Objective: To report the use of a pedicled patellar transplant (d’ Aubigne procedure) in the reconstruction of femoral condyle for unicondylar giant cell tumours, in developing countries where facilities for custom made prostheses are not widely available.

Case Report: A 28 year old male presented with 5 month history of left knee joint swelling and pain and 1 month history of inability to walk. X-ray showed eccentric, expansile lytic lesion of the lateral femoral condyle associated with a pathological fracture of the subchondral bone. A diagnosis of Enniking’s stage-III Giant cell tumour was made based on the x-ray and histopathology findings. Due to the associated subchondral fracture, joint reconstruction using custom made prosthesis was considered as an ideal option. But, as this prosthesis was not available, d’ Aubigne procedure was considered as an alternative, in order to preserve the joint. Femoral condyle was removed “en bloc” with the tumour. Patella was prepared with intact vastus lateralis and fixed in continuity and in level with the medial condyle. Gap between the patella and femoral shaft was filled by combined cancellous and cortical grafts from iliac crest and tibia. Post operative course was uneventful. After a follow up of 2 years there was no recurrence and the range of flexion was 90° without any instability and pain.

Conclusion: In patients with unicondylar giant cell tumours with subchondral fractures, arthrodesis can be avoided and the joint can be preserved using pedicled patellar transfer, when arthroplasty can not be carried out.

Aim: To compare the biomechanical properties of paired flexible steel and titanium nails in simulated transverse fractures of synthetic composite bones.

Methods: Steel and titanium nails (3mm diameter) were individually used in pairs of divergent configuration to study torsion, cantilever bending (anteroposterior and lateral), and axial loading properties of adolescent synthetic composite tibiae model (10mm diameter). Properties of the intact bone, simulated fresh fracture with nails and simulated healing fracture with nails were studied. Instron 4303 universal testing machine was used to study axial loading. Applying fibreglass layers around the fracture with epoxy resin simulated fracture healing with callus formation.

Results: Steel and titanium nails maintained good alignment of fracture fragments. Both the nails demonstrated very poor stability of fresh fractures in torsion loading. Steel nail/bone construct was 57% stronger than Titanium nail/bone construct under similar testing conditions during fracture healing (p< 0.05) but still < 50% stiffness of intact bone. In bending tests, both types of nails showed < 10% of the stiffness of intact bone in fresh fractures (p< 0.05). Mediolateral stiffness was better than anteroposterior stiffness. In fracture healing, the bending stiffness of both types of nail/bone constructs was > 50% that of intact bone. Axial stiffness of both nails was more than bending or torsion stiffness implying that fracture fragments play a significant role in the stability of the fracture.

Although both types of nail/bone constructs demonstrated similar stiffness results in fresh and healing fractures, steel nails performance was statistically better than Titanium nails in all loading tests (p< 0.05).

Conclusion: Fractures fixed with either type of flexible nails should be supplemented with splints or plaster for a short duration until callus formation. Flexible nails should be used with caution in comminuted fractures, over weight patients since they may not provide adequate stability or allow early mobilization. Additional research with cadaver bones may provide further insight into the performance of the flexible nails.

Aim: A case report: Symptomatic Osteochondroma of the Coracoid

Introduction: An osteochondroma is a common developmental tumour of bone characterized by abnormal periphyseal ectopic endochondral ossification. This results in a cartilage-capped subperiosteal bony projection. A solitary osteochondroma is encountered more frequently than are multiple hereditary osteochondromas. They are usually appreciated in the first decades of life and are most commonly located in the long bones, especially the femur, humerus and the tibia. Clinical presentations generally relate to the mass effect of the lesion. These lesions are said to grow to skeletal maturity. Continuous slow growth of the osteochondroma in adults should alert the clinician to the possibility of secondary malignant transformation, usually to a chondroma.

Method: We present an unusual case of shoulder pain in a 36-year-old man with a painful solitary osteochondroma of the coracoid process. Plain radiographs, computed tomographic and magnetic resonance imaging of the lesion showed a solitary osteochondroma with a visible cartilage cap eroding the under surface of the clavicle. The lesion was surgically explored and excised. Histological examination showed a benign osteochondroma. Removal of the tumour resulted in resolution of all signs and symptoms.

Conclusion: We are aware of no reported cases in the literature of osteochondroma of the coracoid process. This case was unusual in terms of age at clinical presentation and location, suggesting a continuous growth of the tumour beyond skeletal maturity.

Aims: To study clinicoradiological correlation with metal levels in patients with metal-on-metal hip resurfacings. Methods: Serum levels of Cobalt (Co) and Chromium (Cr) in 18 patients undergoing metal-on-metal resurfacing were measured preoperatively and at 6, 12, 24 and 36 months postoperatively. Implants were made of cast Co-Cr alloy. Cr analysis was by graphite furnace atomic absorption spectrometry (ETA-AAS) & Co analysis by inductively coupled plasma mass spectrometry (ICP-MS). Results: Patientsñ mean age: 51.6 years. Average preoperative levels of Cr and Co: 10.5 nmol/l & 7 nmol/l respectively. All patients showed increase in serum cobalt and chromium. Maximum Cr levels increased by 20 fold (range 5–106) and Co by 30 fold (range 3–91) after 12 months in 71% cases. In 69% cases, chromium levels were higher than cobalt levels. Downward trend was noted in 4 cases after 2 years postoperatively. Bilateral cases were similar to unilateral cases. Postoperative HHS was 77.2 (range 50.2–87.6). One dislocated hip had 171-fold increase of Cr and Co by 107 fold. No radiological abnormalities were noted. Conclusions: Increase in serum levels of both cobalt and chromium is due to ñself polishing phenomenonñ correlating with an increase of patientñs physical activity. This may stabilise or show a downward trend after 2 years. The patients with very high levels tended to be relatively young compared to others. Level of activity and age may determine amount of metal release from implanties.

Aims: To study whether re-transfusion of autologus blood from solcotrans drains reduced banked blood transfusion requirement in primary total knee arthroplasty (TKR). Methods: 195 patients with unilateral primary TKR using the same surgical technique and implants were prospectively reviewed. Group 1: In 120 cases, solcotrans drain system used for postoperative blood salvage and reinfusion. Group 2: 75 cases had standard redivac drains. Homologous blood transfusions used if post-operative haemoglobin < 9 gm. Factors like weight and height, and pre-operative haemoglobin levels were also studied. Results: Group 1: Average blood loss: 598 ml. 88 cases (71%) had reinfusion of autologous salvaged blood, average re-transfusion: 271 ml (range: 200 Ð 1160 ml). In 29% (32 cases), there was not enough blood in solcotrans drains for re-transfusion. 29 patients (23%) required banked blood transfusion in whom average blood loss was 720 ml, average number of units transfused: 1.6. In 10 of the 29 cases, there was not enough blood in solcotrans drains for re-transfusion. Group 2: Average blood loss: 588 ml. 20 cases (26%) required banked blood transfusion in whom average blood loss was 758 ml. Average number of units transfused: 1.9. Conclusions: In our study, solcotrans system did not reduce the requirement of banked blood transfusion signiþcantly in TKR. In both groups, low levels of preop-erative haemoglobin, low weight and amount of blood loss inßuenced banked blood requirement (p< 0.05).

Aims: To study functional outcome and survivorship of custom designed knee implants for primary and revision TKR where off-the-shelf prostheses were unsuitable. Methods: Clinical and radiological results of twenty-three custom-designed total knee prosthesis in twenty patients were prospectively reviewed. The indications were bone loss following multiple revisions of total knee prosthesis and debridement for infection, periprosthetic fractures, bone deformity with rickets and small bones with juvenile chronic arthritis. All implants designed and manufactured at Centre for Biomedical Engineering, Stanmore, U.K. Four different designs of knee prosthesis used: Condylar knee of miniature size, CAD-CAM knee, Superstabiliser and Rotating Hinges. Hospital for Special Surgery (HSS) score taken preoperatively, at 3 months, and yearly by an independent research physiotherapist. Duration of follow up: 62.5 months (28–126 months) Results: Average HSS score improved from 13.5 points (range 0–48) pre-operatively to 86.5 points postoperatively (range 62–96) (p=0.025). Average maximum flexion post operatively: 86.4° (range 60°–122°). Sixteen knees had excellent, five good and two poor results. Extension lag of 15°–25° in three patients. One patient with juvenile chronic arthritis needed revision at five years after index arthroplasty. Conclusions: Clinical and radiological results for custom designed prostheses compare favourably with standard knee prosthesis for similar indications. Our results support the use of a custom designed knee implant as salvage prosthesis and also as an alternative to arthrodesis or amputation.

Aims: To study clinical outcome of patients treated with a new design of the patellar tendon-tibial tubercle graft, which has reliable stability for transfer in recurrent dislocation of patella. Methods: 22 dislocations in 19 patients (3 bilateral) operated by this new technique were reviewed. There were 14 female and 5 male patients. Indications for surgery included functional disability due to repeated dislocations and failure of conservative management. Average age of the patient: 26 years (15–39 years). Duration of follow-up: 12–88months. Demographic data was collected by reviewing the case notes. Postoperative evaluation based on subjective pain evaluation score and Lysholm knee score. Surgical approach: limited infrapatellar midline incision, no internal fixation in any of the cases. Results: 75% of the patients had excellent to good result. There was no recurrence of instability/dislocation in any of the cases. Fair & poor (25%) results were graded based on stiffness and pain Conclusions: Multiple surgical procedures have been described for the management of recurrent dislocation of patella ranging from soft tissue realignment to bony procedures with internal fixation. Our results showed good functional improvement in the majority of the patients. This procedure is less extensive compared to the original procedure. Also there is the added advantage of no internal fixation and hence a second surgery for the removal of the implant can be avoided.

This study presents the clinical outcome of Boyd-McLeod procedure for lateral epicondylitis of elbow. 29 cases with lateral epicondylitis with failed conservative management (rest, physiotherapy, analgesia and steroid injections) were included in the study. There were 14 male, and 15 female cases of which two had bilateral surgery. Data collection included details of patients’ occupation, number of steroid injections, radiograph evaluation and postoperative complications. Post-operative clinical out come was evaluated by Hospital for Special Surgery Total Elbow Scoring System (HSS2), clinical notes review, and telephone questionnaire.

Average age: 47 years (range: 34–65), mean post-op follow up time: 16 months (range: 6–32). 93% were manual workers. Dominant elbow involvement was seen in 64%. Mean number of steroid injections: 3 (range: 1–10). Conservative measures included NSAIDS (90%) and physiotherapy (83%). Average tourniquet time: 32 min (range: 18–59). Mean HSS2 score pre-op and post-op were 38 and 92 respectively (p value: 0.0001). 91% reported excellent/good results. Average post-op time for the continuation of professional/recreational activity was 5 weeks. 2 cases (9%) had poor results. One case had ectopic bone formation.

Boyd-McLeod procedure is done as a day case procedure involving excision of degenerative tissue from common extensor origin, decortication and decompression of lateral epicondyle and partial release of annular ligament. Although an extensive procedure, this procedure addresses the management of all offending factors that are likely to contribute to pain and disability in tennis elbow. There are few studies regarding the outcome of Boyd-McLeod procedure. There was no evidence to suggest that late presentation had any adverse effect on the post-op success. This study revealed a high success rate and a low complication rate. We conclude that Boyd-McLeod procedure is an effective treatment option in patients with resistant lateral epicondylitis.

This was an assessment of the clinical and radiological outcome of impaction allografting using morselised cancellous bone allograft in femoral component revision in total hip arthroplasty.

27 consecutive femoral revisions operated on by a single surgeon (SJK) since 1995 were reviewed. Morselised bone allograft was used to reconstitute bone stock deficiency. All patients had cemented Exeter X-change technique Patient selection was primarily based on the amount of preoperative bone loss that was graded according to the Endo-Klinik classification. 10 hips were Endo-Klinik grade 2, 16 hips grade 3 and 1 hip grade 4. Both the components were revised in 18 hips.

The duration of follow up was 12–56 months (average: 33 months) Clinical outcome was assessed using the Charnley modification of Merle d’Aubigné and Postel score. Radiographs were standardised & assessment was done on digitised images of the radiographs using the Image Tool program (Wilcox, Dove, McDavid and Greer, UTHSCSA, Texas, USA).

Charnley’s scores improved from a preoperative score of 2.3, 2.6 and 2.6 to 5.3, 4.2 and 4.8 respectively. Radiologically there were 2 cases of subsidence of > 10mm after 24 months postoperatively. Non progressive radiolucent lines of < 2mm were noted in 7 hips at the cement-graft interface while 3 hips had radiolucent lines at the stem-cement interface. There was satisfactory radiological evidence of bone consolidation in 26 of the cases (95%). There have been 2 re-revisions-1 for dislocation and the other for massive subsidence.

Midterm results showed good functional improvement in hips with preoperative grade 2 and 3 bone loss. We believe this technique is effective in treating major bone loss but may be highly operator dependent.

To review the early functional results of Birmingham hip resurfacing. First 116 hips (98 patients), a cohort of consecutive patients prospectively underwent BHR in a single arthroplasty Surgeon’s practice in a University Hospital outside Birmingham. Inclusion criteria fit and active patients. 98 patients mean age 50 years (range 19–67). Pathology OA 85%, Perthes 7%, DDH 4.7% & SUFE 2%. Mean follow-up 30 months (range 12–45). Scoring systems used were Harris hip score (HHS), WOMAC & SF36.

HHS: mean pre-arthroplasty 47 (range 10–73), one year 99 (n=57), at 2 years 97.3 (n=26) and at third year 100 (n=3), statistically significant improvement (P=0.001).

WOMAC: pain: pre-op score 18.8, at 1 year 5.6 and second year 5.7. Stiffness: pre-op 8.5, 1 year 2.7 & 2^nd year 2.7. Physical: 49.3, 1 year 23.4 & 2^nd year 22.6.

This shows a statistically significant improvement in pain score (p=0.025) and physical function score (p=0.025).

SF-36 one-year post op, when analysed against an age/sex match control group normal values using a 2 tailed ‘t’ Test, seven of the eight domains showed no statistical significance. Only the Social Functioning domain showed a statistically significant result (p=0.011).

One fracture following a fall (patient had deep cysts in proximal head now such patients are not offered BHR), one dislocation following RTA and one AVN in a 50 years old post menopausal lady.

Birmingham hip resurfacing can provide excellent level of activity and patient satisfaction. A long-term study is needed to evaluate the long-term benefit and survivorship.

The shape of the femoral canal is variable, infact more variable than most contemporary designs of femoral components would suggest or accommodate. Clinical and experimental studies of total hip replacement have demonstrated the need for a close geometric fit between the femoral component and the supporting bone for a durable implant fixation. In order to provide a basis for design and selection of femoral components in future, we undertook an anthropometric study of proximal femoral geometry on Indian specimens.

74 cadaveric femorae were studied to analyze the difference in the endosteal and periosteal geometry between Indian and Western population. Standard extra-cortical and endosteal dimensions were determined by direct measurements of radiographs. To enable comparison standard horizontal and vertical axis were established using the geometric center of lesser trochanter and the bisecting axis of the medullary canal at the level of the isthmus. Statistically significant differences were found for the following measurements: Femoral head offset, Width at lesser trochanter, Width at lesser trochanter-20mm, Proximal border of isthmus, Neck shaft angle.