Purpose of study

The aim of this study is to evaluate the role of low intensity pulsed ultrasound, Exogen in the treatment of delayed and non unions. Methodology: We conducted a retrospective study of 292 patients who has had Exogen treatment for delayed and non union from 2005 to 2009. Patient's age, sex, associated co morbidities, smoking history, medications, type of fractures (open/closed), infection and site of fractures were sought for. 271 patients' data (228 delayed and 43 non unions) were available during the study with mean age of 53.5 yrs.

Exogen therapy was initiated at 3–4 months for delayed unions and 6–12 months for non unions in 61 tibia (15 open); 31 femur (2 open); 20 scaphoid; 38 5th metatarsal; 31 ankle (2 open); 17 ulna (1 open); 15 radius (3 open); 29 humerus (2 open); 16 clavicles; 6 olecranon; 4 pilon (2 open) and 2 metacarpal fractures.

We report our retrospective multicentre experience of managing periprosthetic knee fractures using locking plates, cemented nails and distal femoral prosthesis. The Aim of this study is to analyze the practicality of management of these injuries using modern methods of fixation or salvation. 62 patients presented to 3 centres between 2003 and 2010. After implementation of inclusion criteria, clinical, radiological and functional outcomes were evaluated in 54 patients, with a minimum follow-up of 6 months. 34 patients were treated with locking plates (10 males, 24 female; mean age 76), 16 with cemented/locking nails (4 males, 12 females; mean age 84.5), and 4 with distal femoral replacement prosthesis (2 males, 2 females; mean age 79).

Locking plates which were used with a minimally invasive pattern produced the best outcomes in our study. A statistical significance of p value of less than 0.01 was found in union time between patients operated on with an open technique (6.69±2.69 months) and those operated on with a minimally invasive technique (3.6±0.91 months). Nailing with augmented cement is a useful technique in patients who are not suitable for challenging surgery & rehabilitation programmes. There was a significant difference in mean time to functional weight bearing (p< 0.01) between the plate group (4.79±2.6 months) and the nail group (2.63±0.5 months). Post-operative range of motion was also better for nails (106.36±14.33^O flexion) compared to plates (93.24±26.8^O), a result that approached significance (p=0.065). We recommend minimal invasive plating in uncompromised physiological conditions, as an ideal method of fracture fixation in view of statistically significant union rates. Cemented nailing is recommended in patients where early rehabilitation is essential. Distal Femoral prosthesis replacement is a useful salvage method.

Aim: To discuss the rationale, selection criteria, indications, and results of using large diameter ceramic heads in primary and revision hip arthroplasty.

Patients and Methods: We routinely use Biolox family of ceramic heads and acetabular liners in patients undergoing total hip replacements. We present our experience in using ceramic articular bearings over the last 20 years and the switch to larger diameter ceramic heads. We also present our rationale for using a large diameter ceramic head instead of a large metal head.

Results: We reviewed a total of 1189 arthroplasties over this time period and we report the outcome of large bearing couples with case examples in primary and revision scenarios. Furthermore we compared a subset of patients (110) with large diameter ceramic heads – Biolox Delta 36mm to patients who had metal on metal (large head 42 mm and above) bearing couples. The performance of the ceramic bearing couples will be discussed along with the functional outcome of these patients. We found no difference in the functional, clinical sports activities (UCLA and Tegner scores) between patients who had large metal bearing couples and large ceramic couples. Complication rate was less with the ceramic bearing arthroplasties, as was patient satisfaction

Conclusion: Ceramic bearing couples have stood the test of time and have demonstrated an excellent long term wear properties. The recent introduction of the large diameter couples proves to be an excellent alternative if not the first choice in young, complex primary and revision case scenarios

Aim: To report the clinical, functional and radiological outcome of consecutive primary hip arthroplasties using large diameter (36mm and above) ceramic bearing couples. We believe this to be one of the first reported series in the UK.

Methods: We prospectively reviewed 319 consecutive primary THA using fully HAC coated acetabular shell and fully HAC coated stem (JRI Ltd) in 302 patients, with minimum follow-up of 12 months. A Biolox-Delta ceramic liner with an 18 deg taper and Biolox-Delta ceramic head (36mm and 40mm) were used in all cases, which were performed in one institution by 3 surgeons. None were lost to follow-up. Clinical outcome was measured using Harris, Charnley Oxford, EuroQol EQ-5D scores. Radiographs were systematically analysed for implant position, loosening, migration, osteolysis. Return to sports and hobbies were recorded.

Results: Mean age was 64.9 yrs (11–82yrs). There were no dislocations. 50–62mm acetabular shells were used. 36 mm head was used in 96% of cases. No acetabular revisions were performed for aseptic loosening. Other re-operations were for infection (1), peri-prosthetic fractures (1). The mean Harris and Oxford scores were 95 (88–97) and 14.1 (12–33) respectively. The Charnley score was 5.7 (5–6) for pain, 5.8 (4–6) for movement and 5.9 (4–6) for mobility. There was a significant improvement in the range of movement of the hip. There was no migration of acetabular component. Acetabular radiolucencies were present around one shell. No acetabular liner wear was demonstrated in CT Scans. Mean inclination was 47.4deg(37–65). Mean EQ- 5D description scores and health thermometer scores were 0.84 (0.71–0.92) and 88 (66–96). With an end point of definite or probable loosening, the probability of survival was 100%. Overall survival with removal or repeat revision of either component for any reason as the end point was 99.1%.

Conclusion: The results of this study show an excellent clinical and functional outcome and support the use of a fully coated prosthesis with ceramic bearing couples. We envisage to monitor and prospectively report the long-term outcome of this series of patients.

Currently, the optimal treatment of pipkin fractures remains controversial. To rovide guidance on the management of these challenging injuries, we systematically viewed the available literature on outcomes following presentation with pipkin fracture dislocations and meta analysis was applied where applicable.

Material and Methods: Electronic databases were searched for studies on “Pipkin fractures”. Thompson & Epstein scale used as primary outcome measure and Merle’d Aubgine score, AVN, Nerve injuries, Heterotrophic ossification used as secondary outcome measures.

Results: This metaanalysis included 242 cases from 13 studies. Mean age of patients is 41.2 (sex ratio 7:3 male to female). Motor vehicle accidents contributes to 93% of cases, followed by fall from height in 6% cases. Patients were divided in to two groups, one with hip reduction with in 6 hours and second group more than 6 hours. ‘P’ value calculated using CMA software has shown no statistical advantage of reducing hip in less than six hours (p – 0.87). Majority of Type I cases treated by excision, type II cases were treated by ORIF. Type III cases predominantly treated by arthroplasty, where as type IV cases mainly treated by open reduction and internal fixation. Thompson & Epstein results were excellent in 13% of cases, 47% good, 16% fair to satisfactory and 24 % cases reported poor results. Incidence of good results descended from Type I to Type IV, where as incidence of poor results increased. Meta analysis of TE results and surgical approach has not shown any advantage of anterior or posterior approach in producing better TE outcomes. Similarly early time to reduction or surgery also failed to show any statistical advantage over delayed reduction or surgery. Analysis of the outcomes treated by non operative and operative methods in type I cases has shown operative methods producing less favourable outcomes in type I fractures with a p value of poor outcomes 0.018, showing advantage of non operative methods in type I fractures.

In type II, III & IV cases, no statistically significant advantage is noticed in this respect. Overall incidence of AVN is 11%, highest incidence is reported in type III fractures.Highest incidence of Heterotopic ossification is reported in anterior or anterolateral approaches. Incidence of nerve injury in Pipkin fractures reported as 13%.

Conclusions: Pipkin fracture is a high energy complex trauma resulting in significant morbidity.

Incidence of poor results increases from type I to type IV cases. Statistically no significant difference is added on to anterior or posterior approaches or timing of reduction within or after six hours in the management of these fractures based on TE results. This meta analysis proving type of fracture is the most important prognostic factor influencing the outcome.