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Trauma and Orthopaedic care has been through
a rapid evolution over the past few decades. This Editorial discusses
some of the advances. Cite this article:
The routine use of patient reported outcome measures
(PROMs) in evaluating the outcome after arthroplasty by healthcare
organisations reflects a growing recognition of the importance of
patients’ perspectives in improving treatment. Although widely embraced
in the NHS, there are concerns that PROMs are being used beyond
their means due to a poor understanding of their limitations. This paper reviews some of the current challenges in using PROMs
to evaluate total knee arthroplasty. It highlights alternative methods
that have been used to improve the assessment of outcome. Cite this article:
Arthroplasty registries are important for the
surveillance of joint replacements and the evaluation of outcome. Independent
validation of registry data ensures high quality. The ability for
orthopaedic implant retrieval centres to validate registry data
is not known. We analysed data from the National Joint Registry
for England, Wales and Northern Ireland (NJR) for primary metal-on-metal
hip arthroplasties performed between 2003 and 2013. Records were
linked to the London Implant Retrieval Centre (RC) for validation.
A total of 67 045 procedures on the NJR and 782 revised pairs of
components from the RC were included. We were able to link 476 procedures
(60.9%) recorded with the RC to the NJR successfully. However, 306
procedures (39.1%) could not be linked. The outcome recorded by the
NJR (as either revised, unrevised or death) for a primary procedure
was incorrect in 79 linked cases (16.6%). The rate of registry-retrieval
linkage and correct assignment of outcome code improved over time.
The rates of error for component reference numbers on the NJR were
as follows: femoral head category number 14/229 (5.0%); femoral head
batch number 13/232 (5.3%); acetabular component category number
2/293 (0.7%) and acetabular component batch number 24/347 (6.5%). Registry-retrieval linkage provided a novel means for the validation
of data, particularly for component fields. This study suggests
that NJR reports may underestimate rates of revision for many types
of metal-on-metal hip replacement. This is topical given the increasing
scope for NJR data. We recommend a system for continuous independent
evaluation of the quality and validity of NJR data. Cite this article:
After implementation of a ‘fast-track’ rehabilitation
protocol in our hospital, mean length of hospital stay for primary
total hip arthroplasty decreased from 4.6 to 2.9 nights for unselected
patients. However, despite this reduction there was still a wide
range across the patients’ hospital duration. The purpose of this
study was to identify which specific patient characteristics influence
length of stay after successful implementation of a ‘fast-track’
rehabilitation protocol. A total of 477 patients (317 female and
160 male, mean age 71.0 years; 39.3 to 92.6, mean BMI 27.0 kg/m2;18.8
to 45.2) who underwent primary total hip arthroplasty between 1
February 2011 and 31 January 2013, were included in this retrospective
cohort study. A length of stay greater than the median was considered
as an increased duration. Logistic regression analyses were performed
to identify potential factors associated with increased durations.
Median length of stay was two nights (interquartile range 1), and
the mean length of stay 2.9 nights (1 to 75). In all, 266 patients
had a length of stay ≤ two nights. Age (odds ratio (OR) 2.46; 95%
confidence intervals (CI) 1.72 to 3.51; p <
0.001), living situation
(alone Cite this article:
Stress fractures occurring in the pubis and ischium
after peri-acetabular osteotomy (PAO) are not well recognised, with
a reported incidence of 2% to 3%. The purpose of this study was
to analyse the incidence of stress fracture after Bernese PAO under
the care of two high-volume surgeons. The study included 359 patients
(48 men, 311 women) operated on at a mean age of 31.1 years (15
to 56), with a mean follow-up of 26 months (6 to 64). Complete follow-up
radiographs were available for 348 patients, 64 of whom (18.4%)
developed a stress fracture of the inferior pubic ramus, which was
noted at a mean of 9.1 weeks (5 to 55) after surgery. Most (58;
91%) healed. In 40 of the patients with a stress fracture (62.5%),
pubic nonunion also occurred. Those with a stress fracture were
significantly older (mean 33.9 years (16 to 50) Cite this article:
Obesity is a risk factor for complications following
many orthopaedic procedures. The purpose of this study was to investigate
whether obesity was an independent risk factor increasing the rate
of complications following periacetabular osteotomy (PAO) and to
determine whether radiographic correction after PAO was affected
by obesity. We retrospectively collected demographic, clinical and radiographic
data on 280 patients (231 women; 82.5% and 49 men; 17.5%) who were
followed for a mean of 48 months (12 to 60) after PAO. A total of
65 patients (23.2%) were obese (body mass index (BMI) >
30 kg/m2).
Univariate and multivariate analysis demonstrated that BMI was an independent
risk factor associated with the severity of the complications. The
average probability of a patient developing a major complication
was 22% (95% confidence interval (CI) 11.78 to 38.21) for an obese
patient compared with 3% (95% CI 1.39 to 6.58) for a non-obese patient
The odds of a patient developing a major complication were 11 times
higher (95% CI 4.71 to 17.60, p <
0.0001) for an obese compared
with a non-obese patient. Following PAO surgery, there was no difference in radiographic
correction between obese and non-obese patients. PAO procedures
in obese patients correct the deformity effectively but are associated
with an increased rate of complications. Cite this article:
We hypothesised that the removal of the subchondral
bone plate (SCBP) for cemented acetabular component fixation in
total hip arthroplasty (THA) offers advantages over retention by
improving the cement-bone interface, without jeopardising implant
stability. We have previously published two-year follow-up data
of a randomised controlled trial (RCT), in which 50 patients with
primary osteoarthritis were randomised to either retention or removal
of the SCBP. The mean age of the retention group (n = 25, 13 males)
was 70.0 years ( Cite this article:
We hypothesised that the use of tantalum (Ta)
acetabular components in revision total hip arthroplasty (THA) was protective
against subsequent failure due to infection. We identified 966 patients
(421 men, 545 women and 990 hips) who had undergone revision THA
between 2000 and 2013. The mean follow up was 40.2 months (3 months
to 13.1 years). The mean age of the men and women was 62.3 years
(31 to 90) and 65.1 years (25 to 92), respectively. Titanium (Ti) acetabular components were used in 536 hips while
Ta components were used in 454 hips. In total, 73 (7.3%) hips experienced
subsequent acetabular failure. The incidence of failure was lower
in the Ta group at 4.4% (20/454) compared with 9.9% (53/536) in
the Ti group (p <
0.001, odds ratio 2.38; 95% CI 1.37 to 4.27).
Among the 144 hips (64 Ta, 80 Ti) for which revision had been performed
because of infection, failure due to a subsequent infection was
lower in the Ta group at 3.1% (2/64) compared with 17.5% (14/80)
for the Ti group (p = 0.006). Thus, the use of Ta acetabular components during revision THA
was associated with a lower incidence of failure from all causes
and Ta components were associated with a lower incidence of subsequent
infection when used in patients with periprosthetic joint infection. Cite this article:
Progressive degenerative changes in the medial
compartment of the knee following lateral unicompartmental arthroplasty
(UKA) remains a leading indication for revision surgery. The purpose
of this study is to evaluate changes in the congruence and joint
space width (JSW) of the medial compartment following lateral UKA.
The congruence of the medial compartment of 53 knees (24 men, 23
women, mean age 13.1 years; Our data suggest that a well conducted lateral UKA may improve
the congruence and normalise the JSW of the medial compartment,
potentially preventing progression of degenerative change. Cite this article:
In this study we randomised 140 patients who
were due to undergo primary total knee arthroplasty (TKA) to have the
procedure performed using either patient-specific cutting guides
(PSCG) or conventional instrumentation (CI). The primary outcome measure was the mechanical axis, as measured
at three months on a standing long-leg radiograph by the hip–knee–ankle
(HKA) angle. This was undertaken by an independent observer who
was blinded to the instrumentation. Secondary outcome measures were
component positioning, operating time, Knee Society and Oxford knee
scores, blood loss and length of hospital stay. A total of 126 patients (67 in the CI group and 59 in the PSCG
group) had complete clinical and radiological data. There were 88
females and 52 males with a mean age of 69.3 years (47 to 84) and
a mean BMI of 28.6 kg/m2 (20.2 to 40.8). The mean HKA
angle was 178.9° (172.5 to 183.4) in the CI group and 178.2° (172.4
to 183.4) in the PSCG group (p = 0.34). Outliers were identified
in 22 of 67 knees (32.8%) in the CI group and 19 of 59 knees (32.2%)
in the PSCG group (p = 0.99). There was no significant difference
in the clinical results (p = 0.95 and 0.59, respectively). Operating time,
blood loss and length of hospital stay were not significantly reduced
(p = 0.09, 0.58 and 0.50, respectively) when using PSCG. The use of PSCG in primary TKA did not reduce the proportion
of outliers as measured by post-operative coronal alignment. Cite this article:
Total knee arthroplasty (TKA) is an established
and successful procedure. However, the design of prostheses continues
to be modified in an attempt to optimise the functional outcome
of the patient. The aim of this study was to determine if patient outcome after
TKA was influenced by the design of the prosthesis used. A total of 212 patients (mean age 69; 43 to 92; 131 female (62%),
81 male (32%)) were enrolled in a single centre double-blind trial
and randomised to receive either a Kinemax (group 1) or a Triathlon
(group 2) TKA. Patients were assessed pre-operatively, at six weeks, six months,
one year and three years after surgery. The outcome assessments
used were the Oxford Knee Score; range of movement; pain numerical
rating scales; lower limb power output; timed functional assessment
battery and a satisfaction survey. Data were assessed incorporating
change over all assessment time points, using repeated measures
analysis of variance longitudinal mixed models. Implant group 2
showed a significantly greater range of movement (p = 0.009), greater
lower limb power output (p = 0.026) and reduced report of ‘worst
daily pain’ (p = 0.003) over the three years of follow-up. Differences
in Oxford Knee Score (p = 0.09), report of ‘average daily pain’
(p = 0.57) and timed functional performance tasks (p = 0.23) did
not reach statistical significance. Satisfaction with outcome was
significantly better in group 2 (p = 0.001). These results suggest that patient outcome after TKA can be influenced
by the prosthesis used. Cite this article:
The purpose of this study was to evaluate whether
the serum level of interleukin 6 (IL-6) could be used to identify the
persistence of infection after the first stage of a two-stage revision
for periprosthetic joint infection. Between 2010 and 2011, we prospectively studied 55 patients (23
men, 32 women; mean age 69.5 years; 36 to 86) with a periprosthetic
joint infection. Bacteria were identified in two intra-operative
tissue samples during re-implantation in 16 patients. These cases
were classified as representing persistent infection. To calculate a precise cut-off value which could be used in everyday
clinical practice, a 3 x 2 contingency table was constructed and
manually defined. We found that a serum IL-6 ≥ 13 pg/mL can be regarded as indicating
infection: its positive-predictive value is 90.9%. A serum IL-6 ≤ 8
pg/mL can be regarded as indicating an absence of infection: its
negative predictive value is 92.1%. The serum IL-6 level seems to be a reasonable marker for identifying
persistent infection after the first stage of a revision joint arthroplasty
and before attempting re-implantation. Cite this article:
We report the outcomes of 20 patients (12 men,
8 women, 21 feet) with Charcot neuro-arthropathy who underwent correction
of deformities of the ankle and hindfoot using retrograde intramedullary
nail arthrodesis. The mean age of the patients was 62.6 years (46
to 83); their mean BMI was 32.7 (15 to 47) and their median American
Society of Anaesthetists score was 3 (2 to 4). All presented with
severe deformities and 15 had chronic ulceration. All were treated
with reconstructive surgery and seven underwent simultaneous midfoot
fusion using a bolt, locking plate or a combination of both. At
a mean follow-up of 26 months (8 to 54), limb salvage was achieved
in all patients and 12 patients (80%) with ulceration achieved healing
and all but one patient regained independent mobilisation. There was
failure of fixation with a broken nail requiring revision surgery
in one patient. Migration of distal locking screws occurred only
when standard screws had been used but not with hydroxyapatite-coated
screws. The mean American Academy of Orthopaedic Surgeons Foot and
Ankle (AAOS-FAO) score improved from 50.7 (17 to 88) to 65.2 (22
to 88), (p = 0.015). The mean Short Form (SF)-36 Health Survey Physical
Component Score improved from 25.2 (16.4 to 42.8) to 29.8 (17.7
to 44.2), (p = 0.003) and the mean Euroqol EQ‑5D‑5L score improved
from 0.63 (0.51 to 0.78) to 0.67 (0.57 to 0.84), (p = 0.012). Single-stage correction of deformity using an intramedullary
hindfoot arthrodesis nail is a good form of treatment for patients
with severe Charcot hindfoot deformity, ulceration and instability
provided a multidisciplinary care plan is delivered. Cite this article:
The LockDown device (previously called Surgilig)
is a braided polyester mesh which is mostly used to reconstruct the
dislocated acromioclavicular joint. More than 11 000 have been implanted
worldwide. Little is known about the tissue reaction to the device
nor to its wear products when implanted in an extra-articular site
in humans. This is of importance as an adverse immunological reaction
could result in osteolysis or damage to the local tissues, thereby affecting
the longevity of the implant. We analysed the histology of five LockDown implants retrieved
from five patients over the last seven years by one of the senior
authors. Routine analysis was carried out in all five cases and
immunohistochemistry in one. The LockDown device acts as a scaffold for connective tissue
which forms an investing fibrous pseudoligament. The immunological
response at the histological level seems favourable with a limited
histiocytic and giant cell response to micron-sized wear particles.
The connective tissue envelope around the implant is less organised
than a native ligament. Cite this article:
Hypovitaminosis D has been identified as a common
risk factor for fragility fractures and poor fracture healing. Epidemiological
data on vitamin D deficiency have been gathered in various populations,
but the association between vertebral fragility fractures and hypovitaminosis
D, especially in males, remains unclear. The purpose of this study
was to evaluate serum levels of 25-hydroxyvitamin D (25-OH D) in
patients presenting with vertebral fragility fractures and to determine
whether patients with a vertebral fracture were at greater risk
of hypovitaminosis D than a control population. Furthermore, we
studied the seasonal variations in the serum vitamin D levels of
tested patients in order to clarify the relationship between other
known risk factors for osteoporosis and vitamin D levels. We measured
the serum 25-OH D levels of 246 patients admitted with vertebral
fractures (105 men, 141 female, mean age 69 years, Cite this article:
National Institute of Clinical Excellence guidelines
state that cemented stems with an Orthopaedic Data Evaluation Panel
(ODEP) rating of >
3B should be used for hemiarthroplasty when treating
an intracapsular fracture of the femoral neck. These recommendations
are based on studies in which most, if not all stems, did not hold
such a rating. This case-control study compared the outcome of hemiarthroplasty
using a cemented (Exeter) or uncemented (Corail) femoral stem. These
are the two prostheses most commonly used in hip arthroplasty in
the UK. Data were obtained from two centres; most patients had undergone
hemiarthroplasty using a cemented Exeter stem (n = 292/412). Patients
were matched for all factors that have been shown to influence mortality
after an intracapsular fracture of the neck of the femur. Outcome
measures included: complications, re-operations and mortality rates
at two, seven, 30 and 365 days post-operatively. Comparable outcomes
for the two stems were seen. There were more intra-operative complications in the uncemented
group (13% This study therefore supports the use of both cemented and uncemented
stems of proven design, with an ODEP rating of 10A, in patients
with an intracapsular fracture of the neck of the femur. Cite this article:
The Nottingham Hip Fracture Score (NHFS) was
developed to assess the risk of death following a fracture of the
hip, based on pre-operative patient characteristics. We performed
an independent validation of the NHFS, assessed the degree of geographical
variation that exists between different units within the United
Kingdom and attempted to define a NHFS level that is associated
with high risk of mortality. The NHFS was calculated retrospectively for consecutive patients
presenting with a fracture of the hip to two hospitals in England.
The observed 30-day mortality for each NHFS cohort was compared
with that predicted by the NHFS using the Hosmer–Lemeshow test.
The distribution of NHFS in the observed group was compared with
data from other hospitals in the United Kingdom. The proportion
of patients identified as high risk and the mortality within the
high risk group were assessed for groups defined using different
thresholds for the NHFS. In all 1079 hip fractures were included in the analysis, with
a mean age of 83 years (60 to 105), 284 (26%) male. Overall 30-day
mortality was 7.3%. The NHFS was a significant predictor of 30-day
mortality. Statistically significant differences in the distribution
of the NHFS were present between different units in England (p <
0.001). A NHFS ≥ 6 appears to be an appropriate cut-point to identify
patients at high risk of mortality following a fracture of the hip. Cite this article:
There has been extensive discussion about the
effect of delay to surgery on mortality in patients sustaining a fracture
of the hip. Despite the low level of evidence provided by many studies,
a consensus has been accepted that delay of >
48 hours is detrimental
to survival. The aim of this prospective observational study was
to determine if early surgery confers a survival benefit at 30 days. Between 1989 and 2013, data were prospectively collected on patients
sustaining a fracture of the hip at Peterborough City Hospital.
They were divided into groups according to the time interval between
admission and surgery. These thresholds ranged from <
6 hours
to between 49 and 72 hours. The outcome which was assessed was the
30-day mortality. Adjustment for confounders was performed using
multivariate binary logistic regression analysis. In all, 6638 patients
aged >
60 years were included. Worsening American Society of Anaesthesiologists grade (p <
0.001), increased age (p <
0.001) and extracapsular fracture
(p <
0.019) increased the risk of 30-day mortality. Increasing mobility score (p = 0.014), mini mental test score
(p <
0.001) and female gender (p = 0.014) improved survival.
After adjusting for these confounders, surgery before 12 hours improved
survival compared with surgery after 12 hours (p = 0.013). Beyond
this the increasing delay to surgery did not significantly affect
the 30-day mortality. Cite this article:
The aim of this study was to report the incidence
of arthrofibrosis of the knee and identify risk factors for its development
following a fracture of the tibial plateau. We carried out a retrospective
review of 186 patients (114 male, 72 female) with a fracture of
the tibial plateau who underwent open reduction and internal fixation.
Their mean age was 46.4 years (19 to 83) and the mean follow-up
was16.0 months (6 to 80). A total of 27 patients (14.5%) developed arthrofibrosis requiring
a further intervention. Using multivariate regression analysis,
the use of a provisional external fixator (odds ratio (OR) 4.63,
95% confidence interval (CI) 1.26 to 17.7, p = 0.021) was significantly
associated with the development of arthrofibrosis. Similarly, the
use of a continuous passive movement (CPM) machine was associated
with significantly less development of arthrofibrosis (OR = 0.32,
95% CI 0.11 to 0.83, p = 0.024). The effect of time in an external
fixator was found to be significant, with each extra day of external
fixation increasing the odds of requiring manipulation under anaesthesia
(MUA) or quadricepsplasty by 10% (OR = 1.10, p = 0.030). High-energy
fracture, surgical approach, infection and use of tobacco were not
associated with the development of arthrofibrosis. Patients with
a successful MUA had significantly less time to MUA (mean 2.9 months; Based our results, CPM following operative fixation for a fracture
of the tibial plateau may reduce the risk of the development of
arthrofibrosis, particularly in patients who also undergo prolonged
provisional external fixation. Cite this article:
A poor response to chemotherapy (≤ 90% necrosis)
for osteosarcomas leads to poorer survival and an increased risk of
local recurrence, particularly if there is a close margin of excision.
We evaluated whether amputation confers any survival benefit over
limb salvage surgery (LSS) with narrow margins in patients who respond
poorly to chemotherapy. We only analysed patients with an osteosarcoma of the limb, a
poor response to chemotherapy and close margins on LSS (marginal/intralesional)
or primary amputation: 360 patients (36 LSS (intralesional margins),
197 LSS (marginal margins) and 127 amputations) were included. Local
recurrence developed in 13 (36%) following LSS with intralesional
margins, and 39 (20%) following LSS with marginal margins. There
was no local recurrence in patients who underwent amputation. The
five-year survival for all patients was 41% (95% confidence interval
(CI) 35 to 46), but for those treated by LSS with marginal margins
was 46.2% (95% CI 38 to 53), 36.3% (95% CI 27 to 45) for those treated
by amputation, and 28% (95 CI 14 to 44) for those treated by LSS
with intralesional margins. Patients who had LSS and then developed
local recurrence as a first event had the same survival as those
who had primary amputation without local recurrence. Prophylactic
adjuvant radiotherapy was used in 40 patients but had no discernible
effect in preventing local recurrence. Although amputation offered better local control, it conferred
no clear survival benefit over LSS with marginal margins in these
patients with a poor overall prognosis. Cite this article:
Cancellous allograft bone chips are commonly
used in the reconstruction of defects in bone after removal of benign tumours.
We investigated the MRI features of grafted bone chips and their
change over time, and compared them with those with recurrent tumour.
We retrospectively reviewed 66 post-operative MRIs from 34 patients
who had undergone curettage and grafting with cancellous bone chips
to fill the defect after excision of a tumour. All grafts showed
consistent features at least six months after grafting: homogeneous
intermediate or low signal intensities with or without scattered
hyperintense foci (speckled hyperintensities) on T1 images; high
signal intensities with scattered hypointense foci (speckled hypointensities)
on T2 images, and peripheral rim enhancement with or without central
heterogeneous enhancements on enhanced images. Incorporation of
the graft occurred from the periphery to the centre, and was completed
within three years. Recurrent lesions consistently showed the same signal
intensities as those of pre-operative MRIs of the primary lesions.
There were four misdiagnoses, three of which were chondroid tumours. We identified typical MRI features and clarified the incorporation
process of grafted cancellous allograft bone chips. The most important
characteristics of recurrent tumours were that they showed the same
signal intensities as the primary tumours. It might sometimes be
difficult to differentiate grafted cancellous allograft bone chips
from a recurrent chondroid tumour. Cite this article:
In 11 paediatric patients (seven girls and four
boys, from 12 to 15 years old) with unilateral obligatory patellar dislocation
and ligamentous laxity vastus medialis advancement, lateral release,
partial patellar ligament transposition and Galeazzi semitendinosus
tenodesis was undertaken to stabilise the patella. The diagnostic criterion
for ligamentous laxity was based on the Beighton scale. Outcomes
were evaluated radiologically and functionally by measurement of
the range of knee movement and isokinetic testing. The evaluation
also included the Lysholm knee scale. Follow-up studies took place
at a mean of 8.1 years (5 to 15) post-operatively. Normal patellar tracking without any recurrence of dislocation
was obtained in ten out of 11 patients. Pain related to vigorous
activity was reported by nine patients. Compared with the opposite
normal side, the isokinetic tests revealed a statistically significant
decrease in the maximal torque values for the affected quadriceps
muscle (p = 0.003 and p = 0.004), but no difference between the
knee flexors (for angular velocities of 60°/s and 180°/s) (p = 0.858
and p = 0.79). The applied surgical technique generally prevents the recurrence
of the disorder in children with habitual patellar dislocation and
ligamentous laxity. Quadriceps muscle weakness can be expected to
occur post-operatively, Cite this article:
A small proportion of children with Gartland
type III supracondylar humeral fracture (SCHF) experience troubling limited
or delayed recovery after operative treatment. We hypothesised that
the fracture level relative to the isthmus of the humerus would
affect the outcome. We retrospectively reviewed 230 children who underwent closed
reduction and percutaneous pinning (CRPP) for their Gartland type
III SCHFs between March 2003 and December 2012. There were 144 boys
and 86 girls, with the mean age of six years (1.1 to 15.2). The
clinico-radiological characteristics and surgical outcomes (recovery
of the elbow range of movement, post-operative angulation, and the
final Flynn grade) were recorded. Multivariate analysis was employed
to identify prognostic factors that influenced outcome, including
fracture level. Multivariate analysis revealed that a fracture below
the humeral isthmus was significantly associated with poor prognosis
in terms of the range of elbow movement (p <
0.001), angulation
(p = 0.001) and Flynn grade (p = 0.003). Age over ten years was also
a poor prognostic factor for recovery of the range of elbow movement (p
= 0.027). This is the first study demonstrating a subclassification system
of Gartland III fractures with prognostic significance. This will
guide surgeons in peri-operative planning and counselling as well
as directing future research aimed at improving outcomes. Cite this article:
Reported rates of dislocation in hip hemiarthroplasty
(HA) for the treatment of intra-capsular fractures of the hip, range
between 1% and 10%. HA is frequently performed through a direct
lateral surgical approach. The aim of this study is to determine
the contribution of the anterior capsule to the stability of a cemented
HA through a direct lateral approach. A total of five whole-body cadavers were thawed at room temperature,
providing ten hip joints for investigation. A Thompson HA was cemented
in place via a direct lateral approach. The cadavers were then positioned
supine, both knee joints were disarticulated and a digital torque
wrench was attached to the femur using a circular frame with three
half pins. The wrench applied an external rotation force with the
hip in extension to allow the hip to dislocate anteriorly. Each
hip was dislocated twice; once with a capsular repair and once without
repairing the capsule. Stratified sampling ensured the order in
which this was performed was alternated for the paired hips on each
cadaver. Comparing peak torque force in hips with the capsule repaired
and peak torque force in hips without repair of the capsule, revealed
a significant difference between the ‘capsule repaired’ (mean 22.96
Nm, standard deviation ( Cite this article:
