Removal of bullets retained within joints is indicated to prevent mechanical blockade, 3rd body wear and resultant arthritis, plus lead arthropathy and systemic lead poisoning. The literature is sparse on this subject, with mostly sporadic case reports utilizing hip arthroscopy. We report on the largest series of removal of bullets from the hip joints using open surgical.

We reviewed prospectively collected data of patients who presented to a single institution with civilian gunshot injuries that breached the hip joint between 01 January 2009 and 31 December 2022.

We included all cases where the bullet was retained within the hip joint area. Exclusion criteria: cases where the hip joint was not breached, bullets were not retained around the hip area or cases with isolated acetabulum involvement.

One hundred and eighteen (118) patients were identified. One patient was excluded as the bullet embedded in the femur neck was sustained 10 years earlier. Of the remaining 117 patients, 70 had retained bullets around the hip joint. In 44 patients we undertook bullet removal using the followingsurgical hip dislocation (n = 18), hip arthrotomy (n = 18), removal at site of fracture fixation/replacement (n = 2), posterior wall osteotomy (n = 1), direct removal without capsulotomy (tractotomy) (n = 5).

In 26 patients we did not remove bullets for the following reasons: final location was extra-capsular embedded in the soft tissues (n=17), clinical decision to not remove (n=4), patients’ clinical condition did not allow for further surgery (n= 4) and patient refusal (n=1). No patients underwent hip arthroscopy.

With adequate pre-operative imaging and surgical planning, safe surgical removal of retained bullets in the hip joint can be achieved without the use of hip arthroscopy; using the traditional open surgical approaches of arthrotomy, tractotomy and surgical hip dislocation.

Aims

Uncemented metal acetabular components show good osseointegration, but material stiffness causes stress shielding and retroacetabular bone loss. Cemented monoblock polyethylene components load more physiologically; however, the cement bone interface can suffer fibrous encapsulation and loosening. It was hypothesized that an uncemented titanium-sintered monoblock polyethylene component may offer the optimum combination of osseointegration and anatomical loading.

Musculoskeletal injuries are one of the leading causes for morbidity within military personnel on operations and are the leading cause for aeromedical evacuation of British military personnel from Afghanistan for Disease and Non-Battle Injury. The objective of this study was to improve our knowledge relating to these injuries.

This prospective cohort study included all British military personnel presenting with musculoskeletal injuries to primary healthcare in Camp Bastion and the rehabilitation team working in British bases forwards of Bastion, Afghanistan. Injury report forms were completed by medical officers and physiotherapists. Data was collected over two separate two week periods during the first and second half of the tour.

273 injury forms were completed in total. Most injured body parts were back (23%), knee (17%), shoulder (13%) and ankle (13%). 53% were attributed to training, 25% were due to overuse and 37% were old injuries.

Leading cause for musculoskeletal injuries sustained on operations was training, not sport. Further studies are required to clarify what training factors are attributing to injuries which will enable design and implementation of prevention strategies.

Background

Following an anterior cruciate ligament (ACL) injury, the affected knee is known to experience bone loss and is at significant risk of becoming osteoporotic. Surgical reconstruction is performed to attempt to restore the function of the knee and theoretically restore this bone density loss. Cross-sectional analysis of the proximal tibia using peripheral quantitative computed tomography (pQCT) enables localised analysis of bone mineral density (BMD) changes. The aim of this study was to establish the pattern of bone density changes in the tibia pre- and post- ACL reconstruction using pQCT image analysis.

Computer-assisted technology has provided surgeons with intra-operative quantitative measurement tools that have led to the development of soft-tissue balancing algorithms based on surgeon-applied varus-valgus stress. Unfortunately these forces tend not to be standardised and the resultant algorithms may at best be surgeon-specific. Furthermore, these techniques are only available intra-operatively and rely on the rigid fixation of trackers to bone. The aim of this study was to develop a non-invasive computer-assisted measurement technique and assess the variation in collateral knee laxity measurements between different clinicians.

An image-free navigation system was adapted for non-invasive use by developing external mountings for active infrared trackers. A leg model with rigid tracker mountings was designed and manufactured for comparison. Multiple kinematic registrations of alignment were made for both the model and the right leg of a volunteer to quantify the soft tissue artefacts. Repeatability of the system was assessed by performing two registration processes on eight volunteers. Collateral knee laxity was assessed on a single volunteer by 16 participants of varying experience each applying a maximum varus and valgus knee stress. Two surgeons performed repeated examinations to assess intra-observer variation.

For repeated registrations of alignment, the SD of the non-invasive mounting (0.8°) was only a third higher than the leg model (0.6°) and the actual range was only 1° larger. The repeated alignment measurements on the volunteers showed a high level of agreement with an intraclass correlation coefficient of 0.93. Varus-valgus stress values showed poor inter-observer variation with a wide range of angles for both varus (1° to 7°) and valgus stress (0.5° to 5°). A Mann-Whitney test between the two sets of repeated tests showed that both varus stress and overall laxity were significantly different (p< 0.0001) but that valgus stress was marginal (p=0.052). Intra-observer measurements overall appeared more consistent.

Soft tissue artefacts did not significantly reduce the repeatability of the assessment of coronal knee alignment using a navigation system and this provided a non-invasive technique for assessing coronal knee laxity. The perception of an ‘end-point’ varied significantly between different clinicians and although there may be a role for surgeon-specific algorithms, to use this quantitative data more widely there is a need to standardise the forces and moments applied.

Background: Resurfacing is becoming increasingly popular as an option for primary hip arthroplasty. However, there is minimal documentation of objective post-operative outcomes which support the perceived benefits of resurfacing over traditional stemmed THR. Most comparative studies have reported differences in X-ray findings, such as component alignment and femoral offset, which only allow speculation of their relative effects on patient function. Studies have also reported general clinical outcomes following resurfacing, and although resurfacing shows promising medium term results, these studies have been largely subjective and have lacked a direct same study comparison with standard THR.

Potential benefits of resurfacing include improved abductor muscle function, resulting from preservation of the femoral neck offset, and greater range of hip motion, resulting from the larger diameter bearings. Mont et al (2007) compared biomechanical outcomes during gait for individuals with unilateral resurfacing and standard arthroplasty and concluded that hip resurfacing yielded superior function, as defined by faster walking speeds. However, comprehensive data of 3-dimensional moments and hip kinematics was not presented and functional assessment was limited to gait analysis only.

Methods: Kinematic and kinetic outcomes were evaluated for 28 individuals (age 40–60) with unilateral resurfacing (Durom, Zimmer) or standard stemmed THR (ceramic-on-ceramic Trident, Stryker) at 3 and 12 months following surgery. Data was collected using an 8 camera Vicon 612 motion analysis system and two Kistler force plates while subjects completed level walking and stair ascent and descent activities using a 4-step stair case, instrumented with a force plate on the second step. A lower limb marker set was used with pointer trial calibration of anatomical landmarks. 3-dimensional hip moments, angles and temporospatial parameters were compared and preferred motion patterns analysed.

Results: Peak hip moments showed no statistically significant group difference during the ambulatory activities although slightly greater peak hip angles were achieved by those with standard THR. Stair negotiation highlighted greater differences in biomechanical outcomes between the groups than level gait analysis. Those with hip resurfacing exhibited less protective motion patterns and performed walking and stair negotiation at a faster pace.

Conclusions: The greater diameter bearings of the resurfacing prosthesis do not appear to yield a greater functional range of motion post-operatively. Preserving the femoral offset with a hip resurfacing does not appear to benefit abductor muscle function. Statistically, both arthroplasty types demonstrate equivalent functional outcomes.

The role of CAOS systems is now well established in several areas of orthopaedic surgery. The increasing use of these systems, particularly in knee arthroplasty, has been supported by clinical trials that demonstrate a more accurate final position of implanted devices compared with conventional instrumentation. CAOS technology is constantly evolving along with its expanding list of potential indications. This requires the adaptation of both software and hardware components. It is therefore essential that potential users have confidence in the accuracy of these systems. The aim of this project was to design and manufacture a standardised measurement object (phantom) to independently evaluate CAOS system performance.

The American Society for Testing and Materials (ASTM) International along with CAOS International recently drafted a standard for measuring technical accuracy of navigation systems. This proposed standard was obtained and its recommendations used to design a phantom model. This consisted of a 150×150×20mm base plate and two additional levels including a single 30° slope. This created a 3D surface on which points could be placed. Co-ordinates for 21 points were given to establish the x, y and z axes of a Cartesian system and then to have points at a variety of known locations in this 3D space. The final model was machined from a billet of marine grade aluminium alloy 6082-T6 (chosen for its dimensional stability) using a vertical computer numerical controlled (CNC) milling machine with the co-ordinate points drilled with a Ø0.8mm 60° BSO centre drill to a depth of 1.2mm. The drill holes, with chamfers of Ø1.0mm, were designed to accommodate a ball-nosed pointer tip of a known diameter. A Perspex base unit with three different sites of rigid tracker attachment was made to hold the phantom and provide its reference frame. This avoided the need to directly modify the phantom itself.

The final design has been used to measure the positional accuracy of a novel portable navigation system and demonstrate that it is not yet suitable for clinical evaluation due to errors of 1 – 6 mm in point location. It has also allowed independent technical validation of current pre-existing navigation systems.

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.

Aim of Prospective Study To assess the long-term survival of Souter-Strathclyde replacements and determine the causes of failure.

Materials and Methods: Between 1977–97, 445 Souter-Strathclyde replacements were undertaken by the presenting author in 321 patients, ranging in age from 25–81 years (mean 59). The Larsen X-ray grading at the time of surgery was Gd III-2%, Gd IV-43%, Gd V-55%. The standard humeral component was used in 76% and the long-stemmed model in 24% of cases, the standard ulna in 91%, and the long-stemmed in 9%.

Clinical and radiological assessments were carried out before surgery and at 6 months and one year after surgery and annually thereafter until the death of the patient or the revision of one or both components, the mean follow-up being 8.9 years (S.D. 5.6).

The survival statistics are based on Kaplan-Meier survival curves and Cox regression analysis applied to 3 Groups with differing end-points: 1) Revision of one or both components of the prosthesis 2) Ditto or the development of a complication, seriously threatening the survival of the arthroplasty and 3) As in (2) or definite evidence of progressive radiological loosening.

Results Very satisfactory pain relief was achieved in 90% of cases. Mean flexion improved from 129° to 144°, pronation from 42° to 59°, and supination from 43° to 62°. Once achieved, these results were well maintained. Mean extension was slightly reduced after surgery (47° to 52°)

For Group 1: the survivorship at 5, 10, 15 & 20 years was 95, 89, 82, & 81% respectively; for Group 2: 93, 87, 76 & 69%; and for Group 3: 91, 84, 72, & 68%. In Group 1, indications for revision or removal of one or both components were persistent dislocation (5), fracture (5), aseptic loosening complicated in some cases by fracture (20) and infection (14). In Group 2 the threatening complications included instability (2), un-united fracture of the ulna (4), infection (7), and clinical loosening (2)

Conclusions This method of elbow replacement offers very successful and durable pain relief and restoration of function in the adult rheumatoid patient. Survivorship in the first decade after surgery is very acceptable. Later, due to increasing disability and reliance on crutches, resulting from multi-joint involvement, more problems are likely to arise from aseptic loosening, fracture and infection.

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.