Aims

Reverse shoulder arthroplasty (RSA) reliably improves shoulder pain and function for a variety of indications. However, the safety and efficacy of RSA in elderly patients is largely unknown. The purpose of this study was to report the mortality, morbidity, complications, reoperations, and outcomes of primary RSA in patients aged > 80 years.

The December 2013 Trauma Roundup. 360 . looks at: Re-operation for intertrochanteric hip fractures; Are twin incisions better than one round the acetabulum?; Salvage osteotomy for calcaneal fractures; Posterior dislocation; Should MRSA be covered in open fractures?; Characterising the saline load test; Has it healed: hip fractures under the spotlight; and stem cells present in atrophic non-union

1. Thirty-nine displaced fractures of the lateral humeral condyle in children are reported. In one-third of the children the injury was accompanied by postero-lateral dislocation of the elbow. In some cases there was evidence that dislocation had occurred even when there was little persistent displacement of the condylar fragment. 2. All the fractures were treated by internal fixation with a specially designed screw. Thirtyfive children attended for review. 3. lt is concluded that all displaced fractures should be treated by internal fixation and that the method described is simple and reliable. Undisplaced fractures, or those with little displacement, may be treated conservatively when there is no evidence of associated dislocation of the elbow

Aims. Our aim was to assess the effectiveness of a protocol involving a standardised closed reduction for the treatment of children with developmental dysplasia of the hip (DDH) in maintaining reduction and to report the mid-term results. Methods. A total of 133 hips in 120 children aged less than two years who underwent closed reduction, with a minimum follow-up of five years or until subsequent surgery, were included in the study. The protocol defines the criteria for an acceptable reduction and the indications for a concomitant soft-tissue release. All children were immobilised in a short- leg cast for three months. Arthrograms were undertaken at the time of closed reduction and six weeks later. Follow-up radiographs were taken at six months and one, two and five years later and at the latest follow-up. The Tönnis grade, acetabular index, Severin grade and signs of osteonecrosis were recorded. Results. A total of 67 hips (51%) were Tönnis grade 3/4 hips. By 12 months, 20 reductions (15%) had not been maintained, and these required open reduction. In all, 55% of these were Severin 1; the others were Severin 2, due to minor acetabular dysplasia. Of the 113 successful closed reductions, 98 hips (87%) were Severin 1. Surgery for residual DDH was offered for ten hips. Osteonecrosis was seen in 32 hips (29%) but was transient in 28. In total, two children (1.5%) had severe osteonecrosis. Bilateral dislocations were significantly more likely to fail and most Tönnis 4 hips failed. Conclusion. Closed reduction, with concomitant adductor and psoas release when required and the use of a short leg plaster of Paris cast for three months, can produce good mid-term results in children with DDH aged less than two years. This protocol is not recommended for Tönnis 4 hips. Cite this article: Bone Joint J 2016;98-B:1548–53

Aims

Our retrospective analysis reports the outcome of patients operated for slipped capital femoral epiphysis using the modified Dunn procedure. Results, complications, and the need for revision surgery are compared with the recent literature.

An abnormal lateral position of the tibial tuberosity causes distal malalignment of the extensor mechanism of the knee and can lead to lateral tracking of the patella causing anterior knee pain or objective patellar instability, characterised by recurrent dislocation. Computer tomography is used for a precise pre-operative assessment of the tibial tubercle-trochlear groove distance. A distance of more than 15 mm is considered to be pathological and an indication for surgery in symptomatic patients. In a prospective study we performed a subtle transfer of the tibial tuberosity according to the information gained from the pre-operative CT scan. This method was applied to two groups of patients, those with painful lateral tracking of the patella, and those with objective patellar instability. We evaluated the clinical results in 30 patients in each group. The outcome was documented at 3, 12 and 24 months using the Lysholm scale, the Kujala score, and a visual analogue pain score. Post-operatively, all but one patient in the instability group who had a patellar dislocation requiring further surgery reported good improvement with no further subluxation or dislocation. All patients in both groups had a marked improvement in pain and functional score. Two patients sustained a tibial fracture six and seven weeks after surgery. One patient suffered a per-operative fracture of the tibial tubercle which later required further fixation. If carefully performed, this type of transfer of the tibial tubercle appears to be a satisfactory technique for the treatment of patients with an increased tibial tubercle-trochlear groove distance and who present with symptoms related to lateral maltracking of the patella

There is controversy whether congenital foot abnormalities are true risk factors for pathological dysplasia of the hip. Previous United Kingdom screening guidelines considered congenital talipes equinovarus (CTEV) to be a risk factor for hip dysplasia, but present guidelines do not. We assessed the potential relationship between pathological dysplasia of the hip and fixed idiopathic CTEV. We present a single-centre 21-year prospective longitudinal observational study. All fixed idiopathic CTEV cases were classified (Harrold and Walker Types 1 to 3) and the hips clinically and sonographically assessed. Sonographic Graf Type III, IV and radiological irreducible hip dislocation were considered to be pathological hip dysplasia. Over 21 years there were 139 children with 199 cases of fixed idiopathic CTEV feet. Sonographically, there were 259 normal hips, 18 Graf Type II hips, 1 Graf Type III hip and 0 Graf Type IV hip. There were no cases of radiological or sonographic irreducible hip dislocation. Fixed idiopathic CTEV should not be considered as a significant risk factor for pathological hip dysplasia. This conclusion is in keeping with the current newborn and infant physical examination guidelines in which the only risk factors routinely screened are family history and breech presentation. Our findings suggest CTEV should not be considered a significant risk factor in pathological dysplasia of the hip. Cite this article: Bone Joint J 2014;96-B:1553–5

Revision arthroplasty of the hip is expensive owing to the increased cost of pre-operative investigations, surgical implants and instrumentation, protracted hospital stay and drugs. We compared the costs of performing this surgery for aseptic loosening, dislocation, deep infection and peri-prosthetic fracture. Clinical, demographic and economic data were obtained for 305 consecutive revision total hip replacements in 286 patients performed at a tertiary referral centre between 1999 and 2008. The mean total costs for revision surgery in aseptic cases (n = 194) were £11 897 (. sd. 4629), for septic revision (n = 76) £21 937 (. sd. 10 965), for peri-prosthetic fracture (n = 24) £18 185 (. sd. 9124), and for dislocation (n = 11) £10 893 (. sd.  5476). Surgery for deep infection and peri-prosthetic fracture was associated with longer operating times, increased blood loss and an increase in complications compared to revisions for aseptic loosening. Total inpatient stay was also significantly longer on average (p < 0.001). Financial costs vary significantly by indication, which is not reflected in current National Health Service tariffs

Aims

To compare complication-related reoperation rates following primary arthroplasty for proximal humerus fractures (PHFs) versus secondary arthroplasty for failed open reduction and internal fixation (ORIF).

We performed a series of 16 anatomical dissections on Caucasian cadaver material to determine the surgical anatomy of the medial femoral circumflex artery (MFCA) and its anastomoses. These confirmed that the femoral head receives its blood supply primarily from the MFCA via a group of posterior superior nutrient arteries and the posterior inferior nutrient artery. In terms of anastomoses that may also contribute to the blood supply, the anastomosis with the inferior gluteal artery, via the piriformis branch, is the most important. These dissections provide a base of knowledge for further radiological studies on the vascularity of the normal femoral head and its vascularity after dislocation of the hip

Lateral instability of the patella was found after recurrent, habitual and permanent dislocations. Contracture of soft tissues lateral to the patella only occurred with habitual and permanent dislocations, but medial laxity was present in all cases. After adequate release of the lateral contracture, the medial stability was improved by transposition of the lower three-quarters of the pes anserinus to the medial border of the patella, and the patellar ligament. This created a relatively unstretchable physiological sling which ensured dynamic stability of the patella. Six recurrent, 21 habitual and nine permanent dislocations of the patella were treated by this method. Results were excellent in 21 patients, good in 13 and fair in two. The follow-up period varied from 21 to 84 months. There have been no recurrences to date

Aims

The aim of this study was to evaluate the outcome of Monteggia-like lesions at midterm follow-up and to determine whether the surgical treatment of the radial head influences the clinical and radiological results.

Aims

Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort.

The painful subluxed or dislocated hip in adults with cerebral palsy presents a challenging problem. Prosthetic dislocation and heterotopic ossification are particular concerns. We present the first reported series of 19 such patients (20 hips) treated with hip resurfacing and proximal femoral osteotomy. The pre-operative Gross Motor Function Classification System (GMFCS) was level V in 13 (68%) patients, level IV in three (16%), level III in one (5%) and level II in two (11%). The mean age at operation was 37 years (13 to 57). The mean follow-up was 8.0 years (2.7 to 11.6), and 16 of the 18 (89%) contactable patients or their carers felt that the surgery had been worthwhile. Pain was relieved in 16 of the 18 surviving hips (89%) at the last follow-up, and the GMFCS level had improved in seven (37%) patients. There were two (10%) early dislocations; three hips (15%) required revision of femoral fixation, and two hips (10%) required revision, for late traumatic fracture of the femoral neck and extra-articular impingement, respectively. Hence there were significant surgical complications in a total of seven hips (35%). No hips required revision for instability, and there were no cases of heterotopic ossification. We recommend hip resurfacing with proximal femoral osteotomy for the treatment of the painful subluxed or dislocated hip in patients with cerebral palsy

Aims

Varus-valgus constrained (VVC) implants are often used during revision total knee arthroplasty (TKA) to gain coronal plane stability. However, the increased mechanical torque applied to the bone-cement interface theoretically increases the risk of aseptic loosening. We assessed mid-term survivorship, complications, and clinical outcomes of a fixed-bearing VVC device in revision TKAs.

Dislocations of the cervicothoracic junction are frequently missed. Experience of this rare injury over 27 years at the Spinal Injuries Unit in Sheffield confirms that nearly two-thirds were not properly diagnosed on admission. Only two of the 14 dislocations studied were reduced by conservative methods and these were both associated with fractures of the posterior bony elements. Open reduction is necessary to replace pure dislocations at the C7-T1 level. It seems likely that the spinal cord lesion is not influenced by reduction of the displacement. The three patients who had an incomplete lesion of the spinal cord made excellent neurological recoveries although none of the dislocations was reduced. It is concluded that on theoretical grounds it is justified to embark on operative reduction of displacements at this spinal level only if the cord lesion is incomplete, nerve root recovery therefore possible, and if the operation can be brought about soon after the injury

Aims

To our knowledge, no study has compared the long-term results of cemented and hybrid total hip arthroplasty (THA) in patients with osteoarthritis (OA) secondary to congenital hip disease (CHD). This is a demanding procedure that may require special techniques and implants. Our aim was to compare the long-term outcome of cemented low-friction arthroplasty (LFA) and hybrid THA performed by one surgeon.

An attempt has been made to describe some of the ways in which the element of rotation, which is so important a part of the function of the normal forearm, has a bearing upon the mechanism and treatment of forearm injuries. In particular, distinction is drawn between those injuries in which the shaft of the radius remains in continuity, and those in which there is a complete fracture of the bone. In the former, rotation of the hand in the reduction will be transmitted to the upper end of the radius, and extremes of rotational movement may safely be used to obtain and hold a reduction. In the latter there is likely to be a rotational deformity between the two radial fragments, and the lower radial fragment must be placed in accurate rotational alignment with the upper. In the first group reduction, and in certain cases immobilisation, in full pronation or full supination has been shown to have a place in the treatment of those cases in which a rotation violence has shaped the pattern of the injury. Soft tissues may be used to guide and hold a reduction in a rotational injury, just as in injuries of other types. An injury caused by forced pronation should logically be treated in full supination, for only thus are the intact soft tissues on the "pronation side" of the limb used to the best advantage. In the mechanism of injuries caused by rotation violence it is emphasized that vertical compression is usually the basic force, to which a rotation force may be added by the direction of momentum of the body weight. Such injuries may be grouped into forced rotation injuries (in which the violence applied has taken the limb beyond the normal ranges of rotational movement), and injuries occurring while the limb is pronating or supinating. In the latter group the rotational element determines the pattern of the injury: pronation and flexion are closely allied, and a fracture occurring while the forearm is pronating will develop a backward angulation: so also a supination injury will produce a forward angulation. On the basis of these considerations injuries of the forearm may be classified as follows:. Injuries in which the shaft of the radius remains in continuity. Forced proiiation injuries:. 1) Forward dislocation of the head of the radius. 2) Backward dislocation of the lower end of the ulna. 3) The anterior Monteggia fracture-dislocation. These injuries should be reduced and immobilised in full supination to prevent recurrence of deformity. The lateral and posterior Monteggia injuries are probably variants of dislocation of the elbow and are not caused by rotation violence. In general it is considered that all dislocations of the head of the radius are best treated in full supination. Pronation injuries:. Greenstick fractures of the radius, and of both bones of the forearm, with backward angulation. Reduction of deformity is most easily obtained by manipulating into full supination. Certain fractures may with advantage be immobilised in this position. Supination injuries:. Greenstick fractures of the forearm with forward angulation. Reduction is best obtained by full pronation. Injuries in which the shaft of the radius is in two separate fragments. This group includes all complete fractures of the shaft of the radius and of both bones of the forearm. There is nearly always a rotational deformity between the two radial fragments and its correction is a dominant factor in the treatment