Introduction

A recent meta-analysis published in the British Medical Journal suggested an increased risk of infection, but none of the studies were large enough to reach statistical significance. A prospective, randomised trial was designed at our institution to investigate the wound healing and complications related to surgery following fracture neck of femur in the elderly.

In order to achieve satisfactory reduction of complex distal humeral fractures, adequate exposure of the fracture fragments and the joint surface is required. Several surgical exposures have been described for distal humeral fractures. We report our experience using the anconeus pedicle olecranon flip osteotomy approach. This involves detachment of the triceps along with a sliver of olecranon, which retains the anconeus pedicle. We report the use of this approach in ten patients (six male, four female) with a mean age of 38.4 years (28 to 51). The mean follow-up was 15 months (12 to 18) with no loss to follow-up. Elbow function was graded using the Mayo Score. The results were excellent in four patients, good in five and fair in one patient. The mean time to both fracture and osteotomy union was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We found this approach gave reliably good exposure for these difficult fractures enabling anatomical reduction and bicondylar plating without complications.

Cite this article: Bone Joint J 2014;96-B:1252–7.

Introduction

Amino acids like arginine and lysine have been suggested to hasten the process of fracture healing by improving the local blood supply, supplementing growth factors, and improving collagen synthesis. We studied the role of lysine and arginine in the fracture repair process with regard to the rate of healing, probable mechanisms involved in the process, and mutual synergism between these agents.

Adequate range of knee motion is critical for successful total knee arthroplasty. While aggressive physical therapy is an important component, manipulation may be a necessary supplement. There seems to be a lack of consensus with variable practices existing in managing stiff postoperative knees following arthroplasty. Hence we did a postal questionnaire survey to determine the current practice and trend among knee surgeons throughout the United Kingdom.

A postal questionnaire was sent out to 100 knee surgeons registered with British Association of Knee Surgeons ensuring that the whole of United Kingdom was well represented. The questions among others included whether the surgeon used Manipulation Under Anaesthaesia (MUA) as an option for stiff postoperative knees; timing of MUA; use of Continuous Passive Motion (CPM) post-manipulation.

We received 82 responses. 46.3% of the respondents performed MUA routinely, 42.6% sometimes, and 10.9% never. Majority (71.2%) performed MUA within 3 months of the index procedure. 67.5% routinely used CPM post-manipulation while 7.3% of the respondents applied splints or serial cast post MUA. 41.5% of the surgeons routinely used Patient Controlled Analgaesia +/− Regional blocks. Majority (54.8%) never performed open/arthroscopic debridement of fibrous tissue for adhesiolysis.

Knee manipulation requires an additional anaesthetic and may result in complications such as: supracondylar femur fractures, wound dehiscence, patellar tendon avulsions, haemarthrosis, and heterotopic ossification. Moreover studies have shown that manipulation while being an important therapeutic adjunct does not increase the ultimate flexion that can be achieved which is determined by more dominant factors such as preoperative flexion and diagnosis. Manipulation should be reserved for the patient who has difficult and painful flexion in the early postoperative period.

Neglected traumatic dislocation of hip in children is very rare and most of the studies are too small to draw a conclusion. There is no consensus on timing for closed VS open reductions and post reduction care. The aim of our prospective study was to analyse and characterise the short term treatment outcome of treating 20 such cases in children (<12 years). All had posterior dislocation without any associated fractures (Thompson & Epstein type 1) sustained during typical childhood play activities and/or a fall from a height less than 10 feet. All attended the hospital between 1-52 weeks of injury. Closed reductions under GA were performed in 12 cases which were less than 3 weeks old, followed by hip immobilisation for 3 weeks and PWB mobilisation for 3 weeks. 8 hips (> 3 weeks old) had open reductions as none of them could be reduced by skeletal tractions and were allowed for FWB mobilisation after 9 weeks. Functional result (Garrett et al) at 2 years follow-up showed a complete range of motion in 18 children while the remaining two had 80% of normal hip movements with no deformity. All the hips showed varying degrees of avascular necrosis, with preservation of joint space on radiographs (Ficat & Arlet stage 1-3). There were no redislocations.

We suggest that closed (for <3 weeks old dislocation) and open (for >3 weeks old dislocations) reductions are satisfactory treatment for traumatic neglected hip dislocations in children

Injury to the spinal cord and kyphosis are the two most feared complications of tuberculosis of the spine. Since tuberculosis affects principally the vertebral bodies, anterior decompression is usually recommended. Concomitant posterior instrumentation is indicated to neutralise gross instability from panvertebral disease, to protect the anterior bone graft, to prevent graft-related complications after anterior decompression in long-segment disease and to correct a kyphosis. Two-stage surgery is usually performed in these cases. We present 38 consecutive patients with tuberculosis of the spine for whom anterior decompression, posterior instrumentation, with or without correction of the kyphus, and anterior and posterior fusion was performed in a single stage through an anterolateral extrapleural approach. Their mean age was 20.4 years (2.0 to 57.0).

The indications for surgery were panvertebral disease, neurological deficit and severe kyphosis. The patients were operated on in the left lateral position using a ‘T’-shaped incision sited at the apex of kyphosis or lesion. Three ribs were removed in 34 patients and two in four and anterior decompression of the spinal cord was carried out. The posterior vertebral column was shortened to correct the kyphus, if necessary, and was stabilised by a Hartshill rectangle and sublaminar wires. Anterior and posterior bone grafting was performed.

The mean number of vertebral bodies affected was 3.24 (2.0 to 9.0). The mean pre-operative kyphosis in patients operated on for correction of the kyphus was 49.08° (30° to 72°) and there was a mean correction of 25° (6° to 42°). All except one patient with a neural deficit recovered complete motor and sensory function. The mean intra-operative blood loss was 1175 ml (800 to 2600), and the mean duration of surgery 3.5 hours (2.7 to 5.0). Wound healing was uneventful in 33 of 38 patients. The mean follow-up was 33 months (11 to 74). None of the patients required intensive care.

The extrapleural anterolateral approach provides simultaneous exposure of the anterior and posterior aspects of the spine, thereby allowing decompression of the spinal cord, posterior stabilisation and anterior and posterior bone grafting. This approach has much less morbidity than the two-stage approaches which have been previously described.

Introduction: Sliding screws has been described to use in hip fractures since 1950s. Failure of fixation varies from 16 – 23%. We aim to assess the effect of audit and re auditing the failure rate after introduction of the Tip apex distance concept since January 2000 to December 2004.

Methodology: We measured the tip apex distance in 161 (93 in the audit group and the rest re audit patients, 140 available for analysis. Their mean age at diagnosis 82.2 years [range 56.2–100.6 years] and male and female ratio was 1:6. Average time to Operation 1.7 days form the day of admission. The average Hospital Stay was 15.8 days

Result & discussion: We found that Patients had recorded Lag screw length 92.6mm [75–115], Side plate: 4 hole:6 hole = 4:1, Measured TAD 27.6 mm [6.3–66.4] in 140 patients,

The mean radiation time was 38.27 sec (7–71) and the dosage 0.68 Cgycm2 (0.93–2.06),

The mean Tip Apex Distance in the failed fixation group of 16 patients with cut out screw (13 in the audit group and 3 in the re audit group) is 43.05 [27.2–65.8]

Conclusion: We found the auditing and re auditing could potentially improve the surgical outcome. Although the Risk of cut out depends on many variable such as increasing age, Unstable fracture, poor reduction, high angle side plate 150deg, TAD is the stronger predictor than any other variable. This variable can be controlled by regular audit of the surgical practice.

Background: Resurfacing hip replacement is becoming increasingly used surgical option for young active patients with disabling hip arthritis.However there is a paucity of published literature describing complications and their avoidance.

Objective The objective of this study was to analyse 6 cases of postoperative subcapital fracture following hip resurfacing with a cohort of 54 cases that did not have a fracture and to identify factors associated with fractures risk.

Materials and Methods Between January 1999 and October 2003, 60 hips in 54 patients were treated with metal on metal resurfacing hip replacement (MMT Birmingham, UK).6 of these sustained a fracture just below the femoral component.The notes and radiographs were reviewed.Demographics data was recorded along with height, weight,smoking habits and medication usage including NSAIDS and antiepileptic use.The radiographs were studied for notching of the neck,offset difference as compared to normal and the stem shaft angle. The results were statistically analysed to determine any significant associations.

Results 57 hips in 51 patients were analysed for comparison. The mean age of the patients was 50 yrs (Range 34–67).In the fracture cases there were three men and three women with a mean age of 48 yrs.Five of six ( 83%) in the fracture cases had notching of the femoral necks compared to 9 (17%) out of 51 of the non fractured patients. The offset was significantly greater in the fractured group(52 ± 7mm) compared to the non fractured group (49 ± 7 mm).The increase in offset appeared to occur as a result of incomplete seating of tight fitting cemented femoral component. The head size appeared smaller in the fractured group but the difference was insignificant. There was no significant trauma in any of the cases. None of the patients who underwent resurfacing for AVN and cyst had a fracture. There were no other significant correlations

Conclusions Increased offset and notching are factors which predispose to fractures following resurfacing hip replacements. AVN and cysts were not associated with fractures in our series. We have changed the cementing technique using smaller volumes of freshly mixed simplex cement and now encourage protected weight bearing if intraoperative notching is noted or if osteoporosis is identified pre or peri operatively. We have had no fractures in the last 18 months.

Traumatic dislocation of the hip in children is rare. Large series have shown this injury to be 25 times less common in children than in adults. Only 70 cases of Neglected traumatic dislocation of hip in children has been reported in the English literatures and most of those studies are too small to draw a significant conclusions. We report our experience of treating 20 such cases of neglected traumatic dislocation of hip in children (< 12 years). All had posterior dislocations without any associated fracture. They attended the hospital between 1–52 weeks after injury.Closed reduction under G.A was performed in 12 cases which were less than 3 weeks old while 8 hips(> 3 weeks old) had open reductions following failed reductions with skeletal traction. At 2 years follow-up, a complete range of motion was found in 18 children while the remaining two had 80% of normal hip movement with no significant deformity. All the hips showed varying degree of avascular necrosis, with preservation of joint space on radiographs.

We suggest that attempted closed reduction of under 3 weeks old and open reductions for older dislocations gives satisfactory results. Also an anatomically placed femoral head maintains the stimulus for growth of pelvis and the femur.

Introduction: The Resurfacing Hip System offers an attractive option for the treatment of arthritis in the young and active patients with gratifying outcome. Currently available Metal-on-Metal Resurfacing Hip Systems in the UK include Cormet 2000 (Corin Medical), the Birmingham Hip (Midland Medical Technologies) and Conserve Plus (Wright Cremascoli) (5). The Cormet 2000 implant design utilises the hybrid principle with an uncemented acetabular and a cemented femoral component. Achieving full seating of the acetabular component in shallow or anatomically deficient sockets can sometimes be technically difficult. On occasion, structural tricortical autografts or allografts are required to obtain a satisfactory positioning of the acetabular component. We describe a simple technique to aid fixation of the uncemented acetabular component in patients with shallow or deficient sockets.

Technical tip: The Cormet acetabular cup is equatorially expanded, resulting in improved stress distribution to the acetabulum. The acetabular component is available as pegless and pegged cup. Both Cormet cups, there are two sets of anti-rotation splines. The original Cormet cup design incorporated two sets of three anti-rotation splines; two long splines with one small spline above. These two sets of fins engage the ischium and pubis snugly. The cup is then firmly impacted in place using the cup introducer.

In shallow or deficient sockets, we describe a simple technique by 180° rotation of the Cormet 2000 metal-on-metal resurfacing pegged acetabular prosthesis. This works by utilising ischio-pubic splines for superolateral socket engagement. We have used this technique in three patients with successful outcome avoiding the need of structural graft augmentation. In one patient, this technique was supplemented with cadaveric allograft.

Conclusion: Rotating the acetabular component 180° in shallow or deficient sockets should be considered as one of the viable option with or without structural augmentation. This works satisfactorily by utilising the ischio-pubic splines for superolateral socket engagement.

In this study, we reviewed the records of 881 patients with fracture neck of femur over 5 years. Of these, 372 patients underwent hemiarthroplasty (231 cemented and 141 uncemented). The aim was to analyse the factors, which may contribute towards the mortality in cemented versus uncemented group.

The mean age in the cemented and uncemented group was 82 and 81 years respectively. 136 (58.8%) patients were operated within 24 hours of admission in the cemented group as compared to 63 (44.6%). The mean operative time was 81minutes for cemented hemiarthroplasty and 61 minutes for uncemented hemiarthroplasty. 77% of the cemented hemiarthroplasty was performed by Registrar grade as compared to 69% in the uncemented group. Of the 231 patients in the cemented group, 52% received general and 48% received spinal anaesthesia. Of the 141 patients in the uncemented group, 30% received general and 70% received spinal anaesthesia.

There was an 8% 30-day mortality compared to 11% 30-day mortality in uncemented group (p< 0.05). The mean age of patients in the mortality group was age 86 yrs in cement and 84 yrs in uncemented group. Most operations were done within 24–48 hours. There was significant co morbidity in patients who died. The average operative time of patients who died in both groups was same.

There was an increased mortality rate in the uncemented group as compared to the cemented group (p< 0.05). Based on our study, we conclude that cement is not a risk factor. Duration and timing of surgery is not associated with increased mortality. There was no difference in 30-day mortality rates between patients receiving general or spinal anaesthesia. Significant co morbid factor is associated with increased mortality.

Clostridium septicum gas gangrene (myonecrosis) is an acutely painful and rapidly fatal infection occurring in the absence of trauma. Urgent surgery is essential both to control pain and to ensure survival. Most patients who develop this infection have an underlying malignancy and clinicians should be aware of this association. We present a case of bifocal myonecrosis which to our knowledge has not been reported previously.