Introduction

Avulsion of abductors from hip is a debilitating complication after total hip arthroplasty performed through a trans-gluteal approach. It results in intractable pain, Trendelenberg limp and instability of the hip.

Techniques described for repairing these abductor tears including direct trans osseous repairs, endoscopic repair techniques, Achilles tendon allograft, Gluteus Maximus and Vastus Lateralis muscle transfers. The aim of our study was to assess improvement in pain, limp and abductor strength in patients operated upon surgically for confirmed abductor avulsion using a modified trans osseous repair and augmentation of repair with a Graft Jacket allograft acellular human dermal matrix (Graft jacket; Wright Medical Technology, Arlington, TN).

Introduction

Obesity has been associated with higher complication rates and poorer outcomes following joint replacement surgery. Body mass index (BMI) is a simple index of body composition and forms part of preoperative assessment. It does not take into account the proportion of lean mass and body fat and can give a false impression of body composition in healthy manual workers. A more accurate measure of body composition is available using non-invasive bioimpedance methods. This study aims to identify whether BMI provides an accurate measure of body fat composition in patients awaiting lower limb arthroplasty surgery.

Aim and design: The Olympia prosthesis was designed to minimise the risk of cement mantle deficiency, seen with some straight stem designs. Initially six stem sizes were produced. The highly polished surface (Ra 10 nm) reduces tensile stresses and cement abrasion. The oval cross-section allows a metaphyseal rotation lock. The natural anteversion is cement mantle friendly. The absence of corners reduces the stress risers and the anatomic shape accommodates the abductor approach and MIS. A size 0 has been added to the range as have lateralised options.

Methods: The first 120 stems in 111 consecutive patients were studied prospectively and reviewed clinically and radiographically by an independent observer. All operations were carried out by the senior author (LJT) with the same team. Rigorous attention to detail was given to femoral preparation and cement technique.

Clinical Results: At a mean follow up 10 years 8 months, 92% of the patients had a Harris Hip score over 80. 97% of outcomes were classified as excellent or good on the Oxford Hip Score. At review the survival was 99.2% (one patient has been revised for non-union of a Vancouver type C peri-prosthetic fracture).

Radiographic Results: Radiographically no stems showed more than 5° varus/valgus angulation (no centraliser was used). In the lateral projection 76% were neutral and 21% posterior. All Gruen zones had an intact cement mantle and 100% of stems had Barrack A or B cement/bone interfaces. No sinkage has been identified on plain AP and lateral radiographs.

The Olympia has only been used at 3 centres until the 10 year clinical and radiographic results were available. The results at 10 years justify further evaluation. It is crucial that meticulous detail to cement technique is adhered to in the operative technique. The ease of insertion and natural anteversion has given confidence to surgeons in training.

Operation on the hips of patients with myelomeningocele is often followed by stiffness or ankylosis. Excision of the upper end of the femur for this condition frequently fails because of extensive new bone formation. Twelve excisions in eight patients are reported. Six of these patients had recently had spinal fusion operations; the consequent loss of ability to compensate for hip stiffness by spinal flexion had made sitting difficult or impossible. Excision or even re-excision of the upper femur failed in most cases. Careful assessment of hip mobility before spinal operations in these patients is essential and osteotomy rather than excision of the upper femur is advised.

Vitamin D deficiency occurs in up to 24% of the Asian immigrant population in the United Kingdom, but pathological fractures are relatively uncommon. We report a case of bilateral fracture of the femoral neck caused by a convulsion secondary to dietary-induced hypocalcaemia. To our knowledge such a sequence has not previously been reported.

Avascular necrosis of bone is a well-recognised phenomenon in patients on long-term steroid therapy, especially after renal transplantation. There are only four cases reported in the literature of multifocal avascular necrosis after short-term high-dose steroid therapy, and three additional cases are reported in this paper. All the hips have needed reconstructive surgery within two and a half years of the onset of symptoms; in one patient, however, this has been prevented by other medical problems. In two of the three patients reported in this paper the shoulders also were affected; eventually they became pain-free but movement was restricted. Short-term high-dose steroid therapy has only recently been recognised as a cause of avascular necrosis and attempts should be made to prevent the incidence increasing.