Aims

The primary aim of this study was to evaluate the performance and safety of magnetically controlled growth rods in the treatment of early onset scoliosis. Secondary aims were to evaluate the clinical outcome, the rate of further surgery, the rate of complications, and the durability of correction.

Aims

Magnetically controlled growing rods (MCGRs) allow non-invasive correction of the spinal deformity in the treatment of early-onset scoliosis. Conventional growing rod systems (CGRS) need repeated surgical distractions: these are associated with the effect of the ‘law of diminishing returns’.

The primary aim of this study was to quantify this effect in MCGRs over sequential distractions.

Aims

We undertook a prospective non-randomised radiological study to evaluate the preliminary results of using magnetically-controlled growing rods (MAGEC System, Ellipse technology) to treat children with early-onset scoliosis.

We assessed the frequency and causes of neurological deterioration in 59 patients with spinal cord injury on whom reports were prepared for clinical negligence litigation. In those who deteriorated neurologically we assessed the causes of the change in neurology and whether that neurological deterioration was potentially preventable. In all 27 patients (46%) changed neurologically, 20 patients (74% of those who deteriorated) had no primary neurological deficit. Of those who deteriorated, 13 (48%) became Frankel A. Neurological deterioration occurred in 23 of 38 patients (61%) with unstable fractures and/or dislocations; all 23 patients probably deteriorated either because of failures to immobilise the spine or because of inappropriate removal of spinal immobilisation. Of the 27 patients who altered neurologically, neurological deterioration was, probably, avoidable in 25 (excess movement in 23 patients with unstable injuries, failure to evacuate an epidural haematoma in one patient and over-distraction following manipulation of the cervical spine in one patient). If existing guidelines and standards for the management of actual or potential spinal cord injury had been followed, neurological deterioration would have been prevented in 25 of the 27 patients (93%) who experienced a deterioration in their neurological status.

Cite this article: Bone Joint J 2015;97-B:527–31.

This study reports the clinical and sonographic outcome of arthroscopic rotator cuff repair in patients aged ≥ 70 years and aimed to determine factors associated with re-tear. A total of 69 consecutive repairs were performed in 68 patients with a mean age of 77 years (70 to 86). Constant-Murley scores were collected pre-operatively and at one year post-operatively. The integrity of the repair was assessed using ultrasound. Re-tear was detected in 20 of 62 patients (32%) assessed with ultrasound. Age at operation was significantly associated with re-tear free survival (p = 0.016). The mean pre-operative Constant score was 23 (sd 14), which increased to 58 (sd 20) at one year post-operatively (paired t-test, p < 0.001). Male gender was significantly associated with a higher score at one year (p = 0.019).

We conclude that arthroscopic rotator cuff repair in patients aged ≥ 70 years is a successful procedure. The gender and age of the patient are important factors to consider when planning management.

Cite this article: Bone Joint J 2013;95-B:199–205.

Compression and absolute stability are important in the management of intra-articular fractures. We compared tension band wiring with plate fixation for the treatment of fractures of the olecranon by measuring compression within the fracture. Identical transverse fractures were created in models of the ulna. Tension band wires were applied to ten fractures and ten were fixed with Acumed plates. Compression was measured using a Tekscan force transducer within the fracture gap. Dynamic testing was carried out by reproducing cyclical contraction of the triceps of 20 N and of the brachialis of 10 N. Both methods were tested on each sample. Paired t-tests compared overall compression and compression at the articular side of the fracture.

The mean compression for plating was 819 N (sd 602, 95% confidence interval (CI)) and for tension band wiring was 77 N (sd 19, 95% CI) (p = 0.039). The mean compression on the articular side of the fracture for plating was 343 N (sd 276, 95% CI) and for tension band wiring was 1 N (sd 2, 95% CI) (p = 0.038).

During simulated movements, the mean compression was reduced in both groups, with tension band wiring at −14 N (sd 7) and for plating −173 N (sd 32). No increase in compression on the articular side was detected in the tension band wiring group.

Pre-contoured plates provide significantly greater compression than tension bands in the treatment of transverse fractures of the olecranon, both over the whole fracture and specifically at the articular side of the fracture. In tension band wiring the overall compression was reduced and articular compression remained negligible during simulated contraction of the triceps, challenging the tension band principle.

Low-energy fractures of the proximal humerus indicate osteoporosis and it is important to direct treatment to this group of patients who are at high risk of further fracture. Data were prospectively collected from 79 patients (11 men, 68 women) with a mean age of 69 years (55 to 86) with fractures of the proximal humerus in order to determine if current guidelines on the measurement of the bone mineral density at the hip and lumbar spine were adequate to stratify the risk and to guide the treatment of osteoporosis. Bone mineral density measurements were made by dual-energy x-ray absorptiometry at the proximal femur, lumbar spine (L2-4) and contralateral distal radius, and the T-scores were generated for comparison. Data were also collected on the use of steroids, smoking, the use of alcohol, hand dominance and comorbidity.

The mean T-score for the distal radius was −2.97 (sd 1.56) compared with −1.61 (sd 1.62) for the lumbar spine and −1.78 (sd 1.33) for the femur. There was a significant difference between the mean lumbar and radial T scores (1.36 (1.03 to 1.68); p < 0.001) and between the mean femoral and radial T-scores (1.18 (0.92 to 1.44); p < 0.001). The inclusion of all three sites in the determination of the T-score increased the sensitivity to 66% compared with that of 46% when only the proximal femur and lumbar spine were used. This difference between measurements in the upper limb compared with the axial skeleton and lower limb suggests that basing risk assessment and treatment on only the bone mineral density taken at the hip or lumbar spine may misrepresent the extent of osteoporosis in the upper limb and the subsequent risk of fracture at this site.

The assessment of osteoporosis must include measurement of the bone mineral density at the distal radius to avoid underestimation of osteoporosis in the upper limb.

National guidelines state that in patients undergoing operations the site of the procedure should be marked. In clinical practice the same marker is used repeatedly. We are not aware of any investigation regarding the theoretical risk of transferring organisms such as methicillin-resistant Staphyloccocus aureus (MRSA) between patients by a skin marker.

In an experimental setting, Penflex and Viomedex skin markers were tested 30 times each after contaminating them with a standard inoculum of MRSA. The survival of the organism on the tip of the markers was assessed by culture on MRSA-indicator nutrient agar plates at 0, 5, 15 and 60 minutes, 24 and 48 hours and at 1, 2, and 3 weeks after contamination.

There was a significant difference between the markers, with the Penflex showing no survival of MRSA after 15 minutes whereas the Viomedex product continued to produce MRSA cultures for up to three weeks.

We wished to estimate the incidence of surgical-site infection (SSI) after total hip replacement (THR) and hemiarthroplasty and its strength of association with major risk factors. The SSI surveillance service prospectively gathered clinical, operative and infection data on inpatients from 102 hospitals in England during a four-year period.

The overall incidence of SSI was 2.23% for 16 291 THRs, 4.97% for 5769 hemiarthroplasty procedures, 3.68% for 2550 revision THRs and 7.6% for 198 revision hemiarthroplasties. Staphylococcus aureus was identified in 50% of SSIs; 59% of these isolates were methicillin-resistant (MRSA). In the single variable analysis of THRs, age, female gender, American Society of Anesthesiologists (ASA) score, body mass index, trauma, duration of operation and pre-operative stay were significantly associated with the risk of SSI (p < 0.05). For hemiarthroplasty, the ASA score and age were significant factors. In revision THRs male gender, ASA score, trauma, wound class, duration of operation and pre-operative stay were significant risk factors. The median time to detection of SSI was eight days for superficial incisional, 11 days for deep incisional and 11 days for joint/bone infections. For each procedure the mean length of stay doubled for patients with SSI. The multivariate analysis identified age group, trauma, duration of operation and ASA score as significant, independent risk factors for SSI. There was significant interhospital variation in the rates of SSI. MRSA was the most common pathogen to cause SSI in hip arthroplasty, especially in patients undergoing hemiarthroplasty, but coagulase-negative Staph. aureus may be more important in deep infections involving the joint.

We have assessed whether an epidural steroid injection is effective in the treatment of symptoms due to compression of a nerve root in the lumbar spine by carrying out a prospective, randomised, controlled trial in which patients received either an epidural steroid injection or an intramuscular injection of local anaesthetic and steroid. We assessed a total of 93 patients according to the Oxford pain chart and the Oswestry disability index and followed up for a minimum of two years. All the patients had been categorised as potential candidates for surgery.

There was a significant reduction in pain early on in those having an epidural steroid injection but no difference in the long term between the two groups. The rate of subsequent operation in the groups was similar.

Instability may present at a different level after successful stabilisation of an unstable segment in apparently isolated injuries of the cervical spine. It can give rise to progressive deformity or symptoms which require further treatment. We performed one or more operations for unstable cervical spinal injuries on 121 patients over a period of 90 months. Of these, five were identified as having instability due to an initially unrecognised fracture-subluxation at a different level. We present the details of these five patients and discuss the problems associated with their diagnosis and treatment.

We used a rabbit model to investigate the mechanism by which the angulation of fractures is corrected in children. We produced a transverse proximal tibial fracture in one leg of 12 eight-week-old New Zealand white rabbits and measured bone alignment and length and the patterns of bone growth and remodelling.

The angle between the joint surfaces changed rapidly to correct the alignment of the limb as a result of asymmetrical growth of epiphyseal plates. In an adult with closed plates, the angle between the joint surfaces cannot therefore improve. The angle at the fracture itself showed slow improvement because of bone drift and the asymmetrical growth of the epiphyseal plates. Remodelling corrected the shape of the bone in the region of the fracture.

Periosteal division on the convex side increased the growth of the epiphyseal plate on that side, thus slowing the correction. The effect was relatively small, providing an indication that factors other than the periosteum are important in inducing correction.

External torsional deformities developed because of helical growth at the plate. This was probably caused by abnormal posture which induced a torque at the growth plate. Helical growth is the mechanism by which rotational deformities can occur and correct.

We reviewed the results of 545 consecutive total hip replacements using a cementless non-coated high-density polyethylene acetabular component combined with a cemented Muller stem at five to 10 years. In all, 421 patients (445 hips) were available for review, 118 by questionnaire and 303 by examination and radiography. Of these, 86% had a good or excellent result. We found a high rate of radiological loosening of the cup after the sixth year, and a high rate of clinical loosening after the eighth year. Loosening was commoner in women, in younger patients and where a smaller size of acetabulum had been used. Calcar resorption was significantly related to loosening of the acetabulum. Loosening appeared to be mainly due to polyethylene debris produced by micro-movement of the acetabulum against the bone, which had resulted in a giant cell foreign body reaction and subsequent bone erosion. We have abandoned the use of this prosthesis and suggest that direct contact between bone and polyethylene should be prevented by a coating of metal or some other material.

We subjected the proximal tibial growth plates of six-week-old rabbits to either compression or distraction of 1 kg on both legs. On one side the proximal tibial periosteum was divided circumferentially and stripped for 1 cm. After six weeks, growth was measured at both proximal and distal growth plates. Compression inhibited total tibial growth and distraction enhanced it. The compressed growth plate grew less and the distracted growth plate grew more, but there was a reciprocal change at the other end of the bone. Periosteal division enhanced growth at the adjacent growth plate but inhibited it distally; the effect of distraction was enhanced and that of compression reduced. We found reciprocal growth rates at the proximal and distal growth plates. Relatively small amounts of compression or distraction did affect total bone growth. Periosteal division appeared to induce overgrowth at least partly by a mechanical effect; it may be useful as an adjunct to other methods of leg lengthening, though not to epiphyseolysis.

Endoprosthetic replacement of the proximal humerus has been performed in our unit on 25 occasions between 1950 and 1982. The indication for surgery was destruction of the proximal half of the humerus so extensive that the only alternatives were reconstruction or amputation. Of the patients with tumours two died from metastases, and three from unrelated causes; local recurrence necessitated amputation in two patients. Minor complications were frequent, but there were no deep infections and, after 1964, no prosthesis became loose. Active shoulder movement after operation was considerably limited, but passive movement was good and function of the elbow and hand were preserved.

We report the long-term clinical follow-up and survivorship analysis of 40 distal femoral replacements performed between 1964 and 1980 for traumatic, locally aggressive and malignant conditions. Custom-made prostheses with fully-constrained knee joints were used to replace a mean of 42% of the length of the femur. Survivorship analysis showed a cumulative success rate of 80% at eight years, with no subsequent deterioration at 18 years. Clinical assessment revealed 78% excellent or good results. Failure was due to infection in three cases, and in two to fracture of a now-outmoded femoral stem.

Entrapment of the superficial peroneal nerve is an unusual cause of pain in the ankle and foot. In such cases decompression of the nerve at the point of exit from the deep fascia will produce a good result. Three cases are described.

Degenerative changes of the first carpometacarpal joint commonly cause pain, weakness and adduction deformity. Many patients respond to conservative treatment, but in resistant cases an abduction wedge osteotomy of the base of the first metacarpal has been found to relieve symptoms with less complications than other operations. Twenty-one patients with 23 osteotomies have been reviewed, with a follow-up from 2 to 17 years. All have had lasting relief from pain and consider that they have full function, with no stiffness or limited abduction. Osteotomy is indicated mainly for cases where the arthritis is confined to the carpometacarpal joint, but also relieves pain in cases of peritrapezial arthritis.

A previously undescribed syndrome affecting the fingers of women is presented. The patients experience a sharp pain and then the fingers become blue and numb. The discoloration resolves within 72 hours without the changes normally associated with an ecchymosis. Clinical and haematological examination of six patients failed to show any common factors or associated systemic disease. This syndrome is of no clinical significance to the patient, but it is important for clinicians to be aware of it because the acute phase can cause anxiety, suggesting more serious vascular disease.

A series of 81 patients has been reviewed to determine the value of endoprosthetic replacement of the proximal femur and hip in the treatment of bone tumours. Standard statistical methods were used to evaluate the survival of the replacements and the patients. Taking removal of the prosthesis, irrespective of the cause, as the criterion for failure the survival of the replacements was found to be 63 per cent after 10 years. If deaths are regarded as failures, then the survival value falls to 48 per cent. The survival of patients with chondrosarcoma and osteoclastoma treated by endoprosthetic replacement compares favourably with survival after amputation or excision of the tumour.