Background

Approximately half of all hip fractures are displaced intracapsular fractures. The standard treatment for these fractures is either hemiarthroplasty or total hip arthroplasty. The recent National Institute for Health and Care Excellence (NICE) guidance on hip fracture management recommends the use of ‘proven’ cemented stem arthroplasty with an Orthopaedic Device Evaluation Panel (ODEP) rating of at least 3B (97% survival at three years). The Thompsons prosthesis is currently lacking an ODEP rating despite over 50 years of clinical use, likely due to the paucity of implant survival data. Nationally, adherence to these guidelines is varied as there is debate as to which prosthesis optimises patient outcomes.

Sciatic nerve palsy following total hip arthroplasty (THA) is a relatively rare yet potentially devastating complication. The purpose of this case series was to report the results of patients with a sciatic nerve palsy who presented between 2000 and 2010, following primary and revision THA and were treated with neurolysis. A retrospective review was made of 12 patients (eight women and four men), with sciatic nerve palsy following THA. The mean age of the patients was 62.7 years (50 to 72; standard deviation 6.9). They underwent interfascicular neurolysis for sciatic nerve palsy, after failing a trial of non-operative treatment for a minimum of six months. Following surgery, a statistically and clinically significant improvement in motor function was seen in all patients. The mean peroneal nerve score function improved from 0.42 (0 to 3) to 3 (1 to 5) (p < 0.001). The mean tibial nerve motor function score improved from 1.75 (1 to 4) to 3.92 (3 to 5) (p = 0.02).The mean improvement in sensory function was a clinically negligible 1 out of 5 in all patients. In total, 11 patients reported improvement in their pain following surgery.

We conclude that neurolysis of the sciatic nerve has a favourable prognosis in patients with a sciatic nerve palsy following THA. Our findings suggest that surgery should not be delayed for > 12 months following injury.

Cite this article: Bone Joint J 2015;97-B:1345–9

We hypothesised that the removal of the subchondral bone plate (SCBP) for cemented acetabular component fixation in total hip arthroplasty (THA) offers advantages over retention by improving the cement-bone interface, without jeopardising implant stability. We have previously published two-year follow-up data of a randomised controlled trial (RCT), in which 50 patients with primary osteoarthritis were randomised to either retention or removal of the SCBP. The mean age of the retention group (n = 25, 13 males) was 70.0 years (sd 6.8). The mean age in the removal group (n = 25, 16 males) was 70.3 years (sd 7.9). Now we have followed up the patients at six (retention group, n = 21; removal group, n = 20) and ten years (retention group: n = 17, removal group: n = 18), administering clinical outcome questionnaires and radiostereometric analysis (RSA), and determining the presence of radiolucent lines (RLLs) on conventional radiographs. RSA demonstrated similar translation and rotation patterns up to six years. Between six and ten years, proximal acetabular component migration and changes of inclination were larger in the retention group, although the mean differences did not reach statistical significance. Differences in migration were driven by two patients in the SCBP retention group with extensive migration versus none in the SCBP removal group. The significant difference (p < 0.001) in the development of radiolucent lines in the retention group, previously observed at two years, increased even further during the course of follow-up (p < 0.001). While recognising SCBP removal is a more demanding technique, we conclude that, wherever possible, the SCBP should be removed to improve the cement–bone interface in order to maximise acetabular component stability and longevity.

Cite this article: Bone Joint J 2015;97-B:35–44.

We compared the incidence of pseudotumours after large head metal-on-metal (MoM) total hip arthroplasty (THA) with that after conventional metal-on-polyethylene (MoP) THA and assessed the predisposing factors to pseudotumour formation.

From a previous randomised controlled trial which compared large head (38 mm to 60 mm) cementless MoM THA with conventional head (28 mm) cementless MoP THA, 93 patients (96 THAs: 41 MoM (21 males, 20 females, mean age of 64 years, standard deviation (sd) 4) and 55 MoP (25 males, 30 females, mean age of 65 years, sd 5) were recruited after a mean follow-up of 50 months (36 to 64).

The incidence of pseudotumours, measured using a standardised CT protocol was 22 (53.7%) after MoM THA and 12 (21.8%) after MoP THA. Women with a MoM THA were more likely to develop a pseudotumour than those with a MoP THA (15 vs 7, odds ratio (OR) = 13.4, p < 0.001). There was a similar incidence of pseudotumours in men with MoM THAs and those with MoP THAs (7 vs 5, OR = 2.1, p = 0.30). Elevated cobalt levels (≥ 5 microgram/L) were only associated with pseudotumours in women with a MoM THA. There was no difference in mean Oxford and Harris hip scores between patients with a pseudotumour and those without.

Contrary to popular belief, pseudotumours occur frequently around MoP THAs. Women with a MoM THA and an elevated cobalt level are at greatest risk. In this study, pseudotumours had no effect on the functional outcome after either large head MoM or conventional MoP THA.

Cite this article: Bone Joint J 2015;97-B:1481–7.

Vascular injuries during total hip arthroplasty (THA) are rare but when they occur, have serious consequences. These have traditionally been managed with open exploration and repair, but more recently there has been a trend towards percutaneous endovascular management.

We performed a systematic review of the literature to assess if this change in trend has led to an improvement in the overall reported rates of morbidity and mortality during the last 22 years in comparison with the reviews of the literature published previously.

We found a total of 61 articles describing 138 vascular injuries in 124 patients. Injuries because of a laceration were the most prevalent (n = 51, 44%) and the most common presenting feature, when recorded, was bleeding (n = 41, 53.3%). Delay in diagnosis was associated with the type of vascular lesion (p < 0.001) and the clinical presentation (p = 0.002).

Open exploration and repair was the most common form of management, however percutaneous endovascular intervention was used in one third of the injuries and more constantly during the last 13 years.

The main overall reported complications included death (n = 9, 7.3%), amputation (n = 2, 1.6%), and persistent ischaemia (n = 9, 7.3%). When compared with previous reviews there was a similar rate of mortality but lower rates of amputation and permanent disability, especially in patients managed by endovascular strategies.

Cite this article: Bone Joint J 2015;97-B:1447–55.

We present the results of 62 consecutive acetabular revisions using impaction bone grafting and a cemented polyethylene acetabular component in 58 patients (13 men and 45 women) after a mean follow-up of 27 years (25 to 30). All patients were prospectively followed. The mean age at revision was 59.2 years (23 to 82).

We performed Kaplan–Meier (KM) analysis and also a Competing Risk (CR) analysis because with long-term follow-up, the presence of a competing event (i.e. death) prevents the occurrence of the endpoint of re-revision.

A total of 48 patients (52 hips) had died or had been re-revised at final review in March 2011. None of the deaths were related to the surgery. The mean Harris hip score of the ten surviving hips in ten patients was 76 points (45 to 99).

The KM survivorship at 25 years for the endpoint ‘re-revision for any reason’ was 58.0% (95% confidence interval (CI) 38 to 73) and for ‘re-revision for aseptic loosening’ 72.1% (95% CI 51 to 85). With the CR analysis we calculated the KM analysis overestimates the failure rate with respectively 74% and 93% for these endpoints. The current study shows that acetabular impaction bone grafting revisions provide good clinical results at over 25 years.

Cite this article: Bone Joint J 2015;97-B:1338–44.

We evaluated the oncological and functional outcome of 18 patients, whose malignant bone tumours were excised with the assistance of navigation, and who were followed up for more than three years. There were 11 men and seven women, with a mean age of 31.8 years (10 to 57). There were ten operations on the pelvic ring and eight joint-preserving limb salvage procedures. The resection margins were free of tumour in all specimens. The tumours, which were stage IIB in all patients, included osteosarcoma, high-grade chondrosarcoma, Ewing’s sarcoma, malignant fibrous histiocytoma of bone, and adamantinoma. The overall three-year survival rate of the 18 patients was 88.9% (95% confidence interval (CI) 75.4 to 100). The three-year survival rate of the patients with pelvic malignancy was 80.0% (95% CI 55.3 to 100), and of the patients with metaphyseal malignancy was 100%. The event-free survival was 66.7% (95% CI 44.9 to 88.5). Local recurrence occurred in two patients, both of whom had a pelvic malignancy. The mean Musculoskeletal Tumor Society functional score was 26.9 points at a mean follow-up of 48.2 months (22 to 79).

We suggest that navigation can be helpful during surgery for musculoskeletal tumours; it can maximise the accuracy of resection and minimise the unnecessary sacrifice of normal tissue by providing precise intra-operative three-dimensional radiological information.

Controversy remains whether the contralateral hip should be fixed in patients presenting with unilateral slipped capital femoral epiphysis (SCFE). This retrospective study compares the outcomes and cost of those patients who had prophylactic fixation with those who did not.

Between January 2000 and December 2010 a total of 50 patients underwent unilateral fixation and 36 had prophylactic fixation of the contralateral hip. There were 54 males and 32 females with a mean age of 12.3 years (9 to 16). The rate of a subsequent slip without prophylactic fixation was 46%. The risk of complications was greater, the generic health measures (Short Form-12 physical (p < 0.001) and mental (p = 0.004) summary scores) were worse. Radiographic cam lesions in patients presenting with unilateral SCFE were only seen in patients who did not have prophylactic fixation. Furthermore, prophylactic fixation of the contralateral hip was found to be a cost-effective procedure, with a cost per quality adjusted life year gained of £1431 at the time of last follow-up.

Prophylactic fixation of the contralateral hip is a cost-effective operation that limits the morbidity from the complications of a further slip, and the diminished functional outcome associated with unilateral fixation.

Cite this article: Bone Joint J 2015;97-B:1428–34.

This preliminary study evaluates a combination of bone morphogenetic protein (BMP)-7 and non-vascularised autologous fibular grafting (AFG) for the treatment of osteonecrosis of the femoral head.

BMP-7/AFG combination was applied in seven pre-collapse femoral heads (five Steinberg stage II, two stage III) in six patients. Pre- and post-operative evaluation included clinical (Harris hip score (HHS), visual analogue scale (VAS) for pain) and radiological assessment (radiographs, quantitative CT) at a mean follow-up of 4 years (2 to 5.5).

A marked improvement of function (mean HHS increase of 49.2) and decrease of pain level (mean VAS decrease of 5) as well as retention of the sphericity of the femoral head was noted in five hips at the latest follow-up, while signs of consolidation were apparent from the third post-operative month. One patient (two hips) required bilateral total hip replacement at one year post-operatively. In the series as a whole, quantitative-CT evaluation revealed similar densities between affected and normal bone. Heterotopic ossification was observed in four hips, without compromise of the clinical outcome.

In this limited series AFG/BMP-7 combination proved a safe and effective method for the treatment of femoral head osteonecrosis, leading to early consolidation of the AFG and preventing collapse in five of seven hips, while the operative time and post-operative rehabilitation period were much shorter compared with free vascularised fibular grafts.

Cite this article: Bone Joint J 2014;96-B:31–5.

We report our early experience with the use of a new prosthesis, the Modular Hemipelvic Prosthesis II, for reconstruction of the hemipelvis after resection of a primary malignant peri-acetabular tumour involving the sacroiliac joint.

We retrospectively reviewed the outcome of 17 patients who had undergone resection of a pelvic tumour and reconstruction with this prosthesis between July 2002 and July 2010.

One patient had a type I+II+III+IV resection (ilium + peri-acetabulum + pubis/ischium + sacrum) and 16 had a type I+II+IV resection (ilium + acetabulum + sacrum). The outcome was assessed at a mean follow-up of 33 months (15 to 59). One patient was alive with disease, 11 were alive without disease and five had died of disease. The overall five-year survival rate was 62.4%. Six patients had a local recurrence. The mean Musculoskeletal Tumour Society score was 58% (33 to 77). Deep infection occurred in two patients, problems with wound healing in five and dislocation in one.

For patients with a primary malignant peri-acetabular sarcoma involving the sacroiliac joint, we believe that this new prosthesis is a viable option for reconstruction of the bony defect left following resection of the tumour. It results in a satisfactory functional outcome with an acceptable rate of complications.

Cite this article: Bone Joint J 2014;96-B:399–405.

The August 2015 Trauma Roundup³⁶⁰ looks at: Thromboprophylaxis not required in lower limb fractures; Subclinical thyroid dysfunction and fracture risk: moving the boundaries in fracture; Posterior wall fractures refined; Neurological injury and acetabular fracture surgery; Posterior tibial plateau fixation; Tibial plateau fractures in the longer term; Comprehensive orthogeriatric care and hip fracture; Compartment syndrome: in the eye of the beholder?

Hip replacement is a very successful operation and the outcome is usually excellent. There are recognised complications that seem increasingly to give rise to litigation. This paper briefly examines some common scenarios where litigation may be pursued against hip surgeons. With appropriate record keeping, consenting and surgical care, the claim can be successfully defended if not avoided. We hope this short summary will help to highlight some common pitfalls. There is extensive literature available for detailed study.

The use of ilioischial cage reconstruction for pelvic discontinuity has been replaced by the Trabecular Metal (Zimmer, Warsaw, Indiana) cup-cage technique in our institution, due to the unsatisfactory outcome of using a cage alone in this situation. We report the outcome of 26 pelvic discontinuities in 24 patients (20 women and four men, mean age 65 years (44 to 84)) treated by the cup-cage technique at a mean follow-up of 82 months (12 to 113) and compared them with a series of 19 pelvic discontinuities in 19 patients (18 women and one man, mean age 70 years (42 to 86)) treated with a cage at a mean follow-up of 69 months (1 to 170). The clinical and radiological outcomes as well as the survivorship of the groups were compared. In all, four of the cup-cage group (15%) and 13 (68%) of the cage group failed due to septic or aseptic loosening. The seven-year survivorship was 87.2% (95% confidence interval (CI) 71 to 103) for the cup-cage group and 49.9% (95% CI 15 to 84) for the cage-alone group (p = 0.009). There were four major complications in the cup-cage group and nine in the cage group. Radiological union of the discontinuity was found in all successful cases in the cup-cage group and three of the successful cage cases. Three hips in the cup-cage group developed early radiological migration of the components, which stabilised with a successful outcome.

Cup-cage reconstruction is a reliable technique for treating pelvic discontinuity in mid-term follow-up and is preferred to ilioischial cage reconstruction. If the continuity of the bone graft at the discontinuity site is not disrupted, early migration of the components does not necessarily result in failure.

Cite this article: Bone Joint J 2014;96-B:195–200.

We describe the routine imaging practices of Level 1 trauma centres for patients with severe pelvic ring fractures, and the interobserver reliability of the classification systems of these fractures using plain radiographs and three-dimensional (3D) CT reconstructions. Clinical and imaging data for 187 adult patients (139 men and 48 women, mean age 43 years (15 to 101)) with a severe pelvic ring fracture managed at two Level 1 trauma centres between July 2007 and June 2010 were extracted. Three experienced orthopaedic surgeons classified the plain radiographs and 3D CT reconstruction images of 100 patients using the Tile/AO and Young–Burgess systems. Reliability was compared using kappa statistics. A total of 115 patients (62%) had plain radiographs as well as two-dimensional (2D) CT and 3D CT reconstructions, 52 patients (28%) had plain films only, 12 (6.4%) had 2D and 3D CT reconstructions images only, and eight patients (4.3%) had no available images. The plain radiograph was limited to an anteroposterior pelvic view. Patients without imaging, or only plain films, were more severely injured. A total of 72 patients (39%) were imaged with a pelvic binder in situ.

Interobserver reliability for the Tile/AO (Kappa 0.10 to 0.17) and Young–Burgess (Kappa 0.09 to 0.21) was low, and insufficient for clinical and research purposes.

Severe pelvic ring fractures are difficult to classify due to their complexity, the increasing use of early treatment such as with pelvic binders, and the absence of imaging altogether in important patient sub-groups, such as those who die early of their injuries.

Cite this article: Bone Joint J 2013;95-B:1396–1401.

The aim of this study was to investigate the incidence of dysplasia in the ‘normal’ contralateral hip in patients with unilateral developmental dislocation of the hip (DDH) and to evaluate the long-term prognosis of such hips. A total of 48 patients (40 girls and eight boys) were treated for late-detected unilateral DDH between 1958 and 1962. After preliminary skin traction, closed reduction was achieved at a mean age of 17.8 months (4 to 65) in all except one patient who needed open reduction. In 25 patients early derotation femoral osteotomy of the contralateral hip had been undertaken within three years of reduction, and later surgery in ten patients. Radiographs taken during childhood and adulthood were reviewed. The mean age of the patients was 50.9 years (43 to 55) at the time of the latest radiological review.

In all, eight patients (17%) developed dysplasia of the contralateral hip, defined as a centre-edge (CE) angle < 20° during childhood or at skeletal maturity. Six of these patients underwent surgery to improve cover of the femoral head; the dysplasia improved in two after varus femoral osteotomy and in two after an acetabular shelf operation. During long-term follow-up the dysplasia deteriorated to subluxation in two patients (CE angles 4° and 5°, respectively) who both developed osteoarthritis (OA), and one of these underwent total hip replacement at the age of 49 years.

In conclusion, the long-term prognosis for the contralateral hip was relatively good, as OA occurred in only two hips (4%) at a mean follow-up of 50 years. Regular review of the ‘normal’ side is indicated, and corrective surgery should be undertaken in those who develop subluxation.

Cite this article: Bone Joint J 2014; 96-B:1161–6.

Most posterior hindfoot procedures have been described with the patient positioned prone. This affords excellent access to posterior hindfoot structures but has several disadvantages for the management of the airway, the requirement for an endotracheal tube in all patients, difficulty with ventilation and an increased risk of pressure injuries, especially with regard to reduced ocular perfusion.

We describe use of the ‘recovery position’, which affords equivalent access to the posterior aspect of the ankle and hindfoot without the morbidity associated with the prone position. A laryngeal mask rather than endotracheal tube may be used in most patients. In this annotation we describe this technique, which offers a safe and simple alternative method of positioning patients for posterior hindfoot and ankle surgery.

Cite this article: Bone Joint J 2013;95-B:1317–19.

The June 2015 Oncology Roundup³⁶⁰ looks at: Infection in megaprosthesis; Impressive results for mid femoral reconstruction; Revered teaching or old myth? Femoral neck protection in metastatic disease; Megaprosthesis about the knee; Malignant transformation in multiple hereditary exostoses; Fracture of intercalary bone allograft; Comorbidity and outcomes in sarcoma; A worrying turn? Use of denosumab for giant cell tumour of bone

In this paper we propose a new classification of neurogenic peri-articular heterotopic ossification (HO) of the hip based on three-dimensional (3D) CT, with the aim of improving pre-operative planning for its excision.

A total of 55 patients (73 hips) with clinically significant HO after either traumatic brain or spinal cord injury were assessed by 3D-CT scanning, and the results compared with the intra-operative findings.

At operation, the gross pathological anatomy of the HO as identified by 3D-CT imaging was confirmed as affecting the peri-articular hip muscles to a greater or lesser extent. We identified seven patterns of involvement: four basic (anterior, medial, posterior and lateral) and three mixed (anteromedial, posterolateral and circumferential). Excellent intra- and inter-observer agreement, with kappa values > 0.8, confirmed the reproducibility of the classification system.

We describe the different surgical approaches used to excise the HO which were guided by the 3D-CT findings. Resection was always successful.

3D-CT imaging, complemented in some cases by angiography, allows the surgeon to define the 3D anatomy of the HO accurately and to plan its surgical excision with precision.

Cite this article: Bone Joint J 2015; 97-B:899–904.

The June 2015 Children’s orthopaedics Roundup³⁶⁰ looks at: ACL reconstruction in paediatric knees; Hips, slips and cams; The adolescent clavicle; 3D fluoroscopy in DDH?; The psychiatric aspects of hip pain in adolescents; Adolescent bunions: dealer’s choice?; Medial epicondylar fractures revisited