The primary treatment goal for patients with femoroacetabular impingement syndrome, a common hip condition in athletes, is to improve pain and function. In selected patients, in the short term following intervention, arthroscopic hip surgery is superior to a pragmatic NHS- type physiotherapy programme. Here, we report the three-year follow-up results from the FemoroAcetabular Impingement Trial (FAIT), comparing arthroscopic hip surgery with physiotherapy in the management of patients with femoroacetabular impingement (FAI) syndrome.

Two-group parallel, assessor-blinded, pragmatic randomised controlled study across seven NHS England sites. 222 participants aged 18 to 60 years with FAI syndrome confirmed clinically and radiologically were randomised (1:1) to receive arthroscopic hip surgery (n = 112) or physiotherapy and activity modification (n = 110). We previously reported on the hip outcome score at eight months. The primary outcome measure of this study was minimum Joint Space Width (mJSW) on Anteroposterior Radiograph at 38 months post randomisation. Secondary outcome measures included the Hip Outcome Score and Scoring Hip Osteoarthritis with MRI (SHOMRI) score.

Minimum Joint Space Width data were available for 101 participants (45%) at 38 months post randomisation. Hip outcome score and MRI data were available for 77% and 62% of participants respectively. mJSW was higher in the arthroscopy group (mean (SD) 3.34mm (1.01)) compared to the physiotherapy group (2.99mm (1.33)) at 38 months, p=0.017, however this did not exceed the minimally clinically important difference of 0.48mm. SHOMRI score was significantly lower in the arthroscopy group (mean (SD) 9.22 (11.43)) compared to the physiotherapy group (22.76 (15.26)), p-value <0.001. Hip outcome score was higher in the arthroscopy group (mean (SD) 84.2 (17.4)) compared with the physiotherapy group (74.2 (21.9)), p-value < 0.001).

Patients with FAI syndrome treated surgically may experience slowing of osteoarthritisprogression and superior pain and function compared with patients treated non- operatively.

Introduction

Over the past 30 years multiple wars and embargos have reduced healthcare resources, infrastructure, and staff in Iraq. Subsequently, there are a lack of physiotherapists to provide rehabilitation after an anterior cruciate ligament reconstruction (ACLR). The implementation of home-based rehabilitation programmes may provide a potential solution to this problem. This study, set in in the Kurdistan region of Iraq, describes the epidemiology and outcomes of anterior cruciate ligament reconstruction (ACLR) followed by home-based rehabilitation alone.

Abstract

Dual mobility (DM) is most often used by surgeons to reduce instability in high risk patients. NJR data on DM has not demonstrated a reduction in all cause revision and has reported an increase in revision for peri-prosthetic fracture (PPF). The aim of our study was:

Prospective F/U of a DM implant since 2016 and enrolled into Beyond Compliance (BC). Primary outcome measure all-cause revision with secondary outcome including any re-operation and Oxford Hip Score (OHS). All patients were risk stratified and considered high risk for instability. Complications were identified via hospital records, clinical coding linkage, NJR and BC. Benchmarking data for comparison was obtained from same data sources we also considered all B type PPF that occurred with cemented polished taper stem (PTS).

159 implants in 154 patients with a mean age 74.0 years and a maximum F/U of 6.7 years. Survivorship for all-cause revision 99.4% (95% CI 96.2–99.8). One femoral only revision. Mean gain in OHS 27.4. Dislocation rate 0.6% with a single event. Patients with a PTS rate of Type B PPF 2.1% requiring revision/fixation. Compared to cTHA this cohort was significantly older (74.0 vs 68.3 years), more co-morbidity (ASA 3 46.5% vs 14.4%) and more non-OA indications (32.4% vs 8.5%). Relative risks for dislocation 0.57 (95%CI 0.08–4.1) and PPF 1.75 (95%CI 0.54–5.72). Every patient had at least one risk factor for falling and >50% of cohort had 4 or more risk factors using NICE tool.

The selective use of DM in high-risk patients can reduce the burden of instability. These individuals are very different to the “average” THA patient. A “perfect storm” is created using a high-risk implant combination (DM & PTS) in high-risk falls risk population. This re-enforces the need to consider all patient and implant factors when deciding bearing selection.

We previously reported that osteoblasts at the curve apex in adolescent idiopathic scoliosis (AIS) exhibit a differential phenotype, compared to non-curve osteoblasts(1). However, the Hueter-Volkmann principle on vertebral body growth in spinal deformities (2) suggests this could be secondary to altered biomechanics. This study examined whether non-curve osteoblasts subjected to mechanical strain resemble the transcriptomic phenotype of curve apex osteoblasts.

Facet spinal tissue was collected perioperatively from three sites, (i) the concave and (ii) convex side at the curve apex and (iii) from outside the curve (non-curve) from six AIS female patients (age 13–18 years; NRES 19/WM/0083). Non-curve osteoblasts were subjected to strain using a 4-point bending device. Osteoblast phenotype was determined by RNA sequencing and bioinformatic pathway analysis.

RNAseq revealed that curve apex osteoblasts exhibited a differential transcriptome, with 1014 and 1301 differentially expressed genes (DEGs; p<0.05, fold-change >1.5) between convex/non-curve and concave/non-curve sites respectively. Non-curve osteoblasts subjected to strain showed increased protein expression of the mechanoresponsive biomarkers COX2 and C-Fos. Comparing unstimulated vs strain-induced non-curve osteoblasts, 423 DEGs were identified (p<0.05, fold-change >1.5). Of these DEGs, only 5% and 6% were common to the DEGs found at either side of the curve apex, compared to non-curve cells. Bioinformatic analysis of these strain-induced DEGs revealed a different array of canonical signalling pathways and cellular processes, to those significantly affected in cells at the curve apex.

Mechanical strain of AIS osteoblasts in vitro did not induce the differential transcriptomic phenotype of AIS osteoblasts at the curve apex.

Cemented total hip replacement (THR) provides excellent outcomes and is cost-effective. Polished taper-slip (PTS) stems demonstrate successful results and have overtaken traditional composite-beam (CB) stems. Recent reports indicate they are associated with a higher risk of postoperative periprosthetic femoral fracture (PFF) compared to CB stems. This study evaluates risk factors influencing fracture characteristics around PTS and CB cemented stems.

Data were collected for 584 PFF patients admitted to eight UK centres from 25/05/2006-01/03/2020. Radiographs were assessed for Unified Classification System (UCS) grade and Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type. Statistical comparisons investigated relationships by age, gender, and stem fixation philosophy (PTS versus CB). The effect of multiple variables was estimated using multinomial logistic regression to estimate odds ratios (OR) with 95% confidence intervals (CI).

Median (IQR) age was 79.1 (72.0–86.0) years, 312 (53.6%) patients were female, and 495 (85.1%) stems were PTS. The commonest UCS grade was type B1 (278, 47.6%). The commonest AO/OTA type was spiral (352, 60.3%). Metaphyseal-split fractures occurred only with PTS stems with an incidence of 10.1%. Male gender was associated with a five-fold reduction in odds of a type C fracture (OR 0.22, 95% CI 0.12 to 0.41, p<0.001) compared to a type B fracture. CB stems were associated with significantly increased odds of transverse fracture (OR 9.51, 95% CI 3.72 to 24.34, p <0.001) and wedge fracture (OR 3.72, 95% CI 1.16 to 11.95, p <0.05) compared to PTS stems.

This is the largest study investigating PFF characteristics around cemented stems. The commonest fracture types are B1 and spiral fractures. PTS stems are exclusively associated with metaphyseal-split fractures, but their incidence is low. Males have lower odds of UCS grade C fractures compared to females. CB stems had higher odds of bending type fractures (transverse and wedge) compared to PTS stems. Biomechanical testing is needed for validation and investigation of modifiable factors which may reduce the risk of unstable fracture patterns requiring complex revision surgery over internal fixation.

Aims

The aim of this prospective cohort study was to evaluate the early migration of the TriFit cementless proximally coated tapered femoral stem using radiostereometric analysis (RSA).

Background

Cam morphology develops during adolescence and predisposes individuals to future hip pain and osteoarthritis. An improved understanding of cam development is required to determine whether the process is modifiable.

Aims

It is unknown whether kinematic alignment (KA) objectively improves knee balance in total knee arthroplasty (TKA), despite this being the biomechanical rationale for its use. This study aimed to determine whether restoring the constitutional alignment using a restrictive KA protocol resulted in better quantitative knee balance than mechanical alignment (MA).

A statement of the purposes of the study and background

Lower back pain (LBP) is one of the ten leading causes of disease burden globally, producing significant detrimental effects on physical and emotional wellbeing whilst having a substantial economic burden for society. There is an inverse relationship between socio-economic status and pain prevalence. The effectiveness of a locally run ‘Back to Fitness Programme’ (6-week education and exercise programme) in the most deprived local authority area in England was evaluated.

Aims

The aim of this study was to determine the stability of a new short femoral stem compared with a conventional femoral stem in patients undergoing cementless total hip arthroplasty (THA), in a prospective randomized controlled trial using radiostereometric analysis (RSA).

Objectives

The aim of this study was to investigate the structural integrity of torn and non-torn human acetabular labral tissue.

Introduction

Registry data from around the world demonstrates instability following primary THA is a leading indication for revision. However, the burden of THA dislocation is poorly documented and is not routinely recorded or reported at a national level. Our aim was to determine the rate of dislocation following primary THA in contemporary practice and in doing so determining the burden of THA dislocation to the NHS in Wales.

Background

Short bone-conserving femoral stem implants were developed to achieve more physiological, proximal bone loading than conventional femoral stems. Concerns have arisen, however, that improved loading may be offset by lower primary stability because of the reduced potential area for bony contact.

Aims

The aim of this study was to describe the epidemiology of closed isolated fractures of the femoral shaft in children, and to compare the treatment and length of stay (LOS) between major trauma centres (MTCs) and trauma units (TUs) in England.

Aims

The aim of this study was to determine whether patients with metal-on-metal (MoM) arthroplasties of the hip have an increased risk of cardiac failure compared with those with alternative types of arthroplasties (non-MoM).

Aims

The aim of this study was to examine the real time in vivo kinematics of the hip in patients with cam-type femoroacetabular impingement (FAI).

Background

Since 2011, the knee service at the Nuffield Orthopaedic Centre has been offering a neutralising medial opening wedge high tibial osteotomy (HTO) to a group of patients presenting with early medial osteoarthritis of the knee, varus alignment and symptoms for more than 2 years. During development of this practice an association was observed between this phenotype of osteoarthritis and the presence of CAM deformity at the hip.

Prosthetic joint infection (PJI) is an uncommon but serious complication of hip and knee replacement. We investigated the rates of revision surgery for the treatment of PJI following primary and revision hip and knee replacement, explored time trends, and estimated the overall surgical burden created by PJI.

We analysed the National Joint Registry for England and Wales for revision hip and knee replacements performed for a diagnosis of PJI and their index procedures from 2003–2014. The index hip replacements consisted of 623,253 primary and 63,222 aseptic revision hip replacements with 7,642 revisions subsequently performed for PJI; for knee replacements the figures were 679,010 primary and 33,920 aseptic revision knee replacements with 8,031 revisions subsequently performed for PJI. Cumulative incidence functions, prevalence rates and the burden of PJI in terms of total procedures performed as a result of PJI were calculated.

Revision rates for PJI equated to 43 out of every 10,000 primary hip replacements (2,705/623,253), i.e. 0.43%(95%CI 0.42–0.45), subsequently being revised due to PJI. Around 158 out of every 10,000 aseptic revision hip replacements performed were subsequently revised for PJI (997/63,222), i.e. 1.58%(1.48–1.67). For knees, the respective rates were 0.54%(0.52–0.56) for primary replacements, i.e. 54 out of every 10,000 primary replacements performed (3,659/679,010) and 2.11%(1.96–2.23) for aseptic revision replacements, i.e. 211 out of every 10,000 aseptic revision replacements performed (717/33,920). Between 2005 and 2013, the risk of revision for PJI in the 3 months following primary hip replacement rose by 2.29 fold (1.28–4.08) and after aseptic revision by 3.00 fold (1.06–8.51); for knees, it rose by 2.46 fold (1.15–5.25) after primary replacement and 7.47 fold (1.00–56.12) after aseptic revision. The rates of revision for PJI performed at any time beyond 3 months from the index surgery remained stable or decreased over time.

From a patient perspective, after accounting for the competing risk of revision for an aseptic indication and death, the 10-year cumulative incidence of revision hip replacement for PJI was 0.62%(95%CI 0.59–0.65) following primary and 2.25%(2.08–2.43) following aseptic revision; for knees, the figures were 0.75%(0.72–0.78) following primary replacement and 3.13%(2.81–3.49) following aseptic revision.

At a health service level, the absolute number of procedures performed as a consequence of hip PJI increased from 387 in 2005 to 1,013 in 2014, i.e. a relative increase of 2.6 fold. While 70% of those revisions were two-stage, the use of single stage revision increased from 17.6% in 2005 to 38.5% in 2014. For knees, the burden of PJI increased by 2.8 fold between 2005 and 2014. Overall, 74% of revisions were two-stage with an increase in use of single stage from 10.0% in 2005 to 29.0% in 2014.

Although the risk of revision due to PJI following hip or knee replacement is low, it is rising. Given the burden and costs associated with performing revision joint replacement for prosthetic joint infection and the predicted increased incidence of both primary and revision hip replacement, this has substantial implications for service delivery.

Image-guided intra-articular hip injection of local-anaesthetic and steroid is commonly used in the management of hip pain. It can be used as a diagnostic and/or therapeutic tool and is of low cost (£75). The aim of this study was to assess how often a hip injection has a therapeutic effect.

This is a retrospective, consecutive, case series of intra-articular hip injections performed in a tertiary referral hospital over a 2-year period (2013–4). Patients were identified from the radiology department's prospectively entered database. Clinical information, reason for injection and subsequent management was obtained from hospital records. All patients prospectively reported their pain levels in a numeric pain scale diary (out of 10) at various time points; pre-, immediately post-, 1st day-, 2nd day- and 2 weeks- post-injection. Only patients with complete pain scores at all time points were included (n=200, of the 250 injections performed over study period, 80%).

The majority of injections were performed for osteoarthritis (OA) treatment (82%). The pain was significantly reduced from a pre-injection score of 7.5 (SD:2) to 5.0 (SD:3) immediately post-injection(p<0.001); only 24 (11%) reported any worsening of pain immediately post-injection. Pain significantly reduced further to 3.8(SD:3) at 2-weeks post-injection (p<0.001). 50% of patients had at least a 3 point drop in reported pain. No improvement was seen in 18 patients and 10 (5%) reported worse pain at 2-weeks compared to pre-injection. Of the OA cohort, 10% have required repeat injections, 45% required no further intervention and 45% underwent or are due for hip replacement. No immediate complications occurred.

Intra-articular hip injection reduced pain in 86% of cases and has delayed any further surgical treatment for at least 2 years in over 50% of OA cases. It is hence a cost-effective treatment modality. Further work is necessary to describe factors predicting response.

Objectives

High failure rates of metal-on-metal hip arthroplasty implants have highlighted the need for more careful introduction and monitoring of new implants and for the evaluation of the safety of medical devices. The National Joint Registry and other regulatory services are unable to detect failing implants at an early enough stage. We aimed to identify validated surrogate markers of long-term outcome in patients undergoing primary total hip arthroplasty (THA).

Introduction

The value of Debridement-Antibiotics-and-Implant-Retention (DAIR) in prosthetic-joint-infection (PJI) is still a matter of debate as most studies to-date are underpowered with variable end-points. In our, tertiary referral, bone infection unit we consider DAIR to be a suitable option in all PJIs with soundly fixed prostheses, despite chronicity. The aims of this study were to define the long-term outcome following DAIR in hip PJI and identify factors that influence it.

To compare the costs of treatment and income received for treating patients with tibial osteomyelitis, comparing limb salvage with amputation.

We derived direct hospital costs of care for ten consecutive patients treated with limb salvage procedures and five consecutive patients who underwent amputation, for tibial osteomyelitis. We recorded all factors which affect the cost of treatment. Financial data from the Patient-Level Information and Costing System (PLICS) allowed calculation of hospital costs and income received from payment under the UK National Tariff. Hospital payment is based on primary diagnosis, operation code, length of stay, patient co-morbidities and supplements for custom implants or external fixators.

Our primary outcome measure was net income/loss for each in-patient episode.

The mean age of patients undergoing limb salvage was 55 years (range 34–83 years) whereas for amputation this was 61 years (range 51–83 years). Both groups were similar in Cierny and Mader Staging, requirement for soft-tissue reconstruction, anaesthetic technique, diagnostics, drug administration and antibiotic therapy.

In the limb salvage group, there were two infected non-unions requiring Ilizarov method and five free flaps. Mean hospital stay was 15 days (10–27). Mean direct cost of care was €16,718 and mean income was €9,105, resulting in an average net loss of €7,613 per patient. Patients undergoing segmental resection with Ilizarov bifocal reconstruction and those with the longest length of stay generated the greatest net loss.

In the amputation group, there were 3 above knee and 2 below knee amputations for failed previous treatment of osteomyelitis or infected non-union. Mean hospital stay was 13 days (8–17). Mean direct cost of care was €18,441 and mean income was €15,707, resulting in an average net loss of €2,734 per patient. Length of stay was directly proportional to net loss.

The UK National Tariff structure does not provide sufficient funding for treatment of osteomyelitis of the tibia by either reconstruction or amputation. Average income for a patient admitted for limb salvage is €6,602 less than that for amputation even though the surgery is frequently more technically demanding (often requiring complex bone reconstruction and free tissue transfer) and the length of hospital stay is longer.

Although both are significantly loss-making, the net loss for limb salvage is more than double that for amputation. This makes treatment of tibial osteomyelitis in the UK National Health Service unsustainable in the long term.

Periprosthetic femoral fracture (PFF) is a potentially devastating complication after total hip arthroplasty, with historically high rates of complication and failure because of the technical challenges of surgery, as well as the prevalence of advanced age and comorbidity in the patients at risk.

This study describes the short-term outcome after revision arthroplasty using a modular, titanium, tapered, conical stem for PFF in a series of 38 fractures in 37 patients.

The mean age of the cohort was 77 years (47 to 96). A total of 27 patients had an American Society of Anesthesiologists grade of at least 3. At a mean follow-up of 35 months (4 to 66) the mean Oxford Hip Score (OHS) was 35 (15 to 48) and comorbidity was significantly associated with a poorer OHS. All fractures united and no stem needed to be revised. Three hips in three patients required further surgery for infection, recurrent PFF and recurrent dislocation and three other patients required closed manipulation for a single dislocation. One stem subsided more than 5 mm but then stabilised and required no further intervention.

In this series, a modular, tapered, conical stem provided a versatile reconstruction solution with a low rate of complications.

Cite this article: Bone Joint J 2015;97-B:1031–7.

A femoral fracture in an adolescent is a significant injury. It is generally agreed that operative fixation is the treatment of choice and rigid intramedullary nailing is a surgical treatment option. We present on experience of treating adolescent femoral fractures using a lateral entry intramedullary nail.

We reviewed 15 femoral fractures in 13 children who we treated in our unit between 2011 and 2014. Two patients had bilateral fractures (non-simultaneous). Data collected included patient demographics, mechanism of injury, type of fracture, associated injuries, size of nail, time to unite and complications.

The mean age of the patients at time of surgery was 12 years (range 10–15). There were 7 male and 6 female. 10 fractures were caused by a fall whilst 5 were due to road traffic collisions (RTC). 8 fractures involved the middle third, 2 of theses were open fractures and were caused by a RTC. The remaining 7 involved the proximal third of the femur. The mean time to radiological union was 3.4 months (range 2.5–5) in 14 fractures. One patient had a delayed union that required bone grafting and united fully at 7.5 months post injury. The only other complications were a broken proximal locking screw in one patient and an undisplaced femoral neck fracture in another patient. These complications did not compromise the outcome. No patients had infection or developed avascular necroses at the latest follow up.

Intramedullary nailing of adolescent femoral fractures using the lateral entry point is safe and effective

The purpose of the study was to investigate the incidence of surgical site infection following elective paediatric orthopaedic surgery.

A pro forma adopted from a pilot study was filled out preoperatively for each elective operation performed during the study period. Each patient was then followed up for six weeks postoperatively to record any SSI that developed. Data collected included patient demographics, type of operation, grade of Surgeon, type of procedure, wound length, skin preparations, use of tourniquet, any antibiotic prophylaxis and length of operation.

This study collated data on 334 operations with 410 procedural sites over a six month period. Infection were recorded in 19 sites equivalent to a SSI rate of 4.63%. None of the patients developed long-term complications.

The mean age of the participants in the study was 11 years (range 0.5 to 17 years), 57% were males and 43% were females.

The infection were detected between 1 and 38 days after surgery. The outcome was not compromised in any of the patients as none of them required long-term treatment. Statistical analysis was undertaken.

The study proves that the surgical site infection after elective paediatric orthopaedic surgery is low and serve as a bases for consenting patients for surgery.

Aims

Femoroacetabular Junction Impingement (FAI) describes abnormalities in the shape of the femoral head–neck junction, or abnormalities in the orientation of the acetabulum. In the short term, FAI can give rise to pain and disability, and in the long-term it significantly increases the risk of developing osteoarthritis. The Femoroacetabular Impingement Trial (FAIT) aims to determine whether operative or non-operative intervention is more effective at improving symptoms and preventing the development and progression of osteoarthritis.

Summary Statement

This study provides preliminary evidence that people with knee osteoarthritis have greater asymmetry in joint loading than healthy controls. Altered loading of the contralateral limb may signify increased risk of injury to other lower limb joints in knee osteoarthritis.

Summary

The dGEMRIC index correlates more strongly with the pattern of radiographic joint space narrowing in hip osteoarthritis at five year follow-up than morphological measurements of the proximal femur. It therefore offers potential to refine predictive models of hip osteoarthritis progression.

Summary

162 patient cohort with serial Metal Artefact Reduction Sequence MRI scans. Patients with normal initial scans can be followed up at 1 year. Those with abnormal scans should be followed up at a shorter interval of 6 months.

Aim

To determine the rate of recurrence of coronal plane deformity in children treated with ‘guided growth’ using 8-plates, from the time of implant removal to skeletal maturity.

The cement used for hemiarthroplasties by the authors and many other surgeons in the UK is Palacos® (containing 0.5g Gentamicin). Similar cement, Copal® (containing 1g Gentamicin and 1g Clindamycin) has been used in revision arthroplasties. We aim to investigate the effect on SSI rates of doubling the gentamicin dose and adding a second antibiotic (clindamycin) to the bone cement in hip hemiarthroplasty.

We randomised 848 consecutive patients undergoing cemented hip hemiarthroplasty for fractured NOF into two groups: Group I, 464 patients, received standard cement (Palacos®) and Group II, 384 patients, received high dose, double antibiotic-impregnated cement (Copal®). We calculated the SSI rate for each group at 30 days post-surgery. The patients, reviewers and statistician were blinded as to treatment group.

The demographics and co-morbid conditions were statistically similar between the groups. The combined superficial and deep SSI rates were 5 % (20/394) and 1.7% (6/344) for groups I and II respectively (p=0.01). Group I had a deep infection rate 3.3 %(13/394) compared to 1.16% (4/344) in group II (p=0.082). Group I had a superficial infection rate 1.7 % (7/394) compared to 0.58% (2/344) in group II (p=0.1861). 33(4%) patients were lost to follow up, and 77 (9%) patients were deceased at the 30 day end point.

Using high dose double antibiotic-impregnated cement rather than standard low dose antibiotic-impregnated cement significantly reduced the SSI rate (1.7% vs 5%; p=0.01) after hip hemiarthroplasty for fractured neck of femur in this prospective randomised controlled trial.

Currently, the cement being used for hemiarthroplasties and total hip replacements by the authors and many other surgeons in the UK is Palacos® (containing 0.5g Gentamicin). Similar cement, Copal® (containing 1g Gentamicin and 1g Clindamycin) has been used in revision arthroplasties, and has shown to be better at inhibiting bacterial growth and biofilm formation. We aim to investigate the effect on SSI rates of doubling the gentamicin dose and adding a second antibiotic (clindamycin) to the bone cement in hip hemiarthroplasty.

We randomised 848 consecutive patients undergoing cemented hip hemiarthroplasty for fractured NOF at one NHS trust (two sites) into two groups: Group I, 464 patients, received standard cement (Palacos®) and Group II, 384 patients, received high dose, double antibiotic-impregnated cement (Copal®). We calculated the SSI rate for each group at 30 days post-surgery. The patients, reviewers and statistician were blinded as to treatment group.

The demographics and co-morbid conditions (known to increase risk of infection) were statistically similar between the groups. The combined superficial and deep SSI rates were 5 % (20/394) and 1.7% (6/344) for groups I and II respectively (p=0.01). Group I had a deep infection rate 3.3 %(13/394) compared to 1.16% (4/344) in group II (p=0.082). Group I had a superficial infection rate 1.7 % (7/394) compared to 0.58% (2/344) in group II (p=0.1861). 33(4%) patients were lost to follow up, and 77 (9%) patients were deceased at the 30 day end point. There was no statistical difference in the 30 day mortality, C. difficile infection, or the renal failure rates between the two groups.

Using high dose double antibiotic-impregnated cement rather than standard low dose antibiotic-impregnated cement significantly reduced the SSI rate (1.7% vs 5%; p=0.01) after hip hemiarthroplasty for fractured neck of femur in this prospective randomised controlled trial.

Treatment for osteoarthritis (OA) has traditionally focused on joint replacement for end-stage disease. An increasing number of surgical and pharmaceutical strategies for disease prevention have now been proposed. However, these require the ability to identify OA at a stage when it is potentially reversible, and detect small changes in cartilage structure and function to enable treatment efficacy to be evaluated within an acceptable timeframe. This has not been possible using conventional imaging techniques but recent advances in musculoskeletal imaging have been significant. In this review we discuss the role of different imaging modalities in the diagnosis of the earliest changes of OA. The increasing number of MRI sequences that are able to non-invasively detect biochemical changes in cartilage that precede structural damage may offer a great advance in the diagnosis and treatment of this debilitating condition.

Cite this article: Bone Joint J 2013;95-B:738–46.

Aim

The Pelvic Support Osteotomy (PSO) or Ilizarov Hip Reconstruction(IHR) is well described for the treatment of septic sequelae of infancy. The purpose of this study was to clinically, functionally and radiographically assess our short-term results of this procedure.

Purposes of the Study

To study the incidence of delayed consolidation of regenerate in children undergoing correction or lengthening of lower limb deformities using an external fixator.

The Pelvic Support Osteotomy (PSO) or Ilizarov Hip Reconstruction(IHR) is well described for the treatment of septic sequelae of infancy. The purpose of this study was to clinically, functionally and radiographically assess our short-term results of this procedure.

25 patients (16 boys, 9 girls) who had undergone a IHR using the Ilizarov/TSF construct over a period of 10 years for a variety of pathologies were reviewed. The mean age at surgery was 15 years 4 months. The pre-operative diagnoses were SCFE(10), hip sepsis (6), DDH (6) and Perthes (3). All had significant leg length discrepancies, 16 had a painful stiff hip, 6 had a painful mobile hip and 3 had a painless unstable hip. At surgery, a mean measured proximal valgus angle of 51° and a mean extension angle of 15° was achieved. Distal femoral lengthening averaged 4.2 cm and distal varus correction was a mean of 8°. The mean fixator time was 173 days.

At a mean of 2 years and 7 months follow-up the lower-extremity length discrepancy had improved from a mean of 5.6 cm apparent shortening to 2.3 cm. Trendelenberg sign was eliminated in 18/25 cases. Improvements in range of hip movements and gait parameters were observed. Stance time asymmetry, step length asymmetry, pelvic dip and trunk lurch improved significantly. One patient had conversion to a total hip replacement after 7 years, 4 patients required re-do PSO due to remodelling of the proximal osteotomies, two had heterotopic ossification and two had significant knee stiffness due to lack of compliance.

The early results of IHR are encouraging to equalise limb lengths, negate trendelenburg gait, provide a mobile hip with a reasonable axis and the possibility of conversion to THR in the future if needed. Complications need to be anticipated and the effects of remodelling and maintaining adequate knee range of motion must be emphasised.

Introduction

The reverse obliquity fractures of the proximal femur are anatomically and mechanically different from most intertrochanteric fractures. These fractures are complex and very difficult to treat. To evaluate the results of the treatment of reverse obliquity intertrochanteric fractures with cephalomedullary nails.

Objectives

The number of surgical procedures performed each year to treat femoroacetabular impingement (FAI) continues to rise. Although there is evidence that surgery can improve symptoms in the short-term, there is no evidence that it slows the development of osteoarthritis (OA). We performed a feasibility study to determine whether patient and surgeon opinion was permissive for a Randomised Controlled Trial (RCT) comparing operative with non-operative treatment for FAI.

Aim

Differing reports about the surgical management of the supracondylar humeral fracture make evidence-based practice very difficult, so knowledge of the contemporary practices and opinions of an expert body can provide a useful benchmark for appraisal; the aim of this study was to obtain this information.

Aim

To determine if the instigation of Magnetic Resonance Extremity (MRE) scanning in our unit as part of the management of suspected paediatric scaphoid fractures has prevented overuse of splints or casts reduced unnecessary clinic appointments and saved our department financially.

Aim

To evaluate the influence of arthrodiatasis in the natural history of the stages of the disease radiologically and also the timing of arthrodiatasis.

Introduction

Hip arthroscopy is a relatively new procedure and evidence to support its use remains limited. Well-designed prospective clinical trials with long-term outcomes are required, but study design requires an understanding of current practice. Our aim was to determine temporal trends in the uptake of non-arthroplasty hip surgery in England between 2001 and 2011.

Introduction

Subtle deformities of the acetabulum and proximal femur are recognised as biomechanical risk factors for the development of hip osteoarthritis (OA) as well as a cause of hip and groin pain. We undertook this study to examine relationships between a number of morphological measurements of the acetabulum and proximal femur and the hip pain in a 20-year longitudinal study.

Introduction

Segmental tibia fractures are high-energy injuries that are difficult to treat. We report on the use of the Ilizarov Method to treat 40 consecutive AO42C (35) and AO42B3 (5) fractures by a single surgeon. Fractures with bone loss requiring transport were excluded, as were fractures initially treated with nail or plate.

Aim

To study the results of using recombinant human bone morphogenic protein-2 (rhBMP-2) to achieve bone union in children with complex orthopaedic problems including skeletal dysplasia, congenital limb deficiencies and complex trauma.

Aim

To review the outcome of deep prosthetic infection in patients following hip hemiarthroplasty surgery.

Aim

To investigate the effectiveness of a decision-based protocol designed to minimise the use of medial incisions when performing crossed-wire fixation of supracondylar fractures of the distal humerus whilst minimising ulnar nerve injury.

Introduction

Solid or cystic pseudotumour is a potentially destructive complication of metal on metal (MoM) couples, usually needing revision surgery. However, complete clearance of the pseudotumour is unlikely at times. This prospective case-controlled study reports cases which had recurrence after revision surgery for pseudotumour related to metal on metal hip couples.

Aim

The aim of the study was to characterise gait in patients with achondroplasia post lengthening.

Purpose

To examine the effect of limb lengthening on the quality of life of people who have disproportionate short stature (DSS).

Introduction

Stem geometry is known to influence the outcome in THA; however it is unknown whether the material properties, stiffness in particular can influence the stem stability and outcome. The aim of this study was to measure the influence of stem material properties on micromotion and migration using Roentgen Stereophotogrammetric Analysis (RSA) system.

Introduction

Since the introduction of 3rd generation Metal-on-Metal-Hip-Resurfacing-Arthroplasty (MoMHRA), thousands of such prostheses have been implanted worldwide in younger patients with end-stage hip osteoarthritis. However, no independent centre has reported their medium-to-long term outcome. The aim of this study is to report the ten year survival and outcome of the Birmingham Hip Resurfacing (BHR), the most commonly used MoMHRA worldwide.

Introduction

Medial calcaneal displacement osteotomy with an FDL tendon transfer is a common method of correcting pes planus deformity secondary to grade II tibialis posterior dysfunction. There is currently no evidence that calcaneal displacement alters the centre of pressure in the foot from a medial to a more central position as the normal shape is reconstituted.

Introduction

Malalignment of some designs of stem is associated with an increased risk of aseptic loosening and revision. We investigated whether the alignment of the cemented polished, double-taper design adversely affected outcome, in a multicentre prospective study.

INTRODUCTION

Studies have suggested that there is a reduction in head-neck-ratio (HNR) associated with MoMHRA. A reduction in HNR at operation would decrease range of movement and increase impingement risk. Impingement could lead to 20 edge loading, increasing wear. Serum ion levels of Chromium (Cr) and Cobalt (Co) are surrogate markers of wear. Although acetabular component orientation has been shown to contribute to wear and PT development, the role of a decrease in HNR has only been highlighted in PT development. This study aimed to measure changes in HNR that occur at resurfacing and determine any gender- and component size-specific differences. In addition it aimed to determine whether changes in HNR could be associated with increased wear.

INTRODUCTION

Although simulation studies have shown superior wear properties of metal-on-metal articulations, increased concern exists regarding the excess in-vivo wear of a small number of Metal-on-Metal-Hip-Resurfacing (MoMHRA) implants. Serum ion levels of Chromium (Cr) and Cobalt (Co) are surrogate markers of wear. Risk factors associated with increased wear include female gender, small components, dysplasia, cup orientation outside safe zone and femoral head downsize during surgery with an associated decrease in Head-Neck-Ratio (HNR). However, these factors are interlinked. This study aims to identify the factors that are most important for subsequent wear of MoMHRA, by performing a multivariate analysis.

INTRODUCTION

The introduction of hard-on-hard bearings and the consequences of increased wear due to edge-loading have renewed interest in the importance of acetabular component orientation for implant survival and functional outcome following hip arthroplasty. Some studies have shown increased dislocation risk when the cup is mal-oriented which has led to the identification of a safe-zone1. The aims of this prospective, multi-centered study of primary total hip arthroplasty (THA) were to: 1. Identify factors that influence cup orientation and 2. Describe the effect of cup orientation on clinical outcome.

Plasma levels of cobalt and chromium ions and Metal Artefact Reduction Sequence (MARS)-MRI scans were performed on patients with 209 consecutive, unilateral, symptomatic metal-on-metal (MoM) hip arthroplasties. There was wide variation in plasma cobalt and chromium levels, and MARS-MRI scans were positive for adverse reaction to metal debris (ARMD) in 84 hips (40%). There was a significant difference in the median plasma cobalt and chromium levels between those with positive and negative MARS-MRI scans (p < 0.001). Compared with MARS-MRI as the potential reference standard for the diagnosis of ARMD, the sensitivity of metal ion analysis for cobalt or chromium with a cut-off of > 7 µg/l was 57%. The specificity was 65%, positive predictive value was 52% and the negative predictive value was 69% in symptomatic patients. A lowered threshold of > 3.5 µg/l for cobalt and chromium ion levels improved the sensitivity and negative predictive value to 86% and 74% but at the expense of specificity (27%) and positive predictive value (44%).

Metal ion analysis is not recommended as a sole indirect screening test in the surveillance of symptomatic patients with a MoM arthroplasty. The investigating clinicians should have a low threshold for obtaining cross-sectional imaging in these patients, even in the presence of low plasma metal ion levels.

Patients with hip fracture are at high risk of venous thromboembolism (VTE). Chemical thromboprophylaxis with low molecular weight heparin (LMWH) is associated with a risk of major bleeding in certain patient groups, such as those with renal failure. In these patients, unfractionated heparin should be used. Our aim was to determine the practice of VTE risk assessment in patients admitted with hip fracture against the national guidance, which states that all should have VTE risk assessment on admission. We also assessed the impact of introducing the VTE risk assessment form on prescribing practice of chemical thromboprophylaxis in patients with renal failure.

Prospective audit of patients of 50 patients admitted with hip fracture from 4/8/10 with re-audit of 50 patients admitted from 17/2/2011 after introducing the VTE risk assessment form into the hip fracture admissions proforma. Retrospective analysis was undertaken to determine chemical thromboprophylaxis prescribing in patients with eGFR <30ml/min/1.73m².

Patient demographics were comparable in both audit loops, with the mean age being equal (84 years) and an equal majority of female patients (76%). There were similar numbers of patients with eGFR <30ml/min/1.73m² in both audit loops with 8% (n=4) in the initial audit, and 10% (n=5) in the re-audit. Frequency of VTE risk assessment significantly increased from 16% to 86% after including the VTE risk assessment form in the hip fracture proforma (p<0.0001). Despite this, there was no significant reduction in prescribing of LMWH in patients with renal failure with eGFR <30ml/min/1.73m², (P=0.52).

Documentation of VTE risk assessment in patients admitted with hip fracture can be improved by simple measures such as inclusion of the VTE risk assessment form in the admissions proforma. However, this did not result in a reduction of LMWH prescribed in patients with significant renal failure and risk of major bleeding.

Cognitive impairment is common in patients with hip fracture both on admission and may develop later on. Reduced cognitive function is a risk factor for development of delirium, correlates with poor rehabilitation, and is an independent predictor of increased mortality. Despite its commonplace and potential for serious morbidity, cognitive dysfunction is often poorly assessed & diagnosed.

Our aims were to 1) assess the practice of cognitive assessment on admission for hip fracture patients according to local guidelines and 2) ascertain whether it can be improved by the formal introduction of Abbreviated Mental Test Score (AMTS) & Clock Drawing Test (CDT) in the hip fracture admission proforma.

A prospective audit was undertaken of cognitive assessment by either AMTS or CDT for 50 consecutive patients admitted with hip fracture from 4/8/2010. Subsequently, the hip fracture admission proforma was amended to include both the AMTS & CDT. A re-audit was performed on 50 consecutive patients admitted from 17/2/2011 to determine the change in practice.

Patient demographics were comparable in both audit loops, with the mean age being equal (84 years) and an equal majority of female patients (76%). Cognitive assessment by either AMTS or CDT significant increased from 28% (n=14) to 86% (n=43) in the re-audit (p<0.0001). All AMTS were completed in accordance with instructions, whereas almost half of CDTs were incompletely or incorrectly filled out (45%).

The assessment of cognitive function can be greatly improved by inclusion of both the AMTS & CDT to the hip fracture admission proforma, allowing the most appropriate multi-disciplinary care to be planned for the patient. Whilst both CDT and AMTS are good screening tools for cognitive impairment, many are unfamiliar with CDT & more training is needed.

Stem geometry is known to influence the outcome in THA; however it is unknown whether the material properties, stiffness in particular can influence the stem stability and outcome. The aim of this study was to measure the influence of stem material properties on micromotion and migration using Roentgen Stereophotogrammetric Analysis (RSA) system.

41 patients were implanted with a collarless polished tapered (CPT) femoral stem (Zimmer, Warsaw, Indiana), which was made of either cobalt-chromium (CoCr) (n=21) or stainless steel (n=20). RSA was used to measure dynamically inducible micromotion (DIMM: difference in stem position in going from double-leg stance (DLS) to single leg stance (SLS)), prosthesis bending (difference in the head-tip distance when going from DLS to SLS), and mean migration of the head, tip and the cement restrictor. DIMM and bending were measured at 3 months, migration at 6, 12 and 24 months. All analyses were carried out using SPSS for windows (v.15.0.0, Chicago. IL, USA). Results were reported as mean ± 95% confidence interval (CI) and regarded as significant when p < 0.05.

Preliminary analysis showed that total head DIMM was significantly (p = 0.02) greater for CoCr (0.97mm ± 0.6mm) than stainless steel (0.27mm ± 0.6mm). The mean stem bending for CoCr was 0.08mm (± 0.06mm) and for stainless steel 0.15mm (± 0.06mm) (p =0.77). Both implants heads migrated posteriorly, medially and distally. The mean subsidence for the cobalt-chromium and stainless steel stems was 1.02mm (± 0.19mm) (p < 0.001) and 1.12mm (± 0.34mm) (p=0.001) (p= 0.07) at 24 months.

It was interesting to note that the dynamically induced micromotion was greater for the stiffer stem, however there were no differences in terms of overall migration, indicating that survival (in terms of loosening) should be the similar for both steel and CoCr versions of this implant.

INTRODUCTION

The risk of dislocation in large diameter metal on metal hip replacement is significantly lower than in standard THR. This is due to the increased primary arc, increased jump distance and possibly a suction effect. Our unit has performed over 1500 of these cases with an overall revision rate of <1%. We report a case series of dislocations in 5 large diameter metal on metal hips undertaken at our unit.

Femoral stem varus has been associated with poorer results. We report the incidence of varus/valgus malalignment of the Exeter polished, double taper design in a multicentre prospective study. The surgical outcomes at a minimum of five year and complication rates are also reported.

A multicentre prospective study of 987 total hip replacements was undertaken to investigate whether there is an association between surgical outcome and femoral stem malalignment. The primary outcome measure was the change in the Oxford hip score (OHS) at five years. Secondary outcomes included the rate of dislocation and revision.

The incidence of varus and valgus malignment were 7.1% and 2.6% respectively. There was no significant difference in OHS between neutral and malaligned femoral stems at 5 years (neutral, mean = 40.2; varus, mean 39.3, p = 0.465; valgus, mean = 40.9, p = 0.605). There was no significant difference in dislocation rate between the groups (p = 0.66). There was also no significant difference in revision rate (p = 0.34).

This study provides evidence that the Exeter stem is extremely tolerant of varus and valgus malalignment, both in terms of outcome and complication rate.

Aim

To determine the outcome, the need for revision surgery, quality of life (QOL) of patients and the financial implications of instability following successful closed reduction of dislocation after primary total hip arthroplasty (THA).

We obtained pre-operative and six-month post-operative Oxford hip (OHS) and knee scores (OKS) for 1523 patients who underwent total hip replacement and 1784 patients who underwent total knee replacement. They all also completed a six-month satisfaction question.

Scatter plots showed no relationship between pre-operative Oxford scores and six-month satisfaction scores. Spearman’s rank correlation coefficients were -0.04 (95% confidence interval (CI) -0.09 to 0.01) between OHS and satisfaction and 0.04 (95% CI -0.01 to 0.08) between OKS and satisfaction. A receiver operating characteristic (ROC) curve analysis was used to identify a cut-off point for the pre-operative OHS/OKS that identifies whether or not a patient is satisfied with surgery. We obtained an area under the ROC curve of 0.51 (95% CI 0.45 to 0.56) for hip replacement and 0.56 (95% CI 0.51 to 0.60) for knee replacement, indicating that pre-operative Oxford scores have no predictive accuracy in distinguishing satisfied from dissatisfied patients.

In the NHS widespread attempts are being made to use patient-reported outcome measures (PROMs) data for the purpose of prioritising patients for surgery. Oxford hip and knee scores have no predictive accuracy in relation to post-operative patient satisfaction. This evidence does not support their current use in prioritising access to care.

Introduction: Metal-on-metal-hip-resurfacing-arthroplasty (MoMHRA) has been associated with the development of inflammatory pseudotumours(IP), especially in females. IPs have been linked to wear debris, which can be related to metal-ion blood levels. Acetabular component position has been shown to influence wear. We have identified an optimum component orientation minimising IP risk around an inclination/anteversion of 40°/20°±10°. Our aim was to see if this optimal position results in lower metal ions and to identify the boundary of an optimal placement zone for low wear.

Methods: A cohort of 104 patients(60M:44F) with unilateral MoMHRA was studied. Blood tests were obtained at a mean follow up of 3.9 years and serum Co/Cr levels were measured(ICPMS). High metal ion concentrations were defined as Co> 4.1ppb and Cr> 5.2ppb. Radiographic cup inclination/anteversion were measured using EBRA. The differences in ion levels between different orientation zones were investigated. Three orientation zones were defined centered on 40°/20°: Z1-within ±5°, Z2-outside ±5°/within ±10° and Z3-within ±10°.

Results: There was a wide range of cup placements. Females had significantly (p< 0.001) smaller components(mean:51, 44–60) than males(mean: 56, 52–64). Cr levels, but not Co, were higher in females(p=0.002) and those with small femoral components(< 50mm, p =0.03). Patients with cups within Z1 (n=13) had significantly lower Co(p=0.005) and Cr(p=0.001). Males with cups within Z3(n=27) had lower ion levels in comparison to those outside, which were significantly lower for Co(p=0.049) but not Cr(p=0.084). Females had similar ion levels within and out of Z3(Cr/Co: p=0.83/0.84). Co levels were significantly lower in Z1(n=13) in comparison to Z2(n=33)(p=0.048) but Cr levels were not different (p=0.06).

Discussion: MoMHRA cups placed within ±5° of the optimum(40°/20°) had significantly lower metal ions indicating lower wear within this narrow zone. This safe zone, could extend to ±10° for males only. The narrower safe zone coupled with smaller components implanted are possible factors contributing to the increased IP incidence seen in females.

Introduction: Metal on metal hip resurfacing arthroplasty-induced pseudotumours are a serious complication, which occur in 1.8% of patients who undergo this procedure in our institution. The aim of this study was to measure the 3D in vivo wear on the surface of resurfacing components revised for pseudotumour, compared to a control group.

Method: Thirty-six hip resurfacing implants were divided into two groups; 18 patients with a clinical and histopathological diagnosis of pseudotumour and 18 controls (revised for femoral neck fracture and infection). Three dimensional contactless metrology (Redlux^™ Ltd) was used to scan the surface of the femoral and acetabular components, to a resolution of 20 nanometers. The location, depth and area of the wear scar were determined for each component. A separate blinded analysis to determine the presence of absence of impingement was performed by one of the authors.

Results: The volumetric wear rate for femoral component of the pseudotumour group was 3.29 mm3/yr (SD5.7) and 0.79 mm3/yr (SD1.2) for the control group (p=0.005). In the pseudotumour group, the volumetric wear rate of the acetabular component was 2.5 mm3/yr (SD6.9) compared to 0.36 mm3/yr (SD0.80) for the control group (p=0.008). Edge-wear was detected in 89% of acetabular components in the pseudotumour group and 21% of those in the control group (p=0.01). Anterior or posterior edge-wear, consistent with impingement was present on the femoral components of 73% of patients in the pseudotumour group and 22% in the control group (p=0.01).

Discussion: This work demonstrates that implants revised for pseudotumour have significantly higher volumetric wear rates than controls. They also have a significantly higher incidence of edge-wear than controls. We suggest that a significant proportion of pseudotumours are associated with high concentrations of metal wear debris; however a minority may result from a hypersensitivity reaction to metal ions.

Introduction: The use of highly cross-linked polyethylene (HXLPE) is now commonplace for total hip arthroplasty, however there is no long-term data to support its use. Hip simulator studies suggest that the wear rate of some types of HXLPE is ten times less than conventional polyethylene (UHMWPE). The outcomes of hip simulator studies are not always reproduced in vivo and there is some evidence that HXLPE wear may increase between 5 and 7 years.

Method: A prospective double blind randomised control trial was conducted using Radiostereometric Analysis (RSA). Fifty-four subjects were randomised to receive hip replacements with either UHMWPE liners or HXLPE liners. All subjects received a cemented CPT stem and uncemented Trilogy acetabular component (Zimmer, Warsaw, IN, USA). The 3D penetration of the head into the socket was determined to a minimum of 7 years.

Results: The total liner penetration was significantly different at 7 years (p=0.005) with values of 0.33 mm (SE 0.05 mm) for the HXLPE group and 0.55 mm (SE 0.05 mm) for the UHMWPE group. The steady state wear rate from 1 year onwards was significantly lower for HXLPE (0.005 mm/yr, SE 0.007 mm/yr) than for UHMWPE (0.037 mm/yr, SE 0.009 mm/yr) (p=0.007). The direction of wear was supero-lateral.

Discussion: We have previously demonstrated that the penetration in the first year is creep-dominated, from one year onwards the majority of penetration is probably due to wear. This study confirms the predictions from hip simulator studies which suggest that the wear rate of this HXLPE approaches that of metal-on-metal and ceramic-on-ceramic articulations. HXLPE may have the potential to reduce the need of revision surgery, due to wear debris induced osteolysis. It may also enable surgeons to use larger couples, thus reducing the risk of impingement and dislocation.

Introduction: Metal on metal hip resurfacing arthroplasty(MoMHRA) is an alternative option to THR in the treatment of young adults with OA. A recognised MoMHRA complication is the development of an inflammatory pseudotumour(IP). Diagnosis is made with the aid of US and/or MRI. To-date, no radiographic indication of the presence of IP has been identified. Neck thinning is a recognised phenomenon in MoMHRA hips not associated with any adverse clinical events. Its pathogenesis is considered multi-factorial. Our aim was to establish whether excessive neck narrowing is associated with the presence of a pseudotumour.

Methods: Twenty-seven hips (26 patients) with IP confirmed clinically, radiologically, intra-operatively and histologically were matched for sex, age, pre-operative diagnosis, component size and follow-up with an asymptomatic MoMHRA cohort (Control n=60). For all patients, prosthesis-neck-ratio(PNR) was measured on plain AP pelvic radiographs post-operatively and at follow-up as previously described and validated.

Results: All IP patients (4M:23F) and all (12M:48F) but two controls had a posterior approach at the time of MoMHRA. Post-operatively, there was no difference in the PNR between the two groups (p=0.19). At an average follow up of 3.5 years (range:0.7–8.3), IP patients(mean 1.26, 1.10–1.79) had a significantly higher (p< 0.0001) PNR in comparison to their controls(mean 1.14, 1.03–1.35). Greater neck narrowing occurred in both genders. IP necks had narrowed by an average of 8% (range:3–23). The degree of neck narrowing was correlated with length of survival of implant (p=0.001).

Discussion: This study shows a strong association between IP and neck narrowing. Processes such as impingement and increased wear are considered to be involved in the pathogenesis of both IP and neck narrowing. Furthermore, the presence of an IP, could lead to altered vascularity via a mass effect and further contribute to neck narrowing. Neck narrowing in symptomatic MOMHRA patients should alert surgeons of the possible presence of IP.

Introduction: The assessment of quality in the provision of healthcare is one of the core features of the National Health Service in the 21st Century. From April 2009 Patient Reported Outcome Measure (PROM) data are being collected for the Department of Health for elective hip and knee arthroplasty using generic and disease specific measures of health status. The perceived uses of these data may be for research, assessment of procedural outcome, measures of health inequalities and to aid commissioning groups in selecting their secondary care providers. Foot and ankle surgery covers a wide spectrum of operative procedures with patient responses less predictable than with major joint arthroplasty. We report the use of a sixteen point satisfaction-based questionnaire in order to investigate the nature of patient outcome after the processes of foot and ankle surgery.

Methods: A prospective series of 100 two-part Visual Analogue Scale (VAS) questionnaires was distributed to patients undergoing elective foot and ankle surgery at the Northern General Hospital under the care of four foot and ankle surgeons over a three-month period. The questionnaires were numbered to allow patient anonymity. The first part of nine questions enquired about pre-operative preparation and information and was distributed before surgery. The second part of seven questions, distributed at the first post-operative clinic sought to investigate their hospital and operative experience. Free text comments were requested in addition to the VAS responses, which were expressed as percentages.

Results: 97% of part one and 85% of part two questionnaires were returned completed. 82% had both parts completed and matched. The day case to inpatient ratio was 55: 45. For part one, all clinically related questions scored more than 90% satisfaction, with only two scores for administration-based questions falling below this level. For part two, satisfaction for clinical questions again scored more than 90% and overall, all scored more than 80% satisfaction. Only 23% of pre-operative and 28% of post-operative questionnaires were returned with free-text comments.

Conclusions: A simple patient satisfaction-based questionnaire may be as useful as existing non-validated generic scoring systems used in foot and ankle surgery when assessing quality in the health service, particularly where regional demographics or referral patterns may be important factors influencing patient outcomes. Active dialogue with the surgical colleges and Department of Health should be pursued to avoid inappropriate outcome measures being imposed in foot and ankle surgery.

Metal on metal hip resurfacing (MMHR) is a popular procedure for the treatment of osteoarthritis in young patients. Several centres have observed masses, arising from around these devices, we call these inflammatory pseudotumours. They are locally invasive and may cause massive soft tissue destruction. The aim of this study was to determine the incidence and risk factors for pseudotumours that are serious enough to require revision surgery.

In out unit, 1,419 MMHRs were performed between June 1999 and November 2008. All revisions were identified, including all cases revised for pseudotumour. Pseudotumour diagnosis was made by histological examination of samples from revision. A Kaplan-Meier survival analysis was performed, Cox regression analysis was used to estimate the independent effects of different factors.

The revision rate for pseudotumour increased with time and was 4% (95% CI: 2.2% to 5.8%) at eight years. Female gender was a strong risk factor: at eight years the revision rate for pseudotumours in men was 0.5% (95% CI 0% to 1.1%), in women over 40 it was 6% (95% CI 2.3% to 10.1%) and in women under 40 it was 25% (95% CI 7.3% to 42.9%) (p< 0.001). Other factors associated with an increase in revision rate were, small components (p=0.003) and dysplasia (p=0.019), whereas implant type was not (p=0.156).

We recommend that resurfacings are undertaken with caution in women, especially those younger than 40 years of age, but they remain a good option in men. Further work is required to understand the patho-aetiology of pseudotumours so that this severe complication can be avoided.

Introduction: Pseudotumours (soft-tissue masses relating to the hip joint) following metal-on-metal hip resurfacing arthroplasty (MoMHRA) have been associated with elevated serum and hip aspirate metal ion levels, suggesting that pseudotumours occur when there is increased wear. This study aimed to quantify in vivo wear of implants revised for pseudotumours and a control group of implants revised for other reasons of failure.

Methods: A total of 30 contemporary MoMHRA implants in two groups were investigated in this Institutional Review Board approved study:

8 MoMHRA implants revised due to pseudotumour;

The linear wear of retrieved implants was measured using a Taylor-Hobson Roundness machine. The average linear wear rate was defined as the maximum linear wear depth divided by the duration of the implant in vivo.

Results: In comparison with the non-pseudotumour implant group, the pseudotumour implant group was associated with:

significantly higher median linear wear rate of the femoral component: 8.1um/year (range 2.75–25.4um/year) vs. 1.79um/year (range 0.82–4.15um/year), p=0.002; and

Similarly, differences were also measured in absolute wear values. The median absolute linear wear was significantly higher in the pseudotumour implant group:

21.05um (range 2.74–164.80um) vs. 4.44um (range 1.50–8.80um) for the femoral component, p=0.005; and

Wear on the acetabular cup components in the pseudotumour group always involved the edge, indicating edge-loading of the bearing. In contrast, edge-loading was observed in only one acetabular component in the non-pseudotumour group of implants. The deepest wear was observed well within the bearing surface for the rest of the non-pseudotumour group. The difference in the incidence of edge-loading between the two groups was statistically significant (Fisher’s exact test, p=0.03).

Discussion: Significantly greater linear wear rates of the MoMHRA implants revised due to pseudotumour support the in vivo elevated metal ion concentrations in patients with pseudotumours. This study provides the first direct evidence to confirm that pseudotumour is associated with increased wear at the MoM articulation. Furthermore, edge-loading with the loss of fluid film lubrication may be the dominant wear generation mechanism in patients with pseudotumour.

Introduction: The use of second generation highly cross-linked polyethylene (HXLPE) is now commonplace for total hip arthroplasty, however there is no long-term data to support its use. Hip simulator studies suggest that the wear rate of HXLPE is ten times less than conventional polyethylene (UHMWPE). The outcomes of hip simulator studies are not always reproducible in vivo. Long term clinical data is required, as there is emerging clinical data, which suggests that some types of second generation HXLPE may have increased wear after 5 years.

Method: A prospective double blind randomised control trial was conducted using Radiostereometric analysis (RSA). Fifty-four subjects were randomised to receive hip replacements with either UHMWPE liners or HXLPE liners. All subjects received a cemented CPT stem and uncemented Trilogy acetabular component (Zimmer, Warsaw, IN, USA). The 3D penetration of the head into the socket was determined to a minimum of 7 years.

Results: The total liner penetration was significantly different at 7 years (p=0.01) with values of 0.33mm (SD 0.17mm) for the HXLPE group and 0.51mm (SD 0.14mm) for the UHMWPE group. The steady state wear rate from 1 year onwards was significantly lower for HXLPE (0.003 mm/yr, SD 0.04 mm/yr) than for UHMWPE (0.03 mm/yr, SD 0.03 mm/yr) (p=0.01). The direction of wear was in the antero-medial direction in both groups.

Conclusion: We have previously demonstrated that the penetration in the first year is creep-dominated, from one year onwards the majority of penetration is due to wear. The wear rate of this second generation HXLPE approaches that of metal on metal bearings. Second-generation HXLPE may have the potential to reduce the risk of revision surgery, due to wear debris induced osteolysis.

Introduction: Metal on metal hip resurfacing arthroplasty-induced pseudotumours are a serious complication, which occur in 4% of patients who undergo this procedure. The aim of this study was to measure the 3D in vivo wear on the surface of resurfacing components revised for pseudotumour, compared to a control group.

Method: Thirty-nine hip resurfacing implants were examined; these were sourced from our institutions prosthesis retrieval bank. They were divided into two groups; 22 patients with a clinical and histopathological diagnosis of pseudotumour and 17 controls. Patient demographics and time to revision were known. Three dimensional contactless metrology (Redlux™ Ltd) was used to scan the surface of the femoral and acetabular components, to a resolution of 20 nanometers. The location, depth and area of the wear scar was determined for each component. Volumetric wear was determined, along with the presence of absence of edge-loading. A separate blinded analysis to determine the presence of absence of impingement was performed by one of the authors. ANOVA was used to test for differences in wear and Fishers Exact test was used to compare the incidence of edge-loading between the groups.

Results: The volumetric wear rate for femoral component of the pseudotumour group was 4.7mm3/yr (SD3.5) and 1.7 mm3/yr (SD1.5) for the control group (p=0.03). In the pseudotumour group, the volumetric wear rate of the acetabular component was 3.5 mm3/yr (SD3.6) compared to 0.02 mm3/yr (SD0.07) for the control group (p=0.01). Edge-loading was detected in 74% of acetabular components in the pseudotumour group and 22% of those in the control group (p=0.01). Anterior or posterior edge-loading, consistent with impingement was present on the femoral components of 73% of patients in the pseudotumour group and 22% in the control group (p=0.01).

Discussion: This work demonstrates that implants revised for pseudotumour have significantly higher volumetric wear rates than controls. They also have a significantly higher incidence of edge-loading and impingement than controls. Edge-loading significantly increases wear. We suggest that pseudotumours are caused by high concentrations of metal wear debris, which have been shown to have a toxic effect on osteocytes and macrophages. This is the one of the first studies to demonstrate a clear link between pseudotumours and increased bearing surface wear. It is also the first to demonstrate that edge-loading, due to impingement, occurs in a significant number of patients who develop this condition. Improved implantation techniques and resurfacing designs may help avoid this serious complication of hip resurfacing.

Introduction: Metal-on-metal hip resurfacing arthroplasty (MoMHRA) has gained popularity as an alternative to THR for younger patients with osteoarthritis. A growing concern has been the association of MoMHRA with the development of inflammatory pseudotumours (IP), especially in women. These have been linked to metal-on-metal wear, which can be related to metal ion concentrations. Elevated metal wear debris levels may result from impingement, rim contact and edge loading. Head-neck ratio (HNR) is a predetermining factor for range of movement and impingement. Neck thinning is a recognised phenomenon post-MoMHRA and we have found an association of IP with increased neck thinning based on a case control study. Our aims were to identify HNR changes a hip undergoes when resurfaced and at follow up; and whether greater neck thinning at follow-up could be associated with the presence of elevated metal ions.

Methods: A cohort of 91 patients (57M:34F) with unilateral MoMHRAs were included in this study. Blood tests were obtained at a mean follow up of 3.9 years (range 1.7–7 years) and serum (Co:Cr) ion levels were measured (ICPMS). High metal ion concentrations were defined as Co> 4.1ppb and Cr> 5.2ppb. For all patients, head-neck ratio (HNR) was measured on plain anterio-posterior pelvic radiographs pre-operatively, immediately post-operatively and at follow-up.

Results: Female patients had significantly bigger HNR pre-op (mean=1.35, range:1.22–1.64) compared to males(mean=1.22, range:1.05–1.38) (p< 0.01). Immediately post-op, female HNRs (mean: 1.26, range: 1.14–1.34) were not different to male patients(mean=1.24, range=1.11–1.38) (p=0.11). At follow-up HNR was once again significantly bigger (p< 0.01) in females (mean=1.35, range: 1.21–1.49), compare to males (mean=1.27, range:1.11–1.38). HNR alterations with operation (p=0.00) and at follow-up (p< 0.01) were significantly bigger in female patients. Furthermore, there was a significant correlation between high ion levels and HNR change at follow-up for both Co (p=0.02) and Cr (p< 0.01).

Conclusion: This study identified gender-specific changes in HNR that resurfaced hips undergo, not previously documented. Female hips have greater HNR pre-operatively, compared to male hips, and appear to be biomechanically disadvantaged when resurfaced. A decrease in HNR with resurfacing could result in impingement and lead to processes, known to be more prevalent in females, such as neck thinning, increased wear and IP development. In addition, we highlight a correlation between high ion levels and greater neck thinning at follow-up. Increased neck thinning in symptomatic MoMHRA hips could be secondary to increased wear and should be investigated further radiologically for the presence of IP.

From 2004–2006, in an attempt to reduce the waiting time for patients listed for total knee and total hip arthroplasty at Cardiff and Vale NHS Trust, 156 total hip replacements (THRs) were performed by Swedish Orthopaedic surgeons at an NHS treatment centre in England.

All patients were contacted and invited to a review appointment with a Consultant specialising in hip and revision hip replacement. Oxford Hip Scores and clinical and radiographic evaluation were performed. Patients who declined an appointment were sent a postal questionnaire. Radiographs were analysed for component position, radiolucent lines, medial floor breach, leg length discrepancy.

One hundred and thirteen hips were reviewed at a mean 23 month follow-up. The mean Oxford score was 26. Mean age at surgery was 69. Cemented THR was performed in 104 hips; hybrid in 7; cementless in 2. The Exeter stem and Cenator cemented cup were used in the majority of cases. 16% had acetabular inclination greater than 55 degrees. Radiolucent lines around the cup were seen in 76/113 hips. Femoral stem position was greater than 4 degrees varus in 47/113. Medial floor breach seen in 13/113. 10/113 had leg length discrepancy > 1cm. There were 3 dislocations, 1 femoral fracture, 1 pulmonary embolus, 3 deep infections, 2 superficial infections.

Revision surgery has been performed in 18/113 – the majority for a painful loose acetabular component. A further 5/113 have been recommended for surgery. The further surgery rate was 12% at 2 year follow-up.

The revision rate far exceeds the 0.5% 5-year failure rate reported in the Swedish Registry for the components used. This initiative has left a legacy of unhappy patients, and increased the workload required in our unit to correct the problems. The lack of long-term ownership of patients may be an important factor.

Roentgen Stereophotogrammetric Analysis (RSA) can predict long-term outcome of prostheses by measuring migration over time. The Exeter femoral stem is a double-tapered highly polished implant and has been shown to subside within the cement mantle in 2 year RSA studies. It has a proven track record in terms of long-term survivorship and low revision rates. Several studies have demonstrated excellent clinical outcomes following its implantation but this is the first study to assess stem migration at 10 years, using RSA.

This is a single-centre study involving 20 patients (mean age: 63 years, SD=7) undergoing primary total hip replacement for degenerative osteoarthritis using the lateral (Hardinge) approach. RSA radiographs were taken with the patient bearing full weight post-operatively, at 3, 6, 12 months and at 2, 5 and 10 years follow-up. The three-dimensional migration of the Exeter femoral stem was determined.

The mean Oxford Hip Score at 10 years was 43.4 (SD=4.6) and there were no revisions. The stems subsided and rotated internally during a 10-year period. The mean migrations of the head and tip of the femoral stem in all three anatomic directions (antero-posterior, medio-lateral & supero-distal) were 0.69 mm posterior, 0.04 mm lateral and 1.67 mm distal for the head and 0.20 mm anterior, 0.02 mm lateral and 1.23 mm distal for the tip. The total migration at 10 years was 1.81 mm for the head and 1.25 mm for the tip.

The Exeter femoral stem exhibits migration which is a complex combination of translation and rotation in three dimensions. Comparing our 10 year with our previous 2 year migration results, the Exeter stems show continued, but slow distal migration and internal rotation. The subsidence continues to compress the cement and bone-cement interface which maintains secure fixation in the long term.

We have evaluated the difference in the migration patterns over two years of two cementless stems in a randomised, controlled trial using radiostereophotogrammetric analysis (RSA). The implants studied were the Furlong HAC stem, which has good long-term results and the Furlong Active stem, which is a modified version of the former designed to minimise stress concentrations between the implant and bone, and thus to improve fixation.

A total of 23 Furlong HAC and 20 Furlong Active stems were implanted in 43 patients. RSA examinations were carried out immediately post-operatively and at six, 12 and 24 months post-operatively.

The subsidence during the first year in the Furlong HAC stem, was approximately one-third that of the Furlong Active stem, the measured mean subsidence of the femoral head at six months being 0.27 mm (95% confidence interval (CI) 0.03 to 0.51) and 0.99 mm (95% CI 0.38 to 1.60), respectively (p = 0.03). One Active stem continued to subside during the second year. All hips, regardless of the type of stem were clinically successful as judged by the Oxford hip score and a derived pain score without any distinction between the two types of stem.

The initial stability of the Furlong Active stem was not as good as the established stem which might compromise osseo-integration to the detriment of long-term success. The changes in the geometry of the stem, to minimise stress have affected the attainment of initial stability.

Pseudotumours are a rare complication of hip resurfacing. They are thought to be a response to metal debris which may be caused by edge loading due to poor orientation of the acetabular component. Our aim was to determine the optimal acetabular orientation to minimise the risk of pseudotumour formation.

We matched 31 hip resurfacings revised for pseudotumour formation with 58 controls who had a satisfactory outcome from this procedure. The radiographic inclination and anteversion angles of the acetabular component were measured on anteroposterior radiographs of the pelvis using Einzel-Bild-Roentgen-Analyse software. The mean inclination angle (47°, 10° to 81°) and anteversion angle (14°, 4° to 34°) of the pseudotumour cases were the same (p = 0.8, p = 0.2) as the controls, 46° (29° to 60°) and 16° (4° to 30°) respectively, but the variation was greater. Assuming an accuracy of implantation of ± 10° about a target position, the optimal radiographic position was found to be approximately 45° of inclination and 20° of anteversion. The incidence of pseudotumours inside the zone was four times lower (p = 0.007) than outside the zone.

In order to minimise the risk of pseudotumour formation we recommend that surgeons implant the acetabular component at an inclination of 45° (± 10) and anteversion of 20° (± 10) on post-operative radiographs. Because of differences between the radiographic and the operative angles, this may be best achieved by aiming for an inclination of 40° and an anteversion of 25°.

Introduction: Percutaneous in situ pinning of severe SUFE can lead to problems. We describe our technique and results for surgical dislocation to reduce severe SUFE.

Method: Ganz’s approach of greater trochanteric flip, safe dissection and surgical dislocation to preserve the femoral head blood supply was followed to anatomically reduce the femoral head. We have treated 16 cases in this way, but describe nine with a minimum follow up of 2 years. Their mean age was 13.6 years (9 to 16 years). All had severe SUFE with four acute on chronic and two unstable slips. Two were previously pinned and another had a partially fused growth plate. The mean follow up was 3.1 years (2.1 to 4.6 years).

Results: All patients had a good to excellent outcome. Their pre-operative deformity was 84 degrees (65 to 110) measured by AP and cross table lateral x-rays, CT or MRI scans. The average hip external rotation deformity was 70 degrees. Post operatively internal and external rotation and all other movements were similar to the contra-lateral uninvolved hip. None developed avascular necrosis (AVN) or chondrolysis

Conclusions: This technique is demanding but can give good results for severe SUFE.

Introduction: Plastic deformation of the regenerate bone is a complication noted soon after limb lengthening. However, less is known about the factors responsible for the development of plastic deformation.

Materials and Methods: Retrospective analysis of 35 X-rays of achondroplast children who had limb lengthening were reviewed. The study compared Monofocal Vs Bifocal and Long lengthenings(> 10 cms) Vs modest lengthenings(≤ 10 cms) of tibial lengthening. Other parameters included in study were Bone healing Index, total length gained and sagittal and coronal axial deformities. There were 20 females and 15 males, 21 long lengthenings and 14 modest lengthenings in the study. The joint orientation and diaphyseal angles(antero-posterior and lateral X-ray views) was used for the measurement of plastic deformation of the regenerate bone.

Results: The mean age at operation was 10 years (range; 6–16 years). There were 29 cases of monolateral fixator and 6 of Ilizarov ring fixator, Of which 26 had monofocal lengthening and 9 had bifocal lengthening (34 callotasis and 1 chondrodiastasis). The total average length gained was 10 cms (range; 23–152). The mean bone healing index and external fixation index/time were 41 days and 352 days respectively. Plastic deformation of the regenerate bone was seen in 26 cases in total. 24 out of 29 cases of monolateral fixator (82%) developed plastic deformation. 44%(4/9) of bifocal group and 84%(22/26) of monofocal group showed evidence of plastic deformation. The long lengthenings showed plastic deformation in 85% (18/21) of the cases, whereas only 57%(8/14) of the cases were positive in modest lengthening group. Most of the axial deviation was in the coronal plane in 92% (24/26) and the sagittal plane accounted to only 23%(6/26) requiring surgical correction.

Conclusions: Long lengthenings and monofocal techniques showed more plastic deformation than bifocal and short lengthenings. However, Ilizarov ring fixator with bifocal corticotomy seemed to be promising with less association with the above entity in our recent experience.

Aim: To review our experience with epiphysiodesis using three different methods to correct LLD and to establish the efficacy of these procedures.

Method: A retrospective review of 42 patients from 1999 to 2008 with at least one year follow-up recorded type and location of the epiphysiodesis, average operating time and hospital stay, complications, method of prediction, timing and the final LLD. CT scanograms and mechanical axis view with grids were used to assess LLD.

Results: Epiphysiodesis was as per Canale for 26, by Metaizeau screw in 14 and by staples in 2. Average operation time was 42 minutes for Canale type, 45 minutes for the screws and 56 minutes for the staple cases. The pre operative LLD of 3.7 cms In the Canale group, improved to 1.2 cms over an average follow-up of 2.1 yrs. There were 4 minor and 2 major complications with a 92% success rate. For the screw group, the mean change was 1.8 cms over 2.2 yrs with 2 minor and 2 major complications giving a success rate of 85%. With staples the success rate was 100% and the mean change was 1.8 cms at an average of 2.3 yrs. In 14 cases where bone age reports were available, the multiplier method seemed better at predicting estimated LLD at skeletal maturity and timing of epiphysiodesis than the Moseley chart.

Conclusions: Percutaneous epiphysiodesis by any method is reliable, minimally invasive and with acceptable complication rate when compared to a corrective osteotomy or open Phemister-type epiphysiodesis. Our experience suggests that the Canale method has the least complications and best success rate. Paleys multiplier method was better at predicting LLD and timing of epiphysiodesis than the Moseley Chart.

Aim: To review our experience with hemi-epiphysiodesis using different methods for the correction of angular deformity about the knee.

Method: This was a retrospective review of 73 patients (101 knees) who underwent hemi-epiphysiodesis from 1999 to 2008. Assessment looked at the type and degree of deformity, implants used, average operating time and hospital stay, complications, degree of correction and the average time to correction.

Results: There were 50 boys and 23 girls with bilateral deformity in 28 cases. There were 88 valgus and 13 varus knees. Average follow-up was 17 months. Staples were used in 28 cases, “8” Plates in 24, Screws in 16 and Drilling in 5 cases. The distal femoral physis was involved in 46 knees, the proximal tibial physis in 21 and both physes in 34 knees (total 135 physes). Average operation time and hospital stay were similar for all methods. There were 6 minor and 3 major complications with staples with an average correction time of 14 months, 3 minor complications with an average correction time of 11 months with “8” plates, 3 minor and 1 major complication with an average correction time of 14 months with screws and 1 minor complication with drilling with an average correction time of 13 months. The outcome was considered as resolved in 47 and pending in 26 cases, with all showing progressive correction of deformity.

Conclusions: Hemi-epiphysiodesis by any method is an effective way to correct angular deformities about the knee in skeletally immature individuals within a reasonable time limit and with minimal morbidity when compared to a corrective osteotomy. Our experience suggests that “8” plates achieve faster correction with the least complications when compared to other methods. Valgus knee deformities corrected faster than varus ones.

The aim of this study was to evaluate the impact of a preoperative education programme on length of hospital stay for primary and revision knee arthroplasty patients.

The programme was introduced at our hospital in October 2006 to encourage patients to play an active role in their postoperative recovery process. It was delivered by a multi-disciplinary team consisting of an arthroplasty nurse, ward physiotherapist, occupational therapist and orthopaedic consultant. Patients were educated about their care pathway, knee surgery, pain management, the expected discharge goal, post operative inpatient and outpatient rehabilitation. Data was prospectively reviewed for 472 patients who underwent (primary or revision) knee arthroplasty for the period between January 2006 and November 2007. There were 150 patients in the Conventional group and 322 patients in the Educational group. The mean length of stay reduced significantly from 7 days in the Conventional group to 5 days in the Education group (P< 0.01). In addition 20 percent more patients were discharged early (within 1 to 4 days) in Education group compared to the Conventional group (P< 0.01). There was no statistically significant difference in the percentage of inpatient complications and readmissions between the two groups.

Our study demonstrates that preoperative education is a safe and effective method of reducing length of stay for knee arthroplasty patients. Significantly more patients achieved discharge within four postoperative days.

Introduction: Despite the satisfactory short-term implant survivorship of MoM hip resurfacing arthroplasty, symptomatic abnormal periprosthetic soft-tissue masses relating to the hip joint, ‘pseudotumours’, are being increasingly reported. These were found be locally destructive, requiring revision surgery in 75% of patients. Asymptomatic pseudotumours have not been previously investigated.

Methods: The aims were: (1) to investigate the prevalence of asymptomatic pseudotumours; and (2) to investigate their potential association with the level of metal ions. A total of 160 hips in 123 patients with a mean age 56 years (range 33–73) were evaluated at a mean follow-up of 61 months (range 13–88). Radiographs and OHS were assessed. Patients with a cystic or solid mass detected on the ultrasound/MRI had an aspiration or biopsy performed. Cobalt and chromium levels were analysed using Inductively-Coupled Plasma Spectrometer.

Results: Pseudotumours were found in 6 patients (5F: 1M). In 80% of bilateral cases, it was found in both sides. Histological examination showed extensive necrosis and diffuse lymphocyte infiltration. The presence of pseudotumour was associated with higher serum cobalt (9.2 μg/L vs. 1.9μg/L, p< 0.001) and chromium levels (12.0μg/L vs. 2.1μg/L, p< 0.001); higher hip aspirate cobalt (1182 μg/L vs. 86.2μg/L, p=0.003) and chromium levels (883μg/L vs. 114.8μg/L, p=0.006); and with inferior OHS (23 vs. 14 p=0.08).

Discussion: The prevalence of asymptomatic pseudotumour (5%) was higher than previously reported for the symptomatic pseudotumours (1%). There was a sixfold elevation of serum and a twelve-fold elevation of hip aspirate levels of cobalt and chromium in patients with pseudotumours. This suggests that pseudotumours may be a biological consequence of the large amount of metal debris generated in vivo. The association between pseudotumour and elevated metal ion levels might theoretically be explained by either systemic hypersensitivity responses to metal ions or local cytotoxic effects due to a high level of metal ions.

Introduction: Obligatory external rotation during flexion is well recognised as a cardinal feature of Slipped Upper Femoral Epiphyses (SUFE). We have evaluated the significance of acetabular version in contributing to the external rotational deformity that is seen in otherwise normal hips. We present a small case series focussing on the characteristics of this pathology, highlighting its significance and outlining a treatment strategy.

Method: Five patients (eight hips) presented with disabling hip pain during non-sporting activities. All their hip radiographs had been reported as normal. The rotational profile of both acetabulum and femur in these patients was evaluated by MRI and CT scans.

Results: Clinical examination revealed otherwise normal hips but for an external rotation deformity which got worse on hip flexion. The average external rotation deformity with the hip in extension was 60 degrees, which worsened to 90 degrees during hip flexion. Three of these hips had been previously treated with in situ pinning for SUFE. Other hips were in patients who were either skeletally mature or close to skeletal maturity. We found that all were “profunda hips” with severe acetabular retroversion. The abnormality in acetabular version was best defined on axial imaging.

Conclusions: The femoral head is a spherical conchoid. The concept of version of the hip (both femoral and acetabular) as described by McKibbin, Tonnis and Ganz is reviewed. Femoral retroversion is common in patients with SUFE, but the addition of acetabular retroversion makes these hips disproportionately symptomatic. This deformity causes a combination of pincer and cam impingement, which is responsible for the marked disability. SUFE alone causes cam impingement, whilst a corresponding degree of slip without retroversion and profunda of the acetabulum is not that disabling.

The presence of pseudotumours, which are soft-tissue masses relating to the hip, after metal-on-metal hip resurfacing arthroplasty has been associated with elevated levels of metal ions in serum, suggesting that pseudotumours occur when there is increased wear. We aimed to quantify the wear in vivo of implants revised for pseudotumours (eight) and of a control group of implants (22) revised for other reasons of failure.

We found that the implant group with pseudotumours had a significantly higher rate of median linear wear of the femoral component at 8.1 μm/year (2.75 to 25.4) than the 1.79 μm/year (0.82 to 4.15; p = 0.002) of the non-pseudotumour group. For the acetabular component a significantly higher rate of median linear wear of 7.36 μm/year (1.61 to 24.9) was observed in the pseudotumour group compared with 1.28 μm/year (0.81 to 3.33, p = 0.001) in the other group. Wear of the acetabular component in the pseudotumour group always involved the edge of the implant, indicating that edge-loading had occurred.

Our findings are the first direct evidence that pseudotumour is associated with increased wear at the metal-on-metal articulation. Furthermore, edge-loading with the loss of fluid-film lubrication may be an important mechanism of generation of wear in patients with a pseudotumour.

Metal-on-metal hip resurfacing is commonly performed for osteoarthritis in young active patients. We have observed cystic or solid masses, which we have called inflammatory pseudotumours, arising around these devices. They may cause soft-tissue destruction with severe symptoms and a poor outcome after revision surgery. The aim of this study was to determine the incidence of and risk factors for pseudotumours that are serious enough to require revision surgery.

Since 1999, 1419 metal-on-metal hip resurfacings have been implanted by our group in 1224 patients; 1.8% of the patients had a revision for pseudotumour. In this series the Kaplan-Meier cumulative revision rate for pseudotumour increased progressively with time. At eight years, in all patients, it was 4% (95% confidence interval (CI) 2.2 to 5.8). Factors significantly associated with an increase in revision rate were female gender (p < 0.001), age under 40 (p = 0.003), small components (p = 0.003), and dysplasia (p = 0.019), whereas implant type was not (p = 0.156). These factors were inter-related, however, and on fitting a Cox proportional hazard model only gender (p = 0.002) and age (p = 0.024) had a significant independent influence on revision rate; size nearly reached significance (p = 0.08). Subdividing the cohort according to significant factors, we found that the revision rate for pseudotumours in men was 0.5% (95% CI 0 to 1.1) at eight years wheras in women over 40 years old it was 6% (95% CI 2.3 to 10.1) at eight years and in women under 40 years it was 13.1% at six years (95% CI 0 to 27) (p < 0.001).

We recommend that resurfacings are undertaken with caution in women, particularly those under 40 years of age but they remain a good option in young men. Further work is required to understand the aetiology of pseudotumours so that this complication can be avoided.

Purpose: Recent animal evidence has suggested that Bupivicaine may be harmful to articular cartilage. The purpose of this study was establish whether, following arthroscopy of the knee, infiltration of Bupivicaine around the portals is as effective as intra-articular infiltration for post-operative analgesia.

Method: Consecutive patients attending for knee arthroscopy were consented and randomised to one of two groups. Following arthroscopy, Group I received 20mls 0.5% Bupivicaine infiltrated into the joint; Group II received 20mls 0.5% Bupivicaine infiltrated around the portals. A Visual Analogue Score (VAS) was collected at one hour post-operatively and rescue analgesia recorded. A power calculation was performed. Ethical approval was granted.

Results: There were 68 patients in Group I (intra-articular) and 69 patients in Group II (portal). There was no significant difference in the age or sex distribution of patients in either group. The mean VAS score was 3.04 in Group I and 3.24 in Group II. There was no significant difference between the two groups (p=0.619). There was also no significant difference in the need for rescue analgesia (p=0.930). The study has demonstrated equivalence between the two groups, within one VAS point (Power = 80%).

Conclusion: We would recommend that following knee arthroscopy, Bupivicaine should be infiltrated around the portals, avoiding intra-articular infiltration.

Introduction: We report on a group of 20 metal-on-metal resurfaced hips (17 patients) presenting with a soft tissue mass associated with various symptoms; these masses we termed pseudotumours. All patients underwent plane radiography; CT, MRI and ultrasound investigations were also performed for some patients. Where samples were available histology was performed.

Methods: All patients in this series were female. Presentation was variable; the most common symptom was pain or discomfort in the hip region. Other symptoms included spontaneous dislocation, nerve palsy, a noticeable mass or a rash. The common histological features were extensive necrosis and lymphocytic infiltration. Fourteen of the 20 cases (70%) have so far required revision to a conventional hip replacement and their symptoms have either settled completely or improved substantially since the revision surgery. Two of the three bilateral cases have asymptomatic pseudotumours on the opposite side.

Conclusions: We estimate that about 1% of patients develop a pseudotumour in the first five postoperative years after a hip resurfacing. The cause of these pseudotumours is unknown and is probably multi-factorial, further work is required to define this; they may be manifestations of a metal sensitivity response. We are concerned that with time the incidence of these pseudotumours will increase.

Aim: To assess the ease of use and reliability of PICC lines for the delivery of intravenous antibiotics in children with septic joints.

Method: Over a twelve month period 22 children with septic joints were prospectively recruited. All received open arthrotomy and washout prior to commencing antibiotic treatment. At the time of surgery, a PICC line was inserted. All children were given intravenous antibiotics for two weeks then oral antibiotics for four weeks. Inflammatory blood markers were reviewed regularly. Upon removal of the PICC line the tip was sent for microbiological testing.

Results: All 22 children made a full recovery with a minimum of twelve months follow up (range 12–20 months). All PICC line tips were negative for microbiological culture after 48 hours.

Conclusion: Peripheral cannulation for intravenous access in children can be challenging. Younger children have chubby limbs and often fragile veins. Even with the use of topical analgesics the procedure can be traumatic for a young child. A PICC line inserted at the time of the surgical washout of the infected joint seems an ideal solution. PICC lines are safe, reliable and allow for at least two weeks of intravenous access, avoiding the need for regular re-cannulation of children.

The administration of intra-articular local anaesthetic is common following arthroscopy of the knee. However, recent evidence has suggested that bupivacaine may be harmful to articular cartilage. This study aimed to establish whether infiltration of bupivacaine around the portals is as effective as intra-articular injection.

We randomised 137 patients to receive either 20 ml 0.5% bupivacaine introduced into the joint (group 1) or 20 ml 0.5% bupivacaine infiltrated only around the portals (group 2) following arthroscopy. A visual analogue scale was administered one hour post-operatively to assess pain relief. Both patients and observers were blinded to the treatment group. A power calculation was performed.

The mean visual analogue score was 3.24 (sd 2.20) in group I and 3.04 (sd 2.31) in group 2. This difference was not statistically significant (p = 0.62).

Infiltration of bupivacaine around the portals had an equivalent effect on pain scores at one hour, and we would therefore recommend this technique to avoid the possible chondrotoxic effect of intra-articular bupivacaine.

Purpose: To alert the Orthopaedic fraternity that smoking needs to be considered in the Paediatric population and highlight it’s adverse effect on bone healing index.

Method: During assessment of Paediatric patients who had undergone limb reconstruction surgery, a sub-population was found to have a prolonged time to consolidation of the regenerate to norm. Screening for contributing factors, we were surprised to learn that this subgroup were active smokers. Revisiting their radiographs, it was felt that the quality of the regenerate appeared to differ from non-smokers.

Results: We identified 12 patients who were active smokers. 2 also had parents who smoked. They all exhibited a prolonged time to regenerate consolidation. We calculated their bone healing indices to compare with non smokers and found significant differences.

Conclusion: Smoking has adverse effects on bone healing in children as well as adults. We have drawn up an advise sheet to make patients and their parents aware of the adverse effects of active and passive smoking on bone healing.

AIM: The purpose of this prospective study was to asses the outcome of antegrade intramedullary wiring of displaced distal end of fifth metacarpal fracture in skeletally immature. Intramedullary wiring for fracture metacarpals have been well described in the literature. Retrograde wiring for neck of metacarpal fractures have been associated with limitation of extension at metacarpo-phalangeal joint due to involvement of gliding extensor mechanism. Foucher described ‘Bouguet’ osteosynthesis with multiple wires for metacarpal neck fracture which can be technically demanding in small bones of children. We describe an antegrade wiring using a single bent K-wire at the tip for reducing and stabilising displaced metacarpal neck fracture by rotating 180 degree after crossing fracture site, a method similar to Methaizeau technique for stabilisation of displaced radial neck fractures using nancy nail.

METHOD: Between 2000 to 2006 we treated 9 boys with displaced distal end of fifth metacarpal fracture +/− rotational deformity of little finger using above technique. All of them had closed injuries and the indication for surgery was rotatory mal-alignment or fracture angulation more than 40 degrees. The assessment involved a clinical and radiological examination. The mean age was 13 years. The mean follow-up was 15 months.

RESULTS: All fractures healed in anatomical alignment. There was no loss of active or passive movement of the little finger metacarpo-phalangeal joint or weakness of grip strength in any children. All children returned to pre-injury activity level within 4–6 weeks. There were no complications.

CONCLUSION: Early results of treating displaced little finger metacarpal neck fracture in children using antegrade intramedullary wire are encouraging.

Aim: Spinal stenosis is a known entity in achondroplasia and a need for screening for the symptomatic children was identified in a tertiary limb reconstruction service. The aim of this study was to evaluate whether clinical and radiological imaging would identify the at risk group.

Materials and methods: 205 achondroplastic children were treated at our service in the last 20 years. A prospective clinical screening programme for spinal stenosis which also included the MRI imaging of entire spine was however introduced only in 1996. 26 patients were available for this study. Case notes were reviewed for clinical symptoms and neurological signs. MR images were assessed for stenosis especially at Cervico medullary junction and lumbar level. Canal diameters were measured at all spinal levels from CMJ to lumbo-sacral junction. Neurosurgical interventions were recorded. An attempt was made to identify high risk factors that required surgical intervention.

Results: Delayed milestones were observed in 7 patients. Positive history of back pain or radicular pain was obtained in 10 whereas 10 patients had symptoms of neurogenic claudication. Brisk reflexes and clonus were consistent findings. Severe foramen magnum narrowing was observed in 23 patients and 13 showed ‘kinking’ or ‘pinching’, suggesting severe compression. Of the 17 patients seen by neurosurgeons 6 required single or multiple surgical decompressions. Ventriculo-peritoneal shunt was inserted in 4. 5 children required CMJ decompression and one required lumbar canal decompression. There was a 7 mm difference in AP diameter measured on MRI at CMJ between the two non operated and operated groups. Female patients with delayed milestones and CMJ narrowing to less than 25 mm were identified as high risk.

Conclusion: The cause of increased morbidity and mortality in young achondroplasts is attributable to severe CM compression. Sudden death can occur by acute or gradual progressive encroachment of respiratory centre at medulla oblongata. We were able to identify symptomatic patients early before developing myelomalacia and cord changes by screening all symptomatic children with achondroplasia. We propose that female gender, especially with delayed milestones as another high risk factor. We stress upon the importance of developing a nationalised selective screening programme with guidelines in specialist orthopaedic and joint multi-disciplinary Skeletal Dysplasia clinics.

Introduction: Ankle fractures accounts for 25% to 38% of all physeal fractures. An accurate diagnosis is the key to the appropriate management of these fractures. Traditionally the management decisions have been based on x-ray findings. We have used computed tomograpy (CT) scans in additon to x-rays in the management of these fractures.

Objective: To determine the usefulness of computed tomograpy (CT) scans in the management of ankle fractures in children.

Materials and Methods: Between 2001 to 2005, 53 patients with ankle fractures who were managed in our unit had CT scans in addition to plain radiographs. The mean age was 12.3 years (+/− 2.1). The radiographs were reviewed by senior paediatric orthopaedic surgeon who classified the fractures and formulated treatment plans (operative/non-operative). The CT scans were then reviewed by the respective surgeon and a similar exercise undertaken. A Radiologist confirmed that the fractures were classified accurately.

Results: In 47% (25 fractures) the x-ray diagnosis/classification tallied with the CT scans whilst in 53% (28 fractures) the CT scans showed the fractures were more extensive/serious than noticed on the x-rays. The management was changed in 34% after reviewing the CT scans, In 9 from operative to non-operative treatment and in the other 9 from non-operative to operative treatment.

Conclusion: We have found CT scans to be more useful than plain radiographs in making an accurate diagnosis of ankle fractures in children and thus planning appropriate management.