Introduction. Patella tendonitis is common amongst sportsmen. No published evidence of this injury in elite professional footballers exists. The aim of this study was to determine the frequency of this injury in the elite professional footballer, along with the impact of such an injury on the amount of time missed and the outcomes of various treatment options. Methods. Data was collected prospectively for injuries suffered by first team players, development squad players and academy squad players over the 2009–10 and 2010–11 English Premier League (EPL) season at one EPL club. Each player's demographics were recorded. The injury was recorded along with the time that the player was absent because of the injury, the treatment that the player received and whether they suffered any recurrence of the injury. Results. 35 knee injuries were observed during the period of this study, 21% of all injuries. Ten were patella tendonopathies, a frequency of 28.6% of knee injuries and 6% of all injuries suffered. Eight injuries were in first team players and 2 in academy players. Mean absence was 67 days in first team and 120 days in academy players. Both the academy players underwent surgery as their primary treatment. No first team player had surgery. Four first team players were treated with local injection (2 with sclerosant and 2 with Platelet Rich Plasma) with a mean absence of 110 days. Four injuries were treated with physiotherapy, mean absence of 24 days. There was recurrence in 4 cases, all within the first team (50%), 2 in each of the physiotherapy and injection groups. No recurrence was observed when undertaking surgery. Conclusions. Patella tendonitis is a common knee injury suffered by elite professional footballers, which results in a prolonged absence and carries a high risk of recurrence. The best treatment option remains debateable

Iliopsoas tendonitis occurs in up to 30% of patients after hip resurfacing arthroplasty (HRA) and is a common reason for revision. The primary purpose of this study was to validate our novel computational model for quantifying iliopsoas impingement in HRA patients using a case-controlled investigation. Secondary purpose was to compare these results with previously measured THA patients. We conducted a retrospective search in an experienced surgeon's database for HRA patients with iliopsoas tendonitis, confirmed via the active hip flexion test in supine, and control patients without iliopsoas tendonitis, resulting in two cohorts of 12 patients. The CT scans were segmented, landmarked, and used to simulate the iliopsoas impingement in supine and standing pelvic positions. Three discrete impingement values were output for each pelvic position, and the mean and maximum of these values were reported. Cup prominence was measured using a novel, nearest-neighbour algorithm. The mean cup prominence for the symptomatic cohort was 10.7mm and 5.1mm for the asymptomatic cohort (p << 0.01). The average standing mean impingement for the symptomatic cohort was 0.1mm and 0.0mm for the asymptomatic cohort (p << 0.01). The average standing maximum impingement for the symptomatic cohort was 0.2mm and 0.0mm for the asymptomatic cohort (p << 0.01). Impingement significantly predicted the probability of pain in logistic regression models and the simulation had a sensitivity of 92%, specificity of 91%, and an AUC ROC curve of 0.95. Using a case-controlled investigation, we demonstrated that our novel simulation could detect iliopsoas impingement and differentiate between the symptomatic and asymptomatic cohorts. Interestingly, the HRA patients demonstrated less impingement than the THA patients, despite greater cup prominence. In conclusion, this tool has the potential to be used preoperatively, to guide decisions about optimal cup placement, and postoperatively, to assist in the diagnosis of iliopsoas tendonitis

Iliopsoas tendonitis after total hip arthroplasty (THA) can be a considerable cause of pain and patient dissatisfaction. The optimal cup position to avoid iliopsoas tendonitis has not been clearly established. Implant designs have also been developed with an anterior recess to avoid iliopsoas impingement. The purpose of this cadaveric study was to determine the effect of cup position and implant design on iliopsoas impingement. Bilateral THA was performed on three fresh frozen cadavers using oversized (jumbo) offset head center revision acetabular cups with an anterior recess (60, 62 and 66 mm diameter) and tapered wedge primary stems through a posterior approach. A 2mm diameter flexible stainless steel cable was inserted into the psoas tendon sheath between the muscle and the surrounding membrane to identify the location of the psoas muscle radiographically. CT scans of each cadaver were imported in an imaging software. The acetabular shells, cables as well as pelvis were segmented to create separate solid models of each. The offset head center shell was virtually replaced with an equivalent diameter hemispherical shell by overlaying the outer shell surfaces of both designs and keeping the faces of shells parallel. The shortest distance between each shell and cable was measured. To determine the influence of cup inclination and anteversion on psoas impingement, we virtually varied the inclination (30°/40°/50°) and anteversion (10°/20°/30°) angles for both shell designs. The CT analysis revealed that the original orientation (inclination/anteversion) of the shells implanted in 3 cadavers were as follows: Left1: 44.7°/23.3°, Right1: 41.7°/33.8°, Left2: 40/17, Right2: 31.7/23.5, Left3: 33/2908, Right3: 46.7/6.3. For the offset center shells, the shell to cable distance in all the above cases were positive indicating that there was clearance between the shells and psoas. For the hemispherical shells, in 3 out of 6 cases, the distance was negative indicating impingement of psoas. With the virtual implantation of both shell designs at orientations 40°/10°, 40°/20°, 40°/30° we found that greater anteversion helped decrease psoas impingement in both shell designs. When we analyzed the influence of inclination angle on psoas impingement by comparing wire distances for three orientations (30°/20°, 40°/20°, 50°/20°), we found that the effect was less pronounced. Further analysis comparing the offset head center shell to the conventional hemispherical shell revealed that the offset design was favored (greater clearance between the shell and the wire) in 17 out of 18 cases when the effect of anteversion was considered and in 15 out of 18 cases when the effect of inclinations was considered. Our results indicate that psoas impingement is related to both cup position and implant geometry. For an oversized jumbo cup, psoas impingement is reduced by greater anteversion while cup inclination has little effect. An offset head center cup with an anterior recess was effective in reducing psoas impingement in comparison to a conventional hemispherical geometry. In conclusion, adequate anteversion is important to avoid psoas impingement with jumbo acetabular shells and an implant with an anterior recess may further mitigate the risk of psoas impingement

Introduction. Hypoplasia of the glenoid is a rare condition caused by incomplete ossification of the postero-inferior aspect of the developing glenoid. It may be isolated or associated with a more generalised condition. The clinical symptomatology is variable depending on the age at time of presentation. Materials and Methods. We performed a retrospective chart review of patients who presented with shoulder complaints, and in whom a radiographic diagnosis of glenoid hypoplasia had been made. From January 2002 to December 2012, 8 patients (9 shoulders) with radiological signs of glenoid hypoplasia were identified. The mean age at presentation was 39 years (range 23 to 77) and the mean symptom duration was 12.5 months (range 1 to 48). Results. The diagnoses encountered included: impingement with rotator cuff tendonitis (2 shoulders), rotator cuff dysfunction with biceps tendonitis (1 shoulder), a SLAP lesion (2 shoulders), calcific tendonitis (1 shoulder), a posterior labral tear (1shoulder), multidirectional instability (1 shoulder), and adhesive capsulitis (1 shoulder). Of these nine, six shoulders were managed non-operatively and three were managed surgically, all with satisfactory results. The mean follow-up period was 30 months (range 5 to 60) and the mean Oxford shoulder score was 46.7 (range 42 to 48). Conclusion. We present a series of patients, who have been managed for a variety of shoulder pathologies, and in whom underlying glenoid hypoplasia has been diagnosed. NO DISCLOSURES

The use of total hip arthroplasty in adolescents for end-stage degenerative hip disease is controversial with few reported outcomes in the literature. The purpose of the study was to report the outcomes of total hip arthroplasty in a cohort of adolescents managed by a multidisciplinary team of paediatric and adult orthopaedic surgeons from a single centre. A multidisciplinary clinic consisting of paediatric and adult hip surgeons was established in 2013 to identify, treat and prospectively follow adolescents who would potentially beneift from a total hip arthoplasty. To date 29 consecutive adolescent patients (20 female, 9 male, 32 hips) with end stage degenerative hip disease have undergone cementless primary total hip arthroplasty. Mean age at decision to treat was 15.7 years (age 11.4–18.5). Ten different underlying paediatric specific pathologies were documented including DDH, cerebral palsy, JIA, skeletal dysplasias, SCFE and idiopathic chondrolysis. Three patients had bilateral staged procedures. Clinical baseline and outcomes were measured using Oxford Hip Score (OHS), WOMAC score and ASKp scores. Radiographic follow-up was conducted at 6 weeks, 6 months and yearly thereafter. Post-operative complications were recorded. Twenty-five hips were eligible for minimum 2-year follow-up scoring at a mean 2.7 years (2.0–3.6 years). No intraoperative complications occurred. One case of recalcitrant postoperative psoas tendonitis occured. OHS improved from 25 (7–43) to 41 (23–48). WOMAC improved from 48 (12–8) to 12 (1–44), and ASKp improved from 78% (33–98%) to 93% (73–100%). Radiographic review revealed acceptable alignment of all components with no signs of loosening or wear. No revision of components was required. One patient died at 6 months post op from an unrelated condition. The early term results of total hip arthroplasty in adolescents from our multidisciplinary program are encouraging. Improvements in quality of life to normal values were seen as were hip scores consistent with satisfactory joint function. Depite the range of complex and varied causes of arthritis seen in this population the establishment of combined paediatric and adult orthopaedic surgical teams appears to be a successful model to manage end-stage degenerative hip disease in adolescents

Since 1997, a patented rim flared cup has been used for both primary and revision total hip arthroplasty with great success. The concept was based on a “stretched” hemispherical geometry to improve initial contact between cup and bone. This improved geometry provided a 1 mm press fit predominantly at the perimeter of the acetabulum much like the footprint of the native anatomic acetabulum. Thousands of these were implanted. A second version of this concept was introduced in August 2011. This similarly “stretched” geometry provides 1.6 mm of press fit. Building on what was learned from the original design, this updated, stretched geometry was created with a single radius for a smooth transition from the apex to the peripheral press fit. Porous coating is the key to implant durability. With this aggressive “sticky” porous coating, only 0.6 mm of press fit is required. This porous coating has 60% porosity, and 150–400 mm pore size. It has a tensile strength of 5000 psi (The FDA requires a minimum of 2900 psi) and a mean thickness of 0.8 mm. Three thousand cups have been implanted with the author contributing 400. In our own primary subgroup done in 2014–15, 142 had 2–4 year follow up with zero loosening. There was one infection and 2 dislocations. One implant was revised on a patient with psoas tendonitis from an oversized cup. At retrieval it showed excellent ingrowth into the porous coating with 38% ingrowth. This graduated rim fit concept has a proven track record spanning 2 decades and provides a stable and reproducible acetabular construct

In years past, the most common reason for revision following knee replacement was polyethylene wear. A more recent study indicates that polyethylene wear is relatively uncommon as a cause for total knee revision counting for only 10% or fewer of revisions. The most common reason for revision currently is aseptic loosening followed closely by instability and infection. The time to revision was surprisingly short. In a recent series only 30% of knees were greater than 5 years from surgery at the time of revision. The most common time interval was less than 2 years. This is likely because of the higher incidence of infection and instability that occurs most commonly at a relatively early time frame. Evaluation of a painful total knee should take into account these findings. All total knees that are painful within 5 years of surgery should be assumed to be infected until proven otherwise. Therefore, virtually all should be aspirated for cell count, differential, and culture. Alpha-defensin is also available in cases in which a patient may have been on antibiotics within a month or less, as well as cases in which diagnosis is a challenge for some reason. Instability can be diagnosed with physical exam focusing on mid-flexion instability which can be usually determined with the patient seated and the knee in mid-flexion, with the foot flat on the floor at which point sagittal plane laxity can be discerned. This is also frequently associated with symptoms of giving way and recurring effusions and difficulty descending stairs. A new phenomenon of tibial de-bonding has been described, which can be a challenge to diagnose. Radiographs can appear normal when loosening occurs between the implant and the cement mantle. This seems to be more common with the use of higher viscosity cement. Obviously this is technique dependent since good results have been reported with the use of high viscosity cement. Component malposition can cause stiffness and pain and relatively good results have been reported by component revision when malrotation has been confirmed with CT scan. When infection, instability and loosening are not present, extra-articular causes should be ruled out including lumbar spine, vascular compromise, complex regional pain syndromes and fibromyalgia, and peri-articular causes such as bursitis, tendonitis, tendon impingement among others. One of the most common causes of pain following total knee is unrealistic patient expectations. Performing total knee replacement in early stages of arthritis with only mild to moderate symptoms and radiographic changes has been associated with persistent pain and dissatisfaction. It may be prudent to obtain the immediate preoperative x-rays to determine if early intervention was undertaken and patients have otherwise normal appearing total knee x-rays and a negative work up. A recent study indicated that this was likely a cause or a major contributing factor to persistent pain following otherwise a well performed knee replacement. A national multicenter study of the appropriateness of indications for TKA also indicated that early intervention was a major cause of persistent pain, dissatisfaction, and failure to improve following total knee replacement

Purpose. The fourth generation ceramic, in which zirconia is incorporated into the alumina matrix, was developed to reduce the risk of ceramic fractures. The purpose of this study was to evaluate the survivorship, clinical and radiographic results, and bearing-related failures associated with total hip arthroplasty using zirconia-toughened alumina ceramic-on-ceramic bearings over a minimum follow-up of 5 years. Materials and methods. We retrospectively analysed 135 patients (151 hips) who underwent cementless total hip arthroplasty using zirconia-toughened alumina ceramic-on-ceramic bearings. There were 58 men and 77 women with mean age of 55.9 years (range, 20 to 82 years) at index surgery. Acetabular and femoral components were cementless in all hips. A 36 mm head was used in 81 of 151 hips and a 32 mm head was used in 70 hips with smaller acetabular shells. The mean duration of follow-up was 6.1 years (range, 5 to 6.8 years). Results. Kaplan-Meier survival analysis with an end point of revision for any reason was 100% at 6.8 years. All acetabular and femoral components showed bony ingrowth. No radiographic evidence of osteolysis was identified. No ceramic fracture occurred. There were 4 (2.6%) noisy hips (1 squeaking and 3 clickings), but no patient could reproduce the noise and required revision. Other complications included one iliopsoas tendonitis and one dislocation. Conclusions. The minimum 5-year results of total hip arthroplasties performed using 32 mm or 36 mm zirconia-toughened alumina ceramic-on-ceramic bearings were encouraging with excellent survivorship. However, it was also found that the risk of noise development remains even for the newest generation of ceramics

Dual mobility components for total hip arthroplasty provide for an additional articular surface, with the goals of improving range of motion, jump distance, and overall stability of the prosthetic hip joint. A large polyethylene head articulates with a polished metal acetabular component, and an additional smaller metal or ceramic head is snap-fit into the large polyethylene. New components have been released for use in North America over the past eight years and additional modular designs will be forthcoming. In some European centers, these components are routinely used for primary total hip arthroplasty. However, their greatest utility may be to prevent and manage recurrent dislocation in the setting of revision total hip arthroplasty. Several retrospective series have shown satisfactory results for this indication at medium-term follow-up times. The author has used dual mobility components on two occasions to salvage a failed constrained liner. However, at least one center reported failure of dual mobility if the abductor mechanism is absent. There are important concerns with dual mobility, including late polyethylene wear causing intra-prosthetic dislocation, and the lack of long-term follow-up data with most designs. Modular dual mobility components, with screw fixation, are the author's first choice for the treatment of recurrent dislocation in younger patients, revision of failed metal-metal resurfacing, total hips, large head unipolar arthroplasties, and salvage of failed constrained liners. There are more recent concerns of iliopsoas tendonitis, elevated metal levels with one design, and acute early intra-prosthetic dissociation following attempted closed reduction. However, in 2016, a dual mobility component, rather than a constrained liner, may be the preferred solution in revision surgery to prevent and manage recurrent dislocation

Patients with painful metal-on-metal bearings presenting to the orthopaedic surgeon are a difficult diagnostic challenge. The surgeon must go back to basic principles, perform a complete history and physical exam, obtain serial radiographs and basic blood work (ESR, CRP) to rule out common causes of pain and determine if the pain is, or is not, related to the bearing. The Asymptomatic MoM Arthroplasty: Patients will present for either routine follow up, or because of concerns re: their bearing. It is important to emphasise that at this point the vast majority of patients with a MoM bearing are indeed asymptomatic and their bearings are performing well. The surgeon must take into account: a) which specific implant are they dealing with and what is its track record; b) what is the cup position; c) when to perform metal ion testing; d) when to perform further soft tissue imaging (MARS MRI, Ultrasound); e) when to discuss possible surgery. Painful MoM THA causes not related to the bearing couple: These can be broken down into two broad categories. Causes that are Extrinsic to the hip include: spine, vascular, metabolic and malignancy. Causes that are Intrinsic to the hip can either be Extracapsular (iliopsoas tendonitis and trochanteric bursitis) or Intracapsular (sepsis, loosening, thigh pain, prosthetic failure). Painful MoM THA causes related to the bearing couple: There are now described a number of possible clinical scenarios and causes of pain that relate to the metal-on-metal bearing couple itself: a) local hypersensitivity reaction without a significant soft tissue reaction; b) local hypersensitivity reaction with a significant soft tissue reaction; c) impingement and soft tissue pain secondary to large head effect. Metal ions: obtaining serum, or whole blood, cobalt and chromium levels is recommended as a baseline test. However, there is no established cutoff level to determine with certainty if a patient is having a hypersensitivity reaction. A 7 parts per billion cutoff has been suggested. This gives high specificity, but poor sensitivity. Metal ions therefore can be used as a clue, and one more test in the workup, but cannot be relied upon in isolation to make a diagnosis. MARS MRI: a useful tool for demonstrating soft tissue involvement, but there are many painless, well-functioning MoM implants that have soft tissue reactions, that don't require a revision. In the painful MoM hip an MRI, or ultrasound, is recommended to look for soft tissue destruction or a fluid-filled periprosthetic lesion (pseudotumor). Significant soft tissue involvement is concerning and is commonly an indication for revision in the painful MoM hip. Treatment: management of the painful MoM hip is directly related to the etiology of the pain. Unique to MoM bearing is the issue of pain secondary to a local hypersensitivity reaction. All above tests should be utilised to help determine the best course of action in any individual patient. The painful MoM bearing, that is demonstrating significant soft tissue involvement is a concerning scenario. Earlier revision, to prevent massive abductor damage, would seem prudent for these patients. The painful MoM bearing with no significant soft tissue changes can probably be followed and reviewed at regular intervals. If the pain persists and is felt to be secondary to a hypersensitivity reaction, then revision is really the only option, although the patient must be cautioned regarding the unpredictable nature of the pain relief

Total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) are excellent surgical options for individuals with shoulder arthritis, providing good to excellent results in the vast majority of patients. Complications are rare, but can be devastating for both the patient and surgeon. An uncommon, but extremely problematic complication following shoulder arthroplasty is shoulder stiffness. While substantial literature discussing post-arthroplasty stiffness is available for other joints such as the hip, knee, and elbow, there is a paucity of research available discussing this complication in the shoulder. As noted in multiple reviews, diminished range of motion following TSA or RSA may be due to a number of factors, including pre-operative diagnosis of proximal humerus fracture, inadequate post-operative rehabilitation, implant-related factors such as malpositioning and/or inappropriate-sized implants, and heterotopic ossification. Often, pathology leading to post-arthroplasty stiffness involves scarring of the long head of the biceps tendon, rotator cuff impingement, as well as cuff tendonitis. Periprosthetic joint infection (PJI) is also important to recognise, and may be difficult to diagnose, especially in cases of Propionibacterium acnes infections. Importantly, PJI may present with stiffness as well as instability, and thus a high index of suspicion with a low threshold to aspirate is necessary in these challenging patients. Treatment of patients with stiffness following arthroplasty is challenging, and may involve arthroscopic intervention with or without manipulation, as well as manipulation under anesthesia alone. This paper will discuss the etiology, work-up, and treatment of patients with shoulder stiffness following TSA and RSA

Pain following total hip arthroplasty is a relatively rare event. Several series place the incidence of some degree of pain post THA at approximately 5%. A systematic approach to determining etiology will direct treatment. Hip pain can be categorised as:. Extrinsic to the Hip. –. Spine +/− radiculopathy. –. Vascular disease. –. Metabolic (Paget's). –. Malignancy. Intrinsic to the Hip. Intracapsular/Implant. Loosening. Sepsis. Prosthetic failure. Osteolysis. Instability. Thigh pain. Stem tip pain. Hypersensitivity/ALVAL. Extracapsular. Iliopsoas tendonitis. Snapping Hip. Trochanter problems (bursitis). Heterotopic ossification. A full history and appropriate physical exam will direct the clinician. The use of routine radiographs, blood tests, and special tests (i.e., blood metal ions, advanced imaging techniques) will be discussed I detail

Hip resurfacing using metal-on-metal bearings has a number of purported advantages over traditional total hip replacement in the young, active patient. Males in particular can benefit from the bone preservation, stability, and higher activity levels seen with this procedure. As more is learned about the factors affecting long-term outcome of hip resurfacing, component position has emerged as one major predictor of success. Given a well-selected patient, and a well-designed device, acetabular positioning is perhaps the most important determinant of long-term survivorship in hip resurfacing. One feature of resurfacing socket design which has not been widely disseminated is the sub-hemispheric arc of the bearing surface. While the outer circumference of the socket represents a complete hemisphere, and radiographic evaluation may assume that the apparent socket angle is satisfactory, the actual bearing is less than a hemisphere, so that the true abduction of the bearing is considerably more vertical. This important fact leads to excessive bearing inclination, edge loading, and all that follows, including runaway wear, metallosis, ALVAL, and pseudotumors. Inadequate socket anteversion can expose the psoas tendon to abrasion and tendonitis. Too much acetabular anteversion, especially when combined with increased femoral neck anteversion, can result in an overall decrease in bearing contact area, and excessive wear. Femoral component positioning is critical in the prevention of femoral neck fractures, which are a chief cause of early failure. Varus placement increases the tensile stresses on the superior femoral neck. Excessive valgus threatens notching. Both increase femoral neck fractures. Sufficient malposition will ultimately result in edge loading. Edge wear is incompatible with fluid film lubrication, the key to longevity of these bearings

Introduction. Micro-arc oxidation (MAO) is an electrochemical method used to treat metal surfaces. It provides nanoporous pits, and thick oxide layers, and incorporates calcium and phosphorus into the coating layer of titanium alloy. This modification on the surface of titanium alloy by MAO coating would improve the ability of cementless stems to osseointegrate. In spite of these structural and chemical advantages, clinical study of total hip arthroplasty (THA) using MAO coated stem has not yet been reported. In this study, we evaluated the clinical and radiographic results associated with cementless grit-blasted tapered-wedge stems that were identical in geometry but differed with regard to surface treatment with or without MAO coating. Materials & Methods. We performed a retrospective review of 141 THAs using MAO coated stem for a minimum of 5 years and compared them to 219 THAs using the same geometry stem without MAO coating. A cementless Bencox femoral component (Corentec, Seoul, Korea) was used in all hips. It is made of titanium alloy with a straight, double wedged, tapered stem with a rectangular cross-section. Surface treatment was performed using grit blasting with a roughness of 5.5ųm that was available either with or without MAO coating. Clinical and radiographic evaluations were performed preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively, and then annually. Results. In the MAO coating group, the mean Harris hip score improved from 43.7 points preoperatively to 93.9 points postoperatively. The mean WOMAC score and UCLA activity score at the final follow-up was 17 points (range, 6–34 points) and 6.9 points (range, 5–10 points), respectively. Thigh pain at final follow-up was reported in 2 hips (1.4%), but neither of these hips showed signs of implant loosening or limited daily activities. Complications included one squeaking, one iliopsoas tendonitis, and one deep vein thrombosis. Postoperative Harris hip scores, WOMAC scores, UCLA activity scores, and complication rates did not differ between the two groups. In both groups, no femoral or acetabular component showed radiographic evidence of mechanical loosening, and no components had been revised at the final follow-up. Conclusions. Primary THA using a cementless grit-blasted tapered-wedge stem with MAO coating showed encouraging medium-term outcomes. Further prospective controlled study is required to investigate the long-term implant survival, possible complications, and cost-effectiveness of utilizing MAO coating in THA

Manipulation under anaesthetic (MUA) is an established treatment for frozen shoulder. Frozen shoulder may coexist with other shoulder conditions, whose treatment may differ from MUA. One such condition is calcific tendonitis. Only one study to date documents treatment of patients with frozen shoulder and concurrent calcific tendinitis. The objective was to demonstrate that MUA and injection is a satisfactory treatment for concurrent diagnosis of frozen shoulder and calcific tendinitis. Patients with a clinical diagnosis of frozen shoulder and radiological evidence of calcific tendinitis were prospectively recruited from Jan 1999 – Jan 2009. Treatment by MUA and injection was performed. Clinical examination, Oxford Shoulder Scores and need for further treatment were used as outcome measures. Fourteen patients (median age 53.5 years) were identified with frozen shoulder and concurrent calcific tendinitis. Significant improvement in both Oxford Shoulder Score and range of movement was achieved following MUA (P values < 0.001). Two patients required further treatment (not for calcific tendinitis). This improvement was maintained in the long term (median 107 wks). It is our belief that MUA and injection is a safe and effective treatment, addressing the frozen shoulder with MUA takes priority, and as such frozen shoulder “trumps” other pathologies occurring simultaneously

Introduction. The purpose of this study was to assess the rate of revision subacromial decompression and identify different pathologies. Materials/Methods. We analysed the patients who underwent Revision Arthroscopic Subacromial decompression from our prospective database of shoulder patients. Between April 2003 and Dec 2010, 797 patients underwent arthroscopic subacromial decompression. Patients who underwent any other procedure i.e. biceps tenotomy, capsular release, cuff repair were excluded from the study. Of these, 37 underwent a revision subacromial decompression (Revision rate 4.6%). The indication for revision procedure was persistent pain or restricted movements not responding to physiotherapy and injections. Results. We found that 1) Patients having cuff pathology i.e. partial tear or degenerate cuff were more likely to need a revision procedure (11/37 and 92/797, p = 0.001). 2) The rate of ACJ excision done for residual pain after primary subacromial decompression was similar to the rate of ACJ excision at the time of the primary procedure (7/37 vs. 100/797, p= 0.5). 3) Presence of Calcific deposits did not have any influence on the risk of having a revision procedure (2/37 and 12/797, p= 0.1). 4) Patients found to have synovitis in the primary procedure were more likely to need revision procedure (10/37 and 81/797, p = 0.001). 5) Presence of biceps tendonitis did not significantly affect the risk of having a revision procedure after arthroscopic subacromial decompression (3 /37 and 21 /797, p = 0.5). Conclusion. Our revision rate is similar to those published in literature. In our failed cases there was a trend for patients to have an associated partial rotator cuff tear and synovitis

Aim. Alumina ceramic on ceramic bearings in total hip arthroplasty (THA) may reduce the prevalence of osteolysis due to its properties of low wear and chemical inertness. This is critical in the younger patient population as they place increased demands over a longer period. This study reports on the clinical and radiographic outcomes of a series of modern cementless ceramic on ceramic THA at a minimum of 10 years in this younger group. Method. A series of 120 consecutive third generation ceramic cementless THA were performed at a single centre in 110 patients from 1997 to 1999. The average age of the patients at the time of surgery was 45 years (20 to 55 years). All procedures were carried out via the posterior approach using the same implant by the two senior authors. Results. At 10 years, 4 patients had died and 6 were lost to follow-up (5%). The mean Harris Hip Score was 94.7 points. All surviving implants analysed radiographically had evidence of stable bony ingrowth, with no cases of osteolysis. Wear rates were undetectable. There were 3 revisions (2.5%). One stem was revised following periprosthetic fracture, one stem was revised to facilitate a femoral shortening osteotomy. One cup was revised for anterior impingement causing psoas tendonitis. There was one incident of intraoperative ceramic liner chipping, which was changed without complication. There were no postoperative bearing fractures. Two patients reported intermittent squeaking at extreme hip flexion and internal rotation, the hips otherwise functioned well. The survival for both components with revision for any cause was 97.5%. Conclusion. Alumina ceramic on ceramic bearings in cementless primary THA in this series have resulted in good clinical and radiographic outcomes with low wear rates and excellent function in the demanding younger patient group at 10 years

Proximal Release of Gastrocnemius (PROG) is a procedure which can be performed to treat various disorders of the foot and ankle. Gastrocnemius contracture/tightening is a condition which can lead to many chronic debilitating foot conditions like Metatarsalgia, Hallux Valgus, Plantar Fascitis, Diabetic foot ulcers etc, which in turn can significantly affect patient's quality of life. In this study we present eight cases who presented with forefoot pain, were treated with PROG and showed a complete resolution of their condition. The test used to determine Gastrocnemius contracture is the “SILFVERSKIOLD TEST”. It measures the dorsiflexion (DF) of the foot at the ankle joint (AJ) with knee extended & flexed to 90 degrees. The test is considered positive when DF at the AJ is greater with knee flexed than extended. We studied eight patients who presented to the orthopaedic outpatients between 2005 and 2010 with diverse foot conditions and having relative equinism. Six out of eight patients suffered from forefoot pain, out of which three had associated diabetic neuropathy and one out of these three had a diabetic foot ulcer. One was in association with arthritis of Talonavicular & Transmetatarsal joint, another had callosity under the head of second metatarsal. One patient had claw toes with associated Rheumatoid Arthritis. One of our patients presented with spasticity in his left calf, severe Hallux Valgus & dislocated MTPJ. He had an unsuccessful Strayer procedure on the same leg in the past. The final case had Achilles tendonitis & spurs. A finding common to all of them pre operatively was a positive Silfverskiold test, all having ZERO degree DF at the AJ with knee extended. Surgical release of the aponeurotic head of gastrocnemius was performed in prone position through a transverse incision. A cam walker was used for two weeks in those patients who were permitted to weight-bear, else a plaster for two weeks. No surgical complications occurred. Success was measured both in returning the ability to dorsiflex and resolution of related condition. DF in extension improved from an average of zero to 16(sixteen) degrees. Seven out of eight patients(including the patient with planter ulcer)had resolution of associated condition. One failure was a patient who continued to experience neuropathic pain. None of the patients complained of any weakness as a result of release. PROG is a straightforward procedure and should be considered in patients where gastrocnemius tightening is likely to be the contributing factor. This seems to improve the success of related procedures

Introduction:. Acetabular revision Jumbo cups are used in revision hip surgeries to allow for large bone to implant contact and stability. However, jumbo cups may also result in hip center elevation and instability. They may also protrude through anterior wall leading to ilopsoas tendinitis. Methods:. The study was conducted using two methods:. Computer simulation study. 265 pelvic CT scans consisting of 158 males and 107 females were converted to virtual 3-dimensional bones. The average native acetabular diameter was 52.0 mm, SD = 4.0 mm (males in 52.4 mm, SD = 2.8 mm and 46.4 mm, SD = 2.6 mm in females). Images were analyzed by custom CT analytical software (SOMA™ V.3.2). 1. and over-sized reaming was simulated. Four distinct points, located in and around the acetabular margins, were used to determine the reamer sphere. Points 1, 2, 3 were located at the inferior and inferior-medial acetabular margins, and Point 4 was located superiorly and posteriorly in the acetabulum to simulate a bony defect in this location, Point 4 was placed at 10%, 20%, 30%, 40%, 50% and 60% of the distance from the superior – posterior margin of the acetabular rim to the sciatic notch to simulate bony defects of increasing size. (Figure 1). Radiographical study. Retrospective chart review of patient records for all cementless acetabular revisions utilizing jumbo cups between January 1, 1998 and March 30, 2012 at UCFS (98 patients with 57 men, 41 women). Jumbo cups: ≥66 mm in males; <62 mm in females. Reaming was directed inferiorly to the level of the obturator foramen to place the inferior edge of the jumbo cup at the inferior acetabulum. To determine the vertical position of the hip center, a circle was first made around both the jumbo and the contralateral acetabular surfaces using Phillips iSite PACS software. The center of this circle was assumed to correspond to the “hip center”. The height of the hip center was estimated by measuring the height of a perpendicular line arising from the interteardrop line (TL) and ending at the hip center. Results:. The computer simulation and radiographic analysis deomonstrated similar results. The computer simulation predicted that the hip center shifted superiorly and anteriorly as the reamer size increased. The hip center shifted 0.27 mm superiorly and 0.02 mm anteriorly for every millimeter in diameter increased for the reaming. (Figure 2) Anterior column bone removal was increased 0.86 mm for every 1 mm of reamer size increase. (Figure 3). Results of radiographical study is shown in Table bellow:. Discussion:. Use of a jumbo cup in revision THA results in elevation of the hip center. Therefore a longer femoral head may be needed to compensate for hip center elevation when a jumbo cup is used. Reaming for a jumbo cup can also result in loss of anterior bone stock and protrusion of the cup anteriorly which may cause iliopsoas tendonitis

Introduction. The success of total hip arthroplasty has meant its indications have been extended to the younger more active patient. Due to the higher activity levels and increased demands of these patients, revision rates have been traditionally higher than when compared to older patients [1]. Ceramic on ceramic bearings may offer a viable long term solution as manufacturing methods have evolved resulting in improved mechanical properties, particularly of third and fourth generation ceramics. We report the outcome of primary cementless, alumina-on-alumina hip arthroplasty with a minimum 10 year follow up in 110 patients under the age of 55 years of age at time of surgery. Methods. A series of 120 consecutive total hip arthroplasties in 110 patients were performed between June 1997 and February 1999 by the two senior authors. All patients had an Osteonics ABC acetabular component and SecurFit or SecurFit Plus femoral component (Stryker Orthopaedics, Mahwah, NJ) with an alumina C-taper ceramic head (Biolox Forte, Ceramtec, Plochingen, Germany). Results. Of the 110 patients originally in the study, 4 (3.6%) patients died, 6 (5%) were lost to follow up and 4 hips (3.6%) were revised by the time of the latest follow up. Clinical information was available for 106 hips in 96 surviving patients at a minimum of ten years of follow-up, and radiographic information was available for 90 hips from the same 96 patients. The mean follow up was 11.5 years (range 10 to 13.5 years). Survivorship analysis with revision for any reason as an endpoint was 96.5% at 10 years (CI 94.5% −98.7%) using the Kaplan-Meier method. Modified mean UCLA scores improved from 6.4 (range 4 to 10) pre operatively to 9 (range 4 to 10) at latest follow up. The mean Harris Hip Score improved from 53.4 points (range 15 to 86) preoperatively, to 94.7 points (range 63 to 100) at latest follow up. All femoral stems had stable bone ingrowth, with no migration. Osteolysis was not observed around the femoral or acetabular components and there were no signs of radiological wear. 98 patients (92.4%) managed to continue with their current occupations during the follow up period whilst 5 patients (4.7%) changed occupation to work that required increased activity. Complications included 3 cases of iliopsoas tendonitis, 2 cases of squeaking, a ceramic liner chipping during insertion and sciatic nerve palsy. There were no cases of ceramic fracture in this younger, active cohort of patients. No evidence of bearing failure was demonstrated nor any signs of adverse reaction to wear debris. Conclusions. Alumina ceramic on ceramic bearings in cementless primary total hip arthroplasty show good clinical and radiological outcomes in the higher demand younger age patient. Based on these results we now support heavy occupational work and regular impact sports in these patients once they have recovered from surgery