Introduction. Large diameter metal on metal cups have been used in total hip arthroplasty advocating superior results with respect to dislocation rates, range of motion and long term survival. The Durom cup used as part of the Durom hip resurfacing system has been incriminated with poor short term results sometimes correlated to incorrect positioning of either the femoral or acetabular component. Our objective was to evaluate short term results of the Durom cup used in conjunction with standard stems. Methods. We prospectively followed all patients with a large diameter metal-on-metal articulation (Durom) and a standard stem operated upon between 9/2004 and 9/2008. Patients were seen at follow-up for a clinical (Harris hip score=HHS, UCLA scale and patient satisfaction), radiographic and questionnaire assessment. Results. 89 primary THAs in 80 patients (74% men) with a mean age of 52 (±12) years were included. Main diagnoses were primary osteoarthritis in 47% and aseptic necrosis in 35%. An uncemented stem was used in 79%. Overall, 80 THAs were controlled at a mean follow-up of 39 months (range 16–67 months), 4 patients were lost to follow-up and 5 patients refused or were unable to attend the visit. However, none of the 5 underwent revision. Overall, 8 THAs (8/85, 9.4%) were revised in mean 28 months (range 8–60) after the operation. One additional patient was awaiting revision for aseptic loosening of both cup and stem. The reasons for revision were aseptic loosening in three cases, presence of a granuloma (histological diagnosis of ALVAL) in three, deep infection in one and impingement in one case. Radiographic analysis revealed linear (n=2) and focal (n=3) osteolysis as well as early cup migration (n=2). In 5 revised patients no radiographic changes were found. 56 (70%) of the 80 patients with follow-up had a HHS between 80 and 100. Among those who were not revised, the mean HHS improved from 55.2 to 88.4 (mean increase 33.2, 95% CI 27.7; 38.7). The mean activity level (UCLA scale) at follow-up was 6.4 (±1.8). Overall, mild to severe pain was reported in 14 cases and occasional pain in 22. Groin pain was present in 18 patients (22.5%), 7 of them belonged to the revised group. 61 (76.3%) of the 80 patients with follow-up were satisfied. Mean patient satisfaction on the VAS scale among those who were not revised was 9.0 (±1.3). Conclusion. This study confirms the increased short-term revision rate of the large diameter metal-on-metal couple (Durom) reported by others. In all revision cases the retrieved cups showed no osteo-integration and were removed easily. The operative indication for revision was based upon groin pain and patient dissatisfaction. Radiographic signs of implant loosening were not always present even though in all revised cases except for one the cup was found loose

During a four-month period we observed 12 stress fractures of the inferior pubic ramus in 11 military recruits undergoing basic training. Eleven of these were in women. This high number was considered to be caused by the introduction of mixed training of male and female recruits; this forces women to increase their stride length when marching. The presenting symptom was chronic groin pain which failed to settle with rest, and the clinical diagnoses were confirmed by radiographs in all but one patient who was diagnosed by . 99m. Tc bone scanning. Since the required stride length has been reduced there have been no new cases of stress fracture of the pelvis

INTRODUCTION. A detailed clinical examination and investigations are required to evaluate the cause of persisting groin pain following a metal on metal (MoM) hip replacement. Adverse reaction to metallic debris (ARMD) is an emerging problem with MoM hip replacements. It is an umbrella term encompassing metallosis, pseudo-tumors and aseptic lymphocytic vasculitis associated lesions (ALVAL). The role of imaging in the diagnosis of this complex problem is still unclear. A study was undertaken to evaluate the efficacy of ultrasound in diagnosis of ARMD following a MoM hip replacement. METHODS. The study group included 35 patients with a clinical and histological diagnosis of ARMD, who had a preoperative ultrasound. All ultrasound procedures were performed on the anterior and lateral aspects of the painful hip with a high frequency probe of 9–13 MHz (Sonoline Antares – Siemens). RESULTS. All patients diagnosed with ARMD had abnormalities identified on ultrasound. Fluid inside the joint was noted in 30 out of 35 procedures (85.7 %). Fluid outside the joint was noted in 33 procedures (94.3 %). Amongst the patients with fluid outside the joint, 32 had iliopsoas and 30 had trochanteric bursitis. Echogenic reflections were noted in 31 out of 35 procedures (88.6 %). Considerable attenuation or absence of iliopsoas and gluteus tendon reflection was seen in many patients with echogenic fluid collections on the anterior and trochanteric aspects of hip. Progression of such changes was noted on further 5 patients, who had a repeat ultrasound within an interval of 3–6 months. 1 patient had a progression from anechogenic to echogenic joint effusion. DISCUSSION. Different radiological investigations including MRI scan have been used for evaluation of painful MoM hip arthroplasty. To our knowledge, this is the first study to demonstrate the efficacy of ultrasound in diagnosis of ARMD. Floating echogenic reflections and fluid collections around iliopsoas and gluteus medius/minimus tendons is highly suggestive of ARMD. Ultrasound is a cheap, non-invasive and dynamic investigation and has been shown to be reliable in diagnosis of ARMD

Introduction. Acetabular labral pathology is now recognized as a more common injury than previously thought. With cost constraints of MRI and invasiveness of MRI arthrogram, physical examination remains essential for diagnosis. Most tests for labral pathology are currently done in the supine position. We have developed the “twist test,” which is done with the patient standing and can evaluate the patient in functional, weight bearing position. The purpose of this study is to describe the twist test and compare its reliability to MRI arthrogram. Material and methods. Between June 2009 and August 2010, the twist test was performed on all patients presenting to our clinic with complaint of hip pain. 371 patients had the twist test performed. Of these, 247 had an MRI arthrogram (MRA) of the affected hip. The twist test results were compared with MRA findings. A labral tear, degeneration, fraying and paralabral cyst were considered as a positive MRA. The twist test is done with the patient facing the examiner, toes pointing forward. The patient bends their knees to 30 degrees and performs a windshield wiper like action with maximal excursion to the left and right. If the patient tolerates this, then the patient first gets on the unaffected leg, again with the knee bent at 30 degrees, and “does the twist” one-legged, with the examiner holding their hands gently for balance. The test is then repeated on the affected hip. A positive test is groin pain on the affected hip, apprehension with performing the test on the affected hip, or gross range of motion deficits on the affected hip compared with the unaffected side. Results. Among 160 patients with positive twist test, 154 patients had positive MRA and 6 had negative MRA. Among 87 patients with negative twist test, 72 had positive MRA and 15 had negative MRA. In comparison with MRA, the sensitivity and specificity of twist test for labral injury were 68.14% and 71.5% respectively. Positive predictive value (precision) of twist test for diagnosis of labral lesion was 96.25% and the accuracy was 68.4%. Conclusions. Physical examination tests for hip pathology are an important screening tool. Current tests include the McCarthy test and the impingement test. We introduce a new test for hip labral pathology, which is done standing. In our study, the twist test had a high positive predictive value (96.25%), so this test can be beneficial for ruling out labral pathology. An added benefit is that this test is quick to perform, so it could be incorporated into a general sports physical screening examination

Introduction. A recent review of the literature on metal-on-metal total hip arthroplasties (THA) revealed the lack of comparative clinical studies with a sufficient sample size and the inclusion of patient-reported outcomes as well as patient activity levels. Methods. We conducted a prospective cohort study including all metal-on-metal and conventional polyethylene (PE)-ceramic THAs with an uncemented cup (Morscher press-fit cup), a 28mm head and operated upon via a lateral approach at our University hospital between 1/1999 and 12/2008. Only THAs for primary osteoarthritis were included. The study population is part of the Geneva Hip Arthroplasty Registry, a prospective cohort followed since 1996. The following outcomes were compared between the two groups (metal-on-metal=group 1 vs. PE-ceramic bearing=group 2): (1) Complication rates with respect to infection, dislocation and revision, (2) Radiographic outcomes (presence of linear or focal femoral osteolysis, loosening), and (3) Clinical outcomes (Harris Hip score increase, SF-12, activity and patient satisfaction evaluation, presence of groin pain). Patients operated between 1/1999 and 12/2004 were evaluated five years postoperatively by an independent assessor. Cox regression analysis was used to compare incidence rates while adjusting for differences in baseline characteristics. Results. 1988 THAs were included, 544 with a metal-on-metal and 1444 with a PE-ceramic bearing. The two groups differed significantly with respect to gender distribution (men 56% vs. 41%), mean age (66 vs. 73 years), co-morbidities and type of stem (uncemented 16% vs. 2%). Crude incidence rates for complications were: 0.16 vs. 0.11 cases/100 person-years for infection; 0.37 vs. 0.35 cases/100 person-years for dislocation; and 0.29 vs. 0.16 cases/100 person-years for all-cause revision (incidence rate ratio 1.8, 95% CI 0.7; 4.6). After adjusting for baseline differences the slightly higher risks for infection and revision in group 1 were attenuated. Osteolytic lesions were found in 3.7% of metal-on-metal vs. 4.7% of PE-ceramic THAs. After adjustment for age, gender and activity the OR was 0.6 (95% CI 0.2;2.1). Five years postoperative, 176 THAs of group 1 and 695 THAs of group 2 were seen at follow-up. Clinical outcomes were similar among the two groups with a mean Harris Hip score increase of 39.2 vs. 40.9 points. SF-12 mental and physical health, patient satisfaction (9.3 vs. 8.9 on visual analogue scale) as well as the incidence of groin pain (1.7% vs. 1.2%) was also similar among the two groups. The activity level was significantly higher in group 1 (6.4 vs. 5.4, p<0.001). Conclusion. Mid-term results with respect to complications, revision rates, presence of osteolysis and clinical outcomes were similar among patients with metal-on-metal and PE-ceramic total hip arthroplasties

Objectives

Bisphosphonates are widely used as first-line treatment for primary and secondary prevention of fragility fractures. Whilst they have proved effective in this role, there is growing concern over their long-term use, with much evidence linking bisphosphonate-related suppression of bone remodelling to an increased risk of atypical subtrochanteric fractures of the femur (AFFs). The objective of this article is to review this evidence, while presenting the current available strategies for the management of AFFs.

The purpose of this study was to describe the anatomical distribution and incidence of fatigue injuries of the femur in physically-active young adults, based upon MRI studies. During a period of 70 months, 1857 patients with exercise-induced pain in the femur underwent MRI of the pelvis, hips, femora, and/or knees.

Of these, 170 patients had a total of 185 fatigue injuries, giving an incidence of 199 per 100 000 person-years. Bilateral injuries occurred in 9% of patients. The three most common sites affected were the femoral neck (50%), the condylar area (24%) and the proximal shaft (18%). A fatigue reaction was seen in 57%, and a fracture line in 22%. There was a statistical correlation between the severity of the fatigue injury and the duration of pain (p = 0.001). The location of the pain was normally at the site of the fatigue injury. Fatigue injuries of the femur appear to be relatively common in physically-active patients.