Background

RHF nail is an important tool for simultaneous ankle and subtalar joint stabilisation +/− fusion. Straight and curved RHF nails are available to use, but both seem to endanger plantar structures, especially the lateral plantar artery and nerve and Baxter's nerve.

There is a paucity of literature on the structures at risk with a straight RHF nail inserted along a line bisecting the heel pad and the second toe (after Stephenson et al). In this study, plantar structures ‘at risk’ were studied in relation to a straight nail inserted as above.

During revision THR, the surgery is often difficult and compromised due to lack of patient's bone especially in the pelvis. Any extra bone in the acetabulum is expected to be of advantage to the patient and the surgeon. The aim of this study was to see if preservation of medial acetabular osteophyte in uncemented total hip replacement had any adverse effect on the prosthesis survival or patient satisfaction.

Conventional acetabular preparation involves reaming down to the true floor. This not only medialises the centre of rotation of the hip but also reduces the acetabular offset. In contrast the main surgeon preserved the acetabular offset by preserving some osteophytic bone between the true floor of the acetabulum and the acetabular cup. This is achieved by reaming the acetabular cavity conservatively while achieving secure primary fixation of the prosthesis. We report the outcome of a single surgeon series of such cases. The endpoint was assessed as the need for revision of the acetabular cup.

A total of 106 consecutive patients were identified who underwent uncemented THR from 2005 to 2010. The medial osteophyte was measured on immediate post-operative x-rays, from the “teardrop” to the nearest point of the acetabular cup, by 3 surgeons (one consultant and 2 registrars). The patients were contacted for a telephone interview and their clinical notes, including x-rays, were reviewed.

Outcome was available for 79 patients. 74 patients were available for follow-up and 5 patients died unrelated to THR. Average follow-up was for 8.3 years (range 5.5–10.8). Average age was 62 years. The average medial osteophyte was 1.98 mm (range 0–14mm). One patient had late infection and one had dislocation. There was not a single failure of the acetabular component. The patient satisfaction was high at 8.8 out of 10.

Preservation of medial osteophyte in the acetabulum whilst doing uncemented THR has the advantage of retaining the patient's own bone stock which can be of great advantage to the surgeon as well as the patient should revision THR be required in future. Our study has shown that this can be achieved without compromising the survival of the prosthesis or the patient satisfaction.

This technique may increase the range of motion of the hip by reducing the risk of bony or soft tissue impingement, and also reduce the risk of dislocation. Furthermore, not recreating the native centre of rotation of the hip does not seem to have any adverse effect for the patients, who are very happy with the outcome. We recommend that whilst doing uncemented THR, the acetabulum should not be reamed to the true floor as has been the conventional teaching, but attempt should be made to preserve some medial osteophyte where possible, at the same ensuring that good primary fixation of the cup is achieved. This is to give the patient and surgeon the advantage of extra available bone should revision surgery be required in the future.

Introduction:

Charcot arthropathy is a complex condition affecting diabetic patients with neuropathy. Diagnosis of acute Charcot arthropathy particularly in absence of any perceptible trauma is very challenging as clinically it can mimic osteomyelitis and cellulitis. Delay in recognition of Charcot arthropathy can result in gross instability of foot and ankle. Early diagnosis can provide an opportunity to halt the progression of disease. We report the role of SPECT /CT in the early diagnosis and elucidation of the natural progression of the disease.

Introduction

The outcome of periacetabular osteotomy in dysplastic hips is dependent on the absence of pre-operative osteoarthritis [OA]. The purpose of this study was to analyze whether Tonnis grading is a reliable predictor of OA in patients with hip dysplasia.

Reconstruction of an acetabulum following severe bone loss can be challenging. The aim of this study was to determine the outcome of acetabular reconstruction performed using trabecular metal shell for severe bone loss.

Between June 2003 and June 2006 a total of 29 patients with significant acetabular bone stock deficiency underwent revisions using trabacular metal shell. According to Paprosky classification, there were 18 patients with grade IIIA and 11 patients with grade IIIB defects. Nineteen patients required augments to supplement the defects. Functional clinical outcomes were measured by WOMAC and Oxford hip. Detailed radiological assessments were also made.

At most recent follow up (average 5.5 years, range 3.5–8.5) the mean Oxford hip score improved from 12 preoperatively to 27.11 postoperatively and WOMAC score from 17.57 preoperatively to 34.14 postoperatively The osseointegration was 83% according to Moore's classification. There were two reoperations; one was for instability, and one for aseptic loosening. One patient has a chronic infection and one had a periprosthetic fracture, both treated conservatively.

Despite challenges faced with severe preoperative acetabular defects the early results using this technique in Grade III A and B is encouraging.

Revision hip surgery is reportedly rising inexorably yet not all units report this phenomenon. The outcome of 1143 consecutive Corin TaperFit primary hip arthroplasties (957 patients) performed between 1995 and 2010 is presented. The implants were cemented under pressurisation and combined the TaperFit stem with Ogee flanged cups.

Data was gathered from local arthroplasty database and case note review of revised joints. 13 hips have been revised (1.1%). Cumulative prosthesis survival is 0.99 +/− 0.0. Two femoral stems were revised (0.2%); one at 6 months for sepsis, one at 14 days after dislodgment during reduction of dislocation. No revisions were undertaken for aseptic loosening of the stem or cup, nor for thigh pain. 32 patients (32 hips) ≥15 year follow up, 13 survive today and none have been revised (0%). Of the 471 with ≥10 year follow up, 38 were aged ≤50 at time of surgery and 1/38 has been revised to date (PLAD for dislocation).

The strong population stability in this region, supported by independent investigation by Scottish Arthroplasty Project, endorses the accuracy of the data quoted. The low incidence of revision in this cohort, and absence of revision for aseptic loosening (mean follow up 8.03 years +/− SD 3.94; range 18 months to 16yrs 2 months), substantially supports the longevity and use of cemented, double-taper, polished, collarless femoral stems in combination with cemented polyethylene cups in primary hip arthroplasty in all patient age groups.

Background

Sterile Surgical Helmet System (SSHS) are used routinely in hip and knee arthroplasty in order to decrease the risk of infection. It protects surgeon from splash and also prevents contamination of surgical field from reverse splash by virtue of its perceived sterility. A prospective study was conducted to confirm if SSHS remain sterile throughout the procedure in Hip (THA) and Knee (TKA) Arthroplasty. We also evaluated if type of theatre had any effect on degree of contamination.

This case series highlights the use of the Ganz approach and surgical dislocation for excision of fibrous dysplasia of the femoral neck, pigmented villonodular synovitis and synovial chrondromatosis of the hip, which has never been described for use with all three tumours together. These are rare benign tumours, which were found incidentally and required excision.

We demonstrate that it is possible to obtain excellent exposure of the femoral neck, head and acetabulum allowing easy inspection, exploration and debridement of these three tumours of the hip.

Hip resurfacing has generally been used in younger patients with early osteoarthritis of the hip. There has been considerable recent interest in this over the past few years. We conducted a prospective randomised trial comparing 2 hip resurfacing implants, Durom and ASR looking at radiological and clinical outcomes.

Forty-nine patients (78% male) with hip osteoarthritis which met the criteria for hip resurfacing were randomised to receive either a Durom or ASR resurfacing implant. These patients have so far been followed up for a minimum of one year. The groups were comparable in age (p=0.124) and gender (p=0.675). The average age in the ASR group was 54.04 years and in the Durom group it was 51.25.

Radiological views were scrutinised immediately post op and at final follow up so far to look at cup inclination, stem-shaft angle, and acetabular osseointegration.

Clinical outcomes were compared using the Oxford hip scores, WOMAC scores and SF12 scores.

At minimum follow up of 1 year the mean post operative Oxford hip score was not significantly different between the Durom (45.32, SD 3.93) and ASR (43.44, SD 8.44). The mean post operative WOMAC score was also not significantly different between the Durom (52.56, SD 6.06) and ASR (49.63, SD 2.23). There was no difference between the groups with regards to signs of osseointegration from radiological assessment (p=0.368). There were 3 periprosthetic femoral neck fractures (5.7%) and one revision for pain.

We conclude from this trial that there is no difference in the clinical or radiological findings between the Durom and ASR implants.

The outcome of periacetabular osteotomy in dysplastic hips is dependent on the absence of preoperative osteoarthritis [OA]. The purpose of this study was to analyze whether Tonnis grading is a reliable predictor of OA in patients with hip dysplasia.

Thirty patients were identified who had undergone hip arthroscopy surgery to assess their suitability for periacetabular osteotomy. Radiographs were assessed for anterior centre edge angle, lateral centre edge angle, Tonnis angle and Tonnis grade for OA changes. The radiographic grading of OA was compared with arthroscopic findings.

The objective was to compare vastus lateralis muscle splitting verses muscle sparing surgical approach to proximal femur for fixation of intertrochanteric fracture.

Of the 16 patients in this prospective randomised double blind study 8 were randomised to vastus lateralis muscle splitting and rest to muscle sparing group. Main outcome measurement was assessment of status of vastus lateralis muscle at 2 and 6 weeks using nerve conduction study. Preoperative demographics were identical for both the groups.

There was no statistically significant difference between the groups with regards to velocity, latency, and amplitude. The postoperative haemoglobin drop, heamatocrit, position of the dynamic hip screw and mobility status were identical.

Both clinical and neurophysiological outcome suggest that damage done to vastus lateralis either by splitting or elevating appears to be identical.

All neck of femur fractures are registered on a national hip database. Here a standardised proforma is used to ensure all relevant information is recorded. It is also essential all trauma admissions are thoroughly clerked and essential clinical information is recorded. Almost all trauma and orthopaedic units in the UK do not have any such proformas and admissions are written on standard headed paper.

We describe a prospective study of all trauma admissions excluding neck of femur fractures. We analysed the comprehensiveness of orthopaedic patient clerking being admitted to a teaching hospital over 2 weeks. We aim to continue with data collection to a total of 100 patients. Here we describe our initial results. We further analysed the differences between levels of postgraduate experience of doctors against the completeness of clerkings.

All orthopaedic trauma admissions were scrutinised for presence of demographic details including, name, number, consultant, date, time. We also considered patient details including presenting complaint, mechanism of injury, past medical history, social history, pulse, blood pressure (BP), respiratory rate (RR), temperature amongst others. Clerking doctor details included name, signature, bleep number. They were classified as either being present and documented or absent.

We analysed 36 case notes in total. Of these 3 (8%) were clerked by a doctor of less than 12 months experience, 18 (50%) were clerked by a doctor with 12– 18 months experience, 8 (22%) were clerked by a doctor with 24– 30 months experience, 7 (20%) were clerked by a doctor with 30– 36 months experience.

We found doctors 100% of the time included name, date, time, mechanism of injury and a plan. All doctors had very poor recording of mental score, allergies, oxygen saturations, temperature being recorded in 0%, 31%, 31% and 28% of cases respectively.

Our results also revealed that doctors with less experience had more complete clerkings than more experienced trainees. In particular doctors with less than 18 months experience were better at recording patient details 30 % of the time. Less experienced doctors were also better at recording basic observations such as pulse, BP and temperature.

These results are surprising as this would not be expected. More experience doctors may be taking ‘short cuts’ and thereby failing to document certain details.

All doctors should ensure accurate and thorough clerkings including essential criteria such as allergies and basic observations, regardless of grade and experience. A standardised trauma proforma has been used by other hospitals with some success and should be considered to be implemented regionally and nationally. This would ensure essential clinical criteria would be included in all admissions.

The merit of staging bilateral total knee arthroplasties (separate procedures) versus replacing both joints at the same anaesthetic (sequential) is a topic debated in literature. The aim of this study was to evaluate & compare the clinical outcome in patients who had undergone either bilateral staged or sequential total knee arthroplasties (TKAs).

METHODS: Computerized database and medical records of patients who had had bilateral TKAs in the Tayside region between 1984 and 2003 were retrospectively evaluated. Outcome was assessed using Knee Society Score, Pain Score, Function Score and Range of Movement.

RESULTS: 438 sequential and 526 staged procedures were evaluated. The sequential group had better function score at 1 and 3 years (P< 0.001). There was no other statistically significant difference in the outcome measures.

The mean ages of the sequential and staged study groups were 70.67 and 69.19 years, respectively (P=0.011).

CONCLUSION: Sequential TKA appears to confer a functional advantage over staged procedures in the short and medium term.

Some patients following operation for Hallux Valgus deformity develop Transfer Metatarsalgia. Many believe that a long oblique osteotomy of the second metatarsal as part of surgical correction of Hallux Valgus deformity reduces the risk of developing transfer metatarsalgia.

Metatarsal Break Angle (MBA) is the angle subtended by one line from the centre of the head of First Metatarsal to the centre of the head of the Second Metatarsal and another from the centre of the head of the Second Metatarsal to the centre of the head of Fifth Metatarsal. The MBA changes following osteotomy of the Second metatarsal.

Is the Metatarsal Break Angle(MBA) altered in patients who undergo long oblique osteotomy of the second metatarsal?. Literature does not mention anything to this effect. We prospectively studied the course of this angle in patients who underwent osteotomy of the second metatarsal at the same time as they had surgical correction of their painful Hallux Valgus deformity.

Twenty-four consecutive patients (thirty-one feet), nineteen Female and five Male, in the age range of eighteen to seventy-one years successfully fulfilled the inclusion criteria. The inclusion criteria being - Hallux Valgus deformity with a dorsally subluxed second Meta-tarsaophalangeal joint(MTPJ) and presence of tenderness/hyperkeratotic plantar patch at the second MTPJ.

The postoperative range of increase in the angle was two to sixteen degrees in all except one patient (decreased by one degree). Median change was eight degree increase. This study concludes that the MBA is altered in patients who undergo long oblique osteotomy of the second metatarsal. This type of osteotomy done so as to provide the head of the second metatarsal a fresh plantar fat pad to rest upon does help to remove the tenderness over the second MTPJ.

To the best of our knowledge this change in MBA has not been mentioned in the medical literature and we believe that our study highlights this important geometrical change in the architecture of post-operative forefoot.

Total hip replacement using components from different manufactures is common and has been known as cross-breed arthroplasty. The implant industry clearly advises against it for primary arthroplasty, even though this has been the accepted practice in revision hip surgery. The response of the Medicine and Healthcare products Regulatory Agency is to agree with the manufacturers. Thus this advice has been implemented in National Institute of Clinical Excellence guidelines without any supportive clinical data.

A consecutive series of 206 crossbreed total hip arthroplasties were performed in 192 patients by a single surgeon between 1990 and 1993. These were observed for an average 11.5 years (range, 10–13years). There were 126 women and 80 men with an average age of 69 (range, 41–89) at the time of surgery. There were 9 failures defined as reoperation. Of these, 5 were for aseptic loosening of cup, 2 for deep infection, 1 for recurrent dislocation and 1 for revision of stem for Periprosthetic fracture following a fall. There was no aseptic loosening of stem. With survivorship to date of 94% these data suggest that it is safe to continue using at least one of the common combinations in primary hip arthroplasty.

Background: To our knowledge, a prospective randomised study comparing blood loss in cemented and uncemented total knee replacement has not been performed.

Method: From 1994 to 2004, 205 consecutive patients (78 men and 128 women) undergoing total knee replacement were randomised to one of the two groups, one using a cemented Kinnimax prosthesis and the other an uncemented LCS knee prosthesis. In 96.1% of the patients the procedures were performed for osteoarthritis whilst 3.9 % for RA. All patients had their haemoglobin and heamatocrit recorded preoperatively and postoperatively. The patient’s height, weight and body mass index were recorded preoperatively. The red blood cell (RBC) volume loss were measured by an indirect method which involved calculations using height, weight and pre op and post op heamatocrit.

Results: The mean red cell volume loss in uncemented knees (0.46lts) was significantly greater than the loss in cemented knees (0.39lts) p = 0.015. There was no statistically significant difference in relation to preoperative deformity, approach or ASA grade.

Conclusion: Our study concludes that the uncemented knees loose more blood compared to cemented knees. There have been smaller studies looking at this, but we believe this to be the largest and most comprehensive to date.

We have performed a prospective review of 590 consecutive patients treated for a displaced intracapsular femoral neck fracture with a Thompson hemiarthroplasty. 113 patients had the prosthesis cemented, 477 had no cement. The outcome at 12 months was obtained for every patient still alive as regards to pain, mobility, re-operation rate and residential status. There was no significant difference between the 2 groups as regards pain (p = 0.482), decrease in mobility or re-operation rate (p = 0.168). The main determination of poor outcome was increasing age at time of injury and whether the patient was already in institutional care at the time of the injury. The use of cement had no bearing on outcome.

This study is of clinical interest because patients who have undergone uncemented hemiarthroplasty have been shown to have similar out come to cemented hemiarthroplasty in terms of function. In addition possible but preventable complications associated with cementing can be minimized. We now believe there is no primary indication to cement the Thompsons hemiarthroplasty in this group of patients.

There have been smaller studies looking at this, but we believe this to be the largest and most comprehensive to date.

Background: To our knowledge, a prospective randomised study comparing blood loss between cemented and uncemented total knee replacement has not been performed.

Method: From 1994 to 2004, 205 consecutive patients (78 men and 128 women) undergoing total knee replacement was randomised to one of the two groups, cemented Kinnimax or uncemented LCS knees. 96.1 % of the procedures were performed for osteoarthritis whilst 3.9 % for RA. All patients had haemoglobin and heamatocrit recorded preoperatively and postoperatively. Each patients height, weight and body mass index were recorded preoperatively. The red blood cell (RBC) volume loss was measured using an indirect method which involved calculations using height, weight and pre op and post op haematocrit. The mean post operative RBC volume in cemented knees was 1.32lts whilst that of uncemented knees was 1.38lts; p value – 0.202.

Results: The mean red cell volume loss in cemented knees was 0.39lts and that of uncemented knees was 0.45lts, p value 0.015 which was statistically significant. There was no statistically significant difference in relation to preoperative deformity, approach or ASA grade. There was statistically significant increase in tourniquet time in cemented knees.

Conclusion: Our study concludes that the uncemented knees loose more blood compared to cemented knees. There have been smaller studies looking at this, but we believe this to be the largest and most comprehensive to date.