Introduction

Open and arthroscopic hip debridement may be used for treatment of femoral acetabular impingement (FAI). There is a paucity of evidence regarding the efficacy of one over the other.

Introduction

Open hip debridement surgery has been used for treatment of femoral acetabular impingement pain for over ten years in our unit. While literature has reported promising short-term outcomes, longer term outcomes are more sparsely reported.

Introduction

Open hip debridement surgery has been used for treatment of femoral acetabular impingement pain for over ten years in our unit. While literature has reported promising short term outcomes, longer term outcomes are more sparsely reported. We aim to assess survivorship and functional outcome at ten years, in patients who have undergone open hip debridement.

We present 346 consecutive revision procedures for aseptic loosening with acetabular impaction bone grafting (AIBG) and a cemented polyethylene cup. Defects were contained with mesh alone. Mean follow up of 6.6 years, range 8 days-13 years. The Oxford Hip (OHS) and Harris Hip (HHS) scores were collected prospectively. Radiological definition of cup failure was either > 5mm displacement, or > 5° rotation. Cox regression analysis was performed on ten separate patient and surgical factors to determine their significance on survivorship.

Kaplan Meier survivorship at 10 years (42 cases remaining at risk) for aseptic loosening was 87% (95% confidence Interval (CI): 81.6 to 92.2) and 85.6% (95% CI: 80.3 to 90.9) for all revisions. These results are comparable to other reported series utilising AIBG. However, there were 88 cases (25%) that exceeded the radiological migration parameters, but their functional scores were not significantly different to the non-migrators: OHS p=0.273, HHS p=0.16. The latest post-operative mean OHS was 33 (SD 10.66). Female gender (p=0.039), increasing graft thickness (p=0.006) and the use of mesh (p=0.037) were significant risk factors for revision, but differing techniques in graft preparation, including artificial graft expanders (p=0.73), had no significant effect when analysed using Cox regression.

The purpose of this study was to investigate whether patients who had had excision of the Ligamentum Teres as part of a surgical hip dislocation for femoro-acetabular impingement exhibited symptoms of acute Ligamentum Teres rupture post-operatively. Recent reports in the literature suggest that injury to the Ligamentum Teres can cause instability, severe pain and inability to walk.

We present the results of a postal questionnaire to 217 patients who had undergone open surgical hip dislocation for femoro-acetabular impingement where the LT was excised. This included seven patients who had undergone bilateral surgery. The questionnaire was designed to enquire about specific symptoms attributed to LT injuries in the literature; gross instability, incomplete reduction, inability to bear weight and mechanical symptoms.

161 patients responded (75%), with a total of 168 (75%) questionnaires regarding 224 hips completed. There were 104 females and 64 males. Median age was 34 and median follow-up was 52 months. All patients were found to have cam deformities, 72% (n=121) had associated labral tears. All patients were able to fully weight bear after surgery. 77% experienced no groin pain and 61% experienced no pain on exercise. 35% of patients experienced popping and locking in their operated hip and 24% had subjective feeling of their hip giving way. Oxford Hip scores and Nonarthritic Hip scores improved by 12 and 28 points respectively (n=47).

Our results show that the symptoms of pain and instability described with LT pathology can be present but are by no means universal. This leads us to conclude that their symptoms may be attributed to labral pathology which is frequently noted to coexist.

Periprosthetic Hip Fractures (PHFs) and Complex Revision Hip Arthroplasty(CRHA) consistently present challenging management decisions. Extramedullary devices alone or in combination with strut graft or long stem prosthesis revisions (cemented and uncemented) have all been described as treatment options. A long distal locked femoral stem provides an alternative allowing immediate stability for weight bearing without impaction bone grafting or external plate fixation and strut grafting. It has a lower risk of subsidence.

24 patients underwent a Cannulok Stem procedure from 2003–2008. Each was reviewed regularly following surgery with clinical examination and Hip scores (Oxford and SF12). The indications for device use, Vancouver classification if a periprostheic fracture, radiological evidence of union and complications were all recorded from medical and radiological records. The results were then compared to similar studies.

The indications for Cannulok use were periprosthetic fracture (50%), infection with bone loss (12.5%), revision for aseptic loosening (33.3%) and subtrochanteric fracture post arthrodesis and metalwork removal (4.2%).

A 75% union rate was seen in periprosthetic fractures. There were 2 deaths, 2 deep infections and 1 superficial infection. The 40 mm offset stems resulted in 6 (25%) dislocations compared to 0% dislocations with the 45 mm offset stem. In addition there was 1 femoral stem revision for subsidence (no distal locking screws used) and 1 acetabular revision. There was an average follow up of 20 months.

This study suggests that the Cannulok Plus femoral reinforcement stem is a potential alternative treatment option in PHFs and CRHA with acceptable complication rates.

Hypothesis Stem surface finish & cement mantle conformity influences pressure at the stem/cement interface, under physiological load.

Method We developed a scaled mechanical analogue of a cemented Exeter femoral stem with a temperature and pressure controlled fluid environment. The stem was subjected to physiological torsional & axial loads using a material testing machine with two perpendicularly mounted actuators. Rough (Ra=2.2μm), matt (Ra=1.16μm) & polished (Ra=0.02μm) stems were tested in both conforming & artificially created, asymmetrically worn, cement mantles. Pressure was recorded at five sites along the interface.

Results Pressure was generated in both conforming and worn mantles. Peak pressures recorded in worn mantles were nearly four times greater than in conforming; peak stem tip pressures, worn: 12000Pa, versus conforming: 4680Pa. The axial load was the main determinant of pressure generation in the conforming mantle. Torsional loads generated a rise in interface pressure in both mantle types but the resultant stem toggle seen in the worn mantle had a significant positive effect on pressure. Pressure fluctuations generated in the conforming mantle had the greatest range at the tip. Peak pressures within the worn mantle were more uniform, but marginally greater on the posterior wall. Surface finish influenced pressure; surface roughness had a positive association with pressure within conforming mantles & the reverse effect in worn mantles.

Conclusion Asymmetrical wear leads to increased pressure generation at the stem/cement interface under physiological loads, with the torsional load playing a key part in pressure generation. Well fixed, debonded stems also generate limited pressure fluctuations at their mantle interface. This is principally due to axial load. Mantle shape dictates the influence of surface finish on pressure; surface roughness increases pressure within conforming mantles, but reduces pressure when the mantle is worn. This may be a confounding effect of worn mantle shape, restricting non-polished stem movement.

General Practitioner (GP) attendances for non-specific disease increase after life events. Whiplash injury has the effect of a life event in some people.

The aim of this study was to compare GP attendance rates in the year before and after whiplash injury to establish their rate and cause.

Ninety-eight subjects (62 women and 36 men) with whiplash injuries examined for medicolegal reports, with complete GP records for a year before and after injury.

The number of attendances and the reason for attendance. Consultations after the accident were subdivided into those for neck pain and for other reasons.

Subjects were reviewed more than one year after injury. All described neck pain 11% mild, 62% moderate and 27% severe. GP attendance rates before the accident were within the normal range but increased after (p=0.0001) because of neck pain symptoms. There was no association between attendance rates before and after injury but consultations for neck pain rose in proportion to severity of symptoms (p = 0.0015). Attendances unrelated to neck symptoms fell after injury (p = 0.002).

GP attendances for non-specific disorders increase after life events, but not after whiplash injury as patients focus on their neck symptoms.