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

Aims

The aim of this study was to report the outcomes of different treatment options for glenoid loosening following reverse shoulder arthroplasty (RSA) at a minimum follow-up of two years.

Lengthening of the humerus is now an established technique. We compared the complications of humeral lengthening with those of femoral lengthening and investigated whether or not the callus formation in the humerus proceeds at a higher rate than that in the femur. A total of 24 humeral and 24 femoral lengthenings were performed on 12 patients with achondroplasia. We measured the pixel value ratio (PVR) of the lengthened area on radiographs and each radiograph was analysed for the shape, type and density of the callus. The quality of life (QOL) of the patients after humeral lengthening was compared with that prior to surgery. The complication rate per segment of humerus and femur was 0.87% and 1.37%, respectively. In the humerus the PVR was significantly higher than that of the femur. Lower limbs were associated with an increased incidence of concave, lateral and central callus shapes. Humeral lengthening had a lower complication rate than lower-limb lengthening, and QOL increased significantly after humeral lengthening. Callus formation in the humerus during the distraction period proceeded at a significantly higher rate than that in the femur. . These findings indicate that humeral lengthening has an important role in the management of patients with achondroplasia

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.

A case of fatal air embolism after Küntscher nailing of a fractured femur is described. Necropsy indicated that the only possible means of air entry was through the bone marrow. Subsequent discussion between the surgeon and the pathologist indicated that air must have been forced into the venous circulation through the marrow by repeated removal and reinsertion of nails, which allowed air to fill the punched-out marrow space when the nail was removed, the same air being forced into the marrow sinusoids when the nail was reinserted and hammered into position. This danger may be overcome 1) by allowing the site of operation to flood with blood by placing the patient in a "head up" position; 2) by flooding the operation site with saline; or 3) by assessing the calibre of nail required by radiological means rather than by trial and error.

Dysphagia is a common complication of anterior surgery of the cervical spine. The incidence of post-operative dysphagia may be as high as 71% within the first two weeks after surgery, but gradually decreases during the following months. However, 12% to 14% of patients may have some persistent dysphagia one year after the procedure. It has been shown that female gender, advanced age, multilevel surgery, longer operating time and severe pre-operative neck pain may be risk factors. Although the aetiology remains unclear and is probably multifactorial, proposed causes include oesophageal retraction, prominence of the cervical plate and prevertebral swelling. Recently, pre-operative tracheal traction exercises and the use of retropharyngeal steroids have been proposed as methods of reducing post-operative dysphagia. We performed a systematic review to assess the incidence, aetiology, risk factors, methods of assessment and management of dysphagia following anterior cervical spinal surgery. Cite this article: Bone Joint J 2013;95-B:868–73

This paper describes the relationship between post-myelographic symptoms and the timing of a subsequent spinal operation. A prospective study was performed comparing the post-operative symptoms of patients who underwent discectomy within 48 hours of myelography (Group 1) with those of patients who underwent discectomy at least seven days after myelography (Group 2). After myelography there was no statistical difference in the incidence of nausea and headache in the two groups. However, after operation the incidence of headache and nausea was significantly greater in patients who underwent early discectomy. The incidence of urinary retention was significantly greater in Group 1 at 24 hours after operation but not at 48 and 72 hours. We conclude that the temptation to perform discectomy shortly after myelography should be resisted until at least one week has elapsed between the two procedures, except in emergency situations.