There has been a significant decline in the use of metal-on-metal (MoM) bearings due to concerns regarding adverse reaction to metal debris (ARMD). The Medicines and Healthcare products Regulatory Agency (MHRA) recommends annual follow-up for life with blood Cobalt (Co) and Chromium (Cr) ion level measurement in all MoM THRs with femoral head size greater than or equal to 36mm. We present the serial ten year serum Co and Cr levels in a cohort of large head MoM THRs and analyse the utility of measuring serum ions levels annually.

All patients who underwent unilateral large head MoM THR between January 2004 and December 2006 were included in this prospective study. Annual serum Co and Cr measurements were measured. Clinical case notes and radiographs were reviewed for failure, revision surgery and the occurrence of ARMD. Mann Whitney test was used to analyse changes in serum Co and Cr levels. Receiver Operating Characteristic (ROC) curve was plotted based on their sensitivity and specificity to detect ARMD.

256 patients were included. There was a significant increase in serum ion values in the first two years. After 7 years, there was no significant change in Co values(p=0.78) and there was a decline in Cr value after 9 years(p<0.001). With 7 µg/l as the cut-off value, the sensitivity and specificity of Co was 82.1% and 65.5% and of Cr was 53.5% and 91.3%.

Annual follow-up of patients with MoM THR based on the MHRA guideline to obtain serum metal ion levels can cost about £9 million/year. Our study noted poor discriminatory ability for both Co and Cr values in the ROC curve. There is poor correlation between serum metal ion levels and the occurrence of ARMD on MARS MRI. Based on our results we find limited utility in doing ion levels after 7 years in asymptomatic patients.

High failure rates have been associated with large diameter metal-on-metal total hip replacements (MoM THR). However there is limited literature describing the outcomes following the revision of MoM THR for adverse local tissue reaction (ALTR).

A total of 98 large diameter MoM THRs underwent revision for ALTR at our institution. The data was obtained from the clinical records and included the demographics, intra-operative findings of ALTR and post-operative complications. Any subsequent procedures and re-revision for any reason was analysed in detail. The clinical outcome was measured using functional outcome scores using the Oxford hip score (OHS), Western Ontario and McMaster Universities osteo-arthritis index (WOMAC) score and Short Form (SF12).

The mean age of the patients at the time of revision was 58.2 yrs. At a mean follow-up of 3.9 years (1.0 to 8.6) from revision for ALTR, there were 15 hips (15.3 %) with post-operative complications and 8 hips (8 %) requiring re-revision. The Kaplan–Meier five-year survival rate for ALTR revision was 91 % (95% confidence interval 78.9 to 98.0). There were no statistically significant predictors of re-revision. The rate of postoperative dislocation following revision was 9.2% (9 hips). The post-operative functional outcome depends on the intra-operative findings of tissue destruction secondary to ALTR.

The short term results following revision of large diameter MoM THR for ALTR are comparable with other reports in the literature. The use of constrained liners reduces the incidence of post-operative dislocation. There is an increased risk of postoperative instability following revision THR for ALTR. Early identification and intervention seems to be the logical approach in the management of patients with ALTR.

Background

Cartilage lesions in chronic lateral ligament deficiency are common with the incidence rates mentioned in the previous literature up to 30%. However, other intra-articular pathologies in the unstable ankle have received little attention. Anterolateral impingement associated with synovitis and scarring is a less recognised feature in the treatment of chronic instability. The aim of our study was to ascertain the incidence of chondral and anterolateral impingement lesions in the symptomatic lateral ligament complex deficiency.

Background

Cartilage lesions in chronic lateral ligament deficiency are common with the incidence rates mentioned in the previous literature up to 30%. However, other intra-articular pathologies in the unstable ankle have received little attention. Anterolateral impingement associated with synovitis and scarring is a less recognised feature in the treatment of chronic instability. The aim of our study was to ascertain the incidence of chondral and anterolateral impingement lesions in the symptomatic lateral ligament complex deficiency.

A significant proportion of children with cerebral palsy (CP) are malnourished. This is particularly the case for trace elements, vitamins and minerals. Children with CP undergoing major orthopaedic procedures lose blood intra operatively leading to post operative anaemia. The aim of our study was to estimate the prevalence of low levels of serum ferritin in children with CP awaiting major orthopaedic surgical intervention.

The ferritin levels and haemoglobin (Hb) were estimated pre-operatively in 35 children with CP (CP group) undergoing major orthopaedic surgery (Hip reconstruction or Single event multi-level surgery). During the same period, we randomly identified 1000 children (Control group) who underwent Ferritin estimation as part of routine investigations. A significant proportion of children in the study group had low levels of serum ferritin in spite of having normal haemoglobin.

It is well-recognised that commencement of iron either orally or intravenously in the post-operative period does not accelerate recovery from anaemia secondary to blood loss. It is important to note that many patients who have normal Hb levels preoperatively are iron deficient. Hb estimation alone is inadequate in this group. We therefore conclude that children with cerebral palsy undergoing major orthopaedic surgery must have their ferritin levels estimated and optimised well in advance of their surgery.

Introduction: Controversy exists in the surgical treatment of unstable ankle fractures in the very elderly age group of over 80 years. Operative fixation in these cases is challenging and the postoperative mortality and morbidity has discouraged surgical intervention in this population. However, the literature regarding the prognosis of surgery in this elderly group is very limited. The purpose of our study was to describe the results of 92 patients aged above 80 years, who underwent operative fixation for unstable ankle fractures.

Methods: 92 consecutive patients aged above eighty years of age had open reduction and internal fixation for unstable ankle fractures during the period of January 1998 – August 2007. The data was collected retrospectively from the case records and radiographs. A standard postoperative rehabilitation programme was followed. The complications were noted and the risk factors for poor prognosis were analysed.

Results: There were 80 women and 12 men in the study. The average age was 85.2 (Range 80.1 – 95.1 yrs). The minimum duration of follow up was 9 months. The superficial wound infection rate was 7% (6 cases) and the deep infection rate was 4.6% (4 cases). The 30 day postoperative mortality was 5.4 % (5 cases). 86 % (75 out of 87 cases) were able to return back to their pre injury mobility at the last follow-up. Diabetes, dementia, peripheral vascular disease and smoking were found to be statistically significant risk factors associated with wound complications. Patient with 2 or more risk factors is 5 times more likely to have wound infection.

Conclusion: The results of operative fixation of unstable ankle fractures are very encouraging with majority of patients returning to pre injury mobility status.

Introduction: Trapeziectomy is a well established surgical procedure for the treatment of osteoarthritis of the carpo-metacarpal joint (CMCJ) o the thumb. The complications have been recognised in the past, but there has been limited literature describing the management and prognosis of long term complications following Trapeziectomy.

Aim: The purpose of our study was to describe our experience in management and prognosis of patients with long term complications associated with Trapeziectomy with particular references to residual pain and sensory branch of radial nerve (SBRN) paraesthesia.

Methods: 118 trapeziectomy procedures were performed in 103 patients for primary osteoarthritis of the CMCJ of thumb during the period of January 2000 – December 2005 at a single centre performed or supervised by a single surgeon (senior author). The data was obtained from the case notes retrospectively. The average follow up period was 12 months. The short term and long term complications and their management were recorded and analysed in detail.

Results: Long term complication rate was 23.7% (28 cases) which included 15 patients (12.7 %) complaining of residual pain at the base of the thumb, 6 patients (5.1%) had symptoms related to superficial branch of radial nerve and 2 patients (1.7%) had FCR rupture. Steroid injection was more successful than physiotherapy or splinting in majority of the patients with residual pain. Superficial branch of radial nerve symptoms resolved with time. However persistent symptoms were treated suceesfully by desensitization therapy.

Conclusion: Trapeziectomy is a fairly benign operation, but the complications are more than expected and the patients must be warned to expect long term complications. Most of the postoperative problems can be effectively managed non-operatively and the prognosis remains good in majority of the cases. Patients must be reassured to expect full recovery with time.

The principles of revision total knee replacement are to understand the cause of failure, adequate surgical exposure, achieving appropriate soft tissue balance, restoration of limb and joint line alignment, correct implant alignment, and a good range of motion. It is a technically and economically demanding procedure and its successful performance requires thorough preoperative planning, adherence to the principles, availability of diverse implant options and adequate bone graft.

We prospectively assessed the survivorship of Co-ordinate Ultra prosthesis (DePuy, Warsaw, Ind) used for revision knee arthroplasty. Forty-nine patients had 53 revision knee replacements performed by the senior author between April 1999 and September 2001. Seven patients (7 knees) had died. At a mean follow-up of 6 years (range: 5–7 years), 46 knees in 42 patients were available for review. None were lost to follow-up. There were 31 women and 11 men, with a mean age of 74.2 years. The reason for revision was instability in 39 knees, infection in 3 knees, pain in 2 knees and stiffness in 2 knees.

Significant improvement was noted in the SF-12 PCS and WOMAC pain and stiffness scores at the latest follow-up. None of these patients required re-revision. None of the knees showed evidence of progressive loosening. Radio-opaque lines were found around the stems and were present in immediate post-operative radiographs; this did not indicate loosening or infection on further follow-up. Cumulative survival analysis (Kaplan-Meier method) was 100% at 7 years.

Clinical and radiological outcome analysis has revealed that the Co-ordinate Ultra revision knee system continues to function satisfactorily at a mean follow-up of 6 years.

Introduction: Operative fixation of unstable ankle fractures is a well recognised form of management. However controversy exists in the surgical treatment of unstable ankle fractures in the very elderly age group of over 80 years. Operative fixation in these cases is challenging and the postoperative mortality and morbidity has discouraged surgical intervention in this population. However, the literature regarding the prognosis of surgery in this elderly group is very limited. The purpose of our study was to describe the results of 85 patients aged above 80 years, who underwent operative fixation for unstable ankle fractures.

Methods: 92 consecutive patients aged above eighty years of age had open reduction and internal fixation for unstable ankle fractures during the period of January 1998 – August 2007. The data was collected retrospectively from the case records and radiographs. The mechanism of injury, fracture pattern, and medical co morbidities were recorded. A standard postoperative rehabilitation programme was followed. 5 patients were excluded as complete medical records were unavailable. The clinical and radiological outcomes following surgery were recorded and analysed in detail. The complications were noted and the risk factors for poor prognosis were analysed.

Results: There were 71 women and 16 men in the study. The most common fracture pattern was pronation external rotation type. The average age was 85.2 (Range 80.1 – 95.1 yrs). The minimum duration of follow up was 9 months. The superficial wound infection rate was 5.7% (5 cases) which settled with oral antibiotic treatment for 1–2 weeks. The deep infection rate was 4.6% (4 cases) which required surgical debridement and implant removal. The 30 day postoperative mortality was 4.6 % (4 cases). Most patients demonstrated radiological fracture union with medial malleolus possessing slightly a higher risk of non union. 88.1 % (74 out of 84 cases) were able to return back to their pre injury mobility at the last follow-up. Diabetes and smoking did not statistically influence the outcome of the surgery.

Conclusion: The results of operative fixation of unstable ankle fractures are very encouraging with good functional recovery and return to pre injury mobility status in most cases. The surgical fixation is technically challenging and careful attention must be given to the osteopenia and soft tissue factors.

Introduction: The principles of revision arthroplasty are to understand the cause of failure, adequate surgical exposure, restoration of limb alignment, achieving appropriate soft tissue balance, correct implant alignment, restoration of joint line and a good range of motion. Revision knee Arthroplasty is a technically and economically demanding procedure and its successful performance requires thorough preoperative planning, adherence to the principles, availability of diverse implant options and adequate bone graft.

Aim: We prospectively assessed the survivorship of Coordinate Ultra prosthesis (DePuy, Warsaw, Ind) used for revision knee arthroplasty.

Materials and Methods: Fifty-three patients had revision knee replacement performed by the senior author between April 1999 and September 2001. Seven patients (7 knees) had died. At a mean follow-up of 6 years (range: 5–7years), 46 knees in 42 patients were available for review. None were lost to follow-up. There were 31 women and 11 men, with a mean age of 74.2 years. The reason for revision was instability in 39 knees, infection in 3 knees, pain in 2 knees and stiffness in 2 knees.

Results: Significant improvement was noted in the SF-12 PCS and WOMAC pain and stiffness scores at the latest follow-up. None of these patients required re-revision. Radiological evaluation was done using the Knee Society system. None of the knees showed evidence of progressive loosening. Radiopaque lines were found around the stems and were present in immediate post-operative radiographs; this did not indicated loosening or infection on further follow-up. Cumulative survival analysis (Kaplan Meier method) was 100% at 7 years.

Conclusion: Clinical and radiological outcome analysis has revealed that the Co-ordinate Ultra revision knee system continues to function satisfactorily at a mean follow-up of 6 years.

Aim: To describe the epidemiology of paediatric bone infections in a single health district in England with particular reference to incidence and the changing pattern of the disease.

Method: Cases of chronic osteomyelitis and chronic regional multifocal osteomyelitis were excluded leaving 53 children diagnosed with acute haematological osteomyelitis (AHO) at a paediatric orthopaedic unit between January 2000 and December 2005. Patients were identified from the hospital coding system using the keywords ‘bone infection’ and ‘osteomyelitis’. The data were collected retrospectively from the patients’ hospital records and included demographic information, the delay between symptoms and presentation, clinical presentation, site of infection, organisms identified and laboratory results.

Results: The mean age of presentation was 40 months (range 0.5–179). The highest age incidence was between 0–3 yrs. There was no sex predilection with 27 girls and 26 boys. The mean duration of symptoms before presentation was 3.4 days (range 0–14 days). The presenting symptoms were pain at the affected site in 100% of cases, pyrexia (temperature > 38°C) in 47.1%, swelling of the affected site in 47.1%. The commonest bone affected was the femoral metaphysis. The commonest bacterium isolated was staphylococcus aureus. WBC, CRP and ESR were elevated in 44%, 84% and 92.1 % of the cases respectively. Plain radiographs and bone scan demonstrated signs of osteomyelitis in 32.1% and 78.8 % respectively. Surgical intervention was required in 21 patients.

Conclusions: The demographics and clinical presentation of AHO has not changed over the years. The commonest organism involved remains Staphylococcus aureus. ESR and bone scans were the most sensitive screening test for diagnosing the condition. Early initiation of third generation cephalosporin antibiotic therapy and surgical decompression, when necessary, was the mainstay of treatment.

Purpose of study: The majority of children with cerebral palsy suffer from fixed flexion contractures of their knees. Procedures commonly used to correct these deformities include hamstring releases, anterior femoral hemi-epiphyseodesis and femoral extension osteotomies. The latter procedure can cause neurovascular complications. Femoral stapling procedures are unpopular because of the risk of permanent physeal closure. Soft tissue procedures are usually only partially effective, with a high recurrence rate. We present our initial experience of correcting of knee flexion deformities using the 8-plate technique which uses guided growth in the distal femoral physis to achieve gradual correction of the knee flexion deformity.

Method: The case notes of patients who underwent an anterior distal femoral hemi-epiphyseodesis using the 8-plate technique between April 2005 and August 2006 were analysed. A total of 18 limbs in 12 patients underwent this procedure. The pre- and post-operative flexion deformity was measured with a goniometer.

Results: The mean age of the patients was 12.8 years (range 9–16) and the mean follow up was 8.5 months (range 3–15). The mean correction achieved was 16.15 degrees (range 5–40)

Conclusions: This is a simple technique with a learning curve of 1 case and with few complications to date. All patients in our series have shown sustained gradual correction. We also present technical tips in the use of the 8-plate for anterior femoral hemi-epiphyseodesis.

Percutaneous fixation is a well recognised technique in the treatment of three-part and four-part fractures of the proximal humerus. Minimal fixation of these fractures do show good functional outcome and may further reduce the incidence of avascular complications. We report a preliminary series of 11 patients who underwent percutaneous minimal fixation of such complex humeral fractures using a new technique. 11 consecutive patients (7 with three-part fractures and 4 with four-part fractures) treated by percutaneous limited fixation in our Hospital were involved in this retrospective study. There were 7 fractures with valgus displacement. Percutaneous technique was employed using small incisions and the fracture was reduced under image guidance. The three-part and the four-part fractures were essentially converted into two part fractures, i.e. only the greater and the lesser tuberosities were re-attached to head with AO cancellous screws after realignment of the fragments. The shaft of the humerus was not fixed to the head in any of the cases. All of these cases had a minimum follow-up of at least 6 months. The results were evaluated using the Constant -Murley Shoulder score. 1 out of 11 cases had to be converted to hemi-arthroplasty due to secondary redisplacement of the fracture. The remaining 10 cases showed good bony union although the greater tuberosity in 2 cases showed a residual superior displacement of 3mm and a residual valgus displacement in 2 out of 7 cases. There were no complications of avascular necrosis in any of the cases. Clinically, compared to the uninjured side the average constant score was 93.7% (range- 68.7% – 100%). 7 patients were very satisfied and 4 were satisfied with the operation. Percutaneous minimal fixation achieves good to very good functional outcome comparable to the conventional methods and theoretically reduces the incidence of infection, avascular necrosis and neurological complications.