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Volume 91-B, Issue SUPP_III September 2009

C. Ruosi D. Marinò M.G. Lettera

The surgical treatment of a secondary gonarthrosis caused by haemophilic arthropathy needs high quality in soft tissue balancing and accurate alignment in total knee arthroplasty (TKA), which are essential for good long-term results. Due to the early-onset severe arthropathy, haemophiliacs undergo prosthetic surgery at a younger age than general population; therefore to ensure a longer duration of implantation is a major objective to be reached in this setting. As several prospective randomised studies could show, Computer navigation in prosthetic surgery improve precision concerning geometry of axes, resection planes and implant alignment, by the determination of joint centres (actual axis), amount of bone resection, size of prostheses and check of ligament balance. At our department, since January 2006, we implanted four TKA in four patients (age range 45–52 years) affected by severe Haemophilia B; the same surgeon used a single system (Orthopilot system) in all cases.

The quality of implantation was studied on postoperative standardized long leg coronal and lateral x-rays. Our results showed that CAS had greater consistency and accuracy in implant placement. Complications influencing the clinical outcome did not occur. In our experience, drawbacks of the navigation systems are the additional costs and the additional operation time between 15 and 25 min. However, one of the most important advantages of using of this technique in patient affected by coagulation disease, according to the international literature, is the reduction of blood loss after operation. A long-term follow-up of these and of larger samples of patients is needed for testing cost/risk-benefit ratio of Orthopilot in prosthetic surgery of haemophiliacs. Therefore navigated total knee arthroplasty in haemophilic arthropathy is not yet a standard procedure, but this technique could become an important surgical choice in management of severe secondary osteoarthritis in the future.


L.M. Longstaff K. Sloan N. Stamp M. Scaddan R.J. Beaver

The aim of this study was to identify what aspects of implant alignment and rotation affect functional outcome after total knee arthroplasty (TKA). 159 TKAs were performed at the Royal Perth Hospital between May 2003 and July 2004. All patients underwent an objective and independent clinical and radiological assessment before and after surgery. A CT scan was performed at six months. The alignment parameters that were measured included: sagital femoral, coronal femoral, rotational femoral, sagital tibial, coronal tibial and femoro-tibial mismatch. The cumulative error score, which represents the sum of the individual errors, was calculated. Functional outcome was measured using the Knee Society Score (KSS).

Good coronal femoral alignment was associated with better function at 1 year (p=0.013). Trends were identified for better function with good sagital and rotational femoral alignment and good sagital and coronal tibial alignment. Patients with a low cumulative error score had a better functional outcome (p=0.015). These patients rehabilitated more quickly and their length of stay in hospital was 2 days shorter.


Y. Zaulan V. Alexandrovsky B. Zilberstein M. Shoham M. Roffman A. Bruskin

Vertebral compression fractures can affect both sexes and constitute a major health care problem, due to negative impact on the patient’s function, quality of life and the costs to the health care system. Patients can be treated conservatively or by conventional fluoroscopic assisted vertebroplasty – injection of polymethylmethacrylate PMMA into the fractured vertebral body. Conventional vertebroplasty imposes technical challenges with possible complications including cement extravasations, nerve root compression, the possibility of breaching the walls of the pedicle by the osteoplasty needle and prolonged fluoroscopic radiation exposure of the surgeon and the medical team at large.

We present here a comparative study of 20 cases of thoraco-lumbar vertebral compression fracture, treated with robotic assisted vertebroplasty (research group) versus 30 cases of fractures treated by conventional fluoroscopic vertebroplasty (compared group). All patients were diagnosed as suffering from acute vertebral compression fractures (up to 3 weeks from the traumatic event) and were scored 7 and above in the VAS. The mean overall operation time of the fluoroscopic assisted vertebroplasty was 35 minutes compared to a mean operation time of 45 minutes at the robotic assisted vertebroplasty. There was a significant difference in the fluoroscopic time and subsequent exposure time to radiation between the groups: in the research group we used only an average of 3 seconds of fluoroscopic exposure (an average of 5 fluoroscopic images) compared to an average of 7 seconds of exposure (an average of 12 fluoroscopic images). No difference was found between the groups in regard with overall admission time or with the time between the operation and physiotherapy.

Conclusion: robotic assisted vertebroplasty is a new and safe approach aiming to shorten the duration of fluoroscopic exposure of the patient and surgeon thus reducing the exposure to radiogenic dose. This novel procedure, promotes better accuracy with regard to the cement injected thus reducing the potential complication of the operation.


J.Y. Jenny R.K. Miehlke A. Giurea

Accuracy of implantation is an accepted prognostic factor for the long term survival of total knee replacement (TKR). The use of navigation demonstrated a significant higher accuracy of implant orientation in comparison to conventional methods. However, these systems are often thought to be technically demanding, to increase operating time and to involve a long learning curve. We performed a prospective, multicenter study to compare the accuracy of implantation of a TKR measured on post-operative X-rays in experienced and less experienced centers.

All centers used the same navigation system (Ortho-Pilot ®, Asculap, Tuttlingen, FRG): 4 had already a significant experience with it (group A – 182 cases), 9 centers were considered as beginners with less than 10 cases performed prior to the study (group B – 221 cases). Accuracy of implantation was measured on post-operative antero-posterior and lateral long leg X-rays with five items: mechanical femoro-tibial angle, coronal orientation of the femoral component, sagittal orientation of the femoral component, coronal orientation of the tibial component, sagittal orientation of the tibial component.

When the measured angle was in the expected range, one point was given. The accuracy note was defined as the sum of all points given for each patient, with a maximum of 5 points (all items fulfilled) and a minimum of 0 point (no item fulfilled). The mean accuracy note was compared in the two groups by a Student t-test at a 0.05 level of significance. Power of the study was 0.80.

There were no significant differences in pre-operative parameters between the two groups, except for the clinical KSS. The mean operative time was significantly longer in group B than in group A (110 minutes vs 90 minutes, p=0.01). However this difference occurred mainly during the first twenty cases in the beginner centres where we observed a clear tendency to achieve the same operative time as the experienced centres at the end of the study. The mean accuracy note was 4.3 ± 0.8 (range, 1 to 5) in the control group and 4.3 ± 0.9 (range, 1 to 5) in the study group (p > 0.05). The power of the study to detect a 0.25 point difference in the post-operative accuracy note was retrospectively calculated to be 0.80. There were no significant differences between the two groups for all individual radiographic items.

This study is, to our knowledge, the first one which investigates the learning curve of navigated TKR The used navigation system allowed a very accurate implantation of a TKR in both experienced and less experienced centers. There was no detectable learning curve with respect to accuracy of TKR implantation, clinical outcome and complication rate. The duration of the learning curve when considering the operating time was 30 cases.


K. Thomason

Sixteen observers measured eight anatomic parameters on digitalised images of six acute distal radial fractures using the Patient Archiving Communication System (PACS) software and repeated the measurements two weeks later. Inter and intra observer variability for each parameter was calculated using intraclass correlation coefficients (ICC) and tolerance limits (TL). Highest inter-observer agreement was demonstrated in dorsal tilt (ICC 0.858; TL ± 14.2°) with poor agreement on the size of the gap and step. When compared with the results of a similar study published 10 years ago looking at observer variability in x-ray measurement of healed distal radial fractures, the reliability of computerized measurements is not significantly different to those achieved by manual techniques (dorsal tilt inter-observer TL on PACS ± 16° compared with TL ± 15° using ruler and protractor). These results suggest the current guidelines in the literature for acceptable radiological reduction limits based on < 10° change in palmar tilt, < 2mm radial shortening, < 5° change in radial angle and < 1–2mm articular step for acute distal radius fractures cannot be reliably measured


J.Y. Jenny E. Ciobanu C. Boeri

Unicompartmental knee replacement (UKR) is accepted as a valuable treatment for isolated medial knee osteoarthritis. Minimal invasive implantation might be associated with an earlier hospital discharge and a faster rehabilitation. However these techniques might decrease the accuracy of implantation, and it seems logical to combine minimal invasive techniques with navigation systems to address this issue.

The authors are using a non image based navigation system (ORTHOPILOT , AESCULAP, FRG) on a routine basis for UKR. We prospectively studied 60 patients who underwent navigated minimally invasive UKR for primary medial osteoarthritis at our hospital between October 2005 and October 2006. We established a navigated control group of 60 patients who underwent conventional implantation of a UKA at our hospital between April 2004 and September 2005. There were 42 male and 78 female patients with a mean age of 65 years (range, 44–87 years). There were no differences in all preoperative parameters between the two groups.

The accuracy of implant positioning was determined using predischarge standard anteroposterior and lateral radiographs. The following angles were measured: femorotibial angle, coronal and sagittal orientation of the femoral component, coronal and sagittal orientation of the tibial component. When the measured angle was in the expected range, one point was given. The accuracy was defined as the sum of the points given for each angle, with a maximum of five points (all items fulfilled) and a minimum of 0 point (no item fulfilled). Our primary criterion was the radiographic accuracy index on the postoperative radiograph evaluation. All other items were studied as secondary criteria.

The mean accuracy index was similar in the two groups: 4.1 ± 0.8 in the study group and 4.2 ± 1.2 in the control group. 36 patients (60%) in the control group and 37 patients (62%) in the study group had the maximum accuracy index of five points. All measured angles were similar in the two groups. There were no differences between the percentages of patients in the two groups achieving the desired implant positions. Mean operating time was similar in the two groups. There were no intraoperative complications in either group. The groups had similar major postoperative complication rates during hospital stay (3% for both).

The used navigation system is based on an anatomic and kinematic analysis of the knee joint during the implantation. The modification of the existing software for minimal invasive approach has been successful. It enhances the quality of implantation of the prosthetic components and avoids the inconvenient of a smaller incision with potential less optimal visualization of the intra-articular reference points. However, all centers observed a significant learning curve of the procedure, with a significant additional operative time during the first implantations. The postoperative rehabilitation was actually easier and faster, despite the additional percutaneous fixation of the navigation device. This system has the potential to allow the combination of the high accuracy of a navigation system and the low invasiveness of a small skin incision and joint opening.


T. Trc D. Rybka V. Havlas Z. Kopecny J. Kautzner

Authors have been using kinematic computer navigation for a total knee replacement surgery since 2003. A contribution and advantage of computer navigation is well recognized. Exact guidance of both tibial and femoral osteotomy along with precise soft tissue balance respecting individual anatomic constitution is achieved by exact collection and computer evaluation of data by a use of special sensors and probes. Use of kinematic navigation in experienced hands minimizes deviation from physiological mechanical Mikulicz axis. This is considered the most important step to achieve a good long term outcome after total knee arthroplasty.

We have been recently using Brain Lab kinematic navigation system in both primary and revision knee arthroplasties. 200 primary and 20 revision knee arthroplasties are included in the retrospective 3 year follow up study. A navigated revision surgery is recently performed only in cases where the axial deformity does not exceed 10 degrees and where no significant bone loss is presented (bone defects less that ½ cm). Standard cemented components are used in both primary and revision cases. A primary navigated knee arthroplasty had no exclusion criteria in the above study.

Technique: Medial patellar approach technique is used, navigation probes are placed in standard distal femoral and proximal tibial position. Data are collected using navigation probes and sensors. Loosen components and cement are removed next. Navigated proximal tibial osteotomy, distal femoral osteotomy and soft tissue balance are performed. Gentamycin cementing of standard components (tibia first) is performed at the end. A final verification of component balance and data storage terminates the procedure.

No need for conversion to a revision knee system using stem and wedges was noticed in the above series. Following the above inclusion criteria standard cemented implants were used only. We conclude that the use of navigation in cases of relatively uncomplicated knee revision arthroplasty guaranties good mid term outcome, good soft tissue balance, saves money on expensive knee revision systems and guaranties an alternative of second stage revision surgery with a use of extensive revision systems. Standard implant selection does not apply for those with deep bone defects and axial deformation higher than 10 degrees.


J.Y. Jenny C. Boeri Y. Diesinger E. Ciobanu

Revision TKR is a challenging procedure, especially because most of the standard bony and ligamentous landmarks are lost due to the primary implantation. However, as for primary TKR, restoration of the joint line, adequate limb axis correction and ligamentous stability are considered critical for the short- and long-term outcome of revision TKR. There is no available data about the range of tolerable leg alignment after revision TKR. However, it is logical to assume that the same range than after primary TKR might be accepted, that is ± 3° off the neutral alignment. One might also assume that the conventional instruments, which rely on visual or anatomical alignments or intra- or extramedullary rods, are associated with significant higher variation of the leg axis correction.

We used an image-free system (ORTHOPILOT TM, AESCULAP, FRG) for routine implantation of primary TKA. The standard software was used for revision TKA. Registration of anatomic and kinematic data was performed with the index implant left in place. The components were then removed. New bone cuts as necessary were performed under the control of the navigation system. The size of the implants and their thickness was chosen after simulation of the residual laxities, and ligament balance was adapted to the simulation results. The system did not allow navigation for centromedullary stem extension and any bone filling which may have been required. This technique was used for 54 patients. The accuracy of implantation was assessed by measuring the limb alignment and orientation of the implants on the post-operative radiographs.

Limb alignment was restored in 88%. The coronal orientation of the femoral component was acceptable in 92% of the cases. The coronal orientation of the tibial component was acceptable in 89% of the cases. The sagittal orientation of the tibial component was acceptable in 87% of the cases. Overall, 78% of the implants were oriented satisfactorily for the five criteria.

The navigation system enables reaching the implantation objectives for implant position and ligament balance in the large majority of cases, with a rate similar to that obtained for primary TKA. The navigation system is a useful aid for these often difficult operations, where the visual information is often misleading. The navigation system used enables facilitated revision TKA.


J.Y. Jenny E. Ciobanu C. Boeri

Anterior cruciate ligament (ACL) reconstruction allows overall good results, but there is still a significant rate of failure. It is well accepted that the main reason for ACL reconstruction failure is a misplacement of tibial or femoral tunnels. Conventional techniques rely mainly on surgical skill for intra-operative tunnel placement. It has been demonstrated that, even by experienced surgeons, there was a significant variation in the accuracy of tunnel placement with conventional techniques. Navigation systems might enhance the accuracy of ACL replacement.

10 cadaver knees with intact soft-tissue and without any intra-articular abnormalities were studied. We used a non image based navigation system (OrthoPilot ®, Aesculap, Tuttlingen, FRG). Localizers were fixed on bicortical screws on the distal femur and on the proximal tibia. Both kinematic and anatomic registration of the knee joint were performed by moving the knee joint in flexion-extension and palpating relevant intra- and extra-articular landmarks with a navigated stylus. The most anterior, posterior, medial and lateral point of both tibial and femoral attachment of the ACL were marked with metallic pins. The navigated stylus was positioned on these points, and the system recorded its position in comparison to the bone contours. Subsequently, we performed conventional plain AP and lateral X-rays and a CT-scan, and measured the position of the pins in comparison to the bone contours. Finally, all measurements were made again with a caliper after disarticulating the knee joint. We calculated the center of the footprint as the mid-point between the four pins of both tibial and femoral attachment for each measurement technique. All measurements were expressed as percentages of the bone size to compensate for the different sizes.

There were no significant difference in the paired measurements of the location of the ACL footprints on both femur and tibia between anatomic, radiographic, CT-scan and navigated measurements. There was a significant correlation between the paired measurements of the location of the ACL footprints on both femur and tibia with either measurement techniques.

Anatomic measurement is the gold standard experimental technique for the positioning of the ACL foot-print, and CT-scan measurement is currently the gold standard technique in clinical situation. According to this reference, the position of ACL attachments on the tibia and on the femur can be accurately defined by the navigation system. Intra-operative measurement of the location of the bone tunnels during ACL replacement with this navigation system should be accurate as well.


E. Sariali A. Mouttet G. Pasquier Y. Catonné

The use of two-dimensional plain X-rays for preoperative planning in total hip arthroplasty is unreliable. For example, in the presence of rotational hip contracture the lateral femoral off set can be significantly under-estimated. Pre-operative planning is of particular importance when using uncemented prostheses. The aim of this study was to determine the precision of a novel 3D CT-based preoperative planning methodology with the use of a cementless modular-neck femoral stem.

Pre-operative computerised 3D planning was performed using HIP-PLAN® software for 223 patients undergoing THA with a cement-less cup and cement-less modular-neck stem. Components were chosen that best restored leg length and lateral off set. Postoperative anatomy was assessed by CT-scan and compared to the pre-operative plan.

The implanted component was the same as the planned one in 86% of cases for the cup and 94% for the stem. There was no significant difference between the mean planned femoral anteversion (26.1° +/− 11.8) and the mean postoperative anteversion (26.9° +/− 14.1) (p=0.18), with good correlation between the two (coefficient 0.8). There was poor correlation, however, between the planned values and the actual post-operative values of acetabular cup anteversion (coefficient 0.17). The rotational centre of the hip was restored with a precision of 0.73mm +/3.5 horizontally and 1.2mm +/− 2 laterally. Limb length was restored with a precision of 0.3mm +/− 3.3 and femoral off set with a precision of 0.8mm +/− 3.1. There was no significant alteration in femoral off set (0.07mm, p=0.4) which was restored in 98% of cases. Almost all of the operative difficulties encountered were predicted pre-operatively.

The precision of the three-dimensional pre-operative planning methodology investigated in this study is higher than that reported in the literature using two-dimensional X-ray templating. Cup navigation may be a useful adjunct to increase the accuracy of cup positioning.


Y. D. Kamat K. Kosygan C. Emeagi A. R. Adhikari

Computer navigation systems enable precise measurement and intra- operative knee range of movement analysis. We present a series of five knees that demonstrated unusual kinematics.

Five of 80 computer navigated knee replacements that were part of a prospective randomised trial were found to have unusual joint lines. Range of motion assessment was performed with computer assisted navigation after exposure and registration of bony landmarks and before bony resection was commenced. This revealed valgus alignment in extension that drifted into varus with knee flexion. We referred to these unusual patterns as ‘oblique joint lines’.

The data from the navigation log files of these five knees was analysed in detail. Average age of patients in this series was 68years and all were female. The average pre- operative angle between femoral axis and distal femoral articular surface was 101 degrees. All five knees had a tibial varus with average angle between the tibial axis and articular surface being 85 degrees. In two knees, more bone was resected from the medial posterior femoral condyle using 4 degrees external rotation. These two knees showed improved kinematics and horizontal joint line post- operatively.

Computer assisted navigation provides a precise understanding of the pre- operative knee kinematics. Bony cuts can be tailored to suit the pre- operative deformity. Increased external rotation of the femur with adequate medial soft tissue release is an alternate approach for difficult knees with ‘oblique joint lines’.


Y. D. Kamat K. Kosygan K. M. Aurakzai A. R. Adhikari

The ligament balancing technique involves precise measurement and equalisation of flexion and extension gaps. A force tension distractor that has separate arms for the medial and lateral joint compartments was used. We describe our experience of 40 total knee replacements (TKR) using this technique.

We undertook a prospective randomised trial using computer assisted navigation in TKRs applying two different soft tissue balancing techniques. The aim was to see how balancing techniques help us achieve a rectangular flexion extension gap. The 40 TKR that underwent the ligament balancing procedure were part of this trial. The distractor used was derived from the Freeman-Swanson knee instrumentation which measures the gap and tension in the medial and lateral compartments. The options to make the gap rectangular were: 1. adjustment of femoral cut by change in external rotation (for the flexion gap); 2. soft- tissue release or 3. a combination of both. Using computer assisted navigation it was possible to perform real time motion analysis during surgery.

We found that three degrees of external rotation for the femoral component was adhered to in only 16 out of 40 knees. The remaining 60% had external rotation of femoral component varying between two and eight degrees. No maltracking of the patella resulted in any of the TKR with increased rotation of the femoral component. The axis of movement was plotted on a graph at the end of the surgery by passive extension to flexion to which the operating surgeon was blinded.

Varying external rotation of femoral component might be an option in balancing difficult knees. Computer navigation enables precise tailoring of bony resection to suit different deformities.


E. Sariali T. Stewart Z. Jin J. Fisher

The use of hard-on-hard hip prostheses has highlighted specific problems like the “stripe-wear” and the squeaking. Many authors have related these phenomena to a micro-separation between the cup and the head. The goal of the study was to model the hip kinematics under micro-separation regime in order to develop a computational simulator for total hip prosthesis including a joint laxity, and to use it to perform a sound analysis.

A three-dimensional model of the Leeds II hip simulator was developed on ADAMS® software. A spring was used to introduce a controlled micro-separation (less than 500 microns) during the swing phase of the walking cycle. The increase of the load during the stance phase induced a relocation of the head in the cup. Values of the medial-lateral separation predicted from the model were compared to experimental data measured using a LVDT of less than 5 microns precision. Theoretical wear path predicted from the model was compared to the literature data. The frequencies of the vibratory phenomena were determined, using the Fourier transformation.

There was an excellent correlation between the theoretical prediction and the experimental measurement of the medial-lateral separation during the walking cycle (0.92). Edge-loading contact occurred during 57% of the cycle according to the model and 47% according to the experimental data. Velocity and acceleration were increased during the relocation phase in a chaotic manner, leading to vibration. The contact force according to the model had also a chaotic variation during the micro-separation phase, suggesting a chattering movement. Fourier transformation showed many frequencies in the audible area.

A three-dimensional computational model of the kinematics of the hip after total replacement was developed and validated with an excellent precision under micro separation. It highlighted possible explanations for the squeaking that may occur during either relocation phase or edge loading.


S. Hakki

There is a significant variation in registering anterior pelvic plane (APP) among experienced navigated hip surgeons reflecting negatively on the accuracy of determining the inclination and anteversion angles. Registering the APP in a lateral decubitus position is more challenging in obese patients as palpation of pubic tubercle or anterior superior iliac spines (ASIS) is inconsistent. We propose an alternative and easier novel method in which palpation of the posts (pegs) that stabilizes the pelvis will accurately determine the APP plane. The computer data obtained from peg’s palpation was compared to data obtained from post-operative CT scan of the pelvis in determining acetabular and cup version and inclination angles.

The APP was defined and registered in 40 navigated total hip arthroplasty (THA) patients using our novel method. The patient is securely stabilized in a lateral decubitus position as routine with multiple pegs. One peg is positioned against both ASIS with 2 EKG pads placed on the pegs (each represent an ASIS). The other peg supports the pubic symphysis with one EKG pad representing the pubic tubercle. All efforts are made to make sure that the distance between the EKG nipples and the corresponding ASIS or pubic tubercle is equal before scrubbing and draping of the hip. Registration is achieved afterwards, by touching the nipples of the EKG pads placed on the pegs through the drape while the patient is secured in lateral decubitus position. This way sterility is uncompromised. To test the validity of our method of identifying the APP plane, a post-operative CT scan measurements of cup inclination and version angles were independently observed and the data were compared to our navigation registration method using t-student test analysis.(p=0.05 is significant)

The mean CT-scan cup version was 19.4(S.D. ±6.3), and the mean of APP navigated cup version was 14.2(S. D.±3.1). There was no statistical significant difference (p=0.045). Similarly, there was no significant difference between mean CT scan cup inclination angle of 42.3(S. D.±3.7) and the mean navigated cup inclination of 40.9(S.D.± 4.6), (p= 0.69). Therefore, we conclude that the APP plane can be registered reliably and accurately by simply touching the EKG pads on the pegs and through the drapes. Not to mention, both the cup version and inclination angles were within safety zone of Lewinick.

It seems that the accuracy of measuring the inclination angle through our method, although not significant, is better than the accuracy of measuring the cup version. This emphasizes the point that identifying the pubic tubercle is difficult whichever method of registration is used. However, inaccessibility of ASIS or pubic tubercle during manual APP registration leads to great cup orientation inaccuracies. The readily palpable EKG nipples on the pegs, irrespective of patient’s weight or the thickness of surgical draping, makes this novel technique a reliable and an easier alternative registration method than the manual palpation of APP in navigated THA.


S. Hakki

The purpose of mini-invasive hip arthroplasty is least damage to skin and muscles. Unlike Roettinger modification to Watson-Jones, our approach requires no special table or instruments. Besides, direction of skin incision is perpendicular to interval between glutei and tensor muscles, thus called a Crisscross Approach. Potentially, a cross shape exposure allows a larger view and therefore a lesser damage to skin and muscles during retraction. Skin incision, being in line with the femur (almost parallel), allows expansion of incision proximally and distally. No tendon or muscles are severed achieving a true inter-muscular minimally invasive approach.

After working with 3 cadavers to perfect the technique and with investigation and research board (IRB) approved consent, 40 prospective patients underwent mini-invasive crisscross technique from December 06–June 07 with 6 months follow up. A standard non-cemented hip was implanted. Previously disrupted hip muscles patients were excluded. Patients were positioned in a lateral decubitus with pelvis secured and flexed 20°–30°. Incision started 2 inches inferior and posterior to ipsilateral anterior superior iliac spine (ASIS) extending distally for 3 inches or more for obese or muscular patients. Acetabulum is exposed using curved Hohmann retractors one above and one below femoral neck after excising most of the anterior capsule with releasing the superior and inferior capsule. The femoral neck is osteotomised as routine extracting the femoral head. Then the same curved retractors are placed behind anterior and posterior rim of acetabulum with an optional third curved retractor may be placed at the inferior rim. The acetabulum is reamed with the usual straight reamers and the cup is then implanted as routine. Angled reamers are not necessary as our skin incision is in line with the reamer direction. Femoral neck exposure starts with the surgeon positioned anterior to pelvis. Paralysis of the muscles is confirmed with anesthesiologist and table is tilted 20°–30° posteriorly. Hip is then extended 20°–30°, externally rotated to 80°–90° and adducted with a retractor underneath femoral neck. Another curved retractor is placed gently on greater trochanter to protect glutei. Leg is allowed to drop in a bag. Canal finder and use of box osteotome is helpful to avoid breaching the femoral cortex or varus positioning of the stem. Broaching or reaming and final implant insertion is done as routine. Hip reduction is achieved as routine by reversing the table tilt and bringing the leg forward with traction and internal rotation.

36 out of 38 eligible patients were sent home after their rehab goals were met in 4 therapy sessions (2–3days). Full weight bearing was allowed in 4 weeks. One stem was undersized, two were in slight varus, and total blood loss was less than 5 gm/dl of Haemoglobin at post op day three. No dislocation or complications related to exposure. No neurovascular injury and no re-operation. Surgery time averaged 20 minutes longer mainly at femoral exposure. As experience is gained the time is lessened. Post-operative intravenous morphine pump administration was stopped in 24 hours in 82% of patients after surgery instead of the 48 hour routine.

Crisscross approach differs by transecting no tendon or muscles, requiring no special table or instruments with incision that gives more exposure, allows expansion and reduces skin damage resulting in true non-invasive approach. Exposure of the femur was difficult in the first few cases. Tilting the operating table posteriorly, releasing superior and inferior capsule as has been recommended by previous authors helped femoral exposure. Recovery from surgery in terms of rehab sessions and postoperative pain control were improved compared to our previous standard of care. Long term follow up is under current research investigation.


S. Hakki

Most common complication of non-navigated classic total knee arthroplasty (TKA) relates to patella. Not resurfacing the patella makes exposure more difficult in a mini-approach which may add to its potential complications. Effect of navigated mini sub-vastus TKA on native patella is clinically and radiologically studied, observing also, whether severity of deformity or obesity adds to patellae complications in such approach.

92 of 100 subjects were eligible. Peri-operative radiological and navigation data with follow up visits to 24 months provided alignment, patella tilting or displacement data. Clinical outcome gauged by “KSS” documented pain from patella movements, or pain generated from stair climbing, or rising from a chair. Patella is considered subluxated if it displaced ≥ 5mm. No exclusion by obesity or severity of deformity. Results were evaluated with descriptive statistics.

Of the 92 patients, 3 had patella pain (3%). 72% had < 5° of patella tilting (of which 3 had patella pain) while 28% had a 5°–17° tilting. As for patellae displacement, 12% displaced laterally (≤3 mm) but with no pain. None had patellar displacement ≥ 4mm (which we define as subluxation), and none had a dislocation. Pre-operative knee deformity ranged from 19° varus to 13° of valgus. 70% of subjects had pre-operative varus/valgus deformity of < 10°. The other 30% had deformity of ≥ 10°. Post-operative mean mechanical axis alignment was 0° (± 1°) with a mean range of motion of −3.8° to 133.6°. No vascular injuries, skin necrosis, deep infection, or fractures.

The BMI ranged from 25–46 Kg/m2. 16% had a BMI ≥ 40 with no patellar pain, tilting or displacement.

Incidence of native patella pain in a navigated mini sub-vastus TKA was low irrespective to body mass or pre-operative deformity. Perhaps navigation helped align the components ideally and thus reducing the complication rate of a mini-approach. However, 28% of native patella tilted > 5° but unlike tilting of a resurfaced patella, it did not correlate with patella pain. In this study, whether non-resurfacing caused the 3% of patella pain is undetermined. Nevertheless, the pain level was not severe to make the patients seek a revision of the patella. Finally, as we compare with other studies, we cannot conclude that mini sub-vastus approach is superior; however its low patella complication rate is comparable if not superior to classic approach.


L.M. Longstaff K. Sloan P. Latimer R.J. Beaver

Femoral component malrotation is a major cause of patello-femoral complications in total knee arthroplasty. In addition, it can affect varus/valgus stability during flexion which can lead to increased tibiofemoral wear.

Debate exists on where exactly to rotate the femoral component. The three principal methods utilise different anatomical landmarks: the posterior condylar axis, the transepicondylar axis and the antero-posterior axis (Whiteside’s line).

A prospective randomised controlled trial was undertaken. Sixty consecutive patients undergoing total knee arthroplasty by a single surgeon (LML) at the Royal Perth Hospital were randomised into 3 groups based on the intra-operative method for measuring femoral rotation using the PFC sigma prosthesis (Depuy) with computer navigation (Depuy/Brainlab). All patients received the usual post-operative treatment, rehabilitation and JRAC (Joint Replacement Assessment Clinic) follow up. All underwent a CT scan according to the Perth CT protocol designed specifically to accurately measure component alignment and rotation.

No significant difference in femoral rotation was found between the three groups using a one-way analysis of variance (p=0.67). However, Whiteside’s line had a significantly greater variability than the posterior condylar or transepicondylar axis using the F Test for variances (p=0.02, p=0.03). In conclusion, whilst there was no significant difference in femoral rotation, Whiteside’s line did show greater variability (−6° to 3°), and therefore we recommend the use of either the transepicondylar or posterior condylar axis in Total Knee Replacement.


S. Hakki

The necessity of soft tissue release to achieve a stable, balanced knee in previous publications has a high rate and a wide range of 50–100% of total knee arthroplasties (TKA). This reflects disagreement regarding the determinants for soft tissue release which is partly due to lack of standardized quantitative measures. Recent advances in navigation may standardize and replace conventional methods regarding soft tissue balancing. We propose two navigation predictors that quantitatively determine the least amount of collateral ligament release necessary to achieve a stable neutral knee, thus reducing the frequency of release.

100 patients underwent navigated TKA. Data of 93 were eligible. Preoperative deformity ranged 18°varus −13° valgus. Ratio of Varus/Valgus= 66/27. Ages were 46–85 yrs. Mean BMI= 36Kg/m2

First navigation predictor determines collateral release when varus/valgus deformity is uncorrectable by stress deflection test before tibia resection. Second predictor determines release when delta mediolateral gap > 4mm before femoral resection using a Tensioner with two independent pads.

10 out of 93 cases (10.75 %), required collateral ligament release to achieve a postoperative mechanical axis of 0° (SE±0.11) with a mean mediolateral deflection in extension of 1.43°, and a mean range of motion of −3° to 127° of flexion. First predictor has 98% accuracy. Second predictor has 96% accuracy but their combination had 100% accuracy with no false negative predictions.

Balanced neutral TKA is achieved by soft tissue release, bone resection or as in this study, by adjusted navigated femoral resection (through rotation, size and level of resection) which balanced knees that otherwise should have soft tissue release. Navigation predictors are reliably accurate to quantitatively determine the necessity of soft tissue release to achieve a neutral stable knee with a significantly lower release rate in comparison to non navigated TKA series rate of 50–100%. (p< 0.001) (95% confidence interval).


J.R. Romanowski M.L. Swank

Studies suggest that specialty hospitals and high surgical volume decrease adverse outcomes related to hip arthroplasty. Little is known, however, concerning the influence of imageless computer navigation systems on a surgeon’s experience and subsequent placement of implants in the setting of hip resurfacing arthroplasty.

A retrospective review of 71 consecutive hip resurfacing arthroplasties placed with computer assisted navigation during 2006 and 2007 was performed. Forty-seven operative days encompassing the surgeon’s entire experience with hip resurfacing were analysed. Within this single surgeon series, operative time, intraoperative cup inclination and femoral stem/shaft angles, as well as postoperative cup inclination and femoral stem/shaft angles were measured and compared over three discreet, sequential operative time intervals.

Intraoperative cup inclination angles were comparable to postoperative radiographic values as there was no significant difference (p=.059). Computer assisted navigation produced consistent values despite different levels of surgeon experience in the setting of intraoperative cup inclination (42.8°, 43.5°, and 40.1°) and postoperative cup (46.1°, 43.9°, and 42.9°) and femoral stem (147.9°, 146.5°, and 144.0°) radiographic alignment. A statistically significant difference existed between intraoperative femoral stem/shaft angles compared to postoperative radiographs measurements (p< .001), however, all means maintained a valgus orientation compared to the native neck angle. There was a correlation between evolving surgeon experience and intraoperative stem placement (143.5°, 142.1°, and 138.0°, respectively) despite the mean values remaining well clustered (p< .001). Operative times significantly decreased (p< .001) with surgeon experience, showing the largest decrease after the 1st sequence interval (109.6, 97.8, and 94.8 min, respectively). No femoral notching (0/71) occurred throughout the series.

Computer assisted navigation provides a dependable method of accurate hip resurfacing arthroplasty component positioning as measured by cup inclination, in addition to a reliable technique for valgus stem placement and avoidance of notching. Furthermore, computer navigation allows for consistency and offers a protective effect on component alignment independent of surgeon procedural experience.


J.K. Seon E.K. Song S.J. Park S.G. Cho S.B. Cho T.R. Yoon

The navigation system recently introduced in an ACL reconstruction is reported that it would be helpful for determining the accurate tunnel position and better clinical results in. It also provides intra-operative information such as knee kinematics and anteroposterior translation and internal-external rotation of the tibia during the reconstruction. Our hypothesis was that a double bundle reconstruction would provide better anteroposterior and rotational stabilities than a single bundle reconstruction.

The aim of this study was to assess the changes of anteroposterior and rotational stabilities using a navigation system achieved by double bundle reconstruction (20 knees) and compare them with those by single bundle reconstruction (20 knees).

After registering the reference points, anteroposterior ad rotational stability test with 30° knee flexion using a navigation system was carried out and measured before and after reconstruction on both groups.

The anteroposterior stability showed significant improvement from 17.5 mm before the reconstruction to 5.1 mm after the reconstruction in the double bundle group and from 16.6 mm to 6.1 mm in the single bundle group, showing a significant inter-group differences (p< .05). The mean rotation stability of the double bundle group showed more significant improvement after reconstruction than those of the single bundle group (9.8° in single and 6.1° in double bundle group, p< .05).

The double bundle ACL reconstruction tends to be more stable in rotational stability than the single bundle reconstruction, but not so much in anteroposterior stability. Clinically the double bundle ACL reconstruction may provide better rotational stability reducing residual pivot shift phenomenon after reconstruction.


M. Ganapathi P.A. Vendittoli M. Lavigne K.P. Günther

The aim of our study was to compare the precision and effectiveness of a CT-free computer navigation system against conventional technique (using a standard mechanical jig) in a cohort of unselected consecutive series of hip resurfacings.

One hundred and thirty nine consecutive Durom hip resurfacing procedures (51 navigated and 88 non-navigated) performed in 125 patients were analysed. All the procedures were done through a posterior approach by two surgeons and the study cohort include the hip resurfacings done during the transition phase of the surgeons’ adoption of navigation.

There were no significant differences in the gender, age, height, weight, BMI, native neck-shaft angles, component sizes and blood loss between the two groups. There was a significant difference in the operative time between the two groups (111 minutes for the navigated group versus 105 minutes for the non-navigated group; p=0.048). There were 4 cases of notching in the non-navigated group and none in the navigated group. There were no other intra-operative technical problems in either of the groups nor were there any femoral neck fractures.

No significant difference was found between the mean post-operative stem-shaft angles (138.5° for the navigated group versus 139.0° for the non navigated group, p=0.740). However there was a significant difference in the difference between the planned stem-shaft angle versus the post-operative stem-shaft angle (0.4° for the navigated group versus 2.1° for the non-navigated group; p=0.005). There was significantly more scatter in the difference between the post-operative stem-shaft angle and the planned stem-shaft angle in the non-navigated group (standard deviation = 3.6°) when compared with the navigated group (standard deviation = 0.9°; Levene’s test for equality of variances = p≤0.01). No case in the navigated group showed a post-operative stem-shaft angle of more than 5° deviation from the planned neck-shaft angle when compared to 33 cases (38%) in the non-navigated group (p≤0.001). While only 4 cases (8%) in the navigated group had a postoperative stem-shaft angle deviating more than 3° from the planned stem-shaft angle, this occurred in 50 cases (57%) in the non-navigated group (p≤0.001).

Hip resurfacing is a technically demanding procedure with a steep learning curve. Varus placement of the femoral component and notching have been recognised as important factors associated with early failures following hip resurfacing. While conventional instruments allowed reasonable alignment of the femoral component, our study has shown that use of computer navigation allows more accurate placement of the femoral component even when the surgeons had a significant experience with conventional technique.


R. Russell S. Kendall D. Singh S. Ahir G. Blunn

Scarf osteotomy is widely used as a surgical treatment for hallux valgus. It is a versatile osteotomy, allowing shortening, depression or medial displacement of the capital fragment but it remains uncertain how stresses within the bone subsequently vary. The aim of this study was to design a computerised model to explore the effect on bone stress of changing the position of bony cuts for a scarf osteotomy.

A computerised image was constructed using finite element analysis. This utilises a mathematical technique to form element equations which represent the effect of applied force to the object appropriate to each finite element. Maximum bone stresses were then measured using different osteotomy variables. The osteotomy variables studied were the length of the longditudinal cut, apex of the distal cut to articular cartilage, resection level of the longditudinal cut and combinations of these variables. A saw bone model was used to test the findings of the study.

The results of this study show that lowering the longditudinal resection level and shortening via the distal cut beyond 6 mm will decrease bone stress. Additionally, raising the longditudinal resection level and shortening via the proximal cut caused an increase in bone stress. A saw bone model confirmed the findings of the study.

In conclusion, our experience is that finite element analysis is a very useful model in studying the bony stresses for a scarf osteotomy and assists in optimising the direction and angle of bony cuts used.


J.K. Seon E.K. Song S.J. Park S.G. Cho S.B. Cho T.R. Yoon

Correct alignment of the leg and positioning of the implant has shown to be an important factor in the successful long term outcome of total knee arthroplasty and navigation systems enable an accuracy of corrections and alignment within intervals of 1 mm or 1 degree. This study is to test if there is any discrepancy in accuracy which was sometimes observed in clinical trials between Orthopilot (Aesculap, Tuttlingen, German) and AxiEM (Medtronic Navigation, CoalCreek, Colo., USA).

A synthetic bone model (Sawbones, Pacific Laboratories, Vashon, Washington) including pelvis and leg with mobile joint made up of titanium which does not affect the electromagnetic field was constructed. Mechanical axis was checked by ORTHODOC system (Integrated Surgical System, CA, USA) that is a preplanning system for ROBODOC (ISS, CA, USA) assisted total knee arthroplasty (TKA) and total hip arthroplasty (THA). The CT images were scanned with 1.25 mm or less slice interval. The CT images were converted to 3-dimensional (3D) volume-rendered model in ORTHODOC. Two orthopaedic surgeons measured it ten times independently.

For the measurement of mechanical axis using navigation, 4 orthopaedic surgeons (two experts having more than 100 navigation experiences and two residents) registered anatomical landmarks and kinematic center of bone model ten times using Orthopilot as well as AxiEM. After that, one surgeon intentionally registered the wrong anatomical landmarks (10 mm medial and lateral to the center of distal femur, proximal tibial and ankle, and both malleoli) in both navigation system and observed the change of mechanical axis.

True mechanical axis was varus 1.25° using Orthodoc, Orthopilot displayed varus 1.10±0.64° and AxiEM did varus 1.78±0.79°. The difference of mechanical axis between two navigations was not observed (P=0.12) and there were no intra and inter-observer variation in statistical analysis (Correlation=0.934, P=0.00). In the case of erroneous identification of the anatomical landmarks, Orthipilot showed much less variation compared to AxiEM. AxiEM altered the mechanical axis more in palpating center of the distal femur and ankle center and Orthopilot did in palpating the center of ankle.

Both navigation systems provide high accuracy and reproducibility of mechanical axis of lower limb in experimental condition. But both were affected by the wrong identification of the anatomical landmarks. AxiEM had more variations. So surgeon should pay attention to register the precise anatomical landmarks.


S.G. Cho E.K. Song J.K. Seon S.J. Park S.B. Cho T.R. Yoon

Unexpected findings were sometimes observed such as hyper extension, oversize of femoral component, or anterior notching of anterior femoral cortex in total knee arthroplasty (TKA) using computer system. We conducted this study to evaluate these findings by a virtual simulation using ORTHODOC and then confirmed them on real patients with TKA.

Virtual simulations of distal femoral cut in 50 patients using ORTHODOC system were made by way of being perpendicular to mechanical axis (CAOS way) and to intramedullary guide (manual way) in the same knee and measured the difference of sagittal cutting planes. We compared the maximum AP dimensions of femoral condyle parallel to distal cut plane. We also compared sagittal alignment and size of the femoral component in 30 bilateral TKAs, one side using ROBODOC (CAOS way) and the other side using IM guide (manual way).

On virtual simulation, distal femoral cut was more extended (3.1±1.6°) in CAOS than in manual way and anteroposterior size of the femoral condyle in CAOS way was also larger than in manual way (p=0.001). Radiographic sagittal alignment of femoral component performed using CAOS way was slightly more extended than those using manual way, showing a significant difference (p=0.024). The larger femoral components were required in six patients on CAOS and in two patients on manual way, whereas twenty-two patients showed same size on both side.

CAOS can provide more accurate sagittal cut perpendicular to mechanical axis than manual system, which may lead to slightly extended position or larger femoral component.


S.B. Cho E.K. Song J.K. Seon S.J. Park S.G. Cho T.R. Yoon

In total knee arthroplasty, navigation systems that help achieve accurate alignment of the lower limbs have been applied widely, and these techniques are currently being used in minimally invasive unicondylar knee arthroplasty (MIS UKA) with good alignment results. To the best of our knowledge, there are no studies showing whether or not MIS UKA using a navigation system has a significant influence on the clinical results. This prospective study investigated the hypothesis that minimally invasive uni-compartmental knee arthroplasty using navigation system (NA-MIS UKA) will produce better short-term clinical results than MIS UKA without navigation system.

After a minimum two-year follow-up, the short-term functional results included the ranges of motion, Hospital for Special Surgery (HSS) scores, and WOMAC scores and the alignment accuracy of the components of 31 NA-MIS UKAs (NA-MIS group) compared with those of 33 MIS UKAs without a navigation system (MIS group). The surgery time was also recorded and compared.

The HSS and WOMAC scores showed significant improvement at the final follow-up in both groups, showing no significant inter-group difference (p=0.071, p=0.096, respectively). The ranges of motion also showed significant improvements in both groups, but there was no significant difference between two groups (p=.687). However, the surgery time was longer in MIS group than in NA-MIS group. NA-MIS UKA produces significant improvement in the desired mechanical axis with prosthetic alignment outliers compared with that without the navigation system.

However, at the final follow-up, there were no significant differences in any of the functional parameters between the two groups.


S.B. Cho E.K. Song J.K. Seon S.J. Park S.G. Cho T.R. Yoon

This prospective study was undertaken to compare the clinical and radiological results achieved using navigation assisted minimally invasive (NA-MIS) and conventional (CON) techniques in bilateral total knee arthroplasty (TKA).

Forty-two bilateral patients with a minimum 2-year follow-up who were available for study after NA-MIS TKA were included in this study. Clinical evaluations (ROM, HSS and WOMAC scores) were performed at 3 and 6 months and at 1 & 2 year postoperatively. Patient subjective preferences and radiological accuracies were compared at 1 year postoperatively.

Preoperative HSS scores were 68.5 in the NA-MIS group and 66.5 in the CON group, and these scores improved to 93.6 and 92.5 at 1 year postoperatively, respectively. Knees had a higher average HSS score in NA-MIS group than in the CON group till six months, but not after nine months postoperatively. In terms of WOMAC scores, pain scores in the NA-MIS group were better up to nine months postoperatively, but not at one & 2 year postoperatively, and total WOMAC scores were better up to six months, but not after nine months postoperatively. ROM was comparable in both groups at all times. However, more patients preferred NA-MIS sides than CON sides. Radiological results demonstrated no difference between the mean values of the two groups, although the NA-MIS group contained fewer outliers than the CON group.

NA-MIS TKA results in better functional scores than CON-TKA over the first or nine months postoperatively. However, no differences in any functional parameters were evident at one & two year postoperatively.


J.K. Seon E.K. Song S.J. Park S.G. Cho S.B. Cho T.R. Yoon

The aim of study was to provide normal value of anteroposterior and rotational stability of knee joints using navigation system.

From March 2007 to November 2007, 35 patients (23 men, 12 women) with a mean age of 36.1(16–57) years, who were treated with arthroscopy, without ligament injury of knee were included in our study. We measured amount of anteroposterior displacement and rotation of the knee in 0, 30, 60 and 90 degrees of flexion position using Orthopilot navigation system. All tests were performed by same single surgeon under manual maximal force.

The mean anterior displacement was 3.7±2.0, 6.6±2.2, 5.8±2.0 and 4.7±1.8 mm in 0, 30, 60 and 90 degrees of flexion respectively. The amount of anterior displacement at 30 degree of flexion was significantly larger than those of other degrees. The mean posterior displacement was 2.0±0.5, 2.2±0.4, 2.1±0.4 and 2.0±0.6 at each degree. There was no statistical difference in posterior displacement. The mean internal rotation was 10.3±2.7, 14.6±3.3, 16.2±2.9 and 15.0±4.3 degree at each degree. The amount of internal rotation at 0 degree of flexion was significantly smaller than those of other degrees. The mean external rotation was 8.4±3.4, 16.5±3.3, 13.3±3.8 and 15.0±4.3 degree at each degree. The amount of external rotation at 0 degree of flexion was significantly smallest and that of 30 degree was largest.

In the measurement of laxity using navigation, we could acquire previously mentioned results. The measurement of stability of knee will be useful in diagnosing ligament injury and evaluating degree of postoperative symptomatic improvement.


J.K. Seon E.K. Song S.J. Park S.G. Cho S.B. Cho T.R. Yoon

Bilateral sequential total knee replacement with a Zimmer NexGen prosthesis (Zimmer, Warsaw, Indiana) was carried out in 30 patients. One knee was replaced using a robotic-assisted implantation (ROBOT side) and the other conventionally manual implantation (CON side). There were 30 women with a mean age of 67.8 years (50 to 80).

Pre-operative and post-operative scores were obtained for all patients using the Knee Society (KSS) and The Hospital for Special Surgery (HSS) systems. Full-length standing anteroposterior radiographs, including the femoral head and ankle, and lateral and skyline patellar views were taken pre- and post-operatively and were assessed for the mechanical axis and the position of the components. The mean follow-up was 2.3 years (2 to 3).

The operating and tourniquet times were longer in the ROBOT side (p < 0.001). There were no significant pre- or post-operative differences between the knee scores of the two groups (p = 0.288 and p = 0.429, respectively). Mean mechanical axes were not significantly different in the two groups (p = 0.815). However, there were more outliers in the CON side (8) than in the ROBOT side (1) (p = 0.013). In the coronal alignment of the femoral component, the CON side (8) had more outliers than the ROBOT side (1) (p = 0.013) and the CON side (3) also had more outliers than the ROBOT side (0) in the sagittal alignment of the femoral component (p = 0.043). In terms of outliers for coronal and sagittal tibial alignment, the CON side (1 and 4) had more outliers than the ROBOT side (0 and 2).

In this series robotic-assisted total knee replacement resulted in more accurate orientation and alignment of the components than that achieved by conventional total knee replacement.


S.G. Cho E.K. Song J.K. Seon S.J. Park S.B. Cho T.R. Yoon

Navigation was used to achieve a balanced flexion-extension gap for total knee arthroplasty and it’s 3 years clinical results were reported.

From 112 osteoarthritic knees with varus deformity the flexion and extension gap were measured with distraction of 50 lb/inch using special torque wrench following completion of controlled medial release with guidance of navigation system & tibial bone cut. Distal & AP femoral bony cut were finished according to the data of measurement of flexion-extension gap. After confirmation of the balanced flexion-extension gap by navigation total knee arthroplasty was completed.

The differences between flexion and extension gap varied from case to case, and could be classified into 3 kinds; balanced, tight flexion gap and tight extension gap.

HSS score was 96.7, ROM was 128.5 degree. 39 patients (35%) can have comfortable kneeling 75 patients(67%) can sit with cross leg. Gap technique with navigation could provide excellent clinical results of total knee arthroplasty and 3 classifications of flexion and extension gap should be taken into considerations for balanced total knee arthroplasty


T.R. Yoon E.K. Song J.K. Seon S.J. Park S.G. Cho S.B. Cho

Computer based navigation system improved the accuracy of limb and component alignment and decreased the incidence of outliers. The majority of previous studies were based on the infrared navigation system. We evaluate the availability and accuracy of the electromagnectic(EM) navigation system in total knee arthroplasty

From July 2006 to January 2007, 40 patients (50 TKAs) with osteoarthritis were participated in this study. AxiEM(Medtronics) was used and Nexgen CR(26 cases), and Nexgen CR flex(24 cases) were used. We analyzed the failure mode of navigation (7 cases), operation time and radiologic results (limb and component alignment)

Total registration time was 4 minutes 45 seconds in average (Range : 3 minutes 45 seconds ~ 6 minutes 55 seconds). Failures in clinical applications resulted from non-recognition of EM tracker or paddle by metallic interference in 4 cases and from informational changes during surgery by fixation loss or loosening of the tracker in 3 cases. Radiologically, the mechanical axis changed from −11.2±7.21 (Range : −25.8~3.1) to 1.0±1.25(Range : −2.1~4.0) and 1 case of outlier occurred (valgus 4°). Component alignment is measured as followed: 89.3±1.6° of Theta angle, 89.9±1.5° of Beta angle, 1.8±2.5° of Gamma angle, 86.1±2.9 of Delta angle°. There were no complications related to the EM navigation.

The EM navigation system helped to achieve accurate alignment of component and lower leg axis without any complications. It had several advantages such as relatively less invasiveness in fitting small instruments, not disturbing operation field, no interrupted line of sight, portable use, and applicability to any implant. However, metallic interference may be still problematic.

The EM navigation had advantages; less invasiveness, no disturbing operation field, no interrupted line of sight, portable use and applicability to any implants. But metallic interference may be still problematic.


J. Baines A.H. Deakin F. Picard

Computer assisted total knee arthroplasty (TKA) is still a relatively novel technique. Surgeons wishing to adopt any new practice undergo a learning curve. The learning curve experienced with navigated TKA, its duration and cost in terms of complications, has not been well defined in the literature. Therefore we set out to analyse the learning curve of a newly appointed consultant with no previous experience of navigated TKA by using a surgeon who has completed over 1000 TKAs in over 10 years of experience with this technique as a baseline.

The study used the inexperienced surgeon’s first ever fifty navigated TKAs and the experienced surgeon’s most recent fifty TKAs over the same period in the same theatre using the same CT free navigation system (Orthopilot®) and prosthesis. Operative time, bone cuts and limb alignment before and after prosthesis implantation were recorded, along with the navigation specific difficulties and complications encountered by the inexperienced surgeon.

There was no statistical difference in the accuracy of postoperative limb alignment in either the coronal (p = 0.33) or sagital (p = 0.35) planes between the novice and experienced surgeon. There was also no difference in the executed bone cut angles (tibial p = 0.79, femoral p = 0.92). The operating time showed a difference between the two surgeons with the novice having a median of 80 mins (inter-quartile range of 20 mins) and the experienced surgeon had a median of 70 mins (inter-quartile range of 20 mins), p = 0.001. However there was a statistically significant reduction in operating time between the inexperienced surgeon’s first twenty and last twenty TKAs (p = 0.001). Comparison of the last 20 TKAs for each surgeon showed no difference in the operative time (medians of 70 mins and 75 mins respectively, p = 0.945). The navigation specific difficulties and complications recorded for the novice navigator were all related to the trackers: one loosening, one tibial tracker placed too proximally, one superficial infection in a tibial tracker wound and one incompletely engaged pin-tracker coupling which brought about the only conversion to manual TKA in this series.

We conclude that in terms of execution and outcome, a beginner using computer assisted TKA can match the results of an experienced navigator from the outset. The only parameter assessed that underwent a clear learning curve was the operative time, which took approximately 20 procedures to approach the same as the experienced surgeon.


S.J. Park E.K. Song J.K. Seon S.G. Cho S.B. Cho T.R. Yoon

Only limited data exists concerning outcomes after total knee arthroplasty (TKA) using a surgical robot. We conducted this study to evaluate the clinical and radiographical results in robotic-assisted implantation of TKAs with a minimum follow-up of two years.

A total of 50 primary TKAs using ROBODOC were included in this study. The mean duration of follow-up was 28.3 months. The radiographic measurement with regard to the change of mechanical axis, and the inclination of the femoral and tibial components were assessed. The value within ± 3° of optimum was classified to be “acceptable”, and the value exceeding more than ± 3° to be “outlier” results. Also we evaluated clinical results with the range of motion (ROM), Hospital for Special Surgery (HSS) scores, and Western Ontario and McMaster University (WOMAC) scores.

The mechanical axis was changed from 6.57 varus to 0.81 valgus. Mean coronal inclination of the femoral and tibial component were 88.61 and 89.76 at the last follow up. Also, mean sagittal inclination of the femoral and tibial component were 0.82 and 85.49. On the other hand, all prostheses had no radiolucent lines. On the clinical assessment, the range of motion improved from 124.9 to 128.4, and the improvement of HSS score and Womac score were 70.06 to 95.72 and 65.64 to 28.92 in each. No major adverse events related to the use of the robotic system have been observed. However, one case of the formation of seroma around the pin track and two cases of the partial abrasion of patellar tendon occurred in relation to procedures.

A surgical robot system in TKAs provides good clinical and radiographical results at least 2 years follow-up, however further study for the long term follow-up may be needed. A clear advantage of robot-assisted TKA seems to be ability to execute a highly precise preoperative planning and intraoperaive procedures. But current disadvantages such as increased operating times and inability of adjusting the preoperative planning during the procedure have to be resolved in the future.


R.B. Abu-Rajab A.H. Deakin M. Kandasami M. Sarungi F. Picard A.W.G. Kinninmonth

Short leg radiographs remain the standard radiographs available in many UK hospitals. The aim of this study was to see if these radiographs are reliable when assessing the post-operative alignment of total knee arthroplasty in comparison to a Hip-Knee-Ankle (long leg) radiograph.

Twenty consecutive 6 week post-operative long leg radiographs, taken with a standardised protocol, and a short leg radiograph derived from the same digital image were each examined on two separate occasions by two observers. On the long leg radiograph the anatomical and mechanical axis were calculated and on the short leg radiograph the anatomical and surrogate mechanical axis were calculated. These data were used to investigate intra- and inter-observer error. A single observer also collected the same measurements on an additional 30 radiographs (total of 50) to further investigate any patterns of error.

On long leg radiographs, intra-observer agreement was good for both anatomical and mechanical axis for both observers (Intraclass Correlation Coefficients [ICC] of 0.95 to 0.98). The anatomical axis on short leg radiographs was also good (ICC = 0.92 and 0.76). Intra-observer agreement for the short leg radiograph derived mechanical axis was not as consistent (ICC = 0.73 and 0.56). Inter-observer variability was good for long leg radiographs for both anatomical (ICC = 0.89) and mechanical (ICC = 0.95) axis. On short leg radiographs, however, agreement was not as good, in particular for the mechanical axis (ICC = 0.51), but also the anatomical (ICC = 0.73). Taking the long leg radiograph values as the “gold standard” there was a difference in the magnitude of errors seen on short leg radiographs dependant on the knee alignment. Varus aligned knees (n=24) had an average error of 1.2° (0° to 3°) for the anatomical axis and 1.6° (0° to 4°) for the mechanical axis. Perfectly aligned knees (n=8) had an average error of 3.0° (1° to 6°) for the anatomical axis and 2.9° (1° to 5°) for the mechanical axis. Valgus aligned knees (n=18) had an average error of 3.4° (0° to 8°) for the anatomical axis and 5.8° (2° to11°) for the mechanical axis. Using a Mann-Whitney test the magnitude of error was greater for valgus knees for both anatomical (p< 0.0001) and mechanical (p< 0.00001) axes when compare to varus knees. Interestingly all except one knee measured on the long leg radiograph as valgus aligned appeared to be in varus on the short leg radiograph.

In conclusion, short leg radiographs are inadequate to make any comment on leg alignment in total knee arthroplasty. This is most pronounced in a valgus aligned knee.


S.J. Park E.K. Song J.K. Seon S.G. Cho S.B. Cho T.R. Yoon

Long term successful results of high tibial osteotomy (HTO) strongly depend on the degree of correction, and inadequate intraoperative measurements of the leg axis can lead to under or over correction, and surgeons have to solve these problems based on personal experience.

This study was undertaken to investigate and compare the clinical and radiological results of navigation assisted open wedge high tibial osteotomy (HTO) versus conventional HTO at 12 months after surgery, for unicompartmental gonarthrosis.

Forty navigated open HTOs with an anterior opening gap of approximately 70% of the posterior gap were included and compared with forty open HTOs performed using the conventional cable technique in terms of intraoperative leg axis assess.

Navigated HTOs corrected mechanical axes to 2.9° valgus (range 0.5–6.2) with few outliers (12.5%), and maintained posterior slopes (7.9±2.3° preoperatively and 8.3±2.8° postoperatively) (P> 0.05). However, in the conventional group, only 63% of cases were within the satisfactory range (valgus 2–5°), and tendencies toward undercorrection and an increase in posterior slope were observed. Clinically both groups showed satisfactory results.

Navigated HTO significantly improved the accuracy of postoperative mechanical axis and decreased correction variabilities with fewer outliers.


S. Martelli F. Iacono S. Zaffagnini S. Bignozzi N. Lopomo D. Casino M. Marcacci

Total knee arthroplasty (TKA) is actually a satisfactory technique to reduce pain and enhance mobility in osteoartritic pathologies (OA) of the knee. However, life of the implant is strictly dependent on restoration of correct knee kinematics, as alteration of motion pattern could led to abnormal wear in prosthetic components and also damage soft tissues. The aim of our study was to evaluate new kinematic tests to be performed during surgery in order to improve the standard intra-operative evaluation of the outcome on the individual case. We used Kin-Nav navigation system to acquire anatomic and kinematic data, which were analysed by a dedicated elaboration software developed at our laboratory. Ten patients undergoing rotating platform cruciate substituting TKA were considered for this study. Immediately before the implant and immediately after component positioning, the surgeon performed 3 complete knee flexion imposing internal tibial rotation (IPROM) and 3 complete knee flexion imposing external tibial rotation (EPROM). Tibial rotation during IPROM and EPROM tests was plotted in function of flexion (in the range 10°–110°). Repeatability of IPROM and EPROM was tested by calculating ICC (Intra-class Correlation Coefficient) between 3 repeated curves. Distance between IPROM curve and EPROM curve was computed at various degree of flexion. Maximum distance obtained during all range of flexion before and after the implant were compared by Student’s t-test (significant level p=0.05).

ICC for repeated motions were 0.99 for IPROM and 0.98 for EPROM. Maximum distance between tibial rotation in IPROM and EPROM was 27.82±6.98 before implant and significantly increased (p=0.001) to 40.09±6.92 after TKA. In one case we observed that the value remained similar before and after implant (from 33.11 to 33.98) while in one case we observed very large increase of rotation (from 30.56 to 50.01).

The proposed kinematic tests were able to quantify the increase of tibial rotation after TKA implant. Future development of the study are encouraging and will include a larger sample and reflections on individual findings.


K. S. Leung

In orthopaedic trauma surgery, X-ray fluoroscopy is frequently employed to monitor fracture reduction and to guide surgical procedures where implants are inserted to fix the fractures. Fluoro-navigation is the application of real-time navigation on intraoperatively acquired fluoroscopic images to achieve the same goals. The theoretical advantages of fluoro-navigation are:

Minimising exposure to X-ray on surgeons, operating room personells and patients,

Accurate positioning of implants,

Expanding the application of minimally invasive surgery,

Shortening the operation time

Fluoro-navigation is particular indicated in orthopaedic trauma as the fracture fragments are mobile and the orientations are not fixed before surgery. At this time, many procedures that require intraoperative fluoroscopic control can now be done with fluoro-navigation. These procedures include:

Fixation of femoral neck fractures with percutaneous cannulated screws,

Intramedullary locked nails for long bone fractures,

Intramedullary fixation of trochanteric fractures

Percutaneous fixation of sacro-iliac fractures dislocations

Percutaneous fixation of iliac wing fractures

Percutaneous fixation of acetabulum fractures

Insertion of Ilizarov tension wires for complex articular fractures

Many percutaneous fixation procedures that need fluoroscopic controls

Since 2001, we have been using fluoro-navigation orthopaedic trauma surgery. 535 different procedures of operative treatment of fractures were carried out. These operative procedures included. Operation, amount, success rate:

Femoral neck fractures, 65, 100%, Gamma nailing, 172, 100%, Femoral locked nails, 77, 98.5%, Tibial locked nails, 53, 100%, Sacro-iliac screws, 45, 95.1%, Pelvic acetabular fractures, 29, 96.1%, Ilizarov tension wires, 13, 100%, Percutaneous screws, 18, 100%, Distal locking without X-ray, 15, 100%, 3-D Navigation, 48 92.7%.

Our clinical experience has confirmed the advantages and the extended applications of this technique benefited many of our patients by enhancing minimally invasive technique in orthopaedic trauma surgery, better implant position and significantly decreasing the radiation of the fluoroscopy (p< 0.05). We have modified the operative procedures in order to adapt better with the fluoro-navigation procedures. We also worked with the industrial partners to design specific instruments as well as modified the existing surgical instruments to facilitate the fluoro-navigation procedures. Most of the failure were due to poor quality fluoro-images, unstable operating system and poorly adapted surgical instruments in the early phase of the applications.

Further improvement is expected in the system on the hardware and software for quicker image acquisition with improved quality, accurate and precise registration, increase interactivities and adaptation of surgical instruments as well as implants. There is a great need for the development of dedicated surgical instruments for orthopaedic trauma sugary in line with the further improvement of the navigation system. With the establishment of image libraries for implants and skeleton, further minimising the need for standard fluoroscopy will be possible. The combination of 3-D fluoroscopy and the navigation will improve percutaneous fixation of articular fractures. At the time, it is only possible to navigate the images obtained during the operation after fracture reduction or manipulation is completed. The possibility to navigate on each individual fracture fragment will extend the technique even more to real-time fracture reduction.

The fluoro-navigation system will also play an important role in surgical training as well as assessment in the virtual surgical environment. We also developed specific training models for fluoro-navigation for preoperative training and practice of standard procedures. This will help to promote further application of fluoro-navigation in orthopaedic trauma.

The recognition of its clinical significance will help to stimulate more research and thus encourages industries to devote more resources in the development of fluoro-navigation for orthopaedic trauma.


J. Ilyas A.H. Deakin C. Brege F. Picard

Flexion contracture is a common deformity encountered in patients requiring total knee arthroplasty (TKA). Both the soft tissue envelope and articular bones are involved in the knee extension lag. A few studies in the past have assessed the relationship between bone cuts and extension deficit by using goniometers and rulers. Using navigation for TKA enables the accurate measurement of knee flexion contracture and bone cuts. The aim of this study was to try to establish a relationship between extension lag correction and the size of bone cuts made.

One hundred and four continuous TKA were completed by a single consultant using the OrthoPilot® (BBraun, Aesculap) navigation system and Columbus implants. Seventy-four knees had preoperative flexion contracture (including neutral knees) while 30 were in hyperextension. Data was recorded prospectively using the navigation system. These included preoperative flexion and extension angles, actual bone cuts of tibia and femur (both medial and lateral), postoperative correction of flexion and extension angle, size of the prosthesis with thickness of polyethylene and soft tissue release. Of the 74 knees with fixed flexion, 57 had no release and 13 had a posterior release (four had an intermediate release and were excluded from the study).

For knees with fixed flexion (n = 70) there was a significant statistical difference between the pre and post implant extension angle (p < < 0.0001). There was no correlation between the thickness of bone cuts and postoperative extension lag either for the group with no release (p = 0.495) or posterior release (p = 0.516). There was also no correlation between bone cuts and preoperative angles for either type of release (p = 0.348 and p = 0.262). There was a significant difference between the preoperative extension deformity for the two soft tissue releases performed (p = 0.00019), the mean fixed flexion angles being −4.4° and −10.4° for no release and posterior release respectively.

Flexion contracture deformity in TKA can theoretically be solved in two ways: either by extensively releasing the soft tissue or by increasing the extension gap by cutting more bone (logically the distal femur). Appropriate soft tissue management and release in TKA is crucial in balancing the prosthesis in the coronal as well as the lateral plane. This study seems to confirm the supremacy of soft tissue management and release over bone cut resection. Cutting more or less bone could in fact lead to a poorer outcome as this will change the joint line level without having any additional beneficial effect in correcting the flexion contracture. Conversely adequate soft tissue release has corrected the flexion contracture when needed. In conclusion, there was no correlation between bone cut resection and extension lag correction and with large extension deficits, a posterior soft tissue release and osteophytes resection was more important than bone cuts.


D. Casino S. Martelli F. Iacono S. Zaffagnini N. Lopomo S. Bignozzi M. Marcacci

Information on knee kinematics during surgery is currently lacking. The aim of this study is to describe intra-operative kinematics evaluations during uni-compartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) by mean of a navigation system. Anatomical and kinematic data were acquired by Kin-Nav navigation system and analysed by a dedicated elaboration software developed at our laboratory. The study was conducted on 20 patients: 10 patients undergoing mini-invasive UKA and 10 patients undergoing posterior-substituting-rotating-platform TKA. In both group of patients the surgeon performed passive knee flexion immediately before and immediately after the prosthetic implant. Pattern and amount of internal/external tibial rotation in function of flexion were computed and significant changes between before and after implant were evaluated adopting Student’s t-test (significant level p=0.05).

UKA implant did not significantly change the pattern of internal/external tibial rotation, nor the total magnitude of tibial rotation (15.75°±7.27°) during range of flexion (10°–110°), compared to pre-operative values (17.87°±7.34°, p=0.25). Magnitude of tibial rotation in TKA group before surgery (8.00°±3.67°) was significantly less compared to UKA patients and did not changed significantly after implant (5.96°±4.88°, p=0.09). Pattern of rotation before and after TKA implant were different between each other and between pattern in UKA patients both before and after implant.

Intra-operative evaluations on tibial rotation during knee flexion confirmed some assumptions on knee implants from post-operative methods and suggest a more extensive use of surgical navigation systems for kinematic studies.


P. Kumar J. Ilyas D. Young F. Picard

Flexion contracture in total knee arthroplasty (TKA) remains a challenge. Soft tissue management and additional bone resection are traditional options for flexion contracture correction. Our hypothesis was that the post implant computer aided measurements would not be significantly different to the extension angles measured at six weeks post-operatively in the follow-up clinic.

One hundred continuous TKA were performed by a single consultant using the OrthoPilot® (BBraun, Aesculap) navigation system and Columbus implants. Of the group, 45 were male and 55 were female. Average age was 68 (range 49–87), mean BMI was 32.86 (22.26–51.86) and mean Oxford score preoperatively was 42 (range 21–56) and post-operatively 28 (range15–50). Data recorded at the preoperative assessment clinic included clinical flexion contracture and Oxford scores. Intra-operatively data were recorded using the navigation system. These included pre-operative flexion and extension angles, actual bone cuts of tibia and femur (both medial and lateral), postoperative correction of flexion and extension angles and soft tissue releases. At six weeks post operation, patients were seen in the follow clinic and clinical flexion contracture and Oxford score reassessed by the Arthroplasty outcome service.

Measurements were grouped and comparisons were made using a Pearson Chi-square test. There was no relationship between post-implant extension angle measurements (by computer) and extension angles at six weeks (by goniometer) (p=0.682). Also, there was no relationship between pre-operative measurement angles collected at the pre-assessment (by goniometer) and the pre-implant angles measured on the table (by computer) (p=0.682). We found that BMI (up to 35) and postoperative Oxford scores were significantly related to the extension levels with values of (p=0.008) and (p=0.027) respectively. Pre-operative Oxford scores, pre-operative extension, amount of bony resection and soft-tissue releases did not show any significant relationship with the post-operative extension obtained at six weeks.

The conclusions that we draw from this study are that there might be other factors that are likely to influence extension lag between the operation and the follow-up at six weeks. One of the factors that we could identify was the BMI. Attention to extensor lag is important because it leads to a poorer knee function, as indicated by the Oxford scores. Despite most of the post-implant measurement angles showing no extensor lag, about 20% of our patients still had more than five degrees flexion contracture at six weeks.


P. Basanagoudar A.H. Deakin A. Vijayan J. Baines A. Gregori F. Picard

Computer assisted total knee arthroplasty (TKA) enables the measurement of the dynamics of the knee both before and after the implant of the prosthesis. Much time has been spent looking at the outcomes of navigated TKA however less time has been invested on understanding how the data collected pre-operatively can inform the surgeon and help the surgical decision making process. The aim of this work was to use navigation as a tool to quantify and classify preoperatively valgus knees.

Between August 2006 and September 2007 a group of 51 patients who demonstrated intra-operative initial neutral or valgus aligned knees underwent navigated TKA using the Columbus knee prosthesis and the Orthopilot® navigation system (BBraun, Tuttlingen, Germany). Demographic data were recorded, along with the preoperative radiograph appearance and clinical assessment of alignment. During the surgery the approach used and the knee mechanical femorotibial (MFT) angle though the range of flexion were recorded. The knees were then categorised as either “True” valgus or “False” valgus based on whether the MFT angle at 30°, 60° and 90° flexion was still valgus (True) or had gone into varus (False).

Five patients were excluded from the study group as they had incomplete data in knee flexion. Of the remaining 46 patients, 28 were True valgus and 18 were False valgus. For the two groups demographic data were compared. Male to female ratio was 9:19 for the True valgus and 4:14 for the False valgus. The mean age of the True group was 70 years (range 52–85 years) and the False was 69 years (range 53–84 years). For BMI the True group had mean of 31 (range 20–40) and False of 33 (range 26–42). Twenty-five of the 28 True valgus knees showed preoperative evidence of clinical genu valgum deformity and radiologic evidence of predominantly lateral compartment osteoarthritis. Five patients had ipsilateral hip replacements in the past and five had rheumatoid arthritis. Seventeen were operated by lateral parapatellar approach. Eighteen required ilio-tibial band release with additional lateral collateral ligament release in five knees. Six true valgus knees did not require any soft tissue release. Five patients required lateral retinacular release to achieve thumb free patellar tracking. The median operating time for the True valgus group was 80 mins. Ten of the 18 false valgus knees showed evidence of clinical varus deformity and radiological evidence of predominantly medial compartment osteoarthritis. Only one patient had an ipsilateral hip replacement in the past and one had rheumatoid arthritis. All 18 knees underwent TKA by medial parapatellar approach, requiring no additional soft tissue release in 17 knees and a moderate release in one knee. The median operating time for the False valgus group was 60 mins.

True valgus knees had more significant deformities clinically and radiologically, longer surgical time and more incidence of soft tissue release when compared to the False valgus knees. False valgus knees behaved like varus knees clinically, radiologically and intra-operatively and should therefore be treated as such when making surgical choices.


W. Dandachli A. Nakhla F. Iranpour V. Kannan J.P. Cobb

Although acetabular centre positioning has a profound effect on hip joint function, there are very few studies describing accurate methods of defining the acetabular centre position in 3D space. Clinical and plain radiographic methods are inaccurate and unreliable. We hypothesize that a 3D CT-based system would provide a gender-specific scaled frame of reference defining the hip centre coordinates in relation to easily identifiable pelvic anatomic landmarks.

CT scans of thirty-seven normal hips (19 female and 18 male) were analysed. The ratios of the hip centre coordinates to their corresponding pelvic dimensions represented its horizontal (x), vertical (y), and posterior (z) scaled offsets (HSO, VSO, and PSO).

The mean HSO for females was 0.08 ± 0.018, mean VSO was 0.35 ± 0.018, and mean PSO was 0.36 ± 0.017. For males HSO averaged 0.10 ± 0.014, VSO was 0.32 ± 0.015, and PSO was 0.38 ± 0.013. There was a statistically significant gender difference in all three scaled offsets (p=0.04, 0.002, and 0.03 for HSO, VSO, and PSO respectively). Inter-observer agreement tests showed a mean intra-class correlation coefficient of 0.95.

We conclude that this frame of reference is gender-specific giving a unique scale to the patient and allowing reliable derivation of the position of the hip centre from the pelvic dimensions alone. The gender differences should be borne in mind when positioning the centre of a reconstructed hip joint. Using this method, malpositioning, particularly in the antero-posterior (or z) axis, can be identified and addressed in a malfunctioning hip replacement. Pathological states, such as dysplasia and protrusio, can also be accurately described and surgery addressing them can be precisely planned.


J.V. Clarke A.H. Deakin F. Picard A.C. Nicol

The role of CAOS systems is now well established in several areas of orthopaedic surgery. The increasing use of these systems, particularly in knee arthroplasty, has been supported by clinical trials that demonstrate a more accurate final position of implanted devices compared with conventional instrumentation. CAOS technology is constantly evolving along with its expanding list of potential indications. This requires the adaptation of both software and hardware components. It is therefore essential that potential users have confidence in the accuracy of these systems. The aim of this project was to design and manufacture a standardised measurement object (phantom) to independently evaluate CAOS system performance.

The American Society for Testing and Materials (ASTM) International along with CAOS International recently drafted a standard for measuring technical accuracy of navigation systems. This proposed standard was obtained and its recommendations used to design a phantom model. This consisted of a 150×150×20mm base plate and two additional levels including a single 30° slope. This created a 3D surface on which points could be placed. Co-ordinates for 21 points were given to establish the x, y and z axes of a Cartesian system and then to have points at a variety of known locations in this 3D space. The final model was machined from a billet of marine grade aluminium alloy 6082-T6 (chosen for its dimensional stability) using a vertical computer numerical controlled (CNC) milling machine with the co-ordinate points drilled with a Ø0.8mm 60° BSO centre drill to a depth of 1.2mm. The drill holes, with chamfers of Ø1.0mm, were designed to accommodate a ball-nosed pointer tip of a known diameter. A Perspex base unit with three different sites of rigid tracker attachment was made to hold the phantom and provide its reference frame. This avoided the need to directly modify the phantom itself.

The final design has been used to measure the positional accuracy of a novel portable navigation system and demonstrate that it is not yet suitable for clinical evaluation due to errors of 1 – 6 mm in point location. It has also allowed independent technical validation of current pre-existing navigation systems.


M. Ganapathi P.A. Vendittoli M. Lavigne

Background: Leg length equality and femoral offset restoration are important parameters related to success of total hip arthroplasty (THA). However, it is not uncommon for errors to occur during surgery which can lead to less optimal functional result and potential source for litigation. Several techniques that are commonly used to assess leg length and femoral offset during THA include pre-operative templating, intra-operative measurements with a ruler using bony landmarks, assessing soft tissue tension and using measurement device with a reference pin in the iliac crest. We have previously reported on our precision to reconstruct the diseased hip with THA done without navigation. Post-operative radiographic analysis demonstrated that leg length was restored to within +/− 4mm of the contralateral side in only 60% of the patients with 4 patients needing a shoe lift. With regards to femoral offset reconstruction, it was increased by a mean of 5.1 mm and restored to within +/− 4mm of the normal contralateral side in only 25% of patients.

Computer navigation has proven to be a more precise tool to achieve optimal positioning of THA implants and precise biomechanical reconstruction of the hip joint. However, performing complete THA using navigation is complex including the requirement to change the position of the patient during registration. A recent stand-alone CT-free hip navigation software from Orthosoft Inc allows navigation to be used for limb length and offset measurements during THA. We report our results from a preliminary study using this technique in 14 hips undergoing THA.

In this technique, a tracker is placed over the iliac crest. There is no need to fix a tracker on the femur. Registration of the following are done: greater trochanter (using a screw), patella (using an ECG lead) and the plane of the operating table (using three points on the surface of the operating table in a triangular configuration). The centre of rotation of the hip is determined by either mapping the acetabulum or by using the appropriate sized calibrated reamer. With the definitive acetabular component in place, the new center of rotation is registered and the hip is reduced with trial femoral component. Re-registration of the new position of the greater trochanter and patella allows the computer to calculate the relative change in the limb length and offset compared to the pre-operative status. The differences in the pre-operative and post-operative limb length and offset were calculated using Imagika software and compared with the navigated values recorded by the computer.

The mean absolute error for the relative change in the limb length as measured by the computer when compared to the radiographic measurement was 1.25 mm with a standard deviation of 1.77 mm. The mean absolute error for the relative change in the offset as measured by the computer when compared with the radiographic measurement was 2.96 mm with a standard deviation of 2.56 mm. The process of navigation was quick and on average adds 10 minutes to the operative time.

Our preliminary study shows that the accuracy of the navigation software is very good in estimating the change in the limb length intra-operatively with a maximum error of 3 mm. The accuracy was also good in estimating the offset (3 mm or less except in one case where the error was 5 mm and this may be due to technical error in registration). This compares favorably with our own data on THA done without navigation. This easy to use navigation technique has the potential to decrease the magnitude of error in restoration of limb length and offset during THA.

We thank Francois Paradois and Michael Lanigan from Orthosoft Inc. for their technical advice.


H. Dixon W. Dandachli F. Iranpour V. Kannan J.P. Cobb

The rotational alignment of the tibia is an as yet unresolved issue for arthroplasty surgeons. Functional variation may be due to minor malrotation of the tibial component. The aim was to find a reliable method for positioning the tibial component in arthroplasty.

CT scans of 21 knees were reconstructed in three dimensions and oriented vertically. A plane was taken 20 mm below the tibial spines. The centre of each tibial condyle was calculated from points taken round that condylar cortex. A tibial tubercle centre was also generated as the centre of the circle that best fit points on the surface of the tubercle in the plane of its most prominent point.

The derived points were identified by three observers with errors of 0.6 – 1mm. The medial and lateral tibial centres were constant features (radius 24mm ± 3mm, and 22mm ± 3mm respectively). An ‘anatomic’ axis was created perpendicular to a line joining these two points. The tubercle centre was found 20mm ± 7mm lateral to the medial tibial centre. Compared to this axis, an axis perpendicular to the posterior condylar axis was internally rotated by 6° ± 3°. An axis based on the tibial tubercle and the tibial spines was also internally rotated by 6° ± 10°.

We conclude that alignment of the knee when based on this ‘anatomic’ axis is more reliable than either of the posterior surfaces. It is also more reliable than any axis involving the tubercle, which is the least reliable feature in the region. The ‘anatomic’ axis can be used in navigated knee arthroplasty for referencing the rotational alignment of the tibial component.


K. Brust V. Khanduja W. Dandachli F. Iranpour J. Henckel A. J. Hart J.P. Cobb

Radiological measurements are an essential component of the assessment of outcome following knee arthroplasty. However, plain radiographic techniques can be associated with significant projectional errors because they are a two-dimensional (2D) representation of a three-dimensional (3D) structure. Angles that are considered within the target zone on one film may be outside that zone on other films. Moreover, these parameters can be subject to significant inter-observer differences when measured. The aim of our study therefore was to quantify the variability between observers evaluating plain radiographs following Unicompartmental knee arthroplasty.

Twenty-three observers, made up of Orthopaedic Consultants and trainees, were asked to measure the coronal and sagittal alignment of the tibial and femoral components from the post-operative long-leg plain radiograph of a Unicompartmental knee arthroplasty. A post-operative CT scan using the low dose Imperial knee protocol was obtained as well and analysed with 3D reconstruction software to measure the true values of these parameters. The accuracy and spread of the pain radiographic measurements were then compared with the values obtained on the CT.

On the femoral side, the mean angle in coronal alignment was 1.5° varus (Range 3.8, SD 1, min 0.1, max 3.9), whereas the mean angle in sagittal alignment was 8.6° of flexion (Range 7.5, SD 1.5, Min 3.7, Max 11.2). The true values measured with CT were 2.4° and 11.0° respectively. As for the tibial component, the mean coronal alignment angle was 89.7° (Range 11.6, SD 3.3, Min 83.8, Max 95.4), and the mean posterior slope was 2.4° (Range 8.7, SD 1.6, Min -2, Max 6.7). The CT values for these were 87.6° and 2.7° respectively.

We conclude that the plain radiographic measurements had a large scatter evidenced by the wide ranges in the values obtained by the different observers. If only the means are compared, the plain radiographic values were comparable with the true values obtained with CT (that is; accuracy was good) with differences ranging from 0.3° to 2.4°. The lack of precision can be avoided with the use of CT, particularly with the advent of low-dose scanning protocols.


M. Pink M. Lisý T. Pink M. Janecek

To evaluate short term results of 126 computer assisted unicompartmental knee arthroplasty (UKA) with ligament balancing.

Between September 2003 and November 2007 we performed 126 computer asssited surgery UKA Preservation. We using kinematic navigation Ci system. This is cemented system with mobile or fixed bearing. Our groups included 72 women and 54 men. Average age at surgery was 71,2 years. The indication for UKA include primary or postraumatic osteoarthritis limited to one compartment, a functional anterior cruciate ligament, no inflamatory disease. In all cases was only medial femorotibial osteoarthritis. Arthroscopic partial medial menisectomy was performed in 25 cases. Approach: medial parapatellar arthrotomy. Clinical evaluation was performed by Hospital for Special Surgery knee scoring system (HSS). Imaging: AP,lateral and stress X-rays.

The average HSS score was 57 point (range, 40–79 points) preoperatively and 94 points (range 62–100 points) postoperatively. 90% patients were classified as excellent or good using the HSS. The average range of motion before surgery: S 0-0-120 gr., 6 days after surgery S 0-0-110 gr. and 3 months after surgery S 0-0-125 gr.

No significant difference in maximum flexion was seen between the preoperative and postoperative values. There were no infection, fracture of tibia plateau, poor pain, or sign of patellar impingement.

UKA together with modern design, reproductible instrumentation and kinematic navigation can eliminate the previous cause of early failures, contralateral tibiofemorial degeneration and tibial loosening. The patient’s selection must be strict regarding (the ideal patient more than sixty years old, low Body Mass Index, low demand of physical activity). Kinematic navigation reduces the possibility of surgeon’s mistake, alignement of the femoral and tibial component, resection level, soft tissue balancing. It increases the accuracy of the comoponent position, especially in the side of the tibia. A continued long term follow-up is necessary to evaluate polyethylene wear after 10 years.


M. Pink M. Lisý T. Pink M. Janecek

To evaluate first short term results of the 82 Articular Surface Replacements (ASR) of the hip joint with kinematic navigation.

Between March 2006 and March 2007 we performed 82 resurfacings of the hip. In all cases we used Articular Surface Replacement of the Hip joint (ASR-DePuy) with kinematic navigation (Ci system). Our group included 47 women and 35 men. Patients’ mean age at surgery was 68.2 years. The indication for resurfacing was just primary osteoarthritis. Clinical evaluations were conducted using the Harris Hip Scoring system. Imaging studies: AP, axial X-rays.

Patients were followed for an average 12 months postoperative (7–20 months). The average postoperative Harris Hip Total Score was 97%, and 98% of the patients were in the good to excellent range of 80–100 points. No patients were lost to follow-up. We noted a greater range of movement, faster postoperative rehabilitation and shorter time of hospitalization compared with traditional total hip arthroplasty. There were no cases of neurological complication, deep infection, wound dehiscence or dislocation. All X-rays refer correct position of femoral component in both projections. Our experiences with Articular Surface Replacement of the Hip Joint (ASR-DePuy) powered by Ci navigation system are good, but long term followup will be continued.

Articular Surface Replacement of the Hip Joint with modern design, reproductible instrumentation and kinematic navigation can eliminate the previous cause of early resurface failures and loosening. The patient selection must be strict regarding. The kinematic navigation define precise position of the components of ASR. A continued long term follow-up is necessary after minimum 10 years.


S. Darmanis P. Schranz A. Toms K. Eyres

There are many reports in the literature about the benefits of computer-aided surgery with regards to improved limb alignment, reduced blood loss and embolic events but surgeons remain sceptical about its routine use because of availability, cost and time implications. To maximise these benefits and overcome the distractions, a modified navigation technique has been developed after evaluation of the standard measurements.

The true varus/valgus angle of the distal femoral cut achieved with navigation is unknown but represents presumed accurate alignment with regards to the mechanical axis through the femoral head. With placement of the femoral tracker in the medial supracondylar region clear of the intramedullary canal, the navigated cut was correlated with the cut placement determined with the standard intramedullary jig in 10 patients undergoing knee replacement. In addition, jigged femoral rotation was checked with the tracker placement. Tibial slope, varus/valgus angle and rotation were determined using surgeon placement of an external alignment jig and confirmed with tracker placement.

The navigated distal femoral cut ranged from +3 degrees to −2 degrees when measured against the distal cutting block stabilised over an intramedullary rod. The femoral rotation was within 1 degree of the trans-epicondylar line as outlined by navigation when a 3 degree externally rotated jig was used. All of the tibial measurements were within 0.5 degrees of the navigated planned positions.

The femoral cuts are presumed to be accurately determined with navigation as judged from long-leg alignment x-rays but this study highlights the potential error if a fixed valgus cut angle with alignment jigs is used. Tibial preparation, however, was accurately predicted by the surgeon using a traditional external alignment jig. Bone preparation time was reduced to 4 minutes (modified technique) compared to 12 minutes (full navigation, p< 0.05).

With this information, computer-aided navigation is now routinely used to determine the distal femoral cut only and an external alignment jig is used for tibial preparation without navigation. The reduction in blood loss and embolic events and improved limb alignment is now achieved with a reduction in preparation time over full navigated techniques. Use of the pinless surface mounted femoral jig alone highlights these advantages further.


R. Thakur P. Lata F. Khan R. Miller

One of the most important factors on which Total Knee Replacements results depend is accuracy of restoration of normal mechanical axis. It is believed that computer navigated TKR give better implants position therefore should improve long term results. We decided to check if computer navigation actually improves restoration of mechanical axis and implants placement in a single surgeon, single implant type series. We prospectively assessed 58 patients (60 knees). Each group (navigated versus non navigated) consisted of 30 knees. Patients were assessed clinically and radiographically using weight bearing full-length AP and short lateral films (PACS and IMPAX software). Clinical Results at 2 years were comparable in both groups (89% vs. 88% good or excellent result). Radiological results proved to be better in navigated knees regarding mechanical axis. There were no statistically important differences in other radiological parameters.


M. Bhattacharyya B. Gerber

This prospective study is designed to assess intra-operative trauma to soft tissue envelope around the knee joint especially quadriceps due to rigid body fixation on the femur and its influence on rehabilitation outcome obtained using a kinematic navigation system for TKR. We also evaluated the impact of the extra time needed to adopt this system on immediate post-operative rehabilitation.

One hundred and sixteen operations were performed with the aid of the kinematic navigation system. Results, including operation time, radiographic alignment of the prosthesis and complications, were compared with non-navigated group. Outcome measures included preoperative knee function, intra-operative factors, blood loss and postoperative rehabilitation.

The operation time (from skin to skin) in the navigation group was average 32 minutes longer compared historical controls. No major complications such as delayed wound healing, infection or pulmonary embolism occurred during this study. Mean blood loss in both the group showed no difference

A higher incidence and duration of early postoperative quadriceps dysfunction was not associated with computer-assisted TKA through the lateral Para patellar approach. No patient who received surgery had a lag of more than 20 degrees, at 48 hours postoperatively, regardless of the duration of intra-operative time used.

Although the total surgical time was longer, it does not translated into increased postoperative morbidity. Use of a kinematic navigation system has a short learning curve, and requires an additional operation time of less than 32 minutes. We found no impact of patients’ perioperative times on short-term outcomes obtained during our learning curve and next two years. The mechanical axis of the leg was within 3 degrees of neutral alignment along with accurate component alignment. The Computer-assisted TKA through a lateral parapatellar approach was not associated with delayed recovery of the patients during early postoperative rehabilitation.


N. Confalonieri A. Manzotti K. Motavalli

The Authors performed a matched paired study between 2 groups UKR or CA-TKR implanted with a mini-incision (MICA group) in the treatment of isolated medial compartment knee arthritis. The Authors hypothesized that UKR offers a real less invasive surgery with lower economical costs despite a worse limb/implant alignment. Furthermore at a minimum 40 months follow-up they hypothesized that this small implant guarantees still both better clinical score and patient satisfaction than in the MICA group.

Thirty two patients with isolated medial compartment knee arthritis who underwent to a medial UKR from February 2001 to September 2002 were included in the study (UKR group). In all 32 knees the arthritic change was graded according to the classification of Älback 1. Arthritic change did not exceed grade IV in the medial compartment and grade II in the patello-femoral compartment. All patients had an asymptomatic patello-femoral joint. All patients had a varus deformity lower than 8° and a body mass index lower than 30. No patient had any clinical evidence of ACL laxity or flexion deformity and all had a preoperative range of motion of a least 110°. At a minimum follow-up of 48 months, every single patients in group A was matched with a patient who had undergone a computer assisted TKR performed with a less invasive approach (shorter than 12 cm) for an isolated medial compartment knee arthritis between August 1999 and September 2002 (MICA group) in our hospital. At latest follow-up the clinical outcome was evaluated using both the Knee Society Score and a dedicated UKR score developed by the Italian Orthopaedic UKR Users Group (GIUM). The HKA angle and the Frontal Tibial Component angle (FTC) were measured at latest follow up on long leg standing anterior-posterior radiographs and the mean values between the 2 surgeons assessments were used as final values. Furthermore during the hospital staying we registered in both the groups when each patient was standing comfortably in full weight-bearing according to a self- answered questionnaire and the data were compared. Statistical analysis of the results was performed using parametric test (Student’s t-test). A statistical comparison of the percentage of results for the GIUM score was performed using the Chi-square test. A statistically significant result was given a p≤ 0.05.

Both hospital stay and operative time were statistically longer obviously in MICA group. In the UKR group the mean surgical time was 51.5 minutes (range: 36–75) (p< 0.001) while in the MICA group was 108.8 minutes (range: 80–132) (p< 0.001). In the UKR group the patients remained in the hospital for a mean of 5.1 days (range: 3–7) and in the MICA group 8.2 days (range: 4–16). At the latest follow-up the mean Knee Society Score was 80.5 (range: 70–100) and 78.4 (range: 70–87) for group A and B respectively. No statistically significant difference was seen for the Knee Society score between the 2 groups (p=0.08). The mean Functional score was 83.5 (range: 73–100) for group A and 78.8 (range: 59–90) for group B. A statistically significant difference was seen for the Functional score with superior results for group A (p=0.02). A statistically significant difference was seen for the GIUM score with better results for group A (p=0.01). The mean GIUM score was 76 (range: 67–90) and 73.02 (mean: 65–85) for group A and B respectively. At latest follow up the mean HKA angle was 176.8° for group A (range: 174°–182°) and 179.3° for group B (range 177–182) (p< 0.001). The mean FTC angle was 86.9° (range: 84°–90°) and 89.4° (range: 87°–92°) for group A and B respectively (p< 0.001). All TKR implants were positioned within 4 degrees of a HKA angle of 180° and FTC angle of 90°.

At the latest follow-up (minimum 48 months) no statistically significant difference was seen in the postoperative Knee Society score for either group. However, significant differences were seen between the 2 groups in the functional results and in the GIUM score with better results in the UKR group. All the patients achieved a range of motion greater than 120° and could walk for longer distances. During the hospital staying in this group the patients reported a statistically significant earlier full weight-bearing. This was despite a significant less accurate limb alignment. In addition to inferior results for the computer assisted mini-invasive TKR group the costs of the procedure were obviously greater because of the expensive implants and technology along with statistically significant longer surgical times and hospital stay


M. J. Chambers B. P. Rooney L. Campton W. L. Leach

The aim of this work was to compare the oxygen saturations in patients in the early period following total knee joint replacement surgery performed using either computer navigation or conventional intramedullary mechanical jigs.

Between August and November 2007 twelve consecutive patients who had computer navigated total knee joint replacements were prospectively reviewed. A comparison group from the same period was made of twenty patients who had knee replacements performed with conventional jigs in this same period. Non-invasive oxygen saturations were measured and recorded as a percentage. Preoperative oxygen saturations measured at the assessment clinic were used a baseline. For the duration of the patients postoperative hospital stay oxygen saturations were measured five times a day as well as their oxygen requirements.

We found that the patients in the computer navigation group on average reached oxygen saturation levels on air equal to those measured in the assessment earlier than the intramedullary jig group (2.2 days versus 2.8 days). There was also a lower need for oxygen and shorter length of stay in the computer navigated group during this early post operative period (4.6 versus 6.0 days).

Previous studies using transcranial Doppler and transoesophageal echocardiograms have shown a reduction of systemic emboli with computer navigated total knee joint replacements. Using oxygen saturation monitoring we have shown there may be a considerable clinical advantage using computer navigated surgery over conventional intramedullary jigs in knee replacement surgery.


S. A.C. Sampath H. Davies S. Voon

Navigated Total Knee Arthroplasty (TKA) is a new technique in our hospital. Any new procedure can be associated with both technical difficulties and difficulties due to patient and theatre staff expectations. The aim of this study was to demonstrate our learning curve and assess patient and staff acceptance. We highlight common technical problems unique to navigation and offer our solutions.

A prospective study of 231 consecutive Emotion TKA were implanted over a 30 month period with Orthopilot version 4.2 Navigation system using soft tissue management (BBraun Aesculap, Tutlingen). They were done by a single knee surgeon previously experienced only in non-navigated TKA. Patient height and weight were measured preoperatively and the BMI calculated. Tourniquet times were recorded digitally with fixed timing criteria. Informed consent was obtained.

Our results showed a significant decrease of tourniquet time with experience (p=< 0.0001) with other possible factors being preoperative deformity and BMI. There was full patient acceptance with the exception of the first patient. The surgical team had to modify patient positioning on the operating table, setup of the theatre and navigation equipment, placement of the scrub staff and delegation of tasks.

Navigated Emotion TKA with Orthopilot software provided a comfortable learning curve. It was readily acceptable to patients and staff and has been adopted as our standard practice. The discussion of problems and the introduction of solutions had a positive effect on building our team. Further investigation is needed to elucidate other variables that affect the tourniquet time.


M. O. Mathew M. Frame K. Periasamy F. Picard F. Leitner B. Mollard

Aim: To evaluate the accuracy of intra-operative point acquisition during navigated hip replacement using an ultrasound transducer probe relative to a percutaneous digitiser stylus (pointer)

To study intra- and inter-observer variability with the use of the ultra-sound transducer and percutaneous digitiser point probes

To assess the learning curve with the use of the ultrasound transducer probe

As part of a larger cadaver study evaluating navigated total hip replacement via the posterior approach, we assessed data relating to acquisition of bony landmarks of the Anterior Pelvic Plane (APP) by four surgeons with an ultrasound transducer and a percutaneous point probe. The surgeons had differing levels of experience with hip surgery in general, and also with surgical navigation per se, but none of them had previously used the ultrasound probe for the specific purpose of landmark acquisition.

Without fixing an absolute positional value for any of the bony landmarks, the points registered for individual landmarks by each surgeon were then studied, looking at the three-dimensional spread of these points relative to each other about the mean value. The data from all four surgeons were analysed, looking at the global dispersion of points acquired by the ultrasound and percutaneous point digitiser probes.

Our results show that with the exception of a few isolated outliers, the ultrasound probe generated values fell within a +/− 10 mm range. For all four surgeons, the global spread of ultrasound-registered points was noted to be less than that acquired by percutaneous point probe acquisition. Of interest was the finding that points registered by individual surgeons using the ultrasound probe tended to be grouped distinctly together but spatially separate from those of the other surgeons; it would appear that each operator was “homing” in on what he perceived to be the bony landmark in question on the projected ultrasound image.

With the percutaneous pointer probe, and with the anterior superior iliac spines as the target, there was closer grouping of points around the mean positional value for the two surgeons who were experienced with its use. However, at the symphysis pubis, the spread of points for these surgeons were not much different from the other two less experienced one, with these points showing a global spread as great as 25 mm.

Regardless of the experience of the surgeon, the use of the ultrasound transducer probe appears to be more accurate than percutaneous pointer probe for acquisition of the bony landmarks that constitute the anterior pelvic plane. The learning curve associated with its use is seemingly short and steep. Its accuracy is limited by the fact that the identification of the bony land marks on the on-screen display is open to interpretation by the individual. Methods to standardise the identification of these landmarks on ultrasound images may help improve its accuracy in the future.


S. A.C. Sampath H. Davies S. Voon

Valgus knees present a surgically demanding challenge. Dissimilar bone and soft-tissue deformities compared to varus knees complicate restoration of proper alignment, positioning of components, and attainment of joint stability. Our study examined the relationship between tourniquet time and valgus deformity.

A prospective study of all valgus knees were implanted over a 30 month period with Emotion Ortho-pilot version 4.2 Navigation system (BBraun Aesculap, Tutlingen). They were done by a single knee surgeon. Tourniquet times (TT) were recorded digitally with fixed timing criteria. The software recorded all pre- and post-operative deformities. We performed the lateral parapatella approach for all valgus knees. No patella resurfacing was done but all tibiae were cemented.

There were a total of 56 valgus knees (1° to 22°, Mean 5.9°, SD 4.9). The TT varied from 42 min to 121 min (mean 72 min, SD 17.4). There was a statistically significant relationship between TT and Valgus deformity. Tourniquet Time = 59.6 + 2.1 * Pre-operative Valgus (p= < 0.0001, R2 = 36.4%)

Thirty six percent of the observations were explained by this analysis. Other factors will need to be considered in future studies. This equation can be used as a guide in the allocation of theatre time. It applies to a specific surgical team and we would expect different teams to have different coefficients. This may be useful in comparisons of different teams.


M. Bhattacharyya B. Gerber

To describe our experience with computer assisted combined anterior cruciate ligament (ACL) reconstruction and osteotomy. It may provide long-term symptom relief and improved function in patients with medial knee arthrosis and ACL-deficiency, while delaying or possibly eliminating the need for further surgical intervention such as arthroplasty.

Two patients who had medial unicompartmental arthrosis and chronic ACL-deficient knees underwent ACL reconstruction along with femoral osteotomy in one case and upper tibial osteotomy in the other. We used Orthopilot software to perform computer assisted combined anterior cruciate ligament (ACL) reconstruction and osteotomy.

Subjective evaluation at postoperatively indicated significant improvement compared to preoperative evaluation and better scores for patients who obtained normal knee range of motion. Objective evaluation by International Knee Documentation Committee showed improved score postoperatively. Both had minor complications occurred in the immediate postoperative period. The average correction angle of the osteotomy was 7 degrees (7–10).

Computer assisted ACL reconstruction and osteotomy may provide long-term symptomatic pain relief, increased activity and improved function. Only Anterior cruciate ligament reconstruction may not effectively provide pain relief to the ACL-deficient knee with degenerative medial arthrosis. The results of this study suggest that combined high tibial or femoral osteotomy and ACL reconstructions are effective in the surgical treatment of varus, ACL-deficient knees with symptomatic medial compartment arthritis. Computer aided surgery allows precise correction of the axial deformity and tunnel orientation intraoperatively.


J M Buchanan

Introduction: Revision hip surgery is likely to become more frequent with the continued use of cemented primary hip prostheses.

Primitive stem cells from bone marrow become osteocytes in the presence of hydroxyapatite ceramic (HAC). Consequently there is osseointegration of an HAC surface in bleeding cancellous bone/marrow.

However, damaged bone in the revision situation does not provide the necessary stem cells for osseointegration. Revision surgery using standard length (150mm) HA coated stems is not always satisfactory.

Using a 200 mm stem will extend the operating field into fresh, undamaged cancellous bone and marrow.

Method: Since 1988 more than 2600 HAC hips have been implanted for primary and revision hip cases. This includes 148 revisions. The continued use of primary HAC hips has reduced the necessity for revision hip surgery. There is a dwindling population of cemented, loosening hips requiring revision. Patients are assessed radiologically and using the Harris Hip Score (HHS) pre. and post-operatively on an annual basis.

Results: Since 1991 the longer 200mm stems have been used in 73 cases. The results have been rewarding.

The system works with improved HHS. Defects from debris disease fill in and stems are seen to bond to the host bone particularly at the tip. There have been no prosthetic fractures.

Only one case has needed re-revision when a stem remained un-bonded in the presence of a transverse femoral fracture. Two other stems are probably not bonded. This represents 4% failure.

Discussion: HA bonding is a successful system of fixation in primary hip arthroplasty. Using a 200mm stem in revision cases allows virgin bone marrow to provide the necessary stem cells for fixation. These longer HA coated stems should be used in revision surgery.


B J Mockford I Stockley

Introduction: There are few published reports outlining the outcome of those patients who have undergone revision hip arthroplasty surgery for recurrent infection.

From a consecutive series of 114 patients who had undergone a two-stage exchange without prolonged antibiotic therapy we report the outcome of those patients who continued to have persistent infection.

Methods: Fourteen patients were identified, all with microbiologically proven recurrent deep infection. Seven patients have undertaken further attempts at cure by a two-stage exchange and where again a prolonged course of antibiotic therapy was not routinely used. Infection was eradicated in six out of the seven patients (84%). The mean follow-up of this group is 90 months (range 25–150 months).

Results: From the initial series an overall cure rate of 93% was seen. The other patient has a pseudarthrosis.

Seven patients elected not to undergo a further two-stage revision. Five patients have retained their arthroplasty with lifelong suppressive antibiotic therapy. One has a pseudarthrosis and one disarticulation has taken place for inadequate tissue cover.

Discussion: This series would suggest that in patients willing to undertake further surgery in an attempt to eradicate infection they stand a good chance of a successful outcome.


S. Mohan U. Box JP Hodgkinson

Introduction: The purpose of this study was to review the results of revision total hip replacement, using cement, done by a single surgeon in a tertiary referral centre. 164 patients underwent revision hip surgery for aseptic loosening, infection or recurrent dislocation.

Methods: 95 patients had a one stage revision, 25 patients had two stage revisions and the remainder had either the stem or socket revised. 10 patients had application of a PLAD for recurrent dislocation. Structural and morselized bone grafting was carried out in patients with extensive bone loss. 46 patients had morselized impaction bone grafting to the acetabulum. The first hundred patients with revision of both components and minimum follow up of twelve months were reviewed. Patients were routinely followed up in the clinic and assessed using the Oxford Hip Score and Merle D’Abigne scores for pain, function and range of movements. Radiographs were assessed for any demarcation or loosening.

Results: The mean age at surgery was 69.99 years (36ys to 95yrs). The mean follow up was 25 months (12 to 60 months). There were 5 dislocations, 2 wound dehiscence, 3 DVT’s and 2 deep infections in the whole group. There were 2 dislocations, 2 DVT, 1 wound dehiscence and 1 infection in the study group. The preoperative scores were available for 83 patients and the average scores for pain, function and range of movements were 3.2, 2.8 and 1.6 respectively. The average scores at the latest follow up were 5.08, 4.2 and 4.0. The mean Oxford Hip scores were 26.65. X-rays showed no demarcation in the acetabulum in 88 patients and in the femur in 92 patients. The trochanter was united in 72 patients. In 13 patients the trochanter had migrated more than 1 cm.

Conclusion: Revision total hip replacement using cement has shown good results in the short term. Cemented revisions are safe, reliable and also cost effective.


S. Subramanian DK. Jain R. Sreekumar U. Box MV. Hemmady JP. Hodgkinson

Introduction: Extensive bone loss associated with revision hip surgery is a significant orthopaedic challenge. Acetabular reconstruction with the use of impaction bone grafting and a cemented polyethylene cup is a reliable and durable technique in revision situations with cavitatory acetabular bone defects. Slooff et al. (1996) reported the use of cancellous graft alone. Brewster et al. (1999) morselised the whole femoral head after removal of articular cartilage. This paper asks, is it really necessary to use pure cancellous graft?

Methods: 42 acetabular revisions using impacted morselised bone graft without removal of articular cartilage and a cemented cup were studied retrospectively. The mean follow up was 2.6 years (1–5yrs). Clinical and radiographic assessment was made using the Oxford Hip score, Hodgkinson’s criteria (1988) for socket loosening and Gie classification (1993) for evaluation of allograft consolidation and remodelling.

Results: 40(95%) sockets were considered radiologically stable (Type 0, 1, 2 demarcations). 2(5%) sockets were radiologically loose (Type 3 demarcation). There was no socket migration in our series. 27(64%) cases showed good trabecular remodelling (grade 3). 12(29%) cases showed trabecular incorporation (grade 2). Only 3(7%) cases showed poor allograft incorporation (grade 1). Average pre operative Oxford hip score was 41 and postoperative hip score was 27. There have been no socket re-revisions (100% survival) at an average of 2.6 years.

Conclusion: Early radiological and clinical survival results with retaining articular cartilage of femoral head allograft are similar and comparable to other major studies for acetabular impaction bone grafting in revisions. Minimal loss of allograft mass is 40% in obtaining pure cancellous graft. When there is a limited supply and demand of allograft, saving up to 40 % of the material is a valuable and cost effective use of scarce resources.


I Stockley B J Mockford A Hoad-Reddick P Norman

Introduction: The use of prolonged courses of parenteral or oral antibiotic therapy in combination with a two-stage exchange procedure in the management of the infected total hip arthroplasty is reported by many major series.

Methods: We present a series of 114 patients, all with microbiologically proven chronic deep infection, treated with a two-stage exchange with antibiotic loaded cement and where a prolonged course of antibiotic therapy has not been used. The mean follow-up for all patients is 74months (range 2–175months) with all surviving patients having a minimum 2 year follow-up.

Results: Infection was successfully eradicated in 100 patients (88%). The infection cure rate in our series is similar to that reported elsewhere where prolonged adjuvant antibiotic therapy was used.

Discussion: Using the technique described a prolonged course of systemic antibiotics does not appear to be necessary; the high costs of antibiotic administration, both to the patient and care facility are not incurred.


AK Malik D Chou D Raptis JD Witt

Introduction: There have been several recent studies outlining the role of femoroacetabular impingement (FAI) as a cause of early osteoarthritis in the non-dysplastic hip. The lesions can either be on the femoral side “cam” or acetabular “pincer”. The aim of surgical treatment of FAI is to improve the femoral head neck offset thereby improving joint clearance and preventing abutment of the femoral neck against the acetabulum. The classic treatment for FAI pioneered by Ganz involves dislocation of the femoral head through a trochanteric flip osteotomy. The procedure is extensive, technically difficult and not without complications.

Hip arthroscopic debridement of FAI lesions offers similar results to open procedures allowing for full inspection of the joint and the treatment of any chondral lesion but with a quicker recovery time. It nonetheless has a very long learning curve and even in the most experienced hands the treatment of impingement lesions is complicated and technically challenging.

The purpose of this cadaveric study was to assess the degree of exposure obtained using two different limited anterior approaches to the hip which would allow effective surgical treatment of cam and pincer FAI.

Methods: We investigated two mini anterior approaches to the hip joint based on the Heuter and direct anterior approach to compare the parts of the acetabulum and femoral head exposed for the treatment of FAI in a total of 20 hips in 10 (5 male, 5 female) cadaveric specimens. Neurovascular structures were recorded in relation to the two approaches. The area of femoral head and acetabular rim exposed via each approach was documented and quantified.

Results: We found that the two approaches were easy and reproducible. Both allowed exposure to the anterolateral aspect of the femoral head. The mean length of acetabular rim accessible via the Heuter approach was 1.9cm (1.1–2.4) and 2.2cm (1.2–3) using the direct anterior approach The area of acetabular rim accessible varied according to the approach (p< 0.001). We also found that the position of the anterior inferior iliac spine in relation to the acetabular rim also affected the area of acetabular rim exposed (p< 0.001). The most proximal nerve branch to sartorious was found 7.3cm (6.5–8.7cm) distal to the anterior inferior iliac spine. The most proximal nerve branch to rectus femoris was located 8.6cm (7–10) distal to the anterior inferior iliac spine and was consistently found to be distal to the nerve to sartorious.

Discussion: Treating impingement of the hip through a direct open approach is not a novel idea. A recent report of failed arthroscopic labral debridement, describes treatment of the underlying bony impingement in some cases by a combination of hip arthroscopy followed by anterior arthrotomy.

In summary cam and pincer impingement of the hip can be treated by either the direct anterior or Heuter approach. The choice of approach would be dictated after careful consideration as to which portion of the anterior acetabular rim required surgery, with more lateral acetabular lesions being favoured by the Heuter approach and more medial impingement sites by the anterior approach we have described.


A Gordon E Kiss-Toth E Greenfield R. Eastell JM Wilkinson

Introduction: Immune responses in patients susceptible to aseptic loosening may differ to those without this susceptibility. We compared stimulated cytokine mRNA and protein expression in peripheral blood mononuclear cells (PBMC) in 34 subjects (M:F 16:18; mean age 75 years) with previous revision surgery for aseptic loosening versus 28 subjects (14:14; 75 years) with well-fixed implants after Charnley THA for osteoarthritis.

Methods: Extracted PBMCs were stimulated with endotoxin (LPS 200ng/mL), endotoxin-free titanium particles (Ti, endotoxin level =0 Eu/mL), or particles with adherent LPS (TiLPS, 140 Eu/mL). Cell lysate IL-1α, IL-1β, IL-1RA, IL-6, IL-10, IL-18, and TNF mRNA were assayed after 3 hours stimulation using standard rqRT-PCR techniques. Cell supernatant IL-1β, IL-1RA, IL-6 and TNF protein were assayed after 24 hours stimulation using a multiplex method.

Results: mRNA and protein levels in non-stimulated cells were lower in revision versus control subjects for all cytokines (p< 0.05 all analyses). mRNA expression relative to baseline was greater in revision subjects versus controls for all cytokines and all modes of stimulation (LPS, Ti, and TiLPS, p< 0.05 all analyses). LPS induced the greatest inflammatory cytokine response at both the mRNA and protein level in both groups, TiLPS particles induced a more attenuated response, and responses to Ti particles were weakest. In the control group endotoxin free particles showed a negative cytokine mRNA response for IL-1α, IL-1β, and IL-6 (p< 0.05), and reduced protein levels for IL-1β, IL-1RA, IL-6, and TNF versus non-stimulated cells (p< 0.05).

Discussion: Patients with a susceptibility to aseptic loosening have lower baseline but greater stimulated immune responses versus patients without loosening that may contribute to the pathogenesis of aseptic loosening.


I Starks G Ayub G Whalley J Orendi PJ Roberts N Maffulli

Introduction: Antibiotic-associated Clostridium difficile diarrhoea may complicate surgery for proximal femoral fracture. We sought to determine whether a change in antibiotic policy in our unit influenced rates of infection with C. difficile following hip fracture surgery.

Methods: A 4 year case controlled study. A change in antibiotic prophylaxis was introduced during a 3 month period in 2005. Infection rates with C. difficile were compared for 2 years either side of this period. The initial regimen was one of three doses of cefuroxime (1.5 g). The new regimen is a single dose of cefuroxime (1.5 g) with gentamicin (240 mg) at induction. Infection was defined as diarrhoea with a positive isolate within 30 days of surgery.

Results: Prior to the change in prophylaxis, 912 patients underwent surgery for neck of femur fracture. Following the change, 899 patients underwent surgery over the period March 2005 to March 2007. 38 patients developed C. difficile infection (4.2%) in the initial group, compared with 14 patients (1.6%) in the group following the change in prophylaxis (P=0.009). Patients with C difficile infection also had a statistically significant increase in antibiotic exposure, inpatient stay, morbidity and inpatient mortality.

Discussion: The main challenges regarding antibiotic selection are failure of prophylaxis, often because of infection with MRSA, and C. difficile-associated diarrhoea as a consequence of antibiotic prophylaxis. Infection with C. difficile is reduced with the new regimen. We advocate the use of the new regimen as an effective alternative to multiple dose cephalosporins for the prevention of C. difficile infection in this group of high risk patients.


L Mills JE Phillips

Introduction: The Scottish Arthroplasty Project (SAP) publishes an annual report including infection rates post-arthroplasty having obtained their results from the patients’ ICD-10 codes. The aim of this project was to validate the THR infection rate for one unit as published in the 2006 Scottish Arthroplasty Project (SAP) Report.

Method: The details of the SAP results were obtained. The BGH keeps its own record of post-operative THR infections; only those that met the dates and criteria of the SAP 2006 report were included and compared. The ICD-10 coding status was analysed in more detail.

Results: Published rate of infection in the 2006 SAP report after total hip replacement is three times lower than the unit recorded. 12 patients were eligible (1.49% infection rate), the SAP report recorded 4 cases of infection.

The SAP searches for infection only using three ICD-10 codes. Six ICD-10 codes had been used to classify these 12 patients.

Discussion: A recent cardiac surgery study comparing postoperative mortality rates from hospital statistics with the central cardiac database statistics found an over reporting by the national central database.* We have found the reverse with a threefold under calculation in the national report. However the unreported figures still do not place BGH as an outlier. The reasons for the discrepancy are multifactorial; but include poor coding practice, narrow range of code searching and difficulties in diagnosing infection. This audit shows that investigating the results of not only the outlying units but also randomly picking those who appear to have excellent results is worthwhile.


LM Fisher PR Kay AK Gambhir

Introduction: The evolving pattern of bacterial resistance at septic revision surgery to the common antibiotics used during total hip arthroplasty is described.

Methods: A retrospective review of 72 case notes and microbiology data inclusive of bacterial sensitivity profiles was undertaken between January 2002 and April 2007. Data collected was combined with a previous study to demonstrate bacteriology trends over the last thirty years (327 cases). Antibiotic sensitivities to the two common infectious agents, Staphylococcus aureus and coagulase negative staphylococi were formulated into a hypothetical model combined with Gentamycin sensitivity, a constant factor (the sole antibiotic in bone cement), to assess the efficacy of the combination of antibiotics used in primary arthroplasty.

Results: When compared to previous microbiology data percentage isolates of each bacterium were found to be similar, confirming that the infectious agents at septic revision had remained the same, and were the common contaminants at primary surgery. The results also demonstrated an overall trend of increased resistance of the major organisms to the major classes of antibiotics used. Staphylococcus aureus and coagulase negative staphylococci were routinely tested against nine common antibiotics, inclusive of Gentamycin. Critical findings showed that the regimen used in routine primary surgery covers only 67% of staphylococcus infections (cefuroxine and Gentamycin); combinations that showed increased coverage included clindamycin and Gentamycin, and rifampicin plus Gentamycin, providing in excess of 100% coverage, and Erythromycin and Gentamycin, coverage in excess of 80%.

Discussion: Consequently we can recommend from prospective analysis of common infections at septic revision, that the antibiotic regimen at primary surgery is not sufficient to prevent infection (in isolation). Dynamic variations continuously develop in bacteria; genetic make up is regulated to optimise survival, continuously detrimentally affecting the efficacy of antibiotics against the power of super bugs, indicating a pattern in need of continuous monitoring and review.


D Morgan G Myers K O’Dwyer

The Exeter Universal Stem has limited published data with greater than 10 year results, this is from specialist orthopaedic centres using predominantly posterior approach. Our aim was to establish whether the published results could be reproduced in a District General Hospital (DGH) using a Hardinge approach.

We reviewed 131 consecutive primary THRs implanted into 127 patients between 1995 and 1997 (minimum10 year follow up). Surgery was performed through a Hardinge approach using the Exeter universal stem with the Ogee Elite acetabular component.

Outcome was assessed by patient review, completing an Oxford Hip Score (OHS) and reviewing the hospital records. Deceased patients’ hospital records were reviewed and their GP questioned.

5 of 131 hips required revision: 3 for infection at 4–7 years following implantation and 2 for aseptic loosening (one acetabulum only, one both components). There have been no cases of dislocation or sciatic nerve palsy. Kaplan-Meir survival analysis demonstrates ten year survival as follows: 95.3% survival with revision for any cause as the end point; 98.9% with revision for aseptic loosening of the stem as the endpoint, 98.1% with revision for aseptic loosening of the acetabular component as the endpoint, 97.2% with revision for infection as the endpoint.

The mean OHS was 22.7 (median =20, interquartile range 15–26).

This is the first series to report on the 10 year results with the Exeter Universal stem used exclusively in conjunction with the Ogee Elite acetabular component. It is also the first series to report the 10 year results using only the Hardinge approach. Our findings are the first to show that the Exeter universal stem in combination with the Ogee Elite acetabular component can be inserted through a Hardinge approach in a DGH setting with results comparable to surgery performed in a specialist unit and through a posterior approach.


BM Wroblewski PD Siney PA Fleming B Purbach

Introduction. Presentation of results by survivorship analysis method offers uniformity of terminology and comparability of results, an essential aspect of scientific communication. The Swedish National Total Hip Arthroplasty Register (SNTHAR) has set the standards with revision as the failure endpoint.

We set out to examine the survivorship after primary Charnley low-frictional torque arthroplasty (LFA) with revision as the end point, but documenting all the operative findings.

Methods & Results. Between November 1962 and June 2005, 22,066 primary operations in 17409 patients had been carried out at the author’s hospital by over 330 surgeons. By June 2006, 1001 (4.5%) hips have been revised.

Survivorship with revision as the end point was: infection 95%, dislocation 98%, fractured stem 88.6%, loose stem 72.5%, loose cup 53,7%.

Infection and dislocation are early problems. With improved cementing techniques stem loosening does not become a problem until 11 years after the primary. Loosening and wear of the ultra high molecular weight polyethylene cup is a significant long-term problem.

Discussion. Since revision is an event interrupting a process, its timing will influence the survivorship analysis pattern and indications and detailed operative findings will become important issues. Since clinical results do not reflect the mechanical state of the arthroplasty to await symptoms would invariably mean that revisions are likely to be carried out late and as such the complexity of complications are likely to increase. Furthermore, if information gathered is of a single “indication for revision”, and not of the operative findings at revision, the information would be of limited value.

Our conclusion is that regular follow-up after hip replacement is essential. The frequency, judged from the revision patterns, would suggest that every two years would not be unreasonable. Recording of all operative findings at revision is essential.


L Young S Duckett A Dunn

Introduction: We describe our experience with the Exeter femoral component in a District General Hospital. We implanted 230 Exeter Universal stems in 215 patients between 1994 and 1996, which were reviewed at a mean of 11.2 years. Unlike previous studies we have used one acetabular implant, the Elite Ogee Cup in the majority of patients (218/230 patients).

Methods: 76 patients (79 hips) had died, and 121 patients were alive and well enough to attend for radiographic analysis at a minimum of 10 years. One patient was lost to follow up.

Results: No stems were revised for aseptic loosening. Three hips were revised for deep infection. Six acetabular components were revised: 4 for loosening, and 2 for recurrent dislocations. Taking the worst-case scenario including the one patient lost to follow up, the overall survival rate was 94.2%.

Discussion: Our results confirm excellent medium term results of the Exeter Universal femoral component, implanted outside of a specialist centre (either originating centre or teaching hospital). The excellent survival of the Exeter stem, in mix and match combination with the Ogee cup would indicate that this is a successful pairing.


CJ Edwards R Reddy A Bidaye ED Fern MR Norton

Introduction: The open treatment of hip impingement is now a well-recognised technique with numerous publications about pathogenesis and surgical technique. There are very few publications of very small series discussing surgical results.

We present the results of 148 hips at a mean follow-up of 20 months (range 4 – 55).

Methods: This is a two surgeon series of sequential patients including the early learning curve. Patients were treated for impingement through a Ganz trochanteric osteotomy and open surgical hip dislocation. Patient data, operative findings and methods, complication and clinical follow up were recorded as a prospective audit and include Oxford and McCarthy Non Arthritic Hip scores.

Results: The patient demographics are as follows:

141 patients, 148 hips.

Average age 35, range 10–65 years

Ratio Male to Female 73:75

All patients underwent femoral osteochondroplasty.

60% of cases had the labrum detached, acetabular rim recession and labral repair with bone anchors.

3 patients had the labrum reconstructed with the ligamentum teres autograft.

We have had 9 failures (6%) as defined by revision to arthroplasty.

2 hips underwent successful revision open surgery for inadequately treated posterior impingement.

3 patients required arthroscopy after open surgery (2 of whom are now pain free).

7 further patients have persistent groin pain but not required further intervention.

We have had the following complications: 4 trochanteric non unions requiring revision fixation, 2 deep vein thrombosis, 2 haematomas, 1 superficial infection, no deep Infections.

Life table survival curve with revision to arthroplasty defined as failure.

Discussion: The early to midterm results of this innovative procedure are encouraging even when including the decision making and surgical technique learning curves. We will present the hip scores and discuss the failures in detail to warn others embarking on this surgery which cases are more likely to lead to unsatisfactory outcomes.


B Purbach BM Wroblewski PD Siney PA Fleming PR Kay

Introduction: The triple tapered polished cemented C-stem has evolved from the study on long-term results of the Charnley design, when first fractures of the stem and then proximal strain shielding of the femur and stem loosening were identified as the continuation of the same process. The design utilises the common engineering principle of male (stem) and female (cement) tapers engaging under load, loading the proximal femur.

Methods and Results: The C-stem was tested extensively and introduced into clinical practice in December 1993. Up to the end of October 2007, 4558 have been implanted in primary operations.

None of the 4558 stems have been revised for aseptic loosening or fracture.

The patient’s mean age at surgery was 48 years (range 15–76), and 171 hips with a mean follow-up of 11 years (range 10–13.7) have now passed 10 years. There were 97 females and 64 males in this group with 10 patients having bilateral C-stems. The main underlying pathologies were Primary Osteoarthritis 30%, Developmental Dysplasia of the hip 27% and Avascular Necrosis of the hip 19%.

Clinical outcome graded according to d’aubigne and postel for pain, function and movement has improved from 3.1, 3.1 and 2.9 to 5.9, 5.7 and 5.6 respectively.

A good quality proximal femur had been maintained in 47.1% and improved in a further 29.9%.

Discussion: The results achieved with the C-Stem design and technique are encouraging and support the concept of loading the proximal femur, but place a demand on the understanding of the technique and its execution at surgery.


DJ Farr KS Conn JM Britton JDF Calder GJ Stranks

Method: This study reports upon 216 patients (97 Minimally invasive and 119 Standard) enrolled into a randomised control trial comparing a standard posterior approach to the hip with a single incision minimally invasive surgery (MIS) posterior approach at 6 weeks and 1 year post-operatively. Primary outcome measures included operative time, blood loss, length of stay and functional hip scores.

Results: The demographics and pre-operative hip scores for both cohorts were statistically similar. Intra-operative blood loss was significantly reduced in the MIS cohort (p=< 0.01). There was no difference in surgical time (p=0.37), time to discharge (p=0.24) or complication rate between the two groups.

Both groups had statistically improved post-operative hip scores, however, at the 1 year follow-up the MIS group were significantly better in terms of WOMAC, Harris Hip, Merle d’Aubigne and SF-12 scores when compared with a standard posterior approach.

Conclusion: This study demonstrates that MIS THA is a safe, reproducible technique in a DGH. We recommend the use of MIS techniques in primary THA and adhere to the principle that an incision need be no longer than necessary to perform the procedure safely.


N W Emms J M Wilkinson I Stockley A J Hamer

Introduction: Between 1987 and 1997 we implanted 319 primary hybrid total hip arthroplasties in 289 patients using the ‘Plasmacup’ (B. Braun Ltd, Sheffield) with a conventional metal on polyethylene articulation. We have observed a high revision rate with this implant recently and therefore undertook a clinical review of this cohort.

Patients and Methods: The indications for surgery were osteoarthritis (223), secondary arthritis (83), inflammatory arthritis (10), and others (3). 17 patients have died and 20 have been lost to follow up. Survival analysis was calculated using implant failure defined as revision (including liner exchange), and includes the censored patients outlined above. Assessment of complications in surviving implants was made using AP radiographs of the hip.

Results: The cup survival rate (Kaplan-Meier method) was 91% at 10 years (95%CI ± 4%) and 67% at 13 years (95%CI +/−9%). The stem survival rate was 96% at 10 years (95%CI +/−3%) and 87% at 13 years (95%CI +/−7%). The median wear in cup revisions for osteolysis was 2.4mm (IQR 1.0–3.2mm), and the median wear in surviving cups was 1.3 mm (IQR 0.8 1.9mm), and was an independent predictor of failure (Cox: p=0.001). There have been 57 revisions (35 cup only, 18 cup and stem, 4 stem only). Indications for revision were osteolysis or loosening (34), wear (18), and infection (5). In surviving cups (214), 29 have expansile acetabular osteolysis and 8 have linear osteolysis. In surviving stems (244), 14 have expansile osteolysis and 23 have linear osteolysis.

Conclusions: There is a high late failure rate of the plasma cup using a conventional metal on polyethylene articulation. Patients with this implant/bearing combination should be closely monitored, particularly after 10 years.


RJK Khan S Haebich D Maor

Despite initial enthusiasm for minimally invasive total hip replacements (THR), there has been a marked paucity of level 1 evidence studies assessing it.

100 patients fulfilling the inclusion criteria were randomised in theatre to a standard posterior or muscle-sparing short incision (MIS) approach. A hybrid hip replacement was used routinely. Post-operative management was the same. Follow-up occurred at 2, 6 and 12 weeks. Patients, as well as functional and radiographic assessors were blinded.

50 patients were recruited to each group. There was no difference in demographics Mean incision length was 12.8cm and 19.1cm respectively. There was no statistically significant difference in operation time, post-op functional recovery (ILOA score) or length of stay. Pain (VAS) was similar post-operatively, and at 6 and 12 weeks. There was no significant difference in 10 metre walking speed or 6 minute walking distance at 2, 6 or 12 weeks; nor was there a difference in Oxford hip score, patient satisfaction with surgery (VAS), or SF-12 score at 6 or 12 weeks. Blood loss, fall in haematocrit, transfusion rate and CRP rise were similar. There was no significant difference in cementation of the stem (Barrack) or cup position (Dorr). There was one death from PE in the MIS group and one deep infection in the standard group. There was one dislocation in the standard group. The only statistical difference between the groups was less dependence on walking aids at 2 and 6 weeks in the MIS group; there was no difference at 12 weeks.

MIS surgery is safe, and may allow earlier independent mobility after THR. However, the claims of significantly reduced pain, less morbidity, better function and improved patient satisfaction appear to be unfounded.


MC Michel P Witschger

Introduction: This minimally invasive (MI) anterior approach has been developed to improve patients’ rehabilitation and long-term function. It is aligned along the interneural plane of Smith-Peterson, with complete preservation of the musculotendinous structures. The femoral neck oeteotomy is performed without dislocation of the joint or resection of the joint capsule. As there is also no additional traction applied to the soft tissues it is one of the most tissue sparing techniques available for THA. The outcome was recorded prospectively and is compared with retrospective data of a conventional lateral approach. No other variables other than the surgical technique were changed for the protocol.

Methods: 55 patients underwent traditional THR (lateral approach) surgery in 2003 and 216 consecutive, non selected patients having an anterior minimal invasive procedure during 2004/05 were followed up for an independent review.

Results: The two groups of patients were comparable in terms of age and BMI. Blood loss dropped by 42%. Hospital stay was reduced by 2.1 days (+/−0.6.) Cup inclination was 45.56 (+/−3.4) in the traditional group and 44.8 (+/−3.7) in the MicroHip group. The dislocation rate was lower in the MicroHip group, being 1/216 compared with 3/55 in the traditional group. Harris Hip score for the MicroHip group was 91.35 at 3 months and 94.43 at 1 year. Average time for return to work was reduced from 8.2 to 2.7 weeks

Discussion: The results show that a truly minimal invasive approach improves the outcome of THR without additional risks. By the use of a treadmill incorporating a dynamic force plate there is even strong evidence that perception and therefore long term results can be improved.


P A Devane J. G Horne

Introduction: Hip Simulator studies show that use of highly cross-linked polyethylene in total hip replacement reduces polyethylene (PE) wear by a factor of 85–98%. Early clinical studies using RSA or computer-aided techniques of polyethylene wear measurement show a reduction of 50–80%. There is speculation about why this discrepancy in the clinical and laboratory data should exist. The results of a randomized, prospective double blinded (surgeon and patient) trial (RCT) of cross-linked versus conventional polyethylene, using a 100% reproducible method of PE wear measurement, are reported.

Materials And Methods: After Ethics Committee approval, the two authors enrolled 124 patients onto an RCT comparing Enduron (non cross-linked PE) and highly cross-linked Marathon PE (DePuy, Leeds, UK). Randomization was performed by the circulating nurse intra-operatively opening an envelope which determined whether the patient received an Enduron or Marathon liner appropriate to the size of the metal shell. Liners were implanted into identical metal shells (Duraloc 300) with one screw. They articulated with identical 28mm CoCr femoral heads and cemented Charnley Elite femoral stems. All patients were followed with anteroposterior and lateral radiographs at 3 days, 6 weeks, 3 months 6 months, 1, 2, 3 and 4 years. PE wear was measured with PWAuto, a validated computer-assisted technique with 100% reproducibility and accuracy of ±0.13mm.

Results: One hundred and thirteen patients had appropriate radiographs and follow-up interval. Mean follow-up was 2.6 years (range 2–4 years). Fifty-eight patients received Enduron liners and 55 patients received Marathon liners. At 6 months (E=0.32, M=0.31mm) and one year (E=0.37, M=0.31mm) the three-dimensional PE wear was identical in both groups. Thereafter, all PE wear measurements showed a significant difference in PE wear between the two groups. Wear of the conventional Enduron group continued (0.51mm at 2 years, 0.70 at 3 years, 0.97 at 4 years), while the crosslinked Marathon group showed virtually no further wear (0.32mm at 2 years, 0.32mm at 3 years, 0.33mm at 4 years).

Conclusions: This is the first study to confirm that Hip Simulator predictions of cross-linked PE wear can be reproduced in-vivo. Randomization, double-blinding, and the use of a 100% reproducible technique for wear measurement add further weight to this data.


M Utting M Raghuvanshi R Amirfeyz AW Blom ID Learmonth GC Bannister

Introduction: The long-term results of 70 Harris-Galante I uncemented acetabular components implanted in 53 patients who were under 50 years of age at the time of their hip arthroplasty are presented.

Methods: Follow up was both clinical, using Oxford and Harris Hip scores, and radiological. Kaplan-Meier survivorship analysis was performed to calculate the survivorship of the acetabular components. Failure was defined as either liner exchange or acetabular component revision due to aseptic loosening, osteolysis, infection or dislocation.

Results: The mean age of the patients at the time of surgery was 40 years (range 19–49 years), with follow up of between 12 and 16 (mean 13.6) years. All patients’ acetabular components were implanted primarily with cemented femoral components. The mean Oxford Hip Score at the end of the follow-up period was 20 out of 60 (range 12–46) and Harris Hip Score 81 (range 37–100).

At the end of the follow up period, 11 of the 70 acetabular components (polyethylene liner or the acetabular shell) had been revised. The cumulative survival was 94.0% (95% confidence interval 88.4–99.7) with revision of the metal shell as the end point, and 84.0% (95% confidence interval 74.5–93.5) with revision surgery of the acetabular shell or liner due to any reason as an end point. Radiologically, 4 patients require acetabular revision and 22 patients had femoral osteolysis in gruen zone 7, indicative of polyethylene failure. This gave a combined revision, impending revision and zone 7 osteolysis cumulative survival of 55.3% (95% confidence interval 40.6–70.0).

Discussion: In contrast to cemented acetabular components which undergo aseptic loosening and give groin pain, high density polyethylene lined metal shells do not give groin pain but cause silent acetabular and femoral osteolysis. The danger time for osteolysis is between 10–20 years, therefore follow up at that time is essential.


A Hart P Maggiore A Sandison B Sampson S Muirhead-Allwood P Cann J Skinner

Introduction: Approximately 0.5 % of patients with metal on metal hip replacements develop post operative pain which is thought to be due to an immune reaction to metal wear particles, known as Aseptic Lymphocyte Dominated Vasculitis Associated Lesion (ALVAL). Treatment usually requires revision to a non metal on metal hip.. Is the development of ALVAL more likely in those patients with high wear rates?

Methods: Retrieved Metal on Metal (MOM) hip implants; periprosthetic tissue and blood samples were obtained from patients (n = 18) undergoing revision for unexplained pain at a mean of 2 years post operatively. The following variables were measured:

linear wear rate (depth of the femoral head and acetabular socket wear patch/time from operation);

the diagnosis and severity of ALVAL from histological sections of periprosthetic tissue (Wilhert grading system);

pre-revision whole blood cobalt, and chromium levels using Inductively Coupled Plasma Mass Spectrometry.

All implants and tissue samples were analysed against control samples from patients undergoing revision of MOM hips for fractured femoral neck or impingement.

Results: Linear wear rates of retrieved implants, and blood levels of cobalt and chromium from patients with unexplained plain were greater than from control patients. Histolopathological analysis of tissue showed dense inflammatory infiltrates with healthy looking endothelial cells in all vessels from both patient groups.

Discussion and Conclusion: A painful MOM hip was associated with high wear rates and blood metal levels. The local inflammatory response was similar to “ALVAL”, ie lymphocyte dominated, but not exclusive to those patients with unexplained pain. We question whether ALVAL represents a vasculitis, or merely a classical lymphocyte driven inflammatory tissue response to metal debris particles.


C Olyslaegers T W Wainwright R G Middleton

Introduction: This study evaluates the effect on hospital length of stay (LOS) of patients receiving a total hip replacement (THR) as part of a patient centred approach. In order to meet the “18 week” target a pathway was developed by combining the latest research evidence with guidance from the NHS Institute for Innovation and Improvement.

Methods: We prospectively studied the first 134 THR patients who followed the new pathway. The pathway included an enhanced pre-assessment process. Admission dates were mutually agreed and a predicted discharge date of 4 days was provided. All patients attended a pre-operative education session. Patients were admitted on the day of surgery with staggered admission times and followed an intensive physiotherapy program. The surgeons, surgical techniques, and discharge criteria all remained unchanged.

Results: 100% of patients were admitted on the day of surgery and the average time between admission and start of surgery was 2hrs 41mins. All patients walked to theatre and 100% of patients received their first physiotherapy intervention within 18 hours post-operatively. The average length of stay was 3.85 days. 87% of patients went home on or before their predicted day of discharge. The patient feedback was excellent and satisfaction rates were very high. There were no alterations in surgical complication rates compared to before the pathway was introduced.

Discussion: This decrease in LOS was dramatic and highly clinically significant. The average LOS for THR patients prior to commencing this new pathway was 7.5 days. High patient satisfaction rates indicate that by adopting a patient centred approach, significant decreases to LOS can be achieved alongside improving the quality of care. Pressure to meet the “18 week” target provided an opportunity to improve working practice as well as increasing surgical capacity.


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H. Pandit S. Glyn-Jones R. Gundle D. Whitwell C.L.M. Gibbons S. Ostlere N. Athanasou H.S. Gill P. McLardy-Smith D.W. Murray

Introduction: We report on a group of 20 metal-on-metal resurfaced hips (17 patients) presenting with a soft tissue mass associated with various symptoms; these masses we termed pseudotumours. All patients underwent plane radiography; CT, MRI and ultrasound investigations were also performed for some patients. Where samples were available histology was performed.

Methods: All patients in this series were female. Presentation was variable; the most common symptom was pain or discomfort in the hip region. Other symptoms included spontaneous dislocation, nerve palsy, a noticeable mass or a rash. The common histological features were extensive necrosis and lymphocytic infiltration. Fourteen of the 20 cases (70%) have so far required revision to a conventional hip replacement and their symptoms have either settled completely or improved substantially since the revision surgery. Two of the three bilateral cases have asymptomatic pseudotumours on the opposite side.

Conclusions: We estimate that about 1% of patients develop a pseudotumour in the first five postoperative years after a hip resurfacing. The cause of these pseudotumours is unknown and is probably multi-factorial, further work is required to define this; they may be manifestations of a metal sensitivity response. We are concerned that with time the incidence of these pseudotumours will increase.


AR Karva TN Board S Mohan ML Porter

Introduction: Hip Resurfacing has increased in popularity, particularly in young, active patients. However, concerns remain regarding metal ion levels, hypersensitivity leading to aseptic lymphocytic-vasculitis-associated lesions(ALVAL) and AVN. The purpose of this study was to document our experience of revising resurfacing arthroplasty for ALVAL.

Methods: All patients undergoing conversion of hip resurfacing to total hip replacement at our institution were reviewed. The notes were reviewed for the reason for revision, the make of the implant, time interval between primary procedure and revision and final diagnosis. Radiographs were reviewed to assess for implant alignment, signs of loosening, neck thinning and AVN.

Results: Out of the 34 patients who had revision surgery 13 were revised for suspected ALVAL, with mean age of 58.8 years at a mean 42.9 months following primary surgery. Of the 13 resurfacings revisions 11 were Birmingham resurfacing and 1 each of Cormet and ASR resurfacing. Groin pain was the presenting complaint in all patients, 5 patients developed their symptoms immediately postoperatively whilst 8 developed symptoms at mean 28.25 months. Haematological investigations were non-diagnostic. Radiographs were normal in 4 patients, whilst 4 demonstrated a loose cup. Thinning of femoral neck and vertical cup alignment were present in 2 patients each while 1 patient had both vertical cup and thinning of femoral neck. All revisions were achieved with primary implants and all patients had immediate pain relief after surgery. Implants and tissue were sent for laboratory analysis. 3 patients had a confirmed histological diagnosis of ALVAL, the remaining cases had identical operative findings and are presumed ALVAL.

Discussion: ALVAL accounts for nearly 1/3 of all our revisions for failed resurfacing arthroplasty. Unexplained pain in patients with resurfacing arthroplasty should be considered for a diagnosis of ALVAL and investigated appropriately. Symptoms tend to resolve reliably following conversion to total hip arthroplasty.


SS Jameson DJ Langton AVF Nargol

Introduction: Patient selection has been critical to the excellent medium-term clinical results following hip resurfacing. Hypersensivity to metal ion debris has been described in previous generations of metal-on-metal bearings. This may also be a problem that affects modern designs. Characteristic histological changes have been identified (ALVAL). There are few studies that include large female numbers, and show separate outcome and implant survival.

Methods: Eighty-one female hips at a mean of 23 months (11–43) had an ASR hip resurfacing procedure at a single-surgeon independent centre. Mean age was 55 years (28–69). Harris Hip Scores (HHS) were recorded at one-year follow-up. Failures were analysed.

Results: HHS improved from 46.4 (11–77) to 90.2 (27–100). Overall, there was a 7.4 % revision rate. There were 3 femoral neck fractures. In the entire series of 98 female patients there were 3 cases of severe pain requiring revision (3.1%). All three patients had HHS < 50 at one year follow-up. Patients had groin pain, reduced flexion and a painful straight leg raise. Blood results were not suggestive of infection. Aspiration of the hip joint in each case revealed copious amounts of milky green grey aseptic fluid. All had similar macroscopic changes at revision. There were characteristic histological changes in keeping with ALVAL. All 3 patients were revised to THRs with ceramic bearings.

Discussion: The failure rate of 7.4% in the older female group is poor at this early stage following hip resurfacing. The incidence of metal hypersensitivity in our series suggests this complication may be more common than previously thought. Patients with persisting pain of unknown aetiology following resurfacing at other centres may have metal hypersensitivity.


R P Baker M Kilshaw M Pabbruwe A Blom G C Bannister

Introduction: Resurfacing hip arthroplasty is a successful option for the treatment of the young and active patient with hip arthritis. However, it is complicated by femoral neck fracture and avascular necrosis, which may result from devascularisation during surgery. Devascularisation maybe caused by thermal necrosis. Thermal necrosis of bone has been shown to occur in temperatures of 47°C and above. We investigated the temperatures generated during femoral head preparation to see if the temperatures reached were great enough to induce osteonecrosis.

Method: Eight patients with osteoarthritis underwent standard resurfacing hip arthroplasty through the posterior approach. From the first over-drilling of the femoral heads until the prosthesis was cemented in place the temperatures generated at the bone surface were recorded using an infra-red thermal imaging camera. Images were captured every 4 seconds as the operation was performed with no interference to the surgeon

Results: The maximum temperatures generated occurred during sleeve reaming at 88.4°C. Seven patients had a temperature recorded greater than 47°C. Removing the femoral caput with an oscillating saw had the highest mean temperature 62.2°C, followed by sleeve reaming (mean 48.7°C). Female patients had the lowest temperature rises and patients receiving the larger femoral prosthesis the greatest temperatures at the bone surface.

Conclusions: Heat generated during femoral head preparation exceeded 47°C in all but one case. Osteonecrosis secondary to thermal insult is likely to occur during femoral head preparation. Strategies need to be devised to decrease the temperatures generated during femoral head preparation.


ED Fern D Williams R Reddy MR Norton

Thinning of the femoral neck occurs in 77% of patients undergoing hybrid Birmingham hip resurfacing using a posterior approach (Shimmin 2007). Villar recently reported lower neck thinning rates in uncemented Cormet resurfacings (11.7%) compared with hybrid Birmingham resurfacing (13.4%), both via a posterior approach.

We have evaluated implant position and femoral neck thinning in a cohort of 273 uncemented HA coated Cormet 2000 hip resurfacings using ‘B’-series (Titanium/HA coated) cups in 269 patients (mean age 54 years, 39% female) with a mean follow-up of 3 years (range 1–4 years).

Mean cup inclination was 45° (30°–63°), mean SSA 138° (120°–178°). No lucent or sclerotic zones have been identified around the stem of the component. Only one femoral neck fracture has occurred (incidence 0.36%)

We have identified only one case of femoral neck thinning in our series (0.36%).

Whilst Villar has demonstrated a slight reduction in neck thinning rates using the same implants compared to a hybrid fixation Birmingham resurfacing, his neck thinning rates are almost 40 times higher than in our series. Shimmins ‘severe neck thinning (> 10%) rates (27%) are approximately 120 times higher than our series. In addition, we have been unable to confirm the relationship between implant position and neck thinning described by Shimmin in our series using the combined Ganz/uncemented resurfacings compared with Birmingham resurfacings.

Implant design and surgical approach have an impact on ‘neck thinning after resurfacing; we should be wary of treating all resurfacing implants and techniques as a uniform cohort.


S Mohan TN Board J Fishwick V Jeffs ML Porter

Introduction: The Birmingham Hip Resurfacing(BHR) has shown encouraging early to medium term results. It has tended to be used in patients wishing to achieve high functional activity. However there is little data available to support this notion. The purpose of the study was to report the functional levels of patients following BHR.

Methods: Since February 2000, 313 patients have undergone resurfacing by the senior author. Two hundred and sixty four patients with a minimum 12 month follow-up were assessed for functional activity using the modified UCLA activity score. Patients were asked to score their activity level during the pre-symptomatic period as well as pre-operatively and during follow-up.

Results: The mean age at surgery was 55.7 years. The mean follow-up period was 46.72 months. The revision rate for any reason was 3.8%. The mean pre-symptomatic, pre-operative, one year post-operative and final follow-up UCLA scores were 7.9, 3.7, 6.6 and 7.0 respectively. At one year 89% (235 patients) had improved by at least one activity grade from pre-operative levels and 35% (93 Patients) achieved functional scores the same as, or better than their pre-symptomatic levels. This increased to 45% at final follow-up. Of the 242 patients previously involved in moderate activity(UCLA> =5), 31% regained this activity level at one year, rising to 40% at last follow-up. Only 19% of the 180 patients participating in very active/impact sports(UCLA> =8) obtained these levels at one year, rising to 30% at last follow-up.

Conclusion: This is the first assessment of function after BHR comparing pre-symptomatic scores with those obtained during follow-up. Functional scores continue to improve beyond one year in all groups. Significant numbers of patients can achieve functional levels at least as good as before they developed symptoms from their hip, however, the proportion of patients achieving this goal reduces with increasing pre-symptomatic activity.


B. Ollivere S. Duckett A. August M. Porteous

Introduction: The Birmingham Hip resurfacing was commercially introduced in 1997 and early originating centre series show good functional outcomes. Concerns have been raised over the longevity, functional outcomes and metal ion release from the implants. There are no series of medium term results from an independent district general hospital reported in the literature. We present a prospective series of 100 patients with mean 5 year follow up from a district general hospital. Each patient underwent yearly clinical, hip scoring, and regular radiographic evaluation.

Radiographic analysis was undertaken using Harris’, Hodgkinson’s and Amstutz’s criteria, evaluation of component position, neck narrowing and migration using diagnostic PACS workstations with standardised scaled images.

Results: Between June 2001 and Feb 2004 100 Birmingham Hip replacements were performed by two consultant surgeons (MP, AA). Mean follow up is 61.2 months (range 38–76 months). Harris hip scores (fig 1) improved from 46 pre-operatively to 90 post-operatively and no significant change over the next five years. There were no revisions in this period. Obese patients (BMI> 30) had a significantly (p< 0.03) lower post operative functional score as compared normal patients. No other factors were significant for outcome.

Component position was satisfactory in 93% of cases. Radiographic analysis showed no cups, or stems were definitely loose. Radiolucent lines were present in 8/100 acetabular and 3/100 femoral components, osteolytic lesions were seen in three acetabular components. Mean neck narrowing was 9mm. No patients show any radiographic evidence of avascular necrosis.

Conclusion This independent series shows the results of the Birmingham hip resurfacing are reproducible and comparable to those reported in the originating centre. The Birmingham hip resurfacing gives excellent clinical results, and there is no early evidence of radiographic failure. The high rate of neck narrowing gives us cause for concern and we would recommend regular radiographic follow up.


GNA Heilpern NN Shah MJF Fordyce

Introduction: Preliminary results of the Birmingham Hip Resurfacing Arthroplasty were promising. The first series with minimum 5 year follow up was published in 2005 and came from the designing centre. Survivorship and functional results were good. This is the first series with a minimum 5 year follow up not from the designing centre.

Methods: All patients who underwent BHR between the dates of October 1999 and May 2002 were included in the study.

Results: We report 114 of 117 (97% follow up) consecutive metal-on-metal hip resurfacings in 105 patients with a minimum of 5 years follow up. Revision of either the femoral or acetabular component during the study period is defined as failure. We had 4 failures giving a survivorship at 5 years of 96.5% (95% confidence interval (CI) 93–100). The mean follow up was 72 months and the mean age at implantation was 54.5 years old (Range 35–75). All patients were followed up clinically and radiographically.

The mean Harris hip score at follow up was 96.4. The mean Oxford Hip Score fell from 41.6 preoperatively (Range 16–57) to 15.3 postoperatively (Range 12–49) p< 0.0001. The UCLA Activity Scale rose from 3.93 preoperatively (Range 1–10) to 7.54 postoperatively (Range 4–10) p< 0.001.

Radiographic analysis revealed an average stem shaft angle of 130.6 degrees (Range 112–148) with average cup alignment of 36 degrees (Range 22–47). Neck thinning was present in 16 hips (14%) and we define a technique for measuring thinning.

Discussion: This study confirms that metal-on-metal resurfacing produces an excellent clinical and functional outcome in the younger patient who requires surgical intervention for hip disease. The results compare favourably with those from the originating centre and confirm that resurfacing is well suited for younger higher demand patients.


A.G. Cobb R.D Oakeshott T O’Sullivan

Introduction: Over 20,000 DePuy ASRTM hip resurfacing procedures have been performed since 2003, the implant design applying modern engineering and tribological principles to minimise metal-on-metal bearing wear. Enhanced fixation of both components, high-carbon cobalt-chromium alloy, reduced material thickness and small diametral clearance 100–150 microns are all supported by non-clinical testing. There are published reports of very low wear on hip joint simulators (Dowson D, et al. 2004 Dec;19(8 Suppl 3):124–30.), low wear on retrieval analysis (Morlock MM et al 1: Proc Inst Mech Eng [H]. 2006 Feb;220(2):333–44.) and excellent clinical results (Siebel T et al, Proc Inst Mech Eng [H]. 2006 Feb;220(2):345–53. We recently reported median whole blood chromium and cobalt ion levels of 1.56 ppb and 1.65 ppb at 24 months (Cobb AG et al, British Orthopaedic Association Congress 2007)

Methods: 1030 consecutive cases carried out by 3 of the surgeon-designers between July 2003 and May 2007 have been studied prospectively at annual intervals. 2 to 4 years follow-up data is available on 293 hips.

Results: There have been 11 revisions for fracture (1.06%), 6 in patients aged over 65 years(3.4%), 5 in patients aged up to 65 years (0.6%) (P< 0.001).

There have been 3 revisions for cup loosening (0.29%) and 3 for pain (0.29%). 5 patients have died (0.51%). There was one revision for infection and one for impingement.

Average Harris Hip Score rose from 57.0 to 97.1, and 60% of patients scored 100.

UCLA activity score was 6 or over in 91%, and the median score was 7.5.

All failures were evident by 12 months

The Cumulative Survival Rate at 3 years was 97.4%,, 99.5% for 55 years and under, 98.3% for under 65 years, and 94.2 % 65 years and over.

Discussion: The 2 to 4 year clinical follow-up of the latest generation of surface hip implants is satisfactory. Technical errors during implantation or patient selection accounted for most of the failures. The risk of failure between 12 months and 4 years is low.


CR Lawrence D Raj GS Keene

Introduction: Total hip-joint arthroplasty is associated with a high rate of peri-operative blood transfusion, which has associated risk. Previous studies have identified individual factors than can predict those patients most at risk of post-operative allogenic blood transfusion. We undertook this study to attempt to identify further factors that may predict post-operative blood transfusion.

Methods: Data was collected pre-operatively for patient demographics including type of surgery, sex, age, BMI, ASA, pre-operative haemoglobin & pre-operative packed cell volume for all total hip arthroplasties performed by a single surgeon over twelve months (Total number 233; 166 primaries, 33 resurfacing & 20 revision arthroplasties: 14 excluded for insufficient data). Post-operative data collection included post-operative haemoglobin levels and allogenic transfusion requirements.

Results: Of 166 patients who underwent primary hip arthroplasty, 25 (15.1%) received allogenic blood transfusions, an average volume of 2.1 units per patient transfused. Analysis revealed significant predictive factors of gender (females > males, p=0.0019), advancing age (p=0.0045), lower height (p< 0.0000), lower pre-operative weight (p=0.0010), lower pre-operative haemoglobin (p< 0.0000), and lower pre-operative packed cell volume (p< 0.0000). Patients who underwent revision surgery were also more likely to have undergone transfusion compared to both primary (6.1% transfused, p=0.025) and resurfacing arthroplasty (35% transfused, p=0.009). BMI and ASA were found to not be significant risk factors. Pre-operative packed cell volume (PCV) showed the strongest correlation with post-operative blood transfusion. Cases with a PCV below the average of 39% had a rate of transfusion of 28%, 6.4 times greater than for those patients above the average at 4.4% (p< 0.0000).

Discussion: Pre-operative measurements of height, weight, haemoglobin and packed cell volume, together with factors including sex & type of surgery can identify those patients who are at greater risk of post-operative transfusion allowing selective transfusion prevention strategies.


C P Challand D Mahadevan A Clarke J Keenan

Introduction: Effective utilisation of blood products is fundamental. The introduction of Maximum Surgical Blood Ordering Schedules (MSBOS) for operations provides guidance for effective cross-matching. A retrospective analysis of blood ordering practices was undertaken to establish an evidence-based MSBOS for revision THR and TKR. The impact of the use of intraoperative cell-salvage devices was also assessed.

Methods: The patient database was searched for cases of revision THR and TKR undertaken over 58months. These records were then cross-referenced with the transfusion database. The cross-match to transfusion ratios (CTR) and transfusion indexes (TI) were calculated using this data.

The gold standard for the CTR is 2:1 or less. Procedures with ratios greater than 3:1 should substitute for a ‘group and save’. The TI establishes the likelihood of blood being transfused for a certain procedure, i.e., the number of units transfused divided by the number of patients having the procedure. If the TI is less than 0.5, then cross-matching blood is considered unnecessary.

Results: For revisions of non-infected THR (n=269), the CTR=2.24 and TI=1.67. In infected cases (n=69), CTR=2.16 and TI=1.68.

In revisions of non-infected TKR (n=95), the CTR=4.33 and TI=0.48. In infected cases (n=54) the CTR=2.16 and TI=1.35.

There was considerable change in the practice of ordering cross-matched blood following the introduction of intraoperative cell-salvage devices (Revision THR: CTR=1.93, TI=0.84; Revision TKR: CTR=1.20, TI=0.16)

Discussion: The analysis confirmed that more blood was requested than was actually required. Overall the results suggest that cross-matching is still necessary for both the non-infected and infected revision THR but the number of units requested could be reduced to 2units. In revision TKR, transfusions were more likely in infected cases and, a ‘group & save’ may be sufficient for non-infected cases.

The introduction of this MSBOS in conjunction with intraoperative cell-salvage, could promote blood conservation and financial savings.


ED Fern P Easwaran MR Norton

Since 2003 we have adopted an aggressive approach to the management of the SUFE deformity, an important cause of anterior femoro-acetabular impingement, associated with the development of early adult hip arthritis.

16 patients aged 16.7 years (range 11–20, 3 female, 13 male, 8 right, 8 left hips) underwent surgery to manage their SUFE deformity.

7 patients had secondary correction of deformity after previous in-situ pinning and 9 underwent primary surgical management using a Ganz approach (7) or primary in-situ pinning with femoral neck resection via a Smith-Peterson approach (2).

Of the 7 patients who had primary in-situ pinning 26 months (range 4–44 months) earlier, 2 had acetabular chondral flap tears with eburnated bone and 6 had significant labral degenerative changes associated with calcification or tears.

Only one of the nine patients who underwent primary aggressive management of their SUFE, had a labral tear.

4 patients underwent mobilisation of the femoral head on its vascular pedicle followed by anatomical realignment.

At an average follow-up of 22.3 months (range 1–41 months) 15 remained well with excellent function. Leg lengths remained equal in 12, with an average shortening of 2cm in the remaining 4 patients.

Segmental AVN occurred in the first patient after damage to the vascular pedicle during drilling of the neck; the technique has been modified to prevent further occurrences.

Removal of the trochanteric osteotomy screws has been performed in 4 cases.

Despite having performed over 400 surgical hip dislocation, the authors continue to find the management of this condition challenging; nevertheless, having seen the direct consequences of femoro-acetabular impingement at an early stage in these young patients, we believe that aggressive management to correct anatomical alignment is essential for the future well being of the hip.


M Hossain J Lewis A Mustafa A Sinha

We present the results of prospective evaluation of digital compared to plain radiographic pre-operative templating for primary total knee replacement. All consecutive patients undergoing primary knee replacement under the senior author (AS) were eligible. Patients with previous knee replacement or without calibrated digital or plain radiographs were excluded. Plain radiographs were templated against acetate templates supplied by the manufacturer. Digital images were templated with the help of commercial software TraumaCad. A 25mm spherical metal ball placed nearest to the affected knee joint acted as calibration object. AS performed all the templating. The ICC value for intra-rater reliability was 0.846 for tibial templating and 0.840 for femoral templating. PFC sigma cruciate substituting components were implanted in all patients. 28 consecutive patients between April 2006 and June 2007 were included. Accurate digital templating score was 80% for tibial implant and 40% for femur. Accuracy of analog templating was 55% for tibial implant and 50% for femur. There was no mismatch of over one size. The differences between templated and implanted sizes were plotted against their mean in Bland-Altman plot. The 95% confidence interval of the differences between digital and actual sizes were: 0.78 to − 0.75 sizes for tibial implant and 1.15 to −0.93 sizes for femoral implant. The 95% confidence interval of the differences between plain and actual sizes were: 0.38 to −0.99 size for tibial implant and 0.93 to −1.32 size for femoral implant. The two tailed P value for difference between digital and analog templating from a Wilcoxon matched pair signed rank test was 0.021 for tibia and 0.006 for femur. We found preoperative templating by the operating surgeon reliable and accurate but digital templating did not offer any additional advantage.


R W Trickett P Hodgson M C Forster A Robertson

We aimed to determine the reliability, accuracy and consequently the clinical role of digital templating in the pre-operative work up for total knee arthroplasty patients.

With the increasing use of digital radiology images, analogue templating may soon be defunct. Digital templating is a more recent development and its role is yet to be determined.

Ten pre-operative digital radiographs were templated by four independent observers. Inter-observer and intra-observer reliability was assessed using the kappa measure of concordance. Subsequently, 40 consecutive total knee arthroplasty patients underwent pre-operative digital templating. This was a blinded process by a consultant surgeon not involved with the operation. Each patient underwent TKR using the PFC Sigma System sized intra-operatively, without the operating surgeon having knowledge of the pre-operative templating result. Comparison was made between the pre-operative digital templates and the blinded intra-operative sizing.

For both the femoral and tibial templating there was good to very good inter- and intra-observer agreement. For the femoral component the templating was correct in 47.5% (± 1 size difference 97.5%). The tibial templating was correct in 55% (± 1 size difference 100%).

The inter- and intra-observer reliability of digital templating process has been shown to be acceptable but the correlation between digital templating and the actual size implanted is poor. Our series shows a similar accuracy to the published data on analogue templating for the same implant. Like analogue templating, its clinical role remains uncertain and its poor correlation to the actual implant sizes limits its usefulness.


D W Murray

There is little good evidence about the relative merits of different knee replacement designs as no adequately powered randomised controlled trials have been undertaken. To address this, a pragmatic multi-centre randomised trial involving 116 surgeons in 34 UK centres was begun in 1999. Within a partial factorial design 1715 patients were randomly allocated to patella resurfacing or not, 539 to mobile bearing or not and 409 to metal backing of the tibial component or not. Primary outcome measures are the Oxford Knee Score (OKS), SF-12, EQ-5D and need for further surgery.

At two years there was no evidence of differences in complications, clinical outcome, functional status or quality of life measures between randomised groups.

95% of the patient are now 5 year post-operation and have been sent questionnaires. 93% of these have been returned. By January 2008, all will be past 5 years and will have been sent questionnaires. When the complete 5 year data set is available it will be analysed. The 5 year data relating to the randomised groups will be presented.


U Ramkumar NC Talwalkar A Amin T Taneja CH Aldam PW Allen

Purpose of Study: To assess the safety of our practice of Bilateral Simultaneous Total Knee Replacements.

Methods: We retrospectively reviewed 202 patients (404 knees) who underwent bilateral simultaneous total knee replacements using the DePuy PFC Sigma Cruciate Sacrificing Endoprosthesis between January 2000 and January 2006. There were 103 males and 99 females with an average age of 71.3 years (range 41–90 years) included. Indication for surgery was Osteoarthritis in 190 patients and Rheumatoid Arthritis in 12 patients. All patients were reviewed at 6 weeks, 1 year and then yearly post surgery.

Results: The average hospital stay was 12.4 days (range 5–38 days) with 6 patients needing HDUadmission post surgery. The average observed blood loss in the drains post surgery was 1200ml (700–2600ml) with an average drop in Haemoglobin of 4.1%, 71% of patients needed a blood transfusion post surgery. Two patients (0.99%) developed a deep vein thrombosis and 2 patients (0.99%) developed a pulmonary embolus.3 (1.48%) deaths were encountered in the immediate post operative period (within 30 days of surgery) and 6 (2.9%) patients suffered a myocardial infarct post surgery.14 (6.9%) patients developed a superficial wound infection of which 10(4.9%) needed a formal washout. 8(3.96%)knees needed a manipulation under anaesthesia for a poor range of movement, and 2(.99%) needed revision total knee replacement for infection.

Conclusion: Bilateral simultaneous total knee replacement is a safe procedure in our experience Complication rates observed comparable to published literature on the subject


L Bayliss P Gikas SA Hanna LA David W Aston R Carrington J Skinner SR Cannon TWR Briggs

Introduction: We report our experience with use of the SMILES prosthesis in primary knee arthroplasty.

Methods: The Stanmore Modular Individualised Lower Extremity System (SMILES prosthesis) has been shown to be effective in complex revision knee surgery. It incorporates a rotating hinge platform knee joint and can overcome the major problems of bone loss and ligamentous laxity.

38 patients (41 knees) who received a primary SMILES knee prosthesis by one of the senior authors between 1990 and 2006 were retrospectively studied. Knee function was assessed pre and post-operatively using the Oxford knee score (0–48 scoring system) and the Knee Society Score. Patients receiving surgery for tumours were excluded. The main indications for primary SMILES were bone loss and ligamentous laxity.

Results: The minimum follow-up was 18 months with a mean of 5 years (1–17). The mean age of the patients was 57.7 years (23–86); 15 of the patients were male. The indications for surgery were trauma (12), osteoarthritis with deficient medial collateral ligament (8), polio (7), rheumatoid arthritis (5), epiphyseal dysplasia (4), achondroplasia (2), avascular necrosis (1), osteogenesis imperfecta (1) and ankylosing spondylitis (1).

2 patients died and 5 were lost to follow-up. 2 patients required revision surgery (one for infection and one for re-bushing). Post-operative complications included peroneal nerve palsy (1) and DVT (1). The mean Oxford knee score improved from 9 pre-op to 44 post-op, and the mean knee society score improved from 24 pre-op to 71 post-op. The average range of motion was 57 degrees pre-op and 88 degrees post-op.

Conclusion: We conclude that the SMILES prosthesis offers significant improvement in clinician and patient assessed outcome scores in complex primary knee arthroplasty. The cost compares favourably with other designs and its use is well established.


D Longino S Hynes R Rout H Pandit D Beard H Gill C Dodd D Murray C Cooper M Javaid A Price

Purpose: The aim of this study is to compare the long-term survival results of TKA in patients under the age of 60, using

revision surgery and

poor functional outcome as the end-points.

Method: From our knee database we identified a cohort of 60 total knee replacements that had been performed over 15 years previously. We identified those who had died, those who had been revised and established the Oxford Knee Score (OKS) for all those still surviving.

Results Using the following endpoint criteria the cumulative 15-year survival was (A) revision surgery alone = 78% (CI 12), (B) revision surgery or an OKS less than or equal to 24 (50% of total OKS) = 63% (CI 13), and (C) revision surgery or moderate pain = 48% (CI 14).

Conclusion The functional survival of TKA in patients under the age of 60 decreases in the second decade following implantation with a significant number of prostheses failing the patient due to knee pain


Full Access
A Lakdawala J Ireland

Introduction: The aim of this study was to investigate the function, limitations and disability of a large cohort of active golfers following total knee replacement (TKR).

Materials & Methods: The study group comprised the membership of the New Knee Golf Society (NKGS), UK. 211 members were reviewed with a questionnaire which asked the patient’s experience & difficulties of playing golf before and after TKR. The functional outcome was recorded using the Oxford knee score.

A total of 299 knees in 209 patients were included in the final analysis. The mean age was 69.6 years. Majority of the prostheses were cemented (95%) and had patellar resurfacing (89.6%). The mean post-operative period was 5.1 years.

Results: 196 patients (94%) returned to playing golf after a mean 4.6 months following the TKR. 184 (88%) continue to play at review. 92.8 % claimed significant improvement in their ability to play and enjoy golf following TKR citing reduction in pain and improved walking ability as the reasons. However, none claimed to have achieved a significant improvement in their handicap.

17 knees (5.7%) underwent revision surgery. 6 knees (2%) were revised for infection at mean 17.3 months & 11 (3.7%) for aseptic loosening or instability at mean 4.9 years. 7 left knees (lead knee) of 11 right-handed golfers required revision for aseptic loosening.

The main problems experienced after playing 18 holes were knee stiffness (47%) & swelling (18%).

Conclusion: Although the ability to play improved the handicap remained the same. The left TKR in a right-handed active golfer is more likely to require revision which may be due to the increased torque on the lead knee.


M J Risebury M Price N P Thomas

To establish the efficacy of a new arthroscopic technique, for the treatment of stiffness after TKR.

Introduction: The usual surgical procedure for stiffness after a total knee replacement is an open arthrolysis, though an arthroscopic procedure can be considered within six months of the index surgery. We have evolved a new procedure of capsulectomy and anterior release which can be used at any time after TKR in patients with a reduced range of movement (ROM).

Methods: 22 patients (10 women and 12 men) underwent arthroscopic capsulectomy and anterior release for the treatment of loss of movement after TKR. The mean age was 62 (range 47–71 yrs). Mean time between TKR and arthrolysis was 27 months (range 3–54). Indication for the arthroscopic procedure was decreased ROM following TKR. Arthroscopy was performed using anteromedial and anterolateral portals. The dense scar tissue was divided and completely excised arthroscopically. ROM was assessed pre-operatively, immediately post-operatively and at 2, 6, 12 weeks, 6 months and 1 year. The Oxford Knee Score (OKS) and American Knee Society Score (AKSS) were used pre-operatively and at 6 months and 1 year post-operatively.

Results: Pre-operatively mean flexion was 50 degrees (Range 20–90°). Post-operatively it was 94.5° (Range 55–125°). At 1 year this was maintained. The mean OKS pre-operatively was 18.4 (range 8–39). At 1 year it was 29.8 (range 9–39). The AKSS (knee and functional components) showed a similar improvement. The mean knee score increased from 47.3 pre-operatively to 71.6 at 1 year. The functional score rose from a mean of 51.3 pre-operatively to 76.9 at 1 year.

Conclusions: Our technique of arthroscopic capsulectomy and anterior release for the treatment of stiffness following TKR is both successful and safe. At 1 year post-operatively the patients have maintained an increased ROM and significantly improved Oxford and American Knee Society Scores.


M J Chambers B P Rooney L Campton W J Leach

The aim of this work was to compare the oxygen saturations in patients in the early period following total knee joint replacement surgery performed using either computer navigation or conventional intramedullary mechanical jigs.

Between August and November 2007 twelve consecutive patients who had computer navigated total knee joint replacements were prospectively reviewed. A comparison group from the same period was made of twenty patients who had knee replacements performed using conventional jigs. Non-invasive oxygen saturations were measured and recorded as a percentage. Preoperative oxygen saturations measured at the assessment clinic were used a baseline. For the duration of the patients postoperative hospital stay oxygen saturations were measured five times a day as well as their oxygen requirements.

We found that the patients in the computer navigation group on average reached oxygen saturation levels on air equal to those measured in the assessment earlier than the intramedullary jig group. There was also a lower need for oxygen in the computer navigated group during this early post operative period.

Previous studies using transcranial Doppler and transoesophageal echocardiograms have shown a reduction of systemic emboli with computer navigated total knee joint replacements. Using oxygen saturation monitoring we have shown there may be a considerable clinical advantage using computer navigated surgery over conventional intra-medullary rod jigs in knee replacement surgery.


GCA Wood S McDonald R McCalden RB Bourne D Naudie

Aim: The purpose of this study was to report our experience mid to long-term results of hybrid cement fixation in revision total knee arthroplasty.

Methods: Patients who underwent revision total knee arthroplasty using a hybrid cement technique (press-fit diaphyseal fixation and cemented metaphyseal fixation) with a titanium fluted revision knee implant were reviewed. There were 127 patients. Mean age at surgery was 71 years (range 41–94 years). There were 56 males and 71 females. Mean follow-up was 5 years (range, 2–12 years). A Kaplan-Meier survivorship analysis using an end-point of revision surgery or radiographic loosening was employed to determine probability of survival at 5 and 10 years.

Results: 127 patients (135 knees), 31 patients (36 knees) died and 2 patients (2 knees) were lost to follow-up. Six patients (six knees) were revised at a mean of 3.5 years (range 1–8 yrs). Of the 6 revisions, two were for re-infection, two were for (MCL) instability, and two were for aseptic loosening. Mean Knee Society clinical and functional scores were 86 and 55 points, respectively. The mean range of motion was 108 degrees. End of stem pain was not reported in this group of patients. Kaplan-Meier survivorship analysis revealed a probability of survival free of revision for aseptic loosening of 98% at 12 years.

Discussion: The results of this study suggest that the use of a hybrid cement technique in revision knee arthroplasty can provide good mid to long-term results. Radiographic analysis has shown continued satisfactory appearances regardless of constraint, stem size and augments. Our experience has shown that the survivorship of a hybrid fixation technique for revision knee arthroplasty is comparable to reported long-term survivorship of cemented revision knee arthroplasty.


I Starks J J Gregory S J Phillips

Purpose: To examine the outcome of primary and revision knee arthroplasty in very elderly patients.

Methods and Results: Patients in their 90th year of life who underwent primary or revision knee arthroplasty between January 2000 and September 2007 were identified. Data was collected regarding demographics, ASA grade, co-morbid factors, complications, length of inpatient stay, the need for transfusion and discharge destination. Thirty day, 1 year and current mortality figures were calculated.

Twenty one procedures were performed on 18 patients with a mean follow up of 18.8 months (3–57.9). There were 14 primary total knee replacements and 7 revision procedures. The mean age at the time of surgery was 90 years and 10 months (89 years 1 month to 94 years 4 months). The majority of patients were female (15). All patients were ASA grade 2 or 3. The average orthopaedic inpatient stay was 17 days. Thirty percent of patients required a period of further inpatient rehabilitation or convalescence after discharge from our institution. Nine patients experienced a post-operative complication. Mortality at 30 days was 0%, at 1 year 6% (1/16), and is currently 17% (3/18).

Conclusion: Very elderly patients are able to tolerate primary and revision knee arthroplasty although there is a high rate of peri-operative complications. We propose that there should be a different tariff for arthroplasty procedures in extremely elderly patients to reflect the increased rate of complications and prolonged postoperative hospital stay.


C Jenkins K Barker H Pandit CAF Dodd DW Murray

The purpose of this study was to determine if a single physiotherapy intervention would enable patients to kneel following Unicompartmental knee arthroplasty (UKA).

Kneeling is an important functional activity that is frequently not performed after knee arthroplasty, thus affecting a patient’s ability to carry out basic tasks of everyday life. There is however no clinical reason why patients should not kneel and many with proposed knee surgery ask about the possibility of kneeling after their operation.

Sixty adults participated in a prospective randomised controlled trial with blinded assessments. At 6 weeks post-operatively UKA patients were randomised to either the Routine care group where no advice on kneeling was given or to the Kneeling intervention group where participants were taught and given advice on how to kneel and were encouraged to do so. They were re-assessed at 1 year. The primary outcome measure was Question 7 of the Oxford Knee Score which asks the question “Could you kneel down and get up again afterwards?”

Pre-operatively there was no difference in the kneeling ability of the two groups. At 1 year the difference in kneeling ability between the two groups was highly significant (p< 0.05). Spearman’s correlation coefficient showed no significant association between a change in score of Question 7 at 1 year and the following factors; scar position, numbness, range of flexion, arthritic involvement of other joints and pain. Linear regression analysis also confirmed that these factors were not successful in predicting a change in kneeling ability.

This study showed that the single factor predictive of kneeling ability was the physiotherapy intervention provided at 6 weeks post-operatively and it is suggested that kneeling should be incorporated into patient’s post-operative rehabilitation programmes.


R Chau A Gulati H G Pandit D J Beard H S Gill C A F Dodd D J Simpson D W Murray

Purpose: To evaluate the effects of underhanging/overhanging tibial components on clinical outcome following the Oxford unicompartmental knee arthroplasty (UKA), and to identify an acceptable sizing limit.

Method: One hundred and sixty-three knees which had undergone the Phase 3 medial Oxford UKA (Biomet, Swindon) were measured. Based on five-year post-operative radiographs, they were divided into groups with tibial component underhang (n=38), none or minimal overhang of less than three millimetres (n=121), and a group with overhang equal to or in excess of three millimetres (n=13). Clinical outcome was assessed by changes in the twelve-question Oxford Knee Score (ΔOKS) and pain score (ΔPS) component (questions 1,4,5,8,9) from pre-operative assessment to five years following surgery.

Results: At five years after surgery, ΔOKS was significantly worse in the overhang group compared to both the neutral and underhang groups (p=0.015, and p=0.028 respectively). ΔPS was also shown to be significantly worse between the overhang and the neutral group (p=0.026 respectively).

Conclusion: Appropriate sizing of the tibial component is essential to optimise load bearing in total knee arthroplasty. In UKA such sizing is critical due to halving of the bony support for the tibial component and the lack of room for a large stem. Excessive undersizing of the prosthesis may lead to subsidence and loosening, whilst excessive overhanging may cause local soft tissue irritation and pain.

This study demonstrates that medial overhang of less than three millimetres for the tibial component is acceptable in the Oxford UKA. Excessive overhang equal to this or more results in significantly worse ΔOKS and ΔPS. However, no difference in the five year ΔOKS and ΔPS was demonstrated between underhang and the other two groups in this study.


PJ Kempshall A Metcalffe MC Forster

Following introduction of the second offer scheme in April 2004, Cardiff and Vale NHS Trust sent 227 patients (254 knees) to the independent sector treatment centre in Weston-Super-Mare for total knee arthroplasty. The Kinemax total knee system was used in all cases.

There was a perception that there were a large number of dissatisfied patients, and a previous British Orthopaedic Association report (of a 14 case sample) questioned the quality of the surgery performed.

All of the patients concerned were offered a review in order to assess the outcome. Of the 227 patients (254 knees), 77% have been reviewed (167 patients, 190 knees). 23% (59 patients, 64 Knees) have not been seen. Of these, 30 patients (34 knees) declined review on the basis that they were happy with the result of surgery. 14 Patients (15 knees) were unobtainable by post of by phone. A further 12 patients (12 knees) did not attend appointments. 3 Patients (3 Knees) had died.

The total number of re-operations was 27/254, giving a re-operation rate of 10.6%. There were 21 revisions, 17 for aseptic causes (oversized components, malalignment, aseptic loosening) and 4 for infection. There were 6 secondary patella resurfacings.

A life table survivorship analysis was calculated for the 254 knees. The cumulative survival rate at 3 years was 85.8%. These results are considerably worse than those reported in the current published literature. This has resulted in a significant economic impact on our service.


R. Sreekumar A. S. Desai T. N. Board V. V. Raut

Aims & Objectives: To assess whether the incidence of infection in Primary Total knee Arthroplasty is increased as a result of previous steroid infiltration into the knee joint.

Introduction: Steroid injection into the arthritic joint is a well-known modality of treatment of the arthritic joints. Its efficacy is well documented. Increased incidence of Infection secondary to steroid injection as compared to uninjected joints is reported in recent literature.

Material & Methods: 440 patients underwent Total Knee replacement (PFC SIGMA-Depuy) by senior author during 1997–2005 at Wrightington hospital. 90 patients had intraarticular steroid injection prior to surgery of which 45 patients had injection with in 1 year prior to surgery. All patients had at least one year follow up. Infection rate was assessed by case note, x-rays and microbiology review till last follow up.180 patients of a matched cohort who had total knee replacement without steroid injection were compared for infection rate.

Results: 2 cases of superficial infection were noted in Injection group and 5 cases of superficial infection in Non Injection group. No cases of Deep infection noted in either group. Stastical analysis showed no significant difference in incidence of infection in either group.

Conclusion: Steroids are useful adjuncts in the management of patients with arthritic joints. This study shows no increased incidence of infection in patients given steroid injection prior to arthroplasty.


A Mohan M Lemon M Browne DS Barrett

Removal of solidly fixed implants is a challenge in revision knee arthroplasty. It is fraught with the risk of intraoperative fractures and bone stock vital for the success of subsequent revision surgery. We describe the double extraction technique for extraction of solidly fixed implants. This technique was first tested in laboratory setting and then replicated in the operation theatre with successful results.

In this retrospective study we analysed all our patients in which we used the double extraction technique for the removal of solidly fixed implants. In this procedure, the surgeon and the assistant each place an osteotome on the cement metal interface at symmetric positions, directly opposite each other on the medial and lateral sides. They deliver synchronous blows with a mallet at positions around the interface until the cement fractures. The femoral component can then be easily removed. The technique was tested in a laboratory before it was used clinically. Polyurethane mouldings, representing a suitable substrate for cementing metal components were fixed on to a steel rod of similar weight and length as the lower leg. Stainless steel discs (40mm diameter × 4mm thickness) were cemented on to the polyurethane substrate to form a model of a cemented implant. The discs were instrumented to allow recording of the mechanical processes caused by the double extraction technique and to allow comparison with the single osteotome extraction technique. The methodology successfully demonstrated that the double osteotome technique increases the contact force of the second blow. When the synchronous blows are delivered, less energy is expended in the movement of tibia and more is contributed to the removal of the component.

In this study we looked at a total of 206 patients were the solidly fixed tibial and femoral components were removed using the double extraction technique. There were 86 men and 126 women. The mean age of the patients was 66.8 years (range 37–87 years). Only patients with solidly fixed implants were included in this study. Stability of implants was assessed with preopera-tive radiographs and then confirmed intraoperatively. Patients with loose implants intraoperatively were excluded from this study. We present our results with use of this technique in 206 patients with follow up of 1 to 5 years.


A D Carrothers R E Gilbert J Gregory M J Oakley

The St Leger total knee replacement is a bicondylar prosthesis developed as an cheaper alternative to other similar implants of its time. Between October 1993 and June 1999, 144 St Leger total knee replacements were implanted in 114 patients.

The aim of this study was to clinically and radiologically assess these patients after a mean follow up of 10.22 years.

Between February and July 2007 ninety-one patients recalled for clinical evaluation (using functional and objective American Knee Society Scores) and radiological assessment (using the American Knee Society Scoring System). 11 patients had died and 12 were lost to follow up or were medically unfit to attend evaluation. Of the ninety-one patients recalled, 18 had had their prostheses revised (19 knees). 63% of prostheses had survived 10 years or more.

Of the patients with St Leger knees in situ (99 knees) the American Knee Scores showed 78% poor, 10% fair, 6% good and 6% excellent results. Radiological assessment identified 12 arthroplasties that had failed (5 femoral components, 5 tibial components and 4 patellae,) 58 that needed close follow up (18 femoral components, 31 tibial components and 38 patellae) and 29 that were well fixed. A best-case Kaplan-Meier cumulative survivorship was 87% at 10 years. (Worst-case was 71% at 10 years)

These 10 year results showed that the St Leger total knee prosthesis did not perform as well as other bicondylar prostheses of the same generation and had a higher revision rate. Despite favourable published mid-term results, the long-term results for the St Leger total knee replacement have shown it to be unreliable and not worth the initial financial saving.


H Pandit B van Duren C Jenkins HS Gill D Beard AJ Price CAF Dodd DW Murray

Introduction: Treatment options for the young active patient with isolated symptomatic medial compartment OA and pre-existing ACL deficiency are limited. Implant longevity and activity levels may preclude TKA, whilst HTO and unicompartmentasl knee arythroplasty (UKA) are unreliable due to ligamentous instability. UKAs tend to fail because of wear or tibial loosening resulting from eccentric loading. Combined UKA and ACL reconstruction may therefore be a solution.

Method: Fifteen patients with combined ACL reconstruction and Oxford UKA (ACLR group), were matched (age, gender and follow-up period) with 15 patients with Oxford UKA with intact ACL (ACLI group). Prospectively collected clinical and x-ray data from the last follow-up (minimum 3 years, range: 3 – 5) were compared. Ten patients from each group also underwent in-vivo kinematic assessment using a standardised protocol.

Results: At the last follow-up, the clinical outcome for the two groups were similar. One ACLR patient needed revision due to infection. Radiological assessment did not show any significant difference between relative component positions and none of the patients had pathological radiolucencies suggestive of component loosening. Kinematic assessment showed posterior placement of the femur on tibia in extension for the ACLR group, which corrected with further flexion.

Conclusions: The short-term clinical results of combined ACL reconstruction and UKA are excellent. Lack of pathological radiolucencies and near normal knee kinematics suggest that early tibial loosening due to eccentric loading is unlikely.


A Gulati C Jenkins R Chau H G Pandit C A F Dodd A J Price D J Simpson D J Beard H S Gill D W Murray

Purpose: Varus deformity after total knee replacement (TKR) is associated with poor outcome. This aim of this study was to determine whether the same is true for medial unicompartmental arthroplasty (UKA).

Methods: 158 patients implanted with the Oxford UKA, using a minimally invasive approach, were studied prospectively for five years. Leg alignment was measured with a long-arm goniometer referenced from Anterior Superior Iliac Spine, centre of patella and centre of ankle. Patients were grouped according to the American Knee Society Score (AKSS). Group A: > 0° varus (n=13, 8.2%); Group B: 0 to 4° valgus (n=39, 24.7%); Group C: 5–10° valgus (normal alignment, n=106, 67.12%). Comparisons were made between the three groups in terms of the absolute and the change in Oxford Knee Score (OKS) and AKSS over the five year period, and the presence of radiolucency.

Results: There was no significant difference in any outcome measure except for Objective-AKSS (p< 0.001). The means and standard deviations of the ΔOKS for the groups were:

24 ± 5,

22 ± 10, and

22 ± 9 and for Objective-AKSS were 84 ± 12, 82 ± 15 and 91 ± 11 respectively.

The frequency of five year radiolucency for the groups A, B, and C were 42%, 35%, and 45% respectively.

Conclusion: The aim of the Oxford UKA is to restore knee kinematics and thus knee alignment to the pre-disease state. Therefore, as demonstrated by this study, about 30% of patients have varus alignment. This study also demonstrates that post-operative varus alignment does not compromise the outcome. The only score which did show worse outcome was the Objective-AKSS. This is because 10 or 20 points are deducted for varus alignment, which is not appropriate following UKA. Therefore, AKSS in its present form is not a reliable tool for assessment of UKA.


H Pandit C Jenkins D Beard HS Gill BEA Marks AJ Price CAF Dodd DW Murray

Introduction: The information in the literature about the relative merits of cemented and cementless unicompartmental knee replacement (UKR) is contradictory, with some favouring cementless fixation while others favouring cemented fixation. Cemented fixations give good survivorship but there is concern about the radiolucency which frequently develops around the tibial component. The exact cause of the occurrence of radiolucency is unknown but according to some, it may suggest suboptimal fixation.

Method: Sixty-two knees (31 in each group) were randomised to receive either cemented or cementless UKR components. The components were similar except that the cementless had a porous titanium and hydroxyappatite (HA) coating. Patients were prospectively assessed by an independent observer pre-operatively and annually thereafter. The clinical assessment included Oxford Knee Score, Knee Society Scores and Tegner activity score. Fluoroscopically aligned radiographs were assessed for thickness and extent of radiolucency under the tibial implant.

Results: At one year there were no differences in the clinical outcome between the groups and there were no loose components. No radiolucencies thicker than 1mm were seen. At one year none of the cementless tibias and 30% of the cemented tibias had complete radiolucencies. One out of 31 cementless (3%) and 12 out of 31 cemented (39%) had partial radiolucencies. This difference between these two groups was high significant (p< 0 0001).

Conclusions: This study clearly demonstrates that the incidence of radiolucency beneath the tibial component is influenced by component design and method of fixation. With identical designs of tibial component none of the cementless components developed complete radiolucences whereas 30% of the cemented components did. We conclude that HA achieves better bone integration than cement.


Y Kwong V Desai

Introduction: The indications for patellectomy have been considerably narrowed in recent years, but there remains a cohort of patients with previous patellectomies that remain symptomatic. In addition, these patients can develop osteoarthrosis or instability, and their treatment is challenging. We report our experience of the use of a novel implant to substitute for the absent native patella.

Materials and Methods: Six patients were treated with the Augmentation Patella (Zimmer, Allendale, USA), which was sutured to the patellar tendon. All 6 patients had previously had a patellectomy for anterior knee pain syndrome or chondromalacia patellae, between 5 and 22 years previously. They all had an arthroscopy to document the extent of degenerative changes. Patients with trochlear changes only had the trochlea resurfaced (4 cases) and those with tibio-femoral changes as well had a total knee replacement (2 cases).

Results: One patient reported excellent relief of pain, with no evidence of radiological loosening. Two patients continued to complain of pain despite the implant being solidly fixed. One patient developed wound complications secondary to difficult closure due to the bulk of the implant. In two patients, the implant loosened within 15 months necessitating further surgery to retrieve the Augmentation Patella.

Discussion: The results of the Augmentation Patella in our series of patients with previous patellectomies have been disappointing. Previous studies, where this implant has been used with a remaining shell of patella, has yielded better results. This suggests that bony ingrowth is important for a successful outcome. We recommend that this device should only be implanted if bony contact is possible.


H Pandit C Jenkins HS Gill D Beard BEA Marks AJ Price CAF Dodd DW Murray

Introduction: The results of the mobile bearing Oxford unicompartmental knee replacement (UKR) in the lateral compartment have been disappointing with a five year survival of 82%. Therefore, it is recommended that mobile bearings should not be used for lateral UKR. This low survivorship is primarily due to high dislocation rate, all occurring in the first year. A detailed analysis of the causes of bearing dislocation confirmed the elevated lateral tibial joint line to be a contributory factor. A new surgical technique was therefore introduced in which care was taken neither to remove too much bone from the distal femur nor to over tighten the knee and therefore ensure that the tibial joint line was not elevated. Other modifications to the technique were also introduced including use of a domed tibial component.

Aim: The aim of this study is to compare the outcome of these iterations: the original series [series I], Series II with improved surgical technique and the domed tibial component [Series III].

Method: The primary assessment of outcome was bearing dislocation at one year. One year was chosen as all the dislocations in the first series occurred within a year. In series I, there were 53 knees, in series II 65 knees and in series III 60 knees, all with a minimum of one year follow up.

Results: In series I, there were 6 bearing dislocations (11%) and the average range of movement (ROM) was 110°. In the second series, there were 2 dislocations (3%) and the average ROM was 118°. In the third series, there were no primary dislocations and the average ROM was 125°.

Conclusions: The improved surgical technique and implant design has reduced the dislocation rate to an acceptable level so a mobile bearing can now be recommended for lateral UKR.


A J Barnett M Prentice V Mandalia CJ Wakeley JDJ Eldridge

A number of measurements of patella height exist all of which use a position on the tibia as a reference. The Patellotrochlear Index has recently been proposed as a more accurate reflection of the functional height of the patella and described in normal knees.

Aim: A comparison of patellar height measurements in patients with patellofemoral dysplasia.

Method: A retrospective analysis of the MRI scans of 33 knees in 29 patients with patellofemoral dysplasia to assess the inter- and intraobserver reliability of four patellar height measurements: the Patellotrochlear Index (PTI), Insall-Salvati (IS), Blackburne-Peel (BP) and Caton-Deschamps (CD) ratios. We also assessed the correlation between the different measurements in predicting patella alta. Three blinded observers on two separate occasions performed the measurements.

Results: There were 21 females and 8 males with a mean age of 21.4 years (13–33).

Statistical analysis revealed good inter-observer reliability for all measurements (0.78 for PTI, 0.78 for IS, 0.73 for BP and 0.77 for CD). Intra-observer reliability was also good (0.80, 0.83, 0.75, 0.78 respectively). When comparing the different measurements for patella alta there was a weak correlation between the PTI and the others. There was a strong correlation between the CD and BP ratios (0.96) and a moderate correlation between IS and CD and IS and BP ratios (0.594 and 0.539 respectively).

Conclusion: All measurements are reproducible. The PTI however suggests patella alta exists in different patients to that suggested by the established measures. We propose the PTI as a more clinically relevant measure.


G. Abbas C.E. Diss

Purpose of Study: To develop a non-invasive technique to assess and analyse patella kinematics during the gait cycle.

Methodology and Results: Ten subjects with no history of patellofemoral syndrome or patella maltracking on clinical examination were individually assessed on eight dynamic walking trials each. Retroreflective markers were attached to the proximal, distal, medial and lateral poles of the patella and the position of the patella relative to the centre of the knee joint was tracked and recorded during their gait cycle using a nine camera (120Hz) ViconTM infra-red motion analysis system.

It was found that there was more medial-lateral motion (shift) of the patella than proximal-distal (tilt) motion during the gait cycle.

It was noted that the patella shift motion occurred in the swing phase or the early stance phase of the gait cycle of all subjects with the maximum patella shift occurring when the knee was flexed between 30–56 degrees in the majority of subjects.

Similarly the patellar tilt motion occurred in the swing phase or the early stance phase of the gait cycle with the maximum patella tilt occurring between 20–36 degrees of knee flexion in the majority of subjects.

Conclusion: The results of this study show that patella motion can be identified non-invasively using the ViconTM motion analysis system. These results indicate that normally the maximum amount of patella shift and tilt occurs in the swing and early stance phases of the gait cycle and that abnormal patella motion can be detected if excessive shift or tilt occurs outside of these phases.


KM Ghosh AM Merican F Iranpour D Deehan AA Amis

Objective: The aim of the study was to test the hypothesis that insertion of a total knee replacement (TKR) may effect range of motion as a consequence of excessive stretching of the retinaculae.

Methods: 8 fresh frozen cadaver knees were placed on a customised testing rig. The femur was rigidly fixed allowing the tibia to move freely through an arc of flexion. The quadriceps were loaded to 175N in their physiologic lines of action using a cable, pulley and weight system. The iliotibial tract was loaded with 30N. Tibiofemoral flexion and extension was measured using an optical tracking system. Monofilament sutures were passed along the fibres of the medial patellofemoral ligament (MPFL) and the deep transverse band in the lateral retinaculum with the anterior ends attached to the patella. The posterior suture ends were attached to ‘Linear Variable Displacement Transducers’. Thus small changes in ligament length were recorded by the transducers. Ligament length changes were recorded every 10° from 90° to 0° during an extension cycle. A transpatellar approach was used when performing the TKR to preserve the medial and lateral retinaculae. Testing was conducted on an intact knee and following insertion of a cruciate retaining TKR (Genesis II). Statistical analysis was performed using a two way ANOVA test.

Results: The MPFL had a mean behaviour close to isometric, while the lateral retinaculum slackened by a mean of 6mm as the knee extended from 60 degrees (Fig 1). After knee replacement there was no statistically significant difference seen in ligament length change patterns in the MPFL, however the lateral retinaculum showed significant slackening from 10 to 0°.

Conclusion: The data does not support the hypothesis that insertion of a TKR causes abnormal stretching of the retinaculuae. This result relates specifically to the TKR design tested.


KM Ghosh AM Merican F Iranpour D Deehan AA Amis

Objective: The aim of this study was to test the hypothesis that malrotation of the femoral component following total knee replacement (TKR) may lead to patellofemoral complications as a consequence of excessive stretching of the retinaculae.

Methods: 8 fresh frozen cadaver knees were placed on a customised testing rig. The femur was rigidly fixed allowing the tibia to move freely through an arc of flexion. The quadriceps and iliotibial tract were loaded to 205N in their physiologic lines of action using a cable, pulley and weight system. Tibiofemoral flexion and extension was measured using an optical tracking system. Monofilament sutures were passed along the fibres of the medial patellofemoral ligament (MPFL) and the deep transverse band in the lateral retinaculum with the anterior ends attached to the patella. The posterior suture ends were attached to ‘Linear Variable Displacement Transducers’. Thus small changes in ligament length were recorded by the transducers. Ligament length changes were recorded every 10° from 90° to 0° during an extension cycle. A transpatellar approach was used when performing the TKR to preserve the medial and lateral retinaculae. Testing was conducted following insertion of a cruciate retaining TKR (Genesis II). The femoral component was rotated using a custom built intramedullary device. Ligament length changes were measured at neutral rotation, 5° internal and 5° external rotation. Statistical analysis was performed using a two way ANOVA test.

Results: Internal rotation resulted in the MPFL slackening a mean of 1.7mm from 70-0° extension (p< 0.001). External rotation resulted in the MPFL tightening a mean of 1.5mm over the same range (p< 0.01). The lateral retinaculum showed less significant differences.

Conclusion: External rotation resulted in smaller length changes than internal rotation. Patellar tilting as a result of internal rotation may be caused by MPFL slackening and not lateral retinacular tension, contrary to popular understanding.


KM Ghosh AM Merican F Iranpour D Deehan AA Amis

Objective: This study tested the hypothesis that complications resulting from overstuffing the patellofemoral joint after total knee replacement (TKR) may be a consequence of excessive stretching of the retinaculae.

Methods: 8 fresh frozen cadaver knees were placed on a customised testing rig. The femur was rigidly fixed and the tibia moved freely through an arc of flexion. The quadriceps and iliotibial tract were physiologically loaded to 205N using a cable, pulley and weight system. Tibiofemoral flexion/extension was measured using an optical tracking system. Monofilament sutures were passed along the fibres of the medial patellofemoral ligament (MPFL) and the deep transverse band in the lateral retinaculum with the anterior ends attached to the patella. The posterior suture ends were attached to ‘Linear Variable Displacement Transducers’. Thus, small changes in ligament length were recorded by the transducers. Length changes were recorded every 10° from 90°- 0° during an extension cycle. A transpatellar approach was used when performing the TKR to preserve the medial and lateral retinaculae. Testing was conducted following insertion of a cruciate retaining TKR (Genesis II). The patella was resurfaced and various patellar thicknesses were achieved by placing 2mm thick nylon washers behind the ‘onlay’ button. The thicknesses measured were 2mm understuff, pre-cut thickness, 2 and 4mm overstuff. Statistical analysis was performed using a two way ANOVA test.

Results: Patellar understuff resulted in the MPFL slackening an average of 1.6mm from 60 to 0° (p< 0.05). Overstuffing the patella 2mm resulted in no significant length changes whereas 4mm overstuff resulted in a mean increase in MPFL length of 2.3mm throughout extension (p< 0.001). No significant length changes seen in the lateral retinaculum

Conclusion: Overstuffing the PFJ stretches the MPFL, because it attaches directly between two bones. The lateral retinaculum attaches to the relatively mobile ITT, so overstuffing does not stretch it.


B Guhan A S Lee

Purpose: To evaluate the patients who underwent acute surgical repair of medial patellofemoral ligament following first lateral dislocation of patella

Methods: Twenty four patients with mean age 19 yrs (12–41) who underwent acute repair of MPFL were reviewed. The mean follow-up was 14 months (2–35 months). All patients had MRI scan preoperatively and most of them were operated within two weeks of injury. Patients were evaluated clinically and Kujala and modified Lysholm were recorded. None of these patients had further dislocations and all had negative patellar apprehension tests. The mean Kujala and modified Lysholm scores were above 85.

Conclusion: Our results strongly support that in selected patients acute repair of MPFL prevents further dislocations and early return to sporting activities. The long term results are to be evaluated.


S Patil L White A. Jones J. Dixon A. Hui

Idiopathic anterior knee pain (AKP) is common in adolescents and young adults. Most believe that the origin of the problem lies in the patello-femoral joint. Hamstring tightness has also been attributed as an important cause.

The aim of our study was to compare biometric parameters in patients with idiopathic AKP and controls. We also wanted to assess whether there was a difference in the relative electromyographic (EMG) onset times of the medial and lateral hamstrings.

We prospectively recruited patients with idiopathic anterior knee pain in the age group 11 to 25. Patients, but not the control population, had AP, lateral and skyline radiographs taken to rule out other pathology.

We had 34 patients (60 knees) with a minimum one year follow up. There was no difference in the symptoms of patients who attended physiotherapy as compared to those who did not. Patients with knee pain had significantly more hip external rotation (63 deg) as compared to the control (47 deg) group (p=0.001). Patients also had significantly more hamstring tightness (p=0.04).

Surface EMG was recorded (17 patients and controls each) from the medial and lateral hamstrings during 3 repetitions of a maximal voluntary isometric contraction exercise with the knee at 45° of flexion. The lateral hamstrings contracted 48.7 m.sec earlier than the medial hamstrings in patients as compared to controls.

AKP is a multifactorial and self-limiting disorder. Earlier contraction of the lateral hamstrings may cause tibial external rotation and contribute to the symptoms. Our data suggests that physiotherapy did not significantly alter the course of the condition. We believe that increased hip external rotation may contribute to the symptoms by increasing medial facet stress.


R Mohammed A Unnithan M Bansal K Durve T Jimulia M A Green D J A Learmonth

Introduction: Patellofemoral arthroplasty (PFA) is an established treatment of isolated patellofemoral osteoarthritis. We present our multi-surgeon, multi-implant series of patellofemoral joint arthroplasty performed over a ten year period.

Material & Results: his study was a retrospective review of all PFA performed in our unit over a ten year period from 1997 to 2006. The unit comprises seven specialist knee surgeons and numerous trainee surgeons. A total of 46 knees had the Lubinus implant (Waldemar Link), 30 knees had the FPV system (Wright Medical) and 25 knees had the Avon system (Stryker Howmedica).

101 arthroplasties in 91 patients were followed up for average period of 48.8 months (6–96 months). The average age was 57 years with female patients thrice as common as male patients. Concomitant procedures in the form of 23 lateral retinacular release or 6 osteochondral autograft transfer system (OATS) were performed. There were 6 complications with 2 infections and 4 stiff knees. Subsequent procedures included arthroscopic debridement (18), arthroscopic lateral retinacular release (8), tibial tuberosity transfer (3) and manipulation for stiffness (2). A total of 4 arthroplasties underwent revision to TKA, 2 for infection and 2 for progression of tibiofemoral osteoarthritis.

Conclusion: Thorough clinical history, physical examination and radiological investigation are essential before embarking on PFJ replacement. Other concomitant procedures like joint debridement, menisectomy or lateral retinacular release may be necessary to obtain optimum results. The necessity of revision surgeries in 31% of the cases of our study suggests that close follow-up of the patients is needed to address any concerns which can be easily resolved. PFJ replacement effectively addresses anterior knee pain, preserves the joint integrity, involves lesser surgical dissection and has good results of revision to TKA.


CE Ackroyd JDJ Eldridge JH Newman

Introduction: The Bristol Knee group has performed over 600 patellofemoral arthroplasties in the last 18 years. Experience with the Lubinus prosthesis led to the development of the Avon Prosthesis. In the last 11 years we have prospectively recorded the results of over 470 consecutive Avon arthroplasties. The main cause of the 9.5% failure is arthritic disease progression in the tibiofemoral compartments.

Patients and Method: Over the last 11 years we have identified 21 patients from our own series and from tertiary referrals that have persistent pain, which was mainly due to technical error rather than arthritic disease progression. The causes can be classified into three main reasons: First, an incorrect anterior cut in the saggital plane which was cut in either too much flexion or extension. Second, the anterior cut had inadequate external rotation, which should be 3–6 degrees to lateralise the groove and facilitate correct tracking. Third, the prosthesis was oversized in several cases leading to retinacular impingement.

Results: The overall results followed up to 10 years showed excellent and consistent improvement in both pain and function as judged by the WOMAC 12 scale. Of those patients with persistent pain, seven had the femoral component revised to either resize the prosthesis or revise the alignment of the anterior resection and correctly inset the prosthesis, with good results. Ten cases were revised to a total knee replacement. In the remaining cases, two had an Insall realignment, one a patella distalisation, and in one no treatment was required. As a permanent solution new instruments were designed to reduce the incision size and increase the accuracy of the saggial alignment and to create an exact amount of external rotation.

Conclusion: The lessons from 11 years experience with the Avon arthroplasty has led to the development of improved instrumentation which should reduce the failures.


DJ Simpson HG Pandit A Gulati H Gray DJ Beard AJ Price DW Murray HS Gill

Statement of purpose: The aim of this study is to evaluate different designs of unicompartmental knee replacement (UKR) by comparing the peak von Mises and contact stresses in polyethylene (PE) bearings over a step-up activity.

Summary of Methods: A validated finite element (FE) model was used in this study. Three UKR designs were modelled: a spherical femoral component with a spherical PE bearing (fully-congruent), a poly-radial femoral component with a concave PE bearing (semi-congruent), and a spherical femoral component with a flat bearing (non-congruent).

Kinematic data from in-vivo fluoroscopy measurements during a step-up activity was used to determine the relative tibial-femoral position as a function of knee flexion angle for each model. Medial and lateral force distribution was adapted from loads measured in-vivo with an instrumented implant during a step-up activity. The affect that varying the bearing thickness has on the stresses in the bearing was investigated. In addition, varus-valgus mal-alignment was investigated by rotating the femoral component through 10 degrees.

Summary of Results: Only the fully congruent bearing experienced peak von Mises and contact stresses below the PE lower fatigue limit (17MPa) for the step-up activity (fully congruent PE peak contact stress, 5MPa). The highest PE contact stresses were observed for the semi-congruent and non-congruent designs, which experienced approximately 3 times the PE lower fatigue limit. Peak PE von Mises stresses for the semi-congruent and non-congruent designs were similar, peaking at approximately 25MPa. Peak PE von Mises stresses were ameliorated with increased bearing thickness. Varus-valgus mal-alignment had little effect on the peak stresses in the three UKR designs.

Statement of Conclusions: Fully congruent articulating surfaces significantly reduce the peak contact stresses and von Mises stresses in the bearing. The FE model demonstrates that fully congruent bearings as thin as 2.5mm can be used without increasing the contact stresses significantly. Fully congruent designs can use thinner bearings and enable greater bone preservation.


DJ Simpson H Gray CAF Dodd DJ Beard AJ Price DW Murray HS Gill

Statement of purpose: Finite element (FE) models of bone can be used to evaluate new and modified knee replacements. Validation of FE models is seldom used, and the quantification of modelling parameters has a considerable effect on the results obtained. The aim of this study is to develop a FE model of a cadaveric tibia and validate it against a comprehensive set of experiments.

Summary of Methods: Seventeen tri-axial rosettes were attached to a cleaned, fresh frozen cadaveric human tibia and the tibia was subjected to 13 loading conditions. Deflection and strain data were used for comparison with the FE model. A geometric model was created on the basis of computed tomography (CT) scans. The CT data was used to map 600 orthotropic material properties to the tibia. All experiments were simulated on the FE model. Measured principal strains were compared to their corresponding FE values using regression analysis. The validated tibia model was reduced in size (75mm to the proximal) and then re-modelled to represent only the proximal tibia. This re-modelled tibia was validated against the reduced size FE model. Virtual surgery was performed on the validated proximal model to implant a UKR.

Summary of Results: For the whole tibia model, the regression line for all axial loads combined had a slope of 0.999, an intercept of −6.24 micro-strain, and an R2 value of 0.962. The root mean square error as a percentage was 5%. For the proximal tibia model, correlation coefficients of 0.989 and 0.976 were obtained for the maximum and minimum principal strains respectively.

Statement of Conclusions: An FE model of an implanted proximal tibia has been validated against experimental data. This model is able to accurately predict the deflection and stresses in a replaced knee joint to obtain clinically relevant information. This will provide a virtual model of unicompartmental arthroplasty, where variables such as fixation method and bearing mechanics can be assessed.


S M McDonnell R Rout A P Hollander I M Clark T Simms R Davidson S Dickinson J Waters H S Gill D W Murray P A Hulley A J Price

Aim: To investigate the molecular features of progressive severities of cartilage damage, within the phenotype of Anteromedial Osteoarthritis of the Knee (AMOA).

Methods: Ten medial tibial plateau specimens were collected from patients undergoing unicompartmental knee replacements.

The cartilage within the area of macroscopic damage was divided into equal thirds: T1(most damaged), to T3 (least damaged). The area of macroscopically undamaged cartilage was taken as a 4th sample, N. The specimens were prepared for histological (Safranin-O and H& E staining) and immunohistochemical analysis (Type I and II Collagen, proliferation and apoptosis).

Immunoassays were undertaken for Collagens I and II and GAG content. Real time PCR compared gene expression between areas T and N.

Results: There was a decrease in OARSI grade across the four areas, with progressively less fibrillation between areas T1, T2 and T3. Area N had an OARSI grade of 0 (normal).

The GAG immunoassay showed decreased levels with increasing severity of cartilage damage (ANOVA P< 0.0001).

There was no significant difference in the Collagen II content or gene expression between areas.

The Collagen I immunohistochemistry showed increased staining within chondrocyte pericellular areas in the undamaged region (N) and immunoassays showed that the Collagen I content of this macroscopically and histologically normal cartilage, was significantly higher than the damaged areas (ANOVA P< 0.0001). Furthermore, real time PCR showed that there was a significant difference in Collagen I expression between the damaged and macroscopically normal areas (p=0.04).

Conclusion: In AMOA there are distinct areas, demonstrating progressive cartilage loss. We conclude that in this phenotype the Collagen I increase, in areas of macroscopically and histologically normal cartilage, may represent very early changes of the cartilage matrix within the osteoarthritic disease process. This may be able to be used as an assay of early disease and as a therapeutic target for disease modification or treatment.


D B Saris J Vanlauwe J Victor J Bellemans F P Luyten Y Fortems

Purpose: This study compared the efficacy and safety of Characterized Chondrocyte Implantation (CCI) to microfracture in the repair of symptomatic cartilage defects of the femoral condyle.

Methods: CCI (n=51) was compared to microfracture (n=61) in patients with grade III–IV symptomatic cartilage defects of the femoral condyles in a prospective, multicenter, randomized, controlled trial. Structural repair was assessed at 1 year by histopathologists blinded to the treatment using

computerized histomorphometry and

an overall histology assessment. Clinical outcome was measured using the Knee Injury and Osteoarthritis Outcome Score (KOOS). Safety was recorded throughout the study.

Results: CCI resulted in better structural repair than microfracture at 1 year post-treatment, as assessed by histomorphometry (p=0.003) and overall histology (p=0.012). Structural repair parameters relating to chondrocyte phenotype and tissue structure were also superior with CCI. Noninferiority of CCI was demonstrated for clinical outcome at 12–18 months, and both treatments were generally well tolerated.

Conclusion: At 1 year post-treatment, CCI resulted in superior tissue repair compared to microfracture. Short-term clinical outcome after 12–18 months was similar for both treatments, as was the safety profile. The superior structural repair achieved with CCI may lead to improved long-term clinical benefits.


D B Saris J Vanlauwe J Victor J Bellemans F P LuytenYFortems

Purpose: As a one-step surgical procedure, microfracture is frequently considered to be technically easier and associated with less postoperative morbidity than autologous chondrocyte implantation (ACI), which involves both arthrotomy and arthroscopy and therefore safety was assessed in patients with symptomatic cartilage lesions of the knee treated with characterized chondrocyte implantation (CCI) or microfracture.

Methods: CCI (n=57) was compared to microfracture (n=61) in patients with grade III–IV symptomatic cartilage defects of the femoral condyles in a Phase III, prospective, multi-center, randomized, controlled trial. Safety assessments included adverse events (AEs), physical examination, vital signs, hematology and clinical chemistry.

Results: At 18 months post-surgery, similar proportions of patients experienced AEs in the CCI (88%) and microfracture (82%) groups; 67% and 59%, respectively, experienced AEs considered treatment related. The AE profile was generally similar between groups, with no significant difference for hypertrophy, although significantly more CCI-treated patients had joint swelling (19% versus 4.9%; p=0.022) and treatment-related joint crepitation (12% versus 1.6%; p=0.028). Although the proportion of patients with severe AEs was similar for CCI (12%) and microfracture (13%), slightly more microfracture-treated patients experienced serious (life-threatening or requiring hospitalization) AEs (13% versus 8.8%). No patients discontinued due to AEs or died during the study.

Conclusion: Contrary to general opinion, the two-step CCI procedure, involving arthroscopy followed by arthrotomy, has a similar safety profile to that of microfracture, a one-step arthroscopic procedure, for treating cartilage lesions of the knee.


A Saithna R Carey Smith P Thompson M Dhillon T Spalding

Aim: To assess the safety and clinical and radiological outcome of the TruFit CB porous, resorbable scaffold for symptomatic osteochondral and chondral articular defects in the knee.

Methods: 11 active sporting patients underwent cartilage repair using TruFit CB plugs (Smith & Nephew) for symptomatic defects on the medial or lateral femoral condyle. All had failed previous treatment (debridement/microfracture) and had persistent symptoms. Postoperatively patients were touch weight bearing for 2 weeks and partial until 4 weeks. Data was collected prospectively. The mean age was 34 (range 19 – 50) and 5 were male. Four lateral femoral condyle defects were treated, all associated with lateral meniscal tears. Four medial defects were associated with ACL injury (1), PCL injury (1) or isolated chondral injury (2). Single plugs were required in 5 (9mm in 3 and 7mm plugs in 2), 2 patients required 2 plugs (9mm and 7mm), and 2 required 3 (2×9mm + 1×7mm).

Results: All 11 patients were improved at a mean follow up of 14.5 months (3–21 months) with 4 currently back to full pre-injury level of sport. Subjective IKDC scores improved from 45 pre-op to 79 post-op (p< 0.05), Lysholm from 47 to 71 (p< 0.05), and latest Tegner activity score at 5. MRI evaluation including T2 mapping demonstrates reformation of the subchondral lamina and resorption of the graft. 2nd look arthroscopy was undertaken in 2 showing a well healed and well integrated surface.

Conclusion: These preliminary results indicate that TruFit CB plugs offer a potential solution for small focal chondral defects, offering an alternative to microfracture or osteochondral grafting with advantages of low morbidity and rapid recovery without the need for prolonged non-weight bearing.


P Hull A Chaudhry M Gohil A Prasthofer G Pattison

Aims: To establish the best teaching method for medical students and ascertain the students’ preferred method of teaching.

Material and Methods: 30 medical students in were picked randomly and divided into two equal groups. Group 1 received Standard bedside teaching and Group 2 watched an interactive DVD. Each group then undertook a validated OSCE and the examiners were blinded as to which teaching method the students had received. The groups then received the other method of teaching followed by another OSCE. A questionnaire was given to all the students, to assess their satisfaction of the teaching session.

Results:

Conclusion: Interactive teaching method can be a useful technique for teaching medical students, however the students’ preferred method of teaching is standard bedside teaching. Efficiency of knowledge transfer can be improved if interactive teaching is followed by standard bed side teaching but not the other way around.


T Coltman N Chhaya T Briggs J Skinner R Carrington

Aim: To review the short-term clinical results of a single-institution cohort undergoing opening wedge high tibial osteotomy (HTO).

Method: We undertook a prospective clinical and radiographic review of our cohort of patients who had undergone opening wedge HTO for varus malalignment. The Cincinnati scoring system was used for objective assessment. Pre- and post-operative radiographs were evaluated and Blackburne-Peel (BP) and Insall-Salvati (IS) ratios recorded, as well as integrity of the lateral hinge.

Results: we reviewed 55 knees (51 patients: 34 men and 17 women; mean age, 44.2 years; range 34–58 years) followed up for a minimum 12 months (range, 12–62 months). All patients had relief of pain, but six met our criteria of failed treatment where either revision fixation was required or proceeded to total knee arthroplasty for persisting symptoms. Cincinnati scores were 94.5% excellent (52/55) and 5.5% good (3/55) at 1 year, whilst at last follow-up they were 87.2% excellent (48/55), 9.1% good (5/55) and 3.6% fair (2/55). There was a significant improvement in mean American Knee Society score at 1 year and maintained at last follow-up (p< 0.05). Radiographically the lateral hinge was noted to be breached in 9.1% (5/55), but no incidence of non-union was identified. There was no significant change in IS index, however BP index diminished by a mean 15.3% (range, 7.4–28.2%).

Discussion: Medial opening wedge tibial osteotomy results in patellar infera, but successful clinical and functional outcomes have been demonstrated. The fact there is inconsistency between the two indices assessing patellar height ratio we believe reflects the inherent variability in the techniques employed. Distalisation of the tibial tubercle will mean the IS ratio remains unaffected, whilst the BP index more accurately demonstrates the lowering of patella relative to the joint line. However there may be other factors which are not immediately appreciated, such as changes in the tibial inclination or antero-posterior translation.


S.M.Y Ahmed R Ahmad R Case R. F Spencer

Introduction: Tourniquets are commonly employed in surgical procedures of the knee. The use of the same tourniquet on a repetitive basis without a standard protocol for cleaning has recently been questioned as a potential source of cross-infection. This study examines the contamination of the tourniquets in our institution and results of cleaning the tourniquets with a disinfectant and detergent wipe.

Material and methods: Tryptone soya agar plates were used to take samples from 20 tourniquets employed in knee replacement. Four specified sites on each tourniquet were cultured and incubated at 37° for 48 hrs.

Results: All sampled tourniquets were contaminated with colony counts varying from 9 to > 385.

Coagulase negative Staphylococcus was the most commonly grown organism from the tourniquets (96%).

Some tourniquets had growths of important pathogens including MRSA, Pseudomonas and Staphylococcus aureus (these organisms have not been previously cultured from tourniquets). On cleaning five tourniquets with clinell (detergent and disinfectant) wipes, there was a 99.2% reduction in contamination of the tourniquets five minutes after cleaning.

Conclusion: Contamination is more worrying in relation to pneumatic tourniquets, as they are commonly employed in knee surgery where implants are frequently used with the tourniquet lying within inches of the operative wound.

We have found a 99% reduction in contamination of tourniquets by employing disinfectant wipes. This is a simple, cost-effective and quick method to clean tourniquets and we recommend the use of wipes before every case in addition to the manufactures guidelines for general cleaning of tourniquets.


A Saithna R Carey Smith M Thomas P Thompson T Spalding

Aim: To assess the results and complications of the opening wedge form of distal femoral varus osteotomy (DFVO) in treating valgus arthritis and ligament instability of the knee.

Methods: Patients undergoing DFVO were assessed prospectively using validated scoring systems and pre/post operative alignment radiographs. All had failed non operative and arthroscopic procedures and were keen to avoid arthroplasty. The lateral based opening wedge osteotomy aimed to correct the weight bearing line to position 50% medial to lateral and was held with either the Puddu femoral plate (Arthrex UK) or the Tomofix plate (Synthes UK).

Results: 26 distal femoral osteotomies were performed in 23 patients with a mean age of 34 (16 –58). The mean duration of follow up is 32.5 months (1–72). 8 were undertaken for primary valgus malalignment, and 15 for secondary valgus with OA due to previous lateral menisectomy. Simultaneous additional procedures included microfracture (3), MACI (1), meniscal transplantation (1), and MCL advancement (1). Mean hospital stay was 4 days (2–6). Post op alignment was out by greater than 10% of intended in 2/3. 3 early major complications required re-operation: 2 for plate and screw cut out and 1 for infection. 2 developed delayed union requiring bone grafting. Failure with conversion to arthroplasty has occurred in 2 (1 lateral UKA, 1 TKA), and 2 patients are awaiting either multi-ligament reconstruction or collagen meniscal implantation. The overall mean Tegner score is 4 (2–6), and 20 of the 23 patients feel satisfied with the outcome having avoided arthroplasty.

Conclusion: Opening wedge DFVO is a technically difficult procedure with significant complications, but in the right indication offers long lasting pain relief and joint preservation prior to arthroplasty. New techniques including accurate closing wedge fixation systems and computer guided operative planning and surgery may offer improvements to this vital surgical option.


M.J Walton J.H Newman

Objectives: This study aims to assess the psychological profile of patients prior to total knee replacement, medial unicompartmental knee replacement and patellofemoral joint replacement and determine its effect on outcome.

Methods: 113 patients were identified (41 TKR, 37 UKR and 35 PFJR). All patients had mental health assessed preoperatively using SF-12. From the 12 questions a mental and a physical summary score can be calculated (MCS and PCS). The reduced WOMAC score was used pre-operatively to assess knee function and symptoms and then recorded at 8 and 24 months post-operation to assess outcome.

Results: 54% of the patients had pre-operative psychological distress. There was no statistically significant difference demonstrated between them mean MCS scores between the three operation groups. Pre-operative MCS had a significant effect such that increasing psychological distress lead to a worse twenty-four month outcome (p = 0.016). The effect of MCS is most marked in postoperative pain levels (p = 0.008) compared to function (p = 0.016). The mean 24-month rWOMAC in the severely distressed group (MCS< 40) was 28.4 compared to 17.4 in the psychologically well group (MCS> 60).

Conclusions: Pre-operative mental function prior to knee arthroplasty may provide useful information to guide patients as to their expected outcome in the consent process. Those patients with a very high mental component may be counseled to that although their distress is likely to improve with surgery, their eventual outcome may be worse. The effect of MCS may however only be clinically relevant in those patients with severe mental symptoms.


Andrew Price Niek C. van Dijk René Verdonk Joerg Jerosch Xavier Chevalier François Bailleul Karel Pavelka

Purpose: The objective of this study was to compare the safety and efficacy of 1 × 6 mL intra-articular administration of hylan G-F 20 with placebo.

Methods: In this prospective, multicenter, randomized, double-blind study, patients diagnosed with knee OA were randomized to one 6-mL injection of hylan G-F 20 or saline. The primary efficacy analysis (WOMAC A) was performed on the intent-to-treat population and was based on a repeated-measures model over the 26 weeks of the study.

Results: 253 patients were randomized to hylan G-F 20 (n=124) or placebo (n=129). Mean age was 63 years (42–84), BMI 29.4 (19.5–52.4 kg/m2), 71% were female, and all had primary knee OA of Kellgren Lawrence grade 2 (45%) or 3 (55%). Patients in the hylan G-F 20 group experienced a mean change from baseline in their WOMAC A Likert pain score (0–4 scale) over 26 weeks (primary efficacy criteria) of −0.84, which was statistically significantly different from the change reported in the placebo group (−0.69, p=0.047). Statistically significant differences favoring hylan G-F 20 were also reported for most of the secondary efficacy criteria: WOMAC A1 (estimate Odds Ratio over 26 weeks placebo/hylan G-F 20, 0.64, p=0.013), patient global assessment (0.69, p=0.029), and clinical observer global assessment (0.71, p=0.041); WOMAC B and C changes were not statistically significant between groups. The OMERACT-OARSI responder analysis indicated that 59% of the patients were responders in the hylan G-F 20 group versus 51% in placebo group (0.66, p=0.059). There was no statistically significant difference in the use of rescue medication (acetaminophen) between the 2 groups.

Discussion and Conclusion: This double-blind placebo-controlled study showed one injection of hylan G-F 20 provided symptomatic relief lasting up to 6 months in patients with knee OA; it avoids the need for multiple injections.


G Thomas M Faisal S Young R Bawale R Asson M Ritson

Aim To review 6 months of early discharge with a dedicated ‘Accelerated Discharge Team’ (A.T.T.) at our institution.

Patients and Methods The team consisted of four nurses and three physiotherapists. Patients undergoing hip or knee arthroplasty were assessed pre-operatively and post-operatively for admission to the care of the A.T.T. against fixed criteria. Patients were visited at home on the day of discharge and every day until released from the care of the team. 333 patients underwent lower limb arthroplasty during the study period of which 305 (91.6%) were admitted to the A.T.T.

Results The mean length of stay for primary knee replacements was 3.30 days. 73% (95% C.I. 64%–81%) of patients undergoing total knee arthroplasty went home by 3 days and 93% (95% C.I. 87%–97%) by 4 days. Results for hip arthroplasty were similar. Of the 305 patients, 12 (4%) were readmitted to hospital within 6 weeks of discharge. Almost 90% of patients responded to a satisfaction survey. 94.2 % of those responding indicated that they would use the A.T.T. scheme again.

Discussion In the year before implementing the A.T.T. the mean stay for primary hip and knee replacements was over 9 days. We reduced this to less than 3.5 days for over 90% of our patients during the study period. The total cost of the scheme was just under £100 000 for the 6 month period. We estimate that 2000 bed days were saved during the same period. This is cost effective on these terms alone. As well as transferring 12 elective orthopaedic beds to a different department we were able to perform an estimated 75 extra lower limb arthroplasty operations in the 6 month period.


S Maret NS Harshavardhana A Dhir A Sahu C Olyslaegers RH Hartley

Purpose: To review the existing coding for knee surgery and ascertain its appropriateness & accuracy for surgical procedures, associated co-morbidities and complications.

Methods: A retrospective review of 100 consecutive knee surgeries (50 arthroplasties and 50 arthroscopies) performed between July-August 2007 was undertaken. The coding data excel sheet and comprehensive hospital records were analysed.

Results: The accuracy of primary procedural codes was 100% & 88% respectively for arthroplasty & arthroscopy. However this respectively fell down to 56 & 60% when the accuracy for entire description of surgical procedure was taken into consideration. The procedural codes did not specifically reflect the surgery performed and lacked reproducibility esp. for arthroscopies. In arthroplasties, patients had similar codes irrespective of whether they had patellar resurfacing or not. Co-morbidities were coded appropriately in 24% of arthroplasty & 36% of arthroscopy patients. The common co-morbidities missed were drug allergies, hypercholesterolemia, heart conditions (IHD, MI, AF, valvular pathologies) and h/o malignancy & deep vein thrombosis. Post-op adverse events were coded in only 2/5 arthroplasties (40%) and 0/3 arthroscopies (0%) respectively.

Conclusion: Coding is a universal language of communication amongst healthcare professionals. Its accuracy is important not just for reimbursement but also for data quality and audit. Coding database also serves as a powerful research tool. The financial implications with respect to generation of appropriate reimbursement i.e. healthcare resource group (HRG) codes (which are dictated by official population and census survey procedural [OPCS4.4] & international classification of diseases [ICD–10] co-morbidity codes) are discussed. The limitations of the existing coding system are highlighted and discussed. Literature emphasizes on the qualification of coders, legible & comprehensive documentation of surgeries & co-morbidities by treating physicians and regular interaction between coders and clinicians. Reimbursement for arthroscopy is less in the NHS unlike in BUPA where it is on par with open surgeries.


J Millington R Pickard K S Conn N D Rossiter G J Stranks J M Britton N P Thomas

It is established good practice that joint replacements should have regular follow-up and for the past seven years at the North Hampshire Hospital a local joint register has been used for this purpose and we compare this with results of the Swedish and UK national registries.

Since March 1999, all primary and revision knee arthroplasties performed at North Hampshire Hospital, Basingstoke have been prospectively recorded onto a database set up by one of the senior authors (JMB). Data from patients entered in the first six years of the register were analysed. All patients have at least one year clinical and radiological review then a minimum of yearly postal follow-up.

As of 31/12/2006, 2854 knee replacement procedures had been performed under the care of 13 consultants. OA was the most common diagnosis in over 75% of knees. 5.2% of patients had died and 4.6% were lost to follow-up. Our revision burden was 3.5% and we had a revision rate of 1.4% for primary total knee replacements. Audit of data for revisions and patello-femoral replacements has enabled us to change our practices. Mean length of stay was 7.2 days for primary total knee arthroplasty versus 4.0 days for unicompartmental knee arthroplasty and 5.4 days for patellofemoral replacement and mean flexion at discharge was 88.4, 93.7 and 88.7 degrees respectively. WOMAC and Oxford scores at 2 years had improved from a mean of 52 and 21 pre-operatively to 74 and 39 respectively for primary total knee arthroplasty. Our costs are estimated at approximately £35 per patient for their lifetime on the register.

Compared to other registries:

Our dataset is more complete and comprehensive

Our costs are less

All patients have a unique identifier (at least 19% of UKNJR data is anonymous)

Our audit loops have been closed


T Halsey P Nicolai M Porteous

Aim: We studied the payments received by our hospital for 109 elective lower limb arthroplasty cases to see if this was fair and consistent under Payment by Results.

Methods: A cohort of patients who had Total Hip Replacement (THR), Total Knee Replacement (TKR), Resurfacing Hip Arthroplasty and Unicompartmental Knee Replacements were taken from the departmental database. Their diagnostic codes, operation details and comorbidities were established and compared with the payment the trust received using the Dr Foster database. This was confirmed with their hospital notes and the finance department.

Results: Twenty THRs and twenty TKRs were paid the standard tariff with one exception. Fifteen Hip Resurfacing arthroplasties showed variable payment from £4690 to £6673 per case. Most interesting were the Unicompartmental Knee Replacements. Despite having almost the same operative and diagnostic codes 46 out of 54 cases were significantly underpaid. During one financial year the trust lost more than £70,000 from this operation alone. This does not meet the Department of Health’s stated aim of being fair and consistent. Out of 109 cases reviewed 51 could have been coded differently and 47 of these were “underpaid”.

Conclusion: In an NHS increasingly driven by financial pressures it is vital that surgeons understand how Payment by Results works. There are significant financial gains to be made by those trusts who pay attention to the small print.


DN Townshend KP Emmerson SM Jones PF Partington SD Muller

Purpose: Recent animal evidence has suggested that Bupivicaine may be harmful to articular cartilage. The purpose of this study was establish whether, following arthroscopy of the knee, infiltration of Bupivicaine around the portals is as effective as intra-articular infiltration for post-operative analgesia.

Method: Consecutive patients attending for knee arthroscopy were consented and randomised to one of two groups. Following arthroscopy, Group I received 20mls 0.5% Bupivicaine infiltrated into the joint; Group II received 20mls 0.5% Bupivicaine infiltrated around the portals. A Visual Analogue Score (VAS) was collected at one hour post-operatively and rescue analgesia recorded. A power calculation was performed. Ethical approval was granted.

Results: There were 68 patients in Group I (intra-articular) and 69 patients in Group II (portal). There was no significant difference in the age or sex distribution of patients in either group. The mean VAS score was 3.04 in Group I and 3.24 in Group II. There was no significant difference between the two groups (p=0.619). There was also no significant difference in the need for rescue analgesia (p=0.930). The study has demonstrated equivalence between the two groups, within one VAS point (Power = 80%).

Conclusion: We would recommend that following knee arthroscopy, Bupivicaine should be infiltrated around the portals, avoiding intra-articular infiltration.


C Meyer A Kotecha S Kakati T Crichlow

Aim: To determine if extended scope physiotherapists perform to the same standards as their orthopaedic colleagues with regards to diagnosing knee pathology and making appropriate referrals for arthroscopy.

Method: Data was collected prospectively from Aug 2005. Patients were seen in a consultant led orthopaedic clinic by an Extended Scope Physiotherapist (ESP), a registrar or the consultant. All patients placed onto the waiting list for knee arthroscopy were considered for the study. The outpatient diagnosis and demographic data were recorded and compared against the arthroscopy findings. A single consultant surgeon performed the arthroscopies.

Results: 300 patients were included in the study (100 in each group). Each group was similar in terms of presenting complaint and demographics. There was no significant difference between the ESP’s and registrars in their ability to diagnose intraarticular pathology (CHI squared test: X 2.031, df 1, p=0.15). When only cruciate and meniscal pathology were considered there was also no significant difference between the ESP’s and the registrars (Fishers test p=0.12 and p=0.22 respectively, 2-tail test) The ESPs performed particularly well in their ability to diagnose cruciate injuries (sensitivity 100%, specificity 100% and PPV 100%). Both ESPs and registrars had high sensitivity but low specificity with regards to diagnosing meniscal pathology suggesting a low threshold for a positive diagnosis and a poor ability to correctly diagnose those patients who did not have a meniscal injury. Of the 300 patients only 9 unnecessary arthroscopies were requested. None were requested by the ESPs.

Conclusions: Extended scope physiotherapists perform a useful role in orthopaedic outpatients. They perform as well as orthopaedic registrars with regards to making the correct diagnosis and the selection of patients for arthroscopy.


A Saithna J Arbuthnot R Carey Smith M Thomas T Spalding

The purpose of this study was to investigate the safety and outcome of bilateral simultaneous ACL reconstruction. In patients presenting with an ACL-deficient knee, 2 – 4% have bilateral ACL deficiency. A staged or simultaneous approach can be adopted when the patient requires reconstructive surgery for both knees. We report a case series of 8 patients (6 male, 2 female, average age 30.4 years) who underwent bilateral simultaneous ACL reconstruction.

Simultaneous or bilateral ACL reconstruction using ipsilateral patella tendon graft has been reported as a safe procedure with outcome and complication rate no different to unilateral procedures. Considerable cost savings of simultaneous over staged procedures have also been described. There are no case series in the published literature that describe the use of hamstring tendon autograft for bilateral simultaneous ACL reconstruction.

We used two camera stack systems and instrument sets to allow for simultaneous bilateral surgery by two surgical teams. Quadrupled hamstring tendon graft was used in 4 patients although in one patient patella tendon graft was used on the second side due to poor quality of hamstring tendons. Patella tendon graft was also used in a further 4 patients. At two weeks all patients were able to discard crutches and were independent in mobility. There was no difference in outcome at one year between those patients undergoing bilateral simultaneous ACL reconstruction in comparison to the outcomes of unilateral ACL reconstruction with respect to Lysholm, Tegner and IKDC scores. The mean follow up period was 2.3 years.

Our results demonstrate that bilateral simultaneous ACL reconstruction is safe and cost effective. A simultaneous approach also has the benefit of reducing the overall period of rehabilitation required by the patient. We report good short-term functional outcome but no long-term data is yet available.


WFM Jackson WM van der Tempel LJ Salmon HA Williams LA Pinczewski

This study evaluated the long term outcome of isolated posterior cruciate ligament (PCL) reconstruction. Thirty patients underwent surgery with hamstring tendon autograft after failing conservative management. At 10 years after surgery patients were assessed with radiographs, full IKDC examination and KT1000 instrumented testing. The mean IKDC subjective knee score was 87 out of a possible 100. Regular participation in moderate to strenuous activities improved from 26% preoperatively to 88% of patients. At 10 years endoscopic reconstruction of the PCL with hamstring tendon autograft is effective in reducing knee symptoms. Patients can expect to continue participating in moderate to strenuous activties over the long term. Osteoarthritis is observed in some patients with 18% showing some loss of joint space which compares favorably with non-operatively managed PCL injuries. This is a successful procedure for symptomatic patients with PCL laxity who have failed conservative management.


S Konan FS Haddad

Purpose of study: The all inside fixation of meniscal tears with bio-degradable products is popular because of its fast application and reduction in risks of serious neurovascular complications. We reviewed the results of a consecutive series of all inside meniscal repairs performed by the senior author in a carefully selected patient population.

Materials & Results: The senior author performed 104 consecutive meniscal repairs (54 lateral & 50 medial meniscus) in 96 patients (66 male, 30 female), using all inside meniscal repair systems (18 Bionxx, 86 FasT Fix; Smith & Nephew). The average patient age at the time of repair was 31.6 years (range 17 – 46 years). On an average 2 arrows (range 1–4) were used in the Bionnx system and 2.5 sutures (range 1–7) for the Fas T fix system. The predominant tear pattern was a peripheral red on white type tear involving the body and posterior horn. Concomitant ACL reconstruction was undertaken in 50% cases. In 26.9 % cases the repaired meniscus was partially trimmed prior to repair and in 25 % cases a tear of the non repaired meniscus was stabilised by trimming alone. A further arthroscopic partial menisectomy was performed in 12 cases of failed repair (4 Bionxx, 8 Fas T fix) at an average of 16.16 months (range 1 month – 44 months). None of the other patients had symptoms or signs suggestive of meniscal pathology on follow up (minimum 12 months). The repair was successful in 90.69 % of Fas T fix repairs and 77.78 % of Bionxx repairs. The meniscal repair failure rate in the group which had an ACL reconstruction was 5.77 %. No major intra or post operative complications were noted.

Conclusion: Successful meniscal preservation is feasible by using an all-inside meniscal repair device. Patient selection and due consideration to the site and geometry of the meniscal tear is crucial.


M Freudmann S R Bollen

Aims: To identify any changes in the demographics of ACL injured patients over the last decade.

Methods: Over a twelve month period, the demographic data from 117 consecutive new patients with ACL injuries attending one consultant’s clinic in 1994 was prospectively recorded. This was then compared with data from a similar cohort of 103 consecutive new ACL injured patients attending the same clinic some twelve years later.

Results:

Since 1994, the proportion of women seen with ACL injury doubled from 12% to 25%

The proportion of skiing related injuries trebled from 9% to 28%

The average age at presentation rose by 6.5 years from 26.5 to 33

The average age of the skiers is 41 and 90% of them are female

Conclusion: The population of patients with new ACL injuries has changed significantly over the last twelve years. The average age, proportion of women and number of skiing related injuries have all increased significantly. We speculate that the most likely cause of these changes is the skiing population, which has enlarged and, due to retention of participants, has aged over the period of this study (1). Most skiing injuries are sustained abroad and the vast majority of skiers buy holiday insurance to cover themselves against injury. Yet it is the NHS that ends up footing the bill for any reconstructive surgery and rehabilitation. We propose that if the insurance companies maintained responsibility for their clients’ injuries until a full recovery had been made, the NHS would save millions of pounds.


A Ajuied A Carlos A Kumar

Introduction: After adopting a new low suspensory bio-absorbable femoral fixation technique for single bundle, four strand, hamstring Anterior Crutiate Ligament (ACL) in conjunction with a rapid rehabilitation program, we observed at routine follow up that there was no evidence of femoral tunnel widening, as often observed with conventional high suspensory fixation systems.

Method: We conducted a retrospective observational cohort study to test the hypothesis that the Rigid-Fix (Mitek) system of femoral fixation, a low suspensory technique, is less prone to tunnel widening than traditional suspensory techniques.

14 subjects were recruited at routine follow up, and assessed by interview, clinical examination and plain digital raiodgraphs.

All radiographs were taken under clinical supervision, with a scale reference, hence allowing digital rescaling.

Results: All subjects had regained knee stability, and all but one had returned to their pre-injury level of sport. Clinically all knees were ligamentaly stable, exhibiting negative Luchman and pivot shift tests.

Examination of the radiographs demonstrated only a 1.1mm (+/− 0.9mm) mean femoral tunnel widening, which represents a 12% increase in diameter (21% increase in area), and compares very favourably to the observed tunnel widening in high suspensory techniques, as cited in the literature.

Conclusions: We conclude that the Rigid-Fix femoral ACL fixation system does not exhibit any evidence of clinically significant tunnel widening, even when used in conjunction with a rapid rehabilitation program.

Systems of low suspension benefit from the advantage of not relying on interference fit which risks posterior cortical ‘Blow Out’. A shorter graft working length within the tunnel lessens graft micro-movement, making early low biological fixation within the femoral tunnel more likely, and reduces the amount of tunnel widening. These micro-movement have been described as the ‘Windscreen Wiper’ and ‘Bungee Cord’ effects, and are well documented in traditional high suspensory fixation.


R Khan A Konyves KR Boddu Siva Rama R Thomas A Amis

A recurrence of objectively measured knee laxity after anterior cruciate ligament (ACL) reconstruction has previously been reported in various papers; the purpose of this study was to accurately measure in vivo knee laxity after both bone-tendon-bone (BTB) and hamstring reconstruction using radiostereometric analysis (RSA), and to differentiate between graft fixation slippage and graft stretching and their relative contributions to any increase in laxity.

Twenty patients were studied prospectively after ACL reconstruction. Ten had been operated on using BTB grafts, and ten using hamstring (four-stranded semitendinosus/gracilis) grafts. Tantalum markers were inserted in the distal femur, proximal tibia and into the graft itself. (RSA) was used to measure sagittal laxity, graft stretching and fixation slippage early post-operatively, and then at intervals up to 1 year.

A steady increase in total anteroposterior laxity was found in both groups over the year. For the BTB group, total mean slippage of the bone plugs increased to 1.28 mm at 1 year. For the hamstring group, the tunnel attachments had slipped by a total of 6.82 mm. More stretching was found for the hamstrings grafts than for the BTB grafts and the amount of stretching increased significantly with time post-surgery. The hamstring grafts stretched by a mean of 4.18%, the BTB grafts by 1.18%.

This is believed to be the most detailed application of RSA in analysing the performance of the two commonly used grafts in ACL reconstruction. Details such as graft stretching and fixation slippage have not been available previously; the data obtained in this study may have implications for clinical practice.


M N Yasin M Y O Garrick P M Phaltankar

Purpose of Study: To study the anatomy of the accessory bands of Gracilis and Semitendinosus in order to avoid inadequate graft harvesting during ACL reconstruction.

Methods and Results: Data was collected from 25 arthroscopically performed ACL reconstructions using the hamstring tendons. For each patient the exact number of accessory insertion bands of the Gracilis and Semitendinosus was recorded, as well as the distance of the proximal most band from the main insertion point on the tibial crest.

Of the 25 Gracilis tendons, the most common number of accessory bands was 2, varying from 0 to 3. The average distance of the proximal most band was 5.14cm. The most common number of accessory bands for the Semitendinosus tendon was 3, varying from 1 to 4. The average distance of the proximal most band was 8.14cm. Five of the Semitendinosus and none of the Gracilis tendons had a proximal band located > 10cm. Average length and diameter of the four strand graft was 7.7cm and 13.2cm.

Conclusion: Gracilis and Semitendinosus tendons are increasingly being used for soft tissue reconstructions. Awareness of accessory bands of these tendons is essential in preventing diversion of the tendon stripper leading to a short and inadequate graft. Previous studies have shown that the anatomy of these bands is highly varied. Such cadaveric studies have shown a high percentage of tendons with bands > 10cm proximal to their insertion [2]. Our study shows that 20% of Semitendinosus and none of the Gracilis tendons had bands more than 10cm proximal to their insertion. Gaining knowledge about accessory insertion bands of the hamstrings should assist reproducible and adequate graft harvest.


J Robinson P Colombet P Christel J-P Francheschi P Djian G Bellier A Sbihi

Purpose: To define the positions of the attachments of the anteromedial (AM) and posterolateral (PL) bundles of the ACL facilitating accurate tunnel placement during two-bundle reconstruction.

Methods: The positions of the femoral and tibial attachments of the AM and PL bundles was determined in 7 fresh-frozen, unpaired, cadaveric knees by 6 independent observers, using landmarks visible at arthroscopy. This included, on the tibia, the retro-eminence ridge (lying just anterior to the PCL), a bony landmark that could be reliably identified arthroscopically. Tantallum beads were then inserted so that the bundle attachments could be clearly identified on a plain lateral radiograph of the knee. The position of the centres of the AM and PL attachments were described relative to Amis and Jakob’s line on the tibia and Bernard’s grid on the femur.

Results: The AM femoral attachment lay high and deep in the notch with the most posterior fibres 1.8 mm anterior to the “over–the-top” position. The PL femoral attachment was low and shallow in the notch with the most anterior fibres 2.8 mm from the border of the articular cartilage. The centres of the bundles were 8.2 mm apart. The position of the bundles relative to Bernhard’s grid is shown in figure 1.

On the tibia, the centre of the AM attachment was located 18 mm anterior to the Retro-eminence ridge (RER). The centre of the PL bundle lay 8.4 mm posterior to the centre of the AM bundle. These positions were at 35% and 52% along Amis and Jacob’s line

Conclusions: This study details the morphology of the AM and PL bundle attachments and demonstrates reliable arthroscopic techniques to assist with accurate tunnel placement in reconstruction surgery. In addition, it provides reference data for radiographic evaluation of tunnel placement.


P Akhbari R Goddard P Gibb PW Skinner

Introduction: The aims of this study were to determine whether patients were transfused appropriately, after a Unilateral Cemented Primary Total Knee Replacement (TKR), and whether it would be cost effective to use autologous transfusion drains compared with standard group & save and cross match protocols.

Method: Retrospective study of the pre- and postoperative day 1 haemoglobin values of all patients who underwent unilateral primary cemented TKR between November 2004 – November 2005 at the Kent & Sussex Hospital, Tunbridge Wells. Haemoglobin data and length of stay was obtained from computerised records & transfusion data from the blood transfusion department.

Results: 150 patients were assessed: 97 (65%) female and 53 (35%) male. 20 (14.6%) patients required blood transfusion. The mean preoperative haemoglobin for non-transfused and transfused patient’s was 13.7 and 12.5g/dl respectively (P = 0.0029). The mean postoperative haemoglobin for non-transfused and transfused patient’s was 11.1 and 9.27g/dl respectively (P< 0.001). The mean blood loss for non-transfused and transfused patient’s was 2.64 and 3.26g/dl respectively (P< 0.001). There was no significant correlation between length of stay and either preoperative haemoglobin or blood loss after surgery; Spearman’s correlation coefficient was 0.0222 and 0.0036 respectively. The cost of a standard group & save and cross match, plus the 56 required units of blood in this study was £15,443.60. The theoretical cost of using a CellTrans Autologous Transfusion System on these 150 patients would be £14,355.00, a saving of only £1,088.60. However, by only using the autologous drains on patients with a preoperative haemoglobin ≤ 12.5g/dl, this saving could be increased to £4,131.20 per annum.

Conclusion: Using autologous transfusion drains on patients with a preoperative haemoglobin ≤ 12.5g/dl would save over £4,000 per annum at Maidstone & Tunbridge Wells Hospital Trust. There is no correlation between length of stay in hospital and either preoperative haemoglobin or blood loss after surgery. Patients transfused had significantly lower pre- and postoperative haemoglobins.


S. Akhtar A. Mofidi C. Wilson R. Williams

Purposes of the study: Anterior cruciate ligament (ACL) deficiency is associated with degenerative osteoarthritis especially when it is present with meniscal injury; We assessed the impact of certain aetiological factors in chondral degeneration in the ACL deficient knee.

Methodology and Results: Fifty-eight patients who underwent consecutive primary arthroscopic anterior cruciate ligament reconstruction using the four strand hamstring graft between 10/06/2004 and 29/06/2006 were retrospectively analysed.

Patient’s charts and radiology findings were reviewed with special attention to operative notes and preoperative knee MR imaging. Patients with knee symptoms prior to presenting injury were excluded.

The mechanism of injury, the time elapsed from the original injury to anterior cruciate ligament reconstruction, associated meniscal injury, and quality of cartilage in the knee- at the time of MR imaging and ACL reconstruction were noted. Degenerative cartilage changes were graded upon reconstruction using the Outerbridge classification.

The average time from Injury to MR imaging and MR to ACL reconstruction was 4.85 and 12.65 months respectively.

We found a direct relationship between the time elapsed after the ACL injury and the severity of the chondral lesion (p< 0.05). Furthermore, a significant worsening in chondral degeneration of the involved knee was seen when the MR imaging and ACL reconstruction were more than 12 months apart (p< 0.01).

Conclusion: We conclude that chondral lesions and degeneration are more likely to be caused by an extended period of knee instability following ACL injury as opposed to age related degeneration or direct trauma to the weight bearing area of the knee.

Early reconstruction may protect the knee from chondral wear and subsequent degenerative arthritis.


S Konan FS Haddad

Purpose of study: The aim of this study was to look at the clinical outcome of PLC interference screws in knee ligament reconstruction surgery.

Materials & Results: We prospectively followed up 60 patients who underwent primary anterior cruciate ligament (ACL) reconstructions using PLC (Calaxo; Smith & Nephew) screws to secure the graft in the tibial tunnel. [(35 male patients & 25 female). Average age 33.72 years]. In addition to the ACL, PLC screws were used to reconstruct the posterior cruciate ligament in one case and posterior cruciate ligament with the posterolateral corner in another three patients. Hamstring autografts were routinely preferred except in multiple ligament reconstructions, when allografts were also used.

25 (41.67%) patients presented with complications (synovitis in 10 patients, prominent tibial swelling in 21 patients and both in 7 patients). In comparison, no complications were noted in 60 other age and sex matched patients in whom PLLA (Bio RCI; Smith & Nephew) screws were used by the same surgeon.

The symptoms in the PLC screw group often settled conservatively and did not affect knee stability. 6 patients underwent exploration of the tibial tunnel site. A sterile white cheesy substance was noted which was removed, leaving an empty tibial tunnel. The ACL graft was found to be well attached to tibial tunnel in all cases. The PLC screw size did not have any correlation to the occurrence of complications. 2 patients required multiple washouts, one of whom developed a deep infection.

Conclusion: The degradation of PLC screws does not follow the gradual and controlled pattern demonstrated in the ovine model [Walsh WR et all, Arthroscopy. 2007 Jul;23(7):757–65. Comparison of PLLA and PLC interference screws in an ovine ACL reconstruction model.]. The unpredictable screw resorption, and the reaction to it can lead to serious clinical consequences.


S Al-Naser AP Davies

The study aims to determine the effects of obesity on the patients’ symptoms and their knee function before knee arthroplasty, as well as their states of anxiety and depression.

Ethical approval was obtained before the start of the study. Weights and heights of all patients were measured and BMI calculated on admission. Anxiety and depression states were recorded using the Hospital Anxiety and Depression Scale (HADS). The severity of pain and loss of function of the knees undergoing arthroplasty was measured using the Oxford Knee Score and the American Knee Society Score. All scores were measured per-op and again at 6 weeks post-op.

To date, 28 patients were included. The mean body mass index was 28.9. Only six patients had a BMI of < 25. Patients with normal BMI (< 25) had mean anxiety and depression scores of 6.8 and 5.67 respectively. Overweight patients (BMI > 25) had scores of 5.59 and 4.9 respectively. Patients with BMI > 30 had scores of 6.71 (p= 0.22) and 7.0 (p= 0.04) respectively.

Patients with BMI > 30 had an improvement in anxiety scores of 1.33 points compared with 0.55 for patients with BMI < 30 (p= 0.3). Depression scores improved by 4 points in the BMI > 30 group compared with 0.67 in the BMI < 30 group (p= 0.03).

Improvements in the knee scores were comparable in both groups.

Obese patients with BMI of > 30 have higher rates of anxiety and depression pre-operatively. At 6 weeks follow up, there is an improvement in both measures of psychological distress but this is more pronounced for depressive symptoms.


S Amanan S Gella R Sidaginamale A Tillu S Parekh

Nerve blocks are a common form of peri-operative analgesia that is administered for patients undergoing joint Replacement surgeries. The long term sequel following these peripheral nerve blocks used in total knee replacement not reported in the literature. Nerve blocks given under the guidance of nerve stimulators are in practice in most of the hospitals and are considered safe.

We report a series of two cases with residual neurological deficit following these peripheral nerve blocks in total knee replacements. In both these cases the femoral, sciatic, obturator and lateral cutaneous nerve of thigh were blocked with 0.25% of Bupivacaine with the help of a nerve stimulator.

First patient post operatively had residual numbness in the right lower leg after 4 weeks of surgery. Nerve conduction studies confirmed absent response in right Saphenous and superficial peroneal nerves. Patient has no improvement in her neurological deficit even after 16 months post operatively. Further to this she developed complex regional pain syndrome on the affected side.

Second patient post operatively developed knee extensor weakness of grade II/V and loss of sensation in femoral nerve distribution. Nerve conduction studies confirmed severe femoral nerve damage around groin. She went through a turbulent phase, knee stiffness range of movements 0–20 degrees requiring Manipulation Under Anaesthesia, later Exploration and Release of adhesions which improved her range of movements to 0–95 degrees. At 12 months post operative the neurological status improved to grade 3/5 in knee extensors.

Conclusion: Long term Complications of Peripheral nerve blocks in total knee replacements are not reported in the literature. These complications though uncommon, unfortunately for patients affect the surgical outcomes. The purpose of this case series is not only to report complications but also to share our experience of managing these complications, their outcomes and relevant literature review.


G Bhatnagar D Karadaglis R Varma G Groom A Shetty

Aims: Kinematics of the arthritic knee joint is to date not very well understood, yet this is a significant parameter affecting the results of knee arthroplasties; we studied the axial rotation of the tibia during knee flexion in osteoarthritic knees in order to understand better the kinematics of the arthritic joint.

Methods: Tibial rotation and the screw home mechanism were studied in 55 consecutive patients (31 females and 24 males) with diagnosed knee OA. The assessment was performed by consultant orthopaedic surgeons using the trackers and the software of a navigation system, prior to any soft tissue release. The Student t-test was used for the statistical analysis.

Results: We identified 3 different patterns of tibial rotation during knee flexion.

26 knees had normal tibial rotation pattern with the tibia rotating internally during knee flexion (mean rotation: 15.5°).

In 22 knees (40%) the tibia was rotating internally and then externally as the flexion was progressing (mean rotation: 6.7°).

In 7 joints (13%) a reverse tibial rotation was recorded, the tibia was rotating externally in all flexion increments (mean rotation: 2.2°).

We also recorded that most of the tibial rotation occurs in the first 0–30° of flexion (70%) p< 0.001.

Conclusion: The screw home mechanism and the normal tibial rotation upon knee flexion were absent or distorted in the majority of osteoarthritic knees. We found three distinctive patterns of the tibial rotation (normal, erratic and reversed) during knee flexion.


G Bhatnagar D Karadaglis R Varma G Groom A Shetty

Aim: Accurate soft tissue balance in total knee arthroplasty (TKA) is not only technically challenging but also difficult to teach to trainees; we believe that computer navigation provides a very useful tool for objective and reproducible soft tissue balance.

Methods: We studied 52 patients (31 females and 21 males) with knee osteoarthritis and recorded the change of the Medial (MCL) and Lateral Collateral Ligament (LCL) length at full extension and at 90o flexion. Pre- and post-operative results were compared. The assessment was performed by consultant orthopaedic surgeons using trackers and navigation knee replacement software. Data was analysed using the student t-test

Results: The navigation software programme was used to measure the change of the collateral ligament length. Ligament laxity is represented by a negative number and a positive number is used to represent stretching and apparent elongation of the ligament.

The medial collateral (MCL) length at full extension ranged from −9mm to 11mm and post-operatively was reduced to −16mm and 8mm, (p=0.042). At 90o flexion the length ranged from −3mm to 9mm and postoperatively was reduced to −8mm and 10mm (p=0.025).

The lateral collateral (LCL) length at full extension changed from −10mm to 9mm pre-operatively to −13mm and 6mm post-operatively (p=0.011). At 90o flexion the range from −8mm and 9mm pre-operatively changed to − 5mm and 11mm post-operatively (p=0.005).

All the above changes correspond to improvement in the post-operative axial alignment.

Conclusion: Our results demonstrate that computer navigation provides a useful adjunct to the accurate and reproducible soft tissue balance in knee arthroplasty which can be used to evaluate results and for training purposes.


I Arunkumar A Lee

To share our results following Medial Patellofemoral ligament (MPFL) reconstruction for patellar instability problems using ipsilateral semitendinosus graft anchored to the patella and the medial femoral condyle using biotenodesis screws.

Study design and methods: 35 patients were assessed with a mean follow up of 18 months. All patients had preoperative true lateral knee x-ray, MRI or CT scan to look at trochlear dysplasia and the sulcus tuberosity distance. They all under went MPFL reconstruction using ipsilateral semitendinosus tendon. Two patients had sulcus tuberosity distance greater than 20 mm and they under went a tibial tubercle transfer in addition. Two patients had trochlear dysplasia and hence a trochlearplasty was also done. In skeletally mature patients the hamstrings tendon were anchored to the medial side of the patella in a 5×15mm blind tunnel using biotenodesis screw. This significantly reduces the risk of having patella fracture. All patients were treated by the same surgeon and assessments were performed by a different surgeon based on kujala scores and tegner scores.

Results: Symptom relief was noted in all patients with in 3 months. No patient had patella dislocation or fracture after this procedure. They all had full range of movements and their kujala scores and tegner scores were good to excellent.

Conclusion: MPFL reconstruction using hamstrings tendon anchored to the medial side of the patella and femur using biotenodesis screw gave a good result clinically and is associated with fewer complications including patellar fractures.


D Karadaglis G Bhatnagar R Varma A Shetty

Aim: The difficulty in accurately assessing coronal alignment of a total knee prosthesis (TKR) is widely accepted in the literature yet standard practice in the UK is to obtain AP and lateral knee views only; we compared standard AP knee films with long leg views of TKR in order to determine the most optimal way of assessment of the prosthetic knee alignment.

Methods: We included all patients who underwent TKR between January and September 2005 at Kings College Hospital under the care of one orthopaedic consultant. We excluded 11 patients with revision surgery, augmented prosthesis, high tibial osteotomies or severe tibiotalar joint arthritis.

We included 50 sets of radiographs from 48 patients (17 men and 31 women). The prostheses used were PFC (40) and Scorpio (10) and six of them were navigated and 44 were standard TKR.

We compared the difference between the angle of the tibial component with the mechanical axis of the tibia in the long leg image and the angle of the prosthesis with the midline of the visualised tibia in a standard antero-posterior knee view. Statistical analysis was carried out using the student t-test.

Results: The mean difference between the two views was 5.34o (range 1.9o – 12o) (p< 0.001). We did not find any difference between the Scorpio and PFC knees or between navigated and non navigated prostheses.

Conclusion:We concluded that the long leg views compared with the standard antero-posterior knee views provide more accurate information on the position and alignment of the tibial component of a TKR.


T J Colegate-Stone P Allen

Purpose of study: The aim of this project was to ascertain whether tibio-femoral joint space width (JSW) measured both on Schuss and full extension radiographic views were predictive and accurate relative to the articular cartilage findings on arthroscopy.

Methods & Results: The study was a prospective trial. The criterion for recruitment was knee pain indicative of arthritis that required arthroscopic assessment with a view to possible surgical management. Joint space narrowing (JSN) was assessed in the affected knee, in both the standing full extension and Schuss views. Joint arthroscopy was performed and each compartment area of the knee was calibrated and graded corresponding to the arthritic changes identified. In the 60 patients recruited, 61.7% were found to have grade 4 arthritic changes on knee arthroscopy. JSN in those with associated grade 4 changes on arthroscopy on either full extension or Schuss views was 75.7% and 78.4% respectively. However in 24.3% of those with grade 4 changes on arthroscopy no JSN was demonstrated on either full extension or Schuss views. Arthroscopic assessment of severe arthritic changes of the knee was significantly superior compared to the radiographic method (p< 0.05).

Conclusions: The findings suggest that despite narrowed JSW measured on either radiographic view being indicative of severe articular cartilage loss, neither view accurately predicts articular cartilage loss in less advanced cases. In cases of grade 4 changes and no JSN the sites of articular cartilage loss corresponded to sites that are less likely to be accurately represented on either radiographic view. Our findings suggest that knee arthroscopy may be better suited to identifying smaller patches of cartilage loss whose surface area may not be sufficient to cause JSN but may still cause symptoms. We suggest knee arthroscopy is indicated in patients with knee pain suspicious of arthritis but who lack obvious JSN on either full extension or Schuss views. This enables micro-fracture techniques to be used with the aim of attenuating disease progression, and offers a thorough lavage that may also provide symptom relief.


C P Charalambous F Alvi P Hirst

Purpose: To evaluate the intra and inter-observer variation of the Schatzker and AO/OTA classifications in assessing tibial plateau fractures, using plain radiographs.

Summary: Fifty tibial plateau fractures were classified independently by 6 observers as per the Schatzker and AO/OTA classifications, using antero-posterior and lateral plain radiographs. Assessment was done on two occasions 8 weeks apart.

We found that both the Schatzker and AO/OTA classifications have a high intra-observer (kappa=0.57 and 0.53 respectively), and inter-observer (kappa=0.41 and 0.43 respectively) variation. Classification of tibial plateau fractures into unicondylar vs. bicondylar and pure splits vs. articular depression +/− split conferred improved inter and intra-observer variation.

Conclusions: The high inter-observer variation found for the Schatzker and AO/OTA classifications must be taken into consideration when these are used as a guidance of treatment and when used in evaluating patients’ outcome. Simply classifying tibial plateau fractures into unicondylar vs. bicondylar and pure splits vs. articular depression +/− split may be more reliable.


R Chau H G Pandit A Gulati H Gray D J Beard H S Gill C A F Dodd A J Price D W Murray

Purpose: To identify associative factors for radiolucency (RL) under the tibial component following the Oxford unicompartmental arthroplasty (UKA), and to evaluate its effect on clinical outcome scores.

Method: One hundred and sixty-one knees which had undergone primary Phase 3 medial Oxford UKA were included. Fluoroscopic radiography films were assessed at five years post-operatively for areas of tibial RL. The two groups of patients, with and without RL, were compared to

patients’ pre-operative demographics for age, weight, height, BMI,

intra-operative variables such as the operating surgeon (n=2), insert and component sizes,

post-operative varus/valgus deformity, and

clinical outcome, assessed by the change in Oxford knee (OKS) and Tegner (TS) scores, from before surgery to five-year post-operatively.

Results: 101 (62%) knees were found to have tibial RL. All RL were categorised as physiological or they were < 1mm thick, with sclerotic margins and non-progressive. No statistical difference was found between knees with RL and those without, in terms of pre-operative demographics, intra- or post-operative factors, and clinical outcome scores (p> 0.1 in all variables).

Discussion: Radiolucency (RL) under the tibial component is a common finding following the Oxford UKA. Many theories have been proposed to explain the cause of RL, such as poor cementing, osteonecrosis, micromotion, and thermal necrosis. However, the true aetiology and clinical significance remain unclear. We attempted to address this.

We found no significant relationship between physiological RL, pre-operative demographics, intra-operative variables and clinical outcome scores in this study. Tibial RL remains a common finding following the Oxford UKA yet we do not know why it occurs but in the medium term, clinical outcome is not influenced by RL. In particular, it is not a sign of loosening. Physiological RL can therefore be ignored even if associated with adverse symptoms following the Oxford UKA.


J F Davies R Grogan M Chandramohan S Bollen

Post traumatic myositisossificans is a benign condition of heterotropic ossification of unknown aetiology which typically is related to trauma from a single blow or repeated episodes of microtrauma. We describe an unusual case of myositis ossificans which developed as a complication at the donor site for hamstring autologous graft used in open anterior and posterior cruciate repair and posterolateral corner reconstruction in a 15 year old girl.

Case report: A 15 year old girl sustained a closed traumatic dislocation of her left knee when she fell from a trampoline. She underwent emergency manipulation under anaesthetic and closed reduction followed by MRI scan which showed a complete disruption of the lateral collateral ligament complex, posterolateral corner injury, complete tears of the anterior and posterior cruciate ligaments and a partial tear of the medial collateral ligament.

13 days later she had an open reconstruction of her anterior and posterior cruciate ligaments with allograft and a repair of popliteus and lateral structures with Larson reinforcement with controlateral hamstring autologous graft.

Eight months following open reconstruction the patient represented to her primary care practitioner with a painful lump in the postero-medial controlateral right thigh. MRI study showed that there was a lobulated hypervascular appearance with a thin enhancing rim of low signal on all sequences indicating calcification. An xray revealed a calcified mass consistent with the diagnosis of myositis ossificans.

Discussion and conclusion: To date we have found no reported cases of myositis ossificans occurring as a result of surgery to harvest hamstring autograft in the setting of ligament reconstruction about the knee. We believe that this is an unusual complication of the donor site which needs awareness amongst clinicians involved in primary and revision cruciate ligament reconstruction. We suggest that a management strategy of surveillance for this lesion is appropriate and excision biopsy should be reserved for specific indications such as malignant features on imaging or mass effect.


J Campion S Masters I Byren A Berendt AJ Price

Purpose: The purpose of this study was to establish patient mortality following salvage treatment (debridement, retention of prosthesis and antibiotic therapy) for infection of primary joint replacement, performed at the unit.

Method: A series of 89 patients underwent salvage treatment for infected primary total joint replacement (47 hips and 42 knees) between 1998 and 2003. The average age of the patients was 70.3 years (range 31.8 to 89.1). A survival analysis was performed using death as the sole endpoint and there were no patients lost to follow-up.

Results: There were a total of 26 deaths with a mean time to death of 3.3 years (range 0.8 to 7.2). The 7-year cumulative patient survival of was 66% (CI 5, number at risk 21).

Conclusions: The morbidity associated with infected total arthroplasty has been well documented. This study highlights that patients undergoing salvage treatment for this condition have significant mortality, with up to a third of patients potentially dying by 7 years.


L A Cooper C Mauffrey R Carey-Smith P Thompson T Spalding

The purpose of this study was to assess the accuracy of a modified version of the pivot shift test in detecting ruptures of the anterior cruciate (ACL) ligament.

Methods: Two groups of patients aged 18 to 50 years were recruited from operating theatre lists examined at a check and consent clinic. One of the groups had ACL deficient knees and the control group had intact ACL, later proven at arthroscopy. A total of 48 independent examinations, 26 with ACL rupture and 22 without, were undertaken by a consultant or registrar proficient in the modified version of the pivot shift test. At the start of the consultation the examiner, who was blinded to the operation that the patient was listed for and to the patient’s history, performed the modified pivot shift test only. The result of the test was reported as positive or negative for ACL rupture to the study co-ordinator before the examiner continued with the consultation.

Results: Of the 26 examinations of ACL deficient knees, 22 were reported as positive and four negative for ACL rupture using the pivot shift test only. Of the 22 examinations of ACL intact knees one was reported as positive for ACL rupture and 21 as negative. This gives a specificity and sensitivity of the modified version of the pivot shift test as 95.5% (95% CI 75.1–99.8%) and 84.6% (95%CI 64.3–95.0%) respectively.

Conclusion: The modified pivot shift test is an accurate test for the detection of ACL rupture. Our modified pivot shift test compares favourably with data from previous accuracy studies of previously described versions of the pivot shift test. We now plan to assess the accuracy of the modified pivot shift test when carried out by medical students and junior doctors.


S Gella S Sharma A Singh S Amanan V Killampalli N Gogi BK Singh

Background: Total knee replacement remains one of the most common knee surgery practices worldwide. The operative procedure universally requires the use of cutting jigs to resect predetermined amounts of bone irrespective of the preoperative anatomy and morphology of the femur and tibia.

Aims: The aims of this study were to elucidate anatomical morphological differences between ethnicities pre-operatively and to assess whether any change elucidated was preserved post-operatively.

Method: This was a retrospective study comparing the pre and postoperative lateral view X-Rays of TKRs performed. Distances measured from most prominent anterior point to midline and the most prominent posterior point to midline and their ratio was compared between two ethnic groups. Each x-ray measurement was triple checked.

Results: The study groups comprised of 60 Caucasian knees and 40 Asian knees. Preoperatively the mean ratio was 0.55 in Caucasians and 0.44 in Asians, with this difference being statistically significant (p value < 0.005). Post operatively the mean ratio was 0.59 in Caucasians and 0.55 in Asians and this difference was not statistically significant (p value =0.166). These findings were also cross-checked with range of movement measurements post-operatively in the same group of patients. There was no comparable improvement in range of movements (ROM) post-operatively in the Asian group.

Conclusion: We infer that the present TKR cutting jigs are not taking into account the anatomical differences within the knee of Asians individuals. This is converting the post operative distal femurs of this group to become morphologically comparable to the Caucasian knee and this is possibly affecting the kinematics of those knees leading to no significant improvement in the post operative ROM and affecting satisfaction with surgery.


G N Gillespie K Lang J L Williams

This study evaluates the relationship between radiographic knee osteoarthritis and the presence of a relevant meniscal tear detected with MRI in symptomatic patients over the age of 60.

Seventy-seven patients over 60 investigated with a knee MRI in a 1 year period were identified. 60 patients had a full set of data available for analysis. The plain radiographs were graded for osteoarthritis using the Kellgren – Lawrence (K-L) scale in a blinded manner. The indication for the MRI was subdivided into: meniscal symptoms, general knee pain and other. These indications were correlated with the K-L grade and result of the MRI.

Overall, 40% of patients with a K-L grade of 0 had a meniscal tear compared to 89% of patients with a K-L score of 3 and 88% with a K-L score of 4. The indication for a MRI was meniscal symptoms in 49, general pain in 6 and other in 5. In the group investigated for meniscal symptoms, the incidence of meniscal tears was 92% and 100% with a K-L grade of 3 and 4 respectively.

In patients with meniscal symptoms and significant radiographic osteoarthritis the outcome of the MRI is so predictable that the scan is unnecessary.


A E Fox D S Johnson D Havely G E Cook

Purpose of Study: We aimed to reduce the work intensity involved in auditing high volume procedures (eg knee arthroscopy) by developing and validating a tool which uses routinely acquired hospital data, to target those patients most likely to have developed an undesirable post-operative outcome.

Methodology: The work was a collaboration effort between the Orthopaedic and Clinical Effectiveness departments. During the period 1997–2003, 2926 elective knee arthroscopies were identified as having been performed in our unit. Linkage of routinely collected data held on the hospital’s computerized Patient Administrative System (PAS), hospital theatre system and A& E system, with data from the Office of National Statistics concerning death, high-lighted 183 cases (Core group) meeting one or more of four indicators: readmission < 28 days, return to theatre < 28 days, return to A& E < 28 days, and length of stay 4+ days (Graph 1). The accuracy of the tool to identify undesirable post-operative outcomes was made comparing the Core group and a Random sample (N=240).

Results: Accuracy of OPCS-4 coding for arthroscopic procedure performed was 77.1% in the core group and 96.4% in the random sample. The new tool yielded a sensitivity of 38% and specificity of 95%. Where major complications were concerned the sensitivity rose to 100%. For major complications the proposed model indicated a 0.6% complication rate vs 0.5% actual rate. For minor complications the proposed model indicated a 1.4% rate vs 3.8% actual rate. Overall complication rate within our unit was comparable to the published literature.

Conclusion: The tool has achieved its aim of identifying all major complications and undesirable events, along with many minor complications. As the tool identifies additional information it must be used as an aid to identifying patients for case note review. However, in our study it reduced the number needed to less than 7% of the total.


A Getgood M Kent I McNamara A Dickinson H Elmadbouh T Bhullar

Introduction: The purpose of this study was to describe our experience of the Calaxo Osteoconductive interference screw (Smith & Nephew) when used for both femoral and tibial graft fixation in Double Bundle ACL reconstruction.

Methods: Since May 2006, all patients with an ACL deficient knee were reconstructed using the Double Bundle technique. All were followed prospectively and outcome data collected.

Evidence of fixation failure was established subjectively by clinical examination (Lachman, Anterior Draw, Pivot Shift) and objectively via KT-1000 arthrometer.

Following ethical approval, post-operative CT scans (immediate and 1 year) were performed on our first 10 patients allowing assessment of tunnel dimensions/fill.

Results: Thirty two patients (29 male, 3 female) with a mean age of 30 (range 18–46) were included. At last follow-up, no evidence of graft/fixation failure was found; KT-1000 mean side-side difference 1.4mm (range −3 to +6). All patients had a positive pivot shift preoperatively which was abolished postoperatively. One patient had a postoperative infection with no other complications reported. Radiologically the screws did not show complete resorption but areas of new bone were identified.

Discussion: We have shown satisfactory results with use of the Calaxo screw when used in Double Bundle Reconstruction. We have not had any cases of the adverse local soft tissue reaction, which has led to this screw being withdrawn from clinical use. Even when using a total of four screws in each knee.

A previous study published by Seibold (2007) has shown tunnel widening and communication when suspensory fixation is used in Double Bundle reconstruction. This has the potential risk of leading to fracture between the tunnels.

This has not been seen with the Calaxo screw which may be a result of the biological action of the screw which should ultimately lead to a reduction in these risks.


A Gulati R Chau J Palan R Rout CAF Dodd AJ Price HS Gill DW Murray

Purpose: To compare the site of lesions in medial and lateral unicompartmental osteoarthritis (OA) of the knee.

Methods: Patients with medial (n=35) and lateral (n=15) OA, having unicompartmental knee arthroplasty, were recruited. Intra-operatively, the distance between the anterior, posterior, medial and lateral margins of the full-thickness lesion and reference lines dividing the condyles was measured. The midpoints of lesions were calculated and groups were compared. Lateral radiographs were used to determine the relationship between the lesion site and knee flexion angle (KFA).

Results: Femoral lesion: In lateral OA, the midpoint of lesions was 25.0mm (SD:8.8) posterior to the reference line passing transversely through the apex of the inter-condylar notch. This was significantly different (p< 0.001) from midpoint in medial OA, which was 10.7mm (SD:9.4) posterior to the reference line.

Tibial lesion: In lateral OA, the midpoint of lesions was 2.0mm (SD:6.5) posterior to the reference line passing through the mid-coronal plane of the resected tibia. This was located significantly more posterior (p=0.038) than midpoint in medial OA, which was 2.2mm (SD:5.7) anterior to the reference line.

Knee Flexion Angle: In lateral OA, the midpoint of lesions was on average at 40° flexion and sites of smaller lesions were very variable. The lesion expanded both anteriorly and posteriorly. In medial OA, smaller femoral lesions occurred in full extension and extended further posteriorly with disease progression.

No significant difference was demonstrated in medial and lateral localisation of the lesions.

Conclusion: Medial OA begins near full extension, progresses in a predictable manner and is perhaps initiated by events occurring at heel strike. Lateral OA begins in flexion in a less predictable manner, at KFA above that seen during the gait cycle. The different sites of lesions in medial and lateral OA suggest different aetiology and pathophysiology. Therefore, prevention and treatment strategies should be different.


V Gulati MZ Choudhury E Tsiridis PV Giannoudis

We report the experience of a Grade 1 Trauma Centre in treating distal femoral and tibial fractures with the Less Invasive Stabilisation System (LISS). Medium term outcomes are presented with a discussion of clinical indications.

We conducted retrospective study of patients presenting to St James University Hospital with distal femoral and proximal tibial fractures. Case notes were reviewed for demographics, mode and severity of injury, clinical time to union and complications. AO fracture classification and radiological time to union were assessed.

24 patients (10 males, 14 females) underwent LISS fixation. Average age was 69.7 years (range 31–95 years). Mean injury severity score was 14 (Range 9–36). Overall, there were five patients with isolated proximal tibial fractures, seventeen with isolated femoral fractures and two with fractures of both the distal femur and proximal tibia. Two of the distal femoral fractures were open (Gustillo type IIb). According to the AO classification, the distal femoral fractures were sub-divided into 4 Type 33A fractures, 5 Type 33B fractures, 6 Type 33C fractures, 2 Type 32B fractures and 2 Type 32C fractures. The proximal tibial fractures comprised 3 Type 41-A2, 2 Type 41-C1 and 2 Type 41-C2 fractures.

HSS scores for the 24 acute cases were 8 excellent, 8 good, 6 fair and 2 poor results. Average HSS score was 78.8 points. Time to union was determined clinically and radiologically. Bony union was achieved in 23 cases (95.8%). Mean time to radiological union was 3.9 months (range 2–5 months), and clinical union at a mean of 4.46 months (range 3–6 months).

We illustrate that the LISS is a useful technique for treating distal femoral and proximal tibial fractures which are often a complex management problem in the elderly population. With increasing incidence of fragility fractures we suggest that this may be an underused treatment option.


D Hartwright A Keogh R Carey-Smith R J K Khan

Objectives: To compare the results of various surgical approaches to the knee in primary arthroplasty surgery.

Design: Systematic review with meta-analysis

Data Sources: Cochrane Bone, Joint, and Muscle Trauma group trials register (2007), Cochrane central register of controlled trials (Cochrane Library issue 2, 2007), Medline (1950 to February 2007), Embase (1974 to February 2007), CINAHL (1982 to February 2007), Pubmed, SCOPUS and ZETOC. If data was insufficient trialists were contacted via telephone, email or letter.

Review methods: Randomised and quasi-randomised controlled trials comparing surgical approaches to the knee in patients undergoing primary arthroplasty surgery.

Results: Twenty-three randomised, controlled trials (1282 patients, 1490 TKAs) were included.

Midvastus vs Medial Parapatellar approach: Quadriceps function in the early post operative period was better preserved in the MV group. Post operative pain, blood loss and the need for LRR tended to be lower in the MV group. There was no difference in ROM, hospital stay, knee scores, complications or radiological alignment.

Subvastus vs Medial Parapatellar approach: Quadriceps function was better preserved in the SV group up to 3 months post operatively. ROM was generally greater up to the 4 week time point. Post operative pain and blood loss was lower in the SV group. There was no difference in operative/tourniquet time, hospital stay, rate of LRR, or complications.

Modified “Quadriceps sparing” Medial Parapatellar vs Mini-Subvastus (MSV) approach: A tendency for earlier restoration of SLR and better early ROM was noted in the MSV group.

Midvastus vs Subvastus approach: The SV group suffered with significantly more pain at six months post operatively.

Conclusions: Approaches preserving the quadriceps tendon improve the early extensor mechanism function and tend to decrease the need for LRR. Combined with a decrease blood loss and postoperative pain, these approaches improve early rehabilitation and allow for a more rapid recovery of knee function. However, these early improvements fail to provide any long term benefit, do not improve knee scores, or decrease the length of hospital stay.


R. M. A. Hawken C Hamer K Holmes M Stocker M Hockings

Objective: The aim of this prospective observational study was to evaluate the feasibility of performing ACL reconstruction with femoral nerve block as a day-case procedure, implement the necessary changes and audit the outcomes following instigation of a day-case protocol.

Methods: From November 2005 to April 2006 all patients undergoing ACL reconstruction were entered into a day-case feasibility study. Any issues preventing day-case discharge were identified, and in November 2006 changes were implemented to address these. Since then all ACL reconstruction patients have been treated as day-cases using femoral nerve blocks. Patients are discharged if safe, and contacted 1 and 7 days postoperatively to detect any problems and to assess patient satisfaction. Patients undergoing ACL reconstruction with femoral nerve block in the independent sector, by the same surgeon but without a strict protocol were used as a comparison group.

Results: 18 patients have followed the day-case pathway, 15 (83%) being discharged as day-cases. The other cases had afternoon surgery delaying discharge. Only 25% (3/12) patients treated in the independent sector were discharged on the day of surgery. All patients had good working femoral nerve blocks, were able to mobilise safely with crutches and reported no adverse effects from their blocks at follow-up phone calls. All reported good analgesia at home and high satisfaction with being a day-case.

Conclusions: With appropriate education of patients and staff, and following a day-case protocol, ACL reconstruction with femoral nerve block is a safe day-case procedure with high patient satisfaction.


B C Hanusch P Ions D O’Connor K Ions P J Gregg

Aim: The aim of this study was to investigate how psychological factors and illness perception can influence the recovery and functional outcome after total knee arthroplasty (TKA).

Patients and Methods: 100 patients who underwent primary total knee arthroplasty were included in this study. Pre-operatively patients were asked to complete a psychological questionnaire consisting of the revised Illness Perception Questionnaire (IPQ-r), Hospital Anxiety and Depression scale (HADS) and Recovery Locus of Control scale (RLOC). Function was assessed using Oxford Knee Score (OKS) and range of motion (ROM) pre-operatively and at six weeks and one year after surgery.

Results: Early results show that individual phychological variables correlate with the post-operative OKS at six weeks. Beliefs that the condition has a major effect on life and less understanding of the illness are associated with a poorer recovery. Women were found to have a higher degree of personal control, but this was not correlated with functional outcome. Patients with higher pre-operative OKS were more likely to suffer from anxiety and depression.

None of the investigated parameters predicted ROM at six weeks.

Discussion: Recovery from TKA surgery can be difficult to predict. This study showed that several psychological variables influence early functional outcome. These should be taken into account when considering patients for TKA surgery. Improving patient education, looking at home environment and social network as well as adressing anxiety and depression may help to improve overall outcome after TKA surgery.


NS Harshavardhana RG Bharadwaj RG Rao C Tsiouri T Alam DF Kader

Purpose: To determine the level of promotion of minimally invasive surgery (MIS) & computer assisted orthopaedic surgery (CAOS) in total knee replacement (TKR) through internet sites by BASK members.

Methods: We obtained an updated list of active members of BASK in March 2007 and permission from the executive committee to undertake this study. Standard search engines commonly used in our daily lives (viz. Google, Yahoo and Ask.com) were used to search for websites related to each surgeon during Sep–Nov 2007 period. The surgeon’s name, initials and job title thereof were used as keywords in conducting the search. Thus for each surgeon, all websites found were browsed and evaluated for MIS/CAOS and TKR/UKR information. Both direct (surgeon’s personal website/private practice) and indirect (group practice/hospital/university affiliation) information from these websites were reviewed and a standard pre-formed questionnaire proforma was filled in against that particular surgeon.

Results: A total of 178 websites were found for 405 members (392 inland + 13 overseas). 2.8% and 4.5% made direct and indirect reference to MIS TKR respectively. The most commonly listed benefits of MIS were quicker recovery, smaller incision and hence lesser pain. Very few specific risks of MIS were outlined by these websites. None of the websites quoted any peer-reviewed publication to support their claims. CAOS was discussed in 1.7% and 2.8% of these sites respectively.

Conclusion: Our study suggests that many active members do not have personal websites and these procedures are not commonly promoted by them via the internet. Many of these are often associated indirectly with group practice/institutional affiliation websites which may not necessarily be endorsed the surgeon. Our plan in near future is to monitor the changes in internet dissemination of information and close the audit loop by next year.


S Gulhane IP Holloway MA Bartlett

Purpose of study: To report arterial injury related to reference pin placement in computer navigated knee arthroplasty.

Methods and results: Our practice is to use computer navigation for all primary total knee replacements (TKR). We use a passive reflector-based system (Brain-lab, Feldkirchen, Germany), with pin fixation of the reference arrays. For the femoral array two threaded pins are inserted anteriorly with the knee in flexion and are placed as proximally as the tourniquet will allow. The pins fixation is bicortical in order to maintain good stability for the duration of surgery.

A 58 year old man underwent TKR with computer navigation using our standard technique. His post operative course was characterized by thigh swelling and pain. He was discharged on postoperative day 3 with a range of movement of 0–30°.

3 days later he was readmitted with increasing thigh pain and swelling. A quadriceps haematoma was suspected and a computerized tomography scan with intravenous contrast was performed. This showed active bleeding into the femoral canal at the site of the pin tract from a branch of the profunda femoris artery as it entered the linea aspera and a large haematoma within the quadriceps muscle centred over the pin tract anteriorly. There was no extraosseous posterior haematoma.

An 800ml haematoma was drained and two small fragment cortical screws were inserted into the pin tracts. Unicortical screws were used to minimize the risk of causing posterior bleeding.

Arterial injury has not been reported before in this setting. The previously reported complications are: pin breakage, superficial wound infection, interference with line of sight, broken pelvic drill, prolonged operation time and prolonged tourniquet time.

Conclusion: This report highlights an important complication of computer navigated TKA which needs to be taken into consideration when deciding upon whether to use computer navigation.


R Indluru A Khanna A Kumar

Aim: To evaluate results of fully congruent Mobile bearing knee arthroplasty for valgus arthritic knees using lateral capsular approach and realignment of vastus lateralis.

Material and Method: We reviewed results of 50 mobile bearing total knee arthroplasties performed consecutively between 2001 and 2006 for Valgus arthritic knees, using lateral capsular approach and realignment of vastus lateralis. Patients were evaluated using oxford and International knee society Score. Radiographs were examined for alignment of the component, evidence of loosening and scanograms assessed to evaluate the restoration of mechanical axis.

Results: The study group consisted of 47 patients, 20 men and 27 women who received fifty knees. The mean age at the primary operation was 71.57 years (range 47–82 years; SD, 9.5). The mean follow up was 4.2 years (range 1–6 years; SD, 1.35). The mean Valgus deformity was 15.92° (rang from 15–20 SD 1.89). Fixed flexion deformity was seen in 15 knees.

The mean Oxford Knee Society ratings was 52 (range 47–55; SD, 3.18) preoperatively, and 19 (range 14–24; SD, 3.72) at final follow up. The pre op mean range motion was 84.28° (range 45°–120°; SD 21.73). At final follow up the average range of motion was 107.5° (range 95°–120°; SD 8.93). According to the system of the Knee Society, the average knee score was 94 points and the average functional score was 89 points at final follow up.

There were no clinical failures or cases of postoperative instability and no cases of radiographic loosening or wear.

Radiological evaluation: None of these knees had radiographic evidence of loosening or osteolysis. Mechanical axis was restored in all the patients.

Conclusion: This study demonstrates satisfactory results of Mobile bearing knee arthroplasty using lateral parapatellar with proximal realignment of vastus lateralis for Valgus arthritic knees.


W S Khan S Anand S Tew J G Andrew D S Johnson T E Hardingham

There is an ever-increasing clinical need for the regeneration and replacement of tissue to replace soft tissue lost due to trauma, disease and cosmetic surgery. A potential alternative to the current treatment modalities is the use of tissue engineering applications using mesenchymal stem cells that have been identified in many tissue including the infrapatellar fat pad. In this study, stem cells isolated from the infrapatellar fat pad were characterised to ascertain their origin, and allowed to undergo adipogenic differentiation to confirm multilineage differentiation potential.

The infrapatellar fat pad was obtained from total knee replacement for osteoarthritis. Cells were isolated and expanded in monolayer culture. Cells at passage 2 stained strongly for CD13, CD29, CD44, CD90 and CD105 (mesenchymal stem cell markers). The cells stained poorly for LNGFR and STRO1 (markers for freshly isolated bone marrow derived stem cells), and sparsely for 3G5 (pericyte marker). Staining for CD34 (haematopoetic marker) and CD56 (neural and myogenic lineage marker) was negative.

For adipogenic differentiation, cells were cultured in adipogenic inducing medium consisting of basic medium with 10ug/ml insulin, 1uM dexamthasone, 100uM indomethacin and 500uM 3-isobutyl-1-methyl xanthine. By day 16, many cells had lipid vacuoles occupying most of the cytoplasm. On gene expression analyses, the cells cultured under adipogenic conditions had almost a 1,000 fold increase in expression of peroxisome proliferator-activated receptor gamma-2 (PPAR gamma-2) and 1,000,000 fold increase in expression of lipoprotein lipase (LPL). Oil red O staining confirmed the adipogenic nature of the observed vacuoles and showed failure of staining in control cells.

Our results show that the human infrapatellar fat pad is a viable potential autogeneic source for mesenchymal stem cells capable of adipogenic differentiation as well as previously documented ostegenic and chondrogenic differentiation. This cell source has potential use in tissue engineering applications.


T Kochhar C Jayadev D L Back K Ratnakumar

Statement: This is the first report of a supracondylar femoral fracture following ACL reconstruction using a transfixation pin

Methods: A 38 yr old secretary was admitted for an elective ACL reconstruction. The operative procedure involved harvesting of the hamstrings, with drilling of an 8 mm tibial tunnel and the graft fixed with a 10 × 35mm screw. Femoral tunnel placement was performed arthroscopically and fixation of the graft in the tunnel was using the Arthrex system. No untoward events were recorded in the notes. Post-operatively, the patient was mobilised according to the surgeons standard guidelines.

At 6 week review, the patient complained of increasing pain, inability to fully weight bear and a decreased range of movement. 35 fixed flexion deformity, 30 degrees external rotation and 20 degrees of valgus of the leg. Radiographs revealed a transverse supracondylar fracture extending through the level of the pin fixation.

Subsequent surgery involved an osteotomy to correct the deformity and application of a lateral femoral plate After fixation direct inspection of the retained anterior cruciate ligament, revealed and intact graft that functioned through the full range of movement.

At nine months, the patient is fully weight bearing has returned to her pre-injury sporting level and has a range of movement of 0–110 degrees. There was no objective knee instability and the patient is satisfied with the outcome.

Femoral fractures have rarely been reported in the literature following ACL reconstruction and these are usually associated with drilling of an enlarged femoral tunnel. We report a rare case of a transverse supracondylar femoral fracture following ACL reconstruction, with the fracture occurring through the fixation tract not the femoral tunnel.


Y Jabbar A Ruiz

Aim: To determine the viability and long term survival of a unique Patellar reconstruction technique, using the posterior femoral condyle, at primary TKR, in patients with previous patellectomy.

Methods: The posterior lateral femoral condyle cut during total knee replacement was used as a non- vascularised bone graft to reconstruct the patella. A medial para- patellar incision was used to create a Patellar pouch. The patient was examined clinically at operation, 6 weeks, 12 months, 2 years and 4 years from operation. Clinical examination and radiographic evidence of patellar position and survival were used.

Results: The patient has a stable, well positioned patella, with no pain from the graft and no clinical evidence of Mal- tracking. Radiographs show excellent survival of the graft and good position at 4 years.

Conclusion: Patellar reconstruction using non- vascularised bone graft via a medial patellar pouch is a viable alternative surgical option to aid stability in those patients undergoing primary TKR with previous patellectomy.


R Jeffs J S Weston-Simons R Twyman

Study Purposes: A retrospective study to assess patient’s height as a predictor for sizing the femoral component of the Phase 3 Oxford Unicompartmental Knee replacement.

Methods and Results: 118 patients post oxford uni-compartmental knee replacement were identified from the elective orthopaedic unit. Their post-operative radiographs were reviewed by 3 independent orthopaedic surgeons according to the Oxford Group criteria, measuring the femoral component fit. Patients were allocated to two cohorts: patients with ill-fitting prostheses and well fitting prosthesis.

Patient’s height and size of femoral component used at time of surgery was recorded. The results showed a positive correlation between the patient’s height and a well fitting femoral prosthesis.

Conclusions: Current templates with the Oxford Phase Three system may not provide accurate guide to the correct femoral prosthesis size for a patient. Recent studies have highlighted the wide range of magnifications used in computerised X-ray systems leading to variance with templating. Other studies have shown large inter-observer variability when sizing the femoral component. A variable as simple as patient height may offer a more accurate guide for choosing the size of the femoral component.

We have demonstrated that the height of a patient can be a used to guide and assist in the sizing of the femoral component of the Oxford uni-compartmental knee replacement. This study may also have implications for the sizing of other prostheses currently in use.


M C Kokkinakis A S Rajeev M AlNaib N S Shankar S Batey D F Kader

There are about 63,000 primary total knee replacements done annually in England and Wales. One of the biggest challenges of modern NHS is to ensure high quality care for the patients. A reduced length of stay in the hospital following primary total knee replacements could be the key factor in significant cost reduction.

The aim of the study was to assess the efficacy of our rapid recovery programme following total knee replacements in terms of reducing length of stay, morbidity, complications, and readmissions rates.

A prospective study of 252 patients who underwent primary total knee replacement for a period of one year between October 2006 to 2007 were included in the programme. There were 123 (49%) males and 129 (51%)females. The average age was 71 (range-53 to 86). The average BMI was 30 (range-22 to 46). The median ASA grade was 2 (range-1 to 4). There were no exclusion criteria. The programme included pre-operative education of patient and relatives, standardised operation protocols, infection control, pain management, continuous motivation by nursing staff and physiotherapists in the ward as well as intensive rehabilitation by a community based physiotherapy team in patient’s own environment. The patients were discharged when they had achieved the ward physiotherapy requirements.

The average length of stay was 5.2 days. The complications encountered during inpatient stay was wound discharge(43), surgical site infection(1), DVT (1), pneumonia(1).12 patients needed post operative blood transfusion. The readmissions rate was 4%. Deep infection was noted in 4 patients, DVT(1), pulmonary embolism(1)and 3 patients had medical complications.

In conclusion the rapid recovery programme following total knee replacement is an efficient method of speeding the recovery and reducing the length of hospital stay after primary knee replacements. It is useful for the modern NHS to achieve a balance between financial savings and a consistent, responsive and high-quality care for patients.


I Mabruk K Subramanian A Goyal AP Chandratreya

Statement: To present the early results of using new implants in the fixation of the hamstrings tendons for ACL reconstruction.

Background and Aim of the study: PINN-ACL system (Conmed UK, Linvatec UK ltd.), is a recently developed implant designed for transverse femoral fixation of hamstrings grafts in ACL reconstruction, allowing for increased pull out strength. It consists of a Graft Harness composed of Poly L-Lactic Acid with a high strength polyethylene fibre loop and a Cross pin composed of Self-Reinforced PLLA. Tibial fixation is achieved by a bioabsorbable Matryx Interference Screw; composed of Self-Reinforced 96L/4D PLA and beta-Tri-Calcium Phosphate(Linvatec Biomaterials ltd.)

We describe our early experience with this new system, the technique of fixation, short-term clinical results, functional outcome and MRI features of these implants.

Materials and Methods: A prospective data collection was undertaken over the past 12 months. The operative steps:, four strand hamstring preparation, tensioning, femoral fixation of graft with graft harness and cross pin, tensioning the graft and tibial fixation with bio- absorbable interference screw. More than 80% of the cases were performed without tourniquet. The follow up were made at 2,12,24,36 weeks and further evaluation as needed for the purpose of the study. Outcomes were assessed with Lysholm, Tegner and IKDC scores.

Results: 24 cases were performed in 23 cases. The mean age, gender and laterality were 34(17–51), 1.7M: 1F, 14L:10 R. The injury pattern: sports (77%) and RTA (11%)

Tunnel view of the harness was excellent in 79%. Linvatec Tensioner was used in 60%. Graft was not detached in 20%. The mean follow up period was 7 months (2 –12). At last follow up Lachman and pivot shift were negative in 85% and grade 1 in 15%, The mean postoperative scores were Tegner-7 (5–10), Lysholm-7 (5–10) and IKDC-71 (57–93) respectively.

1 wound problem required washout. The tibial screw twisted off at final turn in 1 patient. The cross pin drill missed the guide in 1 patient.

At 32 weeks MRI scan: the implants were still evident, However apart form 1 patient, there was no surrounding bone reaction and none showed tunnel widening.

Conclusion: Early results are encouraging, both operative technique and fixation. However, harness size is limited to 8 and 9 mm only and the implants were still evident at a mean period of 32 weeks against the manufactures claim of 24 weeks.


S Konan F Rayan FS Haddad

Purpose of study: The diagnosis of meniscal tears is usually based on the patient’s history and on specific physical tests. Magnetic resonance imaging (MRI) and arthroscopy is often necessary for diagnosis.

Theofilos Karachalios et al. described the new ‘Thessaly test’ and concluded that it could be safely used as a first line screening test for the selection of patients who need arthroscopic meniscal surgery (Ref: J Bone Joint Surg Am. 2005 May; 87(5):955–62). Our objective was to study the role of physical diagnostic tests in screening for meniscal tears and to validate the diagnostic accuracy of the Thessaly test.

Methods & Results: We examined 109 patients [(80 male, 29 female), average age 39.11 years, range (16–66)] who presented with a history suggestive of a meniscal tear. Joint line tenderness,

McMurray’s test and the Thessaly test were assessed by an independent investigator blinded to any imaging data in all patients. MRI and subsequent arthroscopy results were then collated.

Our study showed a much lower diagnostic accuracy for the Thessaly test (61.25 % for medial meniscus and 80 % for lateral meniscus) It is comparable to McMurray’s test (57.14 % for medial meniscus and 77.38 % for lateral meniscus). The Joint line tenderness test has a far superior diagnostic accuracy (80.95 %for medial meniscus and 90.48 % for lateral meniscus). Combining the joint line tenderness test with McMurrays test or the Thessaly test further increased the diagnostic accuracy. Magnetic resonance imaging (MRI) detected 96% of meniscal tears. Arthroscopy was diagnostic and therapeutic in all cases.

Conclusion: Physical tests may not always be diagnostic of meniscal tears. MRI and arthroscopy may be essential in dubious clinical presentations. In our study the Thessaly test in isolation did not have the highest diagnostic accuracy for the detection of meniscal tears but helps increase diagnostic certainty when combined with standard tests.


A Malviya E Lingard DJ Weir DJ Deehan

Background: The determinants of range of movement following knee replacement may be surgically modifiable (tibial slope, posterior condylar offset or the level of the joint line) or non modifiable (pre-operative range of movement, sex or BMI). We aimed to quantify the influence of these factors upon restoration of flexion in the arthritic knee following knee replacement

Methods: Patients were included from two prospective trials for three different designs of knee replacement. Range of movement was recorded using a standard measuring technique preoperatively and 12 months after surgery. Radiological measurement was done by an independent observer and included the preoperative posterior condylar offset and the postoperative tibial slope, posterior condylar offset, posterior condylar offset ratio, varus-valgus alignment and Insall ratio. Multivariate analysis using stepwise selection was performed to determine the significant predictors of the range of movement at 12 months.

Results: The study includes 133 knee replacements performed on 125 patients. Complete clinical and radiographic data for preoperative and 12-month assessment was available for 101 knees and only these were included for the analyses. There was no significant difference between the three groups in terms of postoperative range of movement or the radiological parameters measured. Multivariate analysis after adjusting for age, sex, diagnosis and the type of prosthesis revealed that the only significant correlates of range of movement at 12-months were the difference in posterior condylar offset ratio, tibial slope and preoperative range of movement. Moderate correlation was noted between range of movement at 12 months and posterior tibial slope (R=0.58) and the difference of post femoral condylar offset (that is, post-operative minus preoperative posterior condylar offset, R=0.65). Preoperative range of movement had only a weak correlation with post-operative range of movement (R=0.20).

Conclusions: We found that the posterior femoral condylar offset had the greatest impact upon final range of movement. We would encourage the operating surgeon at pre-operative templating to take this into account when choosing size and design of femoral component.


D Marsland J G Miller A J Hamer

Purpose: To assess the outcome of patients with an infected TKA who developed complex wounds requiring surgical intervention in our institution.

Methods: The computerised local database was searched for patients recorded as having complex knee wounds associated with an infected TKA. Fifteen patients operated on between 1997 and 2007 were retrospectively reviewed. Data including the limb salvage rate, type of soft tissue surgery performed, local wound complications, and re-implantation rate were recorded. Average follow up was 3.2 years. Three patients had died at the time of review.

Results: Eleven out of 15 patients had been referred to our centre from other hospitals with an infected TKA. Fourteen patients were treated with two stage revision surgery. The remaining patient had direct exchange of the infected implant. Mean age at the time of surgery to address the soft tissue defect was 69.6 years.

Nine patients required a medial gastrocnemius flap. Three patients received fasciocutaneous flaps (one bipedicle); one patient was managed with a tissue expander pre-operatively; one with a split skin graft, and one patient required perforating skin incisions in order to close the wound. 60% of patients developed local wound complications and 27% required further soft tissue procedures.

The overall limb salvage rate was 73.3% (four patients required an above knee amputation for persistent infection). Five patients had successful re-implantation surgery. Four patients had arthrodesis surgery with successful eradication of infection. Two patients developed chronic infection.

Conclusions: Intensive specialist input from plastic and orthopaedic surgeons is required with such difficult cases. Contrary to recent literature, the risk of failure may be higher than previously thought. Patients should be fully counselled pre-operatively about the risks of such procedures.


T O Smith L Davies ST Donell

Aim: To systematically review the present evidence-base, assessing the clinical and radiological outcomes following trochleoplasty for trochlear dysplasia.

Methods: An electronic literature search was performed using the AMED, British Nursing Index, CINAHL, Cochrane, EMBASE, ovid Medline, Physiotherapy Evidence Database, PsycINFO, Pubmed and Zetoc databases from their inception to August 2007. Reference lists of identified papers and a hand search of specialist knee journals was also undertaken. All English language, human subject clinical studies, detailing the clinical and/or radiological outcomes of patellar instability patients following a trochleoplasty were included. Two independent reviewers appraised each paper using the CASP tool.

Results: Six papers comprising of 117 trochleoplasty procedures on 99 patients were reviewed. Clinically and radiologically, trochleoplasty was shown to be a safe and effective procedure to correct patellar instability in trochlear dysplasia patients. However, the CASP tool identified that the evidence-base reviewed presented with a number of methodological limitations. These included: limited use of inferential statistics; not applying reliable outcome measurements; poor description of patient recruitment; and evaluating small samples.

Conclusion: Although trochleoplasty may be an effective procedure to correct patellar instability in trochlear dysplasia patients, further study is recommended to assess longer-term outcomes using well-designed studies.


I D McDermott A Day R MacInnes C J Brown P Procter

Purpose: This study examines the structural performance of different devices for the fixation of supracondylar femoral ‘T’-type intra-articular fractures.

Methods: A finite element model was developed to examine three commonly used devices for fixation of ‘T’-type unstable fractures of the distal femur:-

a retrograde distal femoral nail with condylar bolts and multi-planar locking screws,

a retrograde nail with two parallel distal screws, and

a dynamic condylar screw and plate construct.

The distal femoral geometry was been taken from the BEL repository. The bone was aligned with the mechanical axis and a compressive load of 2000N and separately a torsion load of 10Nm were applied. A fracture was introduced by removing a transverse 15mm slice of material and a saggital slice of 1mm thickness.

The FE model examined whether any of the constructs was markedly stiffer than any other.

Results: Both intra-medullary nail constructs were stiffer than the DCS, with the nail with condylar bolts and multi-planar screws being stiffer than the nail with only two parallel distal locking screws. The nail with condylar bolts did, however, produce significant levels of stress within the bone before any axial load was applied – particularly in the region adjacent to the end washers. Under torsion, the nail constructs were always more effective than the side plate construct.

Conclusions: This FE model demonstrates that fixation of supracondylar femoral ‘T’-type fractures is mechanically superior with retrograde nails rather than DCS constructs. Fixation with a retrograde nail with condylar bolts plus multiplanar screws gives the stiffest fixation. High stresses are seen around the condylar bolts, but if the bone quality is adequate then the additional stiffness achieved is significant. These results support the clinical use of intra-medullary nails with compression bolts and multi-planar screws for the fixation of this type of fracture.


SM McDonnell G Thomas R Rout S Osler H Pandit D Beard H Gill C Dodd D Murray AJ Price

Aim: The aim of this study was to asses the accuracy of skyline radiographs in the assessment of the patellofemoral joint, when compared to open intraoperative assessment.

Methods: Eighty nine patients undergoing knee replacement surgery were included in the study. Skyline radiographs were obtained preoperatively. These radiographs were assessed and graded by an experienced musculoskeletal radiologist using the Altman and Ahlbäck classifications. The grades were calculated for both the medial and lateral facets of the PFJ. Intraoperative assessment of the Patellofemoral joint was undertaken at the time of surgery. The damage was graded using the modified Collins classification (0: Normal, 1: Superficial damage, 2: Partial thickness cartilage loss, 3: Focal Full thickness cartilage loss < 2cm2, 4: Extensive full thickness cartilage loss < 2cm2). Data was obtained for the Medial Facet, Lateral Facet and Trochlea.

Results: Spearman’s rank correlation coefficient between the radiographic and macroscopic changes within the lateral PFJ were poor with both the Altman 0.22 (p=0.0350) and Ahlbäck 0.24 (p=0.018). The correlation of the medial PFJ was slightly better with a coefficient for Altman 0.42 (P< 0.0001) and Ahlbäck 0.34 (P> 0.001).

Conclusion: In conclusion skyline radiographs provide a poor to moderate preoperative assessment of the degree of osteoarthritis within the patella-femoral joint. This has significant implications for establishing radiographic criteria for planning patella-femoral joint replacement.


M Norris K Gill D Karadaglis S Chauhan

Aim: To introduce a new concept of Envelope of Laxity (EoL) in knee arthroplasty surgery for balancing a total knee replacement (TKR).

Methods: Twenty consecutive patients with varus knees undergoing TKR were included in the study. All operations were performed by the senior author using the Stryker Navigation system and the Scorpio cruciate retaining (CR) TKR. After registration with the navigation system initial dynamic varus/valgus curves were recorded from 0–120° flexion to give an EoL of the native knee. Repeated measurements were taken after trial components were initially inserted, then after any soft tissue releases and finally after insertion of actual tibial and femoral components. All measurements were taken with the patellar in situ.

Results: The average deformity in the varus group initially was 6.9° varus at 0°, 8.9° varus at 30°, 6.9° varus at 60° and 5° varus at 90° of knee flexion. Postoperatively values were found to be 0.1°, 0°,0.3°and 0.7°respectively. The initial EoL curves showed a mean increase in laxity of 4° between 30° and 60°compared to 0°–30° and 60°–90° through the range of knee flexion. This was seen less in the outcome curves which tended to show more uniform laxity with only an average of 2° difference throughout flexion.

Conclusions: Traditional balancing devices used in TKR surgery balance knees at 0° and 90°, often with the patellar everted which produces errors. The use of EoL curves allows knees to be balanced throughout the arc of movement from 0–150° with the patellar in situ. This study demonstrates the successful use of the EoL concept and that even when knees are balanced at 0° and 90° they may not be balanced at the mid flexion position where clinical problems often arise. This problem becomes worse with the use of poly radii TKR designs.


K A Reilly K L Barker D Shamley M Newman

This observational study was undertaken to explore the relationship of the foot posture of patients with Medial Compartment Osteoarthritis of the knee (MCOA), patients with hip osteoarthritis (OA) and a healthy control group, using the Foot Posture Index (FPI). Goniometric measurement of talocrural dorsiflexion was also included.

The relationship of foot posture to MCOA and hip osteoarthritis OA has not been explored although in other medical fields, such as neurology and sports medicine, the relationship between foot posture, lower limb pain and function has been acknowledged. In view of the current high incidence of lower limb OA, any investigation of associations that may lead to improved assessment and conservative management is worthy of consideration.

Currently, systematic examination of the foot is not undertaken in routine clinical assessment of patients with lower limb OA and, if this were to be introduced, there would be difficulty in selecting suitable clinical outcome measures. The recent development of the Foot Posture Index (FPI) has addressed the need for a diagnostic clinical tool that measures foot posture in multiple planes and anatomical segments

Sixty participants took part: twenty patients with radiographic and clinical evidence of MCOA grade IV, twenty patients with radiographic and clinical evidence of stage IV OA hip, and twenty age-matched healthy volunteers as a control group.

A one way Analysis of variance (ANOVA) was performed to investigate any differences between the 3 groups for foot posture using FPI scores and talocrural dorsiflexion measurements. This showed that there were significant differences between the groups (p< 0.001). Patients with MCOA had a high positive FPI score (indicating a pronated foot), patients with hip OA had a low negative FPI score (indicating a supinated foot). The healthy controls had a normal score distributed over a wider range than the other two groups. In addition, the results of the Pearsons test indicate that the FPI correlated positively with talocrural dorsiflexion (r = 0.55, p< .001).

Differences in foot characteristics may be influenced by specific treatment modalities such as gait reducation, orthotic provision, specific lower limb strengthening and stretching exercises. Foot assessment might therefore be a useful adjunct to conservative management of both MCOA and hip osteoarthritis.


PK Sharda S Maheswaran

We report the results of patellofemoral joint replacement done at our institution for predominantly patellofemoral arthritis.

Patellofemoral joint replacement has always been a controversial subject, particularly in elderly patients where a more predictable result can be obtained with TKA. Patellofemoral joint replacement surgery was commenced at our institute in 2002 using the Avon design (Stryker corp, UK,) pioneered at the Avon Orthopaedic centre, Southmead, Bristol, UK. We report retrospective analysis of 43 consecutive Patellofemoral replacements done in 39 patients between 2002 and 2006, with a minimum of 6 months follow-up. 38 patients (5 bilateral) were available for review while 1 patient died 3 years after the operation following unrelated causes. They were all assessed clinically and radiologically on the last follow up. Follow-up ranged from 6 to 56 months, average being 21 months. Females outnumbered males by 3:1. All patients were scored pre and postoperatively using Melbourne Knee scoring system (Bartlett et al) and Knee Functional Score. The average Melbourne Knee score increased from 10 to 25 postoperatively, while the knee functional score increased from 57 to 85. Postoperative flexion ranged from 100–140°, average being 116°. Commonest complication was clicking (17%), half of which resolved by arthroscopic lateral release. 87% patients graded the result as excellent or good, while 2% (1 patient) rated it as poor. 59% patients had radiologically proven early tibiofemoral arthritis preoperatively, out of which progression was noted in 28% at the last follow-up. No complications related to deep infection or loosening were noted, and one knee needed revision on account of progression of lateral compartment arthritis. With revision as the end point, the survivorship was 97.7% at average of 2 years after surgery.


J Trattles A Singh A Orwin S O’Brien

Purpose: To study the judicious use of re-infusion drains in knee replacement on a target population with strict inclusion criteria and its impact on the transfusion rate and cost savings.

Method: We devised an inclusion criterion after a preliminary study on 200 knee replacements and identified the target population likely to need transfusion after the index procedure. All bilateral total knee replacements, revision total knee replacements and primary total knee replacements were the pre-operative haemoglobin was less then 5 gm/l above the patient’s transfusion trigger were included. These criteria were further validated by retrospective application.

56 patients fulfilled the criteria and 50 patients were included in the study between September 2006 – May 2007. Male/female ratio was 18: 32. Mean age was 66.2 years. Procedure included 33 total knees, 13 bilateral and 4 revision knee replacements.

Results: The overall transfusion rates dropped to 3% (bilateral, revisions 12%) during the period of this study. Mean volume re-infused was 600 ml (0–2600). Average drop in haemoglobin was 2.9 g/dl. No adverse incidents were reported.

Prior to our study the expenditure on allogenic blood transfusion was £13,230. The estimated cost of using the re-infusion system was £6230

A saving of £ 7500 was achieved as a result of using the drain in the “at risk” patient.

Conclusion: Post-operative autologous transfusion is a safe and efficient way to reduce patient’s exposure to donor blood. Use of re-infusion drains directed at a target population reduces need for allogenic blood and is cost effective.


A Unnithan R Mohammed T Jimulia D Learmonth

Introduction: We have come across a subset of patients with advanced patellofemoral osteoarthritis who also had well defined full thickness cartilage loss lesions on the weight bearing femoral condyle. In these patients the findings or the symptoms are not severe enough to warrant a total knee replacement. In this select group of patients, a combination of patellofemoral arthroplasty (PFA) and Osteochondral Autograft Transfer System (OATS) can be performed to address this unique problem.

Method& Results: Out of 38 PFA procedures performed by the senior author, a concomitant OATS was performed in 6 knees in 5 patients. A retrospective analysis of these patients was carried out with the average follow up being 3.8 years (18 months to 84 months). The average age of the patients in our case study was 48.2 years (36 to 59 years) at the time of surgery. Four of the six knees are doing well in the medium term. One patient had progression of tibiofemoral arthritis and underwent a total knee replacement. The only poor result was a young male, who two years following the PFA, developed a deep infection of the knee. Except for this patient awaiting a second stage revision for an infected knee, all the others have achieved their desired level of activity.

Conclusion: The advantage of this combination is that, the donor tubes for the OATS can be harvested from the trochlea or just adjacent to it, which happens to be the bed for the trochlear implant. This area provides good quality thick donor articular cartilage. As the surgical exposure has already been done for the PFA, the operative time is extended by approximately ten minutes for the OATS procedure. This combination procedure offers an alternative to more invasive options such as total knee replacement in younger patients in whom it is preferable to delay such major surgery.


RJ Walls G McHugh NM Moyna J O’Byrne

Background: Quadriceps femoris muscle (QFM) weakness has been implicated in the development of knee osteoarthritis (OA) as well as predicting functional ability after TKA. Preoperative strengthening (prehabilitation) may be facilitated by applying neuromuscular electrical stimulation (NMES) to the affected QFM using a garment-based portable stimulator.

Methods: Single blind, randomised control efficacy study with NMES applied to the affected QFM for 20 min, 5 days a week, for 8 weeks pre-TKA. Isokinetic and isometric strength was assessed at baseline, week 2, week 5 and immediately pre-op. Function was assessed using a 25 metre timed walk test (TWT), timed stair-climb test (SCT), and timed chair-rise test (CRT) at baseline and pre-op.

Results: 13 patients (8 women and 5 men) scheduled for TKA for knee OA were recruited and randomised into a control (n=5) or intervention (n=8) group. Groups were similar in terms of age (65.5 ± 6.8 vs. 61.8 ± 9.0; mean ± SD) and BMI (29.7 ± 2.1 vs.33.2 ± 5.6). There was an improvement in SCT (p< 0.01) and CRT (p< 0.01) in the NMES group at week 8 compared to week 0. Isokinetic hamstring strength and isometric QFM strength increased significantly at weeks 2, 5 and 8 compared to baseline whereas isokinetic QFM strength only increased at week 5 (p< 0.05) and week 8 (p< 0.01) compared to baseline.

Conclusion: The use of a portable home-based NMES program for 8 weeks results in significant strength gains with associated improvements in function in patients scheduled for TKA for knee OA.


RJ Walls T Murphy KJ Mulhall

Introduction: Chronic stiffness is an uncommon complication of total knee arthroplasty (TKA) with reports in the literature citing an incidence of 1–5%. Surgical options to manage this debilitating condition include manipulation under anaesthesia (MUA) and arthrolysis; there is concern regarding revision surgery given the potential for stiffness recurrence.

Methods: Patients undergoing revision TKA for stiffness were prospectively identified. Inclusion criteria required a flexion contracture greater than 10 degrees and/or less than 70 degrees arc of motion. WOMAC and SF-36 self-report questionnaires were completed by all patients’ pre and post revision surgery.

Results: Between July 2005 and Dec 2006, 7 consecutive, aseptic, primary TKA’s were revised to address limited range of motion. Five female and 2 male patients (mean age: 57.6 years) underwent revision TKA 17.1 months (range, 7–25 months) after index TKA. All patients had attempted MUA, with additional open arthrolysis unsuccessful in 1 case. A medial parapatellar approach was performed although 3 required additional quadriceps snip for exposure. Five cases were revised with the Scorpio TS system and 2 with posterior stabilised components. Femoral augmentation was required in 2 cases and tibial in 1. Gap imbalance with increased soft tissue tension was noted intra-operatively in 5 cases with arthrofibrosis found in the remainder. At 6 months follow-up, arc of motion increased from a mean of 41.3° preoperatively to 81.4° (p=0.001) while mean flexion contracture decreased from 17.4° to 2.1° (p=0.004). Subjective improvement was also demonstrated: mean WOMAC decreased from 46.5 to 22.5 (p=0.023) and SF-36 scores increased by a mean of 35.8 points (p=0.001).

Conclusion: When conservative, implant preserving measures fail, revision surgery can be considered a viable option in addressing restricted movement following primary TKA. Aggressive physiotherapy and good patient compliance is required to minimise the recurrence of stiffness.


T Yarashi J Rutherford A Kapoor S Anand DS Johnson

AIM: To create a set of reference data of commonly used scoring systems in the normal population, and to compare these results with published postoperative scores for commonly performed knee operations.

METHODS: This was a questionnaire-based study and a total of 657 questionnaires were sent out, of which 407 replies were received. A further 159 were excluded due to ongoing knee problems or previous knee surgery. Six scoring systems were addressed: Lysholm and Oxford Knee Scores, Tegner and UCLA activity scales and Visual Analogue Scales (VAS) for both pain and function. Data was collected into groups based on age (20–29, 30–39, 40–49, 50–59, 60–69, 70–79, 80–89 years). The reference data obtained was then compared to published postoperative scores for knee arthroplasty and ACL reconstruction, to assess whether these patients did indeed return to “normal”.

RESULTS: The mean scores for sequential age groups (described above) were as follows: Oxford Knee Score – 13, 14, 14, 14, 17, 15, 19; Lysholm Knee Score – 95, 92, 92, 90, 88, 90, 79; Tegener Activity Scale – 5, 5, 5, 4, 4, 3, 3; UCLA Activity Scale – 9, 7, 7, 7, 6, 6, 5; VAS pain – 2, 9, 9, 9, 14, 12, 20; VAS function 97, 94, 92, 90, 86, 86, 83. Symptom based scoring systems (Oxford Knee Score, Lysholm) were independent of age. Activity scores (Tegner, UCLA) showed a statistically significant decrease with age. There was no significant difference detected between scores in different sexes in the same age group. Compared to published scores in an age-matched population following TKR, the data obtained showed that patients do not return to normal scores following arthroplasty. Following ACL reconstructive surgery, activity scores were higher than compared to the data obtained from our population.

CONCLUSIONS: Data generated from this study can be used as reference data and can play an important role in interpreting post-intervention scores following knee surgery.


M. Sterling E. Hodkinson C. Pettiford M. Curatolo

Introduction: Sensory hypersensitivity, central hyper-excitability (lowered nociceptive flexion reflex (NFR) thresholds) and psychological distress are features of chronic whiplash. Relationships between these substrates are not clear. The aim of this study was to investigate relationships between psychological factors (distress, catastrophization) and pain threshold responses to sensory stimuli and spinal cord excitability as assessed by the NFR. The former assessments are considered as global pain responses to sensory stimuli as reported by the patient, whereas the latter, an objective measurement for spinal cord excitability to peripheral stimulation.

Methods: 30 individuals with chronic (> 3 months) whiplash (Grade II or III; Grade IV were excluded) and 30 asymptomatic controls participated. Pressure pain thresholds (PPTs) and thermal pain thresholds (Thermotest, Somedic AB, Sweden) were measured at the cervical spine, upper and lower limbs. The NFR (intensity of electrical stimulation at the sural nerve required to elicit reflex EMG activity of biceps femoris) was measured as per previous protocols (1). Pain and disability levels (NDI), psychological distress (GHQ-28) and catastrophisation (PCS) were also measured in the whiplash group. Ethical clearance for this study was granted by the Medical Research Ethics Committee of the University of Qld. A MANCOVA was used to determine differences between the whiplash group and controls for sensory measures and the NFR. GHQ-28 and PCS scores were used as covariates in the analysis. Group differences for questionnaire data (GHQ-28 and PCS) were analysed using one way ANOVA. Pearson’s correlation coefficients were used to determine the relationship between the psychological measures (PCS and GHQ-28), pain and disability levels (NDI) and the pain threshold measures (mechanical and thermal) and to determine relationships between the psychological measures, pain and disability measures (NDI) and NFR responses (pain intensity at threshold, threshold). p< 0.05.

Results: Whiplash injured participants (23 females, mean (SD) age: 37.7 (11.5) years, NDI: 46.2 (17.6) and VAS scores of pain: 4.2 (2.4)) demonstrated lowered pain thresholds to pressure and cold (p< 0.05); lowered NFR thresholds (p=0.003) and above threshold levels of psychological distress (GHQ-28) compared to controls and levels of catastrophisation comparable to other musculoskeletal conditions. There were no group differences for heat pain thresholds or pain at NFR threshold. In the whiplash group, PCS scores correlated moderately with cold pain threshold (r =0.51, p=0.01). In contrast there were no significant correlations between GHQ-28 scores and pain threshold measures or between psychological factors and NFR responses in whiplash participants. There were no significant correlations between psychological factors and pain thresholds or NFR responses in controls.

Discussion: We have demonstrated that psychological factors have some association with sensory hypersensitivity (cold pain threshold measures) in chronic whiplash but do not seem to influence spinal cord excitability. This suggests that psychological disorders are important, but not the only, determinants of central hypersensitivity in whiplash patients. These findings suggest that both physical and psychological factors will need to be addressed in the management of whiplash.


H. Tsao M. Gales P. Hodges

Introduction: Deficits in motor control of the trunk muscles have been extensively reported in individuals with chronic low back pain (LBP). Recent evidence suggests that these deficits can be improved with motor training. However, whether these changes in motor control are mediated by changes in the motor cortex remains unclear. As deficits in postural activation of transversus abdominis (TrA) is consistently observed in individuals with LBP, the present study aimed to investigate the representation of TrA at the motor cortex in individuals with and without chronic LBP. The potential to change the cortical representation of TrA following motor training in individuals with chronic LBP was also examined.

Methods: Eleven healthy volunteers and twenty individuals with chronic LBP participated. Chronic LBP individuals were randomly allocated into two training groups: specific motor control training that involved practice of skilled activation of TrA, or walking exercise, and trained twice per day for two weeks. Recordings of electromyographic activity (EMG) of TrA were made bilaterally with intramuscular fine-wire electrodes. Motor control of TrA was assessed as the postural activation of the muscle associated with repetitions of rapid arm flexion and extension movements. To evaluate the representation of TrA, transcranial magnetic stimulation (TMS) was delivered over pre-marked scalp sites. EMG amplitude of the responses to TMS at each site was superimposed over the grid to produce a map of response amplitude relative to scalp site. All procedures were repeated two weeks post-training for the chronic LBP group. Onset of TrA EMG relative to prime mover deltoid and the location of the centre of gravity (CoG) of TMS map were compared between individuals with and without chronic LBP, and between pre- and post-training in individuals with chronic LBP.

Results: The CoG of the cortical representation of TrA was located 2 cm anterior and lateral to the vertex in healthy individuals. However, individuals with chronic LBP showed a posterior and lateral shift in the CoG. The shift in location of the CoG of the TrA representation was associated with timing of activation during rapid arm movement tasks. Following two weeks of skilled training of TrA, motor cortical representation shifted towards that observed in healthy individuals. Changes in representation were not observed for the walking exercise group.

Discussion: These findings provide evidence of reorganisation of trunk muscle representation at the motor cortex in individuals with chronic LBP, and that cortical changes are associated with deficits in motor control. Furthermore, this study provides the first evidence that training can induce plasticity of the motor cortex in this group.


N. Bogduk K. West

Introduction: Practice guidelines recommend functional restoration as a cardinal intervention for chronic low back pain. Published studies attest variously to either modest or good efficacy for functional restoration programs. However, although published data might set a benchmark of what outcomes can be achieved in research studies, they do not necessarily indicate what is actually achieved in conventional practice.

Methods: A prospective audit was undertaken of all patients referred for functional restoration in a rehabilitation service dedicated primarily to the treatment of low back pain. In accordance with published principles 1, the program provided education and physical rehabilitation in a cognitive-behavioural milieu. Before treatment, immediately after treatment, and three months and six months later, patients were assessed, by a research nurse not involved in the patients’ care, using a visual analogue scale for pain, the SF36 for function, a patient-specified functional outcome scale, and the treatment helpfulness questionnaire. As well, the need for other care was recorded.

Results: Forty-six patients enrolled in the study, but nine did not complete the rehabilitation program, and five withdrew their consent. Only two were lost to follow-up. Before treatment, those patients who withdrew and those who participated did not differ in presenting features. All had a moderate level of pain; they were moderately disabled in physical functioning, social functioning, and vitality; but were only slightly impaired in general health and mental health. All could nominate four activities of daily living that were impaired by their pain and which most dearly they would want restored. After treatment, median pain scores did not improve; nor was physical functioning, or social functioning, or vitality improved. Only one patient restored their desired activities of daily living. The majority of patients (25/30) restored no activity. These outcomes did not improve at the 3-month or 6 month-review. Patients previously unemployed remained unemployed. The proportion of patients previously employed (80%) fell immediately after treatment (70%) and remained stable thereafter. All patients required some form of continuing care from their general practitioner. Notwithstanding these outcomes, the majority of patients rated the program as helpful (57%) or extremely helpful (33%).

Discussion: The sample size in the present study was similar to that used in the original studies that promoted functional restoration. Statistically and clinically, the outcomes in this audit are incompatible and totally dissonant with published claims of 80% success rates for functional restoration programs. The 95% confidence intervals of a success rate of zero are 0 to 11%, which fails to reach the lower 95% confidence interval of 80%, which is 66%. These results warn that what is achieved in conventional practice may not reflect the benchmarks established in the literature. Evidence from research may not translate into standards of practice. Citing the literature is not a substitute or surrogate for auditing one’s own outcomes.


J.P. Little C. Adam

Introduction: Pre-operative coronal curve flexibility assessment is of key importance in the surgical planning process for scoliosis correction. The fulcrum bending radiograph is one flexibility assessment technique which has been shown to be highly predictive of potential curve correction using posterior surgery, however little is known about the extent to which soft tissue structures govern spinal flexibility. The aim of this study was to explore how the mechanical properties of spinal ligaments and intervertebral discs affect coronal curve flexibility in the fulcrum bending test. To this end a biomechanical analysis of a scoliotic thoracolumbar spine and ribcage was carried out using a three dimensional finite element model.

Methods: CT-derived spinal anatomy for a 14 year old female adolescent idiopathic scoliosis patient was used to develop the 3D finite element model. Physiological loading conditions representing the gravitational body weight forces acting on the spine when the patient lies on their side over the fulcrum bolster were simulated. Initial mechanical properties for the spinal soft tissues were derived from existing literature. In six separate analyses, the disc collagen fibre and ligament stiffness values were reduced by 10%, 25% and 40% respectively, and the effects of reduced tissue stiffness on fulcrum flexibility were assessed by comparison with the initial model. Finally, the effect of discectomy on fulcrum flexibility was simulated for thoracic levels T5 to T12.

Results: Reducing disc collagen fibre stiffness resulted in a greater change in segmental rotations in the fulcrum bending test than reducing ligament stiffness. However, reductions of up to 40% in disc collagen fibre stiffness and ligament stiffness produced no clinically measurable increase in fulcrum flexibility (increase of 1.2%). By contrast, following removal of the discs, the simulated fulcrum flexibility increased by more than 80% compared to the initial case.

Discussion: Disc collagen fibre and ligament stiffness both have minimal influence on scoliotic curve flexibility. However, discectomy simulation shows that the intervertebral discs are of critical importance in determining spinal flexibility.


K. Gowaily N. Bogduk

Introduction: Biacuplasty is an innovative intervention for the treatment of discogenic pain. It involves inserting electrodes bilaterally into the posterolateral corner of the anulus fibrosus. Radiofrequency current is passed between the electrodes, but each electrode is water-cooled. This prevents coagulation occurring around the surface of the electrode, which allows a three-dimensional lesion to develop between the electrodes. Theoretically this lesion would seal radial and circumferential fissures, and coagulate nerve endings throughout the posterior anulus.

Methods: As part of a multi-centre, limited release of biacuplasty, a prospective audit of outcomes was undertaken in 8 patients with chronic low back pain, in whom discography reproduced their pain and post-discography CT demonstrated a radial fissure. They were 6 men and 2 women, aged between 34 and 58 years, who had back pain for longer than 4 years. Four were still working but four were on workers compensation. At the time of writing, all patients had completed clinical assessments before treatment and at one, two, three, and six months after treatment, using a visual analogue scale for pain, and the Oswestry Disability Questionnaire (ODQ) and the SF36 for disability and function.

Results: Performed under local anaesthesia, the procedure was painless, and took less than one hour to complete. No complications occurred, and no patient suffered any side-effects. Group pain scores (median; interquartile range) at inception (69; 53–78) improved significantly at one month (35; 11–65) (p = 0.05); deteriorated by three months (41; 14–72) (p = 0.14); but were stable at 6 motns (40; 22–69). Scores for disability (54; 42–67) and physical functioning (33; 13–48) improved (to 50; 29–62 and 50; 20–59, respectively) but did not achieve statistical significance. In categorical terms, however, four patients obtained no benefit, one patient obtained partial, but worthwhile, reduction in pain, but three patients achieved greater than 50% relief of pain at three months, and four did so at 6 months. Reduction in pain was corroborated by a decrease in disability on the ODQ by 11 (5,2) points at three months, and 10 (−4, 15) points at 6 months; and increases in physical functioning on the SF36 by 15 (6,2) points at three months, and 5 (2,2) points at six months.

Discussion: These results in Australian patients echo those reported in one of the US arms of the study, in which 8 of 13 patients reduced their pain scores by at least 30 points. Attractive about this new procedure was its ease of execution and painlessness. Although the success rate is modest, this procedure could emerge as an entertainable option for the management of discogenic pain, if its effectiveness can be corroborated in a larger sample and for a longer time.


W. Chu D. Wang B. Freeman G. Burwell T. Paus G.C.W. Man A. Cheng H.Y. Yeung K.M. Lee J. Cheng

Introduction: Observation of sub-clinical neurological abnormalities has led to the proposal of a neuro-developmental etiologic model for adolescent idiopathic scoliosis (AIS). We have previously demonstrated prolonged latency in somatosensory evoked potentials (SSEP) and impaired balance control in subjects with AIS. Furthermore we have compared regional brain volumes in right thoracic AIS subjects and normal controls. Significant neuro-anatomic regional differences were observed in the corpus callosum, premotor cortex, proprioceptive and visual centers of the AIS subjects compared to control subjects. Most of these regional differences involved the brain unilaterally, indicating there may be abnormal asymmetrical development in the brain of subjects with right thoracic AIS.

Methods: Following ethical committee approval a total of 29 subjects with AIS were recruited. Patients with congenital, neuromuscular or syndromic scoliosis were excluded from the study. Twenty-eight age- and sex-matched controls were recruited from local schools. All recruits underwent three-dimensional isotropic magnetization prepared rapid acquisition gradient echo (3D_MPRAGE) magnetic resonance (MR) imaging of the brain. Modern morphometric analyses of the MR images were carried out including classification of tissue into grey matter (GM), white matter (WM) and cerebrospinal fluid (CSF). Tissue densities were compared between AIS subjects and controls. Comparisons were made between those subjects with left thoracic AIS (n=9) and age and sex-matched controls (n=11) and those subjects with right thoracic AIS (n=20) and age and sex-matched controls (n=17).

Results: For subjects with left thoracic curves the mean Cobb angle was 19 degrees. For subjects with right thoracic curves the mean Cobb angle was 33.8 degrees There was no significant differences observed between AIS subjects and normal controls when comparing both absolute and relative (i.e. adjusted for brain size) volumes of GM and WM. However voxel-based morphometric analysis identified significant differences in the density of WM in the genu of the corpus callosum, the left internal capsule and WM underlying the left orbitofrontal cortex when comparing those subjects with left thoracic scoliosis to controls. The above differences were not not observed when those subjects with right thoracic scoliosis were compared to controls..

Discussion: This controlled study of regional brain tissue density has demonstrated important differences in the corpus callosum, the left internal capsule and the left orbitofrontal cortex when the brain of those subjects with left thoracic scoliosis is compared to age and sex matched controls. In this study significant regional brain differences have not been identified in those subjects with right thoracic scoliosis. Further studies are warranted to ascertain whether these morphologial differences in the brain are linked with the etiopathogenisis of left sided thoracic scoliosis. A larger sample and a longitudinal study are required to establish whether brain abnormalities are predictive of curve progression.


C. Chia A. Fagan R.D. Fraser D. Hall

Introduction: Epidural steroid injection is commonly used for treatment of sciatica. Traditionally these have been administered through a needle inserted in the posterior mid line via an interlaminar (IL) route. However, in recent years the transforaminal (TF) route of administration has become popular. Potential advantages of the TF route include greater accuracy of injection (with radiological confirmation) and placement of the needle tip closer to the point at which the nerve is compressed.

Methods: Consecutive patients from the practices of 2 surgeons that use an IL technique were compared with those from the practices of 2 other surgeons that use a TF technique. Inclusion criteria were leg pain accompanied by a radiological diagnosis of nerve root compression. Both patients with disc prolapse and spinal stenosis were included. Treatment outcome was measured using the Roland-Morris (RM) Score, the Sciatica Frequency and Bothersome Index (SFBI) and the Euroqol (EQ-5D) questionnaire obtained at recruitment and three months after the epidural steroid injection. A global assessment (GA) of outcome; where patients were asked whether they were

much better,

better,

un changed or

worse after treatment; was obtained at 3 months.

Patients were also asked the duration of any relief obtained. Statistical methods utilized included the two tailed t-test, the Wilcoxon Rank Sum test, Odds ratio (OR) and the Chi Squared Test.

Results: 39 patients received an interlaminar epidural steroid injection and 25 received a transforaminal epidural steroid injection (total 64 patients). Follow-up was achieved for 36/39 (92.3%) and 25 (100%) patients respectively. The median pre-test RM score was 11 (range 3–11) for both groups. Post test RM score was 12(6–16) for the IL group and 3 (6–10.5) for the TF group (p=0.01). Median pre-test SFBI was 25 (0–46) and 26 (4–46) for the IL and TF groups respectively. Post test SFBI was 22 (0–46) and 18 (0–41) for the IL and TF groups respectively (p=0.003). Median pre- test EQ-5D was 0.54 for both groups (range 0.06–0.72 for the IL group and 0.08–0.72 for the TF group). Post test EQ-5D was 0.55 (0.06–1) for the IL group and 0.66 (0.06–1) (p=0.21). According to their GA, 11.1% felt much better, 33.3% felt better and 55.6% felt unchanged at 3 months in the IL group. 64% felt much better, 34% better and 12% felt unchanged in the transforaminal group. The proportion of patients having relief for 3 months or more after the injections was 3/36 (8.3%) for the IL group and 10/25 (40%) for the TF group. The transforaminal injection was 7 times more likely to result in pain relief at 3 months. (OR 7.3 95% CI 1.5 – 45.8, p=0.003).

Discussion: Epidural steroid injection by the transforaminal route is more effective then by the interlaminar route in the short term relief of sciatica.


O. Filo A. Shectmann D. Ovadia E. Bar-On B. Fragniere M. Rigo J. Leitner S. Wientroub J. Dubousset

Introduction: Accurate and quantitative measurements of the spine are essential for deformity diagnosis and assessment of curve progression. There is much concern related to the multiple exposures to ionizing radiation associated with the Cobb method of radiographic measurement, currently the standard procedure for diagnosis and follow-up of the progression of scoliosis. In addition, the Cobb method relies on two-dimensional analysis of a three-dimensional deformity. The Ortelius800TM aims to provide a radiation-free method for scoliosis assessment in three planes (coronal, sagittal, apical) with simultaneous automatic calculation of the Cobb angle in both coronal and sagittal views. This new device is based on direct measurement of the position of the tips of the spinous processes in space. A low intensity electromagnetic field records the spatial position of a sensor attached to the examiner’s finger while palpating the patient’s spinous processes. This study investigates the correlation of spinal deformity measurements with Ortelius800TM radiation-free system as compared to standard radiographic measured Cobb angles in order to assess Ortelius800TM clinical value while enabling a significant reduction of x-ray exposure.

Methods: 124 patients diagnosed with Adolescent Idiopathic Scoliosis (AIS) from four different medical centers were measured with the Ortelius800TM system using the same standard protocol. The entire process required an average of 2 minutes. The Ortelius800TM measurements were correlated with the standard Cobb angle as measured on routine standing coronal and sagittal radiographs. The Pearson correlation coefficient was calculated for matched pair measurements. The mean difference and the absolute mean difference between measurements with the two methods was estimated.

Results: Standing full-spine coronal radiographs were obtained for each patient. Radiograph analysis for these 124 patients revealed 249 deformity measurements. The deformity measurements were comprised of 142 thoracic curves with a mean of 18.3° and 107 lumbar curves with a mean of 17.4°. Lateral radiographs were obtained from 38 patients with a mean of 36.1°. Correlation between Cobb angles measured manually on standard erect posteroanterior radiographs and those calculated by this new technique showed an absolute difference between the measurements to be significantly less than +\−5° for coronal measurements and significantly less than +\−6° for sagittal measurements indicating good correlation between the two methods.

Pearson’s correlation coefficient between deformity angles obtained by the two methods was highly significant (0.86) with a P value < 0.0001. The measurements from four independent sites were not significantly different.

Discussion: The results reveal good correlation between the two measuring methods in both coronal and sagittal views. We propose the Ortelius800TM as a clinical tool for the routine follow-up measurements of AIS patients, thus enabling a significant reduction of radiation exposure.


J. Cordell-Smith M. Izatt C. Adam R. Labrom G. Askin

Introduction: Open instrumented anterior spinal fusion for adolescent idiopathic scoliosis (AIS) is a proven technique for vertebral derotation that, compared with posterior spinal fusion procedures, invariably requires fewer distal fusion levels to be performed. With the advent and evolution of endoscopic anterior instrumentation, further clinical benefits are possible such as reduced pulmonary morbidity, improved cosmesis and less postoperative pain. However, quantitative data on the radiological improvement of vertebral rotation using this method is limited. The aim of this study was to measure preoperative and postoperative axial vertebral rotational deformity at the apex of the curve in endoscopic anterior instrumented scoliosis surgery patients using computed tomography (CT), and assess the relevance of these findings to clinically measured chest wall rib hump deformity correction.

Methods: Between November 2002 and August 2005, adolescent idiopathic scoliosis patients with right-sided thoracic major curves were selected for endoscopic single-rod anterior fusion by the senior authors. Low-dose pre-operative CT was performed as described previously (1) and two-year postoperative CT was also performed on consenting patients in accordance with local ethical committee approval. The pre and post surgical axial vertebral rotation was measured at the curve apex using Aaro and Dahlborn’s method (2). Intraobserver and interobserver variability was assessed. Additional clinical information such as rib hump deformity correction and change in the Cobb angle was retrieved from a surgical database and correlated to the CT findings. Least squares linear regression was used to investigate the correlation between apical vertebral rotation measured on CT and rib hump measured using a scoliometer.

Results: Twenty patients were included in the study. The mean angle of correction achieved in axial vertebral body derotation at the apical vertebra measured by CT was 7.9° (median preoperative angle 17.3° [range 12.5° to 27.3°] and median postoperative angle 10.3° [range 1.8° to 18.1°]. This equated to a 43% improvement (range 20–90%). The preoperative and postoperative clinical measurements i.e. rib hump deformity correction, correlated significantly with CT measurements using regression analysis (p=0.03) and the mean improvement in rib hump deformity was 55% (median preoperative 15.0° [range 10° to 30°] and median postoperative 7.0° [range 4° to 10°]). 95% confidence intervals for intraobserver and interobserver validity were within the ranges ±4.5° to ±6.4°.

Discussion: We believe this is the first quantitative CT study to confirm that endoscopic anterior instrumented fusion for AIS substantially improves the axial vertebral body rotational deformity at the apex of the curve. The margin of correction of 43% compares more favourably than the historically published figure of 24% in a cohort of patients with all-hook-rod constructs used for posterior spinal fusion (3). Patient age and gender demographics, curve magnitude and curve types in the historical study were similar to our group, and an identical CT protocol for measuring vertebral derotation was utilised. In addition, the CT measurements obtained significantly correlated to the clinical outcome of rib hump deformity correction.


M. Barnes L. Ton

Introduction: Autologous bone graft is currently considered the gold standard for anterior cervical discectomy and fusion (ACDF). However, the harvesting of bone graft from the ilac crest is frequently associated with significant patient morbidity. We report on the safety and efficacy of trabecular metal blocks for achieving a stable interbody fusion for ACDF when compared to iliac crest bone graft for a small group of patients.

Methods: This is a prospective trial of patients who underwent consecutive ACDFs between September 2004 and September 2007. Patients received one of two materials for their fusion, either trabecular metal blocks or autologous iliac crest bone graft. Each operation was performed by the same spinal surgeon (LT), and all patients had fixation with an anterior titanium plate to enhance interbody arthrodesis. Clinical outcome was assessed with a neck disability score (Vernon and Mior 1991) that was mailed to all participants; bone graft patients were also asked to complete a bone graft morbidity questionnaire (Silber et al. 2003). Radiological followup was assessed with computed tomography and flexion-extension radiographs. A minimum followup time of 3 months was required for inclusion into the study, and unpaired t-tests were used to evaluate statistical differences between relevant sets of data.

Results: A total of 31 patients were included into the study, with 15 in the trabecular metal group (TM) and 16 in the iliac crest bone graft group (ICBG). The TM group included 10 males (67%) with a median age of 42 years (range 18–72). Median neck disability score was 18% (2–38) and stable bony ingrowth was observed in all patients (100%) on postoperative scans. Median followup time was 8 months (3–16) for TM patients and 20.3 months (7–36 months) for the ICBG group. In comparison, the ICBG group included 8 males (50%) with a median age of 53.3 years (43–70). Median neck disability score was worse at 30% (4–50), with a significant difference of 12% observed after t-test analysis (p value < 0.02). In addition, there was significant morbidity associated with the harvesting of autologous bone graft, with more than 50% of patients experiencing acute and/or chronic symptoms. Two radiological pseudoarthroses (8%) were observed postoperatively, of which one was manifested clinically.

Discussion: These results confirm that, for our population group, trabecular metal implants are both safe and effective for use in ACDF when compared to the gold standard of autologous bone graft. Furthermore, trabecular metal implants avoid the morbidity associated with the harvesting of iliac crest bone graft. We believe the results so far are encouraging for our small group of patients but a larger, randomised control trial is needed to provide definitive results.


T. Ganey J. Meisel W. Hutton M. Hedrick

Introduction: Adipose tissue has been known for some time to contain regenerative cells. These regenerative cells are able to differentiate into a nucleus pulposus-like phenotype when exposed to environmental factors similar to disc. In an effort to develop a clinical option for cell placement and assess the response of the cells to the post-surgical milieu, adipose-derived cells were collected, concentrated, and transplanted under fluoroscopic guidance directly into a surgically damaged disc in a dog model.

Methods: After IACUC approval 12 dogs, 2 years of age, were obtained. Adipose cells were harvested from the super-scapular region of the neck (scruff) and adherent cells separated, collected, and labeled with DAPI. Three lumbar intervertebral disc levels in each dog underwent a partial nucleotomy; other levels served as non-operated controls. Levels of intervention as well as the regimen of treatment were dually randomized. Three interventions were used in this study; adipose-derived cells in hyaluronic acid (HA) carrier, HA alone, or no intervention. All deliveries were guided by fluoroscopy. The dogs were radiographed, received MRI scans and then euthanized by 12 months. The disc tissue was harvested from the lumbar spine in each dog. Cells labeled with DAPI prior to implantation were evident in the tissue. Matrix composition was assessed for aggrecan, Types I and II collagen by both RT-PCR (Table I) and ELISA (Table II) to assess and compare matrix regeneration. mRNA and protein from each level are presented with respect to normal values defined as the 100 percent expression.

Results: The results can be summarized as:

the regenerative cells are viable following implantation.

supplementing adipose cells following injury supports regeneration.

morphology was maintained.

intervertebral disc height was not lost.

MRI signal remained similar to native control.

hyaluronic acid was insufficient to prevent disc degeneration or desiccation.

lack of intervention resulted in progressive degeneration.

Discussion: This study provides evidence that adipose derived cells might offer a reliable source of regenerative potential capable of bio-restitution. The span of this study was sufficient to show that freshly isolated adipose-derived cells can be transplanted percutaneously and will survive the trauma associated with post-surgical inflammation to remain viable and produce appropriate, tissue-specific matrix.


A. Gonsalvo A. Rasi D. de la Harpe

Introduction: The best surgical technique for patients with bacterial spinal infections is still matter of debate. Recent publications suggest that titanium implants can be used safely in infectious sites in combination with debridement and antibiotic therapy. The aim of this study was to provide further evidence in support of debridement and instrumentation as a single-stage procedure for spinal osteomyelitis/discitis.

Methods: We retrospectively review patients with spontaneous spondylodiscitis in whom medical therapy failed, and consequently underwent instrumented fusion by the same surgeon (DD). We defined failed medical treatment as progression of the neurological deficit, lack of improvement of the inflamatory markers after 48 hours of an adequate antibiotic therapy or progression to spinal deformity in the follow-up x-rays. In all cases, the following variables were evaluated: sex, age, relevant medical history, neurological compromise measured by the Frankel scale, level operated and operation performed, source of infection, etiologic agent, antibiotic treatment, postoperative complications, inflammatory markers, length of hospitalization, fusion time. Quality of life was measured after at least 12 months of the operation with the EQ5D questionnaire.

Results: 12 patients (5 men and 7 women), ranging in age from 42 to 85 years, with a Frankel score of D in 10 cases, and of E in 2 cases, underwent a single stage debridement and posterior instrumented fusion with titanium pedicle screws and interbody autogenous bone. Preoperative neurological deficits improved in all cases and solid bone fusion was achieved in all 12 patients (100%) at 6 months. The indication for surgery was progressive neurological deficit in the lower limbs in 9 cases, lack of improvement after 48hrs of antibiotic therapy guided by blood culture results in 2 patients and progression to spinal deformity in the remaining one. The mean follow-up period was 60 months (range 12 to 100). In all patients the infection healed after surgery, not requiring a second operation to remove the metal implants. Quality of life assessed with the EQ5-questionnaire showed the following results: mobility (median 1, range 1 to 2), personal care (median 1, range 1 to 1), usual activities (median 1.5, range 1 to 2), pain/discomfort (median 1.5, range 1 to 2), anxiety/depression (median 1, range 1 to 2), visual analog scale for health state (median 67.5, range 30 to 80).

Discussion: These findings support that debridement and instrumented fusion can be performed as a single-stage procedure without an increase in the recurrence rate or morbidity. The outcome has been satisfactory in our patients in terms of rate of fusion and quality of life in the long term follow up.


M. Melloh T. Barz P. Reiger L. Staub E. Aghayev C. Roeder T. Zweig J-C. Theis

Introduction: Lumbar spinal stenosis is a frequent indication for spinal surgery. The predictive quality of treadmill testing and MRI for diagnostic verification is not yet clearly defined. The aim of our study was to assess correlations between treadmill testing and MRI findings in the lumbar spine.

Methods: Patients with lumbar spinal stenosis who had been admitted for surgical treatment by means of decompression with or without stabilisation were prospectively examined. We included patients with lumbar spinal stenosis as defined by clinical symptoms like low back and/or leg pain, which increased when walking, and by the area of the dural sac examined by MRI. We excluded patients with clinically manifest peripheral arterial disease, polyneuropathy or musculoskeletal impairments compromising the ability to walk. Treadmill tests were performed using the standardized testing protocoll by Deen at a speed of 0.5 m/sec without inclination. After the onset of symptoms (pain, weakness or dysaesthesia), each patient decided when to end the test.

The area of the dural sac and neuroforamina was examined with MRI for the narrowest spinal segment. ODI and VAS were used for clinical assessment.

Results: 25 patients were included with a median age of 67 years (Interquartile range IQR 60–72 yrs). In the narrowest spinal segment the median area of the dural sac was 91mm2 (IQR 67–135 mm2). The median ODI was 66 percent (IQR 64–72 percent). The median walking distance in the treadmill test was 70 m (IQR 30–130 m). The distance reached in the treadmill test correlated with the area of the dural sac (Spearman’s rho=0.53) and ODI (rho=0.51), but not with the area of the neuroforamina and VAS.

Discussion: The treadmill test helps objectifying pre- and postsurgical clinical complaints and verifying a lumbar spinal stenosis by creating a situation of dynamic strain. Moreover, the treadmill test lets the patient experience his own physical limits and enables the examiner to attain a replicable postoperative assessment. The distance reached in the treadmill test predicts the grade of stenosis in MRI but has a limited diagnostic importance for the level of clinical symptoms in lumbar spinal stenosis.


L. Tan W. Ng M. Slattery

Introduction: Spinal fusions have been shown to be useful in correcting spinal deformities resulting from degenerative disc disease. We sought to produce a prospective analysis of functional outcomes following lumbar spinal fusion surgery for degenerative spondylolisthesis or degenerative scoliosis secondary to degenerative disc disease. We present the interim results from our case cohort of 74 patients.

Methods: Over a period of 3 years (2005–2007), all patients who presented to this private practice with symptoms of canal stenosis or radicular pain secondary to degenerative spondylolisthesis or degenerative scoliosis were offered decompressive laminectomy and posterior lumbar interbody fusion (PLIF) surgery with interbody cages, pedicle screw instrumentation, bone morphogenic protein (BMP) and bicalcium phosphate (BCP). Patients who presented only with low back pain and did not have radicular pain or neurogenic claudication were excluded from this study. All patients who were offered spinal fusion surgery were consecutively offered the opportunity to enrol in this functional cohort analysis. Those patients who consented were prospectively entered into this functional analysis and were asked to complete Oswestry and SF-36 function questionnaires preoperatively and post-operatively. Post-operative data has been collected in some cases up to 16 months postoperatively. Patients were also assessed post-operatively by the surgeon and given an Odom clinical assessment score. Complications were also collated.

Results: 102 patients were offered surgery with 18 patients not consenting to participate in this study. Of the 84 patients who consented to participate in this study, 10 patients failed to submit both pre-operative and postoperative questionnaires, leaving 74 patients who were followed for a median 7 months (range of 1.5–16 months). There were 30 males and 44 females in the study with a median age of 73 (range 46–89). Of these 74 patients, 63 had degenerative spondylolisthesis and 11 had degenerative scoliosis. 52 patients had sufficient follow-up to assess bony fusion, of which 1 patient failed to fuse. 32 of the patients who fused reported to have improved, but 16 did not and the remainder did not submit both pre-operative and post-operative questionnaires. For the SF-36 questionnaire, the median pre-operative SF-36 score was 30 (96.6% CI 26–35) and the median post-operative SF-36 score was 48 (95.3% CI 42–56). The mean difference between the preoperative and post-operative SF-36 scores was 14 (95% CI 11–18) (p< 0.0001. The median preoperative Oswestry score was 46 (96.6% CI 42–50) and the median post-operative Oswestry score was 30 (96.6% CI 24–40) and the median post-operative Oswestry score was 30 (96.6% CI 24–40). The mean difference between the preoperative and post-operative Oswestry scores was 14 (95% CI 10–19) (p= 0.0001). 45 patients (61%) reported improvements of greater than 20 between their pre-operative and post-operative scores in either their SF-36 or Oswestry questionnaires. Of these 45 patients, 40 (89%) were also given moderate or good Odom (clinical) scores. 29 patients (39%) reported that they had not experienced improvement in their symptoms based on either their SF-36 or Oswestry questionnaires, with 12 (41%) of those 29 patients scoring poorly on their Odom scores. In all, there were 18 complications ranging from wound collections (4) and breakdowns (2) to repositioning of screws (6) and nerve root injury (2), to DVT (1) and transfusion (3).

Discussion: Interim results suggest that most patients undergoing PLIF and pedicle screw surgery with decompressive laminectomy for treatment of degenerative spondylolisthesis and degenerative scoliosis report significant improvements in function which correlate fairly well with clinical assessments performed by the surgeon at pre-operative and post-operative reviews. IInterestingly, patients generally reported either significant improvements (rather than borderline improvements) or that they had not improved at all, and that those who did report significant improvements also generally scored well on their Odom assessments. These reported improvements currently seem to be independent of whether bony fusion is achieved or not, as 16 of the 29 patients who did not report improvement actually achieved fusion. This is not unexpected as the initial PLIF procedure provides initial pre-fusion in situ rigid internal fixation.


S. Sugiyama M. Wullschleger K. Wilson C. Vasili R. Williams B. Goss

Introduction: It has long been recognised that static plain x-rays are a sub-optimal method for the assessment of lumbar fusion. Blumenthal and Gil showed that radiographic assessment of fusion corresponded with operative findings only 69% of the time. Santos et al suggest that both plain x-rays and flexion/extension x-rays overestimate the fusion rate when compared to helical computed tomography (CT). To date there has been no correlation of CT assessment of fusion with surgical exploration. In this study we present an animal model of lumbar spine pseudarthrosis and compare three imaging modalities with micro-cut CT scanning and cadaveric assessment.

Methods: Approval was gained from the QUT animal ethics committee. Eleven mixed bred ewes were assigned to either a fusion group or an intentional pseudarthrosis (IP) group. A dorsal approach to the facet joints of L2/3 was made. The facet joints were destabilised by resecting the articulating surfaces with a rongeur. In the fusion group, the spinous processes of the destabilised segment were wired tightly together and a bone graft harvested from the iliac crest was placed into the joint space. In the IP group the bone graft bed was prepared similarly except that a small proportion of the articulating surface was left intact and a 1.0 cm2 roll of oxidised cellulose was placed into the facet joint space bilaterally. In the IP group the spinous processes were wired around an interspinous spacer which was later removed to create a similar degree of laxity in the fixation of each of the IP specimens. The animals were sacrificed at 6 months and static and dynamic lateral radiographs obtained. The spine was removed en bloc, and high speed fine cut (2mm) CT Scanning performed. The specimens were individually assessed for fusion by micro-cut CT scanning. Eight independent, blinded orthopaedic surgeons, were asked whether they considered the spine to be fused based on

plain x-ray

plain xray and flexion/extension x-rays and

plain x-ray and flexion/extension x-rays and CT scan.

These results were correlated with a fusion rate based on the micro CT. The specificity and sensitivity of these radiological measures in diagnosing pseudarthrosis and inter-rater reliability using Fleiss’ Kappa scores for each method were calculated.

Results: For assessing pseudarthrosis identified by microCT the plain film sensitivity was 0.41 and the specificity was 0.47. For assessing pseudarthrosis with plain and flexion extension xrays the sensitivity was 0.55 and the specificity was 0.33. For assessing pseudarthrosis with plain flexion extension xrays and CT the sensitivity was 0.81 and the specificity was 0.88. The Kappa score for plain films was 0.15, for flexion extension was 0.07 and CT was 0.54.

Discussion: This study suggests that plain radiographs and flexion extension radiographs are an unreliable measure of posterior lumbar fusion. The current clinical gold standard for assessment of fusion (CT) was able to correctly identify non-union in 80% of cases. Whilst no alternatives to structural assessment of the fusion mass with CT currently exist it is important to recognise the limitations of this technique.


S. Hemley M. Stoodley A. Brodbelt J. Tu

Introduction: Post-traumatic syringomyelia produces a significant burden of pain and neurological deficits for patients with spinal cord injury. The mechanism of syrinx formation is unknown and treatment is often ineffective. Previous studies have demonstrated that fluid flow enters syrinxes from the subarachnoid space via perivascular spaces, however other pathways may be involved. It has been proposed that a damaged blood-spinal cord barrier (BSCB) provides another pathway for fluid to enter syrinxes. The purpose of this study was to investigate whether or not the integrity of the BSCB is compromised in an animal model of post-traumatic syringomyelia, and if so, whether this deficiency plays a role in the induction or subsequent enlargement of a syrinx.

Methods: The excitotoxic amino acid and arachnoiditis model of syringomyelia was used to study the structural and functional integrity of the BSCB in 27 Sprague-Dawley rats. In this model, quisqualic acid is injected into the cord to create an initial cyst. The addition of subarachnoid kaolin to create arachnoiditis results in a reliable model of syringomyelia [1]. Structural integrity of the blood-spinal cord barrier was assessed using immunoreactivity to endothelial barrier antigen (EBA) and loss of functional integrity was assessed by extravasation of intravascular horseradish peroxidise (HRP). Animals were studied at 3 days, or 1, 3, 6, or 12 weeks after surgery. There were laminectomy-only and saline injection controls at each time point.

Results: Syrinxes formed in 15 of 17 animals injected with excitotoxic amino acid. There was loss of structural and functional integrity of the BSCB in the syrinx animals at all time points. There was wide-spread disruption of the barrier at early time points, followed by recovery of the barrier except for vessels immediately adjacent to the syrinx.

Discussion: This study has demonstrated a prolonged structural and functional disruption of the BSCB. Loss of functional integrity of the barrier, with fluid entering the interstitial space of the spinal cord, may contribute to initial cyst formation after spinal cord injury and subsequent enlargement of the cyst to form post-traumatic syringomyelia.


J. Elliott G. Jull T. Noteboom R. Darnell M. Sterling G. Galloway

Introduction: Magnetic Resonance Imaging (MRI) is the gold standard for imaging muscle and fatty infiltrate has featured in low back pain. However, there is little knowledge about in vivo features of neck muscles in chronic WAD. The purpose of this study was to quantitatively compare fatty infiltrate in the cervical extensors in patients with chronic WAD and controls across muscle and segmental level.

Methods: Volunteer subjects were gained through referral from local practitioners and the local university fraternity. A previously established MRI measure was performed in 113 female subjects (79- WAD & 34 healthy controls). Subjects with chronic WAD (> three months – < three years) were included if, classifiable as WAD II per the Quebec Task Force. The cohort was restricted to females (18–45 years) as they best represent those with chronic WAD. Volunteers were excluded when

classified as WAD I, III or IV

lost consciousness as a result of a motor vehicle crash (MVC)

previous history of MVC

previous non-traumatic neck pain

diagnosed with any neurological, metabolic or inflammatory conditions or

were pregnant.

The measure was performed for the rectus capitis minor/major, multifidus, semispinalis cervicis/capitis, splenius capitis and upper trapezius. The values for all muscles were plotted for level and side and linear regression analysis was used to determine segmental trends (C3-7). A multi-factorial analysis of variance (MANOVA) was applied to investigate group means of whiplash and controls for fat indices across muscle, side and level. Bonferroni post-hoc comparisons were used to compare group by muscle interactions at each level. Multiple regression analyses were performed to determine if the score on the Neck Disability Index (NDI), age, Body Mass Index (BMI), compensation status and duration influenced fatty infiltrate. Significance was set at p < 0.05. Data presented as mean ± SD.

Results: The demographic characteristics of the two groups are: WAD (n = 79): age: 29.7 ± 7.8 years, BMI (kg/m2): 25.1 ± 5.7; duration: 20.3 ± 9.6 months and NDI: 45.5 ± 15.9. Healthy Controls (n = 34): Age: 27.0 ± 5.6 years, BMI: 23.0 ± 4.4.. NDI was not collected in controls.

MANOVA revealed significant main effects for group, muscle, segmental level and side (p < 0.0001), and significant interactions between Group:Muscle, Group:Level, Muscle:Level and Group:side (p < 0.0001). Sides were averaged for each muscle and level for post-hoc analysis.

There was a linear decrease in the fat indices from C3 – C7 for each muscle in both groups. No significant differences in fat indices across muscle, levels and side were noted in controls (p = 0.09). For the WAD subjects, the multifidus muscle had significantly higher fat content at each level compared to the other segmental muscles (p < 0.0001) and was highest at C3 (p < 0.0001).

There were higher fat indices in the whiplash group compared to the controls for the rcpmin and rcpmaj muscles (p < 0.0001).

No relationship was found for fat indices in all WAD muscles and NDI scores (p = 0.81), age (p = 0.14), duration (p = 0.99), compensation (p = 0.37) or BMI (p = 0.74).

Discussion: There is significantly greater fatty infiltration in neck extensors, especially in the deeper muscles, in females with chronic WAD when compared with controls. Future studies are required to investigate relationships between muscular degeneration and symptoms.


P. Hodges W. van den Hoorn M. Coppieters J. Cholewicki

Introduction: Recent data report increased trunk stiffness in semi-sitting in people with recurrent low back pain (LBP) during remission. This is likely to be due to increased trunk muscles activity. Although this adaptation may provide a short term strategy to protect the spine from further pain/injury it may increase the potential for pain recurrence due to increased trunk loading and compromised performance of the spine in dynamic functions. An interesting observation was that trunk damping (i.e. decay in trunk velocity) was reduced. Damping is likely to be largely related to reflex control of trunk muscles. It is possible that trunk stiffness increased in this population because reflex control was inadequate. This study aimed to determine whether stiffness and damping adapt in a similar manner in healthy individuals, with presumably normal reflex function, when challenged by pain.

Methods: Fourteen males with no history of LBP were semi-seated with their pelvis fixated and a harness placed over their shoulders. Weights (~15% of body mass) were attached via an electromagnet and force transducer to a pulley system that attached to the front and rear of the trunk harness at T9. Subjects sat upright in a relaxed, neutral posture. At an unpredictable time either the front or back weight was dropped 10 times (each) in random order. Trials were repeated in three conditions; pre-pain, pain and post-pain. During the pain condition subjects were injected with a single bolus of hypertonic saline (5% NaCl, 1.5 ml) into the right erector spinae at L4. Trunk mass (M), damping (B) and stiffness (K) were estimated when the trunk was perturbed either backwards (BW) or forwards (FW) in an identical manner to our earlier study. Parameters were described by a second order linear model and the standard least squares procedure was used to solve the estimation using the equation: F(t)=M.x(acc)(t)+B. x(vel)(t)+K.x(disp)(t). Damping and stiffness were normalized to the peak. Perturbation displacement and duration were calculated from the onset to perturbation maximum. Data were compared with repeated measures ANOVA and Duncan’s multiple range test.

Results: During experimental pain, trunk stiffness decreased in both perturbation directions (both: p< 0.02). Damping increased with FW perturbations (p=0.01). Both the displacement (p=0.03) and duration (p=0.01) of the trunk perturbation were increased during experimental pain with BW perturbation. There was no change in either parameter in the FW direction. Estimated trunk mass was lower during pain and post-pain compared to pre pain (p=0.01) with BW perturbations.

Discussion: In contrast to increased stiffness and decreased damping in people with recurrent LBP, healthy individuals respond to pain by decreasing stiffness and increasing damping of the trunk. However, this was only true for the FW perturbation. In the BW direction, damping was not increased and there was a resultant increase in the displacement and duration of the perturbation. Taken together these data suggest that damping of the trunk is adaptable and is increased to protect the spine in healthy individuals. As trunk damping is associated with reflex control of the trunk muscles these data suggest although healthy individuals may be able to tune this control during pain, this is compromised in spinal pain.


O. Filo A. Schechtmann D. Ovadia M. Fishkin S. Wientroub

Introduction: School screening for scoliosis aims to reduce the need for surgery by detecting curve changes in children at an early stage when bracing may be effective in halting the progression of the deformity. Although the effectiveness of the current screening techniques has not been established yet, AAOS and SRS continue to support school screening.. The major criticism focuses on the cost-ineffectiveness of the process, as too many students are unjustifiably referred to specialists. Moreover, examiner’s skills and experience are important factors in screening outcome. An ongoing, large-scale study of school screening is conducted in public schools at the northern part of Israel comparing the screening performance of a Scoliometer and a new, hand-held computerized device (SpineScan). SpineScan was designed to automatically measure the “angle of trunk inclination” (ATI), and is less dependent on examiner’s level of medical training. Furthermore, this tool enables also fast assessment of the kyphosis angle.

Methods: In a first phase of the study, 1000 children aged 10 to 14 years were screened. Each child underwent “blinded” examinations by two examiners with different skills (a pediatric orthopaedic surgeon and a physiotherapist), each of whom using a different tool (a Scoliometer and SpineScan, respectively). Screening was performed in examination positions specific for true scoliosis (standing and sitting forward bending) and ATI measurements were compared. Children with an ATI =or > 7º measured with either tool at both positions were referred to undergo a standard full spine X-ray in standing position, on which an experienced pediatric orthopaedic surgeon measured the Cobb angles. Curves = or > 10º were considered true positive findings for scoliosis. Statistical analysis included specificity, sensitivity and predictive value estimates of both methods.

Results: Referral rate for Scoliometer was 2.5% and for SpineScan 1.9%. SpineScan reached 80% sensitivity vs. 70% of the Scoliometer. Moreover, SpineScan achieved higher PPV values than the Scoliometer (80% vs. 54% respectively).

Discussion: These results imply that efficient and cost effective screening can be performed by minimally skilled examiner using SpineScan.


A. Pattavilakom K. Seex

Introduction: Anterior cervical spine surgeries are associated with high incidence (up to 60%) of early postoperative dysphagia and hoarseness of voice. These symptoms have been attributed to retraction injury on the larynx, trachea and oesophagus. Pressure from retractors producing ischaemia might explain the soft tissues complications following anterior cervical approach. Conventional retractor systems rely on the soft tissues for stability and create a vertical surgical channel but a novel system (Seex retractor) is fixed directly to the spine and rotates to allow an oblique approach. This may reduce retraction pressure by the Seex retractor on tissues This is the first investigation of retraction pressures using any two different retractor systems for anterior cervical spine surgery. The aims of this study were to measure the retraction pressure on the larynx, trachea and oesophagus during the anterior surgical approach to the cervical spine, in cadavers using conventional (Cloward) retractor and Seex retractor and to investigate the effect of flat or curved blades on retraction pressure

Methods: In a cadaveric model, through a standard anteriomedial approach simulated anterior cervical discectomy procedure was performed in cadavers at C3/4, C4/5, C5/6 and C6/7 levels using Cloward retractor with curved blade (Cervical Large Retractor Set. No. C50-1380: Cloward Instrument Corporation), Seex retractor with flat blade and Seex retractor with curved blade (Patent holder Dr. K. Seex, No PCT/AU05/001205). An online pressure transducer (Tekscan pressure measurement system) was applied between the retractor blade and medial tissues. Retraction pressures were recorded for all the retractors at each level on two separate occasions. Average retraction pressure (ARP), average peak retraction pressure (APRP), pressure distribution along the area of retraction, pressure difference at the edge and surface of the retractor blades, pressure variation with flat and curved blades were determined and compared.

Results: A total of 40 sets of pressure recordings were made from 5 cadavers. Cloward retractor system generated an ARP of 33 mmHg (range 16 – 66 mmHg). ARP of Seex retractor with curved blade was 20 mmHg (range 9 – 50 mmHg) and that of Seex retractor with flat blade was 25 mmHg (range 10 – 74 mmHg). At one level ARP was same for all the three retractors. At another level ARP was same for Cloward retractor and Seex retractor with flat blade but higher than that of Seex retractor with curved blade. At two other levels Seex retractor with flat blade showed higher ARP than others. At 36 levels Cloward retractor showed highest ARP. This was statistically significant with Pearson’s Chi-square test (X2=10.023, degree of freedom=1, p = 0.0015) and Fisher exact test, p = 0.0005. Cloward retractor system showed an APRP of 124 mmHg (37 – 255 mmHg). While that of the Seex retractor with curved blade was 69 mmHg (14 – 254 mmHg) and that of Seex retractor with flat blade was 94 mmHg (18 – 255 mmHg). Of the 40 sets of the recordings at 32 levels Cloward retractor system generated highest APRP. With the Seex retractor itself flat blade generated more APRP than curved blade in 31 sets of measurements; it was reverse in 3 sets and in 6 sets APRP was same. Only at one level curved blade generated higher ARP than flat blade, at 11 levels it was same. At 28 levels ARP was higher with flat blade.

Discussion: Cloward retractor generated significantly high retraction pressure (peak and average contact pressure) than Seex retractor in majority of the cases. Curved blades generate less retraction pressure than the flat ones. Based on these findings a prospective randomised study is underway in live patients.


K. Seex

Introduction: In 1971, Cloward wrote that after anterior cervical surgery, dysphagia occurs in all patients and is due to pressure on the oesophagus by the retractors. Recent studies indicate that dysphagia occurs in 54% of patients at 1 month and 13.6 % at 2 years. Recurrent laryngeal nerve injury occurs in 15 – 23 % producing hoarseness in one third of these. The continuing frequency of these complications even in experienced hands suggests that a review of retractor design and consideration of new designs is worthwhile.

Methods: A Medline search of unlimited years in English using terms: retractors, surgical instruments, development and history was performed. Described retractors and their design principles were reviewed and a novel principle identified from which an anterior cervical device was developed and tested.

Results: The novel general principle states that superior retraction is achieved by combining fixation onto bone with variable rotation of the retractor blade. Bone stabilization within the wound provides optimal stability and mechanical advantage for retraction while variable rotation allows retraction or tissue relaxation. Excluding the ubiquitous handheld retractors which lack stability, 7 different designs of anterior cervical retractors have been described. Anecdotally self retaining retractors are the most commonly used, but to be stable they require equal bilateral tissue counterforce and tissues that do not stretch. They are thus doubly ill suited for the asymmetrical anterior approaches to the anterior cervical spine. In the new anterior cervical retractor a small internal frame is fixed to the spine using standard Caspar screws. The frame slides with distraction. Routine surgery including plating is carried out within the frame. The frame provides stable axes for the independently rotating medial and lateral retractor blades.

Discussion: In the spine intermittent relaxation of retraction has recently been shown to reduce muscle injury and pain after lumbar surgery. This is the first retractor system that can be released without sacrificing stability or exposure. Despite numerous authors implicating cervical retractors as a source of complications there are few investigations and no studies investigating different designs. Rather than accepting or denying common complications we should investigate even our most familiar tools.


A. Gonzalvo F. Soulier G. Fitt S. Liew

Introduction: The aim of this study was to assess the learning curve of spinal internal fixation with pedicle screws of a spinal fellow (AG) with no previous experience with the technique, during a 2-year fellowship at a referral spinal surgery centre in Australia.

Methods: Patients treated with pedicle screw (PS) placement by the spinal fellow under the supervision of the attending orthopaedic or neurosurgery consultant were included in this study. Postoperative plain x-rays and, in some cases, computed tomography scans (CT scans) were obtained. PS position was assessed by two blinded independent reviewers, one radiologist (observer 1) and one spinal surgeon (observer 2), using a grading scale. PS placed by the attending consultants were included in the evaluation as distractors. The screws were classified using a grading scale in 3 groups: Correct, Border-line, and Incorrect. After assessment, the PS were rearranged in groups of 40 screws, in chronological order, for comparison and assessment of the progress in the learning curve.

Results: 94 patients underwent internal fixation of the spine from upper thoracic to the sacral region with PS (584 screws in total) between February 2006 and December 2007. Eight cases (40 screws) were excluded because of lack of image studies or severe spinal deformities. Among the 544 screws under evaluation, 320 (58.8%) were performed by the spinal surgery fellow, 187 (34.4%) by the attending consultant and 37 (6.8%) by orthopaedic and neurosurgery registrars, the latter evaluated but excluded for the statistical analysis. The overall precision for the 507 screws analysed was 84.2% according to observer 1 and 77.9 % according to observer 2. When the analysis was narrowed down to the 320 screws done by the fellow, this precision increased to 84.7% for observer 1 and decreased to 76.6% according to observer 2. A learning curve was created consisting of 8 groups of 40 screws in chronological order. There was a statistical significance (p< 0.05) in the rate of Incorrect and Border-line PS when comparing the first 100 PS with the rest of the series. None of the patients (included and excluded) developed neurological complications because of the misplaced PS.

Discussion: The findings reveal a learning curve of PS placement. In this series, the inflexion point in the learning curve for this technique was between 80 and 120 screws, which in the present series represented the spinal fellow intervention in 20 to 30 cases. After approximately 150 PS no significant changes can be observed: the learning curve remains stable, with a constant decreasing trend. With appropriate expert supervision the fellowship training system is a safe and appropriate method to learn this technique.


P. McCombe

Introduction: Vertebral end plate is both inervated and has been shown to be a source of pain. Clinical experience shows some degree of end plate subsidence, usually posteriorly, in cases of total disc arthroplasty (TDA). It follows therefore that this may be a cause of pain. It is theorized that in quiet standing, a prosthesis with a posteriorly placed centre of rotation (COR) will have maximal end plate stresses posteriorly unless the centroid of the prosthesis end plate lies over the COR of the prosthesis. The rationale is that a posteriorrly weighted non uniform static end plate stress distribution will be produced in order to satisfy the static requirement that the sum of all moments be zero. It is further theorized that removal of portions of anterior end plate to move the centroid closer to the pivot point will make the stress distribution more normal.

Methods: A ball and socket prosthesis with a posterior articulation was subjected to static compression with an Instron testing machine against a foam block (Sawbones 1522-11) with the lower part of the specimen on rollers to allow lateral translation. Load was applied normal to the lower end plate in displacement control at a constant rate of 3 mm/min. Load displacement curves, lateral translation of the lower endplate and subsidence angle into the foam was measured. The experiment was repeated with various shaped end plates with the same outside footprints, though with various cutouts of the endplate footprint, such that the footprint area was reduced though with the centroid now lying over the prosthesis COR.

Results: With the standard prosthesis subsidence was noted to be associated with a translatatory movement of the inferior assembly and tilting, with the posterior portion subsiding more than the anterior portion. The prosthesis continued to subside with an increase in the tilt angle and liftoff of the anterior portion of the end plate until the calculated centroid of the subsidence footprint in the foam was over the prosthesis COR. With an end plate cutout the inferior assembly did not translate and the prosthesis subsided in a parallel fashion. This behavior was unchanged by varying the geometry of the cutout. The area of the modified cutout prosthesis was 69% (564 sq mm cf 817 sq mm) of the area of the original end plate, while the yield load was 89% (2.34 kN cf 2.62 kN) of the original. The Yield stress was higher in the modified prosthesis (4.13 MPa cf 3.21 MPa)

Discussion: A potential reason for end plate subsidence in TDA’s may be mismatch between the position of the end plate centroid and the COR. In static loading this causes a tendency to posterior subsidence and tilting. Removal of part of the end plate footprint such that the centroid is moved closer to the COR results in less of reduction in yield load than would be anticipated by loss of surface area alone. There is also abolition of subsidence by tilting.


S. Veres P Robertson N Broom

Introduction: Compound mechanical loadings have been used to re-create clinically relevant annular disruptions in vitro. However, the role that individual loading parameters play in disrupting the lumbar disc’s annulus remains unclear. Using the recently described technique of nuclear inflation, the role that elevated nuclear pressures play in disrupting the lumbar intervertebral disc’s annulus fibrosus was investigated.

Methods: The nuclei of 12 ovine lumbar motion segments, posterior elements removed, were gradually pressurized by injecting a viscous radio-opaque gel via an injection screw fitted axially through their inferior vertebrae. Pressurization was conducted until catastrophic failure of the disc occurred. Investigation of the resulting annular disruption was carried out in tandem using micro-computed tomography and differential interference contrast microscopy.

Results: 3 of the 12 motion segments tested were excluded from the results due to improper placement of the injection screw, resulting in pressurization of the inferior vertebra rather than the nucleus. Mean failure pressure of the remaining 9 motion segments was 14.1 ± 3.9 MPa. Peak rates of pressurization ranged from 0.1–0.4MPa/s. Gel extrusion from the posterior annulus occurred in 7 discs and was the most common mode of failure. Unlike other aspects of the annular wall, the posterior region was unable to distribute hydrostatic pressures circumferentially. In each extrusion case, sever disruption to the posterior annulus occurred. While intralamellar disruption occurred in the mid annulus, interlamellar disruption occurred in the outer posterior annulus. Radial ruptures between lamellae always occurred in the mid-axial plane.

Discussion: With respect to the annular wall, the posterior region is most susceptible to failure in the presence of high nuclear pressure, even when loaded in the neutral position. The limited ability of the injected gel to cross the posterior-posterolateral boundaries, effectively concentrating hydrostatic stress within the posterior annulus, indicates that the laminate architecture along these radial lines is of mechanical significance. Within the outer posterior annulus, the prominence of inter-lamellar rather than intralamellar disruption indicates weak interlamellar cohesion. This suggests that nuclear material migrating down a radial fissure may easily track circumferentially within an interlamellar space upon reaching the inner lamellae of the outer annulus. This may explain why the majority of herniations are limited to protrusions contained within the outer annular wall.. The tendency for annular fibres to rupture in the mid-axial plane when loaded hydrostatically suggests that for a radial fissure or herniation to occur at the annular-endplate junction, a compounding bending or torsional load is required.


J. Melrose T.K.F. Taylor

Introduction: The Merino sheep breed has been used extensively for intervertebral disc research but it has not previously been documented that the breed displays a mild form of chondrodystrophy with disproportionate dwarfism. The ovine Merino intervertebral disc is similar to human and chondrodystrophic canine discs in structure, absence of notochordal cells in the adult structure, response to trauma, display of an age-dependant loss of proteoglycans and degenerative spinal pathology including Schmorl’s nodes. In contrast, non-chondrodystrophic breeds have a gelatinous nucleus pulposus, notochordal cells which may persist into adulthood and a low incidence of spinal disorders of discal origin thus are unsuitable as models of the human intervertebral disc.

Methods: Haematoxylin and Eosin, Toluidine blue stained and aggrecan and versican immunolocalised sections were examined by bright field and Nomarsky differential interference contrast microscopy.

Results: The ovine merino intervertebral disc undergoes an age-dependant chondroid transformation of the central nucleus pulposus with the appearance of cell nests of chondrocytic morphology within a hyaline cartilage-like matrix rich in aggrecan and type II collagen but deficient in versican and type I collagen. In contrast, the adjacent nucleus pulposus is a fibrocartilage rich in types I and II collagen, versican and aggrecan; the constituent cells are readily distinguished from the aforementioned cell clusters. The ovine femoral epiphyseal growth plate displays dysplastic changes with relatively short columns of flattened, columnar chondrocytes in the pre-hypertrophic region and a disorganised integration of the hypertrophic cells into metaphyseal endochondral bone in the distal growth plate.

Conclusions: These observations warrant the classification of the Australian merino as a chondrodystrophic breed. The Merino is a useful comparative animal model for the human intervertebral disc.


B. Vernon-Roberts R.J. Moore R.D. Fraser

Introduction: The age-related reduction of water-trapping proteoglycans needed to maintain optimal disc hydration may be caused by reduced synthetic ability or fewer chondrocytes but there is a paucity of objective quantitative studies of disc cellularity.

Methods: Sagittal sections of L4–5 discs were subdivided into a nucleus zone and 18 annulus zones prior to determining cell density (cells/mm2) in

the mid-sagittal plane of 10 male and 10 female discs aged 13–79 years;

7 parasagittal slices through a single disc;

discs showing various types of tears.

Results:

Most chondrocytes were unicellular but bicellular and multicellular chondrons were common in the margins of large tears and the nucleus in degenerate discs.

Cellularity was highest in the right posterior quadrant, lowest in the left anterior quadrant, about equal in the left posterior and right anterior quadrants, and substantially higher in the right half of the nucleus.

The correlation of increasing age with declining cell density was much stronger for the nucleus than for the annulus.

Nucleus cellularity continued to decline throughout life whereas the annulus ceased its decline after the age of 50.

Cell density was low in the vicinity of tears but elsewhere the disc was unaffected.

Extensive inferior and superior end-plate separations reduced cellularity throughout the disc.

Increased thickness of the cartilage end-plate was associated with higher cellularity in the nucleus.

Discussion: The findings that cell density is higher in the posterior annulus and in the right half of the disc, tends to be increased if the cartilage end-plate is thicker, and is not uniformly diminished by large tears, indicates that disc cellularity is influenced by a complex interplay of factors which needs to be understood before attempts are made to restore the structural and functional integrity of degenerate discs.


M. Schollum P. Robertson N. Broom

Introduction: The basic architecture of the annulus fibrosus has long been established; successive lamellae containing parallel collagen fibers cross obliquely as you move through the annular wall, with the lamellae anchored in the endplates to form a multi-ply structure. Less is known of the interactions between fiber populations in the multi-laminate annulus fibrosus. Their significant contribution to the material behaviour was highlighted in Elliot and Setton’s 2001 attempt to build a material model based on experimental measurements of properties of the annulus. Recent research has confirmed a localized rather than a homogeneous or dispersed mode of interconnectivity between lamellae. Whilst clearly indicating localized bridging structures these studies have allowed only a glimpse of how these bridging elements fit within the overall lamellar architecture. The aim of this investigation was to analyse the interlamellar interconnectivity in its full 3-dimensional form and in complete segments of the annular wall.

Methods: Anterior segments of ovine lumbar discs in two age groups were sectioned along the oblique fiber angle. A 3-dimensional picture of the translamellar bridging network (TLBN) is developed using structural information obtained from fully hydrated unstained serial sections imaged by differential interference contrast optics.

Results: A high level of connectivity between apparently disparate bridging elements was revealed. The extended form of the bridging network is that of occasional substantial radial connections spanning many lamellae with a subsidiary fine branching network. The fibrous bridging network is highly integrated with the lamellar architecture via a collagen-based system of interconnectivity.

Discussion: This study demonstrates a far greater complexity to the interlamellar architecture of the disc annulus than has previously been recognised. Our findings are clearly relevant to disc biomechanics. Significant degrading of the TLBN may result in annular weakening leading potentially to disc failure. Most importantly this work opens the way to a much clearer understanding of the micro-anatomy of the disc wall.


J. Costi R. Stanley L. Smith H. Tettis H. Tsangari T. Hearn N. Fazzalari

Introduction: Disc degeneration causes structural and biochemical tissue changes resulting in altered stresses that may affect vertebral bone remodelling. We hypothesized that disc degeneration alters vertebral cortical strains and disc mechanics of the motion segment, with and without the presence of zygapophyseal joints.

Methods: Twenty human lumbar functional spinal units (FSUs) were strain gauged on the lateral and anterior vertebral cortices, below the inferior endplate. Each FSU was preloaded overnight (0.2 MPa) in a bath and subjected to dynamic compression (1 MPa), flexion/extension/lateral bending (500N + 5 Nm), and axial rotation (5 Nm), before and after removal of the zygapophyseal joints. After testing, discs were macroscopically assessed and graded (1–4) for degeneration. Stiffness, phase angle (energy absorption) and principal strains were calculated. ANOVAs with the dependent variable of principal strain/stiffness/phase angle versus disc grade were performed for each testing direction.

Results: Assessment of disc degenerative condition revealed six grade 2 discs, eight grade 3, and six grade 4. Age and degeneration were highly correlated (r=0.80, P< 0.0001). The effect of disc grade on stiffness was significant overall in most loading directions, before and after removal of zygapophyseal joints (P< 0.008), apart for axial rotation (P> 0.587). Post-hoc multiple comparisons for all loading directions apart for axial rotation revealed that the stiffness of grade 4 discs was significantly larger than grades 2 and 3 discs in most loading directions.

For phase angle (approximate magnitude 5°), no significant overall effects due to degeneration were found across any loading direction (P> 0.2). ANOVA analyses on maximum/minimum principal strains found no significant effect due to disc grade (P> 0.063). However, a small number of significant effects due to disc grade were found at particular strain gauge locations for the isolated disc in flexion, the intact FSU in extension, and the intact FSU/isolated disc in right lateral bending.

Discussion: This study represents the first of its kind to investigate the effects of disc degeneration on vertebral bone cortical strain and disc mechanical properties. Significant increases in stiffness were found with increasing degeneration in all test directions apart for axial rotation. Changes in disc stiffness were consistent with other studies and may be a result of the structural and biochemical changes within the disc that accompany the degenerative process.

The non-significant small phase angles suggest that the disc behaves more like an elastic solid than a poroelastic material, and that dehydration associated with degeneration does not adversely affect damping. Principal strains were not significantly affected by disc degeneration overall, suggesting that the cortical shell adjacent to the disc-endplate boundary maintains a relatively homeostatic condition, with more dramatic architectural changes probably occurring within the trabecular bone. Applications of this research include providing important validation data for analytical/finite element models of the intact FSU and isolated disc segment, and a better understanding of the magnitudes of cortical strains that need to be maintained in order to avoid damaging vertebral bone stress-shielding effects after treatments for disc degeneration.


P. McCombe

Introduction: Total disc arthroplasty’s (TDA) fall into two groups – constrained ball and socket and sliding core devices. It is commonly theorized that sliding core devices offer the advantage of being able to adapt to varying centres of rotation (COR) of the functional spinal unit (FSU), however no rigorous justification has, so far, been tendered for this. Despite the perceived advantage, differing clinical results have been reported in the lumbar spine, possibly with better results with ball and socket devices. Furthermore abnormal motion with a large hysteresis effect has been identified in in vitro flexibility testing with a physiological preload in the lumbar spine. The purpose of this paper was to develop an understanding of the kinematics of sliding core TDA’s, their ability to match variable COR’s of a normal FSU, and to gain an understanding of theoretical load displacement behaviour when implanted.

Methods: The motion of a biconvex sliding core prosthesis was observed to define the motion as a linked kinematic chain. By the use of sequential multiplication by appropriate transformation matrices that described this kinematic chain, equations for the position and orientation of the upper vertebrae were established. By a similar method equations for the position and orientation of the upper vertebrae were developed for a physiological simple rotation around the FSU COR. Attempts were made to solve these two sets of equations simultaneously to see if motion of the biconvex core prosthesis could match either the position, orientation or both position and orientation of the normal physiological motion. Functions defining the length of the load vector through the COR were obtained. By considering a physiological load in the direction of this vector, a function describing potential energy was defined. This was further modified by the addition of ligament constraints with a “J” shaped non linear load displacement behaviour that approximated normal ligament stiffness. Sensitivity analysis was then performed to establish the behaviour of the prosthesis under differing loads, ligament strains and malplacements and the outcomes were compared to published in vitro results.

Results: The motion of the device could be modeled as a ‘two bar linkage’. Attempts to find simultaneous solutions for the equations for the two bar linkage and physiological movement showed that a solution was possible when matching either position or orientation but not both. The biconvex core prosthesis best approximated the normal motion by a change in the length of the vector joining the FSU COR to the vertebrae above. When the potential energy caused by this change in length was plotted as a two dimensional surface, a ‘saddle shape’, indicating an unstable high energy equilibrium position at neutral was found. The addition of functions to simulate ligament structures showed a ‘metastable’ energy surface with two stable minimum equilibrium positions with an intervening unstable high energy equilibrium position. Sensitivity analysis showed that the prosthesis could adapt quite well to changes in vertical position of the FSU COR though had limited ability to adapt to anteroposterior malplacement.

Discussion: The theoretical potential energy function for a biconvex core prosthesis predicts significant hysteresis with a high energy unstable central position. The equations predict abnormal load behaviour that is similar to observed in vitro testing. This may explain the difference in clinical results.


T. Sabet A. Diwan

Introduction: Lumbar Total Disc Replacement (TDR) is an accepted treatment for recalcitrant Chronic Discogenic Low Back Pain. However, no studies have compared Lumbar TDR to non-operative intervention. The aim of this study was to investigate the two-year outcomes for con-current cohorts of chronic discogenic low back pain patients undergoing either Lumbar TDR or novel non-operative care.

Methods: Data for the TDR cohort was from prospectively collected data of patients who had undergone Prodisc II lumbar TDR during August 2003 to December 2005. Two-year data for the non-operative cohort was collected prospectively from 880 sequential patients who underwent non-operative intervention between January to December 2005 and who met the inclusion and exclusion criteria. Inclusion criteria: age > 20 and < 65, single/two level disc disease, low back pain > 6 months, had failed non-operative intervention. Exclusion criteria were: previous lumbar surgery, listhesis, facet disease, osteoporosis, pregnancy, red flag conditions, or poor command of English. Additional non-operative inclusion criteria were: attended a minimum of 3 non-operative sessions, completed the entry questionnaire. Novel non-operative care consisted of a cognition-driven motor relearning intervention, aimed at altering provocative movements and postures and reintegrating these alterations into daily life. Manual therapy and spinal injections were used as an adjunct where needed. Pre-treatment and two-year follow-up data for the following outcomes were collated from a modified NASS questionnaire: back/leg pain, activity limitation, and global perceived improvement. Data was expressed as mean difference with 95% confidence intervals for the difference between the means. Student-t test and paired student-t test were used to assess between group and within group differences.

Results: 16 patients (9 males) were identified in the lumbar TDR cohort with median age 43 years (29–57) and median duration of symptoms of 3.5 years (0.5–24). 16 patients (9 males) were also identified in the non-operative cohort with median age of 42 years (24–61) and median duration of symptoms of 2.5 years (0.5–24). There were no cross-overs, however one patient in the TDR cohort had previously undergone the non-operative care regime. There were no significant pre-treatment differences observed in age, sex, duration of symptoms and back pain intensity between cohorts. However, significant pre-treatment differences were observed with 25% greater leg pain and 25% greater activity limitation score in the TDR cohort when compared to the non-operative cohort. Following Lumbar TDR the mean differences at two years for back pain, leg pain and activity limitation favoured improvements of 3.6(2 to 5.1) and 3.4(1.8 to 4.9) and 30.5%(19.2–41.8) respectively when compared to pre-treatment. Similar improvements were observed for the non-operative cohort with 5.0(3.7–6.3), 2.8 (0.7–5.0) and 20.9%(9.4–32.4) for back pain, leg pain and activity limitation respectively. 71% of Lumbar TDR patients and 67% of Non-operative patients reported their relief of symptoms as exceeding 60% at the two-year follow-up.

Discussion: The data suggests that prior to treatment, patients undergoing lumbar TDR were worse off in activity limitation and leg pain than the non-operative cohort. However, improvements in back pain, leg pain, and activity limitation are clinically significant at two-year follow-up with either Prodisc II-L TDR or novel non-operative care for chronic discogenic low back pain patients. Clinically, it may be reasonable to offer patients with lesser leg pain intensity and activity limitation ongoing non-operative care. This level 3 evidence needs to be supported with more case cohorts or an otherwise ethically difficult to conduct RCT.


John Liddell

Introduction: Several recently published case series report the development of vertebral body osteolysis following the insertion of bone morphogenetic proteins (BMP) in the interbody space.

The aim of this case report was to highlight the development of severe vertebral body osteolysis following posterior lumbar interbody fusion with recombinant human bone morphogenetic protein (rhBMP-2).

Methods: A 62 year old male who developed adjacent segment disease 13 years after an L4/5 and L5/S1 posterolateral fusion underwent what appeared to be a successful instrumented L3/4 posterior lumbar interbody fusion using morselised posterior elements and scavenged drilled particulate interbody autograft together with a single large sized sponge of rhBMP-2.

Results: He continued to experience intermittent episodes of severe low back pain following that procedure, and a CT scan performed three months post-operatively revealed severe osteolysis of the L3 and L4 vertebral bodies. Although he was a type 2 diabetic, extensive investigations did not reveal any evidence of infection

Discussion: Vertebral body osteolysis has previously been reported following the use of BMP in the interbody space. The mechanism for this is unclear, but may be due to osteoclast activation. The prevalence of this complication following the use of BMP is not known. It is recommended that a process of independent post-marketing surveillance be established to further investigate this possible complication of the use of BMP in posterior interbody fusion.


J. Zigler R. Delamarter

Introduction: Lumbar total disc replacement (TDR) is intended to address discogenic pain and preserve functional motion between two vertebral bodies in patients with symptomatic degenerative disc disease. TDR may thus prevent long-term subsequent accelerated degeneration at adjacent disc levels. The ProDisc®-L TDR (Synthes Spine Company, L.P., West Chester, PA) was compared to circumferential spinal fusion for the treatment of discogenic pain at one vertebral level between L3-S1 and was found to be safe, effective, and superior to fusion in patients who meet the study inclusion criteria. However the safety and efficacy of lumbar TDR at two vertebral levels is still unproven. The purpose is to compare the safety and effectiveness of the ProDisc®-L TDR to circumferential spinal fusion for the treatment of discogenic pain at two vertebral levels between L3-S1.

Methods: A prospective, randomized, multi-center, FDA-regulated IDE clinical trial was conducted at 16 sites, utilizing a 2:1 randomization ratio (ProDisc®-L: Fusion). Patients were assessed pre-operatively and post-operatively at 6 weeks, 3, 6, 12, 18, and 24 months post-surgery. Each evaluation included patient self-assessments, physical and neurological examinations, and radiographic evaluation.

Results: 237 patients were treated on protocol. The patient follow-up rate was 89.6% at 24 months. Overall patient demographics showed no statistically significant differences between treatment groups in age, gender, race, smoking status, height, weight, body mass index (BMI), baseline Oswestry Low Back Pain Disability Questionnaire [Oswestry Disability Index (ODI)], or prior surgical treatment. Intra-operative data showed the ProDisc®-L group was significantly lower with regard to intra-operative time (ProDisc®-L = 132 min (range 66 – 430) min; Fusion = 275 min (range 86– 515 min), p < 0.0001), estimated blood loss (ProDisc®-L = 250 ml (range 0 – 3000 ml); Fusion = 400 ml (range 0 – 2000 ml, p = 0.0006) and hospital stay (ProDisc®-L = 4 days (range 1 – 10 days); Fusion = 5 days (range 2 – 14 days), p < 0.0001). At 24 months, 90.0% of ProDisc®-L and 86.7% of Fusion patients reported improvement in ODI from pre-operative levels and 73.3% of ProDisc®-L and 55.9% of Fusion patients met the 15 point ODI improvement criteria. Overall neurological success in the ProDisc®-L group was superior to the Fusion group (ProDisc®-L = 89.2%, Fusion = 77.9%; p = 0.0260). At all follow-up time points, the ProDisc®-L patients recorded SF-36 scores significantly higher than the Fusion group (p = 0.0523). The Visual Analog Scale (VAS) pain assessment showed statistically significant improvement from pre-operative scores regardless of treatment (p < 0.0001); at 24 months, the ProDisc®-L group showed significantly higher pain reduction than the Fusion group (p = 0.0466). VAS patient satisfaction at 24 months showed a statistically significant difference favoring ProDisc®-L patients over the Fusion group (p = 0.002). Radiographic range of motion was maintained within a normal functional range.

Discussion: Currently the ProDisc®-L TDR is only FDA approved for single level use. However, in this study, it has been found to be effective for the treatment of discogenic pain at two vertebral levels. In properly chosen patients, ProDisc®-L has been shown to be superior to circumferential fusion at two levels by multiple clinical criteria.


C. Little J. Melrose D. Burkhardt T.K.F. Taylor C. Dillon R. Read M. Cake

Introduction: The aetiology of dystrophic disc calcification in adult humans is unknown but a well-described clinical disorder with hydroxyapatite as the single mineral phase. Comparable but age-related pathology in the sheep could serve as a model for the human disorder. The objective of this study was to investigate the mineral phase, its mechanisms of formation/association with degeneration in a naturally-occurring animal model of disc calcification.

Methods: Adult sheep lumbar intervertebral discs (n=134) from animals aged 6 (n=4), 8 (n=12) and 11 years (n=2) were evaluated using radiography, morphology, scanning and transmission electron microscopy, energy dispersive X-ray spectroscopy, X-ray powder diffraction, histology, immunohistology and proteoglycan analysis.

Results: Half of the 6 yr, 84% of the 8 yr and 86% of the 11 yr old discs had calcific deposits. These were not well delineated by plain radiography. They were either:

punctate deposits in the outer annulus,

diffuse deposits in the transitional zone or inner annulus fibrosus with occasional deposits in the nucleus, or

large deposits in the transitional zone extending variably into the nucleus.

Their maximal incidence was in the lower lumbar discs (L4/5-L6/7) with no calcification seen in the lumbosacral or lower thoracic discs. All deposits were hydroxyapatite with large crystallite sizes (800–1300 angstrom) compared to cortical bone (300–600 angstrom). No type X-collagen, osteopontin or osteonectin, were detected in calcific deposits although positive staining for bone sialoprotein was evident. Calcified discs had less proteoglycan of smaller hydrodynamic size than non-calcified discs.

Discussion: Disc calcification in ageing sheep is due to hydroxyapatite deposition. The variable but large crystal size, lack of protein markers indicate that this does not occur by an ordered endochondral ossification-like process. The decrease in disc proteoglycan content and size suggests an association between calcification and disc degeneration in ageing sheep. There are notable dissimilarities between hydroxyapatite deposition disorder in humans and sheep. No mechanistic explanation can be offered for the different spinal distributions, thoracic and upper lumbar in the former and lumbar in the latter; hydroxyapatite deposition disorder has occasionally been seen in the lumbar spines of four year old sheep during the course of other studies but not at an earlier age. Diffferences in spinal biomechanics may be implicated but hydroxyapatite deposition does not primarily affect the most or least mobile discs in either species. Neither can an explanation be offered for the apparent immunity of the ovine lumbosacral disc to calcification. However, it is known that proteoglycan turnover is faster at this spinal level than at more proximal lumbar discs. While we have been unable to elucidate the mechanism of hydroxyapatite deposition disorder in sheep, clearly it is different from that in normal osteogenesis. We contend this animal provides a useful, naturally-occurring model for investigation of the aetiology and pathogenesis of human hydroxyapatite deposition disorder, notwithstanding obvious differences between sheep and man.


R. Zarrinkalam C. Schultze R.J. Moore

Introduction: Current treatments for osteoporosis do not completely eliminate the risk of fracture and bone loss may continue even at a low level. Enhanced bone formation and mineralization could minimize the risk of fracture in osteoporosis and prevent the pain and associated morbidity in these patients. Bone morphogenetic protein-type 2 has been successfully used to promote bone formation and to augment fracture repair in general and in the spine in particular [1]. The aim of this study was to increase local bone formation and mineralization in osteopenic vertebrae by administration of recombinant human morphogenetic proteins (rhBMP-2) in an ovine model.

Methods: Osteoporosis was induced in ten skeletally mature sheep with ovariectomy, low calcium diet and weekly steroid injection. Bone mineral density (BMD) of the lumbar spine was assessed monthly by DXA. When the BMD of the lumbar spine was reduced by at least 25% the induction treatment was stopped and pellets containing inert carrier alone (control) or rhBMP-2 in either slow or fast release formulation were implanted directly into three adjacent lumbar vertebrae of each animal in a random order. BMD was assessed at regular intervals and two and three months later five animals were euthanized and the lumbar spines were collected for histomorphometric analysis using the SkyScan 1076 Micro CT (SkyScan, Belgium). Significant differences between BMD and bone morphometric data (including trabecular bone volume, separation and number) were examined using ANOVA and Tukey’s test with significance set at P< 0.05.

Results: After five months of induction treatment BMD in the lumbar spines of all animals was reduced by at least 25% (p< 0.05). BMD increased insignificantly after cessation of the induction treatment but remained lower than the initial values. As there were no significant differences the histomorphometric data after two and three months were pooled. The trabecular bone volume in the vicinity of both the slow and fast release BMP implants increased by over 15% compared with the control (p< 0.05). Trabecular separation was reduced over 13% and trabecular number around both types of pellets increased by over 12% compared to the control (NS).

Discussion: This animal model provides an opportunity to evaluate systemic and local treatments for osteoporosis. The significant increase in bone formation adjacent to the implants as early as two months suggests that rhBMP-2 in either formulation improves bone quality at sites with high risk of fracture. The impact of the fast and slow release BMPs implants were not significantly different


P. Licina

Introduction: Bone morphogenetic protein (BMP) has become widely used in the interbody space as part of a lumbar fusion. Complications can occur but are not completely understood or well documented.

Methods: A prospective review of consecutive lumbar interbody fusions performed by a single surgeon was undertaken over a 2-year period. Early complications (defined as occurring within the first six weeks) were noted. The interbody cages (titanium Syncage, Synthes cages for ALIFs and PEEK Capstone, Medtronic cages for TLIFs) were filled with Infuse BMP-collagen sponge. Until early 2007, the amount of Infuse used was not strictly measured but after that time, only enough to fill the cage was used, with the volume assessed according to the manufacturer’s guidelines. Patients were routinely assessed preoperatively and at the six-week postoperative review using a visual analogue scale and the Oswestry disability score. Plain x-ray and MRI were obtained preoperatively, and plain x-ray was obtained postoperatively. In addition, if early problems developed, MRI scan was obtained. The incidence of complications was compared to that seen in similar procedures but where BMP was not used.

Results: 114 patients, including 78 transforaminal inter-body fusions (TLIFs) and 36 anterior lumbar interbody fusions (ALIFs) were available for review. Early complications were noted in 10 of 114 patients. Two (both with TLIF) were not directly linked with BMP use: in the first, the cage migrated posteriorly and in the second, a deep infection developed. The remaining eight were associated with an exaggerated inflammatory response likely related to BMP use. Severe back pain associated with marked vertebral body inflammation seen on MRI was noted in two ALIF patients. The response occurred within 2 weeks of surgery, and settled with conservative treatment. Severe back pain and recurrence of leg pain developed in six TLIF patients. Fluid cyst formation within the spinal canal was seen on MRI in 4 of these. The cyst extended from the region of the posterior aspect of the cage into the canal and toward the area of the excised facet joint, resulting in compression of the exiting nerve root. In one case, the surgical site was re-explored and the cyst removed. In two cases, the cyst was aspirated under CT guidance and injected with steroid. In the final case a course of oral Prednisone was administered. In the remaining two TLIF cases, there was a diffuse inflammatory response in the region of the posterior aspect of the cage and adjacent epidural space but without discrete cyst formation. In one, oral Prednisone was prescribed. The second was treated expectantly. The majority of these complications were noted in 2007, after the dose of BMP was titrated in line with the manufacturer’s guidelines. In contrast, no such complications were seen when a similar technique but without BMP was undertaken in 33 posterior and 41 anterior interbody fusions.

Discussion: The incidence of an exaggerated inflammatory response with BMP in the lumbar spine may be under-recognised. The majority of complications published to date relate to vertebral osteolysis and bony overgrowth, although a number of adverse responses to BMP reported to the FDA relate to fluid cyst formation or inflammation. With the rapid increase in BMP use, it is important that surgeons are aware of potential complications, and possible strategies to prevent and address them.


C. Lutton R. Shiu R. Crawford R. Williams T. Barker B. Goss

Introduction: It is well known that the fate of biomaterials is determined by the distribution of proteins attached to the surface from the initial contact with blood or serum. This profile determines wether a material is inert, creates a foreign body response or is bioactive. Bioinert materials, such as polyethylene completely denature surface proteins, whilst materials inducing inflammatory responses are predisposed to complement protein attachment. Bioactive materials such autologous tissue grafts adsorb, but do not denature serum proteins such as fibronectin and Von Willebrand’s factor. This does not interfere with the healing cascade. This aim of this study is to prepare a synthetic bone graft substitute that activates the body’s autologous healing cascade by activating platelets, without activating a complement response through the controlled adsorption of serum proteins.

Methods: Polymers composed of varied concentration of acrylic acid (AA) and comonomers (methyl, ethyl and butyl methacrylates (MMA, EMA, BMA)) were prepared in glass vials by free radical polymerisation. Fresh blood was collected from a healthy donor and pipetted immediately into each chamber. Glass was used as a control. The chambers were incubated at 37o C for 2 hours. The surface morphology was examined using Scanning Electron Microscopy (SEM). Concentration of complement protein C5a and prothrombin fragments 1 and 2 were determined using commercial ELISA kits. Foreign body reaction (FBR) initiated by the biomaterial was estimated by counting leukocytes on clot sections using immunofluorescence.

Results: Extent of coagulation was correlated with plasma concentrations of Prothrombin fragments 1 and 2. These measurements show blood incubated with various polymers composed of different comonomers all promoted the formation of blood clots. It was found that the leukocyte population towards the interface of clot and polymer (AA:MMA) decreased with increasing surface acid concentration (65%AA:MMA 30 leukocytes/0.25mm2, glass 70 leukocytes/0.25mm2 (p< 0.05)). FBR is induced by the activation of complement system. The percentage of C5a concentration detected in blood incubated with various polymers composed of different comonomers relative to normal serum level of C5a (35ng/mL). No significant elevations of C5a were measured from polymer 65% AA:MMA and 65% AA:EMA. Glass induced vigorous complement response as expected. The synergistic combination of surface acid concentration and comonomers had a significant effect on extent of FBR. Increased acid concentration resulted in decreased C5a level with MMA and ET but increased level with BMA.

Discussion: The functional groups exposed on the surface of a material influence whether leukocyte or platelet activation is responsible for the subsequent physiological response. By modifying the combinations of surface acid concentrations and comonomers, we show that a biomaterial with an appropriate surface chemistry promotes the platelet plug formation and coagulation but down regulated foreign body reaction. This study shows that that a biomaterial with the appropriate surface chemistry to evoke the same coagulation response as damaged tissue, mediated through platelet activation and intrinsic and extrinsic coagulation, initiates the initial pathways of the bone healing cascade. This material is a realistic candidate for biomaterial induced bone regeneration.


C. Vasili C. Lutton M. Engman R. Crawford R. Williams B. Goss

Introduction: The biological activity of autologous grafts is due to a number of proteins (growth factors) that control bone cell differentiation, proliferation and expression. Several of these have been isolated including; bone morphogenetic proteins 2 and 7. These are commercially available and regularly used with the intention of accelerating fracture healing, repairing critical sized defects and combating bone mineral loss. Whilst it is commonly recognised that multiple growth factors are present at differing times in the healing cascade, the usual delivery, both in the clinic and the laboratory, is of one growth factor delivered over a very short and early time period. Commonly growth factors are delivered in solution or from a collagen sponge and are quickly metabolised in the proteolytic wound healing environment. The physiological need for BMPs is later than the acute delivery at the time of surgery. The aim of this study is to develop a granular protein delivery system that enables controlled release of multiple proteins at a variety of time points.

Methods: A series of homogenous polymer granules 8mm3 were prepared by photo-polymerising 12uL of mixtures of methacrylated adipic acid anhydride (MAAA) and methyl methacrylate (MMA) or MAAA and butyl methacrylate (BMA) with molar ratios ranging from 100- 55 % (MSAA). Into each granule 5ug of a model drug, carmoisine was loaded and 1%w/w of 2,2-dimethoxy-2-phenyl-acetophenone (DMPA) photoinitiator was added per granule. The granules were exposed to UV light at 390nm for 14 minutes. Multilayered granules were prepared photo-polymerising 4uL layers of different monomer compositions in a similar method to the single layered method above. The composition of the multilayered granules was chosen to optimise the release profile. Carmoisine release profiles were determined by UV-visible spectroscopy.

Results: Homogenous granules composed of 100% MAAA released 90% of their payload by 24hrs, those composed of 90:10 MAAA:MMA released by 48hrs those composed of 70:30 MAAA:MMA released by 80hrs those composed of 60:40 MAAA:MMA released by 170hrs those composed of 70:30 MAAA: BMA released by 288hrs and those composed of 60:40 MAAA:BMA released by 456hrs. The multilayered granule had a sustained release of the model drug over the test period of 19 days.

Discussion: The limitation of most drug delivery systems, such as microspheres or collagen, is poor control over the release profile. The drug is ether released instantly or well after it is required. This multilayered composite drug delivery system enables the controlled release of different bioactive compounds at different time points between 0 and 19 days. By altering the drug loading in each layer we were able to sustain the release of one compound over this time period. This technology enables us to switch compounds at a given time points for example delivery of angiogenic factors for one week, proliferative factors for the second week and differentiation factors for the third week. This technology enables the pre-programmed release of multiple growth factors at times in the healing cascade when they meet the physiological need. A controlled release of growth factors at the appropriate time should improve bone healing rates.


G. Brazenor

Introduction: Recombinant human bone morphogenetic protein-2 (rhBMP-2) (Infuse) has been shown to cause osteolysis rather than accelerated fusion in some series. This paper reports two cases of vertebral osteolysis in patients undergoing anterior cervical corpectomy with stabilization using titanium prosthesis where rhBMP-7 (OP1) has been used in high concentration.

Methods: Case series and review of literature.

Results: OP1 was used in 23 patients undergoing anterior cervical surgery. Each case had at least two CT scans during the first twelve months of follow-up. The two cases of osteolysis were identified amongst a subgroup of 8 patients undergoing anterior cervical corporectomy and reconstruction using a titanium rod and buttress implant. The first case was a 71 year old man who underwent C4-T1 corpectomy for spondylotic cord compression and the second case was a 62 year old man who underwent C3-T1 corpectomy for spondylotic cord compression. In both cases a bottle of OP1 (3.5mg) was mixed with 5mls of carboxy-methyl-cellulose/tri-calcium phosphate (CMC/TCP) putty, approximately half of which was then applied to the ends of the titanium rod and buttress prosthesis and compressed between the buttress end and the vertebral endplate, and some residual OP1-containing putty was placed at the sides of each buttress.

CT scans performed at 3 months postoperative in case 1 and 3.5 months postoperatively in case 2 demonstrated osteolysis in the vertebral bodies adjacent to the implant. In both cases however, CT scans performed 12 months post-operatively showed that the osteolytic cysts were beginning to resolve and fusion at the bone-titanium junction may have begun. No other cases of cystic osteolysis were found amongst other anterior cervical cases or 115 posterior lumbar interbody fusion (PLIF) cases similarly followed-up with serial CT scans. The concentration of rhBMP-7 used in a subgroup of 8 corpectomy cases undergoing anterior cervical corporectomy and reconstruction using a titanium rod and buttress implant was at least twice the concentration used in other anterior cervical cases and approximately one quarter to one fifth the concentration used in lumbar interbody PLIF cages.

Discussion: These are the first reported cases of osteolysis associated with the use of BMP-7.

Osteolysis has been described in association with the use of rhBMP-2. Following these reports, the manufacturers of rhBMP-2 have advised surgeons strongly not to use more than the (recently) recommended dose, despite there being no published evidence that osteolysis is dose-related. Similar recommendations have not been made regarding the use of BMP-7 (OP1).

The concentration of BMP-7 (OP1) which led to osteolysis in these cases was much greater than used elsewhere in the spine, where OP1 (3.5mg) is usually mixed with 10–15 mls of finely-milled autograft. This suggests that the concentration achieved by mixing 3.5 mg of OP1 with 5 mls of CMC/TPC putty may increase the risk of osteolysis when inserted into the anterior cervical spine.


R. Gunzburg M. Szpalski R.J. Moore S. Callary C. Collaca D. Harrison V. Kosmopolous

Introduction: Interspinous implants have recently been proposed as an alternative in the treatment of lumbar spinal stenosis and foraminal stenosis. Interspinous implants are thought to unload the facet joints, restore foraminal height and provide improved spinal stability especially in extension with a minimally invasive approach. It has been proposed that, combined with a tension band, stabilisation could also be obtained in flexion, thus avoiding the need for pedicle screw fixation. Little biomechanical data exists to support these notions. The aim of this in vivo study was to investigate the effect of a novel, minimally invasive, unilaterally inserted interspinous implant on flexion-extension range of motion of the lumbar spine.

Methods: Following the induction of general anesthesia, ten adolescent Merino lambs (24–30 kg) underwent a destabilisation procedure at the level of L1–L2, thus simulating a stenotic degenerative spondylolisthesis, as described previously. All animals were placed in a sidelying posture and lateral radiographs were taken in the neutral posture and in end stage flexion and extension trunk positions with the central ray at the level of L1–L2. The flexion manouvre was reproduced in each subject by securing a rope above the carpus (forelimb) and the tarsus (hindlimb). This same radiographic protocol was repeated following the insertion of an 8 mm InSwing interspinous device at L1–L2, and again with the implant secured by means of a tension band tightened to 1 N/m around the L1 and L2 spinous processes. Care was given to respect the integrity of the supra-spinous ligament. The insertion technique requires a minimally invasive unilateral approach, therefore leaving the attachment of the erector spinae muscle on the contralateral side intact. Using Cobb’s method, intersegmental range of motion (ROM) was assessed in each of the conditions and compared. A paired t-test compared ROM for each of the experimental conditions (P< .05).

Results: The addition of the InSwing interspinous implant reduced mean total flexion-extension ROM from 6.3 degrees to 5.3 degrees which was further reduced to 3.6 degrees with the device secured by means of a tension band. These differences were not statistically significant, but the addition of the tension band to the interspinous device resulted in a significant reduction of lumbar flexion (p< .05).

Discussion: The interspinous device tended to reduce the total flexion-extension ROM at the level of the implant, however the results were not significant. The addition of a tension band was found to significantly stabilize the spine in flexion. To our knowledge, this is the first in vivo study radiographically showing the advantage of using an interspinous device, specifically InSwing, to stabilize the spine in flexion. These results are important findings particularly for patients with clinical symptoms of instable degenerative spondylolisthesis.


D.W. Ardern S.A. Callary M.J. Wilby B. Christensen B. Vernon-Roberts R.D. Fraser R.J. Moore

Introduction: Spondylolysis in skeletally immature individuals is common but only a small proportion of cases develop pain and spondylolisthesis. The pattern of instability and pathologic consequences of surgically created spondylolytic defects have not previously been described. An animal model of lumbar spondylolysis was created using skeletally immature sheep with the aim of observing the intervertebral mobility and pathologic consequences of creating a spondylolytic segment.

Methods: Bilateral spondylolytic defects were created in the fifth lumbar vertebrae of fourteen sheep aged approximately 16 weeks using a posterior surgical approach. Using tantalum markers that were placed in the lumbar spine segments in the vicinity of the lesion, three dimensional translations and rotations in flexion and extension were recorded under general anaesthetic using Radiostereometric Analysis (RSA) at the time of surgery. A novel method of ovine spine manipulation was developed. Briefly, with the animal in a lateral decubitus position spinal extension was achieved by fixing the shoulders and hips in full extension. Similarly, the limbs were brought into apposition to achieve spinal flexion. A control group of seven sheep had tantalum markers only in the same lumbar spine segments. The animals were re-tested under general anaesthetic at six weeks and six months following surgery. After six months the animals were sacrificed and their spines examined using CT and microscopic analysis.

Results: Bilateral spondylolytic defects did not result in significant transverse (x-axis) translation. RSA showed significant differences between the spondylolytic group (mean 1.22°, range 0.30–3.74) and controls (mean 0.28°, range 0.03–0.77)) for rotation in the axial plane (y-axis, p< 0.0025) immediately after surgery. The spines radiologically stabilised over six months.

Discussion: Surgically induced bilateral spondylolytic defects in this immature ovine model result in increased rotation in the axial plane but do not create transverse translation (spondylolisthesis).


M.J. Wilby B. Vernon-Roberts R.D. Fraser R.J. Moore

Introduction: Thickened ligamentum flavum (LF) is a major contributor to the clinical syndrome of lumbar canal stenosis (LCS). The patho-mechanisms responsible for this phenomenon remain unclear. Cysts adjacent to facet joints (FJ) in the spine are regarded as rare entities that may uncommonly contribute to LCS. Inaccurate pathological interpretation and unawareness of a key anatomical feature has generated erratic terminology and confusion about their origin.

Methods: Twenty-seven consecutive patients with radiologically confirmed central canal or lateral recess stenosis underwent lumbar laminectomy for neurogenic symptoms. Surgical specimens comprising en bloc excision of LF and medial inferior facet (to retain LF and FJ relationships) were examined microscopically following staining with haematoxylin-eosin and Miller’s elastic stain. Controls were facet/LF specimens from 89 cadaver lumbar spines.

Results: Mean LF thickness was 8.9 mm (+/− 0.3 mm SEM) at the operated levels and 2.9 mm (+/− 0.3 mm) at the non-operated, adjacent levels (p < 0.01). Twenty-eight synovial cysts (8 bilateral, 12 unilateral) were present at a single level in 20 (74%) patients. Synovial cysts per spine level were: L1/2 = 0; L2/3 = 3; L3/4 = 7; L4/5 = 16; L5/S1 = 2. The cyst levels all showed advanced osteoarthritis and LF degeneration. Ten patients (50 %) with cysts had pre-existing degenerative spondylolisthesis (DS). Only 5 patients had pre-operative radiological apperances of unilateral facet cysts. Therefore 82 % of our observed synovial cysts were microscopic or occult. The synovial cysts communicated with the FJ via a bursa-like cleft within the LF, and their linings of synoviocytes and other cells contained fragments shed from the articular surface. The control cadaver specimens revealed that a synovial bursa or intra-ligamentous out-pouching from the synovial cavity was present in 90% of normal LF at L4/5 and was up to 12 mm in length. This intra-ligamentous synovial recess, either wholly or partially lined by synoviocytes, was only present in 55% of specimens at L1/2 with a maximum length of 5 mm. Several other juxtafacet cyst types were observed in the experimental group and a novel classification based upon pathological findings is presented.

Discussion: Para-facetal intraspinal cysts are common in degenerative lumbar spinal stenosis. DS is also a frequent finding but is statistically unrelated to cyst formation (Chi-square: p=0.187). We have found that debris from osteoarthritic facet joints enters a bursa-like cleft within the LF where it becomes incorporated into the wall where it excites a granulomatous reaction leading to blockage and synovial cyst formation. The existence of this channel has not been reported previously. We suggest that microscopic synovial cysts contribute significantly to the ligamentous thickening seen in LCS. We also present a novel classification of juxtafacet cysts based on our pathological findings.


A. Gharhreman R. Ferch N. Bogduk

Introduction: Minimally-invasive techniques are being advocated increasingly for spine surgery, on the grounds that they are less traumatic and reduce postoperative recovery time. A minimally-invasive technique for posterior lumbar interbody fusion (MPLIF) has become available. In order to compare its efficiency and effectiveness with the open technique (OPLIF), a prospective audit was undertaken.

Methods: Forty-seven adult patients with radicular pain resulting from isthmic or degenerative spondylolisthesis, with a slip less than 50%, and no previous surgery, elected to undergo either MPLIF (n = 23) or OPLIF (n = 24). The MPLIF procedure was performed through two, 2.5cm paramedian incisions using a tubular retractor system and dilators (METRx-MD, Medtronic Sofamor Danek, Memphis). OPLIF was performed thorugh a 10 cm midline incision. In both procedures, the listhesis was reduced using polyaxial pedicle screws, and reduction tabs or bolts (Expedium, Depuy); the disc space was distracted using interbody spacers (R-90, Metronic Sofamor Danek) and packed with iliac crest graft. Intra-operative and postoperative variables were recorded. Clinical outcomes were assessed, before and 12 months after surgery, using a visual analog scale for pain and the SF36 for function.

Results: The two groups were comparable, demographically and with rspect to clinical features at inception, save that the MPLIF group had signficantly greater disc heights. Listhesis (median; interquartile range) was reduced from 25% (20–32) to 8% (1–13) after OPLIF, and from 20% (15–25) to 5% (0–10) after MPLIF. Disc height was increased from 12% (6–17) of vertebral body height to 24% (20–26) after OPLIF, from 17% (10–23) to 30% (26–36) after MPLIF. Fusion was achieved in all patients except one in the PLIF group. After OPLIF, median scores (interquartile ranges) for leg pain reduced from 8 (7–9) to 1 (0–4); scores for back pain reduced from 8 (6–8) to 2 (1–4); social functioning improved from 38 (13–57) to 82 (47–100), and in physical functioning improved from 20 (5–48) to 68 (44–86). After MPLIF, leg pain reduced from 8 (7–9) to 1 (0–3); back pain reduced from 8 (8–10) to 2 (1–4); social functioning improved from 38 (25–66) to 75 (50–91), and physical functioning improved from 20 (10–48) to 65 (34–82). All improvements within groups were significant (p = 0.000), but no statistically significant differences occurred between the groups for any outcome measure. Improvements in leg pain amounted to an 88% reduction for both groups, Back pain improved by 64% after OPLIF and by 78% after MPLIF. Duration of surgery and need for transfusion were not different between groups (5 patients required transfusion during OPLIF, and 1 during MPLIF (p = 0.09)); but the MPLIF patients had significantly shorter delays before commencing and achieving mobilization post-operatively, and had a shorter length of stay (4 days v 7 days).

Discussion: Clinical outcomes after MPLIF and OPLIF were not statistically different. Both procedures reduced back pain as well as leg pain, and restored function. Although there was no detectable correlation between pain and function before treatment, relief of pain was strongly correlated with restoration of function, after treatment. The advantage of MPLIF is that promotes faster recovery and shortens hospital stay. Its only disadvantage is the need to adapt to the technology involved and becoming familiar and confident with its use.


D. Grob A.F. Mannion V. Bartanusz D. Jeszenszky F.S. Kleinstück F. Lattig

Introduction: Fusion is typically indicated for degenerative spinal disorders with concomitant instability or painful spondylosis. Numerous techniques are used, with considerable variation in their invasiveness, risks and costs, although few can boast superiority for a given indication, particularly in relation to patient-orientated outcomes. This cohort study compared outcomes after fusion with translaminar screws (TS) versus transforaminal lumbar interbody fusion plus pedicular fixation (TLIF) plus pedicular fixation (both with decompressive procedures).

Methods: The study was nested within our SSE Spine Tango data acquisition system. The suitability (or otherwise) for inclusion of every Spine Unit patient was indicated at the pre-operative consultation. Inclusion criteria: mono/bisegmental degenerative disc disease, facet syndrome or degenerative spondylolisthesis; German language; no previous surgery (except discectomy). Each surgeon consistently used his pre-stated, preferred method (TS or TLIF) for all his patients fitting the inclusion criteria. Before and 12 and 24 months post-surgery, patients completed the multidimensional Core Outcome Measures Index (COMI; 0–10 scale); after 12-months, global outcome was rated on a Likert-scale and dichotomised into “good” and “poor” groups.

Results: 121 patients took part; 57 in the TS group (1 surgeon) and 64 in the TLIF group (4 surgeons). Gender distribution was identical in the two groups (67% women); TS were significantly older than TLIF (67±10y and 56±15y respectively, p< 0.05). There were no significant group differences at baseline for any COMI domain scores (all p> 0.05). TS had a significantly lower operation duration (p=0.0001) and blood-loss (p=0.01) but a longer hospital stay (p=0.005) than TLIF. Complication rates prior to discharge were similar in each group (2–4%). 94% patients returned questionnaires at 12-months. The groups did not differ in: reduction in COMI score, 3.5±2.9 (TS) vs 4.1±2.6 (TLIF)(p=0.23); % good outcomes, 72% (TS) vs 77% (TLIF)(p=0.58); satisfaction with treatment, 82% (TS) vs 88% (TLIF) (p=0.36). Thus far, 75 patients have reached the 2-yr follow-up and the trend for no group differences remains: % good outcomes, 81% (TS) vs 79% (TLIF)(p=0.91); satisfaction with treatment, 83% (TS) vs 85% (TLIF) (p=0.88)

Discussion: This cohort study showed similar subjective results up to 2 years later for two different surgical techniques done for identical indications, but with differing surgical time, invasiveness and implant costs. The data thus far suggest that, for these degenerative disorders, optimal but invasive three-point stabilization is not required to achieve satisfactory results. Although the study design is not the highest in the “hierarchy-of-evidence”, it includes every single eligible patient and allows each surgeon to use his regular surgical procedure; it hence represents a practicable, complementary approach to the randomised-controlled-trial, with higher external validity (relevance/generalisability).


B. Donaldson G. Inglis

Introduction: Lumbar discectomy is now the operation of choice for lumbosacral radicular syndrome. Few studies of high quality have been performed on the post surgical management of these cases. The studies that have been reported compare one exercise regime to another.

The aim of this study was to compare long term outcomes of usual surgical advice, involving no formal post-surgical rehabilitation, with a non-aggravating six month gym rehabilitation programme post lumbar discectomy. This study is a prospective randomized controlled trial using a cohort followed for three years.

Methods: The patients were computer randomised into two groups. Group A, the control group followed usual surgical advice which was to resume normal activity as soon as pain allowed. Group B, undertook the gym rehabilitation programme. Inclusion criteria were: Age 17 to 65 years, good health and no major medical problems. The surgical level had to be L3, L4, or L5. Patients were excluded if they had central neurological disorders, communication difficulties, any condition making gym-based exercises unsafe, or if the surgery was indicated for spinal infection, tumour or inflammatory disease. Patients were followed for a three year period using validated outcome measures (Roland-Morris Questionnaire and Oswestry Low Back Pain Index) and an annual Quality of Life (QoL) questionnaire. A sample of 40 per group provided the study with 80% power (P< 0.05) to detect a 3.5 point change in the RMQ and a 10% change in the ODI. The annual questionnaire reported information on number of GP visits, other therapist visits, medication levels and time off work.

Results: Ninety three participants were randomised; Control n=46 and trial n=47. Eighty nine participants completed the study. Randomisation achieved a balance of confounding factors, with the exception of work heaviness, where there were a greater number of participants in the very heavy and heavy categories in the trial group (P< 0.01). Thirty nine of 47 participants completed the gym programme (83%). Functional outcome measures did not show statistically significant differences between groups over the three year period. Key findings of cumulative 3 year data for the QoL questionnaire are: on intent-to-treat analysis; fewer patients having GP visits in the trial group P=0.048 (18% vs 5%). In the per protocol subset; fewer episodes off work P=0.074 (range control 0–3 vs trial 0–2), GP visits P= 0.089 (range control 0–12 vs trial 0–3) and in the per-protocol minus re-operation group; GP visits P< 0.008 (range control 0–3 vs trial 0–2), patients requiring medication use P=0.05 (37% control vs 17% trial) days off work P=0.099 (range control 0–30 vs trial 0–3).

Discussion: The results reveal an advantage in terms of episodes off work, GP visits and medication use for participants in the trial group who completed the programme. Time off work is a significant consideration for funding providers. These results suggest that surgeons should consider referral of discectomy patients to appropriate post-surgical rehabilitation programmes.


M. Melloh L. Staub T. Zweig T. Barz P. Reiger J-C. Theis C. Roeder

Introduction: With a life of over five years, Spine Tango can be considered the first truly International Spine Registry. The Swedish Spine Registry has already shown the feasibility of a registry on a national level. But, there is a need for an international spine registry allowing a benchmarking on an international level. Here we demonstrate the genesis of questionnaire development, the constantly increasing activity, and limitations of the International Spine Registry Spine Tango.

Methods: From 2002 until 2007 about 9000 datasets were submitted by 28 hospitals in nine countries worldwide. Three different generations of Spine Tango questionnaires were used for documentation.

Results: To cope with varying international administrative issues and legal requirements of data anonymisation, national Spine Tango modules are necessary. Four national Spine Tango modules are in operation to date, another three modules are in the process of roll-out. Considering all these participants, Spine Tango will soon expand to include data from 52 hospitals in 18 countries. One-fourth of these hospitals are University Hospitals, which are destined to take the lead in the Spine Tango registry as opinion leading hospitals. Although the number of participants is steadily growing, no country is yet represented with a sufficient number of hospitals. Indisputably, a marketing concept is needed. An acquisition of new centres via national spine societies seems an obvious strategic approach. Further limitations of Spine Tango include the low number and short duration of follow-ups and the lack of sufficiently detailed patient based data on subgroup level.

Discussion: Spine Tango has achieved a firm position as international spine registry and with its increasing acceptance it is also gaining importance. The strengths of Spine Tango include a potentially very large network, the participation of a specialized international society and an academic partner with expertise and extensive experience in registry implementation. Data analysis from Spine Tango is possible but complicated by the incompatibility of generations one and two with the more recent generation three. Consequently findings cannot yet be generalized to any specific country or patient population. Nevertheless, the potential benefits of the project for the whole spine community become increasingly visible. In the near future, the established Spine Tango version three with standardised patient based data will make outcome evaluations possible. In parallel to the International Spine Registry Spine Tango, a National Spine Registry in Australia could be set up – comparable to AOA’s National Joint Replacement Registry.


D. Grob A.F. Mannion V. Bartanusz F. Kleinstück F. Lattig D. Jeszenszky J. Dvorak F. Porchet

Introduction: Recent years have witnessed something of a paradigm shift in relation to the assessment of outcome in spine surgery: multidimensional patient-centred questionnaires have superseded the traditional surgeon-based rating of global outcome, and surgical registries have been developed to capitalise on the principle of “strength in numbers”. Interestingly, although recognised as a potential determinant of the patient’s view of the success of the surgery, the assessment of complications — in this context defined as new or unexpected problems arising as a result of surgery — has not enjoyed the same enlightened approach in relation to the patient’s perspective. The present study sought to fill this gap in the current array of outcome measures.

Methods: All German-speaking patients undergoing spinal surgery within our Spine Unit in the two years from Jan 2005 to Dec 2006 were asked to complete the patient-orientated Core-Measures-Index of the SSE Spine Tango Spine Surgery Registry 12 mo after surgery; the surgeon completed a Spine Tango surgery form and follow-up forms at various intervals up to 12 mo postop. In the patient questionnaire, the patient was asked “did any complications arise as a consequence of your operation 1 year ago (e.g. problems with wound healing, paralysis, sensory disturbances, etc.)? If so, give details.” Patients were also asked about their satisfaction with the operation and the global outcome of surgery.

Results: 2080/2259 (92%) patients returned a 12-month questionnaire. 28% patients answered “yes” to the complications question. This compares with complication rates of 3–10% recorded during the various Spine Tango Surgical follow-ups up to 12 months post-op. Patients sometimes listed “complications” that would rarely classify as such in the traditional sense; however, the incidence of their reported complications was significantly associated with outcome/satisfaction, suggesting they were not trivial to the patient. The more recent addition of a question concerning the “bothersomeness” of the reported complications revealed that 6% patients thought the complications were not at all bothersome; 21%, slightly bothersome; 30%, moderately bothersome; 27%, very bothersome and 16%, extremely bothersome.

Discussion: The results indicate that, just like outcome, “complications” should be assessed from both the patient’s and the surgeon’s perspectives, not least to better understand the reasons accounting for dissatisfaction and a poor patient-rated outcome.


W. Sears P. McCombe G. White O.D. Williamson

Introduction: The role of spinal fusion in patients suffering degenerative spine disease may be scrutinized more as costs of surgical treatment rise. Health-related quality of life (HRQL) measurement instruments enable outcome comparisons following treatment of different medical conditions. Rampersaud et al (1) recently presented the results of a comparative study of HRQL outcomes after surgery for lumbar spinal stenosis and hip and knee total joint arthroplasty. The latter are now accepted benchmarks for improvement in patient health.

Methods: A retrospective, observational cohort study was undertaken of 12-item Short Form Health Survey (SF-12) outcome data of 105 consecutive patients of two surgeons (1st and 2nd authors) who underwent single level Posterior Lumbar Interbody Fusion (PLIF) for lumbar spinal stenosis associated with degenerative spondylolisthesis. Minimum 12-month (F/U) data was available for 98 patients (93%). Comparison was made with published SF-12 results of hip and knee total joint arthroplasty (THR and TKR) and with age-related Australian population norms. Analyses were performed using XLSTAT version 7.5.3. Non-parametric statistics were used for assessment of skewed continuous variables. Overlappng 95%CIs were interpreted as indicating lack of significant difference in outcomes between patient and population groups.

Results: Median follow-up was 24months (range: 12–60months). Median age was 65 (Interquartile range: 59–75) years. Male:female ratio 2.8:1

Mean (95%CI) pre-op Physical Component Summary score (PCS) was 28.1 (26.6–29.5). This increased at last F/U to 39.3 (36.9–41.7, P< 0.0001). Mean Mental Component Summary score (MCS) was 47.8 (45.5–50.1) pre-op and 52.3 (50.2–54.5) at last F/U (P=< 0.0001).

While there was no difference in patient demographics, a significant difference existed in the pre-op SF-12 scores between the patients of the two surgeons (mean PCS: 24.9 (22.7–27.0) vs. 29.6 (27.8–31.5) and MCS: 44.0 (39.3–48.6) vs. 49.5 (46.8–52.1)). No significant difference was found in the improvements in mean SF-12 scores between these two patient groups (PCS: 12.3 (7.6–17.1) vs. 10.8 (8.3–13.3) and MCS: 6.3 (1.8–10.8) vs. 3.0 (0.3–5.6)) or in the SF-12 scores at 12-months (PCS: 37.2 (32.8–41.6) vs. 40.2 (37.2–43.2) and MCS: 52 (48.3–55.7) vs. 52.3 (50.1–54.4)). No significant difference was found between post-op PCS of the less disabled patient group or MCS scores of either group and published SF-12 age-matched population norms (65–74 years: mean PCS of 44.4 (42.7–46.1) and MCS of 53.8 (52.7–55.0)).

Three published series (869 patients) were located providing SF-12 data for TKR surgery. Weighted mean age was 69 years and pre-op PCS was 30 (range:27–34). 12-month improvement in PCS was 7.0 (range:7–8.5). For THR, one paper (147 patients from 3 hospitals) containing SF-12 data was found. Mean age was 68 years (range:36–89). Mean pre-op PCS and MCS of 30.5 and 41.4, increased to 45.6 and 49.7 at one year.

Discussion: The current study shows that spinal fusion can return patients’ HRQL to that of age-matched population norms and yield outcomes comparable to those of total hip and knee arthroplasty. Strict comparison with the arthroplasty literature was problematic however owing to variations in the methodology of their data presentation. Prospective collaboration with surgical colleagues in other disciplines is required.


M. Melloh L. Staub E. Aghayev T. Zweig T. Barz P. Reiger J-C. Theis C. Roeder

Introduction: As an example of possibilities of Spine Tango we extracted data on dural tears, one of the most frequent types of complications in posterior spinal fusion. Little is known about their predictors. This study examined which factors predict the occurrence of dural tears in posterior spinal fusion.

Methods: Prospective consecutive documentation of hospital based interventions with an evidence level 2++. Between 05/2005 and 11/2006 data of 3437 patients were documented in the registry. 929 patients, who had been treated with posterior spinal fusion after opening of the spinal canal, were included in this study. Median age was 62.7 yrs (min 12.5, max 90.5 yrs) with a female to male ratio of 2:1. In 18 of 929 cases a dural tear occurred. Dural tears being the most frequent type of complications in the registry were chosen as dependent outcome variable (3–6). Multiple linear regression with stepwise elimination was performed on potential predictor-variables of the occurrence of dural tears. Benchmarking compared the performance of single hospitals with international peers.

Results: Hospital (p=0.02) and number of segments of fusion (p=0.018) were found to be predictors of the occurrence of dural tears in posterior spinal fusion. Number of fusions per hospital (min 25, max 526) and academic status of hospital had no influence on the rate of dural tears. Fusions of four and more segments showed an increase of the rate of dural tears by a factor of three compared to fusions of less than four segments. There was no significant difference between fusions of one segment and fusions of two or three segments (1.3 vs. 1.9%) as well as between fusions of four or five segments and fusions of more than five segments (4.6 vs. 4.2%). Differences between hospitals remained when benchmarking dural lesions with case mix.

Discussion: The feasibility of data analysis and benchmarking from the International Spine Registry Spine Tango could be demonstrated. Predictors of dural tears in posterior spinal fusion are

hospital and

number of segments of fusion.

In fusions of four and more segments a threefold higher risk of dural tears in comparison to fusions of less than four segments should be taken into consideration. A subgroup analysis on the predictor-variable hospital should be performed assessing further covariates. However, this goes beyond the possibilities of documentation in this international spine registry.


B. Freeman N. Steele T. Sach J. Hegarty R. Soegaard

Introduction: A prospective randomised controlled trial of circumferantial spinal fusion has shown superior clinical outcome when a femoral ring allograft (FRA) is used compared to when a titanium cage (TC) is used. The implant cost of the TC is nearly ten fold that of the FRA. However the additional costs of surgery and related costs also need to be considered to determine if there is a real cost advantage of FRA over TC. We can find no previously reported studies which economically evaluate the TC and the FRA in circumferential lumbar spinal fusion. The aim of this study was to investigate cost-effectiveness of TCs in comparison to FRAs for circumferential lumbar spinal fusion over a two year National Health Service (NHS) perspective using a cost-utility evaluation

Methods: This randomised study had the approval of the local ethical committee and the institutional research and development board (Reference OR059844) prior to its commencement. Eighty-three patients were randomly allocated to receive either the TC or FRA as part of a circumferential lumbar fusion between 1998 and 2002. NHS costs related to the surgery and revision surgery needed during the trial period were monitored and adjusted to the base year (2005/6 pounds sterling). The Short Form-6D (SF-6D) was administered preoperatively and at 6, 12 and 24 months in order to elicit patient utility and subsequently Quality-Adjusted Life Years (QALYs) for the trial period. Return to paid employment was also monitored. Bootstrapped mean differences in discounted costs and benefits were generated in order to explore cost-effectiveness.

Results: Baseline demographic data including age, sex, smoking history, previous surgery history and number of operated levels did not differ between the two groups. A significant cost difference of £1,942 (AUD4,255), (95% CI £849 (AUD1,860) to £3,145 (AUD6,891)) in favour of FRA was found. Mean QALYs per patient over the 24 month trial period were 0.0522 (SD 0.0326) in the TC group and 0.1914 (SD 0.0398) in the FRA group, producing a significant difference of −0.1392 (95% CI 0.2349 to 0.0436). With regard to employment, incremental productivity costs were estimated at £185,171 (AUD 405,745) in favour of FRA.

Discussion: From an NHS perspective, the trial data show that TC is not cost-effective in circumferential lumbar fusion. The use of FRA was found to dominate (generating greater QALY gains and less cost). In addition FRA patients reported a greater return to work rate and hence, productivity costs were also in favour of FRA.


M. Shillington C. Adam G. Askin R. Labrum

Introduction: The use of anterior vertebral staples in the fusionless correction of scoliosis has received increased attention in recent literature. Several animal studies have shown stapling to be effective in modulating vertebral growth. In 2005 Betz (1) published the only clinical series to date. Despite the increasing volume of literature suggesting the efficacy of this treatment, little is known about it’s biomechanical consequences. In 2007 Puttlitz (2) measured the change in spinal range of motion after staple insertion in a bovine model. They found a small but statistically significant decrease in range of motion in axial rotation and lateral bending. The clinical significance of this is questionable as the differences were only a few degrees over three vertebral levels. A well designed biomechanical evaluation of the effects of staple insertion on spinal stability is needed. The aim of this study was to evaluate the effect of insertion of a laterally placed anterior vertebral staple on the stiffness characteristics of a single motion segment.

Methods: Four-pronged shape memory alloy staples were inserted into fourteen individual bovine thoracic motion segments. A displacement controlled six degree-of-freedom robotic facility was used to test control and staple constructs through a pre-determined range of motion in flexion, extension, lateral bending, and axial rotation. All data were synchronised with robot position data and filtered using moving average methods. The stiffness in each condition was calculated in units of Nm/degree of rotation. Paired t-tests were used to compare results.

Results: Stiffness measurements in the control condition correlated with previously published measures (3). A significant decrease in stiffness (p< 0.05) following staple insertion was found in flexion, extension, lateral bending away from the staple, and axial rotation away from the staple. Stiffness for axial rotation towards the stapled side was significantly greater than for away. A near significant increase in lateral bend stiffness away from the staple compared with towards was also seen.

Discussion: These results suggest that staple insertion consistently decreased stiffness in all directions of motion. This is contrary to the results of Puttlitz (2), which reported a reduced range of motion (i.e. increased stiffness) for some motions using moment-controlled testing. This decrease in stiffness could not be explained by changes in anatomy or tissue properties between specimens, as each stapled motion segment was compared with its own intact state. Addition of the staple would intuitively be expected to increase motion segment stiffness, however we suggest that the staple prongs may cause sufficient disruption to the vertebral bodies and endplates to slightly reduce overall stiffness. Hence, growth modulation may be achieved through physical disruption of the endplate, rather than static mechanical stress. Further research is planned to investigate the proportion of load carried by the staple during spinal movement and the anatomical effect of the staple on the physis. In conclusion, anterior vertebral stapling causes a slight but significant decrease in the stiffness of treated motion segments.


C. Lutton R. Shiu R. Crawford R. Williams B. Goss T. Barker

Introduction: Acute neurological damage from spinal cord injuries is believed to be localised, however it initiates a cascade of secondary events which usually leads to extensive and permanent neurological deficit. The secondary damage begins with the disruption of the blood-spinal cord barrier which unleashes a protracted inflammatory response. This prolonged inflammatory response is the catalyst for the secondary neurodegeneration and limited repair response that occurs in the chronic phase of a spinal cord injury. In this study it was proposed that the acute delivery of the angiogenic growth factors vascular endothelial growth factor (VEGF) and platelet derived growth factor (PDGF) would mediate inflammation and restore the blood spinal cord barrier. This would minimise the formation of glial scar and reduce the extent of secondary degeneration caudal and cranial to the lesion site.

Methods: Adult male Wistar rats (400g) were anesthetised. Complete laminectomies were performed at T10 and the animals were subjected to T10 hemisection. Animals were randomised to a treatment group (Lesion Control (LC), Gel Control (GC) and Angiogenic Gel (AG)) after the spinal cord was cut. Each treatment group had 6 animals sacrificed 3 months post injury. Sections were stained with antibodies to neurofilament 200, glial fibrillary acidic protein, smooth muscle actin (SMA), and fluorescent secondary antibodies and mounted with DAPI. The lesion size was measured from horizontal histological sections of the midline from 5 animals in each group using Axiovision version 4.6.1.0 (Carl Zeiss Imaging Solutions, Germany).

Results: The mean lesion size for the lesion control group was 2.09mm2, 1.97mm2 for the gel control group and 0.45mm2 for the active gel group. A t-test was used to confirm that the differences between the active gel and the two control groups were statistically significant (AG vs LC p= 0.021 AG vs GC p= 0.026). Histology showed a marked improvement of the morphology of the astrocytes in the treatment group over the control groups indicating that the treatment affected the population of reactive astrocytes. SMA staining showed an increased level of revascularisation in the treated lesions.

Discussion: Spinal cords do not heal because of prolonged inflammation which leads to secondary necrotic events, scar formation and the inhibition of regeneration. In this study we present a method for regulating the post lesion inflammatory signals, significantly reducing post-lesion scar formation. We propose the delivery of VEGF/PDGF significantly increases the permeability of the blood spinal cord barrier to neutrophils and macrophages and promotes angiogenesis observed in the lesion site. This may have two major effects on the progression of the spinal cord injury. Firstly, by increasing the initial influx of inflammatory cells it enables the faster removal of damaged tissue and phagocytosis of apoptotic cells thereby restoring the balance in favour of regulated inflammation and results in a finite and reduced inflammation time. Secondly, combination of VEGF and PDGF provides a robust angiogenic response and reduces ischemia, the population of reactive astrocytes and the capacity to form glial scars. These growth factors appear to moderate the secondary degenerative changes that result from the prolonged inflammation and thus promote the inherent capacity for regeneration.


J. Cordell-Smith C. Adam M. Izatt R. Labrom G. Askin

Introduction: The occurrence of non-union following instrumented scoliosis correction may predispose to pseudarthrosis and subsequent implant failure. Although non-union is often multifactorial, it is widely accepted that bone graft of adequate quality and quantity is fundamental to achieve solid fusion. Conventionally, autologous rib graft or iliac crest harvest has been utilised for endoscopic anterior instrumented scoliosis surgery. However, these techniques increase the operative duration and cause donor site morbidity, both of which may lengthen hospital stay. Alternatives such as allograft bone and bone morphogenetic proteins have gained more widespread use and may improve fusion rates although this remains controversial. The aim of this study was to compare two-year postoperative fusion rates for a series of patients who underwent endoscopic anterior instrumentation for thoracic scoliosis utilising various bone graft types.

Methods: 19 patients who had undergone endoscopic anterior instrumented scoliosis correction using identical instrumentation (4.5mm diameter titanium anterior rod and vertebral body screws, Eclipse, Medtronic) between May 2000 and August 2005 were identified from a surgical database of 132 consecutively treated individuals. All patients received bone graft to supplement thoracic fusion. Discectomy was performed at the levels to be instrumented and intervertebral spaces were packed with autologous rib heads (8 patients), iliac crest (1 patient), or mulched femoral head allograft (10 patients). The quality of thoracic fusion and implant integrity were evaluated two years following scoliosis correction using low-dose CT performed in accordance with local ethical approval. The intervertebral fusion was assessed using a modified Sucato method (1). Each level was graded using a 4-point scale based on calculated percentage of fusion across the disc space. 0 points indicated no fusion; 1 point, fusion < 25%; 2 points, fusion between 25 and 50%; 3 points, fusion between 50 and 75%; 4 points > 75% or complete fusion. The fusion was considered solid with a score of 3 points or more. Data was analysed with non-parametric tests using a significance level of 0.05.

Results: Of the cohort, nine had evidence of implant failure with rod fracture. All implant failures occurred in the group who received either rib head or iliac crest graft. No rod fractures were identified in the femoral allograft group. The mean fusion grade in the autologous bone graft group was 1.91 whereas in the allograft group this was 3.30 (95% confidence intervals 1.38–2.44 and 2.99–3.61 respectively) with a statistically significant difference in fusion rates between these two groups (p=0.001).

Discussion: This study demonstrated significantly better rates of thoracic fusion in endoscopic anterior instrumented scoliosis correction using mulched femoral allograft compared with autologous rib heads and iliac crest graft. This could be partly explained by the difficulty obtaining sufficient quantities of autologous graft. The lower fusion rate seen in the autologous graft group appears to predispose to rod fracture although the longer-term clinical consequence of implant failure in this group is not clear and warrants further study.


T. Cundy C. Delaney L. Sutherland C. Cain A. Oakley P. Cundy

Introduction: Spinal arthrodesis with stainless steel implants is a common procedure to correct scoliosis however, the long-term consequences of retained implants is unclear. Raised serum metal ion levels have been widely published in arthroplasty literature with concern over possible toxic adverse effects associated with chronic exposure. We investigated serum metal ion levels in patients who had undergone instrumented spinal arthrodesis for scoliosis correction.

Methods: The study included patients who underwent posterior spinal arthrodesis using ISOLA instrumentation for scoliosis between 1998 and 2002. The minimal period of follow up was 3 years. Clinical information was available from a comprehensive Scoliosis Database, Department of Orthopaedic Surgery, Women’s and Children’ Hospital, Adelaide (WCH). Patients having post-operative complications, spinal instrumentation removed, revision surgery or additional in situ metal implants were excluded. Participants completed a questionnaire to evaluate exogenous chromium exposure. Blood samples were collected and processed by the WCH Core Laboratory. Serum levels of chromium, molybdenum, iron and ferritin were measured by Sydney South West Pathology Service. Participants with serum chromium levels outside the normal reference range underwent further analysis to evaluate chromium levels in erythrocyte haemolysate preparations (to assess the valency of abnormal chromium levels detected). Comparisons were made with two control groups; the first being individuals with scoliosis who had not undergone operative intervention and the other, “normal” unaffected volunteers. All control group participants underwent serum and erythrocyte analysis (as above). Ethics approval was obtained from the WCH Research Ethics Committee.

Results: Thirty patients (26 females and 4 males) who underwent instrumented scoliosis surgery, 10 non instrumented scoliosis patients and 10 unaffected volunteers were included in the study. Mean age of the operative group at surgery was 13.8 years (11.1–16.9) with a mean length of time from surgery of 5.8 years (3.5–8.2). In the study group, raised serum chromium levels were demonstrated in 11/30 (36.6%) of patients. Five of the 11 patients with raised chromium levels also had low levels of serum iron and/or ferritin. Erythrocyte levels of chromium were undetectable in all of the 11 (100%) patients. There did not appear to be an exogenous source of chromium exposure in any of these patients. In the non-operative control group with scoliosis, none had elevated serum chromium, iron or ferritin levels. 2/10 (20%) had high molybdenum levels. In the unaffected control group, 1/10 (10%) had raised serum chromium and molybdenum levels. Three control patients had low levels of serum iron and/or ferritin. All control participants, but one, had undetectable erythrocyte chromium levels. There was a significant difference in serum chromium levels between the study and control groups (p=0.01) with the group of patients who underwent instrumented scoliosis surgery having a greater proportion with high chromium and lower proportion with normal chromium.

Discussion: Raised serum chromium levels were detected in patients after instrumented spinal arthrodesis for scoliosis correction. This new finding in young patients has relatively unknown health implications but potential genotoxic and carcinogenic sequelae; this is especially concerning with most scoliosis patients being female and with their reproductive years ahead. These findings should prompt further research in this area, particularly to similarly investigate other spinal implant systems and assess the long term implications of raised chromium levels.


W. Claassen J. Nijs Siegfried Jaecques G. Van der Perre M Mulier

Radiostereometric analysis (RSA) is a technique that can be used to measure in-vivo micro-motion of the components of hip arthroplasty.

86 patients received a titanium custom-made prosthesis. The average age was 64 year (20y –84y). During the study 30 patients out of 86 received a cementless femoral stem. The choice of stem fixation is determined by the quality of the bone. In all cases a 36 mm cobalt chromium head is used. Spherical tantalum markers, chosen because of the proven biocompatibility, were inserted into stable locations in the femoral bone during surgery using a specialized insertion tool, according to the protocol. Evaluation was done 1, 6, 12, 24, 52 weeks after surgery.

Overall subsidence follows a parallel pattern for the cemented and uncemented prosthesis that is slightly stronger in for the uncemented prosthesis. Over the 6 months evaluation period the prosthesis migrates towards the lateral side with 0.25 mm in both groups. An anteroversion of 0.5° to 1° is noted at 6 months follow-up. The varus valgus movement of the prosthesis is similar for both groups at 6 months. At 6 weeks a slight valgus flexion is noted, this is reversed at 3 months. At this point in time the effect is more pronounced in the group with a cemented prosthesis.

Micro motion is difficult to assess on plain radiography. In this study more subsidence is noted in the uncemented prosthesis compared to the cemented. The degree of rotation of the stem measured in our study is comparable with those reported by others. In our primary THR we observe a bi-modal micromotion except for the subsidence the initial movement up till 6 weeks is reversed at 3 months follow-up and at 6 months the prosthesis seems stabilized, though longer follow-up is required to confirm stabilization.


J.B. van Aken N. Verdonschot H. Huizenga J.G. Kooloos E. Tanck

Bone metastases occur in about 15% of all cancer cases. Pathological fractures that result from these tumours most frequently occur in the femur. It is extremely difficult to determine the fracture risk with the current X-ray methods, even for experienced physicians. The purpose of this study was to assess whether the use of a predictive finite element model could improve the prediction of strength in comparison to an clinical assessment.

Eight human cadaver femora, with and without simulated metastases, were CT-scanned. A solid calibration phantom was included in each scan. From the scans, eight finite element (FE) models were generated using brick elements. The non-linear mechanical properties were based on bone density. After scanning, laboratory experiments were performed. The femora were loaded under compression until failure. During the experiments the failure forces and the course of failure were registered. These experiments were simulated in the FE-models, in which plastic deformation simulated failure of the bones. Six experienced physicians, were asked to rank the femora on strength using X-rays (AP and ML) and additional information on gender and age.

The results showed a strong Pearson’s correlation (r2 = 0.92) between the experimental failure force and predicted failure force. The Spearman’s rank correlations between experiment and predictions ranged between ρ=0.58 and ρ=0.8 for the physicians, whereas it was significantly higher (ρ=0.92) for the FE-model

This study showed that femur specific FE models better predicted femoral failure risk under axial loading than experienced physicians. When the model is further improved by adding, for example, other loading conditions, it can be clinically implemented to predict in vivo fracture risk for patients suffering, for example, bone metastases or osteoporosis.


M.A. Pérez C. Desmarais-Trépanier P.A. Vendittoli M. Lavigne J.M. García-Aznar M. Doblaré

Hip Resurfacing (HR) is nowadays widely used as an alternative to Total Hip Replacement (THR), especially for the young and active patients. Because of the more physiological distribution of the load in the femur, this technique is particularly known to reduce bone loss due to stress shielding behaviour, a major problem encountered with THA. Different computational studies have analysed the performance of HR prostheses. Therefore, the purpose of this study is to apply a computational approach, in fact a bone remodelling analysis, in order to investigate its application to evaluate the bone structure changes postoperatively.

A Finite Element model was developed of a femur with HR prosthesis. The model was reconstructed starting with the femur medical images, and then the prosthesis was positioned in the clinical implantation angle (5° valgus). A cement mantle thickness of 1mm was included. Then a Finite Element Analysis in combination with a bone remodelling model (bone material properties) was performed. The results obtained predict as there is a certain bone loss in the superolateral and inferior medial zone. Additional bone material apposition is locally found with the aim of fixing the implant stem on the medial side, but also a remarkable distal ingrowth around the stem tip. All these findings are in good qualitative agreement with clinical observations.

We conclude that the numerical simulation used in this study is a useful tool in predicting bone remodelling inside a cemented HR prosthesis. This kind of methodologies will help on the design of devices, surgical techniques, etc.


P. Keeling P.J. Prendergast A.B. Lennon P. O’Reilly J.R. Britton P.J. Kenny

One method of reducing intra-operative complications in revision hip surgery is the cement-in-cement technique. Some concern exists regarding the retention of the existing fatigued cement mantle. It was hypothesised that leaving the existing fatigued cement mantle does not degrade the mechanical properties of the cement in cement revision construct. The aim of this research was to test this hypothesis using in vitro fatigue testing of analogue cement in cement constructs.

Primary cement mantles were formed by cementing a large polished stem into sections of tubular stainless steel using polymethylmethacrylate with Gentamicin. At this stage, the specimen was chosen to be in the test group or the control group. If in the test group, it underwent a fatigue of 1 million cycles. This was carried out in a specifically designed rig and a fatigue testing machine. Into these fatigued and unfatigued primary mantles, the cement in cement procedure was carried out. Both groups underwent a fatigue of again 1 million cycles. Subsidence of the stems and their inducible displacement was recorded. A power calculation preceded testing.

Completion of a Mann Whitney test on the endpoints of the subsidence curves revealed that there is no statistical difference between the data sets (means 0.51, 0.46, n=10 + 10, p = 0.496). This data was also calculated for the inducible displacement. Again, there was no statistical difference in the separate groups for this parameter (means 0.38, 0.36, p = 0.96). This methodology produces a complex 3 dimensional reconstruction of the cement in cement revision which replicates the in vivo structure. This reconstruction has undergone fatigue testing. Neither of these two aspects has been produced for the study of cement in cement revision before.

A fatigued primary cement mantle does not appear to degrade the mechanical properties of the cement in cement revision construct


P. Aspenberg P. Wagner K. G. Nilsson J. Ranstam

Background: RSA cannot discern whether a single prosthesis is fixed or migrating below the detection level. Samples of patients usually show migration values that appear to be continuously distributed. Is there a dichotomy between stable and migrating prostheses?

Methods: We analysed the migration of 147 cemented acetabular cups of 7 different designs, by use of a new set of algoritms for frequency distribution analysis called Rmix. The migration vector lengths were assumed to be a compound of log-normal distributions. The algoritm then calculated if the observed frequency distribution is best explained by one or more log-normal distributions.

Results: After 2 years there was a significant dichotomy (p=0.006) between 2 lognormal subgroups within the sample. Neither cup design, sex or operating department could explain the dichotomy into two groups, which appears to reflect the existence of two different types of behaviour. The migration along the 3 axes in space, showed a similar dichotomy. During the second year, around 80 % of the patients belonged to a distinct, normally distributed subgroup with a mean not different from 0 mm and a small variation, corresponding to the measuring error. The remainder differed significantly from this subgroup and showed migration.

Interpretation: The majority of the cups belonged to a subpopulation that appeared completely stableduring the second year. For a single type of prosthesis, the relative size of the stable subgroup might be a good index of the expected performance.


G. Friedl C. Stihsen R. Radl P. Rehak R. Aigner R. Windhager

Aseptic loosening is the most frequent cause of implant failure in total hip arthroplasty (THA). Additionally, failure rate was still found by some authors to be increased in patients with osteonecrosis of the femoral head (ON-FH). It is well evidenced that low initial fixation and early migration precedes and predicts long-term failure rate of both, the acetabular and femoral component in THA.

This independent, double-blind, randomized, controlled study was primarily designed to evaluate whether a single infusion of 4 mg of zoledronic acid is sufficient to prevent implant migration determined by the EBRA-digital method. Fifty patients were consecutively enrolled between July 2002 and March 2005 to receive either 4 mg zoledronic acid (ZOL) or saline solution (CTR) one day after THA (Zweymüller system, cementless). Plain radiographs were performed postoperatively and all parameters were evaluated at each follow-up meeting interval at 7 weeks, 6 months, 1 year, and yearly thereafter during a median follow-up period of 2.8 years (2 years minimum).

In CTR, subsidence increased up to −1.2 mm ± 0.6 SD at 2 years in CTR (P< 0.001). Less, but a near curve-linear shaped migration pattern was found for the ace-tabular component, with an averaged medialization of 0.6 mm ± 1.0 SD and a cranialization of 0.6 mm ± 0.8 SD at 2 years (P< 0.05, Friedman ANOVA) at 2 years. In ZOL, a significant reduction in bone turnover markers was accompanied by a complete prevention of cup migration in both, the transverse and vertical direction (P< 0.05, ANOVA), while there was only a trend to a decreased subsidence in stems.

The study provides useful data which are promising and support the suggestions that bisphosphonates may offer significant opportunities to reduce and prevent implant migration of THA, thus increasing long-term durability of THA especially in selected high-risk patients.


W. Richter R. Bock T. Hennig S. Weiss

Common in vitro protocols for TGF-β driven chondrogenic differentiation of MSC lead to hypertrophic differentiation of cells. This might cause major problems for articular cartilage repair strategies based on tissue engineered cartilage constructs derived from these cells. BMPs have been described as alternate inductors of chondrogenesis while PTHrP and FGF-2 seem promising for modulation of chondrogenic hypertrophy. The aim of this study was to identify chondrogenic culture conditions avoiding cellular hypertrophy. We analyzed the effect of a broad panel of growth factors alone or in combination with TGF-β3 on MSC pellets cultured in vitro and after transplantation in SCID mice in vivo.

Chondrogenic differentiation in vitro was successful after supplementation of the chondrogenic medium with TGF-β3 as confirmed by positive collagen type II and alcian blue staining. None of the other single growth factors (BMP-2, -4, -6, -7, FGF-1, IGF-1) led to sufficient chondrogenesis as indicated by negative collagen type II and alcian blue staining. Each of these factors, however, allowed chondrogenesis in combination with TGF-β without suppressing collagen type X expression. Combination of TGF-β with PTHrP or FGF-2 suppressed ALP activity, induced MMP13 expression, and prevented differentiation to chondrocyte-like cells when added from day 0. Delayed addition of PTHrP or FGF-2 stopped chondrogenesis at the reached level and repressed ALP activity. The treatment of MSC constructs with FGF-2 or PTHrP in the last 3 weeks before transplantation did not prevent hypertrophy and calcification in vivo.

FGF-2 and PTHrP were potent inhibitors for early and late chondrogenic differentiation in contrast to BMPs. As soon as a developmental window of collagen type II positive and collagen type X negative pellet cultures can be created in this model, both seem to be potent factors to suppress hypertrophy and to generate stable chondrocytes for transplantation purposes.


G. Vadalà A. Rainer C. Spadaccio V. Denaro M. Trombetta

The use of mesenchymal stem cells (MSCs) for cartilage and bone tissue engineering needs to be supported by scaffolds that may release stimuli for modulate cell activity.

The objective of this study was to asses if MSC undergo differentiation when cultured upon a membrane of nanofibers of poly-L-lactic acid loaded with hydroxyapatite nanoparticles (PLLA/HAp).

The PLLA/HAp nanocomposite was prepared by electrospinning. Membranes microstructure was evaluated by SEM. MSCs were seeded on PLLA/HAp membranes by standard static seeding and cultured either in basal medium or Chondrogenic Differentiation Medium. Cell attachment and engraftment was assessed 3 days after seeding and MSC differentiation was evaluated by immunostaining for CD29, SOX-9 and Aggrecan under a confocal microscope after 14 days.

PLLA/HAp membrane obtained was composed by fibers (average diameter of 7μm) with nano-dispersed hydroxyapatite aggregates (average diameter of 0.3μm). 3 days after seeding, MSCs were well adhered on the PLLA/HAp fibers with a spindled shape. After 14 days of culture all MSCs were positive for SOX-9 in both basal and chondrogenic media groups. Aggrecan was present around the cells. MSCs were either CD29 positive or negative.

We demonstrated that PLLA/HAp nanocomposites are able to induce differentiation of MSCs in chondrocyte-like cells. Since HAp has osteoinductive properties, the chondrogenic phenotype acquired by the MSCs may be either stable or an intermediate stage toward enchondral ossification. The presence of CD29 and SOX-9 double positive cells indicate intermediate differentiation phases.

This nanocomposite could be a susceptible scaffold for bone or cartilage tissue engineering using undifferentiated MSCs.


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R. Lee J. Longaray A. Essner A. Wang W. Capello J. D’Antonio

Acetabular rim damge due to rim impingement is frequently found on retrievals and may be associated with increased wear and contact stresses, instability, and implant loosening of total hip replacement devices. Large X3 bearings (> 36mm) from Stryker have increased implant range of motion and improved polyethylene material (sequentially crosslinked and annealed). A hip simulator wear study was performed with and without femoral neck to acetabular rim impingement to determine the wear performance of these new bearings under aggressive impingement conditions. Two sizes of these new components were tested (36mm with 3.9mm thickness and 40mm with 3.8mm thickness) with two standard sized controls (28mm with 7.9mm thickness in X3 and conventional polyethylene. The 36mm component was chosen to be the largest component utilizing the same shell as the standard 28mm size components while the 40mm component was chosen to be the thinnest bearing currently offered.

Impingement significantly increased wear for all bearings (p< 0.05) but no cracking or failures of the rim occurred. Wear rates for all X3 bearings were statistically indifferent under each testing condition despite bearing size and thickness. Average wear rates for X3 bearings were 0.3mm3/million cycles (mc) under standard conditions and 3.5mm3/mc under impingement conditions. Average wear rates for conventional bearings were 19.5mm3/mc under standard conditions and 48.3mm3/mc under impingement conditions. Overall the X3 bearings exhibited a 93% reduction in wear under impingement conditions and 99% reduction in wear under standard conditions.

Increased bearing range of motion reduces the chance of impingement. This study shows the simulated outcome even if these larger bearings were to impinge. We conclude that these larger X3 bearings exhibits the same wear performance as standard X3 bearings and significantly superior wear performance compared to conventional polyethylene bearings under standard and impingement conditions.


M. Stiehler F.P. Seib P. Bernstein A. Goedecke M. Bornhäuser K.-P. Günther

Major drawbacks associated with autologous bone grafting are the risk of donor site morbidity and its limited availability. Sterilized bone allograft, however, lacking osteoinductive properties, carries the risk of graft failure resulting from insufficient osseointegration of the graft.

The aim of this study was to vitalize bone allograft with human osteoprogenitor cells under GMP-conform conditions. For this purpose we investigated proliferation, osteogenic differentiation and large-scale gene expression of human MSCs cultured three-dimensionally on peracetic acid (PAA)-treated spongious bone chips.

MSCs were isolated from healthy donors (N=5) and seeded onto PAA-treated spongious bone samples (~5×5×5 mm, DIZG, Germany) under GMP-conform conditions. Proliferation (total protein assay), osteogenic differentiation (cell-specific ALP activity assay, quantitative gene expression analysis of selected osteogenic marker genes), and morphology were assessed. RNA was isolated and microarray analysis was performed using the PIQORTM Stem Cell Microarray system (Miltenyi Biotec) including 942 target sequences.

Increasing cellularity was observed during the 42 d observation period while cell-specific ALP activity peaked at day 21. Effective proliferation and adhesion of human MSCs on PAA-treated spongious bone was confirmed by histology, scanning electron and confocal laser scanning microscopy. Gene expression of early (Runx-2), intermediate (ALP), and late (osteocalcin) osteogenic marker genes was present during 42 days of cultivation. Microarray analysis of MSCs cultivated on bone allograft versus 2-D tissue culture demonstrated temporal upregulation of genes involved in extracellular matrix synthesis (e.g., matrix metalloproteases, collagens), osteogenesis (e.g., BMPR1b, Runx-2) and angiogenesis (angiopoietin, VEGF).

PAA-treated spongious bone allograft is a biocompatible carrier matrix for long-term ex vivo cultivation of MSCs as observed by favorable proliferation, cell distribution, gene expression profile, and persisting osteogenic differentiation. GMP-grade vitalisation of bone allograft by cultivation with autologous MSCs represents a promising clinical application for the treatment of osseous defects.


A. Dickhut K. Pelttari P. Janicki W. Wagner V. Eckstein M. Egermann W. Richter

Mesenchymal stem cells (MSC) are suitable candidates for the cell-based cartilage reconstruction and have been isolated from different sources such as bone marrow (BMSC), adipose tissue (ATSC) and synovium (SMSC). The aim of this study was to analyse the tendency of BMSC, ATSC and SMSC to undergo hypertrophy during chondrogenic induction in vitro and to evaluate their in vivo development after ectopic transplantation into SCID mice in order to determine which cell source is most suitable for cartilage regeneration.

Human BMSC, ATSC and SMSC were cultured under chondrogenic conditions for five weeks. Differentiation was evaluated based on histology, gene expression, and analysis of alkaline phosphatase activity (ALP). Pellets were transplanted subcutaneously into SCID mice after chondrogenic induction for 5 weeks and analysed 4 weeks later by histology. Similar COL2A1:COL10A1 mRNA ratios were found in BMSC, ATSC and SMSC. BMSC displayed the highest ALP activities, SMSC had lower and heterogenic ALP activities in vitro which correlated with calcification of spheroids in vivo. Most SMSC transplants specifically lost their collagen type II in vivo or were fully degraded. BMSC and ATSC pellets always underwent vascular invasion and calcification in vivo. Single BMSC samples had the capacity to develop into woven bone or fully developed ossicles with hematopoietic tissue surrounded by a bone capsule.

Neither BMSC nor ATSC or SMSC were able to form stable ectopic cartilage. While BMSC and ATSC underwent developmental processes related to endochondral ossification instead of stable ectopic cartilage formation, SMSC tended to undergo fibrous dedifferentiation or degradation. Besides appropriate induction of chondrogenesis, locking of cells in the desired differentiation state is, thus, a further challenge for adult stem cell-based cartilage repair.


G. Hannink P.J. Geutjes T.H. van Kuppevelt B.W. Schreurs P. Buma

The clinical application of bone morphogenetic proteins (BMPs) offers solutions to many challenging problems in orthopaedics. However, a practical clinical problem is to obtain a controlled release of the BMPs. The attachment of heparin to biomaterials may result in an appropriate matrix for the binding, and sustained release of BMPs. Binding of growth factors to heparin stabilizes these growth factors, protects them from proteolytic degradation, and prolongs the half-life of BMPs in culture media 20-fold. We created a carrier based delivery system with a localized sustained release by loading a tricalciumphosphate/hydroxyapatite (TCP/HA) bone substitute coated with cross-linked collagen and heparin, with BMP-7.

TCP/HA granules (BoneSave, Stryker Orthopaedics) were coated with collagen, and subsequently the collagen was cross-linked in the presence (TCP/HA-Col-Hep) and absence (TCP/HA-Col) of heparin. BMP-7 was loaded onto the coated TCP/HA granules. Morphology of the coated collagen with and without heparin, and release kinetics of BMP-7 from the granules were analyzed. TCP/HA granules without coating were used as controls.

Analysis showed a highly porous collagen network on both TCP/HA-Col and TCP/HA-Col-Hep granules. Immersion of the granules in BMP-7 solution, resulted in the binding of 54±3% (62.9±5.4 ng BMP-7/mg granule) to the TCP/HA granules, 64±8% (69.0±9.6 ng BMP-7/mg granule) to the TCP/HA-Col granules, and 78±1% (92.9±4.8 ng BMP-7/mg granule) to the TCP/HA-Col-Hep granules. TCP/HA granules showed a burst release of BMP-7 within the first 4 h. TCP/HA-Col granules showed an initial burst release, followed by a more gradual release. In contrast, BMP-7 release from the TCP/HA-Col-Hep granules was sustained up to 21 days.

The sustained delivery system for BMP-7 developed in this study may provide a powerful tool for bone regeneration. This system could probably also be applied to deliver multiple growth factors that have affinities for heparin, which could for instance synergistically enhance osteogenesis by increasing vascularity.


M. Stiehler C. Stiehler R. Overall M. Foss F. Besenbacher M. Kruhøffer M. Kassem K.-P. Günther C. Bünger

Metallic implants are widely used in orthopedic, oral and maxillofacial surgery. Durable osseous fixation of an implant requires that osteoprogenitor cells attach and adhere to the implant, proliferate, differentiate into osteoblasts, and produce mineralized matrix. We previously observed that human mesenchymal stem cells (MSCs) adherent to smooth tantalum (Ta) surfaces demonstrated superior biocompatibility compared with titanium (Ti) coatings.

The aim of the present study was to investigate the interactions between MSCs and smooth surfaces of Ta and by means of whole-genome microarray technology.

Immortalized human mesenchymal stem cells were cultivated on smooth surfaces of Ti and Ta. Total RNA was extracted after culturing for 1, 2, 4, and 8 days and hybridized to Affymetrix whole-genome microarrays (N=16). Replicate arrays were averaged and the ratios of gene expression by MSCs cultivated on Ta versus Ti coating were calculated. Absolute fold differences were also calculated and lists of upregulated genes were generated. Moreover, gene Ontology (GO) annotation analysis of differentially regulated genes was performed.

For both Ta and Ti coatings, the vast majority of genes were upregulated after 4 d of cultivation. Genes upregulated by MSCs cultivated on Ta coating for 4 d were annotated to relevant GO terms. Ti-regulated GO annotation clusters were predominantly transcription-related. By using the K-means clustering algorithm, 10 clusters containing more than 5 genes were identified. Moreover, various genes related to osteogenesis and cell adhesion were upregulated by MSCs exposed to Ta surface.

Microarray analysis of MSCs exposed to smooth metallic surfaces of both Ta and Ti generally showed a huge increase in transcriptional activity after 4 d of cultivation. According to GO annotation analysis Ta coating may induce increased adhesion and earlier differentiation of MSCs compared to Ti surface making Ta a promising biocompatible material for bone implants.


G. Fried I. Rehak H. Schmidt R. Aigner R. Windhager

The induction of differentiation is a highly programmed lineage-specific process and several studies have provided great insight into the microenvironment affecting differentiation of multipotential hMSCs. In this regard, the importance of physical factors has been recognized for many years, but only little is known about its effects on undifferentiated hMSCs. The study aimed to determine the early osteogenic differentiation response to physiologically-based mechanical tensile strain with possible contributions to donor-specific physiological conditions.

MSCs of ten donors were expanded under standard culture conditions, and the individual response to cyclic tensile strain (CTS) was determined in a two-armed study design (strained versus unstrained (CTR)). CTS was applied with a maximum of 3,000 μstrain. Genotypic characteristics (RUNX2, ALPL, SPARC, SPP1; COL1A1, MKI67, etc) as well as phenotypic effects (cell numbers, cell viability and ALP activity) were compared between CTR and CTS, and possible relations to donor-specific physiological characteristics including anthropomorphometric and biochemical variables were determined.

We found a significant up-regulation of the osteogenic marker genes due to CTS, which was accompanied by an increase in cell-based ALP activity (plus 39.6 ± 9.8% SEM, P< 0.05). Cell density as well as XTT were significantly lower following CTS (minus 20.0 ± 4.7% and minus 17.8 ± 5.6%, respectively, P< 0.05). As a consequence, the ALP activity w/o normalization ranged widely from minus 30.8% to plus 60.1% between individual donors and was a function of donor’s BMI (r=−0.91, P< 0.0001), weight (r=−0.73, P=0.016), and age (r=−0.65, P=0.041).

The findings demonstrate that

the application of CTS provides an inherent osteogenic differentiation stimulus for undifferentiated hMSCs in vitro, and

the functional response of hMSCs to CTS was found to be highly related to donor’s BMI/fat mass, thus suggesting an upstream imprinting process of the hMSCs within bone marrow


I. Nizam L. Kohan D. Kerr

This bone preserving procedure is less well described in the much older population over 65 years of age. Despite good bone quality, independence and active lifestyle, older age seems to be a deterrent for hip resurfacings among most orthopaedic surgeons.

Analysis of 111 Birmingham hip resurfacings in 105 consecutive patients from 1999 to 2007 performed by a single surgeon was carried out to determine radiological and clinical outcome. The unique selection criteria looked at joint disease, activity levels, general health, imaging (Xray/CT/MRI) and Bone density studies.

28 females and 77 males with mean age of 69.5 years (65–87 years, SD +/− 4), body mass index of 27.2 (19–40.4, SD +/− 3.8) underwent resurfacings. 8 patients had bilateral, consecutive 2 stage procedures. Mean Follow up was 3.8 years ranging from 3 months to 7 years. 62 resurfacings were performed in the age group 65–69 yrs, 32 resurfacings in the 70–74 age group, 12 resurfacings in the 75–79 age group and 4 resurfacings in the 80–89 age group. 77 patients (71.3%) stayed one night or less in hospital. 4 patients (3 males and 1 female) had postoperative fracture neck of femora.

Radiographic review at the most recent follow up revealed non of the patients (101) who had the original hip resurfacing components had any evidence of gross loosening, migration or subsidence requiring revision of either the cup or the femoral components. No patients complained of localised hip pain and at the most recent follow up they had very good to excellent function with no report of dislocations.

Hip resurfacing is a challenge in patients who are over the age of 65 years. Using our selection criteria, it may be offered to active, independent patients with good bone quality as this age group in the population becomes larger with time.


AMH. Latif TG. Kavannagh RE. Field

The potential for bone remodeling in the proximal femur may be detrimental to the long term survival of resurfacing prosthesis.

A retrospective analysis of radiological changes in the femoral neck was undertaken for 96 patients (100 hips, 76 males and 24 females), with a minimum of 5 years following hip resurfacing. The mean age at surgery was 53.8 years. Femoral neck diameter was measured post-operatively, at 2 and 5 years. Pre and post-operative head to neck ratios, femoral head-shaft offset, femoral neck and implant stem-shaft angles were also measured.

Two groups of patients were identified with differing rates of reduction in their femoral neck diameter. Over the first 2 years, Group A (24%) mean reduction was 2.02mm/year while Group B (76%) mean reduction was 0.33 mm/year. At 5 years, the Group A mean reduction was 5.64mm (sd±2.03mm) while Group B reduction was 1.16mm, (sd±0.97mm). The difference was significant at both time points (p< 0.01). Larger head-neck ratios were observed in the group A, both pre and post operatively (p< 0.01).

Finite Element Analysis has predicted stress shielding underneath the femoral head and loading of the mini stem. This may explain bone resorption underneath the shell and remodeling around the mini stem. Compromised blood supply of the retained epiphyseal remnant may also play a part in femoral head resorption. Group A with a larger proportion of females and femoral heads will potentially have a larger proportion of epiphyseal remnant retained. A further mechanism that could be influential in the development of neck thinning and bone resorption may be due to fluid pumping mechanism causing osteolytic erosion at the bone cement interface.

In conclusion, femoral neck thinning is a phenomenon of unproven aetiology which is affecting almost 25% of our resurfacing cases. Further investigations are needed to determine its aetiology and remedy.


H. Bertram A. Walther M. Gelinsky B. Mrozik W. Richter

Flock technology is well known from textile industry. Short fibres are applied vertically on a substrate, coated with a flocking adhesive. Until now this technology has not been used in the field of biomaterials although it offers the possibility to create anisotrophic matrices with a high compressive strength despite of high porosity. Matrices presently used in matrix assisted autologous chondrocyte implantation do not show any orientation of the embedded chondrocytes. However column orientation and anisotropic direction of embedded cells and collagen fibers are thought to be necessary for proper cartilage matrix biomechanics. Combination of matrices as a guiding structure and chondrogenically differentiated mesenchymal stem cells (MSC) could offer new possibilities in the treatment of cartilage defects. Our aim was to evaluate whether anisotropic scaffolds are capable to support a cellular cartilaginous phenotype in vitro.

Electrostatically flocked matrices consisted of a collagen substrate, gelatine as adhesive and polyamide flock fibres. Chondrogenic cells and MSC were embedded in the scaffolds. Adherence, vitality and proliferation was assessed using confocal laser-scan microscopy (cLSM). Chondrogenic induction was performed in the presence of TGF-beta 3. Accumulation of proteoglycans was quantified by alcian-blue stain and collagen type II synthesis after extraction of the newly synthesized matrix.

cLSM showed proliferation of embedded MSC as evidenced by DAPI/Phalloidin stain. Vitality of embedded cells remained high over time. Articular chondrocytes and nucleus pulposus cells synthesized proteoglycans and collagen type II in the scaffolds. Also MSC embedded in the flock scaffolds differentiated and increased their chondrogenic phenotype over time.

Using cLSM and biochemical analyses we demonstrated that cells adhered and proliferated well in the new scaffolds. Furthermore we showed that the scaffolds are capable to support induction and maintenance of the chondrogenic phenotype. We conclude that flocking technology is suitable for fabrication of scaffolds for cell cultivation and cartilage tissue engineering.


M. F. Pietschmann B. Frankewycz D. Docheva M. Shakibaei V. Jansson M. Schieker P. E. Müller

Irreparable tendon ruptures constitute a grave clinical problem. Especially for large rotator cuff tears, there often is no primary causal therapy available. As a sad result, the development of a rotator cuff tear arthropathy is more often than not inevitable. Our study investigates the effects of scaffold based tendon regeneration with special focus on mesenchymal stem cells in a rat model.

We used ‘native’ bone marrow stromal cells and cultivated mesenchymal stem cells from male rats that were implanted into female rats. As scaffolds polyglycol acid (PGA) and a collagen I were used. A full-thickness-defect of 2–3 mm in the middle third of the rats achilles tendon was created, which was then filled, with either cell-seeded or not cell-seeded scaffolds and, due to the low primary stability of the scaffolds, fixed with a 4-0 suture. After 12 weeks, a DNA PCR was conducted to verify the existence of male Y-chromosomes in the female regenerated tissue. We determined the maximum tensile load of the regenerated tissue and also did a histological evaluation.

Macroscopically the regenerated tendons were much bigger in diameter, much firmer and also much less elastic than a normal tendon. In the ‘mesenchymal stem cells’ group the implanted cells could be clearly identified after 12 weeks by DNA PCR. The collagen I scaffold yielded better results in the biomechanical study than the PGA scaffold. No evidence of positive influence of the cells on the mechanical stability of the regenerated tissue was found. Collagen I and the use of BMSC histologically lead to increased ossification of the regenerated tissue. In the PGA scaffold group a significant inflammatory reaction was found.

Both scaffold/cell combination seem to be unsuitable for tendon replacement. in-vitro studies on the influence of scaffold material on cell differentiation needs to be done.


J.H. Rutten B. Grimm I.C. Heyligers

Femoral neck fracture is a serious complication in hip resurfacing arthroplasty and reducing its risk is a major challenge. From a biomechanical point of view changing the geometrical characteristics in surgery could affect the stresses in the femoral neck. We analysed standing AP X-rays of 85 randomly selected patients having pain in the pelvic region in order to gain better understanding of the geometrical influences. Patients were selected on age, weight, pelvis visibility and no deformations of the proximal femur. A variety of geometrical characteristics has been measured and analysed using the two-sided t-test.

A significant difference was found between men and women, which was compared to previous publications in order to verify the measurement method. Statistical indication could not be found for leg-dominancy influencing geometrical dimensions. This is not mentioned in literature, but it is mentioned that the BMC and BMD differs between the legs. Several linear relations have been found between geometrical characteristics and demographics. The average head-neck ratio for both left and right was about 1.4 and the ratio of the abductor moment arm and body moment arm was about 2.1. The linear relation between femoral head diameter and femoral neck diameter indicates that the femoral component should be chosen according to the natural head diameter. The ratio between the abductor arm and body arm in combination with the bodyweight determines the static stresses in the femoral neck and can be changed in surgery by altering the hip axis length and neck shaft angle.

Conclusion: The geometrical characteristics can be changed in surgery and can reduce the stresses in the neck, but in hip resurfacing these changes are relatively small. The question is how much can the geometry be changed and could these changes lead to complications.


P. Keeling P.J. Prendergast A.B. Lennon P. O’Reilly J.R. Britton P.J. Kenny

The cement-in-cement femoral revision is a possible method of reducing complications. During recent research on this revision it was observed that a number of the inner cement contained macropores. It was hypothesized that porosity of the mantle influenced the subsidence and inducible displacement of the revision stems. The aim was to calculate the porosity and assess its relationship to the above factors.

Primary cement mantles were formed by cementing a stem into sections of tubular steel. At this stage, the specimen was chosen to be in a test or a control group. If in the test group, it underwent a fatigue of 1 million cycles. This was carried out in a fatigue machine mounted with a specifically designed rig. If in the control group, no such fatigue was undertaken. Into these fatigued and unfatigued mantles, the cement-in-cement procedure was performed. Both groups underwent a fatigue of again 1 million cycles. Subsidence and inducible displacement was recorded. The composites were then sectioned and photographed. The images underwent image analysis to calculate the porosity.

Multiple regression and a general linear model showed subsidence was inversely correlated to the porosity of the “fresh cement” in Gruen zones 3 and 5 (p = 0.021, R2 = 0.36). This relationship was not expected. The reason could be related to the fact that the migration of the stems in each separate direction was not monitored. Inducible displacement was inversely correlated to porosity of the inner cement, again in Gruen zones 3 and 5 (p = 0.001, R2 = 0.61). A possible explanation is that the stem was able to subside more due to the higher porosity and find a more stable position.

The subsidence and inducible displacement of these stems is influenced by porosity, specifically by the porosity of the distal inner cement.


W. Claassen J. Nijs S. Jacques G. Vander Perre M. Mulier

We present the results of a prospective longitudinal follow-up study of Dual X-ray Absorptiometry (DXA) measurements of the evolution of bone mineral density (BMD) of acetabulum and femur in 86 patients who underwent total hip arthroplasty (THA). A standard uncemented cup and intra-operatively manufactured stem prosthesis was used in all patients. Stem fixation was determided by the bone quality Thirthy patients received cementless and 56 patients received cemented stem prosthesis. Post-operative DXA scans were obtained in peri-prosthetic bone at 10 days, 6 weeks, 3, 6 and 12 months after THA. Peri-prosthetic BMD values in the proximal femur were obtained in the 7 Gruen zones. In the acetabulum a 4 region of interest model (ROI) was used.

Bimodal significant femoral BMD changes are found in all Gruen zones except for zone 1 of the cemented group where an immediate recovery is observed. The recovery mostly starts after 6 months of follow-up and the highest remodelling is found in the calcar region reaching even values of −16% at 6 months but no statistical significance was observed between the two groups. Significant linear losses (p< 0.0001) are observed in the pelvis region independent of type of fixation except the opposite change (p< 0.01) in the inferior region observing an immediate recovery in the uncemented group.

We compared the impact of a cemented stem with a non cemented stem on the bone remodelling of the cup and found that there was a correlation between the type of fixation and the mode of remodelling at the acetabular level. This suggest that a parameter such as the flexibility my have an influence on the bone remodelling at the acetabulum level. The pattern of bone remodelling observed on the different Gruen zones reflects the local load transfer to peri-prosthetic bone.


T.M. Thien H. Malchau P. Herberts J. Kärrholm

In a previous report from a randomised study we reported excellent fixation and less proximal periprosthetic bone mineral loss around the Epoch design at 2 years follow-up when compared with a solid stem of similar design. We now present the 7 years follow-up.

Forty consecutive patients (20 men, 10 women, mean age 57, 41–74) with non-inflammatory osteoarthritis were randomised to receive either a cementless porous-coated composite stem with reduced stiffness (Epoch) or a cementless stiff stem with a porous coating (Anatomic). Patients were followed for 7 years with repeated evaluations using radiostereometry, DXA, conventional radiography and Harris Hip Score (HHS).

At 7 years 1 stem had been revised (Anatomic) due to late infection. Subsidence and stem rotations were close to zero without any difference between the two groups (p> 0,12). Median wear rates were lower than expected (0.4mm up to 7 years) for both stem designs. At 2 years loss bone mineral density was less in Gruen regions 1, 2, 6 and 7 for the Epoch stems (p< 0.04), but this difference tended to disappear with time. At 7 years only the calcar region (Gruen region 7) had significantly denser bone in the Epoch group (p< 0.001). The HHS scores did not differ (median 98, 51–100). No stem was radiographically loose.

The Epoch stem achieved excellent fixation. Wear rates were low despite use of conventionally gamma-sterilised polyethylene. This low modulus stem had positive effects on early proximal bone remodeling, but this effect decreased with time.


T.M. Thien J. Thanner J. Kärrholm

Earlier reports have shown that surface treatment influences the survivorship of tapered hip implants. To assess the role of surface finish for other stem shapes we evaluated three modifications of the Lubinus SP2 stem.

Eighty patients (31 male, 49 female, 68 (46–78 years), 84 hips) with non-inflammatory arthrosis randomly received either stem type: cemented matte (M, standard design), polymethylmetacrylate-coated (PC) or polished (P, collarless). Component fixation and wear were studied with radiostereometric analysis and the bone mineral density was measured around the stem in 40 patients at 6 months, 1, 2 and 5 years.

The polished design showed increased distal migration at 6 months (Mean and range) P: −0.21mm(−0.52 to 0.09), M: −0.07mm (−0.34 to 0.26), PC: −0.03 (−0.18 to 0.18) and at 5 years P:0.49mm (−1.46 to 0.16), M: −0.18mm (−0.80 to 0.33), PC: −0.12mm (−1.40 to 0.12 (p< 0.0001). This increased subsidence occurred inside the cement mantle. The rotations of the stem did not differ (p> 0.4). Neither did the migration and the wear (p> 0.1). After 1 and 2 years the polished stems had lost significantly less bone mineral in Gruen zones 1, 2, 6 and 7 (p 0.004 to 0.03). After 5 years this difference had disappeared. The Harris Hip Scores did not differ.

A polished surface without collar on an anteverted stem design resulted in increased subsidence of the stem inside the cement mantle. The improved bone remodeling around the polished version seemed to be transient.


R. Legenstein W. Huber A. Ungersboeck F. Gottsauner-Wolf P. Boesch

The development of metalosis is a not commonly reported complication after THR. The exact reasons are still unknown, but hypersensitivity reaction is favored ahead of toxic effects, immune defects and exogen causes. The phenomenon of metalosis occurred at an unpredictable time in situ and is often misinterpreted as a low grade infection.

In a retrospective study, we analysed all 173 (102 women and 71 men) primary and single cement less PPF THR (STRATEC®) with metal-on-metal (low carbide 0.08%) articulation of 1995. One patient was lost to follow-up, 18 patients were deceased. The average age at the time of surgery was 63.3 years and the follow-up time was 115 months.

40 (23.1%) metalosis cases were observed. Revision was done in 29 (16.8%) patients: three femur fractures, five cases of infection and 21 cases of metalosis. The median HHS at follow-up was 95. 18 cases (10.4%) had metalosis signs: six patients (3.2%) had periprosthetic osteolysis and pain, 16 patients (9.2%) had osteolysis without pain and nine patients (5.2%) had pain without osteolysis in the radiographs. Pain caused by metalosis typically occurred inguinal and at an average time of thirty months postoperatively. Dislocation was observed in 13 cases at an average time of 44 months with an average cup inclination of 48°. Extensive necrosis and diffuse lymphoplasmacytic infiltrates were noted. In most cases the bursa ileopectinea was highly filled and in this synovial fluid extremely elevated levels of chrome (32 – 46095 μg/l) and cobalt (30 – 67410 μg/l) were detected.

Since 2003, we do not implant or recommend metal-on-metal for THR anymore. Close radiographic and computertomographic monitoring with high mark on typical osteolysis and exact clinical evaluation is recommended for metal-on-metal THR. Patients without symptoms with severe osteolysis must be detected, and head and inlay changes must be performed.


S.J. Peters P. Pilot E. de Witte R.L.M. Deijkers S.B.W. Vehmeijer

The anterior supine intermuscular (ASI) approach enables total hip arthroplasty (THA) without dissection of muscles or insertions. This could be beneficial in patient recovery and satisfaction. Study-aim was to assess the learning-curve for the ASI-approach and show short-term results.

Two surgeons performed uncemented THA on 23 (17 and six respectively) consecutive patients. The Taperloc stem, Recap-cup and Magnum head (Biomet, Warsaw, USA) were used. THA was performed without the use of a traction-table. Data was gathered till 3 months follow-up.

Average patient age was 61 years (36–74), ASA-classification was two (one-four). There was a decrease in surgical time from 140 at the beginning to 80 minutes at the end of our series. Average blood-loss was 788 ml. Three patients received erythrocyte-transfusion. Minor non-orthopaedic complications all resolved within 48 hours. Average length of stay was five-and-a-half days. Functional score-lists showed improvement comparing pre-operative scores with scores on 12 weeks follow-up: Harris-Hip-Score from 56 to 94, Oxford-Hip-Score from 43 to 19, Hip-disability-and-Osteoarthritis-Outcome-Score from 109 to 18. On six weeks follow-up 65% and on 12 weeks 100% of patients showed unaided mobilisation. At follow-up we saw one superficial wound-infection, one partial non-disabling sartorius-lesion, one paraesthesia and one transient anaesthesia of the lateral femoral cutaneous nerve area.

ASI-approach for uncemented THA showed good results and rapid patient-mobilisation. This may in part be due to the non-dissecting of muscles or insertions, thus non-compromising the propriocepsis. Off course tissue-damage occurs, though this is likely to be of a fast reversible nature. There were no serious adverse events. We saw a rapid decline in session-duration suggesting a moderate learning-curve. Further research will have to prove the beneficiality of the ASI-approach.


D. Lozano P Esbrit A.J. Salinas J.C. Doadrio M. Vallet-Regí E. Gòmez-Barrena

SBA-15 is a siliceous mesoporous ordered material with hexagonal arrangement of 9-nm tubular pores connected by micropores, high pore volume and abundance of silanol groups. This functionalised material could thus tailor the release kinetics of specific biomolecules to the clinical needs. Non-functionalized SBA-15 and its C8- or C3-alkyl-derivatives were coated with parathyroid hormone–related protein (PTHrP)(107–111) to assess their relative effects on osteoblastic cell growth and function.

SBA-15 was functionalized with either octyl or propyl trimethoxysilane (C8 or C3 precursor, respectively) in ACN for 24h and then were coated (or not) by dipping in 10 nM PTHrP (107–111) solution for 24 h at 4°C. After air drying, biomaterials were transferred to culture dishes. MC3T3-E1 cells were cultured in differentiation medium with SBA-15, C3-SBA-15 and C8-SBA-15, loaded or not with the peptide. Cell viability and proliferation were evaluated by trypan blue exclusion and a proliferation kit (Promega), respectively. Alkaline phosphatase (ALP) activity and collagen secretion were determined by colorimetric methods. Gene expression was analyzed by real-time PCR. Mineralization was assessed by alizarin red staining.

PTHrP(107–111)-coated SBA-15 increased cell proliferation (50%), cell viability (20%), and ALP activity (15%) over control values within 2–4 days. At day 2, collagen secretion increased (20%), and also the gene expression of ALP, PTHrP, and VEGF, which normalized at day 8, in these cells. An increase (by 30–40%) in all of these parameters was induced by peptide-coated C3-SBA-15 at day 4. Similar stimulatory effects were also observed with PTHrP(107–111)-coated C8-SBA-15 but only at day 8. At day 10, collagen secretion slightly increased (10–15%), and also mineralization (30–40%) with both functionalized materials coated with the PTHrP peptide.

In conclusion, PTHrP(107–111)-coated SBA-15 stimulates osteoblastic function in vitro; an effect delayed by C3- or C8-functionalization. These data further support the clinical impact of this bioceramic as functionalized implants in vivo.


E. Yates A. Goel J. Moorehead S. Scott

Posterior dislocation of replacement hips may occur during hip flexion and adduction. Whilst hip braces can restrict hip movement, they are cumbersome and have a low patient compliance. Knee braces are more comfortable to wear and also restrict hip movement by tightening the hamstrings. This study investigated the effect of a knee brace on hip flexion and adduction.

The movement of 20 normal hips in 20 healthy volunteers aged 25–62, were assessed using a magnetic tracking system (Polhemus Fastrak). Tracking sensors were attached over the iliac crest and lateral thigh. Subjects were asked to lie on a couch and flex and adduct their hip three times with their knee bent. A knee brace was then applied and the hip movements were repeated with the knee extended. During each movement the tracker recorded hip flexion and adduction angles with an accuracy of 0.15 degrees.

When the knee was flexed, the mean hip flexion angle was 66.00 (CI95 = 61.1, 70.8). When the knee was braced, the mean hip flexion angle was 35.30 (CI95 = 28.5, 42.1). Hence the knee brace reduced hip flexion by 46 % (30.70). A paired t-test found this highly significant (P < 0.001).

When the knee was flexed, the mean hip adduction angle was 23.70 (CI95 = 20.6, 26.9). When the knee was braced, the mean hip adduction angle was 21.60 (CI95 = 19.2, 24.1). Hence the knee brace reduced hip adduction by 9 % (2.10). A paired t-test found this was not significant (P = 0.3).

These results indicate that a knee brace can restrict hip flexion by almost 50%. This information may be useful for patients in whom restriction of hip flexion provides hip stability. As the knee brace is more comfortable than the hip brace, a better patient compliance can be expected.


U. Butt A. Malik S. Rehaana D. Aspros R. Gleeson

To investigate whether stopping clopidogrel on admission and subsequently delaying surgery in patients with hip fracture increases the risk of cerebrovascular complications and in-hospital mortality.

Retrospectively studied patients with hip fractures on clopidogrel admitted to our trauma unit between January 1, 2006 and May 31, 2007. Fifteen patients aged over 65 years with intra-capsular and extra-capsular hip fracture were reviewed. Demographic details of patients were recorded including the primary diagnosis on admission, timing of surgical intervention performed, pre-and post-operative haemoglobin and classification according to the American Society of Anesthesiologists (ASA) and in hospital mortality.

Eight fractures were intra-capsular and seven extra-capsular. The mean preoperative haemoglobin levels were 12.4 (range 9.9 to 14.1), the mean postoperative haemoglobin level were 9.7 (range 8 to 12.3). Four patients required blood transfusions, 8 unit of blood were transfused in total postoperatively. The mean delay in surgery were 9.1 days (range 7 to 14 days). The mean duration of hospital stay was 21 days (range, 8 to 45 days). The 30-day mortalities were 3/15 (20%). Mortalities were secondary to cerebrovascular events.

In summary, we found increase mortality and requirement for blood transfusion in patients on clopidogrel in whom surgery were delayed. A well designed research is needed to achieve evidence based management, but this may require several years due to the small, but increasing, number patients seen at present. We suggest early surgery for elderly hip fracture patients on clopidogrel. Patients on clopidogrel should be cross matched pre-operatively for red blood cells and platelets and experienced surgeon should perform the procedure.


I. Nizam R. Oliver W. Walsh

Although effects of mechanical stimulation with high frequency, low magnitude vibrations on bone mass and bone mineral density in animal and clinical studies have been proven effective, its effects on fracture healing is less well described.

20 Sham and 20 ovarectomised (Ovx) Sprague Dawley rats at 22 weeks of age, had intra-medullary k-wire fixation followed by controlled mid-shaft fractures.

The animals were divided into subgroups of 3 week Sham and Ovx treated and non-treated and 6 week Sham and Ovx treated and non-treated groups.

The treated animals were vibrated for 20mins daily on a DMT (dynamic motion therapy) platform which had a frequency of 30hz, 8-micron vertical displacement and 3g force, the non treated animals allowed to move freely. Xrays, DEXA studies, micro computed tomography, Histological analysis and Mechanical studies performed at the end point.

DMT treated animals had more bridging callus on radiographic and micro computed tomographic analysis compared to non-treated groups especially the OVX groups at 3 weeks compared to controls or Shams (using Image J software). DEXA studies showed increased bone mineral density and bone mineral content in the treated animals compared to the controls. Histological analysis showed increased callus and woven bone being laid down in the treated OVX groups.

In the 6-week groups, the treated OVX groups had healed, remodelled fractures compared to the non-treated groups or Sham controls where the fracture gaps were still visible. Although significance was not achieved on mechanical analysis due to small sample size, in the OVX non-operated femora group that were treated with DMT there were indications that they were stronger than the control counterparts.

High frequency low magnitude vibrations with the Juvent DMT device enhances fracture healing in oestrogen deficient models and this model could be used as a platform for clinical studies in future.


B. Moretti A. Notarnicola R. Tamma A. Zallone S. Patella V. Patella

The osteoclastogenesis is regulated by a complex signaling system between the pro-apoptotic factors (Bax-Cyclin E2-Cdk2) and the tumor necrosis factor family (RANKL-RANK-OPG).

Extracorporeal Shock Waves Therapy (ESWT) have recently been used in orthopaedic treatments to induce bone repair, but their mechanisms of action are not sufficiently investigated. So we studied the effect of shock-waves on murine osteoblastic cells.

Osteoblast cultures were subjected to a single shock-wave with combinations of low energy intensities (0.05mJ/mm2) and 500 number of shocks (impulses), whereas control cells received no treatment. We valued the cell viability quantifying the expressions of Bax and Opg by PCR.

We found an immediate negative effect on cell viability, that occurs with an increase of Bax protein expression after 3 hours of treatment. After a longer time lapse a stimulatory effect on cell proliferation, as reflected by the increase of a G(1)-S phase marker, was observed. In fact, in the following 24, 48 and 72 hours after ESW treatment, we found a stronger association of Cyclin E2 and Cdk2, forming active cyclin E-Cdk2 kinase, compared to untreated cells at the same times.

We further explored the molecular mechanism for the ESW induction of osteogenesis: by Real Time PCR an enhancement of Runx2 mRNA, evident 48 hours after the treatment, was found. A link between physical ESW and Runx2 activation has been already demonstrated. ESW-induced

O2- production, followed by tyrosine kinase mediated ERK activation and Runx2 activation, resulted in osteogenic cell growth and maturation. Moreover, we analyzed the cytokines RANK-L and OPG osteoblast expression, involved in regulation of osteoclastogenesis. A decrease in RANK-L/OPG ratio was found, perhaps leading to a reduced osteoclastogenesis.

The Shock waves have a repair action on bone and it can been explained by the regulation on osteoclastogenesis by the apoptoic pathway of BAX and OPG.


J. Valle J. Mingo B. Rizo L. Lopez-Durán

In the last years there is an increase in the interest in the study of growth factors that take part in the process of consolidation of the fracture to be used as treatment. The different types of fixations modify the natural process of the fracture healing and the production of growth factors could also be affected. There is not evidence in the literature of the effect that the intramedullary reaming has on the osteogenesis. We did a study to analyse the effect of intramedullary reaming on the production of growth factors during the process of fracture healing in the femur of rats. We did a pospective study in San Carlos Clinical Hospital from Madrid in which was made a fracture on the femur of 64 adults rats type Sprague-Dawley. The rats were divided in two main groups; each group received one different treatment: 30 rats with intramedullary nail and 34 rats did not receive any treatment. The rats of each group were sacrificed in 4 different moments: at the 24th hour, 4th, 7th and 15th days after the fracture was done, and we measured the amount of growth factors that appeared in the callus fracture, by anatomopathology study. The group in which was done the intramedullar nailing recovered normal walk after surgery. In this group were found more production of BMP and PDGF compared to the control group but did not reveal any significant difference between the groups (p> 0,05). Differences about other growth factors as TGF were not found. We conclude that in the results we have taken, the increase on BMP and PDGF could be produced by the intramedullary reaming by the surgery technique but we would need more studies.


S. Checa I. Svensson M. Tägil P. J. Prendergast

The influence of the mechanical environment on tissue differentiation has been widely investigated. However many questions remain about the actual process and the parameters that govern it. It has been proposed that tissue differentiation is driven by a biophysical stimulus which is a combination of fluid flow and octahedral shear strain. In order to further investigate the influence of the mechanical environment on tissue differentiation we have tested this hypothesis within a mechanically controlled bone chamber.

The bone chamber consists of a titanium cylinder with two bone ingrowth openings at one end which allow tissue to grow in from the subcortical cancellous bone. It is equipped with a piston protruding into the chamber for the application of a known pressure to the ingrowth tissue.

A 3D poroelastic finite element model of the inside of the bone chamber was developed. To model the dispersal of the various cell populations inside the tissue a lattice was created within each finite element, representing a space for both the cell and extracellular matrix. The differentiation process was ruled by fluid flow and shear strain. The change in tissue phenotype was implemented through a change in mechanical properties. Loading conditions corresponded to those applied during conducted experiments

High fluid flow and shear strain at the top and bottom of the chamber favoured tissue differentiation towards fibrous tissue. In the middle region, bone formed. A cartilage layer between the bone and the fibrous tissue was predicted, which is qualitatively in agreement with the experiments.

Although acceptable simulation/experiment comparison is achieved, in reality great variation is found in experiments, whereas our simulations are deterministic. It is clear that deterministic simulations can not capture the nature of tissue differentiation in this chamber. Nonetheless, tissue differentiation algorithms based on fluid/strain stimuli and using lattice models for biological activity are a promising tool in their ability to predict tissue differentiation inside a mechanically-controlled bone chamber.


P. Gutiérrez Carbonell P. Doménech Fernández J.A. Lajarín Ortuño A. Pérez Trigueros

Spastic muscles show permanent contraction but also paradoxical muscular weakness. Compartmental muscular pressure in normal subjects oscillates between 0 and 5 mmHg.

To study compartmental pressure in the posterior superficial compartment of the leg in children with spastic paralysis, to identify its variations after a percutaneous tenotomy of the Achilles tendon, and to find any possible connection with arterial pressure or weight.

Twelve patients who had undergone a percutaneous tenotomy of the Achilles tendon were studied. Six of them were tetraplegic and three hemiplegic, with bilateral and unilateral tenotomies respectively. The following variables were taken into consideration: age, weight, systolic and diastolic arterial pressure and pressure of the superficial compartment of the leg, both pre- and post- tenotomy. The measurement of the compartmental pressure was taken using an automatic calibration monitor with an error of measure of ± 1 mmHg. Statistics: descriptive, non-parametric tests (Wilcoxon, Kruskall- Willis).

The average age was 9.3 years old, 11 in men and 7.5 in women. 89.5% of the total population was male and 10.5 % female. The average weight was 27.2 Kilograms, 28.1 Kg. in men and 20.5 Kg. in women. Systolic pressure was 94.1 mmHg and diastolic pressure 41.3 mmHg. Pre-tenotomy compartmental pressure was 12.1 mmHg and 7.9 mmHg post-tenotomy, decreasing 34.5 % (p= 0.08, N.S.). Systolic pressure had no relation to pre-tenotomy (r = −0.16) o post-tenotomy (r = −0.13) compartmental pressure. Diastolic pressure had no relation either (p =0.2 and r=−0.36), respectively. The pressure of the superficial compartment of the leg is higher than normal in spastic patients, decreasing, although not significantly, after a percutaneous tenotomy of the Achilles tendon is performed.


M. Ding L. Cheng P. Bollen P. Schwarz S. Overgaard

There is a great need for suitable large animal models that closely resemble osteoporosis in humans, and that they have adequate bone size for bone prosthesis and biomaterial research. This study aimed to investigate effects of a 7 month glucocorticoid (GC) treatment alone without ovariectomy on the properties of sheep cancellous bone.

Eighteen female sheep were randomly allocated into 3 groups: group 1 (GC-1) received GC (0.60mg/kg/day methylprednisolone) 5 days weekly for 7 months; group 2 (GC-2) received the same treatment regime for 7 months, and further observed for 3 months without GC; and group 3 served as the control group, and left untreated for 7 months. The sheep received restricted diet.

After 7 months of GC treatment. Cancellous bone volume fraction of the 5th lumbar vertebra in the GC-1 group was reduced by −35%, trabecular thickness by −28%, and changed from typical plate structure to a combination of plate and rod structure with increased connectivity by 202%. Bone strength was reduced by 52%. Bone formation marker, serum osteocalcin of GC-1, was reduced by 71% at 7 months, but recovered with an increase of 45% at 10 month in the GC-2 group. Similar trends were also seen in the femur and tibia. At 10 months, the GC-2 group had microarchitectural and mechanical properties similar to the level of the control sheep.

We have demonstrated in this study that 7 month high-dose GC on bone density and microarchitecture are comparable with those observed in human after long-term GC treatment. Moreover, we have shown that the bone quality with regard to strength and microarchitecture recovers after 3 months further observation without GC. This suggests that a prolonged administration of GC is needed for long-term observation to keep osteopenic bone. The model will be useful in pre-clinical studies.


P Eliasson A Fahlgren P Aspenberg

Healing of tendons is sensitive to mechanical loading, and the callus strength is reduced by ¾ after 14 days, if loading is prevented. Exogenous GDFs stimulate tendon healing. This response is influenced by loading: without loading, cartilage and bone formation is initiated. This suggests that BMP signalling is crucial during tendon healing, and that it is influenced by mechanical loading. We investigated if mechanical loading influences BMP signalling in intact and healing tendons, and how BMP gene expression changes during healing.

The Achilles tendon was transected in rats and left to heal. Half of the rats had one Achilles tendon unloaded by injection of Botox in the calf muscles. Ten tendons were analyzed before transection and for each of four time points. Gene expression for OP-1, GDF-5, -6, -7, Follistatin, Noggin, BMP-receptor 1b and BMP-receptor 2 were analysed with real-time PCR.

Loading had no detectable effects on intact tendons. During repair, loading decreased follistatin by more than half (p=0.0001), and increased GDF-5 (p=0.02). All genes showed changes during repair (p=0.0001), but the time sequences differed. GDF-5 and GDF-7 were generally more expressed than OP-1 and GDF-6. GDF-5 and GDF-7 were more expressed in normal tendons than during repair. Noggin was never detected.

Our results suggest that GDF-5 is specific for the mature tendon, and not much involved in repair. This contrasts to GDF-7, which is involved in both. OP-1 and GDF-6 seem to be involved in early healing. There was less expression of follistatin in loaded tendons during healing. The mechanosensitivity is likely of most importance at day 14 and 21 since the difference in strength between loaded and unloaded tendons is huge. An Anova with only these time points reveals effects of loading on GDF-5 and follistatin (p=0.0001 for both) and significant differences between the days for most variables.


P.E. Galibarov A.B. Lennon P.J. Prendergast

Computational modelling has the potential of becoming a useful tool in assessing revision risk on a patient-specific basis. However, there are many difficulties encountered in generating subject-specific computational models that have unknown influences on such predictions, e.g. accuracy of the anatomical geometry and material properties of the patient. This study compares the influence of these two patient-specific parameters on predictions of revision risk due to aseptic loosening.

First, X-rays from seventeen patients were processed using previously developed technique utilising rigid scaling of a generic femur to match selected dimensions from each patient’s post-operative X-ray and, then, the same set of 3D models was obtained by using an automated technique that generates 3D extra-cortical geometries from planar X-rays using a combination of 2D contour extraction and 3D warping of a generic model to match the extracted contour.

A cement and cement-metal interfacial damage accumulation algorithm developed previously was used. For each geometric set two types of simulations were performed. First, constant cortical and cancellous bone apparent Young’s moduli were assumed. A second set of simulations used age-dependent Young’s moduli for each bone type. Walking and stair-climbing activities were simulated. Resultant migration of the prostheses was used to indicate revision risk.

Factorial analysis has shown that the geometry has a larger influence on resultant migration magnitude for each case; however, unexpectedly, using more realistic geometry weakened the strength of predictions. This is most likely to be due ongoing mesh-induced contact problems.


F. Valera FJ. Minaya A. Melián X. Veiga F. Medina C. Ortega

Ultrasound has been shown to have positive biological effects, including increased angiogenic, chondrogenic, and osteogenic activities.

The aim of our study was to evaluate the evidence available in the scientific literature for the ultrasound treatment for tendon healing.

To identify “best evidence” published research a computerized literature search of Medline, Cochrane, PEDro, IME, IBECS and ENFISPO. Keywords used to identify the study population and interventions were: ultrasound, low intensity pulsed ultrasound, physiotherapy, clinical trial, meta-analysis, practice guideline, randomized controlled trial, repair tendon and tendon healing.

The scientific evidence of the group of selected documents were measured using the scale described by the US Preventive Task Force. The assignment of the evidence level to each study was evaluated independently by two reviewers without communication among them. To determine inter-rather reliability Kappa index it was used (K) with a value of CI of 95%.

The study populations were 39 pertinent recovered documents. The findings suggest that therapeutic ultrasound can increase in collagen synthesis and enhance the maturation of collagen fibrils of repairing tendons. Researchers have reported that therapeutic ultrasound could facilitate tissue recovery and US with dosages between 0.125–3 W/cm2 have been used in the treatment of tendon ruptures reported an improvement in both strength and energy absorption capacity of repairing rabbit or rat tendons with 1-MHz continuous US. Best results were: continuous US at 1 MHz, 0.5w/cm2 starting from day 5 after injury, 20 treatment sessions, 4 mi each session. There is not a general consensus on the choice of parameters for US treatment and the evidence for efficacy of therapeutic.

Limits of studies: The time needed to develop such an interface in humans was reported to be much longer than that reported in animal models.

Continuous and low-intensity pulsed ultrasound was able to accelerate tendon healing and facilitating earlier physiotherapy.


A.B. Lennon P.J. Prendergast

Aseptic loosening can be considered as a combination of both mechanical and biological failure scenarios. This study investigated the influence of including bone remodelling in the simulation of aseptic loosening of cemented hip prostheses.

A combined strain and damage stimulated bone adaptation algorithm (Mulvihill et al., Proc. ESB Summer Workshop, p.114–115, 2007) was modified for use on an apparent tissue level. Constant rate resorption or deposition occurs if local strain falls outside a quiescent reference strain range. Furthermore, damage accumulates as a function of tensile stress. Resorption and simultaneous repair is activated above a critical damage level. Model parameters are related to specific surface area expressed as a function of apparent tissue density. Elastic modulus was also a function of accumulated damage. This algorithm was applied in conjunction with a bone cement and cement-metal interfacial damage accumulation algorithm to simulate aseptic loosening for a retrospective dataset of early revision and long-term-unrevised patients (Lennon et al. JOR, 779-88, 2007). One year of walking activity was simulated and resultant migrations of the prostheses were used to indicate revision risk.

The current implementation demonstrated increased migration for simulations with bone remodelling (p= 0.01). Variability was increased but mean predicted migration for early revisions was significantly higher than for the unrevised group (p= 0.03). Bulk bone remodelling was predicted primarily in the proximal regions. Interfacial bone remodelling demonstrated oscillation in damage at the interface due to alternate resorption-repair and deposition cycles. Interfacial bone density changes were more prominent in proximal regions but some models did show small amounts of resorption in more distal Gruen zones.

We conclude that bone remodelling has potential to predict more realistic migration patterns but further development and assessment is needed to identify the correct parameters for the bone adaptation algorithm.


B. Pasternak T. Schepull P. Aspenberg

Local dysregulation of the proteolytic matrix metalloproteinases (MMPs) and their tissue inhibitors of metalloproteinases (TIMPs) is a feature of tendon degeneration and rupture.1,2 To assess the role of systemic MMPs and TIMPs in tendon rupture we compared serum MMPs and TIMPs between patients who have previously suffered Achilles tendon rupture and healthy controls. We also followed serum MMPs and TIMPs prospectively in patients with acute tendon rupture.

At three years after injury, we measured serum MMP-1, -2, -3, -7, -8, -9 and -13 and TIMP-1 and -2 in eight patients who had suffered Achilles tendon rupture. Serum was also obtained from 12 blood donors with similar age and sex distribution. In another eight patients, MMPs and TIMPs were followed over time, with samples taken at the time of Achilles tendon injury, and after 4, 8 and 24 weeks. MMPs were determined using Fluorokine Multi Analyte Profiling kits while TIMPs were analysed using ELISA (R& D systems). The study was approved by the ethics committee and written informed consent was obtained from all patients.

Patients who had previously suffered tendon rupture had increased levels of MMP-2 (median difference (m.d.) 10 %; p = 0.01), MMP-7 (m.d. 15 %; p = 0.02) and TIMP-2 (m.d. 36%; p = 0.02), as compared to controls. In patients with acute tendon rupture, MMP-2 was the only MMP or TIMP to change significantly over time (p = 0.009). MMP-7 appeared to be higher than control values already at the time of rupture. MMP-13 could not be detected in any sample.

In conclusion, patients with a history of tendon rupture had elevated serum levels of MMP-2, MMP-7 and TIMP-2. Changes in MMP-7 might be present already at the time of rupture. This suggests that disturbances in proteolytic control might render tendons prone to rupture.


J. O. Penny O. Ovesen J.E. Varmarken K. Brixen S. Overgaard

Resurfacing THA is claimed to transfer stress naturally to the femur neck and preserve proximal femoral bone mass postoperatively. DXA is an established method in estimating BMD around a standard THA, but due to the anteversion of the femur neck, rotation could affect the size of the neck-regions and thereby the BMD measurements around a RTHA. To our knowledge, this is the first study to analyze the effects of hip rotation on BMD in the femoral neck around a RTHA.

We scanned the femoral neck of 15 patients twice in each position of 15° inward, 0° and 15° outward rotation, and analyzed BMD in a single and a six-region model. CVs were calculated for BMD in the same position as well as between different positions.

For double measurements in the same position we found mean CVs of 3.1% (range 2.5% – 3.7%) and 4.6% (range 2.2% – 8.6%) in the one- and six-region models, respectively. When the 15° outward position was excluded, the CVs decreased to 2.8% and 4.0%. With rotation, the mean CVs rose to 5.4% (range 3.2%–7.2%) and 11.8% (range 2.7% – 36.3%). This effect was most pronounced in the 6-region model, predominantly in the lateral and distal parts of the femoral neck, where the change was significantly different from the fixated position. For the single-region model 15° rotation could be allowed without compromising the precision.

We conclude that rotation adversely affects the precision of BMD measurements around a RTHA, but in the single-region model smaller rotations can be allowed.

With the hip fixated the six-region model produces low CVs, acceptable for longitudinal studies. For maximal topographical detail we prefer the six-region model and recommend that future longitudinal DXA studies, including RTHA, be performed standardised, Preferably, with the hip in the neutral or internal rotation.


E. Audenaert P. Mahieu P.J. De Roo E. Barbaix L. De Wilde R. Verdonk

Biomechanical models have been successfully applied to screen potential risk factors for injuries and to plan and evaluate the effects of orthopedic surgical procedures.[1] These models have made apparent the feasibility and necessity for the generation of subject specific models that are aimed at custom clinical applications. In order to develop such models a methods needs to be developed that allows accurate geometrical visualization and reconstruction of position and characteristics of bone and soft tissues, including neurovascular structures.[2] In this study, we present our approach to obtain both bony as soft tissue features necessary for upper limb modeling from computer tomography alone. As a case study the techniques were applied in a non-anatomic shoulder reconstruction.

In order to determine the muscles of the shoulder girdle, ultrathin flexible metallic markers were sutured from origin to insertion according to the fiber directions in all muscles involved in shoulder movement on a total of ten different cadaver shoulders. The plexus brachialis and upper limb nerves were dissected and injected with a iodium contrast containing mixture. A Ct multi-slice image reconstruction was performed from occiput to the hip joint. The software package Mimics® (Materialise NV, Heverlee, Belgium) was used to segment and reconstruct the different anatomical models that included bone, muscle features, nerves and vascular structures. A clustering method algorithm, was used to filter interruptions of the different masks, scattering rustle and small irregularities due to the different contrasting markers used. Vascular tissue could be reconstructed and segmented as air filled structures. We were able to accurately reconstruct nerve tissue in an highly complex configuration such as the plexus brachialis.

Analysis of the representations showed that the different morphologic parameters were within the normal anatomical ranges and that our method is suitable to create complete anatomical models based on Ct-imaging alone.


E.M. Ooms P. Pilot W.J. van Doorn R.G.H.H. Nelissen R.L.M. Deijkers

Aseptic loosening of the total TMC joint prosthesis occurs frequently and may depend on the design of the prosthesis. Numerous TMC prosthesis designs are available, and new designs are being developed and tested. One of the problems in the clinical studies of TMC prostheses is identifying and predicting prosthetic loosening at an early stage. Roentgen Stereophotogrammetric Analysis (RSA). allows assessment of three-dimensional micromotion of orthopaedic implants with high accuracy. Early micromotion (in the first two postoperative years) of most prostheses is strongly correlated with the development of aseptic loosening. We studied if RSA assessment was possible after total TMC joint arthroplasty.

In five cadaveric hands the TMC joint was replaced by the SR-TMC prosthesis. Tantalum beads of 0.8 mm were implanted in the trapezium and first metacarpal bone without extending the standard surgical exposure. The metacarpal prosthesis component was provided with 0.5 mm beads. A three-dimensional surface model of the trapezium component of the SR-TMC prosthesis was prepared to facilitate model-based RSA. After the surgical procedure, RSA radiographs were made of all hands in two commonly used positions for imaging of the TMC joint. The number of visually detected markers for each bone/implant was recorded. Of one cadaver hand, RSA radiographs were made in ten different positions to calculate the measurement error of the performed technique.

For the metacarpal bone, all beads were visible in all positions and both (L+R) RSA radiographs. For beads in the polyethylene metacarpal prosthesis component three beads seem sufficient, however in exceptional cases the most proximal placed bead might be invisible due to overprojection by the metal trapezium prosthesis component. Therefore the X-rays should be carefully checked at the radiology department before the patient leaves the ward. Alternatively, an extra bead can be placed in the prosthesis, although this is a lesser option due to possible weakening of the component caused by the placement of the beads. The use of different sizes of beads (0.5/0.8 mm) in the metacarpal bone and metacarpal prosthesis made the interpretation for the analyser easier

The accuracy analysis is currently carried out. First results of these measurements are promising and placement of tantalum beads for RSA analysis during TMC-joint replacement seems feasible.


R. Aleksyniene J. Skovhus Thomsen H. Eckardt K. G. Bundgaard M. Lind I. Hvid

Since the approval of parathyroid hormone (PTH) as an anabolic treatment for osteoporosis, PTH has increasingly been investigated for other potential clinical uses such as bone repair and regeneration. The microstructure of newly formed bone during distraction osteogenesis enhanced by PTH treatment has yet to be studied. Therefore, the purpose of the study was to investigate the effects of intermittent parathyroid hormone PTH (1–34) treatment on the microstructure of regenerated bone during distraction osteogenesis in rabbits. After tibial mid-diaphyseal osteotomy the callus was distracted 1 mm/day for 10 days. The rabbits were divided in to 3 groups, which daily received a PTH injection for 30 days, a saline injection for 10 days and a PTH injection for 20 days, or a saline injection for 30 days. The new-trabecular structure of the regenerate callus was assessed by micro computed tomography (μCT). In all 51 specimen obtained from the lengthened tibia were scanned and evaluated morphometrically using three different volume of interests. The investigated μCT parameters included trabecular number Tb.N*, trabecular thickness Tb.Th*, trabecular separation Tb.Sp*, bone volume fraction (BV/TV), bone volume (BV), connectivity density (CD), and degree of anisotropy (DA). The results showed that intermittent treatment with PTH during distraction osteogensis resulted in a significantly higher Tb.N*, a more isotropic trabecular orientation, a higher connectivity density, and a higher bone mass. We also found preliminary evidence suggesting that the newly regenerated calluses treated with PTH were more mature than the non-treated calluses. In conclusion: the study demonstrated that treatment with PTH resulted in an enhanced microstructure of the newly regenerated bone indicating that PTH has a potential role as a stimulating agent for distraction osteogenesis.


M. Tannast S. Mistry S.D. Steppacher S. Reichenbach K.A. Siebenroc G. Zheng

An ample number of radiographic hip parameters on anteroposterior (AP) pelvic radiographs vary significantly with individual pelvic tilt and rotation. We developed specific computer software Hip2Norm to perform 3D analysis of the individual hip joint morphology using 2D AP pelvic radiographs. Twenty-five parameters can be calculated for a neutral orientation. The aim of the study was to evaluate the validity of this method for tilt and rotation correction of the acetabular rim and associated radiographic parameters. The validation comprised three steps:

External and

internal validation; and

intra-/interobserver analysis.

A series of x-rays of 30 cadaver pelves were available for step 1 and 2. External validation comprised the comparison of radiographical parameters of the cadaver hips when determined with Hip2Norm in comparison with CT-based measurements or actual radiographs in a neutral pelvic orientation. Internal validation evaluated the consistency of the parameters when each single pelvis was calculated back from different random orientations to the same neutral pelvic position. The intra-/interob-server analysis investigated the reliability/reproducibility of all parameters with the help of 100 randomised, blinded radiographs of a consecutive patient series.

All but two parameters (acetabular index, ACE angle) showed a good to very correlation with the CT-measurements.

Internal validity was good to very good for all parameters.

There was a good to very good reliability and reproducibility of all parameters except five parameters.

The software could be shown to be an accurate, reliable and reproducible method for correction of AP pelvic radiographs. This computer-assisted method allows standardised evaluation of all relevant radiographic parameters for detection of anatomic morphologic differences. It will be used to study the influence of pelvic malorientation on the radiographic appearance of each individual parameter and the clinical significance of standardising pelvic parameters.


E. Ross TJ. MacGillivray AY. Muir AHRW. Simpson

X-ray is the standard method for monitoring fracture healing however it is not ideal; signs of healing are not normally visible on X-ray until around 6–8 weeks post fracture. Ultrasonography allows the detection of both the initial haematoma, usually formed immediately after fracture, and the small calcium deposits laid down between broken bone ends in the first stages of fracture healing. It has been reported that these early indicators of the healing process are visible as early as 1–2 weeks after fracture. We use Freehand 3D Ultrasound to monitor the early stages of fracture healing as both the bone surface and surrounding soft tissues can be imaged simultaneously.

The Freehand 3D Ultrasound system consists of a standard Ultrasound machine, a PC running STRAD-WIN (Medical Imaging Group, Cambridge University) 3D software, and an optical tracking devise (NDI Polaris) to record the position and orientation of the Ultrasound probe during scanning. Images are transferred from the Ultrasound machine to the PC using RF capture through out a scan. Calibrating the system matches up the correct image with the correct probe position to produce a 3D dataset.

We segment features of interest on the sequence of 2D images to construct a 3D model. These models are rotatable and provide views of the scanned anatomy that are not otherwise achievable using conventional Ultrasound or X-ray. The 3D data set can also be resliced through any plane to provide further views.

To conduct a 3D Ultrasound scan takes the same amount of time as a conventional 2D scan. The production of the 3D model takes between 15–60 minutes depending on the level of detail required. Distances are measurable to within ±0.4mm meaning fracture gaps of sub-millimeter width can be resolved. The system has already been evaluated on healthy volunteers and a clinical study currently underway.


Y. Loosli D. Baumgartner G. Bigolin B. Gasser P. Heini

Posterior internal fixation systems undergo internal constraints resulting in high load bearing requirement for the pedicular screw/bone interface. Only few studies deal with the impact of the vertebral augmentation on the migration of pedicular screws. In this study, the impact of the pedicular screw augmentation has been investigated under physiological load for osteoporotic vertebras. The data have been proceeded to reduce the influence of vertebral geometry, which generally leads to results devoid of statistical meaning

In 8 osteoporotic vertebrae, two screws have been inserted in each vertebra: a non-augmented on one side and an augmented one on the contralateral side.

Compression tests have been performed (two consecutive 50 cycles load steps -100N and 200N-) to observe the displacement of the screw’s head. Two different setups have been employed: a free connection (FC) and a blocked connection (BC). A load step is successful if the migration between two consecutive cycles tends to zero. To reduce the impact of the vertebras’ geometry, the screws’ migration have been compared contra-laterally using the migration ratio (MR). MR of vertebrae is defined as the division of the augmented screw’s migration with the non-augmented screw’s migration.

All the augmented screws survived both test setups whereas the non-augmented failed the 200N FC load step. Significant differences are observable only for the highest successful load steps for each test setup: T-tests (P=0.039 and P=0.007 respectively) put into evidence that the results are statistically smaller than one. It is observable as well, that the BC induced fewer loads into the vertebrae: even non-augmented screw can withstand 200N load step.

As expected, augmentation of pedicular perforated screws increases their stability in osteoporotic vertebras undergoing large physiological load. This could be explained by the fact that the presence of PMMA increases the load transfer interface improving screw/PMMA complex bearing capacity. Smaller loads induce only small differences that are not significant.


D. Baumgartner A. Hegewald P. Schwilch H. Gerber E. Stüssi

The safety of nucleus implants remains an open issue in the treatment of intervertebral disc degeneration. Post-operative migration and subsequent extrusion represent a high risk of potential unsatisfactory outcome. The effectiveness of additionally sewing a biointegrative nucleus implant into an annulus defect was investigated therefore in this experiment.

Laminectomy preserving the facet joints was performed on seven human functional spinal units (FSU’s). A reproducible annulus defect of 6×6 mm was incised, followed by a standard nucleotomy procedure and subsequent introduction of the implants. These woven patches consist of biointegrative, absorbable polyglycolic acid (PGA), lyophilized with hyaluronic acid. The annulus sealing technique requires placing a PGA-patch adjacent to the inner annulus, fixed by sutures (Polysorb 3-0, Syneture) at its four corners. Unsealed annulus defects served as a control group. FSU’s were loaded with a bending torque of 5 to 7.5 Nm. Continual revolution of the specimen around its vertical axis resulted in a combination of lateral, dorsal and flexural bending. During application of loads, implant herniation level was determined every 1 000 cycles according to predefined criteria. Tests were stopped after reaching 20 000 cycles.

Five of totally six sewed specimens withstood 20 000 load cycles, whereas only one of five not sewed specimens terminated successfully. Based on the Mann-Whitney test, significant increase in stability can be detected for the sewed procedure.

Sewing a biointegrative annulus implant into an annulus defect improves nucleus implant containment. It remains to be shown whether this annulus sealing technique is also effective in highly degenerated annulus tissue. Furthermore, a minimally invasive implantation device is crucial for application in a clinical setting.


E. Zamorano F. Valera FJ. Minaya G. Plaza A. Melián X. Veiga

Neurodynamic tests are daily regarded as important in orthopedic physical assesment. Changes in neural tension provoked by these tests over differents nerve trunks in lumbopelvic region may alter the nociceptive responses of nearby tissues.

The aim of our study was to evidence changes in mechanical nociceptive thresholds (MNTs) of lumbopelvic muscles in different neurodynamic positions.

Cross-sectional study. Fifty asymptomatic volunteers were evaluated with algometer in three neurodynamic positions:

Contralateral side-lying position with knees at 90° of flexion, hips at 70° of flexion and spine in neutral;

initial position with the homolateral knee in complete extension to add neural tension of sciatic nerve;

initial position incorporating maximum craniocervical flexion to add neural tension within vertebral canal.

The pressure algometry was tested at one anatomical site on gluteal region 2.5 cm. below iliac crest bone and behind iliotibial band.

One physiotherapist (PT) measured MNTs unilaterally over gluteus medius. Three consecutive measurements was evaluated in the three described positions, while a second PT reported the data in kilograms (kg). A third PT was responsible for modifying the knee and craniocervical range of motion.

The findings revealed significant mean differences (SMD) (0.522 kg; 95% IC: 0.385–0.659 kg) in algometry measurements (P < 0.0001) betweeen position 1 (mean 3.632 kg; SD 1.235 kg) and position 2 (mean 3.110 kg; SD 1.233 kg), SMD (0.590 kg; 95% IC: 0.412–0.768 kg) (P < 0.0001) betweeen position 1 and position 3 (mean 3.042 kg; SD 1.136 kg). Furthermore, no SMD between the two different neural tension positions (P < 0.420).

We concluded that MNTs of lumbopelvic muscles decrease with neural tension positions. MNTs decrease is similar with sciatic nerve and vertebral canal neural tension positions. So, neurodynamic positions are important procedures to be taken into account in clinical reasoning, both physical therapy diagnosis and treatment.


E. Sapin F. Chan G. Ayoub C. Roux W. Skalli D. Mitton

Mechanical tests that have been carried out to validate finite-element models predicting vertebral strength concern vertebral bodies under axial compression. But in standing position gravity loads can induce a flexion component, especially for the last thoracic and first lumbar vertebrae. The aim of the study was to evaluate the strength of complete vertebrae under anterior compression.

15 isolated vertebrae T11-L2 (four women, one man, 88 ± 14 years old) were tested to failure. The load was applied at the one third of the vertebral body depth through a ball constrained in a hole. It was homogeneously distributed on the vertebral endplate through a polymetylmetacrylate (PMMA) layer which completely fills the concavity. The solid composed by the PMMA layer and the steel plate containing the hole for the ball was called “upper plate”. Its 3D orientation was assessed using the Polaris® motion capture system (accuracy: 0.6 mm, 0.6°) thanks to tripods. Before testing, the position of the marker-frames was assessed using 3D reconstructions (obtained by bi-planar X-rays) to express all the movements relatively to the vertebral frame.

The outcome data was the position of the upper plate. The load was calculated from the measurement of the vertical load (using the testing machine sensor) and the orientation of the upper plate (using the Polaris® system).

The mean flexion of the upper-plate is equal to 1° (± 0.7°) before the vertebra collapses. As this value is weak, the optoelectronic assessment could be removed during the test if the initial 3D orientation of the upper plate relatively to the vertebral frame is assessed.

This protocol allowed collecting with accuracy all the data necessary to validate models.


F. Dakhil-Jerew S. Haleem J. Shepperd

Introduction: We report a series of 10 cases from a cohort of 421 Dynesys procedures in which evidence of Accelerated Adjacent Disc Disease (AASDD).

Spinal fusion for degenerative disc disease is known to have inconsistent outcomes. One concern is the possibility of AASDD as a result of the altered kinematics. The Dynamic Neutralisation System (Dynesys) appears to offer an advantage in that it restricts, rather than abolishes movement at the treated segment, and should thereby reduce the problem of AASDD, In the event of failure, it can in addition be removed, returning the spine to the former status quo. Various biomechanical studies confirmed flexibility of Dynesys.

Method: Ten patients developed new and symptomatic disc disease within segments adjacent to Dynesys. The average age of patients was 49 year with range between 36–70 years. Average post Dynesys to secondary surgery for ASD was 24.7 months. Previous discography and MRI in all cases had shown no evidence of disc disease within these adjacent segements prior to Dynesys. All patients were evaluated preoperatively using Oswestry Disability Index, SF 36 and Visual Analogue Scores together with plain x ray imaging, MRI scanning and discography. Of this cohort Dynesys was indicated to treat single disc level in 7 and two levels in 3

Results: Incidence of AASDD associated with Dynesys was 2.1%. Further surgical intervention included:

Extension of Dynesys10

Dynesys combined with MIF2

Dynesys combined with PLIF2

There was no caudal ASD in our cohort.

Discussion & Conclusions: Dyensys did not prevent the development of accelerated ASD. Evidence from Aylott cadaver studies suggests that Dynesys instrumentation alters the Kinematics of the adjacent segment and increases the excursion. It is unclear whether the small number of AASDD reported here is other than the natural progression of degenerative change. 95.7 cases did not progress.


C. Barrios M.J. Gòmez-Benito D.C. Botero J.M. García-Aznar M. Doblaré

A recently developed parametric geometrical finite element model (p-FEM) was adapted to the specific hip geometric measurements of a group of patients with slipped capital femoral epiphysis (SCFE). The objective was to analyze the stress distribution in the growth plate of these patients and to evaluate differences for those patients who developed bilateral disease.

Different geometric parameters were measured in the healthy proximal femur of 18 adolescents (mean age, 12,1 yr) with unilateral SCFE and in 23 adolescents matched in age without hip disease (control group). Five patients developed SCFE in the contralateral side during follow-up. Different geometric measurements were taken from hip conventional X-ray studies. The p-FEM of the proximal femur permits modifications of different geometrical parameters, therefore the X-ray measurements taken from each patient were applied to the model obtaining a subject-specific model for each case. In each model, different mechanical situations such as walking, stairs climbing and sitting were simulated by applying loads on the femoral head corresponding to each own weight. The risk for growth plate failure was estimated by the Tresca, von Misses and Rankine stresses.

In summary, the models shows important differences between the stresses computed at the healthy femurs of patients with unilateral SCFE and femurs that further underwent bilateral SCFE. So, the 95% confidence interval of the percentage of volume of the growth plate subjected to stresses higher than 2MPa was almost similar for the control group and patients with unilateral SCFE. However, those patients who developed bilateral disease had statistically significant large physeal areas with more than 2.0 MPa (p< 0.005). Stresses were also strongly dependent on the geometry of the proximal femur, especially on the posterior sloping angle of the physis and the physeal sloping angle.

In spite of simplifications of the developed p-FEM, this tool has been able to show the influence of femur geometry in growth plate stresses and to predict the sites where growth plate starts to fail.


C.G. Fontecha M. Aguirre F. Soldado J.L. Peiro N. Toran V. Martinez

The continuous leakage of cerebrospinal fluid in the mielomeningocele (MMC) area produces the Chiari II malformation. The aim of our study was to assess the effect of preterm delivery and prenatal corticosteroids administration in the degree of Chiari malformation.

Seventy-five out of 148 foetuses from 17 pregnant New Zealand White rabbits underwent lumbar three-level laminectomy and wide opening of dura-mater (surgical MMC). Animals were distributed in five groups: group T, foetuses with MMC, delivery at term and no other treatment; group TC, foetuses with MMC, delivery at term and prenatal administration of corticosteroids; group P, foetuses with MMC, delivery preterm and no other treatment; group PC, foetuses with MMC, delivery preterm and prenatal administration of corticosteroids; group C, controls. The degree of herniation was measured in percentage of decrease of the cerebellum between the inferior limit of the skull and the superior limit of the first vertebra, and compared among groups.

We obtained 7T, 5TC, 10P, 6PC, and 28C alive newborns. All groups with prenatal delivery or prenatal corticosteroids showed statistically significant minor degree of herniation than T-group: group TC IC 95% between 25.7 and 47.2% minor (p=0.000), group P IC 95% between 30.4 and 47.7% minor (p=0.000), group PC IC 95% between 32.6 and 55.4 minor (p=0.000). There were no statistically significant differences among groups TC and P (p=0,577), TC and PC (p=0,227) or P and PC (p=0,311).

Preterm delivery and prenatal administration of corticosteroids, together or separately, result in lower degree of Chiari malformation in a model of surgical MMC in rabbit fetuses.


C.G. Fontecha M. Aguirre F. Soldado J.L. Peiro N. Toran A. Chacaltana C. Fonseca S. Añor V. Martinez

Open fetal surgery for reparation in myelomeningocele reverses Chiari II malformation and protects exposed neural elements from secondary lesion, but the technique is associated with a high rate of complications. The aim of our study was to assess whether a simple and fast technique of coverage produces the same results as a complete and longer technique of reparation in terms of neural protection.

Twelve sheep’s foetuses underwent lumbar three-level laminectomy and opening of the dura-mater on the 75th day of the gestation. Four of them were not-repaired (NR group). Eight of them underwent coverage with inert material sheet and synthetic surgical sealant on the 95th day (R group). At birth, clinical and histological examination and comparison between groups was performed.

None NR animal were able to stand or to walk nor had sphincter continence; all of them showed a wide defect of closure in the lumbar area, continuous leakage of cerebrospinal fluid (CSF), and histological neural damage; the mean vermis herniation was 75%. All R animals were able to stand and to walk and all of them showed sphincter continence; none of them showed leakage of CSF and showed coverage of the 93% of the defect; all of them showed regeneration of dura-mater, muscle and skin; the mean vermis herniation was 10%.

A simplified technique of coverage produces the same clinical results than a more complex reconstruction in a model of surgical MMC in sheep and the histological study reveals the regeneration of several layers of soft tissues.


P. Gutiérrez Carbonell D. Bustamante P. Domenech Fernández J.C. Rivas I. Llamas

The Acetabular Index and the Physeal Angle of the proximal femur are a radiographic assessment of the morphology of the acetabulum and the proximal physis, respectively. Their values to decrease with age and it remains unknown whether any correlation exists between them or if weightbearing has any influence. X-rays belonging to 30 infants (60 hips), 4 boys and 26 girls, were studied between 2003 and 2006, measuring the Acetabular Index (AI) and the Femoral Proximal Physeal Angle (PPA). Measurements were taken using a goniometer (error ± 1°). All the cases had ultrasound scans at 4 months of age, with alpha angles smaller than 50° (Graf type IIa) and cephalic coverage between 33% and 50%. Anteroposterior hip X-rays were taken at 3 months (pre-weightbearing) and 4–10 months (post-weightbearing). Statistics: t-Test and correlation.

The AI was 21.5° (19.5° boys, 21.8° girls) pre-weightbearing and 20.9° (20.8° boys, 21° girls) post- weightbearing. The PPA was 76.5° (75.9° boys, 76.6° girls) pre-weightbearing and 74.9° (75.5° boys, 74.8° girls) post-weightbearing. AI and PPA decreased pre- and post- weightbearing, 2′8% and 2′1% respectively. The decrease was considered significant in the PPA (p = 0.02), especially in girls (p = 0.009), and not significant in the IA. Differences were found between sexes: the AI increased in boys (+6.3%) and decreased in girls (−8.3%), and the PPA decreased in both boys (−0.5%) and girls (−2.3%). The side had no influence. No relevant correlation was found between AI and PPA, both pre- (r = − 0.15, p = 0.27) and post- weightbearing (r = − 0.24, p = 0.07).

We did not find any relevant correlation between IA and PPA values, neither previous to weightbearing, nor in the months after weightbearing occurs. The measured angles suffered a decrease after weightbearing but the only significant decrease was in the PPA.


C. Barrios O. Riquelme J. Burgos E. Hevia J.L. Gonzalez-Lopez C. Correa

This work was aimed at study the role of paraspinal muscles on spinal tensegrity. Four different models of spinal tensegrity breakage with and without injury of the posterior spinal muscle were investigated.

Fifteen minipigs (mean age 6-week) underwent costotransversectomy (CTT) at 5 consecutive vertebral segments. In 4 animals ribs and transverse processes (T7–T11) were removed through a posterior midline approach with complete desinsertion of paraspinal muscles. In other 3 animals, CTT was performed by a posterolateral approach (T6–T10) without detachment of paraspinal muscles. Other 4 minipigs underwent rib resection (T7-T11) throughout a thoracoscopic approach avoiding damage of posterior spinal muscles. A final group of 4 animals, a complete detachment of the paraspinal muscles was performed from T7 to T11 without removing bony structures and leaving in deep surgical wax attached to the spinous and transverse processes to avoid reinsertion of the muscles after surgery. Anatomic specimens were radiologically and macroscopically studied just at sacrifice 5 months after surgery

All 4 animals operated on of CTT by midline posterior approach developed structural spinal deformity with curve convexity at the side of rib removal (mean Cobb angle 34,6°). Animals undergoing CTT by posterolateral approach without paraspinal muscle detachment did not develop any significant spinal deformity. Absence of spinal deformity was also found in those animals in which rib resection was performed by thoracoscopy without injury of the posterior spinal muscles. All 4 animals undergoing detachment of the paraspinal muscles without CTT and application of the surgical wax developed scoliotic curves (mean Cobb angle of 28°).

In conclusion, a new insight on the underlying pathogenic mechanisms of scoliotic curves is given by using this spinal tensegrity model. Isolated damage of the posterior muscle-ligamentous structures around the costotransverse joints breaking muscles spine tensegrity seems to be mandatory to induce scoliotic deformity. Rib removal alone appeared to have less scoliotic inductive implication. The finding questions previous knowledge on scoliosis etiopathogeny.


C.G. Fontecha F. Soldado M. Aguirre C. Amat M. Esteves J.L. Peiro V. Martinez-Ibañez

Introduction. With the use of fetoscopy (minimally invasive surgery), the indications for foetal surgery have been expanded. Extremities at risk of amputation by EAB are amenable to foetal surgery. A previous model of in uterus reparation of moderate EAB has been reported. The purpose of this study is to evaluate the feasibility of intrauterine foetal release of amputating EAB.

Material and methods. Right limbs of fifteen 60-days gestational age pregnant sheep were ligated with silk suture at the infracondilar level. Left limbs were used for paired comparison. Foetuses were randomized in three groups: early repair group (n=5), late repair group (n=5) and no-repair group (n=5). The limbs of repaired groups underwent foetal release. The limbs obtained from at term foetuses were analyzed morphologically, functionally, radiologically, and histologically. Statistical analysis with paired test was used to compare data.

Results. Non-repaired limbs showed amputation or quasi-amputation; the repaired ones did not. However, those late repaired had significantly reduced passive ankle range of motion, shorter limb length, and mild residual changes.

Conclusions. In uterus release of potentially severe EAB avoids limb amputation and permits its morphological and functional recovery. Early release shows better results.


H. Rouhani J. Favre X. Creviosier B.M. Jolles K. Aminian

Recently, many mathematical descriptors were proposed to quantify 3D motions of the foot and ankle complex. However, since the ranges of rotation in foot joints are rather small, the reliability of these kinematic assessments is questionable. Particularly, achievement of acceptable results for clinical decision makings demands to extract repeatable features. In this study, repeatability of kinematics assessment of multi-segment foot by means of different mathematical descriptors was investigated.

25 tiny markers were mounted on dominant anatomical landmarks of the foot and ankle complex. Six young healthy subjects were asked to walk over a forceplate surrounded by six infra-red cameras. Marker trajectories were captured during one stance phase and several trials per subject were recorded. Foot and ankle complex was considered as six rigid segments:

Shank,

Hindfoot,

Mid-foot,

Medial forefoot

Lateral forefoot

Toes.

3D angles between each pair of segments (i.e., 1~2, 2~3, 3~4, 3~5 and 4~6) were calculated based on three common mathematical descriptors:

helical angle,

joint coordinate system and

projection angles.

Then, the coefficient of multiple correlations (CMC) was used to estimate the degree of similarity among joint angle patterns for intra-subject and inter-subjects trials.

It was observed that the three angle calculation methods had comparable repeatability for both intra-subject and inter-subjects kinematics. No significant difference among their repeatability was noticed. Most of angles showed good pattern repeatability intra-subject and acceptable pattern repeatability inter-subjects. In conclusion, all three calculation methods for foot joint angles can be reliably applied. Further studies enrolling patients with foot and ankle pathology are necessary to investigate the relevance of these measurements for clinical evaluations.


R. Senden K. Meijer H.H.C.M. Savelberg I.C. Heyligers B. Grimm

In joint arthroplasty the currently used patient assessment scores suffer from subjectivity, a low ceiling effect and pain dominance. These effects mask functional differences which are important for today’s demanding patients. Functional assessment tools are needed which can objectively monitor patient outcome. This study investigates whether an acceleration based gait test is able to assess TKR patients.

A cohort of 24 patients (11m, 13f) operated for osteoarthritis receiving unilateral TKR (Stryker Scorpio) were monitored for 3 months post-operative. Classic scores including subscores (KSS, Womac, VAS, PDI) and a gait test were measured pre-operative, at 2 weeks, 6 weeks and 3 months post-operative. Gait was analyzed using a triaxial accelerometer fixed to the sacrum while walking 6 times a 20m distance at preferred speed. Movement parameters like step frequency, step time, step number, vertical displacement, asymmetry and irregularity were calculated based on a peak detection algorithm.

All classic scores were significantly intercorrelated (e.g. KSS and Womac, R=−0.73) indicating a degree of redundancy. Significant correlations were shown between several gait parameters and the KSS, PDI and VAS. Most correlations between gait parameters and a classical score were found for the KSS function subscore indicating it as the most objective functional assessement amongst the classic scores. In contrast Womac did not correlate with any gait parameter. This lack WOMAC capturing objective function was reported before using functional tests.

The classic scales and the gait test cover different dimensions of surgical outcome supporting their combined use to follow up patients The accelerometer based gait test is clinically valid for the follow-up of TKR patients.


L. Verlaan R. Senden G. Storken IC Heyligers B. Grimm

To clinically diagnose and postoperatively monitor the younger or more demanding orthopaedic patients it becomes increasingly important to measure function beyond the capacity of classic scores suffering from subjectivity, pain dominance and ceiling effects. This study investigates whether a stair climbing test with accelerometer derived motion parameters in a group of healthy subjects is clinically feasible and valid to distinguish between demographic differences.

The ascending and descending of stairs (preferred speed, no handrails) was measured in 46 healthy subjects (19m/27f, no orthopaedic pathology) using a triaxial accelerometer attached with a belt to the sacrum. The study group was divided in two age groups: young group (15m/16f; age: 25 [21–38]) and old group (4m/11f; age: 67 [54–74]). Motion parameters were derived by acceleration peak detection algorithms based on step times: tup, tdown, tup-tdown,, step irregularity: irrup, irrdown and asymmetry: asymup, asymdown.

Step times were slightly higher ascending (tup=606ms) than descending (tdown=575ms, p< 0.05). The step time difference between ascending and descending (tup-tdown=31ms) showed a significant difference between the young (47ms) and elderly (−7ms). All subjects with descending times ≥20ms slower than ascending (6/46) were elderly. Irregularity and asymmetry were similar between stepping direction and age groups. Asymmetry identified the dominant leg with equal or faster steps than the non-dominant leg in 43/46 cases. Motion parameters were not correlated to gender, height or BMI.

Slower step times down than up seem a promising parameter to detect general or bilateral orthopaedic pathologies. Asymmetry identifying the dominant leg shall detect unilateral pathologies. The accelerometer assessed stair test seems suitable for routine clinical follow-up complementing classic scores.


C. Green R. Flavin C. Fitzpatrick D. Fitzpatrick W. Quinlan

Complex foot and ankle surgery and reconstruction require accurate preoperative planning. In the foot procedures are challenging and can be associated with a range of complications. The aim of planning is to correct only the deformity and prevent extensive surgery. Knowledge of foot and ankle morphometry is vital. For comparison between different subjects the coordinate system must be constant. To the authors knowledge there has been no previous description of a coordinate system for the foot and ankle.

CT images of ten anatomically normal feet were segmented in a general purpose segmentation program for grey value images and imported to a shape analysis program for biomechanics. A coordinate frame was defined in a 3 × 3 identity matrix using the inter-malleolar axis and a fibular diaphyseal centroidal axis in the construction. Centroidal vectors were defined in the metatarsals. Correlation of metatarsal length, inter-metatarsal angles, inter-malleolar distance and height was carried out.

The forefoot was examined in relation to the medial and lateral columns. Metatarsal length had a significant correlation within each column and between the two columns notably in the 3rd (0.525 – 0.965) metatarsal at the columns junction. The 3rd metatarsals also correlated significantly (−0.583) with the inter-metatarsal angles. There was a weak correlation between the 1st 3rd and the 3rd 5th inter-metatarsal angles directly however, each had a large correlation with the 1st 5th inter-metatarsal angle (0.734 – 0.950). There was also a large correlation between the individual’s stature and the metatarsal length and the inter-malleolar distance.

We have presented a means defining a coordinate system for three dimensional analyses in the foot and ankle. This coordinate system can be used for meaningful comparison of data between multiple subjects. We have shown that this coordinate system to be effective in practice in the morphometrical analysis of the normal forefoot.


M. Cartwright-Terry J. Moorehead A. Bowey S. Scott

Leg length discrepancy (LLD) is a recognised complication of total hip arthroplasty. LLDs can cause abnormal weight bearing, leading to increased wear, aseptic loosening of replacement hips and pain. To compensate for LLDs the patient can either flex the knee of the long leg or tilt their pelvis. The aim of this project was to investigate how stance affects static limb loading of patients with leg length discrepancy.

A pedobarograph was used to measure the limb loading of 20 normal volunteers aged 19 to 60. A 2 second recording with both feet on was taken to establish their body weight. Readings were taken of the left foot with the right level, 3.5cm lower (simulating a long left leg) and 3.5cm higher. In each case three readings were taken with the knee flexed and three readings with the knee extended.

When both feet were at the same level, the left limb took 54% of the load.

When the right foot was lower and the left knee flexed, the left leg took 39 % of the load (P < 0.001) (paired t-test). When the left knee was extended the left leg took 49 % of the load (P = 0.074).

With the right foot higher and right knee flexed, the left leg took 65 % of the load (P < 0.001). When the right knee was extended the left leg took 58 % of the load (P = 0.069).

These results show that weight distribution is increased in the simulated shorter limb. Loading is greater when the longer limb is flexed. Tilting the pelvis reduced the load. However this may cause pelvic and spinal problems.

Uneven load distribution is likely to lead to early fatigue when standing and may explain why some post arthroplasty patients with limb length discrepancy have poor outcomes.


A. Bistolfi P. Bracco Y-L. Lee M. Crova T.S. Thornhill A. Bellare

The performance of ultra-high molecular weight polyethylene (UHMWPE) used in total joint replacement prosthesis depends on its wear resistance, oxidation resistance and mechanical properties. Several studies have now established that radiation crosslinking by applying a dose of 50–100 kGy gamma or electron beam radiation followed by remelting to quench free radicals fulfils the criterion of high wear resistance as well as oxidation resistance. However, post-irradiation remelting leads to a decrease in several mechanical properties of UHMWPE including fracture toughness and resistance to fatigue crack propagation, which are deemed important for components in joints where they are subjected to high stresses, such as in tibial components.

In this study, we used uniaxial compression and high-pressure crystallization to disentangle UHMWPE, expecting that this would assist in increasing its crystallinity since disentangled polymer chains would be more readily incorporated into crystalline lamellae, thereby increasing overall crystallinity. This could then result in an increase in some mechanical properties of irradiated, remelted UHMWPE since high crystallinity is associated with high modulus and yield stress. Uniaxial compression of irradiated, remelted GUR 1050 UHMWPE at 130C to a compression ratio up to 2.5 followed by remelting to recover crystallographic orientation showed no statistically significant increase in crystallinity (p> 0.05, ANOVA). High-pressure crystallization at 500 MPa and temperatures in a range of 130-220C also did not show statistically significant increase in crystallinity of irradiated, remelted UHMWPE. However high-pressure crystallization at 500MPa pressure and 240C, where crystallization occurs via the hexagonal phase, increased the crystallinity from 46.2% to 56.4% (p< 0.05, ANOVA).

We conclude that high-pressure crystallization via the hexagonal phase is more effective than uniaxial compression followed by strain recovery or high-pressure crystallization via the orthorhombic phase in increasing the crystallinity of irradiated, remelted UHMWPE, with potential to recover some mechanical properties.


A. Fritsche F. Lüthen U. Lembke C. Zietz W. Mittelmeier R. Bader

For orthopaedic implants the adhesive strength of bone cells on implant surfaces is of high interest. In some cases the adherence of cells is desirable, e.g. on endoprosthetic implants, in others, mainly temporarily used implants, e.g. intramedullary nails, it is not favourable for the cells to attach to the implant. Therefore, besides cell spreading and proliferation on surfaces the adhesion strength with which cells bond to the substrate is of high interest. There are different approaches to determine bone cell adhesion, but no easy to operate quantitative methods are available. For this purpose, based on the spinning disc principle, we have developed a new adhesion device in conjunction with an inverse confocal laser scanning microscope (LSM).

Polished disc-shaped test samples made of Ti6Al4V were seeded with bone cells (MG-63), stained with a fluorescent dye, at defined radial positions and were incubated for 18 h with cell medium. After incubation the test samples were placed into the adhesion chamber filled with 250 ml cell medium (DMEM). The test samples were rotated at various velocities until a minimum detachment of 50% was achieved. Using the LSM the detachment of the bone cells at the defined radial positions was determined and the cell count was recorded before and after rotation by means of imaging software.

An average shear stress of 50 N/m2 was determined for polished Ti6Al4V surfaces. To calculate the adhesion force, the cross-sectional cell area has to be measured by the xz-scan of the LSM.

Our results are reproducible and comparable to the data found in literature. The advantage of our new approach is that the same cells can be observed before and after rotation as well as different rotational speeds can be applied to the same cell population. Further investigations e.g. using different surfaces are carried out.


J. Esteban D. Molina-Manso N.Z. Martín-de-Hijas D. García-Almeida R. Fernández-Roblas J. Cordero E. Gomez-Barrena

Biofilm development is a major factor in the pathogenesis of implant-related infections. However, there are only a low number of studies that analyses the ability of clinical isolates of bacteria to develop biofilm in vitro. Here we study biofilm development in several strains of Staphylococcus aureus and Coagulase-negative Staphylococcus (CNS) consecutively isolated from retrieved orthopaedic implants from patients diagnosed of implant-related infections.

We have evaluated in vitro biofilm development using the crystal violet technique in microtiter plates. Biofilm development was confirmed by visual microscopy and Confocal Laser Scanning Microscopy. Staphylococcal strains were isolated from implant-related infections by sonication of retrieved prosthesis as previously published by our group, and identified using conventional methods.

Twenty-seven strains (15 S. aureus, nine S. epidermidis, and one each of S. hominis, S. lugdunensis and S. warneri) were included in the study. Four strains of S. aureus (26.7 %) and one strain of S. epidermidis (8.3 %) did not develop biofilm in the test, showing OD lectures almost identical to the negative control. No statistical differences were detected between the two groups. The microscopic examination confirms this finding. Among the biofilm-producing strains, an important difference of the amount of biofilm produced was detected. One strain (S. aureus) produced biofilm in greater amount than all other strains, detectable even by visual examination of the plate.

In conclusion, not all staphylococcal strains isolated from implant-related infections are able to develop biofilm in vitro. There must be other pathogenic factors that are important in the pathogenesis of implant-related infections and need to be studied in order to develop a better strategy for treat these infections.


A. Fahlgren F. Agholme P. Aspenberg

Introduction: Many claim that an inflammatory reaction to wear debris particles is the main cause for prosthetic loosening. We have rat model in which bone resorption can be induced both by fluid pressure and particles. We compared the bone resorptive potency of particles and fluid pressure.

Materials and Methods: The rats received a titanium plate at the proximal tibia. A central plug was inserted. After 5 weeks of osseointegration, the central plug was changed to a piston or a hollow plug with 20mg titanium particles. Commercially pure titanium particles with 90 % of particles lesser than 3,6 microns were used. The pressure piston was subjected to a transcutanous force of 5N. Each episode of pressure comprised 20 pressure cycles at 0.17 Hz, applied twice a day. 60 rats were randomized to 6 groups for particle treatment. One group had particle implantation both at day 1 and 7. Additionally 15 rats were randomized into 3 groups with for pressure treatment. All rats were killed after 5 or 14 days. Bone resorption underneath the piston was evaluated blindedly in hematoxlyin/eosine sections and scored as 0 – 5. Differences between groups were analyzed by Kruskal Wallis and Mann-Whitney U-tests.

Results: Many specimens with titanium particles showed no visible resorption at al, and a few showed dramatic osteolysis. After 14 days, the osteolytic effect was significant. Partice refill made no difference. Titanium particles over 10 μm had minor effect. Fluid pressure always caused bone resorption, and significantly more so than particles both after 5 and 14 days.

Discussion: There was lesser variability in fluid pressure induced osteolysis, which might be due to a different signalling pathway. Titanium particles have an osteolytic effect in this model, but in spite of the massive amount of particles, the effect was less predictable than with pressure.


J. Zelle M. Barink M. De Waal Malefijt N. Verdonschot

Recently, high-flexion knee implants have been developed to provide for a large range of motion after total knee arthroplasty. Since knee forces increase with larger flexion angles, it is commonly assumed that high-flex-ion implants are subjected to large loads in the highflexion range (flexion > 120°). However, high-flexion studies often do not consider thigh-calf contact which occurs during high-flexion activities such as squatting and kneeling. We hypothesized that thigh-calf contact is substantial and has a reducing effect on the prosthetic knee loading during deep knee flexion.

The effect of thigh-calf contact on the loading of a knee implant was evaluated using a three-dimensional dynamic finite element knee model. The knee model consisted of a distal femur, a proximal tibia and fibula, a patella, high-flexion components of the PFC Sigma RP-F (Depuy, Warsaw, USA) and a quadriceps and patella tendon. Using this knee model, a squatting movement was simulated including thigh-calf contact characteristics of a typical subject which have been described in an earlier study.

Thigh-calf contact considerably reduced the implant loading during deep knee flexion. At maximal flexion (155°), the compressive knee force decreased from 4.9 to 2.9 times bodyweight. The maximal joint forces shifted from occurring at maximal flexion angle to the flexion angle at which thigh-calf contact initiated (±130°). The maximal polyethylene contact stress at the tibial post decreased from 49.3 to 28.1 MPa at maximal flexion.

This study confirms that thigh-calf contact reduces the knee loading during high-flexion. Both the joint forces and the polyethylene stresses reduced considerably when thigh-calf contact was included.


S. Utzschneider N. Harrasser W. Plitz V. Jansson

Periprosthetic osteolysis, caused in a chronic inflammatory adverse reaction to wear particles in the surrounding tissues, is one of the major reasons for revision arthroplasty so that articulating surfaces with low wear rates are required. Compared with conventional ultra high molecular weight polyethylene (UHMWPE), highly crosslinked polyethylene (HXLPE) shows a reduced wear rate in a hip simulator. The crosslinking process which is achieved by gamma or electronic radiation, followed by heat treatment either above the melting point (remelting) or below (annealing), reduces the mechanical properties of UHMWPE, particularly its fatigue strength. UHMWPE fatigue occurs more frequently in the knee than in the hip due to its higher contact stresses. This is why HXLPE is still controversially discussed for use in total knee prostheses. We have examined the wear behaviour of different HXLPEs [one cruciate-retaining (CR; sequential irradiation and annealing), one ultra-congruent (remelting), one CR (remelting)], compared with conventional UHMWPE in a knee simulator (Stallforth-Ungethuem). In the fixed bearing knee recommended from the manufacturer the wear rates [gravimetric (mg/year); volumetric (mm3/year)] were determined according to the ISO standard and the wear mechanism was analysed by means of a scanning electron microscope.

All insert showed signs of abrasion, scratching and wear polishing, but no traces of fatigue reactions. All HXLPEs produced lower (p< 0.05) wear rates (0.47–3.3 mg/year; 0.5–3.5 mm3/year) than the UHMWPE (8.1–9.1 mg/year; 8.6–9.7 mm3/year), the inserts of HXLPE manufactured by sequential irradiation and annealing showed the lowest wear rates (p< 0.05) overall.

Due to the reduced wear rates without any fatigue symptoms, we conclude that HXLPE is suitable for total knee prostheses and a monitored clinical investigation can be recommended. HXLPE manufactured by sequential irradiation and annealing seems to produce still lower wear rates than those manufactured by remelting, at least when used in total knee prostheses.


J.L. Williams S.T. Gomaa

A multibody dynamics program (LifeMOD/KneeSIM, LifeModeler, Inc., San Clemente, CA) was used to simulate knee bending. A PFC Sigma® (DePuy, Warsaw, IN) rotating platform (RP) posterior cruciate retaining total knee was subjected to two cycles of knee bending up to 130 degrees of flexion. The RP model (Free RP) included experimentally determined torsional frictional behaviour for the insert-tray bearing as a function of axial load and rotational speed. The analysis was repeated with the exact same implant design, but with the insert locked (Fixed RP) to the tray to prevent internal-external (IE) rotation (a theoretical design). IE rotation and tangential traction (frictional) forces were calculated over the contact patches and averaged at the centres of pressure in the medial and lateral compartments.

Cross-wise tangential traction forces were greater for the Fixed RP than for the Free RP design in both medial and lateral compartments. The tangential traction forces arising from rolling and sliding may cause delamination of the polyethylene, especially if they act cross-wise to the main direction of motion of the contact patches, in accordance with the strain-softening effect proposed as a mechanism of wear for multi-directional motion. Even though the amount of cross-wise motion in existing total knee arthroplasty designs has been shown to be limited, the present study indicates that cross-wise traction forces are greater in a theoretical design which is restrained from rotation at the RP bearing. These theoretical results lend support to the notion that a rotating platform design may reduce wear by reducing cross-shear traction forces between the femoral component and the tibial insert.


P. Aspenberg P. Wagner M. Hilding J. Ranstam

Background: In a previous randomized studiy using Röntgen Stereometric Analysis (RSA), we showed that oral bisphosphonates reduce the mean migration distance during the first 6 months. In a similar randomized study, bisphosphonates applied locally at the operation had a similar effect. These studies showed a 0.1 mm difference in mean value between groups. Does such a small difference matter? We addressed this question by use of frequency analysis.

Methods: The 2 previous studies were combined for analysis, and designated as bisphosphonate (n=44) or control treated (n=49). We analysed the migration vector (for the center of the rigid body) by use of a set of algoritms for frequency distribution analysis called Rmix. The migration vector lengths were assumed to be a compound of log-normal distributions. The frequency analysis determined if the observed frequency distributions were best described as a single, or a sum of 2 or more lognormally distributed subgroups.

Results: After 6 months, the control patients had formed 2 subgroups, one comprising 85% of the patients. The dichotomy was significant (p=0.016).

After 2 years, the dichotomy persisted (p=0.027). In the bisphosphonate-treated patients, no dichotomies could be found. The distribution of the migration vector length appeared similar to the larger and less migrating subgroup among the controls.

Discussion: The risk of aseptic loosening for cemented knees is extremely small. However, the migrating subgroup among our control patients may be at risk of loosening, and would have run a high risk if they were young and active. This subgroup did not appear with bisphosphonate treatment

Summary: In previous comparisons we found a slight decrease in mean value with bisphosphonates. The present analysis shows that this reflects the disappearance of a small subgroup with large migration.


T. M. Grupp S. D. Stulberg C. Kaddick A. Maas J. Schwiesau B. Fritz W. Blömer

Introduction: Total knee arthroplasty (TKA) has become a successful clinical treatment for patients in regard to relief of pain, correction of deformity and restoration of function with promising long term behaviour [Pradhan et al. 2006].

In TKA the generation of polyethylene wear debris is mainly affected by the factors design of the articulating bearing, contact stresses, kinematics, implant material and surface finish [McEwen et al. 2005].

The objective of our study was to evaluate the in vitro wear behaviour of fixed bearing knee designs in comprehension to the contact mechanics and resultant kinematics for different degrees of congruency.

Material and Methods: Wear simulator testing on 12 TKA devices has been performed according to ISO 14243-1 under load control. The knee replacements were tested in the fixed bearing configurations LC, CR and DD with different degrees of tibio-femoral congruency.

For gravimetric wear assessment the protocol described in ISO 14243-2 has been used, followed by a kinematic analysis of the single test stations.

The articulating contact and subsurface stresses have been investigated in a finite element analysis.

Results: The contact areas are increasing from Search® Evolution LC (144 mm2) to Columbus® CR (235 mm2) and Columbus® DD (279 mm2), whereas the peak surface contact stresses are decreasing from Search® Evolution LC (34.4 MPa) to Columbus® CR (20.9 MPa) and Columbus® DD (18.1 MPa). The estimated amount of wear has decreased from Search® Evolution LC (21.4 mg/million cycles) to Columbus® CR (8.9 mg/million cycles) and Columbus® DD (2.2 mg/million cycles).

The wear rates between the knee design configurations differ substantially and statistically analysis demonstrates a significant difference (p< 0.01) between the test groups in correlation with congruency.

Conclusion: The present study demonstrates the influence of different bearing types on contact stresses, abrasive wear and kinematics for three different degrees of tibio-femoral congruency under elimination of production, material and sterilization parameters.

Corresponding author: Dr.-Ing. Thomas M. Grupp

Research and Development: e-mail: thomas.grupp@aesculap.de


N. Bonsfills A. Foruria J. G. Martín R. Ballesteros-Masso A. Nuñez E. Gomez-Barrena

Introduction: Anterior cruciate ligament (ACL) injury is the first cause of knee instability. There is not enough evidence for the best therapeutic option, as operative and non-operative treatments of anterior cruciate ligament (ACL) injuries are often associated with a lack of proprioception and a persistent muscle weakness of unclear origin.

Material and methods: This study in the cat experimentally compares in the long-term both neural and muscular activity in the knee articular nerves (PAN and MAN), quadriceps and hamstrings, in the chronic unstable knee and the reconstructed knee. Experimental section of ACL in twenty four cat’s knees was followed by stable reconstruction in six knees and unstable reconstruction in eight knees, leaving the other ten knees unstable without reconstruction. Electrical activity from muscles and nerves was registered with Ni-Cr electrodes. Mean firing activity and peristimulus time histograms (PSTH) for each structure were obtained. Secondly, it evaluates the neuromuscular response changes due to the graft’s mechanical competence, comparing stable and unstable reconstructed knees. Two different grafts were evaluated in the reconstructed knee, pediculated extensor digitorum longus and free bone-tendon-bone from patellar tendon. Statitiscal analysis consisted in Mann-Whitney’s test with Bonferroni adjustment between groups, and a two-way ANOVA to evaluate the separate effect of graft type and graft competence.

Results: We found an increased periarticular muscle activity during anterior tibial translation in chronically unstable knees. Both reconstructed and non-reconstructed unstable knees lose the fast reactive activity in the articular nerves. When stability was recovered after reconstruction, knees showed a more adjusted, although incomplete, muscular reaction. No differences were observed among grafts, but their mechanic competence was determinant in the neuromuscular firing activity.

Discussion: ACL injured knees in the cat, with or without reconstruction, display confirmed abnormalities in neuromuscular reaction in the long-term, while to regain stability with a competent graft in the reconstructed knee is crucial to lessen this anomalous reaction.


A. Eudier C. Handschin K. Aminian C. Voracek F. Nicolas B. Le Callennec PF. Leyvraz BM. Jolles

The FIRST knee prosthesis (Free Insert in Rotation Stabilized in Translation, Symbios SA) is a new ultra congruent, postero-stabilized total knee arthroplasty (TKA) with a mobile bearing expected to reduce significantly polyethylene wear, to improve the range of motion and the overall stability of the knee while ensuring a physiological ligament balance. We compared subjective and really objective results of this new TKA with two other widespread models of TKA.

A clinical prospective monocentric cohort study of 100 consecutive patients (47–88 yrs) undergoing a FIRST TKA for primary osteoarthritis is currently being done. Pre- and post-operative follow-ups (6 weeks, 4,5 months and 1 year) are done with well-recognized subjective evaluations (EQ-5D and WOMAC scores) and semi-objective questionnaires (KSS score and radiography evaluation) as well as with a really objective evaluation using gait parameters from 6 walking trials, performed at different speeds with an ambulatory in field gait analysis system (Physilog®, BioAGM CH). The outcomes after one year of follow-up of 32 FIRST TKA are compared to 29 NexGen® postero-stabilized TKA (Zimmer Inc) with a fixed bearing and to 26 NexGen® TKA with a mobile bearing using the same methods.

The gait cycle time of the FIRST TKA was statistically significantly shorter at normal speed of walk, as well as double-support periods, as compared to both standard models. The normal walking speed was significantly higher with faster swing speed and stride lengths for the new TKA. Significantly better coordination scores were observed at normal walking speed for the FIRST TKA as compared to the fixed-bearing TKAs.

The FIRST TKA showed statistically significantly better really objective outcomes in terms of gait after one year of follow-up and similar subjective and semi-objective evaluations compared to two widespread TKA designs.


P. E. Müller M. F. Pietschmann V. Fröhlich A. Ficklscherer V. Jansson

Absorbable suture anchors have become more and more important in rotator cuff surgery due to their easy revisability. In osteoporotic bone however they are thought to be of minor primary stability. Purpose of the present study was to compare different absorbable and non-absorbable suture anchors in their pullout strength depending on bone density

The absorbable screw-anchor SPIRALOK5mm (DePuyMitek, Raynham, MA, USA), the titanium screw-anchor SUPER-REVO5mm and the tilting-anchor ULTRASORB (both ConmedLinvatec, Largo, FL, USA) were tested, each anchor representing a different material and design. On the basis of bone density measurement by CT-scans a healthy (mean-age. 42 years) and a osteopenic (mean-age: 74 years) group of cadaveric human humeri were formed. Each anchor was inserted in the greater tuberosity six times. They were inserted according to the manufacturers instructions with the supplied suture material. An incremental cyclic loading was performed, starting with 75N. Until failure the tensile load was increased by 25N after every 50 cycles. The ultimate failure loads, the anchor displacements and the modes of failure were recorded.

In the non-osteopenic bone group, the absorbable SPIRALOK achieved a significantly better pullout strength (mean: 274N) than the titanium screw-anchor SUPER-REVO (mean: 188N) and the tilting-anchor ULTRASORB (mean: 192N). In the osteopenic bone group no significant difference in the pullout strength was found. The failure mechanisms, such as anchor pullout, rupture at eyelet, suture breakage and breakage of eyelet, varied between the anchors. In the osteopenic group the number of anchor pullouts clearly increased.

The present study demonstrates that absorbable suture anchors do not have lower pullout strengths than metal anchors. Depending on their design they can even outmatch metal anchor systems. The results of our study suggest that the anchor design has a crucial influence on primary stability, whereas the anchor material is less important.


C. Green R. Flavin D. Fitzpatrick R. Moran

Graft choices for revision anterior cruciate ligament (ACL) reconstruction and complex ligament reconstructions of the knee are controversial. The aim of our study was to analyze the biomechanical effect of harvesting bone plugs from both the distal and proximal poles of the patella, to simulate a simultaneous harvesting of a Bone – Patellar Tendon – Bone and Quadriceps Tendon – Bone grafts, in a transverse stress environment.

Sixty Bovine Patellae were analysed. They were divided into 4 groups – based on the residual bone bridge (percentage of total length of patella) remaining after bone plug resection. 0 – 10%, 11 – 20%, 21 – 30% and > 30%. All patellae were tested in a modified 4 – point bending environment, to a maximum load of 10,000N, in a customized designed jig. This method simulates the axial bending stress on the patella during knee flexion. All dimensions of the patellae were recorded including Depth of patella at bone resection and wall thickness adjacent to plug resection site.

All patellae with a 0% bone bridge fractured (Ultimate Tensile Strength/UTS) at a mean Tensile Force of 5863N (Range 3140 – 8730N). There was a subgroup of incomplete fractures – extra-articular fractures – which fractured at 6542N (Range 5085 – 9180N). The remaining specimens failed to fracture. Comparing the UTS and the patellar dimensions, using Weibull’s Statistical Analysis we demonstrated that less than 60% bone plug resection carried a very low probability of fracture.

This study demonstrates the safe criteria for bone – tendon graft harvesting from both the proximal and distal poles of the patella. With regards to a normal human patella, a 40% bone – bridge is approximately a 20mm bone – bridge. We conclude that the simultaneous harvesting of Bone – Patellar Tendon – Bone and Quadriceps Tendon – bone grafts from a patella has no significant increase in the fracture risk of the patella.


R. K. Goddard D. Yeoh B. J. Shelton M. A. S. Mowbray

Aims: The aims of this study were to evaluate the biomechanical properties and mode of failure of a technique of anterior cruciate ligament (ACL) reconstruction using the Soffix polyester fixation device. A 2-strand equine extensor tendon graft model was used because a previous study has shown it to have equivalent bio-mechanical properties to that of 4-strand human semitendinosus and gracilis tendon grafts.

Method: Ten stifle joints were obtained from 5 skeletally mature pigs, the soft tissues were removed and the ACL and PCL were sacrificed. Tibial tunnel preparation was standardised using the Mayday rhino horn jig to accurately position a guide wire over which an 8mm tunnel was drilled. A 2-strand equine tendon-Soffix graft was used to reconstruct the ACL of the porcine knee using over the top femoral placement with bicortical screw fixation. Mechanical testing of 10 specimens was performed.

Results: The mode of failure included 4 midsubstance tendon failures, 3 Soffix failures and 3 failures at the suture-Soffix interface. The mean ultimate tensile load for the ACL reconstruction was 1360 N (standard deviation (SD) =354), elongation to failure of 41 mm (SD=7.5) and a structural stiffness of 35 N/mm (SD=8.1).

Conclusion: This in vitro study has shown that the technique of ACL reconstruction using the Soffix soft tissue fixation device with a tendon graft placed in the over the top position is biomechanically strong, providing a sufficiently high UTL immediately following reconstruction, therefore allowing early weight bearing and rehabilitation.


R. J. Walls G. McHugh N. M. Moyna J. M. O’Byrne

Quadriceps femoris muscle (QFM) weakness is associated with the development of knee osteoarthritis (OA). Neuromusclar electrical stimulation (NMES) circumvents neural inhibition causing muscle contraction, however there is little reported data demonstrating its role in knee OA. Our aim was to evaluate the effectiveness of a NMES program in patients with knee OA.

Sixteen patients (10 women, 6 men) with severe knee OA were randomised into control (n=6) or intervention (n=10) groups. These were similar in terms of age (64.8 ± 11.0 vs. 64.6 ± 7.6; mean ± SD) and BMI (31.8 ± 6.11 vs.30.7 ± 2.9). NMES was applied using a garment-based stimulator for 20 min/day, 5 d/wk for 8 weeks. Isokinetic and isometric QFM strength were determined at baseline, and weeks 2, 5, and 8 using a dynomometer. Functional assessments involved a 25 metre timed walk test (TWT), timed stair-climb test (SCT), and timed chair-rise test (CRT) at baseline and week 8. Subjects recorded NMES session duration in a log book while the device also recorded total treatment time.

Function significantly improved in the NMES group as determined by the timed SCT (p< 0.01) and the timed CRT (p< 0.01) at week 8 compared to week 0. Isometric QFM strength was significantly higher in the NMES group at weeks 2, 5 and 8 than week 0. Compared to week 0, isokinetic hamstring strength increased significantly in the NMES group at week 2, week 5 and week 8 while isokinetic QFM strength increased at week 5 (p< 0.05) and week 8 (p< 0.01). Patient recorded compliance was 99.5% (range, 97.1%–100%) and overall usage recorded on the stimulator was 96.1% ± 13.2.

The use of a portable home-based NMES program produced significant QFM strength gain with associated improvement in function in patients with severe knee OA. Compliance was excellent overall.


M. F. Pietschmann V. Fröhlich A. Ficklscherer V. Jansson P. E. Müller

One of the recently introduced anchors is the absorbable suture anchor BIOKNOTLESS-RC, a press-fit anchor whose special feature is the knotless reconstruction of the ruptured rotator cuff. We compared the new knotless anchor BIOKNOTLESS-RC with established anchors.

The absorbable pressfit anchor BIOKNOTLESS-RC (DePuyMitek, Raynham, MA, USA), the titanium screw anchor SUPER-REVO 5mm and the tilting anchor ULTRASORB (both ConmedLinvatec, Largo, FL, USA) were tested 12 times in the greater tuberosity of human cadaveric humeri (mean age: 74 years). They were inserted according to the manufacturers instructions with the supplied suture material. An incremental cyclic loading was performed, starting with 75N. Until failure the tensile load was increased by 25N after every 50 cycles. The ultimate failure loads, the anchor displacements and the modes of failure were recorded.

The anchor displacement of the BIOKNOTLESS-RC (15.3mm) after the first cycle with 75N was significantly higher than with the two others (SUPER-REVO 2.1mm, ULTRASORB: 2.7mm). The ultimate failure loads of the tested anchors were comparable: BIOKNOTLESS-RC 150N, SUPER-REVO 150N, ULTRASORB 151N (p> 0,05).

Rupture of the suture material at the eyelet occurred more frequently with the SUPER-REVO. BIOKNOTLESS-RC and ULTRASORB showed a tendency towards anchor pullout.

Our results do not confirm the higher pullout strength of metal anchors, which was found in other studies. Knotless anchors facilitate surgery by eliminating the technically challenging step of arthroscopic knot tying. The disadvantage of the BIOKNOTLESS-RC is its unsatisfactory primary stability. Its initial displacement of a mean of 15.3 mm is clinically significant and jeopardizes the rotator cuff repair.

Because of the high initial displacement and the possible gap formation between tendon and bone, the use of the BIOKNOTLESS-RC in a zone of minor tension, for instance as a second-row anchor in double row technique only is recommend.


I. Kalouche S. Abdelmoumen J. Crepin D. Mitton G. Guillot O. Gagey

Total shoulder arthroplasty is a well-established and widely accepted method of treatment for a variety of shoulder disorders, loosening of the glenoid prosthesis is the main complication in total shoulder arthroplasty, it is highly dependent on the quality of the glenoid cancellous bone. Very little is known about mechanical properties of this cancellous bone. The objectives of this study were to determine the mechanical properties (elastic modulus and strength) of glenoid cancellous bone in the axial, coronal and sagittal planes including regional variation using a uniaxial compression test. To our knowledge, this kind of study was not done before.

Eleven scapulas were obtained from six fresh-frozen, unembalmed human cadavers (mean age eighty-eight years). Eighty-two cubic cancellous bone specimens of 6×6×6mm3 were used for mechanical testing in the three planes. The test was a uniaxial compression along each direction, Elastic modulus and strength were determined from the stress-strain curve. Apparent density was also calculated.

The study showed significant differences in the mechanical properties with anatomic location and directions of loading. Young modulus and strength were found to be significantly higher at the posterior part of the glenoid with the weakest properties at the antero-inferior part. Cancellous bone was found to be anisotropic with higher mechanical properties in the latero-medial direction (perpendicular to the articular surface of the glenoid). The apparent density was on average equal to 0.29 g/cm3 with the higher values at the posterior and superior part of the glenoid. Good correlation between apparent density and elastic modulus was found only in the sagittal plane but not in the coronal and axial plane, the overall correlation was low (r2 = 0.22, p< 0.0001) which emphasizes the role of trabecular bone architecture in predicting mechanical properties.

The mechanical properties determined in this study provide input data for finite element method analyses and may help to assist in uncemented shoulder prosthesis design.


G. Vilà C. Torrens M. Corrales F. Santana E. Cáceres

The objective of this study is to analyze changes in the force needed to raise the arm caused by using a single or a double-row configuration of cuff repair.

Cadaveric study performed using 5 fresh-frozen shoulders. Supraspinatus tear created in all specimens beginning 0.5 cm from biceps tendon. Repair of tear with single and double-row configuration of anchors placed 1cm apart each one. Sutures fixed to digital dynamometer. Continuous traction applied and registered to elevate humerus to 30° and 45°. Experiment repeated 3 times for each configuration and angle of elevation on each specimen. Paired Student t test was used to compare difference between single and double-row configuration at 30° and 45° of anterior elevation.

Significant differences between force needed to raise the arm to 30° with single-row (4,76 kg) configuration and double-row (6,94) (p< 0,001). Significant differences between force needed to raise the arm to 45° with single-row configuration (10,32 kg) and double-row (15,93) (p< 0,008). Significant differences when comparing mean increase of force needed to raise the arm from 30° to 45° between single and double-row configuration (p< 0,012).

The force needed to raise the arm to 30° and 45° is significantly higher for double than for single-row configuration. Quality of tendon margin should be taken into account when choosing between double and single-row configuration. If repair is done to a frayed and degenerated tendon, surgeon has to imbalance benefits of double-row repair with the fact that tendon suture will have to resist an increased force in active movement.


A. J. Johnstone S. V. Karuppiah

Suture anchors are widely used to secure tendons and ligaments to bone during both arthroscopic and open surgery. However, single stage insertion suture anchors, i.e. anchors that could be inserted without predrilling of the bone, are not currently available.

We aimed to record the impact needed for insertion of the new design single stage suture anchors, and to compare their pull out strength with another range of commercially available suture anchors.

The force required to insert the new design of suture anchors was investigated using an impact hammer capable of recording the number and force of each of the hits. The anchors were inserted in a consistent manner into animal (porcine) bone at sites analogous to common anchor sites used in clinical practice. Pull out strength was assessed using a digital force gauge after tying the suture to create a secure loop. Thereafter, force was applied steadily until either the anchor or the suture failed and compared with a popular range of commercially available suture anchors (Mitek).

Our initial investigations using prototype designs for small, medium and large anchors compared favourably with the Mini-mitek, GII, and Superanchor range of Mitek anchors. Essentially the most common point of failure for each of the suture anchor families was the suture itself with both suture anchor systems performing similarly. In addition, similar pull out strengths were demonstrated for both the Mitek and new design of suture anchors when loaded parallel, or at 90°, to the line of anchor insertion.

The new design single stage suture anchors have an equivalent pull out strength compared with a popular commercially available family of suture anchors, but in addition have the significant advantage of being suitable for single stage insertion in many clinical settings.


P.-J. Vandekerckhove J. Van Nuffel L. Verhelst M. Verhelst E. Audenaert R. Verdonk

We report a long term experience on massive rotator cuff tears treated by the means of a nonresorbable transosseously fixed patch combined with a subacromial decompression

From December 1996 until August 2002, a total of 41 patients were treated with a synthetic interposition graft and subacromial decompression. All patients had a preoperative ultrasound evidence of a primary massive full-thickness tear that was thought to be irreparable by simple suture. All patients were evaluated pre- and postoperatively using the Constant and Murley score, DASH questionnaire, Simple Shoulder Test, VAS scale for pain, ultrasound and plain radiographs.

The patients consisted of 23 men and 18 women aged 51–80 years (mean 67 years). We had a lost of follow up of 6 patients. One patient had a total shoulder arthroplasty at 7.7 years and one patient had a redo with a new synthetic graft at 9.6 years. They were followed up for a mean of 7.2 years. Their mean preoperative Constant and Murley score improved from 25.7 preoperatively to 69.6. Similar improvements were seen with the DASH score (56.6 to 23.3), SST (1.2 to 7.9) and VAS scale (75.4 to 14.1)

Anatomically, the repair resulted in mean acromio-humeral interval of 6.6 mm. Ultrasound showed a further degeneration of the rotator cuff with tears posteriorly from the interposition graft. In 67.7% of all patients the graft was continuous present. Histology – obtained from one patient scheduled for a reversed shoulder arthroplasty- showed partial ingrowth of peri-tendinous tissue.

Despite ongoing degeneration of the cuff in nearly half our population, restoring a massive rotator cuff defect with a synthetic interposition graft and subacromial decompression can give significant and lasting pain relief with a significant improvement of ADL, range of motion and strength.

Role of ultrasonography in shoulder pathology: Consistency with clinical and operative findings K. W. Chan, G. G. McLeod Department of Trauma and Orthopaedic Surgery, Perth Royal Infirmary, Perth PH1 1NX, United Kingdom.

Shoulder disorders are common and main causes of shoulder pain with/without functional deficit include adhesive capsulitis (frozen shoulder), impingement syndrome and rotator cuff pathology. The sensitivity and specificity of ultrasonography have been reported as 80% and 100% respectively in the literature. We carried out a retrospective case note review of patients that underwent ultrasonography of shoulder, comparing the radiological findings with clinical diagnosis and operative findings. 58 patients, 36 male and 22 female attended the orthopaedic outpatient clinic with painful shoulder and underwent ultrasonography of shoulder during the period of study. Mean age of patients is 55 (range 28 to 78 years old). 33 patients had ultrasonography of right shoulder, 20 patients had ultrasonography of left shoulder while 5 patients had ultrasonography of both shoulders. 79% (50/63) of the ultrasonography findings were consistent with clinical diagnosis. 17 patients had normal findings on ultrasonography and were discharged fully. 25 patients with clinical and radiological diagnosis of biceps tendon tear, calcifying tendinosis and partial/full thickness rotator cuff tear were treated conservatively. 19% (4/21) of patients with diagnosis of calcifying tendinosis had decompression surgery. 38% (8/21) of patients with diagnosis of partial/full thickness rotator cuff tear had decompression surgery + rotator cuff repair. The degree of rotator cuff tear in operative findings for 6 out of 8 patients (75%) that underwent decompression surgery +/− rotator cuff repair were consistent with ultrasonography findings. 4 patients had inconclusive ultrasonography findings and had magnetic resonance imaging to further confirm the pathology. We conclude that ultrasonography should be used as the first line of investigation in aiding the clinical diagnosis and management of shoulder disorders as it is non-invasive and cost effective. The sensitivity of ultrasonography in detecting shoulder pathology is 75% from this study.


K. Pelttari S. Boeuf H. Lorenz K. Goetzke M. F. Templin E. Steck W. Richter

Monolayer expansion of human articular chondrocytes (HAC) is known to result in progressive dedifferentiation and loss of stable cartilage formation capacity in vivo. For optimal outcome of chondrocyte based repair strategies, HAC capable of ectopic cartilage formation may be required. Thus, the aim of this study was to establish appropriate quality control measures capable to predict the ectopic cartilage formation capacity of HAC from culture supernatants. This strategy would avoid the waste of cells for quality control purposes, in order to improve cell therapy and tissue-engineering approaches for the repair of joint surface lesions.

Standardized medium supernatants (n=5) of freshly isolated HAC and chondrocytes expanded for 2 (PD2) or 6 population doublings (PD6) were screened for 15 distinct interleukins, 8 MMPs and 11 miscellaneous soluble factors by a multiplexed immunoassay. Cartilage differentiation markers like COMP and YKL-40 were determined by ELISA. Corresponding HAC were subcutaneously transplanted into SCID-mice and their capacity to form stable ectopic cartilage was examined histologically 4 weeks later.

While freshly isolated chondrocytes generated stable ectopic cartilage positive for collagen type II, none of the PD6 transplants formed cartilaginous matrix. Loss of ectopic stable cartilage formation capacity between PD0 and PD6 correlated with a drop of MMP3 secretion to < 10% of initial levels, while changes for other investigated molecules were not predictive. Chondrocytes from donors with low MMP3 levels (< 10%) at PD2 failed to regenerate ectopic cartilage at PD2, indicating that MMP3 levels of cultured chondrocytes, independent of the number of cell doublings and the time in culture, predicted ectopic cartilage formation.

In conclusion, loss of stable ectopic cartilage formation capacity in the course of HAC dedifferentiation can be predicted by determination of relative MMP3 levels demonstrating that standardized culture supernatants can be used for quality control of chondrocytes dedicated for cell therapeutic approaches.


E. Steck H. Lorenz T. Gotterbarm M. Jung W. Richter

Mesenchymal stem cells (MSC) are promising for the treatment of articular cartilage defects; however, common protocols for in vitro chondrogenesis induce typical features of hypertrophic chondrocytes reminiscent of endochondral bone formation. This may implicate a risk for graft stability. We here analysed the early healing response in experimental full-thickness cartilage defects, asking whether and how MSC can differentiate to chondrocytes in an orthotopic environment.

Cartilage defects in knees of minipigs were covered with a collagen-type I/III membrane, and half of them received transplantation of expanded autologous MSC. Integration into surrounding cartilage tissue was poor to moderate after 1 and 3 weeks and no sign of cartilaginous matrix production as indicated by negative safranin-O staining was visible for both groups. At 8 weeks regenerative tissue was integrated into the surrounding tissue and a safranin-O positively stained neocartilage was detectable in 4 tissue regenerates out of 6 in the MSC group compared to 2 out of 6 in the MSC-free group. At 1 and 3 weeks after surgery only marginal Col2A1 and no AGC expression were detectable in both groups. At 8 weeks Col2A1 and AGC levels had significantly increased. Hypertrophic maker induction (Col10A1 and MMP13) was similar in both groups 8 weeks after surgery. Immunostaining for collagen type X, however, was restricted to the regenerative tissue close to the subchondral bone in both groups, while collagen type II staining was detected from below the superficial to the deep zone.

Our data provide molecular evidence for spontaneous differentiation of MSC in cartilage and the development of a collagen type II positive, collagen type X negative neocartilage. Whether by remodelling of defect filling tissue collagen type X positive areas will further diminish or even disappear from repair cartilage at later stages has to be evaluated in a longer follow-up study.


E. Zamorano F. Valera A. Melián X. Veiga FJ. Minaya G. Plaza

Physiotherapists have developed examination techniques known as ‘neural tension tests’ to assess the mechanosensitivity of the major nerve trunks. Changes in neural tension provoked by these tests may alter the nociceptive responses of nearby tissues.

The aim of our study was to evidence changes in mechanical nociceptive thresholds (MNTs) of upper trapezius muscle in different neurodynamic positions.

Cross-sectional study. Fifty asymptomatic volunteers were evaluated with algometer in four neurodynamic positions:

Contralateral side-lying position with knees at 90° of flexion, hips at 70° of flexion and spine in neutral;

initial position with the homolateral knee in complete extension to add neural tension of sciatic nerve;

initial position with the homolateral knee in complete flexion to add neural tension of femoral nerve;

In supine position to add neural tension of median nerve using the Upper Limb Neurodynamic Test 1.

One physiotherapist (PT) measured MNTs unilaterally over TrPs1. Three consecutive measurements was evaluated in the four described positions, a second PT reported the data in kilograms (kg). A third PT was responsible for modifying subjects positions.

The findings revealed significant mean differences (SMD) in algometry measurements (P < 0.0001) between position 1 (mean 2.880 kg; SD 1.012 kg) and position 3 (mean 2.522 kg; SD 0.87 kg), SMD (P < 0.01) between position 1 and position 4 (mean 2.616 kg; SD 0.968 kg). No SMD between position 1 and 2 (mean 2.728 kg; SD 1.103 kg) (P < 0.08) and between positions 3 and 4 (P < 0.378).

We concluded that MNTs of upper trapezius muscle decrease with neural tension positions. MNTs decrease is similar with crural nerve and median nerve tension positions. So, neurodynamic positions are important procedures to be taken into account in clinical reasoning, both physical therapy diagnosis and treatment.


A. S. Ahmed J. Li M. Ahmed G. Bakalkin A. Stark

Rheumatoid arthritis (RA) is a chronic inflammatory disease of unknown aetiology. In RA, inflammation and pain are initial symptoms followed by bone and cartilage destruction. Proinflammatory cytokines play a significant role in the initiation and progress of inflammation and tissue destruction. Sensory neuropeptide substance P (SP) participates not only in nociception but also in pro-inflammatory processes by enhancing vasodilatation and recruitment of inflammatory cells. Ubiquitin proteasome system (UPS) activates a transcription factor, NF-κB which regulates the synthesis of proinflammatory mediators like cytokines; however its role in regulating pro inflammatory sensory neuropeptides is unknown. A number of proteasome inhibitors have been shown to down regulate the activity of NF-κB and hence reduce inflammation. In the present study, the effect of proteasome inhibitor (MG 132) on the severity of arthritis and pain was observed along with the expression of SP-positive nerve fibres in the ankle joint in a chronic inflammatory model of rat adjuvant arthritis.

Histology and mechanical pain tests showed a significant reduction in inflammation and pain in ankle joint by daily administration of proteasome inhibitor MG132 at the dose of 1mg/kg body weight compared to untreated groups. Radiographic analysis of ankle joints indicated a reduction in soft tissue swelling and joint destruction in the treatment group. A marked reduction in the NF-κB activity was observed by EMSA. Furthermore, proteasome inhibition resulted in the normalization of up regulated neuronal response occurred during inflammation by significantly reducing the expression of SP-positive fibres in the ankle joint as demonstrated by immunohistochemistry.

Our data provide the evidence that proteasome inhibitor MG132 can reduce severity of arthritis and reverse inflammatory pain behaviour by influencing the peripheral sensory nervous system. The drugs targeting UPS can be developed for treatment of chronic inflammatory joint disorders.


M. Miranda Mayordomo S. Reche Caballero D. Robreño Roger

INTRODUCTION. The grip test is usually included in common protocols of functional evaluation. Till today a dynamometer Jamar was used to evaluate Maximum Isometric Strength. At this moment we use isokinetic dynamometers to analyse grip strength in isokinetic way. As a few bibliographic references for this valuation techniques we have designed an study at healthy population to obtain the normal values of grip strength and the influence of individual factors, like sex, age and side-dominance.

MATERIAL AND METHODS. A 321 healthy hands serial was included. The average age was 37.2 years old (ranged 17–63). Mostly of them were men (211 cases, 65.7%). 150 are side-dominant cases (46.7%). All of them has been valuated by Dexter Hand Evaluation. Two speeds 30°/s and 60°/s was used in the study. And the extent used was 4.3 cm. Five trials was done in each velocity. We acquired Maximum Isokinetic Strength and Work.

RESULTS. The values were for strength (Kg) 38.4 at 30°/s and 35.0 at 60°/s and for work (Kg-cm) 98.5 at 30°/s and 86.7 at 60°/s. The side-dominant hand are stronger than non-dominant ones (10.3% in 30°/s, p< 0.001; 11.9% in 60°/s, p< 0.001). Women had less strength than men (37% in both speeds, p< 0.001). The age has less important as isokinetic strength values are more or less the same till 39 years old. After that there is a slow drop of the strength in aged cases.

At last we show tables of normal values at healthy population. The influence of sex and side-dominant are shown as a percentile distribution.

CONCLUSIONS. The isokinetic strength evaluation of hand grip is a very value method in the functional evaluation of the hand. This study gives normal values in healthy hands and the influence of sex, age and side-dominance.


J. Díaz Heredia M. A. Ruiz Ibán I. García C. Correa F. Gonzalez I. Cebreiro

Various studies have demonstrated that menisci heal in the vascular region but do not heal in the avascular area. Experimental studies of the promotion of meniscal healing in the avascular area have involved the application of fibrin clot, fibrin glue to the injured area, as well as the construction of an access chanel to the vascular regiòn, all of them with poor results. The multilineage potential of adult stem cells has been characterized extensively. The adipose tissue has been described as a useful source of adult stem cells. We try to show that the use of stem cells from the adipose tissue may promete meniscal healing in the avascular area.

Twelve New Zealand white rabbits with a mean weight of 3 kg were used. The medial meniscus of both knees was aproached, and was performed a longitudinal tear in the avascular area in the anterior horn with a mean length of 0.5 cm. All the tears were sutured with one vertical stitch of nonabsorbable suture. In each rabbit a solution with 1 00 000–1 000 000 stem cells from the fat was introduced in one of the knees, and the other one was used as a control. The rabbits were killed at 12 weeks, and a macro-microscopic study of the meniscus was done, and also a inmunohistochemistry study for the stem cells.

The incidence of healing was better in those menisci with the stem cells solution. Three total and three partial healing was obtained in the stem cells group and none in the control group. The inmunohistochemistry showed that the stem cells were in the repair zone.

We think that stem cells will be very useful in the treatment of the lesion in the avascular area of the meniscus.


P. E. Zollinger W. E. Tuinebreijer H. Ünal M. L. Ellis

Osteoarthritis of the trapeziometacarpal joint can be treated by different surgical procedures. These are known to lead to complications, complex regional pain syndrome (CRPS) type I being one of them. We investigated prospectively our clinical results after total joint arthroplasty under vitamin C prophylaxis.

Patients with trapeziometacarpal joint arthritis stage II or III (according to Dell) underwent joint arthroplasty. Visual analogue scale (VAS) scores for pain, activities of daily living (ADL), satisfaction and first web opening were taken pre- and postoperatively. Vitamin C 500 mg daily was started two days prior to surgery during 50 days as prophylaxis for CRPS. Postoperative treatment consisted of a bandage with collar and cuff for 5 days. Follow-up was at 2 and 6 weeks, 6 months and 12 months (with check radiographs).

We performed 34 arthroplasties in 29 patients (23 females and 6 males) with a mean follow-up of 39 months. Mean age was 61 years. The degree of osteoarthritis according to Dell was stage II in 13 cases, stage III 20 times and in one case there was a traumatic trapeziometacarpal dislocation. Operation was performed in day care under general or regional anesthesia. We implanted a hydroxy-apatite coated, semi-constrained prosthesis, type Roseland (total trapeziometacarpal joint prosthesis; Depuy International Ltd, Leeds, England). First web opening increased with 18 degrees and there was a significant improvement for pain, ADL and satisfaction as well (p = 0.000). There were no signs of loosening of the prosthesis, no infections and no cases of CRPS.

In this study the postoperative treatment was completely functional. The semi-constrained design of the Roseland prosthesis doesn’t require immobilisation. Torrededia reported 5 patients with CRPS after 38 operations with this same implant (13%). The positive trend in preventing CRPS gives us enough arguments to further investigate this in the form of a RCT.


B. Moretti A. Notarnicola F. Iannone L. Moretti R. Garofalo V. Patella

The purpose of this study was to investigate the effects of extra corporeal shock waves (ESW) therapy on the metabolism of healthy and osteoarthritic human chondrocytes, and particularly on the expression of IL-10, TNF-α and β1 integrin.

Human adult articular cartilage was obtained from 9 patients (6 male and 3 females), with primary knee osteoarthritis (OA), undergoing total joint replacement and from 3 young healthy donors (HD) (2 males, 1 female) with joint traumatic fracture. After isolation, chondrocytes underwent ESW treatment (Electromagnetic Generator System, Minilith SL1, Storz Medical) at different parameters of impulses, energy levels and energy fluxes. After that, chondrocytes were cultured in 24-well plate in DMEM supplemented with 10% FCS for 48 hours and then β1 integrin surface expression and intracellular IL-10 and TNF-α levels were evaluated by flow-cytometry.

At baseline, osteoarthritic chondrocytes expressed significantly lower levels of β1 integrin and higher levels and IL-10 and TNF-α levels. It has been recently reported that ESW may be useful to treat OA in dogs, and veterinarians have begun to use ESW also to treat OA in horses.

Following ESW application, while β1 integrin expression remain unchanged, a significant decrease of IL-10 and TNF-α intracellular levels was observed both in osteoarthritic and healthy chondrocytes. IL-10 levels decreased at any impulses and energy levels, while a significant reduction of TNF-α was mainly found at middle energies.

Our study confirmed that osteoarthritic chondrocytes express low β1 integrin and high TNF-α and IL-10 levels. Nonetheless, ESW treatment application down-regulate the intracellular levels of TNF-α and IL-10 by chondrocytes, suggesting that ESW might restore TNF-α and IL-10 production by osteoarthritic chondrocytes at normal levels thus potentially interfering with the pathologic mechanisms causing cartilage damage in OA and representing the theoretical rationale for using ESW as therapy of OA.


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M. Lòpez-Franco O. Lòpez-Franco M. A. Murciano-Antòn M. Cañamero-Vaquero M. J. Fernández-Aceñero G. Herrero-Beaumont O. Sánchez-Pernaute E. Gòmez-Barrena

Meniscus injury is one of the causes of secondary osteoarthritis (OA). Cartilage oligomeric matrix protein (COMP) is a major component of the extracellular matrix of the musculoskeletal system. This study was undertaken to evaluate the changes occurring in meniscus from the knees of anterior cruciate ligament (ACL) transected rabbits during the early stages of OA development, especially regarding COMP changes.

Ten skeletally mature white New Zealand male rabbits underwent ACL transaction of the right knee joint. Left knee joints were used as controls. Animals were sacrificed at 4 and 12 weeks post-surgery. Meniscal tissues were processed for histology and immunohistochemistry.

The number of cells and positive cells were counted per high-power field (HPF). Anti-COMP antiserum was obtained according to Hauser et al. with minor modifications. Monoclonal Ki67 antibody was used to find out cells undergoing active division. TUNEL reaction was used for the study of apoptosis. Alcian blue staining was used to study glycosaminoglycans.

At 4 weeks post-ACL section 2/5 of the medial menisci presented with incomplete vertical posterior tears, while all lateral menisci were no altered. At 12 weeks post-ACL section 5/5 of the medial menisci and 2/5 of lateral menisci presented tears.

At 4 weeks postsurgery menisci showed: a weak increase of cells with a significant increase of cells undergoing active division; an increase in the number of apoptotic cells; glycosaminoglycans staining was increased and COMP staining was weakly increased. At 12 weeks postsurgery cells per HPF reverted to normal number; the number of cells undergoing active division decrease below normal; whereas the number of apoptotic cells was still elevated; glycosaminoglycans staining was more elevated than at 4 weeks postsurgery and COMP staining of extracellular matrix remain elevated.

Areas of large and abundant cell clusters were seen post-ACL around menisci tears.

We concluded that after ACL transaction, extracellular matrix changes and altered cell distribution occur early in the meniscus. Cellular division as well as apoptosis occur early too. Elevated concentrations of COMP after ACL transection might indicate meniscus changes early in osteoarthritis process.


J. D. Moorehead A. Kumar

The aim of this study was to investigate how the rotational axis of the wrist moves as the hand goes from full ulna to full radial deviation.

Fifty normal wrists in 25 subjects were assessed with a Polhemus Fastrak (TM) magnetic tracking system. The subjects, aged 19 to 57, placed their palms on a flat wooded stool. Sensors were attached over their 3rd metcarpal and distal radius. The sensors then recorded movement from ulna to radial deviation. The translational and rotational measurement accuracies were 1 mm and 1 degree respectively.

The mean range of movement was 45 degrees (SD 7). In ulna deviation the axis was in the region of the lunate. As the hand moved towards radial deviation, the axis moved distally. At the end of the movement the mean distal displacement was 21 mm (SD 15). In 32 wrists the distal displacement was accompanied by a mean displacement towards the ulna of 12 mm (SD 8). In 18 wrists the distal displacement was accompanied by a mean displacement towards the radius of 8 mm (SD 5).

The rotational axis position indicates how the wrist is moving during radial deviation. In early movement, when the axis is proximal, there is a high degree of sideways translation. In later movement, when the axis is distal, there is more rotational movement. In some cases the axis moved distally and toward the radius, whereas in other cases it moved distally and toward the ulna. This spectrum of movement may support the theory of 2 types of carpal movement proposed by Craigen and Stanley (J. Hand Surg, 20B, 165–170, 1995).


S. Tabatabai SAH. Mehdinasab E. Hossaini

The treatment of the open tibial fractures is still an orthopaedic challenge and full of complications. In many cases the use of external fixation that has been known as a non-union machine is obligatory with a high incidence of pin track infection and other complications. The aim of this study was to compare the use of external fixation as a definite method of treatment of open tibial fractures with it’s subsequent conversion to internal fixation or casting.

During June 2004 to July 2006 in a randomized controlled trial 67 patients with types A and B of Arbeitsge-meinschaft fur Osteosynthesefragen (AO) open type III Gustilo tibial and fibular diaphyseal fractures were studied. Mean age of the patients was 25 years (18–40 years) and mean follow up time was 8 months.

After the external fixation of the fractures, the patients were divided into three groups by drawing from the random table of numbers. Group one consisted of 20 patients were selected for delayed conversion to internal fixation after 6–8 weeks (after three weeks of removal of external fixator).

Group two consisted of 25 patients in whom external fixation had continued in order to convert to Patellar Tendon Bearing (PTB) cast after developing union.

The remaining 22 patients were considered as group three in whom external fixation was continued until complete union.

There was a meaningful difference only in the union time (P=0.001) and superficial infection (P=0.018) between the first group and the other two groups.

So, in the treatment of the open tibial fractures there is priority for method of conversion of the external fixation to internal fixation compared to the other protocols of treatment.


S. V. Karuppiah A. J. Johnstone

Distal locking screw fixation, in intramedullary nail (IMN) fixation, remains the most technically demanding and problematic portion of the procedure being responsible for as much as one-half of the exposure of the surgeon‘s hands to radiation.

This biomechanical study was undertaken to compare the effectiveness of using one distal locking cross screw instead of two cross screws in femoral fractures fixed with IMN system.

A composite model made from a stainless steel IMN (12mm×1mm), was axially loaded to 2kN (3 times body weight) to reproduce the forces experienced during weight bearing, or until a maximum displacement of 1 mm was reached. The distal locking end of the intramedullary nail was attached to the centre of the cylinder, representing different parts of the distal femur, with a dedicated single or two rods (5mm diameter), made from stainless steel and titanium, to represent the distal locking cross screw.

In the 50mm×5mm cylinder (diaphyseal femur), the mean stability of fracture model using either single or two screws were similar. But in the 75mm×5mm and 100mm×3mm cylinders (metaphyseal and distal femur), the mean stability of the fracture model significantly decreased (50%) with single distal locking cross screw fixation when compared to two distal locking cross screws fixation. Similarly, stainless steel alloy provided more stability compared to titanium alloy cross screws in 75mm×5mm and 100mm×3mm cylinders. However there was no difference between the cross screws performance for 50mm×5mm when comparing both the alloys.

As shown in this experiment, femoral shaft (diaphyseal) fractures fixed with shorter IMN had the same stability for one or two distal locking cross screws. However fractures fixed with longer IMNs, to fix diaphyseo-metaphyseal junction fractures and extreme distal femoral fractures, single distal locking cross screw fixation provide poorer fracture stability compared to two distal locking cross screws fixation.


N. Bertollo D. J. Bell W. R. Walsh

Infrapatellar Contracture Syndrome describes a postoperative complication characterised by a vertical migration of the patella due to Patella Tendon (PT) shortening and/or PT adhesion (PTA) formation. We investigated how removal of the central one-third of the PT influences both PT length (LP) and in vitro knee kinematics in 18 sheep divided into 3, 6, 12 and 24 week groups. At time of sacrifice the pelvis-lower extremities complexes were left in a supine position until rigor mortis set in. Limbs were CT-scanned (0.5mm) whilst frozen and LP measured (ProEngineer, PTC, MA). Specimens were fixed into a loading frame with 50N applied to the rectus femoris and knee kinematics obtained (Polhemus, VT). Bones and associated registration block portions of the receiver assemblies were CT-scanned (0.5mm), reconstructed, and imported into ProEngineer where coordinate systems were created in accordance with the Joint Coordinate System (JCS). Registration was accomplished by aligning models of the receiver assemblies with the reconstructed surfaces. Post-processing and statistical analysis (ANOVA) was performed using Matlab (MathWorks, MA) and data referenced to the contralateral controls.

No significant changes in LP were observed. The mean PT length ratio (LP/LC) in the 3 week group was 1.0028±0.004 (mean±SD). In the 6 week group this ratio had increased to 1.0282±0.0246, returning to 1.005±0.0035 at 12 weeks and back to 1.0159±0.0217 at 24 weeks. No PTA’s were observed. A significant proximal shift of the patella reflecting the increase in LP was observed which correlated well with a retardation of patellar flexion (r = 0.880, p< 0.001). A significant decrease in medial patellar tilt was also observed but was not coupled with changes in tibial rotation. Proximal and lateral tibial shifts were also detected.

The results of this study seem to suggest that the changes in knee kinematics and LP induced by removal of the central one-third of the PT do not recover 24 weeks post-operatively.


F. Valera A. Melián FJ. Minaya X. Veiga F. Lòpez-Oliva MJ. Rodríguez

Although modern operative intervention for calcaneal fractures has improved the outcome in many patients, there still is no real consensus on treatment, operative technique, or postoperative management. Vira® is a system for reconstruction-arthrodesis of severe calcaneal fractures, consisting in minimally invasive surgery using cannulation technique.

The aim of our study was to elaborate a CPG to assist physiotherapists in decision making and to improve the efficacy and uniformity of care for patients with severe calcaneal fractures.

The CPG was developed according to international methods of guideline development. To identify “best evidence” a structured search was performed. When no evidence was available, consensus between experts (physiotherapist and orthopaedic surgeons) was achieved to develop the guideline. To identify “best clinical experience” and “physiopathology reasoning” focus group of practicing physiotherapists was used. They reviewed the clinical applicability and feasibility of the guideline, and their comments were used to improve it.

CPG include three phases determined from the physiopathology and biomechanical reasoning of surgical system (weeks after the surgery: 2a–5a, 5a–14a, 14a–+/−24a). Unfortunately, evidence related to the treatment of severe calcaneal fracture was sparse and often of poor methodologic quality. The recommendations that were included: early onset (2a week after the surgery) with early mobility and loading, program of home exercises, manual therapy (articular and miofascial techniques), walking in swimming pool, continuous electromagnetic fields of 99Hz with an intensity of 99 Gaussian during 30 min/day; electrotherapy of the intrinsic muscles of the feet (80Hz; 8:12, 20 mi), a program of active exercises of the feet (dorsiflexion and plantarflexion, not supination and pronation) and resistive exercises of triceps surae muscle (7a week), criotherapy and anti-inflammatory positions.


D. Lozano L. F. de Castro E. Gòmez-Barrena F. Manzarbeitia P. Esbrit

Type 1 diabetes mellitus (DM) is associated with a decreased bone formation. Osteoblastic expression of parathyroid hormone-related protein(PTHrP) -an important modulator of osteoblast differentiation- decreases in age-related osteopenia. We here examined the putative role of PTHrP on the decreased osteoblastic function in DM.

We performed marrow ablation in the tibiae of diabetic mice after streptozotocin injection (glycemia > 300mg/dl). Some mice were treated with PTHrP(1–36) (100 ng/g/every other day, s.c.) or vehicle for 2 weeks. Both tibiae were then removed for histological evaluation or total RNA isolation. In vitro, MC3T3-E1 cells were grown in differentiation medium (a-MEM), with or without high glucose(HG) (25 mM) (or mannitol, as osmotic control), supplemented (or not) with PTHrP(1–36) (100 nM). In some experiments, anti-PTHrP N-terminal antibody C13 (1:100) or PTHrP(7–34) (1 μM) were added to normal-glucose medium. RANKL secretion was measured in the cell-conditioned medium by ELISA. Gene expression was analyzed by real-time PCR.

DM induced a 10–15% weight loss and a decrease (20–40%;p< 0.05) in the gene expression of the following osteoblastic factors in the regenerating tibia for 6 days: PTHrP, the PTH/PTHrP type1 receptor (PTH1R), osteocalcin, VEGF and its receptors 1 and 2; and in the OPG/RANKL ratio, related to an increased PPAR-γ mRNA expression. Compared to control mice, the regenerating tibia of DM mice showed a 5-fold increase in adipocyte number, and a decreased osteoblast number and osteoid surface. In MC3T3-E1 cells, HG decreased (20–40%) the OPG/RANKL ratio and the gene expression of both PTHrP/PTH1R and VEGF systems. PTHrP(1–36) reversed these HG-related effects in vivo and in vitro. Similar inhibitory effects were induced by a neutralizing PTHrP antibody or the antagonist PTHrP(7–34) in these cells in normal glucose.

In conclusion, a deficit in PTHrP production by osteoblasts seems to be at least in part responsible for the DM-related decreased bone formation in mice.


R. Aquarius L. Walschot P. Buma B. W. Schreurs N. Verdonschot

We investigated the feasibility of using porous titanium particles (TiP) to reconstruct femoral bone defects in revision hip replacement surgery in stead of using morzelised bone grafts. Questions regarding handling, initial stability and titanium particle release were addressed.

Seven composite femurs (Sawbones) were reamed and filled, stepwise, with 32 grams of large (Ø 3.15 – 4 mm) and 9 grams of smaller (Ø 2.8 – 3.15 mm) pure, 85% porous TiP. Subsequently an Exeter stem was cemented into the graft layer. All reconstructions were loaded axially (0–3000 N) for 300,000 loading cycles at 2 Hz. Subsidence of the stem was measured with radio stereometric analysis (RSA) and possible titanium particle release was measured using the laser diffraction technique.

The TiP were impacted into a > 3 mm (SD 1.43 mm) thick, highly entangled, graft layer. An average cement mantle of > 2 mm (SD 0.86 mm) was measured and little cement penetration was observed. The average subsidence of only 0.45 mm (SD 0.04 mm) was measured after 300 000 loading cycles. Most titanium particles were found directly after impaction. Most of these particles (87%) were smaller than 10 μm and could therefore be potentially harmful since they can induce osteolysis.

We can conclude that:

A graft layer of impacted TiP can be constructed,

The graft layer is stable enough to initially support a cemented Exeter stem,

Titanium particles are released during impaction.

These data warrant further animal tests to assess the biological response to these released impaction particles. Also, animal tests should clarify possible particle release upon loading and its effects.


A. Fahlgren A. Nilsson P. Aspenberg

Introduction: In a rat model, fluid pressure causes more bone resorption than particles. Does pressure also cause more inflammation?

Materials and Methods: Rats received a titanium plate at the proximal tibia. A central plug was inserted. After 5 weeks of osseointegration, the central plug was changed to either a piston or a hollow plug with titanium particles. Commercially pure titanium particles with 90% of particles lesser than 3,6 microns were used. The pressure piston was subjected to a transcutanous force of 8N. Each episode of pressure comprised 20 pressure cycles at 0.17 Hz, applied twice a day. 39 rats were randomized to 3 groups: Titanium particles (n=13), fluid pressure (n=13) and controls with neither particles nor fluid pressure (n=13). The rats were killed after 3 days. 6 rats in each group were used for histology and the others for gene expression. Extraction of total RNA was performed using the TRIspin method. Primers for cat K, RANK, RANKL, OPG IL-1, IL-b, TNF-a, iNOS and COX-2 were used. Each sample was normalized to 18S rRNA. Histology was evaluated qualitatively. Differences between the groups were analyzed by Kruskal Wallis and Mann-Whitney U-test.

Results: Both particles and fluid pressure increased the expression of osteoclastic genes. Particles induced an elevated expression of IL-6 and RANK compared to both controls and fluid pressure. There was a tendency that particles induced more expression of other inflammatory genes compared to fluid pressure.

Histology: The controls showed only few osteoclasts at the bone surface. The particle group showed osteoclasts at the surface towards the particles. In contrast, the pressure group showed resorption cavities spread out inside the bone.

Discussion: Although there was more resorption in the pressure group, there was a lesser inflammatory response. This suggests that pressure-induced resorption is mediated via different pathways.


P. C. Rijk W. Tigchelaar C. J. van Noorden

Experimental and clinical studies have documented that meniscal allografts show capsular ingrowth in meniscectomized knees. However it remains to be established whether meniscal allograft transplantation can prevent degenerative changes after total meniscectomy. In this study, functional changes in articular cartilage after meniscus transplantation in rabbits were evaluated quantitatively.

Thirty rabbits were divided into five groups. Group A and Group C were subjected to meniscectomy. Group B and Group D underwent meniscal transplantation immediately after meniscectomy. Group E had delayed transplantation 6 weeks after meniscectomy. Six nonoperated knees served as controls. Using image analysis with QwinPro software ffunctional changes of articular cartilage were examined 6 weeks (Groups A, B) and 1 year (Groups C, D, E, controls) after surgery by measuring the lactate dehydrogenase (LDH) activity in chondrocytes as a measure of their vitality and the proteoglycan content of the extracellular matrix as a measure of its quality.

All experimental groups demonstrated a significant decrease in proteoglycan content of the cartilage as compared with the control group. At 6 weeks and 1 year follow-up, no significant differences were found between the postmeniscectomy group and immediate transplant group. The delayed transplant group showed a significantly decreased proteoglycan content as compared with the postmeniscectomy group. Compared to the control group, no significant differences in cellular LDH activity were found in the postmeniscectomy group and immediate transplant group at 6 weeks and 1 year. However, delayed transplantation caused diminished vitality of chondrocytes. No significant differences were found between the postmeniscectomy group and immediate transplant group at 6 weeks and 1 year. The delayed transplant group showed a significant decrease in LDH activity as compared with the postmeniscectomy group.

It can be concluded that immediate meniscal transplantation in rabbits did not significantly reduce degenerative changes of articular cartilage whereas delayed transplantation leads to even more degenerative changes than meniscectomy.


S. Boeuf M. Burkhardt P. Kunz J. VMG Bovée B. Lehner W. Richter

Chondrosarcomas are hyaline cartilage-forming tumours which can be classified according to malignancy through histological grading. Grade I chondrosarcomas rarely metastasize whereas in grade III chondrosarcoma metastasis is observed in 71% of cases. There is, so far, no clear molecular marker allowing an objective classification of chondrosarcoma. The aim of this project was to identify such marker genes through the comparison of gene expression of chondrosarcoma and normal hyaline cartilage and through the correlation of expression profiles to histological grading.

The mRNA of 19 chondrosarcomas with different histological grades and of eight normal cartilage samples was analysed. Gene expression profiles were assessed on a customised cDNA array including 230 cartilage- and stem cell-relevant genes. Data were analysed by hierarchical clustering and significance analysis of microarrays. Results were confirmed by real-time RT-PCR.

Gene expression profiles clearly discriminated between normal and neoplastic cartilage. Between them, 73 differentially expressed genes were identified. The genes higher expressed in cartilage included several genes encoding matrix proteins. Among the genes higher expressed in chondrosarcoma, molecules involved in PTH and BMP signalling were found. Genes differentially expressed between tumours of different grade were identified. Among others, galectin 1 was significantly higher expressed in highly malignant tumours compared to grade I tumours. This correlation could be confirmed at protein level by immunohistological analysis.

The comparative analysis of normal cartilage and chondrosarcoma gene expression showed that there are important molecular differences between the matrix of normal and neoplastic cartilage. Our results furthermore confirm that genes implicated in the regulation of the growth plate were expressed in chondrosarcoma. Remarkably, we identified galectin 1 as a marker correlating to malignancy on the level of gene and protein expression. More extended studies on this functionally polyvalent molecule would be necessary to establish it as a marker for malignancy in chondrosarcoma.


F. Fakhil-Jerew S. Haleem J. Shepperd

Introduction: The results of the FDA trial for Dynesys stabilisation implied that the procedure was effective as a method of treatment for this condition. However, all the American cases had adjunct decompressive treatment. In this study we report the outcome of the first two years following DYNESYS for Spondylolisthesis in two groups of patients; Dynesys alone and Dynesys with fusion.

Method: Fifty five patients had Dynesys for symptomatic Spondylolisthesis which was indicated for surgical treatment. Average age for group 1 was 51 years with range of 36–85 years whereas in group 2, average age was 59 years with range of 31–79 years. Patients were evaluated preoperatively using ODI, SF36, VAS, plain x-ray, MRI scanning & discography. 33 of the patients underwent Dynesys alone (group 1) while 22 underwent dynesys with fusion (group 2). Previous decompression surgery was noted in 10 in group 1 and 8 in group 2.

Results: In the first year following Dynesys, both groups did show significant improvement in all the four parameters; VAS (back and leg), ODI and SF36. In group 2 slight deterioration was noted in year 2 and while group 1 continued to improve, Subsequently 3 group 1 patients underwent fusion and 12 required removal/revision of Dynesys (40%).

Discussion & Conclusions: Dynesys alone in the treatment of spondylolysthesis resulted in a 45% re-operation rate, and we believe it should not be recommended as an indication.


F. Fakhil-Jerew S. Haleem J. Shepperd

Introduction: We report the outcome two years following Dynesys for the treatment of Spinal Canal Stenosis. In both the FDA trial and the European multicentre study, stenosis was invariably combined with decompression, invalidating conclusions on the results of Dynesys alone.

Method: Eighteen patients had symptomatic Spinal Canal Stenosis with root claudication sufficient to justify surgical intervention. Average age of patients was 68 with a range between 44–86 years. Dynesys was applied for the treatment of a single level in 4, two levels in 8, and more than two levels in 6.

Patients were evaluated preoperatively using ODI, SF36, VAS, plain x-ray, MRI scanning & discography. Questionnaires were evaluated at the first and second years.

Results: 2 patients had undergone previous spinal decompression, and decompression at the time of Dynesys surgery in 7. In the remaining 9 cases, no decompression was used, relying on distraction alone as in the X stop system. In this latter group, stenotic symptoms failed to resolve. Removal of Dynesys was indicated in 3 (16.6%).

Discussion & Conclusions: Dynesys alone is not recommended as a treatment for symptomatic spinal stenosis. A separate study is required to address the question of whether Dynesys adjunct improves the back pain outcome compared with decompression alone.


M. Ángeles Sarti-Martínez M. Ángeles Fuster-Ortí C. Barrios-Pitarque

Kinematics characteristics of the spine and pelvis are one measure proposed to assess lumbar dysfunction. To extent our knowledge about this matter we described the relationship between the orientation of the sacrum, in the sagittal plane, at upright position and the differential lumbar spine and pelvis range of flexion at the toe touch position in free-pain subjects.

Position and motion measurements were recorded by an electrogoniometer. Individuals (n=39), were divided into two groups according to whether they have either pelvis (pelvis -group, n=18) or lumbar spine (spine-group, n=21) dominant movements during flexion. The mean age was 23,67±4,94 years (range18 to 33 years) in the pelvis-group, and 22,55 ± 2,70 years (range 19 to 27 years) in the spine –group. The range of pelvis flexion was significantly greater in the pelvis group than in the spine group, the range of lumbar spine flexion was significantly greater in the spine group than in the pelvis group (α≤.001); however, no differences were found in the range of back flexion (combined lumbar spine and pelvis motion) between the two groups. In the pelvis group the sacrum was significantly more horizontal than in the spine group (α≤.001). In the pelvis-group very strong correlation between sacrum orientation and the maximum range of pelvis flexion was found (r =0, 61). In the Spine group, sacrum orientation showed a negative strong correlation with the maximum range of spine flexion (r= − 0, 71). These results suggest the influence of the individual morphology on the lumbo-pelvic patterns of movements.


F Dakhil-Jerew

Introduction: ACDF involves cancellation of the diseased spinal motion segment, the neighboring spinal segments take the burden of excessive compensatory spinal movements and strain resulting in early degeneration.

Adjacent segment degeneration with new, symptomatic radiculopathy occurs after ACDF in 2–3% of patients per year on cumulative basis. An estimated 15% of patients ultimately require a secondary procedure at an adjacent level.

An alternative to fusion is total disc arthroplasty (TDA). The key advantage of this promising technology is restoration and maintenance of normal physiological motion rather than elimination of motion.

We describe 4 patients with a serious complication observed following implantation of the Bryan disc prosthesis in our cohort of 48 patients.

Material and Results:

Patient #1: 43 M, with neck pain & left brachalgia, with left C6 dermatome signs, with MRI findings of C5/6 disc prolapse with left C6 root impingement, undergoing C5/6 Bryan TDA in April 2004, with treatment recommendation of C3/4 and C6/7 Bryan TDA in January 2006.

Patient #2: 47 M, with worsening gait over 2 years with right brachalgia, with findings of progressive cervical myelopathy with right C5 radiculopathy, with MRI findings of severe C5/6 disc degeneration with spinal cord compression, undergoing C5/6 Bryan TDA in January 2003, with MRI FU findings after 16/12 with new left C6/7 disc prolapse and left C6 radiculopathy, with treatment recommendation of C6/7 Bryan TDA, on waiting list.

Patient #3: 45 F, 6 years of neck pain with right brachialgia, with right C5 dermatome signs, with MRI findings of C5/6 central disc herniation with cord compression, undergoing C5/6 Bryan TDA in December 2000, with FU MRI showing after 5 years and 7/12 (67/12) new C6/7 canal narrowing with right C6 radiculopathy, and treatment recommendation of C6/7 Bryan TDA.

Patient #4: 38 M, worsening gait over 5 years and exam findings of progressive cervical myelopathy, with MRI findings of severe C5/6 disc degeneration with spinal cord compression, undergoing C5/6 Bryan TDA in August 2003, with FU MRI showing after 3 years new C4/5 disc prolapse with C5 radiculopathy, followed by treatment recommendation of C4/5 Bryan TDA.

Discussion & Conclusions: Bryan TDR did not prevent the development of accelerated ASD. Evidence from in vivo X ray studies suggested that the range of motion across the operated levels did not match the physiological ROM.

Despite the MRI images preoperatively, it is difficult to exclude the natural progression of degeneration as a reason for ASD.


F. Dakhil-Jerew S. Haleem H. Jadeja N. Bowman D. Shah A. Cohen A. El-Metwally R. Guy G. Selmon J. Shepperd

Introduction: In this study, we report interobserver reliability of X-ray for the interpretation of pedicle screw osteointegration based on the diagnosis of “Halo zone” surrounding the screw.

Dynamic stabilisation system for the spine relies on titanium screw purchase within the pedicle. Decision on osteointegration is important especially when the patient becomes symptomatic following initial good outcome. From our cohort of 420 Dynesys patients, over all incidence of screw loosening was 17%. Only 35% were symptomatic.

Method: Lumbar spine X-ray images of 50 patients in two views (AP and lateral) randomly selected from our cohort of 420 Dynesys patients. The images were deployed in a CD-ROM. The authors were asked to review the images and state whether or not each pedicle screw is loose (total of 258 pedicle screws).

Seven observers composed of two expert orthopaedic spine consultant surgeons and one spine expert consultant radiologist and four Specialist Registrars in orthopaedics and radiology.

Data gathered were distributed and presented in tables in the form of descriptive statistics. The evaluation of interobserver agreement was performed by obtaining a Kappa (K) index. For continuous variables comparison, the t test was employed, with a significance level of 0.05.

Results: Kappa Index among three experts was 0.2198 at 95% CI (−0.0520, 0.4916) while for all 7 assessors (3 Experts & 4 SpR), KI was 0.1462 at 95% CI (0.0332, 0.2592)

Discussion & Conclusion: Kappa Index among expert assessors was 0.2 which means X-ray is unreliable for the assessment of pedicle screw osteointegration. Validity of X-ray is not applicable as it is unreliable.

We are planning to evaluate a 3D computer reconstruction model based on 2 X-ray views at 45 degree angle to each other which might be sensitive to detect screw loosening.


M.H. Pelletier W.R. Walsh

In vitro testing of spinal motion segments provides valuable information about the effects of surgical procedures on the biomechanics of the spine. Few studies, however have investigated the effect of varying laboratory testing environments on the outcome of these tests. This study aims to identify differences in mechanical properties induced by testing in one of three testing environments, and trends due to repeated testing over time.

27 sheep lumbar motion segments were tested in either,

air at 18°C while wrapped with gauze soaked in Phosphate Buffered Saline (PBS),

a PBS bath at 37°C, or

at 37°C and 100% humidity.

Specimens were cycled through +/−8Nm in axial rotation, lateral bending, and flexion/extension. Tests were repeated every hour for 6 hours. Torque and angle were recorded and each bending mode was repeated for 4 cycles, the last 3 of which were used in calculations. Stiffness (5–7Nm), neutral zone (NZ), NZ stiffness, Range of Motion (ROM) energy under the loading curve and hysteresis area were calculated and evaluated with ANOVA.

Post hoc comparisons found differences in stiffness, hysteresis area and energy of bending between room temperature and both heated conditions during flexion/extension. Differences were also noted between the room temperature and PBS bath conditions for stiffness and hysteresis area during lateral bending. One explanation of the results could be the thermo-sensitive properties of spinal ligaments and intervertebral fibrocartilages.

Repeated testing was a factor that affected the outcome of NZ, NZ stiffness, ROM and energy under the loading curve in all modes of torsion. If not accounted for during repeated tests this could lead to confounding results. Many of the traditionally reported variables (NZ, ROM) showed changes with repeated testing while hysteresis area remained relatively steady during repeated tests while identifying differences between testing groups. This variable may be useful in evaluating the condition of a motion segment with less time related effects.


E. Melendo C. Torrens M. Corrales A. Solano E. Cáceres

Purpose of study was to determine the value of the upper edge of the pectoralis major (UPM) insertion as landmark to determine proper height and version of hemiarthroplasties implanted for proximal humeral fractures.

UPM insertion was referenced with metallic device in 20 cadaveric humerus. Computed Tomography study was performed in all specimens. Total humeral length and distance between the UPM insertion and the tangent to humeral head was recorded. CT scan slice showing UPM superimposition in humeral head was drawn to determine prosthesis retroversion. Qualitative variables are presented in absolute and percentage values. Quantitative variables are presented with mean values and standard deviation.

Mean total humeral length 32,13 cm. Mean distance from the UPM to the tangent to the humeral head 5,64. Mean distance from UPM insertion to the tangent to the humeral head represents the 17,55 % of total humeral length. Mean distance of UPM insertion to the posterior fin of the prosthesis of 1,06 cm. Angle between UPM insertion and posterior fin of the prosthesis 24,65°.

Mean distance from the UPM insertion to the top of the humeral head of 5, 6 cm with a 95% confidence interval. Placement of the prosthesis in the proper retroversion can be achieved by placing the posterior fin 1,06 cm posterior to the UPM or by placing the posterior fin at 24,65° with respect to the upper insertion line. UPM constitutes a reliable reference to reproduce anatomy in hemiarthroplasties for proximal humeral fractures.


E. Audenaert P.J. De Roo P. Mahieu E. Barbaix L. De Wilde R. Verdonk

Physiological studies have revealed that the central nervous system controls groups of muscle fibers in a very efficient manner. Within a single skeletal muscle, the central nervous system independently controls individual muscle segments to produce a particular motor outcome. Mechanomyographic studies on the deltoid muscle have revealed that the deltoid muscle, commonly described as having three anatomical segments, is composed of at least seven functional muscle segments, which all have the potential to be at an important level independently coordinated by the central nervous system.[1] In this study we tried to anatomically describe and quantify these different functional segments within the deltoid muscle, based on the branching out pattern of the axillary nerve.

Forty-four deltoids of 22 embalmed adult cadavers, were analyzed. The axillary nerve was carefully dissected together with his anterior and posterior branch upon invasion into the muscle. According to the pattern of fiber distribution and their fascial embalmment, we then carefully splitted the deltoid muscle into different portions each being innervated by a major branch of the axillary nerve. The position and volume of each segment in relation to the whole muscle was derived.

In 3 cases the axillary nerve branched out in 8 major divisions. In 22 out of 44 cases (50%), the axillary nerve branched out in 7 principal parts. A branching out pattern of 6 major divisions occurred in 14 out of 44 cases. Finally we found a division in 5 major branches in 5 of the specimens. In general, both posterior and anterior peripheral segments seemed to have the largest volume. In nearly all (93%) cases, the central segments were smaller in weight and volume compared to the more peripheral segments.

Based on the innervation pattern of the deltoid muscle a segmentation in 5 up to 8 major segments seem to be found. This confirms from anatomical point of view earlier reports of functional differentiation within the deltoid muscle.


M.A. Sarti-Martínez Alfonso-Beltrán D. Conesa-Guillén

Dimensions of the 60 male human lumbar vertebrae were quantified on their digitalised lateral images, and related to them across the five vertebral levels (range of 20–40 years). Vertebra dimensions’ were defined and referred to the upper endplate. Linear dimensions (mm) were: the length of the whole vertebra and of the spinous process; the anterior/posterior body heights, and the upper/lower endplate lengths. For each of the measurements L3/L1, L3/l2, L3/L4, L3/L5 ratios were calculated. The inclination angle (°) of the lower-end-plate was further calculated.

Significant differences were shown by a randomized complete blocks design, post-hoc test (Student-Newman-Keuls), (α< .05). Anterior bodies’ heights ratios progressively decreased from L1 to L5 level, which means a relative increase of the anterior bodies’ heights. Posterior bodies’ heights ratios progressively increased from L1 to L5 level, which means a relative decrease of the posterior bodies’ heights. Lower-endplates inclination angle significantly and progressively increased from L1 to L5 vertebral level. For L1 and L2 (𝛉< 0°), it means that vertebrae are ventrally wedged, whereas L3, L4, L5 vertebrae are dorsally wedged (𝛉< 0°). It could be suggested that individual vertebra morphology contributes to shape the anterior convexity of the lumbar curvature along with the intervertebral discs. Spinous process and vertebral lengths ratios significantly decreased from L1 to L2, and significantly increased from L4 to L5, but no differences between L1vs. L5 neither for L2 vs. L4. It shows that lengths of the spinous process and vertebrae define two segments with same trends at the lumbar spine, the upper L1 and L2 segment; and the lower L4 and L5, which join together at L3 vertebra. This design allows to drawn the concavity of the lower back while standing upright and its convexity while flexing forward.


P. Ciampi N. Mancini G. Peretti G. Fraschini

The shoulder girdle is an extremely mobile joint. Rotator cuff tears alter the existing equilibrium between bony structures and muscles. The “subacromial impingement syndrome” resulting from this unbalance leads to an extension of the rotator cuff lesion.

Many authors have postulated a “mechanism of compensation”, but its existence still requires evidence. According to this model, the longitudinal muscles of the shoulder and the undamaged muscles of the rotator cuff would be able to functionally compensate, supersede the function of rotator cuff, and reduce symptoms.

The aim of this study was to evaluate muscular activation of the medium fibers of deltoid, the superior fibers of pectoralis major, the latissimus dorsi and the infraspinatus by a superficial electromyographic study (EMG) and the analysis of kinematics in patients with a massive rotator cuff tear.

We evaluated 30 subjects: 15 had pauci-symptomatic massive rotator cuff tear (modest pain and preserved movement), and 15 were healthy controls.

Paired t-test showed significant different activations (p< 0.05) of these 4 muscles between the pathological joint and the healthy one in the same patient.

The unpaired t-test, after comparing the mean EMG values of the 4 muscles, produced a significant difference (p< 0.05) between the experimental group and control group.

This study showed that a mechanism of muscular compensation is activated in patients suffering from rotator cuff tear, involving the deltoid and the infra-spinatus muscle, as already presented in literature, but also demonstrated the activation of 2 other muscles: the latissimus dorsi and the pectoralis major. It is, therefore, probable that, in these patients, these muscles, which would not normally pull the head of the humerus downwards, adapt in order to compensate for the pathological situation. We believe that these data are valuable in the surgical and rehabilitation planning in patients with a massive rotator cuff tear.


E. Audenaert P. Mahieu P.J. De Roo E. Barbaix N. Baelde K. D’Herde L. De Wilde R. Verdonk

The concept of non-anatomic reversed arthroplasty is becoming increasingly popular. The design medializes and stabilizes the center of rotation, and lowers the humerus relative to the acromion, and lengthens the deltoid muscle up to 18%. Such a surgically created global distraction of muscles is likely to affect nervous structures. When nerves are stretched up to 5–10%, axonal transport and nerve conduction starts to be impaired. At 8% of elongation, venous blood flow starts to diminish and at 15% all circulation in and out of the nerve is obstructed. [1] To understand nerve dynamics following reversed arthroplasty, we investigated nerve strain and excursion in a cadaver model.

In a formalin-embalmed female cadaver specimen, the brachial plexus en peripheral upper limb nerves were carefully dissected and injected with an iodine containing contrast medium. At the same time 1.2 mm-diameter leaded markers were implanted at topographically crucial via points for later enhanced recognition on CT reconstructions. After the first session of CT scanning a plastic replica of the Delta reversed shoulder prosthesis® was surgically placed followed by re-injection of the plexus with the same solution. The preoperative and the postoperative specimen were studied using a helical CT scan with a 0,5 mm slice increment. The Mimics® (Materialise NV, Belgium) software package was used for visualization and segmentation of CT images and 3D rendering of the brachial plexus and peripheral nerves.

After surgery, there was an average increase in nerve strain below physiologically relevant amplitudes. In a few local segments of the brachial plexus an increase in nerve strain exceeding 5–10 % was calculated. The largest increase in strain (up to 19%) was observed in a segment of the medial cord. These results suggest there might be a clinically relevant increase in nerve strain following reversed shoulder arthroplasty.


I. Izal P. Ripalda V. Acosta I. Ochoa J.A Bea M. Doblaré P. Aranda R. Escribano G. Mora J.R. Valentí G. Gallego I. Recalde J.L. Gòmez-Ribelles F. Pròsper

Hyaline cartilage is a support tissue with a poor capacity to self repair. In the last years, tissue engineering and cell therapy have focused its efforts in the development of scaffolds that may support the differentiation and the implantation of mesnechymal stem cells (MSC) in the site of lesions performed in femoral cartilage. Among synthetic materials used for the construction of these scaffolds, poly(L-lactic acid) (PLLA) is a suitable option, since some studies have offered promising results. The use of PLLA, nevertheles has an important handicap, as cell seeding easily results in a non uniform distribution and a poor density of cells, wich have been proposed as key steps for the differentiation of MSCs to chondrocytes. In our work we have cultured sheep MSCs, and proved its potentiallity by differentiation to chondrocytes in micromass culture. PLLA scaffolds 1 mm thick and 6 mm in diameter were characterized by determining their porosity and their mechanical properties, and subsequently were used to assay the seeding of MSCs. We measured efficiency and retention by quantification of DNA, and density and distribution by light microscopy of paraffin sections. Our results describe a simple technique of cell seeding by aspirating cells with a syringe that achieves a uniform distribution and a high density of cells. Finally 3D seeded MSCs were cultured with condrogenic medium containing TGF-β3 for 21 days and results analyzed by massons trichrome staining in paraffin embedded sections.


A. Toom S. Suutre T. Talpsep L. Põllumaa A. Lenzner A. Arend A. Märtson T Haviko

Ex vivo cell-growing technique might be a solution for treatment of bone diseases leading to the local bone defects. We assessed the effect of ex vivo-cultured cells in ectopic bone induction in animals with normally functioning connective tissue cells.

Material and methods: Bone marrow cells, harvested via puncture of tibial canal of male Wistar rats, were cultured, and differented into osteogenic lineage using chemical stimulus.

After differentiation osteoprogenitor cells were transferred into beta-tricalcium phosphate scaffolds using either centrifugation or simple diffusion. Six types of implants (beta-tricalcium phosphate matrixes) were implanted into subcutaneous pouches. In the first group saline-immersed implants were used; in the second group the ex vivo cells were transferred into the implant by diffusion and in the third group by centrifuging; in the 4th, 5th and 6th group the implants were processed as in first three groups, respectively, but 12.5 microgram of rhBMP2 was added to the each implant. After 21 days the implants were removed and dissected systematically. Histomorphometry analysis was performed following the principles of stereology.

Results and discussion: Bone formation was found only in the rhBMP2-immersed implants. Other implants consisted mostly of connective tissue and in lesser extent of the unchanged scaffold. No distinctive differences were found between the rhBMP2-implants. The osteoinduction seems to be crucial in ectopic bone formation if there is no cellular dysfunction present. The inductive effect of rhBMP2 cannot be compensated by the abundance of the pre-differentiated osteogenic cells as shown by the absence of bone induction in the groups two and three in this model.

• Supported by Estonian Government SF 0180030s07


L. Meseguer A. Bernabeu M. Clavel-Sainz S. Sánchez S. Padilla A. Martín M. Vallet-Regí F. Lòpez Cl. Meseguer P. Sánchez I. Acien

Introduction: In this work a bioactive glass-ceramic (GC) in the system SiO2-CaO-P2O5 was evaluated as bone substitute biomaterial. In this sense, the capacity of mesenchymal stem cells (MSCs) to adhere, proliferate and differentiate into osteoblast (OBs) with or without GC was investigated. Two types of culture medium, i.e. growth medium (GM) and osteogenic medium (OM), were evaluated.

Materials and Methods: The GC was obtained by heat treatment of a bioactive glass obtained by the sol-gel method. Isolation and culture of MSCs: The adult MSCs were isolated from bone marrow of adult rabbits obtained by direct aspirations of ileac crest. Isolation and culture of OBs: The OBs used as control were obtained by enzymatic digestion. Behavior of MSCs on GC: For the study of the behavior of isolated MSCs on the GC, two series of 96-well plates were seeded, one plate with GM and the other one with OM. The number of cells was evaluated through the XTT assay. OC production and CD90 expression of cells cultured in both media were measured to evaluate the differentiation of MSCs into OBs. Statistical analysis: A variance analysis (ANOVA) was carried out.

Results: The number of cells growing in OM and GM, there were no significant differences between them. The MSCs under the conditions of this study expressed an osteoblastic phenotype (OC production, decrease CD90 expression, mineralized extracell matrix). These two effects took place by either the action of exposing the MSCs to a MO and by the effect of the GC.


F. Ferrero-Manzanal MA. Suárez-Suárez JC. de Vicente-Rodríguez A. Meana-Infiesta P. Menéndez-Rodríguez V. García-Pérez E. García-Díaz M. Álvarez-Rico A. Murcia-Mazòn

Calcification and ossification have been described in artery wall in pathologic conditions and aging. We previously described the use of cryopreserved arterial allografts as membranes for guiding bone regeneration. We hypothesize that artery is as good as synthetic membranes (e-PTFE, gold-standard in guided bone regeneration) due to the osteogenic potential of cells from its medial layer.

A comparative study was made creating 10 mm mid-diaphyseal radial defects in 15 New Zeland rabbits (30 forearms): 10 defects were covered with an e-PTFE membrane and 10 defects with no membrane (control group). Studies: X-rays, CT, MR, morpho-densitometric analysis, electronic and optical microscopy.

To demonstrate the cellular arterial stock, cryopre-served and fresh rabbit thoracic aorta specimens were studied. Medial layer was isolated and cultured as explants in normal medium. Cells were harvested and added to a 3-D scaffold based on plasmatic albumin in osteogenic medium. Immunocitochemical study was made. Radial defects surrounded by cryopreserved arterial membranes showed total regeneration in nine of 10 defects versus seven of 10 defects in e-PTFE group (no statistically significant differences were detected between them). No tissue layer was found between bone and artery while a connective tissue layer was observed between e-PTFE and bone. Neither radiological nor histological healing were detected in the control group.

Cells cultured had smooth muscle features as they showed immunofluorescence with anti-smooth muscle alpha-actin, anti-calponin and anti-vimentin antibodies. When cells were added to a 3-D matrix, they showed chondro and osteogenic differentiation, as they stained positive for types II and X collagen, alkaline phosphatase and von Kossa.

Although no statistically significant differences between artery and e-PTFE groups were detected, histological and cellular findings suggest a superiority of cryopreserved arterial allografts when compared with synthetic membranes of e-PTFE, with a contribution of the cellular stock of the medial layer in the healing process.


R.K. Goddard D. Yeoh B. J. Shelton M.A.S. Mowbray

Aims: The aims of this study were to evaluate the biomechanical properties and mode of failure of a technique of anterior cruciate ligament (ACL) reconstruction using the Soffix polyester fixation device. A 2-strand equine extensor tendon graft model was used because a previous study has shown it to have equivalent bio-mechanical properties to that of 4-strand human semitendinosus and gracilis tendon grafts.

Method: Ten stifle joints were obtained from 5 skeletally mature pigs, the soft tissues were removed and the ACL and PCL were sacrificed. Tibial tunnel preparation was standardised using the Mayday rhino horn jig to accurately position a guide wire over which an 8mm tunnel was drilled. A 2-strand equine tendon-Soffix graft was used to reconstruct the ACL of the porcine knee using over the top femoral placement with bicortical screw fixation. Mechanical testing of 10 specimens was performed.

Results: The mode of failure included 4 midsubstance tendon failures, 3 Soffix failures and 3 failures at the suture-Soffix interface. The mean ultimate tensile load for the ACL reconstruction was 1360 N (standard deviation (SD) =354), elongation to failure of 41 mm (SD=7.5) and a structural stiffness of 35 N/mm (SD=8.1).

Conclusion: This in vitro study has shown that the technique of ACL reconstruction using the Soffix soft tissue fixation device with a tendon graft placed in the over the top position is biomechanically strong, providing a sufficiently high UTL immediately following reconstruction, therefore allowing early weight bearing and rehabilitation.


D. Yeoh R. Goddard N. Bowman P. Macnamara K. Miles D. East A. Butler-Manuel

The most common indication for knee arthrodesis is pain and instability in an unreconstructable knee following an infected knee arthroplasty. In this study, we compare the use of the Mayday arthrodesis nail (Ortho-dynamics, Christchurch, UK) versus external fixation, Orthofix (Berkshire UK) and Stryker Hoffman II (County Cork, Ireland).

All patients in this study underwent arthrodesis between 1995 and 2006 at Conquest Hospital, Hastings. In group A, 11 patients underwent arthrodesis with a Mayday nail. In all cases, the indications were infected total knee replacements (TKR). Three of these patients previously had failed attempts at arthrodesis with external fixation devices. In group B, seven patients underwent arthrodesis using external fixation. In six patients, the indication was infected TKRs. Results were reviewed retrospectively, with union assessed both clinically and radiologically.

The mean inpatient stay for the Mayday nail group was 23 days (range 8 – 45 days) compared with 76 days (range 34 – 122) for the external fixation group (p< 0.01, CI 95). Ten patients in group A went on to confirmed primary arthrodesis. One patient underwent revision arthrodesis with a Mayday nail and subsequently united. In group B only two patients achieved union. The rate of union was significantly greater in the Mayday nail group than the external fixation group (91% vs 29%, p< 0.01). Of those patients that achieved union, there was no difference in the time to fusion between groups.

Our study supported the existing literature and found that the Mayday nail appeared more effective than monoaxial external fixators for arthrodesis in the management of infected total knee replacements.


J. Wilson A. Smith

We aimed to collate guidelines for preoperative marking in orthopaedic surgery, identify areas of convergence and difference and relate them to previous work on guideline effectiveness.

We performed a systematic search of Medline and Google using ‘correct site’, ‘wrong site’, ‘marking’, ‘surgery’, ‘orthopaedics’ and ‘guidelines’. Orthopaedic societies and bodies, personal knowledge and unindexed conference abstracts were also used.

We found nine guidelines from ten institutions in seven different countries; UK National Patient Safety Agency/Royal College of Surgeons of England, Australian College of Surgeons, JCAHO (USA), Canadian Orthopaedic Association, Veterans Health Association (USA), Copenhagen Hospital Corporation, German Coalition for Patient Safety, American Academy of Orthopaedic Surgeons and the New Zealand Orthopaedic Association.

We identified four ‘core-steps’ common to the majority of guidelines. Firstly, using indelible pen. Secondly, the operating surgeon should mark the patient. Thirdly, the patient should be involved in confirming side/site. Finally, a ‘time-out’ before starting the procedure. Only one of the ‘core steps’ is carried out in theatre. The others are carried out before theatre emphasising the importance of accurately identifying and marking early in the patient’s journey.

Common sense suggests guidelines should be simple, user friendly and quick to complete. Making guidelines compatible with existing values and not deviating from existing routines are recognised to increase their use. Guidelines issued by practitioners’ own professional bodies are likely to have more impact than those from outside the profession. However increasing the number of items a guideline contains does not necessarily make it better or safer.

The four core steps we identified are the basis for any marking guideline. It is reasonable to assume that incorporating the guidance into clinical orthopaedic practice will further improve safety. Future work should focus on establishing the relative impact of each guideline aspect.


C.G. Fontecha C. Amat F. Soldado M. Aguirre J.L. Peiro V. Martinez-Ibañez

Amniotic band syndrome (ABS) is a congenital disorder characterized by limb constrictions. The disorder lacks precise definition, and its exact pathogenesis is unknown. Though theories have been advanced to explain the condition’s origin, none have been scientifically validated. The “exogenous” theory, popularized by Torpin, is the most widely accepted. It suggests that early amniotic rupture leads to formation of amniotic strands, which by means of progressive compression induce formation of extremity bands. In this disorder, histological examination of the excised bands demonstrates them to be composed of fibrous tissue. Multiple clinical and experimental data reveal this theory has only low plausibility. Our purpose is to assess whether annular external compression of a fetal rabbit limb will produce a band of subcutaneous fibrous tissue characteristic of amniotic band syndrome.

We operated on one limb of 10 different rabbit fetuses, each at 21 days of gestation. The extremity was ligated with a nylon suture at the infracondylar level. At 30 days gestation, each fetus was delivered by caesarean section. Limbs were analyzed histologically using different techniques. Histological analysis did not show subcutaneous fibrous tissue in the mechanically constricted zone. The distal segment showed dilatation of lymphatic vessels and edema of soft tissue.

Annular external compression of a fetal rabbit limb does not induce development of new fibrous tissue; therefore this experimental study does not support the theory of a mechanical exogenous pathogenesis in amniotic band syndrome.


J. Chardonnens J. Favre F. Gaille K. Aminian

In many fields, such as orthopedics and rehabilitation, measurement of segment orientation or three-dimensional (3D) joint rotation is highly required. However, even if laboratory systems (e.g., optical-based tracker) are enough accurate for human movement measurement, they have some limitations (e.g., cost, complexity, capture volume) that exclude their uses in routine practice.

Recently, our group proposed an original system fusing a low level magnetic tracker (Minuteman®, Polhemus, USA) and 3D gyroscopes (Physilog®, BioAGM, CH) to measure segments orientation. These complementary devices were selected with the aim to provide real time orientation in clinical environment and without restriction on the acquisition duration. The objective of the present study was to assess the performances of this new system in routine clinical applications.

For this evaluation, five healthy young men were enrolled and the orientation of their left thigh was considered. They were asked to perform two times a long scenario (14 min) which included various postures (standing, sitting and lying) and activities (e.g., walking and stairs climbing). These activities were realized both, in the vicinity and far from the magnetic source. Additionally, different metallic objects were inserted and moved in the capture volume to simulate assisted clinical applications. An optical motion capture system (VICON®, UK) was used as reference.

In the absence of magnetic distortion and independently of the activity, we obtained a RMS orientation error of 1.2°. Generally, during distortion periods we obtained a slow growing orientation error of about 0.1°/s whatever the activity.

In conclusion, the proposed system provided an accurate and real-time measurement of orientation in a large capture volume over a long duration. Furthermore the system performances were tested in an environment including representative distortions of routine clinical uses. In combination with a functional calibration, this system was very promising for routine measurements of 3D joint rotations.


S. Suutre Ü. Mätas J. Atna A. Arend A. Märtson A. Toom

Bone growth was compared in six types of (beta-tricalcium phosphate) implants implanted in subcutaneous pouches or close to femoral head of male Wistar rats:

implants immersed in 0.9% sodium chloride solution (control implants),

implants with the progenitor cells from femoral canal,

implants immersed in inductive BMP-2 solution,

implants with the progenitor cells from femoral canal + BMP-2 solution,

implants immersed in inductive BMP-2 solution and implanted closed to the femoral head,

implants immersed in inductive BMP-2 solution and implanted closed to the femoral head while leaving the femoral canal opened for better access of the femoral canal cells.

Implants were removed 21 days after operation and dissected following principles of stereology. Presence of bone or cartilage or connective tissue was evaluated by hematoxylin eosin histochemistry.

Results: Bone formation was only found in the implants where BMP-2 was introduced. However, no distinctive differences were found between the implants where cells and BMP-2 were introduced and between the implants where just BMP-2 was used. Percentages of the bone tissue out of all the implant were as follows: 0.0% in group 1, 1.2% in group 2, 32.4% in group 3, 42.4% in group 4, 44.4% in group 5 and, 54.9% in group 6. Differences in amount of bone tissue were statistically significant between groups 3 and 2, groups 3 and 1 and also between groups 1 and 2 (p=0.0013, p=0.0004 and p=0.0525 respectively). In the other cases, the differences between BMP-2 affected implants and implants without BMP-2 were even greater.

We concluded that presence of osteoconductive matrix and introduction of an osteoinductive agent (e.g. BMP-2) are the main components of designing of bone tissue and introduction of exogenous bone cells is not as important as the first two in subcutaneous pouches or close to the hip joint.


R. Lee L. Loving A. Essner A. Wang M. Mont

Hip and knee wear simulators have been used by implant manufacturers and researchers for many years as a performance predictor and comparator for hip and knee implants. The clinical accuracy of these simulators in predicting wear depends heavily on the type of simulator as well as the methodology used. The joint lubricant used in the simulators is one crucial aspect that has been well studied in hip simulators. This study will compare the wear performance of a modern total knee replacement system using two commonly used simulator lubricants at various dilutions (Alpha Calf Serum and Bovine Calf Serum, Hyclone Labs). The Triathlon knee implant system (Stryker Orthopaedics) was used along with a six station knee wear simulator from MTS Systems to determine the effect of lubricant type and dilution.

Wear rates were found to be dependent on the type and dilution of the lubricant. At 0g/L protein concentration (100% water) wear rates were 4.8mm3/million cycles (mc). With the introduction of Bovine serum, wear rates increase to a peak of 24mm3/mc at 5g/L of concentration. Increased concentration of Bovine serum resulted in a decrease of wear rates. Wear rates for Alpha serum peaked at 28mm3/mc at 20g/L concentration with decreased wear rates at higher concentrations.

Knee implant wear performance is often characterized by wear simulation. As has been previously shown for hip simulations, this study shows the importance of choosing the correct lubricant type and dilution to correctly simulate wear performance. While this study cannot correlate any of the lubricants to the synovial fluid present in vivo, this study shows that 20g/L of Alpha serum produces the highest wear rates and should be used to determine worst case wear rates in the wear performance characterization of knee implants.


U. Butt B Burston G Kamathia R Gleeson

Introduction: Total knee replacement commonly results in postoperative requirement of blood transfusion. Allogeneic blood transfusion carries transfusion related risks, continuing effort to reduce allogeneic blood transfusion is important. The purpose of this study was to asses the economic justification of the use of an autologous blood transfusion after total knee replacement and to determine whether it reduces allogeneic blood transfusion and length of postoperative hospital stay.

Patients and Methods: Retrospectively, 149 patients undergoing primary unilateral total knee replacement using vacuum drain were selected. Demographics, pre and postoperative haemoglobin were recorded. Need for allogeneic blood and postoperative hospital stay were also recorded.

Results: 8% (n12) received allogeneic blood. The average amounts received were 2 units. Mean length of stay in those received allogeneic blood were (n12) 8.1 days. Mean length of hospital stay in those not transfused (n137) were 5.5 days (p< 0.05). The cost of allogeneic blood per patient £29.31. Total cost of retansfusion system per patients £60.8. Excess bed occupancy in those transfused £55.21. The cost saving for employing a retransfuion system (55.21+29.31)−60.8 = £24.44 per patient.

Conclusion: Employing autologous retransfusion system is effective method of reducing allogeneic blood requirement. Retransfusion system will reduce in hospital stay to the level seen patients not transfused. There would be a significant economic benefit in utilising such system in district general hospitals.


R. Meizer N. Aigner E. Meizer C. Radda F. Landsiedl

Bone marrow edema syndrome (BMES) is a common cause of severe bone and joint pain. Intra-articular migrating of bone marrow edema syndrome (BMES) is a very unusual pattern of disease which has been previously described in only a few cases and may raise the suspicion of an aggressive disease.

We reviewed 8 patients (4 female, 4 male) with unilateral BMES located in the knee. The patients were aged 39–56 years (mean 50.2). In all the patients bone marrow edema (BME) found in the primary magnetic resonance imaging (MR imaging) shifted within the same joint, i.e. from the medial to the lateral femoral condyle or to the neighboring bone. Conservative therapy including limited weight-bearing for a period of three weeks was provided for seven patients after initial detection of BMES and one patient underwent surgical core decompression twice.

The final MR investigation performed on average 8 months after baseline (range, 7–11 months) showed full resolution of BMES in 6 patients. One patient had small residual edematous bone areas. No quadrant was newly affected. Improvement of the MR imaging pattern was correlated with the clinical outcome in all patients. The severity of effort-induced pain (VAS) was reduced from 7.5 (2.0–10.0) at baseline to 5.9 (2.4–7.9) after 3 months and to 0.6 (0–0.9) after the final examination. Pain at rest (VAS) diminished from 3.9 (1.5–7.8) to 2.8 (1.4–6.0) after 3 months and to 0 at the final follow-up. All patients became asymptomatic after a mean of 9 months (6–11).

Intra-articular migrating BMES is a condition seen very rarely. The disease is self-limited so that conservative therapy can be recommended.


M. Vitali C. Sosio G. Peretti L. Mangiavini G. Fraschini

PURPOSE OF THE STUDY: We reported of eleven cases of early spontaneous osteonecrosis (SO) of the knee successfully treated with an extracorporeal shock-wave treatment (ESWT).

Traumatic and vascular theories have been proposed as the cause of the SO, lack of blood in some critical areas, such as subchondral bone of femoral condyles or tibial plateaus, has been considered the underlying condition of this pathology.

ESWT can be suggested as an effective conservative treatment for SO of the knee.

MATERIALS AND METHODS: Ten patients with medial femoral condyle osteonecrosis of the knee (one bilateral) were evaluated. Exclusion criteria was evidence of a structural collapse of subchondral bone. Two patients had received a femoro-popliteal by-pass within the last year, while others five presented a deficit of the vascular axis of the homolateral lower limb documented by an eco-colordoppler. A clinical evaluation was taken at the diagnosis using KSS, PPI, NRS and VAS. Plain radiographs and MRI confirmed the diagnosis of osteonecrosis.

Patients were treated with a cycle of three ESWT performed with 2000 pulses of 0,28 mJ/mm2 with Wolf Piezoson 300 with 6,5 MHz ultrasounds for three times in a month.

Clinical evaluation was performed at first and at third month after treatment and a MRI evaluation was performed at fourth month after treatment.

RESULTS: Clinical evaluation showed a significant improvement of symptoms and articular functionality. MRI of all cases revealed the continuity of the cartilage with a reduction in bone marrow edema and no collapse of lesion.

DISCUSSION: In our study, a single cycle of ESWT produced an improvement of the clinical and MRI aspects in eleven cases of SO of the knee. The neo-angiogenetic effect of the ESWT appears to accelerate the time for the symptom remission.

ESWT might have the potential to avoid the need for surgical treatment.


S.P. Dawson T.J. MacGillivray A.Y. Muir A.H.R.W. Simpson

An uncomplicated, quantitative method of determining density from X-rays would be of extreme value to clinicians. In this study we perform a thorough assessment of applying a step wedge to grey level calibration method to X-rays obtained using Computed Radiography (CR).

An Aluminium step wedge of ten, 5mm-thick steps was X-rayed with a Fuji CR system together with a knee phantom (3M) at various energy and Fuji processing settings. Automatic detection of the steps by means of the Hough transform was used to assess optimum CR settings. Background variation due to the anode Heel effect was evaluated by acquiring an “empty field” X-ray at different energy settings and with copper filtering. The effects of beam hardening were considered with a custom-made phantom which was also used to assess correcting for soft tissue and bone thickness.

X-rays taken at higher energy settings and with wider windowing imaged the widest number of steps (nine) and gave the best accuracy in modelling the step thickness to grey level relationship. Fitting a straight line to the log of the net grey levels gives an excellent model of the data (R2 = 0.99). X-rays of copper sheeting show that automatic histogram analysis is performed by the Fuji CR system, which can have unpredictable effects on aluminium thickness to grey level relationship. Background variation in the anode-cathode direction due to the Heel effect was corrected with a 1D exponential model (R2 = 0.99), allowing position-independent measurements to be obtained. Correcting for bone thickness, soft tissue and beam hardening further improves measurement quality.

Use of step wedge calibration to provide quantitative information on plain X-rays without altering their clinical quality is possible using digital radiography. However, a thorough assessment of the entire X-ray process is necessary to achieve accurate and comparable information.


P. Sadoghi M. Glehr C. Schuster B. Kränke H. Schöllnast M. Pechmann F. Quehenberger R. Windhager

Whereas thermography has already been used as an assessment of disease activity in some kinds of inflammatory arthritis, it is a new method for objektive pain evaluation in patients with joint prosthesis. To our knowledge, no study has tested the correlation between increase of temperature and anterior knee pain with total knee prosthesis yet.

Thirteen patients were included in this study who suffered from anterior knee pain of the retinaculum patellae with total knee prosthesis. The patients were asked to walk 3 km before entering a room which was cooled down to 20 degrees Celsius. A black 1 cm times 4.5 cm square stripe was attached on the diameter of the patella and the patients rested for 20 minutes to cool down before thermographic fotos were taken from 90 degrees, 45 degrees, frontal medial and lateral. The evaluation of temperature difference of each side was performed by marking a 1cm times 2cm square field rectangular around the black stripe and comparing it with a reference point of the same size 3 cm distal of the field. The patients were compared with thirteen others, not suffering from anterior knee pain. Statistical analysis was performed using a t- test and a p value < 0.05 was considered to be significant.

The temperature differences between the rectangular field and the reference point increased significantly on the medial (p= 0.00037) or lateral (p= 0.000002) pain side of the knee. The thirteen knees with knee pain had significantly higher temperature differences between medial and lateral temperature differences, than the knees without knee pain.

We demonstrate a significant correlation between anterior knee pain and an increase of superficial skin temperature around the retinaculum patellae. To our knowledge, this is the first report of an objective assessment of pain of the retinaculum patellae with total knee prosthesis.


F. Valera FJ. Minaya A. Melián X. Veiga M. Leyes JL. Gutiérrez

Anterior knee instability associated with rupture of ACL is a disabling clinical problem, especially in the athletic individual. The gracilis and semitendinosus tendon (T4) represent an alternative autograft donor material for reconstruction of the ACL.

The aim of our study was to elaborate a CPG to assist physiotherapists in decision making and to improve the efficacy and uniformity of care for patients with ACL reconstruction with T4.

The CPG was developed according to international methods of guideline development. To identify “best evidence” a structured search was performed. When no evidence was available, consensus between experts (physiotherapist and orthopaedic surgeons) was achieved to develop the guideline. To identify “best clinical experience” and “physiopathology reasoning” focus group of practicing physiotherapists was used. They reviewed the clinical applicability and feasibility of the guideline, and their comments were used to improve it.

CPG include three phases determined from the evidence, physiopathology reasoning and the biological process of autograft (weeks after the surgery: 2a–6a, 6a–10a and 10a–16a). The recommendations included: In postoperative weeks (2a–6a) physiotherapy focused on early range of motion of the knee; manual therapy (passive range of motion (PROM) 0–120° and miofascial techniques), pulsed ultrasound of low intensity with a power of 0.3w/cm2 (1MHz) during 10min/day in tibial tunnel, early active hamstring beginning with static weight bearing co-contractions (closed-kinetic-chain) and adductors, partial weight bearing with crutches, exercises in the swimming pool and cryotherapy to pain control (30 mi/4 hours). In weeks 6 to 10, full weight bearing, manual therapy (PROM 0–140° and miofascial techniques), hamstring strengthening progress complexity and repetitions of co-contractions, electrotherapy hamstring and quadriceps co-contractions. Starting at week 10, progress to more dynamic activities/movements, proprioceptive work, open-kinetic-chain, stationary bike and Theraband squats. In week 12, progress jogging program and plyometric type activities. The patients performed sports-specific exercises by about 3½ months postoperative.


N. Aigner R. Meizer E. Meizer C. Radda F. Landsiedl

Bone marrow edema (BME) is frequently observed on MR images in patients presenting with severe joint pain and may be present in numerous bone and joint diseases. BME may be subdivided into ischemic (bone marrow edema syndrome, BMES), mechanical and reactive BME. Although bone marrow edema of the knee is a common phenomenon, physical tests to diagnose this condition have not been investigated thus far. We hypothesized that a mallet test would be useful as a diagnostic aid as well as a screening tool.

70 patients (36 female, 34 male) were investigated in this blinded controlled study. Group 1 consisted of patients with painful BME in the knee and group 2 of patients with a painful knee without BME. Pain provoked by a reflex mallet was assessed for each quadrant on a visual analog scale (VAS).

The VAS score was 3.7 (±2.1 cm) for quadrants affected by BME (group 1), 1.59 (±1.44) in non-affected quadrants of the knee affected by BME (group 1) and, 0.85 (±0.85) in painful knees without BME (group 2). Pain on the tapping test was significantly correlated with the presence of BME in the affected knee (p< 0.0001) as well as the affected quadrant (p< 0.0001 for the medial femoral condyle and the medial femoral plateau).

The probable mode of action is that high intramedullary pressure in the BME affected bone (normal values are less than 30 mmHg) is additionally raised for a short period of time by the impact of the hammer on the bone surface, causing intense local pain. The test is economical, easy to perform in a doctor’s office, and not time-consuming but the final and evidentiary dignosis of BME can only be made by MRI.

The tapping test is a good screening instrument to diagnose BME in the knee.


R. Rout S.M. Mcdonnell A.P. Hollander I.M. Clark T. Simms R. Davidson S. Dickinson J. Waters H.S. Gill D.W. Murray P.A. Hulley A.J. Price

The aim of this study was to investigate the molecular features of progressive severities of cartilage damage, within the phenotype of Anteromedial Osteoarthritis of the Knee (AMOA).

Ten medial tibial plateau specimens were collected from patients undergoing unicompartmental knee replacements. The cartilage within the area of macroscopic damage was divided into equal thirds: T1(most damaged), to T3 (least damaged). The area of macroscopically undamaged cartilage was taken as a 4th sample, N. The specimens were prepared for histological (Safranin-O and H& E staining) and immunohistochemical analysis (Type I and II Collagen). Immunoassays were undertaken for Collagens I and II and GAG content. Real time PCR compared gene expression between areas T and N.

There was a decrease in OARSI grade across the four areas, with progressively less fibrillation between areas T1, T2 and T3. Area N had an OARSI grade of 0 (normal).

The GAG immunoassay showed decreased levels with increasing severity of cartilage damage (ANOVA P< 0.0001). There was no significant difference in the Collagen II content or gene expression between areas. The Collagen I immunohistochemistry showed increased staining within chondrocyte territorial areas in the undamaged region (N) and immunoassays showed that the Collagen I content of this macroscopically and histologically normal cartilage, was significantly higher than the damaged areas (ANOVA P< 0.0001). Furthermore, real time PCR showed that there was a significant increase in Collagen I expression in the macroscopically normal areas (p=0.04).

In AMOA there are distinct areas, demonstrating progressive cartilage loss. We conclude that in this phenotype the Collagen I increase, in areas of macroscopically and histologically normal cartilage, may represent very early changes of the cartilage matrix within the osteoarthritic disease process. This may be able to be used as an assay of early disease and as a therapeutic target for disease modification or treatment.


P. E. Mueller M. F. Pietschmann A. Horng T. Niethammer I. Pagenstert C. Glaser M. Reiser V. Jansson

Over the last 10 years ACI (Autologous Chondrocyte Implantation) has become an important surgical technique for treating large cartilage defects. The original method has been improved by using cell seeded scaffolds for implantation. The aim of our prospective study was to evaluate the efficiency of a matrix based ACI (MACI) with a collagen type I scaffold for repairing large cartilage defects of the knee. We present the clinical and radiological results of 22 pts. one year after collagen scaffold based ACI.

Out of 39 pts. treated with ACI for cartilage defects of the knee 22 had reached the one year follow up. We documented preoperatively and postoperatively (3, 6 and 12 months) the clinical situation with the IKDC Knee Examination Form. MRI scans were evaluated at all time points.

41% of the pts. were female, 59% male. The average age was 33 yrs. (min:15; max:49), the average BMI 25,4 (min:19; max:36). One third of the cartilage defects were localized retropatellar, the remaining on the medial or lateral femoral condyle. The average defect size was 5.7 cm2. In about 75% of the cases an additional surgical procedure was performed (ACL-reconstruction, lateral release, meniscal surgery). One major complication (a deep wound infection) occured. The IKDC score improved over time during follow up significantly. Patients with retropatellar defects have a poorer outcome compared to femoral defects. The MRI showed an improvement of the implanted scaffold over time as well.

The present study confirms the benefits of MACI in young patients with large cartilage defects of the knee. The matrix based ACI is a surgically less demanding technique then the traditional ACI. We expect a good long term outcome from MACI comparable to that of traditional ACI.


J. Kordelle F. J. Becker S. Tretbar J. Steinmeyer

Animal experimental studies indicate that pulsed low-intensity ultrasound might enhance cartilage repair in early stages of osteoarthritis (OA) and to improve healing of osteochondral defects. The purpose of this in vitro study was to determine systematically whether and to what extent pulsed low-intensity ultrasound

influences the synthesis and release of PGs,

modulates chondrocyte viability within human osteoarthritic cartilage explants, and

is affected by the degree of OA alterations.

Full-thickness cartilage explants of the lateral compartment of the proximal tibia were taken from OA patients undergoing knee replacement surgery. Explants with mild or moderate OA alterations were cultured in a CO2-incubator at 37°C, 5% CO2 and 95% relative humidity. After 2 days, explants were subjected to ultrasound applied in a pulsed-wave form (1: 4) on the following 3 days. The ultrasound application apparatus was specifically designed and constructed to function within an explant culture system under sterile conditions. The effect of the ultrasound parameters intensity (2, 30, 120, 250 mW/cm2), duration (20, 3 × 30 minutes/day) and frequency (0.5, 1.2, 4.7 MHz) on PG synthesis and release were measured. PG synthesis was determined by the incorporation of 35SO4 during the final 22 h of the experiments whereas the content of PGs were quantitated with the DMMB-assay. The viability of chondrocytes was assessed microscopically using fluorescein diacetate and propidium iodide. Results were compared to untreated explants from the same joint. Each experimental condition was repeated five times using explants always obtained frrom 6 different patients (N=6).

Neither the degree of OA alterations of explants, nor the various ultrasound parameters tested displayed any significant effect on the synthesis and release of PGs as well as on the viability of explants.

This work was supported by the Deutsche Arthrose-Hilfe e.V.


F. García-Alvarez M.J. Martínez-Lorenzo M. Royo-Cañas E. Alegre-Aguaròn P. Desportes S. Val L. Larrad

Introduction. Progenitor cells with osteochondrogenic potential have been identified within adipose tissue. These cells present diversity of characteristics that can be explained by differences in tissue origin, isolation methods and culture conditions. Mesenchymal stem cells (MSC) have been isolated from many tissues. MSC have been shown to exhibit tissue protective and regenerative properties.

Methods. Hoffa’s fat samples were obtained from four patients (mean age 44 years), five rabbits (New Zeland aged 12 weeks) and five sheeps (Rasa aragonesa aged 22 weeks). Cells were obtained by means of enzimatic and mechanical digestion. The suspension was centrifuged and washed twice with phosphate buffered saline. The resultant pellet was resuspended and plated in culture medium (37°C, CO2 5%). Cellular markers were studied with specific monoclonal antibodies (CD13, CD44, CD49d, CD90, CD105, CD117).

Results:

Human cells: CD13+ (94–99%), CD44+ (87–99), CD49d (14–70%), CD90+ (92–99%), CD105+ (90–97%), CD 117-BD+ (2–22%).

Sheep cells presented CD13+ (32–70%), CD34-, CD36, CD44+ (90–96%), CD49d (40–80%), CD54+ (50–80%), CD90+ (90–97%), CD105+ (10–25%). CD117-BD+ (48–76%).

Rabbits cells: CD13+ (14–78%), CD44+ (10–80%), CD49d (2–9%), CD90+ (27–92%), CD105+ (2–24%), CD 117-BD+ (15–57%). Human cells number/mL did not show significant differences between patients, or between P0 0 (14 culture days) (average mean: 525000 ± 298956) and P5 (525000), nevertheless the average mean decreased from P5 to P6 (130.000) until P8 (111 culture days) (85.000). Rabbits cells number/mL did not show significant differences between P0 (673000 ± 379697) and P1 (596000 ± 488740) and decreased in P2 (299500 ± 159161) without any significant change in P8. Ovine cells number/mL average mean in P0 was 1.370.600 (± 802758), this decreased in P1 (420000 ± 95197) however, showed no significant changes in P8 (291875 ± 86394).

Conclusions: MSC from human, rabbits and sheeps present differences in cellular concentration and markers.


A.E. Georgiadis X. Liltsis M. Feteli A. Sratech E. Kavantzas I Georgokostas K. Minios X. Moutafis

Recent epidemiological studies have demonstrated that more than half of postmenopausal women with osteoporosis (PWOP) treated with an antiresorptive drug plus calcium (Ca) and vitamin D, have serum levels of 25(OH)D3< 30ng/ml. Chronic low levels of vitamin D can contribute to the inefficiency of main antiresorptive treatment. A possible explanation for this phenomenon is the non-compliance with the daily supplementation of Ca and vitamin D. A fixed combination of Alendronate Once Weekly (OW) 70mg plus 2800 UI of cholecalciferol (AL+D) made its appearance in the market two years ago as a solution to this problem.

The current study was designed to assess the efficacy of AL+D versus the old scheme of Alendronate 70 OW plus daily Ca 500mg + 400 UI of vitamin D (AL+S) on serum levels of 25(OH)D3. 100 randomly assigned PWOP treated already for 1 to 5 years with AL+S have changed their treatment to AL+D for one year. Serum levels of 25(OH)D3 (Biomedica.co.at/vitamind) has been measured before and after 12 months and also their BMD (Hologic Delphi), PTH, TSH, serum chemistry and hematology has been recorded for safety reasons. At the end of the study only 83 PWOP (MA=59,9±6,6 yrs) appeared for comparison.

Our results are as follow:

The mean plasma level of 25(OH)D3 under AL+S treatment and before taking AL+D is 24,3±8,4 ng/mL and

The plasma levels of 25(OH)D3 after 12 months of treatment with AL+D are 33,3±9 ng/mL. The paired t-test has been used to compare the levels of 25(OH)D3 between treatment groups. There is a highly important statistical difference (t=−8.989, df=82, p< 0,0001) between treatment groups.

From the above data it can be concluded that fixed combination of AL+D can improve the 25(OH)D3 status over 12 months versus AL+S probably because it assures a better compliance of vitamin D.


K. Yuasa Y. Ito N. Baldini A. Sudo A. Uchida

Osteoporosis is one of the most common diseases in modern aging society. Receptor activator of nuclear factor-κB ligand (RANKL) plus macrophage colony stimulating factor (M-CSF)-mediated osteoclastogenesis has been recently implicated in the pathogenesis of this disease. Among other causes, the anticoagulant drug heparin is a notable inducer of secondary osteoporosis, although the molecular pathway underlying this process, particularly in human model, has not been clarified yet. Recently, we reported the differentiation of two subtypes of osteoclasts starting from human peripheral blood CD14-positive monocytes (Monocytes), respectively fusion regulatory protein-1 (FRP-1/CD98)-mediated osteoclasts and RANKL+M-CSF-mediated osteoclasts. We, therefore, investigated in details effects of heparin on differentiation and activation using a simple system of human osteoclastogenesis.

When Monocytes were cultured with osteoclastogenesis-relating factors and a high dose of heparin, heparin suppressed osteoclastogenesis in both pathways. However, a proper quantity of heparin enhanced tartrate-resistant acid phosphatase-positive multinucleated giant cell formation. There were significant differences in fusion indices between control osteoclasts and osteoclasts stimulated by moderate concentrations of heparin in two systems (P< 0.05). As a result of osteoclastic activity, FRP-1-mediated osteoclasts treated with a proper quantity of heparin formed larger pits on Ca plates. Moreover, lacunae on dentin surfaces induced by FRP-1-mediated osteoclasts were enhanced with moderate concentration of heparin. In contrast, heparin did not increase pit-formation area on Ca plates and on dentin surfaces by RANKL+M-CSF-mediated osteoclasts. Evaluating the relation between the concentration of heparin and the osteolytic areas on Ca plates, Pearson’s correlation coefficient of the FRP-1 and the RANKL+M-CSF were −0.973 (P< 0.05) and −0.695 (P=0.19), respectively.

In present study, although moderate doses of heparin stimulated differentiation in both systems, in osteoclastic activity, heparin promoted only to the FRP-1 system, not to RANKL+M-CSF system. Our results suggested FRP-1-induced osteoclastogenesis mainly contributes to development of heparin osteoporosis and also that the onset mechanism after long-term administration of heparin may be affected by the characteristic bone resorption ability of FRP-1osteoclasts.


S.A Mehdinasab N. Sarrafan S. Tabatabei

Extensor tondon lacerations are much more common than flexor tendon injuries. The outcome of this lesions depends on mamy factors including severity of initial trauma, coexisting lesions, of the hand, site of the laceration, experience of the surgeon, and post operative rehabilitation. The aim of this prospective study was to review our results of primary extensor tendon repair with regard to the zone of injury.

During a period of 28 months, 32 patients with open extensor tendon laccerations were repaired by modified kessler technique using 4-0 nonabsorbable suture. After tendon repair, immobilization with a volar splint was applied for 4-weeks and physiotherapy was carried out. Patients were followed–up for a mean of 12 months. we used the 5 extensor tendon zones and results were assesed using Miller’s rating system. Patents with closed tendon ruptures or concomitant hand fracture were excluded from the study.

Seventy two extensor tendons were repaired. The mean age of patients was 24.6 years (17–46 y). Excellent and good resalts were obtained as the follows: in zone 5(88/4%), zone 3 (84%), zone 2(55.5%), zone 4(42.7%), zone 1(40%). Results were poor in zone 4(42.8%), zone 1(40%), zone 2(22.2%), zone 3(4%), and zone 5(3.9%). No in fection was seen.

We found a strong correlation between the site of the repair and outcome. More excellent and good results were obtained when the repair was performed distal to the extensor retinaculum (Zone 3), and above the wrist (Zone 5). Unsatisfactory results were seen when the tendon repair was done at or near DIP joint (zone 1), in the region of complex extensor mechanism (zone 2) or beneth the extensor retinaculum (zone 4). We cocluded the anatomic location of tendon repair has an important effect in outcome.


F. García-Alvarez A. Castro J.M. Grasa C. Pastor M. Monzòn A. Martínez M. Navarro-Zorraquino I. García-Alvarez R. Lozano

The most frequent pathogenic organism in arthroplasty infections is Staphylococcus. The immune response impairment is a frequent finding in elderly people. Objective: to investigate the response of some cytokines and the effect of age in an experimental model of osteomyelitis.

Materials and methods. 40 adult male Wistar rats received a stainless steel needle, intramedullarily in the left tibia. Young rats (3 months old) and Old rats (22 months old) were alloted in: Group A: Sterile implant. Group B: Sterile implant + slime producing S. aureus. 9 weeks after surgery, rats were sacrified. Determinations: Cytokines (IL-1b, IL-2, L-4, IL-6, IL-10 and IL-12)(ELISA) in blood (previous to surgery and to sacrifice) and in tibia extract (after sacrifice); the number of bacteria in tibia and implant. The Wilcoxon, Mann-Whitney U test were used (p≤ 0.05 significant).

Results. Infection was detected in all the operated tibias in old rats receiving S.aureus, and in 7/10 of young rats. IL-2 levels increased in blood in the S.aureus group after surgery in old and young rats. Pre and postoperative IL-2 levels in blood were higher in old rats in both groups than in the corresponding groups of young rats. There was a decrease with age in blood of IL-4 (previous and after surgery), and a decrease of IL-1. S.aureus groups increased IL-1 levels in the operated tibia independently of age; increased IL-2 and IL-10 levels in young rats in the operated tibia; increased IL-4, IL-6 and IL-12 in old rats in blood, decreased IL-4 and increased IL-2 and IL-10 in blood in young rats

Conclusions. Significant differences in tibia infection were found with age. Old rats presented differences with young rats in cytokine response in an experimental model of osteomyelitis, showing an immune response impairment associated with old age.


R.K. Goddard D. Yeoh J Shelton M.A.S. Mowbray

Aims: Replacing human cadaveric specimens with fresh frozen animal tissue in biomechanical studies has become increasingly more popular due to the scarcity of young human tissue. The aims of this study were to characterise and compare the biomechanical parameters of tailored strips of equine extensor tendon, with 4 strand young human semitendinosus and gracilis (STG) tendons as an alternative tendon model for testing anterior cruciate ligament (ACL) graft reconstruction techniques using the Soffix Polyester ACL fixation device.

Method: Common digital extensor tendons were harvested from normal equine forelimbs and tailored into 5 mm wide, 2 strand equine tendon strips. The doubled equine tendons were overlapped and braided around the buttonholes of a Soffix fixation device and secured with No 2 Ethibond sutures (Johnson & Johnson Ltd). The Soffix-4-strand young human STG tendon complex was prepared in an identical manner. Mechanical testing was performed measuring ultimate tensile load (UTL) and elongation to failure (EF), structural stiffness (SS) was calculated from load extension curves.

Results: The Soffix-STG and the equine tendon complexes produced a mean UTL of 1186 N +/− 113.89 and 1116 N +/− 208.5 respectively showing no statistically significant difference.

Conclusions: We conclude that a tailored 5mm wide 2-strand equine extensor tendon strip provides a comparable alternative for in vitro testing of young human four strand STG tendon graft using a Soffix polyester fixation device.


S. Pacini L. Trombi S. Spinabella G. Martelli R. Fazzi M. Petrini

In view of possible clinical applications of mesenchymal stromal cells (MSCs), interesting results in repairing the Achilles tendon have been achieved in rabbit models since 1997. Histological and immunochemical studies have demonstrated the quality of repair. A basic problem in tissue repair is the way to administer stem cells. Several questions remain:

have the cells to be differentiated or not?

Could cells be administered without using scaffolds?

Attempting to cure, as a clinical model, horses with a pathological core lesion in the superficial digital flexor tendon (SDFT), MSCs were recovered from autologous bone marrow, expanded ex vivo, suspended in autologous serum and re-injected directly into the core lesion.

All 11 horses implanted with autologous MSCs exhibited no adverse reaction due to the implantation of the cells, either locally or systemically. After rehabilitation therapy nine MSC-treated animals recovered from their clinical conditions, had an excellent ultrasound image of tendons after a period ranging from 3 to 6 months, and returned to racing with good or even optimal results in the previous category of competition in 9 to 12 months without any re-injuring event. All of them are still active more than 2 years from diagnosis. One of the 2 remaining horses received less than 1×106 of MSCs, and its tendon did not heal relapsing after rehabilitation, the other was lost to follow-up. In contrast, most of horses from the control group showed tendon ultrasound images that revealed fibrosis during the healing process, and all of them were re-injured after a median time of 7 months.

The ability of tissue microenvironments to induce cell differentiation could render unnecessary a partial or total ex vivo differentiation and direct infusion of undifferentiated MSCs could represent a safe therapeutic approach to tendon repair.


G. V. Kuropatkin O.N. Sedova Y.P. Eltsev

The problem of prophylaxis and treatment of infected complications after total joint replacement is relevant today, especially in case of revision procedures. The important factor in successful preventive maintenance and treatment of purulent complications is reduction of so-called «dead space» of the operated joint. Aim of this study is to analyze the Taurolin-Gel 4% application for “dead” space filling in patients with high risk of wound infections after total hip replacement.

Follow-up results of 178 operations with Taurolin-Gel 4% application have been studied. Patients were observed from 2 to 12 years (average 6 years). All patients were divided on 4 groups. First group consisted of 46 patients with early postoperative infected complications; second group (38 patients) was with first step of two-step revision in chronic infection. Third group included 35 patients on second stage of two-stage revision and fourth group consisted of 59 patients with medical history of infected problems in affected joint. In all four groups the infection recurrences after Taurolin implantation were noted in 6 patients (3,4 %).

Taurolin-Gel 4%, inserted into joint cavity, is not only a good local antibacterial agent, but it also fills up “dead” spaces in the affected joint and displaces haematoma. Deleting a haematoma, which is the favourable environment for bacterial functioning, risk of infections complication in the postoperative period reduces. Besides, Taurolin-Gel decreases postoperative blood loss for approximately 30 %, causing mechanical haemostasis. In difference from filling of a joint cavity with the moved muscular tissue, Taurolin Gel 4 % using are much easier technically, reduces time of revision intervention and traumatic of operation.


V. Colombo LM. Gallo

Animal models have shown that artificially induced temporomandibular joint (TMJ) disc displacement or perforation affect histology and biochemistry of joint cartilage, leading to osteoarthritic changes. However, it is still unclear whether TMJ disc cartilage fails simply due to wear or is degraded by a biological response to mechanical loading.

In order to gain insight into TMJ cartilage mechanobiology, a system reproducing the dynamic TMJ compression effects on live tissues was developed. Bovine nasal septum (BNS) cartilage was chosen as a convenient tissue model. However, little information is available in the literature on its material properties. Aim of this study was to determine BNS material properties using a viscoelastic model and verify its suitability as model for TMJ disc cartilage.

Cartilage samples were harvested from the central part of BNSs of young, healthy animals. Stress-relaxation tests in unconfined compression were performed on cylindrical plugs samples, obtained by means of biopsy punches. A 10% strain (strain rate 0.01 mm/s) was applied and held for 30 minutes.

Stress was estimated from the compressive force data and the initial cross-sectional area. Experimental data were fit to a mathematical model in MATLAB. Experimental results show a highly viscoelastic behavior of the BNS, with a maximum average stress of 0.73 ± 0.14 MPa and relaxed stress of 0.21 ± 0.03 MPa. The numerical model shows good correspondence to the experimental data (R2=0.96). The average values for the instantaneous and relaxed elastic moduli are E0= 7.72 MPa and ER= 2.30 MPa, in the same order of magnitude as the TMJ disc.

We conclude that bovine nasal septum can be modeled as viscoelastic tissue and can be used as a first approximation to study mechanobiology of the TMJ disc.


A.J. Johnstone S.V. Karuppiah

Introduction: Current existing joint designs, principally flexible silastic spacers, satisfy the initial requirements but commonly lack durability. In particular all flexible silastic joints are prone to early breakage due to abrasion against bone and constant loading of the central section of the flexible implants. The aim of our new small joint design is to overcome many of the deficiencies of the flexible silastic designs while maintaining their main advantage of stabilising joint alignment throughout the flexion range.

Aim: To investigate the wear properties of the new small joint design in both static and dynamic applied loads using finite element analysis (FEA).

Materials: The design is essentially a cross between a flexible spacer and a surface replacement, whereby the spanning flexible spacer is located within the long axes of direct load bearing metacarpal and phalangeal ‘housings’. We have investigated a number of parameters, using finite element analysis (FEA), focussing principally upon the load bearing and wear properties of the new design to both static and dynamic applied loads with reference to the test protocol developed by the Durham group.

Results: Detailed FEA of the new joint design has highlighted the extreme potential durability of the housings and the internal flexible spacer. Our results suggest that the wear characteristics of both housings manufactured from PEEK (Polyetheretherketones) may result in the generation of considerably less wear debris compared with conventional alloy/plastic articulations. In addition, polyurethanes would appear to have better load bearing and wear characteristics than existing silastic materials.

Conclusions: Clearly, if our FEA findings were to be reproduced with biomechanical testing, we would be well placed to introduce durable and readily affordable small joint arthroplasties that may well resolve our current difficulties of treating patients with moderate joint disease in addition to being a realistic alternative for patients with advanced destructive small joint arthritis.


R. Meizer N. Aigner E. Meizer S. Kotsaris F. Landsiedl

Bone marrow edema (BME) is a rare cause of pain in the foot.

We reviewed 19 patients with unilateral bone marrow edema of ischemic, stress or osteoarthritic origin located in the hindfoot treated with the vasoactive prostacyclin analogue iloprost. The patients’ mean age was 61,5 years (25–76) and the duration of symptoms lasted 19 weeks before the therapy started. Bone marrow edema was located 9x in the talus, 3x in the calcaneus, 3x in the navicular bone and 2x in the cuboid. 11 cases were estimated to have a primary ischemic origin, the other 8 ones to be secondary to an activated osteoarthritis or to mechanic stress. Our therapy consisted of a series of five infusions with 20 μg (50 μg in the first six patients) of iloprost given over 6 hours on 5 consecutive days each. Mazur’s foot score was used to assess function before and 3 months after therapy.

During this time, the score improved from a mean of 54,9 (range 23–73) before to 87,8 points (47–100) 3 months after therapy, with the best results in ischemic lesions with an improvement from 56,2 to 93,9 points and inferior results in patients with osteoarthritic edema as well as edema due to stress with a change in the score from 53 to 79,3 points. Magnetic resonance imaging showed complete recovery of the bone marrow edema within 3 months in 12 patients, 3x partial regression and no change in 4 cases with bone marrow edema due to activated osteoarthritis.

We conclude that the parenteral application of the vasoactive drug iloprost might be a viable method in the treatment of bone marrow edema of different origins but especially in ischemic ones. In edema secondary to osteoarthrosis or stress, therapy effect with iloprost is of a symptomatic character depending on the grade of the basic disease.


R. Meizer S. Schenk R. Kramer N. Aigner E. Meizer F. Landsiedl G. Steinböck

For surgical treatment of hallux rigidus many different procedures have been described. Resection arthroplasty (‘Keller procedure’) is a surgical procedure mostly used for older patients suffering from severe osteoarthritis of the first metatarsophalangeal joint. As a modification of this procedure, resection arthroplasty is combined with cheilectomy and interposition of the dorsal capsule and extensor hallucis brevis tendon, which are then sutured to the flexor hallucis brevis tendon on the plantar side of the joint (capsular interposition arthroplasty, IA).

Capsular interposition arthroplasty was performed on 22 feet of 14 patients (six male, eight female) suffering from osteoarthritis of the 1st MTP-joint were included in this study (group 1). These results were compared to the outcome of 30 feet of 22 patients (12 male, 10 female) treated with resection arthroplasty (group 2). The indication for resection arthroplasty were the same as for IA. The mean age was 55.3 years (37.6 to 71.2) in group 1 and 57.8 (43.5 to 75.6) in group 2. The age distribution of our patients at surgery did not differ significantly between both groups (p=0.633). The mean follow-up period was 15.1 month, range 6 to 27 months and did not differ between both groups (group 1: 16.5 month, group 2: 14.1 month; p=0.143).

The mean follow-up period was 15 months. No statistically significant difference was found between both groups concerning patient’s satisfaction, clinical outcome and increase in range of motion of the first metatarsophalangeal joint. At follow-up, patients who had undergone interposition arthroplasty did not show statistically significant better AOFAS forefoot-scores compared to the Keller procedure group. A high rate of osteonecrosis of the first metatarsal head was found in both groups. These radiological findings did not correlate with the clinical outcome at follow-up.

There is no benefit in clinical or radiological outcome for capsular interposition arthroplasty compared to the Keller procedure.


C. Radda R. Meizer F. Landsiedl C. Krasny

Pain free function of the thumb carpometacarpal (CMC) joint is essential for manual work. Osteoarthrithis of the thumb saddle joint is very common. Among different conservative and operative treatment options (ergotherapy, intraarticular infiltration, ligament reconstruction, resectionarthroplasty, arthrodesis, spacer), the implantation of a prosthesis is an alternative. This prospective study reports short time results of the uncemented hydroxilapatite coated Ivory prosthesis. The mean follow up time of the 21 patients was 12.1 months (range 6 to 18 months) and the mean age 57.2 years. The patients suffered from osteoarthritis of the thumb saddle joint stage II–III according to Eaton Littler. We evaluated the Disabilities of the Arm, Shoulder and Hand Score (DASH), pain with the visual analogue scale (VAS), clinical (abduction, flexion, strength) and radiological outcome.

The clinical results showed excellent pain relief with an improvement of the VAS from 7.3 preoperative to 0.8 postoperative (p< 0.05) and a decline of the DASH score from 42.9 to 6.05 points (p< 0.5). We measured an abduction with a mean of 47.5° and a flexion with a mean of 43.2°. The power of the fist grip was in mean 31.3 kg, of the key grip 6.4 kg. Radiological there were no signs of implant loosening. As complications occurred one posttraumatic trapezium fracture with luxation and one tendovaginits De Quervain.

The advantage of a total replacement of the CMC I joint, compared to the standard resection arthroplasty, is faster rehabilitation and preservation of the length of the thumb and so better strength. Our results are encouraging, but we have to wait for long time results mainly concerning implant loosening. In the case of the trapezium fracture with luxation we could remove the prosthesis and performed a resectionarthroplasty.


C. Radda R. Meizer M. Chochole F. Landsiedl C. Krasny

An unstable CMC I joint causes pain and dysfunction. Chronic subluxation can lead to cartilage damage and furthermore to rhizarthrosis. This study should evaluate the results of the Eaton Littler ligament reconstruction, in which a slip of the Flexor carpi radialis tendon (FCR) weaved through the basis of the first metacarpal and around the tendon of the Abductor pollicis longus and back to the FCR. Aftertreatment consists in 4 weeks cast, 4 weeks thermoplastic splint and physiotherapy, full opposition is allowed after 8 weeks.

We performed 10 operations in 8 patients with a mean age of 35.9 years (6 female, 2 male). In 8 times the diagnosis was a rhizarthrosis Eaton Littler stadium I and in 2 times a posttraumatic instability. The mean follow up time was 15.4 months. We evaluated subjective satisfaction with the Disabilities of the Arm, Shoulder and Hand Score (DASH), pain with the visual analogue scale (VAS) and the patients were asked, if they would undergo the operation again. Furthermore the range of motion (ROM) was examined, the strengths (key and pin grip) were measured and radiographs were made.

All patients would undergo the operation again. The mean DASH score was 17.4 points, the mean VAS in rest 0 and under stress 1.29. The mean pin grip strength was 3.98 kg and the mean key grip strength 7.14kg. The ROM was excellent with a mean anteposition of 39.5°, a mean abduction of 49.3°. The mean thumb opposition was Kapandji 9.9. Radiological there was no progression of the Eaton Littler stadium. As complications occurred 1 keloid and 1 hypaesthesia.

Our experiences with the Eaton Littler procedure for stabilisation of the hypermobile thumb saddle joint were positive. Long time results will show, if the procedure can prevent cartilage damage and progression of rhizarthrosis.


Y. Li C.M. Bäckesjö L.A. Haldosén U. Lindgren

Despite developing refinements of chemotherapy regimens for osteosarcoma, multi-drug resistant cases are frequently seen and patients with metastatic or recurrent disease continue to have a very poor prognosis. Recently, the expression of the longevity gene Sirt1 was found to be relatively higher expressed in tumors compared with the normal tissues. Association of high level of Sirt1 expression with the development of multi-drug resistance in tumor cells has also been indicated. Thus, it is interesting to study the therapeutic potential of regulating Sirt1 activity for the treatment of osteosarcoma.

In the present study, we evaluated the effects of two Sirt1 activators, resveratrol and isonicotinamide, on growth and apoptosis in four human osteosarcoma cell lines, HOS, Saos-2, U-2 OS and MG-63. We found that Sirt1 protein was expressed in all osteosarcoma cell lines. Instead of promoting cell survival, both resveratrol and isonicotinamide decreased cell growth and induced cell apoptosis in a dose-dependent fashion. Furthermore, the pro-apoptotic effect of resveratrol could be enhanced by L-asparaginase-induced nutrition restriction of cultured osteosarcoma cells.

Our results demonstrated that Sirt1 activators elicited pro-apoptotic effects in osteosarcomas. Thus, Sirt1 could be a potential target in the treatment of osteosarcoma. However, due to the non-specificity of the Sirt1 activators used further studies, such as knock-down of Sirt1 by siRNA, are needed to confirm the effect of Sirt1 activation on malignant cells.


I. Nizam L. Kohan D. Kerr

Birmingham Hip resurfacings have been a popular mode of treatment for younger and more active patients with arthritis of the hip. However the use of hybrid hip arthroplasty system with a Birmingham hip resurfacing cup and modular head with a variety of cemented/uncemented stems is less well described in the literature.

We analysed radiographic and clinical outcomes of 99 consecutive hybrid hip arthroplasties performed by a single surgeon between 2000 and 2006.

A total of 93 patients (52 females and 41 males) with an average age of 69.9 (47 to 88) and average BMI of 28.8 (18.7 to 140.9) had arthroplasties with a mean follow up of 4.1 Yrs (1 to 6.3 years). 57 right and 42 left hip arthroplasties were performed of which 6 patients had bilateral consecutive hybrid hip arthroplasties.

93 were performed for osteoarthritis, 4 for RA, 5 patients for revision of failed hip resurfacing arthroplasties with #NOF and 1 revision for failed THR.

No patients had dislocations and one patient had revision of a resurfacing cup secondary to hip pain due to excessive cup anteversion, no loosening of components were identified at the most recent follow-up and all patients were mobilising well with no complaints of pain.

Hip Resurfacing procedures are gaining popularity in the younger individuals with arthrosis of the hip. Some patients who are fairly independent and active fall short of satisfying the criteria for a hip resurfacing and we preferred the option of the Birmingham hip resurfacing cup with a large modular head and a compliment of stems. This metal-on-metal option with large heads would ideally increase stability and reduce wear patterns with the prospect of increasing longevity of total hip arthroplasties.


M. Glehr P. Wretschitsch T. Kroneis G. Gruber F. Quehenberger A. Leithner R. Windhager

In several countries fine needle aspiration (FNA) biopsy of soft tissue tumours is regarded as a standard procedure. However, various problems using FNA compared to core needle biopsy have been reported. Less cell amount, blood and other non tumour tissue aspirated and cells torn out of their environment lead to problems in histological diagnose. The aim of this study was to measure the number of cells harvested by two new needle systems (THYROSAMPLER®) in comparison with the conventional fine needle system (C-FNA). The innovation of the new system is aeration after aspiration by a valve, so that undesired aspiration of blood, debris, and cells from outside the tumour during withdrawal of the needle is minimized.

In a blinded setting, 45 punctures from fresh pig thyroid glands were made and analysed – 15 for each needle (C-FNA, single-needle with air valve T-ONE and multi needle system with air valve T-THREE). The aspirated cell material was evacuated into 10ml cell-culture liquid and calculated according to the manufacturer’s recommendations for the CASY cell counter (CASY® technology, Reutlingen).

With each system, 15 punctures each were aspirated and the cells counted. With the T-ONE System the amount of vital cells was 688%, the amount of total cells 521% higher then using the C-FNA system. With the T-THREE System the amount of vital cells was 901%, the amount of total cells 798% higher then using the C-FNA system.

The mean difference between C-FNA and T-ONE was significant regarding total number of cells (p=0.030) as well as number of vital cells (p=0.032).

The needle systems with the air-valve led to a significantly higher cell amount in needle aspiration biopsy. According to the requirement of cytological diagnosis of soft tissue sarcomas more cell volume could be harvested, which is a well-defined benefit.


A.J. Johnstone S.V. Karuppiah

Introduction: The current techniques used for locking the distal end of intramedullary nails with cross screws remain a technical operative challenge for many clinicians. The surgeon uses his/her experience and judgement to locate the distal holes in the intramedullary nail, relying heavily on the use of two dimensional intra operative X-ray images (fluoroscopy) to undertake a three dimensional task. As a result, a large number of X-ray images are frequently required, significantly increasing the radiation exposure to both the patient and the operative team. Also there is an overall proportional increase in the operating time.

Aim: We aimed to develop a simple new radiological alignment jig that would allow the accurate placement of distal locking cross screws during intramedullary nailing, with minimal radiation exposure and without having to visualise the distal screw holes.

Materials and method: Laboratory tests were conducted using plastic femora (Sawbones Limited) fixed with intramedullary nails. Tests were performed three times using each of the different femoral intramedullary nails (Russell-Taylor, Smith & Nephew) investigating whether the length or diameter of the nail had any influence upon the accuracy of distal screw insertion. After successfully concluding the laboratory tests, a limited clinical study was conducted using the new alignment jig to insert distal locking screws in patients.

Results: Both the bench tests and limited clinical study were 100% successful and permitted the clinician to identify the distal holes correctly without needing to visualise the distal screw holes radiologically.

Conclusion: Our initial bench tests and clinical study show that the new alignment jig allows simple and accurate insertion of the distal locking screws with minimal radiological guidance. It also has considerable potential to reduce the overall operating time.


G.A. Buijze L. Blankevoort P. Kloen

New concepts in plate fixation have led to an evolution in plate design for olecranon fractures. The purpose of this study was

to compare the stiffness and strength of a contoured Locking Compression Plate (LCP) with a conventional plating method (one-third tubular plate) in a cadaveric comminuted olecranon fracture model with standardized osteotomy, and

to evaluate the LCP fixation method in a prospectively included group of patients with complex olecranon fractures using validated outcome scores.

In the biomechanical study, five matched pairs of cadaveric elbows were randomly assigned for fixation by either LCP or a conventional plating method. Specimens were mounted to a custom-made testing bench and subjected to cyclic loading until failure occurred while measuring gapping at the osteotomy site. In the clinical study, twenty-one patients treated with LCP for complex olecranon fractures had a mean follow up of 20 months (3–39 months) and functional and patient rated outcome were evaluated.

In the biomechanical study, there was no significant difference in fixation stiffness and strength between one third tubular plating and LCP (p > 0.05). In the clinical study, the mean time to union of the fracture was 6 months (2–28 months). According to the Mayo Elbow Performance Index (MEPI) most patients had a good or excellent outcome. No patients reported difficulty with activities of daily living. Physical capacity showed minimal loss of stability and strength. Six patients had their hardware removed.

Technical ease of application and advantageous features of the LCP -such as unicortical screw fixation and improved holding power in osteopenic bone- make it a good alternative implant for comminuted olecranon fractures.


R. Blakytny S. Laumen A. Ignatius F. Gebhard L. Claes G. Krischak

Although IL-6 mRNA expression in rat is restricted to the first day post-fracture, the inflammatory phase, the protein has been observed later in the healing process, indicating additional roles. The importance of IL-6 was demonstrated by delayed healing in knockout mice through diminished osteoclast numbers, formation thereof being stimulated by IL-6. The aim of our study was to investigate with which cells this cytokine is associated and when during fracture healing.

A closed fracture of the lower right limb was created in rats. The tibia was obtained from six animals at each of 1, 3, 7, 14 and 28 days post-fracture, decalcified and prepared for standard immunohistochemistry with an IL-6-specific polyclonal antibody. The number and types of cells positively stained for IL-6 along the whole length of the periosteal callus on one surface and in the fracture was evaluated.

Mostly inflammatory cells were initially stained, becoming virtually absent by day 7 when this phase has normally ended. Within the immediate vicinity of the fracture where endochondrial ossification occurred, staining of chondrocytes was significant (69%) by day 7 when this cell was laying down cartilaginous tissue that was also calcified. Distally to the fracture where direct bone formation occurred through intra-membranous ossification by osteoblasts, staining of these cells was observed, peaking at day 14 (56%). As this bone started to take on the appearance of cortex and surviving embedded osteoblasts differentiated to osteocytes, the latter cells were stained, suggesting a role in remodelling. At the fracture as bone replaced the cartilaginous tissue and union occurred, staining of chondrocytes decreased, whereas local osteoblasts were positive.

IL-6 appears to play a role throughout fracture healing, in endochondrial and intra-membranous ossification. The level of staining of each cell type reflected the degree of their activity with respect to production of related tissue.


I. Nizam L. Kohan D. Kerr

Pain relief in hip arthroplasty plays an important role in the intra/post operative stages in order to achieve an almost pain free post operative recovery period to mobilise the patient as early and safely as possible and avoid undesirable post surgical complications.

A consecutive series of 99 total hip arthroplasties in 93 patients performed by a single surgeon between December 1996 and January 2006 were assessed for signs of clinical or radiological loosening.

Intra-operative local anaesthetic mixture (Ropivacaine-Ketorolac (30mg) -Adrenaline or RKA mixture) was infiltrated into the joint capsule and surrounding tissue around the acetabular component, and into the different muscle layers in the thigh around the femoral component. A total of 150–200 mls of this mixture was injected and a further 50 mls (with 30mg ketorolac) injected through a catheter left in-situ before discharge 12 to 24 hours later. Radiographic analysis was carried out using the Hodgkinson criteria to predict acetabular component loosening and the Gruen method to determine femoral component loosening.

Of the 99 hybrid hips, 57 were right and 42 were left hip arthroplasties and 6 patients had bilateral consecutive hips done. 5 were performed for revision of fractured necks of femur in Birmingham hip resurfacings and one total hip arthroplasty revised to a hybrid and the remaining 92 were primary hybrid hip arthroplasties. The arthroplasties were performed for Osteoarthritis (89), Rheumatoid arthritis (4), and others (6). At mean follow up of 4.2 years, no aseptic loosening was noted radiologically or clinically, no components have been revised for failure or loosening and no components have dislocated.

The use of high dose local infiltration NSAIDs in the intraoperative and early post operative phase does not seem to affect prosthetic fixation at-least during short to mid term follow up of total hip joint arthroplasties.


J. Gallo F. Mrazek A. Arakelyan M. Petrek

Introduction: The development of periprosthetic osteolysis (OL) in total hip arthroplasty (THA) depends on activation of distinct pathways by wear particles eventually leading to predominance of osteoclasts over osteoblasts at the bone-implant interface. These processes are orchestrated by many cytokines and chemokines. However, interindividual variability in OL was observed even in cases of comparable wear rates and identical prosthesis. To explain it, we hypothesize genetic susceptibility to OL underlined by single nucleotide polymorphisms (SNP) for genes for key signal molecules.

Patients and Methods: In this case-control association study we investigated patients with severe OL around THA (n=116). The control group included patients with the same THA and mild OL (n=89). All were Caucasian, all had a single type of cementless THA implanted at a single institution. Healthy subjects without THA (n=150) served as a genetic background. Severity of OL was determined according to the Saleh’s classification. We used the candidate gene approach and overall, 22 cytokine/cytokine receptor SNPs were genotyped by polymerase chain reaction with sequence specific primers (PCR-SSP).

Results: The results showed an association of the TNF-238*A allele with severe OL (odds ratio, OR=6.59, p=0.005, population attributable risk percentage, PAR% = 5.2), higher risk of revision (OR=infinity, p=0.017) and poorer survival of THA (p=0.022). In addition, carriers of the IL-6-174*G allele were more frequent among the patients with severe OL (OR=2.51, p=0.007, PAR%=31.5). Finally, the genetic variant IL-2-330*G was associated with lower risk for THA revision (OR=0.44, p=0.02), protection from severe OL (OR=0.55, p=0.043) and longer survival of THA (p=0.018).

Conclusions: At least in a Czech population, genetic variants of the pro-inflammatory cytokines TNF-alpha and IL-6 confer susceptibility to severe OL and risk of premature THA failure. Conversely, SNP in the IL-2 gene may protect from development of severe OL and risk of early revision due to OL.


K. Kolios X. Tsatsaronis I. Xavalis I. Tsimpoukis E. Boutlas K. Giannoulis P. Kounelis A. Xatzikiriakos G. Peppas A.E. Georgiadis

Osteoporosis can be caused by many miscellaneous factors. These factors include medical, lifestyle and socioeconomic variables, the latest being not well studied and defined in international bibliography. From these there are the factors regarding the working environment (house or office) and the living environment (urban or countryside). Our hypothesis is based on the fact that women living in an urban environment or working in an office environment should have lower Bone Mineral Density (BMD) and thus, greater fracture possibility because of their lower level of physical activity, greater alcohol/coffee consumption and increased smoking frequency compared to women living in the countryside or women housekeeping.

In order to find whether this hypothesis is true, a population based observational retrospective study has been performed. The fracture rate of 4616 post-menopausal osteoporotic women (PMOW) (mean age=64,1±9,3 years) from 160 centers all over Greece has been compared with the two aforementioned possible risk factors. Descriptive statistics like the mean±SD and frequencies were used to present the data. In order to assess for relationships between categorical variables the chi-square (χ2) test was performed. Statistical analysis was conducted using the software SAS, version 9.1 and statistical significance was established as 5%.

The results are as follow:

16,2% of these PMOW had a history of fracture and for 80,3% of them was a hip fracture.

84,1% of PMOW lived in urban environment and had lower fracture rate than women living in the countryside (p< 0,05).

47,2% of the PMOW worked at home and had lower fracture rate than women working for more than 20 years in an office environment (p< 0,0001).

It can be concluded that more fracture-susceptible PMOW are those working in an office environment and also living in the countryside. It can be assumed that the first is related with lower BMD and the second with the more ‘fall-prone’ nature of the country environment.


N. Dong N. Li M. Thakore A. Wang M. Manley H. Morris

Previous studies suggested the lack of capture wall of acetabular Ultra High Molecular Weight Polyethylene (UHMWPE) liner can significantly increase the risk of hip joint dislocation. To date, the dislocation studies have been focused on the femoral neck impingement models. The purpose of this study was to identify a new Dislocating Force (DF) generated by rim directed joint force alone and investigate the factors to affect the magnitudes of the DF. The 3 D Finite Element Analysis (FEA) models were constructed by (30) 10 mm thick UHMWPE liners with six inner bearing diameters ranging from 22 mm to 44 mm and five capture wall heights in each bearing size from 0 mm to 2 mm. A load of 2 446 N was applied through the corresponding CoCr femoral head to the rim of the liner. The DF was recorded as a function of capture wall height and head diameter. The results were verified by the physical tests of two 28 mm head bearing liners with 0 and 1.5 mm capture wall heights respectively.

The results showed that the highest DF was 1 269N in 0 mm capture wall and 22 mm head. The lowest DF was 171 N in 2 mm capture wall and 44 mm head. The DF decreased as the capture wall and head size increased. When capture wall increased from 0 mm to 1 mm, the DF was reduced more than 50%. Two experimental data points were consistent with the trend of DF curve found in the FEA.

We concluded that the new intrinsic dislocating force DF can be induced by the rim directed joint loading force alone and can reach as high as 51% of the femoral loading force. A capture wall height above 1mm can effectively reduce DF to less than 25% of the joint force. In addition, the larger head diameter also resulted in less DF generation.


B. Masson

Demand for ceramic bearings is increasing rapidly because of excellent clinical results. Alumina offers advantages such as chemical resistance, excellent bio-inertness and tribology. However, alumina has limited strength, therefore the applications are restricted to certain designs. Zirconia materials have been used clinically for ten years, they reveal problems due to poor hydrothermal stability. Thus, there is a strong need for new bearing material that combine strength and stability.

The new ceramic named Alumina Matrix Composite (AMC) uses the following principle of transformation toughening: Firstly, the dispersing of small particles of Y-TZP Zirconia in the alumina matrix and secondly the reinforcement by introduction of an anisotropic crystal like whiskers. This process dissipates the crack energy that is associated with an increase of strength. The examination of the tribological situation of AMC, especially under challenging conditions of hydrothermal ageing and under severe micro separation, shows the aptitude of this material in wear applications.

Alumina Matrix Composite offers a better mechanical resistance than alumina while maintaining the structural stability and equivalent tribological qualities. This is a material that has been very thoroughly evaluated and tested as a permanent implant material for the last 9 years. The results of this evaluation and testing process have been included in the manufacturer’s Master File at the Food and Drug Administration and approved.

The substantial improvement in mechanical properties and the excellent wear behaviour, even under severe microseparation conditions, make this material a promising new addition to the orthopaedic surgical community and a possible solution to the longevity problems seen with many total joint systems in young and active patients. No complications have been reported yet at six-year follow-up, with more than 310,000 components (heads and inserts) implanted. Additionally, due to the enhanced mechanical behaviour, new applications in orthopaedics are possible.


M. Mulier I. Jonkers G. Lenaerts V. VanGeel W. Claasssen S.V.N. Jaecques G. Van der Perre

Success of a total hip replacement is commonly assessed by the Haris Hip Score (HHS), which provides information on pain reduction and regained mobility. Radiographic images provide information relative to the stability of the prosthesis.

We use the intraoperatively manufactured prosthesis since 1989; the initially performed THR were done with uncoated prostheses. After introduction of the hydroxyapatite coating our prosthesis stems were coated.

We retrospectively evaluated the clinical and radiographic outcome of 3 patient cohorts who received intra-operatively custom made stem prosthesis.

Group 1: Uncoated stem prosthesis fixated with tro-chanteric osteotomy.

Group 2: Uncoated stem cementless implant

Group 3: Cementless hydroxyapatite coated stem prosthesis

Clinical assessment and radiographic assessment is performed using pre-operatively and at each follow-up visit.

Baseline data are the pre-operative HHS and first radiography postoperatively. These data are compared with the data of the latest follow-up visit.

RX’s are scored according to the ARA score.

Records were analysed for 83 patients in group 1, with a mean follow-up period of 93 months. In group 2, 35 patients were followed for 105 months and 54 patients from group 3 were followed for 41 months.

In the 3 groups the HHS at follow-up was > 75, this means an improvement of minimum 25 points for group 1 and 2 (baseline HHS for group 2 was not available)

The mean ARA scores at follow-up were 1.6; 1.7 and 5.3 for respectively group 1; 2 and 3.

Clinical outcome is comparable in the three studied cohorts.

The ARA score is indicating poor outcome for the uncoated prosthesis, regardless of the type of fixation, while the coated prosthesis group has a good to excellent ARA score.

These findings tend to confirm the superiority of the hydroxyapatite coated prosthesis.


N. Dong N. Li W. Schmidt M. Kester A. Wang M. Nogler M. Krismer

High tensile stress has been considered as a contributing factor to the rim fracture of polyethylene acetabular cup liner. We performed the 3 D Finite Element Analysis (FEA) to compare the stress patterns at the polyethylene liner rim as a function of polyethylene thicknesses and whether or not rim was supported by the titanium acetabular shell extension. Two 3.1 mm thick generic 52 mm titanium alloy acetabular shells with and without 2 mm high rim support extension were modelled. Six corresponding Ultra High Molecular Weight Polyethylene (UHMWPE) liners with inner bearing diameters ranging from 22 mm to 44 mm and same outer diameters, were fixed in the shells. A 2 450 N load was applied through the corresponding CoCr femoral heads to the rims of liners while the acetabular shells were fixed on the outer spherical surface. The FEA was performed in half body of the assembly. The maximum principal stresses at the rim regions of UHMWPE liners were recorded.

The results showed that in all rim supported conditions, the maximum principal stress were in compressive patterns, a preferred pattern to reduce the potential polyethylene liner fracture. In rim unsupported conditions, the stresses was in tensile on the internal bearing surface when polyethylene liner thickness was bellow 5 mm, or was bellow 9 mm if the average maximum principal stress cross the rim was considered.

We conclude that the metal rim support changes the stress pattern in the rim region of UHMWPE liner to compressive for all liner thicknesses. The stress pattern turns to tensile, or there will be a higher potential for rim fracture, if UHMWPE liner is unsupported and the polyethylene rim thickness is less than 9 mm.

Although components used this study did not include the locking details which add higher stress concentrations, the trend of stress patterns should follow the results found in this study.


R. Meizer N. Aigner E. Meizer C. Radda F. Landsiedl

Bone marrow edema syndrome (BMES) of the femoral head in pregnant women is a very rarely seen disease with disabling pain in the hip, beginning in the second or third trimester and persisting after parturition. Although isolated BMES is generally considered to be a self-limiting disease, progression to irreversible avascular necrosis of the femoral head has occasionally been observed. The conservative standard treatment of BMES consists of analgesic or anti-inflammatory medication combined with reduced weight bearing and physiotherapy. Better results regarding pain reduction are achieved by surgical intervention, with core decompression being the current standard technique for the management of BMES.

The patients were aged between 31 and 43 years (mean 37.5 years). All patients presented with pain on effort, with gait disturbance and pain at rest starting in the third trimester of pregnancy at a mean gestational age of 28 weeks (25 to 32 weeks). Symptoms rapidly progressed over a 2-week period. We treated 4 postpartal women (6 hips) presenting femoral head BMES with infusions of the prostacycline analogue iloprost (20 μg for 5 days) followed by 3 weeks of partial weight-bearing. MRI was used to investigate the outcome of BMES.

Symptoms regressed rapidly during and after therapy. After 4 weeks all patients were asymptomatic with no limitations in ambulation. In the MRI assessment, complete regression of BMES could be detected in three patients and minor residual BMES in the femoral neck of one patient (one hip) after 3 months. Pain did not recur in any patient at a mean follow-up of 31 months (14–43 months).

The vasoactive drug iloprost has good analgesic potency in the treatment of postpartal women suffering from BMES and accelerates the natural course of the disease.


R. Lee M. Cardinale L. Loving J. Longaray A. Essner A. Wang D. Ward

Femoral head roughening is a clinically observed phenomenon that is suspected to cause increased wear of acetabular inserts. Two approaches have been taken to reduce hip bearing wear. Improved femoral head materials may decrease the impact of roughening and reduce the effect of abrasion. Additionally, improved polyethylene materials may be utilized to reduce wear against smooth or roughened femoral heads. This study looks at these two approaches in the form of a toughened alumina femoral head (Biolox Delta) and a sequentially crosslinked and annealed polyethylene (X3). A wear study was performed with new and artificially scratched ceramic femoral heads (28mm Biolox Delta) as compared to new and artificially scratched Cobalt Chromium femoral heads. These femoral heads were articulated against both conventional (N2\Vac) and highly crosslinked (X3) polyethylene acetabular cups. Artificial scratching utilized a Rockwell C indentor loaded at 30N to scratch a multidirectional scratch pattern on the articulating surface of the femoral head to simulate in vivo roughening.

Delta femoral heads exhibited superior resistance to scratching. Peak to valley roughness for CoCr heads was 7.1um while Delta heads only roughened to 0.4um. Head material under standard conditions (no scratch) had no effect on PE wear (p=0.31 and p=0.53). Under abrasive conditions, the Delta femoral head exhibited a clear advantage over CoCr heads (65–97% reduction in wear rate; p< 0.007). X3 polyethylene also showed a clear advantage over conventional PE against either CoCr or Delta heads and under both conditions (all p < 0.012).

This study clearly demonstrates that X3 polyethylene has a clear wear advantage over conventional polyethylene despite head material or abrasive conditions. Secondary to the polyethylene choice, the use of a ceramic femoral head leads to superior performance under abrasive conditions.


I. Jonkers G. Lenaerts V. VanGeel W. Claassen S. Jaecques G. Van der Perre M Mulier

We report the follow-up of a cohort of 86 patients who underwent total hip replacement (THR) with custom-made stem prosthesis. Fixation mode, cemented (group 1) or uncemented (group 2) is based on the bone quality. Aspects of physical health and changes in mental health are documented using 3 patient-administered questionnaires, pre-operatively and 6 weeks, 3, 6 and 12 months post-operatively.

Harris Hip Score (HHS), Hip disability and osteoarthritis outcome score (HOOS) and SF-36, multi-purpose, short-form health survey were used.

Globally HHS increases significantly (p< 0.01). In group 1 up to 3 months post-operatively and in group 2 up to 1 year. (p < 0.05). In group 2 HHS is significantly higher 6 months and 1 year postoperatively (p< 0.05). No significant differences in HOOS subscores between subjects of group 1 and 2 for subsequent time points were found. The scores related to Pain and Symptoms increased significantly 6 weeks after THR (p< 0.01). Sports and recreation scores increased significantly up to 3 months after THR (p< 0.01). Activities of daily living, and Quality of Life (QoL) improved up to 6 months after surgery (p< 0.01).

No significant difference between the 2 groups in QoL was observed. The physical component summary increased up to 3 months after surgery (p< 0.01). The mental component summary did not change significantly after THR.

The difference noted in HHS between group 1 and 2 may be due to the selection of the fixation technique which is often directly related to the patient’s age. The results of the HOOS score confirm the findings of the HHS. Not all patients responded to the questions relative to recreation and sport of the HOOS score. QoL is an important indicator for success as perceived by the patient. In this study a rapid improvement of QoL is observed (3 months) and there is little change at 6 and 12 months.


M. Downing NA. Munro RA. Duthie JD. Hutchison GP. Ashcroft

Introduction: Impaction allografting is an established method for restoring deficient bone during revision arthroplasty of the hip. Graft augmentation with synthetic materials has been proposed and evaluated experimentally. Our aim was to assess clinically whether migration and wear of implants with a synthetic graft mix would be equivalent to pure allograft.

Materials and Methods: Patient inclusion criteria were: acetabular and or femoral defects from aseptically loosened primary THR undergoing cemented revision with impaction grafting; age 55–80 years; initial diagnosis of osteo arthritis; good health with reasonable daily activity level. Patients were randomized to receive either pure allograft or a 50% mixture with a porous hydroxyapatite material (Apapore60, Apatech, UK). Revision was with the Exeter stem, antibiotic Simplex cement (Stryker Howmedica Ltd), and Ogee cup (Depuy Int. Ltd., Leeds, UK). Tantalum markers were inserted into the pelvis, cup, femur, cement and graft in order to measure migration with radiostereometry (RSA). Patients received a sequence of RSA examinations up to 2 years. A total of 26 patients (18 for the femur) have been analysed.

Results: At 2 years no significant differences were seen in cup wear, or migration of the cup, femoral and pelvic graft markers. Stem migration occurred mainly at the stem cement interface. The rate of distal migration for the femoral head was greater for pure allograft in the first year (p < 0.05), however this rate reduced significantly in year two. Higher medial migration in year one was observed for the proximal medial cement mantle for allograft (p < 0.05).

Conclusions: Improved stability and normal cup wear were observed in a randomized clinical study for a synthetically augmented allograft. This agrees with experimental findings1. Longer follow up with increased patient numbers is recommended to confirm these findings.


L.C. Pastrav S.V.N. Jaecques I. Jonkers G. Van Der Perre M. Mulier

In total hip replacement (THR), the initial fixation of the femoral stem has a critical influence on its long term stability. Objective intra-operative assessment of primary stability is a challenge, surgeons having to rely mainly on their clinical experience. Excessive press-fitting of the stem can cause intra-operative fractures in up to 30% of revision cases. In a previous study we demonstrated the feasibility and validity of a vibrational technique for the assessment of the femur-stem fixation in vitro.

In this in vivo study the vibration analysis was applied for the per-operative assessment of stem fixation in 30 THR patients who obtained an intra-operatively manufactured, hydroxyapatite coated, cementless prosthesis.

The surgeon inserted the stem through repetitive controlled hammer blows. After each blow, the frequency response function (FRF) of the stem-bone structure was measured directly on the prosthesis neck in the range 0–10 kHz. The hammering was stopped when the FRF graph did not change anymore. Extra blows would not improve the stability but would increase the fracture risk.

In 26 out of 30 cases (86.7%), the correlation coefficient between the last two FRFs was above 0.99 when the insertion was stopped. In four cases, when the surgeon decided to stop the insertion because of suspected bone fragility, the final correlation coefficient attained lower values.

During the insertion of a cementless prosthesis, the changes of boundary conditions and implant stability between subsequent stages are reflected by the FRF evolution. The higher resonance frequencies are more sensitive to the stability change. The correlation between successive FRFs can be used as a criterion for the detection of the insertion endpoint. Moreover, the FRF analysis can be used to detect dangerous situations during surgery like stem blockage and fracture risk. This study should be completed and validated by a post-operative follow-up of the patients.


G. Pignatti G. Trisolino N. Rani D. Dallari A. Giunti

The use of monoblock tapered stems has shown very good results in hip revision surgery, particularly in case of severe proximal femur bone deficiency.

However a too valgus neck, a short offset, may result in a high risk of dislocation. In addiction monoblock stems make the control of limb length difficult, and potentially increase the risk of subsidence or intraoperative fracture. Different types of modular tapered stems with distal fixation have been developed to allow a more user-friendly restoration of limb-lenght discrepancy and an indipendent proximal control of offset and anti-retroversion.

We assessed 64 hip revisions performed on 63 patients (mean age 62 years). Indication for treatment was: aseptic loosening (42 cases) septic loosening (18 cases) and periprosthetic fracture (4 cases). According to Paprosky classification, femoral defects were staged as type I (2 cases), type II (20 cases), type IIIA (25 cases) and type IIIB (13 cases); periprosthetic fractures were all type B2 according to the Vancouver classification. In all cases we used a Restoration® Modular (Striker, Orthopaedics) cone-conical uncemented stem implanted by a lateral approach, with a trans-femoral osteotomy in 19 cases. A preventive cerclage cable was used in 10 patients in case of very thin cortex. We used the minimum size stem in most of the cases.

Mean follow-up was 20 months (range 6–36). Short-term complications included hip dislocation (1 case), recurrent infection (1 case), stem subsidence > 5 mm (1 case). Mean Harris Hip Score improved from 43 to 81.9 (t test p< 0.0005), while limb lenght discrepancy improved in 97% of cases with symmetry in 76%.

The use of modular revision stems is an effective alternative in hip revision surgery that ensures good primary stability, while modularity enables the implant to be tailored to the patient, allowing restoration of the limb length and correct muscular balancing.


D Cumming C Scrase J Powell D Sharp

Previous studies have shown improved outcome following surgery for spinal cord compression due to metastatic disease. Further papers have shown that many patients with metastatic disease are not referred for orthopaedic opinion. The aims of this paper are to study the survival and morbidity of patients with spinal metastatic disease who receive radiotherapy.

Do patients develop instability and progressive neurological compromise?

Do patients require surgery or are the majority adequately treated by oncologists?

Review of patients receiving radiotherapy for pain relief or cord compression as a result of metastatic disease. Patients were scored with regards to Tomita and Tokuhashi, survival and for deterioration in neurology or spinal instability.

94 patients reviewed. All patients were followed up for a minimum of 1 year or until deceased.

Majority of patients had a primary diagnosis of lung, prostate or breast carcinoma.

Mean Tomita score of 6, Tokuhashi score 7, and mean survival following radiotherapy of 8 months.

11:94 patients referred for surgical opinion.

Four patients developed progressive neurology on follow-up.

One patient developed spinal instability. The remainder of the patients did not deteriorate in neurology and did not develop spinal instability.

All patients with normal neurology at time of radiotherapy did not develop spinal cord compression or cauda equina at a later date.

This study suggests that the vast majority of patients with spinal metastatic disease do not progress to spinal instability or cord compression, and that prophylactic surgery would not be of benefit.

The referral rate to spinal surgeons remains low as few patients under the care of the oncologists develop spinal complications.


F Dakhil-Jerew H Jadeja N Bowman D Shah A Cohen A El-Metwally R Guy G Selmon J Shepperd

Introduction: In this study, we report interobserver reliability of X-ray for the interpretation of pedicle screw osteointegration based on the diagnosis of “Halo zone” surrounding the screw.

Dynamic stabilisation system for the spine relies on titanium screw purchase within the pedicle. Decision on osteointegration is important especially when the patient becomes symptomatic following initial good outcome. From our cohort of 420 Dynesys patients, over all incidence of screw loosening was 17%. Only 35% were symptomatic.

Method: Lumbar spine X-ray images of 50 patients in two views (AP and lateral) randomly selected from our cohort of 420 Dynesys patients. The images were deployed in a CD-ROM. The authors were asked to review the images and state whether or not each pedicle screw is loose (total of 258 pedicle screws).

Seven observers composed of two expert orthopaedic spine consultant surgeons and one spine expert consultant radiologist and four Specialist Registrars in orthopaedics and radiology.

Data gathered were distributed and presented in tables in the form of descriptive statistics. The evaluation of interobserver agreement was performed by obtaining a Kappa (K) index. For continuous variables comparison, the t test was employed, with a significance level of 0.05.

Results: Kappa Index among three experts was 0.2198 at 95% CI (−0.0520, 0.4916) while for all 7 assessors (3 Experts & 4 SpR), KI was 0.1462 at 95% CI (0.0332, 0.2592)

Discussion & Conclusion: Kappa Index among expert assessors was 0.2 which means X-ray is unreliable for the assessment of pedicle screw osteointegration. Validity of X-ray is not applicable as it is unreliable.

We are planning to evaluate a 3D computer reconstruction model based on 2 X-ray views at 45 degree angle to each other which might be sensitive to detect screw loosening.


James Wilson-MacDonald Andrew Farmery

Background: Clonidine is an 2 adrenoreceptor and imidazoline receptor agonist which has analgesic, sedative and MAC sparing effects. It has been used orally, intravenously (including as an additive to morphine in PCA devices) and epidurally in combination with local anaesthetics and alone. We hypothesised that epidural administration of clonidine without local anaesthesia might provide adequate postoperative analgesia following spinal surgery without centroneuraxial block, and that if the drug’s effect site is spinal then this might be achieved with smaller doses and with fewer side effects than if given systemically.

Method: This randomised controlled trial evaluated the effect of epidural clonidine versus saline on analgesia requirement and pain scores following spinal decompressive surgery. 66 patients were recruited and received a standardized general anaesthetic. At the end of surgery group C received a bolus of 1.5 mcg/kg of epidural clonidine followed by an infusion of 25 mcg/h for 36 to 48 hours. Patients in group P received a similar bolus and infusion of saline. Verbal pain scores, morphine consumption by patient-controlled device (PCA), sedation score, haemodynamic variables and the incidence of PONV were recorded for up to 48 hours.

Results: Pain scores in both groups were low, but significantly lower for the first 6 hours in the clonidine group. Cumulative morphine consumption, used as a proxy for pain perception, was significantly lower in the morphine group throughout the whole period; mean (SEM) at 48 hours 62 (7) mg vs 35 (7) mg.

Conclusion: Epidural clonidine has a useful effect in post operative pain relief following spinal surgery with few side effects.


E R S Ross Joellenbech B Rische

Purpose: To evaluate the safety of a novel polymeric one-piece disc arthroplasty.

Introduction: A polymeric disc that can replicate the native function of the natural disc, including three dimensional motion, dynamic stiffness, load sharing capability, and proper maintenance of lordosis provides a promising alternative for management of lumbar back pain caused by symptomatic degenerative disc.

Methods: Forty-four patients with disabling back pain that were unresponsive to non-operative strategies were enrolled in a clinical trial at three sites. Each patient underwent an L4/L5 or L5/S1 lumbar disc replacement with the study device, via a transperitoneal or retroperitoneal approach. Patients were assessed clinically and radiographically at 6 weeks, 12 weeks, 6 months, and 1 year, and 2 years. Oswestry Disability Index (ODI), Visual Analogue Scale (VAS), and SF-36 questionnaires were used to assess patient outcomes. The X-rays were independently analyzed for implant position, subsidence and radiolucency.

Results: For the 26 patients with follow up data at the time of writing, there were no intra-operative complications. An assessment of quantitative radiographic data indicate that the FLD maintains lumbar lordosis, restores and maintains a ‘physiologically appropriate’ disc height and angle, and provides flexion/extension range of motion and translation similar to those provided by the natural disc. Mean ODI scores decreased from 49% pre-operatively to 23 and 26% at 6 months and one year follow up, respectively. Mean VAS scores decreased from 7.7 to 3.1 and 3.0 cm for back pain at 6 and 12 months; from 4.1 to 0.8 and 0.5 cm for right leg pain at 6 and 12 months; and from 3.5 to 0.7 and 2.0 cm for left leg pain at 6 months and one year follow up, respectively. SF-36 component scores also improved significantly, from 31 pre-operatively to 45 and 44 at 6 and 12 months for the physical component, and from 45 pre-operatively to 54 and 51 at 6 and 12 months, respectively.

Conclusions: Although clinical experience is limited to date, results for these pilot patients, while early, indicate that the study device is safe and efficacious in the treatment of symptomatic lumbar degenerative discs. Longer term results will demonstrate the value of a viscoelastic total disc replacement that mimics the performance of the natural disc.


D. Wardlaw L. Bastian J. Van Meirhaeghe J Ranstam S. R. Cummings R. Eastell P. Shabe J. B. Tillman S. Boonen

Background: Balloon kyphoplasty is a minimally invasive treatment for acute vertebral fractures that aims to reduce and correct vertebral deformity by inserting expandable balloon tamps and then stabilize the body by filling it with bone cement. The effect of balloon kyphoplasty on quality of life has not been tested in a randomized trial.

Methods: Patients with up to 3 non-traumatic acute vertebral compression fractures were enrolled within 3 months of diagnosis and randomly assigned to receive either balloon kyphoplasty (N=149) or usual nonsurgical care (N=151). Measurements of quality of life, back pain and function, and days of disability and bed rest and spine radiographs were assessed through 12 months of follow-up.

Results: Compared with those assigned to nonsurgical care, participants assigned to balloon kyphoplasty had 5.2 points (95% CI, 2.9 to 7.4; p< 0.0001) greater improvement in the physical component of the SF-36 quality of life questionnaire at one month and 1.5 points (95% CI, − 0.8 to 3.8; p=0.2) at twelve months. Those in the balloon kyphoplasty group also had greater improvement in quality of life by the EuroQol questionnaire at one (0.18 points; 95% CI, 0.08 to 0.28; p=0.0003) and twelve months (0.12 points; 95% CI, 0.01 to 0.22; p=0.025) and improved disability by the Roland-Morris scale at one month (4.0 points; 95% CI, 2.6 to 5.5; p< 0.0001) and twelve months (2.6 points; 95% CI, 1.0 to 4.1; p=0.0012). Balloon kyphoplasty patients had less back pain on a 0 to 10-point numeric rating scale at seven days (2.2 points; 95% CI, 1.6 to 2.8; p< 0.0001) and twelve months (0.9 points; 95% CI, 0.3 to 1.5; p=0.0034) and reported fewer days of limited activity at one month (2.9 days per 2 weeks; 95% CI, 1.3 to 4.6; p=0.0004) and twelve months (1.6; 95% CI, − 0.1 to 3.3; p=0.068). Fewer patients assigned to balloon kyphoplasty took pain medications or used walking aids during follow-up. There was no significant difference in the number of patients with adverse events or serious adverse events in the kyphoplasty and nonsurgical groups. New radiographically detected vertebral fractures occurred in 41.8% of subjects in the balloon kyphoplasty and 37.8% in the nonsurgical group (4% difference; 95% CI − 7.5 to 15.6; p=0.5) and were not statistically different.

Conclusion: Compared to nonsurgical treatment, balloon kyphoplasty safely improved quality of life and reduced back pain, disability and the use of pain medications and walking aids. Significant improvements in multiple measurements of quality of life, pain and disability continue for at least 1 year. Balloon kyphoplasty did not increase adverse events including the risk of vertebral fractures (Clinicaltrials.gov number, NCT00211211).


A Zubovic M Cassels E Cassidy F Dowling

Purpose: Neck disorders, including both neck pain and injuries, are significant and increasing problem worldwide. The purpose of this study was to assess progression and current condition of patients with neck pain five years after initial treatment in the Back Pain Screening Clinic.

Study design: This study was a randomised cohort Level I study. We randomly selected and reassessed one hundred patients with the neck pain who were treated conservatively out of the first one thousand of patients seen in our clinic five years ago. Outcome measures included SF36 (PCS and MCS), ODI, VAS, HA and DS scores.

Methods and results: One hundred randomly selected patients were interviewed and assessed for initial complaint, progression of symptoms, time out of work, litigation, other treatments and BPSC treatment satisfaction. BPSC treatment consisted of the patient assessment, advice, education, reassurance or course of physiotherapy. All of the patients were treated conservatively. 46 male and 54 female patients with mean male age 44.85 years (SD=14.43) and mean female age 48.56 (SD=15.39) were included in the study. In 72 patients pain started spontaneously. 15 patients had pain related to industrial injury/RTA. 6 patients were excluded from the study (4 with no data available, 1 child, 1 death). Mean time out of work for patients with spontaneous onset pain was 3 weeks (SD 1.12) and for patients with industrial injury/RTA 29.24 weeks (SD 20.92) (p=0.003). Analyzing outcome measures first vs 5y showed: SF36 PCS mean 30.04 vs 51.24 (SD 7.18 vs 6.38) (p< 0.001), MCS mean 30.63 vs 53.0 (SD 11 vs 6.10) (p< 0.001), ODI 41.72 vs 13.22 (SD 19.65 vs 8.41) (p< 0.001), HA mean 8.72 vs 2.37 (SD 4.54 vs 1.32) (p< 0.001), DS mean 6.71 vs 2.01 (SD 4.12 vs 1.20) (p< 0.001) and VAS mean 4.32 vs 0.84 (SD 2.18 vs 1.03) (p< 0.001). Using the patient satisfaction questionnaire, 93% of patients found BPSC treatment useful.

Conclusion: Significant symptomatic improvement is found in this cohort group of patients five years after initial treatment in BPSC. Time out of work is significantly increased in patients pursuing litigation compared with patients with spontaneous onset of neck pain (3/52 vs 29.24/52, p=0.003).


A Zubovic M Cassels E Cassidy F Dowling

Purpose: Back pain is a significant problem in Europe with important socio-economic impact. The purpose of this study was to evaluate the incidence of spinal surgery for patients with back pain.

Sudy design: This was a retrospective Level II type study. Patient sample included five thousand and forty five patients with a five year follow up.

Methods and results: During past five years 5145 patients were seen in the back pain screening clinic. 823 patients (16%) were referred to the spine clinic (p< 0.001). 127 patients (2.47%) were operated on (p< 0.001). 106 patients (2.1%) had lumbar discectomy/decompression, 9 (0.59%) cervical discectomy, 3 (0.06%) pars reconstruction, 9 (0.17%) fusion and PLIF for spondylolisthesis, 5 (0.1%) decompression for spinal stenosis and 1 (0.01%) subtraction osteotomy for kyphosis. 5 patients (0.1%) were referred with “red flag” symptoms: 4 with spinal stenosis and 1 with tumour. 17 patients (0.3%) had discogram. 4 of them went for surgery: 1 had L4/5 PLIF, 2 L5/S1PLIF and 1 L5/S1 discectomy. 289 patients (5.6%) had nerve root blockade. Following NRB 47 patients (0.9%) had discectomy/decompression (p< 0.001). 62 patients had discectomy/decompression without previous NRB. L5/S1 discectomy was the most common (48 pts; 0.9%). 86 patients (1.7%) had facet joint injections. 8 patients (0.15%) had surgery following FJI (p< 0.001). 1 patient had L4 nerve root decompression, 3 L4/5 discectomy, 1 L5/S1 nerve rot decompression, 1 alartransverse fusion and 1 L5/S1 PLIF. 465 patients (9%) did not have nerve root blocks or facet joint injections. 3 patients (0.06%) had epidural injections of local anaesthetic and steroid.

Conclusion: Spinal surgery is not commonly performed in patients with back pain. Majority of patients can be treated conservatively. Prior to surgery nerve root blocks and facet joint injections are useful in selected patients.


C Hammell P Barrett I Shackleford

Lumbar spinal surgery may be associated with considerable pain in the early postoperative period. This often leads to a delay in patient mobilisation and a consequent increase in the risk of developing perioperative complications. Several studies have demonstrated the efficacy of intrathecal opioids for analgesia following spinal surgery.13 Morphine has been the most widely studied opioid and although improved analgesia has been reported with its use the risk of serious side effects such as respiratory depression has resulted in patients having to be nursed postoperatively in a high dependency unit.2 Intrathecal diamorphine has been widely used for analgesia following lower limb joint replacement where it is an effective analgesic agent with a good safety profile.45 Its use for analgesia following lumbar spinal surgery has never been reported.

We present our experience of using intrathecal diamorphine for analgesia following lumbar spinal surgery. Data were collected on all patients undergoing surgery who received intrathecal diamorphine and stored on a database (Microsoft Access).

Results: 194 patients received intrathecal diamorphine following spinal surgery over a 30 month period. All patients underwent lower lumbosacral decompressive and/or fusion surgery. Mean dose of diamorphine administered was 1.6mg (range 1–4mg or 20–50mcg/kg). In all cases intrathecal diamorphine was administered by the anaesthetist once the patient was anaesthetised. Only 9% of patients had a pain score of 2 or greater within the first 24 hours (using a verbal rating scale 0–10). No patients required rescue analgesia with intravenous opiates. All patients except one were nursed on a regular orthopaedic ward. Side effects were rare. Respiratory depression occurred in one patient necessitating supplemental oxygen and monitoring in a high dependency unit for 12 hours. Hypotension was an infrequent finding (3.5%) but was most common upon return to the ward and in the following 24 hours. It was easily treated with the administration of intravenous fluids and vasopressors were never required. Sedation occurred in 4 of the patients whilst in the recovery ward but the incidence was nil once patients had been discharged to the orthopaedic ward. The most common complication recorded was pruritis, occurring in 9% of patients within the first 12 hours.

Conclusion: Intrathecal diamorphine is an effective and safe method of providing analgesia following lumbar spinal surgery. High Dependency nursing care is not required as the incidence of serious side effects is low.


M Shafafy J Nagaria MP Grevitt JK Webb

Background: Treatment of high-grade spondylolisthesis remains controversial. In-situ fusion does not address the sagital balance, reduction and fusion on the other hand is associated with unacceptably high rate of neurological complications.

Aim: To describe the results of a novel technique using Magerl External Fixateur for gradual reduction followed by circumferential fusion.

Methods: From 1988 to 2006, thirteen patients were treated with this technique at our institution. They all had high grade spondylolisthesis. Retrospective case note review and radiographic analysis were carried out. 10 point Visual Analogue Sore (VAS) for pain, Oswestry Disability Index (ODI), Low Back Outcome Score (LBOS), SF-36 Health Survey, and Patient Satisfaction Questionnaire were collected. Complete set of data was available for 9 patients, 7 Female and 2 Male. Mean age at operation was 16 years (range 12–22), and average length of follow-up was 11 years (range 5–19)

Results: Post operatively, Percentage of Slip was improved by an average of 70%(range 32–96%)(p=0.001), Slip Angle by 72%(p=0.0001) and sacral Inclination by 59%(p=0.0016). Radiological fusion was achieved in all but one. VAS for leg and back pain improved from 8.4 (range 8–9) and 8.2 (range 6–10) to 0.8(range 0–2) and 1.2 (range 0–2) respectively. These improvements were statistically significant (p< 0.001). ODI at the latest follow-up averaged 8% (range 0–16%) and LBOS 56.6 (range 44–70). The mean SF-36 for physical domains was 87.5 (range 80–93) and that for the psychological domains was 91.25 (range 81–100). All patients were fully satisfied. 3 cases had culture negative excessive discharge from one pin site. 2 patients developed transient parasthesia and one patient developed asymptomatic pseudoarthrosis.

Conclusion: Our technique albeit in a small cohort of patients, achieved significant correction of the commonly used and widely accepted radiological measurements without any neurological complications. The radiological improvement was also reflected in statistically significant improvement in validated outcome measures.


P Sell T Okoro

Aims: To determine outcomes in somatised patients and identify factors of clinical utility that help predict favourable and unfavourable results.

Introduction: Somatisation is a tendency to experience and express somatic distress and symptoms unaccounted for by pathological findings and to attribute them to physical illness, often with excess seeking of medical help for them. Somatised patients undergoing spinal surgery have less favourable outcomes than the normal surgical population. However a range of outcomes occur.

Methods: Prospective data from a single centre was obtained. Pre-operative modified somatic perception (MSP) and modified Zung depression (MZD) scores were available on 993 patients. The 46 patients with high somatic scores were identified as a discrete sub-group. Some patients did extremely well some patients had poor outcomes. Quantification of the number of consultants seen, outpatient clinic (OPD) reviews and duration of symptoms were compared to indicators of poor outcome (unchanged or increased visual analogue score (VAS), increased or < 10 point decrease in Oswestry disability index (ODI)) at 6 and 12 months of follow up.

Results: In the 46 patients the mean pre surgical scores were ODI 64.9 (SD 12.75) MSP 16 (SD 7.74); MZD 38 (SD 10.4); Prior to surgery they had a mean of 9.6 OPD attendances, the average number of consultants seen was 3.28 (SD 2.83). Overall the post-operative mean ODI was 36.81 (SD 24.58) a clinically satisfactory improvement. At 6 months patients who have a good outcome (ODI) had had an increased number of orthopaedic consultations (60% vs. 39.7%) but this was not statistically significant; p=0.16. At 12 months patients with a good outcome (ODI) had waited a lower number of months before surgery (5.5 vs. 11; p=0.026). Across all other parameters, including gender, age, surgical procedure undertaken, no other significant correlation exists between OPD, consultants seen and the changes in VAS, ODI at 6 and 12 months of follow up.

Conclusions: Dramatic differences exist between somatised patients who have good and poor outcome following spinal surgery. The number of months from decision to operate to surgery appears to predict good outcome at 12 months. No other identifiable pre-op factors were found.


M Shafafy P Singh JCT Fairbank J Wilson-Macdonald

Aim: To report our ten year experience of primary haematogenous spinal infection.

Method: Retrospective case note review of 42 patients presented to our unit with primary spinal infection between 1995–2005 was carried out. Demographic data, timing and modes of presentation, investigations, and methods of treatment were analysed. Information with regard to Mobility, Domestic circumstances, Oswestry disability index(ODI), Hospital Anxiety and depression score(HAD), Visual Analogue Score (VAS) for pain and coping were obtained. The cost benefit of Home Intravenous Antibiotics Service (HIAS) was also investigated.

Results: Mean age was 59.9 years (1–85) with almost equal gender distribution (M 20: F 22). Axial pain was universal. Pyrexia was seen in 62%. Time from presentation to diagnosis averaged 19days (range 0–172). Sensitivity for MRI and plain x-ray was 100% and 46% respectively. Treatment ranged from intravenous antibiotics alone to combined anterior and posterior surgery depending on the presence or absence of significant collection, neurological deficit and structural threat. Mean duration of intravenous antibiotics was 54 days (range 13–240). At mean follow up of 5.4 years (0.6–10.5) there was no mortality directly related to the infection. Recurrence rate was 14%. Significant past medical history(P=0.001), constitutional symptoms(p=0.001) and pyrexia at presentation(0.001) were positively associated with recurrence.

Mobility score dropped in 34% patients whilst domestic circumstances’ score dropped only in 34%. ODI averaged 18% (range 0–53%). Mean HAD for anxiety and depression was normal for 86% and 93% of patients respectively. VAS for pain averaged 1.3 (range 0–9) and that for distress was 1.8 (range 0–9).

Overall it was calculated that HIAS had saved a total of 940 in-patient days.

Conclusion: Primary spinal infection is a treatable condition. Disease and patient characteristics dictate the management strategy. Although most patients can regain their pre infection mobility and go back to their pre morbid domestic circumstances with little or no pain and psychological sequel, a proportion of patients end up with moderate to severe disability, pain and psychological problems despite successful treatment of the primary infection. Finally, HIAS was cost effective.


W D’Souza N Birch

Soon, UK surgeons will need to undergo regular revalidation and relicensing. As a part of this process they will need to collect accurate outcomes data. However, a lack of standardisation has led to numerous generic and disease specific outcome tools being available with increasing complexity in their administration and interpretation. In research and university settings these tools are easily administered, but in a busy general spinal practice with limited human and time resources, it may not be possible to use them reliably and consistently. Web-based systems remove some of these problems, but data-input can be time consuming.

This study evaluates the utility of a subjective Patient Satisfaction Evaluation Questionnaire (PSE) by comparing it to well-known outcome tools, the Oswestry disability Index (ODI) and the Low Back Outcome Score (LBOS).

The PSE (modified Odom’s Criteria) evaluates pain, the willingness to undergo surgery again in similar circumstances, the likelihood of recommending the operation undergone to a friend or family member and satisfaction with the process of care. Pain relief is ranked as “complete”, “good but not complete”, “little” or “no pain relief/pain worse than before surgery”. The responses are scored with three points allocated to complete relief of pain, down to none for no relief. The other questions score one for a positive and zero for a negative response. The maximum score is six. Four, five or six points count as success as long as the pain component is two or three. Nought to three, counts as failure, as does a score of four when pain is rated as “poor”.

The ODI, LBOS and PSE are not directly numerically comparable, but the results of them all can be grouped into “Success” and “Failure” which gives a basis for comparison of the tools.

150 consecutive patients who underwent lumbar spine surgery completed the three questionnaires independently of the treating surgeon. The scores were subjected to regression analysis (R square) and a Pearson’s correlation. Feedback was sought from the patients regarding the “user friendliness” of the questionnaires.

Results showed a good correlation between the ODI and LBOS with a Pearson’s value and R Square (RSQ) value of 0.86 and 0.75 respectively. The PSE compared to the ODI showed a Pearson’s value of 0.86 and RSQ of 0.74. The LBOS and PSE comparison had a Pearson’s value of 0.78 and RSQ of 0.61. The results show that the PSE in the form used correlates well with results from the ODI and LBOS. However, the patient feedback data indicated that the PSE was the most user friendly of the three tools.

The PSE was found to be a useful and user friendly tool, correlating well with recognised outcome measures, being easy to administer, document and interpret. If surgeons with limited resources cannot reliably use a more rigorous outcome tool, using the PSE should provide enough data to meet the standards that are likely to be required for revalidation and relicensing.


T Okoro P Sell

Aim: To assess surgical outcomes between discectomy at the L4/5 level and L5/S1.

Introduction: There is sound biomechanical reasoning to suspect a difference might exist between spinal levels. The L4/5 disc is more susceptible to axial torsion and is the most common site of lumbar instability. The L5/S1 motion segment is protected from torsional strain by extensive iliolumbar ligaments but more exposed to axial compressive forces.1 There appears to be a difference between the L4/L5 motion segment and the L5/S1 in outcomes of disc replacement surgery. The available literature implies a difference but does not include studies with accepted standard outcome measures.

Method: 130 patients from a single centre undergoing a single level discectomy at L4/L5 or L5/S1 for radicular pain with prospectively gathered data. Oswestry disability index (ODI), subjective walking distance, Modified Somatic Perception (MSP), Modified Zung Depression Index (MZD), Low Back Outcome Score (LBOS) and visual analogue score (VAS) were collected over an average of 56 months of follow up. Comparisons between L4/5 vs. L5/S1 levels were made with these outcome measures using student’s t-testing.

Results: There were 78 L5/S1 and 52 L4/5 discectomies identified. Pre-operative walking distance for L5/S1 patients was higher at L4/5 (455m vs. 278m; p=0.027). At 6 months a small clinical difference exists with the back function scores that achieves statistical difference (47.11 (L4/5) vs. 39.47 (L5/S1); p=0.0229). Across all other parameters, no significant difference was found to exist between both groups. There was no difference in the recurrence rate or re-operation rate. There was no difference in early and late outcomes.

Conclusions: No statistically significant difference exists between surgery at the L4/5 level and the L5/S1 level in terms of post-operative outcome. There is no clinically significant difference in outcome. Planned surgical treatment strategies should not be altered by perceptions of difference in outcome when none exists.


N Birch W D’Souza A Isaac

Objective: To evaluate the outcome of treatment for adolescent disc disease (ADD) in individuals regularly involved in high class sport compared to relatively more sedentary adolescents.

Design: Retrospective observational study.

Setting: Private Spinal Orthopaedic Practice.

Patients: 52 individuals with confirmed ADD. 25 competing at county or national level in various sports (Group A). 27 moderately active individuals (Group B), but not elite sports players.

Interventions: History and clinical examination followed by radiological investigations were performed. Both groups were treated with oral medication including simple analgesia, muscle relaxants and NSAIDs as well as physiotherapy. Those with persistent pain were referred for pain management. Surgery was considered for refractory cases.

Main outcome measurements: The clinical and radiological evidence of disease progression, need for minimally invasive and invasive treatments as well as return to previous level of sport.

Results: 11 patients (44%) in group A had a non-invasive programme of treatment based on intensive physiotherapy. 11 (44%) needed minimally-invasive treatments in addition to physiotherapy. Three patients (12%) required surgery. One patient had to give up elite sport because of recurrent pain on significant exercise, but the others resumed their previous level of activity.

Nine patients (33%) in Group B were treated by physiotherapy alone while 13 (48%) had minimally-invasive treatment in addition to physiotherapy. Five patients (18.5%) required surgery. Two patients required revision surgery. All patients returned to their normal level of sporting activity.

Conclusion: Adolescents who play sport at a high level should not be discouraged by a diagnosis of ADD, as the outcomes of treatment are at least no worse than in their less active counterparts.


S M H Mehdian B J C Freeman M Woo-Kie A Littlewood

Introduction: Conventional reduction techniques for high-grade isthmic spondylolisthesis do not address important anatomical constraints on the L5 and S1 nerve roots, thereby leading to a significant risk of neurological deficit. We describe a novel three-stage reduction technique carried out in one operative session that respects these anatomical constraints. We report the results in seven cases.

Methods: Between 2000 and 2006, four female and three male adolescents with high-grade spondylolisthesis (grade 3 or greater) underwent this 3 stage procedure which included: I) extensive posterior decompression of L5 and S1 nerve roots plus sacral dome osteotomy. II) anterior L5/S1 discectomy. III) reduction of spondylolisthesis with pedicle screw fixation and posterior lumbar interbody fusion using interbody cages. Somatosensory and motor evoked potentials were used during the procedure. Patients were followed up for a mean of 4 years (range1–6). Sagittal balance was restored and assessed by measuring sacral slope, lumbosacral angle, pelvic incidence and pelvic tilt.

Results: The mean age at surgery was 14.7 years (range 12–17) and average duration of symptoms was 13.7 months (range6–24). Mean operative time was 6.5 hours (range 5–8), with a mean blood loss of 2242cc (range1400–4200). The mean pre-op slip angle was 57°(range 45°–100°) and the mean post-op slip angle was 37.5°(range28°–57°). Anatomical reduction was achieved in six patients and one patient with spondyloptosis was reduced to grade 2. Sagittal balance was restored in all patients. There were no permanent neurological complications. One patient with grade 4 spondylolisthesis developed transient right L5 nerve root palsy which fully recovered within 3 months.

Conclusion: The safety and efficacy of this 3 stage reduction and stabilization procedure showed that immediate reduction of high grade spondylolisthesis with minimal risk of neurological deficit is possible. The procedure is technically demanding and should be performed by spinal surgeons familiar with the principles of anterior and posterior fusion.


W D’Souza D Neen N Birch

Introduction: Europe has no equivalent of the US Food and Drug Administration (FDA). As a result, spinal implants can be adopted into clinical use in Europe earlier than in the US with a lesser regulatory burden. This may benefit patients, but if a device fails due to design changes that are not fully evaluated, outcomes can be compromised. The classic example in the past was the Capital Hip. If Europe had an equivalent to the FDA, oversight of implant design and design changes might prevent such occurrences.

The Prosthetic Disc Nucleus (PDN) is an implant designed to replace the nucleus of the lumbar disc in early stage symptomatic disc degeneration. The PDN originally was a paired device. Due to technical difficulties encountered by surgeons these were converted to a single implant (PDN Solo range). Mechanical testing suggested the new device would function as well as the original paired device. However, the implant was introduced into clinical practice, outside of the US, without any clinical evaluation.

Study Design: Prospective cohort study with 3 to 5 year clinical and radiological follow-up.

Objective of Study: To review the outcome of PDN Solo implanted anteriorly in the lumbar spine, define the mode of failure and describe revision strategies.

Patients and Methods: PDN Solo was used in 35 patients from September 2002 to January 2005 with a median follow-up of 49 months. Patients with discogenic back pain causing significant disability were offered nucleus replacement after an extensive process of consent. The approach was anterior retroperitoneal with the exception of L5/S1 which was transperitoneal. 17 patients were treated with PDN alone and 18 with a PDN to treat a degenerate level adjacent to an interbody fusion. Outcome measures were the Low Back Outcome Score and a Patient Satisfaction Evaluation.

Results: 14 patients have needed PDN revision. The mean time to failure was 16.5 months. There were three early extrusions, two replaced with PDNs and one converted to a fusion. Revision procedures included seven conversions to STALIF, two circumferential fusions and five posterolateral fusions.

Four more unrevised patients were identified as clinical failures. The total failure rate was therefore 51.4%. In patients with a successful outcome there was a 33 point improvement in the mean LBOS score.

In all cases of failure the PDN jacket became disrupted with concomitant fragmentation of the hydrogel core

Conclusions: Modification of the paired PDN to a single device was introduced outside the US without any clinical evaluation. In the US, the original PDN and the Solo version failed to gain regulatory approval and following the failure of the Solo it has been redesigned again. This study raises questions regarding implant design, testing and approval considering that more than 4500 PDN replacements have been carried out worldwide since 1996. Do these events call for a European equivalent to the FDA?


HV Dabke SMH Mehdian UK Debnath

Introduction: Correction of lumbar spine deformity in ankylosing spondylitis (AS) can be achieved by pedicle subtraction osteotomy (PSO), polysegmental osteotomy (PO) or Smith-Petersen osteotomy (SPO). We report our results with these three techniques.

Methods: 26 males and 5 females with AS and average age of 54.7 years (range 40–74 years) underwent surgery for loss of sagittal balance, horizontal gaze and back pain. 12 patients underwent PSO, 10 SPO, and 9 PO. Osteotomy was carried out at L3 in PSO and SPO with pedicle fixation from T11 to S1. 9 patients with PO had osteotomy from L2–5 and fixation from T10-S1. Sagittal translation during corrective manoeuvre was controlled in 21 patients by application of temporary malleable rods, which were substituted with permanent rods. TLSO was used post-operatively for average period of three months. Mean follow-up was 4.2 years (range 1–9 years). Radiographic and clinical outcomes (ODI, VAS, SRS-22) were analysed.

Results: Mean kyphotic correction in PSO was 380 (range 250–490), in PO was 300 (range 280–400) and in SPO was 280 (range 240–380). The sacrohorizontal angle improved by 190(range 50–300) in PSO, 210 (range 80–280) in PO and 150 (range 50–180) in SPO. Outcome scores were better in PSO and PO as compared to SPO. Blood loss and transient nerve root palsy was slightly higher in PSO group. One patient with SPO had fatal bleeding as a result of aortic injury.

Conclusions: Regular use of temporary malleable rods is recommended to prevent sagittal translation during correction reducing the risk of neurological injury. Better correction of deformity was achieved with PSO and PO at the expense of increased blood loss. SPO can increase the risk of vascular injury, therefore we recommend PSO and PO for correction of deformity in Ankylosing Spondylitis.


S M H Mehdian B J C Freeman M Woo-Kie AP Littlewood

Introduction: We report the result of cervical osteotomy in 11 patients using a controlled reduction technique and assess the safety and efficacy of this operation. Methods: Between 1993 and 2006, 11 patients with ankylosing spondylitis underwent correction of cervical kyphosis utilizing an extension osteotomy at the C7/T1 junction. The procedure was carried out under general anaesthesia with spinal cord monitoring. Lateral mass screws were placed from C3–C6 and thoracic pedicle screws placed from T2 to T5. After completion of the osteotomy, the reduction manoeuvre was carried out by the senior surgeon lifting the halo, while bilateral temporary malleable rods (fixed to cervical lateral mass screws) were allowed to pass through top loading thoracic pedicle screws, before tightening by the assistant when the desired position had been achieved. The temporary malleable rods were then replaced with definitive rods, thereby creating a solid internal fixation. A halo vest was maintained for 12 weeks to support the instrumentation and allow the fusion mass to develop.

Results: Surgery was performed on 10 males and one female. The mean age at surgery was 56 years (range 40–74). Duration of symptoms averaged 2.7 years (range 1–5 yrs). The average duration of surgery was 4.7 hours (range 3–6.5) with a mean blood loss of 1938cc (range 1000–3600). The mean follow up was 6.5 years (range 2–13). The mean pre-op chin brow vertical angle was 54º (range 20–70) reducing to 7º (range 2–20) at final follow-up. The mean pre-operative kyphotic angle was 19.2º reducing to minus 34º at final follow up. Restoration of normal forward gaze was achieved in all cases. No patient suffered spinal cord injury or permanent nerve root palsy.

Conclusion: Cervico-thoracic osteotomy is a potentially hazardous procedure. The technique described reduces the risk of translation during the reduction manoeuvre thereby reducing the risk of serious neurological injury.


P Thomas T Sattar J Nagaria C Bolger

INTRODUCTION: Atlanto-axial instability due to Rheumatoid arthritis has been treated by posterior C1/C2 wiring techniques supplemented with bone graft. Magerls technique of Transarticular fixation provides a three-point fixation by eliminating motion, promoting fusion, increased mechanical strength and treating instability. It allows fixation across the plane of movement and prevents basilar invagination.

The clinical results of transarticular fixation are satisfactory in terms of clinical outcome with few complications. However there are concerns that these patients develop subaxial kyphosis. It is important to highlight that none of these patients in our series had supplementary wiring techniques with TAS The purpose of this study is to analyse postoperative Xrays of patients who have undergone transarticular atlantoaxial fixation and look at the following parameters;

What percentage of patients develop subaxial kyphosis?

Are the ADI and PADI maintained postoperatively?

Is there a late failure rate of TAS despite the absence of supplementary wiring techniques?

MATERIALS & METHODS: 15 patients underwent pre and postoperative cervical spine X-rays in the AP and lateral projections. In addition flexion/extension views were also obtained pre and postoperatively.

We analysed the following parmeters:

Pre and Postoperative ADI and PADI.

C0/C1, C1/C2, C1/C7, C2/C7 angles

C2/C3 slip and C2/C3 osteoarthritis

Any breakage or pullout of screws.

Postoperative basilar invagination.

It is important to highlight that all these 15 patients had bony fusion at the C1/C2 joints and these findings have been analysed and published in the clinical counterpart of this study (Fusion rates 97% in 36/37 patients).

RESULTS: As highlighted, the clinical outcome of these patients has been published. We would like to present the radiological parameters of this subgroup of patients. The ADI improved in 13 patients with a preoperative median of 7 and postoperatively 3.5. The preoperative and postoperative PADI remained at 15. The C0/C1 angle changed from 12 to 17 postoperatively. The C2/C7 angle changed from 21 to 26 postoperatively. C1/C7 angle changed from 39 to 41. The spinal cord diameter remained at 15 pre and postoperatively.

There was only 1 patient with C2/C3 slip on flexion/extension views. 2 patients developed subaxial kyphosis with evidence of significant disc degeneration on preoperative imaging.

There are some interesting conclusions from these 15 xrays.

Only 2 out of 13 patients have developed a subaxial kyphosis.

The 2 patients that have developed subaxial kyphois had subaxial disc degeneration at the level of the kyphois

There was only 1 patient with a C2/C3 spondylolisthesis on flexion/extension.

The ADI and SAC were maintained at the craniocervical junction.

There is no late failure rate despite the absence of a modified gallie fusion


UK Debnath HV Dabke A Shoakazemi SMH Mehdian JK Webb

Introduction: We have compared the results of pedicle screw (PS) construct only with a hybrid sublaminar wire and pedicle screw construct (HS) in a matched cohort of CP patients, to establish which technique is superior in view of deformity correction and its maintenance.

Methods: 22 male and 14 female CP patients with average age of 16 years (range 8–25 years) underwent surgical correction for spinal deformity. Indications for surgery included loss of sitting balance, progression of spinal deformity, pelvic obliquity and back pain. Group 1 (18 patients) had PS construct only and Group 2 (18 patients) had HS constructs. 32 patients (90%) required sacral fixation. 5 patients in Group 2 required anterior release. All patients had a minimum follow-up of 2 years (range 2–13 years). Clinical and radiographic analyses were performed in both groups.

Results: Mean Cobb angle in Group 1 improved from 650 (range 120–950) to 18.50 (range 0–280) and in Group 2 from 77.60 (range 400–1050) to 34.80 (range 100–620) [p < 0.05]. Mean pelvic obliquity in Group 1 improved from 14.30 (range 00–420) to 2.50 (range 00–50) and in Group 2 from 24.70 (100–510) to 9.70 (range 20–180) [p< 0.05]. Mean surgical time in Group 1 was 224 minutes as compared to 260 minutes in Group 2 [P< 0.05]. 6 patients in Group 2 had proximal junctional kyphosis and implant failure requiring revision. One patient in each group had infection treated with antibiotic therapy.

Conclusions: PS fixation in CP patients, allowed significant correction of large curves without anterior release, eliminated proximal junctional kyphosis and instrumentation failure. Correction of pelvic obliquity was also superior due to three-dimensional corrective force of pedicle screws. Although PS fixation is expensive and technically demanding, it outweighs the costs incurred by two-stage surgery because of its superior durability correction.


UK Debnath A Shoakazami SMH Mehdian HV Dabke BJC Freeman JK Webb

Introduction: Historically segmental sublaminar wiring (SLW) fixation has been used for the correction of spinal deformity in neuromuscular scoliosis, however pedicle screw (PS) fixation is gaining popularity. We compared the results of both techniques in patients with Duchenne Muscular Dystrophy (DMD).

Methods: Two groups of patients with DMD were matched according to the age at surgery, magnitude of deformity and vital capacity. Indications for surgery included loss of sitting balance, rapid decline of vital capacity and curve progression. In Group 1 (22 patients) SLW fixation was used from T2 to S1 with the Galveston technique. In Group 2 (18 patients) PS fixation was used from T2 to L5. Minimum follow-up was 2 years (range 2–13 years). Radiographs, SRS-22 and lung function tests were performed at standardised intervals.

Results: Mean Cobb angle in Group 1 improved from 47° (range 26°–75°) to 23.5° (range10°–36°) and mean pelvic obliquity improved from 15° (range8°–25°) to 2.4° (range0°–8°). Mean Cobb angle in Group 2 improved from 46° (range28°–82°) to 8.5° (range 0°–18°) and mean pelvic obliquity improved from 15° (range7°–30°) to 1.1° (range 0°–6°) [p< 0.05]. Mean operating time and blood loss were less in Group 2 [p< 0.05]. In Group 1, the infection rate and instrumentation failure was higher, and SRS-22 outcomes showed no significant difference between the groups. Interestingly the mean Body Mass Index (BMI) in Group 2 was much higher than group 1.

Conclusions: PS fixation resulted in superior correction and controlled pelvic obliquity to a large extent without the need for pelvic fixation. Lower rates of infection and failure of instrumentation were noted with PS fixation, despite high BMI of patients presumably due to steroid therapy. We recommend the use of PS instrumentation for the correction of spinal deformity in DMD.


HN Simms M Strauss WAS Taylor C Santosh E Teasdale

Background: When treatment of a spinal arterio venous fistula (SAVF) is anticipated, precise location of the level and side of the feeding artery are necessary. Digital subtraction angiography (DSA) is the reference standard for imaging SAVFs. Non-invasive vascular imaging by multidetector computed tomographic angiography (MDCTA) and magnetic resonance angiography (MRA) are newer imaging modalities, which are able to demonstrate these lesions.

Objectives: We performed a retrospective analysis of patients with SAVF in our unit to examine the accuracy of MDCTA and MRA compared with DSA and intraoperative findings to illustrate how non-invasive angiography affects treatment.

Results: Between 2001 and 2007, we identified 22 consecutive patients with SAVF. 20 patients had CTA, identifying the site of SAVF in 19. In all of the 11 patients who had MDCTA, the site was correct and confirmed at surgery.

16 patients had MRA, confirming the SAVF in all cases and correct site in 12.

DSA failed to demonstrate the abnormality in one patient.

Treatment: 5 patients have had no treatment. 3 patients were treated by embolisation, with one patient developing a persistent neurological deficit. 14 patients had primary surgical repair with confirmation of the angiographic lesion. In those cases where pre-operative MDCTA was performed, volume rendered spinal reconstructions aided the operative localisation.

Conclusion: Non-invasive angiography for the diagnosis of SAVF is safe and accurate. MDCTA aids operative localisation and DSA should be reserved for patients with inconclusive non-invasive angiography or when identification of the artery of Adamkiewicz is required prior to embolisation.


R Gangone P Lakkireddi V Prasad Kotrba G Marsh

Aim: To assess the outcome of patients with chronic discogenic lumbar back pain who underwent intradiscal electro thermal therapy (IDET).

Design: A prospective longitudinal study

Subjects: Patients undergoing IDET in our unit between April 2000 and October 2007 were included in the study after assessment with discography and diagnostic imaging. Discographic concordant symptoms with subsequent abolition with local anaesthetic led to inclusion in the study regardless of discogram volume.

Outcome Measures: Subjects were assessed preoperatively with VAS pain scores, SF36, demographic data and pain diagrams. Then were then reassessed postoperatively with the, VAS pain scores SF36, employment status and subjective outcome at 6, and 12 months.

Results: 83 patients were treated with IDET. We had a follow up rate of 75% leaving a cohort of 65 patients. Mean follow up 7.6 months.

Overall there was a mean improvement in pain VAS scores of 1.9 (p=0.0875).

SF36 scores showed minimal improvement in both physical and mental parameters and there was minimal improvement in subjective outcome in 55% of patients.

However it was observed that a small subgroup of patients (30%) aged less than 40 with low volume positive discography and single level disease mean pain VAS scores improved by 3.78 from 7.52 to 3.74. 72% of these patients reported a subjective improvement in symptoms and SF36 scores improved significantly compared to the overall group.

Further analysis also revealed that the use of pain diagrams when interpreted according to the principles of Mann et al was the predictive value.

Conclusions: Patient selection seems to be crucial in determining a successful outcome using IDET. We still perform this procedure on those patients aged less than 40 with single level disease, positive low volume discography, no facet joint arthritis and an organic pre procedure pain diagram.


R Gangone P Lakkireddi MR Kotrba G Marsh

Background: A common problem achieving lumbar spinal fusion is developing a pseudarthrosis. The current gold standard in achieving fusion is the use of autograft from pelvis or posterior elements of the spine. However the potential limitations of insufficient quantity and donor site morbidity have led to the use of bone graft alternatives such as DBM which contains osteoinductive BMPs.

Aims & Methods: A prospective randomized control trial comparing the effectiveness of Demineralised Bone Matrix (DBM Putty)/autograft composite with autograft in lumbar postero-lateral or 270 degree spinal fusion.

35 patients were required for the study. They were randomized to have DBM and autograft on one side of the posterior approach and autograft alone on other side of the same approach. Patients were followed up with interval radiographs for total of 24mons. To date 32 patients have been recruited and with an average follow up a15.3 months. The mineralization of fusion mass lateral to the instrumentation on each side was graded as Absent, Mild (< 50%), Moderate (> 50%) or Complete fusion (100%). The assessment was made by independent orthopaedic consultant and a musculoskeletal radiologist who were blinded to graft assignment.

Results: The sex distribution was 17:15 male to females with a mean age of 55.2 (21–87years) and an average follow up of 15.3mons (3–24mons). 50% of patients had single level fusion and the remainder had more than one level fusion. At 12months, on the side of DBM 28% had complete fusion, 65% had moderate fusion, and 7% had no fusion mass. During the same period on the other side (non DBM side) approx 25% did not show any sign of fusion. There was no correlation with number of levels, age or sex.

Conclusions: Osteoinductive properties of DBM would appear to enhance the consolidation of the lumbar spinal fusion. DBM reduces the amount of harvested autograft graft and also minimises the morbidity of donor site complications.


P Sell

Aim: To compare the outcomes and complications of an interspinous distraction device and decompression for single level spinal stenosis in the lumbar spine

Study type: Prospective comparative cohort audit of a new procedure.

Method: Prospective data was gathered on two cohorts of consecutive patients undergoing surgery for single level symptomatic lumbar spinal stenosis. The cohorts were matched for age, level of surgery and follow up. The X-Stop interspinous distraction device was compared to a standard non instrumented decompression.

There were 36 patients, 18 patients in each group, average age 66, average follow up 8 months. There was no commercial support or funding of any sort. Outcome measures were the Oswestry Disability Index (ODI), visual analogue for pain (VAS), and self perceived walking distance in yards. N.I.C.E. guidance IPG 165 was given to all interspinous distraction device patients.

Results: Pre op patient assessed walking distance in the lumbar decompression group was 152 yards; there was a 6-fold improvement to 925 yards. The interspinous distraction device had a 7 fold improvement on average, from 181 yards to 1313 yards. The improvement in ODI was most marked in the decompression group, pre surgery 61%, post surgery 29%. The interspinous group improved from 45% to 32%.

This was a clinically significant and statistically significant difference P=0.002 in favour of simple decompression. The VAS was 7.88 improving to 3.05 in the decompression group, whereas the interspinous distraction group the change was from 7.3 to 4. Complications were 3 spinous process fractures and one late migration of implant in the distraction group. There were 2 incidental durotomies and one epidural bleed greater than a litre in the decompression group. Six of the interspinous distraction devices already demonstrate lucent zones around the implant at post op follow up the significance of which is not clear.

Conclusion: There is a clinical and statistical significant difference in favour of the established procedure of lumbar decompression in terms of improvement in Oswestry Disability Index in this study. Caution with, and scrutiny of new implants and procedures is an essential component of clinical judgement and governance.


Malcolm Nicol Yu Sun Niall Craig Douglas Wardlaw

Introduction: Deep Venous Thrombosis (DVT) and pulmonary embolism (PE) cause significant morbidity and mortality in orthopaedic surgical practice, although the incidence following surgery to the lumbosacral spine is less than following lower limb surgery. Our objective was to compare our rate of thromboembolic complications with those published elsewhere and investigate whether the adoption of additional pharmacological and physical measures had reduced the incidence of clinically evident deep venous thrombosis (DVT) and pulmonary embolism (PE).

Materials and Method: This study was undertaken to investigate the incidence of DVT/PE during the 10 years from 1/1/1985 to 31/12/1994, and then to assess the effectiveness of an anticoagulant policy introduced during 1995 using low dose aspirin or LMH in high risk cases. All records for spinal operations were reviewed for thromboembolic complications by reference to the Scottish Morbidity Record form SMR1. To ensure that all patients were compliant with the policy, data for the whole of 1995 was omitted and the period 1/1/1996 to 31/12/2003 was taken to assess its effectiveness.

Surgery was done with the patient in the kneeling, seated prone position which leaves the abdomen free and avoids venous kinking in the legs.

Results: Records of a total of 1111 lumbar spine operations were performed from 1/1/1985 to 31/12/2004 were reviewed. The overall incidence of thromboembolic complications was 0.29%. A total of 697 operations were performed from 1/1/1985 to 311994 with two cases of DVT and no cases of PE giving thromboembolic complication rate of 0.29%. During the period 1/1/1996 to 31/12/2003, 414 operations resulted in one case of DVT and no cases of PE, a rate 0f 0.24%.

Conclusion: The incidence of thromboembolic complications is low whether or not anticoagulation is used. We believe that the kneeling, seated prone operating position is a significant contributing factor.


AD Tambe S Sharma G White N Chiverton AA Cole

Introduction: Metastatic spinal disease continues to be a challenge in the management of patients with advanced malignancy. Anterior en bloc spondylectomy and stabilisation, a more extensive procedure, is favoured as it is thought to provide a curative resection and improve the overall outcome (Tomita et al,2002; Wiegel, 1999).

Aim: The aim of this study was to see if there is still a role for extensive posterior decompression (Wide laminectomy and transpedicular decompression) with stabilisation in the treatment of these patients which is the mode of treatment used in our institution and favoured by some others (Bauer, 1997)

Patients and Methods: We retrospectively reviewed a cohort of patients treated in our institute by extensive posterior decompression and stabilisation between 2000 to 2006. We excluded patients having haematological primaries and anterior surgery and those with inadequate data.

Outcome measures used were post operative mortality, Post operative improvement in Frankel score, level of pain perception, level of mobility and ability to perform activities of daily living.

Results: 52 patients had posterior surgery with Colarado instrumentation being used in a majority. There was a slight male preponderance with an average age of 67 years. The mean length of follow up was 12 months.57% patients were dead at last review. 52 % patients showed an improvement in Frankel scores. There was a significant decrease in analgesic requirement post operatively with an improvement in pain scores. Similarly there was an improvement in the ability to perform activities of daily living and the level of mobility. No major surgical complications were noted bar a few superficial wound infections. Revision surgery was done in 6 cases. In 2 it was for a tumour recurrence, for broken rods in 2 and converted to anterior in 2. There were 4 immediate peri operative deaths.

Conclusion: Our results are comparable to Bauer et al, 1997 and other series. Posterior spinal surgery is very much a viable treatment option to treat selected cases with metastatic spinal disease. It avoids all the complications and morbidity of anterior surgery while producing an overall improvement in pain, the quality of life, level of mobility and neurological status.


C Critchley V White J Moore-Gillon A Sivaraman C Natali

Introduction: Tuberculosis (TB) continues to cause a significant burden of disease in the United Kingdom (UK). A total of 8113 cases were diagnosed in England, Wales and Northern Ireland in 2005, demonstrating a 28% increase since 2000. The incidence of TB in London is four times greater than the national average, with 43% of cases of TB in 2005 being identified in the capital (n= 3,479). 47% of TB cases in the UK have extra pulmonary involvement and 2–3% of all cases of TB involve the spine (n= 107)

Methods: We reviewed 109 patients treated for spinal TB in East London, UK, between 1997–2006. 59 were male and 50 were female. Their mean age was 39 (range 4–89). 63 patients were Asian (3 UK born), 30 African, 8 UK born Caucasian, 4 Caribbean (1 UK born), 3 patients from Eastern Europe and 1 from the Middle East. Of those patients born outside the UK, the mean time they had been in the country pre diagnosis was 9.6 years (range 0–50 years). They were followed up for a minimum of 1 year post completion of treatment (range 14 to 48 months).

95% of patients presented with back pain, with or without neurological compromise.

All patients were imaged with MRI or CT. 90 (86%) patients had microbiological and/or histological confirmation of TB. The majority of patients (52%) had two vertebral levels affected. The Thorocolumbar junction was the area most commonly affected. 4% of patients had paravertebral abscesses with no bony involvement seen on imaging. 29 patients (26%) had associated psoas abscess.

Combination chemotherapy, according to NICE guidelines, was the main modality of treatment. 67 (61%) patients were managed with combination chemotherapy alone. Surgery was performed for certain indications: deteriorating neurology, instability and post tubercular kyphosis. 42(39%) of patients required surgery.

Results: There were no deaths related to TB or our intervention. Most patients had a full neurological recovery but 21 patients (19%) suffered permanent neurological deficit. (4%) suffered permanent paraplegia or paraparesis severe enough to prevent walking.(out of this anybody had surgery and if so how delayed was that) There was a high incidence of persistent chronic back pain (62%) in our group of patients and was not related to any deformity.

Conclusion: Medical management is the mainstay of treatment for spinal TB, but there are certain instances where surgical intervention will be required.

Because of the high incidence of spinal TB in East London and in order to standardise treatment of these patients we set up dedicated multidisciplinary spinal TB clinic and are managed jointly by respiratory and orthopaedic teams.


M A J Boswell CG Greenough

Introduction: Surgical Site Infection (SSI) in spinal surgery at the James Cook University Hospital was investigated and compared with the published rates of 1–12%. Variables of instrumentation, laminar air flow, duration of operation, and blood units transfused in the first 48 hours were examined.

Methods: 556 spinal operations were carried out in 2005–6. 147 of these involved the use of instrumentation. Infections were defined as positive wound or blood cultures. The duration of surgery, presence of laminar air flow and units of blood transfused were recorded. Statistical analysis was performed using the Fisher’s Exact Test.

Results: Nine cases of SSI were identified in the 147 instrumented spinal operations in comparison to Zero in the 409 non-instrumented patients (p < 0.0001)

The mean duration of instrumented surgery was 4 hours 19mins. The infection rates for operation duration < 5 h versus operation duration > 5 h (3/96 Vs 6/51) were not statistically significant (p = 0.065)

Of the 147 instrumented spinal operations, 8 of 117 operations performed in a laminar air flow system and 1 of 30 performed without laminar air flow were infected (p = 0.69)

Infection rates for those patients transfused < 2 units (4/85) were not significantly different to those in patients transfused > 2 units (5/62), p = 0.49.

Conclusion: The rate of SSI at the James Cook University Hospital in instrumented spinal surgery was 6%.

SSI in spinal surgery was heavily influenced by instrumentation, but was not reduced by laminar airflow. Duration of operation and number of units of blood transfused were not significant factors.


G Swamy L De Loughery R Bommireddy Z Klezl D Calthorpe

Background: The management of radicular pain due to lumbar or sacral nerve root compromise remains controversial.

Caudal epidural steroid injections are widely employed although there is little hard evidence to confirm their efficacy. This empirical treatment still remains a matter of personal choice and experience.

Objectives: To investigate the clinical effectiveness of caudal epidural steroid injections (CESIs) in the treatment of sciatica and to identify potential predictors (clinical subgroups) of response to CESIs.

Main outcome measures: The primary outcome measure was the Oswestry Disability Questionnaire (ODQ). The Visual analogue score (VAS) and the Hospital Anxiety and Depression Scores (HADS) were also employed in all cases to measure pain relief, physical and psychological function.

Method: Prospective study. All patients with corresponding radicular pain received a course of three caudal epidural steroid injections, two weeks apart.

A standard mixture of 80 mgs of triamcinalone plus 7 mls of 1% lignocaine plus 5 mls of 0.9% saline used for all patients.

All patients reviewed at 3 months interval in a dedicated epidural follow up clinic.

The epidural database included age, BMI, duration of symptoms, smoking, employment status and source of referral, any pending litigation, i.e., work or accident related, MRI results, diagnosis and complications.

VAS scores documented both axial and limb pain for actual and comparative analysis. ODI and HADS were recorded prior to treatment and at three months follow up.

Overall patient satisfaction was recorded on a scale of 0–10 and complications noted.

Results: In the largest single series to date, we report on 628 consecutive patients, with 3 months follow up.

58 % were females, 24% smoked and 4.1% had ongoing litigation due to their pain.

The mean age was 56yrs with BMI ranging from 17 to 50 (mean=28).

7 (1%) patients required subsequent surgical intervention due to disc herniation.

BMI did not affect the outcome.

Mean VAS for axial pain reduced from 5.859 to 2.59 at three months.

Mean VAS for limb pain similarily reduced from 6.23 to 2.53.

Mean ODI reduced from 45.49 at first visit to 21.98 at 3 months.

Mean HADS also improved from 17 to 7.

Following treatment, overall Patient satisfaction ranged from 0–10 with mean of 5.4.

Conclusion: Significant improvement in both axial and limb pain in the short and intermediate terms was achieved facilitating onward referral for physical therapy, which is fundamental in optimising outcomes.

Long term follow-up is underway.

Subgroups predicting poor outcome are identified.

Positive primary care feedback encourages further recruitment.


AR Guha A Khurana N Saxena S Pugh A Jones J Howes PR Davies S Ahuja

Introduction: Scoliosis surgery involves major blood loss, at times exceeding estimated blood volume.

Aim: To evaluate the effects of implementing blood conservation strategies (including cell salvage, controlled hypotension and anti-fibrinolytic drugs) on transfusion requirements in adult patients undergoing scoliosis correction surgery. To establish a protocol for cross matching of blood.

Study Design: We retrospectively studied 50 consecutive adult patients who underwent scoliosis correction surgery (anterior, posterior or combined) between 2003 and 2007. All patients were anaesthetised by the same anaesthetist who implemented a standard transfusion protocol. Age, BMI, pre and post operative haemoglobin, levels fused, duration of surgery, hospital stay, antifibrinolytics used and blood transfused was noted.

Results: 50 patients with mean age 24.6 years and mean BMI 21.9 kg/m2 were studied. 14 patients had anterior surgery, 19 patients had posterior surgery and 17 had combined anterior and posterior procedures. Mean number of levels fused was 9.5 (6–15) and mean duration of surgery was 284.6 minutes (135–550 minutes). Anti-fibrinolytics were used in 31 patients (62%), Aprotinin in 21(42%) and Tranexamic acid in 10(20%). Mean blood loss in patients who received anti fibrinolytics was 530mls while mean blood loss in the other patients was 672mls. (p< 0.05). Blood transfusion was not required in any of the patients undergoing anterior correction only while 7 patients (41%) undergoing anterior and posterior correction and 3 patients (15.8%) undergoing posterior correction only required blood transfusion. Mean volume of cell saved blood re-transfused was 693.8 mls and mean hospital stay was 9.2 days. Mean pre-op haemoglobin was 13.2 g/dl (10.4–17.4) and mean post-op haemoglobin was 10.7 g/dl (7.7–15). 4 patients (8%) required intra and post-operative blood transfusion while 6 patients (12%) required blood transfusion postoperatively.

Conclusion: Use of anti-fibrinolytics like Aprotinin and Tranexamic acid reduces blood loss in scoliosis surgery. In the current scenario, with Aprotinin no longer available for use, our study would recommend the use of Tranexamic acid alongwith other blood conservation measures.

In our unit we do not have blood cross matched for anterior surgery alone.


JS Mehta IB Paul K Hammer A Jones J Howes PR Davies S Ahuja

Background: Radicular pain has been reported even in the absence of a compressive lesion. It has been postulated that annular tears provide a conduit for pro-inflammatory substances, which can leak around the nerve root causing radiculitis. A link between the side of back pain and the side of the annular tear has been reported.

Objective: To establish whether the side of the annular tear may influence the side of the leg in a non-compressive setting.

Methods and patients: We identified 121 patients from the patients referred to our unit with back and radicular leg pain. The mean age of the cohort was 50 yrs and 49% were male. All these patients were investigated with an MRI scan that demonstrated no compression of the nerve root. We used strict exclusion criteria to exclude the patients with any neural compression, previous lumbar operation, degenerative deformity or an associated pathology such as peripheral neuropathy.

Results: The annular pathology was described as annular tears (47 patients) and non compressive disc bulges (106 patients). The odds ratio for the concurrence of an annular tear causing ipsilateral leg pain is 1.05 and for a non-compressive disc bulge causing ipsilateral leg pain is 2.14

Conclusion: A non-compressive disc bulge is more likey to cause radicular symptoms than an annular tear. Though, both these annular lesions can cause ipsilateral nerve root symptoms.


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Andrew Quaile

This is a preliminary retrospective report on a novel technique for achieving fusion at the lumbo-sacral disc. Current methods of complete discectomy and instrumented fusion involve either a posterior approach and the insertion of cages or an anterior approach. Both methods involve quite extensive dissections with potential stabilising muscle stripping. They also require significant post operative analgesia, inpatient stay and post operative recovery. There are attendant risks of nerve injury, blood loss and thrombosis.

A novel method of approach from the sacrum via a ‘safe zone’, described by Yuan et al., is presented. The technique along with the anatomical considerations is described. The operation basically consists of a posterior sacrococcygeal incision and an x-ray guided approach to the anterior surface of the S1/S2 junction with blunt obturators. The L5/S1 disc is then accessed by drilling through the sacrum. The disc is then removed from within with shaped tools leaving the bulk of the annulus. The void created is filled with bone graft and the L5 vertebra fixed to the sacrum via a bolt. The initial results of the first 20 patients are presented. 21 patients have been operated upon but one has been lost to follow up due to a psychological disorder. That patients details have been excluded.

The patients underwent surgery between 4/7/06 and 8/10/07. All operative procedures were completed without complication, the operative time improving from 60 minutes to a ‘standard’ 45 minutes. There were no post operative complications. Two patients underwent additional procedures. One was an L4/5 Wallis ligament the other an inter-transverse non instrumented fusion. Several patients required a further pain control procedure, 3 caudal epidurals, 2 facet blocks and 2 coccyx injections. One patient required an L4/5 PLIF 12 months after the first procedure and two patients required posterior stabilisation at the same level. One after 4 months the other at 18 months.

The indications for surgery are the same as for a standard fusion procedure. In this group there were 12 degenerative discs with mechanical LBP, 3 spondylolistheses, 2 previous failed posterior fusions and 3 post discectomy patients. Discography was used for confirmation of the pain source in 15 cases. The duration of symptoms ranged between 2–15 years with a mean of 6.25. There were 12 male and 8 female patients. The age ranged between 34–70 with a mean of 47. The female mean being 48 and the male 46.

The Oswestry disability index showed a mean of 47 pre-operation and 23 post-operation. 13 out of 20 have been discharged with symptoms resolved or easily bearable. The hospital stay varied between 1 night and 4 nights with a mean of 3.3.

This novel approach to the lumbar spine gives rapid and safe access to the lumbar disc space despite the unusual approach for spinal surgeons. Once the initial incision is made the procedure is carried out under x-ray control using techniques which are very familiar to Orthopaedic surgeons. The lack of intra-operative problems and post-operative complications testify to a safe procedure.

The question mark remains on the rate of fusion. Two patients and potentially a third required a secondary posterior instrumented fusion. One was due to demonstrable loosening of the bolt and the other two continued pain possibly due to inadequate stabilisation. In my view, despite the European teaching, posterior instrumentation is desirable. This can be achieved via a percutaneous technique.


A Manoj-Thomas M Nikos IB Paul DA Jones

Aim: To determine the clinical improvement and the radiological time to fusion as well as correction of the lordosis angle in patients undergoing anterior cervical interbody fusion with the use of a silicate substituted calcium phosphate ceramic (Si-CaP) (Actifuse™ Synthetic Bone Graft, ApaTech, Ltd., Elstree, UK) as the bone graft substitute in the cage.

Design: We conducted a prospective clinical and radiological study to evaluate the use of Si-CaP as bone graft substitute in anterior cervical fusion for degenerative cervical spondylosis.

Materials and methods: Thirty patients were selected prospectively by preoperative and postoperative clinical and radiological assessments. All patients were operated on by a single surgeon (D.A.J.). Neck disability index and visual analogue score were used for the clinical assessment. Radiological assessment included improvement in the lordosis angle and time to fusion. Patients were evaluated at three months, six months and one year post-surgery.

Results: At present 14 patients with a total of 19 levels have completed their one year follow-up. The patients had an average of 50.4 years (range 34–69), with ratio of male to female of 6:7. Lordosis angle improved significantly from a mean lordosis angle of 0.31 preoperatively to 4.75 degree postoperatively (p< 0.05). All the levels had fused at the 1 year follow up and there was no radiological evidence of sinkage of the cage.

Conclusion: Substitution of silicate ions into calcium phosphate ceramics has been shown to impart a negative surface charge, leading to greater protein absorption, increased osteoblast proliferation, and higher production of extracellular matrix. Our results show that Si-CaP has excellent clinical performance as a synthetic bone graft in anterior cervical discectomy and fusion. Postoperatively, patients demonstrate a good fusion with an excellent correction and maintenance of the lordosis angle.


G Swamy S Gangopadhyay J Khan D Calthorpe

Background: Pyogenic haematogenous spinal infection in the elderly, described as spondylodiscitis, vertebral osteomyelitis and epidural abscess is still considered a rare but life threatening condition.

Objective: To test our hypothesis that low index of suspicion leads to delayed diagnosis.

Late referral for definitive treatment may result in increased and perhaps avoidable medical morbidity, social and psychological drift, including early mortality.

Method: Retrospective review of medical records over 10-year period.

Patient pool obtained from theatre records, radiology and coding departments.

Post-spinal operative infections and patients under 65 years old excluded.

Initial presentation, admitting speciality, initial investigations and differential diagnosis, time to diagnosis, date and day of referral, mode of definitive treatment, pathologic entities, complications and outcomes were noted.

Patient outcomes were measured as duration of treatment, length of hospital stay, complications, ambulatory status, complications, discharge destination and death.

Outcomes were correlated with delayed diagnosis and referral.

Results: Single largest series [n=46] of elderly [age> 65] patients with pyogenic spinal infections to our knowledge.

Age ranged from 65–91 with mean of 71.

62% referral from Physician colleagues.

Fever with malaise associated with chronic LBP was the commonest presenting complaint.

34 patients had discitis and 12 had epidural abscess.

Time to diagnosis ranged from 2–17 days with mean of 8 days. Mean referral time to spinal team was 9 days with 39% referrals on Friday.

Duration of hospital ranged from two weeks to three months.

46% required surgical decompression with four cases of related mortality during acute hospital stay.

Conclusions: Time duration to Spinal referral had direct correlation with increase in morbidity, social and psychological drift, and mortality.

The incidence of haematogenous spinal infection in the elderly has increased over the years in our series, contrary to popular belief.

A high index of suspicion in elderly patients with PUO promotes early diagnosis and optimises outcome.


Appaji Krishnan Karunagaran Sajan Hegde

Introduction: Pseudoarthrosis in Ankylosing spondylitis is often misdiagnosed as infection. It is a slow progressing lesion resulting in a kyphosis and slow onset weakness of the lower limbs. We are presenting our strategy and experience in treating 9 patients with such a lesion.

Method: 9 patients age range from 40–55 years who presented with pseudoarthrosis of the ankylosed spine underwent back-front surgery during 2001–204. 6 patients had dorsal spine lesion, 2 had dorso-lumbar junctional lesion and 1 had cervico-dorsal junctional lesion. 8/9 patients had insidious onset with progressive weakness of both lower limb. 1 patient had an acute onset with deformity. 7/9 patients had neurodeficit (Frankel C) 1/9 had complete paraplegia. All patients underwent posterior kyphosis correction and decompression of the spinal cord. During posterior decompression 8/9 patients had an incidental dural tear due to adherence fractured lamina. The dura was repaired primarily or patch graft. 5/9 patients had single stage back and front surgery. The rest of the patients had staged surgery. The front surgery was excision of the tough fibrotic psuedoarthosis and reconstruction using strut graft/cage.

Results: Average duration of surgery was 4 ½ hours (3 ½ to 6 hours). Blood loss was 800 ml (600–1300 ml). All patients required blood transfusion. Primary dural repair was done in 7/8 cases, patch graft in 3/8 cases, ceiling with fusion glue and fat graft in 1 patient. 5 patients who had less that 1000 ml blood loss during posterior surgery had same stage anterior reconstruction. Rest of the patient had 2 staged surgery. 4/9 patients had previous THR B/L. All patients showed rapid improvement in the neurological status and at 3 months follow up all were Frankel E.

Conclusion: The surgical outcome of the ankylosing spondylitis patients with Andersson lesion with neurological deficit is encouraging. Excision of the pseudoarthroses anteriorly and posterior spinal stabilization resulted in full recovery of the deficit. However there were difficulties encountered during the posterior decompression due to adhesions of the posterior elements to the dura.


F. Berryman P. Pynsent J. Fairbank

Background: Scoliotic deformity has been traditionally measured by Cobb angle using radiography. This parameter gives a measure of the lateral curve in the spine in the coronal plane. However, patients are often more concerned about their rib humps or other volumetric asymmetries in the surface of their backs. There is often little relation between Cobb angle and the magnitude of the asymmetry. A method of quantifying volumetric deformity, especially if it requires no radiation, would therefore be useful for spinal surgeons and patients alike.

Methods: The three dimensional shape of the back is measured using structured light and digital photography with ISIS2, a non-commercial surface topography system. Markers are placed on bony landmarks so that the surface can be related to body axes. A zero plane is defined through the sacrum and the vertebra prominens, parallel to the line between the markers on the dimples of Venus. A curve is fitted through the markers on the spinous processes on the measured surface and is used as the line of symmetry. The difference in the areas between the surface and the zero plane on each side of the symmetry line is then calculated for each horizontal (transverse) section. The left and right volumetric asymmetry parameters are then calculated by summing the area differences on each side and normalising for back length. These parameters range from zero for a perfect straight back with no transverse asymmetry to over 70 for extreme transverse asymmetry. The variability in these parameters was investigated using pairs of photographs of 59 patients. Two photographs were taken with the patient walking around the room between them. Left and right volumetric asymmetry was then calculated for each measurement and Bland-Altman analysis was carried out.

Results: The mean difference between pairs of measurements was −0.10, the standard deviation was 2.03 and the 95% tolerance limits covering 95% of the population were −4.8 to 4.6 for left volumetric asymmetry; the mean difference was 0.46, standard deviation was 3.13 and the 95% tolerance limits covering 95% of the population were −6.8 to 7.7 for right volumetric asymmetry. There was no evidence of bias from the Bland-Altman plots.

Conclusions: The variability in the volumetric asymmetry was low in comparison to the levels found for subjectively classified ‘moderate’ deformity. Change in degree of volumetric deformity can be monitored by ISIS2 volumetric asymmetry.


P Baker R M Kilshaw R Gardner S Charosky I J Harding

Introduction: The incidence of degenerative scoliosis in the lumbar spine is not known. In the ageing population deformity may coexist or cause stenosis. MRI gives limited information on this important parameter and is often the only investigation used pre-operatively in the treatment of stenosis. The aim of this study was to highlight the incidence of coronal abnormalities of the lumbar spine dependent on age in a large population of patients requiring abdominal and KUB radiographs at our institution.

Method: We reviewed all abdominal and KUB radiographs performed in our hospital in the first ten months from the introduction of our digital PACS system. 2276 radiographs were analysed for the incidence of degenerative lumbar scoliosis and lateral vertebral slips in patients who are ≥ 20 years old, in ten-year age ranges. Evidence of osteoarthritis of the spine was also documented. Radiographs were included if the inferior border of T12 to the superior border of S1 was visualised and no previous spinal surgery was evident (metal work/laminectomy).

Results: 2233 (98%) radiographs were analysed. 48% of patients were female. The youngest patient was 20 and the oldest 101 years. The incidence of degenerative lumbar scoliosis, lateral listhesis and osteoarthritis increased with age.

In all age groups curves were more frequent and had greater average Cobb angles in female patients except in the 30–39 year olds–where the males equalled females in frequency and had the greatest Cobb angles.

Conclusions: Degenerative lumbar scoliosis starts to appear in the third decade of life and increases in frequency every decade thereafter, affecting almost a third of patients in the ninth decade. It is more common in female patients and has a greater magnitude. Deformity may be even greater on standing views and is important to recognise in all patients that are undergoing lumbar spinal decompressive surgery. A failure to do so may lead to inferior results or the need for further surgery.


E Garrido HNN Noordeen SK Tucker

Study Design: Retrospective study with clinical and radiological evaluation of 15 patients with congenital kyphosis or kyphoscoliosis who underwent anterior instrumented spinal fusion for posterolateral or posterior hemivertebae (HV).

Objective: To evaluate the safety and efficacy of early surgical anterior instrumented fusion with partial preservation of the HV in the treatment of progressive congenital kyphosis in children below the age of 3. We discuss the management of patients presenting with neurological compromise.

Summary of background data: A variety of treatments have been described in the literature for the treatment of congenital kyphosis due to HV. We report the results of our technique.

Materials and Methods: Between 1997 and 2005 we have treated 15 consecutive patients with progressive congenital kyphosis with anterior instrumented fusion and strut grafting. 13 patients had a single posterolateral HV and 2 patients a single posterior HV. Of the 15 patients in the study, 5 were girls and 10 boys. Mean age at surgery was 22 months (range 8–33). Mean follow-up period was 6.8 years. 13 HV were located in the thoracolumbar junction (T10-L2) and 2 in the thoracic spine.

Results: The average operating time was procedure was 150 minutes (range, 130 to 210 minutes). The average blood loss 180 mL (range, 100 to 330 mL), equivalent to a mean external blood volume loss of 15% (range, 11 to 24%).

Preoperative segmental Cobb angle averaging 34 º at last follow up. Compensatory coronal cranial and caudal curves corrected by 50%. The angle of segmental kyphosis averaged 39º (range, 20º to 80º) before surgery and 21 º (range, 11º to 40º) at last follow up. This represents a 43% of improvement of the segmental kyphosis, and a 64% of improvement of the segmental scoliosis at last followup.

One case with initial kyphosis of 80 º continued to progress and required revision anterior and posterior surgery. There were no neurologic complications.

Key points:

In progressive congenital kyphoisis, early diagnosis and aggressive surgical treatment are mandatory for a successful result.

Early treatment minimizes the risks of surgery.

Anatomical and physiological pitfalls in the treatment of congenital kyphosis are discussed.

Anterior instrumented fusion of congenital kyphosis provides sagital and coronal correction in very young children with low risk of complications.


Ken-jin Tan Maung Maung Moe Rose Vaithinathan Hee-Kit Wong

Introduction: The natural history of idiopathic scoliosis is not well understood. Previous reports focused on characteristics of curve progression pre-defined at 5–6 degrees. However, the absolute curve magnitude at skeletal maturity is more predictive of long-term curve behavior rather than progression of defined magnitude over shorter periods of growth. It is generally agreed that curves < 30 degrees are unlikely to progress after skeletal maturity. Hence, defining factors that influence curve progression to an absolute magnitude of ≥30 degrees at skeletal maturity significantly aids clinical decision-making.

Methods: Of 279 patients with idiopathic scoliosis detected by school screening of 72,699 adolescents, 186 fulfilled the study criteria and were followed up to skeletal maturity. Initial age, gender, pubertal status and initial curve magnitude were used as predictive factors for curve progression to ≥30 degrees at skeletal maturity. Uni and multivariate, logistic regression and receiver operating characteristic (ROC) analysis was performed.

Results: Curve magnitude at first presentation was the most important predictive factor for curve progression to ≥30 degrees at skeletal maturity. An initial curve of 25 degrees had the best ROC of 0.8 with a positive predictive value of 68% and a negative predictive value of 92% for progression to ≥30 degrees at skeletal maturity. The highest risk was a pre-pubertal female < 12 years of age with a Cobb of ≥25 degrees at presentation; with an 82% chance of progression to a Cobb of ≥30 degrees. Probability of progression to ≥30 degrees was defined by 1/(1 + exp (−z)). [z = −3.709 + 0.931(Gender) + 0.825(Puberty) + 3.314(Cobb) + 0.171(Age)].

Conclusions: Initial curve magnitude is the most important independent predictor of long-term curve progression past skeletal maturity. An initial Cobb of 25 degrees is an important threshold. Combined with other factors, we identify patient profiles with high or low risk for progression.


M.A. Adams P. Pollintine K. Robson Brown

Introduction: Osteoarthritis (OA) of the apophyseal (facet) joints often appears to follow degenerative changes in the adjacent intervertebral discs. We test the hypothesis that facet joint OA is directly related to high compressive load-bearing resulting from disc degeneration.

Methods: Thirty six cadaveric thoraco-lumbar “motion segments” consisting of two vertebrae and the intervening disc and ligaments, were obtained from 22 human cadavers aged 64–92 yrs (mean 77 yrs). Each was subjected to a constant compressive load of 1.5 kN while the distribution of compressive stress was measured along the mid-sagittal diameter of the intervertebral disc, using a miniature pressure transducer, side-mounted in a 1.3 mm-diameter needle. Measurements of compressive “stress” were summed over area to give the compressive force resisted by the disc. This was subtracted from the applied 1.5 kN to indicate compressive load-bearing by the neural arch, including the apophyseal joints. After mechanical testing, the cartilage of each apophyseal joint surface was graded for degree of degeneration. Joints were then macerated, and each bony joint surface was scored for the following four degenerative changes, according to established criteria: marginal osteophytes, pitting, bony contour change, and eburnation. The four bone scores were summed and used to represent the severity of OA for that joint surface, and values were then averaged for the two facet joints (four surfaces) of each motion segment.

Results: Cartilage degeneration and summed bone scores both increased with age, and with each other (P< 0.01). Neural arch load-bearing ranged from 5%–96% (mean 45%) of the applied 1.5 kN compressive force, with values over 50% being found only in specimens with degenerated intervertebral discs. Facet joint summed bone score increased with neural arch load-bearing (P< 0.01), especially when the latter exceeded 50%.

Conclusion: High apophyseal joint load loading, equivalent to neural arch compressive load-bearing above 50%, is strongly associated with severe OA changes in the apophyseal joints. Associations were stronger for bone rather than cartilage changes, possibly because pathological load-bearing by the facet joints can occur between the tip of the inferior articular process and the adjacent lamina, substantially by-passing the articular (cartilage) surfaces.


Mr Guilfoyle H Seeley RJ Laing

Objective: Measuring outcomes from chronic disease in terms of generic, health-related quality of life (HRQoL) instruments is of increasing importance to allow valid comparison of interventions and to accurately assess efficacy of treatment from the patient’s perspective. In this context we sought to establish the role of the generic SF-36 health survey in measuring outcomes from spinal surgery.

Method: A prospective observational study of patients undergoing elective cervical discectomy, lumbar discectomy, and lumbar laminectomy using both disease specific (Myelopathy Disability Index [MDI], Roland Morris Disability Scale [RMDS], Visual Analogue Scales [VAS], Hospital Anxiety and Depression Scales [HADS]) and SF-36 assessment pre-operatively and at 3 months and 12–24 months following surgery. The generic instrument was tested for the components of construct validity in comparison to the established specific measures. Analysis was performed with non-parametric statistics within SPSS.

Results: Six-hundred and twenty patients were followed between 1998 and 2005 (median age 53 years; 203 lumbar discectomy, 177 lumbar laminectomy, 240 cervical discectomy). The principal SF-36 physical domains (Physical Functioning, Bodily Pain) strongly correlated with disease specific scores in all patients (Spearman’s ρ=0.5–0.74, p< 0.001) and similarly SF-36 mental domains correlated with the HADS subscales (ρ=0.30–0.45, p< 0.001) indicating concurrent/convergent validity. Discriminant validity was confirmed by the absence of significant correlation between SF-36 physical domains and the HADS (ρ=0.014–0.14, p> 0.05). In the lumbar laminectomy and cervical discectomy patients disease-specific physical scores prior to surgery strongly predicted early and late outcome (area under the receiver-operating characteristics curve [AUC] = 0.79–0.86, p< 0.001) and the same pattern was mirrored in the SF-36 physical domains (AUC = 0.76–0.78, p< 0.001) demonstrating the predictive validity of the generic measure. Physical Function and Bodily Pain SF-36 domains both had excellent response to change by Cohen’s criteria with effect sizes (standardised mean difference) of 0.86–1.57.

Conclusion: The SF-36 has been shown to possess the necessary features of construct validity in relation lumbar and cervical surgery to be considered as a suitable adjunct or alternative to measuring outcome with disease specific scores. As a widely employed HRQoL instrument the SF-36 should be a convenient means of assessing patients with spinal morbidity in all healthcare settings and the generic measure will permit easier comparison of the clinical and economic efficacy of different interventions.


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M.A. Adams J. Luo P. Pollintine P. Dolan

Introduction: Anterior vertebral body deformities lead to senile kyphosis in many elderly people. Metabolic weakening of bone plays a major role in such osteoporotic “fractures”, but there is evidence also that altered load-sharing in the elderly spine pre-disposes the anterior vertebral body to damage. The insidious onset of many vertebral deformities suggests that gradual time-dependent “creep” processes may contribute, as well as sudden injury. Bone is known to have viscoelastic properties, but creep deformity of whole vertebrae has not previously been investigated.

Methods: 17 cadaveric thoraco-lumbar “motion segments”, consisting of two vertebrae and the intervening disc and ligaments, were obtained from 11 human cadavers aged 42–89 yrs (mean 66 yrs). Each was subjected to a constant compressive load of 1.0 kN for 30 minutes. Vertebral deformations in the sagittal plane were monitored at 50 Hz using an optical MacReflex system, which located pins in the lateral cortex of each vertebral body to an accuracy of < 10 μm. Two pins each defined the anterior, middle and posterior vertebral body height, and deformations were expressed as a % of original (unloaded) height. Elastic deformations included those recorded in the first 10 sec after load application; creep deformation was the continuing deformation (under constant load) during the following 30 min. After 30 min. recovery, 10 of the motion segments were positioned in flexion and damaged by compressive overload. The creep test was then repeated. Additional experiments investigated longer-term creep and recovery.

Results: Creep deformations were similar to the elastic (recoverable) deformations (Table 1). They were greatest anteriorly, giving rise to a typical permanent wedging of the vertebral body of 0.1–1.0o. Creep increased markedly after fracture. Creep continued beyond 2 hrs, but showed little recovery during 2 hrs of unloading.

Discussion: Even at laboratory temperature, creep mechanisms can cause measurable deformity in old vertebrae, and the processes increase greatly after macroscopic fracture. In old spines with degenerated discs, compressive load is concentrated on to the vertebral body margins, and bone loss is greatest anteriorly. This explains why creep was greatest anteriorly. Future work will characterize creep (and recovery) at body temperatures, and determine how it depends on bone density.


M.A. Adams M.S. Al-Rawahi J. Luo P. Pollintine

Introduction: Vertebral body osteophytes are common in elderly spines, but their mechanical function is unclear. Do they act primarily to reduce compressive stress on the vertebral body, or to stabilise the spine in bending? How do they influence estimates of vertebral strength based on bone mineral density (BMD)?

Methods: Spines were obtained from cadavers aged 51–92 yrs (mean 77 yrs) with radiographic evidence of vertebral osteophytes (mostly antero-lateral). Twenty motion segments, from T5-T6 to L3–L4, were dissected and loaded a) in compression to 1.5 kN, and b) in bending to 10–25 Nm. Vertebral movements were tracked at 50 Hz using an optical MacReflex system. Bending tests were performed in random order, in flexion, extension, and lateral bending. Resistance to bending and compression was measured before and after surgical excision of all osteophytes. The bone mineral content (BMC) and density (BMD) of each vertebra was measured in the antero-posterior direction, using DXA. Density measurements were repeated after excision of all osteophytes. ANOVA was used to detect changes after osteophyte excision, and regression was used to examine the influence of osteophyte size and BMC.

Results: Removal of osteophytes reduced-vertebral BMD by 9% (SD 13%). Compressive stiffness was affected rather more, being reduced by an average 17% (p< 0.05). Bending stiffness was reduced in flexion and extension by 50% and 39% respectively (p< 0.01), and in left and right lateral bending by 41% and 49% respectively (p< 0.01). Osteophyte removal increased the neutral zone and range of motion in each mode of bending. Most mechanical changes were proportional to osteophyte mass, and to changes in BMC (p< 0.01).

Conclusions: Vertebral body osteophytes primarily stabilise the spine in bending, and do not play a major role in resisting compression. Animal models show that osteophytes grow in response to experimentally-induced instability, so their formation can be seen as mechanically-adaptive (restoring stability) rather than degenerative. The influence of typical osteophytes on compressive stiffness is greater than their influence on vertebral BMD (17% vs 9%) so predictions of vertebral compressive strength based on BMD measurements are likely to be under-estimates if osteophytes are present.


H Sharma R Reid AT Reece

Introduction: Only 4–13 % of all spine tumours are primary bone tumours. We report on 180 cases of primary malignant bone tumours of the spine from the Scottish Bone Tumour Registry. The aim of the study was to analyse the incidence, demography, pathology and survival patterns of primary malignant bone tumours of the vertebral column.

Materials and Methods: All of the data in the Scottish Bone Tumour Registry is compiled prospectively. This report is based on a retrospective review of all the data from 180 cases of primary malignant bone tumours (excluding metastatic lesions).

Results: Of 4,301 registry cases 4.1% were primary malignant lesions (n=180). Seventy two percent of all spinal tumours were primary malignant neoplasms. There were 22 cervical, 72 thoracic, 45 lumbar and 41 sacrococcygeal lesions. There was a male preponderance (103 males & 77 females). The mean age at presentation was 54 years (range, 4–86 years). The top two ranked tumours were myeloma (42) and chordoma (41). Ewing’ sarcoma (15), Leukaemik-Lymphomatous lesions (13), conventional osteosarcoma (10) and Paget’s sarcoma (9) followed thereafter.

The predominant presenting symptom was pain. Pathological fracture occurred in 7 patients. The operative treatment consisted of curettage (21), excision (51) and resection (9) with supplemented bone grafting (13). Adjuvant chemo (=61) and radiotherapy (=131) was also used in selective cases. Thirty patients were alive with no evidence of disease at a mean 5 year follow-up. Six were alive with persistent primary disease and/or local recurrence and/or metastases at the time of review. Eighty four patients died with persistent primary disease, 30 patients died of metastatic disease, 9 due to local recurrence and 17 of unrelated causes.

Conclusions: Only 4.1% of the musculoskeletal tumours were spinal: 40% involved the thoracic spine. Mean age at presentation was 54 years. Myeloma, chordoma, chondrosarcoma and Ewing’ sarcoma were the most common pathologies. Myeloma predominated: osteosarcoma was much less common in our series compared to previous reports. Early diagnoses resulted into improved outcome.


Naresh Kumar Ni Guo-Xin HK Wong

Study Design: A radiographic study using disarticulated cadaver thoracic vertebrae.

Objective: To determine the accuracy of orthogonal X-rays in detecting thoracic pedicle screw position by different groups of observers.

Summary of Background Data: Pedicle screws are increasingly being used for internal fixation of the thoracic spine. Surgeons and radiologists are often required to make decisions on the pedicle screw position by plain antero-posterior (AP) and lateral radiographs.

Materials and Methods: 23 disarticulated fresh adult thoracic vertebrae were used in this study. Pedicle screws were inserted completely within the pedicle; or deliberately violating the lateral or medial cortex of the pedicle. AP and lateral radiographs of each vertebrae were assessed by 2 spine surgeons, 2 spine trainees, and 2 musculoskeletal radiologists in a sequence of AP alone, and AP + lateral views. They were supposed to cataogorize the pedicular screw as ‘out laterally’/‘inside the pedicle’/‘out medially’ or ‘unsure’. Their assessments were compared to the actual position of the screws determined by the axial views.

Results: For each screw position, trend was found towards slightly better accuracy with availability of AP & lateral views in combination. From either AP alone or AP + lateral views, significantly higher accuracy was found in detecting screws “out laterally” than “inside pedicle” (p< 0.01), or “out medially”(p< 0.05), respectively. Nearly 30% of screws that were deliberately placed through the medial pedicle wall were not correctly identified. In addition, surgeons have highest accuracy from either AP alone, or AP + lateral views, followed by the spine trainees and radiologists. Radiologists provided more “unsure” answers than surgeons or trainees.

Conclusions: Screws that perforated the lateral cortex were the easiest, and those that were wholly within the pedicle were the most difficult to identify correctly. The use of plain radiographs to detect thoracic pedicle screws placed through the critical medial cortex is unreliable. The positions of thoracic pedicle screws appear to be more accurately detected by AP + lateral, however, the major contribution was from AP views. Surgeon experience continues to be vitally important in the safe placement of thoracic pedicle screws.

Key points:

Screws that perforated the lateral cortex were the easiest, and those that were wholly within the pedicle were the most difficult to identify correctly.

The use of plain radiographs to detect thoracic pedicle screws placed through the critical medial cortex is unreliable.

AP + lateral views provides higher accuracy in determining the screw position, while, the major contribution comes from AP views.

Surgeon experience, in the use of tactile skills and anatomical knowledge continue to be vitally important in the safe placement of thoracic pedicle screws.


JA BELL AK BURTON M STIGANT

Introduction: Systematic reviews have found that sitting at work is not associated with LBP, although the biomechanical evidence does offer plausible causative mechanisms. Indeed, exposure to lumbar postures has been assessed using imprecise tools that have limited epidemiological investigations. The aim of this study was to use new technology to measure the seated lumbar postures of sedentary (call centre) workers, and survey their current and future symptoms in order to determine associations with LBP.

Methods: A fibre-optic goniometer (FOG) system was attached to the lumbar spine and hip of 181 sedentary call centre workers at the start of their working shift. The lumbar FOG provides a continuous measure of sagittal lumbar curvature (lumbar position and movement), whilst the hip FOG enables quantification of sitting time. Baseline and 6-month follow-up questionnaires were used to collected symptom data, and logistic regression was used to determine associations between postural and symptom (yes/no) data.

Results: Workers spent a mean proportion of 83% of work-time sitting, with 17% sitting for more than 90 minutes without a break. Current LBP (symptoms lasting more than 24hrs) was associated with a kyphotic (mean lumbar angle> 180°) sitting posture (yes/no) (OR 2.1, 1.1–4.1), although movement (mean standard deviation and angular velocity °sec-1) in sitting was not. Sitting relatively static (AV< 4.26° yes/no) (OR 3.30, 1.06–10.25), using a small amount of range (SD< 10.2° yes/no) (OR 3.79, 1.2–11.7), and adopting a kyphotic posture (yes/no) (OR 2.75, 1.02–7.3) all significantly increased the risk of future LBP.

Discussion: Sitting postures at work are associated with current LBP and are statistically significant risks for recurrence. These results highlight the potential for ergonomic interventions to reduce current symptoms and the risk of future episodes. The findings from this study are novel, and the FOG system should now be used in larger investigations of sedentary risk factors for LBP.


M Tsegaye A Littlewood N Schmitt K Lindsay Jj Mooi C Dirocco B Boszczyk

Cervical spine disorders represent a good proportion of the daily practice of many neurosurgeons. The rapidly increasing knowledge base on spinal conditions and the progressive complexity of surgical interventions appear to be generating a renewed interest in this evolving subspecialty among neurosurgical trainees. In order to assess the current level of spinal surgery training and conveyed competence in dealing with spinal disorders, a self assessment questionnaire was devised and distributed to the neurosurgical trainees attending the EANS (European Association of Neurosurgical Society) training courses. 126 questionnaires were returned with a return rate of 32%. The majority of trainees responding to the questionnaire were in their final (6th) year of training or had completed their training (60,3% of total) representing 25 European nations. A separate analysis of the data pertaining to cervical spine disorders revealed 80% of the trainees completing their training in University hospitals with cervical spine injuries predominantly managed by neurosurgeons (75%). In their practical skill assessment, 78% of the senior trainees were competent in the treatment of cervical disc herniation and cervical spinal stenosis in their anterior microsurgical techniques. In emergency management of cervical spinal trauma, 45% of the senior trainees were competent in being able to perform procedures without direct supervision. Regarding skills in anterior and posterior cervical stabilisation techniques, 33% and 15% respectively were competent in performing as well as dealing with complications & difficulties that may arise. Spinal surgery training in European residency programs has clear strength in the traditional areas of microsurgical decompression for spinal stenosis and disc herniation. Deficits are revealed in the management of spinal trauma and spinal conditions requiring the use of implants, with the exception of anterior cervical stabilisation. In order to achieve a high level of competency, EANS trainees advocate the development of a post-residency spine sub-specialty training program.


J Bridgens M Gleave D Douglas L Breakwell G Davies A Cole

Introduction: Blood conservation is important in surgery for adolescent idiopathic scoliosis due to the potential for significant blood loss and need to avoid allogeneic transfusion in young, commonly female, patients. Previous studies have shown that a combination of blood conservation methods may be effective in reducing the need for allogeneic blood transfusion. We have carried out a study to investigate if the sole use of intraoperative red cell salvage in surgery for adolescent idiopathic scoliosis is effective and can lead to a reduced rate of allogeneic transfusion.

Patients and Methods: 56 patients aged between 10 and 17 underwent posterior spinal surgery for correction of idiopathic scoliosis. In 34 patients intraoperative cell salvage was used and salvaged blood re-infused perioperatively. This group was compared with a control group of 22 patients in whom only allogeneic blood transfusion was used. All patients underwent hypotensive anaesthesia. Other forms of blood conservation, such as predonation, were not used. Data was gathered on patient demographics, operative details, quantity of blood reinfused, pre and post operative haemoglobin levels and total allogeneic transfusion requirement. Operative data was gathered prospectively and blood transfusion data provided by the transfusion centre.

Results: In the cell salvage group an average of 309mls of blood was reinfused and these patients were transfused an average of 1.8 units less allogeneic blood in the peri-and post-operative period (p< 0.001). 74% of these patients required no allogeneic blood compared with 27% in the control group. There were no complications related to the use of intraoperative red cell salvage.

Conclusion: Intraoperative red cell salvage is effective in reducing the need for allogeneic transfusion in children undergoing posterior surgery for scoliosis correction.


D A Inman C Hope P A B Leaver D E Gage P D De Vos Miering

Background: Growing demands upon orthopaedic services in the United Kingdom have resulted in increasing waiting times for orthopaedic consultations. The increasing pressure of new government targets has led to role delegation within the NHS. Magnetic Resonance Imaging (MRI) is a limited resource that requires judicious and validated use. We evaluated the use of MRI in the assessment of patients presenting with back pain to a service managed by an Physiotherapy Extended Scope Practitioner (ESP) working in a secondary care referral centre, against the standard as practiced by orthopaedic surgeons in a separate secondary care referral centre without a dedicated operative spinal service.

Methodology: A retrospective review of 130 lumbar MRI scans requested by an ESP service was compared with a retrospective review of 145 lumbar MRI scans requested by orthopaedic surgeons. In both cases cross-site tertiary referral was required if surgery was to be considered. Presenting symptoms and signs, abnormalities detected on the MRI scans and subsequent management were recorded with rate of listing for operative management used as a measure of appropriate MRI usage. Simple descriptive analysis was undertaken.

Results: 82% and 91% respectively of orthopaedic and ESP referrals for MRI had either neurological signs or symptoms. However, a higher rate of neurological signs was reported by ESP 70% versus 42%).

Despite reported differences in patient presentation the abnormal scan rate was comparable (ESP 91%, orthopaedics 92%).

The tertiary referral rate was also comparable (ESP 47%, orthopaedics 37%).

Of the patients referred to the tertiary referral centres the percentage listed for operative intervention was 68% and 72% respectively for ESP and orthopaedic surgeons. In terms of the number of patients investigated by MRI scan 32% and 26% of patients from the ESP and Orthopaedic centres respectively were listed for surgery.

Discussion: This study shows that physiotherapy ESP use of MRI in the investigation of patients presenting with back pain is comparable to orthopaedic surgeons in a centre without a dedicated spinal service. With adequate training and knowledge of red/ yellow flag signs applicable to assessment of spinal problems we support the role of physiotherapy ESPs in the assessment of patients with spine related problems.


N Haden A Gardner P Millner A Rao R Dunsmuir R Dickson

Introduction: The natural history of scoliosis in the presence of a cord syrinx, either treated conservatively, or post surgically, is disputed. It is generally believed to be associated with a greater likelihood of rapid deformity progression pre-operatively and a much greater likelihood of intraoperative neural injury.

In this study we aimed to retrospectively assess the local experience by reviewing patients, treated over the last 10 years, in whom scoliosis has been established, by means of MR imaging, to be associated with a cord syrinx.

Methods: A retrospective cohort study was undertaken of paediatric patients attending the Leeds Spinal Unit between the years of 1997 and 2007. The entry criteria for this study were spinal deformity with MRI proven cord syrinx, in a patient without underlying tumour or other cord anomaly. Given the association with Chiari malformation this was a measured parameter rather than exclusion criteria. Other parameters assessed were mode of presentation, progression of scoliosis, details of the identified syrinx, chosen mode of treatment for the syrinx and the scoliosis (including conservative) and outcome measures (neurological function and sequelae, change in Cobb angle/deformity correction).

Results: A total of 46 patients were identified with scoliosis and an associated syrinx. The age range was from 3 to 18 years. Only 12 were male. The syrinx was associated with an Arnold Chiari malformation in 24% of patients, and located at the apex of, or local to, the maximum deformity in 73%.

The syrinx was treated surgically in 10 patients, with 80% of these achieving either deformity arrest, or no longer requiring surgical deformity correction. In the 2 patients from the same subset who did undergo deformity correction there was no neurological sequelae. Of the conservatively managed syrinxes, deformity correction with intraoperative cord monitoring was nevertheless undertaken in 31%, all without neurological sequelae. In just 4 patients (of 69%) who did not proceed to deformity correction, surgery was precluded by the inherent risks in the presence of an untreated syrinx.

Conclusion: This small series does not lend support to the literature and anecdotal evidence for significantly increased surgical risk in deformity correction without treatment for syrinx first. However, this may reflect the fact that all syrinxes likely to compromise the surgical procedure were assessed as such and treated first. In the cohort of patients whose syrinxes were treated conservatively, a significant proportion did not require subsequent deformity surgery. Identifying a syrinx by, the mandatory, MR imaging of a patient with a deformity before considering surgical correction, appears to identify a significant proportion of syrinxes which neither significantly accelerate the progression deformity, or which do not lead to poor outcome after deformity surgery.


RK Mathew C Comer R Hall J Timothy

Introduction & Aims: The X-stop interspinous process decompression system is being used as an alternative to laminectomy in the treatment of neurogenic claudication. To date the clinical outcomes are favourable, but the economic value has not been established within the NHS financial model.

Objective: To compare the average hospital costs of performing an x-stop procedure (under general or local anaesthetic) to a laminectomy in patients with neurogenic claudication.

Design: A retrospective analysis of average length of stay, anaesthetic and operative times, equipment and anaesthetic agent costs. Sources included theatre management systems, the British National Formulary and Leeds Teaching Hospitals Trust in-patient stay data. The study period was from April 2005 to October 2006. The number of patients in the two groups were 318 (laminectomy) and 75 (X-stop).

Results: In comparison to laminectomy, patients under-going an X-stop procedure have a reduced average length of in-patient stay (3 versus 5 days), reduced anaesthetic time (25 versus 29 minutes) and operative duration (40 versus 128 minutes). The average cost for each procedure is £3346 for an X-stop under general anaesthetic (profit £119), £2835 for a laminectomy (profit £1177) and £2237 for an X-stop as a day case (profit £1228).

Conclusions: Tariff reimbursement is an important consideration to ensure insertion of these devices is profitable for the hospital. Our results show that even with the additional cost of the implant device, an X-stop procedure under general anaesthetic remains profitable in comparison to a laminectomy, whilst a day-case X-stop procedure is more profitable. Additional savings are be made by reduced bed and theatre occupancy. Future studies will differentiate costs of 1- and 2-level X-stop procedures, complication rates and revision surgery.


F Altaf AS Raman W Hakel HH Noordeen

We describe a case of a three year old girl with Caudal Regression Syndrome (CRS) at the ninth thoracic vertebral level with termination of the spinal cord at the unusually high level of the third thoracic vertebra. We describe this rare condition and discuss the challenging management in an extremely rare case where there is termination of the spinal cord at a high thoracic level.

CRS is a severe congenital neural and skeletal deficiency that is characterized by absence of the entire sacrum and of variable amounts of the lumbar and occasionally thoracic spine with associated neural elements. This is accompanied by a number of congenital visceral abnormalities.

Controversy belies the optimal orthopaedic management of the spinal anomaly and the associated lower extremity deformities in this condition. Affected children have multiple musculoskeletal abnormalities, including foot deformities, knee and hip flexion contractures, dis-located hips, spino-pelvic instability, and scoliosis.

We believe the care of these complex patients should be highly individualized.

Patients with types I and II lumbosacral agenesis have an excellent chance of becoming community ambulators and early interventions should be taken to correct the associated orthopaedic deformities. Treatment of types III and IV lumbosacral agenesis is controversial. In these severe forms of agenesis periodic examinations of the spine for scoliosis should be performed and the patient must be monitored for spinopelvic instability as indicated by a worsening posture. The management of these and other orthopaedic deformities is controversial but we do advocate the surgical correction of fixed deformities of the lower extremities which interfere with sitting or with the wearing of braces or shoes thereby avoiding amputation and maintaining body image.


NM Orpen R Shetty T Corner RW Marshall

Decompression of the lumbar spine for spinal stenosis is the most commonly performed spinal surgical procedure in patients over 60 years old. The aims of surgery are to relieve compression of the spinal nerves and retain integrity of the structural elements of the spinal column and its function as a supportive structure.

In trying to avoid excessive removal of the posterior supportive structures of the spinal column without compromising full and safe decompression of the spinal nerves, techniques are being developed to reduce bone removal but also allow access to the spinal canal. One such micro-decompression involves a hemi-lami-nectomy and lateral recess decompression on the more symptomatic side followed by undercutting the spinous process and facet joints and decompressing the opposite side from within the canal aided by the use the operating microscope, a high speed burr and a metal guard to protect the dura and nerves.

Although previous reports exist, as yet, there is no long-term evidence that the theoretical benefits of this “micro-decompression” translate into real clinical improvement in outcome with a reduction in the incidence of post-operative instability in comparison with the bilateral “fir-tree” type of decompression.

We have reviewed our first 100 consecutive patients who have had a spinal micro-decompression carried out by a single spinal surgeon over a period of 5 years. Patients with central or lateral recess stenosis with unilateral or bilateral symptoms were considered for this procedure with 58 female and 42 male patients included in the follow-up series. Mean age was 65 years. Patients were assessed by a combination of clinical review and self-assessment questionnaires. After a follow-up period of up to 5 years (mean 3 years) we have seen symptomatic late instability develop in 4 patients requiring a further surgical procedure in 2 of these. Symptoms typically developed 2 years after the original operation following an initial improvement in radicular symptoms and back pain. This compares favourably with published results for wide decompression where re-operation rates of 18% are reported. We have analysed the cases of delayed instability in more detail to evaluate whether the late deterioration could have been predicted. This has allowed us to clarify the specific indications and contra-indications to the micro-decompression procedure.

Lumbar micro-decompression has proved to be safe with few complications. It would appear that this technique has advantages over wide decompression without compromising safety but it will be important to continue with longer term follow-up of these cases.


F Altaf E Garrido AS Raman HH Noordeen

We describe the clinical results of a new technique of direct pars repair stabilised with a construct that consists of a pair of pedicle screws connected with a modular link that passes beneath the spinous process. Tightening the link to the screws compresses the bone grafted pars defect providing rigid intrasegmental fixation.

14 patients aged between 10 and 17 years were included in this study. 7 were males and 7 females. Each of the patients had high activity levels and suffered from significant back pain without radicular symptoms or signs. All patients had undergone at least 12 months of activity modification, a trial of bracing and physical therapy before surgical options were discussed. None of the patients had spondylolisthesis. Definitive pseudo-arthrosis and fracture were confirmed via computerize tomography (CT). Magnetic resonance imaging was performed in every patient to assess the adjacent disc spaces which demonstrated normal signal intensity. The pars defect was at L5 in all 14 patients.

A midline incision was used for surgery. The pars intercularis defect was exposed and filled with autolo-gous iliac crest bone graft prior to screw insertion. After screw insertion, a link was contoured to fit, and placed just caudal to the spinous process, deep to the interspinous ligament of the affected level, and attached to each pedicle screw. There was early mobilization post-operatively without a brace.

The average inpatient stay was 3 days. Post-operative complications included 1 superficial wound haematoma. Follow-up was at 6 weeks, 6 months and at 1 year. At the latest follow-up, visual analogue scores ranged between 0 and 4 for all patients, indicating excellent overall pain control. Functional assessments for all patients via the modified Oswestry scores were 0% to 13%, indicating a good overall functional result. All patients had radiographs at follow-up which showed fusion rates of 80% in those patients followed up for 1 year.

This new technique for direct pars repair demonstrates high fusion rates in addition provides the possible benefits of maintaining adjacent level motion. Clinically this group had good-to excellent functional outcomes as indicated by visual analogue scales and the Oswestry Disability Index.


E.C. Maratos R. Trivedi H. Seeley H. RICHARDS R.J.C Laing

Background: Intramedullary spinal cord tumours (ISCT) are rare with an annual incidence of less than 1 per 100,000 population. This makes assessing the efficacy of any treatment regimen difficult. Goals of management currently focus on obtaining a histological diagnosis for prognostic and therapeutic planning, and long-term tumour control. However, current outcome measures are crude and the quality of life outcome after surgery for intramedullary spinal cord tumours remains uncertain.

Aim: The aims of this study are to assess disability and outcome in patients undergoing surgery for ISCT. We aim to provide prospective quality of life data on patients with spinal cord tumours.

Patients and Methods: Data was collected prospectively on patients undergoing surgery for ISCT between 1995–2006 under the care of the senior author. The Short Form 36 (SF36) Health Survey Questionnaire was self-administered prior to surgery and again at 3, 12 and 24 months after surgery. All patients were also classified using the Frankel disability score. SF36 data were analysed using the Friedman test with Dunn’s post-test for multiple comparisons and the Wilcoxon signed rank test for matched pairs.

Results: Sixty-five patients (35 men, 30 women) had surgical interventions for ISCT. The mean age at first operation was 43y and median follow-up time was 60 months. 15% had astrocytomas, 45% ependymomas, 7 haemangioblastomas and 19 miscellaneous tumours.

Seventy-two percent of patients (47/65) were graded Frankel D pre-operatively and 65% (42/65) remained so after surgery. SF36 data were obtained for 17 patients. Pre-operatively, patients with ISCT had significantly lower SF36 physical domain scores when compared with normative data from age-matched population controls (p=0.0096). There was no difference between post-operative scores and those of normal controls. Matched pairs analysis on the patients with complete SF36 data sets (n=12) demonstrated a significant improvement in physical function post-operatively. Eleven of these 12 did not show an improvement in their Frankel grade, remaining Grade D pre- and post-operatively.

Conclusion: From this preliminary study it appears that patients with spinal cord tumours have significantly impaired physical function compared to the normal population. More importantly, we have demonstrated that the SF36 can detect changes in function associated with spinal cord tumour surgery that other, cruder measures, cannot.


E.C. Maratos R. Trivedi H. Richards H. Seeley R.J.C Laing

BACKGROUND: Physical outcomes following surgery for degenerative spine disease have been well studied. It is only relatively recently however that the importance of psychological factors in determining outcome from spine surgery has been addressed. Previous studies suggest that pre-operative psychological distress is a predictor of poor outcome. In the drive to identify patients who will not benefit from spine surgery these patients may in future be denied surgery.

AIM: The aim of the current study was to examine the relationship between the severity of physical symptoms, levels of pre-operative psychological distress and out-come in patients with degenerative spine disease undergoing elective spinal surgery.

PATIENTS & METHODS: The study was a prospective cohort study. Health status and psychological distress were measured pre-operatively and at 12 months or more post-operatively using the Short Form 36 (SF36) Health Survey Questionnaire and the Hospital Anxiety and Depression Scale (HADS). We compared levels of physical disability (SF-36 physical domain scores) and psychological distress (HADS scores) before and after surgery in this group. Comparisons of pre- and post-operative scores were made using the Kruskal-Wallis, Wilcoxon Signed Rank Test and Mann Whitney U tests as appropriate.

RESULTS: A total of 333 patients were included (178 men, 155 women, mean age 54y). Pre-operatively patients with severe levels of anxiety and depression (higher HADS score) had worse (lower) SF-36 physical domain (SF-36 PD) scores compared to those with normal HADS scores (median 181.5 vs 109, p< 0.0001). Both HADS and SF-36 PD scores improved post-operatively (HADS 13 vs 6 p< 0.0001; SF-36 PD 134 vs 250.5 p< 0.0001). Greater reduction in HADS score was observed in patients with severe pre-operative HADS scores compared to those with normal pre-operative HADS scores (p< 0.0001). Patients with severe HADS scores also had greater improvement in SF36 PD scores when compared to patients with normal pre-operative HADS scores (77.24 vs 53.87 p=0.03).

CONCLUSION: Poor physical function pre-operatively correlates with severe psychological distress. Both physical and psychological symptoms improve after surgery. Severe levels of anxiety and depression pre-operatively are associated with the greatest symptomatic improvement and psychological morbidity does not worsen outcome.


F Altaf AK Bhadra AS Raman S Tucker HH Noordeen

The objective of this study was to assess the clinical outcome and efficacy of the X-Stop™ interspinous implant.

67 patients (36 male, 31 female) with mean age of 62.4 years (range 50–94 years) and radiologically proven lumbar stenosis, underwent X-Stop™ implantation during the period of June 2004 to June 2007. Patients were assessed pre-operatively and post-operatively at 3, 6 and 12 months using the Back and Sciatica Questionnaire, the Oswestry Disability and the SF12 questionnaire. Patient’s satisfaction was assessed in each visit. Minimum follow up 2 years in 45 patients and 1 year in 22 patients.

70% had significant improvement in the walking distance following the operation.

With the Back and Sciatica Questionnaire the average preoperative VAS of back and leg pain was 7.1 and 6.7 and improved to 2.5 and 2.6 postoperatively.

86% patient had improvement in their ODI score by 14% and more with average pre and postoperative score 44% (range18%–84%) and 15.8% (range 0%–61%) respectively.

With the SF12 questionnaire 68% patients had significant improvement in physical score and 77% in the mental score. Complications included five superficial wound infections and one wound haematoma. One patient required revision surgery.

This new surgical technique for the treatment of lumbar spinal stenosis, is simple and effective with minimum complications.


JNM Ruiz H Hernstadt L Lim WK Lim HT Hee Hk Wong

Patient outcomes using the Scoliosis Research Society (SRS) questionnaire after thoracoscopic and posterior surgical techniques for thoracic idiopathic scoliosis were compared after > 2 years post-op. Additional comparisons were made with non-operated scoliosis and normal patients. Our objective was to determine if scoliosis surgery and surgical technique used to treat a cohort of patients with the same type of scoliosis deformity affects patient outcome. The SRS-24 questionnaire was prospectively administered to 4 groups of patients:

42 patients with thoracic idiopathic scoliosis who underwent thoracoscopic instrumented fusion surgery (thoracoscopic group);

42 patients with thoracic scoliosis who underwent posterior instrumented fusion surgery (posterior group);

97 patients with thoracic scoliosis who did not have surgery (scoliosis control group);

72 patients who did not have scoliosis (normal group).

The 2 surgical groups were comparable with regards to age at surgery, pre-op Cobbo and follow-up. SRS-24 domian scores were computed for all 4 groups and were compared on SPSSv13 software. Our results show the thoracoscopic group having a significantly smaller mean post-op Cobbo (17° vs 25.1°, respectively; p< .001), which was achieved using less fusion segments (7 vs 9.3 segments, respectively; p< .001). The mean Cobbo of the scoliosis control group was significantly larger than the post-op Cobbo of the thoracoscopic group (p< .001), and was comparable to the post-op Cobbo of the posterior group. Comparing the 2 surgical groups, the thoracoscopic group showed trends towards better scores in 4 of the SRS-24 domains compared to the posterior group, but this only reached statistical significance for the satisfaction domain (p< .05). When comparing the 4 groups, Pain scores of both surgical groups were similar to those who did not have surgery, and were worse than normal patients (p< .0001); Self-image scores after surgery were higher than those who did not have surgery(p< .05) and were comparable to normal patients; Function and Activity scores of the thoracoscopic group was significantly inferior to the scoliosis control group (p< .05). Our study demonstrates that > 2 years after surgery, both thoracoscopic & posterior surgery resulted in pain scores that were similar to patients with scoliosis that did not have surgery, and were worse than the normal group. However, both surgical techniques resulted in self-image scores that are comparable to normal individuals despite a difference in post-op Cobbo. When comparing the two surgical techniques, the SRS-24 showed no difference between the 2 surgical techniques, except for patient satisfaction which was better in the thoracoscopic group.


RJ Newsome M Reddington LM Breakwell N Chiverton AA Cole

Objective: To determine whether extended scope physiotherapists (ESP’s) in spinal clinics are able to accurately assess and diagnose patient pathology as verified by MRI findings.

Methods: This is a prospective study of 318 new spinal outpatients assessed and examined by one of two spinal ESP’s. 76 patients (24%) were referred for an MRI scan. At the time of request for MRI scan the likelihood of specific spinal pathology correlating with the MRI scan was noted on a four point scale dividing the patients into 4 groups:

Group 4 = Very high suspicion of pathology (n=41)

Group 3 = Moderate suspicion of pathology (n=21)

Group 2 = Some suspicion of pathology (n=10)

Group 1 = Pathology unlikely but scan indicated eg thoracic pain (n=4).

Results: Of the 76 patients referred for an MRI scan, 54 (71%) had an MRI scan result that would correlate with the clinical picture. Looking at the percentage of scans correlating with the clinical picture for each of the 4 groups:

Group 4: 88%

Group 3: 67%

Group 2: 40%

Group 1: 0%

Conclusion: Dividing the patients into groups by clinical suspicion is essential for evaluating a clinician’s ability in spinal assessment. Further evaluation of Consultants, Fellows and Specialist Registrars is on going. This type of study could form a basis for competency measures for staff development and training if they are undertaking extended roles.


P Dolan FD Zhao P Pollintine BD Hole MA Adams

Introduction: Endplate fractures are clinically important. They are very common, are associated with an increased risk of back pain, and can probably lead on to intervertebral disc degeneration. However, such fractures tend to damage the cranial endplate much more often than the caudal. In this study, we test the hypothesis that the vulnerability of cranial endplates arises from an underlying structural asymmetry in cortical and cancellous bone.

Methods: Sixty-two “motion segments” (two vertebrae and the intervening disc and ligaments) were obtained post-mortem from human spines aged 48–92 yrs. All levels were represented, from T8–9 to L4–L5. Specimens were compressed to failure while positioned in 2–6o of flexion, and the resulting damage characterised from radiographs and at dissection. 2mm-thick slices of 94 vertebral bodies (at least one from each motion segment) were cut in the mid-sagittal plane, and in a para-sagittal plane through the pedicles. Microradiographs of the slices were subjected to image analysis to determine the thickness of each endplate at 10 locations, and to measure the optical density of the endplates and adjacent trabecular bone. Comparisons between measurements obtained in cranial and caudal regions, and in mid-sagittal and pedicle slices, were made using repeated measures ANOVA, with age, level and gender as between-subject factors. Linear regression was used to determine significant predictors of compressive strength (yield stress).

Results: Fracture affected the cranial endplate in 55 specimens and caudal endplate in 2 specimens. Endplate thickness was low centrally and higher towards the periphery. Cranial endplates were thinner than caudal, by 14% and 11% in mid-sagittal and pedicle slices respectively (p=0.003). Differences were greater in central and posterior regions. Cranial endplates were supported by trabecular bone with 6% less optical density (p=0.004) with this difference also being greatest posteriorly. Caudal but not cranial endplates were thicker at lower spinal levels (p=0.01). Vertebral yield stress (mean 2.21 MPa, SD 0.78 MPa) was best predicted by the density of trabecular bone underlying the cranial endplate in the mid-sagittal slices of the fractured vertebral bodies (r2 = 0.67, p=0.0006).

Conclusions: When vertebrae are compressed by adjacent discs, cranial endplates usually fail before caudal endplates because they are thinner and supported by less dense trabecular bone. These asymmetries in vertebral structure may be explained by the location of back muscle attachments to vertebrae, and by the nutritional requirements of adjacent intervertebral discs.


P Dolan J Luo L Daines A Charalambous DJ Annesley-Williams MA Adams

Introduction: The aim of this cadaver study was to examine how cement volume used in vertebroplasty influences the restoration of normal load-sharing and stiffness to fractured vertebrae.

Methods: Nineteen thoracolumbar motion segments obtained from 13 spines (42–91 yrs) were compressed to failure in moderate flexion to induce vertebral fracture. Fractured vertebrae underwent two sequential vertebroplasty treatments (VP1 and VP2) each of which involved unipedicular injection of 3.5ml of polymethyl-methacrylate cement. During each injection, the volume of any cement leakage was recorded. At each stage of the experiment (pre-fracture, post-fracture, post-VP1 and post-VP2) measurements were made of motion segment stiffness, in bending and compression, and the distribution of compressive stress across the disc. The latter was measured in flexed and extended postures by pulling a pressure transducer through the mid-sagittal diameter of the disc whilst under 1.5kN load. Stress profiles indicated the intradiscal pressure (IDP), stress peaks in the posterior annulus (SPP), and neural arch compressive load-bearing (FN). Measurements obtained after VP1 and VP2 were compared with pre-fracture and post-fracture values using repeated measures ANOVA to examine the effect of cement volume (3.5 ml vs. 7 ml) on the restoration of mechanical function.

Results: Fracture reduced compressive and bending stiffness by 50% and 37% respectively (p< 0.001) and IDP by 59%–85%, depending on posture (p< 0.001). SPP increased from 0.53 to 2.46 MPa in flexion, and from 1.37 to 2.83 MPa in extension (p< 0.01). FN increased from 11% to 39% of the applied load in flexion, and from 33% to 59% in extension (p< 0.001). VP1 partially reversed the changes in IDP and SPP towards pre-fracture values but no further restoration of these parameters was found after VP2. Bending and compressive stiffness and FN showed no significant change after VP1, but were restored towards pre-fracture values by VP2. Cement leakage occurred in 3 specimens during VP1, and in 7 specimens during VP2. Leakage volumes ranged from 0.5–3.0 ml, and were larger during VP2 than VP1.

Conclusions: Unipedicular injection of 3.5 ml of cement reversed fractured induced changes in IDP and SPP, but did not affect stiffness and neural arch load-bearing. Larger injection volumes may provide some extra mechanical benefit in terms of restoring stiffness and reducing neural arch loading, but these extra mechanical benefits can be at the cost of increased risk of cement leakage.


V Gowda G Singh A Kumar N Kumar

Background: Back pain in adult patients with a pars-interarticularis defect may be due to movement at the defect or abnormal inter-segmental movement at the adjacent degenerate disc. The suggested treatment of segmental fusion may not be necessary, if the defect alone was source of pain. We hypothesize that the defect may be the only source of pain in certain adults, even if the MRI scan shows an abnormal disc.

Objective: To form a protocol of management in adults with pars defect and adjacent level disc degeneration. To study the results of primary lysis repair using ‘AO Morscher clamp’ in patients with ‘spondylolysis’ or ‘Grade 1 ‘spondylolisthesis’.

Methods: This is a prospective study involving adults with ‘spondylolysis’ or ‘Grade 1 ‘spondylolisthesis’ not responding to conservative management and requiring interventional treatment. We investigated this subgroup of patients with lysis block and discography. On this basis, of a total of ten patients, seven were offered lysis repair and bone grafting using ‘Morscher’s clamp’; three were offered spinal fusion. Outcome was assessed using Visual Analogue Score (VAS) and Oswestry Disability Index (ODI) done pre-operatively and six months post-op.

Results: Out of ten patients (28 to 45 years; 4males and 6 females), seven patients underwent primary lysis repair using ‘AO Morscher clamp’. Union of pars achieved in all the patients by 4 months (Follow-up 4 months to 2 years). Three underwent fusion. Mean VAS improved from 7.2 to 1.2 in lysis repair group. Mean ODI improved from 68 % to 24%. All patients had full range of spinal movement postop.

Conclusion: A thorough pre-operative workup of patients with pars defect and adjacent level disc degeneration showed that pain is due to the pars defect in 70% of our cohort. This subgroup of patients could successfully be treated with ‘lysis repair’ rather than a more morbid procedure of ‘spinal fusion’.


ND Haden H Qureshi HM Seeley RJ Laing

Objective: To extend the follow up period of previous studies undertaken by the senior author, looking at the clinical outcome and radiological changes observed in patients with either myelopathy or radiculopathy, following anterior cervical discectomy without fusion.

Design: Prospective, observational cohort study of patients undergoing anterior cervical discectomy without fusion and followed up for five years, radiologically, with serial plain radiographs, and clinically, using validated outcome measures including SF36, neck disability index and analogue visual pain scores.

Subjects: 109 Patients undergoing anterior cervical dis-cectomy without fusion under the senior author’s care.

Outcome measures:

Radiological

Occurrence of segmental cervical kyphosis

Loss of overall cervical alignment

Clinical

SF36, Neck disability index, Visual analogue neck and arm pain scores

Results: A total cohort of 109 patients, of mean age 56 years, were followed up after anterior cervical discectomy without fusion, for up to 5 years. Segmental kyphosis was demonstrated on 44%, and loss of overall cervical alignment on 60% of follow up plain radiographs during the third postoperative year. In the cohorts of patients with either loss of cervical alignment or segmental kyphosis at one year the mean clinical outcome scores (Wilcoxon’s matched pairs signed ranks test) continued to improve at the 5 year follow up. The annual rate of loss of cervical alignment in patients unaffected at the first post operative year was around 10% but there was no significant rate of progression of segmental kyphosis. Comparison of the relationship between these radiological changes and clinical outcome (Mann-Whitney U test) did not show any significant correlation.

Conclusions: This study assesses patients over the period during which the anticipated alignment changes associated with undertaking simple anterior cervical discectomy could be having progressive detrimental clinical effects. Where such radiological changes occur they most commonly occur during the first post operative year. However, clinical outcome measures in these patients all improve at one year follow up, and still continue to improve or plateau up to five years post operatively. As anticipated, the most significant clinical improvement, occurs during the first post operative year. During the longer follow up period there is no significant detrimental effect of the radiological changes discussed on clinical outcome.


G Swamy J Crosby Z Klezl D Calthorpe R Bommireddy

Background: Cell Saver technique using intra-operative autologenous transfusion known to conserve homologous blood resources.

Specific indications for use of cell saver in thoracolumbar spinal instrumented fusion not clearly determined.

No previously published literature from Britain to our knowledge.

Objectives: To identify the clinical factors associated with increased risk of intra-operative blood loss.

To analyse the safety and benefits of using cell saver technique.

To determine the cost-effectiveness of use of cell saver technique.

Method: A total of 51 consecutive spinal instrumented fusion cases during last 14 months reviewed.

There was no randomisation; use of cell saver was at surgeon’s discretion.

Cell saver group consisted of 25 patients and control group consisted of 26 cases.

Patients with degenerative scoliosis and tumours excluded.

Demographic data recorded. Clinical notes reviewed to include smoking status, BMI, pre-operative diagnosis, revision surgery, number of levels fused, use of iliac bone graft, pre and post operative haemoglobin, haematocrit and platelets, intra-operative blood loss, amount of blood salvaged, duration of surgery, nature and amount of allogenic blood transfused.

Results: Demographic data including age, weight, smoking and prior surgery were similar between the two groups.

Iliac crest bone graft harvested in 20% of cell saver group and 40% in control group.

Levels of fusion ranged from 1–7 [Mean=2.8] in the cell saver group and 1–4 [Mean=1.9] in the control group.

Study group averaged 4 hrs of surgery, 15 mins longer than control group.

Intra-op blood loss higher in cell saver group (mean=1245 mls vs 800 mls).

Revision surgery did not affect the intra-op blood loss or duration of surgery.

20% in cell saver group and 26% in control group required blood transfusion.

8 units of red cells was transfused cell saver group as against 17 units of red cells plus 2 units of platelets transfused in the control group.

Percentage drop in the post operative haematocrit was 19.1 in cell saver group compared to 36.3 in control group.

Conclusion: 44.38% blood salvaged (35–38% in spinal literature).

Use of cell saver significantly decreased the risk of post-operative need for blood transfusion.

In this study, number of levels of fusion, duration greater than 4 hrs and a low pre-op Hb/Hct were significant parameters in predicting intra-operative blood loss.

If blood loss is less than 700 mls, gains from cell saver is debatable.


A Gardner N Haden P Millner A Rao R Dunsmuir R Dickson

Abstract: It is known that the treatment of intra or extraspinal paediatric tumours with surgery and radiotherapy or radiotherapy alone can lead to the onset of progressive spinal deformity the management of which can be extremely challenging. We review our series of patients who have developed a spinal deformity in these circumstances.

Methods: A review of all patients seen between 1996 and 2007 in the spinal department who have developed a significant spinal deformity following treatment for an intra or extra spinal tumour.

Results: 14 patients were identified. The age of presentation to the spinal service was between 2 years 6 months and 15 years 3 months. The underlying diagnoses were Wilms Tumour treated with surgery and radiotherapy in 3, 1 extraspinal sarcoma treated with surgical resection, radiotherapy and chemotherapy, 1 extraspinal neuro-blastoma treated with surgery, radiotherapy, chemotherapy and stem cell rescue and 9 intra spinal tumours (PNET, astrocytoma, ganglioneuroblastoma and der-moid) all managed with resection with or without radiotherapy. The spinal deformities that have developed were thoracic kyphoscoliosis, thoracolumbar kyphosis and lumber hyperlordosis. The spinal management of these deformities has been conservative in 12 with regular assessment to allow intervention if indicated. 2 patients have undergone surgery, a vascularised fibular strut graft and anterior instrumentation in 1 and a non vascularised rib graft in 1 for progressive deformity felt to lead to neurological dysfunction or lung hypoplasia. The cases managed operatively were complicated by poor posterior soft tissues following previous surgery and radiotherapy requiring an anterior approach. In all patients who were treated with radiotherapy platyspondyly was always seen in the vertebral bodies anteriorly and this corresponded to the apex of the deformity.

Conclusion: In all children who undergo spinal surgery and or radiotherapy for paediatric tumours there must be ongoing surveillance for the development of a spinal deformity. We feel that this is as much a result of anterior growth arrest secondary to radiotherapy as to posterior laminectomy for intra canal tumour excision. The surgical management of this problem is complex and may require innovative solutions.


W Chu L Shi D Wang T Paus A Pitiot B Freeman G Burwell G Man A Cheng H Yeung K Lee J Cheng

Observation of sub-clinical neurological abnormalities has led to the proposal of a neuro-developmental etiologic model for AIS. Our research group have demonstrated longer latency in somatosensory–evoked potential (SSEP) and impaired balance control in AIS subjects. A previous pilot study compared the regional brain volume between right thoracic AIS subjects and normal controls. Significant regional brain differences were found relating to corpus callosum, premotor cortex, proprioceptive and visual centers. Most of these regions involved the brain unilaterally, indicating there might be abnormal asymmetrical development in the brain in right thoracic AIS. In this pilot study, we investigated whether similar changes are present in left thoracic AIS patients who differ from matched control subjects. Nine AIS female patients with atypical left thoracic AIS (mean age 14.8, mean Cobb angle 19°) and 11 matched controls as well as 20 right thoracic AIS (mean Cobb angle 33.8°) and 17 matched controls, underwent three-dimensional isotropic magnetization prepared rapid acquisition gradient echo (3D_MPRAGE) magnetic resonance (MR) imaging of the brain. Fully automatic morphometric analysis was used to analyse the MR images; it included brain-tissue classification into grey matter (GM), white matter (WM) and cerebrospinal fluid (CSF). and non-linear registration to a template brain. Tissue densities were compared between AIS subjects and controls. There was no significant difference between AIS subjects and normal controls when comparing absolute and relative (i.e. brain-size adjusted) volumes of grey and white matter. Using voxel-based morphometry, significant group differences (controls > left AIS) were found in the density of WM in the genu of the corpus callosum, the left internal capsule (anterior arm) and WM underlying the orbitofrontal cortex of the left hemisphere. The above differences were not observed in the right AIS group. This first controlled study of regional tissue density showed that corpus callosum, which is the major commissural fiber tract, was different in the atypical left thoracic scoliosis while significant regional brain changes have not yet been found in those with typical right thoracic scoliosis. Further investigation is warranted to see whether the above discrepancy is related to laterality of the scoliotic curves and infratentorial neuroanatomical abnormalities. A larger sample and a longitudinal study is required to establish whether the brain abnormalities are predictive of curve progression.


A NANDAKUMAR N BILOLIKAR N CLARK F.W SMITH D WARDLAW

Aim: To measure the effect of X-stop interspinous decompression device on the dural sac and foraminal area at 6 and 24 months post operatively at the instrumented level in patients with symptomatic lumbar canal stenosis.

Design: Prospective Observational Study of 48 patients.

Methods: Patients due to have an X stop procedure were included and had a positional MRI scan preoperatively and 6 & 24 months post operatively. Foraminal area was measured in flexion and extension position whereas dural cross sectional area was measured in erect, neutral, flexion and extension positions. Osiris 4.17 software program was used to measure the canal and foraminal dimensions. The data was analysed using paired t test on SPSS ver.15.01.

Results: Forty-eight patients (25 male and 23 female) underwent scans preoperatively and at six months. Twenty-nine patients had single level and 19 had double level procedures. Three patients had removal of X stop and 5 did not have scan at 24 months leaving 40 patients scanned at 24 months. Of these 38 scans were complete and were included. We noted increase in mean dural sac area in all positions. The mean dural sac area increased from 131 mm2 to 143 mm2 (p=0.144) at 6 months and from 137 mm2 to 202 mm2 (p= 000) at 24 months in standing position. The difference in pre-operative measurements in the six and 24-month measurements is because of the different patient numbers scanned. There were similar increased dural sac areas in the other positions. The mean foraminal areas were measured in flexion and extension and the measurements in extension were increased from 66.58 mm2 to 79.51 mm2 (p=. 001) at 6 months and from 68.10 to 69.57 mm2 (p=0.752) at 24 months on left side; and increased from 63.75 mm2 to 71.65 mm2 (p=0.036) at 6 months, from 65.54 mm2 to 68.01mm2 (p=0.440) at 24 months on right side. Thus there is a small increase in foraminal areas and statistically significant increase in dural sac areas at 24 months.

Conclusion: X-stop interspinous device remains effective in decompressing the stenosed spinal segment by increasing the anatomic dural cross sectional areas and foraminal areas of spinal canal at 24 months post operatively, thus providing symptomatic relief from lumbar canal stenosis.


F Hussan H Thambinayagam W Adams T Germon

Aim: To determine any difference which may exist between the interpretation of nerve root compression demonstrated by an MRI scan as assessed by a radiologist compared to a spinal surgeon.

Introduction: There are a few standardized criteria for attempting to quantify the degree of lumbosacral nerve root compression demonstrated by radiological investigations. However, these are not validated and are not commonly employed. It is possible that the interpretation of films by surgeons is different to that by radiologists. If this is the case it could have important consequences, particularly if potential surgical targets are not recognised. We sought to investigate this potential discrepancy.

Method: Data from consecutive patients undergoing lumbosacral nerve root decompression, by a single surgeon, between 2002 and 2005 was prospectively analysed. Inclusion criteria were:

uni- or bilateral single level nerve root decompression

Three month post-operative visual analogue scores (VAS, 10 = maximum pain, 0 = no pain) of less than 2 was required as an indicator that the pre-operative diagnosis had been correct (i.e. the surgery had significantly improved the patient’s pain).

The MRI report of these patients was then scrutinised to see if the decompressed nerve root had been reported as significantly compressed on the pre-operative scan.

Results: Only 75 % of films had a formal radiological report. Of reported films 22% had not reported the surgical target which rose to 33% for L5 nerve root compression.

Conclusion: Consideration needs to be given to the potential placebo effect of surgery, the nature of the compressive pathology, the clinical details supplied to the radiologist and how the surgical decision making was made.

However, in this sample a large minority of MRIs had no formal report. Of those that were reported, there was underreporting of potential surgical targets by radiologists. This implies that there could be a high incidence of false negative MRI reporting with potentially treatable conditions being unrecognised.


E Garrido HNN Noordeen SK Tucker

Summary: Radiographic and clinical outcomes of anterior thoraco-lumbar and posterior instrumented spinal fusion in patients with double major (AIS) curves are evaluated in this retrospective study. The average thoracic curve was 68 degrees before surgery and 29.2 degrees at follow-up (mean correction 58.3%). The average preoperative lumbar curve was 73 degrees, decreasing to 18 degrees postoperatively (mean correction 77.5%). Instrumented anterior lumbar fusion followed by posterior instrumented fusion is a successful technique with low morbidity in AIS with double curve pattern.

Introduction: Options exist for the surgical treatment of double major AIS curves. With the introduction of multi-level pedicle screw fixation in the thoracic and lumbar spines the role of anterior surgery is being questioned. This series demonstrates the results obtained by anterior thoraco-lumbar and posterior instrumented spinal fusion.

Methods: 28 patients with double major curves who underwent anterior spinal release and instrumented fusion, with staged posterior instrumented spinal fusion between 1999 and 2005 were included for analysis. The minimum follow-up was 2 years after surgery (mean, 5 years; range, 2–8 years). The mean age of patients was 17,3 years (range, 13–21 years). Multiple radiographic parameters were assessed.

Results: Successful selective thoraco-lumbar instrumented fusion and posterior instrumented fusion was performed in 28 consecutive patients with adolescent idiopathic scoliosis. The average thoracic curve was 68 degrees before surgery and 29,2 degrees at final follow-up (mean correction 58,3%). The average pre-operative lumbar curve was 73 degrees, decreasing to 18 degrees postoperatively (mean correction 77,5%), with good coronal and sagittal balance achieved. Tilt of the lower instrumented vertebra (LIV) improved from 28.2 degrees to 4.6 degrees on last follow-up. Disc angulation below the LIV averaged 6.1 degrees preoperatively and 3.6 degrees on last follow-up. Translation of the LIV from the center sacral vertical line averaged 34.5 mm preoperatively and 13.6 mm on last follow-up.

Discussion: Instrumented anterior lumbar fusion followed by posterior instrumented fusion is a successful technique in adolescent idiopathic scoliosis with double curve pattern. These results show that this technique is able to restore normal coronal alignment of the distal unfused lumbar segment and saves fusion levels compared to posterior instrumentation only. Despite the extensive surgery, there is a very low morbidity in this population, with no evidence of pseudarthrosis.

Significance: This represents a large unique series of patients treated for double major curve pattern in adolescent idiopathic scoliosis with low morbidity and excellent balanced corrections in both coronal and sagital planes.


Karunagaran Appaji Krishnan Sajan Hegde

Summary: Twenty six consecutive patients with CSM were operated between Jan 2001–Dec 2004 with anterior corpectomy and reconstruction using strut graft/ lordotic cage and stabilization ACP. 10/26 were wheel chair bound/bought on stretcher. 16/26 had spastic lower limbs with myelopathic hands. Post operatively 20/26 had good gait improvement and are community ambulators. 3/26 house hold ambulators and 1 died. 18/26 had good improvement in hand function.

Introduction: Cervical spondylotic myelopathy is a degenerative disease of old age. Patients present with severe disabiling symptoms of spastic gait/inability to walk and varied involvement in the hand. The degenerative spondylosis being the commonest cause, CSM is also caused by OPLL and soft disc herniation.

Methods: 26 consecutive patients who had undergone anterior decompression and reconstruction were evaluated for recovery. The gait pattern, hand functions and return to activities were evaluated pre and postoperatively. No specific scoring system could be used in our studies due to practical reasons.

Results: 18/26 patients had CSM, 5/26 had OPLL and 3/26 soft disc herniations. Soft disc herniation were at 2 levels and all underwent discectomy, tricortical bone grafting and stabilization with ACP. Other patients had corpectomy 1 level – 4, 2 levels – 9, 3 levels – 4, 4 levels – 1. OPLL was removed in 4/5 patients. Xx/10 patients who were wheel chair bound preoperatively became ambulatory, 3/10 had decrease in spasm but still could not walk postoperatively. At 1 year follow up 9/10 patients had good gait pattern and 1 was still wheel chair bound. 18/26 had good hand function recovery with improvement in hand writing, 16/26 returned to previous activity, 1 patient expired.

Conclusion: Anterior decompression for CSN is an effective surgical option. It not only prevents further detoriation, but also improvement is seen in most of the patients.

Significance: Anterior decompression is indicated for all patients with CSM, OPLL and disc herniation as the pathology is anterior based.


A Heydari C Greenough

Previous studies of EMG recordings from lumbar para-spinal muscles have shown correlations between some EMG variables and low back pain. However there are discrepancies in the literature concerning the usefulness of some of these variables. It has been suggested that ordinary fatigue influences the reproducibility of these measurements, introducing a confounding factor.

In this study we have investigated changes in EMG variables, following a day of normal activity. Forty six subjects participated in this study. EMG recordings were performed at the beginning of their shift (time 1) and at 6 h 20 ±5 min afterwards (time 2) under isometric condition at 60% and 40% of their lean body mass (LBM). Variables studied were initial medial frequency (IMF), median frequency slope (MFS) and half width (HW).

At 60% LBM, IMF measurements at time 1 and time 2 were highly correlated (r2= 0.84, p> 0001) and this was the case for HW measurements (r2=0.84, p> 0001) and MF slope (r2=0.52, p=0> 001). Conducting paired sample t-test also showed no significant change in the IMF from time 1 (M=48.6, SD=8.9) to time 2 (M=49.2, SD=7.3), t(45)=−0.9, p=0.38, or in HW from time 1 (M=47.2, SD=15.5) to time 2 (M=45.9, SD=13.9), t(45)=1.7, p=0.29, or MF slope from time 1 (M=−0.2, SD=0.17) to time 2 (M=−0.24, SD=0.16), t(45)=1.67, p=0.10). The relations observed at 40% LBM almost mirrored those reported at 60 % LBM but with even less significant difference from time1 to time2.

We conclude that IMF, HW and MFS are highly reproducible EMG variables that are not affected by ordinary fatigue and may therefore be valuable in examining differences between subjects or over longer time periods. However they are not useful in assessing changes due to daily exertion.


HA Kazi M Dematas R Pillay DS O’Donoghue

Introduction: A high incidence of pin loosening, infection and discomfort as well as pressure ulceration from the jacket were noted in a study performed in 19861 we aimed to compare our figures with published literature.

Methods: A retrospective case note review (1994–2004). One investigator reviewed the casenotes and corroborated these with a spinal database, theatre database and microbiology results system.

Results: 74 halos were applied in the 10-year period. A complete dataset was obtained for 37 patients (others had been destroyed either entirely or relevant volumes). Age range was 22–83 years (median 49), 20 males and 17 females.

28 were applied under local anaesthetic (LA), one with LA and sedation and 8 were applied under general anaesthetic (either for another trauma procedure or due to head injury). All halos applied were Bremer Halo Crown with Classic or Classic II vest (DePuy Spine, Warsaw, IN, USA).

Indications for application included fractures (n=21), tumours (n=6) or subluxations (n=10).

8 patients required pin repositioning. This was due to poor position (n=2), pain (n=5) and pin loosening (n=1, 3%). Pin site infection was diagnosed using an accepted definition2. This occurred in 5 patients. 3 settled with antibiotics, one with debridement and one with repositioning. Overall infection rate was 13.5%, which compares favourably with published rates of 20–22%. Pin site infection dropped significantly after introduction of a pin care regimen introduced and published by our limb reconstruction team2 from three patients to one patient. Pin torque was also checked daily for seven days followed by weekly thereafter.

The halo vest was a cause of significant morbidity in terms of pressure ulceration (3 patients) pneumonia (3 ventilated ITU patients of whom 2 died) and pain in one patient.

Conclusion: Our pin loosening rate was significantly lower than published figures, which we ascribe to regular torque checking and use of a 0.90 Nm torque wrench3.

Our pin site infection rate dropped significantly after use of our limb reconstruction teams pin care regimen. We now utilise this regimen in all halo patients with good effect. A prospective study is ongoing.


AP Littlewood M Tsegayee R Putz B Boszczyk

Introduction: The intricate biomechanical function of the alar ligaments in the craniocervical articular complex has received considerable scientific attention. While allowing the greatest range of axial rotation of the entire spine with 40° to each side, definitive restraint at the extremes of motion by the alar ligaments is of vital importance. Detailed knowledge of the function of these ligaments is essential for comprehending the factors leading to potentially devastating instability.

Methods: Bilateral alar ligaments including the bony entheses were removed from six adult cadavers aged 65–89 years within 48 hours of death. All specimens were judged to be free of abnormalities with the exception of non-specific degenerative changes. Dimensions of the alar ligaments were measured. Schematic multipla-nar reconstruction of axial atlanto-axial rotation was done in the transverse and frontal planes for the neutral position and for rotation to 30° and 40° in the neutral plane to assess schematic fibre elongation during axial rotation and to determine the change in the angle of insertion at the odontoid and condylar entheses. This was repeated with a 1mm descending translation of the occipital condyles at 30° and 3mm descending translation of the occipital condyles at 40° rotation.

Results: The average diameter of the odontoid process measured in the sagittal plane was 10.6 mm (SD 1.1). The longest fibre length was measured from the posterior border of the odontoid enthesis to the posterior border of the condylar enthesis with an average of 13.2 mm (SD 2.5) and the shortest between the lateral (anterior) border odontoid enthesis and the anterior condylar enthesis with an average of 8.2 mm (SD 2.2). Attachment areas of the enthesis revealed an average of 60 mm2 (SD 12.4) for the odontoid and 50,6 mm2 (SD12.6) for the condylar enthesis. Schematic fibre elongation reaches 27,1% for the longest fibres at 40° axial rotation. This is reducible to 7,8% elongation by 3mm caudal translation of the atlas.

Conclusions: This theoretical model confirms that the bi-convex shape of atlanto-axial joint allows for rotation when modelled with oblique alar ligaments. This provides baseline for further research with functional MRI which will be useful for rheumatoid and post traumatic spine.


N A Quraishi M Anraku S Keshavjee G Darling M Johnston T Waddell Y R Rampersaud S L Lewis

Study Design: A retrospective analysis of prospectively collected data on 18 consecutive patients undergoing en bloc resection of primary bronchogenic tumours that locally invaded the adjacent spinal column with a minimum of 12 months follow-up.

Objectives: To report on operative details, outcome scores, survival and satisfaction in this group of patients.

Summary of Background: Primary thoracic tumours with direct spinal extension have traditionally been regarded as being unresectable and thus, associated with a poor prognosis. However, en bloc surgery is now emerging as being the goal of primary tumor surgery offering the best results for survival.

Methods: We reviewed 18 consecutive patients undergoing concomitant lung and vertebral resection performed by a combined team of an orthopedic surgeon and a thoracic surgeon during 2002–2006. All patients had negative staging for systemic disease (T4 N0 M0).

Results: Mean age of patients was 62.5 +/−11.6 years (33–76 years) with a mean follow-up of 26.1 months (13–60 months). Seven patients had a one-stage procedure and 11 had en bloc resections in two stages. Mean length of operation was 995.8 minutes (280–1965 minutes). Mean estimated blood loss was 5425.8 mls (1430–12830 mls). Mean length of hospital stay was 31 days (range 9–122 days). In total, an average of 3.0 (range 2–4) vertebrae were resected – two patients had a partial vertebrectomy, 10 had a hemivertebrectomy, 2 had a total vertebrectomy and 4 had a combination. Three patients had a ‘palliative’ procedure as a result of local tumour invasion (around the great vessels and dura). The remaining 15 patients were operated with ‘curative’ intent.

The ODI (Oswestry Disability Index) score was 27.4 (+/−13) preoperatively and 42.2 (+/−10.9) post operatively (p=0.004). The scores for SF-36 (Short Form-36) were 34.0 (+/−10.9) preoperatively and 29.7 (+/−6.3) post-operatively (physical component summary; p=0.3); 39.2 (+/−7.9) preoperative and 40.6 (+/− 14.9) postoperative (mental component summary; p=0.85).

There were 6 major complications (1- wound break-down, 3 – required extended respiratory support of which 1 required thoracotomy for lung re-expansion, 1- developed severe distal junctional kyphosis requiring revision, 1 – recurrent laryngeal palsy needing thoraco-plasty) and 3 minor (2- dural tears, 1-chyle leak).

The survival in the ‘curative’ group was 10/15 (67%) with a mean follow-up of 27.3 months; five patients died at a mean of 115 days (86–129 days) due to respiratory complications. All ten surviving patients reported that they were satisfied/very satisfied with surgery. The survival in the ‘palliative’ group was 192 days (48–360).

Conclusions: There is a significant complication rate following en-bloc tumour surgery (> 50%), but curative resections are achievable at the expense of pain and function.


N Bilolikar A Nandakumar N Clark F.W Smith D Wardlaw

Aim: To study the effect of X-stop interspinous decompression device on the lumbar spine kinematics at 6 and 24 months post operatively at the instrumented and adjacent levels in patients with symptomatic lumbar canal stenosis.

Design: Prospective Observational Study of 48 patients.

Methods: Patients due to have an X stop procedure were included and had a positional MRI scan preoperatively, 6 and 24 months post operatively in erect, flexion, extension and neutral position. Disc heights, endplate angles, segmental and lumbar spine motion was measured at stenosed instrumented and adjacent levels. Osiris 4.17 software program was used to measure the canal and foraminal dimensions. The data was analysed using paired t test on SPSS ver.15.01.

Results: Forty-eight patients (25 Male and 23 Female) underwent scans preoperatively and at 6 months. Twenty-nine patients had single level and 19 had double level procedures. Three patients had removal of X stop and 5 did not have scan at 24 months, leaving 40 patients scanned at 24 months. Of these, 38 scans were complete and were included. Mean anterior disc height reduced from 7.1 mm to 6.3 mm (p=0.004) from 48 scans at 6 months and from 7.2 mm (pre-operative) to 5.9 mm (at 24 months) – (p=0.000) from 38 scans at 24 months at the instrumented level. We hypothesise that the reduction in anterior disc heights could be a result of the interspinous distraction plus the natural progression of spinal stenosis and ageing. There was no significant change in posterior disc heights at instrumented level or adjacent levels. The mean lumbar spine motion was 22.89o, 21.3 o and 21o (p=0.183) preoperatively, 6 and 24 months respectively. The total range of movements of lumbar spine and individual segments were measured. There was no significant change in the segmental range of motion at instrumented and adjacent levels.

Conclusion: X-stop interspinous device does not significantly alter the kinematics of lumbar spine at instrumented and adjacent levels at 6 and 24 months postoperatively.


Charles Pither Jens Foell Jannie van der Merwe Pauline Godwin John O’Dowd Lauren White

Education is now recognised as a crucial component of the management of non specific low back pain. Mostly education is carried out informally in one to one consultations with health professionals. This has draw backs as it is costly, time limited, labour intensive and biased towards the discipline, training and beliefs of the clinician. The Back Book is a realistic alternative but provides very generic neutral information mostly promoting the message that pain isn’t damage.

We would see the process as one of the facilitation of knowledge acquisition rather than a formal teaching process. The latter implies engagement and responsibility on the part of the learner, rather than a pedagogic exercise by clinician or therapist.

We propose a group based, community delivered, interdisciplinary education module in which 4 different specialists contribute to an afternoon information session aimed at informing patients about: the causes of back pain from a non disease perspective, the complexity of pain perception, the biopsychosocial model, evidence based treatment of pain and some principles of paced pain management. The focus is on dispelling myths (such as the need for MRI scanning, surgery etc.) and enabling sufferers to make improved decisions about their care.

Data from over 120 patient attendances will be presented. These indicate high acceptability and satisfaction with 92% rating the afternoon as good or excellent and only 11% claiming the session had not helped them make better decisions about future treatment.

This model is simple, relatively low cost and accessible to primary care, which is acceptable and seemingly helpful to sufferers. It appears to be a viable model for presenting information to back pain sufferers early in their illness. The aim of this is to help them make more informed decisions and to see the need to incorporate self management approaches early in their history. More data are needed to ascertain whether these are achievable goals.


SE Brown JS Mehta IW Nelson J Hutchinson

Background: Lenke 1 curves can be treated by a selective thoracic fusion. The lumbar curve, if flexible, can spontaneously correct itself in terms of the Cobb angle and the apical vertebral translation. De-rotation of the thoracic spine with current instrumentation systems has been reported. However, it is unclear what effect this would have on the un-instrumented lumbar curve.

Objective: We report on the changes in the apical rotation (AVR) of the un-instrumented lumbar curve following selective thoracic fusion in Lenke 1B and 1C curves.

Methods and patients: 32 patients with idiopathic scoliosis underwent a selective thoracic fusion for a Lenke 1B or 1C curves. We assessed the apical vertebral rotation of the lumbar curve before and after the selective thoracic fusion. This was measured by the Pedriolle method on the pre-, and post-operative erect radiographs. Cobb angle of the thoracic and lumbar curves before and after the fusion were also measured.

Results: The apical lumbar rotation changed form a mean of 10.7 deg (pre-op) to 7.33 deg (post-op), with a correction index of 19.8 %. The Cobb angle of the instrumented thoracic curve changed from a mean of 54.4 deg (pre-op) to a mean 24.9 deg (postop), the mean correction index was 52.9 %. The mean Cobb angle of the un-instrumented lumbar curve changed from 29.36 deg (pre-op) to 17.76 deg (post-op), with a correction index of 38.8 %.

Conclusion: Selective thoracic fusion of Lenke 1B and 1C leads to an improvement of the rotation un-instrumented lumbar curve.


N. Barua P. Plaha W. Adams N. Sudhakar T. Germon

Aim: To determine the distribution of pain which can be most reliably attributed to individual lumbo-sacral nerve root compression.

Introduction: Patients are selected for nerve root decompression based on a correlation between symptoms, signs and imaging findings. However, the belief that a given pain may be attributable to a specific nerve root varies widely between surgeons. Some will only consider decompressing a nerve root in the presence of pain radiating in a classical dermatomal distribution whilst others consider nerve root compression to be a cause of back, buttock or thigh pain.

We sought to determine the distribution of pain which significantly improves following decompression of lumbo-sacral nerve roots.

Methods: Data from consecutive patients undergoing lumbo-sacral nerve root decompression between 2002 and 2005 was prospectively analysed. Inclusion criteria were:

uni- or bilateral single level nerve root decompression

Three month post-operative visual analogue pain scores of less than 2 (0 = no pain, 10 = worst pain).

For individual nerve roots the distribution of pain described on post-operative pain drawings was sub-tracted from that described on pre-operative pain drawings. This produced a composite pain drawing demonstrating the distribution of pain most reliably improved by decompressing a particular nerve root.

Results: 52 cases fulfilled the inclusion criteria. There were 6 L4, 36 L5 and 17 S1 nerve root decompressions. The distribution of dramatically improved pain following nerve root decompression did not follow the classic dermatomal patterns described in standard text books.

Conclusions:

Pain as a consequence of lumbo-sacral nerve root compression does not appear to be restricted to classical dermatomal distributions.

Lumbo-sacral nerve root compression may be a significant cause of back pain.

In order to decide who is likely to benefit from lumbo-sacral nerve root decompression further characterisation of the pain distribution attributable to lumbosacral nerve root compression is required.


JRA Phillips NG Farrar S Elsayed R Bommireddy D Calthorpe Z Klezl

Osteoporotic vertebral fractures predispose to significant morbidity in the elderly and are strongly associated with an overall decline in health, functional status and social drift.

Current evidence supporting the use of kyphoplasty versus medical management alone in the management of these factures is limited and based on several small prospective cohort studies. These published case series report the use of several end points, variously including Visual analogue score (VAS), Vertebral height, kyphosis angle and Oswestry disability index (ODI).

We present prospectively collected data supporting the use of kyphoplasty in a U.K. based population tested by examining VAS, vertebral height, vertebral and kyphosis angles, ODI and hospital anxiety and depression score (HADS).

40 patients in our kyphoplasty group have undergone 70 kyphoplasty procedures. With a mean follow up of 6 months, the mean post-operative VAS score was 3.9 versus a pre op score of 8.5. This reduction was maintained at 6 weeks and 6 months with mean scores of 3.7 and 3.8 respectively.

Functional status ODI scoring improved from a pre-operative score of 53 to 48 post-operatively, to 42 at 6 weeks, and further, to 41 at 6 months. This result was reinforced by HADS scoring at the same time intervals recording 15.3, 12.0, 10.1 and 11.3 respectively.

Post-operative radiographs demonstrated a 24% mean increase in the vertebral angle with increases in the anterior, middle and posterior vertebral body heights of 26, 40 and 11 % respectively. Kyphosis angle has been improved by a mean angle of 2 degrees.

The Derby experience demonstrates that kyphoplasty can improve pain and functional status and may help correct deformity after osteoporotic vertebral compression fractures.

Our experience has encouraged further recruitment for kyphoplasty as the preferred management for those patients who fail to respond to initial non-operative management.


N A Quraishi E Buchanan S Al-Ali

Background: Guidelines for the management of Low Back Pain (LBP) consistently recommend that the initial assessment focuses on the detection of serious spinal pathologies. In 1994 the UK Clinical Standards Advisory Group introduced the concept of “red flags”. One of these red flags is the first presentation of LBP in people over the age of 55 years. The aim of this study was to investigate the incidence of serious spinal pathologies in patients presenting with new onset of LBP over the age of 55 years.

Method/Results: This was a prospective analysis of all patients presenting to a secondary care spinal triage service over a 3 year period (2005–2008). During the study period, in excess of 3000 patients were seen. Of these, a total of 70 patients presented with a first onset of LBP aged over 55 years and had no other red flags. Analysis of this group of patients revealed 2 serious spinal pathologies. Both of which were osteoporotic vertebral compression fractures. Both patients were over age 75. In addition 1 patient had severe central lumbar canal stenosis. Therefore, 2.3% of patients presented with the first onset of LBP > 55 years, of which 2.9% has serious pathology. Patients > 55 years with cancer or infection had other red flags in addition.

Conclusion: In isolation the first onset of LBP over the age > 55 accounts for a small percentage of this secondary care population, of which 2.9% had vertebral compression fractures. Further research into the clinical value of this independent red flag or its added value in combination with other red flags is recommended.


JK O’Dowd N Courtier

Introduction: This is a report on results from the first three years of the British Spinal Registry

Background: The British Scoliosis Society supported a web based scoliosis registry in 2003. At the Britspine meeting in 2004 all four British spine societies (BSS, BASS, BCSS, SBPR) agreed to expand this to include all spinal surgical procedures in the United Kingdom. An extensive marketing and promotional campaign was targeted at all members of the four societies, and online and telephone support was provided.

Aims: To report on the clinical results from the first three years registry activity

Methods: The British Spinal Registry is a web based out-come tool, collecting basic demographic and outcome data on spinal surgical procedures in the UK. Over three years from November 2004, 1410 patient data sets were entered. The activity analysis is party carried out using the online diagnostics that are part of the web based software tool, and partly with downloaded data.

Results: 73 surgeons from 55 centres entered patient data on 1410 surgical episodes between November 2004 and December 2007. The number of patients entered per year has declined marginally, with 540 patients in the first year, 454 in the second and 416 in the third. The majority of cases entered have a low back diagnosis (842) of whom 106 were part of a BASS audit on discectomy. Of the low back cases 40% had disc herniation and 7.4% had previous surgery. The complications included dural tear (3.7%), nerve root injury (0.4%) and infection (1.1%). The BASS study showed that 70% of UK surgeons were not using intraoperative radiographic localisation of surgical level. There were 448 deformity cases, and of these 223 were idiopathic scoliosis, 49 neuromuscular and 20 congenital. 57% had posterior surgery, 20% anterior and 23% combined. There were no intraoperative deaths, no complete spinal cord injuries, 4 partial spinal cord injuries (0.9%), 6 deep infections (1.3%) and 14 implant revisions (3.1%).

Conclusion: The initial clinical results from the British Spinal Registry support the hypothesis that such registries can produce useful audit data. There is no other record nationally of number and type of procedures in spinal surgery in the UK. The complication rates are similar to those reported elsewhere and provide an opportunity for benchmarking and for comparative personal and centre audit. The uptake and usage rates however are low and would not allow scientifically valid clinical results to be reported.


S Batra S Ahuja DG Jones A Jones J Howes PR Davies

In a high-risk technically advanced speciality like spine surgery, detailed information about all aspects of possible complications could be frightening for the patients, and thereby increase anxiety and distress. Therefore, aim of this study was to

Analyze written evidence of the consenting procedure pertaining to (a) nature of operation (b) benefits intended as a result of the operation (c) risks specific to the particular type of operation (c) general risks of spine surgery and anaestheia.

Patients’ experiences of information regarding the risk of such complications and how the information affects the patients.

Methods: 70 adult elective, consecutive patients who had been listed for Lumbar discectomy /decompression surgery were chosen. The patients were presented with questionnaire of broad-based and open-ended questions designed to elicit theirs views in each of the following areas: expectation, knowledge of risks and alternatives, and personal attitude to information and satisfaction.

The study had a non-randomized design and patients divided into TWO groups Group A and group B.

The patients in the group A received standard information and were consented in a routine way without being given written proforma with all complications. The patients in the group B were given the same information as patients in the control group, with written information about common and rare complications. Patients in both groups were assessed on an ‘impact of events scale’ and hospital anxiety and depression scale immediately before ad after the consent process and again after surgery when they were discharged from the hospital.

For comparison of the proportion of Yes and No answers in 2 groups, Fisher’s exact test was used, and for comparison of more than 2 groups, the Chi-square test was used. For graded answers and other ordinal scales, the Mann–Whitney U-test was used for comparison of 2 groups and the Kruskal–Wallis test for comparison of more than 2 groups. Spearman’s test was used when assessing the correlation between 2 variables measured on an ordinal scale.

Results: Many patients (71%) agreed that the consent form made clear what was going to happen to them, and 77%) reported that it made them aware of the risks of the operation they were to undergo. Over a third (36%) saw it as a safeguard against mixups in the operating theatre. Few patients’ decision to accept surgery appeared to depend on risk information; 8% of patients said that they might have changed their decision, had they been advised of the risks of permanent stroke and myocardial infarction. However, 92% were clear that their decision to accept treatment would not have altered. The women in the group B had symptoms of definite anxiety to a significantly higher degree than the men before the operation. Post-operatively, patients receiving extended information were significantly more satisfied with both the written and oral information about common and rare complications than patients in the control group There were no statistically significant differences between the groups for anxiety or depression, as measured by the HADS, either before or after the operation between Group A and B. Provision of extended information describing most of the possible complications did not have any negative effects on the patients. The patients receiving the extended information were more satisfied and experienced to a higher degree that they could discuss alternative treatment methods with the surgeon. Discussion: Provision of extended information describing most of the possible complications did not have any negative effects on the patients. “Ignorance is bliss” may prove to be an excellent preoperative strategy for patients when outcome is good but detrimental to long term adjustment where significant postoperative complications arise. This raises the possibility that a separate consent could be used where these risks are pre-printed and explained in vocabulary easily understood by patients. The added advantages of this form would be less confusion for the patient and there would be written evidence that patients had understood each of the major risks involved with the proposed procedure. This proposed consent form would also reduce the chance that important risks and complications are omitted when consent is being taken, as well as tackling the issue of variability of experience or lack of knowledge by the person obtaining consent.


ROE Gardner E Chaudhury R Baker IJ Harding

Objective: An anatomical study to describe the radiographic pattern of canal, foraminal and lateral recess stenosis in degenerative lumbar stenosis associated with open and closed subluxations of the lumbar spine.

Introduction: Degenerative lumbar scoliosis is a three-dimensional deformity frequently associated with facet joint subluxation. It is suggested that the causative mechanism of open subluxation is vertebral rotation, whereas closed subluxation is driven by erosion of the convex facet joint. Patients with degenerative lumbar scoliosis are predominantly symptomatic on standing. However, standing MRI scans are not currently feasible to investigate this dynamic problem, therefore an accurate interpretation of the standing and lateral radiographs is essential to effectively treat this condition. We have undertaken a study to compare standing radiographs with supine MRI to determine the pattern of nerve root entrapment with open and closed facet joint dislocations in DLS.

Methods: Plain radiographs and MRI scans of 35 consecutive patients with de novo degenerative lumbar scoliosis (average age 72 years) were evaluated. Radiographic measurements included the angle of the dislocation, degree of translation, position of osteophytes, vertebral rotation and the degree and location of any stenosis present on the axial MRI images.

Results: Open dislocations were associated with a pre-dominant contralateral lateral recess and/or foraminal stenosis in 74% of cases. Closed dislocations were associated with ipsilateral lateral recess and/or foraminal stenosis in 82% of cases. Both open and closed dislocations had a similar degree of vertebral rotation.

67% of open subluxations occurred at L3/4. In closed subluxations the most frequent level involved was LI/2 (53% of cases). Open dislocations are located closest to the apex of the curve, with closed dislocations being more peripheral. The curve was noted to rotate towards the apex.

Conclusion: Open and closed subluxations of the lumbar spine result in different, but predictable, patterns of stenosis. The findings are important in the diagnosis and planning of treatment in patients with lumbar spinal stenosis, when associated with degenerative scoliosis and lateral spondylolisthesis.


Appajikrishnan Rajapandian Sivaraman Sajan Hegde

Summary. Between January 2003 and October 2004,12 patients with non tuberculous spondylodiscitis were treated by radical debridment, reconstruction and stabilization. In our group 9 patients underwent posterior procedure and 3 underwent combined anterior and posterior procedures. 3 of these had fungal and 9 pyogenic infections. All the patients had appropriate antimicrobial therapy All patients had excellent to good functional results and no evidence of infection at 2 year follow-up.

Introduction. Surgical treatment of nontuberculous spon-dylodiscitis of lumbar spine is challenging due to extensive bone involvement and comorbid conditions. This study is to assess the role of radical debridment followed by reconstruction and stabilization of affected segments in reducing morbidity and mortality in these patients.

Methods. 12 consecutive patients were operated between January 2003 and October 2004. Patients presented with severe back pain, root compression or paraparesis.7 cases had prior spinal surgery. Blood and radiological investigations were diagnostic. All these patients underwent radical debridement, reconstruction and stabilization of affected segments done with titanium pedicular screws, titanium mesh cages, cancellous iliac crest graft. Only posterior procedure in 9 cases, combined anterior posterior in 3 cases followed by adequate and appropriate antimicrobials therapy. Follow-up ranged from 25 to 35 months.

Results: 3 cases were fungal and 9 were pyogenic infection. Oswestry low back questionnaire, kirkaldy-willis criteria showed dramatic improvement of function. All the blood parameters were normalized in 3 months.1 case had dural tear which was repaired immediately,3 cases had wound exploration and lavage. No major complications were encountered. All cases showed Radiological fusion at last follow-up.

Discussion: Radical debridement of necrotic material, decompression of neurological structures, create a good vascularised environment. Restoring stability compromised by either infection or prior surgery helps in healing process and reduces morbidity of patients

Significance: Reconstruction using pedicular system and interbody devices can safely be used in presence of non tuberculous infection provided debridement has been radical.


A Khurana A Guha J Howes A Jones P Davies K Mohanty A Ahuja

Introduction: Sacroiliac joint (SIJ) is a diarthrodial joint and can often be a source of chronic low back pain complex. We present a percutaneous technique for SIJ fusion and the functional and radiological outcome following the arthrodesis.

Aims and Objectives: To evaluate the functional and radiological outcome following percutaneous technique for SIJ fusion with HMA (Hollow modular anchor-age) screws.

Materials and Methods: 15 consecutive patients operated for SIJ fusion between Sep 2004 and Aug 2007 were included in the study. The diagnosis was confirmed with MRI and diagnostic injections. Pre-operative and post-operative functional evaluation was performed using SF-36 questionnaire and Majeed’s scoring system. Postoperative radiological evaluation was performed using plain radiographs. The Hollow modular anchorage (HMA) screws (Aesculap Ltd, Tuttlingen) packed with bone substitute were implanted percutaneous under fluoroscopic guidance

Results: The study group included 11 females and 4 males with a mean age of 48.7 years. Mean follow-up was 14 months. Mean SF-36 scores improved from 37 to 80 for physical function and from 53 to 86 for general health. The differences were statistically significant (Wilcoxon signed rank test; p < 0.05). Majeed’s score improved from mean 37 preoperative to mean 79 postoperative. The difference was statistically significant (student t test, p< 0.05). 13 had good to excellent results. The remaining 2 patients had improvement in SF-36 from mean 29 to 48. Persisting pain was potentially due to coexisting lumbar pathology. Intra-operative blood was minimal and there were no post operative or radiological complications in any patient.

Conclusion: Percutaneous HMA screws are a satisfactory way to achieve sacro-iliac stabilisation.


GC McLorinan F Younis H Dashti NJ Oxborrow JB Williamson

Background: Prader-Willi syndrome is associated with multiple musculoskeletal manifestations including scoliosis, joint laxity, hip dyplasia and lower limb deformity. Scoliosis is reported in almost half of patients with Prader-Willi; however, only a small proportion ever have surgery. The literature suggests that surgery in this group of patients is often difficult. Obesity and apnea cause anaesthetic concern. The surgical procedure is reported as being complicated by excessive intra-operative blood loss, and difficulty with instrumentation; possibly as a result of osteopenia, is described.

Purpose: To compare the experience of scoliosis surgery in Prader-Willi patients in our institution with that previously reported in the literature.

Methods: The notes and x-rays of 6 patients with Prader-Willi syndrome who had corrective scoliosis were reviewed.

Results: Six patients (4 female and 2male) underwent corrective scoliosis surgery. The mean age at which scoliosis was detected in the patients was 5 years (range 2–7years). The mean Cobb angle at time of initial referral was 30° (range 8°–86°). Indication for surgery in all cases was curve progression. The mean age at time of surgery was 11.8 years (range 10–13years). The mean pre-operative Cobb angle was 70° (range 40°–90°) and mean post-operative Cobb angle was 23° (range 10°–40°). Three patients had posterior surgery with instrumentation, one had anterior instrumentation only and two patients had combined anterior release with posterior instrumentation. The most proximal instrumentation levels ranged from T2–T6 and the most distal instrumentation levels ranged from T11-L5. Three patients had all pedicle screw fixation, 2 had hybrid fixation (with screws at curve apex) and one had anterior all screw fixation. The mean operative time was 335 mins (range 190–540 mins) and the mean blood loss was 29% of total blood volume (range 14–55%). Standard anaesthetic technique was used in each case and all patients were extubated immediately after surgery. Patients were discharged on average 8 days post surgery (range 6–14 days). One patient had a wound infection and a stitch granuloma requiring surgical debridement and one patient required trimming of proximal end of rod because it was prominent.

Conclusion: Scoliosis surgery in patients with Prader-Willi offers adequate deformity correction and in our experience is not associated with operative technical difficulty, major complications or a prolonged hospital stay.


A Nandakumar N Clark N Bilolikar FW Smith D Wardlaw

Aim: To assess the clinical effectiveness of X stop interspinous decompression device in patients with neurogenic claudication due to lumbar canal stenosis at 24 months post surgery.

Design: Prospective Observational Study of 57 patients with X stop procedure.

Methods: Fifty-seven patients with unilateral or bilateral leg pain due to lumbar canal stenosis, who had significant relief from sitting or flexing the lumbar spine, were treated with X stop.

Clinical outcome was assessed by Zurich claudication questionnaire (ZCQ), visual analogue score (VAS), Oswestery disability index (ODI) and SF36 questionnaires preoperatively and at 2 years. ZCQ has three components- symptom severity, physical function and patient satisfaction. ZCQ is considered the most precise, reliable and condition specific questionnaire for lumbar canal stenosis.

Out of 57 patients, 2 died due to unrelated causes, 3 withdrew from study and 3 had the device removed within 2 years. Forty-five, 44, 42 and 48 completed ZCQ, ODI, SF-36 and VAS respectively at 24 months.

Results: The mean age was 71(53–94) and M: F ratio 29:28. X stop device was inserted at single level in 32 (56%) and double levels in 25(44%) patients. In single level cases, 72% reported improvement in symptom severity, 65% in physical function, 68% were satisfied with the procedure, and overall 55% made a clinically significant improvement at 24 months. In double level cases, the figures were 62%, 68%, 78% and 40% respectively. The threshold for changes in symptom severity was 0.46, physical function was 0.42 and patient satisfaction 2.42. Overall clinically significant improvement requires that a patient achieves at least 2 criteria.

The mean ODI improved by 6.5 in single level and 10.8 in double level cases. The SF-36 showed improvement in physical function, role physical, bodily pain and vitality social domain.

Average hospital stay for the procedure was 1.6 days. One patient stayed for 10 days for investigation unrelated to the procedure. There were no major complications.

Conclusions: The results of our study show that the X stop interspinous decompression device remains clinically effective at the end of 2 years. X stop is a relatively less invasive procedure, especially suitable for patients with other co-morbidities, which can be performed as a day case procedure without major complications.


E Garrido F Tome SK Tucker HNN Noordeen TR Morley

Study Design: Retrospective study with clinical and radiological evaluation of 29 patients with congenital scoliosis who underwent 31 short segment anterior instrumented fusions of lateral hemivertebrae.

Objective: To evaluate the safety and efficacy of early surgical anterior instrumented fusion with partial preservation of the HV in the treatment of progressive congenital scoliosis in children below the age of 6.

Summary of background data: A variety of treatments have been described in the literature for the treatment of HV. We report the results of a novel technique.

Materials and Methods: Between 1996 and 2005, 29 consecutive patients with 31 lateral HV and progressive scoliosis underwent short segment anterior instrumentation and fusion with preservation of the HV. Mean age at surgery was 2.9 years. Mean follow-up period was 6.3 years.

Results: Preoperative segmental Cobb angle averaging 39°, was corrected to 150 after surgery, being 15º at the last follow up (60% of improvement). Compensatory cranial and caudal curves corrected by approximately 50% and did not change significantly on follow up. The angle of segmental kyphosis averaged 13º before surgery, 12º after surgery, and 12° at follow up. There was 2 wound infection requiring surgical debridment, 1 intraoperative fracture of the vertebral body and 1 case lost correction due to implant failure. All went on to stable bony union. There were no neurologic complications.

Conclusions: Early diagnosis and early and aggressive surgical treatment are mandatory for a successful treatment of congenital scoliosis and to prevent the development of secondary compensatory deformities. Anterior instrumentation is a safe and effective technique capable of transmitting a high amount of convex compression allowing short segment fusion which is of great importance in the growing spine


RG Bharadwaj NS Harshavardana AS Sahu MS Singh A Singla RH Hartley

Introduction: Spinal pathologies requiring spinal/neurospinal unit’s input/opinion from tertiary centers for their management are initially admitted to DGHs. The referral is usually done by mailing patient’s x-rays/scans with clinical details to the on-call registrar who gets back with a management plan. This arrangement is fraught with delays at various levels having an impact on patient care, mortality & morbidity, financial and medicolegal implications. We discuss these issues between index DGH (Poole Gen Hosp, Dorset) and its tertiary referral centers (Southampton/Reading/Bristol/Oxford/Stanmore).

Objectives: To review the existing management of spinal injury admissions at Poole DGH, analyse critical/ adverse incidents and efforts aimed at minimising them, to identify areas for improving patient care & safety and to draft a regional management protocol/care pathway for spinal admissions.

Methods: A comprehensive retrospective review of all spinal admissions/referrals made to tertiary centers over 6 months (Jan–June 05) was undertaken. 28 of the 64 admissions warranted referrals. A structured proforma was used to document the time of admission, time of formulating clinical diagnosis, time of booking scans, time of performing scans, time of referral to tertiary centre, time of response from tertiary centre and time of transfer were retrieved from case notes and reasons for delay (if any) at each level were critically analysed.

Results: 7 of the 28 referrals had either neurodeficit or spinal instability. Common reasons for delay were delay in obtaining CT/MRI scans (av 2.5 days), delay due to reporting/failing to act on scan results (av 1 day), delays due to missing/‘lost in transit’ scans (av 1.5 day), delay in obtaining opinion from tertiary centre (av 4 days) and non-availability of bed for transfer (av 5.5 days). There was 1 mortality and 5 other complications while awaiting transfer. The financial costs incurred were appx £73,000 & loss of 246 patient-days.

Discussion: Training of junior doctors at induction, implementation of spinal care pathway and diligent documentation/communication coupled with succinct referral to the tertiary centre were strictly enforced following this study. The website www.neurorefer.co.uk was set up by Wessex neurological centre, Southampton to streamline referrals, circumvent lost in transit scans and enhance efficiency which has now grown into a national secure referral portal incorporating other referral centers.


NS Harshavardhana UK Debnath HV Dabke BM Boszczyk MP Grevitt SMH Mehdian

Introduction: The literature regarding the functional outcome following C1–C2 surgeries for non-rheumatoid C1–C2 pathologies following selective arthrodesis is sparse.

Aim: To determine the long term correlation between functional outcome and radiological determinants following C1–C2 fusion for conditions other than RA.

Methods: All C1–C2 surgeris performed between 1988–2002 for non-RA etiologies were reviewed retrospectively. Selective C1–C2 fusion performed in 32 pts with a min f/u of 5 yrs formed the study group. The mean age at surgery was 57.2 yrs (r 22–84yrs). The etiologies were trauma (15), non-union (6), congenital AAD (2), C1–C2 deg. arthropathy (2), os odontoideum (2), tumours (4) and instability due to TB (1). Neurodeficit were present in 7 pts. Transarticular (TA) screws supplemented with posterior wiring was performed in 27 & posterior wiring alone in 5 pts respectively. A monocortical H-shaped autograft from iliac crest was used in all cases. There were two deaths & two pts were lost for F/U. The mean F/U was 7.8 yrs (r 5–13 yrs). Disability & pain using NDI & VAS and subjective satisfaction were recorded in all pts. We measured 1) C1/2 fixation angle, 2) Inclination of C1, 3) Anterior shift of C2 and 4) C2–7 lordosis on pre and final F/U lateral x-rays.

Results: Optimal TA screw placement was seen in 78.5% of pts. The mean improvement in NDI & VAS were from 55.4% to 19.6% and 8.4 to 1.6 respectively and was better in younger pts. Fusion was seen radiologically in 82.1% of pts at 12 mo post surgery. Segmental stability and resolution of symptoms was seen in all patients despite implant failure in 4 and incomplete fusion 5 cases respectively. Two wound dehiscences needed debridement of which one elderly pt died of MRSA sepsis 2 mo post-op. The C1–C2 segmental lordosis was significantly increased by surgery (−4.2 0 vs. −11.80; P=0.016). The subaxial cervical spine became less lordotic in initial few months post-op but eventually regained more lordosis as time progressed. The C1 inclination came into more extended position w.r.t horizontal line post-op with minimal loss of inclination subsequently. C1–C2 fixation angle and anterior shift of C2 did not have significant correlation with long term functional outcome i.e. NDI and VAS (r=0.35, p=0.17).

Conclusion: The functional outcome following C1–C2 arthrodesis is usually good despite metalwork issues and incomplete fusion in these selective group of non-rheumatoid arthritis pathologies.


MR Bapat NS Harshavardhana KS Chaudhary US Metkar AK Sharma SV Marawar VJ Laheri

Introduction: Formulation of surgical protocol in CSM is marred by the diversity in clinico-radiological presentation. Prospective data that assigns a specific surgery with identifiable similarities in clinico-radiological attributes is sparse.

Objectives:

To identify radiological patterns of compression (POC) of the spinal cord

To develop a surgical protocol based on POC and determine its efficacy.

To identify parameters predicting outcome of surgery

Methods: 135 consecutive patients aged 32–75 yrs (mean 48.1yr) operated for CSM from 1999–2005 formed the study group for this prospective series. The objectives were to identify radiological patterns of compression (POC), develop a surgical algorithm based on POC and evaluate outcome. Four POC were identified on MRI.

Pattern I – predominant one/two level compression in normal/narrow canal

Pattern II – anterior & posterior compression at one/ two levels (pincer cord)

Pattern III – Three or more levels of predominant anterior compression with a normal canal

Pattern III(A) – Pattern III in a patient with multiple medical co-morbidities

Pattern IV – Three/more levels of anterior compression in narrow canal +/− posterior compression (beaded cord)

Pattern IV(A) – Pattern IV with one/two level severe compression amongst the multiple anterior compressions.

Mean follow-up was 3 yrs (2–8). ACDF was performed for patterns I, II & III and posterior decompression for pattern IV and III(A). For pattern IV(A), a two stage primary posterior decompression followed by targeted ACDF at the site of maximal compression was performed. The clinical outcome was measured by modified JOA (mJOA) score, Hirayabashi Recovery Rate (HRR) and functional outcome by modified Neck Disability Index (NDI).

Results: The mean pre & post-op mJOA score was 10.40±3.33 & 15.76±1.45 respectively with average HRR of 80.10 ± 26.38. The difference in the mJOA scores was statistically significant (unpaired t test) for each POC. In multilevel CSM, anterior surgery in POC type III had statistically better post op mJOA as compared to those who underwent posterior surgery viz POC types IV and III & IV variants although the difference in their HRR and NDI were not statistically significant.

Conclusion: Anterior surgery has better neurological outcome in judiciously selected patients with multilevel CSM. Surgical decision-making guided by patterns of compression (POC) is pivotal for optimal functional outcome.


MR Bapat NS Harshavardhana KS Chaudhary US Metkar AK Sharma SV Marawar VJ Laheri

Introduction: Cervical kyphosis is failure of posterior osteo-ligamento-muscular restraint secondary to a deficient anterior column. Prospective studies of stand-alone anterior construct in correction and maintainence of cervical column that would otherwise require combined ant & post surgeries is sparse.

Objectives: To evaluate the role of stand-alone anterior surgery for cervical kyphosis, determine its efficacy and analyse complications.

Methods: 42 consecutive patients aged 6 – 70 yrs (Av 31.4 yrs) who had a Kyphosis angle of more than 100 with its apex between lower end-plate of C2 and C7 on a lateral x-ray and underwent anterior only surgery for cervical kyphosis over 6 yrs (2000–06) formed the population for this prospective study. The average follow-up was 2.2 yrs (1 – 5 yrs). The mean pre-op kyphosis was 20.820 (100 – 780). Etiology was tuberculosis in 25, dysplasia in 7, trauma in 6 and tumors in 4 cases respectively. 39 of the 42 patients had myelopathic signs. Mean pre-op mJOA score was 7.4 (0–11). A left anterior cervical approach was used in all cases. Modified manubriotomy was required in 5 cases to instrument the caudal vertebra. Tricortical iliac crest strut graft was used in 40 and cylindrical mesh cage in 2 cases. Correction of kyphosis was achieved by intra-op adjustment of the head assembly & controlled distraction. Post-operatively all wore cervical orthosis for 3 mo.

Results: 41 patients were available for analysis (1 lost for f/u). The average number of corpectomies required were 2.5 (1–4) and the mean anterior column defect reconstructed was 27.3mm (22–42mm). The average graft subsidence was 3mm (0–10mm). 2 patients required revision surgery within 6 weeks for implant failure/graft resorption. Fusion occurred in rest of 39 patients. No further graft subsidence was noticed at 4 years in 17 patients. Spontaneous fusion at 3 mo was seen in normal adjacent segment due to plate overlapping in 2 cases. The average correction achieved was 15.220 (−40–730). The mortality rate was 2.12% (1 case). Visceral complications occurred in 3 cases (esophageal perforation in 1 and recurrent laryngeal nerve palsy in 2). The mean post-operative mJOA score was 14 (9 – 17). There was 1 deep and 1 superficial infection.

Conclusion: Ant decompression & reconstruction with instrumentation facilitates neurological recovery restoring alignment. Intra-op maneuvering allows the graft to be placed in an optimal position that allows fusion under compression.


NS Harshavardhana HV Dabke UK Debnath BJC Freeman

Introduction: Ronald McRae’s textbook clinical orthopaedic examination mentions “Capasso’s method1 of evaluation of coronal plane deformity to be the most sensitive tool of measuring cobb angle. However there is no study to date evaluating/comparing this method against popular & widely used tools viz. cobbometer and traditional protractor.

Objectives: To evaluate Capasso’s method against commonly used measurement aids w.r.t measurement of cobb angle in scoliosis.

Summary of background data: Studies of Cobb method of measurement have multiple sources of error and intra & inter-observer variability. The Capasso’s method which is based on “bi-uni-vocal principle” views the scoliosis curve to be an arc of circumference and to be a true reflection of angular values and hence geometrically more valid.

Methods: 24 scoliosis curves were measured by three different examiners on three separate occasions one week apart by 1) Capasso’s method 2) Cobbometer and 3) Traditional protractor on same set of hard copies of digital x-rays. The three set of Cobb angle readings obtained were statistically analysed for intra & inter-observer reliability and assessed for agreement between the three methods of clinical measurement.

Results: The mean intra observer variability for protractor, cobbometer & Capasso’s methods were 8.50, 5.50 10.00 respectively. The cobb angle readings obtained by Capas-so’s method was higher than the other two methods for all magnitudes of the curves (< 300, 300–600 & > 600) and was more than two times the conventional readings for curves < 300. The disagreement between Capasso’s method with either of the other two methods (cobbometer & protractor) was statistically significant (p< 0.01).

Discussion: This study demonstrates that Capasso’s method significantly overestimates the magnitude of scoliotic deformity esp. for curves < 300 as compared to other existing popular measurement tools. Surgical decision making if were to be based on it would invite criticism and wrath. The present existing methods have their own limitations and the need of the day is a simple three dimensional measuring system to accurately define the magnitude of the deformity.


NS Harshavardhana R Shahid BJC Freeman BM Boszczyk Hegarty A Race J Weston MP Grevitt

Introduction: Accurate and ethical coding is challenging and directly impacts on Payment by Results (PbR). The aims & objectives of this study were to review the existing pattern of coding for spinal surgery and ascertain its appropriateness & accuracy for surgical procedures, medical co-morbidities and post-op complications.

Methods: A retrospective review of 70 consecutive cervical and 100 consecutive lumbar spine patients who were operated from April 2006 onwards was conducted. The excel sheet provided by coding department, hospital notes – clinic letters, physicians’ entries, theatre notes and laboratory reports (biochemistry/microbiology/histology) – were reviewed. Of the 170 cases, 165 were available for analysis.

Results: Coding data of 5 patients who underwent cervical spine surgeries were not available. Of the 165 cases, the accuracy of primary procedural codes was 93.9% (90.8% cervical & 96% lumbar). However this reduced to 77.6% (75.4% cervical & 79% lumbar) when the accuracy for entire description of performed surgery was considered. The procedural codes did not specifically reflect the surgery performed and lacked reproducibility. Surgical levels were coded incorrectly in 9% of the cases. Cervical surgeries were coded as lumbar in 4 and posterior surgery as anterior in 3 cases respectively. Harvest of iliac crest bone graft was not coded in 5 cases. Medical comorbidities were coded appropriately in 64.2% of the patients (55% cervical & 70% lumbar). The commonly missed comorbidities were drug allergies, hypercholesterolemia, smoking and alcoholism. Post-op adverse events were coded in 75% of the cases (16/20 cervical & 5/8 lumbar). The accuracy was better for lumbar as compared to cervical spinal surgeries.

Conclusion: Coding is a universal language of communication amongst healthcare professionals. Its accuracy is important not just for PbR, but for data quality, audit and research purposes too. The financial implications regarding PbR governed by HRG codes (dictated by OPCS 4.4 & ICD–10 codes) are discussed. The awareness of clinical coding is low amongst junior doctors. Following this study, a clinical coding facilitation form has been introduced to improve data quality. Our plan is to close the audit loop and re-evaluate. Literature emphasises qualification of coders, legible documentation by physicians and interaction between coders and clinicians.


R.J. Oakland N.R. Furtado J. Timothy R.M. Hall

INTRODUCTION: In the spinal column, bone metastases (BM) and lesions arising from multiple myeloma (MM) can cause severe weakening of the vertebral body (VB) leading to an increased risk of fracture1. These vertebral fractures may induce severe pain, deformity and increased risk of neurological deficit2. At present, however, there is very little known about the mechanical behaviour either of the infiltrated vertebrae or that following vertebroplasty (VP). The purpose of this preliminary investigation was to evaluate (i) the mechanical behaviour of vertebrae with lesion involvement, and (ii) the effectiveness of VP with coblation.

METHODS: Individual vertebrae from two spines, one with MM (n=13) and one with BM secondary to bladder cancer (n=12) were dissected free of soft tissue with the posterior elements retained. Three MM vertebrae with evidence of previous fracture were excluded. Each vertebrae was fractured under an eccentric flexion load from which fracture strength and stiffness were derived3. VBs were then assigned to two groups. In group 1, lesion material was removed by coblation prior to VP and in group 2, no coblation was performed prior to VP. All vertebrae were fractured post-augmentation under the same loading protocol. At each stage microCT assessments were conducted to investigate lesion morphology and cement volume/distribution.

RESULTS: MM vertebrae were characterised by several small lesions, severe bone degradation and multiple compromise of the cortical wall. In contrast, large focal lesions were present in the BM vertebrae and the cortical wall generally remained intact. The initial failure strength of the MM vertebrae were significantly lower than BM vertebrae (L=2200N vs 950N, P< 0.001). A significant improvement in relative fracture strength was found post augmentation for both lesion-types (1.42 ± 0.51, P=0.0006). Coblation provided a marginally significant increase in the same parameter post-augmentation (P=0.08) and, qualitatively, improved the ease of injection.

CONCLUSIONS: Bladder BM and MM vertebral lesions showed significant variations in lesion morphology, bone destruction and the level of cortical wall breach, causing significant changes in the bone fracture behaviour. Account should be taken of these differences to optimise the VP intervention in terms of cement formulation and delivery. Preliminary results suggest the current VP treatment provides significant improvements in failure strength post-fracture.


BJ O’Daly JM Queally JM O’Bryne K Synnott MM Stephens

Horse riding is a popular competitive sport and leisure pursuit worldwide. Previous research has highlighted the unpredictable and independent nature of horses and high injury risk inherent in travelling at speeds of up to 65kph, 3-metres above the ground on an animal weighing between 450–500kg. In Ireland, jockeys register with the Turf Club as either professional or amateur with the remaining riders participating as unregistered.

The aim of this study is to determine the national incidence of acute spinal cord injury (ASCI) and vertebral body injury (VBI) in horse riding in the Republic of Ireland, and to compare and contrast injury characteristics in registered and unregistered riders over an 11-year period (1995–2005).

Chart review and structured telephone interview was performed in all cases to determine mechanism of injury, discipline, protective equipment, immediate management and whether the rider considered the injury could be prevented. American Spinal Injuries Association (ASIA) impairment score was used to classify outcome. Data for injuries sustained in competitive racing, for both registered and unregistered riders, was correlated with Irish Turf Club race records to ensure accuracy.

Results: Sixteen cases of ASCI and 46 of VBI were identified over the study period (Table 1). Over the study period, there was a mean annual incidence of 1.5 (1 to 4) ASCI and 4 VBI (0 to 7). Cervical injuries were significantly more likely to result in ASCI (n=14 (52%), p=0.004) than either thoracic or lumbar injuries. Riders who had an ASCI spent more days in hospital (p=0.007); were less likely to have had a previous riding injury (p= 0.046); and following injury, less likely to return to horse riding at any level (p= 0.033). Seven ASCI (44%) and ten VBI (22%) patients were managed operatively. Three ASCI (19%) and 4 VBI (9%) occurred in registered riders. A fall in flight jumping was the commonest injury pattern (32%) overall, with 60% of ASCI and 26% of VBI by this mechanism occurring in registered riders. Overall, only 19% of riders report wearing a back protector at the time of injury. Of these, 30% sustained cervical injury, 17% thoracic injury and 0% lumbar injury. For ASCI riders, final ASIA impairment classification was A= 4, B= 2, D= 4 and E= 5.

Conclusion: Equestrian sports, both for registered and unregistered riders pose substantial risk. Despite greater compliance with wearing of protective equipment, registered riders are at increased risk of sustaining ASCI than unregistered risers. Morbidity is significant following ASCI, with ten riders permanently disabled as a direct result of participation.


H Sharma R Reid AT Reece

Introduction: Benign bone-forming tumours are common in children and adolescents. Careful radiographical and histological study is necessary to distinguish slow growing from more aggressive bone forming tumours. We reviewed 25 cases of primary benign bone forming tumours of the spine to investigate whether there were any obvious differences in the biological behaviour of such tumours in adults compared to children.

Materials and Methods: Twenty five cases of primary benign bone forming tumours of the spine were identified from the Scottish Bone Tumour Registry: this data is collected prospectively. A retrospective review of this data was performed. There were 9 osteoid osteomas,15 osteoblastomas and 1 aggressive osteoblastoma. These cases were divided into group A (children) and group B (adults).

Results: There were 16 patients in group A (6-osteoid osteoma, 9-osteoblastoma, 1-aggressive osteoblastoma), 10 boys and 6 girls. The mean age was 12.1 years (range, 6–16 years). There were 2 cervical, 4 thoracic, 8 lumbar and 2 sacral tumours. There were 9 patients in Group B (3-osteoid osteoma, 6-osteoblastoma), 7 boys and 2 girls. The mean age was 26.6 years (range, 18–53 years). There were 1 cervical, 6 thoracic, 2 lumbar and none sacral tumours.

Twenty two tumours were excised and 3 had curettage performed (1 child and 2 adults). There were 2 recurrences (one osteoid osteoma, one osteoblastoma), one from the excision group and one who had curettage, both in adults. These were successfully treated with re-excision. Mean follow-up was 8 years and all were alive at the time of final follow-up.

Conclusions: Benign bone forming tumours of the spine are extremely uncommon. In children they occur more commonly in lumbar spine, while thoracic involvement predominates in adult patients. Good outcomes are obtained with surgical treatment. Recurrence occurred only in the adult group: both of these patients had successful outcomes following further treatment.


W.G.P. Eardley L. Jarvis M.P.M. Stewart

Shoulder Instability impacts on the ability of military personnel to fulfil their operational role and maintain sporting competence. Magnetic Resonance Imaging (MRI) and Arthrogram (MRA) are increasingly available as diagnostic adjuncts. We analysed MR reports from personnel undergoing stabilisation, correlating clinical diagnosis with operative findings and reviewed the literature in order to recommend improvements.

This was a retrospective, consecutive case note analysis of 106 personnel undergoing open anterior capsulolabral reconstruction (ACLR) by a single surgeon.

70 patients had MR (48 MRA, 22 MRI). Commonly reported pathology included Hill Sachs Lesions (41%), Soft tissue (59%) and bony Bankart lesions (16%), capsular laxity (20 %), supraspinatus lesion (20%), ACJ disease (13%) and SLAP tear (12%). The sensitivity of MR for identification of labral lesions was 82% with a specificity of 86%. For bony glenoid lesions, sensitivity was 63% and specificity 94%. Disparity between report and operative findings occurred mainly in standard MRI. Patients with lesions unrelated to instability achieved a pain free functioning shoulder following stabilisation. 100% of patients referred for ACLR with clinical evidence of instability without MR had positive pre-operative and operative correlation with instability. In 5 cases, the original equivocal MRI was repeated by MRA due to clinical suspicion of instability. In all cases the repeat MRA correlated with pre-operative and operative findings of instability. In 5 cases with equivocal clinical findings, MRA provided confirmation of instability. Delay in referral due to scanning and follow up ranged from 0–15 weeks.

The diagnosis of those instigating referral is accurate. Reporting of MR is open to variation and has cost implications. MRA performed by a radiologist with a musculoskeletal specialist interest is recommended on an individual basis only and routine use of non-arthrographic studies should be discontinued. This will improve the efficiency of the fast track pathway.


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E. Spurrier A. Khanna G. Pathak

It is common practice in wrist arthroscopy to suspend the patient’s arm using Chinese finger traps and to distract the wrist joint by applying weight to the arm at the elbow. It is possible that this may cause significant pressure to be applied to the fingers, and potentially damage the digital nerves. We examined the pressure applied by finger traps and consider the risk this poses to the digital nerves.

Standard finger traps were suspended from a spring balance and the author’s fingers inserted along with a length of rubber tubing. The tubing was filled with saline and connected to a digital compartment pressure monitor. The hanging mass was gradually increased and the pressure in the rubber tubing noted. This pressure was taken as analogous to the pressure affecting the neurovascular bundle.

Pressure increases linearly with increasing mass. A pressure of 500mmHg has been suggested as necessary to cause nerve injury1. Using non-invasive technique it was not possible to accurately measure the absolute pressure acting on the digital nerves. However the increase in pressure was noted.

Using weight to distract the wrist during arthroscopy has potential to cause nerve injury. We suggest that pressure insufflation combined with Chinese finger traps with minimum weight traction provides a more than satisfactory view at wrist arthroscopy and can avoid potential digital nerve injury. However traction through finger traps for other purposes such as fracture reduction may be used with caution.


W.G.P. Eardley R.E. Anakwe D.M. Standley M.P.M. Stewart

To review the changing pattern of orthopaedic injury encountered by deployed troops with special regard to the importance of hand trauma sustained in conflict and non- war fighting activities.

Literature review relating to recent military operations (1990–2007) encompassing 100 conflicts worldwide. A subsequent search was performed to identify papers relating to hand injuries from 1914 to the present day. Papers were graded by Oxford Centre for Evidence-based Medicine Levels of Evidence.

Two hundred and ten published works were analysed. Review of the literature revealed a lack of statistical analysis and a tendency towards the anecdotal. These works were primarily level five evidence comprising reviews, correspondence, sub-unit experiences and individual nation database analyses.

The importance of extremity trauma is clear. The combination of changing ballistics and increasing survivability off the battlefield leads to a previously under emphasised increase in complex hand trauma.

Hand trauma is also shown to occur in deployed troops during activities unrelated to war fighting. Articles concerning military hand trauma management were mainly published prior to the conflicts of the last decade. Within these papers injury classification and treatment priorities are highlighted as core knowledge for trauma surgeons.

This paper provides a review of conflict related injury patterns with special regard to hand trauma. The key learning points from historical literature are highlighted. Proposals for improving management of these injuries from battlefield to home nation are discussed with regard to training opportunities and dialogue to ensure past lessons are not forgotten.


T. Wood P. Rosell J. Clasper

Chronic instability of the acromioclavicular joint is relatively common and normally occurs following a fall onto the point of the shoulder. Reconstruction of the joint (Weaver-Dunn procedure) is often required in service personnel, and numerous methods of fixation have been used, including vicryl tape, PDS loops and the use of a hook plate. Many of these operative methods require a second operation to remove the plates and/or screws, and are associated with a failure rate of up to 30%.

The ‘Surgilig’ was designed as a method of revision for failed Weaver-Dunn procedures. However this study evaluates its use in the primary operation.

We prospectively followed up the Modified Weaver Dunn procedures using surgilig. The post-operative x-rays were reviewed at six weeks, 3 months and then 6 months when the patients were discharged to assess the radiological success of the procedure.

We have performed this procedure in 11 patients. Of the eight patients that have reached the six month postoperative time so far, at which they would be discharged from clinic follow-up, none have had radiological failure of the fixation. One patient even had weight-bearing x-rays taken at 6 weeks, with no detrimental effect. Even though a small study, the initial results for primary fixation of acromioclavicular joint disruption with surgilig are extremely encouraging. The study suggests that surgilig should continue to be used in its current role. As patient numbers increase, a follow-up study should be conducted to evaluate these preliminary findings.


D. Griffiths R. Pollock P. Gikas L. Bayliss C. Jowett T. Briggs S. Cannon J. Skinner

We retrospectively studied 67 patients who underwent proximal humeral replacement with the Bayley-Walker prosthesis, for tumour of the proximal humerus between 1997 and 2007. Of the 67 patients 10 were lost to follow up. Of the 41 surviving patients, function was assessed using the Musculoskeletal Tumour Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS) questionnaire.

4 of the 41 patients received the new Bayley-Walker ‘captured’ proximal humeral replacement. The mean age was 46 years (7–87). The mean MSTS score at follow-up was 72.0 % and the mean TESS score was 77.2 %. The sub-group of 4 pts who received the new captured prosthesis had a mean MSTS score of 77.7 %. There was no mechanical failure of any prostheses in the follow up period.

Endoprosthetic replacement for tumour of the proximal humerus with the Bayley-Walker prosthesis, is a reliable operation yielding reasonable functional results and good long-term prosthesis survivorship. The performance of this prosthesis is expected to improve further with the new ‘captured’ prosthesis.


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P. Monk H. Pandit R. Gundle D. Whitwell S. Ostlere N. Athanasou H.S. Gill P. McLardy-Smith D.W. Murray C.L.M. Gibbons

We report on a group of 20 metal-on-metal resurfaced hips (17 patients) presenting with a soft tissue mass associated with various symptoms. We describe these masses as pseudotumours.

All patients underwent plain radiography and fuller investigation with CT, MRI and ultrasound. Where samples were available, histology was performed. All patients in this series were female. Presentation was variable; the most common symptom was pain or discomfort in the hip region. Other symptoms included spontaneous dislocation, nerve palsy, an enlarging mass or a rash. The common histological features were extensive necrosis and lymphocytic infiltration. Fourteen of the 20 cases (70%) have so far required revision to a conventional hip replacement and their symptoms have either settled completely or improved substantially since the revision surgery. Two of the three bilateral cases have asymptomatic pseudotumours on the opposite side.

We estimate that about 1% of patients develop a pseudotumour in the first five postoperative years after a hip resurfacing. The cause of these pseudotumours is unknown and is probably multi-factorial, further work is required to define this; they may be manifestations of a metal sensitivity response. We are concerned that with time the incidence of these pseudotumours will increase.


P.M. Guyver N.P.M Jain M.J.H McCarthy J. Keenan

Classification systems are used for communication, deciding/planning treatment options, predicting outcome and research purposes. The vast majority of subtrochanteric fractures are now treated with intramedullary nails, which questions the need for classification.

Our objective was to assess the intra- and inter-observer reliability of the Seinsheimer, AO and Russell-Taylor (RT) classification systems and assess a new simple system (KMG).

The KMG system was developed to alert the surgeon to potential hazards: Type 1 – subtrochanteric fracture (ST#) with intact trochanters. Type 2 ST# involving greater trochanter (entry point for nailing difficulty). Type 3 –ST# involving lesser trochanter (most unstable).

32 AP and lateral radiographs of subtrochanetric fractures were classified independently by 4 observers twice with a 6-week interval (2 Consultants and 2 Registrars). The observers were asked to rank the systems based on how descriptive they thought they were, whether they felt they influenced treatment plan and whether they would predict outcome.

The intra- and inter-observer variation was poor in all systems. KMG gave the best inter-observer reproducibility (Kappa 0.3 to 0.6) followed by AO and RT, and then Seinsheimer. The observers felt that Seinsheimer and KMG were the most descriptive and would influence the treatment plan, and Russell-Taylor would perform worst at predicting outcomes. All of the fractures in this series united

The classification systems analysed in this study have poor reproducibility and seem to be of little value in predicting outcome of intramedullary nailing. The KMG system may be of some use in alerting the surgeon to potential problems.


A. Ramasamy J.A. Webb I.W. Wallace A. Port I.A. McMurtry

Resurfacing arthroplasty is advantageous over conventional total hip arthroplasty in that femoral bone stock is preserved. However, there has been controversy over the preservation of acetabular bone stock in resurfacing arthroplasty, with the concern that it may result in excess reaming compared with total hip replacement. This is of concern as the prosthesis is primarily advocated in the young patient, who is likely to face future revision surgery.

We prospectively identified a cohort of 68 patients with primary hip osteoarthritis undergoing conventional total hip arthroplasty. During surgery, the excised femoral head and neck diameter was measured, along with the diameter of the final acetabular reamer used to achieve a bed of bleeding cancellous bone. The measured neck diameter was then used to calculate the minimum possible resurfacing head and cup sizes, with corresponding final reamer sizes that could have been used in each patient without neck notching for both Birmingham Hip Resurfacing (BHR, Smith & Nephew, 3rd Generation) and Articular Surface replacement (ASR, De Puy, 4th Generation). Reaming diameter and volume was compared for all 3 groups.

Mean reaming diameters for the THR, ASR and BHR groups were 51, 52 and 56mm respectively. Mean reaming volumes were 39, 40 and 47cc. There was a statistically significant difference between the THR and BHR groups for both reamed diameter and volume (p< 0.001). There was also a significant difference between the ASR and BHR groups for both reamed diameter and volume (p< 0.001). This difference was more pronounced with larger neck diameters.

Our data shows that the BHR results in more ace-tabular bone loss compared to total hip replacement. An implant with a lower profile acetabular cup and a larger variety of sizes such as the ASR may allow better preservation of acetabular bone stock.


D. Miller A. Choksey C. Meyer R. Perkins

The management of displaced femoral neck fractures in independent, healthy patients remains controversial. Acetabular erosion is a time dependant phenomenon and our aim was to assess the long-term outcome of the Universal Head bipolar with an Exeter stem.

49 consecutive cemented bipolar hemiarthroplasties were performed in 49 patients between 1992 and 2000. Mean age was 71.6 (range 54–91). There were 13 male and 36 female. 23 patients were alive at final follow up. 17 patients were assessed in outpatients with clinical and radiographic assessment. 2 patients had a telephone questionnaire and 4 patients were lost to follow up or were unable to attend clinic. Kaplan-Meier Survivorship analysis was performed.

Median follow up was 7.1 years (range 5–13.3 years). 26 patients had died by the time of final follow up. 5/14 patients (36%) with an ASA score of 3 died within 30 days. There was one dislocation and one periprosthetic fracture. There were no deep infections. There were no revisions for aseptic loosening or acetabular erosion. 75.6% of surviving patients returned to their pre-injury mobility level at 1 year. 5 year cumulative survival was 60% (95% confidence interval 46–74%). There was a statistically significant reduction in cumulative survival for ASA grades 3 and 4 compared to 1 and 2 (p=0.004).

Cemented bipolar hemiarthroplasty for femoral neck fractures is a good alternative to Total Hip Arthroplasty for independent, healthy patients. There is no evidence of acetabular erosion. Careful patient selection is necessary as patients with high ASA scores have greater mortality rates regardless of surgical prosthesis.


C. Meyer O. Richards V. Pullicino R. Spencer Jones F. Cooke

Most hospitals have introduced digital radiography (PACS) systems. Accurate pre-operative templating prior to hip arthroplasty requires precise information on the magnification of the digital image. Without this information the benefits of expensive digital templating programs (Orthoview-£10000) cannot be realised.

To determine the magnification of a digital image involves the placement of a “calibration object” at the level of the hip joint. This is unpopular with patients and radiographers alike. We describe a method that requires a single measurement to be made from the greater trochanter to the digital film.

An AP pelvis x-ray was taken of 50 patients with hip replacements. The “predicted” magnification was calculated using the new method. As the size of the head of the prosthesis was known the “actual” magnification could be calculated also. There was no significant difference at 0.05, Wilcoxon T, 2-tail test.

Conventional radiography, which assumes a magnification of 20%, results in errors up to 11%. Templating may therefore predict an incorrectly sized prosthesis. Our method is as accurate as methods using a calibration object whilst being acceptable to patients and staff. Its use should lead to more accurate pre-operative templating prior to total hip arthroplasty


A. Ramasamy S.E. Harrisson M.P.M. Stewart

Following the invasion of Iraq in April 2003, Coalition forces have been conducting counter-insurgency operations in a bid to maintain security within the country. The improvised explosive device (IED) has become the weapon of choice of the terrorist and is the leading cause of death and injury amongst Coalition troops in the region.

From Jan 2006, data was collected on 100 consecutive casualties who were either injured or killed during hostile action. Mechanism of injury, new Injury Severity Score (NISS), ICD-9 diagnosis and anatomical pattern of wounding was recorded in a trauma registry.

During the study period, 53 casualties were injured by IEDs in 23 incidents (mean 2.3 casualties per incident). Twelve (22.6%) were killed or died of wounds. Mean NISS score of survivors was 5.4 (Range 1–50). There was no significant difference in NISS scores of survivors from fatal and non-fatal incidents. A mean 2.61 body regions were injured per casualty. Limb injuries were present in 45 (84.9%) of casualties, but primary blast injuries were seen in only 9 (14%). Twenty (48.7%) of survivors underwent surgery by British surgeons in the field hospital. Sixteen (39%) were deemed fit to return to duty after injury.

IEDs used in Iraq do not follow the traditional pattern of injuries seen with conventional high explosives. Primary blast injuries were uncommon despite all casualties being in close proximity to the explosion. When the IED is detonated, an Explosive Formed Projectile (EFP) is formed which results in catastrophic injuries to casualties caught in its path, but causes relatively minor injuries to personnel sited adjacent to its trajectory. Enhanced vehicle protection may prevent the EFP from entering the passenger compartments and thereby reduce fatalities.


K.V. Brown J.C. Clasper

Despite modern advances, amputation is still a commonly performed operation in war. It is often difficult to decide whether to amputate following high-energy trauma to the lower extremity. To help guide this assessment, scoring systems have been developed with amputation threshold values. These studies were all conducted on a civilian population, encompassing a wide range of ages and methods of injury. The evidence for their sensitivity and specificity is inconclusive. The purpose of this study was to assess the validity of Mangled Extremity Severity Score (MESS), the only verified score, in a population of military patients with ballistic mangled extremity injuries.

52 military patients with 58 limbs who had ballistic mangled extremity injuries were identified, 13 of whom required amputation. Using both the trauma audit and the hospital notes, demographics were assessed. Patients were retrospectively evaluated with the MESS system for lower extremity trauma.

The MESS would not help in the decision-making. However, we were able to develop an algorithm for management, in particular the need for early amputation.

The management of ballistic extremity injuries in military patients should be considered separate to that of civilians with high-energy trauma extremity injuries. The authors have developed an algorithm to provide guidelines for management.


D.E. Hinsley A. Ramasamy A.J. Brooks M.D. Brinsden M.P.M. Stewart

British military forces remain heavily committed in both Iraq and Afghanistan. A recent workload analysis from Op HERRICK identified a high surgical workload, particularly orthopaedic, under the care of a sole consultant orthopaedic surgeon. There are no orthopaedic training posts in UK that consistently provide training in ballistic trauma. In order to prepare Military orthopaedic trainees for future deployment, a new orthopaedic registrar post, on Op HERRICK, was created.

Prospective analysis of trainee and trainer operative logbooks, between Jan 27th and March 24th 2008, was performed. Records were kept of orthopaedic and postgraduate teaching schedules, audit and research projects and all OCAP training assessments.

One hundred and fifty-seven cases and 272 procedures were performed during the study period. Sixty-two per cent of cases were orthopaedic. Fourteen major amputations were performed and 7 external fixators applied. Five fasciotomies, 9 skeletal traction pins were inserted and 7 skin grafting procedures were performed. Limb debridement was the most common procedure (n=59). Eleven per cent of cases were children and 50 per cent of cases were emergencies. Thirty-eight per cent of cases were performed out of hours (18.00–08.00 hrs). Mean operating hours per week was 35 hrs. Four Procedure Based Assessments were performed and 16 hours of postgraduate education was conducted during the deployment. Two major audits were initiated and five publications were prepared, one has already been accepted for publication.

Trainee exposure to high-energy transfer trauma is high when compared to that seen in the NHS. The numbers of certain index procedures, such as external fixation, is similar to those achieved by an average orthopaedic trainee in six years of higher surgical training. The opportunity for one-on-one training exceeds that available in the NHS and learning and academic opportunities are maximised due to the close working environment.


K.V. Brown J.C. Clasper

Extremity injuries on the battlefield are commonly secondary to high energy mechanisms. These cause significant injury to soft tissue and bone and are contaminated. Evacuation to medical care can be difficult in the operational environment and may delay the time to initial surgery. There is already substantial literature on the complications of such injuries but this is the first report from UK forces. Our aim was to assess the complications, but specifically infections, in relation to delay in surgery and also the method of fracture stabilisation.

Military patients who had ballistic mangled extremity injuries were identified from the database (courtesy of ADMEM). Using both the trauma audit and the hospital notes, demographics were assessed. The injuries sustained (including the fractured bones), time to theatre, associated injuries, method of stabilisation at Role 3, definitive fixation and complications were noted.

81 patients were identified with 95 limbs injured (68 lower limb, 27 upper limb). The most commonly fractured bones were the tibia, radius/ulna, femur and humerus. Primary stabilisation was either ExFix (53%) or plaster (44%). Of those stabilised by ExFix, the definitive stabilisation was mainly by either a nail (44%) or plate (17%). Those stabilised by plaster mainly stayed in plaster. 72% of patients developed at least one complication, the most common of which was superficial infections. Other complications were deep infections, delayed union, haematomas, neuropathic pain and flap failures. The main organisms involved were Acinetobacter, Bacillus and Pseudomonas. There was no association between delay to theatre and decision to amputate. There was an association between the use of plaster for definitive stabilisation and superficial infection and plates for definitive stabilisation and deep infections. There was no association between time delay to theatre and infections.

This provides the first report of complications from extremity injuries secondary to ballistic missile devices in UK forces. It allows for comparison with reports from other sources on similar injuries and helps to guide further management of patients. In particular it agrees with recent civilian data that initial surgery does not have to be carried out as soon as possible, which has implications for military planning.


T. Coltman N. Chhaya T. Briggs J. Skinner R. Carrington

Our aim was to review the short-term clinical results of a single-institution cohort undergoing opening wedge high tibial osteotomy (HTO).

We undertook a prospective clinical and radiographic review of our cohort of patients who had undergone opening wedge HTO for varus malalignment. The Cincinnati scoring system was used for objective assessment. Pre- and post-operative radiographs were evaluated and Blackburne-Peel (BP) and Insall-Salvati (IS) ratios recorded, as well as integrity of the lateral hinge.

We reviewed 55 knees (51 patients: 34 men and 17 women; mean age, 44.2years; range 34–58years) followed up for a minimum 12 months (range, 12–62months). All patients had relief of pain, but six met our criteria of failed treatment where either revision fixation was required or proceeded to total knee arthroplasty for persisting symptoms. Cincinnati scores were 94.5% excellent (52/55) and 5.5% good (3/55) at 1 year, whilst at last follow-up they were 87.2% excellent (48/55), 9.1% good (5/55) and 3.6% fair (2/55). There was a significant improvement in mean American Knee Society score at 1 year and maintained at last follow-up (p< 0.05). Radiographically the lateral hinge was noted to be breached in 9.1% (5/55), but no incidence of non-union was identified. There was no significant change in IS index, however BP index diminished by a mean 15.3% (range, 7.4–28.2%). Medial opening wedge tibial osteotomy results in patellar infera, but successful clinical and functional outcomes have been demonstrated. The fact ther e is inconsistency between the two indices assessing patellar height ratio we believe reflects the inherent variability in the techniques employed. Distalisation of the tibial tubercle will mean the IS ratio remains unaffected, whilst the BP index more accurately demonstrates the lowering of patella relative to the joint line. However there may be other factors which are not immediately appreciated, such as changes in the tibial inclination or antero-posterior translation.


A Ramasamy A.J. Brooks M.P.M. Stewart D. E. Hinsley

British military forces are heavily committed in Iraq and Afghanistan. Operation HERRICK, currently supported by a Role 2(Enhanced) medical facility at Camp Bastion, is predicted to continue for the next 10 years.

There has been no large published series on surgical workload on Operation HERRICK. The aim of this study is to determine and plan future medical needs.

A retrospective analysis of operating theatre records between 10th October 2006 and 31st Oct 2007 was performed. Data was collated on a monthly basis, to assess seasonal variation, and included patient demographics, operation type and time of operation.

During the study period 968 cases required 1262 procedures. Thirty-four per cent were ISAF, 27% were Afghan soldiers, police or enemy forces and 39% were civilians, of which, 43% were children. Ninety-one per cent were secondary to battle injury and 50% were emergencies. The breakdown of procedures, by specialty, was 67% (841) were orthopaedic, 16% (199) general surgery, 8% (96) head and neck, 5% (55) burns surgery and a further 4% (50) were non-battle, non-emergency procedures. During the second half of the study period 655 cases were operated on compared to 313 in the preceding half (p< 0.05). Twenty-eight per cent of cases were performed between 6pm and 8am.

Surgical workload remains consistently high throughout the study period, however there was significant seasonal variation with casualty rates being greater in the summer months, this may have bearing on the decision to deploy additional surgeons and trainees in the future.


T. Coltman N. Chhaya T. Briggs J. Skinner R. Carrington

Our aim was to review the short-term clinical results of a single-institution cohort undergoing opening wedge high tibial osteotomy (HTO).

We undertook a prospective clinical and radiographic review of our cohort of patients who had undergone opening wedge HTO for varus malalignment. The Cincinnati scoring system was used for objective assessment. Pre- and post-operative radiographs were evaluated and Blackburne-Peel (BP) and Insall-Salvati (IS) ratios recorded, as well as integrity of the lateral hinge.

We reviewed 55 knees (51 patients: 34 men and 17 women; mean age, 44.2years; range 34–58years) followed up for a minimum 12 months (range, 12–62months). All patients had relief of pain, but six met our criteria of failed treatment where either revision fixation was required or proceeded to total knee arthroplasty for persisting symptoms. Cincinnati scores were 94.5% excellent (52/55) and 5.5% good (3/55) at 1 year, whilst at last follow-up they were 87.2% excellent (48/55), 9.1% good (5/55) and 3.6% fair (2/55). There was a significant improvement in mean American Knee Society score at 1 year and maintained at last follow-up (p< 0.05). Radiographically the lateral hinge was noted to be breached in 9.1% (5/55), but no incidence of non-union was identified. There was no significant change in IS index, however BP index diminished by a mean 15.3% (range, 7.4–28.2%). Opening wedge HTO provides a means of relieving stress distribution through the medial tibiofemoral compartment and results in effective relief of symptoms with improvement in functional outcome and quality of life.


J.J. Matthews P.J. Schranz

Patellar instability is a common clinical problem affecting a young, active population. A large number of procedures have been described to treat patellar instability. We present the clinical results in a case series of 25 medial patellofemoral ligament reconstructions in 21 patients with up to 30 months follow-up (mean 7.3 months).

Reconstruction was performed using either the gracilis tendon (6 cases) or semitendinosus tendon (19 cases) autograft. At follow-up the Tegner activity scores, objective knee function, complications and reoperations were assessed.

No patella re-dislocations were observed. Five patients (20%) required a manipulation under anaesthetic but subsequently regained a satisfactory range of motion. Two patients (8%) had post operative complications. One patient developed a post operative infection which required a washout and one patient developed a neuroma related to the hamstring harvest site which was excised. Both subsequently returned to work with a full range of motion.

Medial patellofemoral reconstruction with both gracilis and semitendinosus tendon graft provided good postoperative patellar stability restoring the primary soft tissue restraint to pathological lateral patellar displacement.


C.H.C. Arthur A. Gorbachevski C. Leeson-Payne S.J. Breusch

Good perioperative analgesia following Total Knee Replacement facilitates rehabilitation and may reduce hospital stay. A multimodal drug injection has been shown to provide excellent pain control and functional recovery, and was introduced into the operating practice of one Arthroplasty surgeon during his Total Knee Replacements.

We compared the rehabilitation of 27 consecutive patients (group 1) following their Total Knee Replacement under spinal anaesthesia receiving the periarticular infiltration mixture, consisting of levobupivacaine, ketorolac and adrenaline at the end of surgery. Their rehabilitation was compared to group 2, a historical group operated on by the same surgeon before the introduction of the multimodal drug injection. These patients were age and sex matched and had received a Femoral and Sciatic block at the time of their operation.

Patients in group 1 had lower analgesic and anti-emetic requirements than group 2. Group 1 also had a shorter time to Strait Leg raise.

Periarticular multimodal drug injection can improve perioperative analgesia and mobilisation following Total Knee Replacement as well as reducing opioid side effects.


D.E. Ayers P.L. Townsend

It has long been recognised that the periosteal membrane has osteogenic capability and experimental studies have concluded that periosteum transplanted to a distant site could also be osteogenic. This ability of periosteum to generate new bone at distant sites may have clinical application. In the laboratory setting however periosteal flaps in animals have demonstrated variable results. Little clinical work using the technique of periosteal transfer has been reported, with only individual case reports in the literature.

A clinical review of a series of three fracture patients in whom vascularised periosteal transfer has been used is presented. Cases involved a primary bony defect at the fracture site (first metatarsal), established non-union (tibia) or post-traumatic AVN (talar dome). The technique is described and clinical follow-up of the patients is presented.

In each instance evidence of lasting new bone formation was demonstrated clinically and radiologically.

The efficacy of this technique in forming new bone is demonstrated. The technique may have utility alongside other techniques in cases where new bone is required.


C. Meyer S. Kakati A. Kotecha T. Crichlow

To determine if extended scope physiotherapists perform to the same standards as their orthopaedic colleagues with regards to diagnosing knee pathology and making appropriate referrals for arthroscopy.

Data was collected prospectively from Aug 2005. Patients were seen in a consultant led orthopaedic clinic by an Extended Scope Physiotherapist (ESP), a registrar or the consultant. All patients placed onto the waiting list for knee arthroscopy were considered for the study. The outpatient diagnosis and demographic data were recorded and compared against the arthroscopy findings. A single consultant surgeon performed the arthroscopies.

300 patients were included in the study (100 in each group). Each group was similar in terms of presenting complaint and demographics. There was no significant difference between the ESP’s and registrars in their ability to diagnose intraarticular pathology (CHI squared test: X 2.031, df 1, p=0.15). When only cruciate and meniscal pathology were considered there was also no significant difference between the ESP’s and the registrars (Fishers test p=0.12 and p=0.22 respectively, 2-tail test) The ESPs performed particularly well in their ability to diagnose cruciate injuries (sensitivity 100%, specificity 100% and PPV 100%). Both ESPs and registrars had high sensitivity but low specificity with regards to diagnosing meniscal pathology suggesting a low threshold for a positive diagnosis and a poor ability to correctly diagnose those patients who did not have a meniscal injury. Of the 300 patients only 9 unnecessary arthroscopies were requested. None were requested by the ESPs.

Extended scope physiotherapists perform a useful role in orthopaedic outpatients. They perform as well as orthopaedic registrars with regards to making the correct diagnosis and the selection of patients for arthroscopy.


N. Eisenstein J. Yu J. Urban

Intervertebral discs (IVDs) are fibrocartilagenous ovoids located between the vertebral bodies of the spine that provide the sole source of flexibility in that structure. IVDs are clinically very important as degeneration has been shown to be strongly associated with lower back pain, sciatica, and disc herniation: potentially disabling conditions that affect a very large section of the UK population.

The aetiology of disc degeneration is poorly understood although upregulation of matrix metalloproteinase (MMP) activity is thought to be involved. Degradation products of the extra-cellular matrix are known to increase MMP production and activity in other tissues. This project concentrated on examining the effects of degredation products of elastin. Elastin fragments (κ-elastin peptides) have been shown to upregulate mRNA levels and increase expression of pro-MMP-1 in human skin fibroblasts, cells that are thought to be similar to those residing in the annulus fibrosus of intervertebral discs. This study examined their effect on disc cells and on skin fibroblasts.

Total MMP-2 and -7 activity produced by cells extracted from the annulus fibrosus of bovine intervertebral disc cells and cultured for 24 hours with 0–300μg/ml κ-elastin was determined using fluorimetric and zymographic analyses. κ-elastin was prepared from bovine ligamentum nuchae or bovine intervertebral discs.

Culture with κ-elastin prepared from bovine ligamentum nuchae caused skin and disc cell potential pro-MMP-2 activity to increase in a dose-dependent manner; the potential pro-MMP-2 activity of both cell types is more than doubled when cultured with 300μg/ml κ-elastin.

These findings suggest that in the bovine disc, matrix breakdown may cause a feedback loop with degraded elastin stimulating disc cells to increase production of pro-MMP-2, with the possibility of further degrading elastin and other proteins and contributing to IVD breakdown.


M.P. Rodger P. Rosell J. Clasper

Failure of fracture healing is a significant problem, resulting in considerable morbidity and financial costs to the NHS. It is also a major complication of ballistic injuries.

We reviewed our experience in the management of non-union by revision of fracture fixation and use of Bone Morphogenic Protein at Ministry of Defence Hospital Unit Frimley Park. Bone Morphogenic Proteins have been identified as promoting osteogenesis and have been used to stimulate bone growth in fracture revision surgery and spinal surgery. BMP’s are a subgroup of the TGF-β family and consist of at least 20 different subtypes of which BMP 2 and BMP 7 are commercially available. Current preparations include a solution for application to a gel matrix and as a powder for reconstitution to a paste for implantation to the fracture site. Costs per graft are in the region of £2,000.

BMPs have been used at Frimley Park since 2005 in the management of 12 patients with established non-union. These included fractures of 4 femurs, 5 humerai, 2 clavicles and 1 metatarsal. Early results are encouraging and support continued use of BMP’s in fracture revision surgery for established non-union.

Non-union remains a difficult problem and even with this treatment there was a significant failure rate, often associated with failure of fixation.


J. Melton L. Cannon

The outcome of arthroscopic ankle fusion has been favourably reported in the literature. The technique allows for early weight-bearing and results in fusion earlier than that of open techniques. All authors state that it a demanding procedure that has a significant learning curve. The purpose of this presentation is to report on that learning curve by analysing the first two years experience of one surgeon. Technical details, difficulties encountered and outcomes are described.

We analysed the results of arthroscopic ankle fusion in 14 consecutive ankles in 13 patients over a two-year period. Average age at fusion was 59 years. There were 12 male patients and one female. Indication for surgery was osteoarthritis in all patients. All were non-smokers at the time of surgery. Anti-inflammatory drugs were not prescribed on discharge, All patients underwent pre-operative sciatic nerve block using a nerve stimulator. Fixation of the fusion was performed with two screws in 13 ankles and a single screw in one. Mean tourniquet time was 117 minutes (first 4 cases averaged 124 minutes; last 4 averaged 105 minutes). Mean hospital stay was a single night. All patients were treated post-operatively with plaster cast immobilisation for two weeks (non-weight bearing). Subsequently, they were instructed to fully weight bearing as tolerated in a removable walking boot.

Radiological union was achieved in 11 ankles within 3 months. One ankle fused at between 9–12 months post-operatively. One ankle failed to unite due to inadequate joint access and preparation and underwent later open revision with bone grafting. One case of superficial portal wound infection treated successfully with antibiotics. No thrombo-embolic events. All patients had excellent or good clinical results at last follow up.

Patient selection issues and intra-operative learning points are discussed. With adequate training, arthroscopic ankle fusion is a safe and reliable technique.

The level of accuracy and precision required for consistently good surgical results will vary depending upon the characteristics of surgical task being undertaken. Training surgeons to achieve these results rapidly and effectively is a continuing challenge. Resurfacing arthroplasty for cam type deformity (a common cause of early osteoarthritis) is a technically demanding operation. We considered it desirable that the operation should be performed within +/− 10¡ of the desired angular orientation, and +/− 6mm of entry point translation in 95% of cases. To achieve that level of accuracy, without learning slowly on real patients, technological aids are now available. Using 3 models of varying severity of cam, we assessed the efficacy of 3 systems of instrumentation in delivering the level of accuracy and precision that is needed to ensure the excellent results that this surgeon and patient group expects.


P.A. Templeton D.J.C. Burton E. Cullen H. Lewis V. Allgar R. Wilson

Our purpose wasto determine if oral midazolam reduces the anxiety of children undergoing removal of percutaneous Kirschner wires (K-wires) from the distal humerus in the Orthopaedic Outpatient Department.

This was a prospective double blind, randomised controlled trial. 46 children aged between 3 and 12 years who had supracondylar fractures of the distal humerus internally fixed with K-wires were randomised into 2 groups. 0.2mg/kg oral midazolam (active group) or the same volume of an oral placebo (control group) was administered 30 minutes prior to removal of K-wires.

Venham Situational Anxiety Score was performed before and immediately after removal of K-wires. University College London Hospital sedation score was recorded every 20 minutes.

42 children with an average age of 7.1 years (range 3.6–12.3 years) had complete documentation for analysis. The two groups had similar demographics. All wires were removed in the clinic with or without midazolam.

There was no significant difference in anxiety scores between the groups either before or after wire removal. The change in scores was not significantly different between the 2 groups. However, 45% of children in the active group had reduced anxiety levels in the active group compared to 18% of children given placebo but this difference was not significant (p=0.102). No child was excessively sedated but one in the active group became agitated and restless.

The anxiety scores before and after wire removal in the active group were not significantly different from the placebo group scores. We do not recommend the routine administration of midazolam (0.2 mg/kg) to all children requiring k-wire removal in the outpatient department.


A.M. Wood A.G. Powell G.A.J. Robertson O.J. Berry C.M. Court-Brown

To illustrate the incidence and epidemiology of fractures due to football.

All inpatient and outpatient fractures from a prospectively collected database for a defined population in 2000 were retrospectively analysed.

There were 396 football fractures, 96% male. Football caused 39% of the 1022 sports fractures in 2000. This represented 5% of the 8151 fractures in total. The incidence was 61/105. 115/105 in males and 5 /105 in females. The average age was 22.9 years; 22.8 in males and 26.6 in females. 77% of fractures were treated as outpatients. The top five fractures representing 84% of the injuries were Radius+Ulna 30%, Phalanx 19%, Tibial+Fibula 18%, Metacarpal 11% and Clavicle 5%. 71% were upper-limb fractures. The busiest two months were October and May 17% and 14% respectively. The quietest two months were February and December at 5%.

Although the epidemiology of football injuries will vary amongst different populations, these results can be generalized to similar population bases. Results will be valuable to medical professionals supporting football teams, enabling them to focus their attention on treating the most common injuries, the majority being treated as outpatients.

Football is the most common cause of fractures in sport. As participation increases, the incidence of fractures is likely to reflect this. Upper limb fractures account for over 2/3 rd of fractures with radius+ulna fractures accounting for up to a 1/3rd of fractures; the majority can be treated as an outpatient. Therefore medical teams should be familiar with standard treatment regimes, possible impact on players’ futures and time out of sport.


J. Cobb

32 students of surgical technology were instructed in hip resurfacing, and shown detailed plans of the desired operative outcome for the 3 cam type hips. They then used conventional instruments, image-free navigation (brainlab) and image based navigation(Acrobot).

Only image based navigation performed well enough at navigating these difficult cam type hips with novice surgeons. Conventional instruments were not sufficient, with a tendency for the novice to put the hip in varus and translated low on the femoral neck. Image free navigation was more accurate than conventional instruments, avoiding the serious complication of notching but the range of error was 18mm and 10¡.

Image based navigation appears to be fit for purpose in delivering both the accuracy and the precision needed by the novice surgeon in the skills laboratory who needs timely feedback so his clinical experience may start substantially further along the learning curve of this or any other technically demanding operation.