The February 2015 Trauma Roundup³⁶⁰ looks at: Evaluating the syndesmosis in ankle fractures; Calcaneal fracture management an ongoing problem; Angular stable locking in low tibial fractures did not improve results; Open fractures: do the seconds really count?; Long-term outcomes of tibial fractures; Targeted performance improvements in pelvic fractures

The February 2015 Knee Roundup³⁶⁰ looks at: Intra-operative sensors for knee balance; Mobile bearing no advantage; Death and knee replacement: a falling phenomenon; The swings and roundabouts of unicompartmental arthroplasty; Regulation, implants and innovation; The weight of arthroplasty responsibility!; BMI in arthroplasty

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 February 2015 Children’s orthopaedics Roundup³⁶⁰ looks at: Hip dislocation in children with CTEV: two decades of experience; Population-based prevention of DDH in cerebral palsy: 20 years’ experience; Shoulder derotation in congenital plexus palsy; Back pain in the paediatric population: could MRI be the answer?; Intercondylar fracture of the humerus in children; The Dunn osteotomy in SUFE; Radiocapitellar line a myth!; Do ‘flatfooted’ children suffer?

Femoral stem version has a major influence on impingement and early post-operative stability after total hip arthroplasty (THA).

The main objective of this study was to evaluate the validity of a novel radiological method for measuring stem version. Anteroposterior (AP) radiographs and three-dimensional CT scans were obtained for 115 patients (female/male 63/72, mean age 62.5 years (50 to 75)) who had undergone minimally invasive, cementless THA. Stem version was calculated from the AP hip radiograph by rotation-based change in the projected prosthetic neck–shaft (NSA*) angle using the mathematical formula ST = arcos [tan (NSA*) / tan (135)]. We used two independent observers who repeated the analysis after a six-week interval. Radiological measurements were compared with 3D-CT measurements by an independent, blinded external institute.

We found a mean difference of 1.2° (sd 6.2) between radiological and 3D-CT measurements of stem version. The correlation between the mean radiological and 3D-CT stem torsion was r = 0.88 (p < 0.001). The intra- (intraclass correlation coefficient ≥ 0.94) and inter-observer agreement (mean concordance correlation coefficient = 0.87) for the radiological measurements were excellent.

We found that femoral tilt was associated with the mean radiological measurement error (r = 0.22, p = 0.02).

The projected neck–shaft angle is a reliable method for measuring stem version on AP radiographs of the hip after a THA. However, a highly standardised radiological technique is required for its precise measurement.

Cite this article: Bone Joint J 2015; 97-B:306–11.

We reviewed the outcome of patients who had been treated operatively for symptomatic peri-acetabular metastases and present an algorithm to guide treatment.

The records of 81 patients who had been treated operatively for symptomatic peri-acetabular metastases between 1987 and 2010 were identified. There were 27 men and 54 women with a mean age of 61 years (15 to 87). The diagnosis, size of lesion, degree of pelvic continuity, type of reconstruction, World Health Organization performance status, survival time, pain, mobility and complications including implant failure were recorded in each case.

The overall patient survivorship at five years was 5%. The longest lived patient survived 16 years from the date of diagnosis. The mean survival was 23 months (< 1 to 16 years) and the median was 15 months. At follow-up 14 patients remained alive. Two cementoplasties failed because of local disease progression. Three Harrington rods broke: one patient needed a subsequent Girdlestone procedure. One ‘ice-cream cone’ prosthesis dislocated and was subsequently revised without further problems. We recommend the ‘ice-cream cone’ for pelvic discontinuity and Harrington rod reconstruction for severe bone loss. Smaller defects can be safely managed using standard revision hip techniques.

Cite this article: Bone Joint J 2014;96-B:132–6.

Reported rates of dislocation in hip hemiarthroplasty (HA) for the treatment of intra-capsular fractures of the hip, range between 1% and 10%. HA is frequently performed through a direct lateral surgical approach. The aim of this study is to determine the contribution of the anterior capsule to the stability of a cemented HA through a direct lateral approach.

A total of five whole-body cadavers were thawed at room temperature, providing ten hip joints for investigation. A Thompson HA was cemented in place via a direct lateral approach. The cadavers were then positioned supine, both knee joints were disarticulated and a digital torque wrench was attached to the femur using a circular frame with three half pins. The wrench applied an external rotation force with the hip in extension to allow the hip to dislocate anteriorly. Each hip was dislocated twice; once with a capsular repair and once without repairing the capsule. Stratified sampling ensured the order in which this was performed was alternated for the paired hips on each cadaver.

Comparing peak torque force in hips with the capsule repaired and peak torque force in hips without repair of the capsule, revealed a significant difference between the ‘capsule repaired’ (mean 22.96 Nm, standard deviation (sd) 4.61) and the ‘capsule not repaired’ group (mean 5.6 Nm, sd 2.81) (p < 0.001). Capsular repair may help reduce the risk of hip dislocation following HA.

Cite this article: Bone Joint J 2015;97-B:141–4.

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.

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.

The December 2014 Foot & Ankle Roundup360 looks at: Charcot feet, biomarkers and diabetes; weight bearing following Achilles tendon rupture; endobuttons and mal-reduced diastasis; evidence for stem cell therapies in osteochondral lesions of the talus; syndesmosis fixation in SER ankle fractures; and self-reporting for foot and ankle outcomes.

We conducted a case-control study to examine the merit of silver-coated tumour prostheses. We reviewed 85 patients with Agluna-treated (silver-coated) tumour implants treated between 2006 and 2011 and matched them with 85 control patients treated between 2001 and 2011 with identical, but uncoated, tumour prostheses.

In all, 106 men and 64 women with a mean age of 42.2 years (18.4 to 90.4) were included in the study. There were 50 primary reconstructions (29.4%); 79 one-stage revisions (46.5%) and 41 two-stage revisions for infection (24.1%).

The overall post-operative infection rate of the silver-coated group was 11.8% compared with 22.4% for the control group (p = 0.033, chi-square test). A total of seven of the ten infected prostheses in the silver-coated group were treated successfully with debridement, antibiotics, and implant retention compared with only six of the 19 patients (31.6%) in the control group (p = 0.048, chi-square test). Three patients in the silver-coated group (3.5%) and 13 controls (15.3%) had chronic periprosthetic infection (p = 0.009, chi-square test).

The overall success rates in controlling infection by two-stage revision in the silver-coated group was 85% (17/20) compared with 57.1% (12/21) in the control group (p = 0.05, chi-square test). The Agluna-treated endoprostheses were associated with a lower rate of early periprosthetic infection. These silver-treated implants were particularly useful in two-stage revisions for infection and in those patients with incidental positive cultures at the time of implantation of the prosthesis.

Debridement with antibiotic treatment and retention of the implant appeared to be more successful with silver-coated implants.

Cite this article: Bone Joint J 2015;97-B:252–7.

We undertook a retrospective comparative study of all patients with an unstable slipped capital femoral epiphysis presenting to a single centre between 1998 and 2011. There were 45 patients (46 hips; mean age 12.6 years; 9 to 14); 16 hips underwent intracapsular cuneiform osteotomy and 30 underwent pinning in situ, with varying degrees of serendipitous reduction. No patient in the osteotomy group was lost to follow-up, which was undertaken at a mean of 28 months (11 to 48); four patients in the pinning in situ group were lost to follow-up, which occurred at a mean of 30 months (10 to 50). Avascular necrosis (AVN) occurred in four hips (25%) following osteotomy and in 11 (42%) following pinning in situ. AVN was not seen in five hips for which osteotomy was undertaken > 13 days after presentation. AVN occurred in four of ten (40%) hips undergoing emergency pinning in situ, compared with four of 15 (47%) undergoing non-emergency pinning. The rate of AVN was 67% (four of six) in those undergoing pinning on the second or third day after presentation.

Pinning in situ following complete reduction led to AVN in four out of five cases (80%). In comparison, pinning in situ following incomplete reduction led to AVN in 7 of 21 cases (33%). The rate of development of AVN was significantly higher following pinning in situ with complete reduction than following intracapsular osteotomy (p = 0.048). Complete reduction was more frequent in those treated by emergency pinning and was strongly associated with AVN (p = 0.005).

Non-emergency intracapsular osteotomy may have a protective effect on the epiphyseal vasculature and should be undertaken with a delay of at least two weeks. The place of emergency pinning in situ in these patients needs to be re-evaluated, possibly in favour of an emergency open procedure or delayed intracapsular osteotomy. Non-emergency pinning in situ should be undertaken after a delay of at least five days, with the greatest risk at two and three days after presentation. Intracapsular osteotomy should be undertaken after a delay of at least 14 days. In our experience, closed epiphyseal reduction is harmful.

Cite this article: Bone Joint J 2015;97-B:412–19.

We investigated the incidence and risk factors for the development of avascular necrosis (AVN) of the femoral head in the course of treatment of children with cerebral palsy (CP) and dislocation of the hip. All underwent open reduction, proximal femoral and Dega pelvic osteotomy. The inclusion criteria were: a predominantly spastic form of CP, dislocation of the hip (migration percentage, MP > 80%), Gross Motor Function Classification System, (GMFCS) grade IV to V, a primary surgical procedure and follow-up of > one year.

There were 81 consecutive children (40 girls and 41 boys) in the study. Their mean age was nine years (3.5 to 13.8) and mean follow-up was 5.5 years (1.6 to 15.1). Radiological evaluation included measurement of the MP, the acetabular index (AI), the epiphyseal shaft angle (ESA) and the pelvic femoral angle (PFA). The presence and grade of AVN were assessed radiologically according to the Kruczynski classification.

Signs of AVN (grades I to V) were seen in 79 hips (68.7%). A total of 23 hips (18%) were classified between grades III and V.

Although open reduction of the hip combined with femoral and Dega osteotomy is an effective form of treatment for children with CP and dislocation of the hip, there were signs of avascular necrosis in about two-thirds of the children. There was a strong correlation between post-operative pain and the severity of the grade of AVN.

Cite this article: Bone Joint J 2015;97-B:270–6.

The December 2014 Shoulder & Elbow Roundup³⁶⁰ looks at: cuff tears and plexus injury;

corticosteroids and physiotherapy in SAI; diabetes and elbow arthroplasty; distal biceps tendon repairs; shockwave therapy in frozen shoulder; hydrodilation and steroids for adhesive capsulitis; just what do our patients read?; and what happens to that stable radial head fracture?

Pre-operative planning for total hip replacement (THR) is challenging in hips with severe acetabular deformities, including those with a hypoplastic acetabulum or severe defects and in the presence of arthrodesis or ankylosis. We evaluated whether a Rapid Prototype (RP) model, which is a life-sized reproduction based on three-dimensional CT scans, can determine the feasibility of THR and provide information about the size and position of the acetabular component in severe acetabular deformities. THR was planned using an RP model in 21 complex hips in five men (five hips) and 16 women (16 hips) with a mean age of 47.7 years (24 to 70) at operation. An acetabular component was implanted successfully and THR completed in all hips. The acetabular component used was within 2 mm of the predicted size in 17 hips (80.9%). All of the acetabular components and femoral stems had radiological evidence of bone ingrowth and stability at the final follow-up, without any detectable wear or peri-prosthetic osteolysis. The RP model allowed a simulated procedure pre-operatively and was helpful in determining the feasibility of THR pre-operatively, and to decide on implant type, size and position in complex THRs.

Cite this article: Bone Joint J 2013;95-B:1458–63.

Stress fractures occurring in the pubis and ischium after peri-acetabular osteotomy (PAO) are not well recognised, with a reported incidence of 2% to 3%. The purpose of this study was to analyse the incidence of stress fracture after Bernese PAO under the care of two high-volume surgeons. The study included 359 patients (48 men, 311 women) operated on at a mean age of 31.1 years (15 to 56), with a mean follow-up of 26 months (6 to 64). Complete follow-up radiographs were available for 348 patients, 64 of whom (18.4%) developed a stress fracture of the inferior pubic ramus, which was noted at a mean of 9.1 weeks (5 to 55) after surgery. Most (58; 91%) healed. In 40 of the patients with a stress fracture (62.5%), pubic nonunion also occurred. Those with a stress fracture were significantly older (mean 33.9 years (16 to 50) vs 30.5 years (15 to 56), p = 0.002) and had significantly more mean pre-operative deformity: mean centre–edge angle (9.8° (-9.5 to 35) vs 12.4° (-33 to 28), p = 0.04) and mean Tönnis angle (22.8° (0 to 45) vs 18.7° (-2 to 38), p < 0.001). The pubic nonunion rate was significantly higher in those with a stress fracture (62.5% vs 7%, p < 0.001), with regression analysis revealing that these patients had 11.8 times higher risk than those without nonunion.

Cite this article: Bone Joint J 2015; 97-B:24–8.

Impaction bone grafting for the reconstitution of bone stock in revision hip surgery has been used for nearly 30 years. Between 1995 and 2001 we used this technique in acetabular reconstruction, in combination with a cemented component, in 304 hips in 292 patients revised for aseptic loosening. The only additional supports used were stainless steel meshes placed against the medial wall or laterally around the acetabular rim to contain the graft. All Paprosky grades of defect were included. Clinical and radiographic outcomes were collected in surviving patients at a minimum of ten years after the index operation. Mean follow-up was 12.4 years (sd 1.5) (10.0 to 16.0). Kaplan–Meier survival with revision for aseptic loosening as the endpoint was 85.9% (95% CI 81.0 to 90.8) at 13.5 years. Clinical scores for pain relief remained satisfactory, and there was no difference in clinical scores between cups that appeared stable and those that appeared radiologically loose.

Cite this article: Bone Joint J 2014;96-B:188–94.

A poor response to chemotherapy (≤ 90% necrosis) for osteosarcomas leads to poorer survival and an increased risk of local recurrence, particularly if there is a close margin of excision. We evaluated whether amputation confers any survival benefit over limb salvage surgery (LSS) with narrow margins in patients who respond poorly to chemotherapy.

We only analysed patients with an osteosarcoma of the limb, a poor response to chemotherapy and close margins on LSS (marginal/intralesional) or primary amputation: 360 patients (36 LSS (intralesional margins), 197 LSS (marginal margins) and 127 amputations) were included. Local recurrence developed in 13 (36%) following LSS with intralesional margins, and 39 (20%) following LSS with marginal margins. There was no local recurrence in patients who underwent amputation. The five-year survival for all patients was 41% (95% confidence interval (CI) 35 to 46), but for those treated by LSS with marginal margins was 46.2% (95% CI 38 to 53), 36.3% (95% CI 27 to 45) for those treated by amputation, and 28% (95 CI 14 to 44) for those treated by LSS with intralesional margins. Patients who had LSS and then developed local recurrence as a first event had the same survival as those who had primary amputation without local recurrence. Prophylactic adjuvant radiotherapy was used in 40 patients but had no discernible effect in preventing local recurrence.

Although amputation offered better local control, it conferred no clear survival benefit over LSS with marginal margins in these patients with a poor overall prognosis.

Cite this article: Bone Joint J 2015;97-B:115–20.

Obesity is a risk factor for complications following many orthopaedic procedures. The purpose of this study was to investigate whether obesity was an independent risk factor increasing the rate of complications following periacetabular osteotomy (PAO) and to determine whether radiographic correction after PAO was affected by obesity.

We retrospectively collected demographic, clinical and radiographic data on 280 patients (231 women; 82.5% and 49 men; 17.5%) who were followed for a mean of 48 months (12 to 60) after PAO. A total of 65 patients (23.2%) were obese (body mass index (BMI) > 30 kg/m²). Univariate and multivariate analysis demonstrated that BMI was an independent risk factor associated with the severity of the complications. The average probability of a patient developing a major complication was 22% (95% confidence interval (CI) 11.78 to 38.21) for an obese patient compared with 3% (95% CI 1.39 to 6.58) for a non-obese patient The odds of a patient developing a major complication were 11 times higher (95% CI 4.71 to 17.60, p <  0.0001) for an obese compared with a non-obese patient.

Following PAO surgery, there was no difference in radiographic correction between obese and non-obese patients. PAO procedures in obese patients correct the deformity effectively but are associated with an increased rate of complications.

Cite this article: Bone Joint J 2015;97-B:29–34.

Conventional growing rods are the most commonly used distraction-based devices in the treatment of progressive early-onset scoliosis. This technique requires repeated lengthenings with the patient anaesthetised in the operating theatre. We describe the outcomes and complications of using a non-invasive magnetically controlled growing rod (MCGR) in children with early-onset scoliosis. Lengthening is performed on an outpatient basis using an external remote control with the patient awake.

Between November 2009 and March 2011, 34 children with a mean age of eight years (5 to 12) underwent treatment. The mean length of follow-up was 15 months (12 to 18). In total, 22 children were treated with dual rod constructs and 12 with a single rod. The mean number of distractions per patient was 4.8 (3 to 6). The mean pre-operative Cobb angle was 69° (46° to 108°); this was corrected to a mean 47° (28° to 91°) post-operatively. The mean Cobb angle at final review was 41° (27° to 86°). The mean pre-operative distance from T1 to S1 was 304 mm (243 to 380) and increased to 335 mm (253 to 400) in the immediate post-operative period. At final review the mean distance from T1 to S1 had increased to 348 mm (260 to 420).

Two patients developed a superficial wound infection and a further two patients in the single rod group developed a loss of distraction. In the dual rod group, one patient had pull-out of a hook and one developed prominent metalwork. Two patients had a rod breakage; one patient in the single rod group and one patient in the dual rod group. Our early results show that the MCGR is safe and effective in the treatment of progressive early-onset scoliosis with the avoidance of repeated surgical lengthenings.

Cite this article: Bone Joint J 2013;95-B:75–80.