We present a novel use for an adult proximal humeral locking plate. In our case an 18-year-old female with cerebral palsy sustained a peri-prosthetic fracture of a blade plate previously inserted for a femoral osteotomy. Treatment was revision using a long proximal humeral locking plate. She had a successful outcome.

We present the history and operative management.

The female had a history of quadriplegic cerebral palsy, asthma, diabetes mellitus and congenital heart disease. She had a gastrostomy tube for enteral feeding. She was on nutritional supplements, baclofen, Omeprazole and movicol. She is looked after by her parents and requires a wheelchair for mobility. She is unable to communicate. Surgical History: Right adductor tenotomy, aged 11. Femoral Derotation Osteotomy & Dega Acetabular Osteotomy, aged 13. Right distal hamstring and knee capsule release, aged 14. Admitted to A&E (aged 18); unwitnessed fall. Painful, swollen, deformed thigh with crepitus. Xrays demonstrated peri- prosthetic fracture below blade plate.

No specific equipment available to revise. Decision made to use PHILOS (Synthes, UK). GA, antibiotics, supine on table. Lateral approach. Plate removed after excising overgrown bone. Reduced and held. 10hole PHILOS applied. Near anatomical reduction. Secure fixation with locking screws proximally away from blade plate defect. Blood loss 800ml. 5 days in hospital. Sequential fracture clinic review. Wound healed well. Fracture healed on Xray at 11 months and discharged.

To our knowledge this is the first reported use of a PHILOS plate for this specific fracture. The complexity of this case and underlying neurological disorder deemed long blade plate revision unsuitable. Fracture rates after femoral derotation osteotomies rare. 5/157 and 1/58 in the two largest studies to date. Conservative measures were the main recommendation. We have demonstrated a straightforward method for revision fixation with an excellent outcome. It would be recommended as an alternative to other surgeons in this position.

The Exeter Stem (Howmedica, UK) has been in use for over 35 years. Over the years it has undergone several modifications with the most recent being a highly polished, tapered stem in 1986. The manufacturers quote a rate of 0.0006%. In the current literature there are 16 (or less) instances of fractures of the Orthinox stem.

We present a case of fracture of an Orthinox Exeter Stem 9 years after insertion.

Our patient, BB, presented, aged 62, with symptoms & signs consistent with OA right hip. THR was performed through a lateral approach utilising a trochanteric osteotomy. A size 0 37.5 stem was inserted. Radiographs were very satisfactory. She suffered a post operative DVT/PTE from which she recovered uneventfully. She was independently mobile at 6 month review and was discharged at the 2 year stage pain free.

Aged 71, BB presented to outpatient clinic with a several month history of generalised groin pain. She had a Trendelenberg gait. Considerable pain was experienced on axial compression of the limb. Radiographs revealed a midstem fracture with cement loosening proximally. No trauma was reported. She underwent revision surgery through a posterior approach. Acetabular component was rigidly fixed. This was revised to a pressfit Trident (Zimmer, UK) cup with screws & polyethylene liner. An extended trochanteric osteotomy was used to remove the broken stem. An uncemented Restoration (Stryker, UK) stem was inserted with a 28mm head. Post-operative recovery was unremarkable and at 6 months osteotomy has healed. The stem was sent to Stryker UK Laboratories for analysis. They reported the stem broke in fatigue with the origin on the antero-lateral surface. No material or manufacturing defects seen. Dimensionally correct. Fracture may be due to abnormal bending stresses secondary to proximal loosening and firm distal fixation.

Our case demonstrates a set of circumstances that led to inevitable fatigue and stem fracture. The method of failure should reinforce the radiograph appearances that may cause concern or be acted upon.

We compared the postoperative wound discharge rates and 3 months clinical results of three types of wound closure and dressing – 2-octylcyanoacrylate with Opstie (G+O), 2-octylcyanoacrylate with Tegaderm (G+T), and Opsite without 2-octylcyanoacrylate (O) in patients having primary total hip arthroplasty.

We randomised 141 patients scheduled for primary total hip arthroplasty into 3 arms of this study- G+O, G+T, or O. The extent of wound discharge was recorded on a diagrammatic representation of the dressing in situ on paper and graded each day. Dressings were left in-situ provided the extent of wound discharge allowed for this. The patient was clinically reviewed at 3 months to assess their scar length, cosmesis, scar discomfort, and evidence of superficial or deep wound sepsis.

A greater number of patients dressings remained dry on day 1 postoperatively in the two groups with 2-octylcyanoacrylate compared to the no glue group p=0.001. G+T group had a significantly lower proportion of patients with increased leakage of wounds on 2^nd postoperative day p=0.044. At 3 months review, there was no statistical difference in the Hollander score or scar discomfort.

In patients who have had primary total hip arthroplasty, usage of 2-octylcyanoacrylate for wound closure along with Tegaderm dressing reduces wound discharge. The same effect is not noted in glue with Opsite group. Whilst dressing changes required in the non-glue group compared from the two glue groups did not reach statistical significance, this may have clinical relevance for patients and nursing staff. No effect on postoperative length of stay, or wound complications was noted.

Short leg radiographs remain the standard radiographs available in many UK hospitals. The aim of this study was to see if these radiographs are reliable when assessing the post-operative alignment of total knee arthroplasty in comparison to a Hip-Knee-Ankle (long leg) radiograph.

Twenty consecutive 6 week post-operative long leg radiographs, taken with a standardised protocol, and a short leg radiograph derived from the same digital image were each examined on two separate occasions by two observers. On the long leg radiograph the anatomical and mechanical axis were calculated and on the short leg radiograph the anatomical and surrogate mechanical axis were calculated. These data were used to investigate intra- and inter-observer error. A single observer also collected the same measurements on an additional 30 radiographs (total of 50) to further investigate any patterns of error.

On long leg radiographs, intra-observer agreement was good for both anatomical and mechanical axis for both observers (Intraclass Correlation Coefficients [ICC] of 0.95 to 0.98). The anatomical axis on short leg radiographs was also good (ICC = 0.92 and 0.76). Intra-observer agreement for the short leg radiograph derived mechanical axis was not as consistent (ICC = 0.73 and 0.56). Inter-observer variability was good for long leg radiographs for both anatomical (ICC = 0.89) and mechanical (ICC = 0.95) axis. On short leg radiographs, however, agreement was not as good, in particular for the mechanical axis (ICC = 0.51), but also the anatomical (ICC = 0.73). Taking the long leg radiograph values as the “gold standard” there was a difference in the magnitude of errors seen on short leg radiographs dependant on the knee alignment. Varus aligned knees (n=24) had an average error of 1.2° (0° to 3°) for the anatomical axis and 1.6° (0° to 4°) for the mechanical axis. Perfectly aligned knees (n=8) had an average error of 3.0° (1° to 6°) for the anatomical axis and 2.9° (1° to 5°) for the mechanical axis. Valgus aligned knees (n=18) had an average error of 3.4° (0° to 8°) for the anatomical axis and 5.8° (2° to11°) for the mechanical axis. Using a Mann-Whitney test the magnitude of error was greater for valgus knees for both anatomical (p< 0.0001) and mechanical (p< 0.00001) axes when compare to varus knees. Interestingly all except one knee measured on the long leg radiograph as valgus aligned appeared to be in varus on the short leg radiograph.

In conclusion, short leg radiographs are inadequate to make any comment on leg alignment in total knee arthroplasty. This is most pronounced in a valgus aligned knee.

We describe the longer term clinical and radiological findings in a prospectively followed series of 49 rheumatoid patients (58 shoulders) who had undergone Neer II total shoulder replacement. The early and intermediate results have been published previously.

At a mean follow-up of 19.8 years (16.5 to 23.8) 14 shoulders survived. Proximal migration of the humeral component was associated with progressive loosening of the glenoid and humeral components, but was independent of the state of the rotator cuff at the time of operation. Despite these changes the range of movement was preserved. Most patients had little or no pain in the shoulder, could sleep undisturbed and could attend to personal hygiene and grooming.

The purpose of this study was to evaluate the effect on movement under load of different techniques of reat-tachment of the humeral tuberosities following 4-part proximal humeral fracture. Biomechanical test sawbones were used. 4-part fracture was simulated and a cemented Neer3 prosthesis inserted. Three different techniques of reattachment of the tuberosities were used – 1)tuberosities attached to the shaft, and to each other through the lateral fins in the prosthesis with one cerclage suture through the anterior hole in the prosthesis, 2)as 1 without cerclage suture, and 3)tuberosities attached to the prosthesis and to the shaft. All methods used a number 5 ethibond suture. Both tuberosities and the shaft had multiple markers attached. Two Digital cameras formed an orthogonal photogrammetric system allowing all segments to be tracked in a 3-D axis system. Humeri were incrementally loaded in abduction using an Instron machine, to a minimum 1200N, and sequential photographs taken. Photographic data was analysed to give 3-D linear and angular motions of all segments with respect to the anatomically relevant humeral axis, allowing intertuberosity and tuberosity-shaft displacement to be measured. Techniques 1 and 2 were the most stable constructs with technique 3 allowing greater separation of fragments and angular movement. True intertuberosity separation at the midpoint of the tuberosities was significantly greater using technique 3 (p< 0.05). The cerclage suture used in technique 2 added no further stability to the fixation. In conclusion, our model suggests that the most effective and simplest technique of reattachment involves suturing the tuberosities to each other as well as to the shaft of the humerus. The cerclage suture appears to add little to the fixation in abduction, although the literature would suggest it may have a role in resisting rotatory movements.

Introduction and Aims: The purpose of this study was to evaluate the effect on movement under load of different techniques of reattachment of the humeral tuberosities following four-part proximal humeral fracture.

Method: Biomechanical test sawbones were used. Four-part fracture was simulated and a cemented Neer3 prosthesis inserted. Three different techniques of reattachment of the tuberosities were used: 1) tuberosities attached to the shaft, and to each other through the lateral fins in the prosthesis with one cerclage suture through the anterior hole in the prosthesis; 2) as one without cerclage suture; 3) tuberosities attached to the prosthesis and to the shaft. All methods used a number five ethibond suture. Both tuberosities and the shaft had multiple markers attached. Two digital cameras formed an orthogonal photogrammetric system, allowing all segments to be tracked in a 3-D axis system. Humeri were incrementally loaded in abduction using an Instron machine, to a minimum 1200N, and sequential photographs taken. Photographic data was analysed to give 3-D linear and angular motions of all segments with respect to the anatomically relevant humeral axis, allowing intertuberosity and tuberosity-shaft displacement to be measured.

Results: Techniques one and two were the most stable constructs with technique three, allowing greater separation of fragments and angular movement. True inter-tuberosity separation at the midpoint of the tuberosities was significantly greater using technique three (p< 0.05). The cerclage suture used in technique two added no further stability to the fixation.

Conclusion: Our model suggests that the most effective and simplest technique of reattachment involves suturing the tuberosities to each other, as well as to the shaft of the humerus. The cerclage suture appears to add little to the fixation in abduction, although the literature would suggest it may have a role in resisting rotatory movements.

Introduction and Aims: The aim of this paper was to assess the 10 to 15-year clinical and radiographic results of uncemented LCS meniscal-bearing total knee replacements used to revise failed uni-compartmental knee replacements.

Method: Eleven (5 M: 6 F) cementless LCS meniscal-bearing total knee replacements were implanted in patients who had failed uni-compartmental knee replacements for medial compartment osteoarthritis. Mean time interval between the uni-compartmental knee replacement and the LCS total knee replacement was 18 months (12–72 months). Minimum follow-up of all patients reviewed was 10 years (mean 12.9 years). Average age of patients at the time of surgery was 60.1 years (47–74 years). Clinical and radiographic analysis was performed. American knee society pain and function scores were determined and Kaplan-Meier survivorship analysis was conducted. Failure was defined as revision due to any cause.

Results: At the time of the 10 to 15-year follow-up, all 11 patients were alive and were all reviewed. Four patients (three males, one female) had a revision of their LCS total knee replacement. The average time to revision of the LCS total knee replacement was 26 months (1–60 months). The average knee society pain and function scores were 80 and 45 at the final follow-up evaluation. The average range of movement was 95 degrees (80–100 degrees). The survival rate of 60% (95 % confidence interval) was noted at 12 years.

Conclusion: After 10 to 14 years of follow-up, the cementless LCS meniscal bearing total knee replacement for a previously failed uni-compartmental knee replacement was found to have a 37% revision rate.