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Background: Total hip and knee arthroplasties (THA/TKA) are clinically effective but high cost procedures. The aim of this study is to perform a cost-effectiveness analysis of THA and TKA in the New Zealand (NZ) healthcare system., Methods: Data were collected from 713 patients undergoing THA and 520 patients undergoing TKA at our local public hospital. SF-6D utility values were obtained from participants preoperatively and 1-year postoperatively, and deaths and any revision surgeries from patient records and the New Zealand Joint Registry at minimum 8-year follow-up. A continuous-time state-transition simulation model was used to estimate costs and health gains to 15 years. Quality-adjusted life years (QALYs), treatment costs, and incremental cost-effectiveness ratios (ICERs) were calculated to determine cost effectiveness. ICERs below NZ gross domestic product (GDP; NZ$60 600) and 0.5 times GDP per capita were considered "cost effective" and "highly cost effective" respectively., Results: Cumulative health gains were 2.8 QALYs (THA) and 2.3 QALYs (TKA) over 15 years. Cost effectiveness improved from ICERs of NZ$74,400 (THA) and NZ$93,000 (TKA) at 1 year to NZ$6000 (THA) and NZ$7500 (TKA) at 15 years. THA and TKA were cost effective after 2 years and highly cost effective after 3 years. QALY gains and cost effectiveness were greater in patients with worse preoperative functional status and younger age., Conclusion: THA and TKA are highly cost-effective procedures over longer term horizons. Although preoperative status and age were associated with cost effectiveness, both THA and TKA remained cost effective in patients with less severe preoperative scores and older ages., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Most public hospitals are receiving more referrals for first specialist assessment than they have capacity to see. Traditional priority categories are too broad for effective discrimination. In New Zealand (NZ) explicit prioritization is required by legislation and supported by the Medical Council of NZ. A new generic National Referral Prioritization tool (NRPT) has been developed which includes a patient impact on life score. This study reports its trial implementation in orthopaedic surgery in a single centre., Methods: Four months of referrals to the orthopaedic department were prioritized using the new NRPT and traditional clinical priority categories. Scores and acceptances were compared across conditions, surgeons and against the traditional categories., Results: The mean NRPT was 60.1 (range 23-99). The correlation with impact on life was 0.59. There was good consistency of scores between surgeons. The NRPT score was significantly different across clinical priority categories (urgent, semi-urgent, routine). A total of 305 referrals (49%) were accepted using the NRPT compared with 493 (79%) if the traditional tool had been used. Patients with foot and ankle, carpal tunnel syndrome and upper limb conditions had the lowest scores and were more likely to be declined., Conclusions: The NRPT is the first tool designed to prioritize referral letters. It is more discriminating than the clinical priority categories used previously. It allows fine-tuning of a threshold score to balance acceptances and capacity., (© 2020 Royal Australasian College of Surgeons.)

Background: Nonoperative management of patients with knee osteoarthritis (OA) through multidisciplinary programs may delay or reduce the need for total knee arthroplasty (TKA). However, avoidance of surgery may not represent success for the patient., Methods: A cohort of 120 patients with knee OA managed with at least 6 months of supervised nonoperative treatment coordinated through the Joint Clinic were reviewed at 5 years. Outcomes including Oxford knee score (OKS), Short Form 12 (SF-12), and SF-6D and other measures including analgesia use, global change, and perception of need for surgery were collected and compared with those from the cohort who had undergone TKA., Results: Seventy (62.5%) surviving patients were still being managed nonoperatively. There was no significant change in any outcome score (OKS, SF-12 physical component score, SF-12 mental component score, SF-6D) (P = .26 to .84). Forty-two patients had undergone TKA with mean time to surgery 29.0 months (range, 9-69 months). In this group, the mean OKS fell from 17.9 at baseline to 10.3 (range, 3-21) preoperatively (P < .0001) and at 5 years there was a significant improvement from baseline in OKS, SF-12 physical component score, and SF-6D scores (P < .0001). All outcome scores and change in scores were significantly higher for the surgical group (all P < .001)., Conclusion: Although a high proportion of patients with knee OA have avoided surgery at 5 years, their outcomes show no improvement from baseline and are poorer than those who have undergone TKA. Avoidance of surgery should not necessarily be regarded as an indicator of success of nonoperative treatment for the patient., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: There are a number of reports of polyethylene liner dissociation of third-generation modular acetabular components. This study compares our experience with 2 contemporary systems to determine whether this is an implant- or class-specific problem., Methods: This is a single-center retrospective study of 961 primary total hip arthroplasties using 2 third-generation modular cementless acetabular shells: Pinnacle (535) and R3 (426) with a polyethylene liner. Details of all revisions were obtained from local databases and the New Zealand Joint Registry. Kaplan-Meier survival curves were calculated for all-cause revision, acetabular reoperation (including liner exchange), and liner dissociation., Results: There were 17 revisions in group 1 (Pinnacle; DePuy Synthes): 17 for recurrent dislocation, 6 for liner dissociations (1.12%), 3 for femoral loosening, and one for deep infection. In group 2 (R3; Smith and Nephew), there were 4 revision procedures: one for infection, 2 for dislocation, and one femoral revision for periprosthetic fracture. There were significantly higher proportions revised in group 1 for all-cause revision, acetabular reoperation, and dissociation ( P  = .024 to 0.038). The 7-year survival for all-cause revision was 96.1% for Pinnacle and 99.0% for R3 ( P  = .022), and that in the acetabular reoperation group was 96.9% for Pinnacle and 99.3% for R3 ( P  = .035)., Conclusions: There was a higher revision rate for the Pinnacle acetabular component than for the R3 at 7 years. This was mainly due to polyethylene liner dissociation that can occur early or late. It appears to be a problem specific to the Pinnacle cup design rather than a feature of similar third-generation acetabular components., (© 2020 The Authors.)

Background: The purpose of this study is to determine outcomes of a nonoperative treatment service for hip and knee osteoarthritis (OA), the "Joint Clinic," at minimum 5-year follow-up, and investigate factors that may influence progression to joint replacement surgery., Methods: This is an observational cohort study of 337 patients with hip (n = 151, 45%) or knee OA (n = 186, 55%) seen at the Joint Clinic, at 5-7 years of follow-up. Kaplan-Meier survival curves were used to determine survivorship of the affected joint and Cox regression used to determine factors associated with time to surgery., Results: At mean 6-year follow up, 188 (56%) patients had undergone or were awaiting total joint arthroplasty, 127 (38%) were still being managed nonoperatively, and 22 (7%) had died without having surgery. Patients with hip OA were more likely to have required surgery (111/151, 74%) than patients with knee OA (77/186, 41%) (chi-square = 33.6, P < .001). The 7-year surgery-free survival for hip OA was 23.7% and knee OA 55.9% (P < .001). Factors associated with increased likelihood of surgery were joint affected (hip, hazard ratio [HR] 2.80), Kellgren-Lawrence (KL) grade (KL 3, HR 2.02; KL 4, 4.79), and Oxford Hip/Knee Score (HR 1.34 for each 5 points worse at baseline)., Conclusion: More than 50% of the patients referred to secondary care with mild-moderate knee OA may not need surgery at 7 years. Patients with hip OA and those with severe radiographic changes are more likely to require surgery and should not be delayed if there is not an adequate response to conservative measures., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: In countries with publicly funded health care, there is an increasing need for explicit rationing for total joint arthroplasty (TJA). The Oxford Hip and Knee Scores (OHS/OKS) have been used to set access thresholds for TJA despite not being developed for that purpose. The aim of this study was to determine whether preoperative OHS/OKS can aid rationing decisions by investigating the changes in general health-related quality of life after TJA., Methods: OHS/OKS, Short Form-12, and Short Form-6D (SF-6D) scores were collected preoperatively and at 1 year postoperatively in a cohort of patients undergoing total hip arthroplasty (THA; n = 713) and total knee arthroplasty (TKA; n = 520). The association between preoperative OHS/OKS and postoperative score and the change in OHS/OKS and SF-6D was investigated, adjusting for age and gender., Results: The mean Oxford scores improved from 13.9 to 40.7 (OHS) and 15.6 to 37.4 (OKS). The mean SF-6D improved after THA (0.53 to 0.80) and TKA (0.56 to 0.78) (all P < .0001). Poorer preoperative Oxford scores were associated with poorer postoperative OHS/OKS and SF-6D but larger improvements. For every 5 points lower preoperative OHS/OKS, the postoperative SF-6D score was worse by a margin of 0.019 (THA) and 0.023 (TKA)., Conclusions: Preoperative OHS/OKS can help inform rationing decisions. A lower preoperative OHS/OKS will result in greater gains but a lower final outcome score in general health-related quality of life., (© 2020 The Authors.)

Aims: To compare long-term survival of all-cemented and hybrid total hip arthroplasty (THA) using the Exeter Universal stem., Methods: Details of 1,086 THAs performed between 1999 and 2005 using the Exeter stem and either a cemented (632) or uncemented acetabular component (454) were collected from local records and the New Zealand Joint Registry. A competing risks regression survival analysis was performed with death as the competing risk with adjustments made for age, sex, approach, and bearing., Results: There were 61 revisions (9.7%; 0.82 revisions/100 observed component years, (OCYs)) in the all-cemented group and 18 (4.0%; 0.30/100 OCYs) in the hybrid group. The cumulative incidence of revision at 18 years was 12.1% for cemented and 5.2% for hybrids. There was a significantly greater risk of revision for all-cemented compared with hybrids (unadjusted sub-hazard ratio (SHR) 2.44; p = 0.001), and of revision for loosening, wear, or osteolysis (unadjusted SHR 3.77; p < 0.001). After adjustment, the increased risk of all-cause revision did not reach significance at age 70 years and above. The advantage for revision for loosening, wear, and osteolysis remained at all ages., Conclusion: This study supports the use of uncemented acetabular fixation when used in combination with the Exeter stem with improved survivorship for revision for aseptic loosening, wear, and osteolysis at all ages and for all-cause revision in patients less than 70 years. Cite this article: Bone Joint J 2020;102-B(4):414-422.

Background: Despite increased use of uncemented and hybrid fixation, there is little evidence of their superiority over cemented implants. The aim of this study is to compare the long-term survivorship of cemented, hybrid and uncemented total hip arthroplasty (THA) at varying ages., Methods: A total of 2156 hips (1315 cemented, 324 uncemented, and 517 hybrid) were performed in a single center between 1999 and 2005 with follow-up through to 2017. Registry and local databases were used to determine revision rates and cause. Unadjusted and adjusted competing risk survival analysis was performed., Results: The cumulative incidence of all-cause revision at 18 years was cemented 10.9%, uncemented 8.9%, and hybrid 6.5%. Cemented fixation had a statistically significant higher risk of all-cause revision than hybrid in the adjusted model for all ages to 65 years (subhazard ratios [SHRs], 2.28-4.67) and a higher risk of revision for loosening, wear, or osteolysis at all ages (SHRs, 3.25-6.07). Uncemented fixation showed no advantage over hybrid fixation at any age, but did show advantages over cemented at younger ages (≤60 years) for all-cause revision (SHRs, 2.3-4.3)., Conclusion: Hybrid fixation with conventional polyethylene shows an advantage over cemented hips at all ages. Uncemented THA showed improved survival over cemented only at younger ages and no advantage over hybrid THA., (Copyright © 2019. Published by Elsevier Inc.)

Background: The objective of the study was to investigate the effectiveness of, and factors associated with, response to a chronic disease management program for patients with hip and knee osteoarthritis (OA)., Methods: Over a 2-year period (2012-2014), 218 patients (97 hip OA; 121 knee OA) were managed with an individualized program of interventions that could include education, physiotherapy, orthotics, occupational therapy, or dietitian referral. Changes in Oxford Hip Score or Oxford Knee Score and Short Form-12 (SF-12) Physical and Mental Component Summary Score (PCS, MCS) were analyzed by joint affected, both unadjusted, and gender and age adjusted. A further analysis also adjusted for body mass index., Results: At mean 12-month follow-up, patients with knee OA had a statistically significant improvement in Oxford Knee Score and PCS, while patients with hip OA had a statistically significant deterioration in all 3 scores. There was evidence that these changes differed between joints for Oxford and PCS scores. Older age was associated with worse outcomes for Oxford scores. Higher body mass index was associated with worse outcomes for Oxford and PCS scores. Patients with hip OA (35%) were more likely to deteriorate to a clinically significant extent (5 points) for Oxford scores than those with knee OA. Gender was not associated with outcomes. Patients with hip OA (54%) were more likely than those with knee OA (24%) to have subsequently had surgery (P < .001)., Conclusions: Patients with knee OA were more likely to improve with a chronic disease management plan than patients with hip OA and efforts should be directed to them., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: There are increasing problems with access to both outpatient assessment and joint replacement surgery for patients with hip or knee osteoarthritis., Methods: Data were collected on all patients seen at the Joint Clinic over a 2-year period with minimum 12-month follow-up. Patients were assessed by a nurse and a physiotherapist, baseline scores and demographic details collected, and an individualized personal care plan developed. Patients could be referred for a first specialist assessment (FSA) if their severity justified surgical assessment., Results: Three hundred fifty-eight patients were seen at Joint Clinic, of whom 150 (44%) had hip and 189 (56%) had knee OA. The mean age was 67.4 years and there were 152 men (45%) and 187 women (55%). The mean baseline Oxford score was 19.8 (standard deviation 8.2). Fifty-four patients were referred directly to FSA (mean Oxford score 13.0, standard deviation 6.7) and 89 after a subsequent review. The scores of patients referred for FSA were significantly worse than those managed in the Joint Clinic (P < .001). Of the 143 referred for FSA, 115 underwent or were awaiting surgery, 18 were recommended surgery but scored below prioritization threshold, and 10 were not recommended surgery. The Oxford scores of the 194 patients managed non-operatively improved from 22.0 to 25.0 (P = .0013)., Conclusion: This study shows that the Joint Clinic was effective as a triage tool with 93% of those referred for FSA being recommended surgery. This has freed up surgeon time to see only those patients most in need of surgical assessment., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to compare the functional results of operative and nonoperative treatment of acute Achilles tendon rupture using an identical rehabilitation program of functional bracing., Methods: Over a 10-year period, 200 patients (99 operative, 101 nonoperative) aged between 18 and 65 years were treated at our institution's physiotherapy department after acute Achilles tendon rupture. There were 132 patients (62 operative, 70 nonoperative) available for a minimum 2-year follow-up (average 6.5 years; range, 2-13 years). Functional outcome was assessed using the Achilles tendon total rupture score (ATRS)., Results: With the numbers available, no significant difference could be detected in ATRS between operative (mean 84.8, median 90) and nonoperative groups (mean 85.3, median 91; P = 0.55). No significant difference could be detected in ATRS between male and female patients however treated ( P = 0.30) or between patients younger and older than 40 years at time of injury ( P = 0.68). There was no correlation between ATRS score and age at injury in all patients (ρ = -0.0168, P = 0.85). In male patients, there was a weak trend with older patients at follow-up having better scores (ρ = 0.21, P = 0.069). However, among female patients, there was a significant negative correlation between ATRS scores and increasing age (ρ = -0.29, P = 0.03). Logistic regression analysis failed to show any significant effect of age at rupture, gender, or mode of treatment on ATRS., Conclusions: This study showed no significant difference detectable in ATRS between operative and nonoperative patients in the treatment of acute Achilles tendon ruptures using an identical rehabilitation program with functional bracing., Level of Evidence: Level II, prospective comparative study.

Background: There are relatively few 20-year results of uncemented acetabular components, and most of these are modular designs. This study reports the 20-year results of a monoblock press-fit acetabular component., Methods: A total of 122 total hip arthroplasties (111 patients) using the Morscher cup were reviewed at a mean of 19.7 years. The average age at implantation was 57.3 years (range, 36-74 years), and 81 (66%) were men., Results: Twenty-two patients (25 hips) had died. Seven hips were revised, including 5 acetabular revisions. Six patients (6 hips) declined to participate but were known not to have been revised. The mean Oxford hip score was 41.1 (range, 22-48), and the mean reduced Western Ontario and McMaster Universities Osteoarthritis Index score was 5.7/48 (range, 0-24). Eccentric wear was seen in 13 (15.7%) and major osteolysis in 14 (17%) of 82 surviving hips with radiographs. The all-cause revision rate was 0.32 per 100 observed component years (95% confidence interval [CI], 0.13-0.66). The 20-year Kaplan-Meier survival was 93.4% (CI, 86.6-96.8) for all-cause revisions, 95.5% (CI, 89.4-98.1) for any acetabular revision, and 97.1% (CI, 91.2-99.1) for acetabular aseptic loosening, wear, or osteolysis., Conclusion: The Morscher acetabular component has continued to perform well at 20 years despite using conventional polyethylene with results that match or surpass other cementless acetabulae., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Enhanced recovery after surgery (ERAS) programs or hip and knee replacements have had a significant effect on streamlining patient care with shorter stays, no increase in complications, and improved outcomes including reduced mortality., Purpose: To compare outcomes following the introduction of an ERAS program for hip and knee replacements developed at our institution with a historical cohort of patients., Methods: ERAS protocols were developed at our institution for patients undergoing hip and knee joint replacements. Key aspects were changes in preadmission, a new education session, improved management of perioperative anemia, standardized anesthetic guidelines, day of surgery mobilization, and improved discharge planning. The results of the first 18 months (528 consecutive patients) were compared with those of a historical cohort of 507 patients from the 18 months prior to their introduction., Results: In the ERAS group, the mean age was 68.3 years for patients who underwent hip replacement and 70.4 years for patients who underwent knee replacement. Thirty-two percent of patients were ASA (American Society of Anesthesiologists) Grades III and IV. The average preoperative Oxford score was 11. The average length of stay (ALOS) fell from 5.6 to 4.3 days for patients who underwent hip replacement and from 5.7 to 4.8 days for patients who underwent knee replacement (p < .001). Ninety-six percent of patients were discharged home. The 30-day readmission rate increased from 3.2% to 5.5% (p = .065). Six-month Oxford knee scores were higher in the ERAS group (39.8 vs. 36.3, p = .03). There was no increase in mortality or early revision rate., Conclusions: Substantial reductions in ALOS can be gained with the introduction of ERAS protocols, with high patient satisfaction and no increase in complications in a consecutive unselected group of public hospital patients. This requires a multidisciplinary approach and a strong clinical input.

Background: There is increasing interest in scoring systems to prioritize patients for hip and knee arthroplasty. The purpose of this study was to determine the effectiveness of the New Zealand Orthopaedic Association (NZOA) score and compare it with patient-reported scores of patients listed for hip and knee arthroplasty., Methods: Over a 1-year period, all patients listed for primary hip and knee arthroplasty were scored by a prioritization nurse. The NZOA score, outcome, preoperative Oxford hip or knee score (OHKS) and reduced Western Ontario McMaster osteoarthritis index (WOMAC) score (RWS) were collected., Results: Overall, 608 patients were listed for hip (319) or knee (289) arthroplasty. The mean scores for knees were all better than hips (P < .001). On initial scoring, 324 patients (53%) were given certainty (mean NZOA, 80.5; OHKS, 10.0; RWS, 35.1), 90 (15%) given clinical over-ride (NZOA, 69.6; OHKS, 12.0; RWS, 33.2), and 194 (32%) returned to general practitioner (NZOA, 64; OHKS, 14.2; RWS, 30.8). Knees (38%) were more likely to be returned than hips (26%; P = .002). Fifty (26%) were re-referred during the study period (mean, 5 months) and given certainty or over-ride. The difference at final outcome between patients with certainty and clinical over-ride was NZOA, 10.3 points; Oxford, 1.6 points; and RWS, 1.4 points. The difference between clinical over-ride and returned to general practitioner was NZOA, 7.2; Oxford, 4.4; RWS, 5.3., Conclusion: The NZOA score is an effective tool for rationing for joint arthroplasty. Patients around the threshold score of 70 may not have a clinically important difference compared with those above threshold., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: To describe the demographics, neurophysiological grading, and incidence of patients undergoing carpal tunnel decompression (CTD) for carpal tunnel syndrome (CTS) in a single region., Methods: A retrospective review of 2,313 patients aged greater than 16 years who underwent 3,073 CTDs between January 2000 and August 2010. Crude annual and age- and sex-specific incidences were calculated for the study period. Nerve conduction study grades were recorded and compared with age and sex., Results: Of the 2,313 patients 1,419 (61%) were female and 890 (39%) were male. Mean age at surgery was 56 years (range, 16-93 years). Females had a significantly higher CTD incidence compared with males (161 vs 108/100,000 person-years, respectively). The highest rates of CTD were seen in the 70- to 79-year age group for both men and women (307/100,000 person-years). Neurophysiological grade increased in severity with increasing age despite using an age-adjusted grading system, with higher grades in patients aged greater than 65 years., Conclusions: This study suggests that carpal tunnel syndrome has the highest incidence in older people who tend to have more severe neurophysiological changes., Type of Study/level of Evidence: Prognostic II., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Whether an occupation can cause carpal tunnel syndrome requiring carpal tunnel decompression (CTD) is contentious. We compared the demographics and incidence rates in lamb-freezing workers with the general population who had CTD. In the general population there were 1002 (63%) females and 583 (37%) males, mean age 48 years, and the rate of CTD was 1.36/1000 per annum. In lamb-freezing workers there were 225 males (mean age 38.4 years) and 60 females (mean age 44.6 years); most workers required CTD in their first three seasons. Compared with the general population, the incidence rate ratios in all freezing workers was 16.8; boners, 51.6; meat packers, 22.8; and slaughtermen, 5.4. All groups had a greater rate of CTD than the general population. This study suggests that carpal tunnel syndrome can be directly caused by an occupation.

Background: This study reports on the demographics of acute Achilles tendon rupture in our region and compares the results of a selective approach to operative and nonoperative treatment using an identical rehabilitation program with functional bracing., Materials and Methods: A consecutive series of 363 patients, aged 15 to 60 years, treated over 8.5 years by either open operative repair (143) or nonoperatively (220) were compared with respect to demographics, re-rupture rate, and major wound complication., Results: There was an almost equal number of males (159) and females (152) up to age 50 years but males comprised 73% of patients aged 51 to 60 years. Netball was the most common cause of injury and explains the relatively high incidence in females. In the 143 patients treated surgically there were two re-ruptures (1.4%) and two reoperations for wound complications (1.4%). In the 220 patients treated nonoperatively there were 19 re-ruptures (8.6%), 13 of 113 males (11.5%) and six of 107 females (5.6%). There was a significantly lower re-rupture rate, and reoperation rate in the surgical group (p < 0.05). In the nonoperative group there was a significantly lower rate of re-rupture in patients over 40 (six of 119) (4.1%) compared with those 40 years and under (13 of 99, 13.1%) and between females over 40 when compared with males 40 years and under., Conclusion: In our region there is a high incidence of Achilles tendon rupture among women due to netball and results in a younger age of injury than previously reported. Our results support surgery in patients less than 40 years, particularly males, if there are no contraindications. Functional bracing as part of nonoperative treatment can result in low re-rupture rates in patients over 40, especially in females.

We present a case in which the radial artery was found running within the carpal tunnel at the time of routine carpal tunnel decompression. It appears to be an anomalous superficial palmar branch of the radial artery that is substituting for the normal radial artery.

The purposes of this study were to determine the interobserver and intraobserver reliability of ultrasound measurements in unstable neonatal hips treated with the Pavlik harness and to determine whether ultrasound measurements correlate with radiological outcome at 6 months. Sixty-four babies treated from birth with the Pavlik harness for neonatal hip instability were scanned at 2 and 6 weeks. The alpha and beta angles of Graf, the combined (H) angle of Hosny, and the femoral head coverage (FHC) were measured by 3 observers and remeasured by each observer on a minimum of 50 scans. From 248 scans, 792 sets of measurements were made. Hips were categorized as normal, abnormal, or borderline for each parameter; and interobserver and intraobserver repeatability coefficients and Kappa values were calculated. The alpha angle had the smallest interobserver range (17 degrees), the H angle range was 21 degrees, and the beta angle 28 degrees. Kappa values were best for the FHC and beta angle (0.66-0.8). The mean acetabular index (AI) of all hips at 6 months was 26 degrees (SD, 4.9). The AI was 30 degrees or greater in 24 hips (18 babies) despite prolonged splintage in 9 hips (6 babies). A stepwise linear regression analysis showed that the FHC at 6 weeks was predictive of AI at 6 months (regression coefficient -0.27; 95% confidence interval -0.42 to -0.12; P<0.001). We recommend the FHC as being reproducible, useful, and predictive of outcome in neonatal hips treated for instability.

We report on seven developmental hip dislocations in five babies (age 6-22 months) in whom ultrasound had demonstrated reduced and stable hips. Four hips in three babies had been diagnosed as having clinical instability (Barlow positive) at birth, which had stabilized by the time of the scan (16-45 days). Femoral head coverage ranged from 36 to 56%. One hip had minimal sonographic laxity on stress examination. Hips that are reduced and stable sonographically at 2-6 weeks of age can subsequently dislocate. Any child with instability at birth should be reviewed with a pelvic radiograph at 4-6 months, even if an ultrasound scan appears to be normal.

Purpose: To review the subjective and functional results of basal thumb metacarpal osteotomy for the treatment of trapeziometacarpal osteoarthritis., Methods: Between July 1993 and November 1998, 35 thumb osteotomies without internal fixation were performed on 33 patients in the Christchurch Hospital, New Zealand. Records of 28 thumbs (13 right and 15 left) of 26 patients (17 women and 9 men) were available for review. Patients were reviewed using strength testing and the Michigan Hand Outcomes Questionnaire., Results: The mean age of the 26 patients was 54 years (range, 30-69 years). Of the 28 thumbs, 22 (21 patients) had good or excellent results, 2 fair, one poor. The remaining 3 thumbs (3 patients) required further revision and were classified as failures. The mean follow-up period of the 25 thumbs (24 patients) not requiring revision was 34 months (range, 12-73 months). Good thumb motion was present in all hands with no trapeziometacarpal instability seen. Compared with the normative data, the strengths of key pinch, pulp pinch, and tripod pinch of our patients were significantly lower (22-32% lower), but not the grip strength. Michigan Hand Outcomes Questionnaire scores increased 28 (range, 1-56) points after surgery, with significant improvement especially in pain (+44 points), activities of daily living (one-handed tasks, +41 points), and satisfaction (+35 points)., Conclusion: Basal thumb metacarpal osteotomy is a straightforward, conservative procedure that should be considered for grades II and III trapeziometacarpal osteoarthritis.

We report a long-term follow-up of a female patient with a multifocal extremity desmoid tumour. She had 3 local recurrences after excision and developed a second unresectable pelvic tumour that has remained unchanged in size for 14 years since starting tamoxifen treatment.

This article reports the results of a neonatal hip screening program comprising clinical screening and targeted ultrasound performed by orthopaedic surgeons. Over 7 years, from 1995 to 2001, there were 15,397 live births in the authors' region. Seven hundred thirty-three babies (4.8% of births) were referred for hip ultrasound: 80% for risk factors and 20% for instability. Eighty-three babies (5.4/1,000) were splinted in a Pavlik harness. Three of these subsequently required surgery (1.9/1,000). Ten patients (0.65/1000) presented with hip dislocation after 12 weeks of age, nine of whom required open or closed reduction (0.56/1,000). From 1978 to 1985, when neonatal pediatricians clinically screened all babies, 18 babies presented late from 13,707 births (1.3/1000). Since the introduction of orthopaedic screening and targeted ultrasound, there has been a significant reduction in late diagnosis in the authors' institution.

Purpose: To determine the outcomes of carpal tunnel decompression in elderly patients and whether outcomes can be predicted by the severity of presurgical nerve conduction study results., Methods: We performed a retrospective study of all patients over 70 years of age who had elective carpal tunnel release at Dunedin Hospital between April 1999 and April 2002 with a minimum of 1-year follow-up evaluation. A grading system for presurgical nerve conduction studies was formulated that scored patients from 1 to 6 according to severity. Patients were evaluated by a mailed questionnaire (Symptom Severity Score) with follow-up telephone calls to nonresponders., Results: Eighty-three carpal tunnel release procedures performed in 70 patients were included in the study. Eighty percent had marked to severe neurophysiologic changes (grades 4-6). The median postsurgical Symptom Severity Score was 1.3 (inter-quartile range, 1.1-1.7). Patients expressed satisfaction with the outcome of the surgery in 78 of 83 cases (94%). There was a significant relationship between presurgical nerve conduction grade and postsurgical Symptom Severity Score., Conclusions: This study shows that elderly patients have low postsurgical symptom scores and express high levels of satisfaction after surgery for carpal tunnel syndrome. There was a significant relationship between severity of neurophysiologic abnormalities and a higher Symptom Severity Score after surgery. Severe abnormality, however, should not exclude elderly patients from surgery.

Three boys with mild osteogenesis imperfecta (OI) who sustained eight apophyseal avulsion fractures of the olecranon were compared with four normal boys with a unilateral apophyseal fracture. The children with OI were younger (11 years 7 months) than the normal children (14 years 3 months). All fractures were treated with tension band wiring (TBW). The contralateral elbow fractured 1 to 12 months later in the children with OI. Refractures occurred in two elbows, 6 to 16 months after the initial fracture and after TBW removal. One refracture presented late as a nonunion and was treated with bone grafting and plate fixation. None of the normal children experienced refracture after TBW removal. Good functional results and range of movement were achieved. Surgical treatment is recommended for all displaced fractures of the olecranon apophysis. There is a high risk of bilateral injury and a risk of refracture following removal of TBW in children with OI.

Bilateral, uncemented hip replacements were performed on a 45-year-old woman with autosomal dominant osteopetrosis. The hips showed degenerative changes and protrusio acetabuli. Difficulties were encountered especially during preparation of the femoral canal. At ten-year follow-up she has an excellent clinical and radiological result with no sign of osteolysis. Uncemented hip replacement, while technically demanding, can be successful in the intermediate term for patients with this condition.

Between August 1996 and August 1997, 130 children were admitted to our pediatric orthopaedic unit with Staphylococcus aureus musculoskeletal infection. Twenty-six of the 130 staphylococcal isolates were resistant to methicillin, an incidence of 20%. All but one of the infections, a femoral fixator-pin infection, were community-acquired. Twenty-two of the infections were superficial; however, there were four cases of deep musculoskeletal sepsis due to methicillin-resistant S. aureus. In areas where methicillin-resistant S. aureus is prevalent in the community, methicillin resistance should be considered in any overwhelming staphylococcal infection not responding to conventional antibiotics despite adequate surgical debridement.

Acute compartment syndrome has multiple causes: fractures, crush injury, vascular trauma and burns. Exertional compartment syndrome may be acute (progressive) or chronic (usually reversible). The acute form usually occurs after intensive exercise. Closed muscle rupture is an uncommon cause with few reports. We report two cases, in the peroneal compartment of the leg and the flexor compartment of the forearm, to show that a high index of suspicion, allowing prompt diagnosis and fasciotomy, will enable a full recovery without complications.