Aims. The aim of this study was to determine whether chilled irrigation saline decreases the incidence of clinical upper limb palsy (ULP; a reduction of one grade or more on manual muscle testing; MMT), based on the idea that ULP results from thermal damage to the nerve roots by heat generated by friction during bone drilling. Methods. Irrigation saline for drilling was used at room temperature (RT, 25.6°C) in open-door laminoplasty in 400 patients (RT group) and chilled to a mean temperature of 12.1°C during operations for 400 patients (low-temperature (LT) group). We assessed deltoid, biceps, and triceps brachii muscle strength by MMT. ULP occurring within two days post-operatively was categorised as early-onset palsy. Results. The incidence of ULP (4.0% vs 9.5%, p = 0.003), especially early-onset palsy (1.0% vs 5.5%, p < 0.001), was significantly lower for the LT group than for the RT group. Multivariate analysis indicated that RT irrigation saline use, concomitant foraminotomy, and opened side were significant predictors for ULP. Discussion. Using chilled irrigation saline during bone drilling significantly decreased the ULP incidence, particularly the early-onset type, and shortened the recovery period for ULP. Chilled irrigation saline can thus be recommended as a simple method for preventing ULP. Take home message: Chilled irrigation during laminoplasty reduces C5 palsy. Cite this article: Bone Joint J 2016;98-B:117–24

Since January 1993 we have carried out MR arthrography on 23 patients with clinical symptoms and signs of abnormality of the acetabular labrum. Most of the patients were young adults. Such symptoms are known precursors of osteoarthritis, and therefore early and accurate evaluation is required. We assessed the value of MR arthrography of the hip as a minimally-invasive diagnostic technique, in a prospective study and compared the findings with those at subsequent operations. All the patients complained of groin pain; 22 had a positive acetabular impingement test and 15 had radiological evidence of hip dysplasia. In 21 of the patients, MR arthrography suggested either degeneration or a tear of the labrum or both. These findings were confirmed at operation in 18 patients, but there was no abnormality of the labrum in the other three. In two of the patients, MR arthrography erroneously suggested an intact labrum. Both MR arthrography and intraoperative inspection located lesions of the superior labrum most often, and these appeared slightly larger on arthrography than at operation. We consider that MR arthrography is a promising diagnostic technique for the evaluation of abnormalities of the acetabular labrum

We retrospectively reviewed 30 patients with a diffuse-type giant-cell tumour (Dt-GCT) (previously known as pigmented villonodular synovitis) around the knee in order to assess the influence of the type of surgery on the functional outcome and quality of life (QOL). Between 1980 and 2001, 15 of these tumours had been treated primarily at our tertiary referral centre and 15 had been referred from elsewhere with recurrent lesions. The mean follow-up was 64 months (24 to 393). Functional outcome and QOL were assessed with range of movement and the Knee injury and Osteoarthritis Outcome Score (KOOS), the Musculoskeletal Tumour Society (MSTS) score, the Toronto Extremity Salvage Score (TESS) and the SF-36 questionnaire. There was recurrence in four of 14 patients treated initially by open synovectomy. Local control was achieved after a second operation in 13 of 14 (93%). Recurrence occurred in 15 of 16 patients treated initially by arthroscopic synovectomy. These patients underwent a mean of 1.8 arthroscopies (one to eight) before open synovectomy. This achieved local control in 8 of 15 (53%) after the first synovectomy and in 12 of 15 (80%) after two. The functional outcome and QOL of patients who had undergone primary arthroscopic synovectomy and its attendant subsequent surgical procedures were compared with those who had had a primary open synovectomy using the following measures: range of movement (114º versus 127º; p = 0.03); KOOS (48 versus 71; p = 0.003); MSTS (19 versus 24; p = 0.02); TESS (75 versus 86; p = 0.03); and SF-36 (62 versus 80; p = 0.01). Those who had undergone open synovectomy needed fewer subsequent operations. Most patients who had been referred with a recurrence had undergone an initial arthroscopic synovectomy followed by multiple further synovectomies. At the final follow-up of eight years (2 to 32), these patients had impaired function and QOL compared with those who had undergone open synovectomy initially. We conclude that the natural history of Dt-GCT in patients who are treated by arthroscopic synovectomy has an unfavourable outcome, and that primary open synovectomy should be undertaken to prevent recurrence or residual disease. Cite this article: Bone Joint J 2014; 96-B:1111–18

A protocol for the treatment of subacute haematogenous osteomyelitis has been used and evaluated in 71 children. A group of 26 children with a radiologically "aggressive" lesion had biopsy followed by antibiotics and immobilisation for six weeks. A group of 45 children with 48 cavities in the metaphysis or the epiphysis or both was further subdivided according to the presence or absence of clinical signs of pus at subperiosteal level or in a joint. Children with evidence of pus had operation followed by antibiotics and immobilisation while the remaining children were treated similarly but without operation. Intravenous cloxacillin or flucloxacillin and benzylpenicillin were given in hospital for 48 hours and oral antibiotics and immobilisation were then continued at home for six weeks. Staphylococcus aureus was the only pathogen cultured. In all, 91% were cured by a single course of treatment. Of the 48 metaphysial and epiphysial lesions, 77% were treated without operation; and of these, 87% were cured by a single course of treatment, this figure reaching 94% in children under 11 years old

Valgus deformity of the hindfoot can occur at the subtalar joint, the ankle joint, or at both sites. In children suffering from spina bifida, the ankle is often the main site of deformity. Thirty-five ankles with valgus deformity of the hindfoot were studied in 23 children with spina bifida. A radiological triad was observed in all patients: shortening of the fibula, lateral wedging of the distal tibial epiphysis, and lateral tilt of the talus at the ankle mortise . There was a definite correlation between the severity of wedging and the degree of talar tilt, and a fair correlation between the severity of wedging and the extent of fibular shortening. The results of operation in 12 feet are presented. It is concluded that any operations performed below the ankle on these patients (subtalar fusion or triple arthrodesis) is unlikely to succeed; the deformity needs to be corrected above the ankle (by epiphysiodesis or supramalleolar osteotomy). Radiological assessment of the ankle by taking weight-bearing films in the anteroposterior plane is essential to determine the true extent of the deformity before undertaking any operation

The results of three different types of meniscectomy have been compared in 219 knees, 71 treated by arthroscopic partial meniscectomy, 45 treated by open partial meniscectomy, and 103 treated by open total meniscectomy, with a mean follow-up of 4.3 years. Knees which had undergone previous operations or had other simultaneous operative procedures or ligamentous damage were excluded. Knees with chondromalacia were included provided that this did not amount to frank osteoarthritis. Simple indicators were used for the rate of early recovery from the operation, and the Tapper and Hoover scale was used to record the symptomatic results in the longer term. It was found that knees treated by arthroscopic partial meniscectomy did considerably better than the others by all the criteria used. In most parts of the study there was a clear gradation between the results of the three types of treatment: arthroscopic techniques did better than open operations, and partial meniscectomy did better than total meniscectomy

A method of analysing the results of knee replacement operations, which makes it possible to estimate the annual failure rate and the proportion of implants which will survive successfully for 10 years, is applied to the post-operative data for 365 operations, using Freeman, Sheehan and Manchester prostheses, carried out from 1972 to 1980 at Harlow Wood Orthopaedic Hospital. Two criteria of success are defined. On both, and for all prostheses, the annual failure rate is found to be much lower in the first two than in the later years. Thus, account must be taken of the period since operation if the success of different prostheses is to be validly compared. This is not possible using conventional statistical methods. But significant trends in annual failure rates and significant differences between prostheses can only be identified from samples larger than are usually available in individual series. Hence it will be necessary for many centres to co-operate in pooling results if reliable conclusions are to be reached and valid comparisons made

The records of 243 patients with Thompson prostheses for displaced femoral neck fractures have been studied. One hundred and seven prostheses were inserted through an anterior approach and 136 by a posterior approach. The short-term results and complications in these otherwise comparable groups are discussed. The infection rate of 18·5 per cent in the group operated upon by the posterior approach was thrice that after operations by the anterior route (6·5 per cent infected). Drained wounds had significantly less infection (6·3 per cent) compared with the undrained group (28 per cent infected). Other factors influencing the infection rate are discussed. The anterior approach offered greater stability. Of the twenty dislocations in the series, nineteen followed operations by the posterior approach. The mortality rate six weeks after operation was 6·5 per cent after the anterior approach and 20·6 per cent after the posterior approach. Statistical analysis significantly favours the anterior approach

The efficacy of modern drugs in the treatment of tuberculosis of the spine has been evaluated by a personal follow-up for three to ten years. Operation on the vertebral lesion was done only for those patients with or without neural complications who failed to respond favourably to drug therapy and rest. Thus absolute indications for operation were present in only 6 per cent of cases without neural involvement and in 60 per cent of patients with neural deficit. Of the patients who responded to drug therapy alone, only 19 per cent revealed increase of kyphosis by more than 10 degrees. The diseased area showed radiological evidence of osseous replacement in 29.6 per cent of cases, of fibro-osseous union in 50 per cent and of fibrous replacement in 202 per cent. The overall results of this regime compare favourably with those of radical operation. It is suggested that freatment should in the first place be by modern antitubercular drugs

1. In 120 of 740 European patients found to be suffering from spinal tuberculosis the disease was complicated by paraplegia. These 120 patients have been studied. 2. The patients could be divided into two groups: those receiving chemotherapy and those not receiving specific drugs. Chemotherapy improves the patient's general condition and makes operation safer, but does not have any significant effect in preventing paraplegia or in promoting recovery from it. 3. Only twenty-four of the fifty patients treated by closed method made full recovery. 4. The recovery rate after decompression was only 60 per cent. The reasons for this relatively low rate are discussed and the advantages of the postero-lateral approach to the cord, combined with focal operation on the lesion, are stressed. 5. Experience has shown that a policy of early and adequate focal operation can eliminate the risk of this serious complication of spinal tuberculosis. 6. The behaviour of spinal tuberculosis in the European is contrasted with that in the African and Asian

1. A survey has been made of 518 operations for hallux valgus and hallux rigidus. 2. The methods of critical examination used in this survey are described. 3. The results obtained have led to the formulation of certain views on etiology and modes of treatment. 4. In hallux valgus in the adolescent, operations aimed at correcting the primary deformity are justifiable when correctly performed, though the exact form such operations should take still requires further study. 5. In hallux valgus in the adult, arthroplasty offers a reasonably good solution in the well chosen case, though no one should consider that the results are so good as to make unnecessary any further research in this field. Metatarsal osteotomy has in the adult only a limited sphere of application. 6. In hallux rigidus arthroplasty alone has no place in the treatment of the adult cases showing metatarsus primus elevatus, nor in the adolescent case. The possibilities of other methods of operative treatment, notably osteotomy, are discussed

It will be seen that the proportion of successful fusions in this series of ninety-five patients treated by ischio-femoral arthrodesis of the hip was over 80 per cent. Similar percentages of successful fusion have been reported by Knight (1945), Freiberg (1946), Langston (1947), and Nisbet, who was resident surgical officer at the Robert Jones and Agnes Hunt Orthopaedic Hospital, and informed me in a personal communication that he had carried out twenty-six operations with an approximate fusion rate of 80 per cent. He stated: "It is the only operation which gives a reasonable chance of a successful arthrodesis in children. Up till now at Oswestry the chances of a fusion by the other methods in children have proved so disappointing that the operation had been abandoned. Dame Agnes Hunt, with her vast experience of the condition, was always very annoyed when she found a surgeon trying to fuse a child's hip. All this has been changed."

We report the results of six trauma and orthopaedic projects to Kenya in the last three years. The aims are to deliver both a trauma service and teaching within two hospitals; one a district hospital near Mount Kenya in Nanyuki, the other the largest public hospital in Kenya in Mombasa. The Kenya Orthopaedic Project team consists of a wide range of multidisciplinary professionals that allows the experience to be shared across those specialties. A follow-up clinic is held three months after each mission to review the patients. To our knowledge there are no reported outcomes in the literature for similar projects. A total of 211 operations have been performed and 400 patients seen during the projects. Most cases were fractures of the lower limb; we have been able to follow up 163 patients (77%) who underwent surgical treatment. We reflect on the results so far and discuss potential improvements for future missions

We studied the changes in plasma viscosity and C-reactive protein to establish normal values after total hip or knee arthroplasty. Viscosity decreased from 1.68 (+/- 0.017) to 1.57 (+/- 0.014) on the first postoperative day and thereafter rose to 1.60 (+/- 0.019), 1.75 (+/- 0.015), and 1.74 (+/- 0.011) on the third, seventh and fourteenth days respectively. Six to eight weeks after operation it had returned to pre-operative levels. A viscosity above the upper limit of the laboratory range, obtained more than two months after operation, may be considered as abnormal. The C-reactive protein level increased significantly on the first postoperative day and then decreased from a peak on the second day, attaining nearly normal levels at six to eight weeks after operation. It may be a more sensitive indicator of deep postoperative infection than plasma viscosity

Aims

To evaluate the influence of discharge timing on 30-day complications following total knee arthroplasty (TKA).

Accurate quantitative measurements of micromovement immediately after operation would be a reliable indicator of the stability of an individual component. We have therefore developed a system for measuring micromovement of the tibial component using three non-contact displacement transducers attached to the tibial cortex during total knee arthroplasty (TKA). Using this system we measured the initial stability in 31 uncemented TKAs. All the tibial components were fixed by a stem and four screws. The initial stability was defined as the amount of displacement when a load of 20 kg was applied. The mean subsidence was 60.7 μm and the mean lift-off was 103.3 μm. We also studied the migration of the tibial component using roentgen stereophotogrammetric analysis (RSA) for up to two years after operation. Most migration occurred during the first six months, after which all prostheses remained stable. We defined migration as the maximum total point motion (MTPM) at two years after operation. The mean migration was 1.29 mm at two years. Our results show that there was a significant correlation between the initial stability and migration (p < 0.05) and emphasise the importance of the initial stability of the tibial component

We review 210 Stanmore knee replacements in 163 patients to assess the survival of the prostheses and the long-term results. The annual rate of failure reached a maximum of 4.6% in the fourth year after operation; thereafter it declined to reach zero by the eighth year. Between two and eight years after operation, 66.3% of the surviving knees were completely free of pain and 30.2% had mild retropatellar pain. Fixed flexion deformities present before operation were completely corrected in 73% of the knees, and varus or valgus deformities were invariably corrected. Stability was always restored to unstable knees and 80.8% of knees flexed to 90 degrees or more after replacement. Aseptic loosening (8.1%), prosthetic infection (4.3%) and femoral fracture (2.9%) led to 8.5% of the prostheses being revised or removed over eight years. Modifications in prosthetic design and operative techniques have been introduced to minimise such complications in the future

Aims

The primary aim of this study was to establish the cost-effectiveness of the early fixation of displaced midshaft clavicle fractures.

An experimental model of osteoarthritis resulting from laxity of the joint was induced in eighteen mature dogs (at least two years old) by sectioning the anterior cruciate ligament of the right knee (stifle) with a stab incision, the left knee providing a control. A sham operation was also performed in three other dogs, in which a stab incision was made but the ligament left intact. The dogs were killed at various intervals from one to forty-eight weeks later. Morphological changes in bone, cartilage, synovial membrane and joint capsule were examined in all the joints and biochemical changes in the cartilage of three dogs killed after two, eight, and sixteen weeks. All the changes resulting from the operation progressed with time and became indistinguishable from those found in three dogs with natural osteoarthritis of the knee. There were no changes in the joints which had sham operations. As the time of onset is known, this experimental model in a larger species enables a study to be made of the biochemical as well as the morphological changes in the early stages of osteoarthritis