PURPOSE OF THE STUDY

To assess if prolonged use of Bisphosphonates in Osteogenesis Imperfecta alters the pattern of femoral fractures.

Osteogenesis Imperfecta (OI) has been treated with Bisphosphonates for many years with some clear clinical benefits. In adult cohorts there are reports of a new pattern of atraumatic subtrochanteric fractures seen with Bisphosphonate treatment.

Introduction: Obligatory external rotation during flexion is well recognised as a cardinal feature of Slipped Upper Femoral Epiphyses (SUFE). We have evaluated the significance of acetabular version in contributing to the external rotational deformity that is seen in otherwise normal hips. We present a small case series focussing on the characteristics of this pathology, highlighting its significance and outlining a treatment strategy.

Method: Five patients (eight hips) presented with disabling hip pain during non-sporting activities. All their hip radiographs had been reported as normal. The rotational profile of both acetabulum and femur in these patients was evaluated by MRI and CT scans.

Results: Clinical examination revealed otherwise normal hips but for an external rotation deformity which got worse on hip flexion. The average external rotation deformity with the hip in extension was 60 degrees, which worsened to 90 degrees during hip flexion. Three of these hips had been previously treated with in situ pinning for SUFE. Other hips were in patients who were either skeletally mature or close to skeletal maturity. We found that all were “profunda hips” with severe acetabular retroversion. The abnormality in acetabular version was best defined on axial imaging.

Conclusions: The femoral head is a spherical conchoid. The concept of version of the hip (both femoral and acetabular) as described by McKibbin, Tonnis and Ganz is reviewed. Femoral retroversion is common in patients with SUFE, but the addition of acetabular retroversion makes these hips disproportionately symptomatic. This deformity causes a combination of pincer and cam impingement, which is responsible for the marked disability. SUFE alone causes cam impingement, whilst a corresponding degree of slip without retroversion and profunda of the acetabulum is not that disabling.

Aim: To study the long term results of rotator cuff repair in patients over the age of 65.

Introduction: Although some patients with rotator cuff tears are asymptomatic, the majority have a combination of pain, weakness and restricted function. Whilst this affects the lifestyle of all patients, in the elderly these symptoms can make the difference between independent living and the need for assistance or sheltered accommodation.

Method: The present study has looked at a consecutive series of 24 patients all of them over 65 years, who underwent rotator cuff surgery between 1993 and 1997. Outcome has been assessed using two validated scoring systems – the Oxford Shoulder Score (OSS) and the DASH questionnaire. All patients had an open subacromial decompression of their shoulders at the time of cuff repair. Two patients could not be contacted for follow up and were therefore excluded. One patient who had a hemiarthroplasty of the shoulder 3 years after rotator cuff repair was excluded as well.

The average follow up period was 6 years (range 4.5 – 9 years). The Oxford Shoulder Score revealed that 72% had good to excellent results, 16% remained unchanged and 12% were worse than prior to surgery. The corresponding DASH scores were 28% excellent, 40% good, 16% fair and 16% poor respectively. In addition 81% of patients were independent with daily activities, with 48% of them living alone and the remaining 33% living with their partners. Only 19% of patients needed significant help with their activities of daily living. These results were irrespective of whether surgery was performed on the dominant or non-dominant shoulder.

Conclusion: We would suggest that age itself should not be considered a contraindication to rotator cuff repair.

Between 1993 and 2002 7 allografts/joint replacement combinations have been used to treat massive bone loss at the elbow.

The original 4 procedures (2 humeral and 2 ulna allografts) used a standard Stanmore total elbow replacement. Of these the 2 humeral allografts failed and revision surgery was necessary. The 2 grafts on the ulna side of the joint remain in situ (average 6 years after surgery) with one of the patients subsequently having a primary joint replacement on the contra-lateral side.

More recently a further humeral and a further ulna allograft/joint replacement have been performed together with one patient having humeral and ulna allografts on both sides of the joint for extensive bone loss. In these cases the Coonrad-Morrey total elbow arthroplasty was used as the joint implant.

The philosophy behind the use of allografts is discussed and the management principles outlined. The possible reasons for failure of the early humerus allograft/joint replacement combinations is addressed and future developments considered.