We studied 108 patients (116 hips) who were followed for a minimum of six years (73 to 89 months) after primary total hip arthroplasty using an uncemented porous-coated anatomic hip. The average age of the patients at operation was 48.4 years, and the diagnosis was avascular necrosis of the femoral head in 46 hips, neglected femoral neck fracture in 27, osteoarthritis secondary to childhood pyogenic arthritis in 24 and to childhood tuberculous arthritis in five, and miscellaneous in 14. The average preoperative Harris hip score was 55, which improved to 91 at latest follow-up. All patients with loose femoral components or disabling thigh pain had received prostheses which were undersized in the coronal or the sagittal plane, or in both. No patient with a satisfactory fit in both coronal and sagittal planes had loosening of the femoral component or disabling thigh pain. Three acetabular components showed aseptic loosening and 20 showed excessive wear (5 to 11 mm) of the polyethylene liner. Excessive wear was related to young age, but not to body-weight, gender, primary diagnosis, hip score, or range of hip movement. There was a high incidence of osteolysis (38 of 116 hips, 33%). We recommend careful preoperative planning, with the use of a contemporary cemented technique when a satisfactory fit cannot be obtained. The high incidence of excessive wear and of osteolysis needs further investigation

We performed a retrospective study to assess the long-term outcome of non-augmented anatomical direct repair of the lateral ankle ligaments, as originally described by Duquennoy et al, for the treatment of chronic lateral instability of the ankle. This procedure aims to restore stability by the re-insertion and tightening of the original talofibular and calcaneofibular ligaments without division of the ligament. We examined the outcome in terms of the post-operative quality of life, the function of the joint and the development of osteoarthritis. Between 1985 and 2002, 23 patients (11 males, 12 females) with a mean age of 32 years (15 to 58) who had undergone this procedure completed the Short-Form 36 assessment of quality of life and the Olerud and Molander Ankle score for the subjective evaluation of symptoms. Clinical re-evaluation, including examination of the ankle and the completion of the American Orthopaedic Foot and Ankle Society questionnaire was performed on 21 patients after a mean follow-up of 13 years (3 to 22.2). At the final follow-up radiographs of both ankles were taken to assess the development of osteoarthritis. The mean total Short-Form 36 and Olerud and Molander Ankle scores in 23 patients at final follow-up were 79.6 points (37 to 100) and 81.6 points (40 to 100), respectively. The mean total post-operative American Orthopaedic Foot and Ankle Society score in 21 patients was 89.7 points (72 to 100). We found a significant post-operative reduction in talar tilt and anterior drawer sign (chi-squared test, p < 0.001). The functional outcome of the procedure was excellent in ten patients (48%), good in seven (33%) and fair in four (19%). The results in terms of ankle function and stability did not deteriorate with time and there was little restriction in movement. This procedure is simple and effective with a very low rate of complications

Aims

Several studies have reported the safety and efficacy of subcapital re-alignment for patients with slipped capital femoral epiphysis (SCFE) using surgical dislocation of the hip and an extended retinacular flap. Instability of the hip and dislocation as a consequence of this surgery has only recently gained attention. We discuss this problem with some illustrative cases.

We conducted a prospective randomised trial to compare the results of anatomical reduction and medial displacement osteotomy in 127 consecutive patients with unstable intertrochanteric fractures, of whom 109 completed the study. After an average follow-up of 11 months, we found no significant differences in walking ability, social status or failure of fixation in the two groups. Postoperative complication rates and the early mortality rate were not significantly different, but operating time and blood loss were significantly higher in the osteotomy group. With the use of modern sliding hip screws, medial displacement osteotomy is rarely indicated for unstable intertrochanteric fractures

We dissected 105 cadaveric shoulders to study the origin of the tendon of the long head of biceps, and examined histologically the interrelationship between the tendon, the supraglenoid tubercle and the superior labrum of the glenoid. In all specimens approximately 50% of the biceps tendon arose directly from the superior glenoid labrum with the remainder attached to the supraglenoid tubercle. The main labral origin was from the posterior labrum in more than half of the specimens, and in a quarter this was the only labral attachment. On the basis of the biceps attachment to the anterior or posterior labrum, we distinguished four types of origin. These normal anatomical variations are significant for arthroscopic diagnosis and may help to explain the various patterns of injury seen in partial or complete detachment of the tendon, the labrum or both

We report a prospective, randomised, controlled trial of 50 severely displaced comminuted Colles' fractures treated by either external fixation or manipulation and plaster. Each patient was assessed radiographically throughout treatment, and functionally by an independent observer at three and six months. The functional result correlated with the anatomical result, which was significantly better in patients treated by external fixation. This resulted in significantly improved function especially in young patients, and also a lower complication rate. We recommend the use of external fixation for young patients with comminuted displaced Colles' fractures unless manipulation and plaster show excellent reduction

Aims

This study analysed the clinical and radiological outcome of anatomical reduction of a moderate or severe stable slipped capital femoral epiphysis (SCFE) treated by subcapital osteotomy (a modified Dunn osteotomy) through the surgical approach described by Ganz.

Low-energy fractures of the proximal humerus indicate osteoporosis and it is important to direct treatment to this group of patients who are at high risk of further fracture. Data were prospectively collected from 79 patients (11 men, 68 women) with a mean age of 69 years (55 to 86) with fractures of the proximal humerus in order to determine if current guidelines on the measurement of the bone mineral density at the hip and lumbar spine were adequate to stratify the risk and to guide the treatment of osteoporosis. Bone mineral density measurements were made by dual-energy x-ray absorptiometry at the proximal femur, lumbar spine (L2-4) and contralateral distal radius, and the T-scores were generated for comparison. Data were also collected on the use of steroids, smoking, the use of alcohol, hand dominance and comorbidity.

The mean T-score for the distal radius was −2.97 (sd 1.56) compared with −1.61 (sd 1.62) for the lumbar spine and −1.78 (sd 1.33) for the femur. There was a significant difference between the mean lumbar and radial T scores (1.36 (1.03 to 1.68); p < 0.001) and between the mean femoral and radial T-scores (1.18 (0.92 to 1.44); p < 0.001). The inclusion of all three sites in the determination of the T-score increased the sensitivity to 66% compared with that of 46% when only the proximal femur and lumbar spine were used. This difference between measurements in the upper limb compared with the axial skeleton and lower limb suggests that basing risk assessment and treatment on only the bone mineral density taken at the hip or lumbar spine may misrepresent the extent of osteoporosis in the upper limb and the subsequent risk of fracture at this site.

The assessment of osteoporosis must include measurement of the bone mineral density at the distal radius to avoid underestimation of osteoporosis in the upper limb.

We describe a medial midline portal between the tendons of extensor hallucis longus and tibialis anterior for arthroscopy of the ankle. We dissected 20 cadaver specimens to compare the risk of neurovascular injury using this approach with that of using standard arthroscopic portals. Compared with the anterocentral portal, the medial midline was a mean of 11.2 mm further from the nearest branch of the superficial peroneal nerve and 10.3 mm further from the dorsalis pedis artery.

This portal allows good access to the joint surface and intra-articular structures and has a lower risk of injury to the dorsalis pedis artery, deep peroneal nerve or the medial branch of the superficial peroneal nerve.

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.

We report the incidence of osteolysis in the femur, tibia, and patella of 44 consecutive patients (60 knees) who were followed for more than seven years after cementless knee arthroplasty with a Porous-Coated Anatomic prosthesis. The average age of the patients was 56.5 years (17 to 73); the operative diagnosis was osteoarthritis (33 knees), rheumatoid arthritis (17), tuberculous arthritis (7) and post-traumatic arthritis (3). All patellae were resurfaced. No femoral or tibial component was loose at the final follow-up examination. Thirty patellar components were loose of which six had been revised. Radiographs revealed osteolysis in 90% of the tibial plateaux and in 80% of the 30 intact patellar prostheses. No osteolysis was seen around any femoral component. In 50 knees (83%) the average wear of the polyethylene liner was 2.5 mm in the medial compartment and 1.7 mm in the lateral compartment. Four of 60 knees (6.7%) were revised for complete wear of the polyethylene liner of the tibial component. Fixation of the tibial and patellar components without cement fails to seal the interface between bone and prosthesis and allows the migration of polyethylene particulate debris which causes osteolysis.

In a prospective, controlled study 58 patients aged under 60 years with Colles' fractures were treated either by a forearm plaster or by the application of an external fixator. In 94% of those treated by a fixator it was possible to insert the distal pins of the frame into the fracture fragment, the fixation obtained being sufficient to forgo additional splintage. The external fixator proved more effective at holding the manipulated position, and the radiological loss of position during fracture union was minimal compared with that seen in patients treated in plaster.

The findings in a child with bilateral congenital dislocation of the hips who died shortly after birth are described. The only significant abnormality present was redundancy of the capsular ligaments and elongation of the ligament of the femoral head. The relationship between the orientation of the femoral neck and of the acetabulum was within normal limits. The significance of these findings in relation to etiology and management are discussed.

The emergence of minimally-invasive total knee replacement (TKR) has led to the refinement of several surgical approaches, including the quadriceps-sparing and sub-vastus. There is some disagreement as to the precise definition of the term ‘minimally-invasive’, especially in regard to the preservation of vastus medialis obliquus (VMO). It is known that the termination of VMO is variable and may make these approaches difficult. We have attempted to assess the factors influencing the insertion of VMO and the impact which they have on the approach for TKR.

The MR scans of 198 knees were examined to assess the variation in the insertion of VMO in relation to the patella and the effect of variables such as age, gender and the presence of concurrent osteoarthritis of the knee on the insertion.

Our findings showed that both age and the presence of osteoarthritis were contributing factors to changes in the level of insertion of VMO. Therefore, not all capsular incisions which extend proximal to the midpole of the patella will violate the quadriceps tendon.

The optimal management of the tibial slope in achieving a high flexion angle in posterior-stabilised (PS) total knee replacement (TKR) is not well understood, and most studies evaluating the posterior tibial slope have been conducted on cruciate-retaining TKRs. We analysed pre- and post-operative tibial slope differences, pre- and post-operative coronal knee alignment and post-operative maximum flexion angle in 167 patients undergoing 209 TKRs. The mean pre-operative posterior tibial slope was 8.6° (1.3° to 17°) and post-operatively it was 8.0° (0.1° to 16.7°). Multiple linear regression analysis showed that the absolute difference between pre- and post-operative tibial slope (p < 0.001), post-operative coronal alignment (p = 0.02) and pre-operative range of movement (p < 0.001) predicted post-operative flexion. The variance of change in tibial slope became larger as the post-operative maximum flexion angle decreased. The odds ratio of having a post-operative flexion angle < 100° was 17.6 if the slope change was > 2°. Our data suggest that recreation of the anatomical tibial slope appears to improve maximum flexion after posterior-stabilised TKR, provided coronal alignment has been restored.

Cite this article: Bone Joint J 2013;95-B:1354–8.