Lateral malleolar plating is associated with complication rates of up to 30%. The fibular nail is an alternative fixation technique, requiring a minimal incision and tissue dissection, with the potential to reduce the incidence of complications. We reviewed our results of 105 unstable ankle fractures fixed with the Acumed fibular nail between 2002 and 2010. The mean age was 65 years and 72% of patients had significant systemic medical comorbidities.

A number of different locking screw configurations were assessed over the study period. A proximal blocking screw resulted in satisfactory stability in 93%, single locking screws in 86%, but nailing without locking in only 66%, leading to the development of our current technique. Of the twenty-one patients treated with this technique there have been no significant complications, and only two superficial wound infections. Good fracture reduction was achieved in all of these patients. The mean physical component SF12, Olerud and Molander and Foot and Ankle Outcome scores were 46, 65 and 83 respectively.

The outcomes of unstable ankle fractures managed with the fibular nail are encouraging, with good radiographic and functional outcomes and minimal complications. This technique should be considered in the management of debilitated patients with unstable ankle fractures.

Techniques for fixation of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce complications.

We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities.

Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and AAOS Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion.

Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture.

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.

Introduction: The incidence of aseptic osteonecrosis is 1.09% to 10.1% following the combination chemotherapy and high dose corticosteroid therapy of acute lymphoblastic leukaemic patients. The treatment of younger patients with advanced avascular necrosis remains controversial. No definite evidence is available yet on the effect of disseminated metal ions on the body. The clinical consequence of systemic absorption of metal degradation products in the causation of leukaemia remains contentious. We describe a 21 year old case with avascular necrosis of the hip joint due to T-Cell Acute Lymphoblastic Leukaemia treated with Metal-on-Metal surface hip arthroplasty with an excellent outcome at 5 year follow-up.

Case report: A 21 year old man presented with painful right hip for a period of four years. The past medical history was significant for T-Cell Acute Lymphoblastic Leukaemia which was treated with high dose corticosteroids and combination chemotherapy. He was diagnosed with avascular necrosis of the right hip and was offered hip replacement. He underwent a metal-on-metal surface hip replacement. The uncemented dual coated 54mm cup and cemented 48mm femoral head (Cormet 2000, Corin Medical) were implanted. Now at 5 years follow up since the surface hip replacement he has an excellent result. His haematological indices remain normal and he remains in remission.

Conclusion: Avascular necrosis of the femoral head is a well-known but rare complication of chemotherapy for leukaemia with a reported incidence ranging from 1 to 10 per cent. Metal-on-metal hip resurfacing arthroplasty is a potentially viable option for younger patients with aseptic osteonecrosis secondary to combination chemotherapy and high dose corticosteroid therapy used in the management of acute lymphoblastic leukaemias. Contrary to the general belief, we found no relapse in the leukaemia with use of metal-on-metal surface hip prosthesis till five years of follow-up.

Introduction: Metal-on-metal hip resurfacing arthroplasty is recommended for younger patients with advanced hip disease who are likely to outlive a conventional primary total hip arthroplasty and wish to be reasonably active. Intraoperative or immediate postoperative femoral neck fracture is a well described technical complication as a result of notching and stress shielding of the femoral head. We report two cases of femoral neck fracture incurred eight to fifteen months following the index operation.

Case 1: A 47 year old lady was admitted after sustaining a fall. Radiograph confirmed left femoral neck fracture with resurfacing prosthesis in situ. She underwent metal-on-metal surface hip replacement 15 months ago for advanced osteoarthritis. The periprosthetic fracture was treated by revising the femoral component, using Eurocone cormet modular endo head 44mm size. At one year follow up, she was able to mobilise unassisted and had a good range of movements.

Case 2: A 52 year old gentleman presented with a painful right hip. While walking in the supermarket, he suddenly felt a click in the right hip. Radiograph confirmed right femoral neck fracture with resurfacing prosthesis in place. The metal-on-metal surface hip replacement was performed 8 months previously for advanced avascular necrosis. His medical history was significant for epilepsy. The Femoral component was revised, using Eurocone cormet modular endo head 52mm. He made a satisfactory progress at 18 months follow up since his periprosthetic fracture.

Conclusion: We recommend that patient selection should be given prime importance before embarking on metal on metal surface hip replacement. The surgeons’ factors are meticulous technique in preventing neck notching and femoral head fixation in varus angulation. Revising femoral component, using large head and leaving resurfaced cups in place should be considered as mode of treatment. Large multicentric trials are needed to evaluate the exact incidence of periprosthetic fractures in metal on metal hip resurfacing