Aims

Femoroacetabular impingement (FAI) describes abnormal bony contact of the proximal femur against the acetabulum. The term was first coined in 1999; however what is often overlooked is that descriptions of the morphology have existed in the literature for centuries. The aim of this paper is to delineate its origins and provide further clarity on FAI to shape future research.

Aims. We studied the safety and efficacy of multimodal thromboprophylaxis in patients with a history of venous thromboembolism (VTE) who undergo total hip arthroplasty (THA) within the first 120 postoperative days, and the mortality during the first year. Multimodal prophylaxis includes discontinuation of procoagulant medications, VTE risk stratification, regional anaesthesia, an intravenous bolus of unfractionated heparin prior to femoral preparation, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient’s risk of VTE. Methods. Between 2004 to 2018, 257 patients with a proven history of VTE underwent 277 primary elective THA procedures by two surgeons at a single institution. The patients had a history of deep vein thrombosis (DVT) (186, 67%), pulmonary embolism (PE) (43, 15.5%), or both (48, 17.5%). Chemoprophylaxis included aspirin (38 patients), anticoagulation (215 patients), or a combination of aspirin and anticoagulation (24 patients). A total of 50 patients (18%) had a vena cava filter in situ at the time of surgery. Patients were followed for 120 days to record complications, and for one year to record mortality. Results. Postoperative VTE was diagnosed in seven patients (2.5%): DVT in five, and PE with and without DVT in one patient each. After hospitalization, three patients required readmiss-ion for evacuation of a haematoma, one for wound drainage, and one for monitoring of an elevated international normalized ratio (INR). Seven patients died (2.5%). One patient died five months postoperatively of a PE during open thrombectomy. She had discontinued anticoagulation. One patient died of a haemorrhagic stroke while receiving Coumadin. PE or bleeding was not suspected in the remaining five fatalities. Conclusion. Multimodal prophylaxis is safe and effective in patients with a history of VTE. Postoperative anticoagulation should be prudent as very few patients developed VTE (2.5%) or died of suspected or confirmed PE. Mortality during the first year was mostly unrelated to either VTE or bleeding. Cite this article: Bone Joint J 2020;102-B(7 Supple B):71–77

Aims. The aim of this study was to determine the long-term risk of undergoing knee arthroplasty in a cohort of patients with meniscal tears who had undergone arthroscopic partial meniscectomy (APM). Patients and Methods. A retrospective national cohort of patients with a history of isolated APM was identified over a 20-year period. Patients with prior surgery to the same knee were excluded. The primary outcome was knee arthroplasty. Hazard ratios (HRs) were adjusted by patient age, sex, year of APM, Charlson comorbidity index, regional deprivation, rurality, and ethnicity. Risk of arthroplasty in the index knee was compared with the patient’s contralateral knee (with vs without a history of APM). A total of 834 393 patients were included (mean age 50 years; 37% female). Results. Of those with at least 15 years of follow-up, 13.49% (16 256/120 493; 95% confidence interval (CI) 13.30 to 13.69) underwent subsequent arthroplasty within this time. In women, 22.07% (95% CI 21.64 to 22.51) underwent arthroplasty within 15 years compared with 9.91% of men (95% CI 9.71 to 10.12), corresponding to a risk ratio (RR) of 2.23 (95% CI 2.16 to 2.29). Relative to the general population, patients with a history of APM were over ten times more likely (RR 10.27; 95% CI 10.07 to 10.47) to undergo arthroplasty rising to almost 40 times more likely (RR 39.62; 95% CI 27.68 to 56.70) at a younger age (30 to 39 years). In patients with a history of APM in only one knee, the risk of arthroplasty in that knee was greatly elevated in comparison with the contralateral knee (no APM; HR 2.99; 95% CI 2.95 to 3.02). Conclusion. Patients developing a meniscal tear undergoing APM are at greater risk of knee arthroplasty than the general population. This risk is three-times greater in the patient’s affected knee than in the contralateral knee. Women in the cohort were at double the risk of progressing to knee arthroplasty compared with men. These important new reference data will inform shared decision making and enhance approaches to treatment, prevention, and clinical surveillance. Cite this article: Bone Joint J 2019;101-B:1071–1080

Although patients with a history of venous thromboembolism (VTE) who undergo lower limb joint replacement are thought to be at high risk of further VTE, the actual rate of recurrence has not been reported. The purpose of this study was to identify the recurrence rate of VTE in patients who had undergone lower limb joint replacement, and to compare it with that of patients who had undergone a joint replacement without a history of VTE. . From a pool of 6646 arthroplasty procedures (3344 TKR, 2907 THR, 243 revision THR, 152 revision TKR) in 5967 patients (68% female, mean age 67.7; 21 to 96) carried out between 2009 and 2011, we retrospectively identified 118 consecutive treatment episodes in 106 patients (65% female, mean age 70; 51 to 88,) who had suffered a previous VTE. Despite mechanical prophylaxis and anticoagulation with warfarin, we had four recurrences by three months (3.4% of 118) and six by one year (5.1% of 118). In comparison, in all our other joint replacements the rate of VTE was 0.54% (35/6528). The relative risk of a VTE by 90 days in patients who had undergone a joint replacement with a history of VTE compared with those with a joint replacement and no history of VTE was 6.3 (95% confidence interval, 2.3 to 17.5). There were five complications in the previous VTE group related to bleeding or over-anticoagulation. Cite this article: Bone Joint J 2014;96-B:1515–19

A family history of shoulder instability in first-degree relatives was found in 24 of 100 patients who had been operated on for recurrent anterior shoulder instability. The patients with and without a family history were similar in respect of sex ratio, age at first dislocation and age at operation. The initial dislocation was non-traumatic in 22% of the patients with and in 13% of those without a positive family history (p = 0.3). Postoperative recurrence of instability was experienced by 34% of patients with and 33% of those without a family history (p = 0.9). In those with a family history, 13% of the recurrences were dislocations and 87% were subluxations. In patients without a family history 52% of the recurrences were dislocations and 48% were subluxations (p < 0.05). The contralateral shoulder was unstable in 50% of the patients with a family history and in 26% of those without (p = 0.03)

Aims. Depression can significantly affect quality of life and is associated with higher rates of medical comorbidities and increased mortality following surgery. Although depression has been linked to poorer outcomes following orthopaedic trauma, total joint arthroplasty and spinal surgery, we wished to examine the impact of depression in elective total shoulder arthroplasty (TSA) as this has not been previously explored. . Patients and Methods. The United States Nationwide Inpatient Sample (NIS) was used to identify patients undergoing elective TSA over a ten-year period. Between 2002 and 2012, 224 060 patients underwent elective TSA. Results. Among the identified patients who had undergone TSA, 12.4% had a diagnosis of a history of depression. A diagnosis of depression was twice as common in women compared with men (16.0% vs 8.0%, p < 0.001), and more frequent in those with low income and Medicaid insurance (p < 0.001). A diagnosis of depression was an independent risk factor for post-operative delirium (odds ratio (OR) 2.29, p < 0.001), anaemia (OR 1.65, p < 0.001), infection (2.09, p = 0.045) and hospital discharge to a placement other than home (OR 1.52, p < 0.001) . Conclusion. A history of clinical depression is present in 12.4% of patients undergoing elective TSA and the disease burden is projected to increase further in the future. Depression is often underdiagnosed and pre-operative screening and appropriate peri-operative management of patients is encouraged. Take home message: The awareness that clinical depression is associated with increased complications following total shoulder arthroplasty provides physicians an opportunity for early intervention in this at-risk population. Cite this article: Bone Joint J 2016;98-B:818–24

The practice of regular radiological follow-up of infants with a positive family history of developmental dysplasia of the hip is based on the widespread belief that primary acetabular dysplasia is a genetic disorder which can occur in the absence of frank subluxation or dislocation. We reviewed all infants who were involved in our screening programme for developmental dysplasia of the hip, between November 2002 and January 2004, and who had a normal clinical and ultrasound examination of the hip at six to eight weeks of age, but who, because of a family history of developmental dysplasia of the hip, had undergone further radiography after an interval of 6 to 12 months. The radiographs of 89 infants were analysed for signs of late dysplasia of the hip and assessed independently by three observers to allow for variability of measurement. There were 11 infants (11%) lost to follow-up. All the patients had normal radiographs at the final follow-up and none required any intervention. We therefore question the need for routine radiological follow-up of infants with a positive family history of developmental dysplasia of the hip, but who are normal on clinical examination and assessment by ultrasound screening when six to eight weeks old

John Kirkup, the distinguished orthopaedic surgeon and archivist recently published a book describing the history of amputation. This annotation highlights the importance of this work and the particular relevance of many of its themes to current orthopaedic and trauma practice

The purpose of this study was to evaluate the natural history of rheumatoid disease of the shoulder over an eight-year period. Our hypothesis was that progression of the disease is associated with a decrease in function with time. A total of 22 patients (44 shoulders; 17 women, 5 men, (mean age 63)) with rheumatoid arthritis were followed for eight years. All shoulders were assessed using the Constant score, anteroposterior radiographs (Larsen score, Upward-Migration-Index (UMI)) and ultrasound (US). At final follow-up, the Short Form-36, disabilities of the arm, shoulder and hand (DASH) Score, erythrocyte sedimentation rate and use of anti-rheumatic medication were determined. The mean Constant score was 72 points (50 to 88) at baseline and 69 points (25 to 100) at final follow-up. Radiological evaluation showed progressive destruction of the peri-articular structures with time. This progression of joint and rotator cuff destruction was significantly associated with the Constant score. However, at baseline only the extent of rotator cuff disease and the UMI could predict the Constant score at final follow-up. A plain anteroposterior radiograph of the shoulder is sufficient to assess any progression of rheumatoid disease and to predict functional outcome in the long term by using the UMI as an indicator of rotator cuff degeneration. Cite this article: Bone Joint J 2014;96-B:1520–4

1. Details are given of sixty-three consecutive cases with a history of pleural effusion seen at an orthopaedic hospital. 2. Twenty-four of these were post-primary effusions occurring before the onset of symptoms of the orthopaedic lesion. The bone and joint lesions ultimately developing in this group of patients were widely scattered throughout the skeleton. 3. Three others were secondary to adult-type pulmonary lesions. 4. Thirty-six patients had a pleural effusion after the beginning of their orthopaedic tuberculous history. Seven were certainly secondary to operative intervention, six in the thorax near the parietal pleura (costotransversectomy or antero-lateral decompression of the cord) and one from a haematogenous dissemination after fusion of a hip joint. 5. The remainder of this group with pleural effusion during the history of their orthopaedic tuberculous disease numbered twenty-nine. Of these, twenty-five suffered from disease of the thoracic spine; in two more details are defective. Only two definitely had neither pulmonary nor thoracic spinal disease; their lesions were in the lumbar spine. The conclusion is drawn that the overwhelmingly common cause of pleural effusion in patients with orthopaedic tuberculosis who have normal lungs and have not recently suffered spinal decompression is transpleural infection from thoracic spinal disease and that the sequence is by no means rare. It had occurred in approximately one in six of 145 patients with thoracic Pott's disease seen during this investigation. 6. Details are given of a group of cases with thoracic paravertebral abscess tracking laterally. When the abscess is well clear of the spine and spinal ligaments it may project forwards and radiologically it may appear in the antero-posterior chest film as a shadow in the middle of one or other lung field rather than as a shadow obviously connected with the central paravertebral abscess. Aspiration will yield pus from this posterior extra-pleural abscess extension. 7. The belief that Pott's disease most commonly follows direct spread from caseous paraaortic glands secondary to tuberculous pleurisy is discussed. It is concluded that the evidence is insufficient for so sweeping a statement

The natural history of primary anterior dislocation of the glenohumeral joint in adolescent patients remains unclear and there is no consensus for management of these patients. The objectives of this study were to report the natural history of primary anterior dislocation of the glenohumeral joint in adolescent patients and to identify the risk factors for recurrent dislocation. We reviewed prospectively-collected clinical and radiological data on 133 adolescent patients diagnosed with a primary anterior dislocation of the glenohumeral joint who had been managed non-operatively at our hospital between 1996 and 2008. There were 115 male (86.5%) and 18 female patients (13.5%) with a mean age of 16.3 years (13 to 18) and a mean follow-up of 95.2 months (1 to 215). During follow-up, 102 (absolute incidence of 76.7%) patients had a recurrent dislocation. The median interval between primary and recurrent dislocation was ten months (95% CI 7.4 to 12.6). Applying survival analysis the likelihood of having a stable shoulder one year after the initial injury was 59% (95% CI 51.2 to 66.8), 38% (95% CI 30.2 to 45.8%) after two years, 21% (95% CI 13.2 to 28.8) after five years, and 7% (95% CI 1.1 to 12.9) after ten years. Neither age nor gender significantly predicted recurrent dislocation during follow-up. We conclude that adolescent patients with a primary anterior dislocation of the glenohumeral joint have a high rate of recurrent dislocation, which usually occurs within two years of their initial injury: these patients should be considered for early operative stabilisation. Cite this article: Bone Joint J 2015;97-B:520–6

There are many reports concerning the aetiology and prophylaxis of deep-vein thrombosis (DVT) but little is known about its natural history. The purpose of our study was to identify the incidence and site of DVT, the risk factors for pulmonary embolism and the natural history of DVT after total hip replacement (THR) in patients who do not receive any form of prophylactic or therapeutic treatment for DVT. Two hundred patients who had a primary THR were included: 100 had one-staged bilateral THR and 100 had unilateral THR and 150 implants were cemented and 150 cementless. Coagulation assays, a full blood count, blood typing and serum chemical profile tests were performed for all patients on three separate occasions. Bilateral simultaneous or unilateral venograms were performed on the sixth or seventh postoperative day and perfusion lung scans preoperatively and on the seventh or eighth postoperative day. Further venograms were performed in all patients who had thrombi six months later. In the patients with bilateral THR, 52 (26%) venograms were positive for thrombi, while in the patients with unilateral THR 20 (20%) were positive (p = 0.89). In the patients with a cemented THR, 31 venograms (20.7%) were positive for thrombi, while in those with a cementless THR 41 (27.3%) were positive (p = 0.654). Further venograms in all 72 patients who had thrombi at six months after operation showed that they resolved completely and spontaneously regardless of their site and size. No patients had symptoms of pulmonary emboli and none were seen on the perfusion lung scans. Two patients died from unrelated causes. Although the prevailing opinion is that patients with proximal venous thrombosis should be treated with anticoagulants, our study has shown that all thrombi regardless of their site and size resolve spontaneously without associated pulmonary embolism

Osteomyelitis is one of the oldest diseases known. It took many years before the acute infection could be brought under control with antibiotics and chronic osteomyelitis remains difficult to manage. The modern history of the disease is reflected in the pages of the

This paper reports on a prospective study undertaken to determine the natural history of untreated idiopathic hooked forefoot. The progress of 130 affected feet in eighty-three children was followed for an average of seven years. At review 86% of the feet were normal or only mildly deformed and all were fully mobile; 10% were still moderately deformed but were asymptomatic; 4% remained deformed and stiff. It was not possible to detect these resistant cases before the age of three years, but the low failure rate would seem to justify a policy of expectant treatment

We studied the natural history of nontraumatic avascular necrosis of the femoral head (ANFH) in 115 hips in 87 patients, 69 steroid-induced, 21 related to misuse of alcohol and 25 idiopathic. The average length of follow-up was over five years. Collapse occurred most often when the focus of bone necrosis occupied the weight-bearing surface of the femoral head. Flatness of the head due to subchondral fracture was an early manifestation of collapse. Classification into six types based upon the radiographic findings provided an accurate prognosis for individual cases of ANFH which is useful in planning treatment and in assessing its outcome

Deep infection, the most serious local complication of total hip replacement, prompted a study of the records of 135 patients (137 hips) thus afflicted in a nationwide survey of Canada. Particular attention has been paid to the natural history of the infection, and the problems of diagnosis are described. Twenty-one patients died after the insertion, or removal, of the prosthesis, and of the survivors of the original 135 patients only eighteen have been able to retain the prosthesis without further problems with the wound. The remaining patients had the prosthesis removed, and most dry wounds. Certain suggestions are made on management. The advice that a second total hip prosthesis should be inserted after a deep infection of the first implant is not supported

We have observed the natural history without treatment of 46 limbs in 29 patients with infantile tibia vara and a metaphyseal-diaphyseal angle (MDA) of more than 11°. The femorotibial angle (FTA) and MDA were measured, and Langenskiöld’s classification of radiological changes in the proximal medial metaphysis of the tibia was used. In 22 limbs which were not in Langenskiöld stages II to III the condition resolved spontaneously without treatment. Of the remaining 24 which were in stages II to III, in 18 it resolved spontaneously by the age of six years, but six showed little or no improvement at the latest follow-up. It was impossible to differentiate by measuring the FTA or MDA whether spontaneous resolution could be expected before the age of four years. There was no difference in the rate of resolution of the deformity between those patients who had been treated by a brace and those who had received no treatment. We advise no initial treatment but review at six-monthly intervals until the age of four years, even in patients with Langenskiöld stage-II to stage-III deformity. When a deformity persisted or progressed we carried out a corrective osteotomy after the age of four years

1. The natural history and prognosis of progressive infantile idiopathic scoliosis are reviewed and twenty-eight cases are reported. 2. Resolving infantile idiopathic scoliosis is described and seven cases are reported. 3. The length of the curve, the degree of rotation, the age of onset of deterioration, and the rate of progression are the important factors in determining the type and severity of the deformity. 4. Infantile idiopathic scoliosis is briefly compared with congenital scoliosis

We reviewed 47 patients with neurofibromatosis and dystrophic spinal deformities; 32 of these patients had been untreated for an average of 3.6 years and in them the natural history was studied. The commonest pattern of deformity at the time of presentation was a short angular thoracic scoliosis, but with progression the angle of kyphosis also increased. Deterioration during childhood was usual but its rate was variable. Severe dystrophic changes in the apical vertebrae and in particular anterior scalloping have a poor prognosis for deterioration. The dystrophic spinal deformity of neurofibromatosis requires early surgical stabilisation which should be by combined anterior and posterior fusion if there is an abnormal angle of kyphosis or severely dystrophic apical vertebrae. Some carefully selected patients can be treated by posterior fusion and instrumentation alone

We report a case of peri-prosthetic tuberculous infection nine years after total hip arthroplasty in a patient with no history of tuberculosis before the procedure. Further investigation revealed active pulmonary tuberculosis which was thought to have spread haematogeneously to the arthroplasty. The infection did not respond to standard antituberculous drugs. Removal of the prosthesis and insertion of an antibiotic spacer were required

To determine the natural history of dislocation of the hip in cerebral palsy, and to evolve methods to predict dislocation, the notes and radiographs of 462 patients with cerebral palsy were reviewed. Dislocation occurred in 10% of patients by progressive migration and subluxation of the proximal femur in the presence of acetabular dysplasia. Statistical analysis identified the radiographic features that helped to predict dislocation. Measurement of acetabular index, by a method that allows for rotation of the acetabulum, was the most powerful single predictor. Measurement of this index at two and four years of age could identify patients who would dislocate unless effective treatment was undertaken, those at risk of dislocation only if scoliosis developed, and those who would not dislocate. On the basis of this method of screening for dislocation, a logical system of surgical prophylaxis is proposed

A total of 60 children and adolescents with rupture of the anterior cruciate ligament (ACL) was seen between 1980 and 1990. Observation of the 23 patients who were treated conservatively revealed that the natural history of the injury resulted in severe instability and poor function of the knee. Associated meniscal tears were present in 15 knees. Three osteochondral fractures occurred and osteoarthritic changes developed in ten knees. In 1990 therefore we introduced reconstruction of the ACL with a four-strand hamstring graft using an anatomical placement with transphyseal tunnels and anchorage well away from the growth plate. Over a period of nine years, 47 knees underwent reconstruction. The mean follow-up was 49 months (12 to 96). No child suffered physeal damage or leg-length discrepancy. The results were satisfactory in 77% and there was little difference between patients treated before the adolescent growth spurt and those treated during or after this time. These results, however, were not as good as those seen in adults during the same period

The scaphoid fracture is commonest in young men in the age group 15 to 29 years, who have the highest incidence of non-union, take the longest time to unite, lose more time from work, and spend the longest time as outpatients. A union rate of 95 per cent can be achieved using standard simple treatment. All but a few fractures are visible on the first radiograph, and failure of visualisation at this stage is not associated with a bad outcome. The postero-anterior and semipronated views are the most important to scrutinise. Crank-handle injuries have a particularly bad prognosis when they produce a transverse fracture of the waist of the scaphoid. Poor prognostic factors are displacement during treatment, the fracture line becoming increasingly more obvious, and the presence of early cystic change. The severity of trauma is an important factor to elicit from the history

We retrospectively examined the prevalence and natural history of asymptomatic lumbar canal stenosis in patients treated surgically for cervical compressive myelopathy in order to assess the influence of latent lumbar canal stenosis on the recovery after surgery. Of 214 patients who had undergone cervical laminoplasty for cervical myelopathy, we identified 69 (32%) with myelographically documented lumbar canal stenosis. Of these, 28 (13%) patients with symptomatic lumbar canal stenosis underwent simultaneous cervical and lumbar decompression. Of the remaining 41 (19%) patients with asymptomatic lumbar canal stenosis who underwent only cervical surgery, 39 were followed up for ≥ 1 year (mean 4.9 years (1 to 12)) and were included in the analysis (study group). Patients without myelographic evidence of lumbar canal stenosis, who had been followed up for ≥ 1 year after the cervical surgery, served as controls (135 patients; mean follow-up period 6.5 years (1 to 17)). Among the 39 patients with asymptomatic lumbar canal stenosis, seven had lumbar-related leg symptoms after the cervical surgery. Kaplan–Meier analysis showed that 89.6% (95% confidence interval (CI) 75.3 to 96.0) and 76.7% (95% CI 53.7 to 90.3) of the patients with asymptomatic lumbar canal stenosis were free from leg symptoms for three and five years, respectively. There were no significant differences between the study and control groups in the recovery rate measured by the Japanese Orthopaedic Association score or improvement in the Nurick score at one year after surgery or at the final follow-up. These results suggest that latent lumbar canal stenosis does not influence recovery following surgery for cervical myelopathy; moreover, prophylactic lumbar decompression does not appear to be warranted as a routine procedure for coexistent asymptomatic lumbar canal stenosis in patients with cervical myelopathy, when planning cervical surgery

The natural history of spontaneous osteonecrosis of the medial tibial plateau remains controversial and incomplete. We have studied 21 patients (aged between 53 and 77 years) with clinical and scintigraphic features of spontaneous osteonecrosis of the medial tibial plateau who were observed prospectively for at least three years (37 months to 8.5 years). The mean duration of follow-up was 5.6 years. The mean duration of symptoms at presentation was 4.7 weeks (3 days to 12 weeks). Radiographs of the affected knee at the first visit were normal in 15 patients and mildly arthritic in six. The characteristic radiographic lesion of osteonecrosis was noted at presentation in five of the mildly arthritic knees and during the evolution of the disease in eight of the radiographically normal knees. During the follow-up, subchondral sclerosis of the affected medial tibial plateau was noted in 16 knees. There are three distinct patterns of outcome: 1) acute extensive collapse of the medial tibial plateau in two knees within three months of onset; 2) rapid progression to varying degrees of osteoarthritis in 12 knees, in eight within a year, in all within two years and deterioration of the pre-existing osteoarthritis in three; and 3) complete resolution in four knees, two of which were normal at presentation and two mildly osteoarthritic. The two patients with acute extensive collapse and three who had rapid progression to severe osteoarthritis required total knee arthroplasty. We conclude that osteonecrosis of the medial tibial plateau progresses in most cases to significant degenerative disease of the knee

We report the results of conservative treatment of stage III and stage IV avascular necrosis of bone (AVN) affecting the hip or knee in renal transplant patients. Twenty-nine patients were followed for a mean period of five years. Conservative management was successful in controlling symptoms in 40% of those with AVN of the hip and in 70% of those with AVN of the knee. Knowledge of the natural history of AVN is important because of the long survival times after renal transplantation

We have evaluated prospectively the incidence and location of deep-vein thrombosis (DVT), the risk factors for pulmonary embolism, and the natural history of thrombosis after total knee replacement (TKR) in patients who did not receive prophylactic or therapeutic treatment for DVT. We studied 227 patients who underwent primary TKR; 116 had one-stage bilateral and 111 unilateral procedures. Coagulation assays, the full blood count and blood typing tests for the serum chemical profile were undertaken in all patients on three separate occasions. Bilateral simultaneous or unilateral venograms were carried out at six or seven days after operation. Perfusion lung scanning was undertaken before and at seven or eight days after operation. Bilateral simultaneous or unilateral venograms were repeated six months after operation in all patients who had thrombi. In the 116 patients with a bilateral replacement, 97 of 232 venograms (41.8%) were positive for fresh thrombi while there were 46 positive venograms (41.4%) in the 111 patients with a unilateral replacement (p = 1.000). Of the 116 venograms in knees with a cemented replacement, 45 (38.8%) were positive for thrombi while 52 of the 116 venograms (44.8%) were positive in those with a cementless replacement (p = 0.675). Further venograms at six months after operation in all 143 limbs which had thrombi showed that all had completely resolved regardless of the size or location. No pulmonary embolism occurred as shown by negative perfusion lung scans and the absence of symptoms. Although the current prevailing opinion is that patients with thrombosis in the proximal veins should receive anticoagulant treatment, our study has shown that all thrombi regardless of their size or location resolved without causing pulmonary embolism

A study of the natural history and aetiology of deep vein thrombosis in 499 patients after total hip replacement is presented. Deep vein thrombosis was diagnosed by scanning the leg for 125Iodine-labelled fibrinogen for a period of 14 to 18 days and by ascending phlebography. It has been shown that deep vein thrombosis occurs ater than in patients who have undergone abdominal operations, and the risk period is longer. The peak of onset of thrombosis is on the fourth day after the hip replacement. Attempts at prophylaxis using subcutaneous heparin or intermittent pneumatic compression of the calves delay the appearance of thrombosis. Analysis of possible aetiology factors shows that the age of the patient, the degenerative disease of the hip, the surgical approach, and under-transfusion of blood, all have a significant effect on the incidence of thrombosis

We have determined the natural history of hip development in 42 patients with multiple epiphyseal dysplasia (MED). Premature osteoarthritis was a frequent outcome and was almost inevitable before the age of 30 years in those with incongruent hips. There were two types of immature hips: type I, the more severe form, had a fragmented and flattened ossific nucleus and acetabular dysplasia, was misshapen at skeletal maturity and osteoarthritic by 30 years of age; the milder type II hip had a small, rounded, uniformly ossified nucleus and a more normal acetabulum. Type II hips were well formed at maturity and were less prone to premature osteoarthritis. Considerable variations were noted in the manifestations of MED between families but not within families. The prognosis of a child's hip could be predicted; in sporadic cases from the type of immature hip, and in familial cases by also taking into account the outcome of affected relatives

One hundred consecutive closed fractures of the adult tibial shaft treated by closed methods were surveyed prospectively in order to observe their natural history. The fractures were analysed with regards to speed of healing and the influence of age, sex, causal force, radiological morphology and concurrent fibular fracture. At 20 weeks 19 fractures had not yet united, but 15 of these had united by 30 weeks with conservative treatment alone. The remaining four cases were operated upon because no further progress in healing was anticipated. These findings suggest that, with regard to healing, open reduction and internal fixation is rarely justified in closed adult tibial shaft fractures

Aims

There is a paucity of long-term studies analyzing risk factors for failure after single-stage revision for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). We report the mid- to long-term septic and non-septic failure rate of single-stage revision for PJI after THA.

A small proportion of patients have persistent pain after total knee replacement (TKR). The primary aim of this study was to record the prevalence of pain after TKR at specific intervals post-operatively and to ascertain the impact of neuropathic pain. The secondary aim was to establish any predictive factors that could be used to identify patients who were likely to have high levels of pain or neuropathic pain after TKR.

A total of 96 patients were included in the study. Their mean age was 71 years (48 to 89); 54 (56%) were female. The mean follow-up was 46 months (39 to 51). Pre-operative demographic details were recorded including a Visual Analogue Score (VAS) for pain, the Hospital Anxiety and Depression score as well as the painDETECT score for neuropathic pain. Functional outcome was assessed using the Oxford Knee score.

The mean pre-operative VAS was 5.8 (1 to 10); and it improved significantly at all time periods post-operatively (p < 0.001): (from 4.5 at day three to five (1 to 10), 3.2 at six weeks (0 to 9), 2.4 at three months (0 to 7), 2.0 at six months (0 to 9), 1.7 at nine months (0 to 9), 1.5 at one year (0 to 8) and 2.0 at mean 46 months (0 to 10)). There was a high correlation (r > 0.7; p < 0.001) between the mean VAS scores for pain and the mean painDETECT scores at three months, one year and three years post-operatively. There was no correlation between the pre-operative scores and any post-operative scores at any time point.

We report the prevalence of pain and neuropathic pain at various intervals up to three years after TKR. Neuropathic pain is an underestimated problem in patients with pain after TKR. It peaks at between six weeks and three-months post-operatively. However, from these data we were unable to predict which patients are most likely to be affected.

Cite this article: Bone Joint J 2014;96-B:1227–33.

We have treated 15 patients with massive lumbar disc herniations non-operatively. Repeat MR scanning after a mean 24 months (5 to 56) showed a dramatic resolution of the herniation in 14 patients. No patient developed a cauda equina syndrome.

We suggest that this condition may be more benign than previously thought.

The designation German ‘Adam Bogen’ (arch) which is the used in the German literature as a description of the thick medial cortex of the femoral neck is incorrect. This arch was described by Robert Adams (1795-1871), who was an Irish anatomist and surgeon. Adams, Colles and Smith were outstanding surgeons who described fractures of the proximal femur in detail during the first half of the 19th century and who together formed the Dublin Surgical School. The most important aspects of these fractures were described between 1818 and 1839.

Two hundred and fifty cases of myelodysplasia were reviewed in relation to spinal deformity. Approximately half of the children had, or were expected to develop, curves severe enough to need operations and only 10 per cent maintained completely undeformed spines. The most frequent deformity was scoliosis which could be subdivided into congenital and developmental types. The latter was of mixed aetiology, neuromuscular imbalance and asymmetry of the neural arch both contributing, while in some cases no causative factors could be identified. The best early indicator that developmental scoliosis was likely to appear was a high segmental level of both the neurological deficit and the neural arch defect. Deformity was very unlikely to start after the age of nine years.

1. Eighty-nine cases of Perthes' disease are reviewed.

2. The prognosis varies with the amount of the epiphysis involved.

3. It is possible to assess the amount of epiphysial involvement by a study of the early radiographs. Cases were allocated to four groups on this basis.

4. It is confirmed that both sex and age at the time of diagnosis influence the final prognosis. The reasons for this are discussed.

5. The concept of "the head at risk" is suggested and radiological signs described to diagnose such cases.

6. It is hoped that the classification suggested may in future act as a basis for comparisons of treatment.

1. The clinical features in twenty cases of osteoid osteoma have been analysed and compared with other cases reported in the literature.

2. The lesion is regarded as a benign neoplasm and its unusual clinical behaviour is attributed to its vascular nature.

3. The frequency with which an erroneous diagnosis of "neurosis" is made is stressed.

We investigated fixed flexion deformity (FFD) after total knee replacement (TKR). Data relating to 369 cruciate-retaining unilateral TKRs performed at a single institution were collected prospectively. Fixed flexion was measured pre-operatively and at one week, six months, 18 months, three years and five years after surgery.

Using binary logistic regression, pre-operative FFD was a predictor of post-operative FFD > 10° at one week (p = 0.006) and six months (p = 0.003) following surgery. Gender was a predictor at one week (p = 0.0073) with 24% of women showing a FFD > 10° compared with 37% of men.

We have shown that a gradual improvement in knee extension can be expected up to three years after surgery in knees with FFD. By this time residual FFD is mild or absent in the majority of patients, including those who had a severe pre-operative FFD.

The progression of post-tubercular kyphosis in 61 children who received ambulatory chemotherapy was studied prospectively. The angles of deformity and kyphosis were measured for each patient at diagnosis, 3, 6, 9, 12 and 18 months later and every year thereafter for 15 years. During the course of the disease signs of instability appeared on the radiographs of some of the children. These were dislocation of the facets, posterior retropulsion of the diseased fragments, lateral translation of the vertebrae in the anteroposterior view and toppling of the superior vertebra. Each sign was allocated one point to create a spinal instability score. The influence on the progression of the deformity of the level of the lesion, the vertebral body loss, the number of segments involved, the angle of deformity before treatment and the spinal instability score was analysed.

The mean angle of deformity at the start of treatment was 35°. This increased to 41° at 15 years. Progression occurred during the active phase of the disease and again after cure when variations in progression were observed. Type-I progression showed an increase in deformity until growth had ceased. This could occur either continuously (type Ia) or after a lag period of three to five years (type Ib). Type-II progression showed decrease in deformity with growth. This could occur immediately after the active phase (type IIa) or after a lag period of three to five years (type IIb). Type-III progression showed minimal change during either the active or healed phases and was seen only in those with limited disease.

Multiple regression analysis showed that a spinal instability score of more than 2 was a reliable predictor of patients with an increase of more than 30° in deformity and a final deformity of over 60°. Since signs of radiological instability appear early in the disease, they can be reliably used to identify children whose spine is at risk for late progressive collapse. Surgery is advised in these cases.

We performed a retrospective review of 27 scoliotic patients with syringomyelia using MRI. Their mean age at the first MRI examination was 10.9 years, and at the final review 15.8 years. The mean ratio of the diameter of the syrinx to the cord on the midsagittal MRI (S/C ratio) decreased from 0.49 to 0.24; 14 patients showed a decrease of 50% or more (reduction group). In this reduction group, the cerebellar tonsillar herniation decreased from a mean of 11.3 mm to 6.0 mm, and some improvement in dissociated sensory disturbance was seen in nine of 13 patients. The scoliosis improved by 5° or more in six patients in the reduction group. Our results indicate that spontaneous shrinkage of syringomyelia in children is not unusual and is associated with improvement in the tonsillar herniation, the scoliosis and the neurological deficit.