Introduction. Most of patients with unilateral hip disease shows muscle volume atrophy of pelvis and thigh in the affected side because of pain and disuse, resulting in reduced muscle weakness and limping. However, it is unclear how the muscle atrophy correlated with muscle strength in the patient with hip disorders. A previous study have demonstrated that the volume of the gluteus medius correlated with the muscle strength by volumetric measurement using 3 dimensional computed tomography (3D-CT) data, however, muscles influence each other during motions and there is no reports focusing on the relationship between some major muscles of pelvis and thigh including gluteus maximus, gluteus medius, iliopsoas and quadriceps and muscle strength in several hip and knee motions. Therefore, the purpose of the present study is to evaluate the relationship between muscle volumetric atrophy of major muscles of pelvis and thigh and muscle strength in flexion, extension and abduction of hip joints and extension of knee joint before surgery in patients with unilateral hip disease. Material and Methods. The subjects were 38 patients with unilateral hip osteoarthritis, who underwent hip joint surgery. They all underwent preoperative computed tomography (CT) for preoperative planning. There were 6 males and 32 females with average age 59.5 years old. Before surgery, isometric muscle strength in hip flexion, hip extension, hip abduction and knee extension were measured using a hand held dynamometer (µTas F-1, ANIMA Japan). Major muscles including gluteus maximus, gluteus medius, iliopsoas and quadriceps were automatically extracted from the preoperative CT using convolutional neural networks (CNN) and were corrected manually by the experienced surgeon. The muscle volumetric atrophy ratio was defined as the ratio of muscle volume of the affected side to that of the unaffected side. The muscle weakness ratio was defined as the ratio of muscle strength of the affected side to that of the unaffected side. The correlation coefficient between the muscle atrophy ratio and the muscle weakness ratio of each muscle were calculated. Results. The average muscle atrophy ratio was 84.5% (63.5%–108.2%) in gluteus maximus, 86.6% (65.5%–112.1%) in gluteus medius, 81.0% (22.1%–130.8%) in psoas major, and 91.0% (63.8%–127.0%) in quadriceps. The average muscle strength ratio was 71.5% (0%–137.5%) in hip flexion, 88.1% (18.8%–169.6%) in hip abduction, 78.6% (21.9%–130.1%) in hip extension and 84.3% (13.1%–122.8%) in knee extension. The correlation coefficient between the muscle atrophy and the ratio of each muscle strength between the affected and unaffected side were shown in Table 1. Conclusion. In conclusion, the muscle atrophy of gluteus medius muscle, psoas major muscle and quadriceps muscle significantly correlated with the muscle weakness in hip flexion. The muscle atrophy of psoas major muscle and quadriceps muscle also significantly correlated with the muscle weakness in knee extension. There were no significant correlation between the muscle atrophy and the muscle weakness in hip extension and abduction

We report a prospective case-series study to evaluate the results of non-operative and operative treatment of symptomatic unilateral lumbar spondylolysis. Non-operative treatment results in healing in most patients with symptomatic unilateral spondylolysis. Surgery however is indicated when symptoms persist beyond a reasonable time affecting the quality of life in young patients particularly the athletic population. We treated 41 patients [31 male, 10 female] with suspected unilateral lumbar spondylolysis. Thirty-one patients were actively involved in sports at various levels. Patients with a positive stress reaction on SPECT imaging underwent a strict protocol of activity restriction, bracing and physical therapy for 6 months. At the end of six months, patients who remained symptomatic underwent a Computed Tomography [CT] scan to confirm the persistence of a spondylolysis. Seven patients subsequently underwent a direct repair of the defect using the modified Buck's Technique. Baseline Oswestry disability index [ODI] and Short-Form-36 [SF-36] scores were compared to two year ODI and SF-36 scores for all patients. In the non-operated group, the mean pre-treatment ODI was 36 [SD=10.5], improving to 6.2 [SD=8.2] at two years. In SF-36 scores, the physical component of health [PCS] improved from 30.7 [SD=3.2] to 53.5 [SD =6.5] [p<0.001], and the mean score for the mental component of health [MCS] improved from 39 [SD=4.1] to56.5 [SD=3.9] [p<0.001] at two years. 20/31 patients resumed their sporting career within 6 months of onset of treatment, a further 4/31 patients returned to sports within one year. The seven patients who remained symptomatic at six months underwent a unilateral modified Buck's Repair. The most common level of repair was L5 (n=4). The mean pre-operative ODI was 39.4 (SD=3.6) improving to 4.4 (SD=4) at the latest follow-up. The mean score of PCS [SF-36] improved from 29.6 [SD=4.4] to 51.2 [SD=5.2] (SD=5.2) (p<0.001) and the mean score of MCS (SF-36) improved from 38.7 (SD=1.9) to 55.5 (SD=5.4) (p<0.001). A specific protocol of conservative treatment for patients with a unilateral lumbar spondylolysis resulted in a high rate of success with 83% of patients avoiding surgery. If symptoms persist beyond a reasonable period (i.e. 6 months) and reverse gantry CT scan confirms a non-healing defect of the pars interarticularis one may consider a unilateral direct repair of the defect with good outcome ultimately

Introduction. Limb length discrepancy (LLD) is one of the major reasons of dissatisfaction after total hip arthroplasty(THR) and limb equalization after THR in unilateral developmental dysplasia of the hip (DDH) is very important. study designed to measure the difference of adult femoral length between normal and dislocated hip in unilateral DDH. Method. Sixty patients with unilateral high riding DDH (crow type 3,4) who were underwent THR included. All the cases had digital lower limb scanograms. Exclusion criteria was any previous hip or femur surgery, any rheumatoid disease, history of any disease that affect the growth. All the scanograms measured by one fellowship of adult reconstruction and one radiologist specialized in musculoskeletal imaging. Each one repeated the measurements two months later blindly and inter observer and intra observer reliability checked. Each one measured femoral length in both sides from greater trochanter(GT), to the distal surface of the femoral condyles. Results. 59 female and one males included. Average age was 27.5 years (19–50 years). Inter observer reliability index were excellent (ICC 98%). Only 6 cases (10%) had exactly equal femoral length, 31(52%) cases were longer on the dislocated side and 23 (38%) cases were shorter. Average overgrowth was 6.1 mm (Range: 1–22) and average undergrowth was 10.7 (Range 1–21). 35 cases (58.3%) cases had 5 mm or more differences and 30% had 5–10 mm .17 cases (28.3%) had at least 10 mm difference that 8 cases (13%) had shorter and 9 cases (15%) had longer femur on dislocated side. Maximum difference was 22 mm over length on dislocated side. Conclusions. More than half of patients with unilateral high riding DDH have longer femur on the dislocated side and 15% of them are longer than 10 mm. we recommend to get the scanograms in all the unilateral DDH cases to avoid post-operative limb discrepancy and detecting the amount of shortening in cases that need femoral shortening

To compare the efficacy of intra-articular and intravenous modes of administration of tranexamic acid in primary Total Knee Arthroplasty in terms of blood loss and fall in haemoglobin level. This randomized controlled trial was conducted from 12th May 2017 to 11th May 2017. Seventy eight patients were included in the study. Patients were randomly divided into group A and B. Group A patients undergoing unilateral primary total knee replacement (TKR) were given intravenous tranexamic acid (TXA) while group B were infiltrated with intra-articular TXA. Volume of drain output, fall in haemoglobin (Hb) level and need for blood transfusion were measured immediately after surgery and at 12 and 24 hours post operatively in both groups. The study included 35 (44.87%) male and 43 (55.13%) female patients. Mean age of patients was 61±6.59 years. The mean drain output calculated immediately after surgery in group A was 45.38±20.75 mL compared with 47.95±23.86 mL in group B (p=0.73). 24 hours post operatively, mean drain output was 263.21±38.50 mL in intravenous group versus 243.59±70.73 mL in intra-articular group (p=0.46). Regarding fall in Hb level, both groups showed no significant difference (p>0.05). 12.82% (n=5) patients in group A compared to 10.26% (n=4) patients required blood transfusion post operatively (p=0.72). Intra-articular and intravenous TXA are equally effective in patients undergoing primary total knee arthroplasty in reducing post operative blood loss. For any reader queries, please contact . drjunaidrmc@gmail.com

The number of hip arthroplasty procedures has steadily increased in the United States over the last decade [Wolford, et. al, 2015]. This trend will continue as this treatment is the most effective approach in relieving pain, improving mobility, reducing fall risk and improving the quality of life in patients with end-stage osteoarthritis. The effectiveness of recovery can be impacted by factors such as access to postoperative physical therapy regimens. During the recovery period, it is important for therapists to be guided in their therapeutic decision making by accurate data concerning the patient's performance on a variety of measures. This project is designed to map the gait recovery curves of individuals who have undergone unilateral hip arthroplasty. To date, eight individuals (4 females, mean age 64.9, SD 11.1) have participated in the study. Five of the patients were treated by traditional press-fit Accolade II implants (Stryker, Mahwah, NJ USA) through a direct anterior approach THA and the other three has been treated by using DAA THA and using neck preserving Minihip. TM. short stem implant (Corin Ltd., Cirencester, UK). Each participant walked on an instrumented treadmill as a self-selected speed for three minutes pre-surgery. Post-surgery data collections occurred at three and six weeks, and three and six months and employed the same treadmill speed as used prior to surgery. Bilateral lower limb kinematic data was collected with a 12 camera motion capture system Vicon® (Oxford Metrics, Oxford, UK) using reflective markers attached to the hip, knee, ankle, heel and toe. Force plates embedded in the treadmill provided kinetic data that aided in the detection of heel strike and toe off. The temporal features associated with gait, including stride, stance time and double support time were obtained for both the surgical and non-surgical limbs and were used to assess changes in performance during the recovery period. The stance and double support data were also converted to a percentage of stance values which provide additional insights into gait control strategies. Repeated measure MANOVAs were used to evaluate any potential differences in the variables either between limbs or over time. Results from the statistical testing revealed that there were no significant differences between the two limbs for either stride or stance time. This was expected since global asymmetrical gait would have led to the participants veer off of the treadmill. There was a main effect of ‘Time’ for both stride and stance times. Post hoc testing indicated that the 6-month post-surgery measures were significantly reduced when compared to the Pre-surgery and 3-week post-surgery measures. Similarly, there were no significant differences in double support times between the two legs but there was a main effect for time. Post hoc testing revealed that the 6-month post-surgery double support time was significantly less than the Pre-surgery and 3-week post-surgery measures. These significant changes clearly indicate that surgery is effective in improving gait parameters. Moreover, clinicians may want to consider assessing double support time as this measure is a particularly robust indicator of the effectiveness of unilateral hip arthroplasty

Introduction. In cases of unilateral clubfoot, the leg and foot is visually smaller than the opposite, uninvolved side. Parents want to know how much smaller the leg and foot will be. The purpose of this study was to answer this question and compare the results of children treated with a posterior medial release (PMR) with those treated with the Ponseti method (PM). Methods. This is a prospective, longitudinal study of calf circumference and foot length. We measured the calf circumference with a tape measure at the visually maximum girth of the uninvolved side and at the symmetrical position of the involved side. We measured each foot length from the tip of the hallux to the end of the heel. We recorded the measurements at each follow-up visit in a database and analysed the data using linear regression analysis. Results. We followed 93 children (65 PMR, 28 PM) for a mean of 68 months (SD 55, range 6-252) The ratio men/women was 53/40. Mean percent calf size difference was 9.83% (95%CL 8.74-10.92%). Mean percent foot size difference was 8.70% (95%CL 7.54-9.87%). From the numbers available, no differences between the two procedures are evident. Conclusion. Children with a unilateral clubfoot have c10% smaller calf circumference and foot length as compared to the uninvolved side. We found no differences between children treated with PMR or PM, implying the smaller size is intrinsic to the condition and not due to type of treatment

Introduction:. The clinical significance of serum metal ion levels alone in patients with stemmed MoM hip arthroplasty remains uncertain. This study aims to measure the metal ion levels in patients with unilateral and bilateral hip arthroplasty to see whether or not the patients with bilateral hips have higher metal ions. Patients and Methods. All the patients with bilateral MoM hip arthroplasty were identified from the research database. These patients were then matched with those in a similar age group who had a unilateral hip arthroplasty, but same University of California Los Angeles (UCLA) activity score. The UCLA activity scores along with other hip scores have been previously gathered for all the patients. Both sets of patients then had measurement of serum cobalt and chromium levels. The results were analyzed and compared. Results:. There were a total of 53 patients with bilateral hips and 53 matched patients with unilateral hips. The average serum Cobalt and Chromium levels were 34 nmol/L (range <10–76) and 23 nmol/L (range <10–104) respectively in the bilateral group; and 14 nmol/L (range <10–45) and 21 nmol/L (range <10–57) in the unilateral group. Given that the MHRA (UK) threshold levels deemed clinically significant are 120 nmol/L and 135 nmol/L for Cobalt and Chromium respectively; the results obtained here are not clinically significant. Conclusions:. One would normally expect, with mathematical reasoning, a patient with bilateral hip arthroplasty to have higher serum metal ion levels than a patient with unilateral arthroplasty. However, this study goes to show that it is not the case

Increasing pressure to use rapid recovery care pathways when treating patients undergoing total hip arthroplasty (THA) is evident in current health care systems for numerous reasons. Patient autonomy and health care economics has challenged the ability of THA implants to maintain functional integrity before achieving bony union. Although collared stems have been shown to provide improved axial stability, it is unclear if this stability correlates with activity levels or results in improved early function to patients compared to collarless stems. This study aims to examine the role of implant design on patient activity and implant fixation. The early follow-up period was examined as the majority of variation between implants is expected during this time-frame. Patients (n=100) with unilateral hip OA who were undergoing primary THA surgery were recruited pre-operatively to participate in this prospective randomized controlled trial. All patients were randomized to receive either a collared (n=50) or collarless (n=50) cementless femoral stem. Patients will be seen at nine appointments (pre-operative, < 2 4 hours post-operation, two-, four-, six-weeks, three-, six-months, one-, and two-years). Patients completed an instrumented timed up-and-go (TUG) test using wearable sensors at each visit, excluding the day of their surgery. Participants logged their steps using Fitbit activity trackers and a seven-day average prior to each visit was recorded. Patients also underwent supine radiostereometric analysis (RSA) imaging < 2 4 hours post-operation prior to leaving the hospital, and at all follow-up appointments. Nineteen collared stem patients and 20 collarless stem patients have been assessed. There were no demographic differences between groups. From < 2 4 hours to two weeks the collared implant subsided 0.90 ± 1.20 mm and the collarless implant subsided 3.32 ± 3.10 mm (p=0.014). From two weeks to three months the collared implant subsided 0.65 ± 1.54 mm and the collarless implant subsided 0.45 ± 0.52 mm (p=0.673). Subsidence following two weeks was lower than prior to two weeks in the collarless group (p=0.02) but not different in the collared group. Step count was reduced at two weeks compared to pre-operatively by 4078 ± 2959 steps for collared patients and 4282 ± 3187 steps for collarless patients (p=0.872). Step count increased from two weeks to three months by 6652 ± 4822 steps for collared patients and 4557 ± 2636 steps for collarless patients (p=0.289). TUG test time was increased at two weeks compared to pre-operatively by 4.71 ± 5.13 s for collared patients and 6.54 ± 10.18 s for collarless patients (p=0.551). TUG test time decreased from two weeks to three months by 7.21 ± 5.56 s for collared patients and 8.38 ± 7.20 s for collarless patients (p=0.685). There was no correlation between subsidence and step count or TUG test time. Collared implants subsided less in the first two weeks compared to collarless implants but subsequent subsidence after two weeks was not significantly different. The presence of a collar on the stem did not affect patient activity and function and these factors were not correlated to subsidence, suggesting that initial fixation is instead primarily related to implant design

Sagittal pelvic tilt (PT) has been shown to effect the functional position of acetabular components in patients with total hip replacements (THR). This change in functional component position may have clinical implications including increased likelihood of wear or dislocation. Surgeons can use computer-assisted navigation intraoperatively to account for a patient's pelvic tilt and to adjust the position of the acetabular component. However, the accuracy of this technique has been questioned due to the concern that PT may change after THR. The purpose of this study was to measure the change in PT after THR, and to determine if preoperative clinical and radiographic parameters can predict PT changes after THR. 138 consecutive patients who underwent unilateral THR by one surgeon received standing bi-planar lumbar spine and lower extremity radiographs preoperatively and six weeks postoperatively. Patients with prior contralateral THR, conversion THR and instrumented lumbosacral fusions were excluded. PT and pelvic incidence (PI) were measured preoperatively for each patient, and PT was measured on the postoperative imaging. A negative value for PT indicated posterior pelvic tilt. Patient demographics were collected from the chart. Average age was 56.8±10.9 years, average BMI was 28.3±6.0 kg/m2, and 67 patients (48.6%) were female. Mean preoperative pelvic tilt was 0.6°±7.3° (range: −19.0° to 17.9°). We found greater than 10° of sagittal PT in 23 out of 138 (16.6%) patients in this sample. Mean post-operative pelvic tilt was 0.3°±7.4° (range: −18.4° to 15.0°). Mean change in pelvic tilt was −0.3°±3.6° (range: −9.6° to 13.5°). PT changed by less than 5° in 119 of 138 patients (86.2%). The mean difference in pre-operative and post-operative PT is not statistically significant (p = 0.395). Pre-operative PT was strongly correlated with post-operative PT (r2 = 0.88, p = 0.0001) (Figure 1). There was not a statistically significant relationship between PI and change in PT (r2 = −0.16, p = 0.06). In conclusion, based on the variability in pelvic tilt in this study population and the relatively small change in pelvic tilt following THA tilt-adjustment of the acetabular component position based on standing pre-operative imaging is likely to be of benefit in the majority of patients undergoing navigated THA. However, we have been unable to predict the relatively rare occurrence of a large change in pelvic tilt, which would confound tilt-adjusted component position

Hip arthroplasty is commonly used as the final treatment approach for patients experiencing end-stage osteoarthritis. The number of these patients needing this treatment is expected to grow significantly by year 2030 to more than 572000 patients [Kurtz et al., 2007]. One of the important outcomes of hip arthroplasty is to improve patients' functions postoperatively. The evaluation of walking can provide a wealth of information regarding the efficiency of this treatment in improving a patient's mobility. Assessing the kinematic features of gait collected with a motion capture system combined with the aid of a motor-driven treadmill provides the advantage of enabling the evaluator to collect precise information about a large number of strides in a short period of time. Body segment kinematics (i.e. joint motion) are most often represented in the form of time series data with the abscissa (X axis) representing time and the ordinate (y axis) representing the motion of a particular joint. Although a great deal of information can be gained from the analyses of time series data, non-linear analyses tools can provide an additional and important dimension to a clinician's assessment of gait recovery. In this study eight patients (4 females, mean age 64.9, SD 11.1) have currently been assessed after unilateral hip arthroplasty. All surgeries were conducted by direct anterior approach by using two different approaches; three of the patients were treated by bone preservation technique and received Minihip short stem implant (Corin Ltd., Cirencester, UK) and five were treated by using a press fit stem implant Accolade II (Stryker, Mahwah, NJ USA). Patients performed a single three-minute trial of walking on a motor-driven treadmill at a self-selected pace. Using a 12 camera system, bilateral lower limb joint motion was collected prior to the surgery, at three and six weeks and at three and 6 months after the surgery. Depending upon the patient's preferred walking pace; between 40 and 45 strides were collected during each trial. Kinematic data obtained from force plates embedded in the treadmill were used to identify the heel strike and toe off events for each stride. After time normalizing the each of the joint angles (i.e. hip, knee, ankle) for each stride to 100 data points the data were then amplitude normalized to the initial point of the pre-surgery data. The non-linear tools of angle-angle and phase plane were used to explore relationships that are not readily apparent with linear wave form analyses. Angle-angle diagrams between a variety of joints angles both within a single limb or bilaterally enabled us to explore segmental coordination patterns and how they changed over the six months after surgery. Phase plane analyses included comparing joint motion relative to the velocity of that motion. This technique provided insights into the nature of the control of the joint. The additional information that results from the use of non-linear analyses provides an additional dimension of that can aide the clinician in understanding the recovery curve. This additional insight can be used to guide therapeutic decision making

Background. To determine the relative contributions of bilateral versus unilateral femoral shaft fracture plus injuries in other body regions to mortality after injury. Study design. A retrospective analysis of the prospectively recorded Trauma Registry data (TARN) from 1989 to 2003. Methods. Patients were divided into groups UFi (isolated unilateral femur injury),BFi (isolated bilateral femur injury) and UFa and BFa if an associated injury was present. Data collected for each patient included age, Injury Severity Scores, Glasgow Coma Scale, mortality, physiological parameters, the timing and extent of prehospital care, the time to arrival at the hospital, initial treatments, time to and type of surgery, length of ICU and hospital stay. Logistic regression data analysis was performed to determine variables that were associated with increased mortality. Results. Patients in group BFa had a significantly higher ISS (23 vs 9),reduced GCS (12 vs 15) and increased mortality rate (31.6% vs 9.8%) than patients in group BFi. Group BFa patients had an increased number of associated injuries than group UFa. Regression analysis of variables evident on admission revealed a significant correlation between bilateral femoral fractures with associated injuries and mortality. However bilateral fracture, even in isolation significantly increased the odds of mortality by 3.07(1.36-6.92). Intramedullary nailing (IMN) was the method of fracture fixation associated with the lowest patient mortality overall. However, when assessing patient mortality in the BFa group with an ISS of more than 40, three other fracture fixation regimens were associated with a lower mortality rate than the IMN group. Conclusions. The increase in mortality with bilateral femoral fractures is more closely associated with the presence of associated injuries and poor physiological parameters than to the presence of the bilateral femoral fracture alone. However contrary to ISS scoring the latter does convey a significant additional risk of mortality. The presence of bilateral femoral fractures should alert the clinician to the very high likelihood (80%) of significant associated injuries in other body systems and their life-threatening potential

In the Unites States, approximately 24% of people undergoing primary total knee or total hip arthroplasty (TKA, THA) are chronic opioid users pre-operatively. Few studies have examined the incidence of opioid use prior to TKA/THA and whether it predicts outcomes post-surgery in the Australian context. The aim was to determine: (i) the proportion of TKA and THA patients who use opioids regularly (daily) pre-surgery; (ii) if opioid use pre-surgery predicts (a) complication and readmission rates to 6-months post-surgery, (b) patient-reported outcomes to 6-months post-surgery.

A retrospective cohort study was undertaken utilising linked individual patient-level data from two independent databases comprising approximately 3500 people. Patients had surgery between January 2013 and June 2018, inclusive at Fairfield and Bowral Hospitals.

Following data linkage, analysis was completed on 1185 study participants (64% female, 69% TKA, mean age 67 (9.9)). 30% were using regular opioids pre-operatively. Unadjusted analyses resulted in the following rates in those who were vs were not using opioids pre-operatively (respectively); acute adverse events (39.1% vs 38.6%), acute significant adverse events (5.3% vs 5.7%), late adverse events: (6.9% vs 6.6%), total significant adverse events: (12.5% vs 12.4%), discharge to inpatient rehab (86.4% vs 88.6%), length of hospital stay (5.9 (3.0) vs 5.6 (3.0) days), 6-month post-op Oxford Score (38.8 (8.9) vs 39.5 (7.9)), 6 months post-op EQ-VAS (71.7 (20.2) vs 76.7 (18.2), p<0.001), success post-op described as “much better” (80.2% vs 81.3%).

Adjusted regression analyses controlling for multiple co-variates indicated no significant association between pre-op opioid use and adverse events/patient-reported outcomes.

Pre-operative opioid use was high amongst this Australian arthroplasty cohort and was not associated with increased risk of adverse events post-operatively. Further research is needed in assessing the relationship between the amount of pre-op opioid use and the risk of post-operative adverse events.

There has been much discussion and controversy in the media recently regarding metal toxicity following large head metal on metal (MoM) total hip replacement (THR). Patients have been reported as having hugely elevated levels of metal ions with, at times, devastating systemic, neurolgical and/or orthopaedic sequelae.

However, no direct correlation between metal ion level and severity of metallosis has yet been defined. Normative levels of metal ions in well functioning, non Cobalt-Chrome hips have also not been defined to date.

The Exeter total hip replacement contains no Cobalt-Chrome (Co-Cr) as it is made entirely from stainless steel. However, small levels of these metals may be present in the modular head of the prosthesis, and their effect on metal ion levels in the well functioning patient has not been investigated.

We proposed to define the “normal” levels of metal ions detected by blood test in 20 well functioning patients at a minimum 1 year post primary Exeter total hip replacement, where the patient had had only one joint replaced.

Presently, accepted normal levels of blood Chromium are 10–100 nmol/L and plasma Cobalt are 0–20 nmol/L. The UK Modern Humanities Research Association (MHRA) has suggested that levels of either Cobalt or Chromium above 7 ppb (equivalent to 135 nmol/L for Chromium and 120 nmol/L for Cobalt) may be significant. Below this level it is indicated that significant soft tissue reaction and tissue damage is less likely and the risk of implant failure is reduced.

Hips were a mixture of cemented and hybrid procedures performed by two experienced orthopaedic consultants. Seventy percent were female, with a mixture of head sizes used.

In our cohort, there were no cases where the blood Chromium levels were above the normal range, and in more than 70% of cases, levels were below recordable levels. There were also no cases of elevated plasma Cobalt levels, and in 35% of cases, levels were negligible.

We conclude that the implantation with an Exeter total hip replacement does not lead to elevation of blood metal ion levels.

Introduction

Alumina Ceramic liners are increasingly used in patients undergoing Total Hip Replacement (THR). The rate of fracture of ceramic liner is decreasing with improved manufacturing techniques from 1^st to 3^rd generation alumina-ceramic liners. We report the first case of a fracture of a modern, 4^th generation alumina bearing ceramic liner, which incorporates a metal sheath to help avoid fracture. Our case is a 60 years old female presenting two years and three months after a bilateral total hip replacement using Stryker Trident cup, securfit stem and alumina on alumina bearing ceramic liner. Ceramic liners are commonly used, especially in young patients because of their excellent biocompatibility, low wear rate and superior tribology. Although fracture of ceramic liner is a less common complication of modern total hip arthroplasty, it is a major concern with the use of ceramic on ceramic THR, the reason being brittleness of ceramic. Cases of 3^rd generation ceramic liner fracture have been reported which might be associated with impingement due to excessive anteversion of the socket in Asian patients who habitually squat. Habitual squatting, sitting cross legged and kneeling were not characteristic of this case.

Arthroscopic hip procedures have increased dramatically over the last decade as equipment and techniques have improved. Patients who require hip arthroscopy for femoroacetabular impingement on occasion require surgery on the contralateral hip. Previous studies have found that younger age of presentation and lower Charlson comorbidity index have higher risk for requiring surgery on the contralateral hip but have not found correlation to anatomic variables. The purpose of this study is to evaluate the factors that predispose a patient to requiring subsequent hip arthroscopy on the contralateral hip. This is an IRB-approved, single surgeon retrospective cohort study from an academic, tertiary referral centre. A chart review was conducted on 310 primary hip arthroscopy procedures from 2009-2020. We identified 62 cases that went on to have a hip arthroscopy on the contralateral side. The bilateral hip arthroscopy cohort was compared to unilateral cohort for sex, age, BMI, pre-op alpha angle and centre edge angle measured on AP pelvis XRay, femoral torsion, traction time, skin to skin time, Tonnis grade, intra-op labral or chondral defect. A p-value <0.05 was deemed significant. Of the 62 patients that required contralateral hip arthroscopy, the average age was 32.7 compared with 37.8 in the unilateral cohort (p = 0.01) and BMI was lower in the bilateral cohort (26.2) compared to the unilateral cohort (27.6) (p=0.04). The average alpha angle was 76.3. 0. in the bilateral compared to 66. 0. in the unilateral cohort (p = 0.01). Skin to skin time was longer in cases in which a contralateral surgery was performed (106.3 mins vs 86.4 mins) (p=0.01). Interestingly, 50 male patients required contralateral hip arthroscopy compared to 12 female patients (p=0.01). No other variables were statistically significant. In conclusion, this study does re-enforce existing literature by stating that younger patients are more likely to require contralateral hip arthroscopy. This may be due to the fact that these patients require increased range of motion from the hip joint to perform activities such as sports where as older patients may not need the same amount of range of motion to perform their activities. Significantly higher alpha angles were noted in patients requiring contralateral hip arthroscopy, which has not been shown in previous literature. This helps to explain that larger CAM deformities will likely require contralateral hip arthroscopy because these patients likely impinge more during simple activities of daily living. Contralateral hip arthroscopy is also more common in male patients who typically have a larger CAM deformity. In summary, this study will help to risk stratify patients who will likely require contralateral hip arthroscopy and should be a discussion point during pre-operative counseling. That offering early subsequent or simultaneous hip arthroscopy in young male patients with large CAMs should be offered when symptoms are mild

Aims. As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach. Methods. A total of 58 patients (median age 17 years (interquartile range (IQR) 15 to 21)) treated by unilateral tibial distraction osteogenesis for a median leg length discrepancy of 41 mm (IQR 34 to 53), and nine patients with disproportionate short stature treated by bilateral simultaneous tibial distraction osteogenesis, with magnetically controlled motorized ILNs inserted via an antegrade approach, were retrospectively analyzed. The median follow-up was 37 months (IQR 30 to 51). Outcome measurements were accuracy, precision, reliability, bone healing, complications, and patient-reported outcome assessed by the Limb Deformity-Scoliosis Research Society Score (LD-SRS-30). Results. A median tibial distraction of 44 mm (IQR 31 to 49) was achieved with a mean distraction index of 0.5 mm/day (standard deviation 0.13) and median consolidation index of 41.2 days/cm (IQR 34 to 51). Accuracy, precision, and reliability were 91%, 92%, and 97%, respectively. New temporary range of motion limitations occurred in 51% of segments (34/67). Distraction-related equinus deformity treated by Achilles tendon lengthening was the most common major complication recorded in 16% of segments (11/67). In 95% of patients (55/58) the distraction goal was achieved with 42% unplanned additional interventions per segment (28/67). The median postoperative LD-SRS-30 score was 4.0 (IQR 3.6 to 4.3). Conclusion. Tibial distraction osteogenesis using motorized ILNs inserted via an antegrade approach appears to be a reliable and precise procedure. Temporary joint stiffness of the knee or ankle should be expected in up to every second patient. A high rate and wide range of complications of variable severity should be anticipated. Cite this article: Bone Joint J 2024;106-B(3):293–302

The purpose of this study is to assess the long term results of combined ACL reconstruction and unicompartmental knee replacements (UKR). These patients have been selected for this combined operation due to their combination of instability symptoms from an absent ACL and unicompartmental arthritis. Retrospective review of 44 combined UKR and ACL reconstruction by a single surgeon. Surgeries included both medial and lateral UKR combined with either revision ACL reconstruction or primary ACL reconstruction. Patient reported outcomes were obtained preoperatively, at one year, 5 years and 10 years. Revision rate was followed up over 13 years for a mean of 7.4 years post-surgery. The average Oxford score at one year was 43 with an average increase from pre-operation to 1 year post operation of 15. For the 7 patients with 10 year follow up average oxford score was 42 at 1 year, 43 at 5 years and 45 at 10 years. There were 5 reoperations. 2 for revision to total knee arthroplasty and 1 for an exchange of bearing due to wear. The other 2 were the addition of another UKR. For those requiring reoperation the average time was 8 years. Younger more active patients presenting with ACL deficiency causing instability and unicompartmental arthritis are a difficult group to manage. Combining UKR and ACL reconstruction has scant evidence in regard to long term follow up but is a viable option for this select group. This paper has one of the largest cohorts with a reasonable follow up averaging 7.4 years and a revision rate of 11 percent. Combined unilateral knee replacements and ACL reconstruction can be a successful operation for patients with ACL rupture causing instability and unicompartmental arthritis

Introduction. Genu valgum is a common presentation in paediatric patients with congenital limb deformities. The aim of this study is to assess the outcome of guided growth surgery in paediatric patients referred via our physiotherapy pathway with isolated genu valgum and associated patellar instability. Materials & Methods. Patients were identified from our prospective patellar instability database. Inclusion criteria was acquired or congenital genu valgum associated with patellar instability in skeletally immature patients. The mechanical lateral-distal femoral angle was assessed on long leg alignment radiographs (mLDFA <85 degrees). Surgical treatment was the placement of a guided growth plate (PediPlate, OrthoPediatrics, USA) on the medial distal femoral physis (hemi-epiphysiodesis). KOOS-child scores were collected pre-operatively and post-operatively (minimum at 6 months). Results. Eleven patients (seven female) with mean age of 12(range 5–15) were identified. Five patients had congenital talipes equinovarus(CTEV), one fibular hemimelia, one di-George syndrome, one septic growth arrest and three had idiopathic genu valgum. Pre- and post-operative KOOS-child scores showed overall improvement: 58(range 36–68) to 88(65–99) and knee symptoms subscores: 64(43–71) to 96(68–100) p<0.01, t-test. Mean follow-up was 10 months (range 3–23). No subsequent dislocations/subluxations occurred during follow-up. Conclusions. Guided growth surgery is an effective way of treating symptomatic patellar instability in skeletally immature patients with genu valgum in the absence of other structural pathology. It was most common in our cohort in patients with unilateral CTEV. We would recommend to screen syndromic and congenital limb deformity patients for patellar instability symptoms in the presence of genu valgum

Proximal femoral focal deficiency is a congenital disorder of malformation of the proximal femur and/or the acetabulum. Patients present with limb length discrepancy and clinical features along a spectrum of severity. As these patients progress through to skeletal maturity and on to adulthood, altered biomechanical demands lead to progression of arthropathy in any joint within the lower limb. Abnormal anatomy presents a challenge to surgeons and conventional approaches and implants may not necessarily be applicable. We present a case of a 62-year-old lady with unilateral proximal femoral focal deficiency (suspected Aitken Class A) who ambulated with an equinus prosthesis for her entire life. She presented with ipsilateral knee pain and instability due to knee arthritis but could not tolerate a total knee arthroplasty due to poor quadriceps control. A custom osteointegration prosthesis was inserted with a view to converting to the proximal segment to a total hip replacement if required. The patient went on to develop ipsilateral symptomatic hip arthritis but altered acetabular anatomy required a custom tri-flange component (Ossis, Christchurch, New Zealand) and a custom proximal femoral component to link with the existing osseointegration component (Osseointegration Group of Australia, Sydney, Australia) were designed and implanted. The 18 month follow up of the custom hip components showed that the patient had Oxford hip scores that were markedly improved from pre-operatively. Knee joint heights were successfully restored to equal when the patient's prosthesis was attached. The patient describes feeling like “a normal person”, walks unaided for short distances and can ambulate longer distances with crutches. Advances in design and manufacture of implants have empowered surgeons to offer life improving treatments to patients with challenging anatomy. Using a custom acetabular tri-flange and osseointegration components is one possible solution to address symptomatic ipsilateral hip and knee arthropathy in the context of PFFD in adulthood

Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure to functionally block the ankle and subtalar joints to treat severe ankle and hindfoot disease. Complication rates range between 20-40%, with below-knee amputation rate 1.5-19%. The heterogeneous patient cohort and indication(s) for surgery make post-operative outcomes difficult to predict. Consulting patients about potential pain and functional outcomes is difficult. When researching this area commonly, PROM data is used, less frequently functional objective measures like the 2-minute-walk-test (2MWT) are used. The aim was to compare the PROMs and objective outcomes between patients who underwent TTCA and BKA. Fifty-two patients underwent a TTCA using an intramedullary hindfoot nail. Indications for TTCA, post-traumatic OA, failed arthrodesis and malalignment. These patients were compared to 11 patients who underwent unilateral below knee amputation (BKA) due to trauma. Outcomes measures PROMs AOFAS ankle hindfoot scale and Shor-Form 36 (SF-36). Objective measures; 2MWT, Timed-up-and-go (TUG). Mean age TTCA 55.9, BKA 46.4. Average follow-up time 53 months. TTCA group had average 6.3 operations prior to arthrodesis (range 1-23). Of the TTCA group two ankles did not unite (7%), all complication rate 35%, 18% reported no pain. A significant negative correlation was demonstrated between the clinical outcome and the number of surgeries prior to the TTCA. TUG and 2MWT had significantly (p<0.05) better outcomes for the BKA group compared to TTCA. SF-36 BKA patients scored higher than the TTCA patients on physical functioning (p<0.01) and mental health (p<0.05) subscales as well as the mental component score (p<0.05). This study gives clinicians evidence about the natural history of hindfoot arthrodesis and functional outcomes from BKA. Hopefully this study will improve evidence to help patients and surgeons make decisions about expected surgical outcomes from TTCA and BKA procedures