Aims

Adult patients with history of childhood infection pose a surgical challenge for total hip arthroplasty (THA) due to distorted bony anatomy, soft-tissue contractures, risk of reinfection, and relatively younger age. Therefore, the purpose of the present study was to determine clinical outcome, reinfection rate, and complications in patients with septic sequelae after THA.

Background

Despite studies into patient consent and their understanding of the potential risks of trauma surgery, no study has looked at the patient's understanding of the procedure involved with neck of femur fracture surgery.

Incidence of pars defect associated with idiopathic scoliosis has been reported as 6% based on roentgenographic evaluation in previous studies. (Fisk et al, 1978). We aim to present our results in an MRI based study.

224 patients of adolescent idiopathic scoliosis (AIS) who had an MRI scan over a period of three years (2006-2008), performed either as a preoperative investigation or due to other symptoms were reviewed. All MRI scans were reviewed by two experienced musculoskeletal radiology consultants independently.

Among 224 patients 13 (5.8%) patients were found to have pars defect. Mean age-group of patients were (19 years, range-11-40). 84.6% (n=11) patients were female and 15.3% patients were male. There was varying severity of curve patterns. We have noted two lumbar/thoraco-lumbar curves (Lenke 5), King Type I-6, King Type II-2 and three King Type III curves. All scoliotic deformities were non-structural. Bilateral pars defect was noted in nine (69%) patients.

Previous studies (Fisk et al, 1978; Mau H 1981) have described the incidence of pars defect as approximately 6.2%. Recent studies have emphasized use of MRI to diagnose pars defect based on signal changes in the pedicle (Sairyo et al.). Our study reveals the incidence of pars defect in AIS to be 5.8 % based on MRI diagnosis which does not seem to be different to previous roentgenographic studies.

In major procedures like scoliosis surgery, parents are often asked to sign the consent on behalf of children because of the pretext that minor may have limited understanding and judgement about the procedure. Scoliosis surgery for patients with AIS is mainly indicated for cosmetic or psychological reasons.

We audited our practice in the department to collect information on the current consent practices involving the minor patients undergoing scoliosis surgery.

We also have conducted a questionnaire survey of the various spinal units in UK to assess their practice in this regard.

Forty-two consent forms (28 patients; multiple procedures in some patients) and case notes of patients between 12 and 16 years undergoing scoliosis surgery were reviewed. We have contacted 12 spinal deformity correction units and 11 spinal trauma units across UK over telephone to assess the current consenting practice as well.

9.5% (n=4) patients signed there own consent forms. Except in one case explanation of risks were documented in detail. Except two units (18%) offering the minor patient to sign their consent, parents are usually asked to sign consent on their behalf in majority (10/12) units. Seven out of the twelve spinal units use standard NHS or department of health consent forms. Few units have their own consent form with some alterations or additions.

There is no specific age when a child becomes competent to consent to treatment: It depends both on the child and on the seriousness and complexity of the treatment being proposed. However, it is still good practice to encourage competent children to more involved along with their families in decision-making.

Incidence of pars defect associated with idiopathic scoliosis has been reported as 6% based on roentgenographic evaluation in previous studies. (Fisk et al, 1978). We aim to present our results in an MRI based study.

Methods: 229 patients of adolescent idiopathic scoliosis (AIS) who had an MRI scan over a period of three years (2006–2008), performed either as a preoperative investigation or due to other symptoms were reviewed. All MRI scans were reviewed by two experienced musculoskeletal radiology consultants independently.

Results: Among 229 patients 18 (7.86%) patients were found to have pars defect. Mean age-group of patients were (19 years, range-11–40). Male -5 (27.7%), female- 13(72.2%). There was varying severity of curve patterns, major thoracic curve-10, major lumbar curve-4, mild thoracic curve-3 and mild lumbar curve in one. Bilateral pars defect was noted in 14 (77.8%) patients.

Discussion: Previous studies (Fisk et al, 1978; Mau H 1977) have described the incidence of pars defect as approximately 6.2%. Recent studies have emphasized use of MRI to diagnose pars defect based on signal changes in the pedicle (Sairyo et al, 2009). Our study reveals the incidence of pars defect in AIS to be 7.86 % based on MRI diagnosis which does not seem to be different to previous roentgenographic studies.

Conflicts of Interest: none

Source of Funding: none

Aim: Volar locking plates are increasingly used in the management of distal radius fractures. As with any new implant, understanding the rate and type of potential metalwork related complications is important. The aim of the study was to determine the type and rate of implant related complications that require further surgery when using volar locking plates in the management of distal radius fractures.

Methods: In this study, we reviewed 114 distal radius fractures treated with volar locking plating. Patient records were reviewed with regards to demographics, operative details and post-operative outcomes. Fractures were classified as intra-articular or extra-articular. They were further classified using the AO classification system

Results: In our series, 12 cases (10%) underwent further surgery for metal work related complications mainly for screw protrusion into the radiocarpal joint following fracture collapse. Intra-articular fractures had a significantly greater complication rate as compared to extra-articular ones (11 vs. 1, P=0.04). There was no significant difference between the three plating systems used in this series with regards to need of further surgery (P=0.43). There was no significant difference between the grade of the operating surgeon with regards to metal work complications (P=0.9). There was no difference in rate of complications between males and females (P=0.27). Similarly there was no difference in metal work complications between patients aged less than 60 as compared to those aged more than 60 years (P=0.58). Our study has shown that volar locking plates may be associated with up to 10% rate of metalwork complications requiring revision surgery. The most common (8 out of 12) cause of re-operation was to remove the screws protruding into the radio-carpal joint.

Discussion: Our results suggest that volar locking plates are associated with a high rate of metal work related complications requiring further surgery. In conclusion our study suggests that volar locking plates are associated with high reoperation rates for implant related complications. Intraoperative screening to ensure that there is no intrarticular penetration is also essential. We favour obtaining intra-operatively a lateral view with the forearm elevated 15–20 degrees to the horizontal plane to allow for the medial-lateral radial inclination and taking the posterior-anterior view at about 20 degrees to the horizontal plane to allow for the normal volar distal radial tilt.

We feel that for a common fracture such as distal radial fractures an ideal implant should be easily reproducible with a low complication rate.

Introduction: The Polarus nail is used in the treatment of displaced surgical neck of humerus fractures, but has been reported to have a high hardware complication rate. A recent change to 5.3 mm “non-toggling” proximal locking screws has been introduced in an attempt to minimise these complications.

The aims of this study were to determine union rates and hardware complications, and to assess whether the “non-toggle” proximal locking option prevented screw back-out.

Methods: We performed a retrospective review of case notes and radiographs of consecutive patients treated with the 150 mm length Polarus nail for acute displaced surgical neck of humerus fractures at our unit between 1st May 2002 and 29th February 2008. All patients were followed up until fracture union.

Results: Forty-nine patients were treated with the Polarus nail during the study period. Eleven patients were lost to follow-up before fracture union, so were excluded. Median age of the patients was 72 years (range: 31 to 94 years). Mean time to surgery was 10.7 days (range: two to 25 days).

Thirty-six fractures (95%) went on to unite following treatment with the Polarus nail. Of the two fractures that failed to unite one had an infective non-union and the other developed avascular necrosis with non-union of the surgical neck.

Twelve patients (32%) developed post-operative hardware complications. In nine (24%) there was backing out of the proximal locking screws, but only two patients had symptoms requiring screw removal. In five patients (13%) the nail was prominent proximally, causing impingement. In one patient (3%) the proximal screws penetrated the gleno-humeral joint, although this was asymptomatic.

There was backing-out in six of the 21 patients (29%) in which the standard 5.0 mm proximal locking screws were used. This compared with three out of 14 patients (21%) in which the 5.3 mm “non-toggling” screws were used. The difference in the rate of screw backing-out between the two groups was significant (P = 0.0474, Fisher’s Exact test). In three patients a mixture of 5.0 and 5.3 mm screws was used.

Discussion: The Polarus nail provides a stable fixation to union when used for the treatment of displaced surgical neck of humerus fractures. It is associated with a high hardware complication rate (32%), however, this is asymptomatic in the majority of cases (60%). The 5.3 mm “non-toggle” proximal locking option was found to reduce the rate of screw back-out compared with the standard 5.0 mm screw. We recommend the use of this “non-toggling” screw option for proximal locking.

Introduction and Aim: The metacarpal fractures constitute 10% of skeletal fractures in general affecting mainly children and young adults. There is a lot of discrepancy and lack of evidence with regards to correctly managing the little finger metacarpal fractures. Our study was aimed at investigating the current practice of management little finger metacarpal fractures among upper limb surgeons in United Kingdom.

Methods: We conducted an online survey between June 2006 and June 2007 consisting of 10 multiple-choice questions that was e-mailed to 278 upper limb orthopaedic specialist surgeons. The response rate was 58% (n = 158) from the upper limb surgeons. Four questionnaires had to be excluded due to multiple responses to each question or incomplete forms.

Results: 43% upper limb surgeons prefer neighbour strapping alone for non-operative management of little finger metacarpal fractures. Ulnar gutter cast or splint was the next choice among 19% upper limb surgeons while 13% respondents apply neighbour strapping to ring finger along with a splint. There was mixed response regarding period of immobilisation. 40% of surgeons were in favour of 3 weeks of immobilisation, 23% for 2 weeks while 28% do not immobilise these fractures at all.

With regard to considering the most important indication(s) for surgical intervention, rotational deformity was the most common indication (84%), followed by open fracture (70%), intra-articular fracture (44%), associated 4th metacarpal fracture (26%), shortening > 5mm (21%) and volar angulation – (15%). If treated non-operatively, the most preferred period of fracture clinic follow up was one visit at 3 weeks by 40% while 36% thought that no follow up is required once decision is made to treat them conservatively.

Conclusion: Isolated undisplaced fractures of little metacarpal are usually managed conservatively using a plethora of methods of immobilisation. The indications for operative intervention are open fracture, rotational deformity, intra-articular fractures and shortening. Many clinical studies have demonstrated that in the conservative care of boxer’s fractures (casting, with or without reduction), between 20 degrees and 70 degrees of dorsal angulation is acceptable. We conclude that contemporary literature provides no evidence as to whether conservative or operative methods of the treatment of these fractures is superior, but rather suggests that they are equally effective. We conclude from our survey that there is no consensus even among the upper limb surgeons with regards to management of little finger metacarpal fractures in United Kingdom.

Background: Satisfaction following anterior and/or posterior spinal fusion varies greatly between individuals. The aim of this study was to assess patient satisfaction with the post-operative scars following surgical correction of scoliosis.

Methods: Prospective study; 31 patients (range 10–37 years), minimum of 2 months post-operation, interviewed in clinic or over the telephone using a questionnaire.

Results: Overall, 18 (58%) patients were disappointed with their scar; it was not what they expected, Patients with anterior scars or both anterior and posterior scars were the most disappointed groups.

39% of patients felt they were inadequately informed or not informed of the nature of scar. However, over 50% of those who had a specialist spinal nurse (SSN) consultation reported the scar to be as they expected. Scar length was the main source of disappointment. 55% reported their scars as being raised (keloid), particularly at the ends. Scar colour and shape was an issue for 23%, whilst 39% experienced prolonged healing. 19 patients had a pre-op consultation with the SSN, 11 did not get this opportunity, 1 declined.

Conclusion: Clearly there’s a need for improved education and understanding with regard to the nature of the scoliosis surgical scar(s). Input from a SSN is important and surgeons must clarify exactly what they mean when discussing operations with patients. This could be done with the aid of pictograms or leaflets detailing issues discussed in consultations along with the opportunity to meet patients who have already had surgery. These measures may lead to increased patient satisfaction with surgery.

Ethics approval: Audit

Interest Statement: None

Incidence of pars defect associated with idiopathic scoliosis has been reported as 6% based on roentgenographic evaluation in previous studies. (Fisk et al, 1978). We aim to present our results in an MRI based study.

Methods: 229 patients of adolescent idiopathic scoliosis (AIS) who had an MRI scan over a period of three years (2006–2008), performed either as a preoperative investigation or due to other symptoms were reviewed. All MRI scans were reviewed by two experienced musculoskeletal radiology consultants independently.

Result

Among 229 patients 18 (7.86%) patients were found to have pars defect. Mean age-group of patients were (19 years, range-11–40). Male-5 (26.3%), female- 4(73.6%). Majority of the patients with were females (72.2%). There was varying severity of curve patterns, major thoracic curve-10, major lumbar curve-4, mild thoracic curve-3 and mild lumbar curve in one. Bilateral pars defect was noted in 14 (77.7%) patients.

Discussion

Previous studies (Fisk et al, 1978; Mau H 1977) have described the incidence of pars defect as approximately 6.2%. Recent studies have emphasized use of MRI to diagnose pars defect based on signal changes in the pedicle (Jon R. Davids et al, 2004). Our study reveals the incidence of pars defect in AIS to be 7.86 % based on MRI diagnosis which does not seem to be different to previous roentgenographic studies.

In a high-risk technically advanced speciality like spine surgery, detailed information about all aspects of possible complications could be frightening for the patients, and thereby increase anxiety and distress. Therefore, aim of this study was to

Analyze written evidence of the consenting procedure pertaining to (a) nature of operation (b) benefits intended as a result of the operation (c) risks specific to the particular type of operation (c) general risks of spine surgery and anaestheia.

Methods: 70 adult elective, consecutive patients who had been listed for Lumbar discectomy /decompression surgery were chosen. The patients were presented with questionnaire of broad-based and open-ended questions designed to elicit theirs views in each of the following areas: expectation, knowledge of risks and alternatives, and personal attitude to information and satisfaction.

The study had a non-randomized design and patients divided into TWO groups Group A and group B.

The patients in the group A received standard information and were consented in a routine way without being given written proforma with all complications. The patients in the group B were given the same information as patients in the control group, with written information about common and rare complications. Patients in both groups were assessed on an ‘impact of events scale’ and hospital anxiety and depression scale immediately before ad after the consent process and again after surgery when they were discharged from the hospital.

For comparison of the proportion of Yes and No answers in 2 groups, Fisher’s exact test was used, and for comparison of more than 2 groups, the Chi-square test was used. For graded answers and other ordinal scales, the Mann–Whitney U-test was used for comparison of 2 groups and the Kruskal–Wallis test for comparison of more than 2 groups. Spearman’s test was used when assessing the correlation between 2 variables measured on an ordinal scale.

Results: Many patients (71%) agreed that the consent form made clear what was going to happen to them, and 77%) reported that it made them aware of the risks of the operation they were to undergo. Over a third (36%) saw it as a safeguard against mixups in the operating theatre. Few patients’ decision to accept surgery appeared to depend on risk information; 8% of patients said that they might have changed their decision, had they been advised of the risks of permanent stroke and myocardial infarction. However, 92% were clear that their decision to accept treatment would not have altered. The women in the group B had symptoms of definite anxiety to a significantly higher degree than the men before the operation. Post-operatively, patients receiving extended information were significantly more satisfied with both the written and oral information about common and rare complications than patients in the control group There were no statistically significant differences between the groups for anxiety or depression, as measured by the HADS, either before or after the operation between Group A and B. Provision of extended information describing most of the possible complications did not have any negative effects on the patients. The patients receiving the extended information were more satisfied and experienced to a higher degree that they could discuss alternative treatment methods with the surgeon. Discussion: Provision of extended information describing most of the possible complications did not have any negative effects on the patients. “Ignorance is bliss” may prove to be an excellent preoperative strategy for patients when outcome is good but detrimental to long term adjustment where significant postoperative complications arise. This raises the possibility that a separate consent could be used where these risks are pre-printed and explained in vocabulary easily understood by patients. The added advantages of this form would be less confusion for the patient and there would be written evidence that patients had understood each of the major risks involved with the proposed procedure. This proposed consent form would also reduce the chance that important risks and complications are omitted when consent is being taken, as well as tackling the issue of variability of experience or lack of knowledge by the person obtaining consent.

Various studies report a correlation between the severity of the primary displacement, carpal malalignment & an expectant loss of reduction over a given time period when treating distal radius fractures with cast immobilization. Recently, studies have attempted to classify carpal malalignments associated with displaced distal radial fractures based on Effective radio-lunate flexion (ERLF) into: midcarpal with ERLF < 250 and radiocarpal malalignment with ERLF > 250. The aim of this study was to assess the frequency of carpal instability as a concomitant lesion to fractures of the distal radius, delineate further various factors including associated carpal malalignment based on ERLF that are predictive of instability based on a timeline of early (one week) and late failure (six weeks) in an attempt to predict the final radiological outcome accurately

Radiographic alignment parameters were compared before and after reduction using paired t-tests and then also analysed in a multiple logistic regression analysis.

Early failure group: Regression analysis showed high correlation between the severity of axial shortening before reduction and at one week. Age, gender, presence of dorsal comminution, ulnar styloid fracture, initial dorsal angulation and flattening of radial angle were unreliable in predicting early failure at one week. Late failure group: We found radial shortening, dorsal tilt, presence of dorsal comminution & ERLF > 25 to be significant predictors of adverse radiological outcome at six weeks. Age, Gender, flattening of radial angle, ulnar styloid fracture as factors for secondary displacement when analyzed independently or in combination were not found to be significant predictors of late failure. The incidence of failure was significantly correlated to radiocarpal malalignment pattern in post reduction radiographs (ERLF> 25) and both at one and six weeks when analysed independently or in combination (p< 0.01)

Our study reaffirms the need to attention to initial fracture characteristics and highlights the importance of radiocarpal instability pattern on post reduction radiographs as a predictor of late instability. This would allow the surgeon to inform the patient of chance of success with closed treatment and alternative treatment options.

The objective of this study was to determine whether immediate mobilisation and unprotected weight bearing of rigidly internally fixed fractured ankles had a significant effect on ankle function or whether it predisposed the ankle to loss of reduction or hardware failure.

We retrospectively reviewed eighty-nine patients with unstable and/or displaced Weber type-A, B or C ankle fractures. Twenty ankle fractures who underwent open reduction and internal fixation. Post operatively the patients were either treated in a non-weight bearing plaster cast (Group A) or were allowed immediate full weight bearing as tolerated without a plaster (Group B. The treatment or weight bearing status was not modified for patients with syndesmosis injuries or deltoid ligament repair. For comparison, twenty-five patients of each group were matched to a same number of historic controls with respect to age, gender, body mass index, and fracture type.

The recovery of the patients was assessed clinically with use of subjective, objective, and radiographic evaluation criteria with reviews at ten to fourteen days, six weeks and three months and one year after the operation. The follow up ranged from twenty-four to fifty-eight months with an average follow up of 37.5 months. Matched-pair analysis revealed no differences for hospital stay and functional outcome (p= 0.858) on Olerud and Molander scoring system but significant difference in time until return to work (mean 91.3 ±20.2 vs. 54.6 ±15.5 days). In the cast group; one patient had loss of internal fixation and one had non-union while four patients in non cast group had mainly wound-healing related problems. Patients in non cast group tolerated earlier full weightbearing and there were no disadvantages concerning hospital stay, pain intensities, and functional Scores.

We conclude that immediate mobilisation and unprotected weight bearing of rigidly internally fixed fractured ankles does not predispose the ankle to loss of reduction or hardware failure and the functional results compared with the conventional cast immobilisation are comparable. In our opinion early mobilization without plaster is recommended in certain populations and may result in faster rehabilitation.

The standard of treatment for most fractures of distal radius remains closed reduction and immobilization. It is essential to discern which fracture patterns are more susceptible to failure so that surgical intervention can be considered when an acceptable reduction cannot be achieved or has a risk of secondary displacement. A correlation between the severity of the primary displacement, carpal malalignment & an expectant loss of reduction over a given time period when treating distal radius fractures with cast immobilization is reported. Recently, studies have attempted to classify carpal malalignments associated with displaced distal radial fractures based on Effective radio-lunate flexion (ERLF) into: midcarpal with ERLF < 25 and radio-carpal malalignment with ERLF > 25.

The aim of this study was to assess the frequency of carpal instability as a concomitant lesion to fractures of the distal radius, delineate further various factors including associated carpal malalignment based on ERLF that are predictive of instability based on a timeline of early (I week) and late failure (six weeks). Radiographic alignment parameters were compared using paired t-tests and then also analysed in a multiple logistic regression analysis. There was a significant improvement in all the parameters measured (p< 0.01) with mean correction falling within acceptable limits. Early failure group: Regression analysis showed high correlation between the severity of axial shortening before reduction and at six weeks. Age, gender, presence of dorsal comminution and ulnar styloid fracture, initial dorsal angulation and flattening of radial angle were unreliable in predicting early failure at one week. The incidence of failure was significantly correlated to radiocarpal malalignment pattern in post reduction radiographs (ERLF> 25) at one week when analysed independently or in combination(p< 0.01). In the late failure group:Radial shortening, dorsal tilt, presence of dorsal comminution & ERLF > 25 to be significant predictors of adverse radiological outcome. Age, Gender, flattening of radial angle, ulnar styloid fracture, for secondary displacement when analyzed independently or in combination were not found to be significant predictors of failure at 6-week. The incidence of failure was significantly correlated to radiocarpal malalignment pattern in post reduction radiographs (ERLF> 25) and at 6weeks when analysed independently or in combination.(p< 0.01) Our study reaffirms the need to attention to initial fracture characteristics and highlights the importance of radiocarpal instability pattern on post reduction radiographs as a predictor of late instability & anticipate the radiological outcome. This would allow the surgeon to inform the patient of chance of success with closed treatment and alternative treatment options.

Plain radiographs remain important diagnostic tools in the initial assessment of patients with suspected fractures or dislocations of the foot. Analysis of foot radiograph is a difficult task even in the hands of experts, which is misinterpreted in 2.1% cases. Human visual system is more sensitive to horizontal and vertical stimuli & cardinal orientations (Vertical and Horizontal) perceived more accurately than others. Any absolute judgement task is subject to two types of error: Systematic error and random error. Hence a system of assessment with very high random error of measurement is unlikely to be a reliable assessment method. We tried to find out the influence of experience and orientation on interpretation of foot radiograph.

AP and lateral radiograph from 25 patients who had some form of foot injury were included in this study. The radiographs were first analysed by an experienced foot surgeons for fractures with clinical details to facilitate the identification of the fracture & then presented in two different orientations (vertical and horizontal) to 38 orthopaedics surgeons of different grades and blinded about the nature of the study. We used Kappa analysis & logistic regression to find out the influence of orientation and experience on interpretation skills.

Overall agreement between the foot surgeon and other observers was 0.4. Overall agreement between the observers and the foot surgeon, in the vertical orientation, was.43 and in the horizontal orientation was.32. When experience was taken into consideration agreement between orthopaedics surgeons and the foot surgeon was.416 and agreement between registrar and foot surgeon was.367 and the SHO and foot surgeon was.369. We found that the regression coefficient for horizontal orientation was −.302 and the regression coefficient for the experience was 0.067. Hence horizontal orientation increases the chance of misinterpreting a foot radiograph by 30.2% and with increasing experience the chance of correctly identifying the fracture increases by 6.7%. From this study it is evident with all the other variables like experience, quality and adequacy of radiographs optimised, orientation of the foot radiograph alone can significantly affect the interpretation skills of the observer.

The objective of this study was to ascertain knowledge of the normal anatomy and appreciation of components of an “adequate” or “acceptable“ reduction by the medical staff responsible for management of distal radius fractures in the emergency departments (A& E) in UK. A nation wide structured questionnaire survey based on literature review was performed on 138 doctors. Of the 100 (72%) respondents, only 40% could cite the correct values for volar tilt, radial inclination, and ulnar variance, there being a significant difference between orthopaedic n=16(64%) and A& E staff n=24(32%); p=0.031; c2 = 12.17. Only 18% respondents were aware of the acceptable ranges of adequate reduction; with orthopaedic staff n=12 (48%) being more aware than A& E staff, n=6 (8%); p=0.002; c2 = 6.38. Only 19% formally measure the key parameters before decision making [52% Orthopaedic versus 8% A& E staff; p=0.018; c2 = 7.31]. Only 14% of respondents from hospitals equipped with picture archive navigation system (PACS) stated that they used the angle measurement function.

A lack of knowledge of the normal anatomical values and implementation of generally accepted measurement criteria predictive of fractures unlikely to benefit from repeat manipulations is evident. It is important to emphasize the influence of factors reported to affect stability such as age, functional demands of the patient and extent of initial fracture displacement in decision making. The introduction of a set of guidelines and further education of the medical staff could reduce the number of inappropriately treated distal radial fractures in the A& E setting with significant economic implications.

Introduction: Rapidly destructive arthrosis of the hip (RDHD) is a rare and incompletely understood disorder with scarce literature about variations in natural history within a population. A series of cases from North Wales with rapid progressive joint destruction and extensive subchondral bone loss in the femoral head and acetabulum are presented.

Methods: A retrospective review of patients with a clinical profile and serial radiographs suggestive of a rapidly progressive hip disease was undertaken. This revealed 15 patients who met our criteria for RDHD. A retrospective analysis of clinical and radiographic records was performed. Radiographic findings mimicked those of other disorders such as septic arthritis, rheumatoid and seronegative arthritis, primary osteonecrosis with secondary osteoarthritis, or neuropathic osteoarthropathy, but none of the patients had clinical, pathologic, or laboratory evidence of these entities.

Results: Rapid progression of hip pain and disability was a consistent clinical feature. The average duration of symptoms was 1.4 years. Radiographs obtained at various intervals before surgery (average 14 months) in 15 patients documented rapid hip destruction, involvement being unilateral in 10 cases. All patients underwent total hip arthroplasty, and osteoarthritis was confirmed at pathologic examination. Histology of femoral heads failed to show the findings typical of primary osteonecrosis & no evidence of sepsis.

Discussion: The authors postulate that these cases represent an uncommon subset of osteoarthritis and regular review, both clinically and radiologically, are required to assess speed of progression and prevent rapid loss of bone stock without the surgeon being aware. These cases are unsuitable for being placed on long waiting list due to technical difficulties in delayed surgery and compromised outcome following surgery. The decisions about the need for surgery and the selection of cases should be made purely on clinical grounds and not on their rank in the waiting lists.(295)

Dynamic Hip Screw fixation for intertrochanteric fracture of femur is one of the most common operations in the trauma list of any DGH. The operation is commonly performed by the registrar or senior house officer as it is considered to be a relatively simple procedure. However the reality is slightly different as we audit our results of DHS fixation over a period of 2 years from May 2002 to August 2004. Out of 184 DHS fixation done during the abovementioned period, we identified 18 (10%) failures within 2–8 weeks postoperative period. We reviewed the pre-operative and post-operative X-rays to identify the possible reasons for failure. The reasons were inappropriate indication for DHS – 3 cases, inadequate fracture reduction – 6 cases, inappropriate implant placement −12 cases. 3 cases (16%) of failure had to be treated conservatively due to poor medical condition, 7 cases (39%) had the implant removed or revised and some type of arthroplasty was done in rest 8 cases (45%). Of the 15 cases treated operatively 12 had satisfactory outcome in terms of pain relief and movement and the rest 3 had residual pain, inadequate restoration of mobility affecting the quality of life. All patients had significant morbidity (prolonged hospital stay, depression) due to the failure of fixation and further operative procedures. Therefore we think appropriate guidance by experienced personnel is necessary for correct indication and meticulous operative technique.