This retrospective cohort study was conducted to investigate whether operative treatment of patients with a pertrochanteric femoral fracture outside working hours is associated with an increased risk of complications and higher mortality. During the study period 165 patients were operated on outside working hours and 123 were operated on during working hours (08.00 to 17.00). There was no difference in the rate of early complications (outside working hours 33% versus working hours 33%, p = 0.91) or total complications during follow-up (outside working hours 40% versus working hours 41%, p = 0.91). Both in-hospital mortality (outside working hours 12% versus working hours 11%, p = 0.97) and mortality after one year (outside working hours 29% versus working hours 27%, p = 0.67) were comparable. Adjustment for possible confounders by multivariate logistic regression analysis revealed no increased risk of complications when patients were operated on outside working hours. On the basis of these data, there is no medical reason to postpone operative reduction and fixation in patients with a proximal femoral fracture until working hours

We report the complications of prophylactic pinning of slipped upper femoral epiphysis with Crawford Adams pins in 95 cases. Complications of pin placement were seen in 13.7%. Although seven hips had penetration of the joint, there were no cases of chondrolysis or avascular necrosis. Excavation of the lateral femoral cortex was required at pin removal in 12.5% of cases. Analysis of the growth around pins allowed recommendations to be made regarding pin protrusion. The use of improved fixation devices may reduce the need for multiple pins

We have reviewed the results of operations to stabilise the paralytic hip and to correct and stabilise the deformed spine of children with myelomeningocele. Despite a high complication rate the spinal operations were frequently successful. The hip operations were less satisfactory, with stabilisation of the hip eventually achieved in 69 per cent of the patients and improved walking in only 27 per cent. We do not recommend that such operations be undertaken on the hips of children with a level of paralysis at L3 or above. If stabilisation is indicated multiple combined procedures produce the best result

We carried out a retrospective cohort study of 3309 patients undergoing primary total hip replacement to examine the impact of tobacco use and body mass index on the length of stay in hospital and the risk of short term post-operative complications. Heavy tobacco use was associated with an increased risk of systemic post-operative complications (p = 0.004). Previous and current smokers had a 43% and 56% increased risk of systemic complications, respectively, when compared with non-smokers. In heavy smokers, the risk increased by 121%. A high body mass index was significantly associated with an increased mean length of stay in hospital of between 4.7% and 7%. The risk of systemic complications was increased by 58% in the obese. Smoking and body mass index were not significantly related to the development of local complications. Greater efforts should be taken to reduce the impact of preventable life style factors, such as smoking and high body mass index, on the post-operative course of total hip replacement

Two neonates, treated by the Pavlik harness for congenital dislocation of the hip, developed inferior dislocation due to excessive hip flexion. Early recognition of the complication and diminution of the angle of flexion gave a stable relocation of the hip in both patients

We investigated the incidence of and risk factors for venous thromboembolism (VTE) following surgery of the shoulder and elbow and assessed the role of thromboprophylaxis in upper limb surgery. All papers describing VTE after shoulder and elbow surgery published in the English language literature before 31 March 2012 were reviewed. A total of 14 papers were available for analysis, most of which were retrospective studies and case series. The incidence of VTE was 0.038% from 92 440 shoulder arthroscopic procedures, 0.52% from 42 261 shoulder replacements, and 0.64% from 4833 procedures for fractures of the proximal humerus (open reduction and internal fixation or hemiarthroplasty). The incidence following replacement of the elbow was 0.26% from 2701 procedures. Diabetes mellitus, rheumatoid arthritis and ischaemic heart disease were identified as the major risk factors.

The evidence that exists on thromboprophylaxis is based on level III and IV studies, and we therefore cannot make any recommendations on prophylaxis based on the current evidence. It seems reasonable to adopt a multimodal approach that involves all patients receiving mechanical prophylaxis, with chemical prophylaxis reserved for those who are at high risk for VTE.

Cite this article: Bone Joint J 2013;95-B:70–4.

We describe two patients in whom poor healing after chemical ablation for ingrown toenails unmasked significant vascular disease of the lower extremities. We have found no similar reports in the English language literature.

After total knee replacement a 57-year-old woman developed increasing pain in her left calf on exercise. This was due to erosion of the popliteal artery by a spur of cement. Removal of the spur with resection and Dacron grafting of the damaged section of the vessel cured her symptoms.

Rocker bottom deformity may occur during the conservative treatment of idiopathic congenital clubfoot. Between 1975 and 1996, we treated 715 patients (1120 clubfeet) conservatively. A total of 23 patients (36 feet; 3.2%) developed a rocker bottom deformity. It is these patients that we have studied. The pathoanatomy of the rocker bottom deformity is characterised by a plantar convexity appearing between three and six months of age with the hindfoot equinus position remaining constant. The convexity initially involves the medial column, radiologically identified by the talo-first metatarsal angle and secondly by the lateral column, revealed radiologically as the calcaneo-fifth metatarsal angle. The apex of the deformity is usually at the midtrasal with a dorsal calcaneocuboid subluxation. Ideal management of clubfoot deformity should avoid this complication, with adequate manipulation and splinting and early Achilles’ percutaneous tenotomy if plantar convexity occurs. Adequate soft-tissue release provides satisfactory correction for rocker bottom deformity. However, this deformity requires more extensive and complex procedures than the standard surgical treatment of clubfoot. The need for lateral radiographs to ensure that the rocker bottom deformity is recognised early, is demonstrated

During the years 1971 to 1975, 378 Charnley low-friction arthroplasties of the hip were performed on 278 patients with rheumatoid arthritis. The average age at operation was thirty-nine years. The follow-up time ranged from one to six years (mean two and a half years). Forty per cent of patients were receiving steroids at the time of operation. The most common complications were loosening of the prosthesis (3.4%), perforation of the femoral cortex and fracture. Deep infection occurred in 0.7%, dislocation in 0.7%, and thromboembolic episodes in 1.3%. Ninety-five per cent of patients were free of pain at follow-up compared to 84% who were severely handicapped by pain before operation. In addition, the increased mobility in 98.5% of patients and their improved independence makes hip replacement a recommendable procedure in these patients

We have studied the placement of three screws within the femoral head and the degree of angulation of the screws in 395 patients with displaced intracapsular fracture of the hip to see if either was related to the risk of failure of the fracture to unite. No relationship between nonunion of the fracture was found regarding the position of the screws on the anteroposterior radiograph. However, we found that a reduced spread of the screws on the lateral view was associated with an increased risk of nonunion of the fracture.

We reviewed 50 capitellocondylar elbow replacements performed by the lateral approach in 42 rheumatoid patients, at a median follow-up of three years. There were two major and 17 minor complications; 18 were early and one was late. Eight elbows required reoperation: soft-tissue surgery was performed in seven and prosthesis removal in one because of a deep infection. There were few problems of instability, but one patient sustained a traumatic dislocation which was stabilised after ligament reconstruction. Wound healing was delayed in two of five elbows which had been immobilised postoperatively for only five days, but healing was rapid in 45 elbows immobilised for 12 days. There was transient ulnar-nerve palsy postoperatively in 11 patients, with permanent palsy in three. All elbows were painfree or only slightly painful at follow-up; 49 were stable and 43 had a range of motion sufficient for activities of daily living. Radiological loosening of the humeral component was suspected in one asymptomatic elbow. The lateral approach is recommended for use with the capitellocondylar type of prosthesis in rheumatoid elbows with reasonably well-preserved bone stock

Despite widespread use of gentamicin beads in the treatment of chronic infections of bone and soft tissue, no serious complications have been reported. This report describes a rupture of the femoral vein which occurred during the attempted removal of a chain of beads after radical excision of a chronically discharging Girdlestone arthroplasty. The patient later had a disarticulation at the hip. In the light of our experience with this and other cases we offer some suggestions as to the positioning of gentamicin beads, as well as the timing and method of their extraction

It is not uncommon to observe bone cement in the pelvis on radiographs after total hip replacement, a finding which is generally considered to be benign. This paper reviews some catastrophic late complications from intrapelvic methylmethacrylate. We also describe a case of progressive, unbearable dyspareunia beginning three years after total hip replacement. A possible explanation of the pathophysiology is suggested. Recommendations for prevention, diagnosis, and treatment of these late complications are offered

We report the results of 62 hips in 62 patients (17 males, 45 females) with mean age of 62.4 years (37 to 81), who underwent revision of the acetabular component of a total hip replacement due to aseptic loosening between May 2003 and November 2007. All hips had a Paprosky type IIIa acetabular defect. Acetabular revision was undertaken using a Procotyl E cementless oblong implant with modular side plates and a hook combined with impaction allografting. . At a mean follow-up of 60.5 months (36 to 94) with no patients lost to follow-up and one died due to unrelated illness, the complication rate was 38.7%. Complications included aseptic loosening (19 hips), deep infection (3 hips), broken hook and side plate (one hip) and a femoral nerve palsy (one hip). Further revision of the acetabular component was required in 18 hips (29.0%) and a further four hips (6.4%) are currently loose and awaiting revision. . We observed unacceptably high rates of complication and failure in our group of patients and cannot recommend this implant or technique

Osteotomies are commonly carried out in orthopaedic surgery, particularly in limb reconstruction. Complications are uncommon provided that sufficient care is taken and a sound technique used. We describe three cases of formation of false aneurysm after osteotomy, with acute, delayed and asymptomatic onset. The diagnosis was supported by ultrasound investigation, and confirmed by angiography. Embolisation with coils was a successful method of treatment. We recommend a safe method of osteotomy with good bone exposure and adequate soft-tissue protection.

We report a series of 640 consecutive cervical hip fractures which were followed prospectively for two years after primary internal fixation with two hook-pins. Secondary arthroplasties were performed as salvage procedures in 75 cases and the early outcome of these was studied retrospectively. The mean time in hospital was 25 days for prosthetic replacement, though 60% of the patients had other medical conditions considered as risk factors. Mortality was 5% after six months and 8% after one year. Dislocation was seen in 11% and additional surgery was required in 4%. There was one case of deep infection and one supracondylar femoral fracture. In some cases there was considerable delay between the primary and secondary operation due to lack of awareness of functional deterioration, but although many patients had poor mobility before the secondary operation this was greatly improved within six weeks of the arthroplasty. We conclude that elective secondary hip arthroplasty for failure of fracture fixation is a safe and successful procedure. Once the decision to perform an arthroplasty is taken, this should be done without delay to avoid deterioration of function.