Object. The authors report the preservation of motion at surgically treated and adjacent spinal segments after placing an artificial cervical joint (ACJ) and they describe the influence of interbody fusion on changes in angulation occurring in the sagittal plane at adjacent levels in the treatment of cervical spondylosis. Methods. The authors conducted a prospective nonrandomized study of patients in whom an ACJ was placed or autologous bone graft interbody fusion was performed. Angular measurements at levels adjacent to that surgically treated were calculated using plain flexion—extension radiographs obtained at 6-month intervals. Analyses of qualitative data, such as increase or decrease in adjacent-level motion, and the degree of disc degeneration were performed. Quantitative data were also analyzed. In the fusion group a significant increase in adjacent-level movement was demonstrated at the 12-month follow-up visit compared with the group of patients in whom ACJs were placed (p < 0.001). The increase in movement occurred predominantly at intervertebral discs that were preoperatively regarded as normal (p < 0.02). An overall reduction in adjacent-level movement was observed in patients who underwent joint replacement, although this was compensated for by the movement provided by the ACJ itself. Conclusions. Fusion results in increased motion at adjacent levels. The increase in adjacent-level motion derives from those discs that appear radiologically normal prior to surgery. It remains unknown whether ACJs have a protective influence on adjacent intervertebral discs.

Objective: To ascertain whether a written information sheet is acceptable to patients and improves recall of the consent interview. Design: Prospective randomised controlled study using questionnaires, comparing a group of patients given information in a written sheet with appropriate explanation to a group given verbal information alone. Setting: A specialist orthopaedic surgery unit. Patients: The test group was 126 patients undergoing revision or primary total hip arthroplasty; 65 patients were given information verbally, 61 patients were given written information. Outcome measure: Patients' recall of information given, tested with a questionnaire completed on admission (mean of 18 days later). Results: The patients receiving written information scored significantly higher (48% correct answers) than the patients receiving verbal information (38% correct answers). Conclusions: Written information sheets contribute to the process of informed consent. As patients' recall of information is generally poor, the sheets may also be useful medicolegally, as a permanent record of what was discussed.

Splitting fractures of the humeral head are rare; part of the humeral head dislocates and the unfractured part remains attached to the shaft. We report eight cases in young patients. In five the diagnosis was made at presentation: three had minimal internal fixation using a superior subacromial approach, one had a closed reduction and one a primary prosthetic replacement. All five patients regained excellent function with no avascular necrosis at two years. In three the injury was initially unrecognised; two developed a painless bony ankylosis and one is awaiting hemiarthroplasty.It is important to obtain the three trauma radiographic views to diagnose these unusual fractures reliably. CT delineates the configuration of the fracture. In young patients open reduction and internal fixation seems preferable to replacement of the humeral head, since we have shown that the head is potentially viable.

Splitting fractures of the humeral head are rare; part of the humeral head dislocates and the unfractured part remains attached to the shaft. We report eight cases in young patients. In five the diagnosis was made at presentation: three had minimal internal fixation using a superior subacromial approach, one had a closed reduction and one a primary prosthetic replacement. All five patients regained excellent function with no avascular necrosis at two years. In three the injury was initially unrecognised; two developed a painless bony ankylosis and one is awaiting hemiarthroplasty. It is important to obtain the three trauma radiographic views to diagnose these unusual fractures reliably. CT delineates the configuration of the fracture. In young patients open reduction and internal fixation seems preferable to replacement of the humeral head, since we have shown that the head is potentially viable.

No abstract

Our previous reports on the pathological anatomy and operative treatment of intra-articular fractures of the calcaneum failed to take account of the fracture pattern anterior to the posterior facet of the subtalar joint. We have reviewed our experience of 63 operative cases and have studied fractures with axial and coronal CT scans reconstructed onto plastic model bones. A constant anterolateral fragment exists, which is displaced by an extended lateral approach to the fracture. If it is unrecognised and unreduced, union in a displaced position may limit hindfoot eversion and disrupt the calcaneocuboid joint. We describe techniques for reduction and fixation of the fragment.

The wrist joint is highly complex and there remain unresolved problems to be overcome in designing a successful wrist joint prosthesis. Consequently, the results of total wrist joint replacements have been poor compared to those for hip and knee joint replacements. A multidisciplinary team of orthopaedic surgeons and engineers is working at Bath to tackle some of the key issues in the engineering of a new wrist joint prosthesis. Following a brief background to the work being undertaken by the group, this paper describes two ongoing research activities. Firstly, an assessment is being made of the optimum geometry for a wrist replacement through the use of a geometric constraint modeller. The second activity is the development of a mechanical simulator to assess wrist prosthesis function and loading. A computer algorithm controls articulation of the wrist using cables that mimic normal wrist tendons. This system allows for full movement of the hand and can also simulate external loading. The forces transmitted at the prosthesis/bone interfaces can be monitored using sensors attached adjacent to the prosthesis.

Although specialist centres have recorded a 75% survivorship of hip arthroplasty after 20 years (1), results in general orthopaedic units are unreported. Thirty-four patients with 45 primary cemented total hip arthroplasties implanted by “first generation” cementing techniques were reviewed after a mean of 20 years, documenting revision, occupation, and function. Twenty of the 35 (57%) hips were revised after a mean of 12 (2 to 21) years and reviewed after a mean of 7.6 years. Three hips had been subsequently re-revised. Seven out of nine (78%) hip arthroplasties in males failed, compared with 13 of 26 (50%) in females. Eighty-five percent failed by aseptic loosening. Five of nine employed patients had retired or changed profession. The mean Harris Hip Score was 73% (unrevised), 75% (revised), and 64% (re-revised). These results justify continuing efforts to improve technique and prosthetic design. Over a quarter of our patients were lost to follow up despite repeated contact over the previous 18 years, which mirrors the world literature. To adequately assess modern designs and techniques, we must improve retrieval. A national database would assist this.