Large-head metal-on-metal (MoM) total hip replacements (THR) have given rise to concern. Comparative studies of small-head MoM THRs over a longer follow-up period are lacking. Our objective was to compare the incidence of complications such as infection, dislocation, revision, adverse local tissue reactions, mortality and radiological and clinical outcomes in small-head (28 mm) MoM and ceramic-on-polyethylene (CoP) THRs up to 12 years post-operatively.

A prospective cohort study included 3341 THRs in 2714 patients. The mean age was 69.1 years (range 24 to 98) and 1848 (55.3%) were performed in women, with a mean follow-up of 115 months (18 to 201). There were 883 MoM and 2458 CoP bearings. Crude incidence rates (cases/1000 person-years) were: infection 1.3 vs 0.8; dislocation 3.3 vs 3.1 and all-cause revision 4.3 vs 2.2, respectively. There was a significantly higher revision rate after ten years (adjusted hazard ratio 9.4; 95% CI 2.6 to 33.6) in the MoM group, and ten of 26 patients presented with an adverse local tissue reaction at revision. No differences in mortality, osteolysis or clinical outcome were seen.

In conclusion, we found similar results for small-head MoM and CoP bearings up to ten years post-operatively, but after ten years MoM THRs had a higher risk of all-cause revision. Furthermore, the presence of an adverse response to metal debris seen in the small-head MOM group at revision is a cause for concern.

Cite this article: Bone Joint J 2014; 96-B:868–75.

Whether patients with asymptomatic bacteriuria should be investigated and treated before elective hip and knee replacement is controversial, although it is a widespread practice. We conducted a prospective observational cohort study with urine analyses before surgery and three days post-operatively. Patients with symptomatic urinary infections or an indwelling catheter were excluded. Post-discharge surveillance included questionnaires to patients and general practitioners at three months. Among 510 patients (309 women and 201 men), with a median age of 69 years (16 to 97) undergoing lower limb joint replacements (290 hips and 220 knees), 182 (36%) had pre-operative asymptomatic bacteriuria, mostly due to Escherichia coli, and 181 (35%) had white cells in the urine. Most patients (95%) received a single intravenous peri-operative dose (1.5 g) of cefuroxime as prophylaxis. On the third post-operative day urinary analysis identified white cells in 99 samples (19%) and bacteriuria in 208 (41%). Pathogens in the cultures on the third post-operative day were different from those in the pre-operative samples in 260 patients (51%). Only 25 patients (5%) developed a symptomatic urinary infection during their stay or in a subsequent three-month follow-up period, and two thirds of organisms identified were unrelated to those found during the admission. All symptomatic infections were successfully treated with oral antibiotics with no perceived effect on the joint replacement.

We conclude that testing and treating asymptomatic urinary tract colonisation before joint replacement is unnecessary.

Cite this article: Bone Joint J 2014;96-B:390–4.

There are no recent studies comparing cable with wire for the fixation of osteotomies or fractures in total hip replacement (THR). Our objective was to evaluate the five-year clinical and radiological outcomes and complication rates of the two techniques. We undertook a review including all primary and revision THRs performed in one hospital between 1996 and 2005 using cable or wire fixation. Clinical and radiological evaluation was performed five years post-operatively. Cables were used in 51 THRs and wires in 126, and of these, 36 THRs with cable (71%) and 101 with wire (80%) were evaluated at follow-up. The five-year radiographs available for 33 cable and 91 wire THRs revealed rates of breakage of fixation of 12 of 33 (36%) and 42 of 91 (46%), respectively. With cable there was a significantly higher risk of metal debris (68% vs 9%; adjusted relative risk (RR) 6.6; 95% confidence interval (CI) 3.0 to 14.1), nonunion (36% vs 21%; adjusted RR 2.0; 95% CI 1.0 to 3.9) and osteolysis around the material, acetabulum or femur (61% vs 19%; adjusted RR 3.9; 95% CI 2.3 to 6.5). Cable breakage increased the risk of osteolysis to 83%. There was a trend towards foreign-body reaction and increased infection with cables. Clinical results did not differ between the groups.

In conclusion, we found a higher incidence of complications and a trend towards increased infection and foreign-body reaction with the use of cables.

Purpose of the study: These fractures, and the patients, are generally unstable. Mortality associated with these fractures remains high. It is mainly due to the haemorrhagic risk of the presacral venous plexus and the iliac system. Different techniques have been described to control the haemorrhage: pelvic girdle, embolisation, ligature of the iliac arteries, pelvic packing, pelvis clamp or external fixator. Our objective was to analyse our series of fractures of this type in order to optimise patient outcome.

Material and methods: A prospective study was undertaken from January 2003 to December 2006. Among 450 multiple injury patients, 68 presented an unstable fracture of the pelvis, type B or C. The 38 patients included in this series were haemodynamically unstable. The mean ISS for these patients was 53, mean age 38.6 years (range 24–51). Fractures were diagnosed on plain x-rays of the pelvis, ap view, completed by a total body scan.

Results: All patients were victims of high-energy traffic accidents and were managed using the ATLS protocol. Five patients died early despite intensive care. The patients were divided into three groups: group X: 19 patients treated with a first-intention external fixator, with or without arteriography, 18 patients survived, 94%; group Y: 8 patients treated with a first-intention external fixator with arteriography and followed by laparotomy, 7 patients survived, 87%; group Z: 6 patients had laparotomy without an external fixator, 6 patients died, 100% mortality.

Conclusion: In our experience, the best way to control bleeding associated with unstable fractures of the pelvis is as follows: pelvic girdle at the scene of the accident to the emergency room, emergency external fixation followed by laparotomy if the ultrasound is positive. False positives occur due to suffusion of the retroperitoneal haematoma. Emergency laparotomy without prior external fixation of the pelvis lead to 100% mortality in our series. Similarly pelvic packing or the retroperitoneal approach cannot be proposed without exploration.

Background: Among patients undergoing total hip arthroplasty (THA) 24–36% are obese. The most important long-term complication is periprosthetic osteolysis. While patient activity, implant type and quality of fixation are known risk factors for osteolysis, the literature concerning obesity is sparse and controversial. Our objective was to evaluate the influence of obesity on femoral osteolysis five and ten years after primary THA with a cemented stem.

Methods: Prospective cohort study conducted between 1996 and 2003 among patients undergoing THA (uncemented cup, cemented stem, 28mm head and ceramic-polyethylene bearing surface) inserted with a third generation cementing technique. All patients were seen at either five or ten years, with information regarding BMI and activity, and with radiographic follow-up. BMI was evaluated in three and four categories (< 25, 25–29.9 (reference category), 30–34.9 and ≥35 kg/m²). Activity was assessed using the University of California, Los Angeles (UCLA) activity scale (1–10 points). Main outcome was the radiographic assessment of femoral osteolysis. Secondary outcomes were polyethylene wear and revision for aseptic loosening.

Results: We included 503 THAs in 433 patients. Of those 241 THAs (48%) were seen at five years and 262 (52%) at ten years. Osteolytic lesions were identified in forty-four cases, twenty-four in 181 normal weight patients (13.3%), eleven in 205 overweight (5.4%), seven in ninety-six obese class I (7.3%), and two in twenty-one obese class II patients (9.5%). Activity was highest in normal weight patients (mean UCLA score 5.5, ±2.0) and lowest in patients obese class II (mean UCLA score 4.8, ±1.7). Univariate as well as multivariate logistic regression analysis adjusting for activity, cementing quality, age, and sex did not show an increased risk of osteolysis in obese compared to overweight patients (adjusted OR 1.4, 95% CI 0.6; 3.7). A significantly higher risk was found in normal weight patients (adjusted OR 2.6, 95% CI 1.2; 5.7). Total mean polyethylene wear was significantly lower in obese compared to normal/overweight patients (p=0.024). Revision for aseptic loosening of the stem was necessary in 4 patients (3 normal weight patients and 1 overweight patient).

Conclusions: We did not find an increased risk for femoral osteolysis or revision for aseptic loosening in obese patients five and ten years after primary THA with a cemented stem.

We conducted a longitudinal study including patients with the same type of primary hybrid total hip replacement and evaluated patient activity and femoral osteolysis at either five or ten years post-operatively. Activity was measured using the University of California, Los Angeles scale. The primary outcome was the radiological assessment of femoral osteolysis. Secondary outcomes were revision of the femoral component for aseptic loosening and the patients’ quality of life. Of 503 hip replacements in 433 patients with a mean age of 67.7 years (30 to 91), 241 (48%) were seen at five and 262 (52%) at ten years post-operatively. Osteolytic lesions were identified in nine of 166 total hip replacements (5.4%) in patients with low activity, 21 of 279 (7.5%) with moderate activity, and 14 of 58 (24.1%) patients with high activity. The risk of osteolysis increased with participation in a greater number of sporting activities. In multivariate logistic regression adjusting for age, gender, body mass index and the inclination angle of the acetabular component, the adjusted odds ratio for osteolysis comparing high vs moderate activity was 3.6 (95% confidence interval 1.6 to 8.3). Stratification for the cementing technique revealed that lower quality cementing increased the effect of high activity on osteolysis. Revision for aseptic loosening was most frequent with high activity. Patients with the highest activity had the best outcome and highest satisfaction.

In conclusion, of patients engaged in high activity, 24% had developed femoral osteolysis five to ten years post-operatively.

Introduction: Early mortality associated with unstable pelvic ring injuries is often secondary to continuous pelvic bleeding. Hemostatic measures such as pelvic binders or external fixation may help to control low pressure bleeding from lacerated veins or broad fracture surfaces, while control of high pressure arterial bleeding may require embolization.

Purpose: Evaluate our experience with the control of hemorrhagic shock associated with pelvic ring injuries during initial patient management.

Methods: From January 2003 until December 2006, all [105] patients admitted to our level I trauma center with a pelvic or an acetabular fracture were prospectively entered into our polytrauma data base. Of 105 patients, 67 were classified with a type B or C pelvic fracture. All these patients received a pelvic strap belt by the paramedic team at the scene of the accident. Pelvic fractures were diagnosed on the initial anteroposterior pelvic radiograph and computed tomography. From this initial group of 67 patients, we identified 38 as unstable requiring blood transfusion and intensive care monitoring. The results and survival rate were evaluated according to the initial sequence of surgical procedures and the patients were divided into 3 groups, X,Y, and Z Follow-up physical examination and radiographs was performed for all survivors at an average of 10 months post-injury (range, 6 months to 3 years).

Results: The average age of the 38 patients was 38.6 years (range, 24–51 years) and their average ISS was 53 (range 21–75).All were injured in a high velocity motor vehicle accident or a fall from a height. The patients were managed in the emergency department by a multidisciplinary team according A.T.L.S. guidelines. Of the 38 patients, five died shortly after arrival in the emergency department despite resuscitation efforts. Within the first 24 hours, pelvic stabilization was performed in 27 patients with either an anterior external fixator frame (n=13), pelvic clamp (n=11) or primary open reduction internal fixation (n=3). In group X, of 19 patients initially treated with external fixation and eventual arterial embolization without laparotomy, 18 (94 %) survived. In group Y, there were 8 patients treated by external fixation, eventual arterial embolization and laparotomy, and 7 (87 %) survived. In group Z, all 6 patients in whom a scratch laparotomy with packing prior to any skeletal fixation was attempted,no patient survived ! All survivors underwent definitive open reduction and plate and screw fixation, with an average ICU stay of 10 days (3–15).

Conclusion: This study shows that optimal control of bleeding associated with pelvic ring injuries is achieved by initial skeletal fixation prior to any other surgical procedures. Immediate laparotomy was associated with a high rate of intraoperative death due to the failure to control bleeding.

Objective: To evaluate the outcome of open reduction and internal fixation of displaced proximal humerus fractures using a new locking plate.

Design: Prospective.

Setting: Level I university center.

Patients: Twenty-eight women and 22 men (mean age, 62.9 ± 19.l years). Twenty-nine patients were 65 years of age or older (mean age, 76.8 years). Fractures were classified according to AO/OTA as 11-A2 (n=3), A3 (n=12), B1 (n=4), B2 (n=18), B3 (n=1), C1 (n=1), and C2 (n=11). Mean follow-up was 19.8 months (range, 12 to 39 months).

Intervention: Open reduction and internal fixation with a proximal humerus locking plate.

Main Outcome Measurements: Raw and adjusted (sex and age) Constant score.

Results: Forty patients were available for follow-up. The mean raw Constant score was 66.6 (adjusted, 82.0). In patients under 65, the raw Constant score was 78.2 (adjusted score, 86.7). In patients over 65, the raw Constant score was 56.1 (adjusted score, 77.8). An excellent or good result was found in 72.5% overall. There was no secondary loss of position or implant cut-out. Seven patients (17.5%) developed avascular necrosis (AVN), 6 in C2 fractures in the older group. Their mean adjusted score was 60.7, as compared to 86.6 ± in those without AVN (p = 0.001).

Conclusions: The outcome was equally good in the younger and older age groups of patients, except in those who developed avascular necrosis. While the latter might be due to the nature of the fracture, it is also possible that surgical technique plays a role.

Background: Bone morphogenetic proteins (BMPs) induce new bone in patients with bone defects and at extraskeletal sites in animals. Standard treatment for symptomatic scaphoid non-unions is bone graft with or without internal fixation by a screw or wires. We tested the ability of human recombinant osteogenic protein-1 (OP-1, BMP-7) with compressed autologous or allogeneic bone graft to accelerate the healing of scaphoid non-union.

Study Design: Randomized and controlled pilot study in 17 patients with a scaphoid nonunion.

Methods: Patients were randomly assigned to one of three groups: (1) Autologous iliac graft (n=6), (2) Autologous iliac graft + OP-1 (n=6) and (3) Allogeneic iliac graft + OP-1 (n=5). Radiographic, scintigraphic and clinical outcomes were assessed throughout the follow-up period of 24 months.

Results: OP-1 improved the performance of both autologous and allogeneic bone implants. Three dimensional helical CT scans and scintigraphy showed that the pre-existing sclerotic bone within proximal scaphoid poles was mainly replaced in OP-1 treated patients with well vascularized new bone. Addition of OP-1 to allogeneic bone implant equalized the clinical outcome with the autologous graft procedure and enabled circumventing the second donor graft harvest procedure resulting in less blood loss, shorter anesthesia and no pain at the donor side.

Conclusion: This is the first evidence that a recombinant human BMP accelerates scaphoid bone non-union repair and resorption of sclerotic bone in this specific microenvironment.

Clinical Relevance: OP-1 might be successfully used in healing of scaphoid non-union.

Aims: To describe the proþle of patients older than 65 years of age with a fracture of the upper extremity, and the consequence of such an injury. Methods: Retrospective cohort study of 667 patients presenting to the emergency department between January 1999 and December 2000 with a fracture of the upper extremity. Variables included sex, age, location of fracture (± additional fractures), treatment, length of stay (in hospital and convalescent care), and place of habitation before and after injury. Follow-up continued until patientsñ deþnitive residential status. Results: The majority of patients were women with fractures of the wrist and proximal humerus. 42% were treated and returned to their previous residence. 37% were admitted to the hospital, of whom 90% had an operation; 97% returned to their previous residence. 21% of patients did not require an operation, but were unable to function independently and were admitted directly to our Geriatrics Hospital. This group was signiþcantly older and more frequently sustained a fracture of the proximal humerus or 2 fractures. 20% required long-term placement. Conclusions: Fractures of the upper extremity in this age group are frequent. A particular subset of signiþcantly older patients are unable to function independently, thus requiring hospitalization, extended periods of convalescence, and a greater likelihood of a permanent change in habitation.

The treatment of multifragmentary, intra-articular fractures of the distal humerus is difficult, even in young patients with bone of good quality, but is worse in elderly patients who have varying degrees of osteopenia. We have evaluated the functional outcome of primary total elbow replacement (TER) in the treatment of these fractures in ten elderly patients followed for a minimum of one year. There were no complications in regard to the soft tissues, bone or prosthesis. The mean range of flexion obtained was 125° (110 to 140) and loss of extension was 23.5° (0 to 50). The mean Mayo score was 94 points (80 to 100) and patient satisfaction was high. We feel that TER provides an alternative to open reduction and internal fixation in the management of these complicated fractures in the elderly.