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Volume 87-B, Issue SUPP_I March 2005

G Kumar S Anand BN Livingstone

Aim: To study the management and survival outcome of patients with metastatic long bone deposits referred to a general orthopaedic unit at a district general hospital.

Methods and materials: 43 patients with pathological or impending long bone fractures were identified between 1998 and 2001. Details of primary tumor, bony metastatic involvement and management were recorded. Additional data was collected regarding prophylactic versus therapeutic treatment, oncological input, time to death and Mirel’s score, where relevant.

Results: The most common areas of long bone metastases were found to be proximal femur 29/43 (67%) and humeral shaft 11/43 (26%). Proximal femoral lesions included subcapital, intertrochanteric and subtrochanteric lesions. Operative stabilisation was carried out in 27/43 (63%), and involved intramedullary fixation (10/27; 37%), extramedullary fixation (15/27; 56%), and arthroplasty (2/27; 7%). Of the initial 43 patients, 14 (33%) presented with impending fractures, with Mirel’s scores ranging from 7 to 11 (average 9).

The duration of pre-existing pain in the in the fracture group varied from 3 days to 6 months (average 55 days). None of these patients received oncological input during this time period. Of these 15 patients, 12 subsequently required surgery.

Patient survival times in the operated group averaged 3 months (2 days to 9 months) – with the exception of one patient who survived for 36 months. This compared equally with survival times for the unoperated group.

Only 2/43 patients received preoperative oncology input. In the postoperative group (27 patients), 16 (59%) received radiotherapy. Of the remaining 11 patients, 9 (33%) did not receive radiotherapy due to significant postoperative complications and died within 8 weeks.

Discussion: The main aims of surgery in patients with metastatic bony disease are pain relief, and preservation of stability and function. In view of the low life expectancy, preoperative oncology input is important in determining patient longevity and in deciding if surgery is beneficial. All patients should be considered for postoperative radiotherapy once the wound has healed. This multi disciplinary approach can be difficult to achieve in the setting of a district general hospital where oncology services are limited.

S. N. Anjum F. Denolf

This is a retrospective study performed to analyse the functional outcome, complications and survival following intramedullary nailings for pathological fractures of long bones in a District General Hospital.

There were fifteen intramedullary nailings (Femur-11, Tibia- 2 , Humerus- 2) done in twelve patients during June 1999 and December 2002. There were twelve nailings in pathological fractures and three cases of prophylactic nailings. Nine patients had metastasis with known primary cancers from Ca Breast (3), Ca Bronchus (3), Ca Prostate (1), Ca Oesophagus (1) and Renal Cell Carcinoma (1). Two patients had metastasis without known primary site. There was one patient who had multiple myeloma with pathological fracture of femur.

We assessed the outcome of the treatment based on pain relief, post-fixation mobility and complications associated with the procedure.

Pain relief was achieved in about 92% cases. 67% cases with fracture of lower limbs were able to walk within a week postoperatively following nailing. One patient had deep infection leading to implant failure that needed nail removal to eradicate the infection. One patient had nonfatal pulmonary embolism. There was an incidence of thromboembolism of brachial artery that was treated by embolectomy without any sequelae.

The patients survival rate was 33% at six months and 0% at 2 years.

Reamings sent from nailing were helpful in confirming the diagnosis in 75% cases.

Despite poor life expectancy our results show good functional improvement following intramedullary nailing of pathological fractures of long bones. It is a safe way to restore limb function and improve quality of life.

A Kulkarni A Abudu RM Tillman SR Carter RJ Grimer

130 consecutive patients with metastatic tumours of the extremity bones treated with resection with or without major endoprosthetic reconstruction were studied retrospectively to determine the indication for surgery, complications, clinical outcome and oncological results of treatment.

The mean age at diagnosis was 61 (22 – 84). The tumours originated from a variety of organs. Lower extremity was involved in 104 and upper extremity in 26. Metastatic disease was solitary in 55 patients and multiple in 75 at the time of surgery. The median follow-up possible from the time of operation to review was 18 months (0–103)

The indication for surgery was radical treatment of solitary metastases with curative intent in 33, pathological fracture in 46, impending fracture in 27, failure of prior fixation devices in 17, painful swelling or extremity in 37. Surgical treatment included excision of expendable bones without reconstruction in 20 patients and resection with endoprosthetic reconstruction in 110 patients. 7 patients received adjuvant chemotherapy and the majority received adjuvant radiotherapy.

At the time of review, 58 patients had died at a mean time of 23 months (0–90) from surgery (53 from progressive metastatic disease and 5 from other causes). 72 were alive at mean follow-up of 22 months (1–103) from surgery. 36 patients (28%) were alive at 2 years post-surgery and 8 (6%) at 5 years. One patient died intra-operatively. Post-operative complications occurred in 32 patients (25%). 18 patients required further surgical procedures for dislocation, infection haematoma, stiff joint, plastic surgical procedures. All the patients had control of pain and 90% achieved desired mobility.

There was no difference in the survival of patients who presented with solitary and multiple metastases, renal and non-renal metastases, and upper or lower limb metastases.

We conclude that selected patients with bone metastases can benefit from resection and major bone reconstruction with acceptable morbidity. We have not identified predictable prognostic factors in these selected patients.

M Ramakrishnan G Kumar SS Prasad JC Kaye

Between April 1999 and December 2001 forty-one patients (forty-five femora) with metastatic lesions in the proximal femur involving intertrochanteric and subtrochanteric regions were stabilised with Proximal Femoral Nail (PFN). Thirty-eight patients (forty-two femora) were followed up for a mean period of 20 months (range 3 weeks to 35 months). There was an overall increase in mobility in 60% of the patients and the rest remained the same. Mean Preoperative Visual analog scale rating for thigh pain was 8.1 versus 3.4 for postoperative score (p< 0.01). There were no complications with respect to PFN. There were three post operative complications – chest infection, superficial wound dehiscence and pulmonary embolism. All these complications resolved without any further deterioration. Since these lesions do not usually heal well a cephalomedullary device is ideal to withstand long-term cyclic loading. Minimal operative trauma, mechanical stability, early mobilisation, pain relief and short hospital stay are the advantages of PFN in stabilising impending fractures of the proximal femur.

A Kulkarni RJ Grimer PB Pynsent SR Carter RM Tillman A Abudu

Purpose: To see if current guidelines for the early diagnosis of sarcomas can be improved.

Method: Data on 1100 patients referred to our unit with a lump suspicious of sarcoma was analyzed to try and identify clinical features more common in malignant than benign lumps. The following five items were analysed: size, history of increasing size, presence of pain, depth, age. For each of these items sensitivity, specificity, accuracy and weights of evidence were collected. ROC curves were used to identify the most sensitive cut off for continuous data.

Results: The best cut off predicting malignancy for size was 8cm and for age 53 years

The weights of evidence (WE) are logs of the likelihood ratios and can be added and a probability then calculated. e.g. a 36 yr old with a 10cm, deep, painless lump that is increasing in size scores −0.39 + 0.4 + 0.4 – 0.11 + 0.58 = 0.88. This equates to a risk of the lump being malignant of 70%.

Conclusion: This analysis shows that increase in size is the strongest predictor of malignancy/benignancy followed by age > 53 and size > 8cm. This data can help formulate strategies for earlier detection of soft tissue sarcomas.

DS Warnock RM Tillman RJ Grimer

Metastatic bone disease resulting in acetabular destruction can provide the orthopaedic surgeon with the difficult challenge of achieving a stable reconstruction of the hip to provide pain relief and restoration of mobility.

We review of twenty patients with metastatic disease requiring major acetabular reconstruction presenting to our orthopaedic oncology unit over a five year period was undertaken. This yielded 15 female and 5 male patients with mean age 59 years. The primary lesion was breast (8 cases), renal (3) prostate (2), myeloma (2) and others (5) with a solitary acetabular metastasis in 75% of cases. Eight patients had received radiotherapy to the region pre-operatively.

In all cases, diseased bone was macroscopically cleared from the pelvis and reconstruction performed by means of a Harrington procedure with threaded pins passed antegrade from the iliac crest 915 cases) or mesh and screws (5 cases), all reinforced with cement around which a total hip arthroplasty was performed.

Mean follow-up was 16 months. Complications were broken pin (1 case), dislocation of femoral prosthesis (1) and deep venous thrombosis (1). Three patients died of their disease at a mean of 12 months from surgery. The remaining 17 patients continue to function at a satisfactory level with no patients having required revision surgery for loosening or deep infection.

We believe that surgical reconstruction of the acetabulum is worthwhile and can provide these deserving patients with improvement in quality of life.

Mr WJ Hart Mr M Hemmady Mr WP Cool

Introduction: The foot and ankle are common sites for benign tumours, ganglia and other conditions. The aim of this review was to look at the case mix requiring surgery that presented to a foot and ankle clinic over an eighteen month period.

Methods: Prospective data collection is performed for all patients presenting with lesions requiring surgery and this is stored on the tumour database in Oswestry.

Results: 80 cases presented over this period that required surgery.. There were 12 malignant primary tumours, 1 malignant metastasis, 5 cases of locally aggressive benign conditions (4 PVNS and 1 ABC) and the remaining 62 cases were benign conditions. There were more malignant conditions than there were ganglia.

Conclusions: In this series 16% of cases presenting as lumps to the foot and ankle clinic represented malignant disease. Although in most clinics this incidence will be diluted by other conditions of the foot and ankle, one must retain a high index of suspicion when dealing with lumps around the foot and ankle.

PJ Watmough SJ Canty G Higgins AS Paul

In contrast to bony metastases, soft tissue metastases from carcinoma are rare. We reviewed all referrals to our Sarcoma Unit over an eight-year period, and found an incidence of soft tissue metastases from carcinoma of 1.4%. The most common mode of presentation was a painless soft tissue lump in a patient with an occult primary. Lung and kidney were the most frequent primary sources. Overall, prognosis was poor, with a mean survival of 9.4 months. Renal tumours however had a much better prognosis that other types of tumours. Treatment should be individualised according to the underlying disease and the prognosis. Although much rarer than primary soft tissue sarcomas, soft tissue metastases from carcinoma should remain a differential diagnosis in any patient presenting with a suspicious soft tissue lump.

Introduction: Carcinoma most commonly metastasises via the lymphatic system firstly to the regional lymph nodes and then into the general circulation. Dependent upon the primary site of tumour, metastases from carcinoma commonly occur to the lungs, liver and bone. Distant metastases to the soft tissues are rare. There are few published case series (1,2) – the majority of the literature containing only case reports. We report a series of 10 cases of soft tissue metastases from carcinoma, collected from retrospective review of the case notes of consecutive patients referred over a eight year period to our Sarcoma Unit with a soft tissue lump, suspicious of a sarcoma.

Patients and Methods: We retrospectively reviewed the case notes of consecutive patients over a eight year period (April 1995 – April 2003) referred to our Unit with a soft tissue lump, suspicious of a sarcoma. All patients underwent magnetic resonance (MR) scanning, and then trucut or open biopsy of the lesion. Dependent on the histological and MR findings, patients then underwent computer tomography (CT) of the chest and ultrasound examination of the abdomen. Included in this series were all patients with a histologically proven, soft tissue (skeletal muscle or subcutaneous tissue) metastatic carcinomatous deposit.

Demographic, diagnostic, clinical, radiological and treatment data was collected on all patients.

Results: Of the 702 referrals to our Unit over the eight-year period with a soft tissue lump suspicious of a sarcoma, 10 cases proved to be soft tissue metastases from carcinomas (incidence 1.4%). Data for the 10 patients comprising the series is shown in Table 1. Eight of the patients were male, two were female. The mean age at presentation was 68 years (range 39–85 years). Two patients presented with a painful lump, and in the other eight patients the lump was asymptomatic. The involved sites included the thigh in four cases, the arm in three cases, the back, buttock and axilla one each.In nine cases, the soft tissue lump was the presenting symptom of an occult primary carcinoma, whilst in one case (Case 4); the patient had a history of previous excision of a hypernephroma. The sources of primary carcinoma were small cell carcinoma of the lung in 4 cases, renal clear cell carcinoma in 3 cases, large bowel adenocarcinoma in 1 case, prostate 1 case, and in 1 case the primary site was unknown.

All but one patient (Case 6) underwent radiotherapy or chemotherapy or both. Case 6 presented with a soft tissue lump over the shoulder, which on biopsy was found to be metastatic adenocarcinoma of large bowel origin. CT scan of the head confirmed multiple brain metastases. He declined any treatment and died within 2 months of presentation. In total, nine of the ten patients have died of their disease. The mean duration from diagnosis of soft tissue metastasis to death was 9.4 months (range 2–31 months). The duration of survival was significantly better for metastatic carcinoma of the kidney (23 months) compared to the other carcinomas (7 months).

Discussion: The most commonly reported primary carcinomas to result in soft tissue metastases are those of the lung, kidney and colon (13), contrasting with those carcinomas which commonly metastasise to bone such as prostate, breast and thyroid which only very rarely metastasise to the soft tissues. Damron and Heiner (1) who reported the largest series to date however had no cases where the patients primary site of carcinoma was of renal or colon origin and suggested that these cases were over-represented in the literature. Our series differs from their findings, concurring instead with the other published literature. Histologically, the most common diagnosis is adenocarcinoma, though many have been reported (13).

Soft tissue metastases from carcinoma are rare, which again contrasts to bony metastases from carcinoma. Tolia and Whitmore (4) reviewed 586 patients with renal cell carcinoma, and whilst a quarter had evidence of distant metastases at presentation, no patient had soft tissue metastases. Chandler et al (5) reported on 726 patients who died following metastatic renal carcinoma; only 3 patients had soft tissue metastases, all of which were only found at autopsy. Our series, which reviewed all patients referred to our Unit over a eight year period with a soft tissue lump initially suspicious of a sarcoma, found an overall incidence of 1.4%.

Damron and Heiner (1) reported that the most common mode of presentation was a painful soft tissue lump. In our series however, the majority were painless. Whilst for most, the lump is the first sign of an occult malignancy, renal cell carcinomas tend to be different, often presenting as a solitary soft tissue deposit a few months to up to 16 years after the initial diagnosis of renal cell carcinoma has been made (1,2). Our series agreed with these findings; only in 1 case (Case 4) was there evidence of previously documented carcinoma prior to presentation with the soft tissue lump.

All patients in our series underwent pre-operative MR scans, the appearances of which were not diagnostic of metastases, though highly suggestive of malignancy. Subsequently patients underwent either Tru-cut or open biopsy which gave the definitive diagnosis. As part of the pre-operative work-up, all patients had a CT of the chest and abdominal ultrasound scanning.

Rao et al (6) reported 5 cases of soft tissue metastases from primary sarcoma, concluding that metastases in these cases were seen as late events and survival was generally poor. In our series of soft tissue metastases from carcinoma, we also found that prognosis was poor (averaging 9.4 months), especially when the primary carcinoma was lung, though the prognosis, if the primary was renal carcinoma was less bleak.

Conclusions: Although rare, soft tissue metastases from carcinoma should remain a differential diagnosis in any patient presenting with a suspicious soft tissue lump. Whilst the MR scan appearances were suggestive of malignancy, they were not diagnostic of metastases. Tru-cut or open biopsy was reliable in confirming the diagnosis of carcinoma and helpful in the detection of the possible origin of the primary. The most common primary sites were lung, kidney and bowel.

J Lothian SA Murray CH Gerrand

Aim: To describe referral pathways and assess delays in order to inform targeting of educational initiatives.

Methods: Anonymised data on all patients with non-gynaecological sarcoma over 2 years (1999–2000), was obtained from the Northern & Yorkshire Cancer Registry.

Results: 362 cases were registered (29 per million). Patients were referred to a maximum of three hospitals. Of 86 managed solely at the first hospital, 13 were treated at a specialist centre. 225 (59.8%) eventually reached a sarcoma specialist centre. Those referred for further treatment were younger compared to those managed at the initial hospital (median age 55–59 vs 65–69 years) p< 0.01, and were symptomatic for a shorter period (292 vs 419 days, NS). Average time between attendance at first and second hospital was 52 days (median 34, range 0–678 days) and between second and third hospitals was 77 days (median 35, range 0–414 days). Onward average referral time by specialty varied from 5 to 93 days.

Conclusion: Evidence suggests that sarcoma treatment is best undertaken by specialist multi-disciplinary teams. However, less than 60% of patients regionally access specialist management, and many experience considerably delay in the referral pathway. Patients referred on from the initial treating hospital tend to be younger and may have had shorter duration of symptoms. Further work is needed to quantify referral delays in primary care. Future guidelines may therefore be usefully targeted both at primary and secondary care.

GL Cribb K Deogaonkar WP Cool

Proximal femoral replacement gives reliable relief of pain and return to function in proximal femoral metastases. However, there can be technical problems with reattachment of muscles and tendons to the prosthesis, inadequate reattachment can lead to loss of function and joint stability.

We were keen to establish how effective our current method of abductor reattachment was. All the post operative x-rays of patients who had undergone Stanmore Mets Proximal Femoral Replacement, over the last 2 years at the Royal Shrewsbury and Robert Jones and Agnes Hunt Orthopaedic Hospitals, were reviewed. Particular note was made of the position of the trochanteric osteotomy, whether it remained attached or not to the prosthesis.

The Stanmore Mets Proximal Femoral Replacement has a plate which secures the trochanteric osteotomy to the prosthesis. Two screws go through the plate, osteotomy and into the prosthesis..

There were six patients, 4 male and 2 female with a mean age of 67 years. The primary carcinomas included 2 breast, 2 prostate and 1 lung and 1 renal. In five of the six patients the trochanters became detached. In 3 of the 5 patients the trochanter became detached in the first post operative week and by 2 months all 5 trochanters were detached.

We have since changed our method of attachment of the trochanteric osteotomy to the prosthesis to a hooked trochanteric plate. The plate is attached to the prosthesis by wires. Short term follow up of five patients have shown that all the trochanters have remained all attached.

CH Gerrand JS Wunder RA Kandel B O’Sullivan CN Catton RS Bell AM Griffin AM Davis

Aim: To explore the relationship between anatomical location in lower extremity soft tissue sarcoma and function as measured by the Musculoskeletal Tumour Society (MSTS 93) rating and Toronto Extremity Salvage Score (TESS).

Methods: 207 patients of median age 54 years (15 to 89) were reviewed. 58 tumours were superficial and 149 deep. Deep tumours were allocated to one of 9 locations based on anatomical compartments.

Results: Treatment of superficial tumours did not lead to significant changes in MSTS (mean 90.6% vs 93.0%, p=0.566) or TESS (mean 86.4% vs 90.9%, p=0.059). Treatment of deep tumours lead to significant reductions in MSTS and TESS (mean 86.9% vs. 83.0%, p=0.001. mean 83.0% vs. 79.4%, p=0.015). There were no significant differences in MSTS and TESS when overall scores were compared by anatomical location. Exploratory analysis of MSTS subscales showed groin tumours were more painful than others, and posterior calf tumours had the lowest scores for gait. TESS subscales analysis suggested groin and buttock tumours were associated with difficulty sitting, and groin tumours were associated with difficulty dressing. Further exploratory analysis suggested “conservative” surgical excision of low-grade liposarcomas in all locations was associated with a significant decrease in functional scores.

Conclusion: There is significant variation in MSTS and TESS subscale scores when anatomical locations are compared. The “conservative” surgery used in the treatment of low-grade fatty tumours in all locations has a significant impact on functional scores.

A Kulkarni RJ Grimer SR Carter RM Tillman A. Abudu

Introduction: A ‘whoops’ procedure is when a lump, which subsequently turns out to be a soft tissue sarcoma (STS), is shelled out by a surgeon who is not aware of the diagnosis. In many cases residual tumour will be left behind necessitating further surgery. The significance of a whoops procedure in terms of survival and local control remains uncertain. This study has used case matched controls to compare outcome between two groups.

Method: 794 patients of soft tissue sarcoma with minimum follow up of 5 years were found on our prospectively collected database. 113 were whoops cases, 96 had restaging and reexcision. An observer blinded to the outcome of patients matched the whoops cases with virgins by known prognostic factors i.e. grade, depth, patient age, site, size and diagnosis of the tumour. We have investigated outcome in terms of local control, metastatic disease and survival by known prognostic factors and by their status at presentation.

Results: 96 patients with a whoops procedure were compared with 96 referred directly to our unit. Despite attempts to match patients with as many variables as possible there was a tendency for the patients with whoops to have smaller tumours that were subcutaneous, they were however well matched for grade and stage at diagnosis. 64% of whoops patients had adequate final margin whereas only 44% of virgins had adequate margins. Overall 1.43 additional operations were needed to achieve final margins for whoops cases as against 0.21% for virgin cases. Overall 27% patients had amputation 20% for whoops and 34% for virgin cases nearly 60% were ray amputations of foot or hand. Overall 50% had radiotherapy and 25% had chemotherapy. There was no statistical difference in local recurrence or survival of patients between whoops and virgins at 5 years follow up. Inadequate margins and residual tumour were significant risk factors for local recurrence and high grade, size more than 5 cm, and age more than 50 years were significant prognostic factors for overall survival of the patients.

Conclusion: Inadvertent surgical excision of a STS is not desirable but does not seem to lead to an adverse outcome in this series in which wide re-excision of the area involved has been carried out.

PJ Papagelopoulos PJ Boscainos EC Galanis KK Unni FH Sim

Background: Amputation of the distal fibula for malignant tumors is accepted practice. Few studies have reported limb salvage surgery for malignant tumors of the distal fibula. After distal fibulectomy, the main concerns are local recurrence of the tumor and ankle instability and deformity related to total resection of the lateral malleolus. Our objective was to analyze the oncologic and functional outcome of lateral malleolus en bloc resection for malignant tumors of the distal fibula, with special attention to operative techniques, reconstruction methods, and postoperative complications.

Methods: The authors identified ten patients who had malignant tumors of the distal fibula requiring total resection of the lateral malleolus. The patients’ medical records, operative reports, radiographs, and the histologic specimens were reviewed. There were four children (mean age, 7.5 years) and six adults (mean age, 42.16 years). The distal metaphysis was involved in seven patients and the epiphysis in three. There were four osteosarcomas, three chondrosarcomas, two Ewing sarcomas, and one adamantinoma. The most common symptoms at presentation were a palpable mass in nine patients, ankle pain in six, and pathologic fracture in one. The mean duration of symptoms before diagnosis and treatment was nineteen months. All patients had operative treatment; two patients with osteosarcoma had perioperative chemotherapy and one patient with Ewing sarcoma had radiotherapy and chemotherapy and another patient with Ewing sarcoma had chemotherapy only. Two types of “en bloc” resection of the distal fibula were performed. Wide (type II) extra-articular resection was performed in seven patients. Marginal (type I) intra-articular resection of the distal fibula was performed in three patients. After resection, a primary ankle arthrodesis was performed in four adults and postoperative bracing without any reconstruction in four children and two adults.

Results: Within a mean follow-up time of 14.4 years (range, three to thirty years), tumor recurred locally in two patients after a marginal type I resection of a chondrosarcoma, and in one after a type II wide extra-articular resection of an osteosarcoma. All ten patients were disease-free at latest follow-up examination. Six patients had reoperation. A below-knee amputation was performed in three patients for chronic osteomyelitis, for local recurrence of chondrosarcoma, and for a late adamantinoma of the tibia. One patient had further soft tissue and bone reconstructive surgery for lateral talus subluxation and cavovarus deformity. Another patient required ankle arthrodesis for recurrent ankle instability and ankle joint degenerative changes. One patient had wide re-resection for local recurrence of an osteosarcoma. All ten patients were ambulatory at latest follow-up evaluation. Four adult patients who underwent primary arthrodesis and one child who had no initial reconstruction and had late ankle arthrodesis had a satisfactory outcome, with an ISOLS functional score of 27.6 (92%). Two adolescents who had postoperative bracing without any soft tissue reconstruction had an ISOLS functional score of 24 (80%) with no ankle pain and satisfactory function; they used an ankle-foot orthosis during sports activities. Three patients who subsequently required below-knee amputation used a below-knee prosthesis for ambulation.

Conclusions: Limb salvage surgery for high-grade malignant tumors of the distal fibula can be achieved by wide extra-articular resection. For low-grade malignant tumors or high-grade tumors responding to adjuvant therapy, a more conservative marginal intra-articular resection may be adequate. Primary arthrodesis is indicated in adults after wide extra-articular resection. In children, repair of the lateral soft tissues and reconstruction of the tibiofibular mortise is necessary after tumor resection to avoid late ankle deformity or instability.

F Wu Z-B Wang W-Z Chen H Zhu

Purpose of study: To investigate the safety, efficacy, and feasibility of using high intensity focused ultrasound (HIFU) for the treatment of malignant bone tumors.

Methods: Forty-four patients with biopsy-proven malignant bone tumors were treated with HIFU (osteosarcoma: 32; chondrosarcoma: 3; periosteal osteosarcoma: 2; Ewing sarcoma: 1; other malignant bone tumor: 3, and unclassified tumor: 2). These tumors were situated as follows: distal femur – 20; proximal tibia – 7; mid-shaft of femur – 6; ilium – 2; shaft of fibula – 2; other – 4. HIFU was given as a noninvasive limb-salvage treatment in combination with neoadjuvant chemotherapy (methotrexate, adriamycin, cisplatin and ifosfamide) in thirty-four patients (Enneking’s Stage_b). Ten patients with stage IIIb (9 patients with lung metastasis) were treated with HIFU alone with palliative intent. The largest dimension of the tumors ranged from 5 to 46 cm. Postoperative biopsy, follow-up imaging (DSA, CT or MRI, and ECT), and functional evaluation were performed, and median survival time was calculated using the Kaplan-Meier method.

Results: Histopathological examination demonstrated clear evidence of tumor destruction and regrowth of normal bone in the treated region. When compared with baseline, follow-up imaging indicated complete coagulative necrosis of the treated tumors. Enneking’s functional scores were > 20, 15–20, and < 15 in 20, 14 and 5 cases respectively. Median follow-up was 23 months (range 10 to 40 months). Total survival rate was 85% (38/44). One patient with stage_b disease, and 5 patients with stage IIIb disease died as a result of distant metastases after HIFU treatment. 5 patients underwent amputation after local recurrence. Few complications were observed during follow-up. These were limited to 3 pathological fractures, 2 cases of peripheral nerve damage, restricted joint movement in 1 case, and epiphyseal separation in 1 case.

Conclusions: HIFU is safe, effective, and feasible in the treatment of patients with malignant bone tumors.

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JM Spencer TC Pollard AJ Carr CML Gibbons N Athanasou

Between 1972 and 2002 74 patients were treated under the combined care of the orthopaedic oncology service and lymphoma clinic with primary bone lymphoma. We reviewed the seventeen cases affecting the upper limb (23%). Of the seventeen patients nine remain alive. Assessment of the patient’s clinical presentation, histopathological definition, treatment and function outcome was made. The nine survivors were assessed clinically and with the Oxford shoulder score and the Toronto extremity salvage score.

Average time from first presentation to diagnosis was 7 months. All seventeen were diagnosed as a B –cell non-Hodgkin’s lymphoma, fifteen cases were high grade and two cases were low grade. The scapula was involved in six, humerus eight and clavicle three cases. Seven patients sustained pathological fractures three of which were at presentation; of these two were treated surgically. Eight patients have subsequently died of their disease. Functional outcome in surviving patients after medical treatment was very good with average TESS score of 79% (52%–99%) and OSS of 27 (12–52).

The presentation of lymphoma of the shoulder girdle may mimic benign shoulder conditions and lead to a delay in radiological and histopathological diagnosis. Pathological fracture is a common presentation and complication of treatment, however these fractures have a high chance of healing with medical treatment alone. Although shoulder stiffness remains a problem following medical treatment, overall upper limb function is good. There is little evidence that these patients require surgery in the short to medium term.

SG Sun M Maki L Danks J Edwards A Sabokbar CLMH Gibbons NA Athanasou*

Purpose: Bone destruction occurs due to the growth of primary malignant bone tumours (sarcomas) that are often not amendable to surgery. Bone resorption is carried out by osteoclasts which are formed from cells of the mononuclear phagocyte system. Primary malignant bone tumours contain tumour-associated macrophages (TAMs) in addition to neoplastic cells. The aim of the study was to determine the cellular and humoral conditions required for TAM-osteoclast differentiation and to assess the affect of an anti-osteolytic agent on osteoclastic bone resorption.

Methods: TAMs were isolated form bone and soft tissue sarcoma by collagenase digestion and cultured in the presence of RANKL and M-CSF on coverslips and dentine slices for up to 21 days. The extent of osteoclast formation and resorption was determined by expression of osteoclast markers (TRAP, VNR, cathepsin K) in cell cultures on coverslips and the extent of lacunar resorption in cell cultures on dentine slices.

Results: Osteoclast formation occurred only when RANKL and M-CSF were added to the TAM cultures. This resulted in the formation of numerous mononuclear multinucleated cells which were strongly TRAP, VNR and cathepsin K positive. In cell cultures on dentine slices, it was noted that these cells were capable of extensive lacunar resorption with formation of multiple large lacunar resorption pits. The addition of the bisphosphonate zoledronate to the cell cultures resulted in inhibition of osteoclast formation and complete absence of lacunar resorption.

Conclusion: These findings indicate that sarcoma-associated macrophages are capable of differentiating into osteoclasts and that both RANKL and M-CSF are required for this to occur. This process is likely to contribute to tumour osteolysis associated with the growth of sarcomas in bone. Further assessment of the use of inhibitors of osteoclast formation/resorption, is also indicated by our results.

E Nobbs R Reid C De Silva D E Porter

Introduction: The aims of the study were to analyse the presenting features of chondroasarcoma for prognostic significance, to observe the effects of grade and surgical management on local recurrence, metastasis and survival: and to assess the significance of delays to consultation and treatment.

Methods: From Scottish Bone Tumour Registry Records, 24 proximal humeral chondrosarcomas were treated between 1937 and 2002 in several hospitals in Scotland. Clinical records were available for all patients. Only 4 patients were eventually lost to follow-up. Age at presentation ranged for 16 to 79 (median 56) and male to female ration was 2:1. Patients were followed up for a range of 5 months to 24 years (median 6.5 years). Tumour histology was systematically reviewed: 5 (22%) were grade 1, 12 (52%) were grade 2, and 6 (26%) were grade 3. Dedifferentiated tumours were considered as grade 3.

Results: Pain was almost invariable (23/24), but its severity increased with grade. In the absence of pathological fracture (fracture in 4 Patients), swelling was significantly associated with increasing grade (X2+8.56, p+0.0139), as was symptom progression (X2=7.52, p=0.0232). Delay in diagnosis was calculated separately as ‘patient delay’ (range 0–69 months) and ‘doctor delay’ (range 0–132 months). No improvement in diagnostic delay was noted in this time period (1937–2002)

All cases were biopsied. 37% of these were excisional biopsies, 29% were incisional biopsies and 17% were needle biopsies. 21 patients (88%) received definitive surgery. Of these 5 had forequarter amputations (24%), 11 cases were excised marginally (52%), and 5 cases curetted (24%). Surgical choice was highly dependent on grade (X2=4.9256, p=0.005). In all cases the intent was curative.

2 patients had metastasis disease at diagnosis, and 5 developed metastases after definitive surgery. 4 patients had local recurrence (all had undergone wide local excision). All patients with grade 1 tumours remained disease free. Cumulative survival at 5 years was 57% and at 10 years 42%. Patient age did not affect survival. 5 year survival in grade 1, 2 and 3 tumours was 100%, 83% and 20% respectively. 4 of 5 patients undergoing amputation developed metastases and survival was significantly worse in the amputation group. Local recurrence in the wide local excision group did not diminish prospects for survival.

Discussion: Swelling predicts aggressive disease; as found in studies in childhood sarcomas. Progressive symptoms and serve pain are additional features indicative of high histological grade. In contract to improvements noted in several other studies, patient delay is highly variable and has not been demonstrably reduced over time.

Curettage was chosen for most grade 1 and some grade 2 tumours. Although maintenance of function is far better, our study provides no evidence that curettage results in increased local recurrence rates. Indeed, local recurrence in the wide local excision group did not depress survival figures. Because of early death in the amputation group, we would recommend avoidance of amputation in favour of wide local excision in almost all cases if possible. Age alone should not be a factor in determining surgical treatment.

E Dunstan A Sanghrajka S Tilley P Unwin S Cannon T Briggs

Retrospective analysis of 25 consecutive metal on metal proximal femoral replacements performed at our unit between 1965 and 1979.

Methods. Patients were: clinically evaluated using the Modified Harris Hip and Enneking Scoring Systems and radiologically using the ISOLOS scoring system.

The concentration of Cr, Co, Ti, Al, V, Mo & Ni in whole blood and urine was also measured by High-Resolution Inductively Coupled Mass Spectrometry and compared with controls and patients with other implants.

Retrieved prostheses (in situ for in excess of 25 years) were analysed for roughness and wear using a Mitutoya form tracer and an electron microscope.

Results. Thirteen patients have since died; nine from metastatic disease and four from other causes. Of the remainder, eleven (44%) are still alive, five still retaining metal on metal articulations and one has been lost to follow up. They have been in situ for an average of 32 years. The average modified Harris Hip score is 76 (53–93) and the average Enneking Score is 74 (63–90).

In the retrieved prostheses the contact zones were found to be smoother (Ra 0.05?m), have fewer and smaller carbides together with evidence of ‘self-healing’ when compared to the original surface (Ra 0.32?m).

Blood & urine levels of Co & Cr were significantly elevated. Co levels were exceptionally elevated in loose prostheses but levels quickly fell following revision.

Conclusion. We have shown the potential longevity of metal on metal arthroplasty. The wear seen in retrieved specimens is low and we might expect to improve the fixation by reducing the torque with apical bearing and encouraging extra-cortical bone bridging with hydroxy-apatite coated collars. Elevated serum and urine Co levels may well predict a loose prosthesis and may be useful as a screening tool.

S Gerrand CH

After resection of a malignant tumour, the options for reconstruction include the use of massive allografts. The potential benefits of allografts include the ability to shape the graft to match the defect at the time of surgery and high rates of union in metaphyseal bone. The options for fixation of allografts include intramedullary nails and plating.

The AO-LISS DF (less invasive stabilisation system for the distal femur) is a new plate designed for fractures of the femur. The screws lock into the plate and the system is thought to provide excellent purchase in metaphyseal bone. A jig allows percutaneous screw insertion.

We describe a case in which a 28 year old woman with a high grade sarcoma of the distal femur underwent reconstruction using an intercalated allograft and two LISS-DF plates. This technique allowed the knee joint to be preserved. Although the surgical approach to the femur was medial, the LISS-DF jig allowed a plate to be placed on the lateral side of the femur in a “less invasive” fashion. Although the plate is designed for application to the lateral side of the femur, in this case adequate fit on the medial side was obtained with a plate from the contralateral limb. This reconstruction provided excellent early stability at the junctions between host and allograft bone.

S R Cannon J Meswena Meswania T W R Briggs

Growing prostheses have been utilised in the United Kingdom since the late 1970s. Various mechanisms have been tried, but to date all have required some form of surgical intervention. This has led to multiple hospital admissions and a large amount of resources, both in theatre time and rehabilitation. Over the last ten years the Department of Bio-Medical Engineering at University College, London, together with the Royal National Orthopaedic Hospital, Stanmore, have developed a prosthesis which does not require surgical intervention to elongate. The total cost of the development has been something in the order of £350,000.00. The design features are the power worm screw mechanism where one turn equals 1 mm of elongation, but attached to this mechanism is an epicyclic gearbox, which has been reduced in size so that it can fit in to the body of the prosthesis. The speed reduction achieved by the gear box is 13061 to 1. The mechanism is capable of withstanding an axial load of 1,350 newtons. When an external magnetic field is applied an external coil speed of 3,000 revs per minute leads to a lengthening of 0.23 mm per minute. To date the prosthesis has been inserted in three patients ages 11, 12 and 13. All were suffering from osteosarcoma of the distal femur and had previously received neo-adjuvant chemotherapy. Early elongation had been achieved in all patients without any major discomfort and without the need for either analgesia or inpatient admission. There had been no loss of range of movement in the early post-lengthening period.

This new prosthesis represents a significant advance in the management of skeletal sarcomas in children.

P Hamilton E Dunstan K Maruthainar P Unwin S Cannon T. Briggs

Retrospective analysis of all uncemented massive endoprostheses inserted at our unit in the management of primary bone tumours with a minimum follow up of 5 years.

Methods. The case notes and radiographs of all patients were reviewed. The group consisted of a total of 52 patients of which 4 (8%) were lost to follow up. Kaplan-Meier Cumulative Survival Graphs were created for mortality, amputation, revision and infection for the whole group and for each individual prosthesis.

Results. The mean follow up was seven years (63–107 months). The average age at time of insertion was 19 years; twenty-six patients were skeletally immature. The majority of implants were distal femoral (31) and proximal tibial (14). Osteosarcoma was the commonest diagnosis.

The rate of infection was 12.5%, aseptic loosening 6%, amputation due to local recurrence 10% and the mortality 21%.

All the deaths occurred within 3 years of the implant being inserted and were all due to systemic progression of the disease. The amputations for local recurrence occurred throughout the follow up period, the latest being at 71 months. Revisions for infections and aseptic loosening all occurred early (within 3 years). All cases of aseptic loosening occurred in distal femoral replacements (10%) and were related to divergent canals. Proximal tibial replacements had the highest rate of infection (23%). Rates of infection were not higher in the minimally invasive grower (12.5 %) when compared to the group as a whole.

Conclusion. We have shown a reduced rate of aseptic loosening (6%), particularly in the skeletally immature, when compared to our units results for cemented fixed hinged prostheses. The uncemented prosthesis is a successful implant that needs careful consideration, especially in the skeletally immature. Careful preoperative planning and surgical technique are of the utmost importance.

A Kulkarni RJ Grimer SR Carter RM Tillman

Aims: Tumours of the distal humerus are rare but a challenge to treat. Options for treatment are excision and flail elbow, arthrodesis with considerable shortening, allograft replacement or endoprosthetic replacement (EPR). A retrospective analysis of 10 cases of EPR distal humerus was done to assess their success in treating tumours.

Methods: A retrospective analysis of 10 distal humeral tumours operated between 1970 and 2001 was done by retrieving data from notes. No patient was lost to follow up. The Toronto Extremity Salvage Score (TESS) was used to assess function in patients still alive.

Results: There were 4 male and 6 female patients, with ages ranging from 15 to 76 years. The period of follow up ranged from 5 months to 31 years. 8 patients had primary tumours and 2 had secondary tumours. 4 out of 10 patients died of metastatic disease 12 to 71 months after operation. None of the 10 patients had local recurrence, infection, amputation or permanent nerve palsy. There were 3 revisions at 48, 56 and 366 months for aseptic loosening. There were 3 rebushings of the plastic inserts at 62,78 and 113 months. Two of the three rebushings were done after revision of the humeral component at 6 months and 30 months. The average TESS Score for these patients was 72.91 out of 100 (29.2 to 93.33).

Conclusion: Custom-made EPR for distal humeral tumours are an effective way of replacing the diseased bone leading to a reasonable level of function and an acceptable failure rate.

Mr WJ Hart Mr M Hemmady Dr C Mangham Dr MWJ Davie Mr DH Williams Mr WP Cool

A 36 year old gentleman presented to the Metabolic Bone Disease Clinic with a progressive history of thoracic and lower limb pain. He had originally been seen by the podiatrists with worsening foot pain for which no cause had been found. Initial investigation revealed a hypophosphataemic osteomalacia and a bone scan demonstrated multiple abnormalities suggesting old fractures.

Investigations were performed to establish the cause of the osteomalacia and we discuss the differential diagnosis and the progression towards a diagnosis based on the results of these tests. The most useful investigation in this case was an octreotide scan which indicated the presence of an endocrine tumour in the medial femoral condyle of the right knee.

Plain x-rays revealed no clear bony abnormality in the area of increased uptake on the octreotide scan. The lesion was therefore localised with an MRI scan.

This subsequently demonstrated the exact location of the lesion and in image guided biopsy was performed in theatre. This confirmed the presence of a benign Phosphaturic Mesenchymal tumour. This rare tumour is usually found in soft tissues and this case is atypical given that the lesion was wholly within the femoral condyle.

Despite the benign appearance of the tumour cells there were some areas of locally invasive growth and excision rather than curettage of the tumour was recommended. It was possible to preserve both the bulk of the femoral condyle and the articular surface although the knee was protected with a hinged brace for six weeks following surgery.

Follow up biochemistry results demonstrate that the serum phosphate and alkaline phosphatase are returning to normal. Symptomatically the patient is much improved.

A TALE OF 2 CYSTS Pages 6 - 6
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Mr W W Wagner Mr WJ Hart Mr M Hemmady Mr WP Cool Mr R Spencer Jones

Introduction: Large cysts of the proximal tibial metaphysis are an uncommon radiological finding amongst the elderly presenting to an arthroplasty clinic. We present two cases of such pathology in elderly patients. These were both associated with advanced degenerate disease in the knee.

In view of the size of the lesions these were both fully investigated with pre-operative radiology and an image guided biopsy. The first case was found to be a large degenerate myxoid cyst involving the majority of the tibial plateau. The second case appeared similar radiologically yet was a large metastasis from a bladder cancer. The only history offered by the after this had been established was that she had had a benign polyp removed some years previously.

Management: When dealing with unusual features of disease a cautious approach should be recommended. Both patients underwent staging investigations and biopsy prior to knee replacement surgery. In each case it was possible to graft the defect and using revision prostheses a good outcome has been achieved.

Conclusion: Large cysts appearing in association with degenerate disease of the knee are uncommon. Whilst these will often be related to the underlying arthritis this is not always the case and appropriate care should be taken to establish a diagnosis prior to surgery.

Mr S R Samsani Mr V Panikkar Mr V Kavarthapu Dr D Georgionnas Mr D Calthorpe

The aim of the study is to review the results of prophylactic reconstruction of subtrochanteric metastatic bone disease of femur using a Long Gamma Nail. Metastasis in the subtrochanteric region of femur can be challenging to treat not only due to peculiarities in biomechanics and anatomy, but also due to weak and deficient bone stock due to metastasis. Between 1996 and 2002, 28 subtrochanteric metastatic lesions of femur in 25 patients (3 bilateral) were treated with Long Gamma Nail. The outcome measures used in this study were pain relief, postoperative mobilization, and medical and implant related complications rate. There were 16 female and 9 male patients with an average age of 64 years. All patients reported marked pain relief. All but one regained pre-operative mobilization status. There were no intra-operative deaths including 3 bilateral nailings. Significant surgical and implant related complications were seen in 3(12%) patients. Postoperative medical complications were seen in 3 (12%) patients. There were no implant failures and reoperations. At the time of study 14 patients died with an average survival of 9 months and 11 patients were alive with an average survival of 16.5 months.

Long Gamma Nail is valuable reconstruction device for the prophylactic treatment of subtrochanteric metastatic bone disease of femur. It is strong, versatile and biomechanically superior to extramedullary devises and compares favourably with other intramedullary devices. In our experience Long Gamma Nail allows immediate unrestricted mobilization with marked pain relief.

M. McCarthy H. Mehdian K. J. Fairbairn A. Stevens

Objective: To present the clinical features, radiological findings and differential diagnosis of this rare benign condition.

Design: Melorheostosis (Leri’s Disease) is a rare mesenchymal dysplasia commonly exhibiting hyperostosis on the internal and external aspect of tubular bones in a sclerodermal distribution. It usually occurs in the limbs, frequently crosses joints and there is often ossification in local soft tissues. Presenting features may include pain, restricted joint movement and skin thickening. It very rarely affects the spine and its cause is unknown.

Subject: A 40-year-old female presented with insidious onset of mild mid thoracic back pain. There was no history of trauma and she had no past medical or family history. She underwent a six-month course of physiotherapy but this failed to help her symptoms. She developed a small lump over the area of pain and her GP arranged an X-Ray. This showed an irregular area of high attenuation over the right side of the tenth thoracic vertebra. A CT demonstrated a “dripping candle wax” appearance of densely calcified cortical bone undulating over the right side of the body and posterior elements of T10. The ossification crossed the synovial zygoapophyseal joint but not the intervertebral disc and a diagnosis of melorheostosis was suggested. MRI supported the CT findings and confirmed the presence of a soft tissue lesion over the dorsal process of T10. A bone scan verified the solitary nature of the lesion and showed widening of the right side of the body of T10 with increased focal uptake. All blood and urine investigations were normal.

Results: The patient underwent an open biopsy to obtain sufficient tissue for histological diagnosis and confirm that the lesion was benign in nature. It was felt that the dense ossification of the lesion would make percutaneous biopsy difficult. The most important differentials to exclude were an osteosclerotic bone metastasis and osteosarcoma. Other differential diagnoses were a parosteal osteoma, a burnt out osteoblastoma and a giant bone island. The soft tissue histology showed a necrotic fibrocartilagenous mass. The bone samples required prolonged decalcification prior to cutting and were composed of compact cortical bone similar to the appearances seen in ivory osteoma and also consistent with melorheostosis. This pathological pattern and the radiological finding of cortical compact bone crossing a synovial joint confirms the diagnosis of melorheostosis.

Conclusions: Spinal melorheostosis is a rare condition. The diagnosis should be considered in the differential of atypical osteosclerotic lesions of vertebrae. Adequate histological sampling is essential in order to exclude malignancy.

M Ramakrishnan G Kumar

A 52 year old male presented with a pathological subtrochanteric femoral fracture secondary to multiple myeloma. While stabilising the fracture with a Long Proximal Femoral Nail (PFN) distal femur fracture occurred, while introducing the distal locking screw, which was fixed with two cables. Partial weight bearing was allowed for the first six weeks.

Three months after surgery the distal static locking screw broke. Eighteen months post surgery patient developed sudden spontaneous right hip pain and was treated with further chemotherapy and radiotherapy. Radiographs showed the fracture had not healed but there was no evidence of implant failure. Two years later patient presented with sudden increase in right hip pain with inability to walk. Radiographs showed that the nail had broken at the proximal hip screw hole.

At revision surgery, with difficulty the broken distal locking screws were removed and the broken nail was removed by pushing it from below through the knee. The non union was stabilised with another long PFN. At four months post revision surgery there were radiological signs of bone healing and patient had no symptoms.

Discussion: Reconstruction nails such as long PFN are bio mechanically suited for proximal femoral fractures and metastases. Bone cement augmentation has been reported to provide additional support in metastases. Dynamisation of the fracture leads to fracture impaction and promotes fracture healing. In this case implant failure was probably due to non union and fatigue failure of the implant. In spite of ‘spontaneous’ dynamisation (broken static distal screw), union did not occur initially.

This is the first reported incidence of failure of long PFN in a pathological femoral fracture stabilisation.

A Abbas J.D. Bromage P.J. Stocks B. Al-Sarireh

Squamous cell carcinoma arising within bone is a rare lesion and is only seen essentially in the jaw and skull bones. Review of the medical literature showed that malignant change has been described in epidermoid cyst particularly in neurosurgical and orthodontic literature. However, no cases have been described in long bones as yet. Diagnosis of these tumours based on radiology and histology can be difficult and primary tumour elsewhere must be excluded. Here , a case of well differentiated squamous cell carcinoma arising from apparently a pre-existing intra-osseous epidermoid cyst in the distal tibia of a 45-year-old woman is reported. Initially treated with curettage and impact bone graft, then subsequently when the histopathology confirmed the above diagnosis, below knee amputation was performed. The differential diagnosis from other bone tumours with epithelial differentiation such as adamantinoma is discussed. This represents a rare primary neoplasm of bone of unknown histogenesis and also warns us to always try to get a histological diagnosis of what could look like clinically and radiologically a benign cyst.

C. Rajasekhar A.S. Paul R.S. Bale H. Stringfellow

Liposarcoma is the most common soft tissue sarcoma accounting for 20% of all mesenchymal malignancies.We report a rare histological variant arising from the dorsum of the foot. A 55 year old lady presented with a slow growing, well defined swelling on the dorsum of the foot. Histological examination following complete excision showed a tumor with zones of dense collagenous tissue containing pleomorphic spindle cells and scattered atypical adipocytes. A diagnosis of spindle cell sarcoma was made and referred to the local Sarcoma unit. Repeat excision and histology confirmed margins free of tumor. Four years after primary excision, patient is well with no evidence of recurrence or metastasis.

Spindle cell liposarcoma is a rare variant of well differentiated liposarcoma characterized by prominent spindle cell component. Previously reported cases originated in the subcutaneous tissues of shoulder girdle and upper limb. Main differential diagnoses include benign lesions such as spindle cell lipoma, and diffuse neurofibroma as well as dermatofibrosarcoma pro-tuberans and other malignancies such as sclerosing liposarcoma, myxofibrosarcoma, malignant peripheral nerve sheath tumor and fibromyxoid sarcoma. Spindle cell Liposarcomas tend to recur locally and may dedifferentiate with a potential for metastasis. Wide excision and long term follow up looking for recurrence and metastasis is necesssary in these rare variants of liposarcoma especially those arising at atypical sites as in our case.

K.N. Subramanian C. Ramamurthy M. Ramakrishnan R.W. Parkinson

Aim: To report on the bone histology of patients undergoing intramedullary stabilisation for a pathological fracture or a metastatic lesion in long bones.

Materials and methods: From 1999 to 2002, 36 long bones in 29 patients (seven had stabilisation of two long bones) were stabilised with an intramedullary nail in patients with a known primary tumour. Prophylactic fixation was performed in 19 bones with metastatic tumour and in 17 for a fracture. Of the 17 fractures, 13 were considered pathological and four were simple fracture unrelated to metastasis. Thirty-three nailings were done for proximal femoral lesions and three were for the humerus. Reaming samples were sent for histological analysis. The various sites of the primary tumour were Breast (13), Myeloma (6), Prostate (5), Lung (4), Unknown (3), Bladder (2), Oesophagus (1), Renal (1), Melanoma (1). The histological results were correlated with the clinical diagnosis.

Results: Thirty-six reaming samples were sent for histological analysis. Twenty-two samples correlated with the clinical diagnosis. Of the 22 tissue samples, two did not have a initial confirmed histological diagnosis of primary and the reaming samples helped to achieve this. Fourteen biopsies gave false negative results.

Conclusion: Approximately two-thirds of the time the reaming sample has correlated with clinical diagnosis. Sensitivity of this test is 61%.

G Kumar M Ramakrishnan

A fifty year old lady with history of rheumatoid arthritis (RA) for 24 years and COPD for 10 years was admitted for investigation of persistent chest infection and for the control of RA flare-up. She was on Sulphasalazine, NSAIDs and had completed a course of gold injections and on admission started on methotrexate, folic acid, Calcium, bisphosphonates and alendronate. Urinanalysis was positive for Bence Jones’ Proteins (BJP). Four days after admission patient developed spontaneous pain in the right thigh with inability to move the right leg. Radiographs showed a supracondylar femoral fracture through a lytic lesion, which was stabilised with a Distal femoral nail. At surgery bone quality of right femur was found to be very poor. Radiographs of the left femur showed a lytic lesion in the subtrochanteric region, which was stabilised prophylactically with a Proximal Femoral Nail. Histopathological examination of the marrow reamings from right femur showed no neoplastic changes and from left femur showed occasional plasma cells. 24 hour urinanalysis showed BJP of 0.22g/hour and protein electrophoresis showed monoclonal antibodies. Bone marrow biopsy was performed which showed only reactive cells. A week later 24 hour urine BJP was down to 0.13g/hour. At three weeks, symptoms of RA were under control and the protein electrophoresis showed no monoclonal banding. Chest infection resolved with appropriate antibiotics. Computerised Tomography of chest showed bronchiectasis with no evidence of neoplasm.

Discussion: In acute stages of RA there is an increase in antibodies production that may present as positive for monoclonal antibodies on electrophoresis and by the same reason urine may be positive for BJP. The spontaneous fracture in this case could be due to severe reactive osteoporosis confounding the clinical picture of active RA. Without clear evidence of myeloma or plasmacytoma, instituting chemotherapy may lead to further complications in patients with RA.

S Kapoor BJ Singh

Aim of presentation: We present a case of patellar metastasis from lung carcinoma resulting in pathological fracture.

Material and methods: A 66 years old man with a clinical diagnosis of carcinoma of lung presented with complaints of severe pain in his right knee after a minor injury. Radiograph revealed undisplaced fracture of patella through a lytic area. A fine needle biopsy was done which showed infiltration of bone by non-small cell carcinoma consistent with origin in lung. Patient was treated conservatively in a splint and received local radiotherapy for pain relief. The fracture healed clinically and radiologically in six weeks time inspite of increase in the size of tumour on x-rays.

Conclusion: Patella is a rare site of metastasis. Mercury et al reviewed the literature from 1900 to 2000 and reported about 15 cases of patellar metastasis from lung carcinoma. Pathological fractures are even rare. This case is presented as a rare case of pathological fracture of patella.

G Kumar S Anand B Y Ng B N Livingstone

A 78 year old lady attended casualty with complaints of low back pain and calf pain following a fall. Radiographs of lumbar spine did not reveal any bony injury. Clinically deep vein thrombosis (DVT) of the calf could not be excluded. Hence, venogram was performed that confirmed the diagnosis of below knee DVT. Patient was then discharged. Patient attended casualty 2 months later with complaints of sudden increase in back pain and difficulty in mictuirition. Radiographs of lumbar spine revealed a collapse of L1 vertebra. Routine blood tests were all normal except for raised International Normalised Ratio (INR), 3.5. Patient developed parapaeresis within three days. Coagulation status was controlled but no obvious primary source could be identified. After discussion with Neurosurgeons, urgent Computerised Tomography (CT) guided biopsy was arranged which was performed one week after presentation. Histopathological examination of the specimens revealed only fibrous tissue and blood. At 3 weeks after presentation patient started recovering rapidly though there was some amount of residual power loss in the lower limbs. Patient did not regain bladder control. A repeat CT guided biopsy at 6 weeks, again revealed only fibrous tissue.

This case is presented to discuss the rarer etiologies that can present as a metastatic spinal cord compression.

H.B. Bosch M.G. Pritchard

We reviewed 36 patients (39 shoulders) who had undergone arthroscopic Mumford procedure via a two superior portal technique for isolated acromioclavicular joint pain, using the Simple Shoulder Score (SSS) and a subjective outcome questionnaire, which included views about the cosmesis of the scars. The mean age of the 32 men and four women was 36 years (19 to 57) and 14 shoulders were on the dominant side. The mean follow-up was 22.7 months (14 to 47). Twenty-five patients reported a history of trauma, including six rugby injuries and five repetitive injuries sustained while bodybuilding.

The mean SSS was 11.5 out of 12. Subjectively 25 shoulders were rated excellent, eight good, two moderate and four poor. In 31 shoulders (79.5%) pain resolved completely. Twenty-five patients considered small scars either very important or extremely important and 33 were either extremely happy or very happy with their scars.

Arthroscopic excision of the distal clavicle via superior portals preserves the capsule-ligamentous structures stabilising the acromioclavicular joint. The procedure gives an excellent subjective outcome. Those patients with a poorer subjective outcome were older, with an increased possibility of occult shoulder pathology.

J.F. de Beer M.G. Pritchard

The results of arthroscopic repair of tears of the sub-scapularis tendon in nine men and six women, ranging in age from 53 to 73 years, were followed up at a mean of 14 months (6 to 24). Three were complete tears, six 50%-tears and six 30%-tears. In seven patients there were associated tears of the supraspinatus and infraspinatus tendons, which were repaired arthroscopically during the same procedure.

In each case the subscapularis tear was identified. In most patients a biceps tenotomy was necessary. The subscapularis footprint was prepared and the tendon was repaired using one or two anchors, each with two sutures, depending on the size of the tear. The mean pre-operative and postoperative Constant scores were 48 and 88 respectively.

In most patients, power returned to almost normal and pain was almost completely relieved. Arthroscopic subscapularis repair is a relatively new procedure and seems to give good results.

G.J. Greeff

This study retrospectively reviewed the pathology after the first traumatic incident of shoulder subluxation or dislocation in 12 male and four female patients with a mean age of 14.9 years (12 to 16). All had undergone surgery and were seen over a five-year period. Patients seen after a second traumatic dislocation were excluded.

All patients had been treated conservatively for between 4 and 18 months. When conservative treatment failed, all patients underwent examination and shoulder arthroscopy. All 16 had Hill-Sachs lesions of varying degrees. Bankart repairs were done in 14 patients with Bankart lesions. Two patients had more than 25% bone loss of the glenoid, and Latarjet procedures were undertaken. One SLAP-III and three SLAP-II repairs were done. The follow-up period varied from three months to five years.

All patients were either examined or interviewed by telephone. Failures were defined as recurrence of symptoms or redislocations. All patients resumed their sporting activities at similar or higher levels. Two patients with multidirectional shoulder laxity had further possible subluxations but were treated conservatively. One sustained a massive bony Bankart lesion a year after a Bankart repair and a Latarjet procedure was subsequently performed.

Patients in this age group should be considered at high risk for recurrence. If intensive short-term rehabilitation fails, they should be managed surgically immediately.

M.G. Pritchard J.F. de Beer

This paper retrospectively reviews the type and outcome of shoulder surgery in 61 professional rugby players (mean age 24.7 years). All competed at provincial level or higher, with 20 competing internationally. Forty-three of the patients played the position of forward, while 33 played back. Most shoulders (41) were on the dominant side. Ten players had multiple procedures and over a seven-year period 76 procedures were performed. The procedures included 16 Latarjets, four arthroscopic stabilisations, four SLAP repairs, four arthroscopic shoulder decompressions, three biceps tenodeses, three HAGL repairs, two revision Latarjets, one posterior Bankart, one pectoralis major repair, one Weaver-Dunn and four combination procedures.

All but two players returned to their previous level of competition. The mean time to return to full contact participation was 3.6 months (1 to 12). The time to return was one month for an arthroscopic Mumford and six months for a stabilisation procedure.

J.F. de Beer M.G. Pritchard

The outcome of the shoulder Delta prosthesis in 22 men and nine women was prospectively studied. The mean age was 74 years (62 to 86). Indications for surgery were cuff deficient arthritis (18), fracture malunion (three), ‘pseudo-paralysis’ (six) and failed total prostheses (four). The mean preoperative Constant score of 39 increased to 69 (10 to 39) at 33 months postoperatively, with the major increases in the scores for active forward elevation and pain relief. The subjective satisfaction was 79%. Although this was a small series with a short follow-up, early results seem satisfactory.

H.R. de Jongh M.G. Pritchard

Over a six-year period, one surgeon operated on 46 men with instability associated with antero-inferior glenoid loss. Thirty-three of them played rugby at a competitive level. The mean number of preoperative dislocations was five (2 to 22). Modifications included a change in orientation of the coracoid bone block and the addition of capsular closure.

A Walch-Duplay score for instability was calculated at follow-up. The mean follow-up was 38 months with a minimum of 6 months. Only one patient had recurrent instability. Thirty-one returned to sport at the same level. Walch-Duplay scores were excellent in 70%, good in 25%, mild in 3.75% and poor in 1.25%. Complications included two fibrous unions (excellent outcome), three broken screws (excellent outcome) and two fixation failures owing to patient non-compliance.

There was no decrease in the range of internal rotation. Eight patients had mild restriction in forward flexion (mean 5°) and 20 patients had mildly reduced external rotation at 90° abduction (mean 5°). All but one patient with recurrent dislocation rated the outcome excellent and would have the operation again. The Latarjet procedure confers outstanding stability and gives excellent subjective and objective outcomes.

S.J.L. Roche B. Vrettos

Over one year a bio-absorbable corkscrew was used in 19 rotator cuff repairs in 17 patients (10 men and seven women) with a mean age of 52 years (25 to 68). Seven were partial thickness tears. The 12 full thickness tears involved only the supraspinatus in all but four patients. Open surgery was performed on these four patients, who had an isolated subscapularis tear, an isolated teres minor tear, a combined supraspinatus and infraspinatus tear and a combined supraspinatus, infraspinatus and subscapularis tear. The remaining patients underwent arthroscopic repair. All patients had an acromioplasty and 13 had the acromioclavicular joint excised. Two patients had a concomitant SLAP repair. One corkscrew was used in 10 cases, two in six and three in two.

The mean follow-up was 8 months (3 to 24). The mean Constant score at follow-up was 80. There were five complications (26%) in which the corkscrew or a fragment of it came loose in the subacromial space. Two patients required further surgery to remove the corkscrew.

The corkscrew was found to be a useful device for rotator cuff repairs, but the complication rate was high.

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B. Vrettos S.J.L. Roche

Of 81 elbow replacements performed over a seven-year period, 11 were total elbow revision (TER) procedures, which were done on two men and nine women with a mean age of 61 years (40 to 70). Seven of the patients had rheumatoid arthritis, three had post-traumatic osteoarthritis and one had haemophilia. The reason for revision was aseptic loosening in eight patients and aseptic loosening with fracture in the other three. The prostheses revised were the Souter in eight patients, the Kudo in one, the GSB I in one and the Dee in one. In revision TER, one long stem Souter prosthesis was used, two Pretoria, one GSB 3 and seven Morrey. The mean time from primary to revision TER was 10 years (2 to 31).

At a mean follow-up of 30 months (6 to 48), all except one patient were pain-free and the arc of flexion had increased by 30°. Complications included one dislocation, one radial nerve palsy, which recovered after six months, and one aseptic loosening. There were no cases of sepsis.

Revision TER is a technically demanding procedure with a high risk of complications. In this series patient satisfaction was high. Our policy is to use a hinged prosthesis, preferably the Morrey, in revision TER.

K. Kastanos B. Karle

This is a retrospective review and analysis of cases of tennis elbow or lateral epicondylitis treated from 1996 to 2002. Of 191 patients treated, only 150 were contactable. These were sent self-administered Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires, which 55% patients returned completed. The rest of the patients were interviewed telephonically. Treated conservatively with avoidance of painful activities,non-steroidal anti-inflammatory medication, steroid injection, bracing, and physiotherapy, 83% of patients responded favourably and did not require surgical treatment. DASH scores ranged from 38 to 105 (mean disability < 12%) and compared favourably with those reported in the literature.

Conservative treatment of lateral epicondylitis is usually successful and minimal residual disability can be anticipated. The few patients who fail to respond to conservative treatment can be salvaged predictably with low residual disability.

A.J. Lambrechts S.J.L. Roche

This study looks at the outcomes of 112 full thickness rotator cuff tears treated by arthroscopic decompression, without repair of the rotator cuff, from 1994. The decision not to repair the tear was taken only if four criteria were met. First, if there was no clinical weakness on manual testing of the individual rotator cuff muscles, secondly, if there was full abduction, thirdly, if there was no riding up of the humeral head on the anteroposterior radiograph and fourthly, if there was well-developed ‘cable’ on arthroscopic visualisation of the rotator cuff.

The mean age of the patients, 38% of whom were men, was 62 years (47 to 83). In 44% the right shoulder was operated on. There were 32% type-II acromions and 68% type-III. There were 58% C2 tears and 42% C3 tears. All had arthroscopic acromioplasty and acromioclavicular joint excision. Later, three required an open acromioclavicular joint excision with one open cuff repair. At a mean follow-up time of 71 months (11 to 110), the clinical and surgical notes and radiographs were reviewed and a modified Simple Shoulder Test (SST) used to evaluate outcomes by telephone. The mean postoperative SST was 11.5 out of 12 (3 to 12). Complete relief was reported in 84% of cases. These subjective results suggest that, with careful selection, not all full thickness tears of the rotator cuff need repair.

B. Lindeque J.L. Botha

From two orthopaedic theatres at Pretoria Academic Hospital 28 samples were randomly selected, including Hibiscrub soap dispensers and both fully-sealed and partially-used bottles of iodine/alcohol, Hibitane/alcohol and Hibitane/water. Samples were taken from the solutions and the bottlenecks and basic microbiological cultures were done. Only the Hibitane/water bottles yielded positive cultures, with Bacillus species cultured from three out of four.

We concluded from this small random study that with the exception of Hibitane/water mixtures it should be safe to use the same bottle of solution in different cases.

B. Lindeque J.L. Botha

This was a prospective study to evaluate the changes in bacterial colonisation of the skin during hospital admission for elective surgery. It involved 48 patients who were admitted the day before surgery to Pretoria Academic and Pretoria East Hospitals. Within two hours of admission, cotton-tipped pus swabs were used to obtain samples from 56 skin sites in 48 patients. Postoperative specimens were obtained the day after surgery. The pre-operative cultures revealed a 73% Coagulase Negative Staphylococcus (CNS). Postoperative cultures revealed a 63% CNS. Preoperative methicillin resistance of the CNS was 6% and postoperative resistance to 49% (p < 0.01). The resistance of the organism to Cefazolin increased from 11% to 37%.

This study clearly indicates that multiple drug-resistant organisms colonise the skin of patients in the perioperative hospital stay. The postoperative rise in methicillin resistance of the CNS was alarming. Questions arising from this study include optimal admission time, length of postoperative stay, choice of perioperative antibiotic, use of occlusive dressings to prevent colonisation of wound site and routine screening for Methicillin-resistant CNS skin contaminants.

M.G. Pritchard B. Berghs

Over 40 months, 264 arthroscopic rotator cuff repairs were assessed prospectively. Preoperatively all patients were assessed using a modified Constant score and Visual Analogue Pain Scale (VAPS). The mean age at surgery was 59 years (19 to 83). In 151 cases (62%) the shoulders were on the dominant side. All patients underwent postoperative ultrasonography to assess cuff integrity at three weeks. Twenty-two patients were lost to follow-up. Of the rest, 210 were clinically reviewed and Constant scores produced. The remaining 32 were assessed using the VAPS and a subjective satisfaction questionnaire.

The Constant score improved by a mean of 29.6, with 166 patients (69%) reporting complete resolution of pain. The subjective outcome was rated excellent by 162 patients, good by 55, moderate by 20 and poor by five. There were 13 retears, 11 of which were identified on the three-week ultrasound. When four of these were revised, two required subscapularis repair. Importantly, five patients with retears had excellent subjective outcome. Complications were five superficial infections, 13 cases of transient neuritis following interscalene nerve blocks, four cases of bursitis, which required debridement and suture removal, and two anchor pull-outs. The overall reoperation rate was 4%.

Arthroscopic rotator cuff repair offers excellent objective and subjective outcomes, particularly pain relief. Ultrasonography at three weeks is a good indicator of whether or not a repair has taken.

J.F. de Beer M.G. Pritchard

In this prospective study of partial articular supraspinatus tendon avulsion (PASTA) lesions treated arthroscopically by an ‘all inside’ method, 12 patients (nine men and three women) with a mean age of 31 years (22 to 36) were followed up for a mean of 16 months (8 to 32). The deep partial rotator cuff tears were usually viewed from the glenohumeral joint side. Viewing the subacromial space usually revealed an entirely normal cuff with no sign of subacromial impingement. With the arthro-scope in the glenohumeral joint, the footprint area of the supraspinatus tendon was prepared and one or two anchors, each preloaded with two sutures, were passed through the rotator cuff into the footprint area of the greater tuberosity. The sutures attached to these anchors were passed through the tendon and tied in the subacromial space.

The Constant score improved from a preoperative mean of 72 to a postoperative mean of 91. The greatest increase was in power and overhead motion, especially abduction and external rotation.

PASTA lesions are difficult to diagnose, even with MRI. The ‘all inside’ method of arthroscopic repair obviates the need to detach intact fibres.

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S. Brijlall

This study was undertaken to determine the most effective way of treating intracapsular femoral neck fractures in HIV-positive patients. Ten patients with a mean age of 36 years were treated. Excision Girdlestone was performed In three patients in whom previous internal fixation had failed: all had poor nutritional status and low CD4 counts (mean 162). Three patients with undis-placed fractures were treated with percutaneous AO screws and a dynamic hip screw. In the remaining four patients, total hip arthroplasty (THA) was performed. At a mean follow-up of 14 months, all patients were fully ambulant with no signs of infection.

The decision to proceed with THA in HIV-positive patients should be made only after weighing the ratio of risks and benefits. The ultimate outcome depends on a number of factors, including displacement of fractures, previous surgery, co-existent medical problems, nutritional status and the stage of the disease.

L. Nordsletten H.M. Bergum

Over 13 months we prospectively monitored C-Reactive Protein (CRP) to assess surgical site infection (SSI) in 148 patients undergoing hip arthroplasty, including 34 hemiprostheses for femoral neck fracture, 35 hemiprostheses for osteosynthesis failure, 17 primary total hip arthroplasties (THAs) and 62 revisions of hemi-arthroplasty or THA. Ten patients who had probably had interaction with CRP were included.

In four out of seven patients with SSI, CRP values peaked three days after the operation, compared to eight out of 131 without SSI (p =0.0001). This gives a 60% sensitivity for detecting SSI by the CRP curve, with a specificity of 94%. The positive predictive value was 33%, and the negative predictive value 98%.

Previous studies have established the normal CRP curve after major joint replacement surgery. This study shows that a peak in CRP after day three may indicate SSI, or point to other deep infections such as pneumonia.

M. Citanich M. Solomons

Over a four-year period, nine patients with tuberculosis of the wrist were treated. The mean time to diagnosis was 5 months (1 to 20). Restricted wrist motion and an increased sedimentation rate were universal. Swelling, pain on motion and severe restriction of metacarpopha-langeal joint flexion, especially in patients with extensor involvement were common. In three patients, the disease involved the carpal bones, while in five it was limited to the tenosynovium. One patient had a cold abscess not involving tendon, sheath or bone. Granulomatous inflammation on the paraffin section was seen in most patients. Only four had a positive tissue culture of Mycobacterium tuberculosis.

These patients were treated either medially or surgically. In the group treated medically, an incisional biopsy was done and antituberculous chemotherapy administered for a minimum of six months. In the group treated surgically, surgical synovectomy and debridement were done and antituberculous drugs administered. All patients had a brief period of splintage followed by intensive physiotherapy.

At a mean follow-up of 12 months (6 to 24) all patients showed improvement in symptoms, with an increased range of motion. At final follow-up 50% of the patients had some residual loss of wrist motion. Those with extensor involvement seldom regained functional metacarpophalangeal joint flexion. The results showed no recurrence of infection in this study. The treatment resulted in good recovery of function, with low morbidity.

I. Robertson

This is a retrospective study of 14 cases from clinical records and the Bone Tumour Registry over the last 20 years. The mean follow-up time was 27 months (3 to 60). Two of the cases were referred elsewhere for final treatment and the relevant clinical records were obtained by correspondence with the treating doctor. Most tumours occurred about the knee, with two in the distal femur and five involving the proximal tibial metaphysis. Three were in the forearm and one in the humerus.

Once diagnosis had been made on clinical and radiological grounds, the tumours were curetted. Cryosurgery was used in four cases and phenol in two. Structural integrity was restored by autogenous bone grafting in most cases. Two of these were vascularised free grafts. Two patients had arthrodeses (one ischiofemoral and one wrist) and two were referred for custom-made joint replacements. There was only one local recurrence. Of the adverse outcomes, three required late amputations, one for varus malunion and recurrence, and two for nonunion and chronic sepsis.

Giant cell tumour of bone has a low rate of recurrence. The treatment challenge is to avoid sepsis and graft collapse. Large bone grafts often fail to incorporate fully, which can lead to angular deformities. A combination of bone cement, reinforced with Ender rods with bone cement to the subchondral surface, promises to be a more satisfactory method in and around the knee.

R.P. Gräbe A. Cloete

To try to find a solution to the high complication rate associated with harvesting bone graft from the iliac crest, a retrospective and prospective study was undertaken to document bone grafting from the proximal tibia in 37 adult patients undergoing a variety of foot procedures. The hospital charts of 17 patients were evaluated retrospectively for complications (mean follow-up of 27 months), while 20 patients were assessed prospectively by means of a questionnaire (mean follow-up of 7 months). There was an overall complication rate of 10.8%, 5.8% in the retrospective group and 15% in the prospective group. All complications were minor and resolved.

Although our overall complication rate is slightly higher than in similar studies, ours is the only prospective study that actively followed the healing of patients’ donor sites. We recommend the proximal tibia as an alternative harvest site. Contrary to popular belief, the proximal tibia provides a large volume of cancellous graft material.

F.A. Weber E. Lautenbach

Between January 1998 and December 2002, 418 hip revisions were performed. Of these, 45 hips were diagnosed as infected and two-stage revisions were done six weeks apart. These were excluded from the study, leaving 373 revisions for mechanical failure. In 310 cases both components were exchanged, in 59 the acetabular prostheses only and in three the stem only. One permanent resection arthroplasty was done for bone loss. Where necessary bone graft was used liberally. In 83 patients (22%) specimens taken at surgery cultured positive.

A first generation cephalosporin was given as systemic prophylaxis. Routine usage of Gentamycin was reinforced by Vancomycin or fucidic acid in the cement and bone grafts. Double lumen irrigation was inserted in only 5% of cases on the basis of operative findings. Gram stains done intraoperatively in suspected cases were non-contributory. Seventy-six percent of cultures were gram positive, with a preponderance of coagulase negative staphylococcus. Twelve percent were gram negative and 12% were mixed cultures of gram positive and gram negative organisms. One methicillin-resistant Staphylococcus aureus and one fungus were identified. As most of these patients were referred from elsewhere, we did not know whether or not Gentamycin had been used in the cement during previous surgery.

Implant failure due to low-grade infection was under-diagnosed in this series. Because of the relatively low number of failures caused by infection in this group, we recommend, with some improvements, the revision protocol presented. The expense of more detailed preoperative evaluation should be weighed against the success of the protocol.

A. Babruam

From May 2002 to April 2003, a prospective, non-randomised, blinded study was undertaken in 30 patients with fractures of the femur and tibia, all treated with unreamed intramedullary (AO) nail fixation. There were 17 (57%) femoral shaft fractures and 13 (43%) tibial shaft fractures. Most of the patients (23) had been injured in road findings accidents, 17 of them pedestrian. No patient had any known co-morbidities.

Fourteen patients (47%) were HIV positive, nine with femoral fractures and five with tibial fractures. Three patients with compound femoral fractures were HIV positive, two HIV negative. The mean age of HIV-positive patients with femoral shaft fractures, two men and seven women, was 33 years (18 to 48). The mean age of the eight HIV-negative men with femoral shaft fractures was 28 years. Five tibial fractures were compound, three in HIV-positive patients and two in HIV-negative patients. The mean age of HIV-positive patients with tibial fractures, three men and two women, was 31 years (18 to 56). The mean age of the HIV-negative patients, seven men and one woman, was 28 years. All the fractures were Gustillo-Anderson grade- II.

At 12 weeks, 29 fractures had united. In one HIV-positive patient with a compound tibial fracture there were no radiological signs of union at 12 weeks, but after bone grafting the fracture united uneventfully. An HIV-positive patient, who had sustained a gunshot femur injury, developed deep wound infection four months after fixation. In all other patients, the wounds healed uneventfully. In asymptomatic HIV-positive patients, wound healing and fracture union rates are comparable with those of HIV-negative patients.

F. Pretorius W.E. Williams

The aim of this retrospective study was to compare the rate of recovery and eventual level of function following total hip arthroplasty (THA) and hip resurfacing. Participants were 47 patients who had undergone THA and 43 who had undergone hip resurfacing. In all cases medical records were reviewed and function assessed, using the Harris hip score, visual assessment of gait and a functional score.

The rate of recovery, as measured by functional activities and range of motion, was notably better in patients who underwent hip resurfacing than in patients who underwent THA. No significant discrepancy was found in the presence of deformity and the levels of postoperative pain following either procedure.

We conclude that the hip resurfacing procedure may have important advantages over conventional THA, including more rapid mobilisation, higher levels of final function, increased range of motion, less physical limitation and shorter hospital stays. An important advantage is that the hip resurfacing procedure allows patients to resume work and sport earlier.

G. Charia

This study evaluated the early results of a new and minimally invasive posterior gluteus maximus splitting approach for total hip arthroplasty (THA) and metal-on-metal (MOM) resurfacing. The approach was used to do 30 THAs through an incision of mean length 7.5 cm and 20 MOM resurfacing procedures through an incision of mean length 8.8 cm. Intraoperative fluoroscopy was not used.

The results were compared retrospectively with a matched control group in which the conventional posterior approach had been used. The mean length of the incision in the control group was 20.5 cm. The groups were not significantly different in respect of body mass index (BMI), preoperative Oxford hip scores, estimated blood loss, or length of hospital stay. BMI was less than 33 in both groups. There was no infection, nerve palsy component malposition or dislocation. Postoperative scores were not significantly different. Patients who underwent minimally invasive hip surgery expressed great satisfaction with the cosmetic appearance of the surgical incision.

THA and MOM resurfacing can be done safely through this approach, with excellent early results and no complications.

J. de Beer S. Kaspar

In this study, 40 patients who underwent total hip arthroplasty (THA) and had a history of previous steroid injections were compared retrospectively with 40 carefully matched patients who underwent THA in the same period but had never received steroid injections. The development of sepsis under standard care was one of the outcome measures. This occurred in 20% of steroid patients within the first 36 months after THA, compared to 0% in the control group. Further, in a detailed analysis of Harris and Oxford scores, patients treated with steroid had a higher incidence of night pain, more severe pain, and greater loss of function in activities of daily living at one year. There were two revisions for deep infection in the steroid and control groups.

Based on the incidence of pain and infectious complications in the first postoperative year, and pending completion of the study, we provisionally suggest that steroid injection of hips may be ill advised in patients who are likely candidates for future THA.

C. Schnitzler

This is an overview of South African iliac crest bone histomorphometric findings. The examination Bone in health: a study of 346 healthy black and white South African subjects revealed thicker trabeculae and greater osteoid and erosion values in blacks. If this finding reflects greater bone turnover, then bone in blacks would be renewed more frequently and be less prone to fatigue failure. The finding of higher bone marrow cellularity in blacks is in keeping with greater bone turnover. Greater bone turnover and sturdier micro architecture may contribute to the lower fragility fracture rates in blacks.

Bone disease in black teenagers is discussed. Rickets, due to dietary calcium deficiency, is associated with grotesque limb deformities and severe osteomalacia (OM). Dietary calcium deficiency was found to aggravate Rickets in endemic fluorosis. Genu valgum and varum deformities were also found to be attributable to dietary calcium deficiency. Some patients developed nutritional secondary hypoparathyroidism before going on to OM. The most severe OM was seen in boys aged 16 to 19 years. Teenagers with slipped upper femoral epiphysis were found to be osteopoenic. This may explain why the slip in blacks is more severe and more frequently bilateral than in whites.

In black adults, African haemosiderosis (from traditional beer brewed in iron pots) was found to be associated with increased erosion depth and disconnection of the trabecular network. Bone formation was not impaired. Alcohol bone disease, on the other hand, showed predominantly osteoblast impairment. Patients with femoral neck fractures (FNF) had both haemosiderosis and alcohol bone disease. FNFs were found in younger black patients than white and were predominantly in males. The osteoporosis was also more severe and OM was not seen.

J.N. de Vos

This was an international single blind phase-III study of patients undergoing orthopaedic surgery to assess the efficacy and safety of HBOC-201. Patients who were expected to require two or more units of red blood cells (RBC) were randomised to HBOC-201 or RBC. Efficacy was defined as the proportion of patients in the HBOC-201 group who did not receive RBC. The HBOC-201 group comprised 350 patients and the RBC group 338. At randomisation, mean haemoglobin levels were similar (~9 g/dl) in the two groups (p =0.760). In the HBOC-201 group, transfusion was avoided in 337 patients (96.3%) on day one, 246 patients (70.3%) through day seven, and 208 patients (59.4%) through day 42. Fewer units of allogeneic red cell units were administered in the HBOC-201 group than in the RBC group, namely 1.4 units v 3.1 units (p < 0.001).

Adverse events in the HBOC-201 group were transient and mild in intensity and did not result in discontinuation of HBOC-201. There was no significant difference in mortality between the groups (p.=0.450). The efficacy of HBOC-201 was demonstrated by the avoidance of allogeneic RBC in about 60% of patients receiving this oxygen-carrying solution over a six-week period. HBOC-201 was well tolerated and appears to be a feasible alternative to RBC.

L. Nordsletten S. Ovre

We operated on five men and seven women, aged 17 to 48 years, for avascular necrosis of the femoral head. Eleven had subchondral collapse and one Calvé-Legg Perthes’ disease. The hip was dislocated through an anterolateral approach. The cartilage over the necrotic area was elevated as a flap with the base towards fovea capitis femoris. The necrotic/cystic area was debrided and channels were drilled into well-perfused bone. Autologous bone from the iliac crest was transplanted, slightly overcorrecting the defect. The cartilage flap was sutured back and the hip relocated.

Postoperatively patients were limited to 15 kg of weight-bearing for 12 weeks and then gradually resumed full weight-bearing over six weeks. Follow-up ranged from three months to three years. No patients have been operated on again and no major complication has occurred. Preoperatively the mean joint space was 4.3 mm (3 to 5 mm); at the last follow-up, it was 3.9 mm (2.3 to 5 mm). The roundness of the femoral head was judged better postoperatively than preoperatively. No patient has so far been scheduled for arthroplasty, but two patients have had relapses of more severe pain.

The Trap Door procedure may postpone the need for arthroplasty in patients with avascular necrosis of the femoral head. Our initial results have been encouraging, but further follow-up is required.

W.E. Williams

This study reviews the short-term results of 36 hip resurfacings performed to treat avascular necrosis (AVN) of the femoral head over a four-year period. The mean age of the 32 patients, 30 men and two women, was 41 years (25 to 50). Treatment options were discussed with patients, who usually preferred resurfacing to osteotomy, vascular fibular grafting, or total hip arthroplasty. No hips were revised, but in one patient both hips will probably be revised because of symptoms arising from anterior impingement between the femoral neck and acetabular cup rim. The other patients had no or minimal symptoms. One manual labourer and one truck driver (the patient with symptoms of impingement) have been unable to resume their previous work. Another manual labourer returned to permanent light duty. All the others resumed levels of work and sports activity comparable to their previous activities.

Resurfacing of the hip is generally advocated for young, active patients. It is therefore an option for treatment of AVN, which typically occurs in the fourth and fifth decades, most commonly in physically and economically active males.

J. de Beer D. Petruccelli

This paper looks at technical details and other issues in 30 primary total hip arthroplasty procedures performed through a direct lateral exposure in which the skin incision was limited according to the preoperatively templated acetabular component external diameter (D), using a formula D/2 + 1cm. All patients were positioned in the lateral decubitis position and stabilised with a vacuum beanbag.

Unpaired t-tests were used to determine difference in outcome between these patients and those operated on conventionally. No differences were noted between the two groups with regard to preoperative diagnosis, Oxford Hip Score, Harris Hip Score, demographic details, and body mass index. No statistically significant differences were noted with regard to operation time, blood loss, postoperative narcotic requirements, time to mobilise, length of hospital stay, postoperative complications and six-week postoperative Harris Hip and Oxford Hip functional outcome scores.

The mini-incision technique does not appear to carry short-term advantages for the patients. We did not encounter technical problems, but the mini-exposure does create technical challenges that could potentially have an adverse effect on the ultimate outcome. We do not advocate its use.

A. Morrish E.B. Hoffman

In a prospective study we assessed the accuracy of 3D-CT in defining the acetabular deficiency in developmental dysplasia of the hip (DDH), comparing pre-operative 3D-CT with plain radiographs, intraoperative stability testing and intraoperative acetabular morphology.

Twenty children (25 hips) with DDH who had open reduction and/or pelvic osteotomy from 1999 to 2001 were studied. On 3C-CT the morphology of the deficiency was described as normal, anterolateral deficient (overlapping shadows), lateral (increased acetabular index only) and global (double acetabulum). At open reduction, the position in which the hip was most stable with axial loading was assessed (Zadeh and Caterall, 2001). The surgeon’s assessment of the acetabular morphology intraoperatively was the standard against which the other modalities were tested. One hip was normal, five had a global and 19 an anterolateral deficiency.

3D-CT correlated well with the acetabular morphology (84%). Plain radiography correlated poorly, especially with the global type (60%). Mid-superior appearance on 3D-CT and lateral appearance on plain radiograph equated with an anterolateral deficiency morphologically. In the global type the hip was unstable in all positions, while the anterolateral type, while in the anterolateral type the hip was always stable in flexion and abduction and in only 31% of hips stable also in abduction and internal rotation.

The mean age at surgery was 3 years (1 to 7). The one hip with a normal acetabulum required open reduction only, the five global types an acetabuloplasty (Tonnis), and the 19 hips with anterolateral deficiency a redirectional (Salter) osteotomy.

3D-CT is helpful in appropriate osteotomy for a specific type of acetabular deficiency in DDH.

G. Grobler

The first 100 consecutive patients with cups inserted a minimum of 10 years ago were recalled and assessed clinically and radiologically. Fixation of the cups was excellent, with no loosening or migration. One liner was replaced because of wear and granuloma formation. The granuloma was curetted and allograft impacted. The patient recovered rapidly and the bone graft showed evidence of incorporation with remodelling after a year. One liner was revised following dislocation and instability. There were no further episodes of dislocation. Five liners had wear of more than 0.2 mm per year. Surprisingly, this occurred not in the patients who were very active but in the patients with smaller cups, where the liner thickness was less than 8 mm.

There was excellent fixation at 10 years. Wear remains a concern, however, and we now recommend that a 22-mm head be used in cups smaller than 52 mm. This ensures polyethylene thickness of at least 9 mm, which will improve wear properties.

I. Sanpera

From 1999 to 2002, eight children, ranging in age from 2 to 12 years, were treated for acute septic arthritis of the hip by arthroscopic debridement. The hip was initially aspirated under image control and distended with clear saline and a routine medium, or a small joint arthro-scope was introduced into the joint. The hip was irrigated and a suction drain inserted. All patients who presented early did well; those presenting later had a poor result. The functional recovery rate was faster than with the classical arthrotomy. Arthroscopic drainage may be a valuable tool in the treatment of acute septic arthritis.

S. van Heerden N. Wiesenthaler E.B. Hoffman

We retrospectively reviewed 45 children treated between 1987 and 2002. Their mean age was 9 years (3 to 13). Fifteen patients had subacute osteitis. Only patients with Bledhill and Roberts type II, III and IV were included. Biopsy provided histological proof of subacute osteitis in nine patients, and six were successfully treated non-surgically with flucloxacillin. Six patients had Ewing’s sarcoma, 24 had osteosarcoma, 23 Enneking stage-IIB (extracompartmental) and one Enneking stage-IIA (intracompartmental).

The preoperative clinical signs, radiographs and MRI studies were reviewed. On plain radiographs, cortical destruction and periosteal reaction were assessed. On MRI the extent and nature of bone marrow involvement and the size of the soft tissue mass/oedema was analysed and correlated clinically. On plain radiographs, cortical destruction was present in all patients with Ewing’s sarcoma and stage-IIB osteosarcoma and in 50% of patients with subacute osteitis. An ill-defined zone of transition was found in all patients with Ewing’s sarcoma and osteosarcoma and in 50% of those with subacute osteitis. These findings therefore did not help to differentiate between the two groups.

The periosteal reaction was well-defined in subacute osteitis and lucencies between laminations were thin. In the malignant group the periosteal reaction was always ill-defined, with or without a Codman’s triangle, sunray spicules and hair-on-end. Lucencies between laminations were broad and broken. This was useful in differentiating between the two groups.

On MRI, patients with subacute osteitis had no soft tissue mass, with an infiltrative type of bone marrow involvement. In the malignant group, the soft tissue mass was large and the bone marrow involvement well demarcated.

We concluded that where there was a well-defined periosteal reaction on plain radiographs, and no soft tissue mass with infiltrative bone marrow involvement on MRI, patients could initially be treated as subacute osteitis without biopsy.

D. Thomas P. Sanchez E.B. Hoffman

This is an ongoing retrospective study of 35 children treated from 1986 to 2001 for chronic osteomyelitis following acute haematogenous osteomyelitis. The purpose was to validate the use of a modified Cierny classification to predict behaviour, to assess the timing of sequestrectomy in relation to involucrum formation, and to evaluate the results of dealing with the resultant defect by conventional methods of bone grafting.

The mean age of the patients was 7 years (1 to 12). All except 18, who were treated within five days of acute onset, were delayed presentations or transfers. In 14 children the tibia was involved, in 13 the femur, in five the humerus and in three the fibula. Monthly radiographs were taken and the size and location of the sequestrum and involucrum was documented.

Our classification represents the size and location of the sequestrum. We divided the patients into cortical (one), medullary (three), corticomedullary (12) and structural (19) types. Fractures occurred in all the structural types, as well as in five of the 12 corticomedullary types. A sequestrum was apparent at a mean of 2.4 months (1 to 3). The mean length of the sequestrum at diagnosis was 8.5 cm and at surgery 5.8 cm, suggesting partial resorption. Involucrum formed in 69% of patients at a mean of 1.9 months (1 to 3) after sequestrum. In 31% of patients no involucrum formed from 4 to 12 months after surgery. This suggests that involucrum formation depends on viable periosteum and not on the sequestrum, and in the absence of involucrum early rather than late sequestrectomy is warranted.

The resultant incomplete bone defects in the corticomedullary type ranged from 1 cm to 15 cm, but had an intact cortical bed on one or more sides. These and complete defects of less than 6 cm in the structural type united after autogenous cancellous bone grafting, with or without an exoskeleton. Four structural defects greater than 6 cm united after fibular strut grafting (humerus) or bone grafting from fibula to tibia via a posterolateral approach (tibia).

Patients were followed up both clinically and radiologically for a mean of 2.9 years. Twenty patients (57%) had an excellent result and 15 (43%) a good result.

M. Oleksak M. Saleh

At Sheffield Children’s Hospital 40 children with leg length discrepancies (caused variously by sepsis, trauma, hemihypertrophy, congenital longitudinal deficiencies) were assessed using three clinical methods: measuring blocks in the standing erect position, supine measurement from the anterior superior iliac spine to the medial malleolus, and prone measurement with the knees flexed, which allowed separate measurement of femoral and tibial discrepancies. All were then subjected to comparative CT scanogram.

The mean age of the 24 boys and 16 girls was 10 years (5 to 16). Children with abnormal pelvic architecture or a fixed pelvic obliquity were excluded from the study. The mean clinical length discrepancy was 29 mm (0 to 80 mm). The mean CT scanogram measurement was 26.4 mm (0 to 75 mm). The mean difference between clinical measurements taken prone and CT scanogram measurements was only 3.6 mm (0 to 14). There was little difference in the accuracy of measuring femoral and tibial discrepancies clinically or by CT scanogram. The prone method of measurements is a useful adjunct to Staheli’s rotational profile in the prone position.

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I.E. Goga P.N. Gongal

This was a retrospective study of all patients with soccer injuries admitted to our orthopaedic unit over 42 months. Patients treated as outpatients were assessed for purposes of comparison.

Thirty-two patients were admitted with severe injuries, including 18 fractures of the tibial and femoral shaft. Two tibial shaft fractures were compound. There were four tibial plateau fractures and five epiphyseal injuries. One patient had a fracture dislocation of the hip. One patient with a popliteal artery injury, who presented 48 hours after a soccer injury, underwent an above-knee amputation. In the same period, 122 patients were treated as outpatients.

The types of injuries in this group were similar to soccer injuries reported in other countries. Very serious injuries are sustained in community soccer players in South Africa and urgent measures need to be taken to prevent such injuries.

M. Rasool

Seven children, aged four to nine years, underwent fibular transfer between 1990 and 2002. Five had chronic osteomyelitis and two had septic compound fractures. Bone defects measured 5 cm to 20 cm. Reconstruction was performed in two stages. Debridement, sequestrectomy, and Gentamycin bead insertion were performed first. Two children required skin grafting and one a gastrocnemius flap.

Fibular transfer was performed as a second stage at four to six weeks, when infection was cleared. Through an anterolateral approach the fibula was divided proximally below the physis and transferred from the lateral to the anterior compartment deep to the tibialis anterior muscle belly. The fibula was fixed with screws to the lateral tibial metaphysis in two children, and placed into the medullary canal and fixed with wires in four. Distal procedures were performed in five children.

Patients were immobilised in a cast for three to six months until bone healing occurred, after which the bone was supported with a calliper. Follow-up ranged from 11 months to 13 years. All transfers united to the proximal tibia by 12 weeks. Fibular hypertrophy occurred in all children. There was shortening of 3 cm to 10 cm. Equinus deformity occurred in two children and varus of the ankle in three. All are ambulant with boots and crutches.

Fibular transfer is a useful salvage procedure and an alternative to ablation in severe tibial infections with defects. It has a free blood supply and hypertrophies with weight-bearing.

B. Theunissen S. Dix-Peek

We retrospectively reviewed the clinical notes and radiographs of children with proven non-accident injury (NAI) who had sustained long bone fractures between 1997 and 2002, and compared them to the clinical and radiological appearances of 32 osteogenisis imperfecta (OI) patients, seen over the last 20 years, who sustained fractures before the age of one year.

In the five-year period, 501 children had NAI. Sexual abuse was involved in 35%, soft tissue injuries in 31%, head injuries in 26% and long bone fractures in 3.6% (18 children). The mean age of these 18 children was 11 months. Six had more than one fracture, and there were 29 fractures (15 femora, five humeri, three elbows, two forearms, two clavicles and two tibiae). Fifty-seven percent of fractures were diaphyseal and 43% were metaphyseal. There were only three metaphyseal buckle or corner lesions (distal femur). In none of these children were there radiological features of osseous fragility, i.e., osteopoenia, anterolateral bowing of the femur and tibia and gracile bones (thin bones with thin cortices).

Of the 32 OA patients, 23 were Sillence type I. There was a positive family history in 84% and 95% had blue sclera and Wormian bones. One patient was unclassifiable. All OI patients had fractures in the first year of life, 38% of them occurring perinatally. All had femoral fractures, with or without other fractures, and 90% were diaphyseal. Two or more features of osseous fragility were present in all type-III and 20 type-I patients. Three type-I patients and the unclassifiable patient had osteopoenia only, without bowing or gracile bones. Howeve, three of the four had a positive family history and all had blue sclera and Wormian bones.

In all patients, the differential diagnosis between NAI and OI could be made radiologically. The family history, blue sclera and Wormian bones were adjuncts.

M. Oleksak M.J. Bell

Nine children with knee and foot deformities were treated by Ilizarov external fixation from 1989 to 2000 at the Sheffield Children’s Hospital. Sixteen cases of arthrogryposis were identified. Progressive correction was combined with soft tissue release, soft tissue distraction or bony correction. Clinical outcomes were assessed and comparisons made between the different treatment modalities. Three fixed flexion deformities of the knee treated with progressive correction and soft tissue distraction were corrected initially, but recurred some time after the removal of fixators. Out of five clubfoot deformities treated with an Ilizarov frame with progressive soft tissue distraction alone, three recurred despite long-term splinting. Eight clubfoot deformities were treated with a bony procedure combined with gradual correction in the circular frame, and all corrections were maintained at follow-up.

The mean treatment time in the fixator was 17 weeks (12 to 50), and the mean follow-up time was 36 months. Complications included four cases of pin-tract sepsis, one case of osteitis requiring a sequestrectomy, one of transient neuropraxia and one fracture following removal of the fixator.

The treatment of joint deformities in arthrogryposis remains challenging and complications occur. Combining the Ilizarov device with a bony procedure seems to give better results, with fewer recurrence of deformities than pure progressive soft tissue correction.

A. Younus J.A. George

Talectomy was performed on 31 rigid clubfeet in 13 boys and 10 girls. Sixteen patients had myelomeningocele and seven arthrogryposis. The procedure was undertaken as a salvage operation on 22 feet. Seven patients had an additional cuboidectomy. The mean age of the patients was 3.7 years (2 to 9).

The patients were followed up for a mean of 4.5 years. Assessment included foot position, appearance and mobility, orthotic or shoe-wear fitting and walking capacity. Calcaneal position at the ankle was assessed radiologically. The results in 18 feet were good and in seven were satisfactory. There were six failures. Primary talectomy produced better results in children above the age of two years than ssecondary procedure in the older children. One of the patients developed a severe vascular complication, followed by sepsis, and required amputation of the foot. The other failures were due to recurrence of equines deformity.

Talectomy performed for severe rigid clubfoot achieved satisfactory correction in most of our patients. Excision of the talus as a salvage procedure carries a risk of incomplete correction and vascular complication.

W. Franck

Over 11 months to January 2001, we stabilised 15 pathological humeral fractures (14 patients) with a new nail that is secured in the medullary canal by hydraulic inflation. Filled with Ringer’s solution through a unidirectional valve, the nail expands by up to 50% of its original diameter. The expanded nail’s cross-section is characterised by four external longitudinal bars that are forced against the cancellous and cortical bone and prevent rotation. The entire length of the nail provides frictional contact. The fact that no locking screws are needed reduces radiological exposure for both theatre staff and patients and shortens operation times.

Ten patients had fractures in highly osteoporotic humeri, four had metastases and one a pseudarthrosis after plate fixation. There were no remarkable intra-operative or postoperative complications. Postoperative radiographic evaluation demonstrated correct axial alignment in all cases. No revisions were required and there were no intraoperative radial nerve injuries. The operative time was around 30 minutes. All fractures were stable enough to permit mobilisation of the arm and all united.

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M. Rasool

Thirty-four acute traumatic dislocations in children aged 5 to 13 years, treated between 1994 and 2002, were reviewed retrospectively. All injuries were caused by a fall. Two injuries were compound. Two children had ulnar nerve injuries, one a radial nerve injury, and one median nerve and brachial artery injury. Posterolateral dislocations were seen in 22 children, posteromedial in eight, posterior in one, anteromedial in two and anterolateral in one. Pure dislocations occurred in eight children and 26 had associated elbow injuries, including 11 medial epicondyle, five lateral mass, one olecranon, one radial head and eight combined injuries. In the combined group, six children had associated fractures and two had divergent dislocation of the proximal radio-ulnar joint. Twenty required open reduction. The injury was initially missed in eight.

The child with vascular and median nerve injury had not recovered by four months. Among the others, at follow-up of 4 to 48 months 22 results were excellent to good, 10 fair and one poor. Complications included pseudarthrosis of the medial epicondyle in one child and loss of flexion and rotation of 10° to 30° in 15. Radial and ulnar nerve injuries recovered. A high index of suspicion, good clinical examination and compared radiographs are recommended to avoid missed injuries.

S. Govender

One hundred and thirty-eight patients from South Africa were part of an international study aimed to determine whether the rate of healing of compound tibial fractures treated with intramedullary nails improved with recombinant human bone morphogenetic protein-2 (rhBMP-2). There were 118 men and 20 women, with a mean age of 33.3 years. According to the Gustilo-Anderson classification, there were 32 type-I, 50 type-II, 38 type-IIA and 18 type-IIIB fractures.

Patients were randomised to one of three groups: the standard care (SC) group, in which 47 patients were treated with intramedullary nail fixation and soft-tissue management, the group treated with SC and 0.75 mg/ml of rhBMP-2, which comprised 50 patients, and the group treated with SC and 1.50 mg/ml of rhBMP-2, which comprised 40 patients.

At 20 and 26 weeks, there was a significant difference (p < 0.027) in the rate of fracture healing in the three groups. At one year follow-up union was achieved in 30 patients (63.8%) in the SC group and in 27 patients (54%) and 30 patients (73.2%) in the two rhBMP-2 groups respectively. All patients with type-IIIB fractures developed nonunion in the SC group, but 56% in the 0.75-mg/ml rhBMP-2 group and 50% in the 1.5-mg/ml rhBMP-2 group achieved union.

Secondary intervention and medical costs were reduced in patients treated with rhBMP-2.

N. Maritz

With the aim of identifying appropriate treatment and diagnosis, this paper discusses 12 of 107 elbow dislocations and 56 elbow fracture dislocations seen over four years.

One patient presented with arterial injury, two with olecranon fractures and dislocation, and three with radial head, olecranon and coronoid fractures. One patient had an intra-articular fracture, two had collateral ligamentous injuries and two had radial head fractures and dislocations.

Depending on treatment, the results can be very poor or excellent. An awareness of the pitfalls in dislocations and fracture dislocations of the elbow is necessary to prevent poor outcomes.

T. Wisniewski B. Muballe

In a retrospective study, we reviewed 45 peri-trochanteric fractures treated between April 1995 and November 2002. The mean age of the 24 men and 21 women was 71 years (57 to 91). There were 34 inter-subtrochanteric, four reverse obliquity intertrochanteric fractures and nine subtrochanteric fractures. On the AO classification, there were 11 type-31A2-2, 21 type-31A2-3 and four type-31A3-1 intertrochanteric fractures. The fracture extended into the femoral neck in one case and into the diaphysis in three. Cardiopulmonary diseases were present in more than 60% of patients.

In most cases, fractures were reduced by closed reduction or reduction through a short incision. In 42 cases, a Smith and Nephew femoral reconstruction nail was used. Three fractures were stabilised with AO undreamed femoral nail with spiral blade. Distal locking screws were inserted in all cases. Progressive passive hip and knee movement was introduced from day one postoperatively. Partial weight-bearing was permitted from the onset. All but two fractures healed within 3 to 6 months. Union was delayed in two subtrochanteric fractures. Functional hip and knee movement was present in all patients. There was no sepsis. Proximal screws backed out in four cases, but this was of no functional significance. In one case the superior proximal screw was too long and required removal. In one case screws backed out of the femoral neck and further surgery was required. No breakage of screws or nail was observed. Inter-subtrochanteric and subtrochanteric fractures in the elderly may be successfully managed with intramedullary femoral reconstruction nails.

T. Wisniewski S. Johnson

In a prospective, consecutive study we reviewed the results of 32 supracondylar femoral fractures treated by Smith & Nephew intramedullary supracondylar nailing between January 1996 and October 2002. The mean age of 23 women and nine men was 67 (58 to 89). All fractures were closed. Two patients had associated upper limb fractures. In four cases, fractures occurred around total knee prostheses. Four patients had previously undergone ipsilateral total hip replacement or had had a sliding hip screw. On the AO classification the majority of fractures were type-33A1 and A2; seven fractures were classified as C1 and C2. The patients were placed in the supine position on a radiolucent operating table with the knee in 30° of flexion.

Postoperatively a hinged knee brace was applied and worn until union. Supported, progressive knee movement was introduced from day one. Partial weight-bearing was permitted as soon as pain subsided and continued until there were radiological signs of union. Within three to six months all but two fractures united. These united after prolonged bracing. There was no sepsis or fixation failure. A functional range of knee movement was observed in all patients.

Retrograde intramedullary nailing is a safe and successful method of management of supracondylar femoral fractures in the elderly and offers a minimally invasive alternative.

N. Maritz H. Snyckers

All patients who had received an Austin Moore hemi-arthroplasty between 6 February 1998 and 14 July 2002 were included in the study. Of the 101 patients, 34 were lost to follow-up, 34 had passed away and one did not give consent for the study. The Physical Performance of Activities of Daily Living (PODL) was evaluated, using a modified version of the functional status index by Jette. The level of social functioning was determined by a questionnaire developed by House . Muscular function was evaluated by a timed ‘carpet run’ of 20 m and measuring the time it took to rise twice from an armless chair. The data were compared to an age-matched control group of 44 volunteers.

The 45% complication rate in the study group included four dislocations (12%), two femoral fractures (6%) and three deep infections (9%). The social functioning questionnaire showed an average or above average score in most of the patients, 22 of whom (69%) were satisfied with the results. On the PODL score 19 patients (60%) were above average in dependency. Ten (31%) reported no functional pain and four (10%) reported severe pain. Muscular function tests showed a statistically significant difference between the operated group and the control group, with the mean ‘carpet run’ three times longer.

Even though the study showed good results as far as dependency and social functioning was concerned, there was a high complication rate and a low objective functional outcome. We concluded it was an effective procedure for patients who did not have high functional expectations, and that physiological status should play a greater role than chronological age in therapeutic decision-making.

M. Hopp

Since October 2001 we have used the FIXION® proximal femoral (PF) intramedullary nailing system to stabilise 93 proximal femoral fractures, 81 of which were pertrochanteric and 12 subtrochanteric.

Postoperative radiographs showed correct axial alignment in all cases. All patients recovered satisfactorily and mobilised early and without pain. Good callus formation was noted about 10 weeks after the procedure. We compared the use of the FIXION® PF with the use of Gamma nails and noted considerably shorter operation and radiological examination times.

T. Wisniewski

This prospective study included 236 open tibial fractures treated by unreamed AO nailing at three to four days after injury. Ten patients were lost to follow-up and 24 were excluded. We reviewed 202 consecutive open tibial fractures treated between January 1994 and December 2000. The mean age was 31 years (18 to 66) and 152 patients were men. There were 74 Gustilo grade-I, 66 grade-II, 32 grade-IIIA and 30 grade-IIIB fractures. The soft tissue injuries were managed by delayed primary closure, split skin graft or local flap. Most fractures were stabilised by unreamed nailing and statically locked.

Below-knee casts were applied routinely for six weeks. Full weight-bearing was permitted and maintained 6 to 12 weeks after the operation. In 16 patients (8%), union was delayed, but union occurred within 12 to 30 weeks in 194 patients (96%). Nonunion was observed in eight fractures (4%). Functional union occurred in all patients. Ten (5%) had mild knee pain. Acceptable shortening was noted in seven cases (3.5%) and varus/valgus angulations in 12 (6%). In two patients the nail was too long and required exchange. Eight locking screws bent or broke. There was no sepsis but three wounds were superficially infected. Compartment syndrome developed in one patient. Twelve additional operations (exchange nailing, bone grafting, fibular osteotomy and dynamisation) were performed for delayed unions and nonunions. Seven additional operations were undertaken for surgical errors where the nail was too long, there was early excessive rotation, or there were missed locking screws.

The delay in final treatment of open tibial fractures allows safe selection of patients for secure and cost-effective unreamed intramedullary nailing, with minor complications.

J.F. de Beer M.G. Pritchard

This study reviews the use of intramedullary fibular allograft in treating nonunion of the humeral neck in 11 patients. Nine women and two men with a mean age of 76 years (63 to 89) were followed up for a mean of 61 months (14 to 72). The nonunion was exposed through a deltopectoral approach and fibular allograft was inserted across the fracture site. As the fibula is a very dense cortical bone, a T-plate could then be applied to the humerus with the screws directed into the intra-medullary fibular peg. Supplementary corticocancellous bone from the iliac crest was used. Bony union was achieved in every case. The preoperative mean Constant score was 26 and the postoperative mean Constant score was 75. The most notable improvement was in patients’ ability to elevate the arm actively. Decreases in pain levels were observed but were less dramatic than the increases in function.

J.C. Coetzee S.G. Resig

Twenty-four patients with 26 symptomatic recurrences of deformity after previous hallux valgus procedures were included in this study. Exclusion criteria were hallux metatarsophalangeal joint fusion, Keller/Mayo procedures, insulin-dependent diabetes, previous ankle or subtalar fusions, peripheral vascular disease or peripheral neuropathy. An AAOS Foot and Ankle Outcomes Data Collection questionnaire, a Visual Analogue Pain Scale (VAPS), and the AOFAS Hallux Metatarsopha-langeal Interphalangeal Scale (HMIS) were administered preoperatively, at six months and then annually. Weight-bearing radiographs were taken preoperatively, at 6 weeks, 3 months, 6 months and 12 months. The mean follow-up was 21.6 months (6 to 36).

At final follow-up, the mean HMIS scores increased from 47.5 to 87.8 and the mean VAPS improved from 6.2 to 1.3. The mean hallux valgus angle improved from 37° to 14° and the mean intermetatarsal angle improved from 18° to 7°. In 77%, patients were very satisfied, in 4% satisfied, and in 19% somewhat satisfied.There were no cases of hallux varus. Complications included three nonunions, all of which occurred in smokers, and two superficial wound infections.

In appropriately selected patients, the Lapidus procedure is a reliable and effective alternative for failed hallux valgus surgery.

N.J. Mouton H.J.S. Colyn

Between 1997 and 2002, seven talipes equino varus deformities in six patients were treated using gradual distraction and correction with the Ilizarov external fixator. Three patients had poliomyelitis, four patients had neglected clubfeet and two patients had relapsed club-feet. The mean age of patients was 13.3 years (5 to 21) and the mean duration of fixator application was 3.25 months. When the plantigrade position was achieved the fixator was removed and a below-knee walking cast was applied. Four months after fixator removal, additional bony correction surgery (triple arthrodesis) was done in three patients. At the time of fixator removal, a plantigrade foot was achieved in all patients.

The mean follow-up time from surgery was 26 months. Pin-tract sepsis in two patients was treated effectively with oral antibiotics. Other complications included meta-tarsophalangeal subluxation from flexor tendon contractures in one foot. There have been no recurrences of deformities.

Compared to preoperative status, gait was subjectively improved in all patients. Correction of the deformity in the patients who had a triple arthrodesis of the foot was achieved with less bone loss than in patients who had undergone a primary triple arthrodesis. These results suggest that treatment with Ilizarov frames is effective in the management of neglected and relapsed clubfoot deformities.

A. Younus J.A. George

We treated 31 feet in 17 children with myelomeningocele by extra-articular subtalar arthrodesis. Two patients were lost to follow-up. In the rest, we assessed the correction of valgus deformity and the growth of the tarsal bones. At operation the mean age of the eight girls and nine boys was 6.3 years (3 to 9). At a mean follow-up period of 5.5 years (3 to 9) patients were evaluated clinically and radiologically. We assessed calcaneal growth by calculating the ratio of calcaneal and naviculo-metatarsal longitudinal length on the preoperative and follow-up lateral radiographs.

Results of valgus correction were good in 19 feet. In eight they were unsatisfactory owing to progressive valgus of the ankle. Orthotic fitting was difficult and pressure sores over the medial malleolus often developed. Four of the patients underwent further correction by distal tibial osteotomy. The growth ratio was increased in 15 feet, remained the same in seven and decreased in five. Extra-articular subtalar arthrodesis produced satisfactory partial correction of a complex valgus deformity and stability of the hindfoot, and did not have a detrimental effect on the growth of the calcaneus.

J.C. Coetzee S. Resig

Between June 1996 and April 2002, 56 patients underwent closed reduction and percutaneous fixation of calcaneal fractures. Of the 39 men and 17 woman, five were lost to follow-up. The patients’ mean age was 38 years (17 to 64). Four had bilateral procedures.

Using the AOFAS Ankle and Hindfoot Scale (AHS) and Visual Analogue Pain Scale (VAPS), we assessed patients preoperatively and at 6 and 12-monthly intervals. Clinical examination was undertaken preoperatively and postoperatively at 2-week, 6-week, 3-month, 6-month and 12-monthly intervals. Except at two weeks, radiographs included weight-bearing axial and lateral views at all intervals. Follow-up was for a mean period of 42 months (12 to 72). The mean time to union was 10.2 weeks (8 to 14).

The AHS improved from 34 preoperatively to 85 at the most recent follow-up. The VAPS improved from 9.1 preoperatively to 2.2 at three years. The satisfaction rate was 86%. Functional results depended on the quality of the reduction of the posterior facet and the severity of the initial injury. Complications included a 5% sural nerve injury and a 3% peroneal tendinopathy. No wound complications were encountered.

In selected cases, closed reduction and internal fixation of calcaneal fractures may produce results similar to those of conventional open reduction and internal fixation, with fewer complications. This technique is best performed within 24 to 72 hours of injury.

J.C. Coetzee

The purpose of this prospective study was to evaluate the functional outcome of patients who underwent the Lapidus procedure as a treatment for moderate to severe metatarsus primus varus and hallux valgus deformities. Inclusion criteria were failure of non-surgical management for moderate or severe deformity, inter-metatarsal angles of more than 14° and hallux valgus angles of more than 30°. Exclusion criteria were any previous hallux valgus procedures, insulin-dependent diabetics, previous ankle or subtalar fusions, peripheral vascular disease or peripheral neuropathy. Bilateral procedures had to be at least six months apart to be included. The AOFAS Hallux Metatarsophalangeal Interphalangeal Scale (HMIS), Visual Analogue Pain Scale (VAPS), Musculoskeletal Function Assessment Scale, clinical examination and weight-bearing radiographs were used for assessment.

All patients were followed up for at least six months. Patients lost to follow-up in less than a year were excluded from the analysis. For a mean of 3.7 years (1 to 6.2), 126 feet in 110 patients were followed up, 105 of them (91 patients) for at least one year. At most recent follow-up, HMIS scores increased from 52 preoperatively to 87 (p < 0.0001). VAPS improved from 5.3 to 1.3 (p < 0.0001). The hallux valgus angle improved from 37° to 16° and the intermetatarsal angle improved from 18° to 8.2°. At 3.7 years, 88.5% of patients were very satisfied, 5% somewhat dissatisfied and 1.5% dissatisfied.

With proper technique and attention to detail, the Lapidus procedure is an excellent alternative for moderate to severe metatarsus primus varus and hallux valgus deformities.

J.C. Coetzee J. Agel

From October 1999 to April 2003, 123 patients (127 ankles) underwent an Agility total ankle replacement. Prospective data were collected preoperatively, at 6 and 12 months after surgery, and thereafter annually, and included the AOFAS Ankle and Hindfoot Scale (AHS), Musculoskeletal Functional Assessment Injury and Arthritis Survey (MFA), Visual Analogue Pain Scale, patient satisfaction and standardised radiographs.

Fifty-six percent of the operations were performed for post-traumatic degenerative joint disease, 41% for primary degenerative joint disease, 1% for rheumatoid arthritis and 2% for avascular necrosis. At least one previous surgical procedure had been performed on 62% of ankles. In 6% there were intra/perioperative complications, including seven wound problems (one major, six minor), five lateral fractures, one medial malleolus fracture, one bone stock deficiency, one tibial nerve injury, one ankle in varus and one flap necrosis. Late complications included eight syndesmosis nonunions that needed bone grafting, one infection that led to a fusion, one unrelated talar fracture that led to a fusion, and one component subsidence that was revised. There were two patients with progressive varus and two with progressive valgus deformities. One patient underwent a below-knee amputation for chronic infection. Most of the perioperative complications occurred in the first 40 patients. The preoperative AHS of 43 (4 to 70) increased six months postoperatively to 75.45 and to 85 at two years. Patient satisfaction preoperatively was 0.92 out of 5 and 4.2 at two years. Baseline MFA values indicative of severe dysfunction (9.26) showed marked improvement in all parameters at two-year follow-up (21.83).

The Agility ankle replacement procedure is technically demanding and there are pitfalls and complications. The early results are promising, but follow-up has not been long enough to permit an objective opinion.

N. Bhagwan

This paper compares over an 18-month period anterior and posterior procedures in 40 patients treated surgically for dislocations and fracture dislocations of the cervical spine. Patients were followed up for a minimum of 12 months. Fifteen patients were neurologically intact, 13 were severely neurologically compromised and 12 presented with radicular symptoms. There were unifacet dislocations in 33 patients and bifacet dislocations in seven. In 23 patients there were associated fractures of the posterior elements. There was a high incidence (35%) of non-spinal injuries.

Posterior fusion (interspinous wiring) was done in 20 patients, anterior surgery (plating) in 18 and combined approaches used in two. Owing to posterior column fractures, four patients undergoing posterior surgery required two-level fusion.

Two of 13 patients with quadriplegia had useful return of function. There were no postoperative neurological complications. Reduction was successful in two of six patients who presented late (after more than 30 days) and the remaining four patients underwent an in situ fusion. In the anterior and posterior approaches operation time, blood loss, hospital stay and time to fusion were comparable. Anterior surgery without instrumentation was inadequate, but patients treated by anterior surgery had less neck and graft site pain, a lower rate of instrument failure and did not require multisegment fusion.

The anterior approach with instrumentation was safe and useful, obviating the need for two-level fusions and reducing the need for orthotic support, especially in the quadriplegic patients.

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O.O. Sulaiman

The results of fluoroscopically-guided closed needle (3.5-mm diameter) biopsies performed under general anaesthesia on 70 consecutive patients with lumbar spine pathology were reviewed. There were 36 men and 34 women with a mean age of 38 years. Sixty-four patients were Frankel-E, four were Frankel-D and two were Frankel-C.

The mean duration of the procedure (three tissue cores) was 17 minutes. Consultants performed 42% of the procedures and registrars the rest under supervision. All specimens were subjected to histological, cytological and microbiological evaluation. The results show a histological diagnostic yield of 88.57%. Of the 47 infective lesions, 34 were due to tuberculosis, three were pyogenic and 10 were reported as chronic non-specific inflammations.

In the 14 patients with neoplastic lesions, nine were metastatic and five were primary bone tumours. Histological diagnosis was inconclusive in six patients. Traction artefacts were noted in two patients with sclerotic lesions and one patient revealed normal bone. In tuberculosis, the culture was positive in only 29% of patients. The combined Lowenstein-Jensen and mycobacterial growth indicator tube media improved detection time and recovery rate of mycobacteria from smear negative specimens by 10%. The overall diagnostic yield for tuberculosis was 72.34%.

The diagnostic accuracy and safety of fluoroscopically-guided closed needle biopsy is comparable to that of CT scan and it is more cost effective. It should be an integral part of the management algorithm for spinal pathology.

A.H. Parbhoo

This paper reviews 32 patients (seven boys and 25 girls, mean age 14.5 years) with adolescent idiopathic scoliosis treated by anterior spinal release, fusion and instrumentation from 1989 to 2001. In 22 patients the thoracic curve was involved, in six the thoracolumbar and in four the lumbar curve. The mean preoperative kyphosis (thoracic curves) was 22.3° and the mean Cobb Angle was 56°. Routine exposure through the convexity was performed (sixth rib for thoracic curve and 10th rib for other curves).

After discectomy (four to nine levels), morselised rib was used as bone graft and instrumentation was applied with correction of deformity and saggital profile. Costo-plasty was performed in 10 patients. The mean operation time was three hours; mean blood loss was 180 ml. Intraoperative problems were partial pull-out of screws from the first proximal vertebra in three patients. In one asthmatic patient, who was on steroids, instrumentation was abandoned because of pull-out of several screws.

The mean hospital stay was 10 days. Two patients developed superficial wound sepsis and one sustained a burn to the right shoulder (cause unknown). Rod breakage occurred in two patients. Angulation at the level below the lowest instrumented vertebra occurred in five patients and was attributed to inappropriate fusion levels. Pseudarthrosis developed in two patients. At final follow-up, the mean Cobb angle was 26° and the mean thoracic kyphosis 30°.

The advantages of anterior surgery for idiopathic scoliosis include fewer fusion levels, correction by shortening the spinal column and less blood loss. Difficulty may be encountered in selection of fusion levels and instrumentation of the proximal vertebrae. In cases of very rigid curves, posterior spinal release may improve results.

E. Coetzee

From April 2001 to January 2003, 60 patients were selected for a circumferential fusion with an ALIF Brantigan cage and posterior titanium instrumentation. The aim of this study was to analyse the complications and the effects of circumferential fusion on functional outcome and lumbar lordosis. Circumferential fusion restored lordosis, provided a higher fusion rate, and showed a tendency towards better functional outcome and reduced back and leg pain.

M. Ngcelwane T. Bam

The aim of this study was to assess whether the pro-lapsed disc fragment type was predictive of recurrent disc herniation or sciatica after discectomy. The records of 39 patients treated by lumbar discectomy only were reviewed. Within two months of surgery, the type of disc fragment prolapse and state of the annulus were assessed on CT scans or MRI. Patients who presented later with recurrent sciatica or disc prolapse were reviewed with MRI. All other patients were contacted and asked whether they had had recurrent sciatica or had undergone repeat surgery elsewhere. The follow-up period was three years.

The results suggest that patients in whom discs required annulotomy at surgery had poorer results than those with extrusion through an annular fissure. The degree of annular competence can be used to assess the risk of recurrence of herniation or sciatica.

E. Coetzee

Thirteen consecutive patients with scoliosis, treated with anterior spinal fusion with a single rigid rod, were followed up clinically and radiographically for 19 months.

The mean major curve, 52° preoperatively, improved to 10° at follow-up.

The results of anterior single-rod spinal fusion in patients with idiopathic scoliosis are excellent. No development of kyphosis or incidence of hardware failure was seen.

M. Mariba

This paper retrospectively reviews 40 quadriplegics treated from 1997 to 2000. Hospital records, spinal unit records and telephonic interviews were used to obtain data on age, sex, mechanism of injury, levels involved, delay in admission, associated injuries, treatment, morbidity, mortality, rehabilitation time and placement on discharge. The mean age of the 36 men (89%) and four women (11%) was 36 years (18 to 66). The mechanism of injury in 34 of the patients (85%) was motor vehicle accidents. Five patients (13%) had sustained gunshot wounds and one patient had hit a wall (2%). The mean delay to admission was 5 days (0 to 42). Injuries were at C5/6 in 40% of the patients. Twenty-five patients (62.5%) were treated conservatively and 15 (37.5%) surgically. The 37.5% mortality rate was related to admission delay, associated injuries and patient age. Placement after discharge was problematic in 36% of the patients.

R.N. Dunn G. Fieggen

Between 1964 and 2002, 26 pairs of conjoint twins were recorded at the Red Cross Hospital. The available radiographs and notes were reviewed, with specific attention to the incidence of spinal anomalies that result in scoliosis. Structural scoliosis was noted to occur only in the ischiopagus and pygopagus subsets, namely those joined by the pelvic outlet and the rump respectively. The abnormalities were largely those of failure of formation, with early onset of severe deformity. The hemi-vertebrae were often remote to the area of conjunction, mostly in the thoracic area. All six ischiopagi had vertebral abnormalities, with two of the four pygopagi demonstrating abnormalities. There were associated lower limb neurological abnormalities in the ischiopagi.

The association of conjoint twinning and vertebral anomaly is currently thought to be due to non-specific teratogenic insult with hypoxia. The fact that the ischiopagus and pygopagus are involved is important: these groups constitute up to 45% of survivors and are reported to have a longer life expectancy. Because they will later develop severe deformities, they need early active management.

U.R. Hähnle

A subgroup of nine patients, five women and four men, who received lumbar disc prostheses in a segment adjacent to previous posterolateral instrumented fusions (one or two levels) is reviewed. Two patients underwent double-level disc replacement. The mean age was 46.1 years (33 to 62). All patients had marked flattening of the lumbar spine before the operation. One patient developed subsidence within two weeks of the procedure but went on to a satisfactory result. One patient with a double-level disc replacement needed another operation because of a missed far out lateral disc. On day five after the procedure, the top-level disc was removed, the level properly decompressed and the disc reinserted, with good results.

The mean postoperative hospital stay was 3.9 days (3 to 8). Within a mean time of 32 days (21 to 42), all patients returned to their previous occupations. Follow-up ranged from 3 to 19 months. At the latest follow-up, four of the patients were satisfied and five were very satisfied.

Disc replacement seems an ideal salvage procedure for junctional failure after previous fusions. The short-term clinical results are good.

H. Mahomed

This pilot study was undertaken to assess the prevalence of low back pain among nurses. Fifty-two women (mean age 44.28 years) working at a provincial hospital completed a questionnaire about low back pain and other health conditions. The duration of pain, number of episodes a year, duration of each episode and treatment were assessed.

Twenty-nine professional, three staff and 17 enrolled nurses responded. Their mean length of service was 18.32 years. Their mean weight was 78.55 kg, with a body mass index (BMI) of 32.2. They commuted a mean distance of 29.02 km (1 to 80), taking 37.12 mins (10 to 90). On average they had 2.18 dependents and 24 had help with household chores. Seventeen respondents participated in sports such as tennis, soccer and swimming.

Forty-six reported episodes of pain lasting five or more days. Symptoms had been present for 6.62 years. Twenty-three had fewer than eight episodes a year. Thirty-eight patients (82.6%) required treatment, including rest, medication and physiotherapy. Seven were admitted to hospital and one had surgery. Sick leave accounted for 751 lost work days. Forty-one nurses (78.8%) wanted to participate in a back care programme.

J. Kruger

The results of an accelerated rehabilitation programme were collected retrospectively from 293 case notes between January 1995 and December 1998. Different grafts were used: bone patellar-tendon bone (BPTB) grafts, hamstrings grafts and allografts. The criteria used to evaluate the knees of these patients were based on patient satisfaction, clinical examination and Cybex evaluation. All 293 patients were followed up for six months or longer. Four to six months after the reconstruction procedure, 94.2% returned to sport activities.

Anterior knee pain seemed not to be a problem when using autogenous BPTB grafts. The rehabilitation programme should decrease the postoperative morbidity.

M. Barrow I.M. Rogan

Between February 2000 and August 2002, 60 Oxford unicompartment knee replacements were done on 51 patients, nine of whom had bilateral surgery. The mean age of patients, 82% of whom were women, was 66 years (45 to 83). Primary osteoarthritis was the pathology in 97% and post-traumatic arthritis in 3%.

A full radiological assessment was done to determine positioning of the prostheses as well as the interfaces. The mean range of movement increased from 113° pre-operatively to 120° at the most recent follow-up. Complications included one case of deep venous thrombosis, one patient with bilateral tibial component loosening and three patients with loose cement particles in the joint. Most patients have no pain, but some have mild or occasional pain. One patient with bilateral unicompartmental replacements now has lateral knee pain.

Unicompartment knee replacements are an alternative to total knee replacements, but there is a significant learning curve, particularly with regard to cementing techniques. Attention needs to be paid to removing all loose cement from the joint. Patient selection is critical. The complication rate remains low, however, and the results seem satisfactory.

L. de Villiers

To determine the prevalence of osteoarthritis in the knee in the long term after anterior cruciate ligament (ACL) reconstruction, the files of patients who underwent the procedure from June 1984 to December 1990 were examined. Forty-three patients were contacted, of whom 33 (subgroup A) were willing to be examined clinically and radiologically. The other 10 agreed to a telephonic interview.

The Lysholm Knee Score (LKS) and the Petersson radiographic grading system for evaluation of osteoarthritis were used as the main measurements of outcome. The mean age at injury was 24.35 years. The mean interval between injury and surgery was 83.83 months. the mean LKS was 84.35. In subgroup A, 18.18% knees were Petersson grade 0, 30.3% grade I, 12,12% grade II, 30.3% grade III and 9.09% grade IV.

The results show that even in the long term a relatively positive outcome may be expected after ACL reconstruction

J. de Beer J. Leone

This study was to evaluate the stability of a delta keel tibial tray using a block prosthesis and to determine whether a long intramedullary stem is a necessary adjunct to augment construct stability. An experimental technique was used employing strain gauges and deflection transducers to assess the stiffness and principle strains conferred to human cadaveric tibiae under various axial loading conditions.

As a control measure, tests were conducted in the absence of any bone loss, and repeated in a simulated bone defect treated with a metal block. The latter was analysed with and without augmentation of the tibial tray with an intramedullary stem. With axial loading of 2000N, the tray and block configuration resulted in 21% less proximal bone strain than the tray alone. The combined tray, block and stem resulted in 35% less proximal bone strain than the tray alone. Using the tray and block produced 1.06 times more deflection of the tibial tray and using the tray, block and stem 1.03 times more deflection of the tibial tray than the tray alone in the absence of a bony defect.

There was no statistical difference in overall construct stability (p < 0.05) despite the large strain-offsetting effect recorded using the tibial tray in conjunction with the block and stem

These results suggest that isolated bone defects that can be dealt with using a single block and modern standard tibial tray may not require additional supplementation with a long intramedullary stem.

U.R. Hähnle

Sixty-one lumbar disc replacements in 50 consecutive patients were performed between June 2001 and October 2002. The mean age of the patients was 42.42 years (24 to 61). All presented with mechanical back and/or leg pain. The primary diagnosis was degenerative disc disease. Three patients underwent fusions of another level during the same operation. Seven patients presented with adjacent level disc disease after previous instrumented posterolateral fusion.

The mean postoperative hospital stay was 3.6 days (2 to 8). One patient with a double-level disc replacement and misplacement of the proximal prosthesis underwent revision surgery three days later. Six patients had subsidence on one of the endplates, all within six weeks postoperatively. All but one patient went back to their previous occupation at a mean time of 26 days (7 to 91).

Patients completed questionnaires at 3, 6, 12 and 24 months postoperatively. In the latest follow-up questionnaire, 47 patients said they were satisfied or very satisfied. Forty-five patients would undergo the same operation again or recommend it to friends, two patients were uncertain and two indicated they would not undergo the procedure again. One patient from another country was lost to follow-up, but a telephonic enquiry six months after surgery suggested that he was doing well.

Although our follow-up period is short, the clinical results compare favourably to those in the literature. The rate of immediate subsidence, which seems to be linked to the anchoring teeth, is of concern.

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S. Govender

Twenty-seven patients with neurological deficit due to burst fractures were treated with fresh frozen allografts following anterior spinal decompression. Their mean age was 28 years. In 19 patients the injury was due to motor vehicle accidents and in five to falls. The mean preoperative kyphosis was 19° (4° to 33°). Three patients with laminae fractures, which resulted in entrapment of the dura, underwent posterior decompression and transpedicular fixation before anterior decompression. Corpectomy was performed in all patients. An appropriate length of femoral allograft was positioned by interference fit and the spine was stabilised with an anterior rod screw construct in 21 patients.

The follow-up ranged from 29 to 72 months. Bridwell grade-I fusion was seen in 23 patients at two years. Subsequent follow-up revealed no fracture, resorption or collapse. The mean neurological recovery was 1.4 Frankel grades. Nine patients (37%) made a complete recovery but in four (16%) there was no improvement. The mean postoperative kyphosis was 9° and at two years the mean loss of correction was 3°. One patient presented with a psoas abscess at two-year follow-up. At surgery the graft was partially resorbed but was stable. At six-year follow-up the patient was asymptomatic with a grade-II fusion.

The use of allografts saves considerable time in surgery and avoids potential donor site morbidity. They are versatile and are easily available.

D. van der Jagt S.K. Magobotha

Four low-cost hip prostheses, explanted because of clinical failure within three years, were subjected to a retrieval analysis study to determine the cause of the early failure. The study aimed to determine whether the low-cost prosthesis was substandard and had consequently contributed to the need for early revision. The retrieval analysis included a photographic record, a fractographic examination, an analysis of the material composition of the components, and a mechanical property analysis. These investigations were done in accordance with the ASTM F561 standards.

Results demonstrated substandard qualities in respect of all parameters analysed. We conclude that the inferior quality of these low-cost hip prostheses contributed appreciably to their early failure and revision.

D. van der Jagt A. Schepers

We have previously reported on early lytic lesions occurring when collared titanium prostheses are used. Previous finite element analysis studies (FEAs) showed that lytic lesions of the calcar were due to concentration of polyethylene wear particles under the collar by a ‘pumping action’. Further follow-up of these calcar lytic lesions showed that their rate of increase in size progressively slowed down. Further FEAs were performed to determine why this was so.

An FEA mesh construct was developed, incorporating the new parameters of no contact between the collar and the calcar bone. A mechanical model to determine displacement parameters was also developed. These FEA studies demonstrated that the pumping action of the collar became less efficient as the size of the lytic lesions increased. This led to less concentration of polyethylene particles under the collar and fewer granulomatous reactions. The change in the proximal prosthesis-cement-bone construct may lead to cement mantle deterioration and earlier failure. We still recommend caution when a collared prosthesis is used, and the material and geometry of the prosthesis remain important.

L. Nordsletten G. Flugsrud

This paper investigates the association between risk factors recorded prospectively before primary total hip arthroplasty (THA) and the risk for later revision surgery. The National Health Screening Service in Norway invited 56 818 people born between 1925 and 1942 to participate in an investigation of risk factors for cardiovascular disease and 92% participated. Matching these screening data with data from the Norwegian Arthroplasty Register about primary THA and revision THA, we identified 504 men and 834 women who had undergone primary THA at a mean age of 62 years. Of these, 75 and 94 were revised during follow-up. The mean age at screening was 49 years and the mean age at censoring was 68 years. The mean age of those who underwent revision THA was 57 years. Men had a 1.9 times higher risk of undergoing hip revision during follow-up (95% CI). For each year’s increase in age at primary THA, the risk of revision THA during follow-up decreased by 14% for men and 17% for women. Men who at screening had the highest level of physical leisure activities had 5.5 times the risk of later revision than those with the lowest level of physical activity (95% CI).

Men have a higher risk for revision THA. The older the patient, the lower the risk for revision. Men with intense physical activity in middle age are at increased risk of undergoing revision THA before they reach 70.

D. van der Jagt J.P. Marin R.H. van der Plank A. Schepers

We managed three elderly patients who had central fracture dislocations with early total hip arthroplasty (THA), using anteprotrusio supports. Bone grafting was used to re-establish acetabular bone stock.

Intraoperatively and postoperatively, these patients had no more complications than did patients undergoing THA for hip fractures. However, the surgical times were longer than for routine THA and blood replacement was slightly higher. Patients were mobilised early and aggressively. All became independent walkers and regained good range of movement. Radiologically the acetabular/pelvic fractures united and good bone-implant interfaces were established. There was no excessive heterotrophic bone formation.

We regard THA in the management of acetabular fractures in the elderly as a reasonable approach, enabling patients to mobilise early and keeping morbidity to an acceptable level.

A. Schepers D. van der Jagt

In June 1999 we instituted a prospective, randomised, double blind study to determine whether in the use of the Profix® total knee replacement system the addition of screws improved the fixation of the tibial base plate. There were 145 arthroplasties in 137 patients, 77% of them female. Their mean age was 66 years. In 86% of the patients there was osteoarthritis and in 14% an inflammatory arthritis. On a random basis, supplementary screws were inserted through the base plate into the tibia in 49% of arthroplasties and the remaining 51% were not fixed. In both groups the postoperative femoral angle measured 95% and at 12-month evaluation the tibial angle measured 89°, giving a total valgus angle of 6°. To date no tibial base plates have come loose. It is felt that the large central titanium peg plays a major role in assisting fixation of the base plate to the tibia and that supplementary screws are unnecessary. There is a small cost saving when screws are not used. We postulate that one may in the future minimise polyethylene debris tracking and osteolysis.

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I.M. Rogan

From September 1995 to March 2003, 15 patellofemoral joint replacements were done on 13 patients. The mean age of the one man and 12 women was 62 years. Osteoarthritis was the reason for surgery in 13 of the 15 knees. In the other two it was post-traumatic arthritis. Three different products were used: Avon (eight), Link Lubinus (five) and LCS patellofemoral prostheses (two). One patient has subsequently been revised to a total knee replacement. Recommendations are made regarding selection of patients and implants.

J. de Beer D. Petruccelli

In a retrospective review, 38 consecutive Workers’ Compensation (WC) patients undergoing primary total knee arthroplasty (TKA) were matched to a cohort of non-WC patients for demographics and preoperative diagnosis. Outcome measures included the Knee Society Score (KSS), the Oxford Knee Score, the McGrory Modified Knee Score (MMKS), patient satisfaction and number of postoperative clinic visits. Unpaired t-tests were used to determine differences in outcomes. Pre-operative KSS, pain and flexion range as measured by KSS, and Oxford scores displayed no statistical differences. The differences in the two groups at six weeks was significant in respect of KSS (p =0.0005) pain as measured by KSS (p =0.015), and flexion range (p =0.012). At six months similar results were noted in pain as measured by KSS (p =0.018), Oxford scores (p =0.005) and flexion range (p =0.035), but KSS function was not significant (p =0.073). One-year Oxford scores (p =0.013) and flexion range (p =0.013) were statistically significant, as were MMKS (p =0.001), patient expectations (p =0.030), perceived quality of life (p =0.009), and number of postoperative clinic visits (p =0.003).

The short-term outcomes of primary TKA in patients receiving workers’ compensation benefits are inferior to those obtained by non-workers’ compensation patients. Workers’ compensation patients are seen more often for postoperative follow-up, which we would attribute to the persistence of subjective complaints following primary TKA.

D. van der Jagt S.K. Magobotha S. Naido A. Schepers

Over five years, 85 low-cost primary total arthroplasties (Eortopal Bulteamex) were done at a referral hospital. These were followed up for a mean of 48 months (minimum of 18 months). There were 11 revisions (13%), with four (4.7%) necessary for aseptic loosening, two (2.3%) for recurrent dislocations, four (4.7%) for sepsis and one (1.3%) for a periprosthetic fracture.

When these results were compared with the Trent Regional Arthroplasty Register, the revision rate was noted to be four times higher than in the Trent study, with aseptic revisions being twice as high and infection rates three times higher. Dislocation rates were half those in the Trent study. We concluded that our lower dislocation rate probably reflected the quality of our surgery. Our higher sepsis rate was probably related to the hospital environment, and the high aseptic loosening rate due to the quality of the ‘low-cost’ prosthesis.

We conclude that to be cost-efficient, ‘low-cost’ pros-theses must be of good quality and that the hospital environment must be optimal. This study highlights the need for an Arthroplasty Register in South Africa.

D. van der Jagt A. Schepers

Complex acetabular defects after failed total hip arthroplasty (THA) remain a major challenge in revision surgery. We managed 29 patients, of whom 27 had type-III and two type-IV defects (AAOS classification).The mean age of the 16 men and 13 women was 68 years (22 to 96).

Use of a modular uncemented acetabular revision system allowed us accurately to position the construct, and then optimise the orientation of the polyethylene liner in respect of stability in the reduced hip. The modularity of the system allowed good access to do an impaction bone graft to restore the defects in the bone stock.

Our follow-up ranged from 2 to 25 months. The orientation of the acetabular construct was measured radiologically and was at 50°. Our complications included four dislocations, two transient nerve palsies, one deep infection, four deep venous thromboses and one death from a pulmonary embolism. We conclude that the use of a modular acetabular reconstruction system is promising in these extremely difficult cases.

L. Nordsletten O. Talsnes

The purpose of this study was to compare old and new techniques in hemiprosthesis for primary femoral neck fractures. We implemented a new technique for inserting the Charnley stem via the Hardinge approach. This included a distal centraliser, broaches and specific entry into the femoral canal via the piriformis fossa. We then compared stem alignment and cement mantle quality in old and new techniques. The sample comprised 42 patients (34 women) who had been operated on with the old technique and 49 patients (39 women) exposed to the modern technique.

Postoperative anteroposterior and true lateral radiographs were taken and evaluated for cementing quality, mantle thickness in the 14 Gruen zones and alignment of the femoral stem in both planes. On the Barrack classification there were nine grade-A with the new technique, compared to none with the old. There was one Grade-B with the old technique. With the new technique, cement mantle thickness and uniformity was better in Gruen zones 1 to 3, 5 to 10, and 12. Alignment as measured in the lateral plane by the mean antero-posterior angle was 5.2° with the old technique and 2.2° with the new (p =0.0001). In the frontal plane there was no difference.

It is hoped the advantages associated with this modern technique for inserting the Charnley stem will confer longer survival.

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R. Craig G. Horne P. Devane

The purpose of this study was to document difficulties encountered by orthopaedic surgeons with the removal of titanium implants.

A postal questionnaire was sent to all members of the New Zealand Orthopaedic Association seeking to document difficulties with the removal of titanium implants: screws, plates or intramedullary nails. The questionnaire included length of device implantation, estimated increase in theatre operating time over the expected time for the procedure, and complications encountered during the device removal.

Twenty six surgeons responded to the study. Six reported no difficulties in removing implants, 18 reported significant difficulties, and 2 had not had to remove titanium implants. Of the 18 surgeons reporting difficulties, 10 had problems with intramedullary nails, 4 with plates, 6 with screws and 1 with another device. The estimated increase in operating time varied between 20 and 140 minutes. Major complications reported included breaking intramedullary nails, screw heads shearing off, and damage to the underlying bone.

This survey demonstrates significant problems in removing titanium implants. Surgeons need to be aware that when using these devices difficulties with their removal can be encountered and patients should be warned that further injury may be sustained during device removal.

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R.O. Nicol

Hallux rigidus was first described by Davies-Colley and Cotterill in 1887 and varied management techniques have been described by authors since. This paper carries out an audit looking at the management of hallux rigidus in 108 patients.

A retrospective study was carried out on 108 patients coded as hallux rigidus/hallux valgus over a ten year period from 1992 to 2002 (33 male and 75 female) with a follow-up range from 3 to 144 months. Thirty three toes (27 patients) were fused, 20 toes had Tel Aviv procedures (17 patients) and 61 patients were managed conservatively.

Of the 33 toes fused, 18 required a second procedure in the form of wire removal, two developed transient transfer metatarsalgia, one developed IP joint pain and one had asymptomatic fibrous non-union. Of the 20 Tel Aviv procedures, one toe developed hallux valgus requiring re-operation and two toes had unrelated complications, one requiring re-operation.

A single method of MTP fusion when the audit was performed revealed an interesting outcome. Hallux rigidus must be managed as an ongoing continuum, not a static state.

P.A. Devane J.G. Horne

We have correlated the ‘bedding-in’ response (the high femoral head penetration seen in the first two years after operation) with changes in offset and leg length from opposite normal hip.

Fifteen patients with serial x-rays taken in the first 5 years after operation had measurement of PE wear, femoral offset and leg length change from the opposite normal hip.

There was a weak correlation between increasing the leg length and increasing the offset during operation and increased femoral head penetration (‘bedding-in’) seen during the first two years after the operation. There was no correlation between offset and PE wear after two years in the PCA prosthesis.

Increased tissue tension in the first two years caused an increase in femoral head penetration. This effect is not continued beyond two years.

B.C. Twaddle S. Green

The aim of this study was to improve data collection, audit and research data by integrating a comprehensive patient data collection database into the day to day running of an orthopaedic department.

The day to day processes of the house surgeon and registrar junior staff were analysed and tasks identified that would allow accurate recording and recall of orthopaedic-specific patient data by automating and performing tasks that would improve junior staff efficiency. A database was then designed and implemented with a “front end” that performed such tasks as generating operating lists, tracking ward locations of patients, producing discharge summaries and auditing complications. This database was then introduced on the hospital intranet and the “back end” constructed to gather accurate patient and injury data to allow improved data collection and research.

Information and data collected was a significant improvement on previous methods available to the department. Junior doctor compliance for data entry was high but the system needed monitoring and “cleaning” on a weekly basis to maintain its accuracy. This method of data collection was more accurate than anything available in the hospital and has been surprisingly useful in producing data to support concerns within the department regarding managerial changes in hospital systems.

Use of a database collection system that gathers information by performing day to day tasks for junior staff has been an effective and reasonably accurate method of obtaining useful patient data. It requires regular monitoring to be most effective but has been easily integrated and accepted within the hospital system.

S. Talbot G. Hooper

We have assessed the comparative function of young patients with hip or knee replacement using a high level function score.

A high level function score was developed for assessing running, walking, stair climbing and recreational activity. This was used on a series of patients after a total of 153 joint replacements including 99 THR and 54 TKR.

The groups were comparable with respect to age (average 57 years), gender and follow-up. Comparison between the groups showed that there was no significant difference in walking, stair-climbing and recreational activity. Patients with THR scored better on running ability and overall total score. Other differences noted included lower scores in bilateral joint replaced patients and posterior cruciate sacrificed knees.

Young patients undergoing hip or knee replacement have similar functional outcomes using a high activity function score. There were trends towards superior running ability and overall scores in the THR group.

P.A. Devane J.G. Horne D. McInnes

We have developed and tested the accuracy of a completely automated method for polyethylene (PE) wear measurement of digitised antero-posterior and lateral radiographs.

New computer algorithms have been developed to measure PE wear on digitised hip radiographs. The only user input required is the file name of the x-ray. Validation was performed by simulation of PE wear in an acrylic phantom. Radiographs were analysed with the new software and results were compared to know penetration of the femoral head.

Accuracy using 10 antero posterior and lateral phantom radiographs was within ±0.08mm (95% CI) of the real femoral head penetration. There was no inter or intra-observer error (identical results with all measurements). Perhaps most importantly, this system gave accurate results in 94% of 600 clinical radiographs of variable quality. Only 74% of this same group of radiographs were considered of sufficient quality to allow reliable manual measurement.

This new method of PE wear measurements eliminated inter and intra-observer error, allowing comparison of wear results between different institutions. Accuracy is improved, but still limited by resolution of the scanned image.

E. Ratahi T. Lynskey

Urinary tract infection is a source of organisms responsible for deep infection of hip and knee joint prostheses. In an attempt to reduce the occurrence of post operative urinary sepsis, some orthopaedic surgeons insert indwelling urethral catheters (IDC) immediately prior to surgery with the aim of avoiding urine retention. The purpose of this study was to determine if preoperative indwelling urethral catheterisation reduces the incidence of urine retention following total hip and total knee arthroplasty.

124 patients who underwent total hip and total knee arthroplasty in New Plymouth between April 2001 and July 2002, were randomly allocated to either have an indwelling urethral catheter inserted preoperatively (IDC group), or no catheter (control group). Prior to surgery all patients completed a questionnaire enquiring about a history of urinary obstructive symptoms, or previous urinary tract infection. The two groups were compared with regard to demographic data, questionnaire findings and the amount of post operative opiate usage. The primary outcome measure for the study was post operative urine retention. Urinary tract infection post operatively was considered as a secondary outcome measure.

No difference was noted between the two groups with regard to age sex arthroplasty type, history of urinary obstruction, or previous urinary tract infection. Post operative urinary retention occurred in a significantly less number of patients in the IDC group compared with the control group. No difference in post operative urinary tract infection was noted between the groups with the sample size used in this study.

Our study suggests that the prophylactic use of indwelling urethral catheters prior to total hip and total knee arthroplasty is effective in reducing the occurrence of post operative urine retention.

R. Rowan G. Horne P. Devane

Forty six periprosthetic femoral fractures adjacent to a hip prosthesis have been retrospectively reviewed. Follow up included chart and radiograph review, Oxford Hip Score and SF-12 Global Function Score. Fractures were treated with internal fixation or revision arthroplasty without the use of allograft.

All the fractures united and functional outcome was good. The mean Oxford Hip Score was 26 and the SF-12 was 33. Complications were related to the severity of the fracture according to the Vancouver classification.

These results and a review of the literature support the ongoing management of periprosthetic femoral fractures without allograft.

S. Talbot G. Hooper G. Inglis M. Coates

Our aim was to assess the clinical and radiological medium-term outcome of a series of 153 consecutive total hip arthroplasties performed by two surgeons in Christchurch using the ABG hydroxyapatite-coated femoral stem and Duraloc 100-series uncemented acetabulum.

An independent clinical review using interviews and patient notes and radiological review of immediate postoperative and most recent x-rays was carried out.

At six to eleven years with approximately 95% follow-up, there were no stem failures, but two revisions following a fracture from significant trauma. Two cups were revised for loosening and one cup bone grafted for osteolysis. A dislocation occurred in 4.7% of cases requiring two liner exchanges and one cup revision. A low incidence of thigh pain and excellent radiographic results of the stem with high rates of bony ingrowth and no incidence of significant loosening was a feature of this series.

We report excellent results at medium-term follow up for an unceme4nted HA- coated femoral stem.

W. Heiss-Dunlop H. Hamer R. Pitto

Although a number of agents have been shown to reduce the risk of thromboembolic disease, their use in total hip replacement (THR) remains controversial. Uncertainty exists regarding the safety of chemical prophylaxis as well as the choice of the most effective agent. Previous studies suggested that pneumatic compression with foot-pumps provide the best balance of safety and effectiveness, however too few patients were investigated in randomised clinical trials to draw evidence-based conclusions.

The purpose of this randomized clinical trial was to compare the safety and efficacy of pneumatic compression with foot-pumps versus low-molecular-weight heparin (LMWH) for prophylaxis against DVT.

Inclusion criteria were hip osteoarthritis and age less than 80 years. Exclusion criteria were history of thromboembolic disease, heart disease, and bleeding diatheses. 216 consecutive patients were considered for inclusion in the trial and were randomized either for management with LMWH (Fraxiparin, Sanofi-Synthelabo, France) or with the A-V Impulse foot-pump (Orthofix Vascular Novamedix, UK). Patients were monitored for DVT using serial duplex sonography and phlebography.

DVT was detected in 3 of 100 patients managed with the foot-pump compared with 6 of 100 patients who received chemical prophylaxis (p< .05). Sixteen patients did not tolerate continuous use of the foot-pump and were excluded from the study. The average postoperative drainage was 259ml in the foot-pump group and 328ml in the LMWH group (p< .05). Patients with foot-pump had less swelling of the thigh (10mm compared with 15mm) (p< .05). The patients of the foot-pump group had less postoperative oozing and bruising than did those who had received LMWH. One patient developed heparin-induced thrombocytopenia.

This study confirms the safety and efficacy of mechanical prophylaxis of DVT in THR. Some patients cannot tolerate the foot-pump.

H. Leslie P.J. Burn

To assess the efficacy of stabilising a femur following debridement of established osteomyelitis with a silver coated titanium plate.

A 19 year old male, with an established staphylococcus aureus osteomyelitis of the proximal femur, was treated with debridement and stabilisation of the proximal femur with a silver coated titanium plate, and intravenous then oral antibiotics.

The plate was removed six months postoperatively. Specimens were obtained for microbiology, histology and the implant sent for electron microscopic examination. Serum silver levels were obtained pre and post implantation and following plate removal.

The debrided defect of the femur healed. Specimens obtained at the time of removal showed no evidence of infection, either on culture or electron microscopic examination. Serum silver levels remained well below occupational safety guidelines.

This is an encouraging preliminary report of the potential for stabilisation of established osteomyelitis or infected non-union with a silver coated titanium implant.

P. Hucker C. Dawe

We reviewed the diagnostic and clinical experience with acute osteomyelitis of the pelvis at Tauranga and Waikato Hospitals.

A retrospective review from a prospectively maintained data base was undertaken looking at all cases of pelvic osteomyelitis between 1988 and February 2003 at the two hospitals. Analysis of the diagnostic pathways, time to diagnosis, blood parameters, organism isolation, and type of imaging was carried out. Subsequent treatment including duration of intravenous antibiotic use was correlated with patient outcome.

There were 15 cases of acute pelvic osteomyelitis treated with an average patient age of 11.9 years. The most common causative organism isolated was Staphylococcus Aureus (S. Aureus) with no cases of MRSA. Inflammatory markers (ESR and CRP ) were elevated in the majority of patients but 75% had a normal white cell count. Blood cultures were positive in 90% of cases.3 patients required surgical drainage ( 1 case of turberculosis, 2 cases of staphylococcus aureus) The average duration of intravenous antibiotic therapy was 10 days with subsequent oral therapy for an average of 4 weeks. The minimum patient follow up was for 3 months, and there was no reoccurrence of infection in any patient. At final review all patients had returned to normal activities

Staphylococcus aureus is the most common causative agent in this population. ESR and CRP are the most useful markers and blood cultures are essential. Most cases can be managed non surgically and a shorter course of intravenous antibiotic therapy in this group was not associated with any adverse outcomes or reoccurrences of infections

S. Faraj G. French A. McAuslan

We report a case of septic arthritis of the hip caused by toxigenic Corynebacterium diphtheria in a healthy, immunized child.

A four-year-old boy was admitted to our hospital with a four-day history of right thigh pain, inability to bear weight on the right leg and sore throat of one-day duration.

He was born in New Zealand and had been immunized against diphtheria. On admission he was febrile (37.3°C) with a congested throat. The right hip was flexed and externally rotated. His inflammatory markers were elevated. Aspiration of the hip yielded 8ml of yellow turbid fluid. Gram stain showed gram-positive bacilli. An arthrotomy was performed and the hip drained

Cultures of the aspirate grew Corynebacterium diphtheriae, the toxigenicity confirmed by the national reference laboratory.

The patient was treated with intravenous and oral antibiotics for 6 weeks and he made a full recovery.

Our patient had a history of immunization to diphtheria and this induces a protective level of antibodies against the toxin but does not prevent the bacteria from invading the blood stream and causing infection.

This is to our knowledge the first reported case of septic arthritis caused by toxigenic strain of Corynebacterium diphtheria.

B. Coleman J.A. Matheson

Several surgical techniques have been described of resistant lateral epicondylitis or tennis elbow with variable results. This retrospective study presents the long-term outcome of a single surgeons experience with a modified surgical technique for the treatment of resistant lateral epicondylitis.

Between 1986 and 2001, the senior author performed 171 surgical procedures in 158 patients for resistant lateral epicondylitis. 147 elbows in 136 patients (88%) were independently evaluated at a mean time to follow up of 9.8 years. Patients were assessed using a functional questionnaire and physical assessment. In addition to physical assessment, provocative testing of the extensor origin and grip strength was performed. Patients subjectively rated the result of surgery and these results were compared to objective elbow performance scores.

Subjectively, 97% of patients assessed the result from surgery as good to excellent. Objectively, 97% results were good to excellent using elbow performance scores. Synovial fistulate developed in two patients by day ten postoperatively. One patient required further surgery for a synovial fistula which healed with no sequelae. There were no other complications following surgery. The postoperative range of motion improved in all patients but remained reduced in four patients. There was a significantly worse outcome for patients with Worker’s compensation claim and for cigarette smokers. There was no difference between grip strengths between the operated arm and the non-operated arm. The majority of patients returned to work by six weeks and were pain free by twelve weeks. Less than 5% of patients experienced lateral epicondylitis pain in their elbow post-operatively. A small group of patients altered their occupation or recreational activities due to tennis elbow symptoms.

The surgical technique described produces excellent results in greater than 87% of patients in the treatment of resistant lateral epicondylitis. This procedure produces a low complication rate and is associated with a high rate of patient satisfaction. Patient selection is critical in the surgical treatment of resistant lateral epicondylitis.

W. Heiss-Dunlop A.T. Hadlow

The purpose of this study was to highlight uncommon and confusing clinical problem of unilateral prolapsed intervertebral disc (PIVD) producing contralateral symptoms based on case reports and literature review.

Four cases of patients with disc prolapse contralateral to the symptomatic limb are presented. Two patients had cervical disc herniations, and one patient had a lumbar disc prolapse. All three patients had resolution of their contralateral radicular pain following discectomy.

Few reports have been published of patients with unilateral sciatica following contralateral lumbar disc herniation. The authors described the unique features of their patients’ anatomy and related this to their respective pathology. Coexistence of lumbar spondylosis and lateral recess stenosis, as well as the unique features of the attachments of the dural sac and nerve root sleeves to the surrounding osseous structures serve to provide an explanation for contralateral symptoms.

The cervical spine is quite different from the lumbar spine. Here the spinal cord rather than the more flexible cauda equina fills most of the spinal canal. A number of reports can be found describing Brown-Sequard syndrome as a consequence of cervical disc herniation. The two cases presented are in our opinion also the consequence of direct pressure on the spinal cord. We suggest that pressure on the ascending spinothalamic tracts leads to contralateral pain without other neurological symptoms.

H.J.E. Love

Surgeons working in orthopaedic operating theatres are exposed to significant noise pollution due to the use of powered instruments. This may carry a risk of noise-induced hearing loss (NIHL). This study was designed to quantify the noise exposure experienced by orthopaedic surgeons and establish whether this breaches occupational health guidelines for workplace noise exposure.

A sound dosimeter was worn by the operating surgeon during 3 total hip replacements and 2 total knee replacements. A timed record of the procedures was kept concurrently. Noise levels experienced during each part of the procedure were measured and total noise exposures calculated. Quantified noise exposures were compared with occupational health guidelines.

Noise exposure in total hip replacement averaged 4.5% (1.52–6.45%) of the allowed daily dose (average duration 77.28 min). Total knee replacement exposure was 5.74% (4.09–7.39%) of allowed exposure (average duration 69.76min). Maximum sound levels approached, but did not exceed recommended limits of 110 dBA (108.3dBA in total hip replacement and 107.6dBA in total knee replacement). Transient peak sound levels exceeded occupational health maximum limits of 140dB on multiple occasions during surgery.

Overall total noise dose during orthopaedic surgery was acceptable, however orthopaedic surgeons experience brief periods of noise exposure in excess of legislated guidelines. This constitutes a noise hazard and carries a significant, but unquantified risk for NIHL.

C.L. Birks D.P. Gwynne Jones B.F. Hodgson

We report intermediate term results of a technique of acetabular augmentation using block femoral head autograft and the uncemented expansion cup for adult hip dysplasia.

A retrospective review of one surgeon (BFH) series of consecutive total hip replacements for hip dysplasia using femoral head acetabular augmentation was carried out. The technique involves sectioning the femoral head longitudinally reversing and fixing it to the deficient acetabulum with 6.5mm AO screws. This is then reamed to accept the uncemented expansion cup. Patients were identified from audit databases. Patients completed clinical questionnaires, examination and radiographic evaluation.

Fifteen hips were identified in twelve patients (three bilateral). The average at age at surgery was 54 (44–58) years. There were eight females (eleven hips). Three patients (three hips) were unable to be contacted. Average follow up was 8.4 (4.8–11.4) years. Preoperative centre edge angle was 14 (−10–30) degrees. One patient developed a deep infection requiring early staged revision. One patient was not satisfied with her results at follow up. Mean Harris Hip Score was 83 (63–100), mean WOMAC Score was 76 (50–95). Range of motion was well maintained in all patients. Four patients had other co-morbidities affecting their results. Radiological review shows all grafts to have united with no screw breakage and no cup loosening.

At eight year follow up there is high satisfaction, good clinical and radiological results. These results demonstrate good intermediate term results using this technique in total hip replacement with acetabular dysplasia.

S. Nachiappan S.M. Dempsey

A retrospective audit to evaluate the effectiveness of Tranexamic Acid (TXA) in reducing blood transfusion requirements in primary total knee and hip joint replacements operated on by a single surgeon (SMD).

A survey is being sent to all Fellows of the New Zealand Orthopaedic Association who are currently in clinical practice to evaluate the strategies currently in use for reducing blood transfusion requirements in joint replacement surgery.

All primary total knee and hip joint replacements are included in this trial since February 2003. Two doses of TXA (Cyclokapron) are given at a dose of 10mg/kg intravenously. The first dose is given 10 minutes before the skin incision and the second dose 10 minutes before wound closure in the case of hip replacements and just before tourniquet release in total knee replacements. Haemostasis is secured by diathermy in the case of total knee joint replacements after tourniquet release. One deep suction drain is used.

The use of Tranexamic acid was continued until September when the numbers were collated and compared to a six-month period prior to the use of TXA. Blood loss (both measured and calculated ) and the need for transfusion were the major outcome measures. Complications related to the use of TXA were recorded.

The response rate was 89%. Various strategies to reduce blood loss were used. The mean calculated blood loss in the control group and TXA group were 1196 and 948 ml respectively. The mean measured blood loss in the control group and TXA were 595 ml and 468 ml respectively. This small number of cases – (control 8 and TXA 13) did not reach statistical significance but there was a trend in favour of reduced blood loss with the use of TXA. There was one wound haematoma in the TXA group.

A wide variety of blood conservation strategies are used by New Zealand Orthopaedic Surgeons. The use of TXA in knee joint replacements is a promising strategy.

D.N. Townshend P. Taylor D. Gwynne Jones

The aim of this study was to determine the outcome of carpal tunnel decompression in elderly patients and whether this can be predicted by the severity of pre-operative nerve conduction studies.

A retrospective study was undertaken of all patients over 70 years who had carpal tunnel release (CTR) at Dunedin Hospital between April 1999 and April 2002 with a minimum one year follow up. A grading system for pre-operative nerve conduction studies (NCS) was formulated which scored patients from 1 to 6 according to severity. Patients were followed up by postal questionnaire (Boston Carpal Tunnel Score) with telephone follow up of non-responders.

There were 105 CTR procedures performed in 96 patients. Median pre-operative NCS Score was 4 with 47% scoring 5 or 6. 4 Patients had died. Post-operative symptom severity scores were low and the majority of patients were very satisfied with the results of surgery.

Despite nerve conduction studies consistent with severe median nerve compression, patients had low postoperative symptom severity scores and overall were very satisfied. Carpal tunnel release in patients over 70 years of age is justified and associated with good outcome.

D. Wardlaw S. Choudhary T. Muthukumar S. Gibson

To assess the radiological outcome of instrumented posterolateral lumbar fusion in a prospective randomised study comparing the use of allograft (fresh frozen human femoral head) to autologous bone (from the posterior iliac crest), using a validated method.

One hundred and twenty four radiographs of patients who had undergone instrumented posterolateral spinal fusion were assessed for fusion or non-fusion by three independent observers using the same criteria, and a second time by one of the observers. The Kappa scores for the inter-observer and intra-observer agreement were calculated. Thirty-three of these patients had fusion status verified by the gold randomised to one of two groups, to receive either allograft bone or autologous bone. The same surgeon using the same surgical technique performed or supervised all cases. The radiological results of the two groups were assessed as well as the quality of fusion.

Both the inter-observer and intra-observer kappa scores (k) were 100%. The sensitivity of the method was 87.9% and the specificity was 100%. Thirty-seven patients received allograft and 32 patients received autograft. There was no significant difference in the fusion rate, or the quality and quantity of the graft between the groups.

There is no difference in the fusion rates comparing the use of autograft and allograft for posterolateral instrumented lumbar fusion.

P.A. Robertson L.D. Plank

This is to report an audit of outcomes improvement in Lumbar Fusion patients in a private practice setting using routine application of a robust functional outcomes instrument – the Modified Rowland Questionnaire (MRQ). The MRQ is a validated responsive disease specific functional questionnaire. It ranges from 23 points (maximum disability) to zero (no disability). Potential changes in score are 46 points (−23 to 23). A 4 point improvement is clinically significant.

Two hundred and sixteen patients undergoing lumbar fusion procedures, over a five year period completed an MRQ prior to surgery and at the routine one-year follow up. Changes to the score were documented and analysed in relation to diagnosis, Accident Compensation corporation (ACC) coverage, and revision procedures.

Data completion was 88%. Median disability improvement was 10 points on the MRM questionnaire. Benefit occurred in 80.0% of patients. Improvements were more marked in degenerative spondylolisthesis and isthmic spondylolisthesis than fusions for discogenic back pain although this was not statistically significant. There was a trend to lesser functional improvements in those on ACC and those who had undergone previous surgery.

This study reports an attempt to audit outcomes in a spinal sub specialist private practice using an instrument that can be applied preoperatively and at one year follow up without undue additional work load for the patients or staff. The data completion was acceptable. Functional improvements were significant in all diagnostic groups. Outcomes in revision and ACC patients were not significantly inferior, as they have been described in similar overseas studies.

P. Turner G. Inglis R. Perry

L5-S1 interbody fusion is a successful technique for treating patients with isolated degenerative disc disease. Traditionally through an open technique, the anterior laparoscopic approach for this was first described in 1991.

The purpose of this study was to review the long-term outcome results of L5-S1 interbody spinal fusion, using an anterior endoscopic technique, performed on patients with isolated degenerative L5-S1 disc disease. The first 41 spinal fusions performed by the senior authors were analysed. Patients received clinical, functional and radiological review by an independent assessor.

Clinical outcomes were excellent with > 90% of patients having significant improvement in back assessment scores (Fraser and Greenough, Japanese Orthopaedic Association). There were no intraoperative complications, no vascular complications, and no reports of retrograde ejaculation.

The anterior endoscopic approach for L5-S1 inter-body fusion results in good clinical outcomes, with a very low rate of morbidity. Surgical recovery time is quicker compared to open techniques, however, two skilled surgeons and an increase in theatre resources is required.

I. Elkinson P.A. Robertson L.H. Galler

Spinal epidural sepsis is more widely recognised with MRI. Treatment includes antibiotics, multisystem support and drainage of pus. Neurological loss will often be stabilised but dramatic recovery is infrequent, explaining the importance of early intervention. This series highlights a very sinister spectrum of spinal infective disease despite ideal traditional treatment for spinal skeletal infection.

This is a retrospective case series review of five patients.

All patients presented with regional spinal pain, fever and regional musculoskeletal infective foci (e.g. discitis). Mild neurological abnormality existed in three patients. Rapid multisystem collapse occurred with the need for ventilatory support, despite institution of appropriate antibiotic treatment for all patients. All had grown Staphylococcus Aureus from blood cultures. Subsequent extensive quadriparesis/plegia developed, and repeat imaging demonstrated wide spread epidural pus in the cervical spine. Surgical treatment was considered but not performed when the prognosis was so poor neurologically and medically, and when the widespread epidural pus was so inaccessible. All patients died rapidly upon withdrawal of supportive treatment.

This paper describes a sinister spectrum of spinal infection with catastrophic complications despite “appropriate” treatment for previously diagnosed spinal foci infection. Positive blood cultures and fever alert to these dangers, and multisystem collapse heralded the development of cervical epidural infection. Possible interventions include early MRI scanning of the whole spine, more aggressive (than traditionally accepted) surgical treatment of infective foci in the spine in these circumstances, and minimally invasive cervical canal decompression procedures with multiple laminotomies.

N Aebli G. Davis J. Krebs D. Schwenke J-C Theis

To investigate the effect of pressurizing vertebral bodies during vertebroplasty using different materials in the development of fat embolism (FE) and any associated cardiovascular changes.

Polymethylmethacrylate (PMMA) is the material of choice for vertebroplasty (VP). However, PMMA has several disadvantages such as exothermic curing, uncertain long-term biomechanical effects and biocompatibility. As a result alternative materials are being developed to overcome these problems.

In order to determine the role of PMMA in the generation of cardiovascular changes following vertebroplasty we compared injection of cement with wax in an animal model.

In twenty sheep, four vertebral bodies were augmented either with PMMA or bone wax. Heart rate, arterial, central venous and pulmonary artery pressure, cardiac output and blood gas values were recorded. At postmortem the lungs were subjected to histological evaluation.

The consecutive augmentation of four vertebral bodies with PMMA induced cumulative fat embolism causing significant deterioration of baseline mean arterial blood pressure (MABP) and blood gas values. Injection of bone wax resulted in similar cardiovascular changes and amount of intravascular fat in the lungs.

Conclusion: In this animal model cardiovascular complications during multiple VP happen regardless of the augmentation material used. The deteriorating baseline MABP during VP is associated with the pressurization and displacement of bone marrow/fat into the circulation rather than caused by polymethylmethacrylate.

G.J. Coldham T. Geddes

To assess the outcome and safety of transarticular C1-C2 screw fixation

The clinical and radiological outcomes of 15 patients treated with posterior atlantoaxial transarticular screw fixation and posterior wiring was assessed at a minimum follow up of six months. Indications for fusion were rheumatoid arthritis in eight (instability in six and secondary degenerative changes in two), non union odontoid fracture four, symptomatic osodontoideum one, C1-C2 arthrosis one and irreducible odontoid fracture one. Fusion was assessed with plain x-rays including flexion – extension films.

Twenty nine screws were placed under fluroscopic guidance. Bilateral screws were placed in 14 patients and a single screw in one patient. This patient had a single screw placed due to the erosion of the controlateral C2 pars by an anomolous vertebral artery. All patients had radiological union. Two screws (7%) were malpositioned, neither was associated with clinical sequelae. No neurological or vascular injuries were noted.

Transarticular C1-C2 fusion yielded a 100% fusion rate. The risk of neurological or vascular injury can be minimised by thorough assessment of pre operative CT scans to assess position of the vertebral artery and use of intra operative lateral and AP fluroscopy.

A.G. Epps K.F. Taylor M-C Waugh

Recent years have seen a decided swing from the longstanding inpatient model of rehabilitation to an outpatient model for all branches of medicine in Australia. This swing has been largely cost-driven and is unlikely to change.

This paper reports on the development of a Paediatric Spinal Outreach Team (ORT) in New South Wales (NSW). The ORT was formed in 1993 and consists of a nurse, physiotherapist, occupational therapist and a social worker. It functions in close collaboration with the two children’s hospitals in Sydney. Approximately 10–11 new cases of paraplegia/quadriplegia occur in children/adolescents (up to 18 years of age) in NSW each year (population approx. 6 million). Their therapeutic needs change with growth, development and maturation. Families in regional NSW have special requirements and web-site information services (distance education) will play an important role for them in the future. Integration with an organisation which provides ancillary services is essential for a comprehensive, state-wide programme.

It is suggested that a comparable service would play an equally important role in other countries. Case studies to demonstrate savings to be made with this type of service need to be done to secure recurrent government funding.

J.S. Yeap A.H. McGregor K. Humphries A.L. Wallace

The purpose of this study was to assess the technique of ultrasonographic evaluation of anterior shoulder translation from an anterior approach.

Anterior translation in the right shoulders of 23 volunteers was evaluated using ultrasound with a 10 MHz, 6 cm wide linear transducer. A translatory force of 90 Newtons (N) was used to translate the humeral head in the adduction and internal rotation position (Position 1), while 60 N was used in the more clinically relevant position of 90° abduction and external rotation position (Position 2).

The overall intraobserver coefficients of variation ranged from 0–13% (mean 3.8 ± 2.5%) for examiner 1 and 0.5–20.9% (mean 5.1 ± 3.9%) for examiner 2. The overall interobserver variation ranged from 0–29.8% (mean 9.3 ± 7.3%). The anterior translation in Position 1 ranged from –2.6 to 12.9 mm (mean 2.1 ± 3.1 mm) for examiner I and from −4.1 to 4.7 mm (mean 1.1 ± 2.2 mm) for examiner II. The anterior translation in Position 2 ranged from −3.3 to 3.7 mm (mean 0.3 ± 1.9 mm) for examiner I and from −8.3 mm to 4.5 mm (mean −0.7 ± 2.6 mm) for examiner II. The intraclass correlation coefficients (r) for the measured anterior translation between the 2 examiners for the 2 positions were 0.029 and −0.058 respectively.

The interobserver coefficient of variation remains excessive and there was poor agreement in the measured anterior translation. The finding of negative values in the measured anterior translation despite translatory force raises further concerns about the prospective clinical use of this technique at the present moment.

P. Turner T. Lynskey

Unicompartmental knee arthroplasty has been a popular treatment option for osteoarthritis, since popularised by Marmor in the early 1970’s. The Miller-Galante prosthesis has been in widespread use in Taranaki since 1992. The initial results were encouraging, however, recently a number of failures have caused us to review our results.

The indications for the procedure were osteonecrosis or osteoarthritis limited to one tibiofemoral compartment of the knee. 145 patients were available for assessment from January 1992 – December 2001. Patients were retrospectively reviewed with a clinical assessment, questionnaire and radiographic examination. The Knee Society Scoring System was used. There were 175 knees available for review.

There was 100% follow-up. The average age of patient was 69 years. The average follow-up time was 6 years. The10 year survival was 94%. The major cause for failure was polyethylene wear (4.5). There was no statistical difference between age, tibial insert size and different surgeons.

The unicompartmental Miller-Galante knee prosthesis has very good results at 10 years. However, a high percentage of polyethylene wear is a concern and requires further investigation into the possible causes for this.

E. Hohmann A. Schmid

Traumatic shoulder dislocations at young age result in a significant re-dislocation rate and lead to chronic instability. Conservative treatment fails in 25–96% of cases especially in young active patients. The accepted standard treatment is the classical open Bankart repair which almost always results in loss of motion. The development of new techniques and devices has lead to an increase in arthroscopic techniques for shoulder stabilisations.

Between September 1996 and October 2000 262 arthroscopic shoulder stabilisations were performed by the senior author: 159 cases FASTak® titanium anchors, 26 Panalok® anchors and 57 cases Suretac® anchors were used. Minimum follow up was 12 months with a mean follow up of 24.9 months (12–50). Rowe score and a visual analogue scale was used to measure patient satisfaction.

The Rowe score increased to 83,1 +/− 20,9. The visual analogue score demonstrated overall patient satisfaction. Complications included redislocations(4.7%) sub-luxations (6.3%) and ongoing instability (6.3%). Return to sports occurred in 89.1% of patients with 68.4% being able to return to their previous sports activity level.

This study demonstrates that arthroscopic shoulder stabilisation is comparable to the gold standard open Bankart repair. It is associated with a high patient satisfaction, lower morbidity, faster return to the previous activity level, better range of motion and less postoperative pain. The disadvantage of the technique is a long learning curve and the potentially longer operating times.

E. Hohmann A. Schmid V. Martinek A.B. Imhoff

Posttraumatic shoulder instability is a common problem in the field of sports medicine. Especially overhead athletes need intact stabilisers to meet the functional requirements. Open procedures often result in limitations of movement postoperatively. Arthroscopic techniques offer potential advantages such as better range of motion and shorter rehabilitation times.

Between September 1996 and October 2000 159 arthroscopic shoulder stabilisations were performed with FASTak® anchors. The mean follow up was 24.9 months (12–50). Rowe score and a visual analogue scale were used to measure patient satisfaction. 72 patients (m=57, f=15)with a mean age of 27.6 years (17–65) were included and clinically examined.

The Rowe score increased to 83.1 after primary stabilisation and 68.1 after revision procedures. The visual analogue score demonstrated overall patient satisfaction. 89.1% (n=64) of the patients could return to sports with 68,4% (n=49) being able to return to their previous sports activity level. Overhead athletes returned to sports in 89.4% of cases and 63.3% to their pre-injury level. In the non-overhead athletes 86% returned to sports with 60% to their pre-injury level.

This study demonstrates that arthroscopic shoulder stabilisation with FASTak® anchors may be offered to the athlete regardless of the sports activity. It allows return to sports in a high percentage and does offer the potential advantages of a faster return to the previous activity level, better range of motion and less postoperative pain. Disadvantages of the technique is a long learning curve and should therefore only be performed by dedicated and experienced shoulder surgeons.

B.C. Twaddle S. Parkinson

The aim of this study was to assess the benefit and durability of isolated lateral release for advanced osteoarthritis of the lateral facet of the patellofemoral joint.

A retrospective study of 23 knees in 20 patients who had isolated lateral patellofemoral joint arthrosis treated with arthroscopic debridement and limited open lateral release was carried out. Patients completed a specific patellofemoral questionnaire (35 points) including questions for pain and functional improvement and pain and functional Fisual Analogue Scores (VAS). Eighteen knees in 15 patients were clinically and radiologically examined.

Patients averaged 50 years of age and 2 years from surgical treatment. Visual analogue scores for pain improved 28% and function 40% with little radiological change. Similar improvements were seen in the patello femoral specific questionnaire. The results appeared to be durable over the 2 year follow up period.

Lateral release for treatment of isolated arthrosis of the lateral compartment of the patellofemoral joint is an effective, reliable, durable procedure in carefully selected patients.

T.K.F. Taylor J. Melrose

Calcification of a thoracic intervertebral disc (IVD) with prolapse and root syndromes/spinal cord compression in humans are well-documented entities. The mineral phases have been identified. Similar pathology occurs very rarely in children. It is also seen in dogs, especially the short-legged, chondrodystrophoid (CD) breeds, which are prone to disc degeneration, and in older sheep. The latter exhibit some morphological CD features.

This study is based on radiological/histological/electron microscopic/x-ray diffraction studies of human operative specimens and post-mortem adult animal tissues

The transitional zone (TZ), the interface between the nucleus pulposus and the annulus fibrosus, is the area of the IVD most sensitive in children and adults to the events which lead to dystrophic calcification. The TZ is the “growth plate” of the IVD and the site of maximal proteoglycan and protein synthesis. Giant hydroxyapatite crystallites are the dominant mineral phase in the human (children and adults) and canine pathology. Nucleation occurs in degraded matrix.

The new observation of the type and distribution of calcification in the elderly ovine IVD suggests this animal is a suitable model for further research into the enigmatic phenomenon of so-called dystrophic IVD calcification.

K. Adams D. Sharp G. Horne P. Devane

Single-stage bilateral total knee arthroplasty is an uncommon and often controversial procedure. Recent reports have refined the data relative to bilateral total knee arthroplasty and complications which include myocardial infarction, deep vein thrombosis, pulmonary embolus and death. Less significant complications, including post-operative ileus and pseudo-obstruction are also more common following bilateral replacement.

A retrospective study of the cases of total knee arthroplasty performed by the senior authors in the last ten years, examines details of surgery and anaesthesia, pre and post-operative management to identify the occurrence of complications. Patients also completed an Oxford Knee Score and a questionnaire relating to their experience of having a bilateral procedure.

While the outcomes and cost benefits of single stage bilateral replacement are established, the risk of complications remains. This study establishes the low complication rate associated with this procedure in the senior authors’ hands, and documents the high patient satisfaction from it.

The study demonstrates that, in selected patients, simultaneous bilateral knee replacement surgery can be performed with good outcomes without a definite increase in perioperative risk.

P.A. Devane J.G. Horne

A new method of polyethylene wear measurement for analysis of serial radiographs of the same patients over a 10 year period is described.

Eighteen patients with a PCA THJR had serial radiographs performed with a minimum of 8.5 year follow up. A total of 560 A-P and lateral radiographs were analysed.

The graphs of PE wear v time fell into two groups: Group 1 – (7 patients) had accelerated PE wear with eventual development of osteolysis. Group 2 – (11 patients) had PE wear of less than 0.16mm/year and their latest radiograph showed no evidence of osteolysis.

With improved accuracy and elimination of user error, measurement of PE wear may now have the ability to make predictions about the longterm survival of a THJR. Clinical decisions may be able to be made based on individual patient measurements.

C. Locke D.P. Gwynne Jones J. Pennington J-C. Theis

To determine whether increased sagittal laxity has an effect on functional outcome following posterior cruciate retaining total knee replacement using two differing tibial insert designs.

Ninety-seven patients were reviewed clinically, radiologically and underwent KT1000 testing of their TKR at a minimum follow up of 5 years (mean 6.5 yrs). The femoral component design was the same in all patients (Duracon/PCA). Fifty two patients had a relatively flat tibial insert design (group 1), while 45 patients had an AP lipped insert (group 2) following a change in design in 1995.

The 2 groups were comparable for age, sex, Charnley category, BMI, tibial slope and follow up. There was no significant difference in laxity measurements, IKS or WOMAC scores between the groups. There was no significant correlation between laxity and outcome score or flexion range.

Increased sagittal laxity in a knee replacement does not have a strong influence on functional outcome. The differing tibial insert designs had no significant effect on either laxity or function.

F. Phillips P. Armour

To review local experience using the Avon patellofemoral arthroplasty

All patients were retrospectively reviewed with respect to function, radiology and satisfaction

Fourteen patients were followed up. There were no revisions and very good functional outcome. Patient satisfaction was high.

The Avon patellofemoral arthroplasty is an effective implant in selected patients.

E Hohmann A.B. Imhoff

High tibial osteotomies are commonly performed for varus/valgus malalignment of the knee. In the past we have been well aware that a high tibial osteotomy corrects the coronal plane but we did not consider changes of the tibial slope. Altering the slope has an impact on the in situ forces of the cruciate ligaments and influences the stability of the knee. The purpose of this study was to investigate the amount of alteration of the tibial slope by a closed wedge osteotomy.

From January 2001 to September 2001 we reviewed retrospectively all Xrays of patients that underwent a high tibial osteotomy or were admitted for removal of hardware. 80 patients were included. 67 patients could be followed up.

The slope on the preoperative xrays was 6,1 degrees (0–12). A closed wedge osteotomy decreased the slope by a mean of 4,88 degrees. A high tibial osteotomy of six degrees in the coronal plane decreased the slope by 4.29 degrees, a HTO of eight degrees decreased the slope by 7 degrees, a HTO of ten degrees by altered the slope by 4.75 and of twelve degrees by decreased the slope by 6.5 degrees.

A closed wedge osteotomy decreases the tibial slope. It is the preferred technique when a combined procedure (HTO and ACL reconstruction) is planned. There is no correlation between the degree of correction of the coronal plane by a closed wedge high tibial osteotomy and changes of the tibial slope.

A.P. Stokes J. Calder

Aspetic loosening is a major problem of total hip arthroplasty, especially in young and/or active patients. This study was performed to assess the clinical performance of non-cemented, metal-on-metal implant and complications including loosening and osteolysis at medium-term follow-up.

Between 1994 and 1998, 38 patients (45 hips) had a THA with a Metasul articulation. Thirty-two patients (39 hips) were available for follow up an average of 5.3 years following the operation. Patients were independently assessed by clinical examination, with use of the Harris Hip Score, patient self-assessment forms and radiographs.

The average age was 53.5 years (range 29 to 68) with a diagnosis of primary OA accounting for 34 hips and other diagnoses for 5 hips. The average Harris Hip Score for those patients without a revision was 94.7 points (range 71 to 100). One patient had a revision of a loose femoral component at 16 months, at last review he had a Harris Hip Score of 99.7 points. No patient had a loose or revised acetabular component. Two patients had an early dislocation without sequelae. Thirty-six hips were rated as very good or excellent. There was no radiological evidence of progressive radiosclerotic lines and no other evidence of loosening.

This group of young and/or active patients with Metasul articulations has clinical results equivalent to metal-on-polyethylene articulations. There is no evidence to suggest that the rate of loosening is higher as was documented by previous metal-on-metal designs. At medium term follow up there is no evidence that the metal-on-metal articulation gave rise to any new problems or complications.

A. P. Stokes A. Panting J.W. Ballance

The aim of this retrospective study was to assess the long-term results (minimum ten years) following treatment of medial compartment osteoarthrosis of the knee with high tibial osteotomy using a simple, reproducible technique with minimal internal fixation and early mobilisation.

Between 1980 and 1993, seventy-five lateral, closing wedge osteotomies were performed in sixty-five patients by a single surgeon (ALP). A lateral approach was utilised, with stabilisation achieved using two staples and no use of external splints. Twenty-three patients had died prior to this review (twenty-six knees) and the remaining forty-two patients were invited to attend for independent review. The patients were assessed using the Knee Society Knee Score, Tegner and Lysholm activity score, a patient self-assessment questionnaire and radiological review.

The average age of the patients at surgery was sixty-two years (range twenty-six to seventy-seven years), reviewed between ten and twenty-three years (average seventeen years) following the procedure. Results will be presented with end-points of conversion to arthroplasty and patient dissatisfaction and complications discussed. There were no major complications observed during conversion to total knee joint replacement.

The current role of high tibial osteotomy for the treatment of medial compartment osteoarthrosis will be discussed.

M. Clatworthy

The aim of this study was to evaluate the efficacy of the anteromedial opening wedge osteotomy for PCL deficient varus knees with medial compartment degenerative changes

Twelve patients had undergone an anteromedial opening wedge high tibial osteotomy for the PCL deficient varus knee using a Puddu plate. All patients were followed for a minimum of one year. Patients were evaluated prospectively pre-operatively and at follow up by visual analogue pain and patellofemoral pain scores, IKDC II, WOMAC, SF-36 and a radiographic evaluation.

All patients improved from Grade III to Grade I PCL instability. Patients reported a significant improvement in visual analogue pain and patellofemoral pain scores, IKDC II, WOMAC and SF-36.

This technique shows encouraging early results for a complex problem.

E. Hohmann R. Schoettle A.B. Imhoff

Osteochondral autologous transplantation (OATS) is a new technique for the treatment of osteochondral defects.

In a prospective study between April 1996 und May 2001 we used the OATS technique to treat 201 patients (125 male, 76 female) with a mean osteochondral defect of 3,3 cm2. The defect was in the medial femoral condyle in 96 cases, the lateral femoral condyle in 16, the patella in 22, the trochlea in seven, the tibial plateau in one, the talus in 48, the tibial plafond in two and capitellum in four. There were 17 other locations. The procedure was performed either open or arthroscopically. A mean of 2,2 cylinders was transplanted.

The Lysholm score in the lower limbs increased from a preoperative mean of 58,3 (20 to77) to a mean of 90,2 (70 to 100). Treatment by OATS alone increased the score from 65,2 to 91,6. With additional ACL/PCL reconstruction, the score increased from 49,9 to 82,6. The combination of OATS, HTO, ACL/PCL reconstruction increased the Lysholm score from 55,5 to 85,5. Ten per cent of patients complained of pain at the donor site in the lateral femoral condyle. There were no complications related to OATS performed in the upper limbs, and control MRI three months postoperatively showed incorporation of all cylinders.

The results are encouraging, and give rise, to the hope that this cost-effective and safe treatment for limited osteochondral defects may delay or even prevent the onset of osteoarthritis.

W.P. Yau J.W.K. Wong K.Y. Chiu T.P. Ng W.M. Tang

Two hundred and thirty six posterior stabilized total knee arthroplasties were performed consecutively. Twenty seven patellar clunk syndromes were identified in 25 patients. Insall-Salvati ratio, position of joint line, postoperative patellar height and anterior-posterior position of tibial tray were measured. We found that post-operative low-lying patella (p< 0.001) and anterior placement of tibial tray (p=0.011) was associated with patellar clunk syndrome. Thirteen patients had bilateral total knee replacements of the same prosthesis (5 bilateral AMK and 8 bilateral IB) but unilateral patellar clunk syndrome. The non-clunk sides were used as control for comparison with the clunk sides. The congruency and tilting of the patellar button in the skyline view were documented. We observed that the congruency of the patella button was less satisfactory in the clunk side (p=0.019).

S.S. Amarasekera R.O. Lander

Our aim was to determine from the general community an understanding of the implications of informed consent, expectations in regard to self-autonomy, appreciation of risk in surgery, the implications of surgical complications, the degree of acceptability of risk for a given complication and views on surgeon liability.

One thousand questionnaires were distributed to members of the general public attending the Palmerston North Hospital as outpatients or visitors (inpatients were excluded).

Less than 20% of respondents appreciated the concepts of battery, negligence, self-autonomy and confidentiality. 59% wanted to know about potential complications in order to assist them in making a decision on whether or not to proceed with surgery. Given options and a discussion of the risks, 64% wished to take responsibility for which surgical procedure they would undergo. 9% were unaware that surgical procedures had risks of serious complications. 10% would not undertake surgery if the risk of a serious complication was one in a million, while 30% would undertake surgery regardless of the risk involved. 21% felt the surgeon would be liable in the event of an unmentioned rare complication.

The grasp of the perceived objective of informed consent is poor amongst the general population. The tolerance for medical negligence is low and expectations in regard to self-autonomy seem unrealistically high. We feel it is necessary to revisit ‘informed consent’ and for the public (and the legal profession) to make ‘informed consent’ a practical goal-orientated patient/doctor friendly process rather than the existing ‘legal obstacle’ that it is.

J-C. Theis D. Schwenke S. van Rij J. Krebs N. Aebli

The ability to assess the blood flow to a bone (IBF) is important for orthopaedic surgeons when deciding the fate of an injured or diseased bone. Currently there is no easy and effective method for quickly assessing the blood flow status of a bone. There is accumulating evidence that suggests that IBF may be correlated to intraosseous pressure (IOP).

Therefore, we aimed to investigate whether the two variables are correlated so that the orthopaedic surgeon could confidently use IOP as an indicator of IBF.

Using 8 mature female ewes (B.W. ~56 kg) we measured cardiovascular (eg. arterial blood pressure – ABP), and intraosseous (ie. IOP and IBF) responses to nor-adrenaline (0–1.5 μg/kg/min. i.v.) and nitroglycerine (0–80 μg/kg. i.v.) IBF was measured using semi-quantitative technique of laser Doppler flowmetry (LDF).

Our results revealed that changes in ABP were directly correlated to changes in IOP (p < 0.001). Due to technical difficulties that were encountered when using LDF, the collected IBF data were limited. However, there was compelling evidence that there is a positive and direct correlation between IBF and IOP.

This opens an exciting possibility of using IOP for quickly and accurately assessing IBF as well as providing insight into the pathological mechanisms responsible for bone and joint disorders.

A. Carstens K. Callon U. Bavu R.P. Pitto J. Cornish

Regeneration of bone is an important goal in orthopaedic surgery, such as in augmentation of fracture healing, spinal fusion and filling of osseous defects. The repair of a critical skull defect is a well-established model for investigating the efficacy of cell signalling factors and biomaterials in inducing new bone formation. We aimed to investigate a 5-mm critical skull defect in the mouse, as an in vivo tool for analysis of potential bone active factors that have been bioprospected from dairy milk protein.

Adult Swiss CD1 mice were divided into 2 groups. Each group contained animals treated with vehicle (n=11), milk protein (4mg, n=10) and TGF-b1 (2μg, n=6). Under anaesthetic a high-speed burr was used to create a 5-mm craniotomy in the left parietal bone and a precut collagen sponge with 20ml of the test factor inserted. Fluorochrome labels were administered to facilitate quantitative histological analysis of the defect. The animals were sacrificed on days 14 and 28 and the calvariae excised and fixed. The defects were assessed for percent closure using radiography, transillumination and histology.

The formal analysis of this study is underway at present. Preliminary work in our laboratory with this milk protein has shown it to be a novel bone active factor. In vivo, local injection above the calvariae in adult mice resulted in significant increase in bone area and dynamic histomorphometric indices of bone formation. In vitro, the protein is anabolic, an effect that is consequent upon its potent proliferative and anti-apoptotic actions in osteoblasts, and its ability to inhibit osteoclastogenesis.

TGF-b1 has been shown in the literature to augment the healing of critical skull defects and is included in this study as a positive control.

We believe the critical skull defect in the mouse may be a useful means to assess the role of potential bone active factors in wound healing.

The purified milk protein used in this study may have a physiological role in bone growth and a potential therapeutic application in bone regeneration. We await formal analysis of the specimens to further elucidate this statement. Further experiments will be required to determine whether it provides results that are reproducible and/or comparable to other models of fracture repair.

G.S. Vane S.F. McMahon D.P. Gwynne Jones

We compared initial fixation strength of two commonly used tibial side hamstring ACL reconstruction fixation implants – the RCI interference screw and the Intrafix device.

Using a sheep model 36 hamstring grafts were prepared and implanted into the distal femoral metaphyseal bone using either a RCI screw or an Intrafix device. They were then pulled out until failure using an Instron Materials Testing Machine. Maximum strength of graft fixation and mode of failure were recorded.

The average strength of the graft was 48kg using the RCI screw and 90 kg using the Intrafix device. This difference was statistically significant. The maximum pull-out strength was 91kg for the RCI screw and 130 kg for the Intrafix device. The most common mode of failure in the RCI screw fixation was graft shredding on the screw and whole graft pullout whereas in the Intrafix device it was intratendinous failure.

The Intrafix device demonstrated a clear strength advantage over the RCI screw with regard to initial fixation strength. The Intrafix device may reduce tibial side graft creep which is a problem with hamstring ACL reconstruction.

A.G.S. Vane D.P. Gwynne Jones S. McMahon

The aim of this surgery was to determine current practice amongst orthopaedic surgeons in New Zealand with regard to Anterior Cruciate Ligament Reconstruction.

All current members of the NZOA were sent a questionnaire on the numbers and proportions of grafts performed, methods of fixation, operative technique and return to sport.

One hundred and ten of 140 questionnaires were returned completed. Ninety two orthopaedic surgeons were performing ACL reconstructions. Eight per cent performed patellar tendon grafts in preference to hamstring grafts, whereas 16% preferred hamstring over patellar tendon grafts. Almost 2000 patellar tendon grafts at an average of just over 20 per surgeon are performed each year compared to just over 500 hamstring grafts at an average of just over 15 per surgeon. Metal interference screws were the most common fixation device in patellar tendon and hamstring grafts.

Patellar tendon grafts are the most common grafts used for ACL reconstruction with 80 % of those surveyed preferring to use patellar tendon over hamstring grafts. Metal interference screws were the most common fixation device. There is reasonable consensus regarding return to activity and sport.

J.M. Monnig

The aim of this study was to assess the injury pattern of patient’s 60 years plus who have required acute orthopaedic admission and the influence this population group will have on orthopaedic services in the future.

A retrospective analysis of orthopaedic patients obtained from our database covering a three-year period (2001–2003) was conducted. We identified those that had been treated with surgical and non-surgical procedures. The demographic injury pattern and length of stay was in-turn assessed in relation to anticipated changes in the population from projected data obtained from Statistics New Zealand.

A review of 1209 orthopaedic patients (60% males) indicated that the majority (92%) required acute orthopaedic admission. Within this group, the most common injury type was a fracture, experienced particularly in the lower limb. Length of hospital stay ranged from 0–188 days. Racial distribution incorporated a number cultures including New Zealand European, New Zealand Maori, Pacific Island, Asian, Middle Eastern, and Indian.

Orthopaedics like many other services should already have begun planning for this population group. Relevant specifications may include increased follow up visits, imbalance between males and females, and the percentage of urban-based patients. With regards to orthopaedic staffing and their skill base services need to look at the possible inclusion of an aged care specialist as part of the orthopaedic hospital team and enhancement of communication between orthopaedics and staff from the geriatric ward. Training packages for orthopaedic staff, in relation to healthcare of the elderly should also be made available.

I.A. Anderson A. MacDiarmid S.F. Malak

Bone autograft contains living cells that participate in the healing process. Fragmentation and heat production during cutting will kill cells. We have investigated how excessive graft fragmentation and heating can be avoided.

Two prototype cutters were fabricated. Each had a single cutting edge at the front end of a 12 mm diameter collection barrel. The principal difference between the cutters was the rake angle (at the cutting edge): 23° on cutter #1 and 45° on cutter #2.

Thrust load, feed-rate, and torque were measured using an instrumented drill press. A total of 58 tests on specimens of fresh bovine cancellous bone (distal femur, ex-abattoir) and medium density polyurethane foam (Sawbones, WA. USA) (density 252 kg/m3) were conducted: twenty-four at 100 rpm and thirty-four at 200 rpm.

Small flake-like fragmented bone chips were encountered at low thrust loads. As thrust load was increased the chips became thicker. The average cutting energy for bone was 43.7 Nm (s.d. 48.2 Nm) for cutter 1 and 37 Nm (s.d. 27 Nm) for cutter 2. The average cutting energy for the foam was 13.9 Nm (s.d. 6.0 Nm) for cutter 1 and 8.1 Nm (s.d. 3.0 Nm) for cutter 2. Polyurethane results showed a similar trend.

A higher rake angle on a bone graft tool is associated with a lower cutting energy. In turn, a lower cutting energy will generate a lower temperature in the graft, a result that is beneficial for cell survival. Graft tool design can also influence bone chip size. These experimental results are being used for the development of cell-friendly tooling.

N. Aebli H. Stich P. Schawalder J-C. Theis

Current research efforts aim at enhancing osseointegration of cementless implants to improve early bone fixation.

The aim of the present study was to investigate whether bone morphogenic protein (BMP) 2 had a positive effect on the osseointegration of hydroxyapatite coated implants.

Hydroxyapatite (HA) implants were coated with BMP-2 and hyaluronic acid (HY) as the carrier or with HY alone. Uncoated HA-implants served as controls. The osseointegration of the implants was evaluated either by light microscopy and pullout tests after 1, 2 and 4 weeks of unloaded implantation in the cancellous bone of 18 sheep.

The BMP-2 coating significantly increased bone growth into the perforations of HA-implants. The proportion of bone-ingrowth at 4 weeks was 32% for the BMP-implants compared to 12% for HA implants. However, BMP-2 did not enhance the percentage of bone implant contact and interface shear strength values.

Conclusion: This study indicates that BMP-2 may help to increase bone growth across gaps of cementless implants in the early stages of bone healing improving fixation and decreasing the risk of loosening.

V. Shim I.A. Anderson R.P. Pitto

Periprosthetic bone density (BD) changes can be tracked using computed-tomography (CT) assisted osteodensitometry. Patient-specific computer-generated models allow for good visualisation of density changes in bone. We describe techniques for generating smooth and realistic finite element (FE) models that contain both BD and geometry from quantitative CT data using cubic Hermite elements.

FE models were created for three patients who had a total hip replacement. CT-scans were performed at 10 days, one year, and 3 years after the operation and calibrated using a synthetic hydroxyapatite phantom. FE models of the proximal femur were automatically generated from the CT data. Each model had on average 300 tri-cubic Hermite elements. Models were least squares fitted to the entire dataset. BD data was also sampled and fitted using the same cubic interpolation functions. Density was displayed using a colour spectrum.

Realistic patient-specific FE models were obtained. Density and changes in BD were easy to identify. The error in the geometric fitting (RMS distance between data points and the model surface) was generally less then 0.5 mm. The average error for the density fitting (RMS difference between each density data point and the interpolation function value at the same point) was 61.64 mg/ml or 3.08%.

CT osteodensitometry’s potential use as a clinical tool for monitoring changes to BD can be significantly enhanced when used in conjunction with realistic patient-specific finite element (FE) models. Realistic models can be generated with an economic use of scan data, thus keeping radiation dosage down.

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A. Carstens U. Bava D. Naot K.E. Callon I.R. Reid S.A. McCowan R.P. Pitto J. Cornish

Paget’s disease of bone is a common disorder characterised by focal areas of increased bone resorption coupled to increased and disorganised bone formation. Pagetic osteoclasts have been studied extensively, however, due to the integral cross-talk between osteoclasts and osteoblasts, we propose that pagetic osteoblasts may also play a key role in the pathogenesis of Paget’s disease. Any phenotypic changes in the diseased osteoblasts are likely to result from alterations in the expression levels of specific genes. To determine any differences in expression between pagetic and non-pagetic osteoblasts and their precursors the gene expression profiles of RANK, RANKL, OPG, VEGF, IL-1beta, IL-6, MIP-1, TNF and M-CSF were investigated in primary cultures of human osteoblasts and in the osteoblast precursor population of bone marrow stromal cells. We present preliminary data of this study.

Trabecular bone explants were finely chopped, washed free of marrow and cellular debris then either snap frozen in liquid nitrogen or placed in flasks to culture outgrowth osteoblast-like cells. Mononuclear stromal cells from bone marrow were isolated and grown in culture flasks. RNA and conditioned media were collected from cultured osteoblasts and stromal cells at confluency. The innovative method of Real-Time PCR, the most accurate technique available at present to quantitatively measure gene expression, was used for the comparison of gene expression levels in our samples. 18S ribosomal RNA was used as an endogenous control to normalise the expression in the various samples.

RANK, MIP-1 and TNF were only detected in stromal cells whereas RANKL, OPG, VEGF, IL-1beta, IL-6 and M-CSF were detected in both osteoblasts and stromal cells. OPG displayed higher expression in osteoblasts while IL-1beta showed higher expression in stromal cells.

To date we have not seen any significant differences in gene expression between pagetic and non-pagetic subjects when comparing a small number of samples. A larger cohort is currently being investigated. We are also comparing levels of secreted proteins in the conditioned media from pagetic and non-pagetic cell cultures. This may lead to further candidate genes involved in the pathology of the pagetic lesion.

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J. Fielden G. Horne P. Devane

Our aim was to assess the impact of the increasing number of patients on orthopaedic waiting lists on general practitioners in New Zealand.

A 10-point questionnaire was developed in association with the General Practice Department at the Wellington School of Medicine, and mailed to 250 randomly chosen general practitioners around New Zealand. One hundred and fifty general practitioners returned the survey.

Sixty three per cent of general practitioners reported having between eleven and thirty patients on an orthopaedic waiting list in their practice. 85% of general practitioners reported spending up to an extra 6 hours per month looking after problems caused by having to provide extra care for the patients. In 90% of cases general practitioners reported that their patients required considerably greater community support in the form of extra physiotherapy, meals-on-wheels and occupational therapy. In 138 cases, general practitioners reported greater levels of stress in the families of patients on waiting lists. The majority of general practitioners reported an increased need for analgesia and night sedation during the period on a waiting list. They also reported substantial increases in paperwork necessary to access social supports.

This study documents the burden on general practitioners produced by the increasing waiting lists, and the re-alignment of waiting lists. This burden is reducing the general practitioner’s ability to deal with routine general practice problems, and likely adversely affects the health of other New Zealanders. There is a need for a study of patients on waiting lists to further assess their needs.

C. Doughty J. Fraser R. Kirk A.D. MacCormick B.R. Parry J.C. Theis N. Trolove J.A. Roake A.M. van Rij

Surgical waiting lists have led to development of clinical priority access criteria (CPAC) for prioritisation of patients selected for surgery. Although introduced widely into clinical practice in New Zealand CPAC tools have not been validated. Reliability studies were therefore undertaken by the CPAC Evaluation Consortium.

Methodology Thirty eight orthopaedic surgeons practising in public hospitals were randomly selected to participate in a prioritisation exercise using computer administered clinical vignettes. Fifty vignettes were developed from the clinical histories of patients selected for total knee arthroplasty (15), carpal tunnel decompression (15) and miscellaneous orthopaedic procedures (20). These were prioritised using each of 3 priority tools producing scores between 0 and 100: visual analogue scale reflecting global clinical opinion (VAS), a generic point scoring system based on points assigned to 5 clinical domains (GOPC), and diagnosis-specific 5 point Likert scale of priority combined with a predetermined table of a range of scores for each diagnosis (ISS).

The extent of inter-surgeon variability was striking but significantly less for ISS than GOPC or VAS. This was entirely explained by the complication of a predetermined table. The other two tools were similar except that the inter centile gap was larger for the clinical opinion based tool (VAS).

As access to elective surgery is determined by a fixed financial threshold a reliable scoring system will ensure equity of access. This seems to be best achieved by using the Integrated Scoring System.

G. Horne D. McInnis P. Devane

The aim of this study was to document the medium-term results of the use of fluted, tapered, titanium femoral stem in revision total hip arthroplasty.

Seventy patients undergoing total hip revision using a tapered, grid-blasted titanium modular femoral stem were reviewed at a mean follow-up time of 47 months. Femoral defects were classified according to the Pak and Paprosky system, and femoral bone quality was assessed with the Bohm and Bischel system. Clinical function was measured by the Oxford Hip Score. Radiograpic analysis was performed in all cases.

Stems were classified as a failure or re-revision in 4.3% of the cases. Three required reoperation for recurrent dislocation, in each case the femoral component alone had been revised during the most recent revision. The postoperative mean Oxford Hip Score was 20.9. Subsidence of the component was noted in 84% of hips but did not cause a significant problem. Final leg length discrepancy was 5.4mm.

The results of this titanium, tapered, grid-blasted modular stem compares favourably with other revision stems including the Oxford Hip Score compared to the results for revisions recorded in the National Joint Register (Oxford Score 24.3). Although technically demanding this stem offers a very satisfactory solution for revision of total hips in almost all circumstances.

T.D. Lamberton J.A. Charity P.J. Kenny A.J. Timperley G.A. Gie

Impaction bone grafting in conjunction with a cemented polished double-taper stem as a technique for revision of the femoral component was introduced in 1987 at our institution.

As at January 2000, 540 cases in 487 patients had been performed by multiple surgeons. All procedures have been studied prospectively, and there are no patients lost to follow-up. We present the survivorship and outcome data for these patients.

Survivorship at 15 years is 90.6 percent (95 percent confidence interval:88–93 percent). Four hundred and six hips in 365 patients remain under active follow up, with 122 patients (134 hips) deceased.

Averaged clinical scores taken preoperatively, 2 years postoperatively and at latest follow up showed marked and sustained improvement: Charnley Pain 2.7, 5.5, 5.3; Charnley Function 2.1, 4.1, 3.6; Charnley Range of Motion 4.0, 5.4, 5.3; Harris Pain 19, 38, 36; Harris Function 18, 32, 28; and Oxford Hip Score 41, 22, 25. There have been 45 failures (8.3 percent) at an average 7.6 year follow up (range 2.6–15.3 years). Technical error contributed to 13 of the 24 non-infective complications, but with improved technique plus the addition of long stemmed impaction grafting, there have been no technical errors since 1996.

Our results show that revision of the femoral component with impaction bone grafting is a reliable and durable technique with an acceptably low complication rate with excellent survivorship at 15 years.

A. Bayan R. Orec R.P. Pitto

In severe hip dysplasia the fixation of the cup becomes a technical hazard, and the augmentation of the acetabulum with an autologous bone graft is helpful when the bone stock is deficient.

Twenty-four patients (25 hips) were operated on between 1993 and 1994; the mean age at operation was 49 years (range, 28 to 71 years). The mean Sharp acetabular angle was 55degrees (range, 45 to 63degrees). The dislocation of the femoral head was graded Crowe 1 in 4 hips, grade II in 5 hips, Grade III in 10 hips, and grade IV in 6 hips. Autologus bone was harvested from the femoral head and from the proximal metaphysis of the femur. The fixation of the graft to the anterior wall and to the roof of the acetabulum was achieved using impaction using the reinforcement ring with hook of Ganz. A separate cohort of 25 patients (25 hips) operated on between 1998 and 1999 was investigated using radiostereometry (RSA).

The clinical outcome of the hips was prospectively reviewed using the Harris hip score at an average of 8.3 years (range 8 to 9 years) postoperatively. Twenty-four hips were pain-free, and had a range of motion of 210 degrees or more except 3. A positive Trendelenburg sign disappeared in 88% of the hips. One cup (4%) showed radiological loosening with migration and required revision surgery. No signs of migration or progressive radiolucent lines were present in the remaining hips. The graft appeared united without resorption in 24 hips. The results of micromotion analysis using RSA confirm the stable fixation of the reinforcement ring in dysplasia.

Satisfactory middle term results of total hip replacement for severe dysplasia can be achieved using appropriate surgery and specific components. The use of reinforcement ring is important to obtain adequate primary stability, and to protect the graft during healing.

D. Ardern T. Lynskey

In 2002, one hundred and thirty nine patients had their names removed from the orthopaedic surgical waiting list at Taranaki Base Hospital for financial reasons. They fell below the “financially sustainable threshold” for access to publicly funded services. We wished to determine the status of these patients and the effects of this management decision.

All patients were invited to attend clinic for assessment. They completed the SF-36 Health Survey and were interviewed regarding effects of not having surgery. In addition, hips were assessed using Harris Hip Scores and knees were assessed using Knee Society Scores.

These standardised methods of assessment allowed comparisons to be made with overseas data. Our group of patients are experiencing significant impairment as a result of not being able to have surgery. A number of resulting medical and social problems were identified in the course of assessment. Patients also expressed a high level of discontent with the process.

Removing patients who have been assessed and placed on an orthopaedic surgical waiting list is an inefficient means of utilising health resources. It has also been met with a high level of patient dissatisfaction.

H. Williams P. Gandar A. Panting J-C. Theis L. Gallagher

This study explores the outcomes of a pilot project involving five Orthopaedic services in developing approaches to improve the consistency and equity of clinical decision-making for access to treatment.

The pilot was conducted in two phases; the first involved development of retrospective and prospective data collection and analysis tools including use of:

The Orthopaedic Integrated CPAC tool:

Euroquol and Oxford Hip and Knee quality of life measures,

A surgical decision construct tool to identify patterns in clinical judgement

A clinician survey Phase two involved a locally managed feedback and improvement process.

Large variations in internal equity were found within most services. Additionally a significant, systemic equity issue is apparent between patients prioritised for major joints versus other conditions. The pilot has made useful progress in developing improvement tools and processes targeting electives service management, improvements in prioritisation and clinical decision making, and funding and planning decisions. The pilot has also raised issues for further CPAC development and national service policy.

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M. Foster T. Lynskey

This is a retrospective study on the Taranaki experience with the Harris-Galante uncemented total hip joint replacement.

Ninety-six Harris-Galante total hip joint replacements were performed in ninety patients between September 1986 and September 1989. Twenty-nine patients died during the study and thirteen patients left the Taranaki area and were lost to follow-up. This left forty-eight patients (fifty hips) for evaluation with an average follow-up of fourteen years (range, thirteen to sixteen years). Results were analysed by questionnaire, clinical examination and x-rays.

Four hips were revised giving a Kaplan-Meier survivorship analysis of 89% at 14 years. Two femoral component was revised due to aseptic loosening at six and eleven years and two acetabular components were revised at 10 and 11 years due to liner dissociation.

The average Harris Hip score improved from 47 points preoperatively to 90 points at six years follow-up then declined to 83 at 14 years follow-up.

Osteolytic lesions were identified adjacent to 17% of acetabular components at follow-up and all were confined to zone two. Eighty-nine percent of femoral radiographs showed evidence of stress shielding however there were no grade four changes.

Osteolytic lesions were identified adjacent to 17% of femoral components at follow-up and were predominantly seen distally in zones three, four and five.

This study demonstrates satisfactory results for the Harris-Galante 1 total hip joint replacement at fourteen years follow-up. Cases should be kept under annual review to assess for progressive osteolysis, liner dissociation and the need for revision surgery.

N.C. Wilson N.S. Stott

Femoral fractures are a common injury in the paediatric population. The purpose of this study was to audit the cost and early outcomes of femur fractures treated at the Starship Childrens Hospital

Forty-eight femur fractures treated between January 1998 and December 2002 were reviewed. 25 fractures were treated by application of an early hip spica, 12 by IM nails and 11 by other methods.

Children treated by early hip spica averaged 3.8 years in age. They went to theatre an average of 29.1 hours after admission and had an average length of stay of 3.8 days. In the 30 days after discharge, five patients were readmitted for loss of fracture position.

Children treated with IM elastic nails averaged 9.5 years and went to theatre on average 35.1 hours after admission. Their length of stay averaged 8.3 days. Complications in hospital included return to theatre to shorten a wire (1 patient), remanipulation and application of a hip spica (2 patients) and difficulty mobilizing (1 patient). In the first 30 days after discharge, two patients required readmission for further surgery due to prominence of the wire.

Children treated with external fixator (7), femoral rod (1) or crossed k-wires (3) averaged 8.7 years in age. They went to theatre on average 58 hours after injury and had an average length of stay of 24 days. Two patients were readmitted with superficial pin-site infections.

Most femur fractures are being operated on the next day, however surgery is delayed in some patients. The readmission rate in the first 30 days is significant and is not reduced by operative fixation. Cost containment should focus on ways to reduce the early readmission rate.

P. Phadke A. Trenholm M. Bosse S. Sims J.F. Kellam

Open long bone fractures have been considered orthopaedic emergencies requiring immediate irrigation, debridement and stabilization. Concomitant traumatic brain injuries may preclude the immediate operative treatment of open fractures. The purpose of this study was to review patients with open tibial diaphyseal fractures whose operative tibial fracture management was delayed because of a concomitant traumatic brain injury to determine if there is an increased rate of infection or non-union.

After obtaining IRB approval, the trauma registry was scanned for patients who sustained both traumatic brain injury with an Abbreviated Injury Scale (AIS) equal to two or greater and an open tibial diaphyseal fracture. From January 1, 1996 to June 1, 2001, 28 patients with 31 open tibial shaft fractures were identified (Grade I=1, II=6, IIIA=17, IIIB= 7). There were 24 males and 4 females with an average age of 35 years (range 13–69 years of age). The mechanism of injury was motor vehicle collision or pedestrian versus motor vehicle accident for all patients. The mean time to operative irrigation, debridement, and stabilization was 11 hours (range 2–152 hours). Thirteen patients underwent operative orthopaedic treatment within 8 hours (mean 4.4 ± 1.3 hours), and 15 patients underwent delayed debridement (mean 35 ± 35 hours). Twenty fractures were stabilized with intramedullary nailing, 9 fractures were stabilized with external fixation, one fracture was stabilized with a compression plate, and one fracture treated in a cast. A review of clinic records and telephone follow-up interviews was used to determine the rates of infection or non-union. Infection was defined as a positive deep surgical culture for bacteria upon repeat irrigation and debridement. Non-union was defined as any clinically and radiographically unhealed fracture requiring further operative procedures.

The average length of follow up was 2.9 years (range 1 month to 6.5 years). Of the 31 open tibial diaphyseal fractures, four fractures (12.9%) were complicated by infection and four fractures (12.9%) went on to non-union. There was no statistical difference in the rates of infection or non-union in patients who underwent irrigation and debridement within eight hours and those that underwent irrigation and debridement after eight hours from the time of initial presentation (odds ratio=1.02, p=0.15). Furthermore there was no correlation between the ultimate presence of infection/non-union and grade of open tibial shaft fracture, initial method of fixation, timing of wound closure (immediate, delayed primary closure, or split-thickness skin graft or flap), severity of overall injury, and epidemiological characteristics.

In this subset of 28 patients with 31 open tibial shaft fractures and concomitant traumatic brain injuries, there was no difference in the incidence of infection or non-union in patients who underwent operative treatment within eight hours of admission to hospital and those who underwent operative treatment after eight hours. The results of this study should be considered in the prioritization of care for the multiply injured trauma patient.

J. Munro R. Schmidt T. Nowak R.P. Pitto

The purpose of this study was to evaluate the clinical outcome of a hydroxyapatite (HA)-coated tapered stem and to assess bone remodelling of the proximal femur using quantitative computed tomography osteodensitometry.

Fifty consecutive hips were managed with total hip replacement using the Cerafit Multicone H-A.C. stem with HA coating and the Cerafit Triradius-M press-fit cup (Ceraver Osteal, Paris, France). The mean follow-up was 3 years (range, 2.9 to 4 years). Current criteria were used for clinical and radiological assessment.

Forty-nine hips (98%) were clinically rated good or excellent. The mean preoperative Harris Hip Score was rated 57, and it has improved to 96 at the time of follow-up. The radiographs showed stable fixation by bone ingrowth in all hips. Fifteen patients (15 hips) were eligible for osteodensitometry. The mean decrease of the overall bone density (BD) in the metaphyseal portion of the femur 3 years after insertion of the stem was rated 14.21%, and the mean decrease of the cortical BD was rated 15.52%. The mean decrease of the overall BD in the diaphyseal portion of the femoral component was rated 10.00%, and the mean decrease of cortical BD was rated 7.76%. Little changes were observed underneath the tip of the stem.

The clinical and radiological outcomes of the tapered stem with HA coating at a mean follow-up of 3 years compares favourably with other reports. Results of osteodensitometry show less proximal femur BD loss in comparison to similar investigations performed using uncemented stems.

K. Karpik K. Stewart

The period of time acute orthopaedic patients await surgery at Middlemore Hospital is of concern to a number of the Health Professionals involved in their care. This study has arisen out of that concern in an attempt to quantify the extent of these delays.

Every patient operated on at Middlemore Hospital between 01 June and 31 December 2002 who had a fracture that fell within the categories studied was analysed. The six categories analysed were: compound fractures, tibial shaft fractures, femoral shaft fractures, ankle fractures, neck of femur fractures and distal radial fractures. Data regarding the age and time to surgery for each patient was analysed and compared with established guidelines. For the patients with neck of femur fractures additional data regarding their medical fitness for theatre was also analysed.

The study showed there was significant delay in acute patients receiving operative treatment at Middlemore Hospital. Furthermore the study highlighted the large volume of acute patients presenting to Middlemore Hospital.

Further investigation should be undertaken to consider how a department such as Middlemore can provide operative treatment within an acceptable timeframe to nearly 6000 orthopaedic patients a year, while still providing timely surgery for elective patients.

B. Twaddle K. Stewart

There has been a growing concern amongst the Orthopaedic Department at Auckland Hospital regarding the time Orthopaedic acute patients are waiting for surgery. To address this concern this study was undertaken to examine the extent of the problem and to establish recommended practice guidelines for waiting times.

A literature search was undertaken to identify universally accepted delays for surgery for the six categories of fracture studied – compound fractures, femoral shaft fractures, tibial shaft fractures, ankle fractures, neck of femur fractures and distal radial fractures. Current practise guidelines were then compared with the literature to ensure they are an acceptable standard of care. Every patient operated on at Auckland Hospital in 2002 that had a fracture that fell within the six categories was included in the study. Data regarding the age and time to surgery for each patient was analysed.

The study demonstrated major discrepancies between recommended practise guidelines and the present acute service. The general trend is that the more acute the fracture, the less likely it is to be operated on within the guidelines.

Further investigation should be undertaken to look at reasons behind the delays and ways to improve access. This will assist in identifying responsibility for ensuring that an acceptable standard of care is maintained.

V. Pai

This is a report of a retrospective clinical review of atypical Achilles tendon rupture. The main purpose to describe pathoanatomy and outcome of these ruptures.

Typically an Achilles tendon rupture is noted 4 to 6 cms above the insertion into the calcaneus and is usually related to a sporting event. However, atypical ruptures are different from the typical ruptures: site of rupture; type of rupture and presentation. In the authors experience, atypical ruptures are not common but probably underreported. The author discusses clinical findings, pathogenesis, operative findings and treatment.

Since 1998, 5 cases of atypical Achilles ruptures were seen at Hawkes Bay Hospital. There were 2 coronal Z ruptures and 3 sagittal ruptures All were treated surgically.

At minimal 18 months follow-up all Z ruptures did very well.

This study highlights atypical Achilles tendon ruptures. Their exact incident is not known but these 5 cases were seen among 104 Achilles tendon ruptures operated on by the author.

R.G. Davidson

We reviewed Complete Proximal Hamstring Ruptures to assess the functional disability and to describe the early and late surgical repair

In the last two years five patients have been seen and treated with this relatively uncommon injury. A retrospective review of the patients diagnosed with complete proximal hamstring rupture, the method of injury, investigations to confirm injury, and the surgical technique was undertaken. Patient assessment using a questionnaire and VAS to compare pre and post operative functional abilities was also performed.

All patients reported a significant improvement in functional ability and a decrease in pain

Surgical repair of complete proximal hamstring rupture is a worthwhile procedure and can be performed both early and late.

R. Craig B. Krause

The purpose of this study is to review the current treatment of Colles fractures by long term follow up and to compare these results with a similar paper published in 1965 by G.B. Smail. And secondly, to evaluate the degree of bone density in these patients and to see what, if any, treatment is being received in those with evidence of osteopenia.

The records and radiographs of 82 patients treated at Hutt Hospital between January 1997 and January 1998 were reviewed. Of these, thirty-two attended for re-examination. Subjective measures of pain, appearance and functional limitations were recorded, as were complications and whether the wrist had reached a stable state.

Anterior-posterior and lateral radiographs of both wrists were taken, from which measurements of residual dorsal tilt and shortening of radius were made.

Of the thirty two patients that presented for re-examination twenty went on to have bone density measurements.

When comparing results from two similar studies, spaced thirty seven years apart, subjective findings show that from a functional and appearance perspective there appears to be little difference between the two cohorts. With respect to pain, patients treated in 1997 complained of a lot less residual pain compared to those treated in 1960.

Objectively, the range of movement in the wrist joint was once again found to be similar in the two cohorts, as was the range of movement in shoulder, elbow appeared to be similar. Finger movement was difficult to compare.

Radiologically the degree of ventral dorsal tilt does not correlate with range of movement at the wrist.

Bone density scan results suggest that the majority of patients with evidence of osteoporosis are not been treated appropriately.

Overall conclusion is that the outcome for treatment of Colles’s fractures has not changed significantly in the past thirty seven years.

B. C. Twaddle P. Poon J. Monnig

The aim of this study was to determine the outcome of patients treated with Achilles tendon rupture randomized to surgical or non-surgical treatment where both groups received the same early motion and weight bearing rehabilitation protocol.

Fifty patients between the ages of 18 and 50 years with a clinical diagnosis of Achilles tendon rupture were randomized to surgical or conservative treatment. All injuries had occurred within ten days. Both groups received the same rehabilitation program with initial cast immobilization then splintage in a removable orthosis with ankle motion commencing at two weeks. Patients completed the MFAI, a validated outcome questionnaire and clinical assessment including range of motion and calf squeeze response at 2, 6 and 12 weeks, 6 months and one year.

There was no difference between the surgical and non-surgical groups for difference in dorsiflexion and plantar flexion between the injured and non-injured sides. There was no difference in the MFAI quality of life scores for either treatment group. There was the same number of re-ruptures in both groups. There were no infections in the operated patients.

Early motion rehabilitation after Achilles tendon rupture results in similar functional results and patient satisfaction in both surgically and non-surgically treated patients.

G. Coulter G. Horne P. Devane

We assessed the functional outcome of fractures of the os calcis a minimum of twenty- four months following injury.

Eighty-three patients with 85 fractures were assessed a minimum of two years following fracture of the os calcis, using a validated functional outcome measure designed specifically for fractures of the os calcis, and an EQ5D. Radiographic analysis of all fractures was performed to attempt to correlate outcome scores with the fracture pattern.

Sixty per cent of the questionnaires were returned completed. Forty percent of the fractures were treated surgically, the remainder with a period of weight relief, followed by physiotherapy and graded weight-bearing. The majority of patients reported a mild hind foot pain (8/10 on a VAS), and all reported some difficulties with walking on uneven terrain. There was no appreciable difference in the outcomes comparing patients treated by open reduction and internal fixation and those treated non-operatively.

This study demonstrates a surprisingly high patient satisfaction rate following fractures of the os calcis whether they are treated operatively or non-operatively. Patients seemed to have compensated for any altered function very well. We were not able to identify specific fracture patterns that were associated with poorer outcomes.

A. Vincent A. Cockfield

The aim of the study was to evaluate the results of the LISS system for distal femur fractures.

Eighteen consecutive patients with fractures of the distal femur treated with the LISS system were followed until fracture union. This group included intra-articular, extra-articular and periprosthetic fractures occurring from both high and low energy trauma.

Fractures united in 17 out of 18 cases and only 1 patient required bone grafting. The patient with the fracture that didn’t unite had an early above knee amputation for major pressure areas and peripheral vascular disease. There were no infections but 2 cases of plate failure proximally.

The LISS system is a good treatment option for fractures of the distal femur in both the osteoporotic patient and the patient with high energy trauma.

T.W. Love S. Mukherjee

This case presentation highlights the problem of thermal necrosis of the tibia following reaming, in a tibia with a narrow canal.

A 2 year follow up of a 19 yr old aspiring dancer, who had a closed low velocity fracture to her midshaft left tibia. This was treated with intramedullary nailing of the tibia. Difficulty encountered while reaming of the canal at the time of operation because of the narrowness of the canal. She subsequently had a refracture of the shaft of the tibia, above the united fracture after the removal of the intramedullary nail. This happened in the narrow isthmic part of the tibia proximal to the fracture and was confirmed to have avascularity with isotope bone scan. This subsequently showed no appreciable sign of healing.

Patient had renailing of the tibia with bone grafting and the fracture. Latest review shows the fracture to be consolidating.

Surgeons have to be aware of the dangers of narrow canal in tibia before intramedullary nailing and appropriate reamers to be used if the canal is too narrow.

S. Faraj G. French A. McAuslan

Treatment of displaced intracapsular fracture of the hip by hemiarthroplasty in old patients is generally satisfactory.

Middlemore Hospital’s agreed criteria for hemiarthroplasty were reviewed and tested.

Two hundred and thirty three patients who had hemiarthroplasty for displaced intracapsular fracture neck of femur between June 199- June 2001. All the patients’ data collected from the hospital computer system and then a search started for these patients to review their current status regarding pain and mobility.

Ninety nine patients (42%) were still alive, of them 13 demented, 13 moved or lost and 7 in a wheel chair.

Sixty six patients reviewed for pain and mobility using Sikorski and Barrington scoring criteria for pain and mobility.

Thirteen patients had painful hemiarthroplasty. Clinical notes of the most active group of these patients (7 patients) reviewed individually to identify the causes.

Two patients had revision to total hip joint replacement within 3 months because of technical errors and two patients placed on the waiting list for revision. The rest had deterioration in their general health that made total hip arthroplasty a risky operation for them.

The revision rate was 1.7 %. We concluded that hemiarthroplasty was an acceptable option for these patients. The selection criteria were correct in 98.2% of the cases. Patients who live in their own home will need a careful assessment before deciding on a hemiarthroplasty for them.

G. Horne G. Coulter L. Vaughan P. Devane

We assessed the functional and health outcomes of patients treated for a hip fracture ,6–12 months following the injury.

One hundred and ninety six patients over 60 years of age ,admitted with a subcapital or intertrochanteric fracture were sent two questionnaires, an EQ-5D, and a Hip specific outcome questionnaire based on the WOMAC .Patients with pre-existing dementia were excluded.108 (55%) returned completed questionnaires.

There were 36 males and 72 females with an average age of 81. The average time since fracture was 8.44 months. There were 46 intertrochanteric and 62 sub-capital fractures.WOMAC scores averaged 35 for intertrochanteric fractures and 25 for subcapital fractures. Males scored higher than females (31 v’s 24)Age had no influence on WOMAC scores.EQ 5D results were compared with the general population, and showed significant problems with mobility, pain, performance of usual activities, and self care.

This study shows that despite seemingly successful treatment of the fracture, patients suffer very significant reductions in function and quality of life. Greater effort needs to be made to address these issues rather than concentrating on the development of new fixation devices, if we are to improve the results of treatment of these increasingly common fractures.

A.M. Hassan C.J.H. Brown

Elbow contracture is a recognized sequel of elbow trauma. We aim at reviewing the clinical outcome of surgical capsulectomy and elbow debridement.

The operative notes as well as pre and post-operative clinical records were reviewed for 15 patients who sustained an elbow trauma which resulted in elbow contracture and were managed with open capsulectomy and debridement. In addition two patients had anterior transfer of the ulnar nerve, twohad removal of loose bodies, two had excision of heterotopic bone, one patient had reconstruction of the medial collateral ligament and one patient had repair of the lateral collateral ligament .

These patients were followed up for a mean of 21 months (6 to 37).

Elbow flexion contracture improved from a mean of 37° (10° to 55°), to a mean of 10° (0° to 25°). Elbow flex-ion improved from a mean of 125° (95° to 140°) to a mean of 129° (90° to 140°). There were no major complications. Two patients underwent repeat debridement due to recurrence of contracture. One patient developed serious collection that settled gradually.

We conclude that open capsulectomy and debridement is a satisfactory way of management of post-traumatic elbow contracture in the short and intermediate term.

M.A. Karunakar M.J. Bosse J.M. Hall S.H. Sims T.T. Le J.F. Kellam J.A. Goulet M.A. Freeborn

This study was designed to prospectively evaluate the efficacy of indomethacin as prophylaxis for heterotopic ossification (HO) after operatively treated acetabular fractures.

An IRB approved, prospective double blind placebo controlled clinical trial was performed at two level I trauma centres to evaluate the efficacy of indomethacin as prophylaxis for heterotopic ossification after the operative treatment of acetabular fractures. Between January 1, 1999 and May 31, 2003, two hundred and thirty-two patients with acetabular fractures were treated operatively through a posterior approach. Patients with the following conditions were excluded from study participation: age < 18, spinal cord injury, ankylosing spondylitis, burns, gastrointestinal bleed, Glasgow coma scale < 12, cerebrovascular accident, pregnancy and use of other non-steroidal anti-inflammatory drugs. One hundred and fifty-seven eligible patients were identified and one hundred and twenty-five patients were enrolled in the clinical trial. One hundred and seven patients have sufficient follow up to be included in data analysis. All patients underwent operative stabilization of their ace-tabular fractures by either a combined anterior and posterior approach or an isolated posterior Kocher-Lan-genbock approach. After fixation and prior to wound closure, any necrotic gluteus minimus muscle was debrided to viable muscle. Sixty-one patients were randomized to the placebo group and forty-six patients to the indomethacin treatment group. Indomethacin 75 mg SR and the placebo were administered to the patients by the investigational drug pharmacy in a blinded fashion. The medication was taken once daily for six weeks. Patient compliance was measured by obtaining indomethacin serum levels at the first postoperative visit (2 weeks). The extent of HO was evaluated on plain radiographs (AP and Judet) at three months postoperatively. The radiographs were scored for the presence of HO using the Brooker classification as modified by Moed. The data were analyzed two ways: 1) by excluding patients with protocol deviations and 2) by using an intent-to-treat model, where all enrolled subjects with 3 month Brooker scores were included in the analysis, regardless of whether they withdrew or were dropped from the study for clinical reasons. The sample size was estimated to produce a statistical power of 80% to detect a difference of 15% between the two treatment groups with alpha = .05.

There were no significant differences with regards to age, sex, body mass index (BMI), ISS (injury severity score) and complications between the two treatment groups. The overall incidence of HO (Brooker I-IV) was 52.8% and the overall incidence of significant HO (Brooker III/IV) was 19.6%. There were four patients with Brooker IV HO. There was no significant difference between the treatment groups in the incidence of HO according to Brooker class (p=0.23). Significant HO (Brooker grades III-IV) occurred in 8 cases (17%) in the indomethacin group and 13 cases (21%) in the placebo group. There was no significant difference in the presence of moderate to severe HO (Brooker III/IV) between the two treatment groups (Fisher’s exact test p=0.81). Eighty-two of one hundred and seven patients enrolled completed the protocol. Twenty-five patients did not complete the treatment protocol for the following reasons: stopped medication due to side effects, did not receive medication at discharge, lost medication, or medication stopped by another physician who did not understand the purpose of the study. Nine patients (8.4%) did not receive the full medication course, sixteen patients (15%) were dropped or withdrew from the study for adverse events or gastrointestinal symptoms. Twelve patients dropped or withdrew from the indomethacin group and three from the placebo group. Forty percent of patients in the indomethacin group had non-detectable serum levels at two weeks. Complications identified in the indomethacin treatment group included deep venous thrombosis (5), wound infection (2), nonunion (1), gastrointestinal bleed (1) and perforated ulcer (1). Complications identified in the placebo group included deep venous thrombosis (6) and wound infection (2).

In this prospective randomized study, a placebo provided as effective prophylaxis against the development of heterotopic ossification as indomethacin. More patients withdrew from the indomethacin group for gastrointestinal side effects or adverse events than in the placebo group. Patient compliance with indomethacin was poor with 40% of patients having no detectable indomethacin serum level. Serious gastrointestinal complications (gastrointestinal bleed and perforated ulcer) occurred in two patients treated with indomethacin.

G.F. Heynen

Minimally invasive hip replacement surgery has become the catch cry of the past 18 months. The technique of two incision surgery has been touted as allowing safe insertion of hip replacement components and early discharge of patients in comparison to standard procedures. The early results and technique developed by the author are discussed with specific reference to early complications and early radiographic and clinical results.

After extensive cadaveric dissection and anatomical study, a comparison was made of the existing exposures used in two incision surgery including pitfalls and benefits.

Following initial study, a two incision approach has been used on forty patients initially chosen as being suitable for the procedure based upon age, weight, and suitability for cementless hip replacement. Data relating to surgical time, hospital stay, post op complications and radiographic and clinical results have been prospectively analysed.

Early clinical results have been very favourable, including no increase in complication, and earlier discharge and recovery from surgery. The results are being validated by a randomised prospective international study, but the ability to discharge patients within 24 hours of surgery does not appear to be a viable option and possibly not a safe option considering the concerns relating to recovery from anaesthesia and post operative postural hypotension. A radiographic assessment has revealed accurate placement of implants compared to an historic group using conventional exposure.

Clinical scores have been better at six weeks and three months compared to mini incision and standard incision patients.

Further research and experience is required for this technique to be fully applicable and available to the general orthopaedic population. Technically the procedure is more challenging and does require adequate instruction and does have a significant learning curve. However, the early clinical results do support earlier discharge and more rapid recovery compared to standard hip replacement surgery.

V. Pai D.P. Gwynne Jones J-C. Theis J.D. Dunbar J.A. Matheson

We report early major complications encountered following TEN fixation of femoral fractures in children.

A case series of four children aged 8– 16 years who had primary TEN fixation of isolated femoral diaphyseal fractures.

Three of the four patients had major complications. These were: significant knee stiffness requiring manipulation, haemarthrosis requiring washout and nail removal, loss of position and refracture. Two required revision to locked intramedullary nails without early complication.

In the skeletally immature child TEN fixation of femoral fractures has a significant major complication rate. This needs to be recognised when comparing TEN fixation with other treatment options.

H. Curry T. Lynskey

The Harris-Galante II acetabular prosthesis was used in Taranaki from 1992 until 1999. An increasing number of failures were noted due to liner dissociation. This lead us to retrospectively review the 237 patients with the Harris-Galante II acetabular prosthesis inserted for primary arthroplasty to assess true failure rates and mechanism of failure.

All of the cases were followed up with clinic interview, home interview, phone interview or review of notes. Harris hip scores were performed and radiographs were taken.

Forty-eight failures were found of which 66% were due to liner dissociation. The Kaplan-Meier 10 year estimate of implant survival was 72.9% ± 7.8%.

Several methods of revision were performed. Forty per cent of cases managed with polyethylene liner exchange alone required further revision for liner dissociation.

The poor survival of the Harris-Galante II cup appeared primarily due to failure of the capture mechanism of the cup. Dislocation and small shell size were both found to be significant independent factors which contributed to the incidence of failure.

G. Heynen W. Donnelly I. Schieicher

Minimally invasive surgery (MIS) for THR may accelerate rehabilitation. The objectives of this study were to determine the effect of 3 surgical approaches (standard, mini (< 10cm), 2 incision Stryker approach (MIS), on length of stay, rehabilitation rates, clinical outcome, quality of life, patient safety, complications and implant position.

This study was conducted in accordance with Good Clinical Practice. Each surgeon completed 6–8 documented cases using the MIS technique before commencing enrolment to eliminate any learning curve effect. Prior to enrolment patients were assessed for eligibility and provided signed informed consent. Patient demographics, medical histories and surgical details were collected. Post-operative rehabilitation was independently documented by a physiotherapist. Clinical evaluations (HHS) were collected pre-operatively, 10 days, 6 weeks, 3 months and 1 year. Patient outcomes (SF 12/WOMAC) were collected pre-operatively and 1 year. Radiological evaluations were completed at 6 weeks. CTs/x-rays were subject to an independent review.

A sample size of 48 patients was determined based on the primary objective – length of stay. Enrolment commenced at the end of 2002 and these results are based on the first cohort of patients; based on current recruitment rates, the authors anticipate that the majority of patients will be enrolled by presentation time.

Preliminary results show mean incision lengths (cm) of 3.5/5.8 for the 2 incision MIS compared to 8.8 and 13.5 for the mini and standard respectively. Mean duration of surgery (mins) was 79 (MIS), 62 (mini) and 42 (standard). The median time (hours:minutes) from end of surgery until the first episode of knee flexion > 45°, straight leg raise, active abduction, standing, out of/in to bed, stair climbing and walking > 20 metres was shortest for MIS compared to mini and standard surgical approaches. The maximum distance walked was greatest for the MIS group. The mean length of stay (days) was shortest for the MIS group. 2.5 compared to 4.7 (mini) and 3.7 (standard).

Mean blood loss (cc) was greatest for the MIS group, 667 compared to 525 (mini) and 467 (standard). There were no intra/post-operative complications or blood transfusions.

Results suggest accelerated rehabilitation, decreased hospital stay and increased surgery duration for the MIS group. There are no safety concerns, however the procedure is felt to be quite technically demanding requiring an appropriate level of training/experience. The authors believe this is the only controlled study of this nature currently being conducted internationally.

D. Ardern S.J.C. Mills

Rising health costs have seen increased emphasis on cost containment. Outpatient follow-up after total joint arthroplasty is one such accumulating cost. Enthusiastic recent media interest in failing implants and unacceptable waiting lists adds further interest to the area.

We wished to determine the current post-operative follow-up practices and views of New Zealand Orthopaedic Surgeons. A postal survey was sent to all New Zealand Orthopaedic Surgeons.

The response rate was 83% (131/158). There was wide variation in routine practice and beliefs. For cemented THJRs, 13% of surgeons routinely saw their patients for less than one year, 38% followed their patients for less than five years and 53% continued to see patients indefinitely. Follow-up for uncemented/hybrid prostheses was higher: 8% for < one year, 29% for < 5 years and 59% indefinitely. A system of periodically re-calling patients for x-rays without necessarily seeing them is used by 20% of surgeons.

The most frequent reasons given for follow-up were the detection of osteolysis, wear, loosening and patient symptoms.

Similar figures for total and uni-compartmental knee replacements were reported.

Almost a third of surgeons reported that they were unable to follow-up their patients as they would like to because of resource limitations within the public health sector. 44% believed that future changes in medico-legal expectations will necessitate longer follow-up of patients.

This survey demonstrates wide variation in practice. Higher follow-up rates for un-cemented/hybrid prostheses may reflect uncertainty about the long-term results. There is concern amongst surgeons that their ability to follow-up patients within the public health-care sector is constrained by cost. Periodic questionnaire and x-ray assessment was suggested by many as a possible alternative for long-term follow-up of selected patients. Few surgeons are however presently using such a system. We propose a standard of care.

A.P. Stokes A.D. Rutherford

The use of modular components for hip and knee arthroplasty, available since the late 1970’s, has become increasingly popular. Modularity increases the inventory of components required for arthroplasty with the increased possibility of implantation of mismatched components.

All members of the New Zealand Orthopaedic Association were sent a confidential questionnaire asking whether they had selected mismatched components for arthroplasty within the last five years and if so, how often. Information was requested on which components were involved, how and when the mismatch was discovered and what action was taken once mismatch identified. Surgeons were asked to comment on factors contributing to the mismatch occurring and their standard practise to avoid this possibility occurring.

One hundred and forty eight questionnaires were sent out and 120 replies received giving a response rate of 81%. Twenty-eight surgeons (23%) had implanted mismatched components within the last five years, occurring during total hip arthroplasty in 20 cases, knee arthroplasty in six and others in four. The mismatch was discovered prior to wound closure in 39%, during the admission in 51% and after discharge in a further 10%. The mismatch led to a further surgical procedure in 13 patients (46%). The elements contributing to the mismatch will be discussed.

Modular arthroplasty is popular and enables the surgeon to modify the components to the individual patient. This is valued by surgeons accordingly and is unlikely to diminish in frequency. The mismatch rate may be higher than recognised as some mismatches may not have been noted if there was no clinical problem. Strategies to avoid this complication occurring will be discussed.