Objectives

Previous studies have evidenced cement-in-cement techniques as reliable in revision arthroplasty. Commonly, the original cement mantle is reshaped, aiding accurate placement of the new stem. Ultrasonic devices selectively remove cement, preserve host bone, and have lower cortical perforation rates than other techniques. As far as the authors are aware, the impact of ultrasonic devices on final cement-in-cement bonds has not been investigated. This study assessed the impact of cement removal using the Orthosonics System for Cemented Arthroplasty Revision (OSCAR; Orthosonics) on final cement-in-cement bonds.

Numerous studies have evidenced cement-in-cement techniques as reliable in revision arthroplasty. The original cement mantle is commonly reshaped to aid accurate placement of the new stem.

Ultrasonic devices selectively remove cement, preserve host bone and have lower cortical perforation rates than other techniques. As far as the authors are aware, their impact on final cement-cement bonds has not been investigated. This study assessed the impact of cement removal using OSCAR (Orthosonics System for Cemented Arthroplasty Revision, ORTHOSONICS) on final cement-cement bonds.

Twenty-four specimens were manufactured by pouring cement (Simplex P Bone Cement, Stryker) into stainless-steel moulds with a central rod polished to Stryker Exeter V40 specifications. After cement curing, rods were removed and eight specimens allocated to each of three internal surface preparation groups: 1) burr; 2) OSCAR; or 3) no treatment. Internal holes were re-cemented, then each specimen was cut into 5mm discs. Shear testing of discs was completed by a technician blinded to original grouping (Instron 5567, UK), recording ultimate shear strengths.

The mean shear strength for OSCAR-prepared specimens (17 MPa, 99% CI 14.9 to 18.6, SD=4.0) was significantly lower than that measured for the control (23 MPa, 99% CI 22.5 to 23.7, SD=1.4) and burr (23 MPa, 99% CI 22.1 to 23.7, SD=1.9) groups (P<0.001, one-way ANOVA with Tukey's post-hoc analysis). There was no significant difference between control and burr groups (P>0.05).

Results show that cement removal technique impacts on final cement-cement bonds. This in vitro study shows a significantly weaker bond when using OSCAR prior to re-cementation into an old cement mantle, compared to cement prepared with a burr or no treatment.

These results have implications for surgical practice and decision-making about specific cement removal techniques used during cement-in-cement revision arthroplasty, suggesting that the risks and benefits of ultrasonic cement removal need careful consideration.

Introduction: Nerve conduction study (NCS) examination of the ulnar nerve is a diagnostic tool when investigating patients presenting with cubital tunnel syndomre (CTS). However, NCS are associated with a false negative rate. Decompressive surgery of the ulnar nerve remains the primary treatment of cubital tunnel syndrome. The aim of our study was to look at:

The correlation between the results of NCS and the subsequent outcome from surgery

Method: A retrospective study of 75 cases of CTS was undertaken. All patients had clinical examination with documentation of features, followed by NCS if indicated. If NCS were carried out, the results of the study was graded (negative, mild, moderate or severe). All patients had decompressive surgery of the ulnar nerve at the elbow. Operative functional outcomes was evaluated pre and post operatively using standard DASH score. A successful outcome was defined as resolution of symptoms.

Results: There were 53 men and 22 women. Patient age showed a normal distribution (range 26–84, mean 49 years). Overall, 65 patients (87%) had resolution of symptoms postoperatively and 10 patients (13%) had unresolved symptoms (5 sensory, 1 pain, 2 sensory & pain, 2 sensory & motor). Outcomes of patients that did not undergo NCS showed a resolution rate of 89% (24/27). Those that had a negative NCS, showed a resolution rate of 100% (12/12), whilst those that had a positive NCS showed a resolution rate of 81% (29/36).

Discussion: Our study highlighted that patients with electro-negative CTS can be effectively and safely treated by simple decompression. Surgical outcome can be correlated to the severity of the pre-operative NCS. There would seem no reason to refer patients for NCS prior to offering operative treatment.

Considerable controversy remains in the literature as to whether hemiarthroplasty or total shoulder arthroplasty (TSA) is the better treatment option for patients with shoulder arthritis. Several cohort studies have compared the outcomes of stemmed hemiarthroplasty with those of stemmed TSA and had inconsistent conclusions as to which procedure is best. However, these studies suggest that stemmed TSA provided better functional outcome. 340 CSRA cases were performed between 1987–2003, 218 Hemiarthroplasty – Humeral Surface Arthroplasty (HSA) and 122 TSA. There was very little difference in the functional outcome and pain in patients with and without a glenoid implant early, as well as, later after surgery. Mean post-operative Constant score for TSA was 85.0% (59.8 points) and for HSA patients 86.8% (62.3 points) with no statistically significant differences (t-test, p=0.4821). A highly significant difference between the overall proportions of revised cases was observed, with (21/122) 17.2% and (6/218) 2.8% of TSA and HSA cases revised, respectively (p< 0.0001). Further, HSA prostheses survive significantly longer than TSA prostheses. The difference between the survival curves was highly significant, both in the earlier post-operative period (Wilcoxon’s test, p=0.0053) as well as the later on (Log-rank test, p=0.0028). Long-term survival of total joint replacement is related to polyethylene wear debris, and therefore its use should be avoided if possible. The difference between our series and those with stemmed prostheses may be due to the fact that with surface replacement the normal anatomy for each patient can be mimicked better than with the stemmed prostheses and there is substantially less place for error as in stem positioning, head sizing or wrong version that may lead to glenoid erosion and less favourable result. Our current practice is and we suggest performing Copeland humeral surface replacement without insertion of glenoid prosthesis.

Introduction Pridie and Steadman independently noticed the development of a smooth layer of fibrocartilage when treating exposed subchondral bone in the knee using their techniques of drilling or microfracture respectively. Since 1997, patients presenting to our unit for a Copeland cementless Surface Replacement Arthroplasty (CSRA) with a congruent glenohumeral joint have routinely undergone biological resurfacing of the glenoid using a technique similar to that described by Pridie and Steadman. We present this technique of glenoid resurfacing, the histological and surgical outcomes in a consecutive group of patients.

Methods/Results Between 1987 and 2002, 218 CSRA were performed without replacing the glenoid. From 1997, 133 CSRA have been performed with multiple drilling of the glenoid face with a guide wire through the subchondral bone in to the underlying soft cancellous bone to stimulate bleeding. This causes formation of a fibrocartilaginous layer – biological resurfacing. 9 (6.8%) of the patients with biological resurfacing have subsequently undergone a shoulder arthroscopy for postoperative impingement pain. This allowed us to evaluate the glenoid surface – macroscopically a layer of cartilage was noted in all patients, intraoperative biopsies have confirmed this layer to be fibrocartilage microscopically. In the biological resurfacing group, the mean postoperative Constant score (CS) is 86.9 (age/sex adjusted), with a mean improvement in CS of 71.0. 3 (2.3%) patients have required revision.

Conclusion Our results confirm that glenoid drilling at the time of CSRA leads to the formation of a fibro-cartilaginous layer over the glenoid, with significant improvements in Constant scores and functional outcomes. These results are comparable to other published results for total shoulder replacement with polyethylene resurfacing of the glenoid and better than patients that have undergone stemmed shoulder hemiarthroplasty.

Subjects who have incurred an osteoporotic fracture are at high risk of further fracture. Recent publications by the Department of Health, the National Osteoporosis Society and the Royal College of Physicians have recommended that these patients should receive appropriate life-style advice and treatment for osteoporosis.

The study aims to determine whether patients who had incurred a fracture of the hip or wrist were aware of the term osteoporosis and whether they had received advice or treatment for this condition following their fracture.

All patients attending Stepping Hill hospital, Stock-port, with a fracture wrist or hip between 1 Jan and 31 May 2000 were identified. A postal questionnaire was sent to these patients in Jan 2001 (at least 6 months following their fracture). The questionnaire sought information on awareness, investigations, advice and treatment received for osteoporosis.

After exclusion of patients who had died, 191 patients (102 wrist fractures, 89 fractured hip) were sent a questionnaire. Response rate was 87%. Although 79% of patients were aware of the term osteoporosis, only 22% had received any investigations, 21 % were given lifestyle advice and only 18% received treatment.

Despite the strong evidence that early treatment decreases the incidence of subsequent fractures, the results from this study continue to confirm that most patients are neither investigated nor treated for osteoporosis. This illustrates the wide discrepancy between knowledge and action in this field. All the patients with minimal trauma fractures will pass through an orthopaedic department at some point in their ongoing management for the fracture – however little responsibility is taken for the management of osteoporosis within the orthopaedic departments – a missed opportunity.