Aims

Adverse local tissue reactions associated with abnormal wear considerably slowed down the general use of metal-on-metal (MoM) hip resurfacing arthroplasty (HRA), now limited to a few specialized centres. In this study, we provide the clinical results of 400 consecutive MoM HRAs implanted more than 20 years ago in one such centre.

Electromyographic and clinical studies were performed on patients undergoing total hip replacement by the modified direct lateral (29 hips), the direct lateral (29 hips) and the posterior approaches (21 hips). Assessments were made three months after operation. The Trendelenburg test was positive (Grade II) in eight cases operated upon by the direct lateral route, but in only one of each of the other two groups. Denervation occurred in only five of the 28 hips with abductor weakness without statistical difference between the groups. In the modified direct lateral group, radiological evidence of union of the trochanteric sliver was associated with significantly better abductor function than in those with malunion or non-union

Ultrasound (US) was used to determine the congruity of the shoulder in 22 children with a deformity of the shoulder secondary to chronic obstetric brachial plexus palsy. There were 11 boys and 11 girls with a mean age of 4.75 years (0.83 to 13.92). The shoulder was scanned in the axial plane using a posterior approach with the arm internally rotated. The humeral head was classified as being either congruent or incongruent. The US appearance was compared with that on clinical examination and related to the intraoperative findings. All 17 shoulders diagnosed as incongruent on US were found to be incongruent at operation, whereas three diagnosed as congruent by US were found to be incongruent at operation. The diagnostic accuracy of US for the identification of shoulder incongruity was 82% when compared with the findings at surgery. US is a valuable, but not infallible tool, for the detection of incongruity of the shoulder

A new technique of shoulder fusion is presented using a posterior approach. After removal of the articular cartilage, a Rush pin is introduced from the spine of the scapula, through the glenoid into the medullary canal of the humerus. This is supplemented by tension-band wiring from the acromion to the neck of the humerus and a muscle pedicle graft attached to the acromion. A shoulder spica is applied for four to six weeks. Four patients with injuries to the upper brachial plexus and 14 with paralysis of the upper arm due to anterior poliomyelitis have been followed for three years. One of the 18 patients developed nonunion; she had removed her own cast prematurely. This method of fixation provides high shear resistance and low axial stiffness without deforming plastically. It does not affect bone growth in young patients, is effective in patients with osteoporosis, and gives a high rate of union

An operation for radical resection of a tumour of the vertebral body and part of the neural arch is described. The approach is posterior and from both sides of the spine. The posterior approach is used to remove the healthy part of the neural arch, mobilise the dura, divide involved nerve roots and carry out the posterolateral parts of the spinal osteotomies or disc divisions. On one side, usually the right, the sides of the vertebral body or bodies are freed and the osteotomies or disc divisions are extended. Then from the other side, a posterolateral thoracotomy or lumbotomy allows completion of the dissection with radical resection by rolling the specimen away from the dura. Ten operations are reported in which up to three and a half vertebrae were resected. Spinal reconstruction was by internal fixation and grafting preferably with vascularised bone. The results were satisfactory after follow-up for as long as eight years

Aims

Optimal exposure through the direct anterior approach (DAA) for total hip arthroplasty (THA) conducted on a regular operating theatre table is achieved with a standardized capsular releasing sequence in which the anterior capsule can be preserved or resected. We hypothesized that clinical outcomes and implant positioning would not be different in case a capsular sparing (CS) technique would be compared to capsular resection (CR).

Injuries to the sciatic nerve are an occasional complication of surgery to the hip and acetabulum, and traction is frequently the causative mechanism. In vitro and animal experiments have shown that increased tensile strain on peripheral nerves, when applied for prolonged periods, impairs nerve function. We have used video-extensometry to measure strain on the human sciatic nerve during total hip replacement (THR). Ten consecutive patients with a mean age of 72 years undergoing primary THR by the posterior approach were recruited, and strains in the sciatic nerve were measured in different combinations of flexion and extension of the hip and knee, before dislocation of the hip. Significant increases (p = 0.02) in strain in the sciatic nerve were observed in flexion of the hip and extension of the knee. The mean increase was 26% (19% to 30%). In animal studies increases of this magnitude have been shown to impair electrophysiological function in peripheral nerves. Our results suggest that excessive flexion of the hip and extension of the knee should be avoided during THR

There is ambiguity concerning the nomenclature and classification of fractures of the ring of the second cervical vertebra (C2). Disruption of the pars interarticularis which defines true traumatic spondylolisthesis of C2, is often wrongly called a pedicle fracture. Our aim in this study was to assess the influence of asymmetry on the anatomical and functional outcome and to evaluate the criteria of instability established by Roy-Camille et al. We studied the plain radiographs and CT scans of 24 patients: 13 were judged to be asymmetrical, ten were considered unstable and 14 stable. Treatment was with a Minerva jacket in 15 fractures and by operation in nine. Surgery was undertaken in patients with severe C2 to C3 sprains. One patient with an unstable lesion refused operation and was treated conservatively with a poor radiological result. Our study showed that asymmetry of the fracture did not affect the outcomes of treatment and should not therefore influence decisions in treatment. The criteria of Roy-Camille seem to be reliable and useful. We prefer the posterior approach to the cervical spine, which allows both stabilisation of the fracture and correction of a local kyphosis

Aims

To report the outcome of spinal deformity correction through anterior spinal fusion in wheelchair-bound patients with myelomeningocele.

Bilateral venography was performed between 12 and 15 days after total hip replacement in 745 consecutive patients, all of whom had heparin prophylaxis. Of these, 81 patients (10.8%) showed evidence of recent deep vein thrombosis: 23 (3%) distal, 44 (5.9%) isolated proximal, five (0.7%) both proximal and distal, and nine (1.2%) extensive thrombosis from calf to thigh. Compared with previous reports heparin appeared to have reduced the number of distal and contralateral thromboses, but was far less effective in reducing proximal femoral thrombosis. In a cadaver study, the femoral veins were inspected during simulated total hip replacement by either an anterior or a posterior approach. In every case the femoral vein became kinked or folded in the thigh position imposed during the preparation of the femur. Local damage appears to be an important factor in proximal thrombosis; care at operation could help to minimise trauma to the femoral veins and reduce the number of such cases

The management of displaced subcapital fracture of the hip is still controversial because of the high incidence of complications after internal fixation or hemiarthroplasty. To avoid some of these complications we have used primary total hip replacement for independently mobile patients over 65 years of age. A total of 163 cases, operated on over four years, have been reviewed. There were relatively more dislocations after operation for fracture than after total replacement for arthritis, and these were associated with a posterior approach to the hip. Only seven revision operations have been required. Of 57 patients who were interviewed an average of 42 months after replacement, 62% had excellent or good results as assessed by the Harris hip score. All the others had major systemic disease which affected their assessment. This inadequacy of current systems of hip assessment is discussed. It is concluded that total hip replacement is the best management for a selected group of patients with this injury, and that further prospective studies are indicated

1. The risk of injury to the sciatic nerve during closed ischio-femoral arthrodesis by nail and graft has been assessed on the basis of clinical evidence and of anatomical studies in the living and in cadavers. 2. The margin of safety for the nerve is nearly always small. 3. The risk of injury to the nerve is prohibitive when there is marked deformity or hypoplasia of the pelvis. The risk is also increased when the buttock is compressed against the table and, because of the technical difficulties that are entailed, when the hip is in marked flexion. The risk is probably greater in children than in adults. 4. In properly selected cases in which none of these adverse factors is present it is submitted that the risk of nerve injury can be eliminated by proper attention to surgical technique and by the observance of certain definite precautions. 5. When there is doubt in the surgeon's mind about his ability to complete the operation without injuring the nerve the closed technique should be abandoned in favour of the open posterior approach

The meniscofemoral ligaments were studied in 84 fresh-frozen knees from 49 cadavers. Combined anterior and posterior approaches were used to identify the ligaments. In total, 78 specimens (93%) contained at least one meniscofemoral ligament. The anterior meniscofemoral ligament (aMFL) was present in 62 specimens (74%), and the posterior meniscofemoral ligament (pMFL) in 58 (69%). The 42 specimens (50%) in which both ligaments were present were from a significantly younger population than that with one MFL or none (p < 0.05). Several anatomical variations were identified, including oblique fibres of the posterior cruciate ligament (PCL), which were seen in 16 specimens (19%). These were termed the ‘false pMFL’. The high incidence of MFLs and their anatomical variations should be borne in mind during arthroscopic and radiological examination of the PCL. It is important to recognise the oblique fibres of the PCL on MRI in order to avoid wrongly identifying them as either a pMFL or a tear of the lateral meniscus. The increased incidence of MFLs in younger donors suggests that they degenerate with age

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).

Surgical dislocation of the hip is rarely undertaken. The potential danger to the vascularity of the femoral head has been emphasised, but there is little information as to how this danger can be avoided. We describe a technique for operative dislocation of the hip, based on detailed anatomical studies of the blood supply. It combines aspects of approaches which have been reported previously and consists of an anterior dislocation through a posterior approach with a ‘trochanteric flip’ osteotomy. The external rotator muscles are not divided and the medial femoral circumflex artery is protected by the intact obturator externus. We report our experience using this approach in 213 hips over a period of seven years and include 19 patients who underwent simultaneous intertrochanteric osteotomy. The perfusion of the femoral head was verified intraoperatively and, to date, none has subsequently developed avascular necrosis. There is little morbidity associated with the technique and it allows the treatment of a variety of conditions, which may not respond well to other methods including arthroscopy. Surgical dislocation gives new insight into the pathogenesis of some hip disorders and the possibility of preserving the hip with techniques such as transplantation of cartilage

Aims

Uncemented metal acetabular components show good osseointegration, but material stiffness causes stress shielding and retroacetabular bone loss. Cemented monoblock polyethylene components load more physiologically; however, the cement bone interface can suffer fibrous encapsulation and loosening. It was hypothesized that an uncemented titanium-sintered monoblock polyethylene component may offer the optimum combination of osseointegration and anatomical loading.

The formation of a painful neuroma after operations on the medial or lateral sides of the elbow is a common problem. Our aim was to determine the relationship of the cutaneous nerves to the three usual skin incisions around the elbow. In 18 freshly frozen cadaver arms we made three standard 16 cm incisions in the skin medially, laterally, and posteriorly and explored them using loupe magnification. The number of nerves crossing each incision was determined by gross observation and their diameter measured by electronic microcallipers. In ten arms, biopsies of the nerves in each incision were sent for histological examination. We found significantly more cutaneous nerves crossing the medial and lateral incisions than the posterior. The diameter of the nerves crossing the posterior incision was significantly smaller than those crossing the lateral incision. Cutaneous nerves are at considerable risk of injury when medial or lateral incisions are used to approach the elbow, but the posterior approach carries less hazard. The routine use of the posterior incision may reduce the incidence of symptomatic paraesthesia and the formation of a painful neuroma after operation

Aims

We present the development of a day-case total hip arthroplasty (THA) pathway in a UK National Health Service institution in conjunction with an extensive evidence-based summary of the interventions used to achieve successful day-case THA to which the protocol is founded upon.

We performed a biomechanical study on human cadaver spines to determine the effect of three different interbody cage designs, with and without posterior instrumentation, on the three-dimensional flexibility of the spine. Six lumbar functional spinal units for each cage type were subjected to multidirectional flexibility testing in four different configurations: intact, with interbody cages from a posterior approach, with additional posterior instrumentation, and with cross-bracing. The tests involved the application of flexion and extension, bilateral axial rotation and bilateral lateral bending pure moments. The relative movements between the vertebrae were recorded by an optoelectronic camera system. We found no significant difference in the stabilising potential of the three cage designs. The cages used alone significantly decreased the intervertebral movement in flexion and lateral bending, but no stabilisation was achieved in either extension or axial rotation. For all types of cage, the greatest stabilisation in flexion and extension and lateral bending was achieved by the addition of posterior transpedicular instrumentation. The addition of cross-bracing to the posterior instrumentation had a stabilising effect on axial rotation. The bone density of the adjacent vertebral bodies was a significant factor for stabilisation in flexion and extension and in lateral bending