The natural history of gait pattern change in children with spastic diplegia is a transition from toe walking to progressive hip and knee flexion with eventual crouch gait. This has been attributed to the adolescent growth spurt, progressive lever arm dysfunction, and iatrogenic weakening of the soleus with isolated tendo achilles lengthening (TAL). The relative contribution of TAL to the development of crouch gait is uncertain. The purpose of this study was to identify the frequency of crouch gait in spastic diplegic patients with and without history of prior TAL. Patients with spastic diplegia greater than 10 years of age with instrumented gait analysis were reviewed. Exclusion criteria included diagnosis other than cerebral palsy, prior dorsal root rhizotomy, or incomplete past surgical history. Patients were divided into three groups: Group 1, no prior orthopaedic surgical intervention; Group 2, prior orthopaedic surgery without TAL; Group 3, prior orthopaedic surgery with TAL. Instrumented gait analysis data was analysed. Gait data were analysed using a single randomised limb from each patient. One hundred and seventy-eight patients were identified: 39 in Group 1, 49 in Group 2, and 90 in Group 3. Mean time from TAL to gait analysis was 7.5 years (range 1.0–14.6 years). Mean age at TAL was 6.3 years (range 1.2–17.5 years). There was no significant difference in age, BMI, walking speed, or cadence between groups. Kinematic analysis showed no significant difference in mean stance phase maximum knee or ankle flexion between groups. There was no significant difference in frequency of increased mid stance knee flexion between groups (Group 1, 53.8%; Group 2 46.9%; Group 3, 43.3%, p=0.546). There was a trend towards increased frequency in excessive stance phase ankle dorsiflexion in Group 3 (60% Group 3 vs 46.2% Group 1, and 40% Group 2, p=0.071). Crouch gait (stance minimum hip flexion > 30, mid stance minimum knee flexion > 200, and stance maximum ankle dorsiflexion > 150) was seen with similar frequency in all groups (Group 1, 23.1%; Group 2, 18.4%; Group 3, 26.7%; p=0.544). There is a trend towards increased frequency of excessive stance phase ankle dorsiflexion in spastic diplegic patients with prior TAL. However, no significant difference in frequency of crouch gait between patients with and without history of TAL was identified. Crouch gait is part of the natural history of gait pattern change in spastic diplegic patients independent of prior surgical intervention

Background: Structural hip deformities including developmental dysplasia of the hip (DDH) and femoroacetabular impingement (FAI) are thought to predispose patients to degenerative joint changes. However, the natural history of these malformations is not clearly delineated. Methods: Seven-hundred twenty-two patients ≤55 years that received unilateral primary total hip arthroplasty (THA) from 1980–1989 were identified. Pre-operative radiographs were reviewed on the contralateral hip and only hips with Tönnis Grade 0 degenerative change that had minimum 10-year radiographic follow-up were included. Radiographic metrics in conjunction with the review of two experienced arthroplasty surgeons determined structural hip diagnosis as DDH, FAI, or normal morphology. Every available follow-up AP radiograph was reviewed to determine progression from Tönnis Grade 0–3 until the time of last follow-up or operative intervention with THA. Survivorship was analyzed by Kaplan-Meier methodology, hazard ratios, and multi-state modeling. Results: One-hundred sixty-two patients met all eligibility criteria with the following structural diagnoses: 48 DDH, 74 FAI, and 40 normal. Mean age at the time of study inclusion was 47 years (range 18–55), with 56% females. Mean follow-up was 20 years (range 10 – 35 years). Thirty-five patients eventually required THA: 16 (33.3%) DDH, 13 (17.6%) FAI, 6 (15.0%) normal. Kaplan-Meier analysis demonstrated that patients with DDH progressed most rapidly, followed by FAI, with normal hips progressing the slowest. The mean number of years spent in each Tönnis stage by structural morphology was as follows: Tönnis 0: DDH = 17.0 years, FAI = 14.8 years, normal = 22.9 years; Tönnis 1: DDH = 12.2 years, FAI = 13.3 years, normal = 17.5 years; Tönnis 2: DDH = 6.0 years, FAI = 9.7 years, normal = 8.6 years; Tönnis 3: DDH = 1.6 years, FAI = 2.6 years, normal = 0.2 years. Analysis of degenerative risk for categorical variables showed that patients with femoral head lateralization >10 mm, femoral head extrusion indices >0.25, acetabular depth-to-width index <0.38, lateral center-edge angle <25 degrees, and Tönnis angle >10 degrees all had a greater risk of progression from Tönnis 0 to Tönnis 3 or THA. Among patients with FAI morphology, femoral head extrusion indices >0.25, lateral center-edge angle <25 degrees, and Tönnis angle >10 degrees all increased the risk of early radiographic progression. Analysis of degenerative risk for continuous variables using smoothing splines showed that risk was increased for the following: femoral head lateralization >8 mm, femoral head extrusion index >0.20, acetabular depth-to-width index <0.30, lateral center-edge angle <25 degrees, and Tönnis angle >8 degrees. Conclusions: This study defines the long-term natural history of DDH and FAI in comparison to structurally normal young hips with a presumably similar initial prognostic risk (Tönnis Grade 0 degenerative change and contralateral primary THA). In general, the fastest rates of degenerative change were observed in patients with DDH. Furthermore, risk of progression based on morphology and current Tönnis stage were defined, creating a new prognostic guide for surgeons. Lastly, radiographic parameters were identified that predicted more rapid degenerative change, both in continuous and categorical fashions, subclassified by hip morphology

Aim

The prevalence of unexpected positive cultures (UPC) in aseptic revision surgery of the joint with a prior septic revision procedure in the same joint remain unknown. The purpose of this study was to determine the prevalence of UPC in aseptic revisions performed in patients with a previous septic revision in the same joint. As secondary outcome measure, we explore possible risk factors associated with UPC and the re-revision rates.

Pre-operative co-morbidities such as known coronary artery disease have commonly deemed a patient at ‘high risk’ for primary elective Total Hip Arthroplasty (THA). We prospectively collected data on 1744 patients who underwent primary elective THA between 1998 and 2004. 273 had a history of cardiac disease defined as a previous hospital admission with a diagnosis of angina pectoris or myocardial infarction. 594 patients had hypertension defined as that requiring treatment with antihypertensives. We also had data on pre-operative age, sex and body mass index (BMI). There was no statistically significant increase in early mortality at 3 months with a history of cardiac disease or hypertension and this remained so when adjusting for the other factors in a multivariate analysis. Sex or BMI also did not have a statistically significant effect on the risk of death within 3 months. Increasing age was the only significant risk factor for early mortality (P<0.001). Longer term mortality at 2 and 5 years in relation to these factors was also examined. Statistical analysis revealed that coronary history now showed a highly significant association (P<0.001) with long term mortality, in patients who survived more than 3 months. 95% confidence intervals for percentage mortality at 5 years were 9.7 - 21.7 with a cardiac history compared to 4.8 - 8.8 without a cardiac history. This remained significant (P=0.002) when adjusted for the other factors. Hypertension continued to have no effect, nor did BMI. Age remained a significant risk factor. Females had a slightly lower long term death rate than males, following THA. The overall long term mortality following THA was less than expected from the normal population, even in the subgroup with a coronary history. This study will assist clinicians when advising patients seeking primary elective THA, who have one of these common risk factors

Purpose. To describe a 10-year long history of recurrent displacement and infection in a 37 yo female patient, HIV+/HCV+, with an history of drug addiction. Clinical History. Starting from avascular necrosis of the hip (caused by prolonged HAART therapy), the patient underwent first uncemented THA in 2003. One month after implant a septic mobilization due to local abscess was treated with first two stage revision surgery (modular stem with use of retention liner for intraoperatory instability and dislocation of the implant) that lasted for almost 6 years. After 6 years of apparent good clinical condition and stability of the implants, the patient came back with a septic state of the hip, and recurrent instability, caused by complete abruption of the cup from acetabulum (Figure 1) Another two stage revision was planned; patient suffered dislocation of the spacer in first hours after intervention and 3 months later was performed second stage revision (stem with modular neck and head, cup with augmentation metal liner). Three days later patient suffered from another dislocation, so implant was further revised (change of modular neck + dual mobility head/cup), and a pelvipodalic cast was even made, considering the poor compliance of the patient,. One month later, due to another local septic state of the hip and in consideration of clinical history, a DAIR procedure was performed with revision of limited modular components until intraoperative stability was assessed (metal spacer + metal liner + dual mobility head and cup). For further assurance, an external fixator was placed around the hip (Figure 2). Results. After last intervention no dislocation occurred and external fixation was removed with success after 2 months. Clinical outcome at 2 years showed a good functional outcome, and painless walking with only one crutch and limited limping. Discussion. This is a challenging case in which the comorbidity of immunosuppression, poor compliance of the patient and multiple hip revision surgery, started a very long sequence of complications and led to poor clinical results for years. Although the use of modularity aids reaching good stability and function in this kind of revision surgery, only a good control of general conditions of the patient and a multidisciplinary approach to correct patient's lifestyle has brought to stability and “up to now” endurance for this THA implant

We present 2 year results of a prospective natural history study of Type III Acromioclaviclular joint dislocation (ACJD) treated non-operatively. Previous natural history studies are compromised by inconsistent definitions of the grade of injury and non-validated scoring tools; they do not identify which patients will have ongoing symptoms. This trial documents the strength and subjective recovery over time, and identifies risk factors for poor outcome and need for surgery. Patients with Rockwood Type III ACJD received a standardised rehabilitation protocol (6 sessions of physiotherapy). Clinical assessment was performed at presentation, 3, 6, 12 and 24 months after injury, including isometric strength testing, pain (VAS/10) and subjective scores – Subjective percentage of normal (SPON), American Shoulder and Elbow (ASES), Oxford Shoulder Score (OSS) and Quick Disabilities of Arm Shoulder and Hand (qDASH). 28 male patients were recruited, 26 reached 12, and 9 to 24 months follow up. Two required surgery and one emigrated. The mean age was 39 (15 to 67). Initial mean pain was 3/10, SPON 51% (6–95) and strength was 76% of the other side. By 3 months mean subjective recovery was 70% and strength 90%. Strength recovered to 99% of normal by 12 months but subjective scores remained at mean 90%; by 24 months subjective scores were mean 94%. 2 patients had subjective scores <80%. There was a wide range of initial subjective scores and weakness after Type III ACJD. 95% of strength had recovered by 6 months and subjective scores recovered to 94% of normal by 24 months. 4 patients (14%) did poorly with 2 requiring surgery. Low initial subjective score and inability to abduct the arm at presentation were risk factors for a poor outcome

INTRODUCTION. Childhood diseases involving the proximal femoral epiphysis often cause abnormalities that can lead to end-stage arthritis at a relatively young age and the need for total hip arthroplasty (THA). The young age of these patients makes hip resurfacing arthroplasty (HRA) an alternative and favorable option due to the ability to preserve femoral bone. Patients presenting with end-stage hip arthritis as sequelae of childhood diseases such as Legg-Calves-Perthes (LCP) and slipped capital femoral epiphysis (SCFE) pose altered femoral anatomy, making HRA more technically complicated. LCP patients can result in coxa magna, coxa plana and coxa breva causing altered femoral head-to-neck ratio. There can also be acetabular dysplasia along with the proximal femoral abnormalities. SCFE patients have altered femoral head alignment. In particular, the femoral head is rotated medially and posteriorly, reducing the anterior and lateral offset. Additionally, many of these patients have retained hardware, making resurfacing more complicated. We report findings of a cohort of patients, with history of either LCP or SCPE who underwent HRA to treat end-stage arthritis. METHODS. Data was retrospectively collected for patients who had HRA for hip arthritis as a result of either LCP (n=67) or SCFE (n=21) between 2004 and 2014 performed by two surgeons. Demographic information, clinical examination and improvement was collected pre and postoperatively. Improvement was determined using Harris Hip Scores (HHS) and UCLA activity scores. Anteroposterior radiographs were measured pre and postoperatively to determine leg length discrepancy. Radiographs were inspected postoperatively for radiolucent lines, implant loosening and osteolysis. Kaplan-Meier survivorship for freedom from reoperation for any reason was calculated. Paired student t-tests were used to compare groups. RESULTS. The average age at the time of surgery was 44 years (11.8–68), with an average follow-up of 3.7 years (.22–11.2). Retained hardware was present in a total of 5 patients, 1 LCP and 4 SCFE. Preoperative HHS was 58.3 (33–83), which increased significantly to 94.9 (55–100) at the most recent postoperative timepoint (p<.0001). The most recent UCLA activity score was 7 (1–10). Average leg length discrepancy preoperatively was 7.5mm (0–20), which significantly improved to 0.6mm (0–7.5) postoperatively (p<.0001). At most recent follow-up, metal ion testing revealed median chromium level of 2.3 parts per billion (ppb, 1–7.7) and median cobalt level of 1.5 (0–9.2). There were three failures in the group with 1 LCP due to instability at 2.7 years, and 2 SCFE due to femoral neck fracture at 1 month in one and clinical failure due to unexplained pain at 5.5 years in one. Revision surgery was done in 2 patients, 1 LCP and 1 SCFE. Radiographic examination of all non-failure HRA patients revealed implants to be in good alignment with no indication of implant loosening at the most recent postoperative timepoint. Kaplan-Meier survivorship for freedom from revision was 96.2 at 5 years. CONCLUSION. The findings demonstrated increase in functional outcomes in patients who underwent HRA for osteoarthritis associated with LCP and SCFE. There was no increase in complications including femoral neck fracture or implant loosening despite technical challenges of the procedure

Osteotomies are performed in patients with lower limb malalignment, usually associated with osteoarthritis of the knee or instability. The surgery realigns the mechanical axis of the leg by either an opening or closing wedge procedure with the goal of decreasing symptoms, improving function, and delaying the progression of osteoarthritis. The 103 patients that had undergone osteotomy surgery were studied prospectively, and data was analysed one year post surgery. We examined subjective outcomes, patient history and surgical variables using backwards stepwise multiple regression models to determine whether there were any associations between these. Subjective outcomes from a total of 103 osteotomy patients at one year post surgery were compared to patient history and surgical variables. All categories of KOOS and WOMAC scores were improved after surgery. The multivariate models showed that variables significantly influencing the outcomes were pre-operative flexion, pre-operative weight, the size of the HTO plate used and tourniquet time. Greater pre-operative flexion; lower weight; larger plate used, indicating larger corrections; and lower tourniquet times were shown to result in improved scores. Not all variables influenced all categories of the scores. While flexion and pre-operative weight influenced across the categories of both scores, plate size influenced KOOS pain and symptoms and tourniquet time influenced KOOS sport and quality of life. Knee flexion and body weight were the most influential variables when considering KOOS and WOMAC outcome scores as a measure of success. The size of the correction may have influenced the pain and symptom scores because patients with greater malalignment may have initially had worse symptoms and their perception of their current function and pain is affected by their previous levels of pain and function. Osteotomy results in improved function and pain scores and our results indicate that there are several variables which significantly influence patient outcomes and may be of greater importance than other variables

Background:. Glomus tumours of the hand are rare benign vascular tumours. The literature shows a limited number of case series with few patients treated over several years. Methods:. Patient records and the literature were reviewed. Case Series:. We present a series of 5 patients with glomus tumour treated over a period of 1 year. All 5 patients presented with a similar history. They were all seen by various medical practitioners for an extended period of time before presenting to the Hand Unit of our institution. All 5 patients had classical symptoms and signs of glomus tumour i.e. pain, cold intolerance and pin-point tenderness over the nail bed, while 4 of the 5 had a purplish spot seen through the nail plate. All 5 tumours were excised and the histology confirmed our pre-operative diagnosis of glomus tumour. In all of them, complete resolution of symptoms was the final outcome and there was no reported recurrence of symptoms in the short period of follow-up. Discussion and conclusion:. Glomus tumours are rare benign vascular tumours. The limited number of case series in the literature report small numbers of patients treated at institutions over long periods of time. It can occur anywhere in the body, but up to three quarters of them are found in the hand. It arises from the neuromyoarterial glomus cells of the nailbed dermis. The triad of pain, cold intolerance and pin-point tenderness is highly suggestive of the condition. Subjective symptoms typically exceed clinical signs for which the diagnosis is delayed for months. Sometimes the tumour is visible through the nail plate appearing as reddish or purplish spot of few millimeters or as longitudinal streaks. Imaging studies except MRI are not very helpful and one must rely on a history of cold intolerance and clinical findings like pin-point tenderness for diagnosis

Introduction. Pseudotumors have been reported following metal-on-metal total hip arthroplasty (THA); however, the natural history and longitudinal imaging findings of pseudotumors have yet to be fully analyzed. Our hypothesis was that pseudotumor size might change over time following metal-on-metal THA. This hypothesis was studied longitudinally using magnetic resonance imaging (MRI). Materials and Methods. Screening for pseudotumors was performed using MRI after large-diameter metal-on-metal THA. Initial MRI was conducted at a mean of 36 months postoperatively. Follow-up MRI was performed at a mean of 20 months after the detection of 24 pseudotumors in 20 asymptomatic patients. Pseudotumors were classified as cystic, solid, and mixed types. Fourteen hips were characterized as cystic type and 10 hips were defined as mixed type. There were three men and 17 women with a mean age of 63 years. Pseudotumor size was determined on MRI by manually outlining the greatest size of the mass. Serum cobalt and chromium ion levels were measured in nine patients with unilateral THA at the time of MRI. Statistical analysis was performed using the Kruskal-Wallis test and chi square test to compare age, gender, BMI, head diameter, cup inclination, cup anteversion, and pseudotumor type among changes of pseudotumor size. We compared the pseudotumor size for the three groups (increase in size, no change, decrease in size) using Kruskal-Wallis test and Mann-Whitney U test. Wilcoxon signed-rank test was used to compare median serum metal ion levels over time. A p value < 0.05 was considered significant. This study was approved by the ethics committee of our institution, and all patients provided informed consent. Results. The mean pseudotumor size changed from 729 mm. 2. to 877 mm. 2. Among the 24 hips, pseudotumors increased in size (Fig. 1) in eight (three cystic and five mixed) and decreased in size in six (four cystic and two mixed). Ten hips showed no changes in size (seven cystic and three mixed). We found no significant differences between changes of pseudotumor size and patient characteristics. The mean initial size of pseudotumor was bigger in pseudotumors with increased in size (1002 ± 309 mm. 2. ) than in those with decreased in size (542 ± 295 mm. 2. , p = 0.020) or no change (622 ± 448 mm. 2. , p = 0.041). The median cobalt ion levels at initial MRI and follow-up MRI were 2.0 µg/L and 1.8 µg/L, respectively. The median chromium ion levels at initial MRI and follow-up MRI were 2.0 µg/L and 3.1 µg/L, respectively. No significant differences were observed between the levels of either metal at initial and subsequent MRI. Conclusions. The present results suggest that pseudotumors frequently change in size in asymptomatic patients, and our hypothesis was verified. The initial size of pseudotumor was bigger in pseudotumors with increased in size than in those with decreased in size or no change. And we might predict that bigger pseudotumors would tend to increase in size

Difficulties arise when counselling younger patients on the long-term sequelae of a minor knee chondral defect. This study assesses the natural history of patients with grade 2 Outerbridge chondral injuries of the medial femoral condyle at arthroscopy. We reviewed all arthroscopies performed by one surgeon over 12 years with Outerbridge grade 2 chondral defects. Patients aged 30 to 59 were included. Meniscal injuries found were treated with partial menisectomy. All patients had five-year follow up minimum. Primary outcome measure was further interventions of total or unicondylar arthroplasty or high tibial osteotomy. We analysed 3,344 arthroscopies. Average follow up was 10 years (Range 5–17 years). A total of 357 patients met inclusion criteria of which 86 had isolated medial femoral condyle disease. Average age was 50 at the time of arthroscopy. Average BMI at surgery was 31.7 and average chondral defect area was 450 mm. 2. Isolated MFC chondral disease had a 10.5% intervention rate. Intervention occurred at a mean of 8.5 years post primary arthroscopy. In young patients Outerbridge II chondral injuries affecting ≥2 compartments have a high rate of further intervention within a decade. This information is crucial in counselling young patients on long-term sequelae of benign chondral lesions

Residual strain development in biological tissue is believed to result from remodeling in response to repetitive loading. This study hypothesized that differences in in-vivo loading between levels of the bovine tail result in differences in intervertebral disc (IVD) annulus fibrosus (AF) microstructural remodeling. The hypothesis was tested by quantifying tail musculature using clinical computed tomography and tissue microstructure using collagen fiber crimp period, which has previously been correlated with residual strain.

Three bovine tail segments (levels c1 through c6) were imaged using a clinical computed tomography (CT) scanner followed by removal of muscle and harvest of IVDs. The discs were frozen, and transverse cryosections were obtained. Additionally, tangential plane cryosections were obtained from the inner and outer zones of the AF.

Transverse CT slices corresponding to each joint level thresholded for both disc and muscle tissue and analyzed in MATLAB. First, the centroid of the disc image was calculated to use as an origin. Then the disc area and moments of inertia about the flexion extension axis and lateral bending axis were calculated. Total muscle area was then calculated, along with muscle moments of inertia relative to the disc centroid. All muscle parameters were normalized by those of the corresponding disc.

Cryosections were imaged using an inverted light microscope equipped with crossed polarizing filters and a digital camera. A MATLAB routine was used to perform Fourier transform analysis on user selected lines of interest in the transverse micrographs, yielding average fiber crimp period in the inner and outer AF. Micrographs from tangential sections were opened in ImageJ, and fiber orientation angles were measured manually.

Muscle moments of inertia were analyzed using a two-way ANOVA with disc level and axis as dependent variables. Normalized muscle area was analyzed with a one-way ANOVA with disc level as a dependent variable. A two-way ANOVA, with disc level and zone (inner versus outer) was used to analyze collagen fiber crimp period and collagen fiber angle.

Normalized muscle moment of inertia showed significant effects of both level and axis (p < 0 .001), decreasing at distal levels, and being lower about the flexion-extension axis than the lateral bending axis. Normalized muscle cross section showed a visible, but not significant (p=0.0721) decreasing trend with disc level. Fiber crimp period had significant effects of both level and zone (p < 0 .001), and was significantly longer in the outer zone than inner at all levels. Significant decrease in crimp period at distal levels were seen in the outer AF, but not the inner. While fiber angle was significantly (p < 0 .001) higher in the inner AF (36±6.6°) than outer AF (24±3.5°)), there was no significant effect of level.

Fiber crimp period in the AF has previously been correlated with residual circumferential strain, with larger crimp period corresponding to increased residual tension. The present study suggests that at proximal levels of the tail, where peak compressive and bending stresses in the AF (as inferred from normalized muscle area and moments of inertia respectively) are greatest, there is more accumulation of residual strain.

Introduction. Patients presenting with osteoarthritis as late sequelae following pediatric hip trauma have few options aside from standard Total Hip Replacement (THR). For younger more active patients, Hip Resurfacing Arthroplasty (HRA) can be offered as an alternative. HRA has been performed in the United States over the past decade and allows increased bone preservation, decreased hip dislocation rates versus THR, and potential to return to full activities. Patients presenting with end-stage hip arthritis as following prior pediatric trauma or disease often have altered hip morphology making HRA more complicated. Often Legg-Calve-Perthes (LCP) patients present with short, wide femoral necks, and femoral head distortion including coxa magna or coxa plana. There often can be acetabular dysplasia in conjunction with the proximal femoral abnormalities. Slipped Capital Femoral Epiphysis (SCFE) patients have an alteration of the femoral neck and head alignment, which can make reshaping the femoral head difficult. In particular, the femoral head is rotated medially and posteriorly, reducing the anterior and lateral offset. We present a cohort of 20 patients, with history of a childhood hip disorder (SCFE or LCP), who underwent HRA to treat end-stage arthritis. Fifty percent had prior pediatric surgical intervention at an average age of 11. Method. After Institutional Review Board approval, data was reviewed retrospectively on patients with pediatric hip diseases of SCFE and LCP who underwent HRA using the Birmingham Hip Resurfacing (BHR) by a single orthopaedic surgeon at a teaching institution. Harris Hip Scores (HHS), plain radiographs and blood metal ion levels were reviewed at routine intervals (12 months and annually thereafter). Those who had not returned for recent follow-up were contacted via telephone survey for a modified HHS. Results. Twenty patients had mean follow up of 2.8 years (range 1–7 years). Twelve had LCP and 8 SCFE. Median implant duration was 2.4 years. One-year metal ion testing revealed median chromium level of 2.3 ppb and median Cobalt level of 1.5 ppb. At one-year follow up, plain radiographs demonstrated all patient implants to be well-fixed, without radiolucent lines or osteolysis. Two patients at three and five-year follow-up exhibited heterotopic ossification. Mean HHS for LCP at 6 weeks post-operative was 88, and 98 at one year. Mean HHS for SCFE at 6 weeks post-operative was 77.5, and 98.6 at one year. LLD was significantly improved with an average pre-operative LLD of 12.6 mm and post op of 2.6 mm (p-value <0.001). At most recent follow-up, all retained their implants with overall average HHS of 98. Conclusion. At minimum of one-year following HRA, an increase in functional outcomes is found in patients who underwent HRA for osteoarthritis associated with LCP and SCFE with a mean HHS of 98. No increase was found in complications including femoral neck fracture or implant loosening despite technical challenges of the procedure related to proximal femoral morphologic abnormalities, or presence of acetabular dysplasia [Fig 1]

The incidence of lateral femoral cutaneous nerve (LFCN) neuropraxia after anterior approach total hip arthroplasty has been reported to occur in up to 50% of patients. In the vast majority of cases there has been no functional impact it is unknown if symptoms persist or diminish over time. The aim of this study was to examine the natural history LFCN neuropraxia in a previously reported cohort of individuals after anterior approach total hip arthroplasty. One hundred and forty three consecutive patients underwent direct anterior hip approach (DAA) between September 2006 and February 2009 of which 107 had been identified with LCFN neuropraxia. These 107 patients (39 THA; 68 HR; 44 Female & 63 male; mean age 55.4 (38.4–88.8)), were provided a self-reported questionnaire for sensory deficits associated with LFCN as well as severity of symptoms on a 10 point visual analogue scale (VAS). These were done at initial assessment and latest follow-up. Sixty of the 107 patients (56%) completed their questionnaires at a mean follow-up of 5.4 years (24 THA; 36 HR). Twenty-two percent (13 of 60: 8 men & 5 women) had complete resolution of their symptoms (9 HR and 4 THR). Of the 47 patients (78%) still reporting symptoms of LFCN neuropraxia, the mean score on VAS decreased from a mean of 2.32 (SD:2.11) to 1.74 (SD:1.99). No limitation in activities was reported for 90% of patients (54 out of the 60). Of the 6 patients (10%) with limited activity they reported a mean VAS score of 4.4 (SD: 3.6 range of 0–8.4). The LFCN symptoms did not appear to be directly related to their activity limitation. While LFCN neuropraxia can be a common complication following direct anterior approach hip replacement, almost a quarter of patients will have complete resolution of symptoms and the majority will have a decrease in their symptomatology. LFCN neuropraxia following DAA hip arthroplasty does not appear to lead to any functional limitations and is associated with a low score on VAS

Financial impact and patient satisfaction with four different anticoagulants for hip and knee arthroplasty in patients with a previous history of VTE- A prospective randomised trial. Introduction. New generation oral anticoagulants (dabigatran/rivaroxaban) have recently become available for the prevention of venous thromboembolism (VTE) following hip and knee arthroplasty. Traditional therapies (warfarin/low molecular weight heparins) are less costly, but have several limitations. The aim of this study was to evaluate the financial impact of substituting enoxaparin and warfarin with newer therapies dabigatran and rivaroxaban. A secondary objective was to investigate patient satisfaction with these treatments. Methods. A randomised prospective study was conducted over a 12 month period. Patients with a history of VTE undergoing hip or knee replacement were randomised to receive one of four anticoagulants for five weeks post surgery. Information was gathered during the hospital stay and then post discharge, by telephone, for five weeks(35 days)to determine costs. The costs included cost of drug, nursing time, blood monitoring and transport costs. The patients were also asked to complete the Duke Anticoagulation Satisfaction Scale (DASS). The DASS is a 26 item questionnaire which has 7 responses for each question. Results. Although dabigatran and rivaroxaban had higher drug acquisition costs, warfarin and enoxaparin were financially more costly overall. These additional costs were mainly due to increased blood monitoring and time for training and administration which is not required for newer therapies. DASS scores were significantly better with dabigatran (38.5±5.1) and rivaroxaban (38.6±8.3) compared to warfarin (71.8±16.2) and enoxaparin (68.5±14.2) (p< 0.001). This indicates more satisfaction for patients prescribed dabigatran or rivaroxaban compared to traditional therapies. Conclusion. The use of new generation oral anticoagulants has the potential to significantly reduce the financial burden of thromboprophylaxis on the NHS with an additional benefit of better patient satisfaction when compared to traditional therapies

Previous studies have shown improved outcome following surgery for spinal cord compression due to metastatic disease. Further papers have shown that many patients with metastatic disease are not referred for orthopaedic opinion. The aims of this paper are to study the survival and morbidity of patients with spinal metastatic disease who receive radiotherapy. Do patients develop instability and progressive neurological compromise? Can we predict which patients will benefit from surgery?

Retrospective review of patients receiving radiotherapy for pain relief or cord compression as a result of metastatic disease. Patients were scored with regards to Tomita and Tokuhashi, survival and for deterioration in neurology or spinal instability.

94 patients reviewed. All patients were followed up for a minimum of 1 year or until deceased. Majority of patients had a primary diagnosis of lung, prostate or breast carcinoma.

Mean Tomita score of 6, Tokuhashi score 7, and mean survival following radiotherapy of 8 months. 11:94 patients referred for surgical opinion. Poor correlation with Tomita scores (-0.25) & Tokuhashi scores (0.24) to predict survival. Four patients developed progressive neurology on follow-up. One patient developed spinal instability. The remainder of the patients did not deteriorate in neurology and did not develop spinal instability. All patients with normal neurology at time of radiotherapy did not develop spinal cord compression or cauda equina at a later date.

This study suggests that the vast majority of patients with spinal metastatic disease do not progress to spinal instability or cord compression, and that prophylactic surgery would not be of benefit. The predictive scoring systems remain unreliable making it difficult to select those patients who would benefit. The referral rate to spinal surgeons remains low as few patients under the care of the oncologists develop spinal complications.

Arthrofibrosis is a less common complication following anterior cruciate ligament (ACL) reconstruction and there are concerns that undergoing early surgery may be associated with arthrofibrosis. The aim of this study was to identify the patient and surgical risk factors for arthrofibrosis following primary ACL reconstruction. Primary ACL reconstructions prospectively recorded in the New Zealand ACL Registry between April 2014 and December 2019 were analyzed. The Accident Compensation Corporation (ACC) database was used to identify patients who underwent a subsequent reoperation with review of operation notes to identify those who had a reoperation for “arthrofibrosis” or “stiffness”. Univariate Chi-Square test and multivariate Cox regression analysis was performed. Hazard ratios (HR) with 95% confidence intervals (CI) were computed to identify the risk factors for arthrofibrosis. 9617 primary ACL reconstructions were analyzed, of which 215 patients underwent a subsequent reoperation for arthrofibrosis (2.2%). A higher risk of arthrofibrosis was observed in female patients (adjusted HR = 1.67, 95% CI 1.22 – 2.27, p = 0.001), patients with a history of previous knee surgery (adjusted HR = 1.97, 95% CI 1.11 – 3.50, p = 0.021) and when a transtibial femoral tunnel drilling technique was used (adjusted HR = 1.55, 95% CI 1.06 – 2.28, p = 0.024). Patients who underwent early ACL reconstruction within 6 weeks of their injury did not have a higher risk of arthrofibrosis when compared to patients who underwent surgery more than 6 weeks after their injury (3.5% versus 2.1%, adjusted HR = 1.56, 95% CI 0.97 – 2.50, p = 0.07). Age, graft type and concomitant meniscal injury did not influence the rate of arthrofibrosis. Female sex, a history of previous knee surgery and a transtibial femoral tunnel drilling technique are risk factors for arthrofibrosis following primary ACL reconstruction

INTRODUCTION. Tuberculosis (TB) is a public health challenge. However, musculoskeletal involvement represents 10–15% of all extrapulmonary cases. Upper extremity involvement is extremely rare. The slow progressive course of clinical symptoms and lack of radiological signs lead to difficulties in establishing early diagnosis. Hence, the patients who have tuberculosis of the wrist are usually misdiagnosed. We report 5 cases of tuberculosis of the wrist seen in our unit from the year 2012 to 2021. METHODS. Cases were retrospectively evaluated on demographics, nature of history, clinical presentation, culture finding, and histopathological findings from 2012 to 2021 at our unit. RESULTS. A total of 5 cases were evaluated retrospectively. Three patients were more than 60 years old and two were less than 30 years old. Four of the patients presented with wrist swelling 2 of them had wrist pain and only 1 patient had discharge from the wound. The duration of the symptoms ranges from 2 months to 3 years. Only one of the patients had a history of pulmonary TB contact whereas the others didn't. All patients underwent surgery. All of the patients had positive cultures for Mycobacterium tuberculosis complex and histopathological examination showed necrotizing granulomatous inflammation from specimens taken intraoperatively, which confirmed the diagnosis of tuberculosis of the wrist. DISCUSSIONS. Our cases show that the common presentation of tuberculosis of the wrist was comparable to other literature. Most of the patients presented with chronic wrist swelling with or without wrist pain. The diagnosis of the disease was delayed an average of 10 - 12 months from symptoms onset to diagnosis. S. Bayram et al reported a case where the diagnosis was made 45 months later. Due to its rarity, it often is misdiagnosed, resulting in delays in the proper treatment. CONCLUSION. The diagnosis of the TB wrist remains difficult because of insidious and non-specific. presentation. However, early diagnosis is essential to avoid delays in treatment and complications. Hence, chronic wrist pain, and swelling with or without unexplained bone erosion around the wrist area must be highly suspected of being osteoarticular tuberculosis

Aim. Mega-endoprosthesis over the last two decades have played a significant role in management of non-neoplastic cases for limb salvage for a variety of indications involving bone loss, infection, fracture and failed revision surgery. This is a retrospective case control study comparing outcomes of Mega-Endoprosthesis (MEP) in non-neoplastic cases with periprosthetic joint infections (PJI), with previous history of PJI and aseptic revision. Failure was defined as persistence/recurrence of infection, all cause revision, and antibiotic suppression during the follow up period. Secondary aims were identification of causative organisms, resistance profile and causative factors for revision surgery. Method. A total of 122 patients undergoing 133 MEPs were identified between January 2012 and December 2020. 60 procedures were categorised as group 1 (infection; 50%), 20 as group 2 (previous history of infection; 16.7%), and 53 controls (no infection; 44.2%). Mean age of the cohort was 70.97 years (37.16–94.17), with a mean follow-up of 44.5 months (0.2–179) including patients lost to follow up. Results. Overall failure rate was 71/133 53.3% (group 1 39/60 (55.56%), group 2 12/20 (60%) and controls 20/53 (37.7%)). Thirteen patients died in the first 2 years (five in group 1, one in group 2 & seven in controls). The most common postoperative infection was polymicrobial followed by Coagulase Negative Staphylococcus Species (CoNS) and Methicillin Sensitive Staphylococcus aureus (MSSA). Nineteen patients had polymicrobial PJI (Eighteen in group 1 and one in control). CoNS led to postoperative infection in Fifteen patients (six in group 1, five in group 2 and four in control group). MSSA was the pathogen in four patients (three in group-1 and one in the control group). The same organisms were responsible for recurrent infection in fourteen patients in group 1 and one patient in group 2. Limb salvage was achieved in 96.2% overall (95% group 1, 90% group 2, 100% control group). Conclusions. MEPs in the context of PJI have a significant risk of failure however they play an important role in limb salvage. Patients should be counselled appropriately prior to surgery

Introduction. Aneurysmal bone cysts commonly found in lower limbs are locally aggressive masses that can lead to bony erosion, instability and fractures. This has major implications in the lower limbs especially in paediatric patients, with potential growth disturbance and deformity. In this case series we describe radical aneurysmal bone cyst resection and lower limb reconstruction using cable transport and syndesmosis preservation. Materials & Methods. Case 1 - A 12-year-old boy presented with a two-week history of atraumatic right ankle pain. An X-ray demonstrated a distal tibia metaphyseal cyst confirmed on biopsy as an aneurysmal bone cyst. The cyst expanded on interval X-rays from 5.5cm to 8.5cm in 9 weeks. A wide-margin en-bloc resection was performed leaving a 13.8cm tibial defect. A cable transport hexapod frame and a proximal tibial osteotomy was performed, with syndesmosis screw fixation. The transport phase lasted 11 months. While in frame, the boy sustained a distal femur fracture from a fall. The femur and the docking site were plated at the same sitting and frame removed. At one-year post-frame removal he is pain-free, with full ankle dorsiflexion but plantarflexion limited to 25 degrees. He has begun graduated return to sport. Results. Case 2 - A 12-year-old girl was referred with a three-month history of lateral left ankle swelling. X-ray demonstrated an aneurysmal bone cyst in the distal fibula metaphysis. The cyst grew from 4.2 × 2.3cm to 5.2 × 3.32cm in 2 months. A distal fibula resection (6.2cm) with syndesmosis fixation and hexapod cable transport frame were undertaken. The frame was in situ for 13 weeks and during this time she required an additional osteotomy for premature consolidation and had one pin site infection. After 13 weeks a second syndesmosis screw was placed, frame removed, and a cast applied. 3 months later she had fibular plating, BMAC and autologous iliac crest bone graft for slow union. At 3 years post-operative she has no evidence of recurrence, is pain-free and has no functional limitation. Conclusions. We describe two cases of ankle syndesmosis preservation using cable transport for juxta-articular aneurysmal bone cysts. This allows wide resection to prevent recurrence while also preserving primary ankle stability and leg length in children. Both children had a minor complication, but both had an excellent final outcome. Cable bone transport and prophylactic syndesmosis stabilization allows treatment of challenging juxta-articular aneurysmal bone cysts about the ankle. These techniques are especially useful in large bone defects