Aims

Precise implant positioning, tailored to individual spinopelvic biomechanics and phenotype, is paramount for stability in total hip arthroplasty (THA). Despite a few studies on instability prediction, there is a notable gap in research utilizing artificial intelligence (AI). The objective of our pilot study was to evaluate the feasibility of developing an AI algorithm tailored to individual spinopelvic mechanics and patient phenotype for predicting impingement.

Aims

To systematically review the predominant complication rates and changes to patient-reported outcome measures (PROMs) following osteochondral allograft (OCA) transplantation for shoulder instability.

Aims

The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques.

Aims

Excessive posterior pelvic tilt (PT) may increase the risk of anterior instability after total hip arthroplasty (THA). The aim of this study was to investigate the changes in PT occurring from the preoperative supine to postoperative standing position following THA, and identify factors associated with significant changes in PT.

Aims

Post-traumatic periprosthetic acetabular fractures are rare but serious. Few studies carried out on small cohorts have reported them in the literature. The aim of this work is to describe the specific characteristics of post-traumatic periprosthetic acetabular fractures, and the outcome of their surgical treatment in terms of function and complications.

Aims. The aim of this study was to identify the optimal lip position for total hip arthroplasties (THAs) using a lipped liner. There is a lack of consensus on the optimal position, with substantial variability in surgeon practice. Methods. A model of a THA was developed using a 20° lipped liner. Kinematic analyses included a physiological range of motion (ROM) analysis and a provocative dislocation manoeuvre analysis. ROM prior to impingement was calculated and, in impingement scenarios, the travel distance prior to dislocation was assessed. The combinations analyzed included nine cup positions (inclination 30-40-50°, anteversion 5-15-25°), three stem positions (anteversion 0-15-30°), and five lip orientations (right hip 7 to 11 o’clock). Results. The position of the lip changes the ROM prior to impingement, with certain combinations leading to impingement within the physiological ROM. Inferior lip positions (7 to 8 o’clock) performed best with cup inclinations of 30° and 40°. Superior lip positions performed best with cup inclination of 50°. When impingement occurs in the plane of the lip, the lip increases the travel distance prior to dislocation. Inferior lip positions led to the largest increase in jump distance in a posterior dislocation provocation manoeuvre. Conclusion. The lip orientation that provides optimal physiological ROM depends on the orientation of the cup and stem. For a THA with stem anteversion 15°, cup inclination 40°, and cup anteversion 15°, the optimal lip position was posterior-inferior (8 o’clock). Maximizing jump distance prior to dislocation while preventing impingement in the opposite direction is possible with appropriate lip positioning. Cite this article: Bone Joint Res 2023;12(9):571–579

Aims

Multiple secondary surgical procedures of the shoulder, such as soft-tissue releases, tendon transfers, and osteotomies, are described in brachial plexus birth palsy (BPBP) patients. The long-term functional outcomes of these procedures described in the literature are inconclusive. We aimed to analyze the literature looking for a consensus on treatment options.

Aims

Dislocation of the hip remains a major complication after periacetabular tumour resection and endoprosthetic reconstruction. The position of the acetabular component is an important modifiable factor for surgeons in determining the risk of postoperative dislocation. We investigated the significance of horizontal, vertical, and sagittal displacement of the hip centre of rotation (COR) on postoperative dislocation using a CT-based 3D model, as well as other potential risk factors for dislocation.

Aims

Registry studies on modified acetabular polyethylene (PE) liner designs are limited. We investigated the influence of standard and modified PE acetabular liner designs on the revision rate for mechanical complications in primary cementless total hip arthroplasty (THA).

Aims

Pelvic incidence (PI) is a position-independent spinopelvic parameter traditionally used by spinal surgeons to determine spinal alignment. Its relevance to the arthroplasty surgeon in assessing patient risk for total hip arthroplasty (THA) instability preoperatively is unclear. This study was undertaken to investigate the significance of PI relative to other spinopelvic parameter risk factors for instability to help guide its clinical application.

Dislocation following total hip arthroplasty (THA) is a well-known and potentially devastating complication. Clinicians have used many strategies in attempts to prevent dislocation since the introduction of THA. While the importance of postoperative care cannot be ignored, particular emphasis has been placed on preoperative planning in the prevention of dislocation. The strategies have progressed from more traditional approaches, including modular implants, the size of the femoral head, and augmentation of the offset, to newer concepts, including patient-specific component positioning combined with computer navigation, robotics, and the use of dual-mobility implants. As clinicians continue to pursue improved outcomes and reduced complications, these concepts will lay the foundation for future innovation in THA and ultimately improved outcomes.

Cite this article: Bone Joint J 2022;104-B(1):8–11.

Aims

Spinopelvic mobility plays an important role in functional acetabular component position following total hip arthroplasty (THA). The primary aim of this study was to determine if spinopelvic hypermobility persists or resolves following THA. Our second aim was to identify patient demographic or radiological factors associated with hypermobility and resolution of hypermobility after THA.

Aims

To determine if primary cemented acetabular component geometry (long posterior wall (LPW), hooded, or offset reorientating) influences the risk of revision total hip arthroplasty (THA) for instability or loosening.

Aims. In the native hip, the hip capsular ligaments tighten at the limits of range of hip motion and may provide a passive stabilizing force to protect the hip against edge loading. In this study we quantified the stabilizing force vectors generated by capsular ligaments at extreme range of motion (ROM), and examined their ability to prevent edge loading. Methods. Torque-rotation curves were obtained from nine cadaveric hips to define the rotational restraint contributions of the capsular ligaments in 36 positions. A ligament model was developed to determine the line-of-action and effective moment arms of the medial/lateral iliofemoral, ischiofemoral, and pubofemoral ligaments in all positions. The functioning ligament forces and stiffness were determined at 5 Nm rotational restraint. In each position, the contribution of engaged capsular ligaments to the joint reaction force was used to evaluate the net force vector generated by the capsule. Results. The medial and lateral arms of the iliofemoral ligament generated the highest inbound force vector in positions combining extension and adduction providing anterior stability. The ischiofemoral ligament generated the highest inbound force in flexion with adduction and internal rotation (FADIR), reducing the risk of posterior dislocation. In this position the hip joint reaction force moved 0.8° inbound per Nm of internal capsular restraint, preventing edge loading. Conclusion. The capsular ligaments contribute to keep the joint force vector inbound from the edge of the acetabulum at extreme ROM. Preservation and appropriate tensioning of these structures following any type of hip surgery may be crucial to minimizing complications related to joint instability. Cite this article: Bone Joint Res 2021;10(9):594–601

Aims

Use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased in recent years due to proposed benefits, including a lower risk of dislocation and improved early functional recovery. This study investigates the dislocation rate in a non-selective, consecutive cohort undergoing THA via the DAA without any exclusion or bias in patient selection based on habitus, deformity, age, sex, or fixation method.

Aims

The complex relationship between acetabular component position and spinopelvic mobility in patients following total hip arthroplasty (THA) renders it difficult to optimize acetabular component positioning. Mobility of the normal lumbar spine during postural changes results in alterations in pelvic tilt (PT) to maintain the sagittal balance in each posture and, as a consequence, markedly changes the functional component anteversion (FCA). This study aimed to investigate the in vivo association of lumbar degenerative disc disease (DDD) with the PT angle and with FCA during postural changes in THA patients.

Aims

To evaluate the rate of dislocation following dual mobility total hip arthroplasty (DM-THA) in patients with displaced femoral neck fractures, and to compare rates of dislocation, surgical-site infection, reoperation, and one-year mortality between DM-THA and bipolar hemiarthroplasty (BHA).

Aims

To report mid- to long-term results of Oxford mobile bearing domed lateral unicompartmental knee arthroplasty (UKA), and determine the effect of potential contraindications on outcome.

Aims

There is evidence that prior lumbar fusion increases the risk of dislocation and revision after total hip arthroplasty (THA). The relationship between prior lumbar fusion and the effect of femoral head diameter on THA dislocation has not been investigated. We examined the relationship between prior lumbar fusion or discectomy and the risk of dislocation or revision after THA. We also examined the effect of femoral head component diameter on the risk of dislocation or revision.

Aims

Patients with abnormal spinopelvic mobility are at increased risk for instability. Measuring the change in sacral slope (ΔSS) can help determine spinopelvic mobility preoperatively. Sacral slope (SS) should decrease at least 10° to demonstrate adequate posterior pelvic tilt. There is potential for different ΔSS measurements in the same patient based on sitting posture. The purpose of this study was to determine the effect of sitting posture on the ΔSS in patients undergoing total hip arthroplasty (THA).

Aims

To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP).

Aims

The aim of this study was to assess the effect of posterior cruciate ligament (PCL) resection on flexion-extension gaps, mediolateral soft-tissue laxity, fixed flexion deformity (FFD), and limb alignment during posterior-stabilized (PS) total knee arthroplasty (TKA).

Aims

While previously underappreciated, factors related to the spine contribute substantially to the risk of dislocation following total hip arthroplasty (THA). These factors must be taken into consideration during preoperative planning for revision THA due to recurrent instability. We developed a protocol to assess the functional position of the spine, the significance of these findings, and how to address different pathologies at the time of revision THA.

There remains confusion in the literature with regard to the spinopelvic relationship, and its contribution to ideal acetabular component position. Critical assessment of the literature has been limited by use of conflicting terminology and definitions of new concepts that further confuse the topic. In 2017, the concept of a Hip-Spine Workgroup was created with the first meeting held at the American Academy of Orthopedic Surgeons Annual Meeting in 2018. The goal of this workgroup was to first help standardize terminology across the literature so that as a topic, multiple groups could produce literature that is immediately understandable and applicable. This consensus review from the Hip-Spine Workgroup aims to simplify the spinopelvic relationship, offer hip surgeons a concise summary of available literature, and select common terminology approved by both hip surgeons and spine surgeons for future research.

Cite this article: Bone Joint J 2019;101-B:808–816.

Aims

The hip’s capsular ligaments passively restrain extreme range of movement (ROM) by wrapping around the native femoral head/neck. We determined the effect of hip resurfacing arthroplasty (HRA), dual-mobility total hip arthroplasty (DM-THA), conventional THA, and surgical approach on ligament function.

Aims

Concurrent hip and spine pathologies can alter the biomechanics of spinopelvic mobility in primary total hip arthroplasty (THA). This study examines how differences in pelvic orientation of patients with spine fusions can increase the risk of dislocation risk after THA.

Aims. The glenohumeral joint is the most frequently dislocated articulation, but possibly due to the lower prevalence of posterior shoulder dislocations, approximately 50% to 79% of posterior glenohumeral dislocations are missed at initial presentation. The aim of this study was to systematically evaluate the most recent evidence involving the aetiology of posterior glenohumeral dislocations, as well as the diagnosis and treatment. Materials and Methods. A systematic search was conducted using PubMed (MEDLINE), Web of Science, Embase, and Cochrane (January 1997 to September 2017), with references from articles also evaluated. Studies reporting patients who experienced an acute posterior glenohumeral joint subluxation and/or dislocation, as well as the aetiology of posterior glenohumeral dislocations, were included. Results. A total of 54 studies met the inclusion criteria. In total, 182 patients were included in this analysis; study sizes ranged from one to 66 patients, with a mean age of 44.2 years (. sd. 13.7). There was a higher proportion of male patients. In all, 216 shoulders were included with 148 unilateral injuries and 34 bilateral. Seizures were implicated in 38% of patients (n = 69), with falls, road traffic accidents, electric shock, and iatrogenic reasons also described. Time to diagnosis varied across studies from immediate up to a delay of 25 years. Multiple associated injuries are described. Conclusion. This review provides an up-to-date insight into the aetiology of posterior shoulder dislocations. Our results showed that seizures were most commonly implicated. Overall, reduction was achieved via open means in the majority of shoulders. We also found that delayed diagnosis is common

Aims

Instability continues to be a troublesome complication after total hip arthroplasty (THA). Patient-related risk factors associated with a higher dislocation risk include the preoperative diagnosis, an age of 75 years or older, high body mass index (BMI), a history of alcohol abuse, and neurodegenerative diseases. The goal of this study was to assess the dislocation rate, radiographic outcomes, and complications of patients stratified as high-risk for dislocation who received a dual mobility (DM) bearing in a primary THA at a minimum follow-up of two years.

Aims

We present our experience of using a metal-backed prosthesis and autologous bone graft to treat gross glenoid bone deficiency.

Aims

The aims of this study were to measure sagittal standing and sitting lumbar-pelvic-femoral alignment in patients before and following total hip arthroplasty (THA), and to consider what preoperative factors may influence a change in postoperative pelvic position.

Aims

The aim of this study was to examine the results of the acetabular distraction technique in achieving implantation of a stable construct, obtaining biological fixation, and producing healing of chronic pelvic discontinuity at revision total hip arthroplasty.

Aims

Controversy about the use of an anatomical total shoulder arthroplasty (aTSA) in young arthritic patients relates to which is the ideal form of fixation for the glenoid component: cemented or cementless. This study aimed to evaluate implant survival of aTSA when used in patients aged < 60 years with primary glenohumeral osteoarthritis (OA), and to compare the survival of cemented all-polyethylene and cementless metal-backed glenoid components.

Aims

We report the clinical results of glenoid osteotomy in patients with atraumatic posteroinferior instability associated with glenoid dysplasia.

Patients with neuromuscular imbalance who require total hip arthroplasty (THA) present particular technical problems due to altered anatomy, abnormal bone stock, muscular imbalance and problems of rehabilitation.

In this systematic review, we studied articles dealing with THA in patients with neuromuscular imbalance, published before April 2017. We recorded the demographics of the patients and the type of neuromuscular pathology, the indication for surgery, surgical approach, concomitant soft-tissue releases, the type of implant and bearing, pain and functional outcome as well as complications and survival.

Recent advances in THA technology allow for successful outcomes in these patients. Our review suggests excellent benefits for pain relief and good functional outcome might be expected with a modest risk of complication.

Cite this article: Bone Joint J 2018;100-B(1 Supple A):17–21.

Aims

The aims of this study were to examine the rate at which the positioning of the acetabular component, leg length discrepancy and femoral offset are outside an acceptable range in total hip arthroplasties (THAs) which either do or do not involve the use of intra-operative digital imaging.

Aims

There has been an evolution recently in the management of unstable fractures of the ankle with a trend towards direct fixation of a posterior malleolar fragment. Within these fractures, Haraguchi type 2 fractures extend medially and often cannot be fixed using a standard posterolateral approach. Our aim was to describe the posteromedial approach to address these fractures and to assess its efficacy and safety.

Aims

Our aim was to evaluate the radiographic characteristics of patients undergoing total hip arthroplasty (THA) for the potential of posterior bony impingement using CT simulations.

Aims

Lumbar fusion is known to reduce the variation in pelvic tilt between standing and sitting. A flexible lumbo-pelvic unit increases the stability of total hip arthroplasty (THA) when seated by increasing anterior clearance and acetabular anteversion, thereby preventing impingement of the prosthesis. Lumbar fusion may eliminate this protective pelvic movement. The effect of lumbar fusion on the stability of total hip arthroplasty has not previously been investigated.

Aims

Modular or custom-made femoral components have been preferred for total hip arthroplasty (THA) in patients with a history of Perthes’ disease because of the distortion in the anatomy of the proximal femur. However, it has not been established whether a monobloc cementless stem will fit the distorted proximal femur or whether the results of the procedure are satisfactory in this group of patients.

Aims

Fracture clinics are often characterised by the referral of large numbers of unselected patients with minor injuries not requiring investigation or intervention, long waiting times and recurrent unnecessary reviews. Our experience had been of an unsustainable system and we implemented a ‘Trauma Triage Clinic’ (TTC) in order to rationalise and regulate access to our fracture service. The British Orthopaedic Association’s guidelines have required a prospective evaluation of this change of practice, and we report our experience and results.

Aims

Post-operative migration of cemented acetabular components as measured by radiostereometric analysis (RSA) has a strong predictive power for late, aseptic loosening. Also, radiolucent lines predict late loosening. Migration has been reduced by systemic bisphosphonate treatment in randomised trials of hip and knee arthroplasty. Used as a local treatment, a higher local dose of bisphosphonate can be achieved without systemic exposure. We wished to see if this principle could be applied usefully in total hip arthroplasty (THA).

Aims

The pelvis rotates in the sagittal plane during daily activities. These rotations have a direct effect on the functional orientation of the acetabulum. The aim of this study was to quantify changes in pelvic tilt between different functional positions.

Aims

Posterior tilt of the pelvis with sitting provides biological acetabular opening. Our goal was to study the post-operative interaction of skeletal mobility and sagittal acetabular component position.

Objectives

Accurate characterisation of fractures is essential in fracture management trials. However, this is often hampered by poor inter-observer agreement. This article describes the practicalities of defining the fracture population, based on the Neer classification, within a pragmatic multicentre randomised controlled trial in which surgical treatment was compared with non-surgical treatment in adults with displaced fractures of the proximal humerus involving the surgical neck.

Aims

The primary aim of this study was to analyse the position of the acetabular and femoral components in total hip arthroplasty undertaken using an anterior surgical approach.

Ideal placement of the acetabular component remains elusive both in terms of defining and achieving a target. Our aim is to help restore original anatomy by using the transverse acetabular ligament (TAL) to control the height, depth and version of the component. In the normal hip the TAL and labrum extend beyond the equator of the femoral head and therefore, if the definitive acetabular component is positioned such that it is cradled by and just deep to the plane of the TAL and labrum and is no more than 4mm larger than the original femoral head, the centre of the hip should be restored. If the face of the component is positioned parallel to the TAL and psoas groove the patient specific version should be restored. We still use the TAL for controlling version in the dysplastic hip because we believe that the TAL and labrum compensate for any underlying bony abnormality.

The TAL should not be used as an aid to inclination. Worldwide, > 75% of surgeons operate with the patient in the lateral decubitus position and we have shown that errors in post-operative radiographic inclination (RI) of > 50° are generally caused by errors in patient positioning. Consequently, great care needs to be taken when positioning the patient. We also recommend 35° of apparent operative inclination (AOI) during surgery, as opposed to the traditional 45°.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):37–43.

Instability is a common indication for early revision after both primary and revision total knee arthroplasty (TKA), accounting for up to 20% in the literature. The number of TKAs performed annually continues to climb exponentially, thus having an effective algorithm for treatment is essential. This relies on a thorough pre- and intra-operative assessment of the patient. The underlying cause of the instability must be identified initially and subsequently, the surgeon must be able to balance the flexion and extension gaps and be comfortable using a variety of constrained implants.

This review describes the assessment of the unstable TKA, and the authors’ preferred form of treatment for these difficult cases where the source of instability is often multifactorial.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):116–19.

In this in vitro study of the hip joint we examined which soft tissues act as primary and secondary passive rotational restraints when the hip joint is functionally loaded. A total of nine cadaveric left hips were mounted in a testing rig that allowed the application of forces, torques and rotations in all six degrees of freedom. The hip was rotated throughout a complete range of movement (ROM) and the contributions of the iliofemoral (medial and lateral arms), pubofemoral and ischiofemoral ligaments and the ligamentum teres to rotational restraint was determined by resecting a ligament and measuring the reduced torque required to achieve the same angular position as before resection. The contribution from the acetabular labrum was also measured. Each of the capsular ligaments acted as the primary hip rotation restraint somewhere within the complete ROM, and the ligamentum teres acted as a secondary restraint in high flexion, adduction and external rotation. The iliofemoral lateral arm and the ischiofemoral ligaments were primary restraints in two-thirds of the positions tested. Appreciation of the importance of these structures in preventing excessive hip rotation and subsequent impingement/instability may be relevant for surgeons undertaking both hip joint preserving surgery and hip arthroplasty.

Cite this article: Bone Joint J 2015; 97-B:484–91.

We report a 12- to 15-year implant survival assessment of a prospective single-surgeon series of Birmingham Hip Resurfacings (BHRs). The earliest 1000 consecutive BHRs including 288 women (335 hips) and 598 men (665 hips) of all ages and diagnoses with no exclusions were prospectively followed-up with postal questionnaires, of whom the first 402 BHRs (350 patients) also had clinical and radiological review.

Mean follow-up was 13.7 years (12.3 to 15.3). In total, 59 patients (68 hips) died 0.7 to 12.6 years following surgery from unrelated causes. There were 38 revisions, 0.1 to 13.9 years (median 8.7) following operation, including 17 femoral failures (1.7%) and seven each of infections, soft-tissue reactions and other causes. With revision for any reason as the end-point Kaplan–Meier survival analysis showed 97.4% (95% confidence interval (CI) 96.9 to 97.9) and 95.8% (95% CI 95.1 to 96.5) survival at ten and 15 years, respectively. Radiological assessment showed 11 (3.5%) femoral and 13 (4.1%) acetabular radiolucencies which were not deemed failures and one radiological femoral failure (0.3%).

Our study shows that the performance of the BHR continues to be good at 12- to 15-year follow-up. Men have better implant survival (98.0%; 95% CI 97.4 to 98.6) at 15 years than women (91.5%; 95% CI 89.8 to 93.2), and women < 60 years (90.5%; 95% CI 88.3 to 92.7) fare worse than others. Hip dysplasia and osteonecrosis are risk factors for failure. Patients under 50 years with osteoarthritis fare best (99.4%; 95% CI 98.8 to 100 survival at 15 years), with no failures in men in this group.

Cite this article: Bone Joint J 2014;96-B:1298–1306.

The October 2014 Knee Roundup³⁶⁰ looks at: microfracture equivalent to OATS; examination better than MRI in predicting hamstrings re-injury; a second view on return to play with hamstrings injuries; dislocation risks in the Oxford Unicompartmental Knee; what about the tibia?; getting on top of lateral facet pain post TKR; readmission in TKR; patient-specific instrumentation; treating infrapatellar saphenous neuralgia; and arthroscopy in the middle-aged.

The aim of this study was to evaluate the risk factors for dislocation of the bearing after a mobile-bearing Oxford medial unicompartmental knee replacement (UKR) and to test the hypothesis that surgical factors, as measured from post-operative radiographs, are associated with its dislocation

From a total of 480 UKRs performed between 2001 and 2012, in 391 patients with a mean age of 66.5 years (45 to 82) (316 female, 75 male), we identified 17 UKRs where bearing dislocation occurred. The post-operative radiological measurements of the 17 UKRs and 51 matched controls were analysed using conditional logistic regression analysis. The post-operative radiological measurements included post-operative change in limb alignment, the position of the femoral and tibial components, the resection depth of the proximal tibia, and the femoral component-posterior condyle classification.

We concluded that a post-operative decrease in the posterior tibial slope relative to the pre-operative value was the only significant determinant of dislocation of the bearing after medial Oxford UKR (odds ratio 1.881; 95% confidence interval 1.272 to 2.779). A post-operative posterior tibial slope < 8.45° and a difference between the pre-operative and post-operative posterior tibial slope of > 2.19° may increase the risk of dislocation.

Cite this article: Bone Joint J 2014; 96-B:914–22.

We compared the rate of revision for instability after total hip replacement (THR) when lipped and non-lipped acetabular liners were used. We hypothesised that the use of a lipped liner in a modular uncemented acetabular component reduces the risk of revision for instability after primary THR. Using data from the New Zealand Joint Registry, we found that the use of a lipped liner was associated with a significantly decreased rate of revision for instability and for all other indications. Adjusting for the size of the femoral head, the surgical approach and the age and gender of the patient, this difference remained strongly significant (p < 0.001).

We conclude that evidence from the New Zealand registry suggests that the use of lipped liners with modular uncemented acetabular components is associated with a decreased rate of revision for instability after primary THR.

Cite this article: Bone Joint J 2014;96-B:884–8.

The orientation of the acetabular component can influence both the short- and long-term outcomes of total hip replacement (THR). We performed a prospective, randomised, controlled trial of two groups, comprising of 40 patients each, in order to compare freehand introduction of the component with introduction using the transverse acetabular ligament (TAL) as a reference for anteversion. Anteversion and inclination were measured on pelvic radiographs.

With respect to anteversion, in the freehand group 22.5% of the components were outside the safe zone versus 0% in the transverse acetabular ligament group (p = 0.002). The mean angle of anteversion in the freehand group was 21° (2° to 35°) which was significantly higher compared with 17° (2° to 25°) in the TAL group (p = 0.004). There was a significant difference comparing the variations of both groups (p = 0.008).

With respect to inclination, in the freehand group 37.5% of the components were outside the safe zone versus 20% in the TAL group (p = 0.14). There was no significant difference regarding the accuracy or variation of the angle of inclination when comparing the two groups.

The transverse acetabular ligament may be used to obtain the appropriate anteversion when introducing the acetabular component during THR, but not acetabular component inclination.

Cite this article: Bone Joint J 2014;96-B:312–18.

The medial approach for the treatment of children with developmental dysplasia of the hip (DDH) in whom closed reduction has failed requires minimal access with negligible blood loss. In the United Kingdom, there is a preference for these children to be treated using an anterolateral approach after the appearance of the ossific nucleus. In this study we compared these two protocols, primarily for the risk of osteonecrosis.

Data were gathered prospectively for protocols involving the medial approach (26 hips in 22 children) and the anterolateral approach (22 hips in 21 children) in children aged <  24 months at the time of surgery. Osteonecrosis of the femoral head was assessed with validated scores. The acetabular index (AI) and centre–edge angle (CEA) were also measured.

The mean age of the children at the time of surgery was 11 months (3 to 24) for the medial approach group and 18 months (12 to 24) for the anterolateral group, and the combined mean follow-up was 70 months (26 to 228). Osteonecrosis of the femoral head was evident or asphericity predicted in three of 26 hips (12%) in the medial approach group and four of 22 (18%) in the anterolateral group (p = 0.52). The mean improvement in AI was 8.8° (4° to 12°) and 7.9° (6° to 10°), respectively, at two years post-operatively (p = 0.18). There was no significant difference in CEA values of affected hips between the two groups.

Children treated using an early medial approach did not have a higher risk of developing osteonecrosis at early to mid-term follow-up than those treated using a delayed anterolateral approach. The rates of acetabular remodelling were similar for both protocols.

Cite this article: Bone Joint J 2014;96-B:406–13.

The February 2014 Hip & Pelvis Roundup³⁶⁰ looks at: length of stay; cementless metaphyseal fixation; mortality trends in over 400,000 total hip replacements; antibiotics in hip fracture surgery; blood supply to the femoral head after dislocation; resurfacing and THR in metal-on-metal replacement; diabetes and hip replacement; bone remodelling over two decades following hip replacement; and whether bisphosphonates affect acetabular fixation.

The February 2014 Research Roundup³⁶⁰ looks at: blood supply to the femoral head after dislocation; diabetes and hip replacement; bone remodelling over two decades following hip replacement; sham surgery as good as arthroscopic meniscectomy; distraction in knee osteoarthritis; whether joint replacement prevent cardiac events; tranexamic acid and knee replacement haemostasis; cartilage colonisation in bipolar ankle grafts; CTs and proof of fusion; atorvastatin for muscle re-innervation after sciatic nerve transection; microfracture and short-term pain in cuff repair; promising early results from L-PRF augmented cuff repairs; and fatty degeneration in a rodent model.

We have reviewed the current literature to compare the results of surgery aimed to repair or debride a damaged acetabular labrum. We identified 28 studies to be included in the review containing a total of 1631 hips in 1609 patients. Of these studies 12 reported a mean rate of good results of 82% (from 67% to 100%) for labral debridement. Of the 16 studies that reported a combination of debridement and re-attachment, five reported a comparative outcome for the two methods, four reported better results with re-attachment and one study did not find any significant difference in outcomes. Due to the heterogeneity of the studies it was not possible to perform a meta-analysis or draw accurate conclusions. Confounding factors in the studies include selection bias, use of historical controls and high rates of loss of follow-up.

It seems logical to repair an unstable tear in a good quality labrum with good potential to heal in order potentially to preserve its physiological function. A degenerative labrum on the other hand may be the source of discomfort and its preservation may result in persistent pain and the added risk of failure of re-attachment. The results of the present study do not support routine refixation for all labral tears.

Cite this article: Bone Joint J 2014;96-B:24–30.

Mobile-bearing unicompartmental knee replacements (UKRs) with a flat tibial plateau have not performed well in the lateral compartment, owing to a high dislocation rate. This led to the development of the Domed Lateral Oxford UKR (Domed OUKR) with a biconcave bearing. The aim of this study was to assess the survival and clinical outcomes of the Domed OUKR in a large patient cohort in the medium term.

We prospectively evaluated 265 consecutive knees with isolated disease of the lateral compartment and a mean age at surgery of 64 years (32 to 90). At a mean follow-up of four years (sd 2.2, (0.5 to 8.3)) the mean Oxford knee score was 40 out of 48 (sd 7.4). A total of 12 knees (4.5%) had re-operations, of which four (1.5%) were for dislocation. All dislocations occurred in the first two years. Two (0.8%) were secondary to significant trauma that resulted in ruptured ligaments, and two (0.8%) were spontaneous. In four patients (1.5%) the UKR was converted to a primary TKR. Survival at eight years, with failure defined as any revision, was 92.1% (95% confidence interval 81.3 to 100).

The Domed Lateral OUKR gives good clinical outcomes, low re-operation and revision rates and a low dislocation rate in patients with isolated lateral compartmental disease, in the hands of the designer surgeons.

Cite this article: Bone Joint J 2014;96-B:59–64.

Despite the worldwide usage of the cemented Contemporary acetabular component (Stryker), no published data are available regarding its use in patients aged < 50 years. We undertook a mid- to long-term follow-up study, including all consecutive patients aged < 50 years who underwent a primary total hip replacement using the Contemporary acetabular component with the Exeter cemented stem between January 1999 and January 2006. There were 152 hips in 126 patients, 61 men and 65 women, mean age at surgery 37.6 years (16 to 49 yrs). One patient was lost to follow-up.

Mean clinical follow-up of all implants was 7.6 years (0.9 to 12.0). All clinical questionnaire scores, including Harris hip score, Oxford hip score and several visual analogue scales, were found to have improved. The eight year survivorship of all acetabular components for the endpoints revision for any reason or revision for aseptic loosening was 94.4% (95% confidence interval (CI) 89.2 to 97.2) and 96.4% (95% CI 91.6 to 98.5), respectively. Radiological follow-up was complete for 146 implants. The eight year survival for the endpoint radiological loosening was 93.1% (95% CI 86.2 to 96.6). Three surviving implants were considered radiologically loose but were asymptomatic. The presence of acetabular osteolysis (n = 17, 11.8%) and radiolucent lines (n = 20, 13.9%) in the 144 surviving cups indicates a need for continued observation in the second decade of follow-up in order to observe their influence on long-term survival.

The clinical and radiological data resulting in a ten-year survival rate > 90% in young patients support the use of the Contemporary acetabular component in this specific patient group.

Cite this article: Bone Joint J 2013;95-B:1617–25.

The December 2013 Trauma Roundup. 360 . looks at: Re-operation for intertrochanteric hip fractures; Are twin incisions better than one round the acetabulum?; Salvage osteotomy for calcaneal fractures; Posterior dislocation; Should MRSA be covered in open fractures?; Characterising the saline load test; Has it healed: hip fractures under the spotlight; and stem cells present in atrophic non-union

Total hip replacement (THR) after acetabular fracture presents unique challenges to the orthopaedic surgeon. The majority of patients can be treated with a standard THR, resulting in a very reasonable outcome. Technical challenges however include infection, residual pelvic deformity, acetabular bone loss with ununited fractures, osteonecrosis of bone fragments, retained metalwork, heterotopic ossification, dealing with the sciatic nerve, and the difficulties of obtaining long-term acetabular component fixation. Indications for an acute THR include young patients with both femoral head and acetabular involvement with severe comminution that cannot be reconstructed, and the elderly, with severe bony comminution. The outcomes of THR for established post-traumatic arthritis include excellent pain relief and functional improvements. The use of modern implants and alternative bearing surfaces should improve outcomes further.

Cite this article: Bone Joint J 2013;95-B, Supple A:11–16.

The femoral head receives blood supply mainly from the deep branch of the medial femoral circumflex artery (MFCA). In previous studies we have performed anatomical dissections of 16 specimens and subsequently visualised the arteries supplying the femoral head in 55 healthy individuals. In this further radiological study we compared the arterial supply of the femoral head in 35 patients (34 men and one woman, mean age 37.1 years (16 to 64)) with a fracture/dislocation of the hip with a historical control group of 55 hips. Using CT angiography, we identified the three main arteries supplying the femoral head: the deep branch and the postero-inferior nutrient artery both arising from the MFCA, and the piriformis branch of the inferior gluteal artery. It was possible to visualise changes in blood flow after fracture/dislocation.

Our results suggest that blood flow is present after reduction of the dislocated hip. The deep branch of the MFCA was patent and contrast-enhanced in 32 patients, and the diameter of this branch was significantly larger in the fracture/dislocation group than in the control group (p = 0.022). In a subgroup of ten patients with avascular necrosis (AVN) of the femoral head, we found a contrast-enhanced deep branch of the MFCA in eight hips. Two patients with no blood flow in any of the three main arteries supplying the femoral head developed AVN.

Cite this article: Bone Joint J 2013;95-B:1453–7.

The sternoclavicular joint (SCJ) is a pivotal articulation in the linked system of the upper limb girdle, providing load-bearing in compression while resisting displacement in tension or distraction at the manubrium sterni. The SCJ and acromioclavicular joint (ACJ) both have a small surface area of contact protected by an intra-articular fibrocartilaginous disc and are supported by strong extrinsic and intrinsic capsular ligaments. The function of load-sharing in the upper limb by bulky periscapular and thoracobrachial muscles is extremely important to the longevity of both joints. Ligamentous and capsular laxity changes with age, exposing both joints to greater strain, which may explain the rising incidence of arthritis in both with age. The incidence of arthritis in the SCJ is less than that in the ACJ, suggesting that the extrinsic ligaments of the SCJ provide greater stability than the coracoclavicular ligaments of the ACJ.

Instability of the SCJ is rare and can be difficult to distinguish from medial clavicular physeal or metaphyseal fracture-separation: cross-sectional imaging is often required. The distinction is important because the treatment options and outcomes of treatment are dissimilar, whereas the treatment and outcomes of ACJ separation and fracture of the lateral clavicle can be similar. Proper recognition and treatment of traumatic instability is vital as these injuries may be life-threatening. Instability of the SCJ does not always require surgical intervention. An accurate diagnosis is required before surgery can be considered, and we recommend the use of the Stanmore instability triangle. Most poor outcomes result from a failure to recognise the underlying pathology.

There is a natural reluctance for orthopaedic surgeons to operate in this area owing to unfamiliarity with, and the close proximity of, the related vascular structures, but the interposed sternohyoid and sternothyroid muscles are rarely injured and provide a clear boundary to the medial retroclavicular space, as well as an anatomical barrier to unsafe intervention.

This review presents current concepts of instability of the SCJ, describes the relevant surgical anatomy, provides a framework for diagnosis and management, including physiotherapy, and discusses the technical challenges of operative intervention.

Cite this article: Bone Joint J 2013;95-B:721–31.

Most fractures of the radial head are stable undisplaced or minimally displaced partial fractures without an associated fracture of the elbow or forearm or ligament injury, where stiffness following non-operative management is the primary concern. Displaced unstable fractures of the radial head are usually associated with other fractures or ligament injuries, and restoration of radiocapitellar contact by reconstruction or prosthetic replacement of the fractured head is necessary to prevent subluxation or dislocation of the elbow and forearm. In fractures with three or fewer fragments (two articular fragments and the neck) and little or no metaphyseal comminution, open reduction and internal fixation may give good results. However, fragmented unstable fractures of the radial head are prone to early failure of fixation and nonunion when fixed. Excision of the radial head is associated with good long-term results, but in patients with instability of the elbow or forearm, prosthetic replacement is preferred.

This review considers the characteristics of stable and unstable fractures of the radial head, as well as discussing the debatable aspects of management, in light of the current best evidence.

Cite this article: Bone Joint J 2013;95-B:151–9.

Antibiotic impregnated articulating spacers are used in two-stage revision total knee arthroplasty to deliver local antibiotic therapy while preserving function. We have observed infection control in greater than 95% of cases with functional outcomes approaching those seen in revision for aseptic loosening. Higher failure has been observed with methicillin resistant organisms.

A total of 12 epileptic patients (14 shoulders) with recurrent seizures and anterior dislocations of the shoulder underwent a Latarjet procedure and were reviewed at a mean of 8.3 years (1 to 20) post-operatively. Mean forward flexion decreased from 165° (100° to 180°) to 160° (90° to 180°) (p = 0.5) and mean external rotation from 54° (10° to 90°) to 43° (5° to 75°) (p = 0.058). The mean Rowe score was 76 (35 to 100) at the final follow-up. Radiologically, all shoulders showed a glenoid-rim defect and Hill-Sachs lesions pre-operatively. Osteo-arthritic changes of the glenohumeral joint were observed in five shoulders (36%) pre-operatively and in eight shoulders (57%) post-operatively. Re-dislocation during a seizure occurred in six shoulders (43%). Five of these patients underwent revision surgery using a bone buttress from the iliac crest and two of these patients re-dislocated due to a new seizure.

Due to the unacceptably high rate of re-dislocation after surgery in these patients, the most important means of reducing the incidence of further dislocation is the medical management of the seizures. The Latarjet procedure should be reserved for the well-controlled patient with epilepsy who has recurrent anterior dislocation of the shoulder during activities of daily living.

Medium-term survivorship of the Oxford phase 3 unicompartmental knee replacement (UKR) has not yet been established in an Asian population. We prospectively evaluated the outcome of 400 phase 3 Oxford UKRs in 320 Korean patients with a mean age at the time of operation of 69 years (48 to 82). The mean follow-up was 5.2 years (1 to 10). Clinical and radiological assessment was carried out pre- and post-operatively. At five years, the mean Knee Society knee and functional scores had increased significantly from 56.2 (30 to 91) pre-operatively to 87.2 (59 to 98) (p = 0.034) and from 59.2 (30 to 93) to 88.3 (50 to 100) (p = 0.021), respectively. The Oxford knee score increased from a mean of 25.8 (12 to 39) pre-operatively to 39.8 (25 to 58) at five years (p = 0.038). The ten-year survival rate was 94% (95% confidence interval 90.1 to 98.0). A total of 14 UKRs (3.5%) required revision. The most common reason for revision was dislocation of the bearing in 12 (3%). Conversion to a total knee replacement was required in two patients who developed osteoarthritis of the lateral compartment.

This is the largest published series of UKR in Korean patients. It shows that the mid-term results after a minimally invasive Oxford phase 3 UKR can yield satisfactory clinical and functional results in this group of patients.

We analysed 54 alumina ceramic-on-ceramic bearings from total hip replacements retrieved at one centre after a mean duration of 3.5 years (0.2 to 10.6) in situ. These implants were obtained from 54 patients (16 men and 38 women) with a mean age of 67 years (33 to 88) who underwent revision for a variety of reasons. Posterior edge loading was found in the majority of these retrievals (32 out of 54). Anterosuperior edge loading occurred less often but produced a higher rate of wear. Stripe wear on the femoral heads had a median volumetric wear rate of 0.2 mm³/year (0 to 7.2). The wear volume on the femoral heads corresponded to the width of edge wear on the matching liner. Anteversion of the acetabular component was found to be a more important determinant than inclination for wear in ceramic bearings. Posterior edge loading may be considered to be a normal occurrence in ceramic-on-ceramic bearings, with minimal clinical consequences. Edge loading should be defined as either anterosuperior or posterior, as each edge loading mechanism may result in different clinical implications.

Dislocation of the shoulder may occur during seizures in epileptics and other patients who have convulsions. Following the initial injury, recurrent instability is common owing to a tendency to develop large bony abnormalities of the humeral head and glenoid and a susceptibility to further seizures. Assessment is difficult and diagnosis may be missed, resulting in chronic locked dislocations with protracted morbidity. Many patients have medical comorbidities, and successful treatment requires a multidisciplinary approach addressing the underlying seizure disorder in addition to the shoulder pathology. The use of bony augmentation procedures may have improved the outcomes after surgical intervention, but currently there is no evidence-based consensus to guide treatment. This review outlines the epidemiology and pathoanatomy of seizure-related instability, summarising the currently-favoured options for treatment, and their results.

We reviewed 101 patients with injuries of the terminal branches of the infraclavicular brachial plexus sustained between 1997 and 2009. Four patterns of injury were identified: 1) anterior glenohumeral dislocation (n = 55), in which the axillary and ulnar nerves were most commonly injured, but the axillary nerve was ruptured in only two patients (3.6%); 2) axillary nerve injury, with or without injury to other nerves, in the absence of dislocation of the shoulder (n = 20): these had a similar pattern of nerve involvement to those with a known dislocation, but the axillary nerve was ruptured in 14 patients (70%); 3) displaced proximal humeral fracture (n = 15), in which nerve injury resulted from medial displacement of the humeral shaft: the fracture was surgically reduced in 13 patients; and 4) hyperextension of the arm (n = 11): these were characterised by disruption of the musculocutaneous nerve. There was variable involvement of the median and radial nerves with the ulnar nerve being least affected.

Surgical intervention is not needed in most cases of infraclavicular injury associated with dislocation of the shoulder. Early exploration of the nerves should be considered in patients with an axillary nerve palsy without dislocation of the shoulder and for musculocutaneous nerve palsy with median and/or radial nerve palsy. Urgent operation is needed in cases of nerve injury resulting from fracture of the humeral neck to relieve pressure on nerves.

We assessed the short- to mid-term survival of metallic press-fit radial head prostheses in patients with radial head fractures and acute traumatic instability of the elbow.

The medical records of 42 patients (16 males, 26 females) with a mean age of 56 years (23 to 85) with acute unstable elbow injuries, including a fracture of the radial head requiring metallic replacement of the radial head, were reviewed retrospectively. Survival of the prosthesis was assessed from the radiographs of 37 patients after a mean follow-up of 50 months (12 to 107). The functional results of 31 patients were assessed using range-of-movement, Mayo elbow performance score (MEPS), Disabilities of the Arm, Shoulder and Hand (DASH) score and the RAND 36-item health survey.

At the most recent follow-up 25 prostheses were still well fixed, nine had been removed because of loosening, and three remained implanted but were loose. The mean time from implantation to loosening was 11 months (2 to 24). Radiolucent lines that developed around the prosthesis before removal were mild in three patients, moderate in one and severe in five. Range of movement parameters and mass grip strength were significantly lower in the affected elbow than in the unaffected side. The mean MEPS score was 86 (40 to 100) and the mean DASH score was 23 (0 to 81). According to RAND-36 scores, patients had more pain and lower physical function scores than normal population values.

Loosening of press-fit radial head prostheses is common, occurs early, often leads to severe osteolysis of the proximal radius, and commonly requires removal of the prosthesis.

The June 2012 Trauma Roundup³⁶⁰ looks at: nerve injuries of warfare; the medical complications of earthquakes; the measuring of tissue pressures in compartment syndrome; the risk of plunging through the bone when drilling; bony nonunion and negative pressure therapy; surgery for the posteriorly dislocated hip; whether to use the sliding screw or intramedullary nail for the trochanteric fracture; antegrade interlocking nailing for the distal femoral fracture; and gunshot wounds to the pancreas.

The April 2012 Trauma Roundup³⁶⁰ looks at fibula-pro-tibia plating, galeazzi fractures, distal radial fractures in the over 65s, transverse sacral fractures, acute dislocation of the knee, posterior malleolar fractures, immobilising the broken scaphoid, the terrible triad, lower limb amputation after trauma, and whiplash injuries

Ceramic-on-ceramic bearings in hip replacement have low rates of wear and are increasingly being used in young adults. Our aim was to determine the incidence of audible phenomena or other bearing-related complications.

We retrospectively analysed 250 ceramic-on-ceramic hip replacements in 224 patients which had been implanted between April 2000 and December 2007. The mean age of the patients at operation was 44 years (14 to 83) and all the operations were performed using the same surgical technique at a single centre.

At a mean follow-up of 59 months (24 to 94), the mean Oxford hip score was 40.89 (11 to 48). There were six revisions, three of which were for impingement-related complications. No patient reported squeaking, but six described grinding or clicking, which was usually associated with deep flexion. No radiological evidence of osteolysis or migration of the components was observed in any hip.

The early to mid-term results of contemporary ceramic-on-ceramic hip replacement show promising results with few concerns in terms of noise and squeaking. Positioning of the acetabular component remains critical in regard to the reduction of other impingement-related complications.

This prospective study describes the outcome of the first 1000 phase 3 Oxford medial unicompartmental knee replacements (UKRs) implanted using a minimally invasive surgical approach for the recommended indications by two surgeons and followed up independently. The mean follow-up was 5.6 years (1 to 11) with 547 knees having a minimum follow-up of five years. At five years their mean Oxford knee score was 41.3 (sd 7.2), the mean American Knee Society Objective Score 86.4 (sd 13.4), mean American Knee Society Functional Score 86.1 (sd 16.6), mean Tegner activity score 2.8 (sd 1.1). For the entire cohort, the mean maximum flexion was 130° at the time of final review.

The incidence of implant-related re-operations was 2.9%; of these 29 re-operations two were revisions requiring revision knee replacement components with stems and wedges, 17 were conversions to a primary total knee replacement, six were open reductions for dislocation of the bearing, three were secondary lateral UKRs and one was revision of a tibial component. The most common reason for further surgical intervention was progression of arthritis in the lateral compartment (0.9%), followed by dislocation of the bearing (0.6%) and revision for unexplained pain (0.6%). If all implant-related re-operations are considered failures, the ten-year survival rate was 96% (95% confidence interval, 92.5 to 99.5). If only revisions requiring revision components are considered failures the ten-year survival rate is 99.8% (confidence interval 99 to 100).

This is the largest published series of UKRs implanted through a minimally invasive surgical approach and with ten-year survival data. The survival rates are similar to those obtained with a standard open approach whereas the function is better. This demonstrates the effectiveness and safety of a minimally invasive surgical approach for implanting the Oxford UKR.

Injury to the sciatic nerve following closed manipulation of a dislocated total hip replacement is rare. We present such a case in an elderly patient with partial recovery following exploration and release of the nerve.

We report the long-term clinical and radiological outcomes of the Aequalis total shoulder replacement with a cemented all-polyethylene flat-back keeled glenoid component implanted for primary osteoarthritis between 1991 and 2003 in nine European centres. A total of 226 shoulders in 210 patients were retrospectively reviewed at a mean of 122.7 months (61 to 219) or at revision. Clinical outcome was assessed using the Constant score, patient satisfaction score and range of movement. Kaplan-Meier survivorship analysis was performed with glenoid revision for loosening and radiological glenoid loosening (sd) as endpoints. The Constant score was found to improve from a mean of 26.8 (sd 10.3) pre-operatively to 57.6 (sd 20.0) post-operatively (p < 0.001). Active forward flexion improved from a mean of 85.3° (sd 27.4) pre-operatively to 125° (sd 37.3) postoperatively (p < 0.001). External rotation improved from a mean of 7° (sd 6.5) pre-operatively to 30.3° (sd 21.8°) post-operatively (p < 0.001). Survivorship with revision of the glenoid component as the endpoint was 99.1% at five years, 94.5% at ten years and 79.4% at 15 years. Survivorship with radiological loosening as the endpoint was 99.1% at five years, 80.3% at ten years and 33.6% at 15 years.

Younger patient age and the curettage technique for glenoid preparation correlated with loosening. The rate of glenoid revision and radiological loosening increased with duration of follow-up, but not until a follow-up of five years. Therefore, we recommend that future studies reporting radiological outcomes of new glenoid designs should report follow-up of at least five to ten years.

We describe the early results of glenoplasty as part of the technique of operative reduction of posterior dislocation of the shoulder in 29 children with obstetric brachial plexus palsy. The mean age at operation was five years (1 to 18) and they were followed up for a mean of 34 months (12 to 67). The mean Mallet score increased from 8 (5 to 13) to 12 (8 to 15) at final follow-up (p < 0.001). The mean passive forward flexion was increased by 18° (p = 0.017) and the mean passive abduction by 24° (p = 0.001). The mean passive lateral rotation also increased by 54° (p < 0.001), but passive medial rotation was reduced by a mean of only 7°. One patient required two further operations. Glenohumeral stability was achieved in all cases

We prospectively evaluated the long-term outcome of 158 consecutive patients who underwent revision total hip replacement using uncemented computer-assisted design-computer-assisted manufacture femoral components. There were 97 men and 61 women. Their mean age was 63.1 years (34.6 to 85.9). The mean follow-up was 10.8 years (10 to 12).

The mean Oxford, Harris and Western Ontario and McMaster hip scores improved from 41.1, 44.2 and 52.4 pre-operatively to 18.2, 89.3 and 12.3, respectively (p < 0.0001, for each). Six patients required further surgery. The overall survival of the femoral component was 97% (95% confidence interval 94.5 to 99.7). These results are comparable to those of previously published reports for revision total hip replacement using either cemented or uncemented components.

Retrieval studies of total hip replacements with highly cross-linked ultra-high-molecular-weight polyethylene liners have shown much less surface damage than with conventional ultra-high-molecular-weight polyethylene liners. A recent revision hip replacement for recurrent dislocation undertaken after only five months revealed a highly cross-linked polyethylene liner with a large area of visible delamination. In order to determine the cause of this unusual surface damage, we analysed the bearing surfaces of the cobalt-chromium femoral head and the acetabular liner with scanning electron microscopy, energy dispersive x-ray spectroscopy and optical profilometry. We concluded that the cobalt-chromium modular femoral head had scraped against the titanium acetabular shell during the course of the dislocations and had not only roughened the surface of the femoral head but also transferred deposits of titanium onto it. The largest deposits were 1.6 μm to 4.3 μm proud of the surrounding surface and could lead to increased stresses in the acetabular liner and therefore cause accelerated wear and damage.

This case illustrates that dislocations can leave titanium deposits on cobalt-chromium femoral heads and that highly cross-linked ultra-high-molecular-weight polyethylene remains susceptible to surface damage.

Subtalar dislocation is a significant injury characterised by late complications, including subtalar arthritis. We describe a rare case of irreducible posterior subtalar dislocation due to incarceration of a fracture of the anterior process of the calcaneum in the subtalar joint, and discuss appropriate management

This study was performed to review the safety and outcome of total shoulder replacements in patients who are ≥ 80 years of age. A total of 50 total shoulder replacements in 44 patients at a mean age of 82 years (80 to 89) were studied. Their health and shoulder status, the operation and post-operative course were analysed, including pain, movement, patient satisfaction, medical and surgical complications, radiographs, the need for revision surgery, and implant and patient survival. A total of 27 patients had an ASA classification of III or IV and medical abnormalities were common. Of the 13 shoulders with bony deficiency of the glenoid, nine required grafting. The duration of hospital stay was prolonged and blood transfusions were common. There were no peri-operative deaths. The mean follow-up was for 5.5 years (2 to 12). Pain was significantly reduced (p < 0.001) and movement improved in active elevation and both external and internal rotation (p < 0.001). Using the Neer scale for assessing outcome, 40 (80%) shoulders had an excellent or satisfactory result. There were medical or surgical complications in 17 cases. Four shoulders developed radiological evidence of loosened glenoid components, and three of these had a poor outcome. Three other shoulders required revision, two for instability. By the time of this review 39 of the patients had died from unrelated causes at a mean of 7.5 years (0.8 to 16.4) after surgery.

Total shoulder replacement is a relatively effective treatment in this elderly group of patients. However, there is a requirement for more intense patient care in the peri-operative period, and non-fatal medical or surgical complications are common. Most of these elderly patients will have a comfortable functional shoulder for the rest of their lives.

We retrospectively reviewed 11 consecutive patients with an infected reverse shoulder prosthesis. Patients were assessed clinically and radiologically, and standard laboratory tests were carried out. Peroperative samples showed Propionbacterium acnes in seven, coagulase-negative Staphylococcus in five, methicillin-resistant staphylococcus aureus in one and Escherichia coli in one. Two multibacterial and nine monobacterial infections were seen. Post-operatively, patients were treated with intravenous cefazolin for at least three days and in all antibiotic therapy was given for at least three months. Severe pain (3 of 11) or severe limitation of function (3 of 11) are not necessarily seen. A fistula was present in eight, but function was not affected. All but one patient were considered free of infection after one-stage revision at a median follow-up of 24 months, and without antibiotic treatment for a minimum of six months. One patient had a persistent infection despite a second staged revision, but is now free of infection with a spacer. Complications included posterior dislocation in one, haematoma in one and a clavicular fracture in one. At the most recent follow-up the median post-operative Constant-Murley score was 55, 6% adjusted for age, gender and dominance. A one-stage revision arthroplasty reduces the cost and duration of treatment. It is reliable in eradicating infection and good functional outcomes can be achieved

Surgical dislocation of the hip in the treatment of acetabular fractures allows the femoral head to be safely displaced from the acetabulum. This permits full intra-articular acetabular and femoral inspection for the evaluation and potential treatment of cartilage lesions of the labrum and femoral head, reduction of the fracture under direct vision and avoidance of intra-articular penetration with hardware. We report 60 patients with selected types of acetabular fracture who were treated using this approach. Six were lost to follow-up and the remaining 54 were available for clinical and radiological review at a mean follow-up of 4.4 years (2 to 9).

Substantial damage to the intra-articular cartilage was found in the anteromedial portion of the femoral head and the posterosuperior aspect of the acetabulum. Labral lesions were predominantly seen in the posterior acetabular area. Anatomical reduction was achieved in 50 hips (93%) which was considerably higher than that seen in previous reports. There were no cases of avascular necrosis. Four patients subsequently required total hip replacement. Good or excellent results were achieved in 44 hips (81.5%). The cumulative eight-year survivorship was 89.0% (95% confidence interval 84.5 to 94.1). Significant predictors of poor outcome were involvement of the acetabular dome and lesions of the femoral cartilage greater than grade 2. The functional mid-term results were better than those of previous reports.

Surgical dislocation of the hip allows accurate reduction and a predictable mid-term outcome in the management of these difficult injuries without the risk of the development of avascular necrosis.

We present the long-term outcome, at a median of 18 years (12.8 to 23.5) of open posterior bone block stabilisation for recurrent posterior instability of the shoulder in a heterogenous group of 11 patients previously reported on in 2001 at a median follow-up of six years. We found that five (45%) would not have chosen the operation again, and that four (36%) had further posterior dislocation. Clinical outcome was significantly worse after 18 years than after six years of follow-up (median Rowe score of 60 versus 90 (p = 0.027)). The median Western Ontario Shoulder Index was 60% (37% to 100%) at 18 years’ follow-up, which is a moderate score. At the time of surgery four (36%) had glenohumeral radiological osteoarthritis, which was present in all after 18 years. This study showed poor long-term results of the posterior bone block procedure for posterior instability and a high rate of glenohumeral osteoarthritis although three patients with post-traumatic instability were pleased with the result of their operations

Traumatic posterior dislocation of the hip associated with a fracture of the posterior acetabular wall and of the neck of the femur is a rare injury. A 29-year-old man presented at a level 1 trauma centre with a locked posterior dislocation of the right hip, with fractures of the femoral neck and the posterior wall of the acetabulum after a bicycle accident. An attempted closed reduction had failed. This case report describes in detail the surgical management and the clinical and radiological outcome. Open reduction and fixation with preservation of the intact retinaculum was undertaken within five hours of injury with surgical dislocation of the hip and a trochanteric osteotomy. Two years after operation the function of the injured hip was good. Plain radiographs and MR scans showed early signs of osteoarthritis with some loss of joint space but no evidence of avascular necrosis. The patient had begun skiing and hiking again. The combination of fractures of the neck of the femur and of the posterior wall of the acetabulum hampers closed reduction of a posterior dislocation of the hip. Surgical dislocation of the hip with trochanteric flip osteotomy allows controlled open reduction of the fractures, with inspection of the hip joint and preservation of the vascular supply

We have tested the reliability of a recently reported classification system of hip morphology in adolescents with cerebral palsy in whom the triradiate cartilage was closed. The classification is a six-grade ordinal scale, based on the measurement of the migration percentage and an assessment of Shenton’s arch, deformity of the femoral head, acetabular deformity and pelvic obliquity.

Four paediatric orthopaedic surgeons and four physiotherapists received training in the use of the classification which they applied to the assessment of 42 hip radiographs, read on two separate occasions. The inter- and intra-observer reliability was assessed using the intraclass correlation coefficient and found to be excellent, with it ranging from 0.88 to 0.94. The classification in our study was shown to be valid (based on migration percentage), and reliable. As a result we believe that it can now be used in studies describing the natural history of hip displacement in cerebral palsy, in outcome studies and in communication between clinicians.

Using a prospective database of 1309 displaced acetabular fractures gathered between 1980 and 2007, we calculated the annual mean age and annual incidence of elderly patients > 60 years of age presenting with these injuries. We compared the clinical details and patterns of fracture between patients > 60 years of age (study group) with those < 60 years (control group). We performed a detailed evaluation of the radiographs of the older group to determine the incidence of radiological characteristics which have been previously described as being associated with a poor patient outcome.

In all, 235 patients were > 60 years of age and the remaining 1074 were < 60 years. The incidence of elderly patients with acetabular fractures increased by 2.4-fold between the first half of the study period and the second half (10% (62) vs 24% (174), p < 0.001). Fractures characterised by displacement of the anterior column were significantly more common in the elderly compared with the younger patients (64% (150) vs 43% (462), respectively, p < 0.001). Common radiological features of the fractures in the study group included a separate quadrilateral-plate component (50.8% (58)) and roof impaction (40% (46)) in the anterior fractures, and comminution (44% (30)) and marginal impaction (38% (26)) in posterior-wall fractures.

The proportion of elderly patients presenting with acetabular fractures increased during the 27-year period. The older patients had a different distribution of fracture pattern than the younger patients, and often had radiological features which have been shown in other studies to be predictive of a poor outcome.