Medical and Health care products Regulatory Agency (MHRA) released an alert in 2010 regarding metal on metal (MoM) bearings in hip arthroplasty owing to soft tissue reactions to Metal debris. Following this, we adopted a targeted screening protocol to review patients with this bearing couple.

218 Patients (252 hips), mean age 53.2 (25–71) years were assessed clinically using Oxford hip score (OHS) and X-ray examination. The mean follow up was 44.5 (12–71) months. Patients were considered at higher risk (118 patients/133 hips) if they had deterioration of OHS (50 hips), Small sized heads <50mm (114 hips), acetabular inclination >500 (37 hips), neck thinning (17 hips). These patients (107/118), (120/133 hips) were further investigated through measuring metal ion levels and magnetic resonance imaging (MRI).

The mean blood levels of cobalt and chromium in this group were 6.7, 8.62 ug/L respectively. Metal ions increased significantly with high acetabular inclination angles (p=0.01, 0.004 respectively), but was not affected by the size of the head (p=0.13). MRI showed periprosthetic lesions around 28 hips (26 fluid collections, 2 pseudotumours).

The screening protocol detected all patients who subsequently required elective revision. We believe that this protocol was beneficial in detecting problematic MoM hip replacements.

Abstract

The specific methods of skeletal reconstruction of massive bone loss remains a topic of controversy. The problem increased in case of massive bone loss, extensive soft tissue scar, vascular compromise, and short tibial remnants.

Distal radio-ulnar joint (DRUJ) instability is increasingly recognised and can lead to disabling symptoms. Clinical assessment can detect gross instability but is much less reliable for subtle instability. The normal range of DRUJ dorso-palmar translation is not known. Previous biomechanical research has studied DRUJ kinematics using cadaveric models.

We aim to develop a simple, reliable and reproducible tool to measure DRUJ stability and thereby assess the normal range of DRUJ dorso-palmar translation in-vivo.

A test rig was designed and 20 volunteers recruited. The rig held the subject’s elbows at 90° flexion with the distal ulnar secured and the forearm in neutral rotation. Dorso-palmar shear force was applied to the distal radius and displacement measured 3 times on each wrist alternately by the same operator. Volunteers with previous wrist injuries were excluded.

Ten male and 10 female volunteers were recruited. Mean male age 39.1 years (range 22–74). Mean female age 35.8 years (range 25–57). Mean male translation 5.4mm (range 3–9, SD 1.1). Mean female translation 5.5mm (range 4–7, SD 0.9). Mean right sided translation 5.3mm (range 3–8, SD 1.0). Mean left sided translation 5.6mm (range 3–9, SD 1.0). Total mean translation 5.5mm (SD 1.0). Same-sided mean measurements for two subjects taken days apart varied by only 1mm. Intraclass correlation coefficient was 0.93.

The rig is reliable, reproducible and appears to be a valid test of DRUJ translation. The mean DRUJ translation in neutral is 5.5mm. Contralateral sides and between sexes were comparable. We anticipate that the rig will be a research tool to guide clinical practice in DRUJ instability.

The specific methods of skeletal reconstruction of massive bone loss remains a topic of controversy. The problem increased in case of massive bone loss, extensive soft tissue scar, vascular compromise, and short tibial remnants.

Aim of the work: We evaluate the use of fibula in association of Ilizarov external fixator in management of massive post traumatic bone loss of tibial shaft.

Materials and Methods: Between December 1999 and 2004, we treated 8 adult patients with bone loss 10 cm and more. The indication was massive bone loss, extensive soft tissue scar, vascular compromise, and short tibial remnants. Whole fibula was used in 6 conditions and partial fibula in 2. The average age was 30.5 years (range: 25:51). The fibulas was prepared for transfer either as a whole or partially transfer. Ilizarov device was applied with a special construct for each condition accordingly. Free latismus dorsi was applied in 1 patient, and fasciocutanious flaps in 2. Four patients with whole fibula transfer continued to wear orthosis for outdoor activities.

Results: The mean follow-up period was 40 months (range: 24:96) after healing. All fractures heeled between 8 and 24 months.

Conclusion: We concluded that the Ilizarov external fixator is effective in management of management of massive post traumatic bone loss of tibial shaft. It provides advantages of compensation of bone defects, length, and early rehabilitation. It has the disadvantages of long healing time, long orthotic support. Its advantages are clear in case of massive bone loss, extensive soft tissue scar, vascular compromise, and short tibial remnants

Treatment protocols of tibial hemimelia comprised joint reconstruction and amputation or knee disarticulation and prosthetic fitting. However, amputation is not acceptable in our community. Therefore we tried to treat these cases without amputation.

From 1993 till 1999, 2 cases of tibial hemimelia type IA, and 4 cases type II were referred to our center. All the cases presented late as the age of patients ranged from 3 _ years to 13 years. For type IA we applied Ilizarov External Fixator on the femur, fibula and foot to centralize the fibula between the femoral candyles and talus using gradual distraction. The second step comprised a Brown procedure. Then, the fixator was reapplied to correct the knee and foot deformities using the bloodless technique. For type II, synostosis of the tibia and fibula was performed followed by differential lengthening. Then we over lengthened the femur. Results: After follow up 2 to 5 _ years all patents were satisfied with good function. The tibial lengthening ranged from 6 to 9 cm and femoral lengthening ranged from 5 to 7.5 cm.

Complications:

Pin tract infection in all cases.

Up to our knowledge this is the first report tfor treatment of complete congenital tibial absence without amputation. Our early results are encouraging, as there are marked functional improvements in these patients.

Post – traumatic nonunion is unusual in children. The presence of more than one site for nonunion in a single bone, infection, shortening, osteoporosis and deformity makes the treatment more complicated. Case Report: A 10-y old boy presented to us with a post-traumatic 12 cm Rt. tibial shortening, unstable knee and a discharging sinus over the upper tibia. Roentgenograms revealed 3 sites of nonunion: in the upper middle and lower 1/3 of the tibia. The deformity of the upper tibia was varus 20° and recurvatum 25° while there was varus of the lower part 15°. The fibular head was over hanging the tibia. Treatment: Ilizarov Ext. fixator was applied concomitant with freshening of the upper site, sinus excision and osteotomy of the fibula. The lower fibula was fixed to the tibia leaving the upper part free. Then, gradual correction of deformities by distraction using properly positioned hinges was applied through the upper and lower sites for nonunion. Compression – Distraction was applied alternatively to stimulate the regenerate till we reached the sum of 12 cm lengthening from the 3 sites. The fixator was removed after 9 months where there was union and consolidation from all sites for non-union. The patient was followed up for 4 years.

Complications: Included wire tract infection, mild bowing of the regenerate after fixator removal and refracture.

Conclusion: Using the nonunion sites to correct complicated deformities and lengthen the bone is an effective method in children. Up to our knowledge, this is the first time to report the results of trifocal lengthening.