Journal of Bone and Joint Surgery - British Volume (J BONE JOINT SURG BR )

Publisher: British Editorial Society of Bone and Joint Surgery, British Editorial Society of Bone and Joint Surgery


The Journal of Bone and Joint Surgery is the principal orthopaedic publication in the English language, covering all aspects of orthopaedic surgery, trauma and rheumatology. It is available in 132 countries and bought by over 30,000 surgeons and physicians. All major scientific and medical libraries and commercial organizations subscribe to keep abreast of current developments in orthopaedics. The British Volume is published in London in January, March, April, May, July, August, September and November (8 issues, identified by numbers 1, 2, 3, 4, 5, 6, 7 and 8). Three issues of the Orthopaedic Proceedings Supplement, containing abstracts from worldwide orthopaedic meetings, will normally be published in 2000 as part of the British Volume at no additional cost. The American Volume is published in Boston monthly (12 issues, identified by month of issue).

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British Editorial Society of Bone and Joint Surgery

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Publications in this journal

  • [Show abstract] [Hide abstract]
    ABSTRACT: We describe the impact of a targeted performance improvement programme and the associated performance improvement interventions, on mortality rates, error rates and process of care for haemodynamically unstable patients with pelvic fractures. Clinical care and performance improvement data for 185 adult patients with exsanguinating pelvic trauma presenting to a United Kingdom Major Trauma Centre between January 2007 and January 2011 were analysed with univariate and multivariate regression and compared with National data. In total 62 patients (34%) died from their injuries and opportunities for improved care were identified in one third of deaths. Three major interventions were introduced during the study period in response to the findings. These were a massive haemorrhage protocol, a decision-making algorithm and employment of specialist pelvic orthopaedic surgeons. Interventions which improved performance were associated with an annual reduction in mortality (odds ratio 0.64 (95% confidence interval (CI) 0.44 to 0.93), p = 0.02), a reduction in error rates (p = 0.024) and significant improvements in the targeted processes of care. Exsanguinating patients with pelvic trauma are complex to manage and are associated with high mortality rates; implementation of a targeted performance improvement programme achieved sustained improvements in mortality, error rates and trauma care in this group of severely injured patients. Cite this article: Bone Joint J 2014;96-B:1090-7.
    Journal of Bone and Joint Surgery - British Volume 08/2014; 96-B(8):1090-1097.
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    ABSTRACT: The literature remains divided on whether the development of pathological fracture affects prognosis in patients with osteosarcoma of the extremities. We conducted a comprehensive systematic review and meta-analysis of papers which reported outcomes in osteosarcoma patients with and without pathological fractures. We selected 8 eligible papers for final analysis. This included 1713 patients, of which 303 had pathological fractures. The pooled estimates of local recurrence rates in osteosarcoma patients with and without pathological fractures were 14.4%(8.7-20.0) vs 11.4%(8.0-14.8). The pooled estimate of relative risk was 1.39(0.89-2.20). The pooled estimates of 5-year event-free survival rates in osteosarcoma patients with and without pathological fractures were 49.3%(43.6-54.9) vs 66.8%(60.7-72.8%). The pooled estimate of relative risk was 1.33(1.12-1.59). There was no significant difference in local recurrence rates in osteosarcoma patients with pathological fractures who were treated with amputation or limb salvage. The development of pathological fracture is a negative prognostic indicator in osteosarcoma, being associated with decreased 5-year event-free survival and possibly higher rate of local recurrence. This is not an absolute indication for amputation since similar local recurrence rates can be achieved in carefully selected patients for limb salvage.
    Journal of Bone and Joint Surgery - British Volume 07/2014;
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    ABSTRACT: ummary Aim of this study is to design, develop and preclinical test PET nanostructured scaffolds for the transplantation and differentiation of MSCs in he treatment of bone defects. The interaction of cells with nanotopographical eatures has proven to be an important signaling modality in controlling MSC differentiation. Introduction The wide bone defects, caused by trauma, tumor, infectious, periprosthetic osteolysis, need to be surgically treated because their low potential of repair. Nowadays the bone allograft and autograft represent 80% of all transplantation done in the world. However this technique shows many disadvantages, such as the risk of infections, the immunological rejection, the ow bone availability and the high costs. These reasons have motivated extensive research to find alternative strategies. As shown in literature, the uture strategies are based on the synergic combination of different methodologies: use of biomimetic scaffold in order to support bone egeneration, use of mesenchymal stromal cells (MSCs) and growth factors. Successful regeneration necessitates the development of tissue-inducing scaffolds that mimic the hierarchical architecture of native tissue extracellular matrix (ECM). Cells in nature recognise and interact with the surface opography they are exposed to via ECM proteins. Here we are going to show he guidelines recently published for the design and development of nanostructured scaffolds for the bone regeneration, and the morphofunctional changing of MSCs interacting with nanogratings. Methods Aim of this study is to design, develop and preclinical test PET nanostructured scaffolds for the transplantation and differentiation of MSCs in he treatment of bone defects. The first step of our study was the extraction of patient's bone marrow and the isolation of MSCs. After characterizing demonstrating the typical cell surface markers) and isolating the MSCs were cultivated on the PET substrates. The PET nanosubstrates were obtained by a ow temperature embossing lithography (HEL) achieving low-damage nanotopographic surface modifications. After MSC cultivation on PET substrates we made a cytotoxicity evaluation, an optic and confocal microscopic evaluation (cells adhesion, cells polarization...) and tests to optimise cell differentiation towards osteogenic fate. Results PET is a highly suitable thermo-plastic material, able to sustain the necessary methods to obtain nanostructured substrates. MSCs cultivated on nanostructured PET rapidly align with the direction of the nanostructure itself without any cytotoxic effects. After the cultivation on the nanostructures, MSCs sustained cytoskeleton changes suggesting the activation of intracellular signaling (mechanotrasduction) promoting osteogenesis. Discussion The mechanisms by which nanotopographic cues influence stem cell proliferation and differentiation appear to involve changes in cytoskeletal organization and structure, potentially in response to the geometry and size of he underlying features of the ECM by a process called mechanotrasduction. The interaction of cells with nanotopographical features such as pores, ridges, groves, fibers, nodes, and their combinations has proven to be an important signaling modality in controlling cellular processes. Integrating nanotopographical cues is especially important in engineering complex tissues that have multiple cell types and require precisely defined cell-cell and cell- matrix interactions at the nanoscale. Thus, in the next-generation regenerative engineering approaches, nanoscale materials/scaffolds are expected to play a parimary role in controlling MSC fate and the consequent regenerative capacity. We believe that the continuous development of nanotechnology and deeply comprehension of how mechanical inputs can affect cell biology is fundamental to design the future scaffold for orthopedic application.
    Journal of Bone and Joint Surgery - British Volume 07/2014; vol. 96-B(SUPP 11 244).
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    ABSTRACT: Metatarsus primus varus deformity correction is one of the main objectives in hallux valgus surgery. A 'syndesmosis' procedure may be used to correct hallux valgus. An osteotomy is not involved. The aim is to realign the first metatarsal using soft tissues and a cerclage wire around the necks of the first and second metatarsals. We have retrospectively assessed 27 patients (54 feet) using the American Orthopaedic Foot and Ankle Society (AOFAS) score, radiographs and measurements of the plantar pressures after bilateral syndesmosis procedures. There were 26 women. The mean age of the patients was 46 years (18 to 70) and the mean follow-up was 26.4 months (24 to 33.4). Matched-pair comparisons of the AOFAS scores, the radiological parameters and the plantar pressure measurements were conducted pre- and post-operatively, with the mean of the left and right feet. The mean AOFAS score improved from 62.8 to 94.4 points (p < 0.001). Significant differences were found on all radiological parameters (p < 0.001). The mean hallux valgus and first intermetatarsal angles were reduced from 33.2° (24.3° to 49.8°) to 19.1° (10.1° to 45.3°) (p < 0.001) and from 15.0° (10.2° to 18.6°) to 7.2° (4.2° to 11.4°) (p < 0.001) respectively. The mean medial sesamoid position changed from 6.3(4.5 to 7) to 3.6 (2 to 7) (p < 0.001) according to the Hardy's scale (0 to 7). The mean maximum force and the force-time integral under the hallux region were significantly increased by 71.1% (p = 0.001), (20.57 (0.08 to 58.3) to 35.20 (6.63 to 67.48)) and 73.4% (p = 0.014), (4.44 (0.00 to 22.74) to 7.70 (1.28 to 19.23)) respectively. The occurrence of the maximum force under the hallux region was delayed by 11% (p = 0.02), (87.3% stance (36.3% to 100%) to 96.8% stance (93.0% to 100%)). The force data reflected the restoration of the function of the hallux. Three patients suffered a stress fracture of the neck of the second metatarsal. The short-term results of this surgical procedure for the treatment of hallux valgus are satisfactory. Cite this article: Bone Joint J 2014;96-B:502-7.
    Journal of Bone and Joint Surgery - British Volume 04/2014; 96-B(4):502-7.
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    ABSTRACT: We investigated the incidence of anomalies in the vertebral arteries and Circle of Willis with three-dimensional CT angiography in 55 consecutive patients who had undergone an instrumented posterior fusion of the cervical spine. We recorded any peri-operative and post-operative complications. The frequency of congenital anomalies was 30.9%, abnormal vertebral artery blood flow was 58.2% and vertebral artery dominance 40%. The posterior communicating artery was occluded on one side in 41.8% of patients and bilaterally in 38.2%. Variations in the vertebral arteries and Circle of Willis were not significantly related to the presence or absence of posterior communicating arteries. Importantly, 18.2% of patients showed characteristic variations in the Circle of Willis with unilateral vertebral artery stenosis or a dominant vertebral artery, indicating that injury may cause lethal complications. One patient had post-operative cerebellar symptoms due to intra-operative injury of the vertebral artery, and one underwent a different surgical procedure because of insufficient collateral circulation. Pre-operative assessment of the vertebral arteries and Circle of Willis is essential if a posterior spinal fusion with instrumentation is to be carried out safely. Cite this article: Bone Joint J 2014;96-B:535-40.
    Journal of Bone and Joint Surgery - British Volume 04/2014; 96-B(4):535-40.
  • Journal of Bone and Joint Surgery - British Volume 02/2014; 94-B(3):294.
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    ABSTRACT: This cohort study investigated the influence of psychological factors, including perception of illness, anxiety and depression on recovery and functional outcome after total knee replacement surgery. A total of 100 patients (55 male; 45 female) with a mean age of 71 (42 to 92) who underwent a primary total knee replacement for osteoarthritis were recruited into this study. In all 97 participants completed the six week and 87 the one year follow-up questionnaires. Pre-operatively patients completed the revised Illness Perception Questionnaire, Hospital Anxiety and Depression Scale and Recovery Locus of Control Scale. Function was assessed pre-operatively, at six weeks and one year using Oxford Knee Score (OKS) and the goniometer-measured range of movement (ROM). The results showed that pre-operative function had the biggest impact on post-operative outcome for ROM and OKS. In addition questionnaire variables and depression had an impact on the OKS at six weeks. Depression and anxiety were also associated with a higher (worse) knee score at one year but did not influence the ROM at either six weeks or one year. Recovery from total knee replacement can be difficult to predict. This study has identified psychological factors that play an important role in recovery from surgery and functional outcome. These should be taken into account when considering patients for total knee replacement. Cite this article: Bone Joint J 2014;96-B:210-16.
    Journal of Bone and Joint Surgery - British Volume 02/2014; 96-B(2):210-6.
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    ABSTRACT: Introduction Physical disruption of the extracellular matrix influences the mechanical and chemical environment of intervertebral disc cells. We hypothesise that this can explain degenerative changes such as focal proteoglycan loss, impaired cell-matrix binding, cell clustering, and increased activity of matrix-degrading enzymes.Methods Disc tissue samples were removed surgically from 11 patients (aged 34–75 yrs) who had a painful but non-herniated disc. Each sample was divided into a pair of specimens (approximately 5mm3), which were cultured at 37°C under 5% CO2. One of each pair was allowed to swell, while the other was restrained by a perspex ring. Live-cell imaging was performed with a wide field microscope for 36 hrs. Specimens were then sectioned at 5 and 30 μm for histology and immunofluorescence using a confocal microscope. Antibodies were used to recognise free integrin receptor α5β1, matrix metalloprotease MMP-1, and denatured collagen types I-III. Proteoglycan content of the medium, analysed using the colorimetric DMMB assay, was used to assess tissue swelling and GAG loss. Constrained/unconstrained results were compared using matched-pair t-tests.Results Time-lapse cinematography revealed small cell movements in unconstrained specimens, for up to 12 hrs. By 36 hrs, unconstrained (free swelling) samples showed greater: loss of GAG's (p<0.003), loss of integrin binding (p<0.02), synthesis of MMP-1 (p<0.03), and collagen denaturation (p<0.009). Cell clustering was evident in all tissues after 36 hrs.Conclusion Swelling of disrupted disc tissue disturbs cell-matrix binding, increases matrix degradation, and allows increased proteoglycan loss. This sequence of events could follow disc injury or herniation in-vivo.
    Journal of Bone and Joint Surgery - British Volume 01/2014; 96-B:18.
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    ABSTRACT: Introduction Herniated disc tissue removed at surgery is mostly nucleus pulposus, with varying proportions of annulus fibrosus, cartilage endplate, and bone. Herniated nucleus swells and loses proteoglycans, and herniated annulus is invaded by blood vessels and inflammatory cells. However, little is known about the significance of endplate cartilage and bone within a herniation.Methods Herniated tissue was removed surgically from 21 patients (10 with sciatica, 11 without). 5-μm sections were examined using H&E, Toluidine blue, Giemsa, and Masson-trichrome stains. Each tissue type in each specimen was scored for tears/fissures, neovascularisation, proteoglycan loss, cell clustering, and inflammatory cell invasion. Proportions of each tissue type were quantified using image analysis software.Results Herniations from patients with sciatica had greater nerve and blood vessel invasion (P<0.05), and a greater proportion contained cartilage endplate (7/10 vs 3/11, p<0.05). Cartilage fragments were generally small (5–20% of herniated mass) and showed little swelling or proteoglycan loss, or inflammatory cell invasion, although chondrocytes often formed small clusters. Most cartilage endplate fragments had a straight edge where it had been stripped from bone. Two cartilage fragments showed some bone still attached, and three showed small defects that were filled with nucleus tissue, bone, or endothelial cells.Conclusion More than 50% of disc herniations contained cartilage endplate. The relatively stable nature of cartilage fragments may explain why they are less likely to resorb, and therefore more likely to cause persisting sciatica. Loss of cartilage will increase endplate permeability, increasing the risk of Modic changes, and disc infection.
    Journal of Bone and Joint Surgery - British Volume 01/2014; 96-B:19.
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    ABSTRACT: Objective: The most dreaded and crippling complication of spinal tuberculosis is pott’s paraplegia. The use of instrumentation in the presence of infection is usually deferred for the fear of formation of a focus, persistence bio material centered infection, preferential bacterial colonization and production of a bio-film (glycocalyx) which protects them from host defenses and chemotherapeutic agents. Fortunately, mycobacterium tuberculosis is less adhesive and produces less bio-film than other bacteria and the likelihood of persistence infection in the presence of implants is smaller.
    Journal of Bone and Joint Surgery - British Volume 10/2013; 88.
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    ABSTRACT: We evaluated the outcome of 41 consecutive Charnley low-friction arthroplasties (LFAs) performed by a single surgeon in 28 patients aged ≤ 35 years at operation between 23 and 36 years previously. There were 20 women and eight men with a mean age of 32 years (23 to 35) at surgery. Two patients (three hips) were lost to follow-up at 12 and 17 years post-operatively, respectively, and one patient (one hip) died at 13 years post-operatively. These patients were excluded from the final evaluation. The survival rate of the acetabular components was 92.7% (95% confidence interval (CI) 88.7 to 96.7) at ten years, 67.1% (95% CI 59.75 to 74.45) at 20 years and 53.2% (95% CI 45.3 to 61.1) at 25 years. For the femoral component the survival was 95.1% (95% CI 91.8 to 98.5) at ten years, 77.1% (95% CI 73.9 to 80.3) at 20 years and 68.2% (95% CI 60.7 to 75.8) at 25 years. The results indicate that the Charnley LFA remains a reasonable choice in the treatment of young patients and can serve for comparison with newer techniques and implants. Cite this article: Bone Joint J 2013;95-B:1052-6.
    Journal of Bone and Joint Surgery - British Volume 08/2013; 95-B(8):1052-1056.
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    ABSTRACT: We report the results at a mean of 24.3 years (20 to 32) of 61 previously reported consecutive total hip replacements carried out on 44 patients with severe congenital hip disease, performed with reconstruction of the acetabulum with an impaction grafting technique known as cotyloplasty. The mean age of the patients at operation was 46.7 years (23 to 68) and all were women. The patients were followed post-operatively for a mean of 24.3 years (20 to 32), using the Merle d'Aubigné and Postel scoring system as modified by Charnley, and with serial radiographs. At the time of the latest follow-up, 28 acetabular components had been revised because of aseptic loosening at a mean of 15.9 years (6 to 26), and one at 40 days after surgery because of repeated dislocations. The overall survival rate for aseptic failure of the acetabular component at ten years was 93.1% (95% confidence interval (CI) 86.5 to 96.7) when 53 hips were at risk, and at 23 years was 56.1% (95% CI 49.4 to 62.8), when 22 hips remained at risk. These long-term results are considered satisfactory for the reconstruction of an acetabulum presenting with inadequate bone stock and circumferential segmental defects. Cite this article: Bone Joint J 2013;95-B:887-92.
    Journal of Bone and Joint Surgery - British Volume 07/2013; 95-B(7):887-892.
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    ABSTRACT: Whether to combine spinal decompression with fusion in patients with symptomatic lumbar spinal stenosis remains controversial. We performed a cohort study to determine the effect of the addition of fusion in terms of patient satisfaction after decompressive spinal surgery in patients with and without a degenerative spondylolisthesis. The National Swedish Register for Spine Surgery (Swespine) was used for the study. Data were obtained for all patients in the register who underwent surgery for stenosis on one or two adjacent lumbar levels. A total of 5390 patients fulfilled the inclusion criteria and completed a two-year follow-up. Using multivariable models the results of 4259 patients who underwent decompression alone were compared with those of 1131 who underwent decompression and fusion. The consequence of having an associated spondylolisthesis in the operated segments pre-operatively was also considered. At two years there was no significant difference in patient satisfaction between the two treatment groups for any of the outcome measures, regardless of the presence of a pre-operative spondylolisthesis. Moreover, the proportion of patients who required subsequent further lumbar surgery was also similar in the two groups. In this large cohort the addition of fusion to decompression was not associated with an improved outcome. Cite this article: Bone Joint J 2013;95-B:960-5.
    Journal of Bone and Joint Surgery - British Volume 07/2013; 95-B(7):960-965.
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    ABSTRACT: Total knee replacement in a commonly performed procedure in the United Kingdom with more than 76000 primary procedures performed in 2010. With so many procedures performed there has to be a robust way of assessing the outcome of the procedure. Gait analysis is a valuable tool in objectively assessing the these patients. Inertial movement units (IMU's) are a fairly new development in gait analysis. The aim of our project is to use IMUs to assess the differences in gait profile between a cohort of healthy controls, a group of pre operative knee replacement patients, a group of 8 week post operative patients and finally a group of post operative knee replacement patients at 1 year. We studied a total of 47 patients. We also had data from a previous study done on healthy controls using the same measurement tool. We measured three parameters: peak swing phase flexion, peak stance phase flexion and stride duration. Our findings indicate that pre-operative patients have a significantly reduced peak flexion in swing and stance with increased stride duration. This shows no improvement at the 8 week mark. At the 1 year mark peak flexion in swing returns to pre operative levels but flexion in stance and stride duration are still poor. These findings may not have been identified without gait analysis. Gait analysis using intertial movement units will add much information to radiographs and clinical examination. This information can also be used to tailor individual patients rehabilitation.
    Journal of Bone and Joint Surgery - British Volume 05/2013; 95 B(Supp 13 - 6):6.
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    ABSTRACT: Surgical repair of posterosuperior rotator cuff tears has a poorer outcome and a higher rate of failure compared with repairs of supraspinatus tears. In this prospective cohort study 28 consecutive patients with an irreparable posterosuperior rotator cuff tear after failed conservative or surgical treatment underwent teres major tendon transfer. Their mean age was 60 years (48 to 71) and the mean follow-up was 25 months (12 to 80). The mean active abduction improved from 79° (0° to 150°) pre-operatively to 105° (20° to 180°) post-operatively (p = 0.011). The mean active external rotation in 90° abduction improved from 25° (0° to 70°) pre-operatively to 55° (0° to 90°) post-operatively (p < 0.001). The mean Constant score improved from 43 (18 to 78) pre-operatively to 65 (30 to 86) post-operatively (p < 0.001). The median post-operative VAS (0 to 100) for pain decreased from 63 (0 to 96) pre-operatively to 5 (0 to 56) post-operatively (p < 0.001). In conclusion, teres major transfer effectively restores function and relieves pain in patients with irreparable posterosuperior rotator cuff tears and leads to an overall clinical improvement in a relatively young and active patient group with limited treatment options.
    Journal of Bone and Joint Surgery - British Volume 04/2013; 95-B(4):523-9.
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    ABSTRACT: McFarland fractures of the medial malleolus in children, also classified as Salter–Harris Type III and IV fractures, are associated with a high incidence of premature growth plate arrest. In order to identify prognostic factors for the development of complications we reviewed 20 children with a McFarland fracture that was treated surgically, at a mean follow-up of 8.9 years (3.5 to 17.4). Seven children (35%) developed premature growth arrest with angular deformity. The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale for all patients was 98.3 (87 to 100) and the mean modified Weber protocol was 1.15 (0 to 5). There was a significant correlation between initial displacement (p = 0.004) and operative delay (p = 0.007) with premature growth arrest. Both risk factors act independently and additively, such that all children with both risk factors developed premature arrest whereas children with no risk factor did not. We recommend that fractures of the medial malleolus in children should be treated by anatomical reduction and screw fixation within one day of injury.
    Journal of Bone and Joint Surgery - British Volume 04/2013; 95(B):419-423.

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