromioclavicular displacement of 2 cm or more, early surgery produced better results. Conservative management is best for most acute dislocations, but younger patients with severe displacement may benefit from early reduction and stabilisation.

Antibiotic levels in bone and fat were measured in patients undergoing knee replacement to determine the time that should elapse between intravenous injection and tourniquet inflation. The tissue levels increased progressively with time, and there was wide variation in absorption rate between patients and between the two cephalosporins assessed. Five minutes should probably be left between systemic injection and inflation of the tourniquet, though two minutes may be long enough for drugs which are rapidly absorbed.

In order to define the predisposing factors and outcome of infected arthroplasty of the knee, a retrospective analysis of a consecutive series of 471 knee arthroplasties was performed. There were 23 cases of superficial wound infection and 25 of deep infection. Superficial wound infection alone resulted in a painfree gait, with little limitation of movement. Rheumatoid arthritis, the use of constrained prostheses and the presence of a superficial wound infection, all predisposed to deep infection. Deep infection was eradicated by long-term antibiotics in only two patients in whom skin cover was successfully provided by a gastrocnemius musculocutaneous flap. Excision of a sinus track, wound debridement and exchange arthroplasty were universally unsuccessful. Arthrodesis, however, in 11 out of 12 cases, provided the painfree gait these patients desire.