We report a prospective study of gait and tibial component migration in 45 patients with osteoarthritis treated by total knee arthroplasty (TKA). Migration was measured over two years using roentgen stereophotogrammetry. We used the previously established threshold of 200 μm migration in the second postoperative year to distinguish two groups: a risk group of 15 patients and a stable group of 28 patients. We performed gait analysis before operation and at six months and at two years after TKA. On all three occasions we found significant differences between the two groups in the mean sagittal plane moments of the knee joint. The risk group walked with higher peak flexion moments than the stable group. The two groups were not discriminated by any clinical or radiological criteria or other gait characteristics. The relationship which we have found between gait with increased flexion moments and risk of tibial component loosening warrants further study as regards the aetiology of prosthetic loosening and possible methods of influencing its incidence

As part of a prospective study of 476 total knee replacements (TKR), we evaluated the use of manipulation under anaesthesia in 47 knees. Manipulation was considered when intensive physiotherapy failed to increase flexion to more than 80°. The mean time from arthroplasty to manipulation was 11.3 weeks (median 9, range 2 to 41). The mean active flexion before manipulation was 62° (35 to 80). One year later the mean gain was 33° (Wilcoxon signed-rank test, range −5 to 70, 95% CI 28.5 to 38.5). Definite sustained gains in flexion were achieved even when manipulation was performed four or more months after arthroplasty (paired t-test, p < 0.01, CI 8.4 to 31.4). A further 21 patients who met our criteria for manipulation declined the procedure. Despite continued physiotherapy, there was no significant increase in flexion in their knees. Six weeks to one year after TKR, the mean change was 3.1° (paired t-test, p = 0.23, CI −8.1 to +2)

Two different classifications of discograms have been used in a prospective study of 279 injected discs in 100 patients. The five-stage classification of Adams, Dolan and Hutton (1986) showed increased degeneration in the lower lumbar discs and more degenerative changes in men than in women. Exact reproduction of the patient's pain on injection was more common in fissured or ruptured discs than in less degenerate discs, with 81% sensitivity and 64% specificity of the discogram for pain. The additional information obtained by comparing computerised tomography (CT) with discograms was minimal. Discography was found to be useful in the evaluation of chronic low back pain in patients whose ordinary CT scans, myelograms and flexion-extension radiographs were normal. In spondylolysis and spondylolisthesis, discography can disclose whether fusion needs to be extended above the lytic level, and it may show if the pain in patients who have had posterolateral fusion is discogenic. Thus, discography gives information which is useful in deciding whether to operate on patients with chronic low back pain

We carried out a prospective study of 71 patients who had undergone reconstruction of the anterior cruciate ligament with the ABC scaffold. Their mean age was 28 years (18 to 50). All had either sub-acute or chronic traumatic deficiency of the ligament. The mean period of follow-up was five years (four to seven). Assessment included the use of the International Knee Documentation Committee score, the modified Lysholm score, the Tegner Activity score, the Knee Injury and Osteoarthritis Outcome score and measurement with the KT-1000 arthrometer. Two patients had mild recurrent synovitis. There were no infections and no failures of the ligament. During the period of study, two patients sustained a traumatic fracture of a femoral condyle. The implants retained their integrity in both cases. All patients returned to their previous or enhanced levels of daily activity by three months after operation and 56 (79%) achieved their pre-injury level of sporting activity by six months. The patients who were competing in National level sports returned to play at one level less after operation than before. The Lysholm score showed that 58% of the patients (41) were excellent, 34% (24) good, and 8% (6) fair, with a mean post-operative score of 93. According to the International Knee Documentation Committee score, 35% of knees (25) were ‘normal’, 52% (37) ‘nearly normal’ and 13% (9) ‘abnormal’. Complete satisfaction was noted in 90% of patients (64). The development of osteoarthritis and the management of anterior cruciate deficiency associated with laxity of the medial collateral ligament remains uncertain. Our results indicate that in the medium-term, the ABC ligament scaffold is suitable and effective when early and safe return to unrestricted activities is demanded. We acknowledge the current general hostility towards reconstruction of the anterior cruciate ligament with artificial materials following reports of early failure and chronic synovitis associatiated with the production of particulate debris. We did not encounter these problems

We report a prospective study of the incidence of fractures in the adult population of Edinburgh, related to age and gender. Over a two-year period, 15 293 adults, 7428 males and 7865 females, sustained a fracture, and 5208 (34.0%) required admission. Between 15 and 49 years of age, males were 2.9 times more likely to sustain a fracture than females (95% CI 2.7 to 3.1). Over the age of 60 years, females were 2.3 times more likely to sustain a fracture than males (95% CI 2.1 to 2.4). There were three main peaks of fracture distribution: the first was in young adult males, the second was in elderly patients of both genders, mainly in metaphyseal bone such as the proximal femur, although diaphyseal fractures also showed an increase in incidence. The third increase in the incidence of fractures, especially of the wrist, was seen to start at 40 years of age in women. Our study has also shown that ‘osteoporotic’ fractures became evident in women earlier than expected, and that they were not entirely a postmenopausal phenomenon

We made a prospective study of 111 children with acute hip pain to assess whether ultrasound can replace traditional radiography. An effusion was diagnosed in 71% by ultrasound but in only 15% by radiography. This effusion persisted for a mean of nine days; symptoms lasted for five days. Two patients found to have Perthes' disease had longer-lasting effusion and symptoms. Patients without an effusion had no obvious cause for their pain, so the pressure of an effusion from a transient synovitis does not account for all patients with irritable hips. Patients with an effusion persisting for over 24 days (the mean + 2 s.d. of our series) had more symptoms, a significantly larger effusion and greater limitation of movement. They may be more at risk for avascular necrosis. We found that radiographic examination influenced the immediate management of only two patients, those with Perthes' disease. We therefore propose a protocol of management for irritable hip, using ultrasonography at the first presentation of certain categories of patients. This would reduce the number of early radiographs by 75%

We calculated the rates for perioperative mortality and fatal pulmonary embolism (PE) after primary total hip replacement in a single UK health region, using a regional arthroplasty register and the tracing service of the Office of National Statistics. During 1990, there were 2111 consecutive primary replacements in 2090 separate procedures. Within 42 days of operation a total of 19 patients had died (0.91%, 95% CI 0.55 to 1.42). Postmortem examination showed that four deaths (0.19%, 95% CI 0.05 to 0.49) were definitely due to PE. The overall perioperative mortality and fatal PE rates are low and in our study did not appear to be altered by the use of chemical thromboprophylaxis (perioperative mortality rate: one-tailed Fisher’s exact test, p = 0.39; fatal PE rate: one-tailed Fisher’s exact test, p = 0.56). The routine use of chemical thromboprophylaxis for primary THR is still controversial. The issue should be addressed by an appropriate randomised, prospective study using overall mortality and fatal PE rate as the main outcome measures, but the feasibility of such a study is questioned

1. In a prospective study of sixty patients with cerebral palsy and contracture of the hamstrings, 112 operations were performed by three different techniques after any necessary correction of flexion contracture of the hip or equinus of the ankle. 2. Transposition by the method of Eggers has been abandoned because simple lengthening has been found to have several advantages. 3. Proximal lengthening, at or near the ischial tuberosity, is employed when fixed flexion of the knee does not exceed 5 degrees, and is now the standard method. A transverse incision in the natal fold avoids cheloid formation. 4. Distal lengthening behind the knee is reserved for cases in which the fixed flexion exceeds 5 degrees. 5. After lengthening and weakening of the hamstrings, these spastic patients could stand more easily and walk with straighter knees, the length ofstride became greater, stairs could be climbed more easily, the feet could be lifted more from the ground, and the wear on the front of the sole became less. In addition the sitting position often improved because flexion of the hips became normal

We made a prospective study of 58 consecutive Neer II total shoulder replacements in 49 rheumatoid patients. Cemented glenoid and press-fit humeral components had been used. After a mean follow-up of 9.5 years (7 to 13), 11 patients (15 shoulders) had died, one shoulder had been arthrodesed and five patients (five shoulders) had been lost to follow-up. Of the remaining 37 shoulders 29 were painfree or had only slight discomfort, four had pain on unusual activity, and four had moderate or severe pain. There were satisfactory improvements in the mean range of active elevation (53° to 75°) and external rotation (5° to 38°); satisfactory performance of the activities of daily living had been maintained throughout follow-up. Radiographs showed loosening in ten shoulders of nine glenoid and nine humeral components but of these only three had significant symptoms. Three loose glenoid components and two loose humeral components required revision. We consider that the Neer total shoulder replacement provides a reasonable medium to long-term outcome in rheumatoid arthritis, but recommend that the humeral component should be routinely cemented

Patients with pain and loss of shoulder function due to nonunion of a fracture of the proximal third of the humerus may benefit from reverse total shoulder replacement. This paper reports a prospective, multicentre study, involving three hospitals and three surgeons, of 35 patients (28 women, seven men) with a mean age of 69 years (46 to 83) who underwent a reverse total shoulder replacement for the treatment of nonunion of a fracture of the proximal humerus. Using Checchia’s classification, nine nonunions were type I, eight as type II, 12 as type III and six as type IV. The mean follow-up was 51 months (24 to 99). Post-operatively, the patients had a significant decrease in pain (p < 0.001), and a significant improvement in flexion, abduction, external rotation and Constant score (p < 0.001), but not in internal rotation. A total of nine complications were recorded in seven patients: six dislocations, one glenoid loosening in a patient who had previously suffered dislocation, one transitory paresis of the axillary nerve and one infection. Reverse total shoulder replacement may lead to a significant reduction in pain, improvement in function and a high degree of satisfaction. However, the rate of complications, particularly dislocation, was high. Cite this article: Bone Joint J 2014;96-B:1239–43

We developed a 12-item questionnaire for completion by patients having shoulder operations other than stabilisation. A prospective study of 111 patients was undertaken before operation and at follow-up six months later. Each patient completed the new questionnaire and the SF36 form. Some filled in the Stanford Health Assessment Questionnaire (HAQ). An orthopaedic surgeon assessed the Constant shoulder score. The single score derived from the questionnaire had a high internal consistency. Reproducibility, examined by test-retest reliability, was found to be satisfactory. The validity of the questionnaire was established by obtaining significant correlations in the expected direction with the Constant score and the relevant scales of the SF36 and the HAQ. Sensitivity to change was assessed by analysing the differences between the preoperative scores and those at follow-up. Changes in scores were compared with the patients’ responses to postoperative questions about their condition. The standardised effect size for the new questionnaire compared favourably with that for the SF36 and the HAQ. The new questionnaire was the most efficient in distinguishing patients who said that their shoulder was much better from all other patients. The shoulder questionnaire provides a measure of outcome for shoulder operations which is short, practical, reliable, valid and sensitive to clinically important changes

We performed a prospective study to assess the long-term outcome of 57 arthroscopic debridement procedures carried out to treat anterior impingement in the ankle. Using preoperative radiographs, we grouped patients according to the extent of their osteoarthritis (OA). The symptoms of those with grade-0 changes could be attributed to anterior soft-tissue impingement alone. Patients with grade-I disease had both anterior soft-tissue and osteophytic impingement, but no narrowing of the joint space. In those with grade-II OA, narrowing of the joint space was accompanied by osteophytic impingement. Radiographs taken before and after operation and at follow-up were compared to assess the recurrence of osteophytes and the progression of narrowing of the joint space. At a mean follow-up of 6.5 years (5 to 8) all patients without OA had excellent or good results. There were excellent or good results in 77% of patients with grade-I OA, despite partial or complete recurrence of osteophytes in two-thirds. In most patients with grade-II OA, narrowing of the joint space had not progressed at follow-up. There was a notable improvement in pain in these patients, 53% of whom had excellent or good results. Although some osteophytes recurred, at long-term follow-up arthroscopic excision of soft-tissue overgrowths and osteophytes proved to be an effective way of treating anterior impingement of the ankle in patients who had no narrowing of the joint space

Aims

This study reports the outcomes of a technique of soft-tissue coverage and Chopart amputation for severe crush injuries of the forefoot.

We have developed a 12-item questionnaire for patients having a total knee replacement (TKR). We made a prospective study of 117 patients before operation and at follow-up six months later, asking them to complete the new questionnaire and the form SF36. Some also filled in the Stanford Health Assessment Questionnaire (HAQ). An orthopaedic surgeon completed the American Knee Society (AKS) clinical score. The single score derived from the new questionnaire had high internal consistency, and its reproducibility, examined by test-retest reliability, was found to be satisfactory. Its validity was established by obtaining significant correlations in the expected direction with the AKS scores and the relevant parts of the SF36 and HAQ. Sensitivity to change was assessed by analysing the differences between the preoperative scores and those at follow-up. We also compared change in scores with the patients’ retrospective judgement of change in their condition. The effect size for the new questionnaire compared favourably with those for the relevant parts of the SF36. The change scores for the new knee questionnaire were significantly greater (p < 0.0001) for patients who reported the most improvement in their condition. The new questionnaire provides a measure of outcome for TKR that is short, practical, reliable, valid and sensitive to clinically important changes over time

A prospective study involving 500 consecutive patients undergoing hip replacement was performed to find out whether a combination of heparin and dihydroergotamine was effective in preventing postoperative fatal and non-fatal emboli. Deep-vein thrombosis was demonstrated in 131 cases (26.2%), in 99 of whom thrombi were confined to the ipsilateral (operated) limb and in 13 to the contralateral limb; 19 patients developed bilateral thrombi. Nine patients (1.8%) died during the first four weeks after operation, before they were discharged from hospital; in one, major emboli were demonstrated in the right pulmonary artery. Three of the 500 patients developed non-fatal pulmonary emboli. Excessive bleeding occurred in 21 (4.2%) and in 19 of these prophylaxis was discontinued. Wound haematomas developed in 25 patients (5.0%); only six required evacuation but in none of these six did deep infection occur while in hospital; in three patients, however, the wound haematoma prolonged the stay in hospital. Thus the combination of heparin and dihydroergotamine proved an effective prophylaxis against pulmonary embolism in patients undergoing total hip replacement. The risk of bleeding complications is wholly acceptable when balanced against the advantages of the therapy

A prospective study was made of 100 knees which had been operated on for various kinds of internal derangement. An observer, who did not know the clinical condition of the knee, recorded whether or not there were articular lesions of the femoral condyles. Lesions were found to be localised to a triangular area on the medial condyle and to a strip on the lateral condyle. Similar lesions have been described in association with flexion deformities in rheumatoid and osteoarthritic knees. Lesions were found in 49 out of 50 knees which had been locked for more than three days. They were also found in 29 knees in which there appeared to be full extension before operation, but where there was either a torn meniscus with a history of intermittent locking or serious anterolateral instability. In these cases it was considered that the final "screw-home" mechanism of full extension had been lost. Lesions were not present in 10 knees which appeared locked, but in nine of these the interval between injury and operation was less than three days. Lesions were not found in eight knees where there was full extension and no history of locking or instability. In four knees with a plica syndrome similar lesions were present

Aims

Magnetically controlled growing rod (MCGR) systems use non-invasive spinal lengthening for the surgical treatment of early-onset scoliosis (EOS). The primary aim of this study was to evaluate the performance of these devices in the prevention of progression of the deformity. A secondary aim was to record the rate of complications.

Surgical decompression of the spinal canal is presently accepted worldwide as the method of treatment for thoracolumbar burst fractures with neurological deficit in the belief that neurological recovery may be produced or enhanced. Our clinical and laboratory experience, however, indicates that the paralysis occurs at the moment of injury and is not related to the position of the fragments of the fracture on subsequent imaging. Since the preoperative geometry of the fracture may be of no relevance, our hypothesis, backed by more than two decades of operative experience, is that alteration of the canal by ‘surgical clearance’ does not affect the neurological outcome. We have reviewed the existing world literature in an attempt to find evidence-based justification for the variety of surgical procedures used in the management of these fractures. We retrieved 275 publications on the management of burst fractures of which 60 met minimal inclusion criteria and were analysed more closely. Only three papers were prospective studies; the remainder were retrospective descriptive analyses. None of the 60 articles included control groups. The design of nine studies was sufficiently similar to allow pooling of their results, which failed to establish a significant advantage of surgical over non-surgical treatment as regards neurological improvement. Significant complications were reported in 75% of papers, including neurological deterioration. Surgical treatment for burst fracture in the belief that neurological improvement can be achieved is not justified, although surgery may still occasionally be indicated for structural reasons. This information should not be withheld from the patients

We describe the results of a prospective study of 28 children with spastic diplegia and in-toed gait, who had bilateral femoral derotation osteotomies undertaken at either the proximal intertrochanteric or the distal supracondylar level of the femur. Preoperative clinical evaluation and three-dimensional movement analysis determined any additional soft-tissue surgery. Distal osteotomy was faster with significantly lower blood loss than proximal osteotomy. The children in the distal group achieved independent walking earlier than those in the proximal group (6.9 ± 1.3 v 10.7 ± 1.7 weeks; p < 0.001). Transverse plane kinematics demonstrated clinically significant improvements in rotation of the hip and the foot progression angle in both groups. Correction of rotation of the hip was from 17 ± 11° internal to 3 ± 9.5° external in the proximal group and from 9 ± 14° internal to 4 ± 12.4° external in the distal group. Correction of the foot progression angle was from a mean of 10.0 ± 17.3° internal to 13.0 ± 11.8° external in the proximal group (p < 0.001) compared with a mean of 7.0 ± 19.4° internal to 10.0 ± 12.2° external in the distal group (p < 0.001). Femoral derotation osteotomy at both levels gives comparable excellent correction of rotation of the hip and foot progression angles in children with spastic diplegia