Frozen shoulder is commonly encountered in general orthopaedic practice. It may arise spontaneously without an obvious predisposing cause, or be associated with a variety of local or systemic disorders. Diagnosis is based upon the recognition of the characteristic features of the pain, and selective limitation of passive external rotation. The macroscopic and histological features of the capsular contracture are well-defined, but the underlying pathological processes remain poorly understood. It may cause protracted disability, and imposes a considerable burden on health service resources. Most patients are still managed by physiotherapy in primary care, and only the more refractory cases are referred for specialist intervention. Targeted therapy is not possible and treatment remains predominantly symptomatic. However, over the last ten years, more active interventions that may shorten the clinical course, such as capsular distension arthrography and arthroscopic capsular release, have become more popular.

This review describes the clinical and pathological features of frozen shoulder. We also outline the current treatment options, review the published results and present our own treatment algorithm.

Aims

The aims of this study were to evaluate the morphology of the ankle in patients with an osteochondral lesion of the talus using 3D CT, and to investigate factors that predispose to this condition.

Radiological assessment of total and unicompartmental knee replacement remains an essential part of routine care and follow-up. Appreciation of the various measurements that can be identified radiologically is important. It is likely that routine plain radiographs will continue to be used, although there has been a trend towards using newer technologies such as CT, especially in a failing knee, where it provides more detailed information, albeit with a higher radiation exposure.

The purpose of this paper is to outline the radiological parameters used to evaluate knee replacements, describe how these are measured or classified, and review the current literature to determine their efficacy where possible.

Dislocation of the shoulder may occur during seizures in epileptics and other patients who have convulsions. Following the initial injury, recurrent instability is common owing to a tendency to develop large bony abnormalities of the humeral head and glenoid and a susceptibility to further seizures. Assessment is difficult and diagnosis may be missed, resulting in chronic locked dislocations with protracted morbidity. Many patients have medical comorbidities, and successful treatment requires a multidisciplinary approach addressing the underlying seizure disorder in addition to the shoulder pathology. The use of bony augmentation procedures may have improved the outcomes after surgical intervention, but currently there is no evidence-based consensus to guide treatment. This review outlines the epidemiology and pathoanatomy of seizure-related instability, summarising the currently-favoured options for treatment, and their results.

The forces under the foot while walking have been measured using a high sensitivity force-plate of the strip-suspended type combined with simultaneous filming of the sole of the foot. The recording of data and the calculation and plotting of results were much simplified by computer aid. Normal and abnormal feet, both barefoot and shod, were investigated in sixteen subjects. It was found that in normal barefoot walking the forefoot carried a total load of the order of three times that of the heel. When footwear was worn the function of the forefoot was progressively reduced as the rigidity of the sole of the shoe increased. Painful conditions of the forefoot also produced a large reduction in the proportion of the total load transferred.

1. The detailed anatomy and calcification of the upper half of the tibia in rabbits varying in age from six weeks to twelve months has been studied.

2. The structure of the bone varies at different levels, but a section taken from the same level in the tibia from animals of the same age presents a reasonably constant picture.

3. It has been shown that this variation in structure at different levels is directly related to a difference between the axis of growth and the bone axis. This difference is a result of the unique shape of the tibia.

4. Autoradiographic studies confirm the localised concentration of radioactive strontium in areas of active bone formation where uptake is rapid.

5. The long retention of radioactive strontium in the skeleton (that is, the slow turnover) is a result of the slowness of resorption of bone (endosteal, periosteal or Haversian) in the cortex. Not only is the process slow but it is extremely localised.

6. The significance of these anatomical and physiological characteristics in relation to radiation injury is discussed.

1. The literature dealing with the reaction of tissues to metals has been briefly reviewed and discussed.

2. It is suggested that the "anodic back EMF" of metals, under the conditions of the experiment, is a measurable electrical quantity which can be correlated with their behaviour in tissues.

3. Details of the method for obtaining this "anodic back EMF" are given.

4. A correlation between the "anodic back EMF" and the loss of weight due to corrosion in vitro has been demonstrated.

5. The inertness of eighty-seven metals has been classified by this method.

6. It must be emphasised that these results are based on in vitro experiments only. In vivo experiments are in progress and the results will be published in due course. Preliminary work suggests that there is some correlation between the ABE and the behaviour of metals in tissue (Hickman 1953).

We compared the effects of continuous passive motion with those of intermittent active motion on the results of the resurfacing with autogenous periosteal grafts of full-thickness defects on the articular surface of rabbit patellae. Of 45 rabbits with defects, 30 received grafts. Fifteen of these had continuous passive motion for two weeks and intermittent active motion for four weeks; the other 15 had intermittent active motion for six weeks. In 15 the defects were not grafted (control group) and they had intermittent active motion for six weeks. Ten more rabbits had a sham operation. Six weeks after surgery, the results were assessed by the gross appearance, histology, histochemistry, immunohistochemistry and electron microscopy. By all assessments the quality of neochondrogenesis produced by periosteal grafts was superior to that in ungrafted defects (p less than 0.05) and the results in continuous passive motion treated animals were superior to those in intermittent active motion treated animals (p less than 0.05). The periosteal grafts produced hyaline cartilage containing type II collagen but the organisation of its fibres was irregular.

Benefits of early stabilization of femoral shaft fractures, in mitigation of pulmonary and other complications, have been recognized over the past decades. Investigation into the appropriate level of resuscitation, and other measures of readiness for definitive fixation, versus a damage control strategy have been ongoing. These principles are now being applied to fractures of the thoracolumbar spine, pelvis, and acetabulum. Systems of trauma care are evolving to encompass attention to expeditious and safe management of not only multiply injured patients with these major fractures, but also definitive care for hip and periprosthetic fractures, which pose a similar burden of patient recumbency until stabilized. Future directions regarding refinement of patient resuscitation, assessment, and treatment are anticipated, as is the potential for data sharing and registries in enhancing trauma system functionality. Cite this article: Bone Joint J 2023;105-B(4):361–364

Aims. The aim of this study was to report the medium-term outcomes of impaction bone allograft and fibular grafting for osteonecrosis of the femoral head (ONFH) and to define the optimal indications. Methods. A total of 67 patients (77 hips) with ONFH were enrolled in a single centre retrospective review. Success of the procedure was assessed using the Harris Hip Score (HHS) and rate of revision to total hip arthroplasty (THA). Risk factors were studied, including age, aetiology, duration of hip pain, as well as two classification systems (Association Research Circulation Osseous (ARCO) and Japanese Investigation Committee (JIC) systems). Results. After a mean follow-up period of 8.61 years (SD 1.45), 81.3% (52/64) of enrolled cases had a good or excellent HHS at latest follow-up (declining to 76.0% (38/50) for those with more than eight years of follow-up). Overall survival was 92.1% at eight years’ follow-up (95% CI 83.2% to 96.4%). A total of 12 hips (19.0%) failed (reoperation or HHS < 70 points) at final follow-up. Rate of success was adversely affected by increasing age, duration of pain, and more severe disease as measured using the ARCO and JIC classifications, but not by aetiology of the ONFH. Conclusion. We report favourable medium-term results of this procedure. Best outcomes can be expected in patients matching the following indications: younger than 40 years; less 12-month hip pain before surgery; femoral head collapse being less than 2 mm; and integrated lateral wall of femoral head. Cite this article: Bone Joint J 2020;102-B(7):838–844

Aims. We evaluated a large database with mechanical failure of a single uncemented modular femoral component, used in revision hip arthroplasty, as the end point and compared them to a control group treated with the same implant. Patient- and implant-specific risk factors for implant failure were analyzed. . Methods. All cases of a fractured uncemented modular revision femoral component from one manufacturer until April 2017 were identified and the total number of implants sold until April 2017 was used to calculate the fracture rate. The manufacturer provided data on patient demographics, time to failure, and implant details for all notified fractured devices. Patient- and implant-specific risk factors were evaluated using a logistic regression model with multiple imputations and compared to data from a previously published reference group, where no fractures had been observed. The results of a retrieval analysis of the fractured implants, performed by the manufacturer, were available for evaluation. Results. There were 113 recorded cases with fracture at the modular junction, resulting in a calculated fracture rate of 0.30% (113/37,600). The fracture rate of the implant without signs of improper use was 0.11% (41/37,600). In 79% (89/113) of cases with a failed implant, either a lateralized (high offset) neck segment, an extralong head, or the combination of both were used. Logistic regression analysis revealed male sex, high body mass index (BMI), straight component design, and small neck segments were significant risk factors for failure. Investigation of the implants (76/113) showed at least one sign of improper use in 72 cases. Conclusion. Implant failure at the modular junction is associated with patient- and implant-specific risk factors as well as technical errors during implantation. Whenever possible, the use of short and lateralized neck segments should be avoided with this revision system. Implantation instructions and contraindications need to be adhered to and respected. Cite this article: Bone Joint J 2020;102-B(5):573–579

The introduction of a trabecular tantalum rod has been proposed for the management of early-stage osteonecrosis of the femoral head but serves as a single-point of support of the necrotic lesion. We describe a technique using two or three 4.2 mm (or later 4.7 mm) tantalum pegs for the prevention of collapse of the necrotic lesion. We prospectively studied 21 patients (26 hips) with non-traumatic osteonecrosis of the femoral head treated in this manner. Of these, 21 patients (24 hips) were available for radiological and clinical evaluation at a mean follow-up of 46 months (18 to 67). Radiological assessment showed that only eight hips deteriorated according to the Association Research Circulation Osseous classification, and four hips according to the Classification of the Japanese Investigation Committee of Health and Welfare. Functional improvement was obtained with an improvement in the mean Harris hip score from 65.2 (33.67 to 95) to 88.1 (51.72 to 100), the mean Merle D’Aubigné-Postel score from 13 (6 to 18) to 16 (11 to 18), a mean visual analogue score for pain from 5.2 (0 to 9.5) to 2.6 (0 to 7), and the mean Short-Form 36 score from 80.4 (56.8 to 107.1) to 92.4 (67.5 to 115.7). Of these 24 hips followed for a minimum of 18 months, three were considered as failures at the final follow-up, having required total hip replacement. One of the hips without full follow-up was also considered to be a failure. In more than two-thirds of the surviving hips a satisfactory clinical outcome was achieved with promising radiological findings. The estimated mean implant survival was 60 months (95% confidence interval 53.7 to 66.3)

Aims

The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems.

Severe traction injuries may damage the brachial plexus at any level from the spinal cord to the axillary outlet. Investigation aims to determine the level of the injury for each of the nerves, trunks or cords, with particular reference to obtaining firm evidence of any intradural (pre-ganglionic) damage. We report the results of computerised axial tomography of the cervical spine in comparison with conventional myelography and with surgical exploration of the plexus. CT scanning with contrast enhancement greatly improves diagnostic accuracy, particularly at C5 and C6 root levels

Six major and seven minor diagnostic criteria have been developed by the Japanese Investigation Committee for osteonecrosis of the femoral head (ONFH). We have carried out a multicentre study to clarify these. We studied prospectively 277 hips in 222 patients, from six hospitals, who had ONFH and other hip pathology and from whom histological material was available. We identified five criteria with high specificity: 1) collapse of the femoral head without narrowing of the joint space or acetabular abnormality on radiographs, including the crescent sign; 2) demarcating sclerosis in the femoral head without narrowing or acetabular abnormality; 3) a ‘cold-in-hot’ appearance on the bone scan; 4) a low-intensity band on T1-weighted images (band pattern); and 5) evidence of trabecular and marrow necrosis on histological examination. With any combination of two of these criteria, the sensitivity and specificity of the diagnosis were 91% and 99%, respectively

Aims

We compared the clinical outcomes of curved intertrochanteric varus osteotomy (CVO) with bone impaction grafting (BIG) with CVO alone for the treatment of osteonecrosis of the femoral head (ONFH).

Aims

The aims of this study were to determine the diagnostic yield of image-guided biopsy in providing a final diagnosis in patients with suspected infectious spondylodiscitis, to report the diagnostic accuracy of various microbiological tests and histological examinations in these patients, and to report the epidemiology of infectious spondylodiscitis from a country where tuberculosis (TB) is endemic, including the incidence of drug-resistant TB.

Aims

The primary aim of this study was to assess whether non-fatal postoperative venous thromboembolism (VTE) within six months of surgery influences the knee-specific functional outcome (Oxford Knee Score (OKS)) one year after total knee arthroplasty (TKA). Secondary aims were to assess whether non-fatal postoperative VTE influences generic health and patient satisfaction at this time.

Aims

Injury to the lateral femoral cutaneous nerve (LFCN) is one of the known complications after periacetabular osteotomy (PAO) performed using the anterior approach, reported to occur in between 1.5% and 65% of cases. In this study, we performed a prospective study on the incidence of LFCN injury as well as its clinical outcomes based on the Harris Hip Score (HHS), Short-Form 36 Health Survey (SF-36), and Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ).

Aims

Our unit was identified as a negative outlier in the national patient-reported outcome measures (PROMs) programme, which has significant funding implications. As a centre that carries out a high volume of unicompartmental knee arthroplasty (UKA), our objectives were: 1) to determine whether the PROMs programme included primary UKA when calculating the gain in Oxford Knee Score (OKS); and 2) to determine the impact of excluding primary UKA on calculated OKS gains for primary knee arthroplasty.

Aims

Cementless primary total hip arthroplasty (THA) is associated with risks of bleeding and thromboembolism. Anticoagulants are effective as venous thromboprophylaxis, but with an increased risk of bleeding. Tranexamic acid (TXA) is an efficient antifibrinolytic agent, but the mode and timing of its administration remain controversial. This study aimed to determine whether two intravenous (IV) TXA regimens (a three-hour two-dose (short-TXA) and 11-hour four-dose (long-TXA)) were more effective than placebo in reducing perioperative real blood loss (RBL, between baseline and day 3 postoperatively) in patients undergoing THA who receive rivaroxaban as thromboprophylaxis. The secondary aim was to assess the non-inferiority of the reduction of blood loss of the short protocol versus the long protocol.

Aims

The aim of this study was to determine how the short- and medium- to long-term outcome measures after total disc replacement (TDR) compare with those of anterior cervical discectomy and fusion (ACDF), using a systematic review and meta-analysis.

Patellar instability most frequently presents during adolescence. Congenital and infantile dislocation of the patella is a distinct entity from adolescent instability and measurable abnormalities may be present at birth. In the normal patellofemoral joint an increase in quadriceps angle and patellar height are matched by an increase in trochlear depth as the joint matures. Adolescent instability may herald a lifelong condition leading to chronic disability and arthritis.

Restoring normal anatomy by trochleoplasty, tibial tubercle transfer or medial patellofemoral ligament (MPFL) reconstruction in the young adult prevents further instability. Although these techniques are proven in the young adult, they may cause growth arrest and deformity where the physis is open. A vigorous non-operative strategy may permit delay of surgery until growth is complete. Where non-operative treatment has failed a modified MPFL reconstruction may be performed to maintain stability until physeal closure permits anatomical reconstruction. If significant growth remains an extraosseous reconstruction of the MPFL may impart the lowest risk to the physis. If minor growth remains image intensifier guided placement of femoral intraosseous fixation may impart a small, but acceptable, risk to the physis.

This paper presents and discusses the literature relating to adolescent instability and provides a framework for management of these patients.

Cite this article: Bone Joint J 2017;99-B:159–70.

Aims

The aim of this consensus was to develop a definition of post-operative fibrosis of the knee.

We have previously described the mid- to long-term results of conventional simple varus intertrochanteric osteotomy for osteonecrosis of the femoral head, showing that 19 of the 26 hips had good or excellent results. We extended the follow-up to a mean of 18.1 years (10.5 to 26) including a total of 34 hips in 28 patients, with a mean age at surgery of 33 years (19 to 53). There were 18 men and ten women and 25 hips (74%) had a satisfactory result with a Harris hip score ≥ 80. In all, six hips needed total hip replacement (THR) or hemiarthroplasty. The collapse of the femoral head or narrowing of the joint space was found to have progressed in nine hips (26%). Leg shortening after osteotomy was a mean of 19 mm (8 to 36). With conversion to THR or hemiarthroplasty as the endpoint, the ten-year survival rate was 88.2% (95% confidence interval (CI) 82.7 to 93.7) and the 20-year survival rate was 79.7% (95% CI 72.1 to 87.3); four hips were converted at ten years and other two hips were converted at 20 years.

Shortening of the leg after osteotomy remains a concern; however, the conventional varus half-wedge osteotomy provides favourable long-term results in hips with less than two-thirds of the medial part of the femoral head affected by necrotic bone and with normal bone superolaterally.

We investigated the factors related to the radiological outcome of a transtrochanteric curved varus osteotomy in patients with osteonecrosis of the hip. We reviewed 73 hips in 62 patients with a mean follow-up of 12.4 years (5 to 31.1). There were 28 men and 34 women, with a mean age of 33.3 years (15 to 68) at the time of surgery. The 73 hips were divided into two groups according to their radiological findings: group 1 showed progression of collapse and/or joint-space narrowing; group 2 had neither progressive collapse nor joint-space narrowing. Both of these factors and the radiological outcomes were analysed by a stepwise discriminant analysis. A total of 12 hips were categorised as group 1 and 61 as group 2. Both the post-operative intact ratio and the localisation of the necrotic lesion correlated with the radiological outcome. The cut-off point of the postoperative intact ratio to prevent the progression of collapse was 33.6%, and the cut-off point to prevent both the progression of collapse and joint-space narrowing was 41.9%.

The results of this study indicate that a post-operative intact ratio of 33.0% is necessary if a satisfactory outcome is to be achieved after this varus osteotomy.

Transtrochanteric curved varus osteotomy was designed to avoid some of the disadvantages of varus wedge osteotomy, such as post-operative leg-length discrepancy. In this retrospective study we investigated the leg-length discrepancy and clinical outcome after transtrochanteric curved varus osteotomy undertaken in patients with osteonecrosis of the femoral head. Between January 1993 and March 2004, this osteotomy was performed in 42 hips of 36 patients with osteonecrosis of the femoral head. There were 15 males and 21 females with a mean age at surgery of 34 years (15 to 68). The mean follow-up was 5.9 years (2.0 to 12.5). The mean pre-operative Harris hip score was 64.0 (43 to 85) points, which improved to a mean of 88.7 (58 to 100) points at final follow-up. The mean varus angulation post-operatively was 25° (12° to 38°) and the post-operative mean leg-length discrepancy was 13 mm (4 to 25). The post-operative leg-length discrepancy showed a strong correlation with varus angulation (Pearson’s correlation coefficient; r = 0.9530, p < 0.0001), which may be useful for predicting the leg-length discrepancy which can occur even after transtrochanteric curved varus osteotomy.

We report the clinical and radiological outcomes of a series of contemporary cementless ceramic-on-ceramic total hip replacements (THRs) at ten years in patients aged ≤ 55 years of age. Pre- and post-operative activity levels are described. A total of 120 consecutive ceramic cementless THRs were performed at a single centre in 110 patients from 1997 to 1999. The mean age of the patients at operation was 45 years (20 to 55). At ten years, four patients had died and six were lost to follow-up, comprising ten hips. The mean post-operative Harris hip score was 94.7 (55 to 100). Radiological analysis was undertaken in 90 available THRs of the surviving 106 hips at final review: all had evidence of stable bony ingrowth, with no cases of osteolysis. Wear was undetectable. There were four revisions. The survival for both components with revision for any cause as an endpoint was 96.5% (95% confidence interval 94.5 to 98.7). The mean modified University of California, Los Angeles activity level rose from a mean of 6.4 (4 to 10) pre-operatively to 9.0 (6 to 10) at the ten-year post-operative period.

Alumina ceramic-on-ceramic bearings in cementless primary THR in this series have resulted in good clinical and radiological outcomes with undetectable rates of wear and excellent function in the demanding younger patient group at ten years.

Cite this article: Bone Joint J 2013;95-B:1603–9.

The sternoclavicular joint is vulnerable to the same disease processes as other synovial joints, the most common of which are instability from injury, osteoarthritis, infection and rheumatoid disease. Patients may also present with other conditions, which are unique to the joint, or are manifestations of a systemic disease process. The surgeon should be aware of these possibilities when assessing a patient with a painful, swollen sternoclavicular joint.

We present two cases of metastatic lung cancer which occurred at the site of a previously united tibial fracture. Both patients were treated with a locked intramedullary nail. The patients presented with metastases at the site of their initial fracture approximately 16 and 13 months after injury respectively.

We discuss this unusual presentation and review the relevant literature. We are unaware of any previous reports of a metastatic tumour occurring at the site of an orthopaedic implant used to stabilise a non-pathological fracture. These cases demonstrate the similar clinical presentation of infection and malignancy: a diagnosis which should always be considered in such patients.

Iliacus haematoma is a relatively rare condition, which may cause a local compressive neuropathy. It is usually diagnosed in adults with haemophilia or those on anticoagulation treatment and may occur after trauma. We present the case of a healthy 15-year-old boy with a femoral neuropathy due to an iliacus haematoma which resolved following conservative treatment.

The mechanical performance of the cement-in-cement interface in revision surgery has not been fully investigated. The quantitative effect posed by interstitial fluids and roughening of the primary mantle remains unclear. We have analysed the strength of the bilaminar cement-bone interface after exposure of the surface of the primary mantle to roughening and fluid interference. The end surfaces of cylindrical blocks of cement were machined smooth (Ra = 200 nm) or rough (Ra = 5 μm) and exposed to either different volumes of water and carboxymethylcellulose (a bone-marrow equivalent) or left dry. Secondary blocks were cast against the modelled surface. Monoblocks of cement were used as a control group. The porosity of the samples was investigated using micro-CT. Samples were exposed to a single shearing force to failure.

The mean failure load of the monoblock control was 5.63 kN (95% confidence interval (CI) 5.17 to 6.08) with an estimated shear strength of 36 MPa. When small volumes of any fluid or large volumes were used, the respective values fell between 4.66 kN and 4.84 kN with no significant difference irrespective of roughening (p > 0.05). Large volumes of carboxymethylcellulose significantly weakened the interface. Roughening in this group significantly increased the strength with failure loads of 2.80 kN (95% CI 2.37 to 3.21) compared with 0.86 kN (95% CI 0.43 to 1.27) in the smooth variant. Roughening of the primary mantle may not therefore be as crucial as has been previously thought in clinically relevant circumstances.

We report the survival, radiological and functional outcomes of a single surgeon series of his first 144 consecutive Birmingham hip resurfacing procedures (130 patients) at a minimum of ten years. There were ten revisions during this time. Although no patients were lost to follow-up some did not complete the scoring assessment or undergo radiological assessment at ten years.

The ten-year survival for male patients was 98.0% (95% confidence interval 95.2 to 100). The ten-year survival for the total cohort with aseptic revision as the endpoint was 95.5% (95% confidence interval 91.8 to 99.0) and including revisions for sepsis was 93.5% (95% confidence interval 89.2 to 97.6). The median modified Oxford hip score at ten years was 4.2% (interquartile range 0 to 19) and the median University of California, Los Angeles score was 7.0 (interquartile range 5.0 to 8.0).

This study confirms the midterm reports that metal-on-metal hip resurfacing using the Birmingham Hip provides a durable alternative to total hip replacement, particularly in younger male patients wishing to maintain a high level of function, with low risk of revision for at least ten years.

We have investigated the accuracy of the templating of digital radiographs in planning total hip replacement using two common object-based calibration methods with the ball placed laterally (method 1) or medially (method 2) and compared them with two non-object-based methods. The latter comprised the application of a fixed magnification of 121% (method 3) and calculation of magnification based on the object-film-distance (method 4). We studied the post-operative radiographs of 57 patients (19 men, 38 women, mean age 73 years (53 to 89)) using the measured diameter of the prosthetic femoral head and comparing it with the true value.

Both object-based methods (1 and 2) produced large errors (mean/maximum: 2.55%/17.4% and 2.04%/6.46%, respectively). Method 3 applying a fixed magnification and method 4 (object-film-distance) produced smaller errors (mean/maximum 1.42%/5.22% and 1.57%/4.24%, respectively; p < 0.01). The latter results were clinically relevant and acceptable when planning was allowed to within one implant size. Object-based calibration (methods 1 and 2) has fundamental problems with the correct placement of the calibration ball. The accuracy of the fixed magnification (method 3) matched that of object-film-distance (method 4) and was the most reliable and efficient calibration method in digital templating.

We describe the survivorship of the Medial Rotation total knee replacement (TKR) at ten years in 228 cemented primary replacements implanted between October 1994 and October 2006, with their clinical and radiological outcome. This implant has a highly congruent medial compartment, with the femoral component represented by a portion of a sphere which articulates with a matched concave surface on the medial side of the tibial insert.

There were 78 men (17 bilateral TKRs) and 111 women (22 bilateral TKRs) with a mean age of 67.9 years (28 to 90). All the patients were assessed clinically and radiologically using the American Knee Society scoring systems. The mean follow-up was for six years (1 to 13) with only two patients lost to follow-up and 34 dying during the period of study, one of whom had required revision for infection.

There were 11 revisions performed in total, three for aseptic loosening, six for infection, one for a periprosthetic fracture and one for a painful but well-fixed replacement performed at another centre.

With revision for any cause as the endpoint, the survival at ten years was 94.5% (95% CI 85.1 to 100), and with aseptic loosening as the endpoint 98.4% (95% CI 93 to 100). The mean American Knee Society score improved from 47.6 (0 to 88) to 72.2 (26 to 100) and for function from 45.1 (0 to 100) to 93.1 (45 to 100). Radiological review failed to detect migration in any of the surviving knees.

The clinical and radiological results of the Medial Rotation TKR are satisfactory at ten years. The increased congruence of the medial compartment has not led to an increased rate of loosening and continued use can be supported.

Our aim in this pilot study was to evaluate the fixation of, the bone remodelling around, and the clinical outcome after surgery of a new, uncemented, fully hydroxyapatite-coated, collared and tapered femoral component, designed specifically for elderly patients with a fracture of the femoral neck.

We enrolled 50 patients, of at least 70 years of age, with an acute displaced fracture of the femoral neck in this prospective single-series study. They received a total hip replacement using the new component and were followed up regularly for two years.

Fixation was evaluated by radiostereometric analysis and bone remodelling by dual-energy x-ray absorptiometry. Hip function and the health-related quality of life were assessed using the Harris hip score and the EuroQol-5D.

Up to six weeks post-operatively there was a mean subsidence of 0.2 mm (−2.1 to +0.5) and a retroversion of a mean of 1.2° (−8.2° to +1.5°). No component migrated after three months. The patients had a continuous loss of peri-prosthetic bone which amounted to a mean of 16% (−49% to +10%) at two years. The mean Harris hip score was 82 (51 to 100) after two years.

The two-year results from this pilot study indicate that this new, uncemented femoral component can be used for elderly patients with osteoporotic fractures of the femoral neck.

Kienböck’s disease is a form of osteonecrosis affecting the lunate. Its aetiology remains unknown. Morphological variations, such as negative ulnar variance, high uncovering of the lunate, abnormal radial inclination and/or a trapezoidal shape of the lunate and the particular pattern of its vascularity may be predisposing factors. A history of trauma is common. The diagnosis is made on plain radiographs, but MRI can be helpful early in the disease. A CT scan is useful to demonstrate fracture or fragmentation of the lunate. Lichtman classified Kienböck disease into five stages. The natural history of the condition is not well known, and the symptoms do not correlate well with the changes in shape of the lunate and the degree of carpal collapse. There is no strong evidence to support any particular form of treatment. Many patients are improved by temporary immobilisation of the wrist, which does not stop the progression of carpal collapse. Radial shortening may be the treatment of choice in young symptomatic patients presenting with stages I to III-A of Kienböck’s disease and negative ulnar variance. Many other forms of surgical treatment have been described.

To clarify the pathomechanisms of discogenic low back pain, the sympathetic afferent discharge originating from the L5-L6 disc via the L2 root were investigated neurophysiologically in 31 Lewis rats. Sympathetic afferent units were recorded from the L2 root connected to the lumbar sympathetic trunk by rami communicantes. The L5-L6 discs were mechanically probed, stimulated electrically to evoke action potentials and, finally, treated with chemicals to produce an inflammatory reaction. We could not obtain a response from any units in the L5-L6 discs using mechanical stimulation, but with electrical stimulation we identified 42 units consisting mostly of A-delta fibres. In some experiments a response to mechanical probing of the L5-L6 disc was recognised after producing an inflammatory reaction. This study suggests that mechanical stimulation of the lumbar discs may not always produce pain, whereas inflammatory changes may cause the disc to become sensitive to mechanical stimuli, resulting in nociceptive information being transmitted as discogenic low back pain to the spinal cord through the lumbar sympathetic trunk. This may partly explain the variation in human symptoms of degenerate discs.

The majority of patients with osteoarthritis present to orthopaedic surgeons seeking relief of pain and associated restoration of function. Although our understanding of the physiology of pain has improved greatly over the last 25 years there remain a number of unexplained pain-related observations in patients with osteoarthritis. The understanding of pain in osteoarthritis, its modulation and treatment is central to orthopaedic clinical practice and in this annotation we explore some of the current concepts applicable. We also introduce the concept of the ‘phantom joint’ as a cause for persistent pain after joint replacement.

Impacted bone allograft is often used in revision joint replacement. Hydroxyapatite granules have been suggested as a substitute or to enhance morcellised bone allograft. We hypothesised that adding osteogenic protein-1 to a composite of bone allograft and non-resorbable hydroxyapatite granules (ProOsteon) would improve the incorporation of bone and implant fixation. We also compared the response to using ProOsteon alone against bone allograft used in isolation. We implanted two non-weight-bearing hydroxyapatite-coated implants into each proximal humerus of six dogs, with each implant surrounded by a concentric 3 mm gap. These gaps were randomly allocated to four different procedures in each dog: 1) bone allograft used on its own; 2) ProOsteon used on its own; 3) allograft and ProOsteon used together; or 4) allograft and ProOsteon with the addition of osteogenic protein-1.

After three weeks osteogenic protein-1 increased bone formation and the energy absorption of implants grafted with allograft and ProOsteon. A composite of allograft, ProOsteon and osteogenic protein-1 was comparable, but not superior to, allograft used on its own.

ProOsteon alone cannot be recommended as a substitute for allograft around non-cemented implants, but should be used to extend the volume of the graft, preferably with the addition of a growth factor.

Over a 13-year period we studied all patients who underwent major hip and knee surgery and were diagnosed with objectively confirmed symptomatic venous thromboembolism, either deep venous thrombosis or non-fatal pulmonary embolism, within six months after surgery. Low-molecular-weight heparin had been given while the patients were in hospital.

There were 5607 patients. The cumulative incidence of symptomatic venous thromboembolism was 2.7% (150 of 5607), of which 1.1% had developed pulmonary embolism, 1.5% had deep venous thrombosis and 0.6% had both. Patients presented with deep venous thrombosis at a median of 24 days and pulmonary embolism at 17 days after surgery for hip fracture. After total hip replacement, deep venous thrombosis and pulmonary embolism occurred at a median of 21 and 34 days respectively. After total knee replacement, the median time to the presentation of deep venous thrombosis and pulmonary embolism was 20 and 12 days respectively. The cumulative risk of venous thromboembolism lasted for up to three months after hip surgery and for one month after total knee replacement. Venous thromboembolism was diagnosed after discharge from hospital in 70% of patients who developed this complication.

Despite hospital-based thromboprophylaxis, most cases of clinical venous thromboembolism occur after discharge and at different times according to the operation performed.

Treatment strategies for osteoarthritis most commonly involve the removal or replacement of damaged joint tissue. Relatively few treatments attempt to arrest, slow down or reverse the disease process. Such options include peri-articular osteotomy around the hip or knee, and treatment of femoro-acetabular impingement, where early intervention may potentially alter the natural history of the disease. A relatively small proportion of patients with osteoarthritis have a clear predisposing factor that is both suitable for modification and who present early enough for intervention to be deemed worthwhile. This paper reviews recent advances in our understanding of the pathology, imaging and progression of early osteoarthritis.

We have investigated the changes in anterior laxity of the knee in response to direct electrical stimulation of eight normal and 45 reconstructed anterior cruciate ligaments (ACLs). In the latter, the mean time from reconstruction was 26.7 months (24 to 32). The ACL was stimulated electrically using a bipolar electrode probe during arthroscopy. Anterior laxity was examined with the knee flexed at 20° under a force of 134 N applied anteriorly to the tibia using the KT-2000 knee arthrometer before, during and after electrical stimulation.

Anterior tibial translation in eight normal and 17 ACL-reconstructed knees was significantly decreased during stimulation, compared with that before stimulation. In 28 knees with reconstruction of the ACL, in 22 of which the grafts were found to have detectable somatosensory evoked potentials during stimulation, anterior tibial translation was not decreased. These findings suggest that the ACL-hamstring reflex arc in normal knees may contribute to the functional stability and that this may not be fully restored after some reconstructions of the ACL.