Arthroplasty in patients who are intravenous drug abusers presents a complex challenge, frequently requiring intervention at a younger age. The cohort suffer increased complication rates due to significant co-morbidities and poor engagement in medical services, in comparison to other patients undergoing lower limb arthroplasty. Multiple small studies show arthroplasty in this patient cohort is associated with high complication and mortality rates.

A search of electronic databases were undertaken with the assistance of the library services from the Rotherham NHS Foundation Trust, including Chocraine, SCOPUS and PubMed.

Abstracts were reviewed and relevant studies extracted for full review. Full text articles were reviewed based on strict inclusion and exclusion criteria.

Searches identified Two thousand and forty-four papers; twenty-seven studies were identified for full review of the paper based on the inclusion criteria above. From this, nine studies were deemed appropriate to for data extraction.

These nine papers present one hundred and thirty-two cases of lower limb arthroplasty, fifty nine Total Knee Arthroplasty and seventy three Total Hip Arthroplasty. From this the authors examined incidences of implant failure due to infection, revision, mortality, dislocation, aseptic loosening, peri-prosthetic fracture, or other causes. Of these, 58% of patients (n = 77) with a history of intravenous drug abuse suffered some form of significant complication; 4% of this cohort (n = 5) were lost to follow up. Infection was reported in 32% of cases and a mortality rate of 4.7%.

The rising demand of lower limb arthroplasty for intra-venous drug abusers presents a very real problem for the modern Orthopaedic surgeon. Within the studies examined, more than half report implant failure. This study synthesises the available literature regarding treatment of these patients to help facilitate decision making and informed consent.

Constrained acetabular inserts provide a solution for both complex primary and revision hip arthroplasty, but there have been ongoing concerns for high risk of failure and their longevity. The Stryker® Trident acetabular insert is pre-assembled with its constrained ring. We believe this to be the largest series of constrained acetabular inserts with a minimum of 5 year follow-up.

We retrospectively reviewed all Stryker® Trident ‘All-Poly’ constrained acetabular inserts cemented into bone in our unit between 2008 and 2016. We collated demographic details and reviewed all patients’ radiographs and clinical notes. Indications for surgery, latest Oxford Hip Scores (OHS) and clinical and radiographic complications were identified.

117 consecutive Stryker® Trident ‘All-Poly’ constrained inserts were cemented into bone in 115 patients during the study period with a mean age of 80 (47–97). Most common indications for surgery were recurrent dislocation (47), complex primary arthroplasty (23), revision arthroplasty (19) and failed hemiarthroplasty (12). 41 patients required revision of the acetabular component only. Follow-up was a minimum of 5 years (mean 8.6, range 5–13). There were three 30-day mortalities and six 1-year mortalities. The mean latest OHS was 37 (24–45). Four cups failed in three patients, one at the cement-bone interface, two at the cement-prosthesis interface and one at the bipolar interface. These were treated conservatively in three patient and with excision arthroplasty in one patient. There were four peri-prosthetic fractures, one Vancouver C distal femur fracture treated conservatively and three Vancouver B1 fractures, two treated conservatively and one treated with open reduction internal fixation. There was breakage of one constrained ring with no adverse effects and one superficial wound infection requiring oral antibiotics only.

This series demonstrated that despite the elderly and complex nature of these patients’ clinical situations, constrained acetabular inserts offer a useful and pragmatic solution, with relatively low complications, including in our series a cup failure rate of 3% and peri-prosthetic fracture rate of 3%.

The results of hip and knee replacement surgery are generally regarded as positive for patients. Nonetheless, they are both major operations and have recognised complications. We present a review of relevant claims made to the National Health Service Litigation Authority. Between 1995 and 2010 there were 1004 claims to a value of £41.5 million following hip replacement surgery and 523 claims to a value of £21 million for knee replacement. The most common complaint after hip surgery was related to residual neurological deficit, whereas after knee replacement it was related to infection. Vascular complications resulted in the highest costs per case in each group.

Although there has been a large increase in the number of operations performed, there has not been a corresponding relative increase in litigation. The reasons for litigation have remained largely unchanged over time after hip replacement. In the case of knee replacement, although there has been a reduction in claims for infection, there has been an increase in claims for technical errors. There has also been a rise in claims for non-specified dissatisfaction. This information is of value to surgeons and can be used to minimise the potential mismatch between patient expectation, informed consent and outcome.

Cite this article: Bone Joint J 2013;95-B:122–6.

Introduction: Leg length inequality (LLI) following arthroplasty, though often asymptomatic, can be cause for considerable morbidity and has increasing medicolegal consequences.

There are various methods of quantifying leg length inequality on plain AP radiograph. The aim of this study is to review the established practice in the measurement of leg length inequality and compare it to two methods used locally.

Methods: This is a retrospective study assessing the radiographs of 35 patients with a mix of native, unilateral and bilateral total hip arthroplasty. Two methods of measuring leg length inequality were prominent in the literature, the Woolson method and the Williamson method. A further two methods are used locally. Measurements for all four techniques were made by two senior consultant radiologist to on the trust PACS to assess inter and intra observer variability. Data analysis was performed using SPS 16 to produce intraclass correlation co-efficient (ICC) and Bland Altman plots.

Results: ICC for all methods in the measurement of LLI is excellent (≥0.90). The repeatability ICC for the four methods is; Woolson 0.65, Williamson 0.87, Direct 0.96 and the Leeds method 0.95.

Discussion: This study demonstrates that all four methods have excellent correlation; however the repeatability is better for the Direct and the Leeds methods than the two that are more widely used in the literature. While the Direct measurement is able to give an overall measurement for the leg length inequality, the Leeds method is able to distinguish between any inequality due to cup malpostion and stem malposition. It is therefore of particular value in the assessment of bilateral or revision arthroplasty and the audit of practice.

We review the results of the Gamma nail fixation to elucidate its effectiveness in the treatment of peritro-chanteric and subtrochanteric fractures of the neck of femur.

We report the result of 718 cases of Gamma nail fixation in all such cases presenting at our institution since 1988. 573 cases of peritrochanteric and 145 cases of sub-trochanteric fractures were treated by means of standard and long Gamma nail. Age groups of the patients are from 33 to 99 years. No distal locking screw was used in cases of standard nails. All grades of surgeons were involved. Full weight bearing was allowed on the first post operative day. Cases were followed up for one year.

No intraoperative iatrogenic fracture was encountered. Minimal post operative pain was experienced and mobility was regained early. All fractures healed satisfactorily except the following: 51 cases developed coxa vera deformity; 37 cases of undisplaced fractures of base of greater trochanter were noticed at 6 weeks follow up - all healed spontaneously; 1 case of external rotational deformity occurred in a long nail where no distal locking screw was used. 2 cases of deep infection were treated successfully by removal of nail and antibiotic treatment; 4 cases of fracture at the level of the distal end of the prosthesis, presented at 6 weeks to 2 year period following a subsequent trauma, were treated with exchange of device with long nail. Upward penetration of hip screw 22. No case of metal failure observed.

Gamma nail provides a stable fixation in both simple and complex fractures of proximal femur with a much less invasive tehcnique which allows minimal disturbance of fracture haematoma, less incidence of wound infection and less amount of postoperative pain. Early mobility is regained with immediate and unrestricted weight bearing. Biomechanically also Gamma nail produces a better means of osteosynthesis.

We present a case of superior dislocation of the patella trapped by interlocked osteophytes. Unlike previous reports, in which the mechanism resulted from a blow to the inferior pole, it is postulated that increased load on the extensor mechanism, combined with patella alta and patellofemoral osteophytes, caused locking of the knee in extension.

After total knee replacement a 57-year-old woman developed increasing pain in her left calf on exercise. This was due to erosion of the popliteal artery by a spur of cement. Removal of the spur with resection and Dacron grafting of the damaged section of the vessel cured her symptoms.