The options for treatment of the young active patient with isolated symptomatic osteoarthritis of the medial compartment and pre-existing deficiency of the anterior cruciate ligament are limited. The potential longevity of the implant and levels of activity of the patient may preclude total knee replacement, and tibial osteotomy and unicompartmental knee arthroplasty are unreliable because of the ligamentous instability. Unicompartmental knee arthroplasties tend to fail because of wear or tibial loosening resulting from eccentric loading. Therefore, we combined reconstruction of the anterior cruciate ligament with unicompartmental arthroplasty of the knee in 15 patients (ACLR group), and matched them with 15 patients who had undergone Oxford unicompartmental knee arthroplasty with an intact anterior cruciate ligament (ACLI group). The clinical and radiological data at a minimum of 2.5 years were compared for both groups.

The groups were well matched for age, gender and length of follow-up and had no significant differences in their pre-operative scores. At the last follow-up, the mean outcome scores for both the ACLR and ACLI groups were high (Oxford knee scores of 46 (37 to 48) and 43 (38 to 46), respectively, objective Knee Society scores of 99 (95 to 100) and 94 (82 to 100), and functional Knee Society scores of 96 and 96 (both 85 to 100). One patient in the ACLR group needed revision to a total knee replacement because of infection. No patient in either group had radiological evidence of component loosening. The radiological study showed no difference in the pattern of tibial loading between the groups.

The short-term clinical results of combined anterior cruciate ligament reconstruction and unicompartmental knee arthroplasty are excellent. The previous shortcomings of unicompartmental knee arthroplasty in the presence of deficiency of the anterior cruciate ligament appear to have been addressed with the combined procedure. This operation seems to be a viable treatment option for young active patients with symptomatic arthritis of the medial compartment, in whom the anterior cruciate ligament has been ruptured.

Limited access surgery is thought to reduce post-operative morbidity and provide faster recovery of function. The percutaneous compression plate (PCCP) is a recently introduced device for the fixation of intertrochanteric fractures with minimal exposure. It has several potential mechanical advantages over the conventional compression hip screw (CHS). Our aim in this prospective, randomised, controlled study was to compare the outcome of patients operated on using these two devices.

We randomised 104 patients with intertrochanteric fractures (AO/OTA 31.A1–A2) to surgical treatment with either the PCCP or CHS and followed them for one year postoperatively.

The mean operating blood loss was 161.0 ml (8 to 450) in the PCCP group and 374.0 ml (11 to 980) in the CHS group (Student’s t-test, p < 0.0001). The pain score and ability to bear weight were significantly better in the PCCP group at six weeks post-operatively. Analysis of the radiographs in a proportion of the patients revealed a reduced amount of medial displacement in the PCCP group (two patients, 4%) compared with the CHS group (10 patients, 18.9%); Fisher’s exact test, p < 0.02.

The PCCP device was associated with reduced intra-operative blood loss, less postoperative pain and a reduced incidence of collapse of the fracture.

There are few reports on the treatment of pyogenic lumbar spondylodiscitis through the posterior approach using a single incision. Between October 1999 and March 2003 we operated on 18 patients with pyogenic lumbar spondylodiscitis. All underwent posterior lumbar interbody fusion using an autogenous bone graft from the iliac crest and pedicle screws via a posterior approach. The clinical outcome was assessed using the Frankel neurological classification and the criteria of Kirkaldy-Willis. Under the Frankel classification, two patients improved by two grades (C to E), 11 by one grade, and five showed no change. The Kirkaldy-Willis functional outcome was excellent in five patients, good in ten and fair in three. Bony union was confirmed six months after surgery in 17 patients, but in one patient this was not achieved until two years after operation. The mean lordotic angle before operation was 20° (−2° to 42°) and the mean lordotic angle at the final follow-up was 32.5° (17° to 44°). Two patients had a superficial wound infection and two a transient root injury. Posterior lumbar interbody fusion with an autogenous iliac crest bone graft and pedicle screw fixation via a posterior approach can provide satisfactory results in pyogenic spondylodiscitis.

The use of impaction bone grafting during revision arthroplasty of the hip in the presence of cortical defects has a high risk of post-operative fracture. Our laboratory study addressed the effect of extramedullary augmentation and length of femoral stem on the initial stability of the prosthesis and the risk of fracture.

Cortical defects in plastic femora were repaired using either surgical mesh without extramedullary augmentation, mesh with a strut graft or mesh with a plate. After bone impaction, standard or long-stem Exeter prostheses were inserted, which were tested by cyclical loading while measuring defect strain and migration of the stem.

Compared with standard stems without extramedullary augmentation, defect strains were 31% lower with longer stems, 43% lower with a plate and 50% lower with a strut graft. Combining extramedullary augmentation with a long stem showed little additional benefit (p = 0.67). The type of repair did not affect the initial stability. Our results support the use of impaction bone grafting and extramedullary augmentation of diaphyseal defects after mesh containment.

Periprosthetic fracture of the femur is an uncommon complication after total hip replacement, but appears to be increasing. We undertook a nationwide observational study to determine the risk factors for failure after treatment of these fractures, examining patient- and implant-related factors, the classification of the fractures and the outcome.

Between 1979 and 2000, 1049 periprosthetic fractures of the femur were reported to the Swedish National Hip Arthroplasty Register. Of these, 245 had a further operation after failure of their initial management. Data were collected from the Register and hospital records. The material was analysed by the use of Poisson regression models.

It was found that the risk of failure of treatment was reduced for Vancouver type B2 injuries (p = 0.0053) if revision of the implant was undertaken (p = 0.0033) or revision and open reduction and internal fixation (p = 0.0039) were performed. Fractures classified as Vancouver type B1 had a significantly higher risk of failure (p = 0.0001). The strongest negative factor was the use of a single plate for fixation (p = 0.001). The most common reasons for failure in this group were loosening of the femoral prosthesis, nonunion and re-fracture.

It is probable that many fractures classified as Vancouver type B1 (n = 304), were in reality type B2 fractures with a loose stem which were not recognised. Plate fixation was inadequate in these cases. The difficulty in separating type B1 from type B2 fractures suggests that the prosthesis should be considered as loose until proven otherwise.

Injury to the common peroneal nerve was present in 14 of 55 patients (25%) with dislocation of the knee. All underwent ligament reconstruction. The most common presenting direction of the dislocation was anterior or anteromedial with associated disruption of both cruciate ligaments and the posterolateral structures of the knee. Palsy of the common peroneal nerve was present in 14 of 34 (41%) of these patients. Complete rupture of the nerve was seen in four patients and a lesion in continuity in ten.

Three patients with lesions in continuity, but with less than 7 cm of the nerve involved, had complete recovery within six to 18 months. In the remaining seven with more extensive lesions, two regained no motor function, and one had only MRC grade-2 function. Four patients regained some weak dorsiflexion or eversion (MRC grade 3 or 4). Some sensory recovery occurred in all seven of these patients, but was incomplete. In summary, complete recovery occurred in three (21%) and partial recovery of useful motor function in four (29%). In the other seven (50%) no useful motor or sensory function returned.

We report the clinical and radiographic outcome of a consecutive series of 138 hydroxyapatite-coated total knee replacements with a mean follow-up of 11 years (10 to 13). The patients were entered into a prospective study and all living patients (76 knees) were evaluated. The Hospital for Special Surgery knee score was obtained for comparison with the pre-operative situation. No patient was lost to follow-up. Radiographic assessment revealed no loosening. Seven prostheses have been revised, giving a cumulative survival rate of 93% at 13 years. We believe this to be the longest follow-up report available for an hydroxyapatite-coated knee replacement and the first for this design of Insall-Burstein II knee.

We used three-dimensional movement analysis by computer modelling of knee flexion from 0° to 50° in 14 knees in 12 patients with recurrent patellar dislocation and in 15 knees in ten normal control subjects to compare the in vivo three-dimensional movement of the patella. Flexion, tilt and spin of the patella were described in terms of rotation angles from 0°. The location of the patella and the tibial tubercle were evaluated using parameters expressed as percentage patellar shift and percentage tubercle shift. Patellar inclination to the femur was also measured and patellofemoral contact was qualitatively and quantitatively analysed.

The patients had greater values of spin from 20° to 50°, while there were no statistically significant differences in flexion and tilt. The patients also had greater percentage patellar shift from 0° to 50°, percentage tubercle shift at 0° and 10° and patellar inclination from 0° to 50° with a smaller oval-shaped contact area from 20° to 50° moving downwards on the lateral facet.

Patellar movement analysis using a three-dimensional computer model is useful to clearly demonstrate differences between patients with recurrent dislocation of the patella and normal control subjects.

The type II Monteggia (posterior) lesion is a rare injury which is sometimes associated with ulnohumeral instability. We have reviewed 23 of 28 patients with this injury. A clinical and radiographic assessment was undertaken at follow-up. Functional outcome scores, including the Broberg and Morrey Index and the Disabilities of the Arm, Shoulder or Hand (DASH), were used. The results from the six patients with associated posterior ulnohumeral dislocation were compared with 17 without ulnohumeral injury. Those with dislocation had reduced movement of the elbow and had outcome scores indicative of greater disability compared to those without associated dislocation.

There have been few reports in the literature of total elbow arthroplasty extending beyond 10 to 15 years. We reviewed 40 patients (41 elbows) with a mean age of 56 years (19 to 83) who had undergone a Coonrad/Coonrad-Morrey elbow arthroplasty by one surgeon for various diagnoses between 1974 and 1994. Surgical selection excluded patients with previous elbow infection or who refused to accept a sedentary level of elbow activity postoperatively. Objective data were collected from charts, radiographs, clinical photographs and supplemented by the referring orthopaedic surgeons’ records and radiographs if health or distance prevented a patient from returning for final review. Subjective outcome was defined by patient satisfaction.

Of the 41 elbows, 21 were functional between 10 and 14 years after operation, ten between 15 and 19 years and ten between 20 and 31 years. There were 14 complications and 13 revisions, but no cases of acute infection, or permanent removal of any implant.

A postal questionnaire was sent to 10 000 patients more than one year after their total knee replacement (TKR). They were assessed using the Oxford knee score and were asked whether they were satisfied, unsure or unsatisfied with their TKR. The response rate was 87.4% (8231 of 9417 eligible questionnaires) and a total of 81.8% (6625 of 8095) of patients were satisfied. Multivariable regression modelling showed that patients with higher scores relating to the pain and function elements of the Oxford knee score had a lower level of satisfaction (p < 0.001), and that ongoing pain was a stronger predictor of this. Female gender and a primary diagnosis of osteoarthritis were found to be predictors of lower levels of patient satisfaction. Differences in the rate of satisfaction were also observed in relation to age, the American Society of Anesthesiologists grade and the type of prosthesis.

This study has provided data on the Oxford knee score and the expected levels of satisfaction at one year after TKR. The results should act as a benchmark of practice in the United Kingdom and provide a baseline for peer comparison between institutions.

We reviewed 39 patients with displaced three- and four-part fractures of the humerus. In 21 patients (group A) we had used an anatomical prosthesis for the humeral head and in 18 (group B) an implant designed for fractures.

When followed up at a mean of 29.3 months after surgery the overall Constant score was 51.9 points; in group A it was 51.5 and in group B 52.4 points. The subjective satisfaction of the patients was assessed using a numerical rating scale and was similar in both groups. In group A complete healing of the tuberosities was found in 29% and 50% in group B. Partial integration was seen in 29% of group A and in only one patient in group B, while resorption was noted in 43% of group A and 44% of group B. The functional outcome was significantly better in patients with complete or partial healing of the tuberosities (p = 0.022). The specific trauma prosthesis did not lead to better healing of the tuberosities. The difference in clinical outcome obtained by the two designs did not reach statistical significance.

We examined the rates of infection and colonisation by methicillin-resistant Staphylococcus aureus (MRSA) between January 2003 and May 2004 in order to assess the impact of the introduction of an MRSA policy in October 2003, which required all admissions to be screened. Emergency admissions were treated prophylactically and elective beds ring-fenced. A total of 5594 admissions were cross-referenced with 22 810 microbiology results. The morbidity, mortality and cost of managing MRSA-carrying patients, with a proximal fracture of the femur were compared, in relation to age, gender, American Society of Anaesthesiologists grade and residential status, with a group of matched controls who were MRSA-negative.

In 2004, we screened 1795 of 1796 elective admissions and MRSA was found in 23 (1.3%). We also screened 1122 of 1447 trauma admissions and 43 (3.8%) were carrying MRSA. All ten ward transfers were screened and four (40%) were carriers (all p < 0.001). The incidence of MRSA in trauma patients increased by 2.6% per week of inpatient stay (r = 0.97, p < 0.001). MRSA developed in 2.9% of trauma and 0.2% of elective patients during that admission (p < 0.001). The implementation of the MRSA policy reduced the incidence of MRSA infection by 56% in trauma patients (1.57% in 2003 (17 of 1084) to 0.69% in 2004 (10 of 1447), p = 0.035). Infection with MRSA in elective patients was reduced by 70% (0.56% in 2003 (7 of 1257) to 0.17% in 2004 (3 of 1806), p = 0.06). The cost of preventing one MRSA infection was £3200.

Although colonisation by MRSA did not affect the mortality rate, infection by MRSA more than doubled it. Patients with proximal fractures of the femur infected with MRSA remained in hospital for 50 extra days, had 19 more days of vancomycin treatment and 26 more days of vacuum-assisted closure therapy than the matched controls. These additional costs equated to £13 972 per patient.

From this experience we have been able to describe the epidemiology of MRSA, assess the impact of infection-control measures on MRSA infection rates and determine the morbidity, mortality and economic cost of MRSA carriage on trauma and elective orthopaedic wards.

The tensile strength of the medial patellofemoral ligament (MPFL), and of surgical procedures which reconstitute it, are unknown. Ten fresh cadaver knees were prepared by isolating the patella, leaving only the MPFL as its attachment to the medial femoral condyle. The MPFL was either repaired by using a Kessler suture or reconstructed using either bone anchors or one of two tendon grafting techniques. The tensile strength and the displacement to peak force of the MPFL were then measured using an Instron materials-testing machine.

The MPFL was found to have a mean tensile strength of 208 N (SD 90) at 26 mm (SD 7) of displacement. The strengths of the other techniques were: sutures alone, 37 N (SD 27); bone anchors plus sutures, 142 N (SD 39); blind-tunnel tendon graft, 126 N (SD 21); and through-tunnel tendon graft, 195 N (SD 66). The last was not significantly weaker than the MPFL itself.

We have studied cellular and vascular changes in different stages of full thickness tears of the rotator cuff. We examined biopsies from the supraspinatus tendon in 40 patients with chronic rotator cuff tears who were undergoing surgery and compared them with biopsies from four uninjured subscapularis tendons. Morphological and immunocytochemical methods using monoclonal antibodies directed against leucocytes, macrophages, mast cells, proliferative and vascular markers were used.

Histological changes indicative of repair and inflammation were most evident in small sized rotator cuff tears with increased fibroblast cellularity and intimal hyperplasia, together with increased expression of leucocyte and vascular markers. These reparative and inflammatory changes diminished as the size of the rotator cuff tear increased. Marked oedema and degeneration was seen in large and massive tears, which more often showed chondroid metaplasia and amyloid deposition. There was no association between the age of the patient and the duration of symptoms. In contrast, large and massive tears showed no increase in the number of inflammatory cells and blood vessels.

Small sized rotator cuff tears retained the greatest potential to heal, showing increased fibroblast cellularity, blood vessel proliferation and the presence of a significant inflammatory component. Tissue from large and massive tears is of such a degenerative nature that it may be a significant cause of re-rupture after surgical repair and could make healing improbable in this group.

Our aim was to determine the total blood loss associated with surgery for fracture of the hip and to identify risk factors for increased blood loss. We prospectively studied 546 patients with hip fracture. The total blood loss was calculated on the basis of the haemoglobin difference, the number of transfusions and the estimated blood volume. The hidden blood loss, in excess of that observed during surgery, varied from 547 ml (screws/ pins) to 1473 ml (intramedullary hip nail and screw) and was significantly associated with medical complications and increased hospital stay. The type of surgery, treatment with aspirin, intra-operative hypotension and gastro-intestinal bleeding or ulceration were all independent predictors of blood loss.

We conclude that total blood loss after surgery for hip fracture is much greater than that observed intra-operatively. Frequent post-operative measurements of haemoglobin are necessary to avoid anaemia.

We undertook a multicentre, prospective study of a series of 112 unstable trochanteric fractures in order to evaluate if internal fixation with a sliding screw device combined with augmentation using a calcium phosphate degradable cement (Norian SRS) could improve the clinical, functional and radiological outcome when compared with fractures treated with a sliding screw device alone. Pain, activities of daily living, health status (SF-36), the strength of the hip abductor muscles and radiological outcome were analysed.

Six weeks after surgery, the patients in the augmented group had significantly lower global and functional pain scores (p < 0.003), less pain after walking 50 feet (p < 0.01), and a better return to the activities of daily living (p < 0.05). At follow-up at six weeks and six months, those in the augmented group showed a significant improvement compared with the control group in the SF-36 score. No other significant differences were found between the groups. We conclude that augmentation with calcium phosphate cement in unstable trochanteric fractures provides a modest reduction in pain and a slight improvement in the quality of life during the course of healing when compared with conventional fixation with a sliding screw device alone.