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Spiral fractures are one of the most common fractures seen in non-accidental injury. In such cases, with radiographic evidence for the mechanism of injury, the physician is more capable of identifying any inconsistencies in the offered explanatory history.
The objectives of the study were to detail and differentiate the fracture patterns created by rotation forces in different directions and to determine the reliability of that recognition method applied to standard radiographs.
Twenty rabbit femurs were fractured using a torque transducer and imaged using standard anterior-posterior and lateral radiographs. The radiographic interpretation skills of paediatric, radiology, orthopaedic and emergency room doctors were assessed before and after being given the findings of this study.
The radiographic propagation of the spiral fractures was consistent and followed six simple principles. There was a statistically significant difference in the numbers of correctly diagnosed radiographs, before and after the explanation of our findings, by these doctors (chi-squared=14.06, df=1, p=0.002).
The direction of the torsional force producing spiral fractures can be determined from characteristic features on routine radiographs but does not seem to be intuitive. These derived six principles will be a useful aid to physicians who manage paediatric spiral fractures where non-accidental injury is being considered.
The purpose of the study was to establish an algorithm for the treatment of pathological fractures in children.
Pathological fractures can compromise radiographic and histological diagnosis. The need for histological diagnosis and indications for surgical treatment are not clearly defined.
We reviewed our Centre’s Tumour Registry records of children who presented over the past 7 years with a fracture as the first manifestation of primary bone pathology. There were 23 patients (average age 12 years and 2 months).
There were 9 fractures through simple bone cysts, all treated conservatively initially. All patients were subsequently treated with needle biopsy and bone marrow injection. Three patients suffered refracture and underwent flexible intramedullary nail fixation.
There were 5 cases of fibrous dysplasia. Histological diagnosis was obtained in all cases, followed by prophylactic intramedullary nailing in 3 patients.
There were 2 patients with giant cell tumour, 3 with aneurysmal bone cyst and one with chondroblastoma. Histological diagnosis preceded curettage and grafting in all cases.
Finally, there were 3 patients with Ewing’s sarcoma of the femur. One underwent palliative intramedullary nailing for extensive local disease. The second patient was treated conservatively initially. She subsequently underwent segmental resection and vascularised fibular graft. The third patient underwent internal fixation in another unit for what was considered to be a benign lesion. The histological diagnosis of Ewing’s sarcoma was based on intra-operative specimens. Definitive surgery required wide resection and prosthetic replacement.
We recommend that primary fixation of pathological fractures should be avoided until histological diagnosis is obtained. All lesions should be appropriately imaged and biopsied if aggressive characteristics are present. However, if radiographic appearances are reassuringly benign, biopsy can be delayed until conservative fracture management is completed. Definitive treatment of benign lesions with protective intramedullary nailing or curettage and grafting can follow frozen section under the same anaesthetic.
Venham Situational Anxiety Score was performed before and immediately after removal of K-wires. University College London Hospital sedation score was recorded every 20 minutes.
There was no significant difference in anxiety scores between the groups either before or after wire removal. The change in scores was not significantly different between the 2 groups. However, 45% of children in the active group had reduced anxiety levels in the active group compared to 18% of children given placebo but this difference was not significant (p=0.102). No child was excessively sedated but one in the active group became agitated and restless.
A two-way analysis of variance (ANOVA) explored differences in gait between the various walks. Fried-man’s test tested for differences in PBS scores between subjects and conditions.
Three-dimensional motion of the lower limbs was measured using gait analysis. Transverse plane kinematics, including hip rotation and foot progression angles were recorded.
The 2 patients with the most severe contractures have undergone surgical intervention for their contracture, and 2 were managed conservatively with splinting. All 4 cases have residual problems with hand function (mean follow-up 5.5 years, range 2–11).
There were 12 patients [17 hips, 5 bilateral] 5 male 7 female with an average age of 13. Seven were diplegic, two hemiplegic and three had asymmetric diplegia. Data was assessed using SPSS 13.0. As the data was found to be normally distributed the Fisher exact test and the Spearman’s Co-relation Coefficient was used.
On testing the hypothesis it was found that there is no relationship between weak hip abductors and persistent internal rotation. [Fisher exact test: p value: 0.8, r = -0.07]
The purpose of the study was to assess the usefulness of this combination of operations in this challenging patient group.
18 patients (19 hips) with cerebral palsy and painful subluxed or dislocated hips underwent hip resurfacing with shortening and rotation osteotomy of the femur between 1999 and 2005. The mean age was 25 (range 14–59) and follow-up averaged 47 months. Eleven patients were quadriplegic, five were diplegic and two were hemiplegic.
There were no infections. There were two plate cut-outs and two dislocations. All stabilised following necessary treatment. Four plates were removed after about one year. All quadriplegic and four of the diplegic patients were chair-bound pre-operatively. Their carers all felt that their comfort sitting had improved. Seventeen patients (eighteen hips) were pain-free at latest follow-up. One patient, whose plate had not been removed had some lateral tenderness on transferring, but no apparent pain on sitting. Three of the previously chairbound diplegic patients were able to stand and one was able to walk.
As all eighteen of the carers were very satisfied with the outcome, this approach to the treatment of these challenging patients has proved promising
The aims of this study were to compare the outcome of epiphysiodesis in patients with limb length discrepancy (LLD) as a result of cerebral palsy with those as a result of other causes in order to test our hypothesis that the hemiplegic / monoplegic limb may respond differently to epiphysiodesis, to evaluate the accuracy of the Moseley method and evaluate whether there is any difference between the outcomes of left or right hemiplegic limbs with LLD bearing in mind that the left hand is used for bone age calculations.
We reviewed the case notes and radiographs of 34 children who had undergone epiphysiodesis for the management of LLD by the same surgeon, using the Moseley method between February 1999 and May 2005 to final follow up at skeletal maturity. Of the 34 patients, 9 had a LLD as a result of cerebral palsy (4-Left, 5-Right) and 25 as a result of other causes. In the cerebral palsy group the mean residual LLD was 0.59cm and in the other group it was 1.18cm. Both groups were similar in terms of age and sex distribution. There was no demonstrable statistically significant difference in outcome between the 2 groups (unpaired T test, P=0.734). The Moseley method appeared accurate and there was no difference demonstrated in the outcome between left and right hemiplegic LLD.
We conclude that the Moseley method is reliable. We have not found any evidence that the hemiplegic limb behaves any differently. We have not demonstrated any difference in the outcome of left or right hemiplegic limbs.
The healing pattern went through different phases although they were not distinctively exclusive from each other and did show considerable overlap. First phase showed formation of bulbous mass with some continuity of scar tissue across tendon gap. The transition zone between new fibre and the original tend quite distinct. However dynamic ultrasound showed the Achilles tendon moved as a single unit. Second phase showed fibres resembling normal tendon crossing the gap and reduction of bulbous mass. The transition zone was still discernible. Final stage demonstrated more homogenous fibres of Achilles tendon with an indistinct transition zone. Two older children showed a distinctly longer process of healing.
At 3 weeks there was no evidence of healing. At 6 weeks an irregular mass of fluid and soft tissue structures was seen. At 12 weeks there was evidence of continuation of tendon fibres, but transition zone partly visible.
Older Child-Safe to consider percutaneous tenotomy in children up to 3 years of ages provided the period of immobilisation is extended.
Although Bohler’s & Gissane’s angles are measured in adult calcaneal fractures, it is not known if such measurements are reliable in children nor how such measurements vary with the age of the child.
The Picture Archiving and Communications System (PACS) databases of 2 London Teaching Hospitals were searched and all children who had a lateral ankle xray taken as part of their attendance to the A& E department were identified. Films were excluded if there was a fracture of the calcaneus or if the film was oblique or of poor quality. Bohler’s and Gissane’s angles were measured using the image viewer software. All patients’ films were measured on two separate occasions and by two separate authors to allow calculation of inter- and intra-observer variation. Interclass Correlation Coefficients (ICC) were used to assess the reliability of the measurements.
347 children were identified and after exclusions, 218 films were used for the study. The overall ICC for Bohler’s angle inter-obsever error was 0.91 and for intra-observer error was 0.92, giving excellent correlation. This reliability was maintained across the age groups. Gissane’s angle inter-observer error was very poor and the intra-observer error poor across the age groups, although accuracy did improve as the patients approached maturity.
Further analysis of the Bohler’s angle showed a significant variation in the mean angle with age. Contrary to published opinion, the angle is not uniformly lower than that of adults but varies with age, peaking towards the end of the first decade before attaining adult values.
We feel that measurement of Gissane’s angle is unreliable in children but measurement of Bohler’s angle is accurate and reproducible. Bohler’s angle varies with age and knowledge of Bohler’s angle variation is important in the evaluation of os calcis fractures in children.
57 controls and 69 subjects were found to be low risk for emotional disorder (p> 0.05).
Similarly 58 control and 74 subjects were predicted to be low risk for behavioural disorder. 16 controls and 18 subjects had medium or high risk for hyperactivity or concentration disorder (p> 0.05; student t test). There was no significant difference between the self report and parent questionnaires for difficulties or their impact.
Emergency ultrasound was only available in 9 patients. Only 5 (38%) of these 13 patients had septic arthritis.
Septic arthritis group.
– Emergency ultrasound unavailable in 2 patents. They proceeded straight to arthrotomy yielding pus. – 3 had a preoperative ultrasound which confirmed the hip joint had an effusion.
“Non Septic Arthritis of Hip” (8 patients).
– In 2 patients emergency ultrasound unavailable. They underwent emergency arthrotomy with negative findings of pus. – 1 actually had septic arthritis of knee. – 6 patients did have emergency ultrasound which showed no effusion. Emergency arthrotomy was cancelled. – They proceeded to MRI of Hip. MRI revealed pathology close to but not involving the hip: Pelvic osteomyelitis, Psoas abscess, Gluteal abscess secondary to small bowel fistula Cellulitis of medial thigh Femoral Epiphysis osteomyelitis and inflammation of tendon secondary to line insertion. Inflammation of rectus femoris tendon (secondary to central line insertion). Conclusion: Use of ultrasound avoided unnecessary arthrotomy in 6 patients (48%).
If ultrasound was available in all cases, then 8 (63%) patients would have avoided an unnecessary arthrotomy.
Out of hours urgent hip ultrasound may be difficult to request. However our recent experience leads us to propose that if available ultrasound should be performed in all suspected case of hip septic arthritis prior to surgical drainage.
Pathology in the vicinity of the hip can often masquerade convincingly as a septic hip joint.
The aim of the study is to highlight the skeletal changes that result from untreated DDH if it is decided to leave the hip unreduced, as may occur if a child presents at a late age. This is of interest today as the data with which we try to determine prognosis in such cases is very old and comprised of small patients numbers. The method used is the study of c.10,000 human skeletons excavated from the medieval cemetery of Spitalfields in London, dating from 1100–1530AD. Diagnosis was made by the presence of an abnormal true acetabulum incompatible with articulation with a femoral head in life, with an associated false acetabulum on the iliac wing. The results demonstrated a range of skeletal consequences in the 13 dislocated hips present. At the hip joint itself, degenerative change was only present in cases with a well developed, cup-shaped false acetabulum. Only 17% of cases had such a cup-shaped false acetabulum. Cases with no such false acetabular cup (83%), presumably with soft tissue articulation, showed no degenerative change. Hip adduction with valgus knee was common, as was femoral neck anteversion with compensatory tibial torsion. Scoliosis in unilateral cases caused lateral wedging of vertebral bodies and markedly asymmetric degenerative change in older individuals. We conclude that the presence or absence of a deep cup-shaped bony acetabulum at late presentation may have prognostic implications as to whether degenerative change in the hip, and so pain, may occur in adulthood. If confirmed by clinical studies, this may influence whether an attempt at reduction should be made. From the viewpoint of the spine, if a hip is reduced late, surgeons should be aware that the scoliosis may not correct as they would expect if the vertebrae are already laterally wedged by the time the child presents.
In 6 of 8 primarily explored brachial arteries the vessel was observed to be tethered to the fracture site.
Following release, in 6 of 8 cases the radial pulse had returned within 24hrs. Satisfactory radiological reduction of the fracture does not preclude vessel entrapment.
In 8 cases there was an associated median nerve palsy. All of these cases were found to have an anatomical obstruction to the brachial artery.
On follow up there were 12 (41,4%) excellent, 14 satisfactory (48,2%), 3 poor (10,4%) results. All fractures united and a mean time to achieve solid union was 20,7 weeks. Leg length discrepancy occurred in 20 children (71,4%), and in 10 (35,7%) was greater than 10 mm. Four children required in early secondary surgical procedures to achieve better alignment or fracture stabilization. One femoral osteomyelitis required in surgical drainage and prolonged intravenous antibiotic therapy.
A different technique of glenoplasty is now used. An osteotomy of the glenoid is performed postero-inferiorly, elevating the glenoid forward to decrease its volume. Bone graft, often taken from an enlarged and resected coracoid is then packed into the osteotomy and the whole assembly is held with a plate. In a series of 11 patients with a mean age of 6.7 years (1–18 years) we describe good results at short term followup, suggesting that this is a technique warranting further investigation.
We focussed on a single surgeon series with a once weekly afternoon operating list. We identified 24 “major operations” on 19 patients that were performed as a day case over 21 months. The parents of each patient were contacted by telephone to complete a satisfaction survey. We demonstrate that there were no problems that should have warranted an inpatient stay.
The overall Oxford hip score improved significantly from a mean pre-operative value of 35 to a mean post operative value of 22.9 at 3 months (p< 0.001).
The mean score at 1 year increased slightly to 27.3 points but this remains lower than the pre operative average.
We report no cases of osteonecrosis. One patient has since been scheduled to undergo resurfacing arthroplasty.
In the Dunn group the Harris Hip Score ranged from 78 to 100, mean 92 (excellent) and the Oxford Hip scores from 12 to 21, mean 17. The Harris Hip Score for the Imhauser group ranged from 50 to 98, mean 76 (fair), and the Oxford scores from 13 to 34, mean 25. Range of motion was similar for both groups in all directions.
Only the GMTJ of medial head was located as it usually has a lower attachment and is thicker. The soleus muscle has short multipennate fibres running obliquely between aponeuroses overlying its anterior and posterior surfaces. GM has long parallel fibres and merges distally with the posterior aponeurosis of the soleus muscle. The GMTJ has a unique conical appearance on ultrasound. Pre operative skin markings were compared with the location of GMTJ during surgery.
Relapses within 6 months of instigating the foot abduction splint were classed as early and subsequent relapses as late.
The severity of clubfoot was assessed using the Pirani scoring system which comprises two sub-scores – Midfoot Contracture Score (MFCS) and Hindfoot Contracture Score (HFCS). MFCS and HFCS can each be 0.0–3.0, giving rise to a Total Pirani Score (TPS) of 0.0–6.0.
In five patients radiographs revealed an OCD. MR scans were obtained in eleven patients, which revealed OCDs in five, evidence of tarsal coalition in two, features suggesting posterior ankle impingement in 1 and normal scans in the remaining three.
At arthroscopy OCDs were visualised in nine cases, two of which were grade 4, four were grade 3 and three were grade 2. The grade 4 lesions were debrided and drilled, the grade 3 lesions had their edges debrided and the rest were stable. There were 3 false positive MRI scans where an OCD was reported but not seen on arthroscopy.
Impingement lesions were seen in twelve ankles (8 antero-lateral, 2 syndesmotic, 1 medial and 1 posterior), which were debrided. MRI scans had been performed in eight of these twelve cases but only one suggested an impingement lesion.
Twenty two tumours were excised and 3 had curettage performed (1 child and 2 adults). There were 2 recurrences (one osteoid osteoma, one osteoblastoma), one from the excision group and one who had curettage, both in adults. These were successfully treated with re-excision. Mean follow-up was 8 years and all were alive at the time of final follow-up.
Biopsy was performed in 11 patients and surgical treatment was carried out in 3 patients including curettage (2) and excision with bone grafting (1). All patients were treated with adjuvant radiotherapy while 87% also received adjuvant chemotherapy. Seven patients were alive with no evidence of disease at a mean 6 year follow-up. Six patients died of metastatic disease, one due to local recurrence and one with persistent primary disease. The mean follow-up time was 65 months (median 28 months; ranging from 12 to 218 months).
Failure of non-operative management was deemed as non-union or poor patient tolerance of halo, and occurred in 4 patients (17%). All four had type II odontoid peg fractures, and had transarticular screw fixation. One postoperative complication of screw fracture was recorded.
The ‘disc’ group was significantly younger than ‘degenerative’ group (49.4 yrs vs. 58.4 yrs; p=0.004). There were significant improvements in low back pain (LBP), leg pain (LP), and ODI at 2 months in all patients. At 5 years the disc group did better with both leg and back pain; whilst there was only a significant reduction in leg pain in the degenerative group. Over 90% (n=56) of patients had no operative intervention; a subgroup of 8 had further injections. Within the degenerative group, ODI and VAS deteriorate early on indicating that a second injection option in this group may be worthwhile.
At 3 months there was no significant difference in VAS or ODI between the groups. Only two trials reported ODI data at 6 months but a significant effect in favour of the control arm was noted (P = 0.040). Four of the five trials reported the need for further injection or surgery due to failure but no significant difference between the groups was found (P = 0.038).
The study was designed to quantify the hit/miss ratio of non-radiologically assisted caudal epidurals, assessing both accuracy of entry into the epidural space and adequacy flow of contrast and therapeutic agents to the level of pre-defined pathology.
We studied 146 consecutive patients listed for a caudal epidural under sedation for either radicular pain or spinal stenosis. When the surgeon was happy with placement of the needle its position was assessed using image intensifier and injection of radio-opaque dye (Omnipaque). The epidurogram was also used to confirm the level of pathology had been reached by the steroid and local anaesthetic.
Three patients were excluded because of inadequate records. Five patients did not attend for their procedure. Of the remaining 138 patients Consultant spinal surgeons carried out 75 procedures and the remaining 63 cases were performed by “middle grade” surgeons. 36 of 138 patients (26%) had placement of spinal needle outside the epidural space after first blind placement. Hit rate was not related to surgeon grade, patient age or patient diagnosis. In 6% of cases the radio-opaque dye did not reach the level of documented pathology had been reached by the dye. 2 patients had a “spinal” pattern of block requiring overnight admission, there were no other complications recorded.
A miss rate of 26% in the blind placement of spinal needles through the sacral hiatus in caudal epidurals is unacceptable. We would therefore recommend position of the needle is confirmed radiologically and epidurogram is used to confirm accurate delivery of the therapeutic agents.
Less blood loss and operative times were found with skip laminectomy. Similar degrees of decompression with both techniques. Significantly improved axial pain scores with skip laminectomy. Significantly improved preservation of range of movement with skip laminectomy.
Our aim was to determine the exactly whether bone incorporation may be correctly assessed by this method by comparing the results to those obtained by spiral CT imaging.
18 patients underwent surgery to treat a neural axis lesion: Foramen magnum decompression (12); cord untethering (4) and the surgical treatment of diastematomyelia (2).
Preoperative MRI scans should extend from the cranio-cervical junction to the sacrum, reflecting the potential locations of neural axis lesions.
A significant proportion of patients required surgery to treat their neural axis lesions. Centres treating patients with scoliosis should therefore have the necessary facilities to treat not only scoliosis but also its associated intradural spinal lesions.
Neck pain scores improved from 5.1 pre-operatively (range 0–10, s.d. 4) to 2.8 post-operatively (range 0–10, s.d.5), t=3.7, P< 0.0002.
Arm pain scores improved from 5.3 pre-operatively (range 0–10, s.d. 5) to 2.5 post-operatively (range 0–8, s.d. 3), t=2.8, P< 0.009.
Pre-operative myelopathy scores averaged 10.6 (range 7–16, s.d. 4.7) rising to 12.8 post-operatively (range 10–17, s.d. 3.9). Although there was no statistically significant change in myelopathy scores, no patient experienced a worsening of their myelopathy score after surgery.
There were no operative complications. Radiological follow-up demonstrated early improvement in disc space heights (pre-op 3.1 mm, range 1–6 mm; post-op 5.6 mm, range 4–9 mm) but, at 12 months, two patients demonstrated asymptomatic evidence of cage settling and loss of disc height. There was no incidence of pseudarthrosis. No patient has thus far required further surgery.
Complications included dural tear in 5 patients, subsidence in 4, laryngeal nerve palsy in 2, postoperative haematoma in 2 and infection in 1 patient.
At mean follow-up of 25 months (range 3 to 52), 84% were better, 10% remained same and 4 % of patients worsened.
Angle of ipsilateral outer lamina cortex to pedicle axis Virtual screw trajectory 2 mm from and parallel to the lamina was placed through the LM. Potential violation of the transverse foramen and LM width available for screw purchase was assessed
Females: Right: C3–84.8°(2.6), C4–85.2°(3.1), C5–86.7°(3.3), C6–89.2°(2.5), C7–92.3°(2.4); Left: C3–84.0°(3.1), C4–84.5°(3.9), C5–86.6°(3.7), C6–89.6°(2.6), C7–92.1°(2.3) No significant difference between males and females (P<
0.05) Violation of transverse foramen C3–C7: 0% LM width (trajectory parallel to LM) in millimetres (standard deviation): Males: Right: C3–5.5(0.7), C4–6.1(0.7), C5–6.8(0.8), C6–7.1(1.1), C7–6.1(1); Left: C3–5.2(0.8), C4–5.9(0.8), C5–7(1.2), C6–7.3(1.1), C7–6.3(1.4) Females: Right: C3–5.3(0.8), C4–5.5(0.9), C5–6.6(1.2), C6–6.3(1.3), C7–5.4(1.4); Left: C3–5.2(1), C4–5.7(1), C5–7.1(1.1), C6–6.5(1.3), C7–5.5(1.6)
LM screws placed parallel to the lamina find sufficient LM width and are highly unlikely to injure the vertebral artery in bi-cortical placement. This technique appears favourable over conventional 30° LM placement.
A cohort of 69 patients having clinical and radiological evidence of spinal stenosis. Selected according to recommendations of clinical trials groups for the x-stop, i.e. sitting tolerance of greater than 30 minutes.
Clinical outcome data at average of 10 month (6–24) available for 66 patients (95% FU).
Average age 67 years ( Range 49–84). The average outcomes were Pre op ODI 42, Post op ODI 27. A change from baseline of 15 points. Pre op VAS leg 7.2 post op 4.4, and VAS Back Pre 4.8, post op 3.6
Taking a 16 point change in ODI as representing a clinically significant improvement half the study group failed to achieve this. A small number (17 patients 25%) had a dramatic improvement of greater than 24 points, which significantly skews the average change from baseline.
17 Revisions have occurred so far (24% failure rate)
2 yr follow up data were available for 13 of the 15 people who had the surgery. One had died of an unrelated condition before follow up, the other had further lumbar surgery thus affecting the interpretation of the data. Mean duration of follow up was 30.5 months.
Both ODI and SF-36 BP detected sustained improvements 2 yrs after surgery. Results for both scales were statistically significant (z = −3.059 & −3.062; p = 0.002). Mean change scores for both scales were substantial (ODI = 31.7; SF36 BP = 47.4), and effect sizes were very large (ODI = 1.35; SF-36 BP = 1.37) indicating clinically significant improvement. There have been no complications.
11 patients have had implants removed, a 24% implant failure rate. Clinical failure also occurred in two patients unfit for revision. Prospective data on standard spine outcomes were analysed as well as the radiological and biomechanical features of failure.
There were two modes of failure, early, with a failure to improve after the procedure, and late, with an initial improvement and subsequent deterioration.
A consistent feature of late failure is bone resorption around the implant. This is apparent on post operative radiographs and is a progressive. Scalloping and erosion of bone is seen at revision surgery with the implant within a fibrous capsule. Late spinous process fracture occurred in a two level implant as a result of erosion.
Retrieved implants demonstrate scouring of the PEEK surface which increases with time.
The mean pre and post-operative lumbar lordosis was 34.58 and 53.48 respectively. The mean sagittal rotation was 6.5 degrees at 5 year follow-up, while the mean translation was 0.83 mm. The mean AVM, MVM and PVM were 0.59 mm, −3.96 mm and 3.69 mm respectively at 5 year follow-up.
Results: The Pearson product moment correlation coefficients were calculated for the group using SPSS v.13. The results show low negative correlations for the whole group with low to moderate negative correlations for the male group. There were no statistically significant correlations for the physical performance measures and ODI in the female sub-group.
The following measurements were performed on the replaced motion segment using a lateral radiograph:
The anterior-posterior (AP) dimension of the end plates. Amount of subsidence. The distance between the TDA and the posterior and anterior borders of the vertebra bodies (to represent the extent of uncoverage of the endplate by the TDA). The AP dimension of the TDA metal endplate.
The ratio between the actual and radiographic AP length of the metal endplate was calculated and utilized as the correction factor for the error of magnification on all other radiographic measurements.
At L4–L5 the mean subsidence was 1.48 mm (L4) and 0.56 mm (L5). Posterior uncoverage of L4 and L5 vertebrae were 4.81 and 2.22 mm, respectively.
Subsidence of more than 1 mm was present in all cases where the posterior uncoverage of the end plate with the TDA was more than 2 mm (odds ratio: 5.7). Subsidence was non – progressive in all cases.
An anatomic mismatch exists between L5 and S1 endplates in the AP dimension; in more than half the patients S1 is shorter than L5.
to determine what aspects of people’s lives (domains of impact) where most affected by their spinal problems, to determine the extent to which the SF-36 and ODI represent these domains, to compare the domains of impact resulting from neck and low back pain.
Cervical pathology (n=200 people).
19 domains were identified. Of domains identified as first most important (n=164) 3 domains predominated: work (28%), sleep (24%), walking (24%). Others ranged from 0 – 7.6%. Of all domains identified by all people (n=399), 4 predominated: sleep (62%), work (54%), walking (41%) sitting (36%). Others ranged from 0.6% to 9.8%.
Thoraco-Lumbar pathology (n=537 people).
25 domains were identified. Of domains identified as first most important (n=429) 4 domains predominated: walking (49%), working (18%), sitting (12%) and sleeping (11%). Others ranged from 0 – 7.6%. Of all domains identified by all people (n=1096), 4 predominated: sleep (76%), work (50%), walking (47%) sitting (45%). Others ranged from 0.2% to 11.9%.
Racial and ethnic disparities in pain perception diagnosis and management have become apparent in different specialities.
Oswestry Disability Scores (ODI) (completed at every outpatient visit), and other information were obtained retrospectively for 1568 patients seen at our spinal unit over the last two years. Statistical analysis using analysis of variance (ANOVA) was used to determine any true difference in ODI scores between Caucasian, Afro-Caribbean and South Asian different groups pre and post surgery.
Overall scores were significantly higher for the South Asian group when compared with the white using analysis of variance (ANOVA) p< 0.001. Afro-Caribbean patients also showed a trend to higher overall scores from the white group p=0.091 (least squares difference post-hoc test).
From a total of 280 patients who had undergone surgery, South Asians had significantly higher pre-operative scores compared to Caucasians (p> 0.001). Afro-Caribbean’s also scored higher than Caucasians pre-operatively although the difference was not significant (p=0.091). Scores for South Asians and Afro-Caribbean’s remained higher than those for Caucasians postoperatively. All groups however, did show a statistically significant reduction in ODI score compared to the pre-operative score.
Despite the differences in symptom perception or expression we have found to exist between ethnic groups, we conclude that in appropriately selected patients, this does not affect their ability to benefit from surgery
The primary outcome measure was the presence of clinical adverse events during the first 30 days. The secondary outcome was the extent of radiological soft tissue swelling at the C6 level as measured on plain radiographs in the early post-operative period and compared to a historical post-operative anterior cervical fusion cohort.
There was no mortality and no re-operation in this series. 2.4% of patients experienced complications: transient brachalgia (1/123), persistent dysphagia (1/123), sudden dysphagia and dysphonia (1/123).
Mean pre-vertebral soft-tissue measurement in 20 patients from the BMP-7 group was 20.9 mm (16–27 mm). This compared with 18.7 mm (15–25 mm) in 7 patients from the non-BMP-7 group, and 18 mm in the historical control group.
Spinal lipomatosis is seldom reported in spinal literature and although the condition occurs commonly, we seldom recognise it in reviewing spinal MRI scans. We aim to highlight the condition and show MRI signs to allow easier recognition. We also introduce a new method of evaluation of the severity of the condition using T1 MRI axial views to evaluate the area of the spinal canal involved in the pathological process.
We have evaluated 30 patients with a diagnosis of spinal lipomatosis made on sagittal MRI scanning of the spine. The T1 and T2 axial images have been evaluated using standard digital software which allows calculation of the surface area occupied by fat and allows representation of this as a ratio to total canal diameter. This has then been correlated to the traditional method of classifying lipomatosis on sagittal MRI sequences.
We have found this method useful and believe it provides a more accurate representation of how fat in the canal may produce symptoms of nerve compression. This shows that the condition behaves more like our traditional understanding of spinal stenosis with symptoms more likely when the relationship of fat to canal reaches greater than 50%. This approach to spinal lipomatosis has not been described before but we feel produces a better understanding of the condition than we have had before by using a classification based on purely on sagittal MRI sequences.
Dynesys was designed to offer physiological motion at the lumbar spine. An advantage which is superior to abolishing movements through spinal fusion.
This study aims to evaluate the accuracy of sheer off self limiting screw drivers and to assess repeatability with age.
It has been reported that overzealous tightening of halo pins is associated with co-morbidity. Our unit has recently received a tertiary referral where the patient over tightened a pin leading to intracranial haematoma, hence our interest in this subject. The torque produced by six new and nine old screw drivers was tested using an Avery Torque Gauge and a Picotech data recorder. These devices are designed to produce a torque of 0.68 Nm, any greater than this is potentially hazardous. Accepted error for each device was +/− 10%. The average torque produced by the new screw drivers was 0.56 Nm with a range of 0.35–0.64 Nm (SD 0.120). The older screw drivers produced an average torque of 0.67 Nm ranging from 0.52–0.85 Nm (SD 0.123).
In conclusion, sheer off self limiting screw drivers are not accurate devices. The older devices are more likely to produce a torque exceeding a safe range and therefore we would recommend the use of new devices only.
The distribution of shading was categorised as head pain (subdivided into face, vertex and occiput) and arm pain. The incidence of head pain and its distribution was analysed along with its relationship to arm pain.
Data collected from patients presenting with thoracolumbar pain over the same period was used as a control.
Of 200 patients presenting to the clinic with cervical problems, 58 had head pain. 50 had occipital pain, 28 had vertex pain and 8 had facial pain. None of the thoracolumbar patients had head pain although 12 had upper limb pain.
Of the 26 cervical patients who had unilateral arm pain & head pain, the head and arm pain were always on the same side.
+ Assistant model would play a pivotal role in managing patient flow efficiently.
An increase in the number of new referrals seen in OPD by 50% from 8 to 12 per clinic. An increase in the volume of hip &
knee replacements from 490 in 2003 to 834 in 2007. Increased theatre efficiency with routinely 2 joints per session. A reduction in length of stay from mean of 10.75 days in 2003 to 6.89 days in 2007. Continuous monitoring of post-operative infections with current cumulative rate of 0.71%. Improved patient satisfaction as measured by patient feedback sessions.
The average duration of surgery was 44 min. All patients survived the procedure and until discharge form hospital.
We recommend the consideration of this technique for management of patients with severe co-morbidity and fracture of the femoral neck in order to optimise their chance of survival and avoid the morbidity associated with bed rest.
Participants were classified as:
Normal morphology, no clinical features Abnormal morphology, no clinical features Abnormal morphology, clinical signs but no symptoms Abnormal morphology with symptoms and signs Osteoarthritis.
Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) permits inference of glycosaminoglycan (GAG) distribution. We aimed to determine whether hips with cam deformities have altered GAG content, using dGEMRIC.
2 regions of interest (ROI) were studied:
acetabular cartilage from 12 to 3 O’Clock (T1-Index-acet). total cartilage (femoral and acetabular) for the joint from 9 to 3 O’Clock (T1-Indextotal).
The average of all pixels within the given ROI defined the T1-index.
For each hip, the ratio of the GAG content T1-Index-acet/T1-Indextotal was calculated. Mean T1-Indexto-tal and T1-Indexacet/T1-Indextotal were compared.
At 10 years we have a survivorship, if femoral aseptic loosening is used as an end point, of 97.6%. There was a deep infection rate of 1.2%, and a dislocation rate of 1.9%. There were no cases of thigh pain, and no intra-operative femoral neck/shaft fractures.
This group of patients were compared with previous data collected over a 6 month period (Jan to Mar 2007 and Oct to Dec 2005) from the same hospitals for infection rates in Lower Limb Arthroplasty using 3 doses of Cefuroxime 750mg as antibiotic prophylaxis.
Return to theatre data was collected independently after introduction of gentamicin to compare with previous data.
Surgical site infection was detected in 9 THRs (2.2%) and 2 TKRs (0.44%) in the study group as compared to infection in 13 THRs (3.1%) and 12 TKRs (2.9%) in the control group.
Using the Fisher Exact test the infection rates in THRs were not significantly different between the 2 groups (p value – 0.52) but the infection rates were significantly reduced in the study group for TKRs (p value – 0.005).
There were no complications with the use of Gentamicin as antibiotic prophylaxis.
The return to theatre was 2.42% (28/1157) after introduction of Gentamicin as compared with 1.85% (37/2005) [p value – 0.172] before this. This was a cause for concern, although not a significant difference.
Cefuroxime is known to promote Clostridium difficile infection and was removed from the hospital pharmacy to help meet a UK government targets to reduce the incidence. The rate of Clostridium difficile infection was reduced within the hospital with the use of single dose antibiotic prophylaxis although other measures to reduce its incidence were also introduced.
However, be wary of increased rate of return to theatre following use of gentamicin.
Further period of evaluation and study is needed before it is recommended for routine use in present or modified form.
Indications were peri-prosthetic fractures in 9 cases (Vancouver B1 in one case, B2 in 4 cases and B3 in 4), aseptic loosening with significant bone loss in 3 (Paprosky IIIA in one case, Paprosky IIB in one and Type IV in one), osteolysis (Paprosky IV) secondary to infection in 1, non-union of peri-prosthetic fracture in 2 (Vancouver B2 and B3) and fracture around a spacer in one case.
The mean HHS at 3 months post-operatively was 72 (range, 57 to 76). The median pre-operative/pre-injury University of California, Los Angeles hip rating system (UCLA) was 1. The median UCLA at longest follow-up was 3.5 (range, 1 to 4) with 10 patients having a score greater than 3. Mean time to clinical evidence of implant integration was 4 months (range, 2 to 12). No evidence of subsidence was noted. Four dislocations were seen. No dislocation was seen in the 6 patients who had a Posterior Lip Augmentation Device (PLAD™) inserted at the time of revision THA. One stem fracture occurred requiring revision surgery with a longer REEF™ implant. Two patients died in the immediate post-operative period.
RSA after two years: (table deleted)
One of the many challenges in revision hip arthroplasty is massive bone loss. Subsidence of the collarless stem with impaction allografting has been reported by several authors. Impaction grafting has emerged as a useful technique in the armamentarium of the revision total hip arthroplasty surgeon. The original technique proposed by Ling has been associated with complications, including femoral shaft fractures, recurrent dislocations, and uncontrolled component subsidence. Modifications in that technique seem to be associated with a reduction in complications.
The aim of this study was to assess the functional outcome of radial impaction grafting in femoral bone defects and the use of collared long stem prosthesis.
A total of 107 patients underwent radial impaction allografting and collared long stem prosthesis during revision THA between 1997 and 2005. The patients with Paprosky type II, IIIA and IIIB defects were included in this study. Average duration between the primary and revision surgery was 9.4 years (Range 6–23 years). Assessment was done using Oxford Hip Score, Harris Hip Score and with plain X-rays. Three patients were lost to follow-up and three patients died due to unrelated causes.
The follow-up period lasted between 12 to 114 months (average – 68.8 months). Three patients who sustained post-operative peri-prosthetic fracture had standard stem inserted in them. None of the patients with long stem sustained peri-prosthetic fracture. Four patients had infection and underwent revision procedure. In this study, using revision for any cause as the end-point, survival of the femoral stem was 93.8%. Subsidence was not recorded in any of the patients in this study. Oxford Hip Score improved from mean pre-operative value of 41.2 to 19.2 post-operatively. Mean Harris Hip Score improved from 40.8 pre-operatively to 83.4 post-operatively.
Subsidence of the prosthesis is commonly encountered with collarless stems and this was not a problem in this study. The risk of peri-prosthetic fracture can be reduced by using long stem prosthesis which bypasses the existing cement mantle by at least two femoral diameters. The radial impaction grafting technique permits the use of revision femoral components with variable stem lengths, neck lengths, and neck offsets.
We conclude that radial imaction graftind along with collared long stem prosthesis is a good solution for massive femoral bone defects while performing total hip arthroplasty.
Patients requiring revision hip surgery are a particular burden on such limited resources.
Hospital trusts are dependent upon adequate remuneration for such complex procedures, a process reliant on accurate coding.
However certain procedures enable an additional tariff uplift of up to 70%. Yet these additional procedures (performed in 81% of our procedures) had not been coded; loosing these additional tariff uplifts of 70%.
We involved and educated our coding staff, creating a ‘tick box’ sticker to be placed on every revision hip operation-record and completed by the operating surgeon.
Our subsequent tariff uplifts for these procedures have been significant.
In the modern NHS, surgeons must have a good understanding of complex tariffs. Coding staff are a notoriously poorly paid and undervalued component of any Hospital Trust, and invariably lack the surgical experience to interpret complex procedures.
Trusts must take measures to ensure such large tariff uplifts are not missed for complex procedures.
We explain the tariff process and discuss how improvements can easily be achieved by individual trusts.
We analyzed the effects of Tranexamic acid on Intra- operative blood loss, post Operative haemoglobin and haematocrit drop, blood transfusion requirement, incidence of deep vein thrombosis and hospital stay in Patients undergoing Total hip arthroplasty.
The mean age at revision with allograft was 64.3 years (26 to 97). 86 hips (70%) in 74 patients were reviewed both clinically and radiologically.
At the time of review 28 patients (29 hips) had died and 5 patients (5 hips) were lost to follow up. Of those patients who had died 18 hips had been followed up to a mean of 66 months (12–145). A further 3 hips were unable to attend for clinical review but had accurate implant-allograft survivorship data.
Their data were included in survivorship analysis to the time of last clinical review.
122 (67%) had apparent limb lengthening – mean 3.2% and in 43 (24%) limb lengths were equal, 91% had a well preserved architecture and the proximal lever system.
We have observed that some patients perceive their LLD to be much greater than the true LLD. A large LLD is sometimes reported by therapists, despite only a small true LLD.
We have found that abduction tightness is a potent cause of apparent LLD, and report our investigations into this phenomenon.
Clinical photographs and videos have been produced to demonstrate this phenomenon.
A 2-dimensional model has been made to demonstrate how the degree of abduction, offset and over-lengthening affect this phenomenon.
A computer model has been used to quantify these effects.
Even with only minor abductor tightness, increasing the true length will disproportionately increase the apparent LLD. In the presence of tight abductors, increasing the offset will cause apparent shortening in the contra-lateral limb. Patients are who have adequate adduction are frequently unaware of true lengthening.
Reports are beginning to emerge of unexplained failure, pseudotumour formation, individual cases of metallosis. Joint registry data also demonstrates an unexplained high early failure rate for all designs of hip resurfacing. This paper examines the rate and mode of early failures of the BHR in a multi-centre, multi-surgeon series.
The likely rate of metallosis is 3.1% at five years. Risk factors for metallosis in this series are female sex, small femoral component, high abduction angle and obesity. We not advocate use of the BHR in patients with these risk factors.
The aim of the paper is to provide an independent single surgeon experience with BHR after a seven-year follow-up.
A cohort of 117 hips in 101 consecutive patients operated by the senior author between Jan 1998 and Dec 2002 were assessed to note their clinical, radiological and functional outcome after a mean follow-up of 7 years (5–9.4 years). Primary osteoarthritis was seen in 73 hips and secondary in 44 hips. Their mean age at surgery was 54 years (range 20–74years). At latest follow-up their mean flexion was 100°and their mean functional outcome scores were respectively: Oxford hip score of 21.5 (12–52, mode 12); Harris hip score of 84.8 (25–100, mode 97), Charnley modification of Merle d’ Aubigné and Postel scores were 4.8 for pain, 4.3 for walking and 5.4 for movement; and SF-36 (physical component 43.9 and mental component 51.45). Failure in the study was defined as revision for any reason. Revision was undertaken in 8 hips (6.8%), five within the first year for periprosthetic fracture neck of femur and 3 hips after the end of 5-year follow-up (2 for advance collapse of the femoral component in patients’ with avascular necrosis of the femoral head and 1 hip for sepsis).
The Kaplan-Meier survival with revision as end point at minimum 5-years of follow-up was 95.7% (95% CI 92–99%) and overall survival at an average 7-years was 91.7% (95% CI 86–97.6%). All the failures were due to the femoral component. However, the reported survival with the use of traditional uncemented and cemented femoral stems is beyond 99% at similar period of follow-up. Patient selection particularly in patients with secondary osteoarthritis is therefore a critical factor when choosing BHR components.
174 have been revised, of which 60 were failures of the femoral component.
We reviewed modes of failure and post-revision clinical outcomes in this sub-group.
All acetabular components were left in situ. At revision surgery 25 cemented, 25 uncemented and 10 unknown femoral prostheses were used with 56 BHR modular heads, 2 custom-made Exeter heads and 2 Thrust Plate heads.
47 patients completed outcome scores post-revision surgery. Median modified Harris Hip Score was 82 (IQ range=63–93) and Merle d’Aubigne score was 14 (IQ= 9.5–15) at a mean follow up of 3.9years post-revision.
The 4526 surviving resurfacings had a median hip score of 96 (IQ=87–100) p≥4.558x10-8 and median Merle score of 17 (IQ=14–18) p≥1.827x10-7. Mean 7.0 years follow up.
There was no difference in outcomes between cemented and uncemented revision components nor were there differences between fractured neck of femur and femoral loosening, head collapse or AVN.
In our independent centre, in the period from January 2003 to august 2008, over 1100 36mm MoM THRs have been implanted as well as 155 Birmingham Hip Resurfacing procedures, 402 ASR resurfacings and 75 THRs using ASR XL heads on SROM stems.
During this period we have experienced a number of failures with patients complaining of worsening groin pain at varying lengths of time post operatively. Aspiration of the hip joints yielded a large sterile effusion on each occasion. At revision, there were copious amounts of green grey fluid with varying degrees of necrosis. There were 11 failures of this nature in patients with ASR implants (10 females) and 2 in the 36 MoM THR group (one male one female).
Tissue specimens from revision surgery showed varying degrees of ‘ALVAL’ as well as consistently high numbers of histiocytes. Metal debris was also a common finding.
A fuller examination of our ASR cohort as a whole has shown that smaller components placed with inclinations > 45° and anteversions < 10 or > 20° are associated with increased metal ion levels. The 11 ASR failed joints were all sub optimally positioned (by the above definition), small components.
Explant analysis using a coordinate measuring machine and out of roundness device confirmed greater than expected wear of each component. The lower number of failures in the 36mm MoM group, as well as the equal sex incidence, suggests that the majority of these failures are due to the instigation of an immune reaction by large amounts of wear debris rather than adverse reactions to well functioning joints. It is likely that small malpositioned ASRs function in mixed to boundary lubrication, and this, combined with the larger radius of these joints compared to the 36mm MoM joints, results in more rapid wear.
Pre operative oxford, Harris and WOMAC scores in the THA group were 41.1, 46.4 and 50.9 respectively while the post operative scores were 14.8, 95.8 and 5.0. In the HR group, pre- operative scores were 37.0, 54.1 and 45.9 respectively compared to 15.0, 96.8 and 6.1 post operatively. The degree of improvement was similar in both groups.
In conclusion we found significantly reduced wear for aluminumoxide heads compared to cobalt chrome heads which could be beneficial for young and active patients.
We graded the contralateral hip for severity of joint space narrowing on plain radiographs.
The review of the first 325 Exeter Universal hips reported good long term survivorship despite the majority of cups being metal backed. We have reviewed the long term performance of the concentric all-polyethylene Exeter cups used with the Universal Exeter stem.
Clinical and radiographic outcomes of 263 consecutive primary hip arthroplasties in 242 patients with mean age 66 years (range, 18 to 89) were reviewed. 118 cases subsequently died none of whom underwent a revision. Eighteen hips have been revised; thirteen for aseptic cup loosening, three for recurrent dislocation and two for deep infection. Three patients (four hips) were lost to follow-up. The minimum follow-up of the remaining 123 hips was 10 years (mean 13.3 years, range 10–17). Radiographs demonstrated 6 (6%) of the remaining acetabular prostheses were loose. The Kaplan Meier survivorship at 14.5 years with endpoint revision for all causes is 91.5% (95% CI 86.6 to 96.2%). With endpoint revision for aseptic cup loosening, survivorship is 93.3% (CI 88.8 to 97.8%).
This series included a number of complex cases requiring bone blocks and/or chip autograft for acetabular deficiencies. The concentric all polythene Exeter cup and Exeter stem has excellent long term results particularly when factoring in the complexity of cases in this series.
Of the 6 patients who had MRI proven increased signal 5 patients had significant improvement. The average improvement in the VAS was 10 to 2.3 and their HOOS scores were 349.2 (range 427–243).
Leg length discrepancy (LLD) following total hip arthroplasty (THA) is a well-known and documented phenomenon. LLD can pose a substantial problem for both the patient and the surgeon. Patient dissatisfaction with LLD after THA is the most common reason for litigation against orthopaedic surgeons. Failure to restore limb length may lead to an unstable hip, whereas over-lengthening may cause low back pain, sciatic nerve palsy and early mechanical loosening.
Several intra operative techniques both invasive and non invasive have been reported in the literature to over-come LLD during THA. The accuracy of all the methods that measure from pins anchored into pelvis to point on the greater trochanter may be affected by the inherent variability of the leg position when measurements are made. Bending or dislodging the pins and using of calliper devices can be cumbersome during the THA surgery and can compromise the measurements.
Hence we describe a simple, safe and reliable intra operative technique to overcome LLD by using a stout braided suture material tied to the stout Judd pin used to retract the soft tissues in posterior approach. Utilising the routine incision for the posterior approach to the hip, this technique can be easily carried out in primary THA surgery as compared to other techniques used to avoid LLD, which require further incision, and specialised equipment which are time consuming, cumbersome and may not be very secure. This technique of using a suture mark over the Judd pin is simple, inexpensive and easily adaptable.
Above a certain threshold, distal migration may predict medium-to-long-term failure of “shape-closed” (collared, textured) stems. However, no such threshold exists for “force-closed” stems, and these may continue to migrate after 3 years. We believe that the tendency towards stabilisation 2–3 years postoperatively could be the best predictor of good long-term performance.
With the knee flexed, a 1 cm difference produced a 3 % increase in loading. This was significant (P< 0.05). All subsequent increases were also significant. The largest increase in load was observed between 1 cm & 2 cm (+5 %). At 6cm the left leg load was 70.9 %.
With the pelvis tilted, there were smaller increases in loading. These did not become significant until a difference of 5 cm. The maximum load was 62.1 % at 6 cm.
In the high density, the hemispheric design had better characteristics (lower seating force and higher pull-out force to seating force ratio) than the peripherally enhanced design, which are more favourable in clinical settings.
36 patients received chemical prophylaxis (injections) for 10 days, 5 for 7 days, 8 for a few days and 1 patient for 6 weeks post-op. 38 patients (76%) self administrated the injections while 6 had family members help and 3 had district nurse visit. 47 patients (94%) received injections for the complete duration. 3 patients did not receive injections regularly at home (missed nurse visit – 1, not advised – 1, forgot to inject – 1).
25/41 patients had full response to the injection. 80% were listed for surgery as a result (documented reasons in those not listed). 6/41 patients had a partial response to the injection – 66% were managed conservatively (due to co-morbidities elicited at review, or spinal pathology). 10/41 patients had no benefit – 3 were offered surgery (one after MRI confirmation, one after prolonged physiotherapy and one after discussion about diagnostic overlap).
Hip replacement completely reduced symptoms in 19/21 (90%) and partially in 2/21 (10%) (1 had undergone a successful pre-operative IAJ).
There were no deep infections in patients undergoing surgery after injection. 1 patient had a superficial infection (resolved at review).
There were 6 complications (3.8%) in this series; a periprosthetic fracture of the femoral diaphysis (1), posterior dislocation (2), failure secondary to aseptic loosening of the implant (1) and deep vein thromboses (2)
A novel adaptor was designed to correct for the differential radii and enable removal of the well fixed BHR socket with the explant. We present the results of our initial experience with this device.
The explant cup extractor was used with its standard centering head and curved blades. The size of the explanted cup, last reamer size and size of the implanted component were recorded
Thirty cemented THRs and 13 hybrid THRs were performed through trochanteric osteotomy approach (23), posterior approach (17), Hardinge approach (2) and anterior approach (1). In the cemented group there were 3 cases of superficial wound discharges, 1 recurrent dislocation, 1 complete femoral nerve palsy, 2 cases of neuropraxia and 1 case with persistent hip pain but no cases of infection. In the hybrid group there was one case of partial femoral nerve palsy. None of the patients has undergone any revision surgery till the latest follow up. Radiologically only one case showed aseptic loosening in both femoral and acetabular components, which is not revised as the patient is asymptomatic.
Data was analysed for both inter-observer and test-retest reliability using the intra-class correlation coefficient and the Bland-Altman method (use of two methods provides a better estimation of accuracy).
We compared these two groups, focussing on pre-operative delays, length of stay in hospital and in-hospital mortality.
Five blinded orthopaedic registrars then used EBRA (Einzel-Bild-Roentgen-Analysis, University of Inns-bruck, Austria) software to determine the radiological anteversion from the AP films. Twenty-five ASR and twenty-five BHR images were analysed.
At the same time each observer was asked to grade the cups as “1” (< 10°) “2” (10–20°) “3” (20–30°) or “4” (> 30°) depending on the appearances of the cup vertices.
Cups graded as “1” or “4” showed high sensitivity and specificity for the true grade as determined on the lateral radiographs.
The aim of this study was to investigate the influence of cup inclination angle and head position on the wear of ceramic-on-ceramic total hip replacements.
With the knee flexed, the mean hip adduction angle was 23.70 (SD 7.1). With the knee braced, the mean hip adduction angle was 21.60 (SD 5.6). Hence the knee brace reduced hip adduction by 9 % (2.10). This was not significant (paired t-test, P = 0.3).
We describe our novel approach to managing infected periprosthetic fractures using a revision implant for temporary fracture stabilisation.
A series of 12 consecutive patients aged between 74 and 83 years (average age 81.51, SD 6.32) who were referred to the senior author with periprosthetic fracture and microbiologically proven infection, were managed by radical debridement and antibiotic therapy along with temporary implantion of a long stem cannulated, proximally hydroxyappatite coated and distally locked femoral prosthesis (Cannulock, Orthodesign, Christ-church, UK). Strut grafts, demineralised bone matrix and cable plating system where used in addition where indicated. Post operatively patients were allowed to mobilise as allows and antibiotics were continued until biochemical markers returned to normal.
A good clinical outcome and excellent functional outcome was noted in all 12 cases. No cases of immediate post operative complications such as DVT or PE were noted in any cases. In particular there were no instances of infections associated with prolonged immobilisation and hospital stay. Ten patients underwent a definitive revision hip replacement procedure within an average of 4.3 weeks (range 3.9 to 5.7, SD 2.15). Two patients required a second debridement and delayed definitive treatment due to persistently high inflammatory markers.
We believe that this novel approach significantly improves functional outcome in the management of infected periprosthetic fractures.
Flexing forward to pick up an object between the feet Standing to the side of the object and bending Squatting to pick up an object between the feet Kneeling on one knee to pick up.
Measurements were taken from 50 hips in 25 normal subjects aged 21 to 61. Sensors were attached over the iliac crest and the mid-shaft of the lateral thigh. Data was collected as each technique was repeated 3 times. The tracker recorded hip flexion and rotation data at 10 hertz, with an accuracy of 0.15 degree.
Flexion: 75.8(28.6), 79.2(27.2), 87.5(29.7) and 30.4(17.3). Extension: −0.2(2.5), 0.5(1.9), 0.1(2.3) and −0.4(3.3). Internal rotation: 2.9(5.2), 1.4(3.4), 10.1(9.9) and 8.5(6.9). External rotation: 12.6(10.3), 20.1(12.1), 11.9(6.5) and 7.3(7.1)
Kneeling had significantly less flexion and external rotation than all the other techniques (paired t-test, P< < 0.001).
Kneeling has the least amount of movement, therefore, it minimises the risk of dislocation when retrieving an object from the floor.
Data on retrieval analysis of current generation metal on metal hip replacements is scarce. Such analysis may help to reduce the incidence of failure and revision procedures. Our aim was to investigate the wear characteristics of explanted (ie failed) metal on metal (MOM) acetabular components in terms of; 1) wear rate; and 2) distribution of the wear (specifically edge loading).
30 hips were collected from 20 centres. The types of prostheses were: 15 BHR; 10 Cormet and 5 ASR. Wear of the acetabular components of the prostheses was measured using an out of roundness (Rondcom 60A) machine. We recorded the implantation and removal date of each hip.
The median linear wear rate was 7.32μm/year; this is at least 3 times greater than steady state wear rates reported for similar components worn in hip simulator studies. For 24 out of 30 cups, the greatest linear wear was recorded at the cup edge.
Failed metal-on-metal acetabular components were associated with higher than expected wear rates. The highest wear was seen closest to the cup edge in the majority of patients suggesting edge loading had occurred and probably explained the high wear rates. Accurate cup placement (to avoid edge loading) may reduce the failure of MOM hips.
Some authors have suggested that metal wear in patients with well-functioning MM bearings occurs only during the run-in wear phase and that continued corrosion of metal particles released during that period is responsible for metal level elevation later on. However the reducing trend in the later phase following revision in this study suggests that metal ion elevation from corrosion is not sustained indefinitely and therefore cannot by itself account for the persistent elevation of systemic metal levels throughout. Bearing wear continues to occur throughout bearing life.