Of a consecutive series of 117 one-year-old infants with 130 established dislocations of the hip, 11% failed to respond to primary surgical treatment. Genetic and iatrogenic factors accounted for half the failures. There were no obvious causes in the remainder, though a few had the superficial stigmata of spinal dysraphism, and by two years of age, most of the group had developed a lateral rotation posture of the affected leg associated with a relatively smaller foot on that side. Radiologically, the femoral head had drifted and rotated laterally out of the surgically deepened acetabulum, causing persistent subluxation. Although there was no clinical evidence of sensory or motor denervation, sensory spinal evoked potential tests revealed the presence of neurological deficits in the majority of patients in this group

We have examined 26 retrieved, failed titanium-alloy femoral stems. The clinical details, radiological appearances and the histology of the surrounding soft tissues in each patient were also investigated. The stems were predominantly of the flanged design and had a characteristic pattern of wear. A review of the radiographs showed a series of changes, progressive with time. The first was lateral debonding with subsidence of the stem. This was followed by calcar resorption and fragmentation or fracture of the cement. Finally, osteolysis was seen, starting with a radiolucency at the cement-bone interface and progressing to endosteal cavitation. Three histological appearances were noted: granulomatous, necrobiotic and necrotic. We suggest that an unknown factor, possibly related to the design of the stem, caused it to move early. After this, micromovement at the cement-stem interface led to the generation of particulate debris and fracture of the cement. A soft-tissue reaction to the debris resulted in osteolysis and failure of fixation of the prostheses

Aims

Osteolysis, secondary to local and systemic physiological effects, is a major challenge in total hip arthroplasty (THA). While osteolytic defects are commonly observed in long-term follow-up, how such lesions alter the distribution of stress is unclear. The aim of this study was to quantitatively describe the biomechanical implication of such lesions by performing subject-specific finite-element (FE) analysis on patients with osteolysis after THA.

1 . The results of transplanting the greater trochanter in 225 "low-friction" arthroplasties of the hip have been examined. 2. Non-union occurred in an average of 7 per cent of cases. 3. When non-union occurred the results still showed improvement. 4. Four different methods of fixation were used, of which that using two wires, crossed in the horizontal and coronal planes, never failed to secure union. 5. Transplantation of the greater trochanter to the best position is only possible if the neck of the femur is shortened or if the centre of motion of the arthroplasty is displaced medially by deepening the acetabulum, or by a combination of both. 6. In the best position the transplanted trochanter considerably improved active abduction against gravity

We retrospectively reviewed 17 hip arthroplasties in 15 patients having haemodialysis for chronic renal failure. The duration of haemodialysis before the operation averaged 8.6 years and the average age of the patients was 61 years. All patients were followed for more than two years (mean 4.6 years). Six arthroplasties in four patients had failed due to loosening, and one of these patients died from undiagnosed infection of both hips at 7.6 years after the operation. General skeletal abnormalities caused by maintenance haemodialysis may explain the high incidence of loosening and it is important to be aware of the danger of postoperative infection. The risk-to-benefit ratio of hip arthroplasty is high in patients on haemodialysis

Aims

Double-level lengthening, bone transport, and bifocal compression-distraction are commonly undertaken using Ilizarov or other fixators. We performed double-level fixator-assisted nailing, mainly for the correction of deformity and lengthening in the same segment, using a straight intramedullary nail to reduce the time in a fixator.

The role of inflammatory cells in aseptic loosening and failure of cemented joint replacements is unclear. Inflammatory cells from the revision joint capsule of four failed hip arthroplasties were examined to determine their nature and resorptive capacity. The capsules contained numerous macrophages and abundant foreign-body macrophage polykaryons, distinguished from osteoclasts by their antigenic phenotype and lack of response to calcitonin. When cultured on cortical bone slices in vitro, both macrophages and macrophage polykaryons produced small resorption pits and were associated with areas of superficial resorption of the bone surface. These results indicate that foreign-body induced macrophages and macrophage polykaryons are capable of a type of low-grade bone resorption which may be of pathogenic significance in the loosening of cemented joint prosthetic components

Aims

Instability continues to be a troublesome complication after total hip arthroplasty (THA). Patient-related risk factors associated with a higher dislocation risk include the preoperative diagnosis, an age of 75 years or older, high body mass index (BMI), a history of alcohol abuse, and neurodegenerative diseases. The goal of this study was to assess the dislocation rate, radiographic outcomes, and complications of patients stratified as high-risk for dislocation who received a dual mobility (DM) bearing in a primary THA at a minimum follow-up of two years.

We treated 22 patients with type-two odontoid fractures in halothoracic vests for six to eight weeks followed by a Philadelphia collar for four weeks. Eighteen patients were reviewed by questionnaire and radiography at a mean of 40 months after injury. We assessed union, fracture position, the degree of permanent pain and stiffness, satisfaction with the treatment and the outcome. The overall union rate was 82%. Posterior malunion with residual posterior displacement or angulation was associated with a higher incidence of persisting pain. The position at union did not correlate with the residual cervical stiffness. Fractures failed to unite in four patients (18%) none of whom had late neurological sequelae, although they had more late pain. There were associations between the development of nonunion and an extension-type injury, age over 65 years and delay in diagnosis

We performed resection of part of an injured peripheral nerve in 20 patients with post-traumatic neuralgia, after conservative treatment had failed. All had burning pain, paraesthesia and dysaesthesia in the area innervated by the injured nerve. We resected the nerve in the area in which the patient felt pain, and a further 3 cm proximal to the site of injury. In all cases, the local pain disappeared or markedly decreased. The areas of pain relief and of nerve resection coincided completely in 17 patients and partially in three. The results were assessed as excellent by five patients, good by 11, and fair by four. There were no poor results. Histological examination of the resected nerves showed Wallerian degeneration and immunohistochemical tests indicated that substance P, a polypeptide which may contribute to nociceptive transmission, was present in the tissue around the degenerated nerves

Exchange nailing for failure of union after primary intramedullary nailing of the tibia is widely used but the indications and effectiveness have not been reported in detail. We have reviewed 33 cases of uninfected nonunion of the tibia treated by exchange nailing. This technique was successful without open bone grafting in all closed fractures and in open fractures of Gustilo types I, II and IIIa. The requirement for open bone grafting was reduced in type-IIIb fractures, but exchange nailing failed in type-IIIb fractures with significant bone loss. For these we recommend early open bone grafting. The most common complication was wound infection, seen more often than after primary nailing. We discuss our protocol for the use and timing of exchange nailing of all grades and types of tibial fracture

We treated 110 fractures of the middle third of the clavicle in 108 patients aged between 14 and 66 years, by fixation with 2 mm Kirschner wires. The wire was introduced, using an air drill and a telescoping guide, from the medial into the lateral fragment. The medial end of the wire which perforated the anterior cortex of the medial fragment was bent backwards to prevent migration into the lung or mediastinum. In cases of nonunion and acute fracture in which a bone gap was present, bone graft was laid around the fracture site after internal fixation. All the fractures united. No wires broke but in three patients one migrated before union was achieved. Twenty-one patients failed to return for removal of the wire; nine of them had radiological evidence of union before they were lost to follow-up

Hyperphosphatasia, or hereditary bone dysplasia with hyperphosphatasaemia, is a rare genetic disorder which is characterised by failure to transform woven into lamellar bone. Clinical, radiological and histological features establish the diagnosis, fractures, deformities, diffuse sclerosis on radiographs and high serum alkaline phosphatase being characteristic. We report the case of a 27-year-old man with follow-up at the same hospital for 20 years. Attempts at treatment with calcitonin and disocium etidronate (EHDP) failed, but stapling of the growth plates at the knee was successfully performed. Transverse "brittle" fractures of the humerus, lower leg and ribs healed normally, but internal fixation and late bone grafting were required for a subtrochanteric stress fracture of the femur at the age of 24 years. At present the patient has no clinical problems and leads a normal life

Eleven patients with metastases in the cervical spine had operations for severe pain due to a pathological fracture which, in eight of the cases, was unstable. Conservative treatment had either failed or was unsuitable. In the first five patients internal fixation with tension band wires and bone grafts was supported by a halo-brace. The method has evolved to the use of posterior instrumentation with laminar wires from two levels above the lesion to two levels below. Stability is increased by the use of bone cement with or without bone autografts applied to one side of the spine. This technique enables the patient to get up within a few days of operation--a great advantage when life expectancy is limited. The operations were successful in all except one case

Fifty-three failed knee replacements were revised using minimally constrained implants with smooth uncemented intramedullary stems and metal-backed tibial components. Polymethylmethacrylate was used only to replace lost bone near the surface of the implant. Excluding four knees which had serious postoperative complications, 91% had successful relief of pain, 84% had over 90 degrees of movement and 80% could walk for more than 30 minutes. Review of the radiographs showed that there were no progressive lucencies at the interface between bone and cement, and no subsidence of components or changes in alignment. At the uncemented stem-to-bone interface, thin white lines developed near the metal, and their significance is discussed. This revision technique is an effective treatment for aseptic failure of primary total knee arthroplasty

Thirteen patients with dystrophic spinal deformities from neurofibromatosis treated by anterior and posterior fusion have been reviewed. The shortest follow-up was five years, the average seven years. Combined fusion produced satisfactory results in patients with a smooth kyphoscoliosis or with scoliosis without kyphosis, but it was unsatisfactory in patients with an angular kyphoscoliosis. Of the five patients with angular kyphoscoliosis, one had a persistent pseudarthrosis after operation and all had progression of the kyphosis despite the treatment. The morbidity rate also was high in this group of patients. Many of the complications were related to soft-tissue manifestations of the disease. It is recommended that very special attention be paid to the dystrophic angular deformity in neurofibromatosis; even anterior and posterior spinal fusion may fail to control its progression

In order to study the effect of pure torsional forces upon the rotational development of the growing tibia, 35 immature rabbits underwent torsional loading of one tibia in vivo with a spring-loaded cylinder while the other tibia was a control. The radiographic results showed rotation occurring only at the epiphysial plate. Histologically this was assocaited with angulation of the hypertrophic cartilage columns occurring as little as 24 hours after loading which with longer periods of loading produced angled primary and secondary trabeculae. Radiographic and histological analyses of the diaphysis using tetracycline labelling and Spalteholtz injection techniques failed to show any evidence of cortical remodelling or reorientation of the cortical vessels of a rotational nature, suggesting that rotational modelling occurs solely at the epiphysial plate

Aims

The number of rotator cuff repairs that are undertaken is increasing. Reverse shoulder arthroplasty (RSA) is the procedure of choice for patients with rotator cuff arthropathy. We sought to determine whether patients who underwent rotator cuff repair and subsequent RSA had different outcomes compared with a matched control group who underwent RSA without a previous rotator cuff repair.

Aims

Prosthetic joint infections (PJIs) of the hip and knee are associated with significant morbidity and socioeconomic burden. We undertook a systematic review of the current literature with the aim of proposing criteria for the selection of patients for a single-stage exchange arthroplasty in the management of a PJI.