A pelvic discontinuity occurs when the superior and inferior parts of the hemi-pelvis are no longer connected, which is difficult to manage when associated with a failed total hip replacement. Chronic pelvic discontinuity is found in 0.9% to 2.1% of hip revision cases with risk factors including severe pelvic bone loss, female gender, prior pelvic radiation and rheumatoid arthritis. Common treatment options include: pelvic plating with allograft, cage reconstruction, custom triflange implants, and porous tantalum implants with modular augments. The optimal technique is dependent upon the degree of the discontinuity, the amount of available bone stock and the likelihood of achieving stable healing between the two segments. A method of treating pelvic discontinuity using porous tantalum components with a distraction technique that achieves both initial stability and subsequent long-term biological fixation is described.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):73–7.

Dysplasia of the hip, hypotonia, osteopenia, ligamentous laxity, and mental retardation increase the complexity of performing and managing patients with Down syndrome who require total hip replacement (THR). We identified 14 patients (six males, eight females, 21 hips) with Down syndrome and degenerative disease of the hip who underwent THR, with a minimum follow-up of two years from 1969 to 2009. In seven patients, bilateral THRs were performed while the rest had unilateral THRs. The mean clinical follow-up was 5.8 years (standard deviation (sd) 4.7; 2 to 17). The mean Harris hip score was 37.9 points (sd 7.8) pre-operatively and increased to 89.2 (sd 12.3) at final follow-up (p = 1x10^-9). No patient suffered a post-operative dislocation. In three patients, four hips had revision THR for aseptic loosening at a mean follow-up of 7.7 years (sd 6.3; 3 to 17). This rate of revision THR was higher than expected. Our patients with Down syndrome benefitted clinically from THR at mid-term follow-up.

Cite this article: Bone Joint J 2014;96-B:1455–8.

Pelvic discontinuity represents a rare but challenging problem for orthopaedic surgeons. It is most commonly encountered during revision total hip replacement, but can also result from an iatrogentic acetabular fracture during hip replacement. The general principles in management of pelvic discontinuity include restoration of the continuity between the ilium and the ischium, typically with some form of plating. Bone grafting is frequently required to restore pelvic bone stock. The acetabular component is then impacted, typically using an uncemented, trabecular metal component. Fixation with multiple supplemental screws is performed. For larger defects, a so-called ‘cup–cage’ reconstruction, or a custom triflange implant may be required. Pre-operative CT scanning can greatly assist in planning and evaluating the remaining bone stock available for bony ingrowth. Generally, good results have been reported for constructs that restore stability to the pelvis and allow some form of biologic ingrowth.

Cite this article: Bone Joint J 2013;95-B, Supple A:109–13.

The increasing need for total hip replacement (THR) in an ageing population will inevitably generate a larger number of revision procedures. The difficulties encountered in dealing with the bone deficient acetabulum are amongst the greatest challenges in hip surgery. The failed acetabular component requires reconstruction to restore the hip centre and improve joint biomechanics. Impaction bone grafting is successful in achieving acetabular reconstruction using both cemented and cementless techniques. Bone graft incorporation restores bone stock whilst providing good component stability. We provide a summary of the evidence and current literature regarding impaction bone grafting using both cemented and cementless techniques in revision THR.

Cite this article: Bone Joint J 2013;95-B, Supple A:98–102.

The best method of managing a fracture of the distal humerus in a frail low-demand patient with osteoporotic bone remains controversial. Total elbow arthroplasty (TEA) has been recommended for patients in whom open reduction and internal fixation (ORIF) is not possible. Conservative methods of treatment, including the ‘bag of bones’ technique (acceptance of displacement of the bony fragments and early mobilisation), are now rarely considered as they are believed to give a poor functional result.

We reviewed 40 elderly and low-demand patients (aged 50 to 93 years, 72% women) with a fracture of the distal humerus who had been treated conservatively at our hospital between March 2008 and December 2013, and assessed their short- and medium-term functional outcome.

In the short-term, the mean Broberg and Morrey score improved from 42 points (poor; 23 to 80) at six weeks after injury to 67 points (fair; 40 to 88) by three months.

In the medium-term, surviving patients (n = 20) had a mean Oxford elbow score of 30 points (7 to 48) at four years and a mean Disabilities of the Arm, Shoulder and Hand score of 38 points (0 to 75): 95% reported a functional range of elbow flexion. The cumulative rate of fracture union at one year was 53%. The mortality at five years approached 40%.

Conservative management of a fracture of the distal humerus in a low-demand patient only gives a modest functional result, but avoids the substantial surgical risks associated with primary ORIF or TEA.

Cite this article: Bone Joint J 2015;97-B:1132–8.

Patients with transfemoral amputation (TFA) often experience problems related to the use of socket-suspended prostheses. The clinical development of osseointegrated percutaneous prostheses for patients with a TFA started in 1990, based on the long-term successful results of osseointegrated dental implants.

Between1999 and 2007, 51 patients with 55 TFAs were consecutively enrolled in a prospective, single-centre non-randomised study and followed for two years. The indication for amputation was trauma in 33 patients (65%) and tumour in 12 (24%). A two-stage surgical procedure was used to introduce a percutaneous implant to which an external amputation prosthesis was attached. The assessment of outcome included the use of two self-report questionnaires, the Questionnaire for Persons with a Transfemoral Amputation (Q-TFA) and the Short-Form (SF)-36.

The cumulative survival at two years’ follow-up was 92%. The Q-TFA showed improved prosthetic use, mobility, global situation and fewer problems (all p < 0.001). The physical function SF-36 scores were also improved (p < 0.001). Superficial infection was the most frequent complication, occurring 41 times in 28 patients (rate of infection 54.9%). Most were treated effectively with oral antibiotics. The implant was removed in four patients because of loosening (three aseptic, one infection).

Osseointegrated percutaneous implants constitute a novel form of treatment for patients with TFA. The high cumulative survival rate at two years (92%) combined with enhanced prosthetic use and mobility, fewer problems and improved quality of life, supports the ‘revolutionary change’ that patients with TFA have reported following treatment with osseointegrated percutaneous prostheses.

Cite this article: Bone Joint J 2014;96-B:106–13.

There is a North Atlantic divide, with cementless femoral stems being used more frequently in the USA and cemented stems being used more frequently in many countries in Europe. This is primarily because different cemented stems have been used on different sides of the Atlantic and the results of the cemented stems in the US have often been poor, whereas the results of the stems used in Europe have been good. In the National registers in Europe, cemented stems have tended to achieve better results than cementless.

Cite this article: Bone Joint J 2013;95-B, Supple A:51–2.

The June 2015 Research Roundup360 looks at: Tranexamic acid: just give it – it’s not important how!; The anterolateral ligament re-examined; Warfarin a poor post-operative agent; Passive exoskeleton the orthosis of the future?; Musculoskeletal medicine: a dark art to UK medical students?; Alendronic acid and bone density post arthroplasty; Apples with oranges? Knee functional scores revisited

The June 2015 Foot & Ankle Roundup³⁶⁰ looks at: Syndesmosis and outcomes in ankle fracture; Ankle arthrodesis or arthroplasty: a complications-based analysis; Crosslinked polyethylene and ankle arthroplasty; Reducing screw removal in calcaneal osteotomies; Revisiting infection control policies; Chevron osteotomy: proximal or distal?; Ankle distraction for osteoarthritis

We evaluated the outcome of 41 consecutive Charnley low-friction arthroplasties (LFAs) performed by a single surgeon in 28 patients aged ≤ 35 years at operation between 23 and 36 years previously. There were 20 women and eight men with a mean age of 32 years (23 to 35) at surgery. Two patients (three hips) were lost to follow-up at 12 and 17 years post-operatively, respectively, and one patient (one hip) died at 13 years post-operatively. These patients were excluded from the final evaluation. The survival rate of the acetabular components was 92.7% (95% confidence interval (CI) 88.7 to 96.7) at ten years, 67.1% (95% CI 59.75 to 74.45) at 20 years and 53.2% (95% CI 45.3 to 61.1) at 25 years. For the femoral component the survival was 95.1% (95% CI 91.8 to 98.5) at ten years, 77.1% (95% CI 73.9 to 80.3) at 20 years and 68.2% (95% CI 60.7 to 75.8) at 25 years. The results indicate that the Charnley LFA remains a reasonable choice in the treatment of young patients and can serve for comparison with newer techniques and implants.

Cite this article: Bone Joint J 2013;95-B:1052–6.

There are few reports describing the technique of managing acetabular protrusio in primary total hip replacement. Most are small series with different methods of addressing the challenges of significant medial and proximal migration of the joint centre, deficient medial bone and reduced peripheral bony support to the acetabular component. We describe our technique and the clinical and radiological outcome of using impacted morsellised autograft with a porous-coated cementless cup in 30 primary THRs with mild (n = 8), moderate (n = 10) and severe (n = 12) grades of acetabular protrusio. The mean Harris hip score had improved from 52 pre-operatively to 85 at a mean follow-up of 4.2 years (2 to 10). At final follow-up, 27 hips (90%) had a good or excellent result, two (7%) had a fair result and one (3%) had a poor result. All bone grafts had united by the sixth post-operative month and none of the hips showed any radiological evidence of recurrence of protrusio, osteolysis or loosening. By using impacted morsellised autograft and cementless acetabular components it was possible to achieve restoration of hip mechanics, provide a biological solution to bone deficiency and ensure long-term fixation without recurrence in arthritic hips with protrusio undergoing THR.

Cite this article: Bone Joint J 2013;95-B, Supple A:37–40.

Acetabular bone loss is a challenging problem facing the revision total hip replacement surgeon. Reconstruction of the acetabulum depends on the presence of anterosuperior and posteroinferior pelvic column support for component fixation and stability. The Paprosky classification is most commonly used when determining the location and degree of acetabular bone loss. Augments serve the function of either providing primary construct stability or supplementary fixation.

When a pelvic discontinuity is encountered we advocate the use of an acetabular distraction technique with a jumbo cup and modular porous metal acetabular augments for the treatment of severe acetabular bone loss and associated chronic pelvic discontinuity.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):36–42.

Tribocorrosion at the head–neck taper interface – so-called ‘taperosis’ – may be a source of metal ions and particulate debris in metal-on-polyethylene total hip arthroplasty (THA).

We examined the effect of femoral head length on fretting and corrosion in retrieved head–neck tapers in vivo for a minimum of two years (mean 8.7 years; 2.6 to 15.9). A total of 56 femoral heads ranging from 28 mm to 3 mm to 28 mm + 8 mm, and 17 femoral stems featuring a single taper design were included in the study. Fretting and corrosion were scored in three horizontally oriented concentric zones of each taper by stereomicroscopy.

Head length was observed to affect fretting (p = 0.03), with 28 mm + 8 mm femoral heads showing greater total fretting scores than all other head lengths. The central zone of the femoral head bore taper was subject to increased fretting damage (p = 0.01), regardless of head length or stem offset. High-offset femoral stems were associated with greater total fretting of the bore taper (p = 0.04).

Increased fretting damage is seen with longer head lengths and high-offset femoral stems, and occurs within a central concentric zone of the femoral head bore taper. Further investigation is required to determine the effect of increased head size, and variations in head–neck taper design.

Cite this article: Bone Joint J 2015; 97-B:911–16.

We report the long-term survival and functional outcome of the Birmingham Hip Resurfacing (BHR) in patients aged < 50 years at operation, and explore the factors affecting survival. Between 1997 and 2006, a total of 447 BHRs were implanted in 393 patients (mean age 41.5 years (14.9 to 49.9)) by one designing surgeon. The mean follow-up was 10.1 years (5.2 to 14.7), with no loss to follow-up. In all, 16 hips (3.6%) in 15 patients were revised, giving an overall cumulative survival of 96.3% (95% confidence interval (CI) 93.7 to 98.3) at ten years and 94.1% (95% CI 84.9 to 97.3) at 14 years. Using aseptic revision as the endpoint, the survival for men with primary osteoarthritis (n = 195) was 100% (95% CI 100 to 100) at both ten years and 14 years, and in women with primary osteoarthritis (n = 109) it was 96.1% (95% CI 90.1 to 99.9) at ten years and 91.2% (95% CI 68.6 to 98.7) at 14 years. Female gender (p = 0.047) and decreasing femoral head size (p = 0.044) were significantly associated with an increased risk of revision. The median Oxford hip score (OHS, modified as a percentage with 100% indicating worst outcome) at last follow-up was 4.2% (46 of 48; interquartile range (IQR) 0% to 24%) and the median University of California, Los Angeles (UCLA) score was 6.0 (IQR 5 to 8). Men had significantly better OHS (p = 0.02) and UCLA scores (p = 0.01) than women. The BHR provides excellent survival and functional results in men into the second decade, with good results achieved in appropriately selected women.

Cite this article: Bone Joint J 2013;95-B:1172–7.

Total hip replacement for developmental hip dysplasia is challenging. The anatomical deformities on the acetabular and femoral sides are difficult to predict. The Crowe classification is usually used to describe these cases – however, it is not a very helpful tool for pre-operative planning. Small acetabular components, acetabular augments, and modular femoral components should be available for all cases. Regardless of the Crowe classification, the surgeon must be prepared to perform a femoral osteotomy for shortening, or to correct rotation, and/or angulation.

Cite this article: Bone Joint J 2013;95-B, Supple A:31–6.

In this retrospective study we evaluated the proficiency of shelf autograft in the restoration of bone stock as part of primary total hip replacement (THR) for hip dysplasia, and in the results of revision arthroplasty after failure of the primary arthroplasty. Of 146 dysplastic hips treated by THR and a shelf graft, 43 were revised at an average of 156 months, 34 of which were suitable for this study (seven hips were excluded because of insufficient bone-stock data and two hips were excluded because allograft was used in the primary THR). The acetabular bone stock of the hips was assessed during revision surgery. The mean implant–bone contact was 58% (50% to 70%) at primary THR and 78% (40% to 100%) at the time of the revision, which was a significant improvement (p < 0.001). At primary THR all hips had had a segmental acetabular defect > 30%, whereas only five (15%) had significant segmental bone defects requiring structural support at the time of revision. In 15 hips (44%) no bone graft or metal augments were used during revision.

A total of 30 hips were eligible for the survival study. At a mean follow-up of 103 months (27 to 228), two aseptic and two septic failures had occurred. Kaplan-Meier survival analysis of the revision procedures demonstrated a ten-year survival rate of 93.3% (95% confidence interval (CI) 78 to 107) with clinical or radiological failure as the endpoint. The mean Oxford hip score was 38.7 (26 to 46) for non-revised cases at final follow-up.

Our results indicate that the use of shelf autografts during THR for dysplastic hips restores bone stock, contributing to the favourable survival of the revision arthroplasty should the primary procedure fail.

Cite this article: Bone Joint J 2013;95-B:777–81.

We report the five year outcomes of a two-stage approach for infected total hip replacement. This is a single-surgeon experience at a tertiary centre where the more straightforward cases are treated using single-stage exchange. This study highlights the vital role of the multidisciplinary team in managing these cases.

A total of 125 patients (51 male, 74 female) with a mean age of 68 years (42 to 78) were reviewed prospectively. Functional status was assessed using the Harris hip score (HHS). The mean HHS improved from 38 (6 to 78.5) pre-operatively to 81.2 (33 to 98) post-operatively. Staphylococcus species were isolated in 85 patients (68%).

The rate of control of infection was 96% at five years. In all, 19 patients died during the period of the study. This represented a one year mortality of 0.8% and an overall mortality of 15.2% at five years. No patients were lost to follow-up.

We report excellent control of infection in a series of complex patients and infections using a two-stage revision protocol supported by a multidisciplinary approach. The reason for the high rate of mortality in these patients is not known.

Cite this article: Bone Joint J 2014;96-B:1312–18

Total hip replacement (THR) is a very common procedure undertaken in up to 285 000 Americans each year. Patient satisfaction with THR is very high, with improvements in general health, quality of life, and function while at the same time very cost effective. Although the majority of patients have a high degree of satisfaction with their THR, 27% experience some discomfort, and up to 6% experience severe chronic pain. Although it can be difficult to diagnose the cause of the pain in these patients, this clinical issue should be approached systematically and thoroughly. A detailed history and clinical examination can often provide the correct diagnosis and guide the appropriate selection of investigations, which will then serve to confirm the clinical diagnosis made.

Cite this article: Bone Joint J 2013;95-B, Supple A:70–3.

Rebound growth after hemiepiphysiodesis may be a normal event, but little is known about its causes, incidence or factors related to its intensity. The aim of this study was to evaluate rebound growth under controlled experimental conditions.

A total of 22 six-week-old rabbits underwent a medial proximal tibial hemiepiphysiodesis using a two-hole plate and screws. Temporal growth plate arrest was maintained for three weeks, and animals were killed at intervals ranging between three days and three weeks after removal of the device. The radiological angulation of the proximal tibia was studied at weekly intervals during and after hemiepiphysiodesis. A histological study of the retrieved proximal physis of the tibia was performed.

The mean angulation achieved at three weeks was 34.7° (standard deviation (sd) 3.4), and this remained unchanged for the study period of up to two weeks. By three weeks after removal of the implant the mean angulation had dropped to 28.2° (sd 1.8) (p < 0.001). Histologically, widening of the medial side was noted during the first two weeks. By three weeks this widening had substantially disappeared and the normal columnar structure was virtually re-established.

In our rabbit model, rebound was an event of variable incidence and intensity and, when present, did not appear immediately after restoration of growth, but took some time to appear.

Cite this article: Bone Joint J 2015;97-B:862–8.

We determined the short-term clinical outcome and migration within the bone of the humeral cementless component of the Instrumented Bone Preserving (IBP) total elbow replacement in a series of 16 patients. There were four men and 12 women with a mean age at operation of 63 years (40 to 81). Migration was calculated using radiostereometric analysis. There were no intra-operative complications and no revisions. At two-year follow-up, all patients showed a significant reduction in pain and functional improvement of the elbow (both p < 0.001). Although ten components (63%) showed movement or micromovement during the first six weeks, 14 (88%) were stable at one year post-operatively. Translation was primarily found in the proximal direction (median 0.3 mm (interquartile range (IQR) -0.09 to 0.8); the major rotational movement was an anterior tilt (median 0.7° (IQR 0.4° to 1.6°)). One malaligned component continued to migrate during the second year, and one component could not be followed beyond three months because migration had caused the markers to break off the prosthesis.

This study shows promising early results for the cementless humeral component of the IBP total elbow replacement. All patients had a good clinical outcome, and most components stabilised within six months of the operation.

Cite this article: Bone Joint J 2014;96-B:229–36.