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.

We assessed differences in the incidence and appearance of the radiological signs of loosening of the cup for various types of design. This was an observational study based on hip registry data of 15 340 patients with 17 951 total hip arthroplasties collected over a period of 33 years in 49 hospitals in Central Europe.

The threaded and the press-fit titanium cups showed significantly less aseptic loosening than the other systems. The direction of migration and the frequency of the radiological signs of loosening differed between the cup systems and were time-dependent.

Our findings indicate the superiority of uncemented threaded cups and press-fit titanium cups over other designs of cup.

We analysed follow-up data from 18 486 primary total hip arthroplasties performed between 1967 and 2001 to assess the validity of clinical procedures in diagnosing loosening of prosthetic components. Sensitivity, specificity and predictive values were estimated with the radiological definition of loose or not loose as the ‘gold standard’.

The prevalence of acetabular loosening increased from 0.6% to 13.9% during the period of the study and that of femoral loosening from 0.9% to 12.1%. Sensitivities and positive predictive values were low, suggesting that clinical procedures could not replace radiological assessment in the identification of loose prostheses. Specificities and negative predictive values were constantly above 0.86. The possibility of there being a prosthesis which is not loose in asymptomatic patients was consequently very high, particularly during the first five to six years after operation.

The necessity of periodic clinical and radiological follow-up examinations of asymptomatic patients during the first five to six years after operation remains questionable. Symptomatic patients, however, require radiological assessment.

We have compared the survival and radiological outcome at ten years after total hip replacement using two techniques for preparing the femoral canal. The same prosthesis was used throughout and all operations were performed by the same surgical team. In technique 1 the canal was over-reamed by 2 mm and in technique 2 it was reamed to the same size as the prosthesis. Technique 1 was performed on 92 patients and technique 2 on 97 patients.

The survival at ten years was 97.2% (90.6 to 99.2) for technique 1 and 98.8% (92.9 to 99.8) for technique 2. Vertical migration was greater in technique 1 (1.8 mm versus 1.0 mm at five years; p = 0.36). There were significantly more lytic lesions and radiolucent lines at five years (p = 0.0061) with technique 1. We conclude that technique 2 is not worse and may produce better long- term results than current teaching suggests.

As the surgical indications for total knee replacement (TKR) expand to include younger, heavier and more active patients, knowledge of the effect of these demographic variables on the outcome and survival of the implant is increasingly important.

Between November 1986 and September 1990, 402 patients underwent 562 primary cemented cruciate-retaining TKRs carried out by a single surgical team. The overall results showed a survival of 96.8% at 14 years with 1.44% lost to follow-up. Evaluating the demographics of these patients showed that certain groups fared significantly less well. The best results were seen in non-obese women with osteoarthritis who were over 60 years of age in whom there was ten-year survival of 99.4%. The worst results were in obese men with osteoarthritis who were less than 60 years of age in whom there was a ten-year survival of 35.7%. Caution should be exercised when considering TKR on a patient with this combination of poor risk factors.

By identifying demographic factors at the time of consultation the surgeon is better able to predict the survival of the TKR. This information is important when considering the best options for treatment of a patient and in providing accurate information during preoperative counselling.

Nine patients underwent arthrodesis of the knee using a customised coupled nail (the Mayday arthrodesis nail), five after infected arthroplasty, one following failed arthrodesis, one for intractable anterior knee pain, one for Charcot instability and one after trauma. Comparison was made with 17 arthrodeses, eight undertaken using external fixation, four with dual compression plates, and five with long Küntscher nails. Union was achieved in all patients (100%) at a mean time of ten months using the customised implant. There were no complications despite early weight-bearing. No further procedures were required. This contrasted with a rate of union of 53% and a complication rate of 76% with alternative techniques. Of this second group, 76% required a further operative procedure.

We compared the Mayday arthrodesis nail with other techniques of arthrodesis of the knee. The differences in the need for further surgery and occurrence of complications were statistically significant (p < 0.001), and differences in the rate of nonunion and inpatient stay of less than three weeks were also significant (p < 0.05) using Fisher’s exact test.

We conclude that a customised coupled intramedullary nail can give excellent stability allowing early weight-bearing, and results in a high rate of union with minimal postoperative complications.

Before proceeding to longer-term studies, we have studied the early clinical results of a new mobile-bearing total knee prosthesis in comparison with an established fixed-bearing device. Patients requiring bilateral knee replacement consented to have their operations under one anaesthetic using one of each prosthesis. They also agreed to accept the random choice of knee (right or left) and to remain ignorant as to which side had which implant. Outcomes were measured using the American Knee Society Score (AKSS), the Oxford Knee Score (OKS), and determination of the range of movement and pain scores before and at one year after operation.

Preoperatively, there was no systematic difference between the right and left knees. One patient died in the perioperative period and one mobile-bearing prosthesis required early revision for dislocation of the meniscal component.

At one year the mean AKSS, OKS and pain scores for the new device were slightly better (p < 0.025) than those for the fixed-bearing device. There was no difference in the range of movement.

We believe that this is the first controlled, blinded trial to compare early function of a new knee prosthesis with that of a standard implant. It demonstrates a small but significant clinical advantage for the mobile-bearing design.

We used calcium-phosphate cement combined with minimal internal fixation to treat 49 fractures of the lateral tibial plateau. There were 25 split depression fractures, 22 pure depression fractures and two bicondylar fractures. Anatomical reduction was obtained in 38 fractures, satisfactory reduction in nine and imperfect reduction in two. Of 44 patients reviewed at one year, 33 were rated as having an excellent reduction. Functional outcome as measured by the Rasmussen score was good or excellent at six months in 92% (44/48) of patients and in 95% (42/44) at one year. Eight (16%) showed some loss of reduction of the plateau. In seven of these the loss of reduction was slight (< 3 mm) and no action was taken. One patient with a deep infection had gross loss of reduction and a poor functional outcome. Calcium-phosphate cement is a useful alternative to bone grafting for the treatment of fractures of the tibial plateau.

Between 1993 and 2000 we treated 14 patients with nonunion of fractures of the distal humerus; 11 had already had previous fixation which had failed. The mean time to surgery was 21 months after injury. All the fractures were very low which made it difficult to obtain a firm hold of the small distal fragment. The problem of fixation was addressed by inserting a Coventry infant hip screw into the humeral condyles. The screw has a thread of wide diameter which gives excellent purchase on the small distal fragment. The condyles can then be compressed on to the humeral shaft using a 4.5 mm narrow tibial dynamic plate. Of these 14 difficult cases of nonunion, 12 progressed to union.

We carried out a randomised, prospective, multicentre clinical trial of the treatment of Colles’ fractures. A total of 339 patients was placed into two groups, those with minimally displaced fractures not requiring manipulation (151 patients) and those with displaced fractures which needed manipulation (188 patients). Treatment was by either a conventional Colles’ plaster cast (a control group) or with a prefabricated functional brace (the Aberdeen Colles’ fracture brace).

Similar results were obtained in both groups with regard to the reduction and to pain scores but the brace provided better grip strength in the early stages of treatment. This was statistically significant after five weeks for both manipulated and non-manipulated fractures. At the tenth day the results were statistically significant only in manipulated fractures. There was no significant difference in the functional outcome between the two treatment groups. However, younger patients and those with less initial displacement had better functional results.

We analysed the CT scans and radiographs of 76 vertebrae in 49 patients who underwent vertebroplasty for painful osteoporotic compression fractures. Leaks of cement were classified into three types: those via the basivertebral vein (type B), via the segmental vein (type S), and through a cortical defect (type C).

More leaks were identified on CT scans than on radiographs by a factor of 1.5 (74/49). Most type-B (93%) and type-S (86%) leaks were missed or underestimated on a lateral radiograph which is usually the only view used during the injection of cement. Of the leaks into the spinal canal, only 7% (2/28) were correctly identified on radiographs. The areas on lateral radiographs where this type of leak may be observed were divided into four zones, and their diagnostic value in predicting a leak into the spinal canal was evaluated. The results showed that cement in the neural foramina had the highest positive predictive value (86%).

Intraoperative pulmonary fat and bone-marrow embolism is a serious complication of bone and joint surgery. We have investigated the occurrence and incidence of intraoperative embolism in patients undergoing elective lumbar spinal surgery with or without instrumentation.

Sixty adult patients with lumbar degenerative disease were examined by intraoperative transoesophageal echocardiography while undergoing posterior lumbar surgery. Of these, 40 underwent surgery with instrumentation and 20 without.

Moderate to severe (grade 2 or 3 according to the grading scale of Pitto et al) embolic events were seen in 80% of the instrumented patients but in none of the non-instrumented patients (p < 0.001). The insertion of pedicle screws was particularly associated with large numbers of pulmonary emboli, while the surgical approach, laminectomy, disc removal and bone harvesting were associated with small numbers of emboli.

We consider that, as in arthroplasty and intramedullary fixation of fractures, these embolic events are relevant to the development of potentially fatal fat embolism during spinal surgery.

Degenerative changes of the knee often cause loss of extension. This may affect aspects of posture such as lumbar lordosis. A total of 366 patients underwent radiological examination of the lumbar spine in a standing position. The knee and body angles were measured by physical examination using a goniometer. Limitation of extension of the knee was significantly greater in patients whose lumbar lordosis was 30° or less. Lumbar lordosis was significantly reduced in patients whose limitation of extension of the knee was more than 5°. It decreased over the age of 70 years, and the limitation of extension of the knee increased over the age of 60 years. Our study indicates that symptoms from the lumbar spine may be caused by degenerative changes in the knee. This may be called the ‘knee-spine syndrome’.

We present a prospective study of patients with tuberculosis of the dorsal, dorsolumbar and lumbar spine after combined anterior (radical debridement and anterior fusion) and posterior (instrumentation and fusion) surgery. The object was to study the progress of interbody union, the extent of correction of the kyphosis and its maintenance with early mobilisation, and the incidence of graft and implant-related problems. The American Spinal Injury Association (ASIA) score was used to assess the neurological status.

The mean preoperative vertebral loss was highest (0.96) in the dorsal spine. The maximum correction of the kyphosis in the dorsolumbar spine was 17.8°. Loss of correction was maximal in the lumbosacral spine at 13.7°. All patients had firm anterior fusion at a mean of five months. The incidence of infection was 3.9% and of graft-related problems 6.5%.

We conclude that adjuvant posterior stabilisation allows early mobilisation and rehabilitation. Graft-related problems were fewer and the progression and maintenance of correction of the kyphosis were better than with anterior surgery alone. There is no additional risk relating to the use of an implant either posteriorly or anteriorly even when large quantities of pus are present.

The role of radiotherapy and/or surgery in the local treatment of Ewing’s sarcoma has still to be determined. The outcome of Ewing’s sarcoma may differ according to its location and a selection bias towards surgery limits the ability to compare methods of local treatment. We have carried out a retrospective review of 91 consecutive patients treated for non-metastatic Ewing’s sarcoma of the femur. They received chemotherapy according to four different protocols. The primary lesion was treated by surgery alone (54 patients), surgery and radiotherapy (13) and radiotherapy alone (23). One was treated by chemotherapy alone.

At a median follow-up of ten years, 48 patients (53%) remain free from disease, 39 (43%) have relapsed, two (2%) have died from chemotherapeutic toxicity and two (2%) have developed a radio-induced second tumour.

The probability of survival without local recurrence was significantly (p = 0.01) higher in patients who were treated by surgery with or without radiotherapy (88%) than for patients who received radiotherapy alone (59%). The five- and ten-year overall survival rates were 64% and 57%, respectively. Patients who were treated by surgery, with or without radiotherapy, had a five- and ten-year overall survival of 64%. Patients who received only radiotherapy had a five- and ten-year survival of 57% and 44%, respectively.

Our results indicate that in patients with Ewing’s sarcoma of the femur, better local control is achieved by surgical treatment (with or without radiotherapy) compared with the use of radiotherapy alone. Further studies are needed to verify the impact of this strategy on overall survival.

Fractures of the clavicle in the neonate are usually diagnosed by clinical examination and confirmed by plain radiography. Exposure of newborn infants to irradiation should be avoided if possible. Following the clinical examination of 2978 neonates, 15 had suspected fractures of the clavicle. All were confirmed by ultrasound.

In combination with clinical examination, ultrasound is a satisfactory alternative to radiological assessment for the diagnosis of fractures of the clavicle in newborn children.

In this prospective study of 18 hips we compared the efficacy of ultrasound with CT in determining the position of the femoral head in a spica cast after closed or open reduction in children with developmental dysplasia of the hip. Ultrasound was performed through the perineal opening of the cast. With a transinguinal approach, the superior ramus of the pubis, the acetabulum, the femoral head and the femoral neck can be depicted in one plane. The CT and ultrasound images were blinded and reviewed by two of the authors. Ultrasound was inconclusive in the first two reductions since the perineal opening was too small to see all the landmarks in one plane. In the following 16 reductions the landmarks were well defined and interpretation of the CT and ultrasound was similar. The perineal opening in the spica cast should be made in such a way that the ultrasound probe can be positioned in the groin so that the landmarks can be shown in one plane.

We studied radiographs of 125 children (105 boys, 20 girls) with unilateral Legg-Calvé-Perthes’ disease to examine the epiphyseal development of the femoral head in the contralateral (unaffected) hip. The epiphyseal height (EH) and width (EW) of the unaffected hip were measured on the initial anteroposterior pelvic radiograph.

In 109 of the patients (87.2%) the EH was below the mean for normal Japanese children and a significantly small EH (below −2 sds) was observed in 23 patients (18.4%). By contrast, the EW of most patients (95.2%) lay within ± 2 SDs of normal values except for six with a significantly small EW. A strong positive linear correlation (R = 0.87) was observed in the EH:EW ratio in the patients. A smaller EH than expected for EW in our series indicated epiphyseal flattening of the femoral head in Legg-Calvé-Perthes’ disease.

Our findings support the hypothesis that a delay in endochondral ossification in the proximal capital femoral epiphysis may be associated with the onset of Perthes’ disease.

A major pathway of closed soft-tissue injury is failure of microvascular perfusion combined with a persistently enhanced inflammatory response. We therefore tested the hypothesis that hypertonic hydroxyethyl starch (HS/HES) effectively restores microcirculation and reduces leukocyte adherence after closed soft-tissue injury. We induced closed soft-tissue injury in the hindlimbs of 14 male isoflurane-anaesthetised rats. Seven traumatised animals received 7.5% sodium chloride-6% HS/HES and seven isovolaemic 0.9% saline (NS). Six non-injured animals did not receive any additional fluid and acted as a control group. The microcirculation of the extensor digitorum longus muscle (EDL) was quantitatively analysed two hours after trauma using intravital microscopy and laser Doppler flowmetry, i.e. erythrocyte flux. Oedema was assessed by the wet-to-dry-weight ratio of the EDL.

In NS-treated animals closed soft-tissue injury resulted in massive reduction of functional capillary density (FCD) and a marked increase in microvascular permeability and leukocyte-endothelial cell interaction as compared with the control group. By contrast, HS/HES was effective in restoring the FCD to 94% of values found in the control group. In addition, leukocyte rolling decreased almost to control levels and leukocyte adherence was found to be reduced by ~50%. Erythrocyte flux in NS-treated animals decreased to 90 ± 8% (mean sem), whereas values in the HS/HES group significantly increased to 137 ± 3% compared with the baseline flux. Oedema in the HS/HES group (1.06 ± 0.02) was significantly decreased compared with the NS-group (1.12 ± 0.01).

HS/HES effectively restores nutritive perfusion, decreases leukocyte adherence, improves endothelial integrity and attenuates oedema, thereby restricting tissue damage evolving secondary to closed soft-tissue injury. It appears to be an effective intervention, supporting nutritional blood flow by reducing trauma-induced microvascular dysfunction.

Wear products of metal implants are known to induce biological events which may have profound consequences for the microcirculation of skeletal muscle. Using the skinfold chamber model and intravital microscopy we assessed microcirculatory parameters in skeletal muscle after confrontation with titanium and stainless-steel wear debris, comparing the results with those of bulk materials.

Implantation of stainless-steel bulk and debris led to a distinct activation of leukocytes combined with a disruption of the microvascular endothelial integrity and massive leukocyte extravasation. While animals with bulk stainless steel showed a tendency to recuperation, stainless-steel wear debris induced such severe inflammation and massive oedema that the microcirculation broke down within 24 hours after implantation. Titanium bulk caused only a transient increase in leukocyte-endothelial cell interaction within the first 120 minutes and no significant change in macromolecular leakage, leukocyte extravasation or venular diameter. Titanium wear debris produced a markedly lower inflammatory reaction than stainless-steel bulk, indicating that a general benefit of bulk versus debris could not be claimed. Depending on its constituents, wear debris is capable of eliciting acute inflammation which may result in endothelial damage and subsequent failure of microperfusion. Our results indicate that not only the bulk properties of orthopaedic implants but also the microcirculatory implications of inevitable wear debris play a pivotal role in determining the biocompatibility of an implant.

Bone apatite contains carbonate and is therefore not pure hydroxyapatite. We have successfully developed sintered carbonate apatite (CA) with a concentration of carbonate of 6 weight% and have evaluated its osteoconductive and bioresorption characteristics. Cylindrical porous sintered CA and sintered hydroxyapatite (HA) measuring 4 × 4 mm with a porosity of 20% were implanted into surgically-created bone defects in the knees of rabbits. The animals were killed after 1, 3, 6 and 12 months. The defects were evaluated by microfocus CT and histology.

Bone growth into and around both materials increased. Newly-formed bone was placed in direct contact with both. Osteoclast-like cells resorbed only CA, and were coupled with osteoblasts. The porosity of sintered CA increased, indicating bioresorption, whereas that of sintered HA did not increase. Our findings indicate that sintered CA may be useful as a bioresorbable bone substitute.