At our institution between 1994 and 2003 a total of 36 revision total elbow Arthroplasties were performed in 34 patients. We clinically reviewed 25 patients and reviewed the notes and x-rays of all of them. Of eleven who were not reviewed clinically seven had died from an unrelated cause and four were unable to attend because of illness but we were able to include them as sufficient data were available in the notes. There were 24 female and 12 male, Average age was 67 years and twelve had elbow Arthroplasty in a non-dominant side. The average follow up was 6 years (range 5–13 years). The mean period between the primary and revision surgery was sixty three months (range 3–240 months). The indication for surgery was mainly for aseptic loosening in 15 cases, followed by septic loosening in twelve. All cases of septic loosening had two stage revisions. Other reasons for revision in this series include unstable elbows, implant fracture and peri-prosthetic fractures. Twelve of these revisions had a further revision for a variety of reasons at an average period of twenty eight months. Seven patients had thirteen complications in this series, two radial nerve palsies (one recovered), one distal humeral fracture, five cortical perforations and five triceps weakness. Most of the patients are satisfied with their elbows. The mean Mayo elbow Performance Score was 79 points. We conclude that revision Elbow Arthroplasty is a specialized surgery which is technically demanding, with high risk of complications and high re-revision rate and therefore, should be done in a specialised centres.

Introduction: Since the first repair of coracoclavicular ligament complex in 1886 there have been more than sixty operative procedures described in the literature. Open methods of reduction and stabilization of AC joint are associated with increased morbidity and violation to the surrounding soft tissue and result in less cosmetic scar and possibly a further surgery to remove the hardware. We propose an arthroscopic technique using Tightrope (Arthrex) to reduce and stabilize the joint with low morbidity.

Materials and Methods: We reviewed 26 (21 male, 5 female) consecutive patient’s (notes, radiographs and Oxford shoulder score) who underwent arthroscopic stabilization of AC joint. The average age was 33 years (min.22, max.53). The average period from injury to surgery was nine days. The primary indication for surgery was grade IV to VI injuries and grade III injuries in upper extremity athletes and workers with the need for overhead activities. Patient’s satisfaction and functional improvement were observed.

Results: Short-term preliminary results are encouraging and show an excellent functional outcome without significant residual pain. We had four radiological recurrences of the deformity, two of which were completely asymptomatic, one associated with painless clicking and one requested revision surgery (same technique) to improve cosmesis. There were no infections or neurovascular injury in this series.

Conclusion: This method of surgically stabilizing the AC joint is minimally invasive, done as a day case and yielding satisfactory results. Among the advantages of the technique are that it does not require specific expensive instrumentation and offers the possibility of visualizing the glenohumeral joint for associated lesions. However, there is a learning curve and experience with arthroscopic procedures is essential.

There is a paradox surrounding the use of bisphosphonates and bone biology. On one hand, it has been used to treat osteoporosis, osteogenesis imperfecta, Pagets disease, osteonecrosis, and other disorders associated with low bone mass. On the other hand, there have been a number of cases reported suggesting an association between treatment with bisphosphonates and osteonecrosis of the jaw. Answers to why this paradox exists lies in a better understanding of the pathogenesis of osteonecrosis and the mechanism of action of bisphosphonates. This seminar was created to explore the perspectives of three different medical disciplines concerning the use of bisphosphonates.

Aim:This study was carried out to assess various factors responsible for the development of avascular necrosis and the effect of treatment on clinical outcome.

Methods: We studied the clinical notes and radiographs of patients presenting with SCFE during the period between 1994 and 2003.

Results: Seventy three patients (n=73) with ninety two (n=92) hips were included in the study. There were 16 acute, 43 acute-on-chronic, 29 chronic and 4 preslips. Seventy Seven (n = 77) slips were classified as stable and 15 as unstable slips. Fifty three slips (57.6%) were mild, 34 (37%) were moderate and five (5.4%) were severe slips. Despite no deliberate attempts to reduce the slip at the time of surgery eighteen hips (n=18) showed a median decrease in slip angle of 8 degrees (range 2–36) in acute and acute-on-chronic slips. The mean preoperative slip angle was 32 degrees (range 9–76) compared to postoperative slip angle of 29.9 degrees (range 10–75) (p=0.004). Four patients developed avascular necrosis (AVN). Intraoperative reduction of the slip was significantly related to development of AVN (p< 0.001). According to the criteria of Heyman and Herndon eight patients had functional deficit at the time of final follow up and clinical outcome was fair, poor or failure. All of these patients had a reduction in the angle of slip at the postoperative radiographs compared to their preoperative radiographs.

Conclusion: Reduction of slipped capital femoral epiphysis is responsible for poor outcome and also related to the development of avascular necrosis. We recommend single in situ pinning for these cases regardless of severity of slip.

Introduction: The Centrament® (Aesculap, Tuttlingen, Germany) is modular hip system combined with a range of modular heads and acetabular components, enabling the system to cover a wide range of applications. We looked at medium term results in a district general hospital.

Methods: This is a retrospective cohort study. Information was obtained from patient notes and radiographs.

Results: One hundred and ninety two (n =192) total hip arthroplasties in 178 patients (14 bilateral) were followed up for at least 5 years (mean: 5.8 years; range: 5–9 years). The mean age of the patients at the time of surgery was 71.8 years (range, 38–91 years). The most frequent indication for surgery was osteoarthritis (94%). One acetabular cup was revised for aseptic loosening, and 2 cups were revised for recurrent dislocation. Two stems have been revised (one for aseptic loosening and one for prosthetic fracture). The dislocation rate was 4.2% during the initial fifty arthroplasties that reduced to 0.9% in the subsequent years. For radiological evaluation Gruen zones for the stem and DeLee and Charnley zones for the cup were used. The acetabular cup was satisfactory in 186 hips radiographs and showed asymptomatic non-progressive osteolysis in three cups. Two stems showed signs of osteolysis at nine years but the patients had no symptoms. Using the recommendation of revision as the endpoint, Kaplan Meier Survival Analysis showed a cumulative survival for the prosthesis as 97.3%, with stem survival of 99% and cup survival of 98.5%.

Discussion: In the medium-term, these results are comparable to other cemented hip prosthesis used in the UK.

Introduction: The increasing use of metal-metal bearings in hip arthroplasty raises concerns of elevated systemic metal levels. Lubrication theory and in-vitro studies suggest that larger diameter bearings generate less wear. Does this hold true in real life?

Methods: This is a cross-sectional study of 181 patients with either a Birmingham Hip Resurfacing or a 28mm Metasul THR. Whole blood levels (at 1year) and urinary metal ion output in the early (1 to 3) years and medium term (4 to 6years) in patients with these bearings were compared. None of the patients had other metal devices or compromised renal function. Both devices used a high-carbon cobalt-chrome bearing with no post-casting heat treatment. Cementless porous-ingrowth titanium cups and cemented polished tapered stainless steel stems or cementless porous-ingrowth titanium alloy stems were used in THRs.

Results: Whole blood metal levels at 1-year and daily output of metal ions in the early years and medium term (figure 1) in both bearings were in the same range and without a significant difference.

Discussion: Metal ion monitoring is the best way to estimate bearing wear in vivo and the best measure of device safety in the long term. Total wear over a given time period is best estimated from timed metal ion excretion rates. Blood levels represent a balance between the release of metal from the device and its renal clearance.

An earlier study (Clarke et al JBJS(Br) 2003) suggests that smaller bearings generate less wear. In that study bearings with different metallurgy and wear properties were grouped together, a potential confounding factor. The present study does not suffer from that error and our findings do not support the view that a larger bearing diameter leads to either an increase or decrease in metal ion generation.

We present a case of idiopathic osteonecrosis of the humeral capitellum in a 44-year-old female in the absence of any associated risk factors. Arthroscopy was undertaken to remove the loose bodies and debride the capitellum, with a satisfactory outcome.

The recent resurgence in the use of metal-on-metal bearings has led to fresh concerns over metal wear and elevated systemic levels of metal ions.

In order to establish if bearing diameter influences the release of metal ions, we compared the whole blood levels of cobalt and chromium (at one year) and the urinary cobalt and chromium output (at one to three and four to six years) following either a 50 mm or 54 mm Birmingham hip resurfacing or a 28 mm Metasul total hip replacement. The whole blood concentrations and daily output of cobalt and chromium in these time periods for both bearings were in the same range and without significant difference.

Aim: To evaluate the outcome of various methods of treatment of displaced supracondylar fractures of the humerus in children, by clinical & radiological means. Material and Method: 96 patients with displaced supra-condylar fractures of the humerus admitted between January 1990 & September 1998 were recalled to clinic for a clinical & radiological assessment. The results of treatment by 4 different methods were assessed & compared. The mean length of follow up study was 4.1 years (range 1 to 8 years). Results: By Flynnñs criteria, 32 of the 41 patients treated with percutaneous kirschner wire þxation had an excellent result (78%). This was followed by (72.7%) with open reduction & internal þxation & (71.4%) with skeletal traction. Closed reduction & application of an above elbow cast had signiþcantly lower excellent results (51.4%) & higher percentage of complications including compartment syndrome & cubitus varus. The smallest mean change in carrying angle was in the percutaneous kirschner wire þxation group with the highest incidence of cubitus varus in the closed reduction & cast group (6/37 patients-16.2%). Conclusion: Treatment with a cast is inappropriate in the management of a displaced supracondylar fracture of the humerus as either the initial or the subsequent method of treatment. Crossed medial & lateral percutaneous K- wire þxation is advocated as the treatment of choice for majority of the displaced fractures keeping 2 lateral kirschner wires for the swollen elbow in which the medial epicondyle is barely palpable. Principal advantages would be fewer sequelae, more stable þxation & better anatomical results. Traction still has its indications. ORIF should be reserved for open fractures, irreducible fractures & fractures needing vascular exploration.

Aims: is to evaluate the efficiency of the Sheffield Ring Fixator (SRF) in the management of posttraumatic tibial Deformity. Introduction: Correction of tibial deformity as a consequence of malunion or injury to the growth plate is challenging. Progressive correction is usually necessary due to the low compliance of the anatomical compartments. The SRF provides an effective solution. Materials and Methods: a consecutive series of 30 patients with posttraumatic tibial deformity treated by progressive correction using the SRF between 1997 and 2000. The mean age was 33 years (range 18 to 65). Cases were analysed to ascertain the degree of deformity, treatment time, final outcome in terms of the accuracy of correction of deformity, and incidence of complications. Results: Full correction was achieved in 27 of the 30 cases: two patients had residual angular deformities of 7 and 10 degrees and one had 15mm residual shortening. Satisfactory bone formation occurred in all cases. There were no significant complications. The mean correction time was dependent on whether or not lengthening had been performed (72 and 53 days respectively). From this study the correction time can be estimated as 2 days per degree plus an extra 0.5 days per degree for every centimetre of length to be gained. Conclusion: Knowledge of the efficiency of the system will enable an estimation of treatment times to be made thereby facilitating the setting of goals for both patient and surgeon. Accuracy of correction and total treatment times were satisfactory suggesting that the fixation system was both stable and yet sufficiently elastic to permit good bone healing

The aim of this study is to evaluate the efficiency of the Sheffield Ring Fixator (SRF) in the management of tibial deformity.

Tibial deformity correction is challenging and requires an efficient system with strong bony fixation.Progressive correction is usually necessary due to the low compliance of the anatomical compartments. The SRF provides an effective solution, employing a combination of wire and screw fixation for metaphyseal corrections and all screw fixation for diaphyseal corrections.

We reviewed a consecutive series of 50 patients with tibial deformity treated by progressive correction using the SRF between 1997 and 2000. The mean age was 33 years (range 18 to 65). Thirty nine cases were due to post-traumatic deformity and eleven as sequelae of childhood disease. Cases were analysed to ascertain the degree of deformity, treatment time, final outcome in terms of the accuracy of correction of deformity, and incidence of complications.

All patients had significant angular deformity and 12 had a rotational deformity. 21 patients had clinically significant shortening. The mean deformities were: varus 10.5, valgus 13, posterior 11.8, anterior 20.6 (giving a mean oblique plane deformity of 24° ) rotation 17° and 26mm of shortening. Full correction was achieved in 45 of the 50 cases: Three patients had residual angular deformities of 5,7 and 10 degrees and two had residual shortening (15mm& 5mm). Satisfactory bone formation occurred in all cases. There were no significant complications. The mean correction time was dependent on whether or not lengthening had been performed (72 and 53 days respectively). From this study the correction time can be estimated as 2 days per degree plus an extra 0.5 days per degree for every centimetre of length to be gained.

A knowledge of the efficiency of the system will enable estimation of treatment times to be made thereby facilitating the setting of goals for both patient and surgeon. Correction and total treatment times were satisfactory suggesting that the fixation system was both stable and yet sufficiently elastic to permit good bone healing. Even when the rotation translation systems were used prescribed movements led to satisfactory corrections suggesting few if any losses in the system. The SRF provides a strong and efficient system for the accurate and controlled correction of tibial deformities.