Revision hip arthroplasty presents a challenge in the setting of femoral bone loss. Tapered stems are susceptible to subsidence which leads to leg length inequality, hip instability and may necessitate repeat femoral revision surgery.

The purpose of this study was to compare radiographic outcomes in two modular tapered revision systems with different distal stem geometries. We sought to establish the minimum postoperative stem bi-cortical contact length that predicts subsidence for tapered stems.

This study examined revision total hip arthroplasties between 2009 and 2016 in a European university affiliated major trauma center. Modular stem A has a taper of 3 degrees whereas modular stem B has a taper of 2 degrees. Radiologic assessment compared x-rays at two time points: immediately post-surgery and most recent x-ray available at a minimum follow up of two years. Leg length discrepancy, subsidence and postoperative bi cortical contact was assessed. Descriptive summary statistics calculated clinical factors (i.e. age, gender, Paprosky classification).

122 arthroplasties were completed. Complete data was available for 112. Revisions were carried out for Paprovski grade 3a/ 3b femoral deficits. Post-operative bi-cortical contact of the proximal stem < 20mm was associated with higher subsidence rates (P = 0.047). Subsidence rates for implant A and B system were 4.27mm (0.12–25.62mm) and 3.43 mm (0.3–11.1 mm) respectively. Significant subsidence was noted in 9.8% (n=8) in implant A and 5.2%(n=2) in implant B.

We conclude that immediate postoperative bi-cortical stem contact of <20mm was associated with significantly higher subsidence rates in this study.

Revision total hip arthroplasty (THA) presents with increasing challenges, potentially compromising the integrity of a revision. The objective of this study was to assess radiologic outcomes of patients who underwent revision THA with a modular tapered stem (Reclaim, DePuy Synthes). This study retrospectively examined all revision Reclaim THAs between 2012 and 2016. Radiologic assessment compared x-rays at two time points: immediately after surgery and the most recent x-ray available. Leg length discrepancy, subsidence and line-to-line fit was assessed. Significant subsidence was considered ≥10mm. Adequate line-to-line fit was considered ≥30mm of bicortical contact. Descriptive statistics included clinical factors (i.e. age, Paprosky classification). P values <0.05 were considered significant. A total of 81 femoral revisions were completed. There were 42 females and 38 males with a mean age of 71 years (range, 46–89). Of these, 6 were revised (dislocation, fracture or infection), and 7 were lost to follow up. Average follow up time was 18 months (range, 1–46 months). Femoral revisions were classified as Paprosky 3a or 3b. Mean stem subsidence was 4.15mm (range, 0–25.6mm). Subsidence of the femoral stem was <10mm in 88% of patients. A total of 62% of patients had both subsidence <10mm and ≥30mm of bicortical contact. In patients with <10mm subsidence, 70% had ≥30mm of bicortical contact. There was a positive trend between cortical contact and stem stability (OR 2.3). The Reclaim modular femoral system has demonstrated radiographic stability. Inadequate initial fit is a potential determinant of subsidence.

Aims

Falls are a common occurrence among hospital inpatients and can lead to injury, prolonged hospitalisation and delayed rehabilitation. There is major economic burden associated with this. Post operative orthopaedic patients have certain risk factors that predispose them to falls including decreased mobility, use of opioids and, in some cases, history of previous falls.

Objective

To determine differences in fracture stability and functional outcome between synthetic bone graft and allograft/autograft with internal fixation of tibia plateau metaphyseal defects.

Background

Post operative analgesia is an important part of Total Knee Arthroplasty (TKA) to facilitate early mobilisation and patient satisfaction. We investigated the effect of periarticular infiltration of the joint with chirocaine local anaesthetic (LA) on the requirement of analgesic in the first 24 hrs period post op.

Aim: To prospectively compare the quantity of bone removed from the acetabulum in hip resurfacing arthroplasty and uncemented total hip replacements.

Methods: Sixty four patients were prospectively enrolled in the study. We compared 32 birmingham hip resurfacing acetabular components with 32 trident uncemented acetabular cups. To assess the pre-reaming size of the acetabulum, and to allow comparison between acetabular sizes, the size of the femoral head was assessed to the nearest millimetre intraoperatively with the use of a measuring calliper. The reamings from the acetabulum were collected. This bone was then dehydrated and defatted with five washes of acetone followed by five washes of diethyl ether. The bone was then placed in a furnace at 200 degrees Celsius until a consistent dry weight was achieved. The size of acetabular component used was recorded in all cases.

Results: The mean weight of bone removed from the acetubulum of the resurfacing group was 13.79 g. The corresponding mean weight of bone removed from the acetabulum of the total hip replacement group was 11.71g. Using a non-parametric analysis of covariance (ANCOVA) to account for the covariate of acetabular size, regression analysis indicated no evidence of a difference between the mean bone weight removed in the two groups (p-value of 0.57).

Conclusions: Close attention to surgical technique in preparing the femoral head during resurfacing will allow the use of an appropriately small femoral component. If performed accurately this will avoid oversizing the acetabular component and removal of excess bone stock.

Purpose of study: Study and prove the benefits and efficacy of the use of extracorporeal shockwave therapy (ESWT)for the treatment of planter fasciitis.

Introduction: Planter fasciitis is the second most common cause of heel pain. Conservative treatment modalities for the treatment of planter fasciitis includes NSAIDS, heel cushions, ultrasound, physiotherapy, injections, etc and these often do not offer satisfactory results. We present the results of the use of ESWT in the treatment of planter fasciitis with good results.

Methodology: 129 patients, 77 males and 52 females with a 152 heels were treated with ESWT from July 2002 until August 2004 and were included in the study. The average age was 53.2 years (Range 28 to 83 years). All patients had previously undergone other conservative forms of treatment with poor results. Inclusion criteria included age greater than 18 years, male or female, no previous history of surgery on the heel or foot, visual analogue score of over 5 for pain. Treatment was done on an outpatients basis. Each patient received between minimum of one and maximum of three sessions of ESWT at two weeks interval.

Results: 116 patients, 69 males and 47 females with 136 heels were reviewed with 13 patients with 16 heels lost to followup. 52 patients (44.8%) with 60 heels (44.1%) had excellent results. 45 patients (38.8%) with 53 heels (38.0%) had good results. 13 patients (11.2%) with 16 heels (11.8%) had fair results. 6 patients (5.2%) with 7 heels (5.1%) had poor results. Overall 104 patients (89.7%) with a 121 heels (89.0%) considered the outcome to be successful.

Conclusion: Based on our results, we recommend ESWT fot the treatment of planter fasciitis especially in patients with failed other forms of conservative treatment and as an alternative to surgery with good results.

To date the principal focus of the mechanism of cervical spine fracture has been directed towards head/neck circumference and vertebral geometric dimensions. However the role of other measurements, including chest circumference and neck length, in a standard cervical fracture population has not yet been studied in detail. Cervical fractures often involve flexion/extension type mechanisms of injury, with the head and cervical spine flexing/extending, using the thorax as an end point of contact. Thus, the thorax may play an important role in neck injuries.

Study design: We prospectively studied all patients with cervical spine fractures who were admitted to the National Spinal Injuries Unit from 1 July 2000 to 1 March 2001. Anthropometrical measurement of head circumference, neck circumference, chest circumference, and neck length were analysed. Ages ranged from 18 to 55 years, and all patients with concomitant cervical pathology were excluded from the study. Mechanism of injury involved flexion/extension type injuries in all cases; those with direct axial loading were excluded. A control group of 40 patients (age 18–50 years) involved in high velocity trauma with associated long bone fractures, in whom cervical injury was suspected, but who were without any cervical fracture, or associated pathology, were similarly measured.

Results: Our analysis revealed a statistically significant increase in chest size in the male control group versus the male fracture group (97.89 cm versus 94.19 cm, P < 0.05, Student’s t-test). There was a correspondingly significant increase in chest circumference between the female controls versus the female fracture group (92.33 cm versus 88.88 cm, P < 0.05, Student’s t-test). Our results revealed no statistical difference in head circumference, neck circumference, or neck length between each of the groupings. These results indicate a proportionately larger chest may be a protective factor in cervical spine fractures.

Currently, data on the complication rates of primary total hip arthroplasty (THA) in Ireland is not available. We surveyed all consultant members of the Irish Orthopaedic Association (IOA) to determine the self reported complication rates of primary THA and analysed national audit data from the Economic and Social Research Institute (ESRI) for 2002. We received an 83% response rate to our survey. 58 surgeons reported data on 5,424 primary THAs for the year 2003. The mean dislocation rate was 1.02% and those using a posterior approach reported a significantly higher dislocation rate (p< 0.05). Deep infection rates were 0.44% and 29% of these were MRSA infections. There was no significant benefit reported from the use of body exhaust operative attire. The mean rate of venous thrombo-embolism (VTE) was 3.5%. There was no statistical difference reported in VTE rates when prophylaxis was commenced pre or post operatively, neither was there any significant benefit reported from using VTE prophylaxis for an extended period beyond the length of inpatient stay, nor from patients wearing graduated compression elastic stockings. ESRI national audit rates for dislocation were 25.7%, and rates of deep infection and VTE were 0.87% and < 0.1% respectively in 2002. Deficiencies in available ESRI data and questionable reliability of self reported rates, underline the necessity for a national Hip Register database in Ireland. The accurate recording of objective data on primary THA could provide an evidence base to improve surgical THA practices and patient outcomes and provide significant healthcare savings.

Plantar faciitis is a repetitive microtrauma overload injury of the attachment of the plantar fascia at the inferior aspect of the valvaneus. Several aetiological factors have been implicated in the development of plantar faciitis, however the role of hamstring tightness has not previously been assessed.

Materials and Methods: 15 volunteers (mean age 25 years) were prospectively analysed for the difference in forefoot loading using a don-Joy brace applied to each knee simultaneously. The brace was locked at varying degrees of knee flexion (0°, 20°, 40°). Body weight was measured for each volunteer. 15 patients (mean age 41 years) with a diagnosis of plantar faciitis were similarly analysed on the pedobarograph, however they also had their hamstring tightness assessed by means of measuring the popliteal angle. The mean popliteal angle measured was 28.5°. 15 age and sex matched controls (mean age 42 years) then had their hamstring tightness assessed. The mean popliteal angle was 12.5°.

Increasing the angle of flexion from 0–20° at the knee joint led to statistically significant increase in pressure in the forefoot phase by an average of 0.08K/cm2s (p, 0.05,t-test). An increase from 20 – 40° led to increased forefoot phase pressure of 0.15 kg/cm2s (p0.05, t-test). The percentage time spent in contact phase reduced from 30 to 26.5 to 16 with increasing flexion (P< 0.05). However there was an inverse increase in the time spent in the forefoot phase 51–58–69 with increasing degrees of flexion (P< 0.05). Thus the authors feel that an increase in hamstring tightness may induce prolonged fore foot loading.

The thoracic spine has always been associated with a stability that is considerably augmented by the rib cage and associated ligaments. Fractures of the thoracic spine require great forces to be applied, causing high levels of other injuries. In addition, the narrow spinal canal dimensions result in high levels of neurological compromise when fractures occur.

Between February 2nd 1995 and March 21st 2001, 1249 patients were admitted to our spinal tertiary referral unit. Of these, 77 had suffered fractures to some part of their upper thoracic spine (T1–T6), of which, 32 required surgical procedures. Using patient case notes, we retrospectively studied this series.

Twenty-six of the 32 patients were male, with an average age of the group of 24.4 +/− 11.3 years and an average impatient stay of 17.5 +/− 10.5 days. 29 patients suffered fractures at more than one level and 23 patients suffered complete neurological compromise. Only 2 patients were neurologically intact. 90.7% sustained their injuries in road traffic accidents, with 53.9% of the male group being involved in motorcycle accidents. Multiple imaging (in addition to plain film radiography) was required in 30 cases with 20 patients suffering injuries apart from their spinal fracture. Of these, 15 had associated chest injuries. Cardiothoracic surgical consultants were required in 56.3% of cases, and from the general surgeons in 37.5% of patients. 59.4% of patients required intensive care unit therapy, with another 4 patients going to the high dependency unit.

Fractures to the upper thoracic spine are injuries with devastating consequences, both due to high levels of neurological compromise and concomitant injuries. This series would suggest that patients suffering from these injuries are best treated in a multi-disciplinary approach within a general setting, rather that in a specialist orthopaedic unit, where other medical and surgical services may not be readily available.

Aim: To evaluate the necessity for further radiological investigation in patients with suspicion of rotatory subluxation of the atlanto-axial complex on plain radiography following acute cervical trauma. To outline guidelines for assessment of patients with atlanto-axial asymmetry on plain radiography.

Methods: A retrospective review of all patients who had undergone atlanto-axial CT scanning as a result of radiographic C1–C2 asymmetry following cervical spine trauma in the 3 year period from January 1999 to December 2001. The plain X-ray and CT images were reviewed retrospectively and correlated with their clinical presentation and outcome by the senior author.

Results: Twenty-eight patients were included in the study. Acute cervical spine trauma had occurred most commonly following a road traffic accident. No patient was found to have acute cervical spine torticollis or severe cervical pain. Patients age ranged from 21–44 years (M:F – 15:13). All patients were found to have atlanto-odontoid asymmetry on initial plain X-ray. No patients were found to have rotatory subluxation on CT images. 3 patients were found to have minor degrees (< 10°) of rotation on the CT scan which is within normal limits. 9 patients (32%) were found to have congenital odontoid lateral mass asymmetry. All patients were treated conservatively and had no further intervention. All plain radiographs were then assessed to determine the underlying reason for asymmetry. In 19 cases the orientation of the radiographic beam in combination with head rotation was found to be at fault.

Conclusion: Rotatory subluxation of the cervical spine is a rare but serious condition in the adult. The condition is suspected radiologically in the presence of odontoid lateral mass asymmetry on open mouth view. The application of ATLS principles in the initial assessment of trauma patients has resulted in a significant increase in the number of radiological examinations performed. This has led inevitably to an increase in the number of anomalies identified. An average of 400 c-spine X-rays per year are performed for trauma in our casualty department. In this study, we have identified 9 patients out of a total of 29 with congenital odontoid lateral mass asymmetry over a 3 year period. This represents approximately 0.75% of the cervical spine X-rays and should be considered in the differential diagnosis following acute cervical trauma. We outline guidelines for recognising benign atlanto-axial asymmetry.

The thoracic spine has always been associated with a stability that is considerably augmented by the rib cage and associated ligaments. Fractures of the thoracic spine require great forces to be applied, causing high levels of other injuries. In addition, the narrow spinal canal dimensions result in high levels of neurological compromise when fractures occur.

Between 2 February 1995 and 21 March 2001, 1249 patients were admitted to our spinal tertiary referral unit. Of these, 77 had suffered fractures to some part of their upper thoracic spine (T1-T6), of which 32 required surgical procedures. Using patient case notes, we retrospectively studied this series.

26 of the 32 patients were male, with an average age of the group of 24.4 ± 11.3 years and an average inpatient stay of 17.5 ± 10.5 days. 29 patients suffered fractures at more than one level and 23 patients suffered complete neurological compromise. Only 2 patients were neurologically intact. 90.7% sustained their injuries in road traffic accidents, with 53.9% of the male group being involved in motorcycle accidents. Multiple imaging (in addition to plain film radiography) was required in 30 cases with 20 patients suffering injuries apart from their spinal fracture. Of these, 15 had associated chest injuries. Cardiothoracic surgical consultations were required in 56.3% of cases, and from the general surgeons in 37.5% of patients. 59.4% of patients required intensive care unit therapy, with another 4 patients going to the high dependency unit.

Fractures to the upper thoracic spine are injuries with devastating consequences, both due to high levels of neurological compromise and concomitant injuries. This series would suggest that patients suffering from these injuries are best treated in a multi-disciplinary approach within a general setting, rather than in a specialist orthopaedic unit, where other medical and surgical services may not be readily available.

Acute haematogenous osteomyelitis remains a significant cause of morbidity in the paediatric population. The clinical presentation has changed, however, over the last number of decades. The typical picture of established osteomyelitis is less commonly seen. Children more often present with a less fulminant picture.

The treatment of acute haematogenous osteomyelitis remains controversial. Antibiotic therapy, initially intravenous, then orally, is the gold standard. Hover, the role of surgery is unclear. Some centres, particularly in North America treat 25–40% of patients surgically.

We present our experience with acute haematogenous osteomyelitis in children over a three year period. The total number of patients was forty-five. The mean age was 6.1 (range 6 months to thirteen years). The most common isolated organism was Staphylococcus Aureus. The mode of treatment was intravenous antibiotics for two weeks, or until clinical, and laboratory evidence of improvement, and the oral antibiotics for six weeks. No patients required surgical interventioin. All patients made a satisfactory recovery.

We conclude that the treatment of acute haematogenous osteomyelitis in the paediatric population should consist of antibiotic therapy only, and that there is no place for surgery.

The longevity of total joint arthroplasty relies on articulating surfaces that are durable and produce little polyethylene debris and consequent osteolysis and loosening. In an effort to improve wear characteristics of the acetabular line, Hylamer (Du Pont Depuy Orthopaedics, Warsaw, Indiana) was produced as an alternative to ultra high molecular weight polyethylene. To date however reports using Hylamer with Cobalt chrome, stainless steel and alumina ceramic femoral heads have yielded results that have not reached the potential of initial in vitro trials. No study has examined the outcome following a Zirconia femoral head and a Hylamer acetabular shell. The tribological properties of Zirconia make it an ideal countersurface with low friction and long term durability. This study examines the outcome when these components were used in combination with a select cohort of patients and evaluates the benefit of their continued use.

From 1994 to 1997 fifty one patients had Hylamer cup with zirconia femoral head elite total joint arthroplasty performed. Forty-seven patients with fifty-eight arthroplasties were included in this study. All patients were less that fifty years with a male preponderance. There were eleven bilateral arthroplasties all of which had the second procedure at least two months from the index procedure. The principle diagnosis was osteoarthritis in forty-three hips with rheumatoid disease in twelve hips. The remaining two patients were operated on for end stage osteonecrosis.

The Elite total joint arthroplasty (DePuy, Warsaw in.) was used in all cases. The 22.225mm zirconia head was used exclusive in this study. The Hylamer shell used was a solid polyethylene block with a minimum depth of 6mm. Both the acetabular and femoral component were cemented with Palacos polymethylmethacrelate (Howmedica, Rutherford NJ) using third generation cementing techniques.

Patients were evaluated both clinically and radiographically three months and six months following surgery and thereafter at yearly intervals. Both the SF36 questionnaire and Mayo score were used to evaluate subjectively and objectively patient outcome. Regression analysis was used to determine if the age, sex and weight of the patient as well as the angle of inclination of the acetabular cup correlated with polyethylene wear and outcome. Kaplan Meir survival analysis was used to calculate the probability of survival of the original prosthesis.

There was no correlation between age, weight nor sex of the patient and outcome. The angle of inclination was correlated with a poorer ourcome but this did not reach statistical significance. The mean linear wear rate was 0.021mm year (range 0.011–0.055). Ten year survivalship analysis was calculated at 97%. SF 36 scores were standardised and the mean post operative score was 89 (range 62–97).

The results presented are significantly better than previously described in clinical trials using Hylamer liners. The reasons for this are multifactorial. This study used 22.225 mm heads in association with a solid cemented polyethylene acetabular block. Both have been associated with lower volumetric wear but neither have been used on previous studies of Hylamer. In addition the tribological properties of Hylamer may have been undermined in previous studies by poorly conforming countersurfaces using a different manufacturer for femoral and acetabular components. Finally the use of a second generation ceramic, zirconia with a Hylamer liner has produced medium term outcomes that confound previous reports and that exceed many published reports on traditional polyethylene liners.