Aims

This study reports the results of 38 total hip arthroplasties (THAs) in 33 patients aged less than 50 years, using the JRI Furlong hydroxyapatite ceramic (HAC)-coated femoral component.

Abstract

Abstract:

Abstract

Aims

With increasing burden of revision hip arthroplasty (THA), one of the major challenges is the management of proximal femoral bone loss associated with previous multiple surgeries. Proximal femoral arthroplasty (PFA) has already been popularized for tumour surgeries. Our aim was to describe the outcome of using PFA in these demanding non-neoplastic cases.

Abstract

Introduction

Patients with metastatic spinal cord compression (MSCC) or unstable spinal lesions warrant early surgical consultation. In multiple myeloma, chemotherapy and radiotherapy have the potential to decompress the spinal canal effectively in the presence of epidural lesions. Mechanical stability conferred by bracing may potentiate intraosseous and extraosseous bone formation, thus increasing spinal stability. This study aims to review the role of non-operative management in myeloma patients with a high degree of spinal instability, in a specialist tertiary centre.

Trabecular metal (TM) augments are designed to support an uncemented socket in revision surgery when adequate rim fit is not possible. We have used TM augments in an alternative arrangement, to contain segmental defects to facilitate impaction bone grafting (IBG) and cementation of a cemented socket. However, there is a paucity of literature supporting the use of this technique. We present one of the largest studies to date, reporting early outcomes of patients from a tertiary centre.

A single-centre retrospective analytical study of prospectively collected data was performed on patients who had undergone complex acetabular reconstruction using TM augments, IBG and a cemented cup. All patients operated between 2015 and 2019 were included. We identified 105 patients with a mean age of 74yrs. The mean follow-up was 2.3 years(1–5.5yrs). Our primary outcome measure was all-cause revision of the construct. The secondary outcome measures were, Oxford hip score (OHS), radiographic evidence of cup migration/loosening and post-op complications.

Eighty-four out of 105 patients belonged to Paprosky grade IIb, IIc or IIIa. Kaplan-Meier survivorship for all-cause revision was 96.36% (CI, 90.58–100.00) at 2 years with 3 failures. Two were due to early infection which required two-stage re-revision. The third was due to post-operative acetabular fracture which was then re-revised with TM augment, bone graft and large uncemented cup. Pre-op and post-op matched OHS scores were available for 60 hips(57%) with a mean improvement of 13 points. Radiographic analysis showed graft incorporation in all cases with no evidence of cup loosening. The mean vertical cup migration was 0.5mm (Range −5 to 7mm). No other complications were recorded.

This study shows that reconstruction of large acetabular defects during revision THA using a combination of TM augments to contain the acetabulum along with IBG to preserve the bone stock and a cemented socket is a reliable and safe technique with low revision rates and satisfactory clinical and radiographic results. Long term studies are needed to assess the possibility of preservation and regeneration of bone stock.

Aims

The exact risk to patients undergoing surgery who develop COVID-19 is not yet fully known. This study aims to provide the current data to allow adequate consent regarding the risks of post-surgery COVID-19 infection and subsequent COVID-19-related mortality.

Purpose

Infections in orthopaedic surgery are costly, debilitating complications. The search for new treatments and prevention strategies has led to the use of antibiotic-filled calcium sulfate (CaS) as a bone void filler that is both safe and effective. The purpose of this study was to examine the available data on the efficacy of this technology.

Summary

A meta-analysis was performed to compare rate of SSI after application of chlorhexidine vs. iodine in total joint arthroplasty. Chlorhexidine had significantly lower odds of SSI.

Objective

To evaluate the clinical and functional outcomes obtained by combination of high-flexion Freedom® Total Knee System (TKS) and mini-subvastus approach in total knee replacement patients.

With increasing burden of revision hip arthroplasty, one of the major challenge is the management of bone loss associated with previous multiple surgeries. Proximal femoral replacement (PFR) has already been popularised for tumour surgeries. The inherent advantages of PFR over allograft –prosthesis system, which is the other option for addressing severe bone loss include, early weight bearing and avoidance of non-union and disease transmission. Our study explores PFR as a possible solution for the management of complex hip revisions. Thirty consecutive hips (29 patients) that underwent PFR between January 2009 and December 2015 were reviewed retrospectively for their clinical and radiological outcomes. The Stanmore METS system was used in all these patients.

Mean age at the index surgery (PFR) was 72.69 years (range 50–89) with number of previous hip arthroplasties ranging from 1–5. At mean follow up of 32.27 months, there were no peri-prosthetic fractures and no mechanical failure of the implants. Clearance of infection was achieved in 80% of cases. There was 1 early failure due to intra-operative perforation of femoral canal needing further revision and two were revised for deep infection. Instability was noted in 26.7% (8) of the hips, of which, 87.5% (7) needed further revision with constrained sockets. Out of these 8 hips with instability, 5 had pre-operative infection. Deep infection was noted in 20% (6) of the hips, of which, 5 were primarily revised with PFR for septic loosening. However, further surgeries were essential for only 3 patients. One patient has symptomatic aseptic acetabular loosening and 1 had asymptomatic progressive femoral side loosening (lost to follow up).

Severe proximal femoral bone loss in complex revision arthroplasties has necessitated the use of PFR prosthesis. Our study supports the fact that PFR is probably a mechanically viable option for complex revisions. Significant numbers of dislocations and infections could be attributed to the poor soft tissue envelope around the hip. Further surgical techniques in the form use of dual mobility cups and silver coated PFR implants need to be explored.

The ideal operative treatment of displaced sub capital femoral fractures in the elderly is controversial. Recently, randomised controlled trials have suggested a better outcome with the use of total hip arthroplasty (THA) to treat displaced intra capsular fractures of the femur for elderly patients in good health. More recently the concept of dual mobility cups is being promoted to avoid dislocations in this cohort of patients. However, overall there is limited evidence to support the choice between different types of arthroplasty. Dislocation remains a main concern with THA, especially when a posterior approach is used.

We analysed the outcome of 115 primary THR (112 cements and 3 uncemented) THR using a posterior approach with soft tissue repair in active elderly patients presenting with displaced intra capsular femoral neck fractures. Size 28 mm head was used in 108 and a size 32 mm head in the rest. All surgery was performed by specialist hip surgeons.

Satisfactory results were noted in terms of pain control, return to pre-morbid activity and radiological evidence of bone implant osteo-integration. The 30-day mortality was nil. There were two dislocations and only one needed revision surgery due to recurrent dislocation.

In conclusion, with optimal patient selection, THA seems to provide a good functional outcome and pain relief in the management of displaced intracapsular femoral neck fractures. Excellent outcome can be achieved when done well using the standard cemented THR and with 28mm head. A good soft tissue repair and a specialist hip surgeon is preferable.

Background

One of the major concerns of hinge knees have been reported in literature is mechanical failure. Failure in the form of component fracture (2–10%) and hinge dislocation/ failure are worrisome. In addition, higher risk of aseptic loosening with hinge knee prosthesis has been attributed to stress transfer at bone cement interface.

Distal femoral replacement is an operation long considered as salvage operation for neoplastic conditions. Outcomes of this procedure for difficult knee revisions with bone loss of distal femur have been sparsely reported.

We present the early results of complex revision knee arthroplasty using distal femoral replacement implant, performed for severe osteolysis and bone loss.

Retrospective review of clinic and radiological results of 25 consecutive patients operated at single centre between January 2010 and December 2014. All patients had single type of implant. All data was collected till the latest follow up. Re-revision for any reason was considered as primary end point.

Mean age at surgery was 72.2 years (range 51 – 85 years). Average number of previous knee replacements was 2.28 (range 1 to 6). Most common indications were infection, aseptic loosening and peri-prosthetic fracture. Average follow up was 24.5 months (range: 3–63 months). 1 patient died 8 months post-op due to unrelated reasons. Re-revision rate was 2/25 (8%) during this period. One was re-revised for aseptic loosening and one was revised for peri-prosthetic fracture of femur. Two other peri-prosthetic fractures were managed by open reduction and internal fixation. All 3 peri-prosthetic fractures occurred with low energy trauma.

It is noteworthy that there was no hinge or mechanical failures of the implant. Peri-prosthetic fracture in 12% of patients in this series is of concern. There are no similar studies to compare this data with. The length of the stem, type of fixation of the stem, weight of the distal femoral component of implant can be postulated as factors contributing to risk of peri-prosthetic fracture.

Primary total hip replacement (THR) in patients with abnormal/altered proximal femoral anatomy/narrow canals presents a technical challenge. There are only limited standard prosthetic stems available to deal with narrow canals or abnormal morphology. Many prefer to use expensive custom implants which often have a lag time to manufacture and do not always have long term published outcomes.

We present results of the Asian C-stem (which is a standard implant available on the shelf) used in patients predominantly of Caucasian origin with abnormal proximal femoral anatomy.

We retrospectively reviewed clinic-radiological results of 131 patients (131 stems) who underwent primary THR using Asian C-stem at Wrightington Hospital till their latest follow up. Revision for any reason was considered as primary end point.

Mean age at surgery was 50.8 years (16 – 80). The 2 commonest indications were primary osteoarthritis (66 patients) and hip dysplasia (54 patients). Mean follow up was 43.5 months with a minimum follow up of 12 months and maximum follow up of 97 months. There were 2 recurrent dislocations and 1 hip subluxed twice. One dislocation needed revision surgery. 1 patient underwent acetabular revision for loosening. There was no stem failure, obvious loosening or loss of fixation in any patients in our series with regards to the Asian C-stem. There were no infections and intra-operative perforations or fractures.

C-stem Asian is a reliable implant for patients undergoing THR with abnormal proximal femoral anatomy or narrow canals. Long term follow up is essential.

Background

A grossly deformed knee is believed to be an indication for PS -TKA. However, the role CR-TKA in such knees is unclear in the literature. Considering the obvious advantages of CR, we analysed the mid term follow up of CR knees in gross deformities.

Background

Subvastus approach for Total Knee Arthropalsty (TKA) allows a faster recovery. It is traditionally not utilized for revision surgeries because of difficulty in exposure of the knee and eversion of the patella. It is considered to have limited indications. We hypothesized that revision TKA should not really pose a problem as the exposure gained is adequate with added advantage of preserving the extensor mechanism, thereby allowing faster functional recovery. We present an analysis of the use of subvastus approach for revision TKAs.

Introduction

The longevity of total hip replacements in young active patients is a cause for concern as increased cyclical loading can result in early loosening of implants resulting in multiple revisions during the patient's lifetime. The study presented demonstrates excellent survival of the HAC-coated femoral stems in young active individuals.

This study reports the results of 38 total hip arthroplasties (THAs) in 33 patients aged <  50 years, using the JRI Furlong hydroxyapatite ceramic (HAC)-coated femoral component. This represents an update of previous reports of the same cohort at ten and 16 years, which were reported in 2004 and 2009, respectively. We describe the survival, radiological and functional outcomes at a mean follow-up of 21 years (17 to 25). Of the surviving 34 THAs, one underwent femoral revision for peri-prosthetic fracture after 21 years, and one patient (one hip) was lost to follow-up. Using aseptic loosening as the end-point, 12 hips (31.5%) needed acetabular revision but none needed femoral revision, demonstrating 100% survival (95% confidence interval 89 to 100).

In young patients with high demands, the Furlong HAC–coated femoral component gives excellent long-term results.

Cite this article: Bone Joint J 2015;97-B:749–54.

Stoppa approach has recently been adapted for pelvic surgery as it allows direct intra-pelvic reduction and fixation of the quadrilateral plate and anterior column. We report our early experience, indications and complications with this exposure introduced in 2010 in our tertiary unit.

A Retrospective review of all Stoppa approaches in pelvic-acetabular fixations was performed from a prospectively maintained database.

Of the 25 patients, mean age 40 years (range 15–76), who underwent pelvic-acetabular fixation using Stoppa approach, 21 patients had mean follow up of 7.3 months (1–48 months). All except 24% of patients had one or more additional systemic injury some requiring additional surgery. There were 6 acetabular fractures, 13 pelvic ring injuries and 6 combined fractures. Mean injury-surgery interval was 9 days (range 3–20). 8 patients had an isolated Stoppa approach whilst the remaining others also had an additional approach. Mean surgical time was 239 minutes. Anatomical reduction was achieved in 96% (24/25) cases. There was 1 minor intra-operative vascular injury, repaired immediately successfully, and no late wound infections, or other visceral complications. One patient reported new onset sensory numbness which resolved after the first review. Two patients reported erectile dysfunction thought to be caused by the initial injury. One patient had asymptomatic plate loosening. None required revision surgery.

Despite the obvious learning curve, we found this approach safe and it did not compromise accuracy of reduction in well selected patients, but early surgery within 10–14 days is recommended to aid optimal reduction.

The radiological evidence of implant failure following plate fixation of traumatic pubic symphysis diastasis can be up to 75%. We report the complications following symphyseal double orthogonal plating in patients with pubic symphysis diastasis over a period of 2.5 years. Patient records and radiographs of 38 consecutive patients were reviewed with mean follow up of 12.5 months. 5 patients (13%) had radiological evidence of implant failure with one patient (2.6%) requiring revision surgery. There was no evidence of wound complications. We conclude that our lower rate of revision surgery and metal work failure is attributed to double orthogonal plating.

Whiplash injury is surrounded by controversy in both the medical and legal world. The debate on whether it is either a potentially serious medical condition or a social problem is ongoing. This paper briefly examines a selection of studies on low velocity whiplash injury (LVWI) and whiplash associated disorder (WAD) and touches upon the pathophysiological and epidemiological considerations, cultural and geographical differences and the effect of litigation on chronicity. The study concludes that the evidence for significant physical injury after LVWI is poor, and if significant disability is present after such injury, it will have to be explained in terms of psychosocial factors.

Hip replacement is a very successful operation and the outcome is usually excellent. There are recognised complications that seem increasingly to give rise to litigation. This paper briefly examines some common scenarios where litigation may be pursued against hip surgeons. With appropriate record keeping, consenting and surgical care, the claim can be successfully defended if not avoided. We hope this short summary will help to highlight some common pitfalls. There is extensive literature available for detailed study.

Background:

Morbidity of any surgical procedure is undefined. Major surgeries and minor surgeries have different morbidities but the morbidity after any surgical procedure is neither quantified nor defined in literature. Minimally invasive surgeries have evolved in all surgical branches and are known to have less morbidity after the surgery. There is no score or index to assess early recovery after any surgical procedure.

Introduction

The gamma nail is a cephalomedullary implant used in proximal femoral fracture management. Short gamma nails are technically less demanding, but there is concern over potentially higher complication rate.

Background

The current literature tends to suggest that all the different approaches used for Knee Arthroplasty give similar results. The literature also cautions that the MINI quadriceps sparing approaches are to be utilized in very select cases as they are difficult to perform, take longer time, have a greater intra-op complication rate and are associated with a higher number of component malpositioning. Despite these warnings of the literature, the author has been impressed by the physiological nature of the subvastus approach for knee arthrotomy and the author has used this approach exclusively for all Knee arthroplasties in the last 4 years. All primary Knee Arthroplasties have been performed through the mini-subvastus approach, utilizing the principle of a mobile window, irrespective of the degree of pre-operative deformity, obesity, range of motion or previous surgery. All revision Knee Arthroplasties have also been performed through the subvastus approach. All the surgeries have been performed in the private sector in a highly competitive environment with the patient having easy access to various other high volume surgeons performing arthroplasties through a more standard approach.

Background Computer navigation is increasingly being recognized as a valuable tool in restoring the mechanical axis post TKR. Its use is as yet not universal due to the costs involved, its availability and the fact that it can be cumbersome and time consuming to use. Additionally it requires the insertion of Schanz pins in the femur as well as the tibia which can be a matter of concern as regards stress fracture and infection. However, it is able to reliably locate the center of the femoral head which is an elusive landmark in the standard method. The center of the ankle involves registration for the medial and lateral malleoli which are subcutaneous and easily palpable. We decided to navigate only the distal femoral cut with a specialized navigation unit called Articular Surface Mounted navigation which does not require the insertion of additional pins through the femur or the tibia. We purposely did not use navigation for the rest of the bony cuts as all the other landmarks i.e. femoral epicondyles, tibial malleoli, and tuberosity etc are all easily palpable. This dramatically reduced the surgical time and increased its user friendliness. We are presenting our results.

We are presenting a prospective analysis and assessment for the results of the Coflex@ inter-spinous dynamic stabilization device with a 2 year follow up. The purpose of this study is to assess the efficacy and safety of the Coflex@ Posterior Dynamic Stabilization Implant.

A prospective analysis was performed on 121 patients (176 devices) treated with the Coflex@ Interspinous Implant. Indication for the treatment was spinal canal foraminal stenosis with nerve root irritation.

Pre- and postoperative disability and pain scores were measured using Oswestry disability score, functional assessment a radiological evaluation at pre-operative - three - six twelve and twenty-four month interval.

Data analysis revealed a high rate of patient satisfaction 92% of patients are satisfied and will have the surgery again 81% of patients had major improvement of their leg symptoms. 72% of patients reported improvement of their back pain symptoms this was more noted in the decompression group.

Two revision surgeries were carried out. One due to implant back-out and the second due to infection.

The Coflex@inter-spinous implant is a simple surgical treatment strategy with a low risk. Early results show a good improvement of both clinical and radiological parameters combined with patient satisfaction with better outcome achieved if combined with spinal decompression.

Obesity has been associated with degenerative osteoarthritis of knee joint The over all incidence of osteoarthritis of the knee is also more in patients with obesity. Increasing obesity leads to faster progression of OA, which is due to increased joint load. Body mass index (BMI), dividing an individual’s weight (in kg) by his or her height (in square meters). BMI: Normal = 18.5 to 24.9, Overweight BMI −25–29.9 Obese=30 to 39.9, Morbidly Obese BMI 40 or Greater. Recent article focused on the thigh girth of obese patients and opined that if thigh girth > 55cms, subvastus approach should not be utilized, as it is difficult to evert the patella. We believed that obesity should not really cause a problem for the patients undergoing a TKA with the mini subvastus approach as the anatomy of the quadriceps in the obese and the non-obese patient population is the same. We decided to evert the patella only after osteotomy of tibia and the femur.

All patients who underwent primary total knee arthroplasty with minisubvastus approach between January 2006 to July 2007 and who were obese (BMI> 30) were included in our study. Out of 425 primary Total knee arthroplasty were performed during this period. Out of these, there were total 97 obese patients with 109 knees which form the part of the study.

There were 81 females and 16 males and 12 patients had staged bilateral knee arthroplasty. The weight varied from 63 to 125 kgs. 91 patients had varus deformity of < 15 degree, 15 patients had varus deformity of > 15 degree, 3 patients had valgus deformity. The thigh girth in obese group (BMI: 30–40) ranged from 45 to 58 cms with average of 50.17. The thigh girth in morbidly obese (BMI > 40) group ranged between 55 to 67 with average of 61.01 cms.

Mini-subvastus approach provided satisfactory exposure in all knees that were operated. In no case was this approach abandoned.

The average surgical time was 90 minutes with range. The average blood loss was 400 cc. The patellar tracking was immaculate in every case and in fact it was difficult to displace patella laterally after 30 degrees of knee flexion. Our 89 patients had flexion of > 120 0,and 20 patients had flexion of > 90 but < 120. The knee society score improved from average 42 (range 17–62) preoperatively to 89 (range 72–95) post operatively. The Knee Society functional score improved from 48 (range 15–60) pre operatively to 65 (range 50–80) post operatively.

Mini subvastus approach offers adequate intraoperative exposure even in obese and morbidly obese patients. It did not result in increased complications in our hands even in morbidly obese patients with higher thigh girth. It is extremely patient friendly and its wider use is recommended.

Introduction: Between June 2005 and September 2007, ten male athletes underwent repair of the pectoralis major tendon using a new double row surgical technique whereby employing three bone anchors to produce a large foot print of the pectoralis major tendon. Here, we present our new surgical technique for the repair of the pectoralis major tendon with the results.

Patients: The mean age was 33.9 years (23–46 years) and the average follow up was 20.3 months (12–39). The mean time between surgery and the original injury was 11.6 weeks (1–48 weeks). We used the visual analogue scale for determining the level of satisfaction with regards to cosmesis and pain. Also, the patients were asked them about their subjective loss of strength.

Results: Eight patients were in pain prior to surgery and all patients were unsatisfied with the appearance of their chest. The average loss of strength was 75% pre-operatively. At the final follow up, none of the patients complained of any pain while pushing things away from their body; nine patients had no pain on moving their arm across the chest whilst one patient reported mild pain. Nine were satisfied with the appearance and the average regain in strength was around 90%. One patient developed a deep infection requiring a further washout and antibiotics. No re-rupture was seen amongst our patients. Hence, we conclude that satisfactory results can be achieved with this new technique.

Introduction: There is paucity in guidance on when and what should be said or who should take the consent for patients undergoing lower limb arthroplasty. Never before, the specialists been contacted for current practice and their recommendations on the content and timing of obtaining the consent in these patients.

Materials and Methods: A postal questionnaire was sent to 154 Orthopaedic consultants in the 14 units in NorthWestern region of England. We acquired information on their current practice, awareness of the guidelines and their preferences and recommendations.

Results: A total of 117/154 (76%) consultants responded, of which 84 (55%) fulfilled the inclusion criteria. Currently, 36% patients are consented at preoperative assessment clinic and 40% on admission. 75% of the consultant consent themselves or are consented by their registrars. 70% were aware of local or national policies on who should consent patients and 40% on what should be explained and documented. 75% recommended that operating surgeon should obtain consent. The recommended time for the consent was at preoperative assessment by 57%.

Discussion: If the act of signing the consent form is to be more meaningful it should be signed by the surgeon who is going to perform the operation. This study demonstrates that the consultants agree on the common complications but have a varied threshold for giving the less common risks. With shortening of the waiting time, there is a growing body of surgeons suggesting that the consent should be done at the listing itself.

We report 114 of 117 (97% follow up) consecutive metal-on-metal hip resurfacings in 105 patients with a minimum of 5 years follow up implanted between October 1999 and May 2002. Revision of either the femoral or acetabular component during the study period is defined as failure. No other revisions have been performed or are impending. We had 4 failures giving us survivorship at 5 years of 97% (95% confidence interval (CI) 94 – 100). The mean follow up was 72 months and the mean age at implantation was 54.5 years old (Range 35 – 75). All patients were followed up clinically and radiographically.

The mean Harris hip score at follow up was 96.4. The mean Oxford Hip Score fell from 41.6 preoperatively (Range 16 – 57) to 15.3 postoperatively (Range 12 – 49) p< 0.0001. The UCLA Activity Scale rose from 3.93 preoperatively (Range 1 – 10) to 7.54 postoperatively (Range 4 – 10) p< 0.001.

Radiographic analysis revealed an average stem shaft angle of 130.6 degrees (Range 112 – 148) with average cup alignment of 36 degrees (Range 22 – 47). Neck thinning was present in 12 hips (10%) and we define a technique for measuring thinning. Heterotropic ossification was present in 17 hips and lucent lines around the femoral component in 10 hips.

This study confirms that metal-on-metal resurfacing produces an excellent clinical and functional outcome in the younger patient who requires surgical intervention for hip disease. The results compare favourably with those from the originating centre and confirm that resurfacing is well suited for younger higher demand patients. It is the first study with a minimum 5 year follow up from outside the originating centre.

Purpose: We report a series of 117 consecutive metal-on-metal Birmingham Hip Resurfacings in 105 patients with a minimum of 5 year follow up.

Method: Patients were followed up both clinically and radiographically for a minimum of 5 years following implantation. Revision of either the femoral or acetabular component during the study period is defined as failure.

Results: We followed up 114 of 117 hips (97%). We had 4 failures giving us survivorship at 5 years of 97% (95% confidence interval (CI) 94–100). The mean follow up was 72 months and the mean age at implantation 54.5 years old. The mean Oxford Hip Score fell from 41.6 preoperatively to 15.3 postoperatively (p< 0.0001). The mean Harris Hip Score at 5 year follow up was 96.4. The UCLA Activity Scale rose from 3.93 preoperatively to 7.54 postoperatively (p< 0.001). Radiographic analysis revealed neck thinning in 12 patients (10%) and we define a method of measuring this. The average stem shaft angle in our cohort was 130 degrees and the average cup angle was 36 degrees. Heterotropic ossification was present in 17 hips (15%).

Conclusion: This study confirms that metal-on-metal resurfacing produces an excellent clinical and functional outcome in the younger patient who requires surgical intervention for hip disease. The results compare favourably with those from the originating centre and confirm that resurfacing is well suited for younger higher demand patients. It is the first study with a minimum 5 year follow up outside the originating centre.

Introduction: Preliminary results of the Birmingham Hip Resurfacing Arthroplasty were promising. The first series with minimum 5 year follow up was published in 2005 and came from the designing centre. Survivorship and functional results were good. This is the first series with a minimum 5 year follow up not from the designing centre.

Methods: All patients who underwent BHR between the dates of October 1999 and May 2002 were included in the study.

Results: We report 114 of 117 (97% follow up) consecutive metal-on-metal hip resurfacings in 105 patients with a minimum of 5 years follow up. Revision of either the femoral or acetabular component during the study period is defined as failure. We had 4 failures giving a survivorship at 5 years of 96.5% (95% confidence interval (CI) 93–100). The mean follow up was 72 months and the mean age at implantation was 54.5 years old (Range 35–75). All patients were followed up clinically and radiographically.

The mean Harris hip score at follow up was 96.4. The mean Oxford Hip Score fell from 41.6 preoperatively (Range 16–57) to 15.3 postoperatively (Range 12–49) p< 0.0001. The UCLA Activity Scale rose from 3.93 preoperatively (Range 1–10) to 7.54 postoperatively (Range 4–10) p< 0.001.

Radiographic analysis revealed an average stem shaft angle of 130.6 degrees (Range 112–148) with average cup alignment of 36 degrees (Range 22–47). Neck thinning was present in 16 hips (14%) and we define a technique for measuring thinning.

Discussion: This study confirms that metal-on-metal resurfacing produces an excellent clinical and functional outcome in the younger patient who requires surgical intervention for hip disease. The results compare favourably with those from the originating centre and confirm that resurfacing is well suited for younger higher demand patients.

Aim: To determine whether operator’s experience and time of operation (MUA) affects the outcome of fractures in paediatric age group as measured by re-MUA rate.

Method: Retrospective analysis of 918 children with fractures requiring MUA over a period of eight years was carried out.

Results: Re-MUA rate for those 910 children was 9.8%(90). There was a significant difference in these fractures requiring re-MUA depending upon the operator’s experience and time. Amongst all (90) who required re-MUA 7(7.7%) had index surgery by consultants and 83(93.3%) had MUA by trainee surgeons. 23(17.4%) patients were operated between 9 to 1700 hours and rest of them had MUA after 1700 hours (82.6%). At repeat procedure 4(4.4%) required some sort of fixation. (K wiring or ORIF)

Conclusion: The current overall re-MUA rate is higher than data published from the specialised centres and surgeons, but is probably more representative of norm, when performed in a general setting. Exact fracture personality should be evaluated carefully to reduce re-MUA rate. Re-MUA rate for trainee needs to be improved.

Delays in the surgical treatment of acetabular fractures often results in extensile or combined approaches being required. This study reports the outcome from a regional centre aiming to treat these fractures via a single surgical approach where possible.

Seventy-two patients (73 displaced acetabular fractures) with an average age of 39.5 years (range 15–76 years) were studied with an average follow up period of 45.5 months (range 24–96). All radiographs were reviewed together with a full clinical assessment of each patient including the Harris Hip Score.

Thirty-four fractures were simple and 39 were complex including 27 both column fractures. Eight were noted to have an associated injury to the femoral head. The average time from injury to surgery was 11.7 days (range 1–35 days) with 80 percent of cases being operated on within two weeks after injury.

In 67 fractures (92%), including 24 both column fractures, a single approach alone was used (Anterior Ilioin-guinal 26 cases; Posterior Kocher-Langenbeck 41 cases). Five fractures needed an extensile triradiate approach and only one case required a combined anterior and posterior approach. A congruent reduction (gap or step of 2mm or less) was achieved in 65 cases (89%). Functional outcome was good with an average Harris Hip Score of 85 (range 20–100). There were 2 cases of deep infection (2.7%) and 4 patients (5.5%) required later hip replacement. There were no cases of venous thrombosis. Twenty cases exhibited heterotopic ossification of varying degree but none of these were grade IV.

Conclusion: In most cases, internal fixation of a displaced acetabular fractures is possible via a single surgical approach. Morbidity and complications are much reduced but single approach surgery requires that patients are assessed and treated early and prompt referral to a specialist unit is recommended.

The Phantom based Computer assisted orthopaedic surgical system (CAOSS) has been developed collaboratively by the University of Hull and the Hull Royal Infirmary, to assist in operations like dynamic hip screw fixation. Here we present summary of our system.

CAOSS comprises a personal computer based computer system, a frame grabber with video feed from a C-arm image intensifier, an optical tracking system and a radiolucent registration phantom which consists of an H arrangement of 21 metal balls. The phantom is held in position by the optically tracked end-effector. Knowing the optical position of the phantom, a registration algorithm calculates the position of C-arm in coordinate space of the optical tracking system.

Computer based planning uses an anteroposterior (AP) and lateral image of the fracture. Marks are placed on the 2D projections of femoral shaft, neck and head on the computer screen, which are then used to create 3D surgical plan. The computer then plans a trajectory for the guide wire of DHS. The depth of the drill hole is also calculated. The trajectory is then shown on both AP and lateral images on the screen.

CAOSS meets all the requisite of electrical and electromagnetic radiation standards for medical equipment. There has been extensive validation using software simulation, performance evaluation of system components, extensive laboratory trials on plastic bones. The positional accuracy was shown to be within 0.7mm and angular accuracy to be within 0.2°. The system was also validated using Coordinate Measurement Machine.

Our system has the unique feature of the registration phantom which provides accurate registration of the fluoroscopic image.

Though the perceived advantages of computer assisted orthopaedic systems (CAOS) have been claimed incessantly over the years, these systems are far from commonplace in most orthopaedic theatres. Here, we present a summary of those very reasons.

Health Technology Assessment report elicited no proof of clinical benefits of the Robodoc over conventional procedures. Mazoochian et al were unable to confirm the same accuracy of implant position while using the Caspar. Honl et al found a higher revision and dislocation rate accompanied with longer surgery durations when robotic assisted technology was used.

Shortcomings identified in the CT-based navigation systems included an additional CT scan, which represents extra costs for the acquisition as well as additional radiation to the patient. Sistan et al claims that image-free navigational systems in knee arthroplasty do not provide a more reliable means for rotational alignment as compared to traditional techniques. Computer assisted pedicle screw insertion in the spine has also not demonstrated any significant clinical advantages.

To date, long term results of computer-guided or robot-assisted implantation of endoprosthetic devices are still lacking. With the unproven long-term clinical and functional results of patients who had computer aided surgery and given the multi-factorial complexities of patient outcome, it is difficult to claim via small scale short term studies that these systems present a significant benefit to the patient or the healthcare providers. Potential benefits of long-term outcome, better implant survival and functional improvement require further investigation and until that information is available this technology must be further developed before its widespread usage can be justified.

Substantial bone loss and bone defects are the most challenging problems faced by the surgeon performing revision surgery. Of the many techniques available, impaction bone grafting aims to achieve stability of an implant with the use of compacted, morselized bone graft and subsequently allows restoration of bone stock by bone ingrowth. This technique was proposed with a highly polished double tapered stem. This technique has also been subsequently used with stems of varying surface finish and shape. We report here our experience with impaction grafting using Charnley stem and variants with 8–10 year results assessing the radiological appearance and subsequent behaviour of the impacted allograft.

A prospective radiological study of revision hip arthroplasty done for aseptic loosening with femoral bone loss is presented. Pre operative bone loss was assessed using the Endo Klinik grading system. Impaction grafting with fresh frozen femoral head allograft and the flanged 40 size Charnley stem was used in 17 cases and extra heavey flanged 40 size was used in 9 casaes. Post operative and annual review radiographs were examined for graft distribution, graft consolidation, cortical repair and subsidence of the stem.

Twenty six revisions performed in 25 patients between May 1994 and November 1996 were followed up for 8–10 years. Mean age was 66 years(range 26–83 years). There were eighteen male and 7 female patients. One patient died 2 years and 9 months after the operation. Pre operatively Endo Klinik grade 2 bone loss was seen in 7 cases and grade 3 bone loss was seen in 19 cases. Post operative radiographs showed even graft distribution in twenty cases, five patients had poor filling in Gruen zone 3 and one patient had poor filling in zone 2. All cases demonstrated evidence of graft consolidation by one year. Twenty two cases showed no further changes after 8–10 years. Two cases of subsidence have been revised and one patient is awaiting revision ( 8 years after revision). Two of these were extra heavy flanged 40 stems. Three cases showed subsidence > 5mm and were associated with graft deficiency in zone 2 or 3. Out of these three one had an extra heavy flanged 40 stem inserted. There were no medical complications or deep infection following surgery in these patients. One patient had dislocation.

In conclusion, femoral revision using impaction grafting with the Charnley stem produces satisfactory radiological results in the medium to long term. Good graft distribution on a postoperative radiograph is associated with graft consolidation, cortical repair and minimal stem subsidence. Extra heavy flanged 40 stems perform less satisfactorily compared to the flanged 40 stems. Inadequate graft filling is associated with stem subsidence and revision. These findings highlight the importance of meticulous surgical technique to ensure even graft distribution. This study supports the taper of the Charnley stem and suggests that a vaquasheen finish is not contraindicated.

Aim We have prospectively investigated the effect of tranexamic acid in reducing blood loss and transfusion requirements in primary and revision total hip arthroplasty in a comparative study.

Patients and Methods In the study group, tranexamic acid was given half an hour before the skin incision. (10 mg/kg as an intravenous bolus, followed by 10 mg/kg as intravenous infusion over 6 hours). We recorded the haemoglobin level preoperatively and prior to discharge, and number of units of blood transfused. The total peri-operative blood loss and the fall in haemoglobin after surgery was calculated in consultation with our haematologist. There were 9 primary and 17 revision hip replacements in the study group. We compared the results with a control group of 10 primary and 20 revisions performed during a similar period, without tranexamic acid, recording identical parameters. Thrombo-embolic and wound complications were recorded.

Results Patients receiving tranexamic acid had a mean fall in haemoglobin level of 3.1 g/dl and mean blood loss of 4.1 litres. The control group operated without tranexamic acid had a mean fall in the level of haemoglobin of 3.7 g/dl, and the mean blood loss 5.4 litres. The average number of units of blood transfusion required was 0.77 per patient in the study group compared to 2.03 per patient in the control group. The differences were significant (p value of 0.05). There was no increase in the incidence of complications such as deep vein thrombosis, pulmonary embolism, or wound problems in the study group.

Conclusion Tranexamic acid given prior to surgery reduces blood loss and need for blood transfusion, not only in primary but also in revision hip arthroplasty, without any increase in the rate of thrombo-embolic complications.

Aim: To review results and complications of revision knee replacements.

Materials and Methods: We retrospectively reviewed 41 cases of cemented revision knee arthroplasty in 39 patients (15 male, 24 female) performed between 1993 and 2003. Data regarding clinical and functional outcomes and complications was recorded.

Results: Mean age at index (revision) operation was 67.8 years (32 to 86) and mean follow-up was 6.8 years (1.5 to 12). Average time to revision was 80 months (9 months to 23 years).

The indication for revision was aseptic loosening in 16 cases, and deep sepsis in 13 cases, (12 were done in 2 stages). Others included polyethylene wear in 4 knees, instability in 2, and 1 each of peri-prosthetic fracture, implant breakage and pain of undetermined origin. 3 revisions were performed for failed Link Lubinus patello-femoral replacement. Mean interval between staged procedures for sepsis was 2 months.

Reconstruction was performed using the Kinemax Revision system with the use of augments and stems. The modular rotating hinge was used in 4 cases. Surgical exposure included additional lateral release in 7 cases, tibial tubercle osteotomy in 4 and quadriceps snip in one.

Complications: Included 1 post-operative death due to haematemesis and 2 non-fatal cardiac complications. 1 patient was re-revised for aseptic loosening at 3.5 years, 1 needed an above knee amputation for intractable sepsis after multiple failed reconstructions and 1 is awaiting patellar revision.

At latest review, 7 patients had died due to unrelated causes with a pain free functioning knee prosthesis. Of the remaining 31, 26 patients had none or minimal pain. 21 were independently mobile with a satisfactory range of motion.10 patients needed a walking stick.

Conclusion: Revision total knee replacement can give satisfactory results in the short to medium term, although the complication rate can be significant. The procedure should be performed in specialist units. Revision in 2 stages for sepsis resulted in satisfactory control of infection in our study.

Aim: To review the results and complications of revision of the socket in total hip arthroplasty using rim mesh and impaction allograft for reconstruction of segmental and complex defects

Patients & Methods: 43 patients who underwent a revision of the socket in 47 total hip replacements were retrospectively reviewed over a 3 ½ year period. All the patients had segmental or complex bone loss around the acetabulum which was reconstructed using Stryker Howmedica rim mesh, impaction bone grafting and a cemented cup through the posterior approach. Final analysis included clinical review at latest follow-up, radiological evaluation to assess graft incorporation and socket migration and any other complications.

Results: All patients were followed up for a mean period of 14.2 months (range: 2 months-33 months). The mean age at surgery was 58.2 yrs. There were 14 males and 29 females. This was a re-revision in 5 patients. The most common indication for revision was aseptic socket loosening with migration in 39 patients. One patient had a two stage revision for infection, one had socket fracture, and two patients had collapse of bulk graft and socket migration. Superior segmental defect of varying sizes were present in all patients, in addition to which there were central deficiencies, anterior and/or posterior column deficiencies and complex defects. 4 patients had post-operative dislocation, 1 had significant limb length discrepancy, 1 had infection and 1 had transient sciatic nerve palsy. At the latest follow-up all patients had good graft incorporation and no socket migration.

Conclusion: Rim mesh helps in containing a segmental defect of acetabulum provides good immediate support for impacted graft and socket and has produced good early results. However, long term follow-up is necessary to determine the outcome of this construct.

Aim: To review treatment, results and complications of pelvic ring injuries.

Materials & Methods: We reviewed 39 pelvic ring injuries, mean age 37 years, referred to a tertiary unit, with mean follow up 19 months (6 to 60). Data regarding type of fracture, associated injuries, treatment, injury surgery interval, complications and outcome was documented.

Results: Vehicular accidents in 21 were the commonest mechanism of injury and 30 had vertical shear fractures. There were 4 associated head injuries, 5 chest, 4 maxillo-facial, 4 perineal/ vaginal tears, 7 urological, 1 anorectal, 2 each of abdominal and ophthalmic, and 1 each of vascular, spine and brachial plexus injuries. Also there were 15 skeletal fractures, 12 soft tissue injuries and 11 associated acetabular fractures of which 8 needed fixation, and 17 had lumbosacral plexus injuries. 6 compound pelvic fractures were treated with debridement, fixation and early life saving bowel diversion. 19 patients had anterior external fixators, 9 were applied elsewhere for resuscitation.

Complications: There were 10 systemic complications, 4 ARDS, 2 wound infections and 1 colovesical fistula, 1 infected pubic plate, and 3 late inguinal hernias. 8 patients had pin track infections, and 5 iatrogenic problems including 2 nerve lesions, 2 vascular injuries and 1 bladder rupture, none of which left any residual problem.

Results: 20 patients had no pain, 31 were fully mobile without aids, and 22 had returned to original level of activity. 6 complained of sexual dysfunction, and 1 had double incontinence. 6 patients were on disability allowance, and 10 had full recovery of lumbosacral plexus injury.

Conclusion: Severe associated injuries and soft tissue trauma significantly affect outcome and complications, inspite of sound bony fixation and healing, and multi-disciplinary management is obligatory. Posterior ring lesions were often underestimated, and anterior external fixation alone can make them worse. Early colostomy is lifesaving in compound pelvic fractures. Early involvement of a specialist surgeon is desirable for optimal outcome, which can be achieved in most patients.

Aims: The aim of this study was to þnd out if undisplaced displaced distal radial fractures require plaster immobilisation. Methods: In this prospective study, undisplaced distal radial fractures were divided into two groups; plaster immobilisation was used for one group while removable volar splint was used for the other group. Follow up was at six weeks, three months and six months. Patients were assessed by clinical examination, grip strength, radiological assessment, EQ-5D and a Short Form 12 questionnaire. Results: At 3 months, no difference was found between the two groups in clinical evaluation, radiological assessment, the functional outcome, grip strength, and visual analogue score for pain. Conclusions: We conclude that undisplaced distal radius fractures can probably be treated with out a plaster cast and put straight into wrist orthosis.

Aim: We report results of surgical treatment of acetabular fractures and highlight the importance of single approach for complex fractures. Methods: 50 acetabular fractures referred to a specialist unit between 1994 and 1999 were treated surgically with anatomic reduction and internal þxation. Mean follow up was 32.3 months (14 to 67). Patients were regularly followed up in a special pelvic clinic for documentation of Harris hip score (pain, function, movement, activity), and radiological evidence of healing, avascular necrosis or other complications. Results: 18 patients were treated with the anterior ilioinguinal approach for 11 both- column, 3 anterior column, 3 transverse fractures and 1 central dislocation. 28 patients had posterior Kocher-Langenbeck approach for 17 posterior fracture dislocations, 2 both-column, 6 posterior wall and 1 each of transverse, posterior column and Tshaped fracture. 4 needed combined anterior- posterior or extensile triradiate approach due to comminution or delayed referral. Mean hospital stay was 24.7 days and mean injury surgery interval was 10.8 days. Of the 42 transfers from other units, 7 had surgery after 3 weeks from the injury. Outcome: 47 patients were followed up. Mean Harris hip score was 82.7 (31–100) for the posterior approach group, and 78.1 (27–99) for anterior approach group.3 patients needed total hip arthroplasty for secondary arthritis. Grade3–4 Brooker ectopic bone was noted in 3 posterior and 1 anterior approaches. There was no infection or avascular necrosis. Conclusion: Single approach surgery was possible in 46 patients and had a low rate of complications. Poor outcome occurred in highly comminuted fractures or with a delay in referral. Anterior ilioinguinal approach, although demanding, was the approach of choice for both column fractures. Early referral to a specialist unit is recommended.

Aims: To compare the results between intramedullary hip screw (IMHS) and dynamic hip screw (DHS) regarding operative time and radiation exposure time Methods:We reviewed radiation exposure times obtained during the fixation of 281 extracapsular proximal femoral fractures. Dynamic hip screw was used in 148, and intramedullary hip screw was used in 133. Results: The results showed that there was no statistical difference in ionising radiation exposure in closed reduction of these fractures regardless of fracture configuration or surgical experience of the surgeon, but there was a statistical difference in implant insertion time and radiation exposure (p= < 0.05). Conclusions: We conclude that intramed-ullary implant takes more radiation exposure because they take more time for insertion, which is irrespective of surgical experience and complexity of fracture.

Aims: Dynamic hip screw (DHS) is a common implant used for extracapsular fracture neck of femur. Accurate placement of the guide wires for the DHS insertion is the most important surgical step. In order to improve precision and accuracy of the guide wire placement, Computer Assisted Orthopaedic Surgery System (CAOSS) was used which was developed at the University of Hull. Early clinical experience in 14 cases is presented. Methods: CAOSS helps in surgical planning and aid surgeons for accurate guide wire placement into femoral neck. After fracture reduction, intraoperative computer based surgical planning was performed using one ßuoroscopic image in two planes each. A trajectory obtained thus helped surgeon to place a guide wire along with the required course under the computer guidance. Results: CAOSS system was used on 11 patients for guide wire placement. Intraoperative ßuoroscopic images of all the patients showed accurate position of the guide wire both in AP and lateral planes. Only 4 ßuoroscopic images were required during the surgical procedure in total, both pre and post guide wire insertion. Conclusions: The computer aided surgery used in guide wire placement for dynamic hip screw insertion proves to be accurate and reliable. It also reduces ionisation radiation exposure to the surgeon, patients and theatre personnel.

Aim: We audited medical complications after revision hip arthroplasty, in elderly and young patients and correlated its occurrence to the preoperative medical status. Methods: 104 revision hip replacements in 100 patients (mean age 71.5 years) were followed up for a mean of 33.9 months. (9–67). 49 were above 75 years of age. The American Society of Anaesthetists grading system was used to assess preoperative medical fitness. 50% patients were in ASA grade III. Medical complications in the first 3 postoperative months were classified into major, moderate and minor (Phillips). There were pre-existing cardiac problems in 57, COPD in 13, vascular disease in 7, cerebro vascular disease in 7, previous DVT in 6 and renal/endocrine problems in 16. Results: Overall medical complication rate was 35% (7% major, 14% moderate and 14% minor). The rate in elderly patients was 21%. There was 1 postoperative death due to cardiac reasons at 2 months. There were cardiac complications in 23%, anaemia in 17%, respiratory problems in 10%, hematemesis in 7%, renal in 7%, circulatory in 7%, deep vein thrombosis in 5%, pulmonary thromboembolism in 5%. Mean hospital stay was 17.8 days. 83 patients had no pain, 88 were independent, and 7 had poor mobility. 85% were satisfied with the operation. The major medical complications were not significantly higher in elderly than in younger patients. Conclusion ASA grade correlated positively with frequency and severity of medical complications (Fisher exact test p < 0.001). The occurrence was independent of the age of the patient (p=0.106). Revision hip arthroplasty was well-tolerated in elderly patients and age alone is not a contra-indication. This compared favourably with other reported series. Good anaesthetic and medical support is vital.

Aim: 40 linked total elbow replacements were inserted into 35 patients over a 12-year period. The mean age was 67.3 (48–87) years and the mean follow up 50 (8–134) months. Each patient had undergone at least 1 operation prior to the index arthroplasty (1–10). 27 elbows were ßail and 13 unstable due to previous failed total elbow replacements in 23, gross bony erosion due to rheumatoid arthritis in 9, distal humeral non-union in 6 and Charcot joints due to syringomyelia in 2. Methods: A Coonrad Morrey sloppy hinge prosthesis was implanted in 25 elbows and a Snap þt Souter Strathclyde prosthesis in 15. The technique included preservation of the triceps mechanism and early mobilisation in most cases. Results: At review 38 elbows had no or mild pain, 2 moderate, and no patient with severe pain. All patients achieved a functional range of movement. There was no linkage failure of any implant. Complications included revision for aseptic loosening of one humeral and one ulnar component, debridement for infection in 1 and curettage and bone grafting of a cement granuloma in 1. One patient with a Charcot joint developed a non- union after failure of plating and grafting of a periprosthetic fracture at the tip of the humeral component. In addition 6 had delayed wound healing, 2 ulnar nerve symptoms and 2 triceps weakness. Conclusions: In conclusion, a linked elbow replacement can reliably provide stability, mobility and pain relief in a ßail or unstable joint allowing the hand to be positioned in space and therefore the function of the limb is dramatically improved. This method is especially appropriate in elderly frail patients.

Aim: The aim of the study was to analyse the long-term follow-up of patients who were treated with chemonucleolysis for single level disc prolapse. Method: In our retrospective study we reviewed 112 cases that underwent chemonucleolysis for single level lumber disc herniation during the period of 1988–1996. Mean follow up was 9.5 years. In order to estimate the functional outcome of chemonucleolysis Oswestry Disability Index questionnaire was used. Results: An excellent or good response occurred in 79 patients (70.5%); 12 patients (10.7%) showed moderate response with minimal disability. Treatment failed in 21 patients (18.5%) who showed poor response and 12 of these 21 patients went for surgery within a mean period of 6 months. One patient had surgery at different level than chemonucleolysis. There was only one incident of procedure termination because of epidural contrast leak. There was no case of anaphylaxis or discitis. Conclusion: We conclude on the basis of our results that chemonucleolysis is a safe and effective treatment modality for lumber disc herniation in carefully selected patients.

Aim: To assess the radiological appearance and subsequent behaviour of impacted allograft in revision hip surgery using the Charnley femoral prosthesis. Method: A prospective radiological study of hip arthroplasty revised for aseptic loosening with femoral bone loss was performed. Preoperative bone loss was assessed using the Endo Klinik grading. Impaction grafting with fresh frozen femoral head allograft and the Charnley stem was used in all cases. Postoperative X-rays and annual review films were examined for graft distribution, cortical repair and stem subsidence. Graft consolidation and cortical repair was assessed. Results: Twenty cases were followed up for 6 to 8 years. Fourteen cases had even distribution of graft and 6 had deficiency in one Gruen zone. Graft consolidation was identified in all cases at one year. Cortical repair was noted in 14 out of 15 Endo Klinik III cases. One patient died after 2 years and 9 months. Two stems have subsided by more than 5 mm and are asymptomatic. Two cases with subsidence have been revised. All cases with subsidence were associated with graft deficiency in Gruen zone II or III on the postoperative X-ray. Conclusions: Good initial graft distribution on the postoperative X-ray is associated with graft consolidation, cortical repair and minimal stem subsidence. Initial deficiency in graft distribution is associated with stem subsidence and revision. These findings highlight the importance of a surgical technique, which ensures even graft distribution.

Aims: Dynamic hip screw (DHS) is a common implant used for extracapsular fracture neck of femur. Accurate placement of the guide wires for the DHS insertion is the most important surgical step. In order to improve precision and accuracy of the guide wire placement, Computer Assisted Orthopaedic Surgery System (CAOSS) was used , which was developed at the University of Hull.

Methods: CAOSS helps in surgical planning and aid surgeons for accurate guide wire placement into femoral neck. After fracture reduction, intra-operative computer based surgical planning was performed using one fluoroscopic image in two planes each. A trajectory obtained thus helped surgeon to place a guide wire along with the required course under the computer guidance.

Results: CAOSS system was used on 11 patients for guide wire placement. Intra-operative fluoroscopic images of all the patients showed accurate position of the guide wire both in AP and lateral planes. In theory only 4 fluoroscopic images are required during this surgical procedure in total. But in practice, more than 4 were required depending upon the experience of the radiographer. None of the patient had any intra-operative complication. Conclusions: The computer aided surgery was found to be safe, accurate and reliable for guide wire placement for dynamic hip screw insertion.

Rotator cuff pathologies are related with higher incidence of morbidity in the modern society in young patients. Although it is well known that rotator cuff is sandwiched between the acromion and humeral head during various movements of the shoulder joint, only few studies have investigated this looking at the humeral head as a culprit for the rotator cuff pathology.

We carried out the cadaveric study of 15 shoulder joints to find out the influence of the humeral head anatomy on the rotator cuff pathology. We dissected 15 shoulder joints and looked at the rotator cuff tears. All the specimens were examined and photographed digitally from the superior aspect of shoulder joint. All these images were entered into a computer and using special software, we carried out 3D reconstruction of these images. With this software, the outermost point of intersection of humerus head with acromion decided. We calculated the area of the humeral head in an outside the acromion and correlated with the rotator cuff tear.

We found that the area of the humeral head outside the acromion is variable, ranging from 18% to 50% of diameter of humeral head (mean 34%, median 33%, mode 20%, 33%, 45%). When the area of humerus head outside the acromion is less than 32% of the diameter of head (i.e. humerus head was more under the acromion and less outside the outer most point of acromion), those specimens had either incomplete or complete rotator cuff tear.

We conclude that when the area of humeral head, covered under the acromion is more than 68% of the diameter of the head, they have more chances of developing rotator cuff pathology as compare to other individual.

The results of hip injections for 63 patients with hip pain are presented. Injection of 80mg of methylprednisolone and bupivacaine by an anterior approach was performed with x-ray screening. Patients were noted as having either a normal x-ray (10), mild osteoarthritis (21), moderate osteoarthritis (13) and severe osteoarthritis (19), those in the severe group were generally unfit for hip surgery. Outcome was judged by an Oxford hip score, which was calculated pre-injection, at one month, and at three months. At three months all with a normal x-ray were improved, 19 with mild changes were improved 2 deteriorated, 9 with moderate changes improved, 2 stayed the same, 2 deteriorated and 13 with severe changes were improved, 4 deteriorated and 2 were unchanged. Improvements were with pain scores not function. Of those improved all thought the procedure worthwhile. Two patients described numbness and weakness at the anterior thigh area, which recovered quickly. We feel that this is a useful technique to give symptomatic relief in-patients not suitable for hip replacement.