Cobalt-chrome alloys are widely used in dentistry and Orthopaedic implant industry. Vitallium is a similar alloy which contains 60% cobalt, 20% chromium, 5% molybdenum along with traces of other substances. It has been in use along with stainless steel for the last century because of its lightweight, favourable mechanical properties and resistance to corrosion. We present an unusual case of synovial cyst formation following Vitallium plating mimicking a sarcoma. To our knowledge, we are the first to report a delayed tissue reaction to Vitallium plating 40 years after its implantation.

A 78 yrs old man had a right femoral intertrochanteric fracture 40 years ago, which was fixed with a Vitallium nail plate. His postoperative recovery was uneventful and he regained full function of his leg. 3 years prior to excision, he presented with a painless swelling around his right upper thigh to our unit. Aspiration of the swelling and investigations were requested but patient was lost to follow up due to social reasons. Seven months prior to excision, he represented as the swelling had increased to the extent that it was involving the anterior and posterior aspect of the upper thigh with pressure necrosis of skin posteriorly. Examination revealed painless, transilluminable, fluctuant multilobular swelling over the right proximal femur overlying the healed surgical scar. Compression of the larger lobe in the buttock clearly forced fluid into the anterior compartment of the thigh where again swelling was extensive. Surprisingly he had full range of movements at the hip joint.

Radiograph of the hip showed a soft tissue swelling with a healed fracture and Vitallium implant insitu. Cytology was negative. MRI scan showed multiloculated cystic lesions extending anteriorly, laterally and posteriorly into the intermuscular and subcutaneous planes around the right proximal femur. Multiple small dependent foci likely representing debris or synovial proliferation was seen within loculations.

Excision of the cystic lesions with removal of metal work was performed. The old incision was reopened in the lateral position and a large cystic lesion with a thick capsule was dissected down to the metal work. The lesion was lying superficial to the vastus lateralis but was communicating with metal work. The metal work was removed with difficulty, no visible metallosis. A second cystic lesion was located more posteriorly but its neck was communicating with the thin hole into the first lesion. The lesion was excised completely.

Macroscopic examination showed two cysts 9×8×5.5cm and 20×10×7.5cm with a smooth external surface and the lumen appeared trabecular containing numerous loose (rice) bodies. Microscopy showed a dense fibrotic cyst wall with lumen with multiple small nodules containing organised fibrinous and eosinophilic material. Several foci of cellular debris including lymphocytes and macrophages were scattered in nodules best representing a synovial cyst with loose/rice bodies. No malignancy was seen.

We recommend early removal of metal work if it shows any signs of local reaction provided fracture is united. Be aware of large foreign body/ hypersensitivity reaction and incompatible equipment for removal.

Introduction

Femoral neck fractures are an increasingly common injury in the elderly. Frequently these patients present taking Clopidogrel, an irreversible inhibitor of platelet aggregation. Although this is associated with an increased risk of intra-operative bleeding and also an increased risk of spinal haematoma where regional anaesthesia is employed, the recent SIGN (Scottish Intercollegiate Guidance Network) guidelines recommend that surgery should not be delayed.

Aims

To assess the early subsidence rate of the femoral stem for patients who had collarless Corail total hip replacement.

Aim: To audit the accuracy and efficacy of injections for subacromial impingement administered by our medical staff and specialist role physiotherapist.

Methods: 49 patients presenting to the outpatient clinic with subacromial impingement agreed to take part in the study. They were allocated according to date of referral to either the consultant, the physiotherapist or registrar grade for injection via an anterior approach into the subacromial bursa. The therapeutic injection contained a specified volume of radiocontrast as well as depomedrone and lignocaine.

Antero-posterior and scapula-Y radiographs were performed immediately after injection. The Constant shoulder score was evaluated before and at six weeks after injection and all radiographs were reviewed by an independent, blinded radiologist recording the position of contrast.

Results: Accuracy rates of 67% through an anterior approach were obtained by both the consultant and the physiotherapist. At registrar level 48% accuracy was achieved.

Improvement in shoulder score was obtained in 70% of patients with accurate injections, but additionally in 59% of patients with inaccurate injections.

Only 7% of cases had contrast confined to the subacromial space; in the remainder, contrast tracked medially around the rotator cuff muscle bellies in 59%, gleno-humeral joint in 20% and within the cuff tendon in 16%.

Conclusions: In our practice, the specialist physiotherapist already has an established role in administering therapeutic subacromial injections. Our audit demonstrates acceptable and equal accuracy to the consultant which we feel justifies this particular part of their role. However, at registrar grade the level of accuracy is reduced and most likely reflects inexperience, as over time accuracy improved.

Interestingly, shoulder function scores have improved in over half of impingement patients with inaccurate injections which may reflect a generalised ‘field’ effect of steroid on the shoulder.

To establish whether there were features present on the initial post-operative radiographs of total hip replacements (THR) predictive of aseptic loosening.

Our data was derived from the Trent Regional Arthroplasty Study (TRAS) which is the only hip register of its kind in the country. The TRAS commenced in 1990 and has recorded clinical and operative details of all THRs in the region.

Our current study was concerned with a cohort of grossly loose THRs, identified from the five-year follow up of those patients who had undergone THR in 1990. Our cohort are those which failed specifically due to aseptic loosening and comprises those revised or listed for revision as well as a number of previously undiagnosed cases.

The post-operative radiographs were analysed, recording the following: (1) number, width and location (Gruen zone) of radiolucencies at both cement-bone and cement-prosthesis interfaces; (2) presence of stem-cortex contact; (3) width of the cement mantle in each Gruen zone; and (4) Barrack cementation grade.

Occasionally, if the initial post-operative radiograph was of poor quality, then further information was gained from the next available ones (usually at six weeks) to improve accuracy.

Comparisons were made with 60 control hips randomly generated from the same 1990 cohort but which had not failed.

Chi-squared tests were used to test the probability of obtaining the observed data by chance and odds ratios were calculated to describe relative risk of failure for different risk factors.

Hips with inadequate cementation grades (C and D) had a 9.5 times greater risk of failure compared to those with adequate cementation grades (A and B) [p< 0.0001].

We have demonstrated that the grade of cementation has a major effect on the probability of failure. This emphasises the importance of good cementing, which is particularly relevant in this era of clinical governance where there is greater accountability on the surgeon for adequate performance.