Purpose of study: We aimed to compare the efficacy and effect of Ender nail and unreamed interlock nail in the management of Type I, II and IIIA fractures.

Methods: 33 cases of open tibial shaft fractures in 32 patients were included in this prospective study. 17 tibial fractures were fixed with Ender nails introduced by antegrade approach and 16 tibial fractures were fixed with statically locked Interlocking nails. The mean follow-up period was 17.8 (6 to 32) months. The mean injury-surgery interval was 5.6 (1 to 16) days.

Results: In the Ender nail group, the average union time for open fracture was 19.5 weeks and 18.3 weeks for Type-I fracture. In the Interlock nail group, the average union time for open fracture was 24.8 weeks and 23.8 weeks for Type-I fracture. Mann-Whitney test revealed significant difference between the two groups for the data described above. Treatment with either nails showed no significant difference in union time for Type-II and type-IIIA fractures. Ankle movement restriction was noted more in interlock nail group (p = 0.04). Anterior knee pain, chronic osteomyelitis and breakage of distal screw were observed in interlock nail group. No complication was seen in Ender nail group.

Conclusion: Ender nailing is a safe and effective choice for treatment of open tibial shaft fractures due to faster fracture union rate and fewer complications. Ender nail is a good implant in treatment of open tibial shaft fractures especially in regions with limited access to specialized, sophisticated and expensive facilities.

Purpose: The objectives of this study were to determine the effect of posterior instrumentation extension and/or cement augmentation on immediate stabilization of the instrumented level and biomechanical changes adjacent to the spinal instrumentation.

Methods: This study was designed for repeated measures comparison, using 12 T9-L3 human cadaveric segments, to test the effects of posterior rod extension and cement augmentation following T11 corpectomy. The spine was stabilized with a vertebral body replacement device and with posterior instrumentation from T10 to T12. The T12 pedicle tracts were over-drilled to simulate loosened screws in an osteoporotic spine. The T10 screws were not over-drilled but cemented so as to keep the superior segments constant. Flexibility tests were first carried out on the intact specimen, followed by 3 randomized surgical conditions without cement and lastly the 3 conditions after cement augmentation. The 3 conditions were: 1) no posterior extension rods to L1, 2) flexible extension rods, and 3) rigid extension rods. A combined testing/analysis protocol that used both the traditional flexibility method and a hybrid technique [Panjabi 2005] was adopted. Flexibility tests with +/−5 Nm pure moments in flexion-extension, axial rotation and lateral bending were carried out and vertebral bodies’ motion in 3-D were collected. Two-way repeated measures ANOVA analyses were carried out on ROM between cement augmentation (factor 1) and the posterior rod extension (factor 2) on each flexibility test direction. An alpha of 0.05 was chosen. Newman-Keuls post-hoc analyses were carried out to compare between surgical techniques.

Results: Using the flexibility protocol, a reduction in ROMs at the destabilized level was observed with cement augmentation of screws or extension with rigid or flexible posterior rods to adjacent distal level. With the hybrid protocol, ROMs at adjacent level (T12-L1) were reduced with rod extension, but not with cement.

Conclusions: The results of this study suggest that cement augmentation would enhance stabilization, but create possible adjacent level effects due to increased motion and strain, while additional flexible extension rods would reduce biomechanical changes at the level of extension. Funding: 2 Funding Parties: CIHR

We describe the clinical and radiological results of thirty eight consecutive total hip replacements, using the JRI Furlong Hydroxyapatite ceramic coated femoral component (JRI Instrumentation Ltd, London, UK) in patients under the age of 50 at the time of surgery. The mean age at the time of operation was 42 years (range 22 to 49 years). The average length of follow up was 10 years (range 63 to 170 months). All patients receiving a Furlong HAC THR were included regardless of their primary aetiology. These included patients on whom previous hip joint surgery had taken place.

The mean Harris hip score improved from 44 pre-operatively to 92 at the latest post-operative review. The mean WOMAC and Oxford scores at the latest review for this study were 29 and 16 respectively. Using the Charnley modification of the Merle d’Aubign_ and Postel hip score, at the latest follow up the mean scores were as follows: Pain 5.37, Function 5.47, and Range of Motion 5.71.

The mean pain visual analogue score was 1.1 and 94% of patients returned to outdoor activities or sports. There were no reports of thigh pain at any review. There was no loss to follow-up. There were no revisions of any femoral component. Radiological review of the femoral components revealed no continuous or progressive radiolucent lines around the stem. No osteolysis was noted. Using revision or impending revision as the end point at 12 years the cumulative survival for the stem was 100% (95% CI 89 to 100).

We present excellent clinical, radiological and survivrship results with the use of HAC components in young, active patients with varying primary pathology, after ten years use.

Background: Resurfacing hip replacement is becoming increasingly used surgical option for young active patients with disabling hip arthritis.However there is a paucity of published literature describing complications and their avoidance.

Objective The objective of this study was to analyse 6 cases of postoperative subcapital fracture following hip resurfacing with a cohort of 54 cases that did not have a fracture and to identify factors associated with fractures risk.

Materials and Methods Between January 1999 and October 2003, 60 hips in 54 patients were treated with metal on metal resurfacing hip replacement (MMT Birmingham, UK).6 of these sustained a fracture just below the femoral component.The notes and radiographs were reviewed.Demographics data was recorded along with height, weight,smoking habits and medication usage including NSAIDS and antiepileptic use.The radiographs were studied for notching of the neck,offset difference as compared to normal and the stem shaft angle. The results were statistically analysed to determine any significant associations.

Results 57 hips in 51 patients were analysed for comparison. The mean age of the patients was 50 yrs (Range 34–67).In the fracture cases there were three men and three women with a mean age of 48 yrs.Five of six ( 83%) in the fracture cases had notching of the femoral necks compared to 9 (17%) out of 51 of the non fractured patients. The offset was significantly greater in the fractured group(52 ± 7mm) compared to the non fractured group (49 ± 7 mm).The increase in offset appeared to occur as a result of incomplete seating of tight fitting cemented femoral component. The head size appeared smaller in the fractured group but the difference was insignificant. There was no significant trauma in any of the cases. None of the patients who underwent resurfacing for AVN and cyst had a fracture. There were no other significant correlations

Conclusions Increased offset and notching are factors which predispose to fractures following resurfacing hip replacements. AVN and cysts were not associated with fractures in our series. We have changed the cementing technique using smaller volumes of freshly mixed simplex cement and now encourage protected weight bearing if intraoperative notching is noted or if osteoporosis is identified pre or peri operatively. We have had no fractures in the last 18 months.

We describe the clinical and radiological results of 120 consecutive revision hip replacements in 107 patients, using a titanium alloy femoral component fully coated with Hydroxyapatite ceramic (HAC). The mean age at operation was 71 years (range 36 to 92). The average length of follow up was 8.0 years (range 5.0 to 12.4). All patients receiving a JRI Furlong HAC coated femoral component (JRI Instrumentation Ltd, London, UK) with a minimum follow up of 5 years were included. These included patients on whom previous revision hip joint surgery had taken place.

Patients were independently reviewed and scored using the Harris Hip Score (HHS), the Charnley modification of the Merle d’Aubigne and Postel Score (MDP), and The Western Ontario and McMaster Universities Osteoarthritis index (WOMAC). Radiographs were assessed by three reviewers (blinded to clinical details) for new bone formation, osteolysis, osteointegration and radiolucent lines in each Gruen Zone.

The mean Harris hip score was 85.8 (range 42 to 100) at the latest post-operative review. The mean WOMAC and MDP scores were 34.5 and 14.8 respectively. The mean pain visual analogue score (range 0 to 10) was 1.2 overall and 0.5 specifically for mid-thigh pain. There were no revisions of any femoral component for aseptic loosening. There were four stem re-revisions (3 cases of infection, 1 recurrent dislocation). Radiological review of all femoral components, including the four mentioned, revealed stable bone ingrowth with no new radiolucent lines in any zone. Using revision or impending revision for aseptic loosening as the end point, at 10 years the cumulative survival for the stem was 100% (95% CI 94 to 100). We present excellent medium to long term clinical, radiological and survivorship results with the use of a fully HAC coated titanium stem in revision hip surgery.

Aim: To assess long-term outcome of Silastic Joint Replacement of the þrst metatarsophalangeal joint. Methods: 32 patients (42 feet) with double stem silicone implant arthroplasty of the 1st MTPJ were reviewed at average 8 years (range 4 Ð 19 years). Surgery was for Hallux rigidus in 25 cases and for Hallux valgus with degenerative osteoarthritis in 17 cases. Patients with Rheumatoid arthritis were excluded. Mean patient age was 64 years. Results: 28 of the 32 patients were very satisþed with the procedure. No patients were dissatisþed. Pain relief was subjectively excellent or good in 28 patients. Three of the four patients with fair or poor relief of pain had surgery for Hallux Valgus with degenerative osteoarthritis. Radiographs showed sclerosis around all prostheses with cysts with bony erosions in 17 cases. 12 had clinical features of silicone synovitis in the early postoperative period but this was not present at þnal review despite radiological þndings of new bone formation (57%) and localised osteolysis (40%). Two patients had transfer metatarsalgia with a stress fracture. No patients required revision surgery. Conclusion: Our long-term study shows patients to have very good subjective and objective results despite poor radiological results. There is a role for double stemmed silicone implant arthroplasty in low demand patients.

Tibialis posterior tendon (TPT) dysfunction is a disorder of unknown aetiology. Trauma, inflammatory processes, anatomical abnormalities and iatrogenic factors have all been implicated as causative mechanisms. The condition presents with pain and swelling around the medial malleolus. The pain is characteristically worse on exercise and relieved by elevation. The disorder has been classified by Johnson and Strom (1989); stage I is characterized by pain around the medial malleolus and mild weakness of single heel raising. Without treatment the condition may progress to a fixed valgus deformity along with pes planus.

Aim

To assess the outcome of surgical decompression of stage I TPT dysfunction.

Method

Ten cases were identified, operated on by a single surgeon over a three-year period. The patients were assessed in a dedicated clinic by administration of a questionnaire and by clinical examination.

Results

Nine patients with an average age of 30 years (13–51) agreed to participate in the study. Six of the nine patients recalled a sporting injury to the ankle prior to onset of symptoms. Eight of these of patients underwent a course of physiotherapy prior to surgery. After decompression all patients reported reduction of pain as measured using a visual analogue scale, with five patients reporting complete resolution of pain. Patients experienced relief of pain on average four weeks (1.5–6) after surgery. All patients were able to return to work and normal leisure activities after appropriate rehabilitation.

Conclusions

Decompression of the tibialis posterior tendon in stage I dysfunction leads to pain relief and enables an early return to normal activities. Therefore surgical decompression of the tibialis posterior tendon may be considered in cases of stage I dysfunction which are refractory to conservative measures, particularly in young and active patients.

Introduction: Developmental dysplasia of the hip (DDH) is a common cause of secondary osteoarthritis of the hip. The severity of the hip dysplasia varies considerably leading to a broad spectrum of reconstructive challenges. The custom CAD/CAM femoral stems offer a useful solution to fit and correct the abnormalities in the anatomy of the proximal femur.

Materials and Methods: The purpose of the study was to review at the functional and radiological outcome of uncemented CAD/CAM stems where the primary diagnosis is DDH. Uncemented sockets were used in all cases. Pre-operative planning consisted of a CT scan to assess the available acetabular coverage, estimate the degree of femoral anteversion and precisely evaluate the limb-length inequality. The hips were classified according to Crowe and Hartofilakidis. Patients with less than two-year follow up were excluded. The outcome was determined radiologically and using the Harris, Oxford and WOMAC scoring systems.

Results: Ninety-nine cases were identified and included in the study. The mean age of the group was 43.8 (range 26–79) with a female to male ratio was 4 to 1. The average follow up time was 5 years (range 24–118). The majority of the patients had excellent outcomes with a significant improvement in their clinical scores. The pre-operative scores were Harris Hip score 43.8 (range 9–81), Oxford 41.6 (range 19–59) and WOMAC 77.3 (range 10–120). Post operatively the scores have improved to Harris Hip Score 84.2 (range 38–99), Oxford 20.3 (range 12–48) and WOMAC 37.1 (range 24–92).

Conclusion: Total hip replacement for the sequelae of hip dysplasia is associated with high failure and complication rates. CAD/CAM stems afford a great deal of flexibility for the management of a broad spectrum of anatomical problems in these cases and provide a very useful alternative to modular prostheses. We present excellent medium term results.

Introduction: Patients with developmental dysplasia of the hip with secondary osteoarthritis are often found to have severe anatomical deformities of the hip. Total hip replacement in such patients is a complex undertaking associated with complication and failure rates. Subtrochanteric derotational osteotomy with customized uncemented total hip arthroplasty has been described to combat the problems of severe femoral anteversion. We present the medium term follow up of 12 patients where such a procedure was undertaken.

Materials and Methods: 11 female and 3 male patients with an average age of 49 (range, 32–79 years) were reviewed by an independent observer. The mean follow up was 50 months (range, 24–93 months). Patients were classified on AP radiographs according to Crowe and Hartofilakidis. All have femoral neck anteversions of greater than 45° on CT scans. The patients were followed up radiographically and clinically using the WOMAC, Oxford and Harris hip scores.

Results: 1 patient died due to unrelated causes. The average Harris hip score improved from 44 (range, 38–57) preoperatively to 88 (range, 67–94). The average WOMAC score improved from 83 (range, 45–112) pre-operatively to 36 (range, 25–72). The average Oxford score improved from 44 (range, 38–57) preoperatively to 19 (range, 14–34). Radiologically, the prosthesis appears to have osseointegrated with union of the osteotomy site in all cases and there is no evidence of implant migration or osteolysis.

Conclusion: Custom total hip arthroplasty with subtrochanteric osteotomy provides a method whereby the hip centre can be restored to its normal level, proximal bone stock is preserved and a more normal proximal femoral morphology is created. We have undertaken this procedure routinely in patients with excessive femoral anter-version and report excellent medium term clinical and radiographic results.