Aims

Several radiological methods of measuring anteversion of the acetabular component after total hip arthroplasty (THA) have been described. These are limited by low reproducibility, are less accurate than CT 3D reconstruction, and are cumbersome to use. These methods also partly rely on the identification of obscured radiological borders of the component. We propose two novel methods, the Area and Orthogonal methods, which have been designed to maximize use of readily identifiable points while maintaining the same trigonometric principles.

The Norwich Health District (population 400,000) has been studied during a five-year period in an attempt to assess the value of examination of the hip in the newborn. It is confirmed that complicated deliveries produce higher rates of neonatal instability. But, in sixteen out of the seventeen cases with hip dislocations diagnosed late, delivery had been normal. It is estimated that after normal deliveries, hospital doctors detect only 50%, and family doctors only 28%, of cases of instability of the hip. It is concluded: 1) that the problem of congenital dislocation of the hip will not be eliminated by neonatal examination alone, even if skill in clinical examination could be improved and maintained; 2) that repeated examinations should be considered mandatory until the child is walking. In this regard, the value of the sign of limitation of abduction requires study; 3) that the public should be made aware by an appropriate health education programme that the problem of congenital dislocation of the hip has not yet been solved

1. Attention is drawn to the powers of resistance of the growing ends of bones in suppurative pyogenic arthritis of the knee and hip in infancy. 2. It is emphasised that a translucent zone in the radiograph does not necessarily mean that this part of the bone, epiphysial cartilage or plate is destroyed. 3. Diagnostic criteria are described to confirm that cartilage or decalcified bone has survived the infection in the knee joint. 4. The prognosis for the knee joint is discussed. 5. The hip joint presents greater difficulties in diagnosis and greater issues are at stake. It is recommended therefore that the hip joint be manipulated or explored if the radiograph and the physical signs suggest that destruction of the joint has either caused dislocation or has so damaged it that dislocation is likely to occur in the future. In favourable cases stability may be restored to the hip. In the others a diagnosis of irreparable destruction is established and the surgeon is satisfied that an opportunity to help the patient has not been lost

Arthrogryposis multiplex congenita (AMC) is a rare disease with multiple joint contractures. It is widely believed that bilaterally dislocated hips should not be reduced since movement is satisfactory and open reduction has had poor results. Since 1977 we have performed a new method of open reduction using an extensive anterolateral approach on ten hips in five children with AMC. The mean age at surgery was 31.5 months (17 to 64) and the mean follow-up was 11.8 years (3.8 to 19.5). At the final follow-up all children walked without crutches or canes. Two managed independently, one required a long leg brace and two had short leg braces because of knee and/or foot problems. The clinical results were good in eight hips and fair in two and on the Severin classification seven hips were rated as good (group I or group II). We recommend the extensive anterolateral approach for unilateral or bilateral dislocation of the hip in children with arthrogryposis or developmental dislocation of the hip

We reviewed 19 revision hip arthroplasties in which the new femoral component had been recemented into the old, intact cement mantle. The mean time from the first operation to revision was 64 months and the average follow-up was 59 months. There were 7 excellent, 11 good, and one fair result. No femoral component had been revised for loosening and all the stems appeared radiographically stable. Complications included intraoperative perforation of the femur on two occasions and one dislocation. The use of the cement-within-cement technique requires that the old cement surface be dry and roughened to increase the surface area and that the cement be injected in the liquid phase to prevent lamination. The indications for this technique include a broken stem with an intact distal cement mantle, the removal of a femoral component for revision of a loose cup to improve exposure and/or increase offset, recurrent dislocation secondary to component malposition, and debonding of the femoral component within an intact cement mantle

We have carried out in 24 patients, a two-stage revision arthroplasty of the hip for infection with massive bone loss. We used a custom-made, antibiotic-loaded cement prosthesis as an interim spacer. Fifteen patients had acetabular deficiencies, eight had segmental femoral bone loss and one had a combined defect. There was no recurrence of infection at a mean follow-up of 4.2 years (2 to 7). A total of 21 patients remained mobile in the interim period. The mean Merle D’Aubigné and Postel hip score improved from 7.3 points before operation to 13.2 between stages and to 15.8 at the final follow-up. The allograft appeared to have incorporated into the host bone in all patients. Complications included two fractures and one dislocation of the cement prosthesis. The use of a temporary spacer maintains the function of the joint between stages even when there is extensive loss of bone. Allograft used in revision surgery after septic conditions restores bone stock without the risk of recurrent infection

We report on a radiographic screening programme at four months of age for infants who were clinically normal at neonatal examination but were considered to be 'at risk' for congenital dislocation of the hip because of their family history, breech presentation, or a persistent click. From a total population of 13,662 live births over a two-year period, 357 (2.6%) infants at risk were identified. Of these 46 had abnormal radiographs (six subluxations, 40 acetabular dysplasia). In 12 infants treatment resulted in a normal hip; 34 required no treatment but were followed up until their radiographs were normal and walking had begun. Of the 311 infants with normal radiographs, 256 (82%) were examined after 15 months of age; none had any detectable abnormality. We suggest that radiography of the hip at four months is a valuable adjunct to neonatal screening for infants at increased risk of congenital dislocation of the hip

The hip problems in 116 children with myelomeningocele are discussed. The management described stresses the importance of selection of the type of operation; major surgery is appropriate only for those children who benefit significantly, and this generally means only those with strong quadriceps muscles on both sides. Some children with acetabular dysplasia gain immediate stability if acetabuloplasty is combined with other hip operations. Children who lack strong quadriceps muscles are best served by simpler procedures, such as tendon excision, designed to rid them of fixed deformity and to prevent recurrent deformity. The operations described are performed whenever possible under one anaesthetic and are combined with any other limb operation that may be necessary. It is suggested that the aim in management is not the treatment of paralytic dislocation of the hip but the correction of fixed deformity so that the child can stand with a stable posture. Subluxation and dislocation are treated incidentally to procedures designed to prevent or correct fixed deformity

Aims

Increasingly, patients with bilateral hip arthritis wish to undergo staged total hip arthroplasty (THA). With the rise in demand for arthroplasty, perioperative risk assessment and counselling is crucial for shared decision making. However, it is unknown if complications that occur after a unilateral hip arthroplasty predict complications following surgery of the contralateral hip.

1. The pathology and pathogenesis of dislocations and fracture-dislocations of the cervical spine has been reviewed. 2. A method of treatment using skeletal traction and manipulation under relaxant general anaesthesia is described. Results of treatment are given for all patients admitted to the Centre with flexion-rotation dislocations of the cervical spine complicated by neurological lesions, between November 1961 and December 1968. 3. After reviewing the literature and considering the results obtained in seventy-six cases, we advocate a policy of conservative management with gentle manipulation of the cervical spine in selected cases, reduction being maintained thereafter by skeletal traction. We reserve operation for the few cases that demonstrate late instability or for those rarer cases in which manipulation fails and the patient has either an incomplete neurological lesion or a double skeletal injury. 4. The low incidence of late instability after adequate conservative treatment is stressed, and the danger of overdistraction of the cervical spine by heavy traction in patients with severe ligamentous damage is emphasised

Objectives

The long head of the biceps (LHB) is often resected in shoulder surgery and could therefore serve as a cell source for tissue engineering approaches in the shoulder. However, whether it represents a suitable cell source for regenerative approaches, both in the inflamed and non-inflamed states, remains unclear. In the present study, inflamed and native human LHBs were comparatively characterized for features of regeneration.

We report complications from the use of modular components in 20 hip replacements in 18 patients. Fifteen complications (in 13 patients) were related to failure of a modular interface after operation. Femoral head detachment from its trunnion was seen in 6 hips from trauma (3), reduction of a dislocation (2), and normal activity (1). In one case the base of the trunnion fractured below an extra-long modular head. In seven other hips the modular polyethylene liner dislodged from its shell, causing severe damage to the shell in four cases with extensive metallosis. In one other hip an asymmetrical polyethylene liner rotated, resulting in impingement of the femoral component and recurrent dislocation. Operative errors were seen in five cases: implantation of a trial acetabular component in one; and mismatching between the size of the femoral head and the acetabular component in the others. Surgeons who use hip replacements with modular components should be aware of the potential for operative error and of the importance of early treatment for postoperative mechanical failure

Injury to the sciatic nerve is one of the more serious complications of acetabular fracture and traumatic dislocation of the hip, both in the short and long term. We have reviewed prospectively patients, treated in our unit, for acetabular fractures who had concomitant injury to the sciatic nerve, with the aim of predicting the functional outcome after these injuries. Of 136 patients who underwent stabilisation of acetabular fractures, there were 27 (19.9%) with neurological injury. At initial presentation, 13 patients had a complete foot-drop, ten had weakness of the foot and four had burning pain and altered sensation over the dorsum of the foot. Serial electromyography (EMG) studies were performed and the degree of functional recovery was monitored using the grading system of the Medical Research Council. In nine patients with a foot-drop, there was evidence of a proximal acetabular (sciatic) and a distal knee (neck of fibula) nerve lesion, the double-crush syndrome. At the final follow-up, clinical examination and EMG studies showed full recovery in five of the ten patients with initial muscle weakness, and complete resolution in all four patients with sensory symptoms (burning pain and hyperaesthesia). There was improvement of functional capacity (motor and sensory) in two patients who presented initially with complete foot-drop. In the remaining 11 with foot-drop at presentation, including all nine with the double-crush lesion, there was no improvement in function at a mean follow-up of 4.3 years

This is a prospective study of 107 repairs of obstetric brachial plexus palsy carried out between January 1990 and December 1999. The results in 100 children are presented. In partial lesions operation was advised when paralysis of abduction of the shoulder and of flexion of the elbow persisted after the age of three months and neurophysiological investigations predicted a poor prognosis. Operation was carried out earlier at about two months in complete lesions showing no sign of clinical recovery and with unfavourable neurophysiological investigations. Twelve children presented at the age of 12 months or more; in three more repair was undertaken after earlier unsuccessful neurolysis. The median age at operation was four months, the mean seven months and a total of 237 spinal nerves were repaired. The mean duration of follow-up after operation was 85 months (30 to 152). Good results were obtained in 33% of repairs of C5, in 55% of C6, in 24% of C7 and in 57% of operations on C8 and T1. No statistical difference was seen between a repair of C5 by graft or nerve transfer. Posterior dislocation of the shoulder was observed in 30 cases. All were successfully relocated after the age of one year. In these children the results of repairs of C5 were reduced by a mean of 0.8 on the Gilbert score and 1.6 on the Mallett score. Pre-operative electrodiagnosis is a reliable indicator of the depth of the lesion and of the outcome after repair. Intra-operative somatosensory evoked potentials were helpful in the detection of occult intradural (pre-ganglionic) injury

We analysed the results of different strategies in the revision of primary uncemented acetabular components reported to the Norwegian Arthroplasty Register. The aim was to compare the risk of further acetabular revision after isolated liner exchange and complete component revision. The results of exchanging well-fixed components were also compared with those of exchanging loose acetabular components. The period studied was between September 1987 and April 2005. The following groups were compared: group 1, exchange of liner only in 318 hips; group 2, exchange of well-fixed components in 398; and group 3, exchange of loose components in 933. We found that the risk of a further cup revision was lower after revision of well-fixed components (relative risk from a Cox model (RR) = 0.56, 95% confidence interval 0.37% to 0.87%) and loose components (RR = 0.56, 95% confidence interval 0.39% to 0.80%), compared with exchange of the liner in isolation. The most frequent reason for a further acetabular revision was dislocation, accounting for 61 (28%) of the re-revisions. Other reasons for further revision included pain in 27 (12%), loosening in 24 (11%) and infection in 20 (9%). Re-revisions because of pain were less frequent when complete component (fixed or loose) revision was undertaken compared with isolated exchange of the liner (RR = 0.20 (95% confidence interval 0.06% to 0.65%) and RR = 0.10 (95% confidence interval 0.03% to 0.30%), respectively). The risk of further acetabular revision for infection, however, did not differ between the groups. In this study, exchange of the liner only had a higher risk of further cup revision than revision of the complete acetabular component. Our results suggest that the threshold for revising well-fixed components in the case of liner wear and osteolysis should be lowered