Between October 2001 and September 2009 we lengthened 242 lower-limb segments in 180 patients using the Intramedullary Skeletal Kinetic Distractor (ISKD). Mechanical failure was defined either as breakage of the ISKD or failure of the internal mechanism to activate. Retrieved nails which failed mechanically were examined by the manufacturer for defects. In all, 15 ISKDs in 12 patients (13 limbs) failed mechanically representing an overall failure rate of 6.2%, with fracture of the device occurring in ten of the 15 failures. Two nails in one patient failed to lengthen and had to be replaced. The manufacturer detected an error in the assembly of the nail, which prompted a wide recall. One nail jammed after being forcefully inserted, and two nails failed to lengthen fully. Lengthening was achieved in all 12 patients, although three required a second operation to exchange a defective nail for a new, functioning device. The ISKD is a complex mechanical device which lengthens by the oscillation of two telescopic sections connected by a threaded rod. The junction between these sections is surrounded by a keyring collar. This keyring collar is the weakest part of the device.
Bone sarcomas are rare cancers and orthopaedic
surgeons come across them infrequently, sometimes unexpectedly during
surgical procedures. We investigated the outcomes of patients who
underwent a surgical procedure where sarcomas were found unexpectedly
and were subsequently referred to our unit for treatment. We identified
95 patients (44 intra-lesional excisions, 35 fracture fixations,
16 joint replacements) with mean age of 48 years (11 to 83); 60%
were males (n = 57). Local recurrence arose in 40% who underwent
limb salvage surgery Cite this article:
A delay in establishing the diagnosis of an occult
fracture of the hip that remains unrecognised after plain radiography
can result in more complex treatment such as an arthroplasty being
required. This might be avoided by earlier diagnosis using MRI.
The aim of this study was to investigate the best MR imaging sequence
for diagnosing such fractures. From a consecutive cohort of 771
patients admitted between 2003 and 2011 with a clinically suspected
fracture of the hip, we retrospectively reviewed the MRI scans of
the 35 patients who had no evidence of a fracture on their plain
radiographs. In eight of these patients MR scanning excluded a fracture
but the remaining 27 patients had an abnormal scan: one with a fracture
of the pubic ramus, and in the other 26 a T1-weighted
coronal MRI showed a hip fracture with 100% sensitivity. T2-weighted
imaging was undertaken in 25 patients, in whom the diagnosis could
not be established with this scanning sequence alone, giving a sensitivity
of 84.0% for T2-weighted imaging. If there is a clinical suspicion of a hip fracture with normal
radiographs, T1-weighted coronal MRI is the best sequence
of images for identifying a fracture.
This review considers the surgical treatment
of displaced fractures involving the knee in elderly, osteoporotic patients.
The goals of treatment include pain control, early mobilisation,
avoidance of complications and minimising the need for further surgery.
Open reduction and internal fixation (ORIF) frequently results in
loss of reduction, which can result in post-traumatic arthritis
and the occasional conversion to total knee replacement (TKR). TKR
after failed internal fixation is challenging, with modest functional
outcomes and high complication rates. TKR undertaken as treatment
of the initial fracture has better results to late TKR, but does
not match the outcome of primary TKR without complications. Given
the relatively infrequent need for late TKR following failed fixation,
ORIF is the preferred management for most cases. Early TKR can be
considered for those patients with pre-existing arthritis, bicondylar
femoral fractures, those who would be unable to comply with weight-bearing restrictions,
or where a single definitive procedure is required.
Femoroacetabular impingement causes groin pain
and decreased athletic performance in active adults. This bony conflict
may result in femoroacetabular subluxation if of sufficient magnitude. The ligamentum teres has recently been reported to be capable
of withstanding tensile loads similar to that of the anterior cruciate
ligament, and patents with early subluxation of the hip may become
dependent on the secondary restraint that is potentially provided
by the ligamentum teres. Rupture of the ligamentum may thus cause
symptomatic hip instability during athletic activities. An arthroscopic reconstruction of the ligamentum teres using
iliotibial band autograft was performed in an attempt to restore
this static stabiliser in a series of four such patients. Early
clinical results have been promising. The indications, technique
and early outcomes of this procedure are discussed.
Few studies have examined the order in which
a spinal osteotomy and total hip replacement (THR) are to be performed
for patients with ankylosing spondylitis. We have retrospectively
reviewed 28 consecutive patients with ankylosing spondylitis who
underwent both a spinal osteotomy and a THR from September 2004
to November 2012. In the cohort 22 patients had a spinal osteotomy
before a THR (group 1), and six patients had a THR before a spinal
osteotomy (group 2). The mean duration of follow-up was 3.5 years
(2 to 9). The spinal sagittal Cobb angle of the vertebral osteotomy
segment was corrected from a pre-operative kyphosis angle of 32.4
(SD 15.5°) to a post-operative lordosis 29.6 (SD 11.2°) (p <
0.001). Significant improvements in pain, function and range of
movement were observed following THR. In group 2, two of six patients
had an early anterior dislocation. The spinal osteotomy was performed
two weeks after the THR. At follow-up, no hip has required revision
in either group. Although this non-comparative study only involved
a small number of patients, given our experience, we believe a spinal osteotomy
should be performed prior to a THR, unless the deformity is so severe
that the procedure cannot be performed. Cite this article:
The objective of this study was to determine if a synthetic bone
substitute would provide results similar to bone from osteoporotic
femoral heads during Pushout studies were performed with the dynamic hip screw (DHS)
and the DHS Blade in both cadaveric femoral heads and artificial
bone substitutes in the form of polyurethane foam blocks of different
density. The pushout studies were performed as a means of comparing
the force displacement curves produced by each implant within each
material.Introduction
Methods
Progressive retroversion of a cemented stem is
predictive of early loosening and failure. We assessed the relationship
between direct post-operative stem anteversion, measured with CT,
and the resulting rotational stability, measured with repeated radiostereometric
analysis over ten years. The study comprised 60 cemented total hip
replacements using one of two types of matt collared stem with a
rounded cross-section. The patients were divided into three groups
depending on their measured post-operative anteversion (<
10°,
10° to 25°, >
25°). There was a strong correlation between direct
post-operative anteversion and later posterior rotation. At one
year the <
10° group showed significantly more progressive retroversion
together with distal migration, and this persisted to the ten-year
follow-up. In the <
10° group four of ten stems (40%) had been
revised at ten years, and an additional two stems (20%) were radiologically
loose. In the ‘normal’ (10° to 25°) anteversion group there was
one revised (3%) and one loose stem (3%) of a total of 30 stems,
and in the >
25° group one stem (5%) was revised and another loose (5%)
out of 20 stems. This poor outcome is partly dependent on the design
of this prosthesis, but the results strongly suggest that the initial
rotational position of cemented stems during surgery affects the
subsequent progressive retroversion, subsidence and eventual loosening.
The degree of retroversion may be sensitive to prosthetic design
and stem size, but <
10° of anteversion appears deleterious to
the long-term outcome for cemented hip prosthetic stems. Cite this article:
The aim of this retrospective cohort study was
to identify any difference in femoral offset as measured on pre-operative
anteroposterior (AP) radiographs of the pelvis, AP radiographs of
the hip and corresponding CT scans in a consecutive series of 100
patients with primary end-stage osteoarthritis of the hip (43 men
and 57 women with a mean age of 61 years (45 to 74) and a mean body
mass index of 28 kg/m2 (20 to 45)). Patients were positioned according to a standardised protocol
to achieve reproducible projection and all images were calibrated.
Inter- and intra-observer reliability was evaluated and agreement
between methods was assessed using Bland-Altman plots. In the entire cohort, the mean femoral offset was 39.0 mm (95%
confidence interval (CI) 37.4 to 40.6) on radiographs of the pelvis,
44.0 mm (95% CI 42.4 to 45.6) on radiographs of the hip and 44.7
mm (95% CI 43.5 to 45.9) on CT scans. AP radiographs of the pelvis
underestimated femoral offset by 13% when compared with CT (p <
0.001).
No difference in mean femoral offset was seen between AP radiographs
of the hip and CT (p = 0.191). Our results suggest that femoral offset is significantly underestimated
on AP radiographs of the pelvis but can be reliably and accurately
assessed on AP radiographs of the hip in patients with primary end-stage
hip osteoarthritis. We, therefore, recommend that additional AP radiographs of the
hip are obtained routinely for the pre-operative assessment of femoral
offset when templating before total hip replacement.
We conducted a retrospective study to investigate the effect of femoral bowing on the placement of components in total knee replacement (TKR), with regard to its effect on reestablishing the correct mechanical axis, as we hypothesised that computer-assisted total knee replacement (CAS-TKR) would produce more accurate alignment than conventional TKR. Between January 2006 and December 2009, 212 patients (306 knees) underwent TKR. The conventional TKR was compared with CAS-TKR for accuracy of placement of the components and post-operative alignment, as determined by five radiological measurements. There were significant differences in the reconstructed mechanical axes between the bowed and the non-bowed group after conventional TKR (176.2° ( For patients with significant femoral bowing, the reconstructed mechanical axes were significantly closer to normal in the CAS group than in the conventional group (179.2° (
Revision after failed femoral components may
be technically demanding due to loss of peri-prosthetic bone. This retrospective
study evaluated the long-term results of femoral revision using
the cementless Wagner Self-Locking stem. Between 1992 and 1998,
68 consecutive hips in 66 patients underwent femoral revision using
this implant. A total of 25 patients died from unrelated causes
without further revision; the remaining 41 hips in 41 patients (12 men
and 29 women) with a mean age of 61 years (29 to 80) were reviewed
at a mean follow-up of 13.9 years (10.4 to 15.8). A transfemoral
approach was used in 32 hips. A total of five stems required further
revision because of infection in two, progressive subsidence in
two and recurrent dislocation in one. Four hips had dislocated and
eight stems had subsided ≥ 10 mm. The mean Harris hip score improved
from 33 points pre-operatively to 75 points at final follow-up (p
<
0.001). In all, 33 stems (91.7%) showed radiological signs
of stable bone fixation. The cumulative survival rates at 15.8 years
with femoral revision for any reason and for stem failure as the
endpoints were 92.0% (95% confidence interval (CI) 86.0% to 98.4%)
and 96.6% (95% CI 92.2% to 100%), respectively. The survivorship
with revision and ≥ 10 mm migration of the stem as the endpoint
was 83.6% (95% CI 76.6% to 91.4%). This study shows quite good survival and moderate clinical outcome
when using a monoblock tapered titanium stem for supporting the
regeneration of bone in complex revision hip surgery.
We report the short-term follow-up, functional
outcome and incidence of early and late infection after total hip replacement
(THR) in a group of HIV-positive patients who do not suffer from
haemophilia or have a history of intravenous drug use. A total of
29 patients underwent 43 THRs, with a mean follow-up of three years
and six months (five months to eight years and two months). There
were ten women and 19 men, with a mean age of 47 years and seven
months (21 years to 59 years and five months). No early (<
6
weeks) or late (>
6 weeks) complications occurred following their
THR. The mean pre-operative Harris hip score (HHS) was 27 (6 to
56) and the mean post-operative HHS was 86 (73 to 91), giving a
mean improvement of 59 points (p = <
0.05, Student’s Cite this article:
The technical advances in arthroscopic surgery
of the hip, including the improved ability to manage the capsule
and gain extensile exposure, have been paralleled by a growth in
the number of conditions that can be addressed. This expanding list
includes symptomatic labral tears, chondral lesions, injuries of
the ligamentum teres, femoroacetabular impingement (FAI), capsular
laxity and instability, and various extra-articular disorders, including snapping
hip syndromes. With a careful diagnostic evaluation and technical
execution of well-indicated procedures, arthroscopic surgery of
the hip can achieve successful clinical outcomes, with predictable
improvements in function and pre-injury levels of physical activity
for many patients. This paper reviews the current position in relation to the use
of arthroscopy in the treatment of disorders of the hip. Cite this article:
We compared case-mix and outcome variables in 1310 patients who sustained an acute fracture at the age of 80 years or over. A group of 318 very elderly patients (≥ 90 years) was compared with a group of 992 elderly patients (80 to 89 years), all of whom presented to a single trauma unit between July 2007 and June 2008. The very elderly group represented only 0.6% of the overall population, but accounted for 4.1% of all fractures and 9.3% of all orthopaedic trauma admissions. Patients in this group were more likely to require hospital admission (odds ratio 1.4), less likely to return to independent living (odds ratio 3.1), and to have a significantly longer hospital stay (ten days, p = 0.01). The 30- and 120-day unadjusted mortality was greater in the very elderly group. The 120-day mortality associated with non-hip fractures of the lower limb was equal to that of proximal femoral fractures, and was significantly increased with a delay to surgery >
48 hours for both age groups (p = 0.04). This suggests that the principle of early surgery and mobilisation of elderly patients with hip fractures should be extended to include all those in this vulnerable age group.
This conversation represents an attempt by several
arthroplasty surgeons to critique several abstracts presented over
the last year as well as to use them as a jumping off point for trying
to figure out where they fit in into our current understanding of
multiple issues in modern hip and knee arthroplasty.
We present the extended follow-up (≥ 20 years)
of a series of fully hydroxyapatite-coated femoral components used in
72 primary total hip replacements (THRs). Earlier results of this
cohort have been previously published. All procedures were performed
between 1986 and 1991. The series involved 45 women and 15 men with
12 bilateral procedures. Their mean age at the time of surgery was
60 years (46 to 80) and the mean duration of follow-up was 22.5
years (20 to 25). At final follow-up, the mean Merle d’Aubigné and
Postel hip scores were 5.5 (4.5 to 6), 3.8 (3.5 to 5) and 3.3 (3.0
to 5.0) for pain, mobility and function, respectively. Of the patients
92% were very satisfied at the time of final follow-up. There were seven revisions: six of the acetabular component for
aseptic loosening and one of both the stem and the acetabular component
for loosening due to deep infection. The survival of this prosthesis
at 22.5 years with revision for any reason as the endpoint was 91.7%
(95% confidence interval (CI) 84 to 99). Survival with aseptic loosening
of the stem as the endpoint was 100% (95% CI 90 to 100). This prosthesis provides pain relief in the long term. Survival
of this component is comparable to the best results for primary
THR with any means of fixation. Cite this article:
The removal of all prosthetic material and a
two-stage revision procedure is the established standard management of
an infected total hip replacement (THR). However, the removal of
well-fixed femoral cement is time-consuming and can result in significant
loss of bone stock and femoral shaft perforation or fracture. We
report our results of two-stage revision THR for treating infection,
with retention of the original well-fixed femoral cement mantle
in 15 patients, who were treated between 1989 and 2002. Following
partial excision arthroplasty, patients received local and systemic
antibiotics and underwent reconstruction and re-implantation at
a second-stage procedure, when the infection had resolved. The mean follow-up of these 15 patients was 82 months (60 to
192). Two patients had positive microbiology at the second stage
and were treated with six weeks of appropriate antibiotics; one
of these developed recurrent infection requiring further revision.
Successful eradication of infection was achieved in the remaining
14 patients. We conclude that when two-stage revision is used for the treatment
of peri-prosthetic infection involving a THR, a well-fixed femoral
cement mantle can be safely left
The February 2014 Children’s orthopaedics Roundup360 looks at: flexible plasters; dual 8-plate or ablation for knee epiphysiodesis; ultrasounds for pulled elbow; leg length without the radiation; Boyd amputation in limb deficiencies; gold standard club foot treatment; quadrupled semitendinosis graft effective in paediatric ACL reconstruction; and predicting complications following cerebral palsy hip reconstruction
Total hip replacement (THR) still is a rare intervention
in many African countries. In Burkina Faso it is not performed on
a regular basis. A visiting programme for THR was started in a district
hospital with no previous relevant experience. In this paper we
present an analysis of the surgical technical problems and peri-operative
complications of 152 THRs in 136 patients and three bipolar hemiarthroplasties
in three patients undertaken in this new programme with limited
orthopaedic equipment. There were 86 male and 53 female patients
with a mean age of 49 years (21 to 78). We identified 77 intra-operative
technical problems in 51 operations. There were 24 peri-operative complications
in 21 patients, 17 of which were bony in nature. So far, ten revision
THRs have been performed in nine patients. Regular analysis of the technical problems and complications
was used to improve quality, and we identified patient selection
adapted to the local circumstances as important to avoid complications.
Our reflections on the problems encountered in initiating such a
programme may be of help to other teams planning similar projects. Cite this article:
In Japan, osteoarthritis (OA) of the hip secondary
to acetabular dysplasia is very common, and there are few data concerning
the pathogeneses and incidence of femoroacetabular impingement (FAI).
We have attempted to clarify the radiological prevalence of painful
FAI in a cohort of Japanese patients and to investigate the radiological findings.
We identified 176 symptomatic patients (202 hips) with Tönnis grade
0 or 1 osteoarthritis, whom we prospectively studied between August
2011 and July 2012. There were 61 men (65 hips) and 115 women (137
hips) with a mean age of 51.8 years (11 to 83). Radiological analyses
included the α-angle, centre–edge angle, cross-over sign, pistol
grip deformity and femoral head neck ratio. Of the 202 hips, 79
(39.1%) had acetabular dysplasia, while 80 hips (39.6%) had no known
aetiology. We found evidence of FAI in 60 hips (29.7%). Radiological
FAI findings associated with cam deformity were the most common.
There was a significant relationship between the pistol grip deformity
and both the α-angle (p <
0.001) and femoral head–neck ratio
(p = 0.024). Radiological evidence of symptomatic FAI was not uncommon
in these Japanese patients. Cite this article: