Aims. To discover how the management of traumatic anterior shoulder dislocation in the young patient (17-25) has changed, if at all, over the past six years. Methods. The same postal questionnaire was sent in 2002 and 2009 to 164 shoulder surgeons. Questions were asked about initial reduction, investigation undertaken, timing of surgery, preferred stabilisation procedure, period of immobilisation and rehabilitation programme instigated in first-time and recurrent traumatic dislocators. Summary of Results. Response rate - 92% (2009), 83% (2002). The most likely management of a young traumatic shoulder dislocation:. Reduction under sedation in A&E by A&E doctor (80%). Apart from X-ray, no investigations are performed (80%). Immobilisation for 3 weeks, followed by physiotherapy (82%). 68% would consider stabilisation surgery for first time dislocators (especially professional sportsmen) compared to 35% (2002). Of them, nearly 90% would perform an arthroscopic stabilisation vs. 57.5% (2002). For recurrent dislocators:. 75% would consider stabilisation after a second dislocation. 85% would investigate prior to surgery, choice of investigation being MR arthrogram (52%), compared to 50% (2002). 77% would perform arthroscopic stabilisation vs. 18% (2002), commonest procedure-arthroscopic Bankart repair using biodegradable bone anchors (62% 2009 vs. 27% in 2002). Immobilisation for 3 weeks, full range of motion 1-2 months and return to contact sports 6 - 12 months. Conclusion. There has been a remarkable change in practice compared to the previous survey. A significant proportion of Orthopaedic Surgeons would consider stabilisation in young first-time dislocators instead of conservative management. Arthroscopic stabilisation is now the preferred technique compared to open stabilisation whenever possible. Surgeons are using more investigations prior to listing the patient for surgery, namely the MR arthrogram. There is also an increased use of bio-degradable anchors as compared to metallic bone anchors in 2002

A fracture of the tuberosity is associated with 16% of anterior glenohumeral dislocations. Manipulation of these injuries in the emergency department is safe with less than 1% risk of fracture propagation. However, there is a risk of associated neurological injury, recurrent instability and displacement of the greater tuberosity fragment. The risks and outcomes of these complications have not previously been reported. The purpose of this study was to establish the incidence and outcome of complications associated with this pattern of injury. We reviewed 339 consecutive glenohumeral dislocations with associated greater tuberosity fractures from a prospective trauma database. Documentation and radiographs were studied and the incidence of neurovascular compromise, greater tuberosity fragment migration and intervention and recurrent instability recorded. The mean age was 61 years (range, 18–96) with a female preponderance (140:199 male:female). At presentation 24% (n=78) patients had a nerve injury, with axillary nerve being most common (n=43, 55%). Of those patients with nerve injuries 15 (19%) did not resolve. Greater tuberosity displacement >5mm was observed in 36% (n=123) of patients with 40 undergoing acute surgery, the remainder did not due to comorbidities or patient choice. Persistent displacement after reduction accounted for 60 cases, later displacement within 6 weeks occurred in 63 patients. Recurrent instability occurred in 4 (1%) patients. Patient reported outcomes were poor with average EQ5D being 0.73, QDASH score of 16 and Oxford Shoulder Score of 41. Anterior glenohumeral dislocation with associated greater tuberosity fracture is common with poor long term patient reported outcomes. Our results demonstrate there is a high rate of neurological deficits at presentation with the majority resolving spontaneously. Recurrent instability is rare. Late tuberosity fragment displacement occurs in 18% of patients and regular follow-up for 6 weeks is recommended to detect this

Polyimide (MP-1, MMATech, Haifa, Israel), is a high performance aerospace thermoplastic used for its lubricity, stability, inertness and radiation resistance. A wear resistant thin robust bearing is needed for total hip arthroplasty (THR). After independent laboratory testing, in 2006, the author used the material as a bearing in two Reflection (Smith and Nephew, USA) hip surgeries. The first, a revision for polyethylene wear, survives with no evidence of wear, noise, new osteolysis or complications related to the MP-1 bearing after 16 yrs. The second donated his asymptomatic MP-1 hip at 6.5yrs for post-mortem examination. There were no osteoclasts, cellular reaction bland in contrast to that of polyethylene. In 2013 a clinical study with ethical committee approval was started using a Biolox Delta (Ceramtec, Germany) head against a polyimide liner in 97 patients. MMATech sold all liners, irradiated: steam 52:45. Sixteen were re-machined in New Zealand. Acetabular shells were Delta PF (LIMA, Italy). The liner locked by taper. The cohort consisted of 46:51 M:F, and ages 43 to 85, mean 65. Ten received cemented stems. For contralateral surgery, a ceramic or polyethylene liner was used. Initial patients were lower demand, later, more active patients, mountain-biking and running. All patients have on-going follow up, including MP-1 liner revision cases. There has been no measurable wear, or osteolysis around the acetabular components using weight-bearing radiographs. Squeaking within the first 6 weeks was noted in 39 number of cases and subtle increase in palpable friction, (passive rotation at 50 degrees flexion), but then disappeared. There were 6 revisions, four of which were related to cementless Stemsys implants (Evolutis, Italy) fixed distally with proximal linear lucencies in Gruen zones 1 and 7, and 2 and 6. No shells were revised and MP-1 liners were routinely changed to ceramic or polyethylene. The liners showed no head contact at the apex, with highly polished contact areas. There were no deep or superficial infections, but one traumatic anterior dislocation at 7 years associated with 5 mm subsidence of a non-collared stem. The initial squeaking and increased friction was due to the engineering of the liner / shell composite as implanted, not allowing adequate clearance for fluid film lubrication and contributed to by shell distortion during impaction. The revised bearings were “equatorial” rather than polar, and with lack of wear or creep this never fully resolved. Where the clearance was better, function was normal. The “slow” utilization was due to my ongoing concern with clearances not being correct. The revision of 4 Stemsys stems, tribology issues may have contributed, but non “MP-1” / Stemsys combinations outside this study have shown the same response, thought to be due to de-bonding of the hydroxyapatite coating. With correct engineering and clearances, a 3.6 mm thick MP-1 bearing, a surface Ra<0.5, steam sterilized, shows no appreciable wear, and with confidence, can be used as a high performance THR bearing

Introduction. Dislocation is one of severe complications after total hip arthroplasty (THA). Direct anterior approach (DAA) is useful for muscle preservation. Therefore, it might be also effective to reduce dislocation. The purpose of this study is to investigate the ratio and factors of dislocations after THA with DAA. Materials & methods. Nine hundred fifity two primary THAs with DAA are examined. Mean age at operation was 64.9 yrs. 838 joints are in women and 114 (joints) in men. All THAs were performed under general anesthesia in supine position. We reviewed the ratio, onset and frequency of dislocations, build of the patients, preoperative Japanese Orthopaedic Association (JOA) Hip scores, implant setting angles, pelvic tilt angles and diameter of inner heads. Results. The ratio of dislocation was 14 joints (1.47%). All patients were women and mean age was 67.1 yrs. Anterior dislocation was in 9 joints and posterior was in 5 joints. Primary diagnosis for THA was the following: osteoarthritis in 9 hips and rheumatoid arthritis in 5 (hips). About primary onset, 7 joints were within 3 weeks, 5 joints from 3 weeks to 3 months and 2 joints after 3 months. About frequency, 9 joins were simple and 5 joints were multiple. Revision surgery was done in 2 joints due to ceramic fracture and cup migration. About build of the patients, mean body height was 153.1cm, mean body weight (was) 55.6 kg and mean BMI (was) 23.6. Mean preoperative JOA score was 40.0 points. Implant setting angles were the following: mean cup inclination was 42.4 degree, mean cup anteversion (was) 24.8 degree and mean stem anteversion (was) 18.7 degree. Cup inclination and anteversion in the anterior dislocation group were bigger than that in no dislocation group. Stem anteversion in the posterior dislocation group was smaller than that in no dislocation group. The difference of pelvic tilt angle between supine and standing position was 6.4 degree. It was significant bigger in the posterior dislocation group. The most of used Inner head was 28mm in 375 joints. There was no significant difference of the dislocation rate among inner head size. Discussion and conclusion. DAA-THA can expect the reduction of dislocation rate due to intermusclar approach; however there are some reports of high dislocation rate because of difficult technique. In our study, dislocation ratio was 1.47%. Risk factors of dislocation after THA was rheumatoid arthritis, large cup inclination and anteversion for anterior dislocation, small stem anteversion and large difference of pelvic tilt angle between supine and standing position for posterior dislocation

The traditional treatment for a primary anterior shoulder dislocation has been immobilisation in a sling with the arm in adduction and internal rotation. The recurrence rates after the initial traumatic event range from 20% to 94%. However, recent results have suggested that recurrent instability after primary shoulder dislocation may be reduced with immobilisation in external rotation. Since then, controversy exists regarding the position of immobilisation following these injuries. The objective of the present study was to compare immobilisation in internal and external rotation after a primary anterior shoulder dislocation. Fifty patients presenting to our fracture clinic with a primary traumatic anterior dislocation of the shoulder were randomly assigned to treatment with immobilisation in either internal rotation (IR; 25 patients) or external rotation (ER; 25 patients) for three weeks. In addition of a two-years clinical follow-up, patients underwent a magnetic resonance imaging (MRI) of the shoulder with intra-articular contrast within four days following the traumatic event, and then at three months of follow-up. The primary outcome was a recurrent dislocation within 24 months of follow-up. The secondary outcome was the healing rate of the labral lesion seen on MRI (if present) within each immobilisation group. The follow-up rate after two years was 92% (23 of 25) in the IR group and 96% (24 of 25) in the ER group. The recurrence rate in the IR group (11 of 23; 47.8%) was higher than that in the ER group (7 of 24; 29.2%) but the difference did not reach statistical significance (p=0.188). However, in the subgroup of patients aged 20–40 years, the recurrence rate was significantly lower in the ER group (3 of 17; 6.4%) than that in the IR group (9 of 18; 50%, p<0,01). In the subgroup of patients with a labral lesion present on the initial MRI, the healing rate of the lesion was 46.2% (6 of 13) in the IR group and 60% (6 of 10) in the ER group (p=0.680). Overall, the recurrence rate among those who showed healing of the labrum (regardless of the immobilisation group) was 8.3% (1 of 12), but patients who did not healed their labrum had a recurrence rate of 45.5% (5 of 11; p=0.069). This study suggests that immobilisation in ER reduces the risk of recurrence after a primary anterior shoulder dislocation in patients aged between 20 and 40 years. At two years follow-up, the recurrence rate is lower in patients who demonstrated a healed labrum at three months, regardless of the position of immobilisation. Future studies are required in order to identify factors that can improve healing of the damaged labrum following a traumatic dislocation of the shoulder

Introduction. Reverse total shoulder arthroplasty continues to have a high complication rate, specifically with component instability and scapular notching. Therefore, the purpose of this study was to quantify the effects of humeral component neck angle and version on impingement free range of motion. Methods. A total of 13 cadaveric shoulders (4 males and 9 females, average age = 69 years, range 46 to 96 years) were randomly assigned to two studies. Study 1 investigated the effects of humeral component neck angle (n=6) and Study 2 investigated the effects of humeral component version (n=7). For all shoulders, Tornier Aequalis® Reversed Shoulder implants (Edina, MN) were used. For study 1, the implants were modified to 135, 145 and 155 degree humeral neck shaft angles and for Study 2 a custom implant that allowed control of humeral head version were used. For biomechanical testing, a custom shoulder testing system that permits independent loading of all shoulder muscles with six degree of freedom positioning was used. (Figure 1) Internal control experimental design was used where all conditions were tested on the same specimen. Study 1. The adduction angle and internal/external humeral rotation angle at which impingement occurred were measured. Glenohumeral abduction moment was measured at 0 and 30 degrees of abduction, and anterior dislocation forces were measured at 30 degrees of internal rotation, 0 and 30 degrees of external rotation with and without subscapularis loading. Study 2. The degree of internal and external rotation when impingement occurred was measured at 0, 30 and 60 degrees of glenohumeral abduction in the scapular plane with the humeral component placed in 20 degrees of anteversion, neutral version, 20 degrees of retroversion, and 40 degrees of retroversion. Statistical analysis was performed with a repeated measures analysis of variance with a Tukey post-hoc test with a significance level of 0.05. Results. Study 1. Adduction deficit angles for 155, 145, and 135 degree neck-shaft angle were 2 ± 5 degrees of abduction, 7 ± 4 degrees of adduction, and 12 ± 2 degrees of adduction (P <0.05), respectively. Impingement-free angles of humeral rotation and abduction moments were not statistically different between the neck-shaft angles. The anterior dislocation force was significantly higher for the 135degree neck-shaft angle at 30 degrees of external rotation and significantly higher for the 155 degree neck shaft angle at 30 degrees of internal rotation (P<.01). The anterior dislocation forces were significantly higher when the subscapularis was loaded (P <0.01). Study 2. Maximum external rotation was the limiting position for impingement particularly at 0 degrees of abduction. Maximum external rotation before impingement occurred increased significantly with increasing humeral retroversion (p < 0.05) (Figure 2). No impingement or subluxation occurred at any humeral version in 60 degrees of glenohumeral abduction. Conclusion. In reverse shoulder arthroplasty, 155 degree neck-shaft angle was more prone to impingement with adduction but had the advantage of being more stable. In addition, 40 degrees of retroversion has the largest range of humeral rotation without impingement

There are a multitude of studies internationally that have considered the rates of redislocation of shoulders, where, after first time anterior dislocation, initial management has consisted of an internal rotation sling immobiliser or no immobility. The majority of these have indicated poor results. This is in comparison with recurrence rates of dislocation, post shoulder stabilisation (arthroscopic or open), after first time anterior dislocation, which have demonstrated excellent results. The question remains, is there a non-operative alternative that will give similarly good results for these patients. A selection criteria was set up for use of the external rotation brace for first time anterior dislocators. Thirty-five patients were used that fit the criteria and were able to be followed over time. A physiotherapy program was initiated at the two-week stage in combination with clinic reviews. We encouraged use of the brace for six weeks in total, with removal only for hygiene purposes. At two years, post first time anterior dislocation, patients were reviewed clinically and a quick DASH score performed. Any recurrence of dislocation was recorded and an MRI was also undertaken to show residual injury. The compliance with the brace and physiotherapy program were excellent, with only one reported redislocation, during this period, in the 31 patients that were followed up. The majority of patients were functioning at predislocation levels at review and no one had required surgical intervention for instability. Quick-Dash results were also very good, with a vast majority scoring less than 2/100 level of disability. Conclusion. The external rotation brace with a Physiotherapy program is an excellent alternative to early shoulder stabilisation for first time anterior dislocators

Introduction & aims. Apparently well-orientated total hip replacements (THR) can still fail due to functional component malalignment. Previously defined “safe zones” are not appropriate for all patients as they do not consider an individual's spinopelvic mobility. The Optimized Positioning System, OPS. TM. (Corin, UK), comprises preoperative planning based on a patient-specific dynamic analysis, and patient-specific instrumentation for delivery of the target component alignment. The aim of this study was to determine the early revision rate from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) for THRs implanted using OPS. TM. . Method. Between January 4. th. 2016 and December 20. st. 2017, a consecutive series of 841 OPS. TM. cementless total hip replacements were implanted using a Trinity acetabular cup (Corin, UK) with either a TriFit TS stem (98%) or a non-collared MetaFix stem (2%). 502 (59%) procedures were performed through a posterior approach, and 355 (41%) using the direct superior approach. Mean age was 64 (range; 27 to 92) and 51% were female. At a mean follow-up of 15 months (range; 3 to 27), the complete list of 857 patients was sent to the AOANJRR for analysis. Results. There were 5 revisions: . a periprosthetic femoral fracture at 1-month post-op in a 70F. a ceramic head fracture at 12-months post-op in a 59M. a femoral stem loosening at 7-months post-op in a 58M. a femoral stem loosening at 16-months post-op in a 64M. an anterior dislocation in a 53M, that was revised 9 days after the primary procedure. CT analysis, prior to revision surgery, revealed acetabular cup orientation of 46°/31° (inclination/anteversion) and femoral stem anteversion of 38°. Conclusions. These preliminary findings suggest the OPS. TM. dynamic planning and delivery system provides good early results, with a low rate of revision for dislocation. Limitations of the study will be discussed

Background:. A shoulder dislocation is defined as chronic when it has been unreduced for more than one week. Chronic anterior shoulder dislocations are commonly encountered in Kwazulu-Natal for various reasons. Different surgical options exist to treat chronic anterior shoulder dislocations. However the outcome of surgically treated chronic shoulder dislocations has not been favourable in all studies. Methods:. We report on a combined case series of chronic anterior shoulder dislocations previously treated at Edendale Hospital (EDH), Pietermaritzburg and Inkosi Albert Luthuli Central Hospital (IALCH), Durban. Patients were identified retrospectively using departmental databases and their case files were retrieved. Patient demographics, duration of dislocation, mechanism of injury and reason for delayed treatment were recorded. When available, X-rays, CT scans and MRI scans were retrieved to identify associated bony and soft tissue pathology. Surgical outcome was assessed using range of movement (ROM), change in pain severity, patient satisfaction, as well as Oxford Shoulder Instability Score (OIS) and Rowe and Zarins score. Post-operative complications including redislocations were also identified. Results:. Twenty-six patients with chronic anterior shoulder dislocations were surgically treated. The average duration of dislocation was 9 months (range 2 weeks to 7 years). The most common reason for chronicity was delayed presentation to clinic or hospital (9 patients). A Hill Sachs lesion was present in 20 patients, and a pseudo-glenoid was often encountered in dislocations present for more than 4 weeks (14 of 23 patients). Three supraspinatus ruptures and 4 biceps tears were encountered while neurological injury was uncommon (2 patients). Surgical treatment included open reduction (1 patient), open reduction and Latarjet (15 patients), hemi-arthroplasty (2 patients), hemi-arthroplasty and Latarjet (3 patients) and reverse total shoulder arthroplasty (5 patients). Eighteen patients were available for follow-up. Most patients (16 out of 18 patients) were satisfied with their outcome. This was due to improvement in pain. Regardless of the type of surgery done, post-operative range of motion and surgical outcome scores were generally poor. Two patients were unsatisfied, due to redislocations. Conclusion:. Surgical treatment of chronic anterior shoulder dislocations resulted in satisfactory pain relief but marginal improvement in range of motion and overall shoulder function

Anterior shoulder instability is associated with osseous defects of the glenoid and/or humeral head (Hill-Sachs lesions). These defects can contribute to the pathology of instability by engaging together. There is a need to continue to develop methods to preoperatively identify engaging Hill-Sachs lesions for determining appropriate surgical management. The objective was to created a working moveable 3D CT model that allows the user to move the shoulder joint into various positions to assess the relationship between the Hill-Sachs lesion and the anterior glenoid rim. This technique was applied to a cohort series of 14 patients with recurrent anterior dislocation: 4 patients had undergone osteoarticular allografting of Hill-Sachs lesions and 10 control patients had undergone CT scanning to quantify bone loss but had no treatment to address bony pathology. A biomechanical analysis was performed to rotate each 3D model using local coordinate systems through a functional range using an open-source 3D animation program, Blender (Amsterdam, Netherlands). A Hill-Sachs lesion was considered “dynamically” engaging if the angle between the lesion's long axis and anterior glenoid was parallel. In the classical vulnerable position of the shoulder (abduction=90, external rotation=0–135), none of the Hill-Sachs lesions aligned with the anterior glenoid in any of our patients (Figure 1). Therefore, we considered there to be a “low risk” of engagement in these critical positions, as the non-parallel orientation represents a lack of true articular arc mismatch and is unlikely to produce joint instability. We then expanded our search and simulated shoulder positions throughout a physiological range of motion for all groups and found that 100% of the allograft patients and 70% of the controls had positions producing alignment and were “high risk” of engagement (p = 0.18) (Table 1). We also found that the allograft group had a greater number of positions that would engage (mean 4 ± 1 positions of engagement) compared to our controls (mean 2 ± 2 positions of engagement, p = 0.06). We developed a 3D animated paradigm to dynamically and non-invasively visualize a patient's anatomy and determine the clinical significance of a Hill-Sachs lesion using open source software and CT images. The technique demonstrated in this series of patients showed multiple shoulder positions that align the Hill-Sachs and glenoid axes that do not necessarily meet the traditional definition of engagement. Identifying all shoulder positions at risk of “engaging”, in a broader physiological range, may have critical implications towards selecting the appropriate surgical management of bony defects. We do not claim to doubt the classic conceptual definition of engagement, but we merely introduce a technique that accounts for the dynamic component of shoulder motion, and in doing so, avoid limitations of a static criteria assumed traditional definition (like size and location of lesion). Further investigations are planned and will help to further validate the clinical utility of this method. For any figures or tables, please contact the authors directly

Purpose. While changes in lower limb alignment and pelvic inclination after total hip arthroplasty (THA) using certain surgical approaches have been studied, the effect of preserving the joint capsule is still unclear. We retrospectively investigated changes in lower limb alignment, length and pelvic inclination before and after surgery, and the risk of postoperative dislocation in patients who underwent capsule preserving THA using the anterolateral-supine (ALS) approach. Methods. Between July 2016 and March 2018, 112 hips (non-capsule preservation group: 42 hips, and capsule preservation group: 70 hips) from patients with hip osteoarthritis who underwent THA were included in this study. Patients who underwent spinal fusion and total knee arthroplasty on the same side as that of the THA were excluded. Using computed tomography, we measured lower limb elongation, external rotation of the knee, and femoral neck/stem anteversion before operation and three to five days after operation. We examined the pelvic inclination using vertical/transverse ratio of the pelvic cavity measured by X-ray of the anteroposterior pelvic region in the standing position before and six to 12 months after operation. All operations were performed using the ALS approach and taper wedge stem. Results. No dislocation was found in both groups. Lower limb elongation was 14.5±6.3 (mean±SD) mm in the non-capsule preservation group and 9.4±8.8 mm in the capsule preservation group. A significant reduction was found in the capsule preservation group (p<0.05). Changes in knee external rotation was 7.2±10.5 degrees in the non-capsule preservation group and 3.5±10.3 degrees in the capsule preservation group. A trend toward decreased knee external rotation in the capsule preservation group (p=0.07) was observed. There was no difference in femoral neck/stem anteversion and vertical/transverse ratio of the pelvic cavity between both groups. Discussion. Patients in the capsule preservation group tended to have reduced external rotation of lower limb, which might prevent postoperative anterior dislocation due to preservation of anterior structures. The capsule preservation group had significantly reduced lower limb elongation, suggesting that preservation of the hip joint capsule ligament contributes to joint stability. There was no significant difference in the pelvic inclination between both groups. Long-term changes will be assessed by regular follow up after operation

(Case) 79-year-old woman. Past history, in 1989, right femur valgus osteotomy. in 1991, THA at left side. Follow-up thereafter. Hyaluronic acid injection for both knee osteoarthritis. (Clinical course)Her right hip pain getting worse and crawling indoors from the beginning of July 2013. We did right hybrid THA at August 2013(posterior approach, TridentHA cup, Exeter stem, Biolox Forte femoral head 28mm). But immediately, she dislocated twice than the third day after surgery because she became a delirium. It has been left by nurse for about 6 hours because of the midnight after the second dislocation. Next morning, check the dislocation limb position, closed reduction wasdone under intravenous anesthesia. As a result of waking up from the anesthesia, and complained of paralysis and violent pain in the right leg backward. A right lower extremity nerve findings, there is pain in the lower leg after surface about the calf, there was no apparent perception analgesia. Toe movement is weak, but the G-toe planter anddorsiflexion possible about M2, and neurological symptoms to relieved by flexion(above 70 degrees) of the right hip joint. Therefore, we thought that she suffered anterior dislocation of the sciatic nerve by the stem neck (retraction), judged to closed reduction was impossible, open reduction surgery was performed after waitingat hip flex position. But paralysis is gradually worsened during waiting surgery, toes movement had become impossible to operating room admission. Sciatic nerve is caught in front of the stem neck as expected, operative findings were able to finally reduction after removing the femoral head after dislocation. Anteversion of the cup was changed to 25 degrees from 15 degrees, and changed to 32mm diameter metal head and polyethylene liner. And we needed Intensive Care Unit(ICU) management after surgery for prevent recurrence of dislocation. Fitted with a hip brace for her, has not been re-dislocation. The sciatic nerve palsy improved in three months after the operation, the patient became able to walk without a cane. (Summary) We experienced a rare case suffered anterior dislocation of the sciatic nerve by the stem neck, and she had a good result after open reduction surgery

Introduction. Impingement of total hip arthroplasties (THAs) has been reported to cause rim damage of polyethylene liners, and in some instances has led to dislocation and/or mechanical failure of liner locking mechanisms in modular designs. Elevated rim liners are used to improve stability and reduce the risk of dislocation, however they restrict the possible range of motion of the joint, and retrieval studies have found impingement related damage on lipped liners. The aim of this study was to develop a tool for assessing the occurrence of impingement under different activities, and use it to evaluate the effects a lipped liner and position of the lip has on the impingement-free range of motion. MATERIALS & METHOD. A geometrical model incorporated a hemi-pelvis and femur geometries of one individual with a THA (DePuy Pinnacle® acetabular cup with neutral and lipped liners; size 12 Corail® stem with 32mm diameter head) was created in SOLIDWORKS (Dassault Systèmes). Joint motions were taken from kinematic data of activities of daily living that were associated with dislocation of THA, such as stooping to pick an object off the floor and rolling over. The femoral component was positioned to conform within the geometry of the femur, and the acetabular component was orientated in a clinically acceptable position (45° inclination and 20° anteversion). Variation in orientation of the apex of the lip was investigated by rotating about the acetabular axes from the superior (0°) in increments of 45° (0°−315°), and compared to a neutral liner. Results. When a lipped liner was used, implant (neck on acetabular rim) impingement was found to occur when performing sit-to-stand from a normal seat, leg cross and pivot, whereas no impingement occurred with a neutral liner. The presence and position of the lip reduced the impingement-free range of motion, compared to the neutral liner. Impingement occurred when the lip was positioned superiorly and anteriorly, when performing most of the activities that were prone to posterior dislocation, and posteriorly, posterior-superiorly and posterior-inferiorly when performing activities prone to anterior dislocation. During sit-to-stand from a normal seat no impingement occurred when a lipped or neutral liner was used. Bone impingement was observed when the performing the roll activity with both lipped and neutral liners. DISCUSSION. Impingement was observed more with lipped liners compared to neutral liners, this agrees with the findings of some clinical studies. The results indicate that the positioning of the lip influences the possible range of impingement-free motion. Considering this and the improved joint stability of using a lipped liner, a balance is required to achieve an optimal range of motion without increasing the risk of dislocation. This tool could potentially to be used to optimise lipped liner design and position, and could assist with the liner selection for patients based on their activities

Purpose. Shoulder dislocations account for 50 % of all dislocations, of which 98% are anterior dislocations. Different techniques have been described in literature with variable success, which depends upon type of dislocation, technique used and muscle relaxation. Method. A retrospective review of data of all shoulder dislocations presented to accident and emergency department over a one-year period was undertaken. Over a 1-year period total of 52 patients presented with mean age of 41 years. Closed reduction was attempted in all patients by accident and emergency department using various techniques and combination of analgesia. Unsuccessful reductions and those with associated fractures were referred to orthopaedics department. This group had closed reduction utilising Sahas zero position technique in accident and emergency department. Post reduction all patients had two views of radiograph to confirm reduction and poly-sling for 2–3 weeks. Results. We had 37 (71.1%) males and 15(28.8%) females with shoulder dislocations. In our patients 98% were anterior dislocations and 14 % were dislocations associated with fractures. Of 52 patients 33 (63%) were first time dislocations and 17(33%) had recurrent dislocations In cohort of 52 patients 7(13.4%) had neurological deficit prior to reduction, which was sensory hypoesthesia along the regimental badge area, and 1(2%) had a post reduction neurology using modified Milch technique. Most of our patients 38 (73%) were reduced using various techniques for reducing shoulder dislocation. In these 38 patients analgesia varied from Entonox to combination of Entonox with intravenous morphine with or without diazepam. Our department was referred 14(27%) patients. Seven patients were referred due to failure of reduction where several attempts with different techniques were made and 7 were directly referred due to association of fracture with the dislocations. 14(27 %) of our patients were reduced using zero position of shoulder in first attempt without the need for additional analgesia. Of these 14 patients 7 had complex shoulder dislocation associated with fractures. We had only one failure of reduction using Sahas zero position of shoulder. This patient had recurrent dislocation with large Hill Sachs defect. This was reduced under general anaesthesia using zero position of shoulder as described by Saha. Conclusion. This study demonstrates that zero position of shoulder described by Saha is safe, effective and easy method for reducing both anterior, posterior and fracture dislocations of the shoulder. Given the principles of reduction in zero position no additional analgesia and traction is required. The feedback from patients in regards to discomfort and pain was also positive. We conclude that this data suggests the routine use of Sahas technique in reducing both simple and complex shoulder dislocations

The Taperloc Microplasty stem design was based on that of the Taperloc stem with flat tapered wedge and the distal portion of the Taperloc stem was shortened by 35mm. We report the minimum two-year follow up (mean, 26 months) of 68 primary total hip arthroplasty using the Taperloc Microplasty stem. 39 Magnum acetabular cups and 29 M2a Taper acetabular cups were inserted with metal on metal articulation. The series comprised 67 patients (20 men, 47 women) with a mean age at operation of 65 years (31 to 85). The principal diagnosis was osteosrthritis. Their mean JOA Hip Score improved significantly from 36 points preoperatively to 96 points at two-year follow up. Radiological asseement showed good bony stability in all implants. There was one case of post operative anterior dislocation. We did not see intra-operative fracture previously reported for this implant. There were no clinical and radiological complications related to MOM articulation. This short-term follow up study demonstrates that the clinical outcome of the Tapeloc Microplasty stem is comparable with that of standard Taperloc stem and other flat taper wedge stems

The Royal Marines regularly deploy to Norway to conduct Cold Weather, Arctic and Mountain Warfare training. A total of 1200 personnel deployed to Norway in 2010 over a 14-week period. Patients, whose injuries prevented them from continuing training, were returned to the UK via AEROMED. The aim of this investigation was to describe the epidemiology of musculoskeletal injuries during cold weather training. All data on personnel returned to the UK was prospectively collected and basic epidemiology recorded. 53 patients (incidence 44/1,000 personnel) were returned to the UK via AEROMED. 20/53 (38%) of cases were musculoskeletal injuries (incidence 17/1000 personnel). 15/20 musculoskeletal injuries were sustained while conducting ski training (incidence 13/1,000): 4/20 were non-alcohol related injuries, 1/20 was related to alcohol consumption off duty. Injuries sustained whilst skiing: 5/15 sustained anterior shoulders dislocation, 5/15 Grade 1-3 MCL/LCL tears, 2/15 sustained ACJ injuries, 1/15 crush fracture T11/T12, 1/15 tibial plateau fracture and 1/15 significant ankle sprain. Non-Training injuries: 1 anterior shoulder dislocation, 1 distal radial fracture, 1 olecranon fracture, 1 Scaphoid Fracture and one 5th metatarsal fracture. 60% of injuries were upper limb injuries. The most common injury was anterior shoulder dislocation 6/20 (Incidence 5/1000). Our results suggest that cold weather warfare training has a high injury rate requiring evacuation: 4% of all people deployed will require AEROMED evacuation, and 2% have musculoskeletal injuries. Ski training causes the majority of injuries, possibly due to the rapid transition from non-skier to skiing with a bergen and weapon. Military Orthopaedic and rehabilitation units supporting the Royal Marines, should expect sudden increases in referrals when large scale cold weather warfare training is being conducted. Further research is required to see if musculoskeletal injury rates can be decreased in cold weather warfare training

Introduction. The low-contact stress (LCS) knee prosthesis is a mobile-bearing design with modifications to the tibial component that allow for meniscal-bearing (MB) or rotating-platform (RP). The MB design had nonconstrained anteroposterior and rotational movement, and the RP design has only nonconstrained rotational movement. The anterior soft tissues, including patellar tendon (PT), prevent anterior dislocation of the MB. The PT may consistently be exposed to overstressing. Therefore, we hypothesized that the PT thickness and width in MB prosthesis revealed more morphological changes than those of RP prosthesis due to degeneration of the PT induced by much mechanical stress of the MB movement. To confirm this hypothesis, we analyze the PT thickness and width induced by mobile-bearing inserts. Objectives. Sixty LCS prostheses in 30 patients were analyzed. The average follow-up time was 61 months. MB prosthesis was used on one side of the knee and RP prosthesis was used on the contralateral side of the knee. All patients were chosen from group with no clinical complication, and all had achieved passive full extension and at least 90°of flexion. The average Hospital for Special Surgery Score was 94.6 ± 2.7. Methods. We measured the thickness and width of PT at joint line level, which were confirmed by sagittal section using ultrasound in knee extension between MB and RP design prosthesis. Results. The mean thickness of PT was 4.7 mm (1.2) with MB and 4.7 mm (1.0) with RP design prosthesis. The mean width of PT was 30.6 mm (3.2) with MB and 31.3 mm (3.5) with RP design prosthesis. No significant differences were found between both groups. Conclusion. The current results showed that the PT thickness and width in MB prosthesis did not reveal more morphological changes than those of RP prosthesis due to degeneration of the PT induced by much mechanical stress of the MB movement. The possible reasons are the following: (1) We did not remove infra-patellar fat pad, which might play shock absorber of mechanical stress from MB, and prevent from significant degeneration of PT, (2) MB inserts did not stimulate the middle of the PT directly, unlike LCS A/P-Glide inserts, and might come into contact with the both ends of the PT and (3) MB inserts did not move so as to cause degeneration in the PT

The majority of patients who develop hip arthritis have a mechanical abnormality of the joint. The structural abnormalities range from instability (DDH) to impingement. Impingement leads to osteoarthritis by chronic damage to the acetabular labrum and adjacent cartilage. In situations of end-stage secondary DJD, hip arthroplasty is the most reliable treatment choice. In young patients with viable articular cartilage, joint salvage is indicated. Treatment should be directed at resolving the structural abnormalities that create the impingement. Femoral abnormalities corrected by osteotomy or increased head-neck offset by chondro-osteoplasty creating a satisfactory head-neck offset. This can safely be done via anterior surgical dislocation. The acetabular-labral lesions can be debrided and/or repaired. Acetabular abnormalities should be corrected by “reverse” PAO in those with acetabular retroversion or anterior acetabular debridement in those with satisfactory posterior coverage and a damaged anterior rim. Often combinations of the above are indicated

In previously published work, MR arthrogram (MRA) has sensitivities and specificities of 88–100% and 89–93% respectively in detection of glenoid labrum tears. Our practice suggested higher frequency of falsely negative reports. We aimed to assess accuracy of this costly modality in practice. We retrospectively reviewed MRA reports of 90 consecutive patients with clinical shoulder instability who had undergone arthroscopy. All had history of traumatic anterior dislocation and had positive anterior apprehension tests. All underwent stabilisation during the same procedure. We compared the findings, using arthoscopy as gold standard in identification of glenoid labral tears. 83/90 patients had glenoid labrum tears at arthroscopy. Only 54 were correctly identified at MRA. All normal labra were identified. This gave sensitivity of 65% and specificity of 100% in identification of all types of glenoid labrum tear. The majority had anterior glenoid labral tears, which were detected at an even lower rate of sensitivity (58%). Sensitivity of MRA in this series is significantly lower than previously published. This study highlights the importance of an accurate history and clinical examination by specialist shoulder surgeons in the management of glenohumeral instability. The need for this costly investigation may not be as high as is currently the case

We retrospectively reviewed 54 patients (92 hips) who underwent cementless total hip arthroplasty for bony ankylosis in ankylosing spondylitis between September 1988 and 2002. Clinical assessment was done at follow-up, which envisages assessment of the pain, function, deformities and range of motion using the Harris Hip Score. Radiographic analysis was done. Kaplan-Meier survivorship analysis was done at 5 and 8.5 years using the revision for the removal of femoral component, acetabular component or both due to any cause as the end point. The mean age of the patients was 25.5 years. The mean duration of follow up was 8.5 years. The average preoperative Harris Hip Score of 49.5 improved to 82.6 post operatively. Post operatively 10 hips had mild to moderate pain. Anterior dislocation occurred in four hips (4.3 %) and sciatic nerve palsy in one hip. Heterotopic ossification was seen in 12 patients, reankylosis rate was 0%. Thirteen arthroplasties were revised due to aseptic loosening. Kaplan-Meier survivorship analysis with revision as end point revealed 98.8% survival at 5 years and 85.8% survival at 8.5 years 11 follow up. Cementless THA in osseous ankylosis in ankylosing spondylitis is a worthwhile surgical intervention in bony ankylosis. Newfound mobility, manoeuvrability and improved ability to sit comfortably were the outcomes, which alleviated the patients’ daunted morale. However, the technically demanding nature of the procedure should not be underestimated