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Volume 90-B, Issue SUPP_II July 2008

J.J. Candal-Couto G. Gamble T. Astley A. Rothwell C. Ball

The aim of the New Zealand Elbow Arthroplasty Register is to evaluate the provision of elbow arthroplasty across the entire country by both recording accurate technical information and measuring the clinical outcomes of all elbow replacements performed in New Zealand. An initial form is completed at the time of surgery which includes details of the patient, surgical indications, the surgical procedure, the implant and the operating surgeon. Six months following surgery, all registered patients are asked to complete a questionnaire to measure the pain and function of the replaced elbow and to comment on any post operative complications. Data from 99 consecutive primary and 16 revision elbow arthroplasties was prospectively collected from January 2000 till December 2003. Rheumatoid arthritis was the commonest indication (63 cases) and the outcome was significantly better than for trauma and osteoarthritis. The Coonrad-Morrey was the most commonly used prosthesis (86 cases) followed by the Kudo (eight cases) and the Acclaim (five cases). 21 surgeons performed elbow arthroplasty during the study period but only five performed on average more than one case per year. Their results at six months were statistically superior to those provided by other surgeons. The number of complications reported by patients and the revision rate within the study period was low. An infection was seen in only two patients. The New Zealand Elbow Arthroplasty Register has become a robust method of assessment of the provision of elbow arthroplasty within the country. Our findings support the idea that elbow arthroplasty should not be performed by general orthopaedic surgeons on an occasional basis.

A.G. Martin D. Simmons L.P. Tiessen C.E. Bache

We compare the management and outcome of two management stratergies for the perfused but pulseless hand following stabilisation of grade III supracondylar fractures in children.

For this study we looked at 15 patients treated in two centres (all treated by the senior author) between 1995 and 2004. The patients were designated to group I if the pulseless hand had been observed or group II if they underwent immediate exploration. Data collected included time to surgery, neurological deficit, time to return of pulse and subsequent symptoms of forearm claudication. All patients were seen at week 1,3 and followed for at least 6 months post surgery. Radiographs were reviewed to determine the adequacy of reduction of the fracture.

The mean age of patient was 3.8 years. Median time to surgery was 6 hours. 6 children had evidence of anterior interosseus nerve palsy. 12 cases were reduced anatomically, 3 had minimal fracture gap. Of the 8 patients in group I (observation) 2 had secondary exploration and one developed claudication symptoms. All had palpable radial pulse at 3 months.6 of the 7 patients in group II (exploration) were seen to have brachial artery tethering, 2 with median nerve entrapment. 5 of them had subsequent return of radial pulse within 24 hours.

Satisfactory radiological reductionof the fracture does-not exclude vessel or nerve entrapment. We would advocate early exploration of the artery if the pulse does not return within 24 hours.

A. Rajeev J. Pooley

Goodfellow & Bullough (1968) first described the pattern of articular cartilage wear in the elbow. More recent post mortem studies have shown that advanced degenerative changes can develop in the radio-capitellar (lateral) compartment of elbow joints of elderly subjects in which the humeroulnar (medial) compartment remains remarkably well preserved. We have reviewed the findings in a consecutive series of 117 elbow arthroscopies performed on patients with elbow pain resistant to conservative treatments (age range 21–80 years: mean age 51 years). We documented established degenerative changes involving articular cartilage in 68 patients (59%). In this group we found that in 60 patients (88%) the degenerative changes were confined to the lateral compartment and contrasted with normal appearances of the articular cartilage of the medial compartment.

The post mortem studies carried out on mainly elderly subjects demonstrated that the degree of degenerative change in the elbow is age dependant and involves predominantly the lateral compartment of the joint. Our study would support these observations, but indicates that symptomatic degenerative change occurs at a much earlier age than had previously been thought.

We consider that lateral compartment degenerative change is a distinct clinical entity. It begins in relatively young patients in whom the x ray appearance may be normal or near normal and is often diagnosed as lateral epicondylitis. Our observations taken together with the reported post mortem studies indicate that primary osteoarthritis of the elbow begins in the lateral compartment of the joint and may remain confined to the lateral compartment throughout life. We believe that new treat ment strategies need to be developed specifically for patients with primary osteoarthritis as opposed to degenerative joint disease due to other causes.

Mr M. D. Brinsden Mr J. L. Rees A. J. CarrNuffield

We present a single-surgeon series of surgical release of post-traumatic flexion contracture of the elbow performed via a limited lateral approach. We undertook a retrospective review of patients having surgery for established post-traumatic flexion deformity of the elbow. All patients underwent anterior capsulectomy via a limited lateral approach. Patients with an intrinsic contracture also had the intra-articular lesion addressed at the time of surgery. Short-term follow-up was available from clinical review until discharge. Medium-to-longterm follow-up was conducted by telephone interview supplemented by clinical review in selected cases.

Between 1998 and 2004, 23 patients were treated surgically for established flexion contracture of the elbow. There were 15 males and 8 females with a median age of 35yrs (range 16–52yrs). In sixteen patients the contracture was not associated with damage to the joint surface (extrinsic) and in seven it was (intrinsic). The mean pre-operative deformity was 55 degrees (95%CI 49 “ 61) which was corrected at the time of surgery to 18 degrees (95%CI 12 “ 23). The mean residual deformity was 25 degrees (95%CI 20 “ 31). The difference between the pre-operative and discharge deformities was significant (Wilcoxson test p< 0.001). In the extrinsic group the mean deformity at discharge was 21 degrees (95%CI 17 “ 25) compared to 34 degrees (95%CI 19 “ 49) in the intrinsic group “ this difference was significant (Mann-Whitney U test p< 0.01). In those patients with an extrinsic contracture all elbows had a return of functional extension. One patient suffered a post-operative complication with transient dysaesthesia in the distribution of the ulnar nerve which resolved after six weeks. Surgical release of post-traumatic flexion contracture of the elbow via a limited lateral approach is a safe, reliable technique with the best results achieved in patients with an isolated extrinsic contracture.

S Thomas GH Broome

Aim: To assess the outcome of open release of the common extensor origin in the management of tennis elbow after the failure of non operative treatment methods.

Methods: 18 patients (24 elbows) between the age group of 38 to 59 who underwent open release of the common extensor origin by the same team after a mean waiting time of 23 months from the onset of pain and a trial of failed non operative methods like analgesics/nsaids, physiotherapy, local steroid injections were contacted and asked to score the effectiveness of surgery after a gap of six months. Since the predominant troubling symptom for all patients was pain they were asked to score the pain relief correlating with the surgery.

Results: In 15 patients (83%) excellent pain relief (defined as an 8 or more out of 10 improvement) was achieved and they regained normal use of the limb. One patient (5%) had moderate improvement (score between 6 and 7 out of 10) and two further (11%) patients gained minimal benefit with persistent symptoms (score 5 out of 10). None of the patients suffered deterioration as a result of surgery.

Conclusion: This study proves that despite new advances in the treatment of tennis elbow, release of the extensor origin by the open method which is a simple and economical day case procedure, still remains an excellent option in cases where trial of non operative management has failed.

A.G. Martin D. Simmons A. Malviya C.E. Bache

The aim of this study was to establish the consensus of opinion amongst trauma surgeons for the management of displaced supracondylar fractures of the humerus in children.

We carried out a postal questionnaire involving 130 orthopaedic surgeons with an interest in paediatric trauma. They were identified as being members of the British Society for Children’s Orthopaedic Surgery.

We received a response rate of 65%. One third of respondents believe that in uncomplicated fractures, reduction should occur within 6 hours of injury and one half felt that ‘pulseless’ fractures should be treated in the same time frame. 60% said they would explore a pulseless arm after midnight, but only 20% would reduce and stabilise uncomplicated fractures. 82% of surgeons stabilise displaced grade III fractures with K wires, of these, the majority would use a‘crossed’ configuration. If after stabilisation the arm remained pulseless, only 16% said they would explore the brachial artery immediately, 23.5% would seek a vascular opinion and 60.5% of surgeons would observe for 24 hours. If the arm remained pulseless but pink after 24 hours, the majority of surgeons would continue to observe and rely on collateral circulation for distal perfusion.

The majority of surgeons would stabilise displaced supracondylar fractures as soon as possible but not after midnight unless the arm was pulseless. If the hand remained pink but pulseless, most felt that continued observation beyond 24 hours was acceptable.

A. Kontaxis G. R. Johnson

The normal shoulder requires the basic mechanical characteristics of range of motion, stability and strength. However, each of these characteristics can be compromised by arthritis or rotator cuff tear and are often associated with strong pain. Shoulder arthoplasty is one of the most common solutions for pain relief and to restore shoulder functionality. There are many available designs of prosthesis trying to address different shoulder pathologies. Despite this, there are relatively few studies investigating the biomechanics of a total joint replacement and suggest advantages, disadvantages and possible solutions.

The Newcastle shoulder model has been used to investigate the biomechanical properties of a total shoulder replacement having a reverse anatomy design. This model allows the simulation of implantation of the prosthesis and the prediction of muscle and joint forces. To address the requirement of accurate insertion of the prosthesis, the standard surgical procedure has been simulated. The current model was modified to represent the bones, muscles and implant alignment after surgery.

Load sharing results for standardised tasks (Abduction, Forward Flexion) showed great differences between anatomical and prosthetic models. In the latter the shear forces on the glenoid site were reversed, the compression stresses were reduced and the joint contact vectors were always within the humeral cup providing joint stability. This is an important effect of the reverse design, which reverses the envelope of the joint forces increasing also the muscle moment arms crossing the GH joint. The most affected group is the m.deltoid that becomes able to compensate for the dysfunctional rotator cuff muscles. The biomechanical model suggests that a reverse anatomy design can restore GH joint stability for patients with severe RC damage. Increased muscle moment arms also compensate for the lost contribution of the RC muscles to elevation.

A. Kontaxis G. R. Johnson

Introduction The complex movement of scapula is significant for the support of the arm and the stability of the shoulder joint. Recent investigations showed an adaptation in scapula rhythm after total shoulder replacement with a big variability within subjects. The latter can change the loading pattern in the glenohumeral contact forces and affect the performance of shoulder prosthesis.

Methods In this study, Newcastle shoulder model was used to simulate a total shoulder arthroplasty and investigate joint stability. The model describes the DELTA ® prosthesis; a reverse anatomy design with a socket component attached to the humeral head and a hemi-ball to the glenoid. Scapula kinematics data of 6 shoulders were recorded using a palpating technique. The subjects had a total shoulder replacement after severe rotator cuff damage. Standard and daily activities were then analysed.

Results and Discussion Scapula kinematics data show an increased scapular lateral rotation, which influences the joint contact forces. Comparing contact forces on the Glenohumeral joint, results indicate that the scapula rhythm adaptation reduces the compressive forces and shifts the shear component more superiorly to the glenoid. The scapula rhythm data used in this study show a large variability, which also affect the loading results. This effect is more significant in “reaching tasks”, where high humeral elevation is required and joint contact loads are maximum. The anterior shear forces in these tasks can be as great as 19% of body weight

Conclusions The adaptation in scapulohumeral rhythm after a shoulder joint replacement has already been reported. The reason for this adaptation cannot be explained yet and may be pain related or due to muscle adaptation that takes place after the arthroplasty. This change in kinematics influences the loading pattern of the glenohumeral joint. In particular the increased shear forces must be taken into considered in prosthetic design.

R.S. Bassi D. Simmons F. Ali D. Nuttall A. Birch I.A. Trail J.K. Stanley

We present the early results of 36 primary total elbow arthroplasties using the Acclaim prosthesis. The Acclaim prosthesis was used in 46 primary total elbow arthroplasties between July 2000 and August 2002. All operations were performed or directly supervised by the two senior authors (IAT and JKS). There were 32 females and 14 males. The mean age at surgery was 64 years (range, 34–93). The underlying pathology was rheumatoid arthritis in 39, osteoarthritis in five and post-traumatic arthritis in two. The early results of 36 cases are presented at a minimum follow-up of two years. Patients were assessed using the American Shoulder and Elbow Surgeons patient self assessment form and the range of movement of the elbow measured. The Wrightington method was used for radiographic analysis of lucencies. There was good relief of pain and range of movement improved. The mean preoperative pain score was 8.1 and decreased to 2.1 at latest follow up. The mean disability score increased from 34.2 to 66.1. The mean overall satisfaction rating following surgery was 9.3 on a visual analogue scale from zero to ten. The mean range of flexion increased from 83oto105o. The mean flexion gain was just over 10o and the mean extension gain was just over 12o. There were 11 cases of intraoperative fracture of the humeral condyle. One of these fractures failed to unite and required revision to a linked prosthesis because of persistent instability. There was one case of deep infection. There were three cases of ulnar neuropathy, one of which resolved. There was no evidence of loosening. The Acclaim total elbow arthroplasty gives good symptomatic relief and improvement in function according to the American Shoulder and Elbow Surgeons patient self assessment form. These early results are encouraging but the frequency of intra-operative fractures is of some concern.

M. Tryfonidis G. K. Jass C. P. Charalambous S. Jacob D. Stanley

A significant number of patients return with persistent symptoms following surgical release of the posterior interosseous nerve for radial tunnel syndrome. The aim of this study was to attempt to explain this fact in anatomical terms by defining the anatomy of the posterior interosseous nerve and its branches in relation to the supinator muscle and arcade of Frohse. Using standard dissection tools 20 preserved cadaveric upper limbs were dissected. The radial nerve and all its branches within the radial tunnel were exposed and a digital calliper was used to measure distances. The bifurcation of the radial nerve to posterior interosseous nerve and superficial sensory branch occurred at a median distance of 4.35mm proximal to the elbow joint-line. The bifurcation was proximal to the joint-line in 11 cases, at the level of the joint-line in one case and distal in eight cases. There was a range of 0–5 branches to the supinator originating proximal to the entry point of the posterior interosseous nerve under the arcade of Frohse at a median distance of 10.27mm (medial branches) or 11.11mm (lateral branches) distal to the elbow join-line. These branches either passed under the arcade of Frohse or entered through the proximal edge of the superficial belly of the supinator. In 10 limbs there was a variable number of branches to the supinator originating under its superficial belly and in five limbs multiple perforating posterior interosseous nerve branches within the muscle were identified. This variation in anatomy we believe may explain the persistence of symptoms following surgical release of the posterior interosseous nerve for radial tunnel syndrome and suggests that careful exploration of all the nerve branches during surgical decompression should be routinely performed.

Joshua T. Wies Helen Humphreys Melanie Latham Petra Enrico Therese Viljoen Brian Hazleman Cathy Speed

The purpose of this study was to assess the efficacy of physiotherapy approaches to treatment of rotator cuff tendinopathies (RCT). Ninety shoulders were randomised in the study. A power calculation performed demonstrated using a factorial study design, 85 shoulders would be needed for 80% power at 95% confidence. All participants gave informed consent and ethical approval was granted by the Cambridge LREC. The primary outcome measure was the Shoulder Pain and Disability Index. Participants were blinded to their allocation and were randomised to one of four groups: Therapeutic Exercise(T), Manual Therapy(M), combined T/M (X), or Placebo(P). Participants were seen for two baseline assessments with a 4-week interval and then randomised. Final assessments were performed one week after the last session. The analysis involved a comparison between groups in change from baseline SPADI using ANCOVA adjusting for baseline scores. This involved testing for any interaction between M and T, and subsequently testing for main effects of M and T. Adjusted baseline and final SPADI scores (SD) by group were: X 41.6(15.4), 21.1(20.8); T 47.6(19.3), 26.3(14.7); M 44.1(17.9), 33.1(23.3); and P 39.5(24.7), 36.6(30.6). The main effects (with Significance, Standard Error and Confidence Interval) by group were: Baseline=0.686 (SE=0.104;CI=0.479,0.892); T=−13.347 (p=0.002;SE=4.091;CI=−21.479,−5.215); X=5.479 (p=0.510;SE=8.284; CI=−10.991,21.950); M=−4.126 (p=0.314;SE=4.077;CI=−12.230,3.978). A statistically significant reduction in SPADI was observed for the T group alone. There was no significant interaction effect with the addition of manual therapy and the M group did not improve significantly. It appears that best practice for treatment of RCT should centre around therapeutic exercise.

A.K. Al-Shawi T.D. Bunker

Ultrasound imaging has become an essential adjunct to clinical examination when assessing a patient with suspected rotator cuff pathology. With the new high-resolution portable machines it has become feasible for the shoulder surgeon to perform the scans himself in the clinic and save a great deal of time. This study was conducted to examine the accuracy of the ultrasound scans performed by a single surgeon over a period of four years. The ultrasound findings were uniformly documented and collected prospectively. Out of a total of 364 scanned patients we selected 143 who ultimately received an operation and we compared the surgical findings with the ultrasound reports. The intra-operative findings included 77 full thickness supraspinatus tears, 24 partial thickness tears and 42 normal cuffs. Three full thickness tears were missed on ultrasound and reported as normal / partially torn. Four normal/ partially torn cuffs were thought to have a full thickness tear. This presents 96.3% sensitivity and 94.3% specificity for full thickness tears. Three partial thickness tears were reported normal on ultrasound and eight normal cuffs were thought to have partial thickness tears. This presents 89% sensitivity and 93.7% specificity for partial thickness tears. The size estimation of full thickness tears was more accurate for large/massive tears (96%) than moderate (82%) and small/pinhole tears (75%). The tear sizes were more often underestimated which may partly reflect disease progression during the unavoidable time lag between scan and surgery. We conclude that shoulder ultrasound performed by a sufficiently trained orthopaedic surgeon is a safe and reliable practice to identify rotator cuff tears.

C.A. Peach Y. Zhang M.A. Brown A.J. Carr

Progressive arthritis can occur in association with massive tears of the rotator cuff. Altered joint kinematics are commonly proposed as the principle causative factor but this does not explain the absence of arthropathy in some patients. We have investigated the role of the ANKH gene in patients with cuff tear arthropathy. The transmembrane protein ANKH promotes intracellular to extracellular inorganic pyrophosphate channelling which regulates calcium pyrophosphate dihydrate and hydroxyapatite crystal deposition. Genomic DNA was prepared from peripheral blood leucocytes from 20 patients with cuff tear arthropathy diagnosed clinically and radiologically and 24 healthy matched controls. All 12 exons and exon-intron boundaries from the ANKH gene were PCR amplified and sequenced with BigDye version 3.1 terminator kit (ABI), and analysed using ABI PRISM ® 3100 Genetic Analyser. We have identified 5 single nucleotide polymorphisms (SNPs) including 4 that have previously been identified in patients with chondrocalcinosis. These are in exon 2 (GCC†’GCT 294), intron 2 (G†’A +8), exon 8 (GCA†’GCG 963) and intron 8 (T†’G +15). We also identified an A†’G variant in 3′-UTR, 30 base pairs after the stop codon which has not been reported before in crystal deposition diseases, and is also not seen in any of the healthy controls. Further elucidation is necessary to demonstrate a causal relationship between these ANKH mutations and cuff tear arthropathy, which will add to our understanding of pathogenic mechanisms in this condition.

CP Roberts P Huysmans T Cresswell CJF Muller K Van Rooyen DF Du Toit J De Beer

The management of bony lesions associated with glenohumeral instability has been open to debate. Invariably a significant period of time elapses between injury and surgery during which the bony fragment may atrophy and reduce both in size and in quality. Histomorphometric bone analyses were prospectively performed on the glenoid bone fragments harvested during the modified Latarjet operation. The main purpose of the study was to assess the viability of the bone. Biopsies were obtained from 21 patients that had given informed consent. Median age was 21 years (range 16–50). All were male patients. The most important sports identified were rugby (64%) and water sports (surfing, water polo, water skiing, surfing (21%)). Mean glenoid bone loss on CT scan was 17% (range 10–50%). Thirty-three percent had bone loss greater than 20%. Gross morphology of glenolabral fragments identified a single large fragment (11/21); dominant large fragment plus smaller fragments (7/21); multiple fragments (4/21). Single large fragments comprised 52% of the study. Mean volume and mass of bony fragments were 2.18 ml (range 1–3 ml) and 1.64 gms (range 0.43–2.8 g), respectively. Histology of the specimens revealed no bone in three of the 21 specimens. Bony necrosis was present in 8/18 (44%) of the specimens. From a histopathological point of view, reattachment of these devitalized bone fragments by screws or anchors may result in predictable operative failure and recurrent instability. We can therefore not support the practice of “repair” of bony Bankart lesions based on the above findings.

S. Joshy A. Iossifidis

The aim of this study was to assess the accuracy of Magnetic Resonance Arthrography (MRA) in symptomatic shoulder joint instability. Data were collected prospectively from MR Arthrograms performed in 40 consecutive patients with recurrent symptomatic instability. MR Arthrograms included views in the stress ABER position of the shoulder. Subsequently all patients underwent an arthroscopic shoulder stabilisation and the arthroscopic and MR Arthrographic findings were correlated. In case of discrepancy the films and operative findings were reviewed.

There were thirty three male and seven female patients with a mean age of 28 years (range 18–40). MR Arthrography showed 37 anterior-inferior tears (22 displaced Bankart tears, 8 nondisplaced Bankart tears, 5 chronic ALPSA lesions and 2 AGL lesions) and 3 posterior lesions. There were 3 discrepancies of which 2 were cases of missed Bankart lesion on MRArthrogram and one case of reverse Perthes lesion present on MRArthrogram but not seen on arthroscopy. Despite a review of the films, the missed Bankart’s lesions were not visualised. In the present study, MR arthrography had a 95% sensitivity in detecting ligamentolabral pathology and a positive predictive value of 0.975 in diagnosing a lesion in recurrent shoulder instability.

The results show that MR Arthrogram is a highly useful tool for investigating recurrent shoulder instability with very high sensitivity and positive predictive value. Of the 40 patients who underwent arthroscopy there were only 2 cases where MR Arthrography did not demonstrate an arthroscopically detected abnormality.

Mr M. D. Brinsden Dr H. S. Gill Mr P. Reilly A. J. Carr Mr J. L. Rees

Background: Objective assessment of technical skill in orthopaedic surgery remains elusive. The general surgeons have validated a motion analysis model as a measurement of surgical ability for laparoscopic procedures. The aim of this study was to validate the motion analysis model in the context of simulated shoulder arthroscopy and use it to assess technical ability in a mixed population.

Methods: 35 volunteer subjects were recruited from the Oxford University Medical School and the Nuffield Orthopaedic Centre and stratified into groups according to their professional background. There were seven groups: consultant arthroscopic orthopaedic surgeons; senior orthopaedic SpRs (year 5/6); junior orthopaedic SpRs (year 1/2); basic surgical trainees; musculoskeletal physicians; graduate medical students; and hospital managers. Each subject completed a questionnaire to record previous arthroscopic experience and underwent psychometric testing. After receiving standardised instructions, each subject performed one diagnostic and one therapeutic procedure using the Alex Shoulder Professor (Sawbones Europe AB, Malmo, Sweden) model. The Patriot (Polhemus, Colchester, USA) electromagnetic tracking system was used to track hand movements during each procedure.

Results: We present the results of psychometric testing and motion analysis (time, distance and number of hand movements) data in subjects with a variety of experience of arthroscopic surgical techniques. We have demonstrated differences between the groups.

Conclusions: Objective assessment of arthroscopic surgical skills using motion analysis is valuable in identifying differing surgical abilities. We believe that this may help with the career development of trainees and in the development of specific teaching programmes for arthroscopic surgery.

M. Ravenscroft S Pai J DerTavitan I Trail

We report our experience of revision shoulder arthroplasty at Wrightington Hospital. Thirty-Nine patients had undergone revision surgery and followed up for a minimum of two years. Patients were scored using the Constant score and the ASES score pre-operatively and post operatively. All patients had X-ray evaluation for loosening and migration. Of the thirty-nine patients, 16 were failed humeral head replacement (HHR) and 16 were failed total shoulder replacement (TSR). All but two of the HHR were revised for glenoid erosion to a TSR, there was an equal proportion of patients with rheumatoid arthritis and osteoarthritis. Of the 16 patients undergoing revision surgery for failed TSR 6 were rheumatoid, 4 had osteoarthritis and 5 had posttraumatic arthritis. The main reasons for revision include glenoid loosening (7) instability (4) and peri-prosthetic fracture (2). The average constant scores post operatively for HHR and TSR were 35.5 (sd+/− 21.1) and 29.1 (sd+/− 12.1) respectively. The average ASES scores for HHR and TSR were 60.5(sd +/ 27.8) and 50.1(sd +/− 22.0) respectively. There was no statistical difference between the two groups in respect to the constant scores (p value 0.18) or ASES scores (p value 0.16). Overall, the pain relief was good post operatively following both HHR and TSR. The mean visual analogue score for pain following HHR was 3.2 and following TSR 3.5. Range of movement, function and strength was poor following both HHR and TSR.

HHR fail in a predictable way and can be revised with conversion to a TSR. TSR fail in a variety of ways and there revision surgery is demanding and complex. Both types of revision offer good pain relief but poor function.

D Chan D Philip A Mahon RYL Liow

Introduction We have evaluated the early outcome of arthroscopic excision of the distal clavicle (Mumford procedure) for acromioclavicular joint pathology.

Method Forty-one patients with acromioclavicular joint pathology underwent arthroscopic distal clavicle resections between 2002 and 2004. Preoperatively, all patients had acromioclavicular joint tenderness, 90% had a positive horizontal adduction test and 62% had a positive O’Brien’s AC compression test. All provocative signs were abolished on re-examination after acromio-clavicular joint injection. Surgery was indicated with failure of conservative management. Surgery was performed through a subacromial approach to the acromio-clavicular joint, using a Acromionizer (Smith-Nephew Dyonics, Andover, MA) burr through the anterosuperior portal. A supplementary Neviaser portal was used in 9 cases. Patients were clinically assessed at average of 18 months post surgery (range; 9–36). Functional rating was obtained with the Constant Score, WORC score and the Oxford Score. Results

Thirty-five patients (85%) reported none or minimal pain. 81% were negative for provocative AC signs. Internal rotation increased by average of 5 vertebrae levels. The Constant, the WORC and Oxford Scores were improved by 23 points, 674 points and 16 points respectively (p< 0.05). 71% reported good or excellent function by the 3rd post-operative month.

Conclusion The arthroscopic Mumford procedure effectively treats acromioclavicular joint pathology. The procedure has low associated morbidity and high patient satisfaction.

A. R. McAndrew R. B. Simonis

Purpose of Study We present a method of treating these infected humeral shaft non-unions with an open debridement procedure followed by stabilisation with the Ilizarov frame.

Materials Thirteen infected non-unions of the humerus in adult patients have been treated by this method. Ten patients have completed their treatment and three are still undergoing treatment.

The site of the non-union is approached through the pre-existing scar and any remaining metalwork is removed. The ends of the non-union are mobilised and bone is resected from both ends until there is fresh bleeding. The two bone ends are fashioned such that one will fit as a spike inside the medullary cavity of the other. The bone ends are held in position with two temporary K wires until the frame has been applied.

A standard four ring Ilizarov frame is applied with Rancho pins in the proximal humerus and a half ring in the distal humerus. The temporary K wires are removed and the frame is compressed to increase the contact between the bone ends. The routine hospital stay is one week and the patients are given intravenous antibiotics throughout their admission.

They are reviewed in the outpatient clinic at monthly intervals and the frame is used to compress the bone ends by two to three millimetres on each visit. When there are radiographic signs of union the frame is removed under a general anaesthetic.

Results Nine of the ten patients who have completed their treatment have gone on to union in a mean of 8.25 months with a good functional result. Unfortunately three patients had transient radial nerve palsies.

Conclusions This technique has achieved union and eradication of infection in nine out of ten patients in whom all other forms of treatment had failed.

H.C. Brownlow

The purpose of this study was to test the null hypothesis that patients with partial thickness rotator cuff tears do not suffer more pain or stiffness than those with full thickness tears. A power study determined that 68 partial thickness tears were required in the study in order to prove a clinically important difference (± = 0.05 and 2 = 0.2). Consecutive patients undergoing arthroscopy and bursoscopy for rotator cuff related problems were assessed using a pain analogue scale and their shoulder movements were measured. Information was gained both pre- and intra-operatively about possibly relevant confounders including age, site size and thickness of tears, and endocrine disorders. Exclusion criteria included glenohumeral arthropathy, frozen shoulder, instability and major traumatic injuries, as well as the inability to understand the pain score. 439 shoulders (428 patients) were included in the study; 216 shoulders had no cuff tear, 95 had partial thickness tears (75 joint side, 1 intrasubstance, 19 bursal side), and 128 shoulders had full thickness tears. There was no significant difference (p< 0.05) in the pain scores or range of movement between full and partial thickness tears. Age was the only independent variable to have an effect on pain score.

The null hypothesis has been upheld. This study contradicts the findings of previous research and challenges commonly held assertions on this topic. Neither pain nor stiffness can be used clinically as discriminators between partial and full thickness rotator cuff tears.

T.J.W. Matthews G.C.R. Hand J.L. Rees N.A. Athanasou A.J. Carr

The aim of this study was to observe cellular and vascular changes in different stages of full thickness rotator cuff tear.

Biopsies of the Supraspinatus tendon in 40 patients with chronic rotator cuff tears undergoing surgery were analysed using histological and contempary immunocytochemical techniques. Sections were stained with primary antibodies against PCNA (Proliferating cell nuclear antigen), CD34 (QBEnd 10), CD45 (Leucocyte Common Antigen), CD68, D2-40 (Lymphatic Endothelial Marker) and Mast Cell Tryptase. A histological analysis was performed with Mayer’s Haemotoxylin and Eosin, Congo Red and Toluidine Blue.

The reparative response and inflammatory component (figure 1) of the tissue was seen to diminish as the rotator cuff tear size increased. This was evidenced by increasing degeneration and oedema, reducing fibroblast proliferation, reduced thickening of the synovial membrane and reducing vascularity. Macrophage, other leucocyte and mast cell numbers also reduced as tear size increased. Large and massive tears revealed a higher degree of chondroid metaplasia and amyloid deposition when compared to smaller sized tears. There was no association with the patient’s age or duration of symptoms.

Small sized rotator cuff tears retain the greatest potential to heal and have a significant inflammatory component. Tissue from large and massive tears is of such a degenerate nature that it may never heal and this is probably a significant cause of re-rupture after surgical repair in this group. Selection of patients for reconstructive surgery should take into account the composition and healing potential of tendon tissue and its relationship to tear size in chronic tears of the rotator cuff.

A. Nisar M.W.J. Morris J. Freeman J. Cort P. Rayner S.A. Shahane

Background: Subacromial decompression surgery is associated with significant postoperative pain. We compared the effect of intrascalene block (ISB) and sub-acromial bursa block (SBB) with simple opiate based analgesia

Methods: In a prospective, randomised controlled trial, fifty-three (n = 53) patients scheduled for arthroscopic subacromial decompression were randomised into three groups receiving Intrascalene block (n =19), Subacromial Bursa block (n =19) or neither of the two blocks (n =15 controls). Patients with cuff pathology were excluded. ISB was performed preoperatively with 20 mls of 1% Prilocaine and 10 mls of 0.5 % Bupivacaine. SBB was given with 20 mls of 0.5% Bupivacaine postoperatively. All patients received standardised general anaesthetic and postoperative analgesia. Pain, sickness and sedation scores were noted at 1, 2, 4, 8, 12 and 24 hours postoperatively. The postoperative consumption of morphine and the time when the first bolus of morphine was required were also noted.

Results: The visual analogue pain scores in the ISB and SBB group were lower than the control group in the first twelve hours postoperatively achieving statistical significance but there were no significant differences between the SBB and ISB groups. The controls consumed more morphine postoperatively (mean 32.3 mls) than SBB (21.21 mls) and ISB groups (14.00 mls) (p < 0.001). The time for first bolus was earlier in the controls (mean 30.2 mins) as compared to both SBB (72.7 mins) and ISB groups (105.8 mins) (p< 0.001). The oral analgesic intake was less in the SBB and ISB groups than the controls (p = 0.004), but there was no difference between the two treatment groups.

Conclusion: Whilst intrascalene block remains the gold standard where expertise is available for its administration, subacromial bursa block is a safe alternative in patients with intact rotator cuff undergoing arthroscopic subacromial decompression.

Mr N A Quraishi Mr P Johnston Mr J Bayer Dr M Crowe Mr A Chakrabarti

This is a prospectively randomised blind study to determine which treatment- Manipulation under anaesthesia (MUA) or Hydrodilatation is more effective for proven shoulder adhesive capsulitis. Forty patients with adhesive capsulitis were randomised to receive either of the two treatments. All patients were assessed by an independent investigator, with Visual Analogue Scores (VAS) and Constant scores, at three intervals “ pre-treatment, 2 months and 6 months following treatment. Twenty patients (mean age 55.2 years (44–70); duration of symptoms 33.7 weeks (8–76)) received hydrodilatation and eighteen (mean age 54.5 years (39–69); duration of symptoms 43.5 weeks (12–102)) underwent MUA (two patients dropped out). VAS scores in the hydrodilatation group were pre treatment 6.1 (n=20), 2.4 (n=18;p=0.001) at 2 months and 1.7 (n=17; p=0.0006) at 6 months. VAS scores in the MUA group were pre treatment 5.7 (n=18), 4.7 (n=16) at 2 months, and 2.7 (n=15;p=0.0006) at 6 months. The VAS pain scores in the hydrodilatation group were significantly better than the MUA group over the six month follow-up (p< 0.0001)Constant scores in the hydrodilatation group were 30.8 pre treatment, 57.4 (p=0.0004) at 2 months and 65.9 (p=0.0005) at 6 months. In the MUA group, Constant scores were 38 pre treatment, 60.2 (p=0.001) at 2 months and 59.5 (p=0.0006) at 6 months. Constant scores in the hydrodilataion group were again significantly better than the MUA group over the six month follow-up (p= 0.02). At final follow up, 93% of patients were satisfied or very satisfied after hydrodilatation compared to 71% of those receiving an MUA.

We have for the first time prospectively measured the outcome of two treatments “ MUA and hydrodilatation in patients with adhesive capsulitis. Our results suggest that although both treatments are effective in the majority of patients, hydrodilatation is significantly more effective than a manipulation under anaesthesia.

A Richards S Ridgeway C Pearce RJ Sinnerton

To study the outcome of complex proximal humeral fracture sequelae (Type 3 & 4) treated with the Delta III Total Shoulder Replacement (TSR) Prosthesis. This is a prospective outcome study involving 10 patients mean age (71.5 yrs). All patients failed conservative treatment of proximal humeral fractures. Mean time from injury to surgery was 10.5 (+/− 11.5) months. All patients underwent a Delta III TSR via McKenzie approach by a single surgeon. Patients were assessed clinically with Constant scores, asked whether they were satisfied, and radiologically with plain film radiographs. Since last review one patient has died. Mean time at follow up was 20.8 months post-operation (12 “32 months). Three patients had undergone early revision for dislocation. Since last review two patients have developed deep infection, one treated with washout and suction drain, one with removal of prosthesis. One patient has a clinical diagnosis of complex regional pain syndrome. Three patients are very happy with the outcome of surgery, one is happy, one unhappy and four very unhappy. The mean pre-operative Constant scores was 8.9 (2–15), at first review 44.4 (15–96) and now 35.8 (4–76). The mean pain score on a visual analogue scale (0–10) was 3.6 (0–10). Radiographs showed no progressive notching of the glenoid in any patient. Mean flexion was 93 degrees (10,170), mean abduction 61 degrees (10,100) and mean external rotation was “1 degrees (−20,20).

This is a new technique for treating proximal humeral fracture sequelae. Some individual results are excellent. There has been a high complication rate and a significant rate of poor results. At this time we cannot recommend the reverse geometry prosthesis for the treatment of proximal humeral fracture sequelae.

S. Joshy A. Iossifidis K Khaled

This study was performed to evaluate the efficacy of interscalene block combined with general anaesthetic for common surgical procedures of shoulder and the potential of this procedure for providing day case shoulder surgery.

114 consecutive patients undergoing shoulder surgery were audited using a questionnaire immediately after operation and at 6, 12 and 48 hours after operation. Pain scores were recorded based on visual analogue scale, type of operation, duration of operation, postoperative stay and complications. At 48 hours overall pain control was assessed and patients were asked about having their operation done as a day case.

104 patientswho responded to the questionnaire were included in the study. There were 52 males and 52 females with overall mean age of 49 years (range 18–85). 75 patients underwent arthroscopic decompression, 15 patients underwent arthroscopy assisted mini open cuff repair, 9 underwent open glenohumeral stabilisation and the rest five underwent open Mumford procedure. Mean operation time was 47 minutes (range 25–90). 97 (93%) patients had no pain immediately postoperatively, 76 (73%) patients were pain free at 6 hours and 39 (38%) were pain free at 12 hours. Mean pain scores art 6 hours was 3 and at 12 hours were 4. 101 patients said their pain was well controlled throughout the first 48 hours by simple oral analgesics. 84 (83%) patients expressed an opinion that they could have been managed as day case provided they were adequately counselled about the procedure. 6(5.7 %)patients showed signs of Horner’s syndrome that resolved by 12 hours. No other complications related to inter scalene block occurred.

This study has shown that interscalene block is a safe procedure providing sustained adequate pain relief after shoulder surgery. It could allow a high percentage of patients undergoing shoulder surgery to be discharged home on the day of surgery.

A Pillai R Shenoy R Reid P Tansey

Introduction: Frozen shoulder is a general term denoting all causes of motion loss in the shoulder. As the syndrome is very common, many patients do not undergo detailed imaging studies before treatment.

Objectives: A series of 15 patients with primary neoplasms of the shoulder girdle mimicking frozen shoulder syndrome is presented.

Results: There were 6 male and 9 female patients. The common presentation was pain and stiffness of the shoulder joint. Mean age at diagnosis was 46.63Yrs (range 23 “ 71 Yrs). 73% were less than 50 Yrs of age. Only 2 gave history of trauma. Most received local steroids and physiotherapy before diagnosis. There were 10(66.6%) proximal humeral lesions and 5(33.3%) scapular lesions. Humeral lesions included chondrosarcoma (2), Ewing’s (2), lymphoma (2), chondroma (2) and osteoblastoma (1). Scapular lesions included chondrosarcoma (3), lymphoma (1) and fibromatosis (1). Scapular tumors involved older individuals. The mean delay in diagnosis after onset of symptoms was 15.8 mts (range 2 weeks- 48 months). All patients had X rays and CT / MRI. Treatment included a combination of surgery, chemotherapy and radiation. 3 patients with humeral lesions died at a mean of 20.6 mts, and 3 patients with scapular lesions died at a mean of 4.3 mts after diagnosis. The common cause of death was pulmonary metastasis.

Discussion: Many so called frozen shoulders are joints inhibited by pain rather than by true contracture. The commonest lesion to mimic a frozen shoulder is a slow growing low/middle grade chondrosarcoma. Young patients presenting with persistent pain or night pain must be examined for this possibility. Consideration should be given for further investigation before instituting treatment. Delay in diagnosis adversely affects survival. Surgeons are reminded that although rare, a tumor should be suspected when clinical presentations are unusual.

DJ Cloke H Watson S Purdy IN Steen JR Williams

The aim of this randomised, controlled trial is to compare subacromial steroid injections, physiotherapy and both interventions with a control treatment in early painful arc of the shoulder.

Over a six-month period patients with “painful arc”, of less than six months duration, were recruited via their GPs. Eligible patients were consented to enter the trial and were then randomised, by sealed envelopes, to one of four arms of the study: control (normal analgesia and/or non-steroidal anti-inflammatory medication), a specified and repeatable Exercise and Manual Therapy Package (EMTP), a course of up to three subacromial steroid injections or both the EMTP and the steroid injections. The interventions and clinic follow-ups were over an 18-week period. A final postal questionnaire was sent out at one year. The progress of the patients was monitored using the Oxford Shoulder Score (OSS) and the SF36 general health questionnaire.

Seventy-nine GPs referred 186 patients, of whom 112 were randomised (Control=27, EMTP=29, Injections=28, Both=28). 64 patients were female and 48 male. The mean age was 54.5 years (range 23–88 years). Ninety patients completed the trial (Control=20, EMTP=22, Injections=26, Both=22). Sixty-two returned the follow-up questionnaire. By paired sample t-tests, no significant differences were found between the OSS scores or SF-36 (physical health total) at the beginning and end of the intervention period, or at one year. Two patients in the injection group went on to surgery, along with one each in the control and EMTP groups.

We have found no significant differences in outcome between steroid injections, a physiotherapy package, both treatments, or symptomatic treatment in our group of patients presenting with symptoms of painful arc of the shoulder.

B. Venkateswaran A.S. Montgomery T. Zaman T. Even S. Copeland O. Levy

The purpose of this study is to report the 1 to 5 year results of arthroscopic Rotator Cuff repairs.

Between November 2001 to May 2003, 115 consecutive patients were operated (73 males and 42 females) with arthroscopic repair. 13 patients were lost to follow up, leaving 102 patients available for follow up. Patients were evaluated using the Constant score, satisfaction levels and ultrasound scan to evaluate cuff integrity. Failures were defined as dissatisfied patients and those who had had a re-operation. Re-tear rate was recorded.

The mean follow up time was 23.8 months (range 12–61). Mean age was 57.3 years (range 23–78). 47% had a history of trauma. There were 107 patients (95.5%) with full thickness tears and 5 (4.5%) had partial thickness tears. Of the full thickness tears, 8 (7.6%) were massive in size, 36 (34%) large, 44 (41.5%) medium and 18(17%) small. Isolated Supraspinatus (SSP) tear was recorded in 83.5% and subscapularis tear in 7 %. A combination of SSP tear with infraspinatus and teres minor was found in 9.6%.

86% had Acromioplasty (ASD) with or without an AC joint excision arthroplasty. Two patients had Bankart repairs in addition at the time of cuff repair.

The mean pre op Constant score was 40.9 points (95% CI 37.3 to 44.5), which had improved to 84.8 (CI 82.2 to 86.9) at last follow-up. 78% returned to same work and 82% returned to pre injury leisure activity. There were 20 re-tears (19.6%). eight of the 102 patients were not satisfied. Five of these patients had revision operation.

Arthroscopic cuff repair shows high satisfaction rate (92%) and good functional results with 20% re-tear rate, while offering all the advantages of arthroscopic surgery.

N K Anjarwalla R K Morcom R D Fraser

Objectives: The purpose of this study was to assess the effect of different types of posterior stabilisation on the fusion rate of anterior lumbar interbody fusion (ALIF)

Thin section CT scanning has shown a higher rate of pseudarthrosis with ALIF than previously reported with standard radiological modalities. Cadaveric studies have demonstrated that posterior stabilisation would increase stiffness of the motion segment and is likely to enhance the rate of fusion with ALIF. The results of thin section CT scanning of ALIF, with and without posterior stabilisation, has not been reported previously.

Methods: Patients with discogenic back pain confirmed by discography underwent ALIF surgery as a stand alone procedure or with posterior stabilisation – using trans-laminar screws, unilateral pedicle screws or bilateral pedicle screws. Patients were followed up prospectively and thin section CT scanning was used to assess inter-body fusion.

Results: The fusion rate for stand alone ALIF was 51%, for patients with supplementary stabilisation with trans-laminar screws 58%, with unilateral pedicle screws 89% and with bilateral pedicle screws 88%. When ALIF was combined with pedicle screw stabilisation a significant difference in the fusion rate was found (p< 0.01).

Conclusion: The addition of pedicle screw fixation at the time of ALIF produces a significant increase in the rate of interbody fusion.

AH McGregor AK Burton G Waddell P Sell

Background/purpose: Clinical outcomes of surgery for disc herniation and spinal stenosis are variable. Surveys show that post-operative management is inconsistent, and spinal surgeons and their patients are uncertain about what best to do during the recovery phase. The aim of this study was to develop a patient-centred, evidence-based booklet that spinal surgeons can give to their patients to reduce uncertainty, guide post-operative management and facilitate recovery.

Methods: A systematic literature search led to a best-evidence synthesis of appropriate information and advice on post-operative activation, restrictions, rehabilitation, and expectations about surgical and functional outcomes. Data were extracted into evidence statements which were graded by consensus for consistency and practicality so as to inform and prioritise the booklet’s messages. Following peer review (n = 16), a sample of patients (n = 11) gave a structured evaluation of the draft text.

Results: The review found scant evidence in favour of post-operative activity restriction, yet an early active approach to post-operative rehabilitation can improve clinical, functional and occupational outcomes. Thus, the text of the booklet presents carefully selected messages to reduce uncertainty, promote positive beliefs, encourage early reactivation, and provide practical advice to aid self-management. Peer reviewers’ comments were incorporated into the text; all the spinal surgeons (n = 7) said they would find the booklet useful. Patients found it readable, interesting and helpful; they understood and accepted the intended messages.

Conclusions: Following careful development, an evidence-based booklet to aid post-operative management in spinal surgery is now available, and is factored into a RCT of post-surgical rehabilitation.

M Underwood

Objective: To explore the views of patients’ differing treatments received within a randomised controlled trial of physical treatments for low back pain.

Methods: Within a randomised controlled trial, that found small to moderate benefits from adding a manipulation package or an exercise programme to General Practice care, we elicited participants’ views on their treatment from free text responses to an open question completed by respondents at the end of baseline and follow-up questionnaires. These data were organised and analysed using an adapted ‘Framework’ approach.

Results: We received a total of 1,259 comments from 1,334 participants. Participants randomised to general practice care reported dissatisfaction with only receiving ‘usual care’ that consisted of no more that providing analgesic medication without providing an explanation for their pain. Those randomised to a manipulation package felt the intervention was appropriate to their needs, commonly reporting quite striking benefits. Participants assigned to the exercise programme developed a sense of self reliance in managing back pain although some failed to be sufficiently motivated to continue their exercise regimen outside of the classes.

Conclusions: This qualitative analysis has found much more dramatic differences between the groups than the main quantitative analysis. This suggests that some of the ‘value added’ to general practice care from being allocated to additional physical treatment for low back pain is not being captured by existing methods of measurement. Improved methods of assessment that consider a wider range of domains may be needed when interpreting the added value to individual patients of such treatments.

RE Johnson C Roberts GT Jones NJ Wiles C Chaddock RG Potter P Watson DPMS Symmons GJ Macfarlane

Background: Each year, 7% of the adult population consult their General Practitioner (GP) with low back pain (LBP). Approximately half of these patients still experience disabling pain after three months. Evidence suggests a biopsychosocial approach may be effective at reducing long-term pain and disability. This study aimed to evaluate, for persistent disabling LBP, the effectiveness of an exercise, education and cognitive behavioural therapy intervention compared to usual GP care plus educational material, and to investigate the effect of patient preference.

Method: Design: randomised controlled trial. Patients, aged 18–65yrs, consulting their GP with LBP were recruited. After 3 months those still reporting disabling LBP (≥20mm on 100mm pain visual analogue scale (VAS) and ≥5 Roland and Morris Disability Questionnaire (RMDQ) points) were randomised, having first established preference, to 2 groups. VAS and RMDQ were assessed at 0, 6, and 12-months post-intervention.

Results: 234 patients were randomised; 116 to the intervention. The intervention showed small non-significant effects at reducing pain (3.6mm) and disability (0.6points RMDQ) over one year. Preference showed significant interaction with treatment effect at one-year; patients had better outcomes if they received their preferred treatment.

Conclusion: The above intervention program produces only a modest effect in reducing LBP and disability over a one-year period. These results add to accumulating evidence that interventions for LBP produce, at best, only moderate benefits. The challenge for future research is to evaluate interventions tailored for specific LBP sub-populations. These results suggest that if patients receive treatment which they believe is beneficial their outcome can be optimised.

RK Trehan J Chan G Helipern I Packham G Marsh A Knibb

Objective: This is a prospective, randomised, double blind trial to assess the effectiveness of intrathecal fentanyl in the relief of post-operative pain in patients undergoing lumbar spine surgery.

Method: 60 patients were recruited. All received our standard analgesic regime with morphine PCA via a syringe driver. They were electronically randomised to two groups – one received 15 micrograms of fentanyl intathecally; the other had nothing. The fentanyl was administered by the operating surgeon under direct vision at the end of the procedure.

All patients were monitored in recovery for two hours. Visual Analogue Scale (VAS) pain scores were assessed at 2, 4, 24 and 48 hours post-op. The time to first bolus delivery of PCA was recorded as was the total amount of morphine PCA used. Both patient and assessor were blinded.

Results: The patients randomised to receive fentanyl showed a significant decrease in their mean VAS pain scores for the first 24 hours. Their time to first bolus of PCA was significantly increased. They also used 40% less morphine PCA (p< 0.05 in all cases). None of the patients suffered respiratory compromise requiring treatment and they all left recovery after 2 hours to be nursed on the general ward.

Conclusion: Intrathecal fentanyl is effective at reducing post-operative pain and PCA morphine use after lumbar spinal surgery. We support its use over morphine because of the reduced incidence of respiratory complications and the ability to nurse patients on a general ward.

IF IT HURTS- MOVE IT! Pages 218 - 218
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G M Knox J R Wiles T P Nash

Purpose and Background: A clinical scenario and questionnaire was used to examine how back pain advice may be influenced by a clinician’s interpretation of an investigation and by their pre-existing beliefs about pain.

Methods: All pain clinics in the Dr. Foster report and a randomized sample of 200 General Practitioners were sent a questionnaire based on a presenting 42 yr old male patient with chronic back pain but no sciatica. An MR scan shows “degenerative changes in the L4/L5 discs, both of which are narrowed and dehydrated. A disc tear can be seen at L4/5 with a small central prolapsed disc. There is no evidence of any significant thecal or root compression.”

The questionnaire comprised statements paired with a 7-point scale, ranging from 0 (do not agree) to 6 (completely agree), therefore respondents marking 0–2 would be disagreeing, and those marking 4–6 would be agreeing with that statement.

97/109 (90%) respondents agreed the patient could continue to live normally, 38 (35%) would say the scan is essentially normal and 51 (47%) would not. 21/109 (19%) would say the scan is significantly abnormal and were likely to give restrictive movement advice (13/21 v 26/88: p=0.01). Clinicians who advise against painful movements were likely to seek a surgical opinion (19/32 v 13/77: p< 0.0001)

Conclusions: Clinicians advising against painful movements are highly likely to seek surgical opinions for back pain and those who interpret an investigation as abnormal are likely to give restrictive movement advice. Clinician education in back pain should take account of these findings.

S N Casserley-Feeney G Bury L Daly D Hurley

Background: In the Republic of Ireland, physiotherapy for low back pain (LBP) is delivered in both public and private sectors via hospital-based departments (H) and community-based private practices (P) respectively. However, there is inequity in access and minimal evidence of the physiotherapy management of LBP in these two settings.

Purpose: To investigate any differences in patient profile and physiotherapy management of LBP in H and P settings.

Methods: A random sample of one Dublin city hospital and neighbouring private practices (n=3) were recruited. A retrospective chart survey of all LBP patients who commenced physiotherapy during 2003 was conducted. Data were analysed using Statistical Package for Social Sciences (SPSS, v.11). Ethical approval was granted by the participating hospital.

Results: In total, 249 charts were identified: H=93 [male n=32, female n=61, mean age (SD) = 46 years (20)]; P =156 [male n=78, female n=78, mean age (SD) = 36 years (10)]. Statistically significant differences between settings were found for:

percentage of patients with ‘acute’ (< 12 weeks) and ‘chronic’ (≥12 weeks) LBP [H: acute LBP = 4.7%, chronic LBP = 95.3%; P: acute LBP= 84.7%, chronic LBP= 15.3%; χ2 = 120.34, df=1, p< 0.001];

mean number of treatments [H=5 treatments (SD=3.8); P=2.5 treatments (SD=2); t = −6.0, df = 123, p< 0.0001];

median duration of treatment [H=6 weeks (IRQ=4-12); P=1 week (IRQ=0.14-2) p< 0.0001].

Conclusion: Findings suggest a two-tier system of health care for LBP patients in Ireland. A randomised controlled trial evaluating patient outcomes in both settings is currently underway by the Research Team.

AA Harte GD Baxter JH Gracey

Background and purpose: Lumbar traction is a common treatment for LBP with radiculopathy. Despite this, its benefits remain to be established. This paradox has significant economic and therapeutic consequences as 3–10% of patients with LBP in the UK have radiculopathy and over 40% of UK physiotherapists use this approach (Harte et al 2005). The purpose of this pragmatic randomised clinical trial was to assess the benefit of lumbar traction in addition to a manipulation package with these patients in a manner that reflects clinical practice.

Methods: 30 patients meeting the inclusion criteria for lumbosacral radiculopathy were recruited from the NHS and randomly assigned to one of two treatment groups: Group 1 received manipulation, advice and exercises; Group 2 received traction, manipulation, advice and exercises. Outcome measures were recorded at baseline, completion of treatment and at 3 and 6 months post completion of treatment (MPQ, RMDQ, SF36, and the ALBPSQ). In addition VAS scores for back and leg pain and the percentage of overall improvement (patients perception) were recorded after each treatment.

Results: 30 patients were recruited over an 11-month period: 40% male, mean age 44 years, mean duration of current episode 7 weeks. Post treatment results (n = 27) showed a significant improvement in all outcomes for both groups (paired t-test, p > .01) but there was no significant difference demonstrated between groups (ANCOVA).

Conclusion: This pilot study demonstrates the feasibility of a trial with this sub-group of LBP patients and a large multi-centred trial would need to be conducted to fully address this research question.

J A Bell M Stigant

Background: Researchers have measured exposure to sitting using self-reported questionnaires and observational analysis. Such methods are not a reliable measure of daily exposure or sensitive enough to take into account lumbar posture when seated. Recent innovations have produced a fibre-optic goniometer (FOG) that can continuously measure sagittal lumbar posture, although this single sensor is unable to identify if the user is sitting, standing or walking.

Methods: A new system was developed utilising a second FOG attached to the hip. Movement characteristics of the hip and lumbar spine were described and used to develop software to predict activity (sitting, standing, walking). Subsequently 10 participants were asked to wear the FOGs for 8 minutes whilst their behaviour was recorded using a video camera. MPEG video sequences were produced and each activity was coded at a point in time and compared against the 2 FOG software model.

Results: All Participants found the system comfortable to wear. Validation of the software against the MPEG files showed high sensitivity for sitting (90%), standing (98%), and walking (95%). Positive predictive value was high for sitting (93%), standing (89%) and walking (94%). The overall agreement between video analysis and the FOG software was 92%

Conclusions: Developing the FOG has produced a practical system capable of continuously measuring sedentary workers basic activity in terms of sitting standing and walking. This novel tool will now be used in a prospective study of sedentary workers to determine the influence of seated lumbar posture on the development of LBP.

T Vemmer R Shankar R Hill S Dolin

Lumbar facet joint pain cannot be reliably diagnosed clinically, the International Spinal Injection Society recommends two diagnostic local anaesthetic blocks before radiofrequency (RF) denervation [1].

Scoring systems may improve diagnostic accuracy. The two most popular scores disagree on the interpretation of pain induced by extension/rotation:

‘Cochin Criteria’ [2]: pain on extension/rotation _ not facet joint problem

Helbig & Lee [3]: pain on extension/rotation _ facet joint problem

Methods: Retrospective study of all patients who had RF denervations of the lumbar facet joints in 2004.

Patients were selected clinically and did not undergo diagnostic blocks.

Cochin criteria, Helbig & Lee scores, work status, and outcome were taken from the case notes.

Likelihood ratios were calculated for the scores, their individual components, and work status.

Results: 145 patients underwent RF facet joint denervation, for 127 all data was available. In 68 patients the procedure was successful (53.5%).

Conclusion: Neither the Cochin Criteria nor the Helbig & Lee score can predict the response to radiofrequency denervation of the lumbar facet joints.

Pain on extension/rotation weakly indicates a poor response to facet joint denervation.

X-rays do not help with the diagnosis.

Social factors may be more important than clinical signs.

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L C Roberts S Fraser E Murphy

Purpose: ‘Red flags’ are patient responses and findings on history taking and physical examination that are associated with an increased risk of serious spinal disorders. The purpose of this paper is to identify red flags reported in the low back pain literature, establish consensus on whether (or not) they are considered red flags, and review the evidence for these signs and symptoms.

Methods: The following databases were searched using key words ‘red flag’ and ‘low back pain’:

MEDLINE (1951→)

EMBASE (1974→)

CINAHL (1982→)

PsycINFO (1806→)

AMED (1985→)


In addition, national guidelines and key texts were hand-searched. Each red flag identified in the literature was classified using The Guidelines Development Group’s format (where 100% coverage = ‘unanimity’; 75–99% = ‘consensus’; 51–74% = ‘majority view’; and 0–50% = ‘no consensus’), and the findings summarized.

Results: The electronic searches revealed 54 papers, with the resultant ‘red flags’ ranging from ‘no consensus’ to ‘unanimity’. Evidence for these signs and symptoms is variable. Case reports and series justify labelling some features ‘red flags’, whilst others owe their label to clinical experience and expert opinion.

Conclusion: Case reports and series should be reported/ published to help identify those signs and symptoms suggestive of serious spinal disorders and those more likely to be ‘red herrings’. Despite their importance, there is inconsistency within the literature in identifying true red flags and, an ability to identify these signs and symptoms is essential for all who practise spinal assessments.

K Deogaonkar B Kerr A Harris C Hughes S Roberts S Eisenstein R Evans C Dent B Caterson

Introduction: Several small leucine-rich proteoglycans (SLRPs) are involved in the regulation of collagen fibril size(s) in a variety of different soft and hard musculosk-eletal tissues. In the intervertebral disc (IvD) the major SLRPs involved in regulation of types I & II collagen fibril size are believed to be decorin, fibromodulin and lumican. Research into IvD degeneration and backpain is hampered by a lack of specific biomarkers to detect and monitor the disease process. We have discovered that two keratan sulphate (KS) substituted members of the SLRP family, Keratocan and Lumican (that are major KS-pro-teoglycans found in cornea) were unusually expressed in extracts from degenerative disc tissues.

Methods: Non-degenerate disc tissue (n=10) was obtained from 2 scoliosis patients and degenerate disc tissue from 11 patients undergoing surgery. The degenerate discs were graded using criteria described by Pfir-rman et al (Spine26: 1873; 2001). Tissue samples were extracted with 4M guanidine HCl and after dialysis subjected to SDS-PAGE and Western blot analyses using monoclonal antibodies that recognise epitopes on kera-tocan and lumican.

Results & Discussion: Keratocan was not found in the non-degenerate disc tissue but was present in all degenerate IvD tissues tested. Lumican showed and increased expression in extracts of degenative IvD tissues. Our working hypothesis is that the increased expression of these two SLRPs in degenerative disc tissue results from a reparative depostion of a type I collagen fibrillar ‘scar’. This unusual expression suggests their potential as biomarkers for detecting the onset of degenrative disc disease.

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JC Hill KM Dunn R Mullis M Lewis CJ Main EM Hay

Background: Patients with LBP, ‘at risk’ of persistent symptoms, require targeted treatment in primary care. We have therefore developed and validated a new screening tool to classify these patients into appropriate management groups.

Methods: A list of LBP prognostic indicators was compiled by reviewing published studies and analysing existing datasets. Indicators were selected for the tool according to face and construct validity, consistency and strength of association. For each indicator outcome measure (e.g. Pain Catastrophising Scale) an individual question (e.g. ‘I feel that my back pain is terrible and that it is never going to get an better’) was selected for inclusion (ROC analysis). The tool was modelled to classify patients into 3 categories of risk. The screening tool and corresponding complete scales were mailed to 244 consecutive primary care LBP consulters. Individual items were validated against complete scales. Reliability was examined on 53 responders.

Results: This new screening tool classifies patients using 9-items to cover 8 key prognostic indicators. The questionnaires returned by 131 consulters demonstrated excellent construct validity for all individual items. 33% of patients were classified as ‘high risk’ (psychosocial and physical factors), 44% ‘intermediate risk’ (physical factors alone) and 23% ‘low risk’. Discrimination between groups across relevant constructs such as pain, disability, days off work and psychological distress was highly significant. Test-retest reliability was moderate (kappa = 0.54).

Conclusions: A novel LBP screening tool has been validated in primary care and effectively classifies patients ‘at risk’ of persistent symptoms. This will facilitate appropriate targeting of treatment.

R Niemeläinen T Videman M C Battié

Background and Purpose: Epidemiologic studies of low-back and neck pain are abundant, but research on mid-back pain is scant. No studies reporting the characteristics of mid-back pain in the general population were found. This study reports the one-year prevalence, severity, frequency and associated disability of mid-back pain, and compares these findings to those of neck and low-back pain.

Methods and Results: Male twins aged 35–70 years (n=600), from a general population sample, were interviewed with standardized questions. Stata’s survey methods were used to adjust for any correlation between the twins. The one-year prevalence of mid-back pain was 17.0% (95% CI 14.3–19.7) compared to 64.0% (95% CI 60.6–67.5) for neck and 66.8% (95% CI 63.4–70.3) for low-back pain. Among those reporting spinal pain, 55.1% with neck pain experienced frequent symptoms (daily to monthly), as compared to 33.3% with mid-back and 39.9% with low-back pain. The mean severity of the worst pain episode was highest for low-back pain, followed by neck and mid-back pain. Associated disability tended to be less common from mid-back pain (23.5%) than low-back (41.1%), with neck pain intermediate (30.3%). Mid-back pain was associated with higher likelihood of low-back and neck pain. Odds ratios for reporting neck and low-back pain were 2.32 (95% CI 1.53–3.51) and 2.86 (95% CI 1.80–4.54) higher, respectively, when mid-back pain was reported than when not.

Conclusion: The one-year prevalence of mid-back pain is approximately one-quarter that of neck or low-back pain, with associated disability tending to be less common. Other spinal co-morbidity is nearly always reported in cases of mid-back pain.

P Pollintine P Dolan GK Wakely MA Adams

Introduction: Osteoporotic fractures in elderly people are usually attributed to hormonal changes and inactivity. But why should the anterior vertebral body be affected so often?

Materials and Methods: Forty-one cadaveric thoraco-lumbar motion segments aged 62–94 yrs were loaded to simulate upright and flexed postures. A pressure transducer was used to measure “stress” inside the disc, and calculations showed how compressive loading was distributed between the neural arch, and the anterior and posterior halves of the vertebral body. Compressive strength was measured in flexed posture. Regional volumetric bone mineral density (BMD) and histomorpho-metric parameters were measured.

Results: Upright posture. Compressive load-bearing by the neural arch increased with grade of disc degeneration, averaging 52+25% in specimens with grade 3 or 4 discs. In these same specimens, the anterior half of the vertebral body resisted only 16+18% of the applied load. Relative unloading of the anterior vertebral body was associated with low BMD and with histomorphometric evidence of inferior bone quality. Flexed posture. Flexion always transferred loading to the anterior half of the vertebral body, so that it resisted 55+17% in specimens with grade 3/4 discs. Compressive strength measured in this posture was most closely proportional to BMD in the anterior vertebral body (r2 = 0.75), and inversely proportional to neural arch load-bearing in the upright posture (r2 = 0.39).

Conclusion: Disc degeneration causes the anterior vertebral body to be unloaded in habitual upright postures, reducing bone density and quality within it. This predisposes to wedge fracture when the spine is flexed.

S. Kobayashi J.P.G. Urban A Meir K. Takeno K. Negoro H. Baba

Purpose: The inflammatory response around herniated tissue in the epidural space is believed to play a major role in the spontaneous regression of herniated lumbar disc. Numerous macrophages invade the herniated tissue along with newly formed blood vessels which influence oxygen gradient. Inflammatory cytokines such as interleukin-1 are produced by macrophages. These chemical mediators could stimulate disc cells to produce proteases such as MMPs which degrade the intervertebral disc matrix and could hence influence regression of the herniation. Here we have examined the influence of IL-1β and oxygen tension on proteoglycan turnover using a three-dimensional disc-cell culture system.

Methods: Cells were isolated from the nucleus pulposus of 18–24 month bovine caudal discs by enzyme digestion. They were initially cultured for 14 days in alginate beads in DMEM containing 6% FBS at 4.106 cells/ml under 21% oxygen to accumulate matrix. They were then cultured for 6 days under 0% or 21% oxygen and with or without IL-1β. Glycosaminoglycan (GAG) accumulation (as a measure of proteoglycan content) was measured using a DMB assay. Lactate and glucose production were measured using a standard enzymatic method. Rates of sulfated GAG synthesis was measured from rates of 35S-sulfate accumulation. MMP activity was measured using coumarin fluorescent assay.

Results: The results showed that IL-1β had a significant effect on GAG accumulation and production and that its effect was dependent on oxygen tension. GAG production and sulfate incorporation rates decreased in the presence of IL-1β at high oxygen but low oxygen inhibited the effects of this cytokine. MMP activity increased with IL-1β under 21% oxygen, but not at low oxygen.

Conclusion: Exogenous IL-1β can activate MMP activity and digest the extracellular matrix of the disc but only at high oxygen tensions. Angiogenesis as well as inflammation is thus required for resorption of herniations.

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Z. Li O Boubriak Z Cui A Recklies J P G Urban

Purpose: High levels of the chitinase 3-like protein HC-gp39 (human cartilage glycoprotein 39) have been found in the synovial fluid and sera of patients with arthritis. Although the function of this protein is unclear, in chondrocytes at least it appears to limit catabolic responses to cytokines such as Il-1b. Here we have investigated secretion of this protein by intervertebral disc cells and determined if its production is influenced by extracellular osmolarity.

Methods: Cells were isolated from bovine caudal discs by enzyme digestion and cultured in DMEM in alginate beads for 6 days. Medium osmolarity was increased in the physiological range by sodium/potassium addition. Supernatants were collected every 2 days and replaced with fresh media. At the end of experiment the supernatants were used for lactate determination and for detection of GP-39 by western blotting. Beads were assayed for glycosaminoglycans, cell viability and cell density.

Results: GP-39 was a major protein secreted by disc cells. It was evident on day 2 at low osmolarities. By day 4 concentrations in the medium had increased significantly and the protein was present mainly in fragmented form, particularly at high osmolarities. Osmolarity had no effect on cell density or viability. Rates of lactate production and GAG accumulation were greatest at high osmolarities.

Discussion: Changes in osmolarity, equivalent to those experienced by disc cells during the diurnal loss and regain of fluid content, had significant effects on cell metabolism and influenced production of GP-39. Osmotic changes might thus influence responses of disc cells to inflammatory signals.

K. Takeno S. Kobayashi K. Negoro H. Baba J.P.G. Urban

Purpose: Proteoglycan loss is one of the first signs of disc degeneration. There is increasing interest in developing biological methods for its replacement both by in vivo repair and through tissue engineered constructs. Many factors influence the rate of proteoglycan accumulation. In this study, we examine how physiological levels of extracellular osmolality and oxygen tension influence proteoglycan accumulation in nucleus pulposus cells in a three-dimensional culture system.

Methods: Cells were isolated from the nucleus pulposus of 18–24 month bovine caudal discs. They were cultured for 6 days in alginate beads at 4 million cells/ml in DMEM containing 6% FBS under 0%, 5% and 21% O2, Medium osmolality was altered by NaCl addition over the range 270–570 mOsm. Cell viability was determined by manual counting using trypan blue. Lactate production was measured enzymatically and glycosaminoglycan (GAG) accumulation was measured using a DMB assay.

Results: There was no difference in the cell viability. Lactate production decreased under hypo- (270 mOsm) after 6 days in culture. After 6 days GAG accumulation was maximal in beads cultured at 5% O2 in 370 mOsm where GAG accumulation was 86.1% greater than at 21% O2 and DMEM at standard Osmolarity (270 mOsm).

CONCLUSION: In our model the prevailing osmolality was a powerful regulator of GAG accumulation by cultured nucleus cells. In vivo prevailing osmolality is governed by GAG concentration. These results thus indicate GAG synthesis rates are regulated by GAG concentration, with implications both for the aetiology of degeneration and for tissue engineering.

J Yu N Eisenstein Y Cui J C T Fairbank S Roberts J P G Urban

Introduction: Elastin is a structural protein forming a highly organised network in the annulus and nucleus of the intervertebral disc (IVD). It appears important in maintaining annulus structure as it is densely located in the interlamellar space and forms cross-bridges between lamellae. Here we have investigated elastin fibre organisation in degenerate discs and compared it to that seen in normal human and bovine discs.

Methods: Human lumbar IVD were obtained from consented patients undergoing surgery either for disc degeneration, tumour or trauma. The disc segments were collected from operating theatre and graded. A radial profile of the specimen was dissected and snap-frozen. Sections of 20μm in thickness were cut with a cryostat microtome and mounted on slides. To visualize elastin fibres, sections were digested with hyaluronidase after fixation with 10% of formalin. Elastin fibres were immunostained and fibre organisation mapped.

Results: In degenerate disc, the elastin fibre network appeared sparse and disorganised in comparison to that seen in non-degenerate human or in bovine discs in which elastin fibres are well organised. In addition, in degenerate discs the elastin fibres appear fragmented. Fragmentation of the elastin network within lamellae of the annulus in particular increased with both degeneration grade and with age.

Discussion: The loss of elastic network integrity observed in degenerate discs could contribute to loss of annulus integrity and affect disc mechanical properties adversely. Furthermore, our initial results have suggested fragmented elastin degradation products could upregulate MMP expression by disc cells thus stimulating a degenerative cascade.

D Skrzypiec P Pollintine A S Przybyla M A Adams

Introduction: There are extensive differences in structure and composition between cervical and thoracolumbar discs, yet practically nothing is known about the time-dependent “creep” behaviour of cervical discs.

Methods: 41 cadaveric cervical motion segments aged 48–89 yrs were subjected to a static compressive load of 150N for 2 hrs. Specimen height was recorded by the displacement of the actuator of the testing machine. Digitized radiographs were analysed to obtain dimensions of the vertebrae and discs. A three-parameter solid viscoelastic model was fitted to experimental data using nonlinear regression. Model parameters represent compressive stiffness of the wet tissue (E2) and of the drained solid matrix (E1), and tissue viscosity (η1).

Results:Model and experimental data were in good agreement (r2> 0.98) and the average absolute error was always < 2%. E1 was 11% and 39% lower than published values for thoracic and lumbar discs, respectively, whereas E2 was 43% and 53% higher. The ratio E2/E1 for cervical discs (1.63) was greater than for thoracic (1.01) and lumbar (0.66) discs. η1 for cervical discs was 108% and 21% higher than in thoracic and lumbar discs, resulting in a creep rate (E11) which was lower by 51% and 43% respectively. Comparisons between younger (mean age 58 yrs) and older (79 yrs) cervical discs showed that in the latter, η1 was reduced by 32% (p=0.01), E2 reduced by 18% (p=0.06), whereas E11 was increased by 47% (p=0.02).

Discussion: Cervical discs appear to resist water loss more than thoracolumbar discs, but this resistance falls in old age.

DW Evans NE Foster S Vogel AC Breen M Underwood T Pincus

Background: The three professional groups of chiropractic, osteopathy and musculoskeletal physiotherapy are involved in the management of 15–20% of all people with low back pain (LBP) in the UK. Exploratory and descriptive research suggests that the management of non-specific LBP by some members of these groups does not follow best available evidence.

Purpose: To test the short-term effectiveness of a directly-posted, contextualised, printed educational package about the evidence-based management of acute LBP on changing UK chiropractors’, osteopaths’ and musculoskeletal physiotherapists’:

reported practice (based on a vignette of a patient with non-specific LBP)

beliefs and attitudes about LBP(using the HC-PAIRS, Rainville et al 1995)

Methods: A prospective, pragmatic randomised trial was designed to test the effectiveness of the printed educational package versus a no-intervention control. Questionnaires were posted to simple random samples of UK registered chiropractors (n=611), osteopaths (n=1368) and physiotherapists (n=1625). Intervention packages were sent to consenting practitioners in March 2004, and follow-up questionnaires were sent 6 months later.

Results: Good response rates to the baseline questionnaire were obtained, and most respondents were willing to participate in the RCT. Following exclusions based on criteria determined a priori, 1758/3380 (52.0%) consenting practitioners were recruited for the RCT: chiropractors 335/601 (55.7%), osteopaths 600/1335 (44.9%) and physiotherapists 823/1444 (57.0%). Overall response to the 6 month follow-up was 1557/1758 (88.6%): chiropractors 280/335 (83.6%), osteopaths 520/600 (86.7%) and physiotherapists 757/823 (92.0%).

Conclusions: Data analysis is now being carried out. The main trial results will be presented at the meeting.

E Karadimas M Siddiqui M Nicol W Bashir T Mushakumar F Smith D Wardlaw

Purposes Of The Study-Background Data: Dynesys is claimed that allows motion in the operative levels. This study measures the changes in the lumbar spine in different postures, pre- and after insertion of the device.

Thirty patients with were treated with Dynesys system. All had discography and positional MRI preoperatively and nine months post-operatively.

The patients were divided in to two groups. The first in which only Dynesys was used and the second in which Dynesys was used with fusion.

Results: The operated levels were 63. The results of the pMRI measurements showed that the range of movement(ROM) of the L1/S1 angle in group-A reduced by 11.89o{pre-op=39.26o,postop=27.37o(p=0.008)} while in group-B reduced by 13.73o {preop=36.18o,po stop=22.45o(p=0.002)}.

The ROM of the end plate angle at the instrumented segments in group-A reduced from 5.24o to 2.18o{difference 3.06o(p< 0.005)} and in group-B reduced from 6.69o to 2.46o,{difference 4.23o(p=0.008)}. The ROM of the end plate angle at adjacent level in group-A changed from 8.26o to 7.0o {reduction 1.26o(p=0.388)},while in group-B increased from 6.91o to 8.64o, {difference 1.73o(p=0.149)}

The mean anterior disc height in-group A reduced by 1.43mm (p< 0.005) from 9.75mm to 8.32mm, and the posterior one was increased from 6.27mm to 6.77mm {difference of 0.5mm,(p=0.008)}. In group-B the anterior disc height reduced by 1.11mm (pre-op=10.44mm,post-op= 9.33mm,p=0.049) and the posterior one by 0.16mm (pre-op 6.98mm to post-op 6.82mm,p=0.714).

Conclusion: This study shows that in the Dynesys stabilizing system allows small range of movement at the instrumented levels, with no significant increased mobility in the adjacent levels. Also the device acted to compress the anterior annulus.

R Brecon A I Heusch P W McCarthy

Background and purpose: There have been a number of surveys of adolescents that have considered the incidence of back pain and its relation to backpack use and carry load. However, none have considered whether the problem can be directly related to school term and associated extra-curricular activities. The objective of this study was to compare the incidence of back pain in twelve year old males at the end of summer term with that over the latter part of the summer vacation.

Design: A questionnaire based study, pre- and post summer vacation in a local Welsh language School.

Method: A cohort of 56 male school children in year 7 (12yr old) was given a structure questionnaire before and after their summer vacation. The questionnaire was designed to obtain information about back pain and contributory factors, with particular reference to load carried (backpacks, carrying style, load and duration) and additional physical activities including extra-curricular (types, standard and duration).

Results: A significant decline in the incidence of adolescent back pain was found over the summer vacation: 55% (29/53) pre to 40% (16/40) during the vacation (p = 0.016). Back pain did not appear to be affected by the use of backpacks or activities that required sitting down, such as watching television or play computer games.

Conclusion: A decrease in back pain prevalence occurs over the summer vacation. However, extra-curricular pastimes with relative inactivity (computer games, TV) or backpack use do not appear to be significant factors.

T Pincus NE Foster S Vogel AC Breen M Underwood

Background: Chiropractors, osteopaths and physiotherapists play key roles in the management of low back pain patients in the UK In our previous work we used mixed methods to investigate theor cognitions and attitudes to treating back pain. We developed and tested a scale, the Attitudes to Back Pain- Musculoskeletal Practitioners Scale, which includes both a personal and professional dimensional

Purpose: The purpose of this study was to investigate the differences between the attitudes of three professional groups: Chiropractors, Osteopaths and Physiotherapists.

Methods: A cross-sectional questionnaire survey was sent to 300 practitioners randomly selected from the registers of each profession. The returned questionnaires (N=465, response rate 61%), including the new ABS-mp and a questionnaire about personal and professional factors were analysed, using ANOVA, to compare the responses from the three groups.

Results: Physiotherapists tend to limit the number of treatment sessions offered to LBP patients. They work more clearly within a re-activation approach than their colleagues in the either of the other two professional groups. When practice setting (NHS versus private practice) was considered, the differences in personal interaction attitudes were unchanged but the differences in treatment orientation attitudes become less marked.

Conclusions: Aspects associated with practice settings, and especially those concerned with working within the NHS or privately impact on practitioners attitudes. There are also some professional differences, indicating that physiotherapists hold attitudes more closely in line with current guidelines.

N E Fowler E Healey

Stature change has been used to indicate the stress associated with specific tasks. Interpretation of stature change is often related to the diurnal change found in healthy participants. However, it has not been determined whether individuals with chronic Low Back Pain (LBP) experience a similar diurnal pattern. The aim of this study is to investigate diurnal stature change in individuals with and without CLBP.

Eight participants with LBP and eight matched asymptomatic controls took part in the investigation. Twenty-four stature measurements were made across a 24 hour period using a standing stadiometer. Differences between the two groups were analysed using two-way ANOVAs (time x group). Correlations between stature change and levels of low-back discomfort were examined using Spearman’s rho.

A clear diurnal variation was found for both groups, with the trough to peak variation in stature of 17.9 mm (LBP) and 17.6 mm (control) groups did not differ significantly (P > 0.05). Both groups experienced their greatest stature change in the 1st hour after rising 31.3% (LBP) and 44.6% (Control) of the total stature change. Towards the end of the day stature in the chronic LBP group reached a plateau while the control group continued to shrink. Between 2pm and 6pm both groups demonstrated a previously unreported recovery of stature. Reasons underlying this finding could be hormonal, behavioural or due to hydration status and require further investigation. A significant correlation was found between low-back discomfort and stature change in the LBP group, whereby when stature was lost greater discomfort was experienced and when stature recovery discomfort decreased.

D Carnes D Ashby M Underwood

Background: Pain is complex and multifaceted. We can convey information about pain by communicating verbally, textually and non-verbally. We investigated the use of pain drawings as an aide to communication and compared it with verbal and other pain measurement tools.

Method: We conducted a qualitative study using in-depth interviews with a purposive sample of pain patients. Data were analysed using the ‘Framework Approach’.

Results: Aches and pains are seen as an increasing continuum, aches distract people, pain stops them doing things. As pain progresses along the continuum patients pain reports progress from verbal through textual to visual representation. Verbal and textual communication about pain was inconsistent, especially for those with multi site pain. Visual communication was more about significant pain, verbal covered the range. As pain worsened so did the complexity, the need for help, life change and communication all increased. Current measuring tools do not seem adequate to assess multi site pain, transient pain and pain with movement.

Conclusions: Two methods of describing pain exist, clinical (physical symptoms) and behavioural (effect on life). Patients felt confident communicating about the latter but perceived a need for active help by the clinician for the former.

The effect of pain on lifestyle is paramount to the patient, physical symptoms for the clinician. Acknowledging this disparity may reduce frustration experienced in consultations as both have different communication and management needs. Indicating treatment success by focusing on lifestyle improvement in patients rather than reductions in physical symptoms may be more appropriate.

D Carnes D Ashby S Parsons M Underwood

We conducted a community survey of the prevalence, health impact and location of chronic pain. We explored the relationship and patterns of chronic pain that commonly occur, with a view to understanding why some treatment approaches may be more appropriate than others for particular patterns of pain.

In 2002, 2504 randomly sampled patients from 16 General Practices in the South East of England responded to a postal questionnaire about chronic pain. Those with chronic pain completed a pain drawing. We calculated descriptive statistics, relative risk and correlations to identify the associations and risks of having linked pain.

The highest prevalences were low back (23%), shoulder (20%) and knee (18%) pain. The number of pain sites experienced was age related in men but less so in women. Lower body pain was more age related than upper body and non musculoskeletal pain. Multi site pain was more common than single site pain. Of those with low back, knee and shoulder pain, 14%, 4.5 % and 1.9% had only low back, knee and shoulder pain respectively. Correlations and minimum spanning trees showed that chronic upper and lower body pain are distinct and axial pain link the two.

Chronic pain is more likely to be multi site, especially at middle age. Research, physical treatments and approaches to managing chronic pain are often site specific, therefore specialising treatment to one area eg low back pain often negates the bigger issue. This may help explain the self perpetuating problem of persistent chronic pain.

Y. Schroeder D. McNally K. McKinlay W. Wilson J.M. Huyghe F.P.T. Baaijens

Introduction: In vivo measurements of intradiscal stresses are difficult. McNally measured stress profiles in human discs. It is unclear why some exhibit stress peaks in posterior annulus while others do not. Therefore finite element (FE) models are useful to improve the knowledge of stress distribution in the disc. We compared experimental and numerical stress in discs under axial loading, in non degenerated and degenerated disc.

Methods: The FE disc model resembles one fourth of a full disc. The annulus contains both matrix and fibers, while the nucleus only consists of matrix. Similar load profiles were applied and model predictions of matrix stress were compared to experiments (stress profilometry).

Results: Both experimental data and numerical simulations exhibit a peak of axial stress in posterior annulus and lower peaks in anterior annulus. Simulating a “normal” disc results in a uniform matrix stress profile from posterior to anterior. By reducing the fixed charged density (FCD) to 50% in both nucleus and annulus, stress profiles become non-uniform. Stresses in the nucleus decrease. Axial annulus stresses exhibit peaks on anterior and posterior side. Stress peaks increase when FCD decrease under the same loading.

Discussion: The size of the peaks computationally depends on the FCD in discs. Decreasing the FCD shows development of stress peaks in the annulus. A uniform stiffness is seen in nucleus region, but not in annulus. The hydrostatic pressure, due to the FCD, is not high enough to evenly distribute the load over the whole disc. The posterior stress peaks may explain why hernia develops particularly in the posterior annulus.

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A S Przybyla S Blease M A Adams P Dolan

Introduction: Neck pain often arises without any evident trauma suggesting that everyday loading may cause fatigue damage to spinal tissues. However, little is known about the forces acting on the cervical spine in everyday life. The purpose of this study was to determine spinal compressive forces using an electromyo-graphic (EMG) technique.

Methods: Eight subjects performed a number of tasks while cervical flexion/extension and surface EMG activity of upper trapezius and sternocleidomastoid were measured. Dynamic EMG signals were corrected for contraction speed, using a correction factor obtained from lumbar muscles, and were then compared with isometric calibrations in order to predict moment generation. Calibrations were performed in different amounts of cervical flexion/extension by each subject to account for changes in the EMG-moment relationship with muscle length. Compressive force on the C7-T1 intervertebral disc was determined by dividing the generated moments by the resultant lever arm of flexor or extensor muscles obtained from MRI scans on the same subjects.

Results: Peak values (mean ± SD) of extensor and flexor moments increased from 1.9±1.6Nm and 1.4±1.0Nm respectively in standing to 52.7±32.2Nm and 4.2±1.8Nm when lifting above the head. Resultant muscle lever arms ranged between 3.0–5.2cm and 1.6–3.5cm for extensor and flexor muscles respectively. Therefore, peak compressive forces on the C7–T1 disc were 110±74N in standing and 1570±940N during overhead lifting.

Conclusion: Neck muscles generate high forces in activities such as overhead lifting. If applied on a repetitive basis, such forces could lead to the accumulation of fatigue damage in life.

IW McCall J Menage P Jones S Eisenstein T Videman A Kerr S Roberts

Background: Many studies have examined magnetic resonance images (MRI) with a view to the anatomy and signaling properties of the intervertebral disc and adjacent tissues in asymptomatic populations. In this study we have examined MRIs of a discrete population of patients undergoing surgery for symptomatic disc herniations.

Methods: Sixty patients (aged 23–66 years, mean 41.5±8.4) had sagittal T1 and T2- weighted turbo spin echo imaging of the lumbar spine prior to surgery. One disc was herniated at L2-3, 3 at L3-4, 22 at L4-5 and 31 at L5-S1; 3 patients had herniations at both L4-5 and L5-S1. The images were scored for disc narrowing and signal, degree of anterior and posterior bulging and herniation, and assessed for Modic I and II endplate changes and fatty degeneration within the vertebrae. These were carried out for each of 6 discs (T12-S1) for all patients (ie 360 discs and 720 endplates).

Results: There were trends of increasing disc narrowing, disc bulging and fatty degeneration with increasing age in these patients. 83% of patients had disc bulging, 53% had endplate irregularities and 44% had fatty degeneration. There was a significant correlation between patient weight and fatty degeneration. 7.5% of vertebrae (in 22% of patients) demonstrated Modic I changes whilst Modic II changes were seen in 14% of vertebrae (40% of patients). This is considerably higher than the incidence reported in asymptomatic individuals where Modic I changes were seen in 0.7% of vertebrae (3% of individuals) and Modic II changes in 1.9% of vertebrae (10% of individuals).

Conclusion: There is a higher incidence of Modic I and II changes in disc herniation patients than in asymptomatic individuals.

L Dang D Wardlaw D Hukins

Introduction: This abstract describes the development of an effective procedure for removing as much nucleus as possible from an intervertebral disc with minimal disruption to the annulus. The procedure was developed on cadaveric sheep discs which are well established as a model for human discs in studies of this kind. The purpose of the study was to develop a method for removing the nucleus as part of a laboratory study of nucleus replacement; however, it is also intended to guide the development of procedures for the removal of residual nucleus when indicated in surgical procedures that involve replacing the nucleus with synthetic materials.

Methods: All procedures were performed via a 3 mm trocar. Four procedures were compared: (I) unilateral approach using rongeurs alone, (II) bilateral approach using rongeurs alone, (III) unilateral approach using rongeurs followed by chymopapain and (IV) bilateral approach using rongeurs followed by chymopapain. Chymopapain was administered as a solution (30 units in 0.1 cm3 de-ionised water) to a disc at 37oC. For each procedure (I–IV) 14 discs were used.

Results: The percentages of nucleus removed were: (I) 34 ± 2%, (II) 41 ± 2%, (III) 52 ± 3% and (IV) 75 ± 8%; ANOVA showed a significant differences between the four sets of results (P < 0.05).

Conclusions: Significantly more nucleus is removed using a bilateral than a unilateral approach; significantly more nucleus is removed if chymopapain is used in addition to rongeurs.

M Hossain LDM Nokes

Background: Sacro-iliac (SI) joint is vertically oriented and subject to a large shear force on weight bearing. Gluteus maximus is strongly active when we experience an abrupt limb loading and need a stable SI joint. Suboptimal gluteus activity could disrupt weight transference and lead to low back pain as the body attempts compensation by recruiting biceps femoris, which could exert its influence through attachment to sacrotuberous ligament. A biomechanical model of SI joint dysfunction was proposed. The model was tested on a pilot study.

Methods: Two male volunteers participated in the study. One was a normal subject. The other had pain suggestive of SI origin. Electromyogram was recorded using pairs of disposable bipolar surface Ag/AgCl electrodes on the symptomatic side for the lumbar multifidus, gluteus maximus and biceps femoris muscles. Subjects were asked to walk in a straight line. Each test was taken three times for two full gait cycles. Two dimensional high speed video was used to capture data of walking motion. Raw electromyogram data was processed according to published protocols.

Results and discussion: Gluteus activation was poor in the symptomatic individual and failed to reach a peak in loading response. Biceps remained activated on terminal swing event with another peak activation in ipsilateral pre-swing event. Unlike normal volunteer, gluteus failed to show increased activity in terminal stance to pre swing events. The study showed a difference in gluteus maximus and biceps femoris activity in between the two volunteers. A larger study is planned to validate the model.

T Grünhagen C P Winlove J P Urban

Background and Purpose: During normal loading of the spine, the intervertebral disc (IVD) experiences large changes in hydration. Current techniques to determine IVD hydration in vitro non-destructively are costly (e.g. MRI). Here we determined the variation in hydration in loaded IVDs electrochemically using needle microelectrodes.

Methods: The relation between hydration and electrochemical current measured in the tissue at a polarising voltage of −0.65V was established in bovine caudal disc nucleus slices. Bovine caudal IVDs were then placed in a culture chamber and tissue hydration varied by applying static loads. Silver needle microelectrodes were inserted into the nucleus at defined locations and the polarising voltage applied. The electrochemical current was measured and hence hydration of the disc determined in relation to duration and magnitude of the applied load.

Results: Intradiscal current was found to correlate directly with tissue hydration, falling 45% as hydration decreased from 0.8 to 0.6. Changes in tissue hydration in response to static load were monitored at different positions in the disc in real-time by measuring electrochemical current and were found to vary spatially and in time as predicted from theory.

Conclusions: Electrochemical measurements can be used as a non-destructive and relatively inexpensive method for real-time measurements of changes in IVD hydration in response to mechanical loading in vitro.

S D Liddle G D Baxter J H Gracey R A Deyo

Focus group methodology was used to explore the experiences, beliefs and treatment expectations of chronic low back pain (LBP) patients in order to identify what components of treatment they considered to be of most value: specific emphasis was placed on the importance of advice and exercise to these patients.

Methods: Using a purposive sampling procedure, three focus groups were convened. All participants (n=18) were currently experiencing chronic LBP (> 3months), with no red flags, and had received advice and exercise as part of treatment. Each group was facilitated by an independent moderator, and guided by a series of pre-determined questions, although participants were encouraged to freely air their personal opinions. Discussions were tape-recorded and transcribed, with the written consent of all participants. Transcribed data were categorised into a series of ‘nodes’ from which a series of common themes emerged.

Results: A variety of occupations and age groups were represented; one group consisted solely of females, and the other two were of mixed gender. The appropriateness of treatment was largely weighted upon the provision of a precise diagnosis. Participants acknowledged the value of advice and exercise provided by practitioners, however their lack of compliance with such programmes was a key factor limiting their long-term self-management of symptoms.

Conclusions: Clinical practice must incorporate strategies to improve compliance with advice and exercise. Individually tailored treatment programmes with follow-up support and direction, along with a better understanding of the physical and emotional impact of chronic LBP by practitioners, is recommended by patients.

M Bhattacharyya

Introduction: Primary manifestation of Non Hodgkin’s lymphoma in the urinary tract has been sporadically reported [1,2,3,4,5]. 2.7% of extra nodal Non Hodgkin Lymphoma manifest in urinary tract and commonly disseminate in the vertebrae. We report an unusual presentation of primary B cell lymphoma, presenting as upper back pain and acute retention of urine in a female. To our knowledge it has never been repoted in the literature.

Material: Illustrative Case report of a 63 years non smoker retired old female presented to us with a history of acute urinary retention and back pain.

Discussion: Upper back pain and urinary retention in a female is very uncommon presentation. It may be associated with sinister pathology. In our case study extra nodal manifestation of B cell lymphoma in the female urethra with dissemination and its rare clinical presentation is unique early diagnosis and multidisciplinary involvement is essential.

CJ McCarthy JA Oldham

Introduction: A large number of patients with non-specific low back pain (NSLBP) are examined by physiotherapists. Physiotherapists ask their patient’s questions, as part of their clinical examination, however the reliability of the information elicited by these questions has never been examined.

Methods: Following a Focus group with a sample of physiotherapists (n=30), and subsequent Delphi technique questionnaire, a list of questions and tests for the clinical examination to NSLBP was developed. The clinical examination list was then tested for item inter-tester reliability with 100 NSLBP patients and 16 physiotherapists. Patients were assessed by both physiotherapists on one day. Data were analysed using kappa coefficients for nominal data and weighted kappas for ordinal data.

Results: The physiotherapists rated issues regarding the location and quality of pain with good levels of reliability, kappa values ranged from 0.49 to 0.64. Diurnal changes in pain and history of pain were also reliably ascertained (Kappa values ranging from 0.49 to 0.73), with symptoms other than pain demonstrating good reliability (values ranging from 0.50 to 0.77). Issues regarding the affect of psychosocial issues as barriers to recovery and the degree to which the patient’s pain was affecting their function were not as reliable (kappa values from 0.14 to 0.51)

Conclusions: It is clear that whilst the questions typically used in the clinical examination of NSLBP are reliable when addressing simple issues relating to the report of symptoms, more complex issues are less reliable and further work is required to improve the reliability of the information obtained.

D W Neen N C Birch

Statement of purposes of the study and background: Validated outcome measures should be an essential tool in clinical practice. The Oswestry Disability Index (ODI), since its publication in 1980, is now a principle measure of condition-specific outcome in spinal management. The Low Back Outcome Score (LBOS), another popular measure, emphasises objective questions and gives a broad based status for low back illness. We have analysed the use of these instruments to see if they were directly comparable.

Method: Fifty five consecutive patients attending our clinic between February and June 2005 for treatment of low back disorders completed the questionnaires. These were then scored in the conventional manner. To directly compare LBOS with ODI the LBOS score was converted to a percentage and inversed. The individual LBOS evaluations were then marked in two ways. Firstly the questions that did not appear to correlate to the ODI were removed. Secondly the weighting system was adjusted to match the ODI weighting. Statistical regression analysis was performed.

Results: Direct comparison of ODI versus an inverse of the LBOS percentage score gave a scatter of results. The R squared result was 0.117

Removing the non-core answers from the LBOS gave an R squared value of 0.130

Removing the weighting of the LBOS gave an R squared value of 0.132

Removing the non-core questions and weighting system of the LBOS gave an R squared value of 0.133

Conclusion: These two validated disease specific outcome tools provide very different results when applied to the same group of patients. This has significant implications for outcome research especially when comparing studies which do not use similar instruments.

D K Gakhal E M Reynolds R C Chakraverty P B Pynsent

Purpose And Background: In patients with chronic low back pain (LBP), selective injection procedures (provocative discography, medial branch, facet and sacroiliac joint blocks) have shown the pain source to be the intervertebral disc in 40%, the sacroiliac joint in 13–19% and the facet joints in 15–40%. No individual features in the history or examination are of consistent discriminatory value in diagnosis.

This study aimed to assess whether patients with different pain sources could be differentiated using the Oswestry Disability Index (ODI) (a validated patient questionnaire scoring ten different aspects of pain and function in patients with LBP; higher scores correlating with greater disability).

Methods And Results: ODI scores were recorded from 67 patients (46 female, age 17–82) whose source of LBP was subsequently confirmed by selective injection. The scores for each section of the ODI were compared between patients grouped according to pain origin; disc (n=11), sacroiliac (n=31) or facet (n=25).

Patients with disc pain had significantly greater overall disability and scored higher for sitting, sleeping and social activity than those with facet or sacroiliac pain as judged by the 95% confidence limits of the median (p< 0.05). Patients with facet pain scored higher for walking and standing compared to those with sacroiliac pain.

For disc pain scores were higher for sitting and standing than for walking, and for facet pain scores were higher for standing than for sitting or walking.

Conclusion: Although the ODI is not a diagnostic tool, analysis of its components reveals characteristic pain and disability patterns in patients sub-grouped according to pain source.

LJ Potter C McCarthy J Oldham

Introduction: Algometry has been shown to be an effective way of quantifying pressure pain threshold (PPT), although it’s reliability in assessing spinal muscle pain (excluding trigger points) has not been robustly analysed.

Method: Intra-rater test re-test reliability PPT assessment by algometry over the belly of four pairs of spinal muscles, (iliocostalis, multifidus, gluteus maximus and trapezius) in a healthy sample (80 assessments) was analysed. Healthy subjects were tested twice (within 15mins) on three occasions (separated by a week); 240 sets of assessments revealed good within-session reliability (ICC> .91) and good between session reliability (ICC> .87), with a relatively small measurement error (approximately 3kg/cm2) and no systematic difference within session or between sessions.

Conclusion: In conclusion, PPT assessment by algometry is a reliable, both within and between sessions, measure of a subject’s pain. This study provides further validity to the use of this measure as a suitable, convenient method of monitoring treatment effects.

M Bhattacharyya

Introduction: The potential medical applications of cannabis in the treatment of painful muscle spasms and other symptoms of multiple sclerosis are currently being tested in clinical trials. The active compound in herbal cannabis, Delta(9)-tetrahydrocannabinol, exerts all of its known central effects through the CB(1) cannabinoid receptor. Research on cannabinoid mechanisms and antinociceptive actions is evolving.

The aim is to study whether cannabis has any role as a pain relief agent in chronic degenerated disc disease without spinal stenosis.

Method: Prospective audit observational study

Material: During two years periods 17 afrocarribean male patients who are regular cannabis user and MRI confirmed disc disease participated in this survey who had opiates and epidural injection therapy.

Result: All had used cannabis such as marihuana, hashish as a recreational drug before the onset of their illness. 64.7% of the patients stated the symptoms of their illness to have ‘much improved’ after cannabis ingestion, 29.4% stated to have ‘slightly improved’. 76.4% stated to be ‘very satisfied’ with their therapeutic use of cannabis.

Conclusion: This survey reveals use of cannabis products for symptomatic relief of back pain. However it is limited by highly selected patient group, no conclusions can be drawn about the quantity of wanted and unwanted effects of the medicinal use of the plant for particular indications. Physician supervision of medical marijuana use would allow more effective monitoring of therapeutic and unwanted effects. Medicines based on drugs that enhance the function of endocannabinoids may offer novel therapeutic approaches in the future.

M Bhattacharyya H Win S Sakka

Introduction: Spinal stenosis may present as intermittent claudication and may be indistinguishable from vascular claudication as both could co exist. These patients often required expertise from both the speciality. Combined Vascular and spinal clinic after primary screening with the help of MRI scan may reduce the waiting time to the appropriate speciality.

Aim: We prospectively reviewed all the patients referred to senior author from vascular unit to assess the final outcome and evaluate whether primary to referral to vascular surgeon was unnecessary.

Study Design: Prospective study from November 2004 to May 2005

Methodology: Review of Hospital case notes – 23 patients were referred to us from one of the vascular surgeons’ unit after excluding vascular etiology as the cause of the leg pain and MRI confirmation of spinal stenosis.

Result: Mean waiting time to see the spine consultant 103 days [20–195] from the date of referral by the vascular team. The waiting time to primary referral to vascular team was 164 days [43–194]. 43.5% of the referred patients required to have spinal decompression.

Conclusion: To improve the waiting time primary physician should have access of MRI scan to delineate the pathology and combined vascular and spinal clinic may achieve waiting time target.

B.K. Derham J Urban

Purpose: To investigate the effect of timed incubations and osmolarity on the cellular protein profile between nucleus pulpous cells and articular chondrocytes to identify possible cellular markers. Both cell types exists in a constantly interchanging environment in which osmolality changes significantly during disc and joint loading.

Methods: Bovine nucleus pulpous and articular chondrocyte cells were isolated and digested with collagenase. The cells were resuspended in alginate beads and incubated in DME medium. DMEM was prepared with increasing osmolarity (280–580mOsm). At T=0,1,3 & 5 cells were collected by dissolving the alginate beads and then washed. Cellular proteins were analysed by large SDS-PAGE, scanned and analysed by computer package. Bands of proteins of interest were cut out for mass spec analyses.

Results: Analysis of whole cells from the nucleus pulpous and articular chondrocytes by SDS-PAGE at T=0 revealed very similar protein patterns. Over 5 days a peak at around 26kDa that appeared in both cell groups. Differences occurred when the cells were incubated with increasing osmolarity. Nucleus pulpous cells showed a loss of peak intensity around 60kDa and 32kDa. Chondrocyte cells showed increased peak intensity around 140kDa, as well two peaks flanking a major peak at around 55kDa.

Conclusion: Incubation of both cell types in alginate beads caused the appearance of a new peak on SDS-PAGE. When both cell types were incubated with increasing osmolarity new protein peaks appeared which may assist in deciphering between the two cell types. Mass spec will identify the protein peaks.

W W Yoon G Askin P Cole C Natali

Introduction: This study highlights the occurrence of significant post operative scoliosis associated with en-bloc resection of pancoast or superior sulcus tumours. We observed the rapid onset of high thoracic scoliosis following en-bloc resections. The Magnitude of the scoliosis, and predisposing surgical factors were reviewed in each of the cases implicating the role of the transverse process or its associated structures in the stabilization of the spine.

Methods: Sixteen patients undergoing en-bloc resection for pancoast tumour were retrospectively reviewed. This was a single surgeon series where all patients had tumour resection over a 3 year period. The number of upper ribs and transverse processes resected were analysed and compared with the magnitude of scoliosis that developed over a follow up period of 2 years.

Results: Four patients had significant resection of the transverse processes of T1 to T3. All of these patients developed scoliosis of rapid onset, convex to the side of the resection. Of the remaining 12 patients either no scoliosis developed, (6 of 12), or scoliosis of less than 12 degrees.

Discussion: We observed rapid development of thoracogenic scoliosis in patients following lung tumour and chest wall resection. Our study shows that excision of the transverse processes is associated with subsequent development of an upper thoracic scoliosis. Preservation of the transverse process appears to be protective. Large resections can be performed with no subsequent scoliosis provided the transverse processes remain intact.

This suggests that the transverse process or its associated structures have an important stabilizing function on the spine.

W W Yoon W Ryan C Natali

Introduction: Postoperative overdistention of the bladder produces chronic, irreversible changes in the detrusor muscle. This study investigated whether an effective epidural, may cause postoperative overdistention of the bladder.

Methods: A retrospective single surgeon/unit study of 144 male patients who had undergone spinal surgery over a two year period was undertaken. Data was collected into two groups: Patients requiring catheterisation and those that did not. All patients received a 16G epidural catheter inserted at the end of the procedure.

Demographics, operation type and epidural rate were all correlated with the need for catheterization. In all cases the residual volumes were recorded.

Results: Patients remained on postoperative epidural analgesia for an average of 50hours. 54 patients required urinary catheterisation. The average postoperative duration until catheterisation was 18hours, with a maximum of 33hours.

The average residual volume at catheterization was 936mls, with a maximum of 2200mls. All patients were managed with intermittent catheterisation, most, (63%) requiring only a single episode before spontaneously voiding.

Discussion: Although patients in the catheterised group were older, (p< 0.05), we found no other significant differences in patients that subsequently required catheterisation, when compared for operation type, or epidural infusion rates.

We were therefore unable to predict which patients would require catheterisation. Questioning and bladder palpation was found to be unreliable when assessing overdistention.

Our study demonstrated that patients undergoing spinal surgery using epidural analgesia should be closely monitored in order to prevent overdistention of the bladder and has led to a proactive regimen for spinal patients with epidural analgesia in our unit.

Jm Huyghe S Wognum Y Schroeder W Wilson Fpt Baai Jens

Degeneration of the intervertebral disc results in patent cracks [1] and a decrease in osmotic pressure associated with loss of fixed charges. The relationship between mechanical load and damage in the disc is very poor [2]. This finding is at odds with physical intuition. The subject of this study is relationship between the development of patent cracks and the decrease in osmotic pressure in the degenerating disc in the light of the physics of swelling [3–7]. We restrict the experimental part of this study to hydrogel, thus avoiding complications associated with biological variability. The finite element modelling [6,7] used in this study catches salient features of stress profiles measured by Mc Nally and al.

Thin hydrogel samples with a crack of 5 mm are used. The crack opens as a result of decreasing osmotic pressure in the experiments and in the simulation. The initial uniform stress distribution turns into a distribution with a decreased average stress level and a high stress around the crack tip. A decrease in osmotic pressure opens an existing crack in swelling materials independently from external mechanical load. Hence, disc degeneration causes the overall stress to decrease, while local stress around a crack tip increases. This mechanism may explain why damage in the disc is so poorly correlated with mechanical load [3] and why the degenerated disc is characterized by patent cracks [1]. The process of crack opening in the degenerating disc is comparable to the crack development in an aging oaken beam, while loosing its turgor.

M Bhattacharyya S. Mcneil S Sakka

Aim: We present a pilot study on the conservative treatment of chronic low back pain (LBP) using an orthosis. It consists of a pneumatic custom made lumbar vest (Orthotrac), which permits both support-stabilisation and decompression. This system allows patients to perform any activity while wearing it.

Material: The study included 9 patients with radicular pain due to degenerative discopathy including: dark disc, discal protrusion with neural foramina involvement, stenosis of the foramina. Patients had to wear the Orthotrac vest according to a precise protocol, 60 minutes 3 times a day for 5 weeks.

Results: 5 patients (55.5%) have showed a significant subjective and clinical improvement with subsequent better quality of life. All patients referred a decrease or disappearance of radicular pain. Outcome measures were evaluated VAS pain scale and SF-36 follow up questionnaires. Two (22.2%) patients reported to have no benefit.

Conclusion: The pneumatic vest can play an important role in non-surgical therapy for low back pain. The system seems to give an effective spinal decompression and deserves a careful consideration when lumbar discal disease is treated non operatively.

J Luo D Skrzypiec P Pollintine P Dolan

Introduction: To evaluate whether a biologically-active cement “Cortoss” confers any short-term mechanical advantages when compared with a polymethylmethacrylate bone cement “Spineplex” which is currently in widespread use.

Methods: Two thoracolumbar motion segments were harvested from each of six spines (51 – 82 yrs). Specimens were compressed to failure in moderate flexion to induce vertebral fracture. Pairs of specimens were randomly assigned to undergo vertebroplasty with either Cortoss or Spineplex. Compressive stiffness and compressive stress on the disc were measured before and after fracture, and after vertebroplasty. Compressive stress was measured by pulling a pressure- sensitive needle through the mid-sagittal diameter of the disc whilst under 1.5kN load. Intradiscal pressure (IDP), peak stress in the annulus and neural arch compressive load were obtained from the resulting stress profiles.

Results: No differences in IDP, annulus stress, neural arch load bearing and compressive stiffness were observed between the groups before fracture, after fracture or after vertebroplasty (p> 0.05). After fracture, IDP decreased from 1.02 to 0.68 MPa in flexion and from 0.75 to 0.34 MPa in extension (p< 0.05), neural arch load bearing increased from 13% to 37% of the applied load in flexion (p< 0.05), and compressive stiffness decreased from 2441 to 1478 N/mm (p< 0.05). After vertebroplasty, these changes were largely reversed: IDP increased to 0.45 MPa in extension (p< 0.05), neural arch load bearing fell to 20% in flexion (p=0.1), and compressive stiffness increased to 1799 N/mm (p< 0.05).

Conclusion: Vertebroplasty using either Cortoss or Spineplex was equally effective in reversing fracture-induced changes in motion segment mechanics.

M Ismail P Rosenfeld

Isolated arthrodesis of the subtalar joint has the advantage that it preserves some motion at the midfoot. In cadaveric studies, movement at the Talonavicular joint is reduced by up to 74% and at the Calcaneocuboid joint by up to 44%. This allows some midfoot flexibility, which would not occur with a triple arthrodesis.

There are several methods of performing a subtalar arthrodesis, broadly divided into extra or intra articular techniques, using structural or cancellous bone graft and a variety of fixation methods.

Earlier studies on primary arthrodesis have shown rate of non union from 0 – 6%. More recently, larger studies have reported higher rates of non union from 14 – 17%.

We present the results of 95 subtalar fusions performed with a standard technique, using one screw from the calcaneum to the talar dome, with 100% follow up.

Between 1993 and 2003 the senior author performed 105 subtalar arthrodeses. We performed a retrospective chart review. All patients with a primary subtalar fusion were included. All cases had been refractory to conservative therapy.

The senior author reviewed all patients until fusion had occurred or a diagnosis of nonunion was established. Fusion was diagnosed when the patient were pain free while fully weight bearing, with a clinically rigid subtalar joint and radiographs showing trabeculae crossing the arthrodesis. A CT scan was performed in all cases where nonunion was suspected, and the patient complained of persistent pain.

A total of ninety five subtalar arthrodeses were performed in ninety two patients. All were reviewed with clinical and radiological examination, until union had occurred or nonunion diagnosed. The average time to union was 5.0 months, range 3 – 12 months. The outcomes, graded using the method of Angus and Cowell, were 21 Fair, 7 Poor and 67 Good results

I Winson P Laing N Makawana S Hepple W Harries

Introduction: Osteochondral lesions of the Talar Dome(OCD) remain a difficult therapeutic problem. One solution has been to consider using autologous chondrocyte implants. Though initial results of this technique are interesting the donor sites have always been in a normal knee. The presence of knee symptoms subsequently in some patients might be regarded as inevitable. This paper reports on the viabilty of donor material taken from the ankle.

Materials: Twenty four patients have been recruited to a pilot study of the viability of obtaining donated chondral material for Matrix Autologous Condrocyte Implantation. There were 14 men and 10 women. Their mean age was 37.3 years (range 17–63). All were complaining of presistent symptoms of pain and some insecurity following previous conventional surgery for treatment of a symptomatic OCD. All had MRI evidence of ongoing changes in keeping with persistent problems related to an OCD.

Methods: All patients had an initial arthroscopy of the affected ankle to reassess the state of the joint surface. Donor articular cartilage was obtained from one of three sites. The anterior part of the joint surface on the talar neck, from the medial articular facet of the talus or rarely from an area of articular cartilage on the edge of the lesion. The mean weight of the donor harvest was 133 micrograms(range51–450).

Results: All donated graft material produced viable implantable graft material between 5 and 7 weeks from harvest. Cell counts ranged from 12.3 million to 20 million with cell viabilities of 98% or above. These figures are directly comparable with the results obtained from the knee despite the original donor weights being less.

Conclusion: If this technique is contemplated the use of the affected ankle as a donor site is a viable alternative to the knee.

N Gougoulias S Parsons

Purpose: Methods: Evaluation of the results of arthroscopic ankle arthrodesis, performed in 49 consecutive patients (52 ankles), with disabling ankle arthritis, between 08/1998 and 12/2004. Thirty ankles had no significant deformity (group A), whereas 22 ankles had a varus or valgus deformity greater than 10° (mean 21.7°, max 45°) (group B). Mean age in groups A and B was 49.7 and 57.5 years respectively (p=0.15). The primary diagnosis in groups A and B was post-traumatic arthritis in 66% and 27% and idiopathic osteoarthritis in 17% and 59%, respectively. Average hospital stay was 3.63 and 3.68 days in groups A and B respectively (p=0.96). Postoperative treatment included ankle immobilization for 3 months. Progressive weight-bearing was initiated at two weeks. Mean follow-up was 14.9 months (range 6–60).

Results: No infections or neurovascular problems occurred. Fusion occurred in 29/30 cases in group A at an average time of 11.52±5.2 weeks and in 21/22 patients at 11.67±2.3 weeks in group B (p=0.89). Not planned surgical procedures were required in eight cases (15.4%). Symptomatic arthritis from the adjacent joints developed in three cases during the follow-up period. The arthrodesis position angle measured in the sagittal plane from the lateral post-operative plane film averaged 105°±3° and 103°±6° in groups A and B respectively (p=0.27). The outcome in groups A and B was graded as very good in 73% and 72.7%, fair in 23% and 22.7% and poor in one case in each group, respectively (p=0.26).

Conclusions: The arthroscopic technique offers a high fusion rate, decreased time to fusion, short hospital stay and absence of limb-threatening complications. Deformity correction can be attempted with equally good results.

R Ramiah S Hepple I Winson

Aim: A medium term review of total ankle replacements with a view to reviewing follow up protocols, reassessing the usefulness of the SF12 Health Survey questionnaire, and to determine factors that may indicate early failure.

Method: Sixty-five ankle replacements in 58 patients with an average age at operation of 65 (44–80) (32 males: 23 females, 3 died) were reviewed after a mean of 41 months (8–97 months). They were assessed via postal questionnaire and a research clinic with regard to their pain, difficulty and SF 12 scores, their outcome perception and range of movement. Additionally, we looked retrospectively at their notes and latest X-rays.

Results: Indications for operation were OA (79.5%), RA (18.2%) and psoriatic arthropathy (2.3%). Patients’ perceptions of their outcomes were 41(78.8%) good, 5(9.6%) moderate and 6(11.5%) poor. The average “mean pain score” was 3.6 and average “mean difficulty score “ was 4.0. There was no significant change between the pre and post-operative mean SF 12 scores. Save for 2 anomalies, poor outcomes and SF12 scores were only seen in post-traumatic OA(100%) and RA patients. Prostheses used were Beuchel-Pappas, OSG and DePuy Mobility. There are no revisions to date. The average range of movement was 26°. X-rays generally showed good prosthesis alignment, minimal insert wear, occasional non-enlarging, small (1–2mm) cysts around the tibial component.

Conclusions: The SF 12 scores seem to be unresponsive. The pain and difficulty scores more reflect the patients’ perception of outcome. With the low incidence of revision, risk factors for early failure are difficult to establish but patients with radiological cysts, talar collapse or more severe deformities of the foot/ankle might be the ones who need regular review.

R Smith P LR Wood

We aim to assess the outcome of ankle arthrodesis performed for painful osteoarthritis in the presence of a coronal plane deformity of 20 degrees or more. To our knowledge this is the first reported series of such a cohort of patients. We have a consecutive and complete series of 24 patients with 26 ankle arthrodeses which were all performed for painful osteoarthritis in the presence of large coronal plane deformity. These patients have a minimum of twelve months clinical follow up. The results showed a low non union rate of 8% (2 ankles). These have subsequently been refused satisfactorily, and were excluded from further analysis. The results of the remaining 24 ankles which united primarily show that they were very pleased with the outcome of their surgery. AOFAS scores were used to measure pain and function both pre operatively and post operatively. These scores showed large improvements for both pain and function, and had a high statistical significance (p< 0.0005). All patients improved in their walking distance and many patients reduced their need for walking aids. Stair climbing ability was also improved in some patients. It is recognised that an ankle arthrodesis usually relieves pain but does not result in a normal gait and full function. We feel that the high level of patient satisfaction in this series was due to the combination of deformity correction, restoring a functional foot position, and achieving a painless ankle. Arthroplasty of the ankle is a good procedure for relief of pain and restoration of function. However In the presence of a large coronal plane deformity ankle arthroplasty is known to fare badly with early failure. Therefore for patients with painful osteoarthritis and a coronal plane deformity of 20 degrees or more, we recommend ankle arthrodesis as the procedure of choice.

M Changulani N Garg A Bass Nayagam C Bruce

Aim: To evaluate our initial experience using the Ponseti method for the treatment of clubfoot.

Materials and Methods: 85 feet in 56 patients treated at Alder Hey Hospital, Liverpool between Nov 2002 – Dec 2004 were included in the study.

The standard protocol described by Ponseti was used for treatment.

Mean period of follow up was 12 months (6– 30 months).

Evaluation was by the Pirani club foot score.

Results: Results were evaluated in terms of the number of casts applied, the need for tenotomy and the recurrence of deformity.

Average number of casts required were 6.

Tenotomy was required in 80% of feet.

At the latest follow up approximately 15% of feet recurred following treatment and were managed surgically. Poor compliance was noted to be the main cause of failure in these patients. We have recently modified our splint and hope this will address some of the reasons for poor compliance. There was also a smaller subgroup of patients (approximately 5%) which failed to respond to the treatment regime and could not be brought to the point were tenotomy would be appropriate.

Conclusion: In our hands the ponseti technique has proved to be a very effective treatment method for the management of CTEV but like all treatment methods does have some limitations.

M Costa K Logan D Heylings K Tucker S Donell

Introduction: Tendon lengthening is an important cause of morbidity after Achilles tendon rupture. However, direct measurement of the tendon length is difficult. Ankle dorsiflexion has therefore been used as a surrogate measure, on the assumption that it is the Achilles tendon that limits this movement. The aim of this investigation was to assess the relationship between Achilles tendon length and ankle dorsiflexion. The primary research question was whether or not the Achilles tendon is the structure that limits ankle dorsiflexion. The secondary purpose was to quantify the relationship between Achilles tendon lengthening and dorsiflexion at the ankle joint.

Methods: Five cadaveric specimens were dissected to expose the tendons and capsular tissue of the leg and hindfoot. Fixed bony reference points were used as markers for the measurements. In the first specimen, the Achilles tendon was intact and the other structures that may limit ankle dorsiflexion were sequentially divided. In the other specimens the Achilles tendon was lengthened by 1cm intervals and the effect upon ankle dorsiflexion movement was recorded.

Results: Division of the other tendons and the capsular tissue around the ankle joint did not affect the range of ankle dorsiflexion. When the Achilles was divided the foot could be dorsiflexed until the talar neck impinged upon the anterior aspect of the distal tibia. There was a mean increase of 12 degrees of dorsiflexion for each centimetre increase in tendon length.

Conclusion: The Achilles tendon is the anatomical structure that limits ankle dorsiflexion, even when the tendon is lengthened. There was a linear relationship between the length of the Achilles tendon and the range of ankle dorsiflexion in this cadaveric model. Ankle dorsiflexion would appear to be a clinically useful indicator of tendon length.

A Malviya B Ashton J Kuiper N Makwana P Laing

Aim: Concerns have been expressed that DMARDS may interfere with bone healing. Previous studies give conflicting advise and no consensus exist in current practise especially with the newer DMARDS such as Leflunomide, Etanercept, and Infliximab. The aim of this study was to assess the in-vitro effect of DMARDS and cox-2 inhibitors on Osteoblast activity.

Method: Osteoblasts were cultured from femoral heads obtained from five young otherwise healthy patients undergoing total hip replacement The cells were cultured using techniques that have been previously described. A computer aided design of experiment was used as a model for setting up the experiment on samples obtained from the five patients. Normal therapeutic concentration of the various DMARDS was added alone and in combination to the media. The cell growth was estimated after two weeks using spectrophotometric technique using Roche Cell proliferation Kit. Multiple regression analysis was used to estimate the best predictor of the final result.

Results: The most significant factor (p< 0.001) in predicting the ultimate response was the patient themselves. Cox-2 inhibitor (Etoricoxib) was found to have the most consistent effect although always in combination with some other drug which varied amogst different patients. Etoricoxib in fact had a stimulatory effect (R=0.219) on the osteoblast growth.

Conclusion: Different patients respond differently to the drugs. None of the DMARDS tested inhibit osteoblast proliferation and differentiation in-vitro. If osteoblastic activity is considered to be the primary factor responsible for bone healing, then an inhibition should not result in patients who are on these drugs.

S Palmer R Venn J Coates S Umarjii F Middleton

Purpose: The aim was to determine whether intra-articular bupivacaine provides effective analgesia following ankle arthroscopy and whether it reduces the need for supplemental analgesia.

Methods: A power calculation revealed that 40 patients were required to provide a 5% significant level using a visual analogue scale. 40 patients were therefore randomised to receiving 20 mls of either bupivacaine or saline (control) after routine anterior ankle arthroscopic surgery. The tourniquet was released 10 minutes later. In recovery, supplementary analgesia of 2 tablets of co-codomol 30/500 orally or 50–100mg tramadol IV was available on request. A 10 day supply of 50mg diclofenac (8 hourly) and co-codomol 30/500 2 tablets (6 hourly) was provided.

A visual analogue scale (VAS) was employed as a direct indicator of pain and indirectly, supplemental analgesic requirement. Measurements were made pre-operatively and postoperatively.

Age, weight and tourniquet times were compared with Mann Whitney U test and Chi-square. Pain scores and analgesic requirements were compared using ANOVA at a 5% significance level.

Results: Pain scores were lower in the bupivacaine group compared to the control as was the need for supplemental analgesia.

Significance: We conclude that postoperative intraarticular bupivacaine provides effective analgesia following ankle arthroscopy.

H Kurup G Taylor

Arthrodesis of the ankle joint gives satisfactory short and medium-term results; however, in the longer term, it frequently leads to sub-talar and mid-tarsal osteoarthritis which is difficult to treat. Use of mobile bearings have significantly improved the results of ankle replacement. This a mid term follow up (1 to 5 years)of Buechel-Pappas ankle replacements performed by the senior author.34 total ankle replacements performed by one surgeon from October 1999 to May 2004 were reviewed retrospectively. Pre and post operative VAS scores, AOFAS scores were evaluated to find patient satisfaction and outcome. Tourniquet time as recorded in operation notes showed the learning curve for the procedure. Males : Females- 1:1.4. Mean age was 65 years (range : 33 to 83). Indication for surgery was primary osteoarthritis in 13, post traumatic arthritis in 14 and rheumatoid arthritis in 8. Average VAS score was 8.2 pre operative and improved to 2.0 at follow-up. AOFAS score improved from 39.1 to 72. Operating time averaged 113 minutes in 1999 and 85 in 2004. Significant complications were medial impingement (8) out of which 3 patients needed further surgery, intra-operative malleolar fractures (medial 4, lateral 1 and posterior 1, all healed successfully) and injury to cutaneous nerves (4) 3 patients had superficial infection which settled with antibiotics, but there were no cases of deep infection. 58 % were very happy, 32.5 % were happy, 9.5 % were not happy with the result. 2 patients had ankle fusion on the opposite side earlier, both were happier with the replaced side. Ankle replacements appear to offer a good alternative to fusion in selected patients. There is a significant risk of minor complications. Medial impingement may need further debridement at a later stage.

H Prem P Wood

Purpose: We evaluated the role of the Distal Tibial Line (DTL by Saltzman et al, 2005) in measuring the pre-operative and postoperative position of the talus on ‘lateral’ radiographs following a Total Ankle Replacement (TAR). Currently there is no validated measure of anteroposterior (AP) alignment of a TAR.

Arthritis in the ankle causes considerable malalignment in the anteroposterior plane. The DTL is not affected by the destruction of the tibiotalar joint and is independent of slight variations in the positioning of the foot and radiological magnification.

Method: DTL divides the talus into two sections and the proportionate length of the posterior segment is presented as a ratio. The size of the posterior segment and ratio decreases with anterior subluxation.

Radiographs of 200 cases of TAR were reviewed. The anterior and posterior outlines of the talus could not be seen in all cases (e.g. preoperative talonavicular fusion). As a result 49 cases of inflammatory arthritis (49 of 119) and 6 of osteoarthritis (6 of 81) could not be assessed.

Results: The osteoarthritic ankle (OA) in particular showed a tendency for anterior subluxation. The average ratio in OA cases increased from ‘34.8′ before surgery to ‘40.4’ after surgery, confirming a trend for this subluxation to reduce with a TAR.

There was a lesser tendency for subluxation in the inflammatory group of patients although the body of the talus itself was more deformed. The average preoperative value was ‘36.1’ and the post operative value was ‘38.9’.

Conclusion: We found the Distal Tibial line to be a reproducible parameter for measurement of AP alignment in TAR in the vast majority of OA cases. The change of anteroposterior alignment post surgery appears to be due to the restoration of soft tissue balance.

N Cullen A Robinson N Chayya J Kes

Introduction: The Distal metatarsal articular angle (DMAA) is a radiographic measure of orientation of the first metatarsal articular surface, it is frequently used in the management of hallux valgus. There is a great deal of conflict regarding accuracy, reproducibility and validity of the DMAA within the literature. This study aims to test the validity of the measurement of the DMAA from standard radiographs, to explore the trigonometric relationship of first metatarsal rotation and the DMAA and to assess inter-observer reliability.

Materials/Methods: 34 seperate dry cadaveric first metatarsal bones were mounted onto a customized light-box/protractor allowing controlled incremental changes in rotation and inclination. A series of 39 digital photographs were taken of each metatarsal in 5 degree increments of rotation between 30 degrees supination and 30 degrees pronation and 10, 20 and 30 degrees of inclination. Three reviewers performed blinded DMAA measurements from each image; the data was collated for statistical analysis.

Results: The data was analysed using a mixed effects linear model comparing the DMAA with rotation of the first metatarsal. A strong statistically significant trend of increasing score with increasing pronation is observed, the relationship of which is approximately linear. There is a strong effect of inclination, but the strength of this varies with rotation this is amplified at higher inclinations. Inter-observor error was noted in line with other studies, the linear relationship is maintained.

Discussion: This study has shown that the distal metatarsal articular angle varies significantly, in an almost linear pattern, with axial rotation of the first metatarsal. Inclination of the first metatarsal is also shown to affect the magnitude of the angle.

This study does not refute the distal metatarsal articular angle as an entity, but does confirm the inaccuracy of extrapolating the DMAA from plain AP radiographs.

S Gwilym P Loxdale G Lavis R Sharp P Cooke

Introduction: Lesser toe deformities which require surgery are often treated using a technique of interphalyngeal joint fusion. This procedure is an effective way of reducing the deformity and pain associated with lesser toe deformity but necessitates internal fixation until fusion is achieved. The Kirschner wire used to provide peri-operative stability is undesirable for a number of reasons, most importantly, the risk of interosseous infection and the lack of patient satisfaction due to the need for a second procedure for the wires removal. The ‘Oxford’ procedure was developed by the senior author (PHC) both in an attempt to remove the need for Kischner wire fixation and to maintain some mobility at the interphalyngeal joint.

Patients and methods: Between January and October 1994, 14 patients underwent ‘Oxford’ procedures on isolated lesser toe deformities. Their mean age was 59 at the time of surgery (range 26 – 79, 3 male and 11 female). Each patient was reviewed in November 1995 and an assessment was made of their post-operative pain levels, function, footwear, cosmetic appearance, time to return to work and any complications they had experienced. In March 2005 (ie: at least 10 years postop) an attempt was made to review these patients and make assessments of their pain in the operated toe, any subsequent surgery in that, or other toes, and the stability of the toe. In addition, an assessment was made of the patients view of the cosmetic outcome and their satisfaction levels. 12 patients were successfully contacted and reviewed.

Results: All 12 patients were satisfied with their long term results in terms of pain relief and cosmesis.

Conclusion: The ‘Oxford’ proceedure for lesser toe deformities has good long term clinical results and avoids k-wire fixation.

J Calder T Kane E Gardner

Introduction: A recent clinical study has suggested that topical GTN may improve the outcome of non-insertional Achilles tendinopathy. The mechanism for this improvement is obscure but is thought to be due to modulation of local nitric oxide (NO) levels. The purpose of this study was to assess the clinical and histological results of topical GTN for non-insertional Achilles tendonitis.

Methods: 40 patients with non-insertional Achilles tendonitis underwent standard non-operative therapy. 20 patients also used topical GTN daily. AOFAS, AOS visual analogue scores and SF36 forms were completed pre-treatment and 3 months later.

Patients who failed conservative treatment and underwent surgery had histological examination of achilles tendon and histochemical analysis for isomers of NOS (eNOS and iNOS) as a marker of NO production.

Results: There was an overall improvement in symptoms in both groups but no significant difference in the improvement bewtween them – there was no additional benefit in using GTN patches. 4 patients also had to stop using patches within 3 weeks because of headaches.

Histological examination did not show any difference in collagen synthesis or remodelling between the 2 groups and there was no evidence of stimulated wound fibroblasts in the GTN group. There was no difference between the groups in the expression of eNOS or iNOS.

Conclusion: This study fails to demonstrate any improvement in symptoms when using GTN patches. There is no histological evidence that GTN promotes degenerate tendon to stimulate wound fibroblasts and increase collagen synthesis and remodelling. GTN patches do not appear to modulate the expression of NOS enzymes in diseased Achilles tendon. The use of GTN patches in the treatment of non-insertional Achilles tendonitis remains questionable and the role of NO as a mediator of inflammatory response remains elusive.

J J G Malal J Shaw-Dunn C S Kumar

Aim: Chevron osteotomy is a commonly performed procedure for the treatment of hallux valgus and results in AVN of the first metatarsal head in up to 20% of cases. This study aims to map out the arrangement of vascular supply to the first metatarsal head and its relationship to the limbs of the chevron cuts.

Methods: 10 cadaveric lower limbs were injected with an Indian ink – latex mixture and the feet dissected to evaluate the blood supply to the first metatarsal. The dissection was carried out by tracing the branches of dorsalis pedis and posterior tibial vessels. A distal chevron osteotomy through the neck of the metatarsal was mapped and the relationship of the limbs of the osteotomy to the blood vessels was recorded.

Results: The first metatarsal head was found to be supplied by branches from the first dorsal metatarsal, first plantar metatarsal and medial plantar arteries of which the first one was the dominant vessel in 8 of the specimens studied. All the vessels formed a plexus at the plantar – lateral aspect of the metatarsal neck, just proximal to the capsular attachment with varying number of branches from the plexus then entering the metatarsal head. The plantar limb of the proposed chevron cuts exited through this plexus of vessels in all specimens. Contrary to the widely held view, only minor vascular branches could be found entering the dorsal aspect of the neck.

Conclusion: The identification of the plantar – lateral corner of the metatarsal neck as the major site of vascular ingress into the first metatarsal head suggests that constructing the chevron osteotomy with a long and thick plantar arm exiting well proximal to the capsular attachment may decrease the incidence of AVN.

K Mannan C Belcham H Beaumont J Ritchi D Singh

Purpose: Evaluation of a hands free crutch. This interesting device is intended for patients who have undergone foot and ankle surgery and should be non-weight bearing. It involves a knee tray attached to a vertical beam with a rubber foot. The crutch is strapped to the lower limb and weight is transferred though the proximal tibia.

Methods: Five Volunteers were assessed using the crutch, the K9 walker and 2 standard crutches in a simulated environment.

A comparison was made between this device and the K9 walker which has been shown to be a liberating walking aid indoors. Tasks from activities of daily living, productivity and transfers were included. Assessment was undertaken by the Occupational Therapy Team.

The hands free crutch was also compared with non weight bearing using two crutches to gauge performance outdoors. Assessment of ease of use and safety was undertaken by the Physiotherapy Team.

Results: Domestic chores including cleaning, cooking and shopping were possible using this device. Sitting activities were noted to be more difficult, because of the necessity to remove the crutch on each occasion.

Although speed was significantly greater (p< 0.0001.) using two crutches, the hands free crutch permitted safe outdoor mobilisation on even or uneven ground, up and down slopes with a gradient of 1 in 10 and up and down stairs. Good single leg stance stability was predictive of ease of use and safety for the hands free crutch.

Discussion: The hands free crutch is suited to motivated and physically able patients. Other lower limb pathology contraindicates the use of this device, but in patients with upper limb pathology it would permit non-weight bearing mobilisation. Good balance is paramount and perhaps a falls risk assessment should be performed prior to use.

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G Holt M Kay R McGrory S Kumar

Introduction: Patients undergoing surgery to the foot frequently ask when it is safe to return to driving. The ability to drive is important both in social and economical terms. There is currently little data in the literature relevant to foot surgery. We are conducting a prospective cohort control study to asess the effect of forefoot surgey on break-response time. Methods- Individuals attending for first MTP joint arthroplasty and SCARF/Chevron osteotomies for hallux valgus are recruited. A driving simulator was constructed consisting of a steering wheel, foot pedals, an LCD display, a CPU and a control unit. The patient follows an image on the LCD screen using the steering wheel. The examiner then randomly initiates the machine and a stop sign is displyed. The patient would then release the accelerator pedal and depress the brake. The CPU claculates the “respone-time”, the “break-time” and total breaking time. In addition the “stick test” and “stand test” were performed as further measures of lower limb function. Each individual was assessed pre-operatively and at 2 and 6 weeks postoperatively. Both drivers and non-drivers are included and a control population of age and gender matched individuals was included for comparison. Results – 25 individuals are currently enrolled as study cases, 12 of which have 2 week follow-up and 3 have completed the study. Control data is being collected.

Conclusion: Early results indiciate that break response time is increased at 2 weeks post-operatively, however this returns to pre-operative levels by 6 weeks. (204ms vs 256ms vs 206ms) These early results may be validated when all individuals have completed the study. Further study of the period 2–6 weeks after surgery will now be subject to study to assess the optimum time to return to driving.

P Singh N Perera

Background: There is increased concern regarding radiation exposure to surgeons using fluoroscopic guidance throughout various procedures. However, relatively little information exists on the level of radiation exposure to the foot and ankle surgeon during fluoroscopically assisted foot and ankle surgery.

Methods: We are conducting an ongoing proespective study to measure radiation exposure to the hands of a single orthopaedic foot and ankle surgeon (RD). Over a 12-month period, thermoluminescent dosimeter rings are worn on the little finger of each hand of the operating surgeon. The rings are changed at six week intervals. Measurement of the overall radiation exposure is being recorded over this time period.

Results: This is an ongoing prospective study started in December 2004. We are measuring: total number foot and ankle cases using fluoroscopy, the total screening time for foot and ankle procedures, the mean screening time per procedure and the total radiation exposure to the thermoluminescent dosimetry rings.

Conclusion: Preliminary results show that radiation exposure is well below the current annual dose limit. In our study, radiation exposure during orthopaedic foot and ankle procedures is expected to comply with current recommendations of the European Committee on Radiation Protection and is well below dose limits set by the International Commission on Radiological Protection.

S Lines I Winson M Bradley

Morton’s syndrome is an entrapment of a digital nerve between the metatarsal heads in the foot causing pain between the metatarsal heads. 41 subjects with signs and symptoms of Morton’s syndrome were prospectively examined with an ultrasound scan and the size of the bifurcation of the interdigital nerve was recorded if it was visible. Each subject completed a Visual Analogue Scale and short form McGill Pain Questionaire before an injection of local anaesthetic and corticosteroid was administered. The subjects were reviewed after 6 weeks and the pain scores repeated.

26 subjects had positive ultrasounds with a mean width of 5.1 mm, range 2.7–9.8 mm and 15 subjects had negative ultrasounds. Differences in mean ranks of VAS scores between the two groups were borderline statistically significant for scores before injection (p=0.064). Difference in mean rank of VAS score was significant after injection (p=0.013).

Differences in mean ranks of MPQ scores were borderline statistically significant for changes in scores (p=0.062). Difference in mean rank of MPQ score was significant after injection (p=0.007). None of the correlations between nerve width and any of VAS or MPQ outcome measures were statistically significant.

This study demonstrates that the larger the neuroma on the ultrasound, the more painful it is for the patient. This study suggests that patients who have a small or absent neuroma demonstrated on the ultrasound scan are more likely to have their pain reduced to an acceptable level with an injection of local anaesthetic and corticosteroid than those patients with a large neuroma. Ultrasound examination is a useful tool in the management of patients with Morton’s syndrome.

M Costa F Robinson S Donell L Shepstone R Chester

We performed two independent randomised controlled trials to assess the potential benefits of immediate weight-bearing mobilisation for Achilles tendon ruptures. The first trial on surgically treated patients provides strong evidence of improved functional outcome for patients mobilised fully weight-bearing after operative repair of their Achilles tendon rupture. The two cases of re-rupture in the treatment group suggest that careful patient selection may be required as patients need to follow a structured rehabilitation regime.

The second trial performed upon non-operatively treated patients provides only weak evidence of a functional benefit from immediate weight-bearing mobilisation. However, the practical advantages of immediate weight-bearing did not predispose the patients to a higher complication rate. In particular there was no evidence of tendon lengthening or a higher re-rupture rate. We would therefore advocate the use of immediate weight-bearing mobilisation for the rehabilitation of all patients with rupture of the Achilles tendon.

A Shah L Murray M Siddique

Purpose: The purpose of this study was to assess the subjective, clinical and radiological improvement in patients with moderate to severe hallux rigidus undergoing Proximal Phalangeal Dorsomedial Closing-wedge Osteotomy with Cheilectomy.

Methods: Between March 2003 and November 2004, 17 patients (18 feet) underwent Proximal Phalangeal Dorsomedial Closing-wedge Osteotomy with Cheilectomy, 14 were available for clinical follow-up; pre and post-operative X-rays were available for all of them.

The Clinical assessment was based on modified American Orthopaedic Foot and Ankle Society’s hallux-metatarsophalangeal scale. The subjective assessment was done by a questionnaire and radiological assessment was done by using digital radiographs.

Results: Out of the 18 feet we studied, 1 was of Grade 1, 9 of Grade 2 and 8 of Grade 3. 12 out of 14 patients (85%) were satisfied with the outcome after an average follow-up period of 14 months. There was an increase in the Mean mAOFAS score of 49.6 (from a mean score of 26.2 to 75.8); the improvement in pain score was 27.4. With a mean osteotomy thickness of 1.78 mm, the proximal phalangeal length was decreased by a mean of 3.7mm. The medialization achieved in the men M1-P1 angle was 6.8 degrees. There was a highly significant gain of 25 degrees in Mean Dorsiflexion which cannot be explained by a mean increase of only 0.9 mm in the lateral dorsal joint space attributable to cheilectomy.

Conclusion: Dorsomedial Proximal Phalangeal Closing-wedge Osteotomy combined with Cheilectomy gives good subjective and clinical results regarding satisfaction, pain relief and gain in dorsiflexion; at least in the short-term. This gain in movement might be explainable by an improved EHL lever-arm resulting from dorsome-dial nature of the phalangeal osteotomy.

D MacDonald G Holt K Vass A Marsh S Kumar

Lumps of the foot present relatively infrequently to the orthopaedic service. There have been very few published studies looking at presenting characteristics or the differential diagnosis of such lesions. We report our experience of foot lumps treated surgically looking at the patient demographics, presenting characteristics, diagnoses encountered and the diagnostic accuracy of the surgeon. All patients who underwent excision or biopsy of a foot lump over a period of 4 years were studied; 101 patients were identified. Average age was 47.3 years (range 14–79); there was a significant female preponderance with 73 females and 28 males (p< 0.0001). Pain was the single most common presenting complaint followed by footwear problems. Only three patients attended because of cosmetic reasons and neurological symptoms were very rare with only one patient complaining of paraesthesia. Certain lesions were more commonly encountered in specific zones of the foot. 32 different histological types were identified, ganglion cysts were the most commonly encountered lesions and there was only one malignant lesion encountered in this study. Only 58 out of the l01 lumps were correctly diagnosed prior to surgery.

We have shown that there are a wide variety of potential diagnoses, which have to be considered when examining a patient with a foot lump. There is a low diagnostic accuracy for foot lumps and therefore surgical excision and histological diagnosis should be sought if there is any uncertainty.

S Godey R Tandon O Thomas

Claw toes are treated by a variety of soft tissue and bony proceduresbased on the severity of the deformity. We evaluated the results of Stainsby procedure for claw toes. This is a retrospective analysis of the results of Stainsby procedure for claw toes of the foot done by a single surgeon over a 10 year period. All patients who had claw toes,secondary to Rheumatoid and Non rheumatoid causes and treated by this procedure were included in the study. All the patients operated between Jan 1995 -Dec 2004 and who had minimum follow-up of 6 months after surgery were included in the study. Follow up evaluation was by clinical examination, review of case notes and telephone conversation.

42 patients underwent this procedure of which 38 were available for evaluation. Average follow-up was 43.5 months (6–110months). 26 rheumatoid and 21 non-rheumatoid feet were evaluated based on the AOFAS score. The mean AOFAS score was 76.5. The scores for the Rheumatoid and Non-Rheumatoid groups were 81.5 and 72.6 respectively.81% were satisfied with the result of the operation and 83% would recommend this surgery for friends and relatives. Six patients had superficial infection, 2 had broken k-wires, 2 had DVT, and 2 had recurrence of deformity.

We conclude that Stainsby procedure for claw toes is a procedure which has good results in the long term and can be taken up as a procedure of choice for severe claw toes.

M Costa D Kay S Donell F Robinson

One of the factors that influence the outcome after Achilles tendon rupture is gait abnormality. We prospectively assessed 14 patients with Achilles tendon rupture and 15 normal control subjects using an in-shoe plantar pressure measurement system. There was a significant reduction in peak mean forefoot pressure in the early period of rehabilitation (p < 0.001). There was a concomitant rise in heel pressure on the injured side (p=0.05). However, there was no difference in cadence, as determined by the duration of the terminal stance and pre-swing phases as a proportion of the total stance component of the gait cycle. The forefoot pressure deficit in the Achilles tendon rupture group was smaller when assessed six months after the injury but was still significant (p=0.029). Pedobarographic assessment of patients after Achilles tendon rupture confirms that there are marked abnormalities within the gait cycle. Rehabilitation programmes which address these abnormalities may improve outcome.

N Maffulli V Testa G Capasso F Oliva A Sullo

Objective: To report the outcome of surgery for chronic recalcitrant Achilles tendinopathy in sedentary and athletic subjects.

Design: Case control study

Participants: We matched each of the 61 non-athletic patients with a diagnosis of tendinopathy of the Achilles tendon with an athletic patient with tendinopathy of the main body of the Achilles tendon of the same sex who was within two years of age at the time of operation. A match according was possible for 56 patients (23 males and 33 females). 48 sedentary subjects and 45 athletic subjects agreed to participate.

Main Outcome Measure: Outcome of surgery, return to sport, complication rate.

Results: Non-athletic patients were shorter and heavier than athletic patients. They had greater BMI, calf circumference, side-to-side calf circumference differences, and subcutaneous body fat than athletic patients. Of the 48 sedentary patients, only 25 reported an excellent or good result. Of these, three had undergone a further exploration of the Achilles tendon. The remaining patients could not return to their normal levels of activity. In all of them, pain significantly interfered with daily activities.

Conclusions: Non-athletic subjects experience more prolonged recovery, more complications, and a greater risk of further surgery than athletic subjects with recalcitrant Achilles tendinopathy. Key words: Achilles tendinopathy, surgery.

B Yates D Williamson

Purpose: An audit was undertaken to evaluate the patients’ experience of foot surgery at the great Western Hospital in 2004 following the appointment of a podiatric surgeon to the orthopaedic department.

Method: The first 100 patients that were operated on by the podiatric surgeon (Group 1) were matched by OPCS code to a randomly selected patient cohort that had been operated on by orthopaedic surgeons (Group 2). All patients were at a minimum of 6 months post-surgery (range 6–10 months Gp. 1, 11–20 months Gp. 2). The audit department sent out an anonymous questionnaire relating to the patients’ experience both before and after their surgery as well as current levels of satisfaction with the outcome of their surgery.

Results: The response rate was 64% in Gp.1 and 68% in Gp.2.

The patients’ overall satisfaction with the result of their foot surgery was determined using a Likert scale and the results can be seen in Table 1.

Patients in the podiatric surgical group were significantly more satisfied with the result of their foot surgery than those in the orthopaedic group (p< 0.008; Mann Whitney U test).

Similar statistically significant differences were also seen between the two groups relating to patient satisfaction with their pre and post-operative consultations and information concerning their proposed surgery and its outcome.

Conclusion: The results of this audit suggest that the satisfaction of patients following foot surgery can rise significantly following the appointment of a podiatric surgeon to a general hospital orthopaedic department.

V Kumar R Bhattacharyam F Attar A Hameed I McMurty

CT- scan as an management tool is being used extensively in managing calcaneal fractures. We set out to see if a CT-scan makes any difference to the management plan as obtained by looking at the plain radiograph. We also looked at the correlation with the actual management.

Methodology: This was a retrospective study involving 24 patients with fracture of the calcaneum. These patients had both a plain radiograph and a CT- scan to help decide on management. The actual management that each of these patients had was documented. Three consultants who were blinded to the actual management and names of the subjects were independently asked to grade the radiographs, as operative or non-operative. They were then similarly, asked to decide on operation or no-operation based on blinded CT- scans. The data obtained from the three observers were compared to the actual management and were subjected to statistical analysis.

Results: As the data was categorical and matched, the Mcnemars test was used to test the association between the management plan obtained from the radiographs and the management plan obtained from the CT scans, for each consultant. They were also compared with the actual management. The statistical analysis showed that there was no statistically significant association between the management decision obtained from the radiographs and the CT san, for all three observers. Radiograph and CT scan based management decisions also did not correlate with the actual management.

Conclusion: The CT scan should only be done when a definite decision is made to operate on a patient, based on plain radiographs. Calcaneal fractures which are decided not to operate, based on X rays, should not have a CT scan as a routine as it provides no valuable additional information.

V Kumar F Attar M Maru A Adedapo

Aim: Our aim was to measure plantar foot pressures in normal individuals and to compare them with variations in patients with metatarsalgia.

Methodology: We measured the plantar foot pressures in different parts of the foot in normal subjects of various ages and then compared this with foot pressures of patients with metatarsalgia. For measurement and statistical analysis, the plantar contact of the foot was divided into six anatomical divisions. The foot pressures were measured under the hallux, head of first metatarsal, over heads of second, third and fourth metatarsals, the fifth metatarsal, midfoot and hindfoot. This was measured using the FSCAN insole pedobarograph system (Tekscan, Inc, Boston, MA).

The foot pressures were measured in Kilopascals(Kpa). Independent T-tests was used to compare mean pressure distributions in the six anatomical divisions. We found the mean pressures through the 5th metatarsal head – 217(t=−2.32,p< 0.05) and midfoot 94(t=−3.17, p< 0.05), were significantly higher when compared to pressures in normal subjects (table 1).

Conclusion: We have demonstrated increased pressures transmitted through the outer aspect of the sole of the foot, in patients suffering from metatarsalgia. This can be used further to plan any foot- orthosis or surgery to distribute pressures more evenly across the sole of the foot.

C Nguyen D Singh M Harrison G Blunn I Dudkiewicz

Introduction: Many mini compression screws are now available for fixation in procedures such as metatarsal osteotomies or arthrodeses of the foot.

The aim of the current study is to compare the compression forces achieved by mini compression screws on cortical and cancellous bone models.

Material and Methods: The screws that were tested are listed in the table below. The compression forces were tested by inserting a pressures load measurement cell between longitudinally-split sheep tibia as a cortical bone model and longitudinally split retrieved femoral heads as a cancellous bone model.

Results: The Headed AO 3.5 mm cortical screw gave the best compression force and the Bold was the weakest, both in cortical and cancellous bone. The relative compression forces of the other tested screws were different between cortical and cancellous bone. Compression with the headless screws was lost as soon as the screw penetrated through the cortex in the cortrical bone model.

Conclusions: The indications for using headless self-tapping screws should be reserved for fixation of cancellous bone or of metatarsal or Akin osteotomies where compression is not required for union. When compression is important, such as in MPJ, tarso-metatarsal or talonavicular arthrodeses, Headed AO 3.5 mm or 2.7 mm cortical or 4 mm cancellous screws, which give better compression, should be used.

W S Khan M. Aggarwal C Warren Smith

Proximal fifth metatarsal fractures distal to the tuberosity, also known as Jones’ fractures, are troublesome fractures to manage with a high incidence of delayed union and nonunion.

We conducted a retrospective study of 32 patients with fractures of the fifth metatarsal distal to the tuberosity over a three year period. The aim was to assess healing with non-weight bearing and variations of weight bearing mobilization including minimal, partial and full weight bearing. This is one of the largest reported series of such fractures. These fractures were classified as acute fractures (14 fractures), fractures with features of delayed union (15 fractures) and fractures with features of nonunion (three fractures) at presentation according to the radiological classification used by Torg in 1984. These patients were treated in a plaster cast and mobilised either non-weight bearing or with variations of weight bearing. These patients were followed up for a mean of 16 months.

Our findings correspond with those observed by Torg and we describe a correlation between the radiological appearance of the fracture at presentation and the clinical course. Prevailing guidelines for the management of these fractures are ambiguous. A standardized classification is important because there is great variability in the types of fractures and appropriate treatment. It is important that radiological features are correlated with clinical features and appropriate treatment instituted. The treatment of choice for acute fractures is immobilization of the limb in a below-knee non-weight bearing plaster for 6 to 8 weeks. Fractures with delayed union may eventually heal if treated non-operatively, although this may take up to 20 weeks. An active athlete will benefit from early surgery. Fractures with symptomatic nonunion require surgery.

H Hassouna D Singh

Morton’s Metatarsalgia is a painful condition and can often be debilitating. The value of surgical exicion has been doubted due to low success rate of surgical intervention.

Objective: The purpose of this study is to examine the variation in the management steps of Morton’s Metatarsalgia.

Methods: Several Surgeons from different European countries answered a questionnaire in regard to their routine management of a typical Morton’s Neuroma patient.

Results: 25 surgeons (100%) stated they would routinely elicit intermetatarsal tenderness in comparison to 14(56%) and 10 (40%) surgeons who would routinely elicit Intermetatrsal tenderness and Mulder’s click respectively. The majority of them (84%) will routinely request plain foot radiograph, while 7 surgeons(28%) uses ultrasound routinely. Coservative management is initiated by 16 surgeons(64%). Local injection was first line of treatment among 13 surgeons (56%). Surgical treatment is favoured by 10 surgeons(40%), while only one surgeon (4 %) would use ultrasound guided injection routinely. The popular surgical approach is dorsal incision (75%). If surgical option was chosen then neurectomy is attempted by 17 (68%) surgeons.

Conclusion: Considerable variation exists among continental surgeons in their initial management of a typical Morton’s Neuroma patient. This is probably due to lack of understanding of the true aetiology of the Morton’s “Neuroma”.

S Hakkalamani K Meda V Prasanna J Stamer

Objective: To assess functional outcome and complications in patients with Weber C fracture following syndysmotic screw removed.

Patients & Methods: Forty three consecutive patients with closed Weber C type ankle fractures between 2002–20003 were studied. The syndysmotic screw was removed at 6–12 weeks time post operatively. Postoperative complications and functional outcome were studied.

Results: Following removal of the syndysmotic screw 6 patients had superficial wound infection, 4 patients had pain due to instability, one patient had DVT and one patient had broken screw. The functional outcome using ankle scores compared to the other studies in the literature did not show any significant difference.

Conclusion: Syndysmotic screw removal has significant morbidity. Guidelines with randomised control studies are recommended.

B Sarai A Ebinesan G Walley D Miller D McBride N Maffulli

Introduction: We reviewed the complications and recovery of patients treated for Achilles tendon rupture by percutaneous repair, open repair, and non-operative management in a tertiary referral centre between 2001 and 2003.

Materials and Methods: We identified patients who underwent Achilles tendon rupture repair by percutaneous or open methods from the logbooks of Consultants and the operating theatre register. We used plaster room records were also used to identify patients who received non-operative treatment. We collated demographic and management details, and compared them with published rates relating to average age range, demographic, and management details.

Results: In the 20 patients who underwent open repair, one (4.8%) patient sustained a re-rupture, four (19%) sustained minor complications, and one (4.8%) had a major complication. In the 31 patients who underwent percutaneous repair, one (3.2%) patient sustained a major complication, six (19.4%) patients experienced minor wound complications, and there were no re-ruptures. In the 12 patients who underwent conservative management, re-ruptures occurred in one patient (8.3%), minor complications occurred in five patients (41.7%), and there were no major complications. The median recovery time in the open, percutaneous and conservative groups was 25 weeks, 26 weeks and 18.5 weeks respectively.

Discussion and Conclusion: In our setting, percutaneous repair is the most successful management method, with no re-ruptures and very few complications. Although conservative management produced the highest rate of complications, each patient will have different needs due to their age, occupation or level of sporting activity. Ultimately, the decision of the management regime used probably lies with the patient.

J J G Malal C S Kumar

Shape memory phenomenon whereby the metal changes its characteristics depending on the ambient temperature it is exposed to is well described in the metallurgical literature. In cold conditions (0–5° C) the alloy becomes plastically deformable and its shape can be changed at will, but would rapidly regain its original shape and strength at higher temperatures. This study assesses the effectiveness of shape memory staples as a method of internal fixation in foot and ankle surgery.

All patients who underwent foot and ankle surgery in which Memory® staples were used for fixation were included in the study. The patients were evaluated with regard to period of immobilisation in cast, period of restricted weight bearing and time to radiological joint fusion or union of osteotomy.

Memory® staples had been used in a total of 40 procedures; 13 procedures (6 MTPJ fusions, 7 Akin osteotomies) were done in the forefoot while the rest were carried out in the mid or hind foot. Bone grafting was used only in one hind foot arthrodesis. A strong arthrodesis or union was achieved in all the patients. The average time to fusion was 7.2 weeks (range 6–12) with an average period of immobilisation of 4.3 weeks (range 0–12). The average time to full weight bearing was 5.2 weeks (range 0–6). Breakage of the staple was noticed in one patient but the joint went on to unite satisfactorily. Staple back out or displacement was not noticed in any of the cases.

The early experience with the use Memory® staples in foot and ankle surgery is encouraging; we did not encounter any technical problems and there is a suggestion that these implants may reduce the time to fusion/ healing thereby reducing the recovery time following foot and ankle surgery.

S Godey R Tandon O Thomas

Claw toes are treated by a variety of soft tissue and bony proceduresbased on the severity of the deformity. We evaluated the results of Stainsby procedure for claw toes. This is a retrospective analysis of the results of Stainsby procedure for claw toes of the foot done by a single surgeon over a 10 year period. All patients who had claw toes, secondary to Rheumatoid and Non rheumatoid causes and treated by this procedure were included in the study. All the patients operated between Jan 1995 -Dec 2004 and who had minimum follow-up of 6 months after surgery were included in the study. Follow up evaluation was by clinical examination, review of case notes and telephone conversation.

42 patients underwent this procedure of which 38 were available for evaluation. Average follow-up was 43.5 months (6–110months). 26 rheumatoid and 21 non-rheumatoid feet were evaluated based on the AOFAS score. The mean AOFAS score was 76.5. The scores for the Rheumatoid and Non-Rheumatoid groups were 81.5 and 72.6 respectively.81% were satisfied with the result of the operation and 83% would recommend this surgery for friends and relatives. Six patients had superficial infection, 2 had broken k-wires, 2 had DVT, and 2 had recurrence of deformity.

We conclude that Stainsby procedure for claw toes is a procedure which has good results in the long term and can be taken up as a procedure of choice for severe claw toes.

A Bhargava E Greiss

Introduction: Every ten seconds, somewhere in the world, someone dies of tobacco-related causes. The adverse effects of smoking on the cardiovascular, respiratory, and immune systems have been well documented. Results of foot surgery are also gravely affected by cigarette smoking, with poorer clinical outcomes, lower rates of osteotomy union, bony fusion and higher rates of postoperative infection. However, data on surgeon’s awareness and their practices to overcome the adverse effects of smoking in elective foot surgery is limited.

Aim: The purpose of this study was to report the results of a survey of experienced foot and ankle surgeons regarding their awareness about detrimental effects of smoking and the measures they take in their practice to prevent them.

Methods: A survey of members of British Foot and Ankle Society was done to document surgeon’s awareness and attitudes towards detrimental effects of smoking in patients undergoing elective foot surgery and the measures they take to prevent these problems. Survey was returned by 104 of the 225 surgeons (47%).

Results: One hundred and two (99%) of the surgeons were aware of the damaging effects of smoking in foot and ankle surgery. Eightynine (84%) of these recorded the smoking habits of their patients in their dictated notes. However, only 9% respondent admitted recording the smoking habits of their patients in consent form and warn them about forthcoming risk of complications at the time of consenting. Only twentyfour (23%) had varying protocol’s to prevent smoking related operative complications.

Conclusions: Most of the surgeons appreciate the harmful effects of smoking. However they are unaware of the extent to which it causes problems. Majority of the members would like the society to propose a unified policy or evidence based guidelines to deal with smoking related problems in foot surgery.

N Maffulli W Leadbetter

Introduction: Neglected Achilles tendon ruptures are a management challenge. Several surgical techniques have been described. A two centre, two surgeon, two year longitudinal study was undertaken to report the results of reconstruction of neglected Achilles tendon rupture using a free autologous gracilis tendon graft

Methods: Fourteen patients underwent surgery for a neglected rupture of the Achilles tendon occurring between 65 days and nine months before the operation. All were prospectively followed up for two years.

Results: No patients experienced any problems in the wound used to harvest the tendon of gracilis. Four patients were managed conservatively following a superficial infection of the achilles tendon surgical wound. No patients developed a deep vein thrombosis or sustained a re-rupture. All patients were able to walk on tiptoes, and no patient used a heel raise or walked with a visible limp. The maximum calf circumference remained significantly decreased in the operated leg at latest follow up. The operated limb was significantly less strong than the non-operated one.

Conclusions: The management of neglected subcutaneous tears of the Achilles tendon by free gracilis tendon grafting is safe but technically demanding. It affords good recovery, even in patients with a neglected rupture of nine months’ duration. These patients should be warned that they are at risk of post-operative complications, and that their ankle plantar flexion strength can remain reduced.

A Young

Thirty patients underwent tibio-talo-calcaneal fusion using an interlocking arthrodesis intramedullary nail device with locking screws. Although the nail is described as being stiffer in flexion, rotation and cantilever bending it was noted that the placement of the locking screw holes were not sufficiently in-tune with the variations found in nature. The placement of the holes and locking screws with relation to the heights of the talus and calcaneum were measured on post operative xrays and conclusions drawn from the variations found. It was felt that the intramedullary nail is a good device when used for tibio-talo-calcaneal fusion but that the design could be improved in order to improve patient outcome.

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H Kurup G Taylor

Ankle replacements appear to offer a good alternative to fusion in most arthritic conditions. Use of mobile bearings have significantly improved results of ankle replacement. These have a significant minor complication rate including nerve injury, fractures. One of the significant complications noted in our series was medial impingement. 34 Buechel-Pappas total ankle replacements performed by the senior author from October 1999 to May 2004 were reviewed retrospectively. Mean follow up of 2.8 years. 8 patients reported medial impingment symptoms at follow up. 3 patients underwent repeat surgery for this problem. One patient underwent arthroscopic debridement of scar tissue and impinging bone by another surgeon which gave good symptomatic relief. Two other patients had tibialis posterior tendonitis and underwent surgical decompression of the tendon. Both were found to be having degenerative tendons with partial tears. We discuss the findings, literature review and other complications of ankle replacements as well. Whether medial impingement is due to implant design or inherent pathology of ankle has to be studied further. Other implant designs like Agility may treat arthritis in medial and lateral gutters but can still cause soft tissue impingement. Whether these are due to implant design, residual arthritis in medial recess or soft tissue pathology is uncertain. This may be caused by the cylindrical shape of talar component (the physiologic talus has a cone shape with smaller radius on medial side). This has not been proven yet, but has been addressed in newer designs like Salto and Hintegra prostheses.

A Crombie C Kumar

Background: Since 2003 we have offered correction of bilateral hallux valgus to suitable patients as a daycase but there is nothing in the literature to support this as safe practice. Two published series support unilateral hallux valgus surgery as a daycase. We prospectively evaluated 30 bilateral daycase patients assessing complications and overall satisfaction rating.

Methods: The study group comprised 15 bilateral Scarf osteotomies, 9 bilateral Chevron osteotomies, 4 unilateral Scarf plus unilateral Chevron osteotomies, 1 bilateral 1st MTP joint fusion and 1 bilateral Lapidus procedure. All surgery was performed as a daycase under GA and ankle block. All patients were evaluated clinically and radiologically pre & post-operatively and had AOFAS scores measured. 21 patients were telephoned on the 3rd post-operative day to document their pain scores (0–10) and all patients responded to a patient satisfaction questionnaire at their discharge around 4.5 months.

Results: 18 of the 21 patients interviewed on day 3 had mild pain (0–4) as their maximum pain score. 3 reported problems (2 of pain and 1 of poor mobility). There was one unilateral superficial wound infection which required oral antibiotics. No other patients required to call or attend their GP nor attend A& E. The mean overall patient satisfation rating (0–10) was 8.8 (median 9). If having similar repeat surgery 4 of the 30 patients (13%) would prefer an overnight stay. The reasons given by these 4 patients were: pain (1), poor mobility (1), a desire to be looked after by the nursing staff (2).

Conclusions: Bilateral hallux valgus surgery can be performed safely as a daycase and with acceptable levels of patient satisfaction. It does not appear to result in an increased complication rate. To our knowledge this has not been previously documented in the literature.

R Kotnis S David S Ostlere K Willet

Hypothesis: If the lower re-rupture in operative treated patients was an effect of tendon-end apposition, then patients in whom that could be demonstrated in equinus by ultrasound could be equally well treated non-operatively without the attendant surgical risk.

Method: All patients undergoing ultrasound for a suspected Achilles tendon repair between January 2000 – 2005 were included. Patients with a residual gap, 5mm or more in equinus; were treated by surgical repair. Those with a gap of less than 5mm were treated non-operatively. We excluded patients with no rupture, partial rupture and musculo-tendinuous junction (MTJ) tears. We recorded the following: clinical findings, ultrasound measurements of tendon gap in neutral and equinus, distance of rupture from distal insertion, the treatment and complications. All patients were followed up to a minimum of 6 months.

Results: 156 patients were treated for a clinical Achilles tendon rupture during the study period. We excluded 5 patients with no rupture, 15 with a MTJ tear, 7 with a muscle tear and 4 patients did not follow the protocol. 125 patients comprising 88 males and 37 females were entered into the study. 67 patients were treated operatively (37 open, 30 percutaneous) and 58 non-operatively. There was no significant difference between the 2 groups with respect to age, sex and injury mechanism. There were 2 re-ruptures in the non-operative group and 1 with surgery. The operative group had 2 patients with superficial wound infection and 2 with temporary dorsal foot numbness. One patient in the non-operative group had a DVT. There was no significant difference for any of the complications between the two groups.

Conclusions: It may be possible to reduce the risk of re-rupture and surgery using dynamic ultrasound to determine which treatment the patient receives.

J Ritchie D Singh

Introduction: Adolescent peroneal spastic flatfoot (PSF) is often regarded as synonymous with tarsal coalition. Inflammatory arthropathies, infections and tumours may, however, all present in this way, and in a few patients with PSF no definitive pathology may be identified.

We aim of to evaluate the causes of adolescent PSF and to develop an an algorithm for its investigation and the management of those patients in whom no underlying pathology is identified.

Methods: All adolescent patients presenting to the senior author with PSF over a two year period were evaluated first for tarsal coalition by means of clinical examination, plain x-rays and CT scanning. If this proved inconclusive an MRI scan was performed and bloods sent for inflammatory and infective markers. If these too identified no treatable cause the patients were treated with a manipulation under anaesthetic, injection of steroid and local anaesthetic into the subtalar joint and immobilization in a below knee cast for 4 weeks. They then received physiotherapy and a talar neutral orthosis. Follow-up was at 4 weeks post-injection and continued until symptoms resolved.

Results: Five patients were found to have PSF with no identifiable cause. All were male, aged 12–17 at presentation. Four completed the treatment. Mean final follow-up was at 10 months post-procedure. All patients reported relief of pain following the procedure and returned to normal activity. At final follow-up, three were still participating in regular sport. One patient suffered a recurrence of his pain.

Conclusion: Adolescent peroneal spastic flatfoot is often, but not always due to tarsal coalition.

If this and other treatable causes have been excluded, treatment with the regime described may give good symptomatic relief in the short to medium term.

D Osarumwense D Jena A Feldman

Background: Ankle fractures in adults are an increasing part of the workload of orthopaedic surgeons today. Stable ankle fractures are usually managed conservatively and followed up in the fracture clinic to identify any later displacement which may lead to the need for surgical treatment. the guidelines for follow up varies from place to place with equally varying outcomes. the aim of this study was to look at the pattern and outcome of follow up of these fractures and also the influence, if any, of serial radiological imaging during this period.

Methods: We retrospectively reviewed the follow up of patients who were refered to the clinic as stable ankle fractures and who were treated conservatively following their first clinic attendance. the period covered was April 2002 to march 2003 and we also assessed the documentation of medial side tenderness from the casenotes.

Results: 66 patients were identified consisting of 44 Weber A, 20 Weber B and 2 Weber C fractures with an average follow up of 10weeks. 82% of cases had documented medial side tenderness. None of the Weber A fractures displaced, irrespective of weight bearing instructions and medial side tenderness. Only 2(10%) of the Weber B and 1 (50%) of the Weber C fractures required surgical intervention due to displacement detected after clinic review at week one.

Conclusion: Weber A fractures are inherently stable injuries, do not displace over time and hence do not require further clinic attendances and xrays after the first consultation. Beyond the first week, regular clinic reviews and serial xrays are not necessary in the treatment of Weber B ankle fractures. The presence of medial side tenderness was a poor indicator for joint instability in this series. with proper protocols in place, these can lead to a significant decrease in the workload of orthopaedics surgeons.

R Dalal E Mulgrew G Devarajan

Subtalar joint stiffness is an under recognized complication of ankle fractures. We set out to objectively measure its prevalence and impact on Activities of Daily Living (ADL).


60 ankle fractures included in study. All patients had contralateral normal ankle.


Average age: 36 (19 – 84)

Weber: A B C

21 27 12

27 patients underwent ORIF (12C + 15B)

39 patients had plaster casts for between 2 and 6 weeks. (27B + 12C)

Postop regimes included early mobilization and POP application (AO recommendation)

Weber A (21) treated symptomatically.

Examinations for study at 3/12 and 6/12 post injury.

Subtalar and ankle movements were assessed by the same examiner (as per Hoppenfeld)

Subjective questions about subtalar stiffness and their impact on ADL were asked.


At 3/12, 56 patients (17A + 27B + 12C) had subjective and clinical impairment of subtalar movement.

32 patients (2A + 20B + 10C) had moderate to severe impairment (> 30%)

At 6/12, 42 patients (9A + 23B + 10C) had subjective symptoms and clinical impairment of subtalar function. Of these, 26 (0A + 18B + 8C) had > 30% impairment vs. controls.

Conclusions: Symptomatic subtalar joint stiffness with limitation of ADL is a significant sequel of ankle fractures and results in long term morbidity. This has implications in assessing functional outcome of these common injuries.

D Osarumwense T Millar Y Feldman

The recognition, investigation and management of osteoid osteoma has been well documented. Treatment can either be medical or surgical, studies have shown both options to have almost equal long term outcomes. However only surgical treatment involving complete excision of the lesion allows for confirmatory tissue diagnosis of osteoid osteoma especially important in cases where symptoms and signs are atypical. Several methods of surgical treatment with varying degrees of success have been described in literature. Here we describe a surgical techniques for the treatment of osteoid osteoma which enables removal of the lesion in a precise manner using a precision bone graft trephine with minimal excision of bone. This technique will be very useful in the excision of lesions in areas in which excessive excision of bone can lead to an unstable bony structure which can predispose to fracture. To our knowledge this surgical technique in the management of osteoid osteoma has not been described in the literature.

R Dalal E Mulgrew K Lammin

We present our results with a modified Mann-Thompson procedure in 47 patients (86 feet). Minimum follow up was 24 months.

All patients had moderate to advanced forefoot deformities.



43/47 bilateral

Simultaneous procedures in bilateral cases.

Popliteal block analgesia used routinely.


Medial incision centered on MTP1 joint. Minimal bony and soft tissue resection. Fixation carried out with staples (78 feet),K-wires (8 feet)

Transverse incision centered on the lesser MTP joints made. Combination of soft tissue release, lesser MT head resection in cascade fashion from dorsal distal to proximal plantar performed. Lesser toe deformities treated by a combination of closed osteoclasis, soft tissue release and bony resection. Transarticular K-wire fixation then performed for all lesser toes.

Bulky postop dressing and post op shoes used.

Immediate FWB permitted.

Transarticular K-wires removed at 4/52.


AOFAS Forefoot Scores assessed at preop,6/12,12/ 12,and24/12.

Subjective patient assessment of procedure requested.

Average AOFAS scores improved from 37to72(67 – 84)

40 patients extremely pleased with the results. 5 patients pleased with reservations and 2 patients disappointed with the outcome.


3 superficial wound infections

2 metal work related problems

2 early loss of lesser toe correction

3 late deformities of lesser metatarsals requiring surgery

Conclusion: This procedure offers excellent, reproducible biomechanical correction with high rates of patient satisfaction.

P Watmough N Roberts R Freeman J Lishman J Barrie

Primary care trusts (PCTs) are encouraged to create musculoskeletal services to improve access and reduce pressure on orthopaedic clinics. Previous reports have suggested problems can arise.

A PCT with a population of 100,000 launched a musculoskeletal service in July 2004. The foot and ankle component was in partnership with the local secondary care foot team. Treatment and referral guidelines were agreed. The PCT staff reviewed GP referrals to orthopaedic clinics. They could forward letters to the acute trust orthopaedic department or initially treat the patients in primary care.

We audited referrals from October-December 2004, allowing 3 months to establish the service and 6 months follow-up.

617 orthopaedic referrals were received, including 123 (19.9%) adult foot and ankle problems. 82 patients were treated initially in primary care: 54 by the podiatrist, 20 by the physiotherapist and 8 by the specialist GP. Commonest problems were metatarsalgia (12), hallux valgus (10), Achilles tendonopathy (9), plantar heel pain (9), generalised foot pain (8) and arthritis (6). The commonest intervention was attendance at a physiotherapy programme (26) followed by advice (22), usually about shoewear, insoles (14) and injections (8). Ten patients were referred to secondary care after initial treatment in the community, all in accordance with guidelines; four were listed for surgery. Four patients failed to attend and information was missing on six.

31 referrals were sent directly to secondary care, 29 of which were according to guidelines. 9 were offered surgery, 9 had other specialist care, 6 required services which could not be accessed directly by the PCT team and 3 failed to attend.

Primary and secondary care can work together successfully to deliver services for patients with foot and ankle problems, though waiting time remains a challenge.

G Shah R Dega

Arthrodesis of 1st MTP joint is a reliable procedure for hallux rigidus. We have studied the effects of first MTP joint arthrodesis on activities of daily living and leisure activities

Methods: We retrospectively evaluated 103 1st MTP fusion, done by a single orthopaedic surgeon with special interest in foot surgery over seven years period. All patient underwent two cross screw fixation for primary operation. Same operative technique was used in all patients.

We evaluated pre op scoring for pain, walking distance, walking up hill – stairs, foot wear, return to leisure activity and work, chronicity of symptoms, associated symptoms, radiological appearance pre op, post op and at radiological fusion and complication rate.

All patients were followed up.

The patients were contacted with questionnaire to evaluate the function after the fusion.

The patients were asked whether they would participate in the foot pressure study; which was done with the help of podiatrist at same trust.

We have tried to correlate the functional outcome and its relation to foot pressure.

Results: Fusion was achieved in all patients. (three after revision). Pain scores evaluated using the visual analogue scale, indicated effective pain relief. High levels of return to functions were noted. The pressure (under 1st or 2nd Metatarsal heads or laterally) study has revealed a pattern of changes with various symptoms.

Conclusion: Arthrodesis of first MTP joint, using two cross screws, is a successful surgical technique for Hallux rigidus and also allows high level of function in daily activities of living and leisure activities.

R Dalal E Mulgrew L Checkley

We present our results in 89 consecutive patients (138 feet), minimum FU of 24/12.

Methods: Typical indications were IM angles > 13 degrees, incongruent MTP1 joints.

Contraindications included abnormal DMMA, significant 1st MTP arthritis, hypermobility of 1st MTC joint, revision surgery.

All patients underwent a 3-in-1 procedure with soft tissue release in 1stwebspace, medial bunionectomy with capsulorraphy and basal crescentic osteotomy.

A 25 mm blade on oscillating driver was used. Fixation was staples(70%),screws(20%),K- wires(10%).

Post op, PWB, progressing to FWB at 3/52.

AOFAS forefoot scores at pre-op, 6/12, 12/12 and 24/12.

Weight bearing radiographs obtained at pre-op, 3/12, 12/12.



Age 31–79 (Mean 64)

89 patients, 138 feet

AOFAS scores improved from average 42/100 preop to 76/100 at 6/12.

Radiographic correction excellent in78% of patients.

74 % of patients extremely satisfied,15 %satisfied,11 %unsatisfied with outcome.



Infection=2 superficial,1 deep

Recurrence of deformity at 6/12 = 2

12/12 = 2

Transfer metatarsalgia M2 due to overriding of distal M1=3

Conclusions: Basal Dome Osteotomy with soft tissue correction is powerful and reproducible for the correction of moderate and severe Hallux Valgus. There is an initial learning curve. Much less soft tissue dissection required compared to the SCARF procedure. Results are very satisfactory.

Purpose of the study: Titanium cases are used to achieve mechanical stable spinal reconstruction immediately after corpectomy. Bone grafts is often associated to ensure long-term success. Plain x-rays do not allow correct visualization of the graft within the cage, hindering evaluation of the fusion. The objectives of this study were to obtain a precise evaluation of the graft outcome within the cage using computed tomography (CT) and to search for factors affecting bone fusion.

Materials and methods: This was a retrospective analysis of a consecutive series of patients undergoing anterior reconstruction of the thoracolumbar spine with a titanium cage and a bone autograft. 3D CT reconstructions were obtained at least three months after reconstruction surgery. Three independent observers (two surgeons and a radiologist) analyzed the images. Standard CT criteria for graft fusion are not described in the literature for this type of arthrodesis so the criteria used were based on a descriptive analysis of the CT slices. A statistical analysis was then conducted to search for factors affecting fusion: epidemiological features, etiology, type of graft, size of the case, number of levels reconstructed, associated posterior arthrodesis. The regional angle was analyzed postoperatively and at last follow-up to determine how the sagittal correction was maintained.

Results: Twenty-eight cases were reviewed. Reconstructions had been performed for burst fractures, tumor resection, or deformed callus. CT analysis demonstrated three fusion zones to be examined: the upper, middle and lower part of the cases. Bony bridges were noted at the extremities in all cases. The middle part of the cage generally presented a heterogeneous image which was insufficient to confirm fusion. Loss of correction was not significant. No co-factors could be identified which influenced fusion.

Discussion and conclusion: Most of the cases reviewed did not present a continuous bony bridge from one end to the other of the cage yet the sagittal correction was satisfactory and persistent. The structure of the cages might be modified with a solid intermediary zone which could «spare» graft material.

Hector Malvarez

Purpose of the study: Increased cost of care and limited resources have become important factors in patient treatment. We wanted to ascertain the cost of hospital care, the duration of the hospital stay, the number of rest days, and the degree of correction achieved in a group of patients with idiopathic scoliosis treated surgically over a period of 40 years using four different surgical techniques: Hibbs, Harrington, Harri-Luque, and a multiple hook system.

Material and methods: This retrospective analysis included 50 patients treated in the same center (Scoliosis Center of the Buenos Aires Italian Hospital. Duration of hospitalization before surgery, total duration of the hospital stay, duration of rest, degree of correction, updated hospital cost and updated expenditures for implants and physician fees were noted.


Purpose of the study: Spastic hypertony of the upper limb produces pronation of the forearm with flexion of the wrist and fingers. Treatment is generally based on injections of botulinum toxin and sometimes on selective neurotomy.

Material and methods: In order to achieve better selection of the motor branches innervating the muscles requires a precise knowledge of the extramuscular innervation. Similarly, for botulinum toxin, injections must be made as close as possible to zones with the greatest density of intramuscular nerve endings, considered as the zones having the greatest number of neuromuscular junctions. Knowledge of these zones is currently insufficient. We therefore conducted a macroscopic then microscopic dissection of the muscles of the ventral forearm in 30 specimens to study extra- and intra-muscular innervations and the distributions of the nerve endings.

Results: Surface maps were drawn to describe the precise localization of the motor branches for each muscle. These maps were designed as guides for surgical approaches for selective neurotomy. Then for each muscle, the zones with the greatest density of nerve endings were delimited in segments which could be used to define optimal zones of injection of botulinum toxin.


Purpose of the study: PEEK (polyetheretherketone)is increasingly used for spinal fusion since its elasticity modulus is close to that of cancellous bone. This favors harmonious force distribution within and around the implant and thus stimulates bone healing by remodeling. The purpose of this work was to report the mid-term radiographic outcome with this material used for sagittal correction.

Material and methods: Fifty-seven patients aged 54.6 years on average were reviewed 4 to 8 years after isolated intervertebral fusion for degenerative disease. Levels varied from L2L3 to L5S1. Posterior instrumentation used a rigid or semi-rigid pedicle screw-plate configuration associated with an anterior approach to install a lordozing intersomatic PEEK cage and a cancellous autograft. Six patients were overweight. Regional lordosis was unchanged postoperatively for 47 patients but increased 8.2° on average for ten. The clinical outcome and radiographic fusion were noted using the Brantigan classification. Multivariate analysis was used to search for correlation between regional sagittal correction at last follow-up and the following variables: age, body weight, level, quantity of intersomatic autograft as assessed by CT, rigidity of the posterior instrumentation, posterior regional correction and size of the cage.

Results: The clinical outcome was excellent for 24 patients, good for 25, fair for 6 and poor for 2. Mean sagittal correction was decreased in 13 (5.6° on average). Multivariate analysis demonstrated a significant correlation (p< 0.01, R2=0.590) between loss of correction and the following variables: degree of initial correction, rigidity of the posterior instrumentation, age, lower level, size of the cage.

Discussion and conclusion: Despite the excellent rate of fusion, sagittal correction of the regional lordosis did not persist over time and tended to return to the initial state irrespective of the patient’s weight or the quality of the initial graft. A rigid posterior instrumentation should be considered in parallel with the effect of the PEEK for explaining its role in the loss of correction.

Olivier DRAIN Raphaël VIALLE Ludovic RILLARDON Pierre GUIGUI

Purpose of the study: Experimentally, posterolateral fusion only allows incomplete control of flexion/extension, rotation and lateral inclination. This defect of posterolateral fusion is most marked with there is a wide anterior gap. For certain authors, this situation justifies use of intersomatic arthrodesis. The purpose of this work was to evaluate, within a spinal segment immobilized by posterolateral fusion, the changes observed in disc height and the possible clinical and radiographic impact of a change in disc height.

Material and methods: This was a retrospective analysis of a consecutive series of patients who underwent posterolateral fusion from January 1999 through December 2003 performed in addition to radicular release for degenerative spondylolisthesis were included. Functional symptoms were noted using: VAS, Beaujon function scale, Beaujon self-administered questionnaire, satisfaction scale, GHA28 anxiety/depression scale, and SF36 quality of life questionnaire. Spineview® was applied at the olisthesic level (disc height, listhesis, anglulation), at adjacent levels, for pelvic parameters, sagittal tilt, and vertebral motion on stress views. We searched for a correlation between the consequences of changes in these variables was and the functional outcome as well as the quality of the fusion. The effect of variations in the following preoperative variables was studied with multivariate analysis: disc height, intervetebral angulaion, listhesis, vertebral motion, sagittal balance, use of osteosynthesis or not.

Results: Forty patients were reviewed with a mean follow-up of 38 months (range 15–70 months). Decreased disc height at the olithesic level was associated with local kyphosis. The level above tended towards lordosis while the level below towards kyphosis. These variations had no effect on the final functional outcome.

Discussion: No formal argument could be found in the literature favoring the use of intersomatic arthrodesis to complete posterolateral fusion for the treatment of degenerative spondylisthesis. Disc height is lost after isolated posterolateral fusion with a risk of local kyphosis and persistent intervertebral motion, but these effects do not appear to influence the functional outcome nor the rate of fusion. More than disc height, it would appear that sagittal balance should be preserved to improve functional outcome.

Conclusion: This study enabled us to observe, as is reported in the literature, decreased disc height after posterolateral fusion for degenerative spondylolisthesis. However, there appears to be no correlation between this decreased disc height and the functional outcome. More than disc height, sagittal balance appears to be the determining factor.


We present our four-year experience with a new minimally invasive method for ambulatory treatment of lumbar discal herniation: micro video endoscopic dissectomy.

Video endoscopic surgery associates microsurgical procedures similar to those used in conventional surgery with a very precise technique. This method was used for 50 patients presenting lumbar disc herniation diagnosed with magnetic resonance imaging using the MacNab criteria, placing priority on the neurological risk of sensorimotor deficit.

Clinical outcome was also evaluated with the MacNab criteria. These patients were able to walk early, resumed work rapidly, and had little lumbar pain and few complications.


Exact knowledge of the site of the lesion, and a better understanding of the traumatic mechanisms have led to a major improvement in the surgical approach used for the treatment of thoracolumbar fractures.

The first reports of a combined anterior and posterior approach recommended a two-week recovery period between the two stages.

It was observed however that the rate of complications was higher and that at the time of the second stage patients had a poor nutritional status which increased the rate of mortality. It was also remarked however that a sequential approach performed on the same day could be achieved.

Recently, the simultaneous anterior and posterior approach was reported by Farcy and others. Their preliminary results indicate that in terms of duration of anesthesia, blood loss, and complications, the simultaneous method is better than the sequential method.

The purpose of our work was to report an analysis of the mechanical and biological benefits of the simultaneous approach for the treatment of thoracolumbar spinal fractures.

Luc BOSCA Charles COURT Thomas NODARIAN Véronique MOLINA Jacques-Yves NORDIN

Purpose of the study: This study was conducted to assess short- and mid-term radiographic outcome of percutaneous posterior osteosynthesis (Sextant®)of thoracolumbar spine fractures and to identify indications and complications.

Material and methods: The Sextant® material was used for 14 patients with a lumbar spine or low thoracic spine fracture. Mean patient age was 40 years (range 19–84). Outcome was reviewed retrospectively. Osteosynthesis was performed for 11 fractures Mager 1 A3, 2 B2, 1 C1 with no neurological deficit. A complementary graft and anterior decompression were used 11 times (9 fibular, 1 posterior crest + rib, 1 cage). The pre- and postoperative and 3 month ART were noted. The position of the implants was assessed on the postoperative CT.

Results: Mean follow-up was 9.2 months (range 2–16). On average, ostheosynthesis was performed 15 days after trauma (range 1–90 days). There were no neurological or infectious complications. Sutures had to be resected in two cases due to cutaneous suffering. Nine patients wore a corset for three months. The absolute ART score improved from 18 preoperatively to 7 postoperatively and was noted at 14 at three months. Seven patients required heterologous blood transfusion after the anterior approach. Three screws (5.3%) were ectopic but without consequence.

Discussion: Indications for percutaneous osteosynthesis include spinal fractures without neurological complications with sagittal deformation for which an anterior approach is planned initially for mechanical reasons. An isolated anterior approach is possible in this type of fracture; nevertheless, percutaneous posterior osteosynthesis enables emergency reduction and fixation of the fracture, a simplified secondary minimal anterior approach for release, and bone grafting without anterior instrumentation. Three patients did nor require complementary anterior stabilization as the percutaneous oseosynthesis played the role of «internal fixation». The advantages of percuteneous osteosynthesis are the absence of bleeding and damage to the paravertebral muscles which limits morbidity, particularly infection. This technique can be performed in the emergency setting, especially for multiple trauma victims. The drawbacks of percutaneous osteosynthesis are the impossibility of performing a posterior fusion and release the spinal canal. The loss of correction observed were probably related to the type of graft (fibular). Use of a cage should limit graft impaction and loss of correction.


Purpose of the study: Conventional treatment for recurrent lumbar disc herniation is repeated discectomy. Other methods such as fusion, ligamentoplasty or implantation of a discal prosthesis are sometimes proposed but all increase morbidity. The purpose of this work was to ascertain the efficacy of isolated repeated radicular release for the treatment of recurrent discal herniation.

Material and methods: Thirty-four patients underwent surgery for recurrent discal herniation. Repeated radicular release was used in all patients included in this analysis who completed a self-administered questionnaire at last follow-up to assess the final functional outcome.

Results: The cohort included 13 women and 21 men, mean age at surgery 45 years. Mean time from first discectomy to revision surgery for recurrence was 55 months. At the time of the review, four patients had died, all four from cancer. None of these patients had undergone a revision procedure on the lumbar spine. One patient was lost to follow-up so 85% of the cohort was analyzed with 60 months average follow-up. A dural tear occurred during the proscedure in six patients (17%. Five patients (14.7%) required revision surgery, one for deep infection, four for recurrent or persistent lumboradiculalgia (recurrent discal herniation, isthmic fracture, lateral stenosis associated with inflammatory discopathy). The rate of revision for painful failure was 11.4%. The final outcome could be assessed for 25 patients and was satisfactory for 22/25 (88%). The self-administered questionnaire revealed 65% average improvement with more than half of the patients reported better than 80% improvement. Ten patients (40%) complained of lumbar pain and a third had residual, generally intermittent, radiculalgia. Eighteen of 25 patients resumed their work at a comparable level after six months on average; 84% of the patient would accept the same operation again.

Discussion: In terms of morbidity and rate of revision, the results are comparable to reports in the literature. Repeated release does not increase the risk of a new recurrence.

Conclusion: This work enabled us to demonstrate that in the large majority of patients repeated discectomy provides satisfactory functional outcome with little morbidity.

Xavier CHIFFOLOT Mohammed AOUI Ioan BOGORIN Patrick SIMON Jean-Michel COGNET Jean-Paul STEIB

Introduction: Surgical treatment of thoracolumbar spine fractures from T11 to L2 with correction of the traumatic kyphosis should be expected to avoid the deceptions observed with former treatments.

Material and methods: Seventy trauma victims (41 men and 29 women) underwent surgery between 1996 and 2003. According to the Denis classification, they presented: 16 compressions, 43 burst fractures, 8 seat belt fractures, and 3 disclocations. The Frankel classification was E:62, A:2, C2, D:2. Mean follow-up was 30.7 months. A pedicle screw protected with sublaminal hooks below and pediculotransverse claws above was used in 50 patients with a hybrid configuration in 20. Reduction was achieved by in situ cerclage. A secondary anterior graft was implanted for 38 patients.

Results: Patients were allowed to rise without contention on day 3. The traumatic angle measured with the sagittal index of Farcy (SIF) (the quality parameter used to study reduction) was 17 preoperatively and 1.6 after surgery. The loss at last follow-up was −2.2° with 81% of patients presenting normal or over correction. The loss was greatest (5.2°) for uniquely posterior approaches. The final Oswestry score was 29.8 (range 6–80) with a better result for the double approaches (20.7 versus 37.4, p< 0.001). Complications were phlebitis (n=1), sutured dural breaches (n=2), disassembly and nonunion (revision with a double approach) (n=1), infection (treated by wash-out and antibiotics) (n=10), retroperitoneal hematoma (treated by embolization) (n=1). Thirty-two patients resumed their work at seven months on average and 13 did not (25 without professional occupation).

Discussion: The overall results are better than those after orthopedic treatment. The rate of resumed work was 71%. This is an excellent result with a less aggressive treatment protocol (no corset) and shorter hospital stay (5–19 days). The protective hooks facilitate in situ cerclage, avoiding catching the screws and the risk of disassembly. The anterior graft is necessary when the reduction is discal and reduces the angle loss leading to less morbidity.

Conclusion: In situ cerclage enables constant sustained reduction of thoracolumbar fractures. Indication for surgery is often retained because of major deformation. Spinal fractures should be examined with the same assessment criteria as used for fractures of long bones and weight bearing should begin early to avoid the risks associated with prolonged bed rest.


Purpose of the study: We describe a surgery navigation system based on virtual fluoroscopy images established with a 3D optic localizer. The purpose of this work was to check the accuracy of the system for posterior spinal implants in comparison with conventional surgery. Duration of radiation and duration of surgery were compared.

Material and methods: A 3D optic localizer was used to monitor the position of the instruments in the operative field, as well as the fluoroscopy receptor. The surgeon took two views, ap and lateral, with a total exposure of two seconds. The C arm was then removed. After image correction, the ap and lateral views were displayed on the work station screen where the computer superimposed to tools on each image. Twenty osteosynthesis procedures for implantation of pedicular screws via a posterior approach to the thoracolumbar spine were performed with this virtual fluoroscopy technique (20 patients, 68 screws). During the same study period, twenty other procedures were performed with the conventional technique (ap and lateral x-ray with the C-arm after drilling the pedicle, 20 patients, 72 screws). The position of the spinal implants was compared between the two series on the ap and lateral views and postoperative CT. Similarly time of exposure to x-rays and duration of the surgical procedure were recorded.

Results: The rate of strictly intrapedicular implantation was less than 8% (5/68 screws) in the virtual fluoroscopy series versus 15% (11/72 screws) in the conventional series. Time of exposure to radiation was significantly lower in the virtual fluoroscopy series with a 1 to 3 improvement (3.5 s versus 11.5 s on average) over the conventional method. With training, this method is not more time consuming (10 min per screw for the conventional method versus 11.25 min for virtual fluoroscopy).

Discussion and conclusion: Compared with conventional fluoroscopy, the virtual technique enables real time navigation while significantly reducing the dose of radiation, both for the patient and the surgery team. There are two types of advantages of virtual fluoroscopy over CT-based systems: first virtual fluoroscopy is immediately available without specific preoperative imaging and secondly it provides real non-magnified images acquired once during the procedure, after which the C-arm is removed. 3D virtual fluoroscopy is probably the next step but requires further experience.


Purpose of the study: We report the results of a series of seven cases of non-tuberculos infectious lumbar spondylodiscitis treated by posterior instrumentation and secondary anterior curettage of the infectious focus with bone grafting. This particular osteosynthesis method produces a short monosegmentary fixation limited to the space of the infected disc.

Material and methods: The series included six men and one woman (mean age 61.7 years, age range 37–82 years). The causal germ was identified in all cases: Staphylococcus aureus in five, and in one each, Staphylococcus epidermidis and Pseudomonas aeruginosa. Levels were L1L2 in one, L2L3 in two, L3L4 in three and L5S1 in one. Predisposing factors were history of prostatic cancer in two patients, coronary heart disease in one and chronic renal failure in one. One patient had received corticosteroid injections and two had no recognized co-morbid conditions. The surgical procedure was undertaken due to persistent pain in three patients (one with quadriceps amyotrophy and weakness), spinal instability with risk of neurological injury in two, and after failure of medical treatment in two patients who had persistent abscesses.

Results: Excepting one patient who died from renal failure four months after the surgical procedure, mean follow-up was 31.5 months (range six months to six years). Outcome was excellent in four patients, good in one, and a failure in one patient who was operated on because of instability. Failure of the instrumentation required surgical revision to extend the initial assembly. At last follow-up, all patients had achieved fusion of the instrumented zone and were considered to be cured of their infection.

Discussion: Classically, it is advisable to avoid instrumenting close to an infectious area in order to avoid the vicious circle of infection. Configurations described in the literature are usually extensive, blocking healthy levels beyond the infected area and compromising spinal mobility. However, a short instrumentation limited to one segment can be proposed when the end plates at the outer limits of the infectious focus are theoretically healthy. Careful analysis of the imaging data is required to carefully select patients who can benefit from this short configuration. Magnetic resonance imaging is most helpful.


Purpose of the study: Prenatal screening and search for risk factors has lead to early diagnosis of congenital hip dysplasia. The percent of excentration of the dysplastic hip can be quantified with ultrasonography. The purpose of this study was to evaluate the usefulness of ultrasound monitoring of confirmed hip dysplasia as a method for determining the appropriate time to discontinue treatment.

Material and methods: We collected a series of patients presenting unstable hips one month after birth. Ultrasonographic examinations were performed to quantify the instability. Initial treatment was forced abduction. If the infant’s weight was greater than 5.6 kg, a Pavlik harness was used. Physical examination and control ultrasound examinations were performed at 4, 8 and 12 weeks. Forced abduction and ultrasound surveillance were discontinued when the percent of acetabular cover was greater than 50%. Long-term surveillance consisted in physical examination and plain ap view of the pelvis at four months and at onset of walking.

Results: Ultrasound monitoring was instituted for 71 hips in 51 patients. Mean age at onset of the monitoring scheme was 37.7 days (range 38–74 days). Mean acetabular cover, as evaluated by ultrasound before treatment, was 35.5% (range 20–45%). After four weeks, mean cover for 42 hips was 54.7% (range 50–85%). For the other 29 hips, mean acetabular cover was 41.4% (range 36–47%) at four weeks. At eight weeks, 26 of these 29 hips had a mean cover of 60% (52–85%). Acetabular cover remained below 50% for three hips at twelve weeks. Mean HTE at four months was 20.7° (range 10–26°). At walking, all hips were centered and no irregularities were noted on the x-rays of the femoral nucleus.

Discussion: The majority of infants with unstable hips diagnosed at birth achieve spontaneous cure without treatment. For others, cure can be achieved with forced abduction but with a risk of osteochondritis. In our study, ultrasound monitoring enabled a reliable assessment of the proper moment to interrupt treatment.

Conclusion: Ultrasound examination of the hip joint is a satisfactory method for monitoring hip dysplasia in infants aged less than four months. It appears to be useful for determining the moment to interrupt treatment.


Purpose of the study: the Pavlik harness has been used for the treatment of congenital hip dislocation since it was designed by Arnold Pavlik in 1950. There remains however a certain debate concerning the best moment to start treatment and its duration. We advocate early use of the Pavlic harness for a short period.

Material and methods: Forty-five hips (34 infants) were treated. The diagnosis of dislocation was clinical. The Barlow and Ortolani maneuvers were used to search for clinical instability classed as «positive dislocation test» or «negative test but presence of piston movement». Different classifications of positive tests were used to search for an association with increasing severity of hip instability. Static and dynamic ultrasound was then used to confirm the diagnosis of hip dislocation. A Pavlik harness was installed immediately after diagnosis of congenital hip dislocation, on the day of birth if possible, according to the precepts proposed by the inventor.

Results: Among the 43 hips analyzed I the present series, reduction and stabilization was successfully achieved with the Pavlic harness in 40 used as early as possible for a short a period as possible. This 95.6% success rate (2 failures, 0 complications) was achieved within 3 o 8 weeks.

Discussion: Our results are comparable with other series reporting early use of the Mubarak method. The duration of treatment was shorter with our therapeutic method. We did not attempt to treat the dysplasia, spontaneous regression was monitored radiographically.

Conclusion: We consider congenital hip displasia to be a therapeutic emergency. Treatment should be undertaken as soon as the dislocating intrauterine constraints cease. Early use of the Pavlik harness on easily dislocated or dislocated reducible hips has given excellent results. The shorter treatment duration does not lead to any recurrence as long as clinical stability with formal radiographic confirmation at treatment end.


Purpose of the study: It is relatively rare to observe villonodular synovitis in children. The predominant localization is in the large joints. Histology is required for definitive diagnosis but specific sequences of magnetic resonance imaging (MRI) has greatly improved diagnostic performance.

Material ad methods: we report four cases of hemopigmented villonodular synovitis observed in four girls aged 11–16 years (mean age 12 years) at diagnosis. Localizations were the knee joint in two, the metacarpophalangeal joint of the third finger in one and an intracarpal joint with scaphoid defects in the fourth. Plain x-rays centered on the joint involved and MRI spin echo T1 and T2 with fat saturation were obtained for all four children. Echo gradient with long TE sequences were also performed for the last two children because of the anomalies observed in the first two.

Results: The MRI findings enabled the diagnosis of hemopigmented villonocular synovitis in all four patients and was confirmed histologically (two biopsy specimens followed by dissection and two first-intention dissection specimens).

Discussion: The large joint localizations are often reported but the two cases involving the wrist and fingers are less common. The condition is usually revealed by repeated joint effusion which if punctured generally reveals a hematic discharge. Pain is classical and a mass is often palpated. Standard x-rays show intraosseous defects and MRI, using the three sequences together, generally provides the diagnosis. On the spin echo T1 sequence the synovial mass gives an intermediate signal compared with the low intensity signal of the joint fluid since the cholesterol deposits enhance the signal. In spin echo T2 sequence with fat saturation, the lesion produces a heterogeneous signal which is still intermediary because of the hemosiderin and cholesterol deposits which decrease the inflammatory aspect of the synovitis. These signs are highly suggestive and should be followed by an echo gradient long TE sequence. This is not a routine sequence but provides objective evidence of hyposignals within the synovial mass. This type of signal is specific for the presence of iron and thus hemosiderin.

Conclusion: MRI is the exploration of choice for the diagnosis of hemopigmented villonodular synovitis. It enables postoperative monitoring in search of recurrence.


Purpose of the study: The appropriate treatment for Legg-Perthes-Calvé disease (LPCd) remains a subject of debate. Certain teams consider orthopedic treatment adequate. Others advocate surgery to improve prognosis. Is surgery necessary? When is the proper time? We reviewed retrospectively 91 surgically treated hips (Salter osteotomy or triple pelvis osteotomy) at the end of growth.

Material and methods: Among 485 hips with LPCd, 349 (71.9%) presented massive involvement (Catterall 3 and 4, Herring B and C, Salter B). Ninety-one patients with severe disease were reviewed at the end of growth. Complementary explorations included magnetic resonance imaging, scintigraphy and arteriography using the Dias protocol which enables an assessment of the excentration and the femoral head deformation and identifies hips at risk. Surgical treatments were Salter osteotomy (SA) or triple osteotomy (TO). Three groups were identified depending on the age at disease diagnosis: less than 5 years, 5–9 years, more than 9 years. Using the Stulberg and Mose classifications, outcome was considered good (Stulberg 1 and 2, Mose good), fair (Stulberg 3, Mose fair), or poor (Stulberg 4 and 5, Mose poor).

Results: There were 50 Carttell 3, Herring B, Salter B hips and 41 Catterall 4, Herring B and C, Salter B hips (80% boys). Distribution by group of age at diagnosis was: 34 (37.4%) less than 5 years, 48 (52.7%) 6–9 years, 9 (9.9%) more than 9 years. Salter osteotomy was performed on 32 hips (35.2%) and triple pelvic osteotomy on 59 (94.8%). Outcome at end of growth was: less than 5 years Catterall 3: 77% good, 15.4% fair, 7.6% poor; Catterall 4: 52.4% good, 33.3% fair, 14.3% poor; 6–9 years: Catterall 3: 70% good, 20% fair, 10% poor; Catterall 4: 55.5% good, 22.2% fair, 22.2% poor; more than 9 years: Catterall 3: 42.9% good, 42.9% fair, 14.2% poor; Catterall 4: 50% good, 50% poor.

Conclusion: Outcome worsens with increasing age at diagnosis. Despite surgery, a spherical femoral head (Stulberg 1 or 2) is achieved in only one hip Catterall 4 hip out of two. This result is observed in Catterall 3 hips only in children whose diagnosis is established after the age of nine years. Prognosis is better in Catterall 3 hips.


Purpose of the study: Special care is warranted only for severe forms of Legg-Perthes-Calvé disease (LPCd) (Catterall 4, Herring B and C, Salter B, involvement > 50%). Should we propose specific treatment or simply monitor the inevitable disease course?

Material and method: Among a series of 485 hips with LPCd, 148 (30.5%) with massive involvement were identified. Ninety-six (64.9%)severe forms were analyzed at the end of growth. Magnetic resonance imaging, scintigraphy and arteriography were used to better assess the femoral head and identify hips at risk. These hips were treated surgically: Salter osteotomy (SA), triple pelvis osteotomy (TO), or varus osteotomy (VA). Three groups of infants were identified according to age at diagnosis of LPCd: less than 6 years, 6–9 years, more than 9 years. Outcome was considered good (Stulberg 1 and 2, Mose good), fair (Stulberg 3, Mose fair), or poor (Stulberg 4 and 5, Mose poor).

Results: There were 54 hips (56.3%) in the less than 6 years group, 26 (27.1%) in the 6–9 years groups, and 16 (16.6%) in the greater than 9 years group. Outcome was good for 45 hips (46.9%), fair for 22 (22.9%) and poor for 29 (31.2%) hips and was independent of age at onset of treatment. In the less than 6 years group, 54 hips (56.3%) were Catterall 4, Herring B or C, Salter B. Among the 24 Catterall 4 hips (44.4%) treated orthopedically, outcome was good for 15 (62.5%), fair for 7 (29.2%) and poor for 2 (8.3%). Among the 30 Cartell 4 hips treated surgically, outcome was good for 16 (53.3%), fair for 9 (30%) and poor for 5 (16.7%). In the 6–9 year group, 26 hips (27.1%) were Catterall 4, Herring B or C, Salter B. Among the 10 Catteral 4 hips treated orthopedically (38.5%), outcome was good for 3 (30%), fair for 2 (20%) and poor for 5 (50%). For the 16 Catterall 4 hips treated surgically, outcome was good for 8 (50%), fair for 2 (12.5%) and poor for 6 (37.5%). In the greater than 9 years group, there were 16 (16.6%) Catterall 4, Herring B or C, Salter B hips. Among the 10 Catterall 4 hips treated orthopedically, outcome was good for 1 (10%), fair for 2 (20%) and poor for 7 (70%). Among the 6 Catterall hips treated surgically, outcome was good for 2 (33.3%), fair for 0 and poor for 4 (66.7%).

Conclusion: Good outcome decreases with age. Surgery increases the rate of good outcome in all age groups, but before the age of six years, there is no significant difference between orthopedic and surgical treatment. Before six years, spherical heads (Stulberg 1 and 2) were achieved in six out of ten hips in the 6–9 year group and in only two of ten in the group aged over 9 years.

André GAY Régis LEGRÉ Jean-Luc JOUVE Yann GLARD Franck LAUNAY Gérard BOLLINI

Purpose of the study: Assessment of limb reconstruction results using vascularized fibular grafts after bony resection for malignant tumors in children.

Material and methods: Thirty children (9 girls and 21 boys)underwent surgery between 1993 and 2000. Mean age was 11 years. Tumor localizations were: femur (n=17), tibia (n=6), humerus (n=5), radius (n=1) and distal ulna (n=1). Mean length of bone resection was 16 cm (range 10–26 cm). For 22 children, the adjacent epiphysis was preserved. For the eight others, fusion was also performed. Two surgical teams operated sequentially: the first team performed the tumor resection and the second (an orthopedist for the osteosynthesis and a plastician for the vascularized fibular transfer) the limb reconstruction. Radiographic and clinical assessment was completed with bone scintigraphy. The index of graft hypertrophy was determined with the De Boer and Wood method. Functional outcome was assessed with Enneking criteria.

Results: Mean follow-up was 51 months (range 2 – 9 years). Early amputation was necessary for two children due to local oncological complications. One patient died of pulmonary metastasis eight months after limb reconstruction. Among the 27 other patients, primary healing was achieved in 22. In the five with primary nonunion, bone scintigraphy showed objective signs of a lack of blood supply to the graft. Secondary union was achieved with a complementary autologous bone graft in four cases. All cases of stress fracture healed with orthopedic treatment. For the 22 patients with primary union, the graft hypetrophy was 22–190% (mean 61%). For the five patients without bone vascularization on the scintigraphy, the fibular graft failed to hypertrophy. Functional outcome was satisfactory. The modified Enneking score (30 point scale) was 26 (range 19–30 points).

Discussion: Limb reconstruction results are directly related to good patency of vascular anastomoses. Postoperative bone scintigraphy is useful to determine blood supply to the graft and to establish the final prognosis. In the case of vascular failure, an autologous bone graft can be proposed early to enable union. Close collaboration between the plastic surgery and the orthopedic team is the key to successful limb reconstruction with a vascularized fibular graft.

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Purpose of the study: Determining bone age at the wrist is not an easy task and can be a source of error. We elaborated a method for determining bone age at the elbow using an analysis of bone maturation at this localization.

Material and methods: The method finetunes the Sauvegrain method and is based on more than ten years of data for the analysis of more than 3600 x-rays. Bone maturation evolves from 0% at birth to 100% marking the end of growth. We propose a digital system for drawing the growth curve from 50% to 100% bone maturation as a function of chronological age. This curve gives the distribution of bone age around the median for each gender. Fifty percent maturation corresponds to onset of adolescence and can be used to define onset of puberty before any other clinical sign; 100% bone maturation corresponds to maximal growth or stature. Specific bone landmarks are used and the method for calculating bone age is presented.

Results: It is interesting that a shift of one year or more between bone age calculated at the elbow and that calculated from the wrist. This observation was frequent and suggests that bone age determined at the elbow gives a better reflection of limb maturation. In addition, regular use of this method in daily practice confirmed its usefulness, reliability, and inter- and intra-observer reproducibility.

Conclusion: This is a reliable simple method for determining bone maturation. It is easier to use than the wrist method and probably better reflects bone maturation of the limbs.

Mourad CHAKER Christophe GARIN Bruno DOHIN Rémi KOHLER

Purpose of the study: There remains some debate on the proper treatment of congenital dislocation of the patella in children and adolescents. Ligament-periosteum transfer (green-stick method) is a technique adapted for pediatric patients which realigns the distal extensor system.

Material and methods: Between 1979 and 2000, 36 children (51 knees) were treated with this method described by Grammont. Section of the lateral wing and medial capsulomyoplasty were associated in all procedures. Other complementary procedures used as needed included lengthening of the quadriceps, trochleoplasty, and quadriceps release. Mean age at surgery was 11 years (range 5–15 years). All patients were reviewed at bone maturity with a mean follow-up of 7.5 years for functional (IKC criteria) and radiographic assessment. A computed tomography and/or magnetic resonance imaging was obtained preoperatively and at last follow-up to assess TAGT, patellar height, trochlear angle, femoral anteversion, external tibial torsion, and knee rotation. Tibial slope was specifically studied to assess the possible epiphysiodesis effect.

Results: Two groups of patients were distinguished: congenital dislocation of the patella (persistent or usual) and objective patellar instability. Functional outcome was good in 74% and 87% of the knees. There were eight cases of recurrent dislocation: five knees were operated on with good outcome. The trochlear angle was improved in both groups, more significantly in the congenital dislocation group. There was one case of an inverted tibial slope (−2°) and two cases of cancelled slope.

Discussion: Our functional results are in agreement with earlier reports (Grammont, Bensahel, Langeskiold) but comparison is hindered by the heterogeneous nature of the different cohorts. Radiographically, we observed that trochlear remodeling, a sign of good stability, is better if the operation is performed early (before the age of ten years). On the contrary, in adolescents with major patellar instability, complementary trocheloplasty should be performed in addition to the recentering procedure. We observed that a small tibial slope became smaller in eleven knees in comparison with the nonoperated knee and in comparison with the preoperative slope for the bilateral cases. There appears to be a discrete epiphysiodesis effect but with no functional consequence.

Conclusion: We propose a classification of congenital dislocation of the patella in children. The ligament-periosteum transfer technique, associated with other procedures as needed, enables stabilizing the extensor system and a normal trochlear angle if surgery is performed at a young age. Remodeling of the tibial tubercle may result from transient disruption of the vascular supply.


Purpose of the study: Even more so than adults, children are exposed to serious foot trauma caused by lawn mowers, bicycle spokes, or car wheels. These different mechanisms produce specific lesions to the rear foot or the toes and the dorsal aspect of the foot. Each type of lesion raises specific problems concerning emergency cover. Sequelae evolve with growth. We present a series of thirteen children given emergency treatment then long-term care over periods of six months to twenty years.

Material and results: The heel was amputated in four children (lawn mower or bicycle spoke accidents). Cover was obtained with a sural (three first-intention) neurovascular island flap with a distal pedicle. The long-term assessment evaluated function as well as residual growth of the calcaneum. Four lawn mower accidents produced lesions involving the toes and the mediotarsal area which did not require emergency flap cover. Dorsal retractions occurred in all four cases and progressed secondarily, later requiring a good quality skin flap and dorsal release. In five children lesions of the toes, forefoot, or the entire foot occurred in five children whose foot was crushed under car (or truck) wheels or was injured during fall from a wall. In these children, the urgent or secondary skin problems predominated in the dorsal area and required a variety of flaps.

Discussion: «Dorsal trauma» appears to have a predominant effect in children because the toe alignment during growth is directly dependent on the flexibility of the dorsal tissues. Several flaps can be used for this indication but are often difficult to achieve for the more distal areas (commissures and toes). Heel reconstruction is also a difficult challenge with the problem of sensitivity and tissue quality. It does not resolve the problem raised by amputation of the posterior calcaneal growth nucleus.


Purpose of the study: Appropriate treatment of displaced supracondylar fractures of the distal humerus in children remains a controversial topic. Blount reduction followed by percutaneous or open pin fixation have been widely used. The purpose of this study was to analyze outcome after open surgical treatment of these fractures in pediatric trauma victims.

Material and methods: The study included all pediatric patients who underwent surgical treatment for displaced supracondylar fractures of the distal humerus over a ten year period. Fractures were classified III or IV according to Lagrange and Rigault. Cross pinning was used in all cases, via a posterior approach or a double lateral and medial approach. The mechanism of the fracture and pre- and postoperative vascular and neurological complications were noted. The long-term assessment included standard x-rays of the elbow joint (ap and lateral views) and a physical examination to search for misalignment and residual neurological disorders.

Results: We identified 110 patients, 61 boys and 49 girls, mean age 7.61 years (range 2–15 years). There were 96 grade IV fractures and 24 grade III. Mechanisms were: sports accident (n=44), fall from height (n=36), fall from own height (n=30). A neurological complication was observed in 29 children, skin opening in three and regressive vascular damage in six. A posterior approach was used for 95 patients and a double approach for 15. There was one revision for secondary displacement. Five patients developed transient paresthesia of the ulnar nerve which resolved without sequela. Three patients presented a moderately hypertrophic or deformed callus which had little functional impact. One patient with an open fracture required surgerical arthrolysis for stiffness six months after fracture.

Discussion and conclusion: Open surgery is a very reliable treatment for supracondylar elbow fractures with a low rate of short- and long-term complications. Ulnar nerve palsy, the classical complication of percutaneous cross pinning, can be attributed to the medial pin (7–16% of cases in the literature). The Blount method and Judet or Métaizeau fixations can sometimes be complicated by secondary displacement or a deformed callus, complications which were almost never observed in our series. The results obtained in this series favor our approach for open surgery for the treatment of displaced supracondylar fractures of the distal humerus in children.


Purpose of the study: Joint puncture-wash-out is generally recommended for septic arthritis in children, but the debate is still open concerning the proper attitude for the hip joint. The purpose of this work was to examine our failure cases after treatment of septic hip arthritis using the puncture-wash-out option. We wanted to know whether first-intention primary arthrotomy might be a valid option.

Material and methods: We reviewed retrospective 29 cases of septic hip arthritis treated initially by puncture-wash-out between January 1996 and June 2003. We excluded all cases of first intention arthrotomy. The series included 19 boys and ten girls aged four years three months on average at time of diagnosis (age range 8 months to 9 years). Mean follow-up was one year five months (range 1 month the 4 years). Mean delay to diagnosis was two days (range 0–6 days). In addition to intravenous antibiotics, the 29 hips were drained and washed out with saline solution under general anesthesia until a clear wash-out was obtained. Surgical revision (arthrotomy) was required for seven patients within 3 to 21 days.

Results: Outcome was assessed at days 2, 5, and 10. Assessment variables were pain relief, normal blood tests, and apyrexia. Seven children required surgical revision for arthrotomy due to persistent clinical or biological disorders. Cure was achieved after all seven arthrotomies. At last follow-up, there was no difference, clinically or radiographically, between the children treated by puncture-wash-out or by arthrotomy. The factors which appeared to be the most significant to distinguish the two groups were, at admission: time to diagnosis and management greater than four days and C-reactive protein > 100. On day 5, the most significant factors were persistent joint pain and C-reactive protein > 100.

Discussion: These results suggest that puncture-wash-out remains a simple and reliable treatment but that it has its limitations: a synovial biopsy cannot be obtained, visual examination of the joint cartilage is not possible, trepanation of the metaphysis is not possible. Our factors favoring poorer outcome are similar to those reported in the literature to which can be added age less than one year. When these factors are present, first-intention arthrotomy should be discussed.


Purpose of the study: The sub-fibular bone occurs as an ossicle adjacent to the apex of the lateral malleolus. Observed in 2% of children, it is generally a fortuitous x-ray discovery considered as a normal variant. Its rather high frequency in victims of former ankle trauma suggests the hypothesis of a traumatic origin. We have observed a high frequency of subfibular bone associated with functional ankle instability after trauma in children. The purpose of this study was to evaluate the function outcome after inverted ankle trauma in children with an avulsion fracture of the distal point of the lateral malleolus or a subfibular bone. We tested the hypothesis that presence of a subfibular bone corresponds to a sequelae of a former trauma and that it could led to a high frequency of mid- and long-term ankle stability.

Material and methods: This series included 50 children with a diagnosis of subfibular bone identified after trauma with ankle inversion. At least six months after the trauma, stability measurements were made to quantify residual functional instability of the ankle. Clinical signs of subjective instability were noted. A standardized protocol for stress x-rays was performed using the trauma-free contralateral ankle as the control.

Results: In more than 50% of patients, presence of a subfibular bone was associated with clinical signs of functional instability one year after ankle trauma. The quantitative measures of joint stability confirmed the significant presence of this instability, rarely associated with residual ligament laxity.

Discussion: In our series, most of the subfibular bones were interpreted as fracture-avulsions of the point of the lateral malleolus.

Conclusion: Discovery of a subfibular bone after an ankle «sprain» in children is a significant risk factor for subjective sequelar ankle instability after orthopedic treatment with a plaster cast.


Purpose of the study: Prognosis is generally considered poor for patients with an iliac bone localization of Ewing sarcoma because the deep tumor is often large with initial metastases. This study demonstrates that the predictive value of these factors is related to treatment and that early en bloc resection can modify the prognosis.

Material and method: We have treated 62 cases of Ewing tumor of the iliac bone since 1976, 36 males and 25 females, mean age 16.5 years (range 4 – 47). Thirteen patients presented primary metastases. Mean tumor size, measured by digital imaging, was 729 cm3. Adapted chemotherapy was given in all cases. Local treatment included exclusive radiotherapy in 20 patients, radiochemotherapy in 15 and exclusive en bloc extratumoral resection in 27.

Results: At 15 years mean follow-up, overall relapse-free survival at ten years was 38%. This rate was 43% among patients without metastasis and 18% for those with initial metastasis (the three other patients underwent surgical resection of a primary focus and a bone metastasis). For patients with localized disease, prognosis was essentially determined by type and timing of local treatment. Surgical resection did not appear to have a significant effect on prognosis for patients operated on after three months; for these patients, only those with total histological response survived. Conversely, patient who underwent surgery before three months with en bloc resection and chemotherapy with at least five drugs had a relapse-free survival of 80% at ten years.

Conclusion: The prognosis of Ewing sarcoma is seriously dependent on the therapeutic modality, even when the localization is known to have a poor prognosis such as the iliac bone. Early en bloc extratumoral resection (before three months) greatly improved the prognosis of patients without metastasis, even for those with a very large tumor. Conversely, prognosis remained very poor for patients given exclusive radiotherapy or operated on late.


Purpose of the study: We wanted to assess long-term outcome after treatment for Ewing tumor of the pelvis.

Material and method: We reviewed 62 patients aged 5 to 28 years treated from 1983 through 1993. There were 35 males and 27 males. Sixteen patients had pulmonary metastases at diagnosis. Patients were given chemotherapy using three protocols (Ew 84, Ew 88, Ew 93) proposed by the French Society of Pediatric Oncology. Fourteen patients were give high-dose chemotherapy with a bone marrow graft. The local treatment was not randomized. Radiotherapy was used alone in 25 patients and 15 underwent surgery and radiotherapy. Eighteen underwent surgery without complementary radiotherapy. For patients were not given local treatment. Outcome at last follow-up was assessed retrospectively.

Results: Mean follow-up was 6.6 years (3 months to 18 years); 29 patients were in remission, 6 had progressive disease, and 27 had died. Two patients who had bone marrow grafts developed a second tumor in the radiated territory. The overall chances of survival were 55±6% at five years and 53±7% at ten years. There was no significant difference by type of chemotherapy. In the group of operated patients, the five year survival was 68% versus 43% in the group of non-operated patients (p=0.007). In patients with initial metastases, chances of survival at ten years were 19.7±10% versus 65.9±7% in patients without metastasis. Only two patients who presented metastases initially were in remission at last follow-up. Five patients developed local recurrence after surgery and none had been radiated despite incomplete response to chemotherapy or presence of contaminated resections.

Discussion: Rigorous comparison between operated and non-operated patients is hindered due to the different indications. Results of treatment of Ewing tumors of the pelvis without metastasis are comparable to those obtained for tumors in other localizations. The fact that a second tumor can develop in the radiated territory is a particularly important factor in patients given high-dose chemotherapy with a bone marrow graft.

Conclusion: Surgical treatment appears to improve local control of Ewing tumors of the pelvis. If initial metastasis is not present, the prognosis appears to be similar to other localizations. Radiotherapy remains and indispensable adjuvant in the event of surgical resection or incomplete response to chemotherapy.


Purpose of the study: To analyze survival and prognostic factors in a series of patients treated for chondrosarcoma of the pelvis.

Material and methods: The series included 106 patients (53 women and 53 men) treated for non-metastatic chondrosarcoma of the pelvis. Minimum follow-up was two years. Mean age at diagnosis was 44 years. Tumors were grade 1 (n=47), grade 2 (n=37), grade 3 (n=22). Conservative surgery was performed in 73 patients (resection with or without reconstruction) and interilio-abdominal disarticulation for 33.

Results: Resection margins were sufficient for 34 patients (wide or radical resection), marginal for 35, and intratumoral or malignant for 37. Local recurrence was noted in 39 patients (37%). Prognostic factors affecting local recurrence were: quality of resection (p=0.03), grade (p=0.01). Overall survival at 5, 10 and 15 years were 72, 56, and 46% respectively. Survival was strongly correlated with grade (p=0.08) and survival after five years was also correlated with resection margins.

Conclusions: In this series, tumor grade was the most important prognostic factor for patients with chondrosarcoma of the pelvis but achieving satisfactory resection with wide margins also has a significant effect on prognosis for local recurrence and long-term survival.

François GOUIN Françoise RÉDINI Dominique HEYMANN

Purpose of the study: Wide en bloc surgical resection is the treatment of choice for cure of chondrosarcoma. Despite local control of this primary bone tumor in 60–80% of patients, mortality remains high. Recent studies suggest that biphosphonates can provide promising perspectives for the treatment of malignant bone tumors, even for primary tumors such as osteosarcoma. We report here the results obtained when using zoledronate for Swarm chondrosarcoma in an in vivo rat model and the effect of this compound on tumor cells in vitro.

Material and methods: Swarm chondrosarcoma was implanted in three series of 12 male Sprague Dawley rats. In series A, the animals were treated after implantation to death or sacrifice. In series B and C, the animals were treated a few days before curettage-resection then to death or sacrifice. Tumor growth was assessed by tumor size, presence of metastasis and death. Control series with PBS injections were also studied.

Results: Treatment with zoledronate inhibited tumor growth in all series. In series A, tumor size was significantly smaller in the treated animals (p=0.046). Tumor progression from day 19 to day 32 was significantly less for treated animals (p=0.046). Chance of survival was 0.667 for treated animals versus 0.3 for the controls. For series B and C, recurrence developed later in animals given zoledronate. Tumor size was greater in control animals compared with treated animals (p=0.043). Tumor progression from day 39 to day 49 was significantly greater in the control group (p=0.025). Cultures of cells extracted from the Swarm chondrosarcoma tumor also showed significantly inhibited growth in vitro for concentrations of zoledronic acid from 10 to 100 ml/l.

Discussion and conclusion: Zoledronic acid appears to inhibit growth of Swarm chondrosarcoma in all in vivo therapeutic schemas studied, confirming in vitro data. A more precise animal model better fitting clinical situations should provide more detailed information for use of this treatment after recurrence or in the event of intralesional surgery.


Purpose of the study: Nearly all published series of Ewing sarcoma present the present of bone metastasis as a factor of very poor prognosis. Reviewing our experience, we noted that the prognosis is not as bad as expected in these patients if surgical resection of all known foci can be achieved.

Case reports: Case n° 1 was a 16-year-old girl who presented a Ewing sarcoma involving the left iliopubic ramus. No other foci could be identified on the plain x-rays, scintigraphy and bone computed tomography. Preopeartive magnetic resonance imaging revealed a metastatic focus in the neck of the homolateral femur. The two foci were resected after preoperative chemotherapy: resection of the left hemi-pelvis and resection of the upper potion of the femur with replacement with a pelvic prosthesis and and massive prosthesis for the proximal femur. Eight years later, the patient has remained in complete primary remission, consulting for orthopedic gait problems related to prosthetic loosening. Case n° 2 was a 13-year-old boy who presented an Ewing sarcoma of the upper tibial metaphysic. Preoperative magnetic resonance imaging revealed three other metastatic localizations in the homolateral femur. Bifocal resection of the tibia and the femur was performed with implantation of an active growth prosthesis. Chemotherapy was continued. Seven years later, the patient remains in primary complete remission. Lengthening the prosthesis has enabled equivalent growth for the two limbs. The patient has a normal life style excepting contact sports which are prohibited. Case n° 3 was a 17-year-old boy who presented a voluminous Ewing sarcoma of the right pelvis. Search for extension revealed a unique metastasis in the fourth lumbar vertebra. The patient was given preoperative chemotherapy before resection of the pelvic tumor then two months later resection of the vertebral metastasis. The patient died 4.5 years later from a traffic accident. He had remained in complete remission.

Discussion and conclusion: These three cases of complete long-term primary remission of patients with primary bone metastases show that like other bone sarcomas, eradication of all recognized bone metastases is essential for the prognosis of Ewing sarcoma.


Purpose of the study: The purpose of this study was to compare two reconstruction procedures in terms of efficacy for tumor eradiation, reconstruction complications, and potential joint consequences.

Material and methods: This retrospective study included 43 patients with a giant-cell tumor located in the knee. Patients were treated by curettage combined with phenolization. Mean follow-up was seven years. Bone defects were filled with cement in 22 patients and with a fragmented allograft in 21. The reconstruction and potential joint degradation were assessed on standard x-rays obtained in the two groups.

Results: There were four cases of local recurrence (9%), two in each group. Three patients in the cement group required revision because of joint degradation in two and cement intrusion into the joint in the third. In the allograft group, two patients developed complications (fracture and massive resorption). Plan x-rays revealed joint deterioration in 10/17 patients with an allograft. The difference was significant (p=0.019).

Conclusion: The rate of local recurrence and complications after reconstruction requiring a revision procedure was not significantly different in the two groups. There was however a significantly greater radiographic degradation in patients with a bone defect filled with cement compared with those with a defect filled with a fragmented allograft.


Purpose of the study: Infection is the most severe orthopedic complication observed after conservative surgery. The purpose of this study was to ascertain the incidence and causes of such infection and analyze progress achieved over the last ten years.

Material and methods: From 1983 to 2004, surgical procedures were performed in more than 600 patients with bone sarcomas; 520 underwent reconstruction with a prosthesis and/or massive allow graft and were followed for at least six months. Age ranged from 4.5 to 82 years. Deep infections occurred in 47 patients requiring one or several revisions. Three other cases of infection, in patients initially given in other institutions, were included in the series. The study population thus included 50 deep infections after massive reconstruction. Forty-five of these patients had received chemotherapy and 20 radiotherapy. All patients were given adapted antibiotic therapy. Four patients required emergency amputation, and cleaning was attempted in 26. When the infection persisted, or when the infection became chronic, implanted material was removed systematically with insertion of an antibiotic-loaded spacer (gentamycin alon before 1990 then gentamycin+vancomycin). Reimplantation was attempted three to six weeks later when the laboratory results were satisfactory and the muscular and cutaneous situation was sufficient.

Results: Mean follow-up after infection was 8.5 years. At last follow-up, amputation had been necessary in 21 of the 50 patients. The limb was intact in the 29 others but the prosthesis could be reimplanted in only 27 after an average of 2.4 operations. The statistical analysis demonstrated that radiotherapy is a factor of poor prognosis (14 amputations in 20 radiotherapy patients versus 7 amputations in 30 patients without radiation) and that adjunction of vancomycin into the spacer cement has a beneficial effect (15 amputations in 23 patients without vancomycin versus 6 amputations in 27 patients with vancomycin.

Conclusion: Infection of a massive prosthesis is the most serious orthopedic complication because limb survival is compromised. Preventive treatment is crucial: radiotherapy should be avoided and duration of aplasia limited by the use of hematopoietic growth factors. Curative treatment can be achieved with early removal of implanted material, surgical cover with a muscle flap, and adjunction of vancomycin to the spacer cement. The role of prolonged systemic antibiotics remains controversial.

David BIAU Antoine BABINET Valérie DUMAINE Philippe ANRACT

Purpose of the study: Composite knee prostheses using a massive implant and an allograft is one option for joint reconstruction after extensive resection of the knee joint for bone tumor. Implant survival after resection of the proximal tibia is not well documented. We analyzed survival and complications in 26 composite knee prostheses.

Material and methods: A composite prosthesis was implanted in 26 patients after resection of a tumor of the proximal tibia. Median length of resection was 14 cm (range 9–20 cm). A GUEPAR massive implant was used in all cases. Allografts were sterilized with gamma radiation. Median length of the tibial stem was 30 cm (range 20–38 cm). The stem was cemented in the allograft and in the tibia.

Results: Median patient survival was 68 months. At last follow-up, 19 patients were living disease free. Among the 26 allografts, seven had fractured and five were partially resorbed. Seven allografts exhibited signs of fusion at the junction with the recipient bone. Seven reconstructions of the extensor system failed (rupture). Conversely, there were no ruptures in patients whose extensor system could be preserved (continuity) at tumor resection. Six composite prosthesis were infected, four early (< 2 months) and two late. There were four cases of local recurrence. Globally, 48 secondary procedures were required in 21 patients: 26 for mechanical defects, 13 for infection, 7 for local recurrence and 2 for postoperative complications (necrosis of the tibialis anterior in both). There were 14 revisions: 9 composite prostheses were replaced, fusion was performed in 2 patients, and 3 patients required amputation. Median survival of the reconstructions, considering all failures together, was 102 months (95%IC 64.3-Inf). Median survival, including all failures for local recurrence, was 105 months (95%IC 101-Inf).

Discussion: The rate of failure and of complications is high for massive knee prosthesis combined with a radiated allograft for reconstruction of the proximal tibia. There is no series reported in the literature. When possible, the extensor system should be preserved.

Conclusion: We currently use massive knee prostheses without allografts, reconstructing the extensor system with a vastus medialis flap.

David BIAU Philippe ANRACT Florent FAURE Eric MASCARD Antoine BABINET Valérie DUMAINE Valérie LAURENCE

Purpose of the study: The rate of failure can be high for massive reconstruction prostheses after tumor resection. We studied the causes and possible factors of failure.

Material and methods: The series included 91 patients who underwent surgery from 1972 to 1994 for resection of a bone tumor involving the knee joint. A GUEPAR prosthesis was implanted in all cases for reconstruction (megaprosthesis in 58 cases and composite prosthesis in 33). The extensor system had to be reconstructed in 37 patients. A GUEPAR II implant was used in 73 patients; 48 of these implants had an antirotation system. The analysis was retrospective. Outcome was studied in terms of survival and independent factors predictive of failure unrelated to the tumor.

Results: Mean follow-up was 72 months. At last follow-up, 68 patients were living disease free. There were nine cases of rupture of the extensor system. Preservation of a continuous extensor system at the time of bone resection reduced the risk of rupture (p=0.036). Seven allografts fractured, two loosened, and six became infected. Use of an allograft did not reduce the risk of loosening (p=0.17). Intraxial laxity was observed in 17 patients. Use of an antirotation system was a factor of risk of intraxial laxity (p=0.0023) but not of aseptic loosening. Aseptic loosening was observed in 18 patients: 10 femur reconstruction and 8 tibia reconstruction. The difference was not significant (p=0.6). In all, 104 revisions were required in 53 patients; 36 revisions of the prosthesis, 23 of them for mechanical causes. Overall median survival, excepting tumor-related causes, was 130 months. It was 130 months for femur reconstructions and 117 for tibia reconstructions (p=0.57). Age, length of resection, tumor location, use of an allograft, and use of an antirotation system were not found to be significant prognostic factors for implant survival.

Discussion: As reported by many others, we found that the rate of failure of massive prostheses for infectious and mechanical causes remained high in patients treated for bone tumors involving the knee joint. Survival of massive implants is much lower than that of gliding prostheses.

Conclusion: Technical progress is required to improve the survival of massive implants used for the treatment of bone tumors involving the knee joint.

Claude ABI-SAFI Antoine BABINET Valérie DUMAINE Bernard TOMENO Philippe ANRACT

Purpose of the study: Diagnosis and treatment of primary malignant tumors of the pelvis raise difficult problems. The purpose of this retrospective study was to analyze the functional and cancerological results observed after surgical treatment in a single center.

Material and methods: Between 1973 and 2002, 24 patients (16 men and 8 women) underwent surgery in our unit for histological proven malignant tumors. A posterior approach was used for curettages and sacrectomies of the apex. A combined anterior and posterior approach was used for total sacrectomy and hemisacrectomy. Oncological results were assessed in terms of local recurrence, presence of metastasis and patient status at last follow-up. Overall survival and disease-free survival were calculated with the Kaplan-Meier method.

Results: Mean age was 53.38 years. Mean follow-up in our series was 54 months. Mean time to diagnosis was 16 months. Pain was the predominant symptom. Sixteen patients presented neurological manifestations and the digital rectal examination was positive in all. Chondroma was the most frequent histological type (18/24). None of the patients had metastatic disease at diagnosis. A posterior approach was used for 15 patients and a combined approach for the others. There was a clear correlation between type of resection and volume of blood loss (p=0.0002). Wide dissection was wide in five patients, marginal in five and oncologically insufficient in 14. Mean operative time was 1.34 hours for posterior approaches and 9 hours for combined approaches. The postoperative period was uneventful for ten patients. Infection was the most frequent complication. Adjuvant radiotherapy, delivered in 16 patients, effectively retarded the occurrence of local recurrence. Functional disorders were correlated with the level of the neurological sacrifice. At least one S3 root had to be preserved to limit the urological and digestive incapacity. At last follow-up, local recurrence was present in 12 patients. Mean time to first recurrence was 32 months. There was a strong correlation between quality of the resection and time to local recurrence. There was a significant difference between patients with a wide resection and those with an oncologically insufficient resection (p=0.0312). Five patients had metastases. Five-year actuarial survival was 73±12%. At ten years it was 32±14%. Local recurrence-free survival was 55±11% at five years and zero at 10 years.

Discussion and conclusion: In light of these results, factors of poor prognosis were: late diagnosis, soft tissue invasion, proximal extension, marginal or insufficient resection.


Purpose of the study: Acetabular dysplasia is a recognized cause of premature hip degeneration. With increasing use of arthroplasty, the role of conservative treatment can be debated. The purpose of this work was to describe technical advances achieved with Ganz triple periacetabular osteotomy and evaluate long-term results.

Material and methods: This study included 32 dysplastic hips in 28 patients treated by Ganz triple osteotomy and assessed a mean 12 years follow-up (range 2 – 20 years). Mean age was 32 years (range 18–47). There were 24 women and four men. Hip joint measurements were made on preoperaive standard x-rays with complementary recentered views if needed as well as computed tomography (CT) to better distinguish progressive degeneration. For early patients, the iniail osteotomy involved three cuts (ilioischial, iliopubic, ilial) starting close to the acetabulum and performed via three approaches: sub coxofemoral, intrapelvic, extrapelvic. The first technical change involved osteotomy of the anterosuperior iliac spine and an oblique iliac cut farther from the acetabulum.

Results: Mean preoperative angles were: 135° (121 to 150°) for CC’D, 23.2° (3 to 40°) for HTE, 8.4° (−14 to 22°) VCE, 11.3° (−26 to 32°) for VCA. The postoperative values were: 134.5° (121 to 150°) for CC’D, 9.5° (−9 to 20°) for HTE, 31.7° (14 to 60°) for VCE, 31.7° (10 to 48°) for VCA. Six patients required total hip arthroplasty on average four years later (range 2 – 9 years), including one patient with aseptic necrosis of the acetabulum.

Discussion and Conclusion: This study confirms the usefulness of triple periacetabular osteotomy for conservative treatment of acetabular dysplasia. In light of our results, the following changes have been instituted:

all three cuts are performed via a single intra-pelvic approach;

For severe extreme dysplasia (Hip Study Group classification), a two-thirds triple osteotomy is performed (original technique). Currently the best indication appears to be a young patient (less than 30 years) with moderate to severe dysplasia, without intra-articular suffering and without any sign of early stage joint degradation.


Purpose of the study: Coxofemoral conflicts can sometimes lead to early degenerative disease in young patients. Open surgery for surgical dislocation with joint cleaning had provided promising short- and mid-term results. Arthroscopy of the hip joint is a less invasive alternative. The purpose of this work was to compare prospectively the outcome achieved with open surgical or arthroscopic treatment of coxofemoral conflicts after a minimum follow-up of two years.

Material and methods: Sixty-three patients, mean age 30 years (range 19–54) with arthroMRI-proven coxofemoral conflict were evaluated two years after treatment. Surgical dislocation was used for 31 patients and arthroscopy for 32. Clinical outcome was assessed on the basis of WOMAC scores noted preoperatively, postoperatively and at two years follow-up. Complications were noted.

Results: Results were similar in the two groups at two years: preoperative WOMAC score: 65/100 (41–95) pour open dislocation, 57/100 (15–96) for arthroscopy; postoperative WOMAC score at two years: 79/100 (41–99) for open dislocation, 84/100 (50–99) for arthroscopy. The rate of patient satisfaction was similar: (open dislocation: 75% and arthroscopy: 82%). Complications: open dislocation : 3 case of POA including 1 Brooker stage III and one 1 case of ossifying myositis of the thigh; arthroscopy: 2 case of hematoma (spontaneous resolution) and 1 case of transient irritation (48 h) of the lateral femoral cutaneous nerve. Surgical revisions at two years: open dislocation: one total hip arthroplasty at 15 months and one resection of ossification (POA) at 15 months; arthroscopy: two total hip arthroplasties at 5 and 15 months.

Discussion: The results obtained with the two methods are encouraging at two years. A satisfaction rate of 80% can be expected.

Conclusion: Arthroscopy appears to be the more advantageous alternative for young patients since it is less invasive and provides similar results at two years.


Purpose of the study: Hemophilic pseudotumor is actually an extended encapsulated hematoma which produces clinical symptoms related to its anatomic position. It is more a clinical entity than a pathological lesion. From 1990, precutaneous aspiration was proposed for significant cysts and pseudotumors treated at the Mariano R. Castex Institute. After aspiration, the cavity was filled with a bone graft for larger tumors or with spongostan or fibrin glue for smaller defects. The pseudocapsule was not removed. We report here results obtained in 17 patients.

Material and results: The 17 patients (all males) presented 19 cysts, mean age 21 years. All had hemophilia (16 A, 1 B), five were HIV-positive, nine were seropositive for hepatitis C and two presented inhibitors. All patients received coagulation factors. One patient died from histoplasmosis. Cure and successful filling of the bone defect was achieved in 15 patients. Revision for conventional resection was required in one case of recurrence.

Discussion: Percutaneous aspiration is a minimally invasive method which enables restoration of the bone tissue. We have not observed any difference between HIV-positive and HIV-negative patients.


The femoroacetabular conflict is a recognized cause of hip pain in young patients. It is associated with rim tears. Two types of conflict have been described: impingement due to retroversion of the acetabulum and «cam effect» associated with insufficient head/neck offset. A recent subject of debate has been isolated treatment of the rim tear without treating the often unrecognized bone anomaly. The purpose of this study was to assess short-term outcome after surgical remodeling of the head/neck junction for the treatment of femoroacetabular conflicts.

Material and methods: There were 37 hips (18 men and 16 women) with chronic pain for more than three months. Mean patient age was 41 years (range 24–52). Preoperative 3D CT and MRI with gadolinium arthrography were available for all patients. Surgical remodeling of the head/neck junction via digastric trochanterotomy with surgical dislocation was performed. Preoperatively, the mean Notzli alpha angle was 65.6° (range 42–95°). Among the 34 patients, only four practiced sports requiring large range hip motion. MRI revealed a rim lesion in all patients. The following tests were performed: UCLA hip test, WOMAC (Western Ontario McMaster Osteoarthritis) index, and SF-12.

Results: Mean follow-up was 2.5 years (range 2–4); pre- and postoperative scores were: WOMAC 59.2 and 81.0 (p< 0.001), UCLA scores 4.2 and 7.9 for pain, 7.3 and 9.0 for gait, 6.2 and 8.5 for function, 4.3 and 6.9 for activity (p< 0.05). The physical component of the SF-12 improved from 37.4 to 44.2 (p< 0.006) and the mental component from 46.0 to 51.6 (p< 0.03). None of the hips required revision to modify the joint configuration. Two complications were noted: one rupture of the greater trochanter and one heterotopic ossification requiring resection. Osteonecrosis was not observed. The trochanter implants were removed in nine patients because of pain.

Discussion: The femoroacetabular conflict results from insufficient concavity of the anterolateral head/neck junction associated with a rim tear. Correction of the bony anomaly provided significant short-term functional improvement both for the hip and for the patient’s general health. Correction of the offset by surgical dislocation of the hip is effective and safe treatment of the femoroacetabular conflict with preservation of the rim.

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Osteoid osteoma is a benign bone tumor usually observed in children and adults, generally in the femur or tibia. Pain relief with aspirin is a classical clinical characteristic. Computed tomography is the exploration of choice providing reliable diagnosis. Cure can be achieved with surgical resection. We present an exceptional case of osteoid osteoma located in the patella.


Purpose of the study: Coxofemoral conflicts can sometimes lead to early degenerative disease in young patients. Hip arthroscopy is a less invasive alternative which can remove all of the coxofemoral conflicts. Like open surgery, a purely arthroscopic technique enables all the necessary corrections, even involving the rim. Arthroscopy has provides promising short- and mid-term results. The purpose of this work was to present the surgical technique, its drawbacks and complications, and present suggestions for improvement.

Material and methods: Fifty-one patients, mean age 31 years (range 15–54 years) underwent purely arthroscopic treatment of coxofemoral conflicts between February 2001 and November 2003. Prospective follow-up was at least six months. The type of conflict and the corresponding corrections were noted. The Pre- and postoperative WOMAC scores were used for clinical assessment. Complications were noted as well as means for avoiding them.

Results: The operative technique, the potential dangers, and suggestions for successful arthroscopy are presented. The clinical outcome with at least six months follow-up was: hip R/L: 21/31. Head and acetabular correction: 46 cases. Head correction alone (head/neck offset): 5 cases. Preoperative WOMAC score: 59/100 (15–99). Postoperative WOMAC score: 85/100 (49–99). Complications: spontaneously resolutive hematoma (n=2), transient (48h) irritation of the lateral femoral cutaneous nerve (n=1).

Discussion: Purely arthroscopic correction of a coxofemoral conflict is as safe as the open surgical technique. The arthroscopic method provides very promising short- and mid-term results with no major complications. The lower morbidity with this technique enables ambulatory treatment with shorter recovery time.


Purpose of the study: The anterior rim of the arthroplasty cup can overhang the bone in certain situations: oversized cup, insufficient anteversion, insufficient ace-tabular reaming, cylindrospherical reaming overriding the acetabular opening. The straight or concave shape of the anterior wall of the acetabulum also affects prosthetic overhang. The purpose of this anatomic study was to use a navigation system to quantify, in vitro, the height of the iliopubic psoas notch.

Material and methods: Sixty-eight acetabuli from 34 cadaver pelvi free of osteoarthritis (13 male and 21 female) were analyzed using the Stryker™ hip navigation system. Morphological data were collected for mathematical processing which defined the diameter and the center of the articular surface.

Results: Considerable intra- and inter-individual differences in the shape of the acetabular rim were noted and quantified, particularly concerning the psoas notch. When the lateral view of the acetabular rim is projected onto a plane it produces a succession of three summits and three valleys explaining the difficulty encountered in obtaining a precise mean plane for the acetabular opening.

Discussion: More or less pronounced protrusion of the cup could explain potentially painful anterior impingement of the psoas, especially for certain types of acetabular morphology.

Frédéric PICARD Gilles SCHOCKMEL François LEITNER Philippe MARTIN

Purpose of the study: Knee prosthesis surgery has reached a high level of reproducibility, providing very satisfactory results in the large majority of patients. There remains however a certain lack of precision concerning this surgical procedure concerning the determination of the hip center. This point is used to establish the mechanical axis of the femur for positioning the prosthesis. Navigation systems can be used to localize this center. We conducted a cadaver study to determine the accuracy and repeatability of this method for determining the center of the hip joint.

Material and methods: A computerized navigation system was applied to seven fresh cadavers with normal hips. We compared the anatomic center of the hip joint with the point determined with the navigation system. We also compared the navigation technique using different navigation techniques: marker fixed on the iliac crest and without marker fixed on the iliac crest. We also determined the accuracy of the result as a function of hip circumduction during acquisition (5°, 8°, 10°).

Results: There was no statistical difference between investigator A (0.66±0.15, max error: 0.99) and B (0.68±0.10, max error: 0.87), p=0.98 (inter or intra-observer) for comparisons between the anatomic center of the hip joint and the point determined by the navigation system. The results were not statistically different between the navigation techniques (with and without a marker fixed on the iliac crest):(mean < 0.71 ± 032, max. error: 1.91) for each hip with the iliac marker (0.66 ± 0.20, max. error max: 0.99) or without the iliac marker (0.61 ± 0.41, max. error: 1.29) for hip 1. Accuracy was better for hip movement at 10° (0.60 ± 0.21, max. error: 0.92) than at 8° (0.81 ± 0.52, max. error: 1.91) or at 5° (0.67 ± 0.46, max. error: 1.91). In addition, without an iliac crest marker, 75% of the errors were less than 1, and 95% less than 1.5.

Discussion: Acquisition of the hip center of rotation using a computerized navigation system with or without use of markers fixed on the iliac crest is remarkably accurate.

Conclusion: New algorithms and control systems should help improve reproducibility above that obtained with the conventional technique.

Didier MAINARD Laurent GALOIS Stéphanie VALENTIN

Purpose of the study: Correct positioning of the prosthetic cup requires reliable anatomic landmarks, particularly for navigation systems. Referring uniquely to the three dimensions fails to recognize interindividual differences in pelvic position. The anterior plane of the pelvis is a good indicator of the pelvic position which can be determined from radiographic measurements. Standard values are poorly known (age, gender, weight). The purpose of this study was to measure the APP radiographically in the upright and reclining positions before and after total hip arthroplasty and to correlate the observed values with those obtained with navigation and ultrasound.

Material and methods: Strictly standardized x-rays of the pelvis in the upright and standing position were obtained in 110 patients (40 men, 70 women, mean age 65 years). Films which did not meet strict standard criteria were removed from the analysis which thus included upright views in 57 patients, reclining view in 36, and upright and reclining views in 28. Navigation measurements were made in 20 patients and ultrasound measurements in 10.

Results: Before arthroplasty, anteversion was 6.42±6.9° in the reclining position, 0.29±7.39° in the upright position (significant difference). After arthroplasty, anteversion was 6.9±5.3° in the upright position and 0.28±5.03 in the reclining position (significant difference). The values ranged from −15° to +18° (three patients without change, four with anteversion). There was no significant difference by gender. There was no clear correlation between the navigation values and those measured on the standard x-rays. The navigation and ultrasound values appeared to be correlated.

Discussion: The anterior pelvic plane can be easily measured on standard x-rays (upright and reclining position). Its landmarks can be easily accessed by navigation enabling the constitution of a reference plane. Several authors have demonstrated the influence of pelvic tilt on the position of the prosthetic cup. Posterior tile produces acetabular anteversion and inversely. The difference between the reclining and upright position is to the order of 6°. There are however variants up to 20° observed in certain patients and which might explain malpositions or instabilities. A cup with correct anteversion in the reclining position may be malpositioned on the upright film because of pelvic tilt.

Conclusion: Pelvic tilt should be taken into consideration when positioning the cup. The anterior pelvic plane can be correctly measured on standard x-rays and used to evaluate this tilt then serve as a reference for navigation. It should be proposed in all patients to search for extreme values.


Purpose of the study: Malposition of the acetabular implant of a total hip arthroplasty can provoke dislocation, limited joint movement, and early wear. The purpose of this prospective randomized study was to assess the efficacy of a image-free navigation system to achieve correct acetabular position for total hip arthroplasty.

Material and methods: The navigation software for the acetabular component used intraoperative anatomic acquisition. The prospective randomized study included two groups of 20 patients. In the first group, the acetabular implant was inserted using the computer-assisted system and in the second using the conventional method. The same operator performed all procedures via an anterolateral approach and using the same non-cemented hemispheric cup. The postoperative assessment was performed by an independent investigator who noted the cup inclination on the standard ap view and cup anteversion on the computed tomography; then using a dedicated system for 3D reconstruction, the same values were determined one month after surgery.

Results: Each group included ten men and ten women, mean age 63 years and mean body mass index 24. For the computed-assisted group, mean additional operative time for navigation was 13 minutes (range 8–20 min). The intraopeartive concordance with the surgeons subjective impression was excellent for 12 patients and good for 8. Mean intraoperative values were for the computer-assisted group were: for operative mode: inclination 30° (25–46°), anteversion 14° (0–25°), radiographic mode: inclination 35° (25–47°), anteversion 13° (0–26°), anatomic mode: inclination 36°, anteversion 19° (0–27°). There was no significant difference between the intraoperative and postoperative values for the computer-assisted group. There was no significant difference between the average values between the computer-assisted and conventional groups but the standard deviation was smaller in the computer-assisted group.

Discussion and conclusion: The image-free navigation system enables reliable positioning of the prosthetic cup for total hip arthroplasty and increases the precision of acetabular implantation without increasing significantly operative time. This first step must be integrated into the computerized preoperative planning for total hip arthroplasty. The next step will be to use the navigation system for implanting the femoral component.


Purpose of the study: Dislocation of total hip arthroplasty remains a frequent complication, occurring for 0.5% to 10% of implants depending on the series. In about 30% of the cases, the orientation of the acetabular cup is involved. It is sometimes difficult to visualize the acetabular landmarks during surgical procedures performed for revision or with a minimally invasive technique. The surgeon uses the position of the pelvis on the operative table as a guide. It can be noted however that the patient’s weight bearing on the table is not constant during the entire operation, potentially changing the position of the pelvis during the procedure. We evaluated the use of a visual referential visible within the operative field for implanting the prosthetic cup.

Material and methods: The method materialized the anterior plane of the pelvis then transferred geometrically this plane for display on the ipsilateral iliac crest. The pelvis was masked under a drape, in lateral decubitus. The cup was implanted 12 times using the plane of the floor as the reference, 8 times using the acetabular rim as the reference, and 10 times using the iliac reference. The goal was 20° anteversion in the sagittal plane and 45° inclination in the frontal plane. The position of the pelvis was randomized. The final positions of the cup, of the iliac reference, of the anterior plane of the pelvis and of the floor were recorded with an optical system. Spearman’s test was used to search for correlations.

Results: Using the floor referential, mean anteversion was 21.8° (15–30.9°) and mean inclination 43.2° (37–47.6°). Using the acetabular referential, mean anteversion was 21.7° (18.1–26.6°) and mean inclination 45.8° (40.9–48.6°). With the iliac referential, mean anteversion was 20.3° (17.3–25.5°) and mean inclination 43.3° (41.1–44.8°). Mean error between the pelvic plane and the iliac referential was, for anteversion −0,32° (−1.07 to 0.8°) and for inclination, −0.1° (−0.95 to 1.43°). Implantation with the iliac referential was not correlated to the position of the pelvis. When the plane of the floor was used, the position of the implant was correlated with pelvic anteversion (p< 0.01) and inclination (p< 0.01).

Discussion: Insertion of the cup was independent of the position of the pelvis within a 3D referential in the operative field. In addition to computer-assisted navigation, simple tools can be developed to improve the surgeon’s perception in difficult indications, especially when they can provide satisfactory accuracy. A clinical feasibility study is currently under way.


Purpose of the study: During resurfacing arthroplasty, excessive valgus of the femoral neck or an insufficient surgical technique can lead to formation of a notch in the femoral head. Although the mechanisms weakening the femoral neck and subsequent fractures are well described, the effects of altered blood supply via the retinacular vessels on potential ischemia of the femoral head are largely unknown. The purpose of our study was to assess blood supply to the femoral head when a notch occurred in the femoral neck during total hip replacement surgery and to deduct possible implications concerning the resurfacing procedure.

Material and methods: Blood supply to the femoral head was measured with laser Doppler fluorometry in 14 hips undergoing total hip replacement for osteoarthritis via a lateral approach with anterior dislocation. An optical laser probe for the fluorometry (Moor Instruments, Wilmington Delewar, 20 mW laser, probe length 780 nm) was introduced via a 3.5 mm hole drilled in the antrolaeral quadrant of the femoral head (leg in neutral position). The position of the probe was checked on the x-ray of the femoral head after resection. A notch was simulated in the lateral posterior portion of the femoral neck using a bone gouge.

Results: Mean patient age was 65 years (range 48–77 years). There were eight men and six women. Two measurements were made: one after dislocation of the hip and the second after simulating the notch. A significant decrease in blood supply measured at more than 50% was observed in all but four hips after simulating the notch. The median decrease in blood flow was 76% (4.4–90.4, p< 0.001).

Conclusion: The retinacular vessels appear to be equally important for the blood supply for osteoarthritic and non-osteoarthritic femoral heads. A notch occurring during hip resurfacing would not only weaken the mechanical resistance of the neck but would also increase the risk of osteonecrosis and subsequent loosening of the femoral component. Consequently, approaches compromising retinacular blood supply (for example the posterior approach) would add a supplementary danger for the integrity and viability of the femoral head.


Purpose of the study: Most systems used for computer-assisted total hip arthroplasty require preparatory computed tomography acquisition or use of multiple bone markers fixed on the pelvis. In order to overcome these problems, we developed a novel system for CT-free computer assisted hip surgery based on a functional approach to the hip joint. The concept is to orient the cup within a cone describing hip motion. The purpose of the present study was to analyze preliminary results obtained with this new system.

Material and methods: This new system was used to implant 18 primary total hip arthroplasties in 16 women and 2 men (mean age 68±7.8 years, age range 54–83 years) with degenerative disease. Two optoelectronic captors were fixed percutaneously on the pelvis and the distal femur. The acetabulum was reamed, then the femur prepared with instruments of increasing caliber. The last reamer positioned in the shaft carried an upper head which matched the size of the prepared acetabulum. Hip joint motion was recorded to determine the cone of maximal hip mobility. The system then oriented the cup so that this cone was completely included the cone described by the prosthesis.

Results: There was one traumatic posterior dislocation (fall in stairs) at three weeks, without recurrence. The Postel Merle d’Aubigné score improved from 8±2.9 (3–12) preoperatively to 17±0.8 (16–18) at last follow-up. None of the patients complained about the sites where the percutaneous markers were inserted and ther were no cases of hematoma or fracture. Mean leg length discrepancy was 5.6±7.5 mm (range 0–25 mm) before surgery and 0.6±3 mm (range −5 to 10 mm) at last follow-up. Mean anteversion of the femoral implant was 22.3±6.7° (14–31). Anatomic anteversion of the cup (measured from a marker linked to the pelvis and thus independently of the position of the pelvis) was 25.9±10.4° (12–40). The sum of the femoral and acetabular anteversions was 48.2±14.6° (range 27–71°).

Conclusion: This method can be used in routine practice without lengthening operative time excessively. It provides a safe way to control the length of the limb and helps position the cup. This study demonstrated that there is no ideal position for the cup that can be applied for all patients. Because of the wide spread of the inclination and anteversion figures, half of the cases were outside the safety range recommended by Lewinnek.


Purpose of the study: The extramedullary anatomy of the femur must be reproduced during total hip arthroplasty in order to ensure correct tension on the gluteus muscles. This requires:

correct offset of the femur, measured as the distance between the center of the head and the anatomic axis of the shaft;

offset of the center of rotation, measured as the distance between the center of the head and the pubic symphesis. Addition of these two offsets gives the overall offset. The purpose of this work was to analyze postoperative offset after standard total hip arthroplasty as a function of the preoperative head-shaft angle.

Material and methods: Prospective study of 150 files of patients who underwent first-intention total hip arthroplasty. A prosthesis with matched increasing head size was implanted. The head-shaft angle was 135°. Mean offset was 41.7 mm (range 33–47 mm) for the 0 head-neck. The preoperative neck-shaft angle was measured on the upright ap view (comparable rotation of the two hemipelvi). Pre- and postoperative femur and center of rotation offset were noted.

Results: The preoperative neck-shaft angle varied from 118° to 1400. Mean preoperative femur offset was 40.2 mm (range 29–52 mm). Mean postoperative femur offset was 42.2 mm. This gave a 2 mm lateralization of the femur, which was apparently negligible, favorable, and therefore satisfactory. Mean offset was 90.5 mm preoperatively and 84.5 mm postoperatively, medializing the center of rotation 6°. Mean overall offset was thus displaced medially (6 mm minus 2 mm = 4 mm). This was considered acceptable. Among these 150 files, 24 were coxa vara hips with a neck-shaft angle 125°. For these 25 coxavara hips, the mean preoperative femur offset was 44.5 mm. The mean postoperative femur offset was 42.2 mm. This produced, inversely, a medial displacement of the postoperative femur offset of 2.3 mm. The center of rotation was displace medially 6 mm. Thus globally the medial displacement was 6 mm plus 2.3 mm = 8.3 mm. This appeared to be excessive.

Discussion: The postoperative offset of the femur is prosthesis-dependent. The majority of implants currently marketed have a mean offset in the 40–45mm range. The offset of the center of rotation is operator-dependent: as the acetabular reaming is accentuated, the center of rotation is displaced medially. Acetabular reaming is necessary to reach the subchondral bone. The medial offset can be limited but at least some displacement is inevitable. Thus in the event of a coxavara hip, it is very difficult to limit excessive overall medial offset when using a standard prosthesis. If the goal is to mimic the anatomic femur offset, it would appear justified to use prostheses with a smaller neck-shaft angle for patients with coxavara. A 10° reduction, from 135° to 125° would increase the femur offset 5 mm and thus enable reproduction of the preoperative anatomy.


Purpose of the study: Morton neurinoma is a well defined anatomic entity despite certain questions about the pathogenic mechanisms. Diagnosis of the metatarsalgia sometimes produced can be difficult due to the frequency of an associated static metatarsalgia. Magnetic resonance imaging has not met expectations. We have oriented our research towards ultrasonography which can provide high quality information with good reliability.

Material and methods: We reviewed the files of 11 patients with Morton neurinoma which led to 14 operations (bilateral cases or two localizations on the same foot). The series included three men and eight women, mean age 56 years. The operation was conducted under locoregional anesthesia and consisted in tumor resection via the plantar commissure, with removal of the entire neurinoma. Ultrasonography used a high-frequency probe (6–13 MHz linear scan). The compartments were studied via the plantar aspect and the dorsal aspect using static and stress positions. MRI had been performed in two patients before the ultrasound.

Results: Eight of the eleven patients had an associated syndrome (hallux valgus, disharmonious length with mid metatarsal weight bearing). Objective signs (Mudler’s sign, hyoesthesia), were noted in seven patients. The neurinoma was confirmed in all cases at surgery; in two cases, ultrasonography demonstrated a neurinoma where the MRI had been negative. The operative specimen was typical. Two compartments were explored because of the ultrasound results which were highly suggestive; two tumors were demonstrated at surgery. Clinical outcome at mean seven months was good in ten patients and fair in one.

Discussion: Ultrasonography should no longer be considered as «operator-dependent». It enables the detection of mid-sized neurinomas measuring about 2 cm. Magnetic resonance imaging has been less productive for diagnosis; many studies have been reported without surgical confirmation of MRI-negative cases. False negatives are frequent and patient follow-up is insufficient to determine whether the symptoms persist or resolve after surgery.

Conclusion: Ultrasonography is a simple examination devoid of iatrogenic risk. The use of stress images has greatly improved performance. This low cost examination may not however be necessary because the diagnosis of Morton is basically clinical.

Patrice-François DIEBOLD Walter MAC DOUGAL

Purpose of the study: The choice between preservation of the joint shape and straight cuts for arthrodesis of the metatarsophalangeal joint (MPJ) remains a subject of debate.

Material and methods: Sixty patients (74 feet), mean age 67 years, underwent fusion of the first MPJ. There were 52 women and 8 men. Follow-up was 38 months. The operation was performed with a tourniquet and locore-gional anesthesia. The procedure consisted in resection of the remaining cartilage and subchondral bone with preservation of the joint shape. Axial reduction was achieved with back-and-forth pinning the compression stapling on the dorsal aspect. The patient wore a postoperative boot for six weeks.

Results: mean time to healing was 15 weeks (rate of fusion 94.6%). The AOFAS score improved from 29.2/100 preoperatively to 77.1/100 postoperatively. 83% of patient resumed their normal activities. The mean M1P1 angle improved from 34.7° preoperatively to 23.8° postoperatively. Dorsal flexion was 26.8° postoperatively. 79.7% of patients were completely satisfied and 13.5% partially satisfied.

Conclusion: Arthrodeis of the first MPJ is a good technique for selected patients. Use of two dorsal staples for compression is more economical and gives the same rate of fusion as more sophisticated methods. Preservation of the joint shape has no influence on the rate of fusion. There is no mid-term impact on the interphalaneal joint.


Purpose of the study: Chronic foot compartment syndrome is a rather new notion illustrated by four cases reported in the international literature. We report a new case with bilateral involvement. The diagnosis was established by dynamic thallium scintigraphy and suggested that a less invasive management would be appropriate.

Case report: A 32-year-old male Foreign Legion recruit developed exercise-induced pain in the medial portion of the plantar aspect of both feet. The pain persisted for several months and resisted medical treatment. No medical or surgical event could be identified in the patient’s history. Pain developed systematically with exercise which had to be interrupted. It regressed progressively after interruption of exercise. The physical examination and podoscopy were not contributive. Laboratory tests, plain x-rays, MRI, and bone scintigraphy were normal. The diagnosis of chronic foot compartment syndrome was entertained. Dynamic thallium-201 scintigraphy was performed on both feet to compare the soft tissue images. Intense uptake was observed on the early images and late images of the plantar vault. These images, present on both feet, were considered compatible with chronic foot compartment syndrome. Positive diagnosis was confirmed with pressure measurements in the medial compartment. Fasciotomy was performed for the medial compartment. The patient was able to run normally at one month with complete regression of the symptoms. The patient was symptom free at two years.

Discussion: Compartment pressure measurements currently constitute the gold standard diagnostic approach. MRI, Doppler, spectroscopy, and scintigraphy have been proposed. For this functional disorder, which occurs only after exercise, we consider that compartment pressure measurement is overly invasive and painful. Furthermore, dynamic thallium-201 scintigraphy has been found to be as reliable as pressure measurements. Comparative studies would be required to determine the best evidence-based choice.

Conclusion: Chronic foot compartment syndrome is a rare entity observed in the active young subject. The medial compartment is always involved. Fasciotomy is effective treatment. Compartment pressure measurements remain the gold standard but dynamic scintigraphy would be a promising examination which merits evaluation.

Patrice-François DIEBOLD

Purpose of the study: When it became popular in the 1980s, the wedge osteotomy proposed by Kenneth John-son of the Mayo Clinic was not advocated for patients over 50 years of age. We wanted to known whether it could work in patients over 60.

Material and methods: Between January 1987 and December 1988, 62 patients underwent surgery for moderate hallux valgus. Wedge osteotomy was performed in all cases associated with phalangeal osteotomy and lateral release of the metatarsophalangeal joint (MTJ). Mean patient age was 60.2 years. Patients were followed ten years on average.

Results: Thirty-nine patients (48 feet) were reviewed. Radiological recurrence was noted in nine feet. The average hallux valgus M1P1 angle was 35° preoperatively and 9.8° postoperatively. The average M1M2 angle was 11.4° preoperatively and 4.6° postoperatively. Joint motion was good for the first MPJ, with average 51° dorsiflexion, and 14° plantar flexion. These results were obtained despite the opinion that wedge osteotomy stiffens the MTJ after 50 years. Patient satisfaction was very good, especially for shoe wearing, the esthetic result, and pain relief. Most recurrences involved non-correction of the distal articular angle, an observation which would be rather surprising in older patients. There were no cases of necrosis of the metatarsal head and the degenerative changes observed radiographically had little clinical impact.

Conclusion: This series has enabled us to conclude that the risk of wedge osteotomy of the metatarsal is not greater after the age of 60 years and that it provides very satisfactory long-term results.


Purpose of the study: Scarf osteotomy is currently the gold standard treatment for hallux valgus. The purpose of our work was to search for anatomic and clinical factors affecting the outcome.

Material and methods: This retrospective review concerned 125 osteotomies performed in 105 patients (101 women and 4 men, mean age 48 years, age range 16–75 years). For 55 cases, Scarf osteotomy was associated with osteotomy of the proximal phalanx. Osteotomies to reduce the lateral metatarsals were performed in 32 cases. Clinical outcome was assessed in terms of pain, hallux function and motion using the AOFAS and Groulier systems. AP and lateral weight-bearing views were used to assess the metatarsophalangeal, intermetatarsal, interphalangeal, PPAA, DMAA, and Djian angles and metatarsal slope.

Results: Mean follow-up was 45 months (range 24–95). The Kiaoka and Groulier score improved respectively from 50 to 84/100 points and 38 to 68/100 points (p< 0.0001). Pain relief was total or nearly total in 95% of patients. MPJ stiffness was related to gastrocnemius retraction, osteoarthritic degeneration, and residual deformation (p< 0.05). Subjectively, 72% of patients were satisfied or very satisfied, corresponding to 73% good or very good results. At last follow-up M1P1, M1M2 and DMAA had decreased significantly (p< 0.001) respectively improving from 33° to 18°, 14° to 9.5° and 13.2° to 9.4°. Conversely, mean P1P2 and PAA increased significantly (p< 0.05) because certain inter- and intraphalangeal deformations, radiographically masked by the preoperative hallux pronation, were not corrected. There were 29 recurrences (MP angle > 25°) statistically related to under correction of the intermetatarsal angles (p< 0.0001), M1M5, DMAA (p< 0.05), persistent hallomegaly (p=0.015), and presence of an oblique cuenometatarsal space (p=0.02). Recurrence was more frequent in patients with flat foot (p=0.04); greater calcanceal valgus was associated with wider MP angle (p=0.02).

Discussion and conclusion: Scarf osteotomy enabled complee correction of 80% of the deformations. To improve the final outcome, displacement of the first metatarsal should correct the metatarsus varus and the DMAA. Careful radioclinical analysis pre- and intra-operatively should held detect posterior (flat foot) and anterior (hallomegaly, inter- and intraphalangeal crossover) of the MPJ because they significantly influence persistence or recurrence of the deformation.


Purpose of the study: Hallux valgus is often associated with metatarsalgia due to insufficiency of the first ray. The purpose of this prospective study was to learn whether osteotomy of the first metatarsal can correct both conditions.

Material and methods: This series included 35 women and 2 men, mean age 55 years. Metatarsalgia predominated in M2 in these patients with a round forefoot. Pain was a constant sign. Thirty-six patients wore special shoes for comfort with or without an orthesis. The mean preoperative metatarsal varus, measured radiographically was 16°. Scarf osteotomy used a horizontal cut at of the first metatarsal forming a 45° angle with the plantar aspect. Patients were reviewed at three years with a computed tomography of the forefoot. The Kita-oka score was determined.

Results: Thirty-four feet were pain-free at last follow-up. The frontal scan of the forefoot showed the shaft of the first metatarsal had been lowered 2 mm on average. According to the Kitaoka score, outcome was good or very good for 31 feet, fair for 5 and poor for 5. There was a significant correlation between lowering of the first metatarsal and persistent metatarsalgia.

Discussion: Barouk suggested the Scarf technique does not enable sufficient lowering of the first row to correct for around forefoot. The CT scan however showed the metatarsal was lowered 2 mm, which would appear to be sufficient to correct for the insufficient weight-bearing. The result of this series would appear to show that outcome is better then hallux valgus cure plus Weil oseotomy if there is no hallomegaly.

Conclusion: This series shows the usefulness of lowering the first metatarsal for the treatment of hallux valgus with metatarsalgia without hallomegaly.


Purpose of the study: The efficacy of metatarsophalangeal joint (MPJ) fusion for the treatment of hallux rigidus has been well defined in the literature. There is however still some debate about the efficacy of conservative treatment, especially concerning the respective role for each of several different techniques.

Material and methods: This study reports the analysis of 113 patients treated for hallux rigidus with minimum one year follow-up. Mean age of this predominantly female population was 58 years. Fusion of the MPJ of the great toe was performed for 77% of patients and conservative treatment for 23%: isolated osteophytectomy (n=5), dorsal cheilectomy and shortening osteotomy of P1 (5 cm on average) with or without dorsal flexion for the others. The clinical outcome was assessed with the Groulier criteria.

Results: Overall outcome was satisfactory in 85% of the patients treated by MPJ fusion; MPJ pain resolved in 92%. There was however late healing or nonunion in 13% with no apparent clinical impact. Conservative treatment successfully relieved pain in 80% of patients who were able to wear ordinary shoes and had improved dorsal flexion of the MPJ.

Conclusion: The results of this study are helpful in determining the appropriate indications for surgery as a function of the clinical and radiological presentation of hallux rigidus.

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