Purpose

Femoroacetabular impingement syndrome (FAI) is a common cause of hip and groin pain in young adults. Physiotherapy and surgery have both been used to treat FAI syndrome, but there is no robust evidence of comparative effectiveness. UK FASHIoN compared the clinical and cost-effectiveness of arthroscopic hip surgery (HA) versus best conservative care in patients with FAI syndrome.

Background

There is a 20% dissatisfaction rate with knee replacements. Calls for tools that can pre-operatively identify patients at risk of being dissatisfied postoperatively have been widespread. However, it is unclear what sort of information patients would want from such a tool, how it would affect their decision making process, and at what part of the pathway such a tool should be used.

Background

Knee replacement surgery is currently facing three dilemmas: a high dissatisfaction rate; increasing demand with financial constraints; and variation in utilisation. A patient centred approach, usually achieved through shared decision-making, has the potential to help address these dilemmas. However, such an approach requires an understanding of the factors involved in patient decision-making. This is the first study examining decision-making in knee replacements that includes patients at different stages of decision-making – this is critical when considering decision-making as a process. We base our findings in a theoretical model, proposed by Elwyn et al, that highlights the distinction between deliberation and decision-making, and propose modifications to this model specific to knee replacement decision-making.

Background

Total Knee Replacement (TKR) is an effective treatment for knee arthritis. One long held principle of TKRs is positioning the components in alignment with the mechanical axis to restore the overall limb alignment to 180 ± 3 degrees. However, this view has been challenged recently. Given the high number of replacements performed, clarity on this integral aspect is necessary. Our objective was to investigate the association between malalignment and outcome (both PROMs and revision) following primary TKR.

Objectives

A patient-centred approach, usually achieved through shared decision making, has the potential to help improve decision making around knee arthroplasty surgery. However, such an approach requires an understanding of the factors involved in patient decision making. This review’s objective is to systematically examine the qualitative literature surrounding patients’ decision making in knee arthroplasty.

Introduction

There is an ever increasing demand for Randomised Controlled Trials (RCTs) in Trauma and Orthopaedic Surgery. Patient recruitment is often challenging. Among other factors, individual surgeon's preference is often quoted as a major obstacle. Collective equipoise based on present or imminent controversy in the expert medical community has been proposed as a solution, but could not help in everyday running of a trial. We wanted to develop a new trial eligibility assessment tool using the Collective Equipoise Principle.

Introduction

Simulation is increasingly perceived as an important component of surgical training. Cadaveric simulation offers an experience that can closely simulate operating on a living patient. We have explored the feasibility of providing cadaveric training for the whole curriculum for trauma and orthopaedic surgery speciality trainees, before they perform those operations on living patients.

Study aim

There is an ever increasing demand for quality clinical trials in surgery. Surgeons' co-operation and enthusiasm to participate are important, if not crucial in success of such studies, especially if they are multi-centred. Clinician's individual uncertainty (equipoise) about a case has been often cited as an ethical basis for inviting a patient to take part in a clinical trial. This study aims to establish current attitudes of surgeons participating in a national multi-centred randomised controlled trial and explores an on line tool for instant assessment of collective uncertainty (equipoise) for individual clinical cases eligible for a trial.

Background

Cam-type femoro-acetabular impingement (FAI) is increasingly recognised as a cause of mechanical hip symptoms in young adults. It is likely that it is a cause of early hip degeneration. Ganz et al have developed a therapeutic procedure involving trochanteric flip osteotomy and dislocation of the hip, and have reported good results. We have developed an arthroscopic osteochondroplasty to reshape the proximal femur and relieve impingement.

Background

Femoro-acetabular impingement (FAI) is increasingly recognised as a cause of mechanical hip symptoms in sportspersons. In femoro-acetabular impingement abnormal contact occurs between the proximal femur and the acetabular rim during terminal motion of the hip as a result of abnormal morphologic features involving the proximal femur (CAM) or the acetabulum (Pincer) or both (Mixed) leading to lesions of acetabular labrum and the adjacent acetabular cartilage. It is likely that it is a cause of early hip degeneration. Ganz developed a therapeutic procedure involving trochanteric flip osteotomy and dislocation of the hip, and have reported good results. We have developed an arthroscopic technique to reshape the proximal femur and remove prominent antero-superior acetabular rim thereby relieving impingement.

We investigated the blood flow to the femoral head during and after Resurfacing Arthroplasty of the hip.

In a previous study, we recorded the intra-operative blood flow in 12 patients who had a posterior approach to the hip and 12 who had a trochanteric flip approach. Using a LASER Doppler flowmeter, we found a 40% drop in blood flow in the posterior group and an 11% drop in the trochanteric flip group (p<0.001). The aim of this current study was to find out whether the intra-operative fall in blood flow persists during the post-operative period.

We therefore conducted a Single Positron Emission Tomography (SPECT) scan on 14 of the same group of patients. The proximal femur was divided into four regions of interest. These were the mid-shaft, proximal shaft, inter-trochanteric and head-neck regions. The data was analysed for bone activity and comparisons made between the two groups for each region of the femur. We found that the bone activity in the mid-shaft, upper-shaft, and head-neck regions was the same eleven months after the surgery irrespective of the approach to the hip. However there was higher activity in the trochanteric flip group in the inter-trochanteric region.

We conclude that the intra-operative deficit in blood flow to the head-neck region of the hip associated with the posterior approach does not seem to persist in the late post-operative period. We believe the reason for increased bone activity in inter-trochanteric region to be due to the healing of the trochanteric flip osteotomy.

Several factors have been identified that may affect outcome after total knee replacement (TKR). We performed a systematic review of studies that looked at the association of pre-operative factors and outcome after primary total knee replacement for osteoarthritis.

All study types that investigated TKR for osteoarthritis were considered except retrospective case-series. Studies that included patients undergoing revision TKR were excluded if they did not provide separate results for primary and revision knee replacement. Any patient factor that was measured in the pre-operative period was included.

The factors measured included age, sex, race, income, body mass index (BMI), medical or joint co-morbidity, level of education, disease specific scores and their subcategories and general health scores. Studies that recorded outcome measures were only included if evidence of validation for use after total knee replacement was available.

We identified 590 studies purporting to evaluate TKR for OA. Of these, 25 studies were retrieved for in-depth consideration and 10 were found to meet the inclusion criteria. Most of these were cohort studies that used some form of regression analysis.

The results showed that the strongest and most consistent correlations were between pre-operative pain scores, pre-operative function scores, co-morbidity and post-operative function scores. Age, gender and level of education were not significant predictors of outcome. However, even the best models could only predict 36% of the variance in outcome.

Understanding which factors influence outcome the most will be of great benefit to patients and those who plan and deliver healthcare.

The aim of this study was to assess the risks and benefits of mini-incision TKR. The limited exposure afforded by the small skin incision in the new technique of mini-incision TKR has the potential for increasing the risk of mal-positioning of components. Minor mal-positioning of components has the potential to increase polyethylene wear and may lead to early loosening and poor functioning of the TKR. The literature supports the concept that alignment within +/- 3 degrees of neutral mechanical alignment in the coronal plane is associated with a better outcome. If the mechanical axis falls outside this range it may have up to a 30% failure rate at 10 years.

We report the results of 166 mini-incision TKR that have been undertaken in 154 patients (96F; 58M; mean age 72; mean BMI 29; 96% OA) since November 2003. The pre-operative mechanical axis ranged from 8 degrees valgus to 15 degrees varus. Surgery was undertaken with a precise skin incision and a midvastus split approach. Specialised cutting blocks were used to facilitate a smaller incision. The prosthesis inserted was a cemented Zimmer NexGen TKR of either posterior stabilised or cruciate retaining form.

Long leg weight bearing alignment radiographs were available in 52% of patients. The mechanical axis was measured in the coronal plane and found to lie within +/- 3 degrees of neutral in 86% of patients. This compares favourably with the current literature which reports the mechanical axis falling within this range in between 72% and 85% of cases.

We believe the mini-incision TKR is a safe, reliable and reproducible technique offering substantial savings to the patient and health service without compromising accuracy.

We used a laser Doppler flow-meter with high energy (20 m W) laser (Moor Instruments Ltd. Milwey, UK) to measure the blood flow to the femoral head during resurfacing arthroplasty.

Twenty-four hips were studied; 12 underwent a posterior approach and twelve a Ganz's trochanteric flip osteotomy. The approach was determined according to surgeon preference. Three patients were excluded, The exclusion criteria were previous hip surgery, history of hip fracture and avascular necrosis (AVN). All patients had the hybrid implant with cemented femoral component.

During surgery a 2.0mm drill bit was passed via the lateral femoral cortex to the superior part of the head neck junction. The position was confirmed using fluoroscopy. The measurements were taken during five stages of the operation: when the fascia lata was opened (baseline), at the end of soft tissue dissection, following dislocation of the hip, after relocation back into the socket, after inserting the implants prior to closing the soft tissues and, finally, at the end of soft tissue closure.

The results were analysed and the values were normalised to a percentage of the baseline value. We found a mean drop of 38.6 % in the blood flow during the posterior approach and a drop of 10.34% with the trochanteric flip approach. The significant drop occured between the baseline (1st stage) and the end of the soft-tissue dissection (2nd stage). In both groups the blood flow remained relatively constant afterwards.

Our study shows that there is a highly significant drop in blood flow (p<0.001) during the posterior approach compared with the trochanteric flip approach.

Thromboprophylaxis remains a controversial issue and many disagree about the optimum method or even if it is required at all.

We present a new method of performing meta-analysis incorporating studies with both experimental and observational study designs. We have developed a model that compares study cohorts of several different methods of thromboprophylaxis with a simulated matched control group whose variance helps to adjust for bias. This allows meaningful comparisons between studies and treatments that have not been directly compared.

We performed a systematic review of the literature from 1981 to October 2004. Studies where more than one method of prophylaxis was used were excluded from analysis. For each individual method of prophylaxis, data was extracted, combined and converted to give estimates of the rates of symptomatic, proximal DVT, fatal PE and major bleeding events. We identified 1242 studies of which 203 met the inclusion criteria for further analysis. This represented the results of over fifty thousand studied patients. We expressed the results for the different prophylactic methods as odds ratios compared to no prophylaxis.

All methods showed a beneficial effect in reducing VTEs apart from stockings and aspirin which showed an increase in the number of PE events. These results are particularly interesting when viewed from the standpoint of an individual NHS hospital trust that performs around 500 hip and knee replacements per year. Over a 5 year period, the more effective methods of prophylaxis prevented between 15 and 40 symptomatic DVTs and up to 3 fatal PEs compared to no treatment. However, they cause between 8 and 40 more major bleeding events. We do not know the proportion of these major bleeding events that are fatal.

Introduction: Injuries to the ligamentum teres are being recognised more often with developments in imaging, such as MR arthrography, and the increasing use of hip arthroscopy. But they are difficult to diagnose, and it is not clear how best to treat them. Little is known about the mechanism of injury, nor the potential impact on hip stability of such injuries. The relationship between capsular and ligamentous contributions to stability has not been investigated.

Methods: We examined the movement of the ligamentum teres in intact, fully reduced, cadaveric hip specimens by trans osseus arthroscopy. The movement of the ligamentum teres was captured with video throughout the excursion of the hip joint. The influence of restraining capsular structures was determined by sequential transection and repeat excursion testing. Ligamentum teres injuries were generated by extreme movements, and compared with clinically observed injuries.

Results: The action of the ligamentum teres was successfully recorded in by video. The ligament was found to be the principal restraint to external rotation in extension and abduction. Injuries generated by forced rotation in this position resembled those seen in clinical practice.

Conclusion: Knowledge of the action of the ligamentum teres will improve our understanding of injury to this structure. It helps to identify described mechanisms which should raise suspicion of such an injury, and may help to design investigation and treatment protocols.

Introduction: Pain and mass lesions around hip resurfacing are reported with increasing frequency. The aetiology is unknown but reaction to metal wear debris and mechanical impingement have both been suggested. We are aware of a group of our patients with significant pain following resurfacing. We sought to correlate metal ion levels with X-ray findings and any local soft tissue reaction around the prosthesis.

Methods: Patients with significant groin pain following hip resurfacing were identified from routine clinics. Blood was tested for cobalt and chromium levels using inductively coupled mass spectrometry in all patients. Cup abduction angle and femoral stem version were estimated from plain radiographs. Patients underwent ultrasound scan (USS) of the affected hip joint. Bilateral prostheses were excluded to avoid confounding.

Results: 47 unilateral painful hip resurfacings (24 female) were identified. USS was performed in 42 patients and was abnormal in 25 (15 female). Abnormalities ranged from simple joint effusion with or without synovial thickening, through to cystic masses in the posterior joint and solid masses related to the ileopsoas tendon similar to the appearances previously described in pseudotumours.

A two sample t-test demonstrated cobalt and chromium ion levels were significantly higher in patients with abnormalities on USS (p=0.038, p=0.05 respectively), patients with normal USS were more likely to have a retroverted femoral component (p=0.01).

Discussion: We describe two groups of patients with a painful hip resurfacing: those with raised metal ions and local soft tissue reaction, and those with lower metal ions and no soft tissue reaction. The retroverted stems in the second group could cause an iatrogenic cam-type impingement. Metal ion levels are useful to guide further imaging. Raised levels should prompt investigation for a soft tissue abnormality with either USS or MRI, lower levels suggest investigation should look for mechanical impingement with imaging such as CT.

Introduction: Chondral lesions are the second most common pathology encountered during hip arthroscopy. Microfracture is a simple and effective technique to treat chondral lesions with proven long term results in the knee. However, there is little evidence to confirm the ability of microfracture to produce repair tissue in hip joint.

Methods: Patients with acetabular chondral defect treated with microfracture during primary arthroscopy and who had a subsequent hip arthroscopy enabling visualisation of the treated chondral defect were included in the study. Over a three year period 185 patients had microfracture for treatment of full thickness chondral defect. 11 patients (8 males and 3 females) with a mean age of 35 years (range 17–54 years) who had revision hip arthroscopy form the study population. The size of chondral defect was measured at the time of primary arthroscopy. Microfracture was performed using arthroscopic awls with a standard technique. Postoperatively a strict rehabilitation protocol was followed. The extent and quality of repair tissue was assessed by visual inspection at second look arthroscopy

Results: All patients had chondral lesions confined to the antero-superior aspect of the acetabulum with an associated labral tear. None had diffuse osteoarthritis. The average defect measured 180 mm2 (range 50–300). The mean time interval between primary and revision arthroscopy was 12 months. Excluding one failure the overall percent fill of the defects was 95% (range 75 – 100) with good quality cartilage.

Discussion: Only one other series has reported on the macroscopic results of microfracture in the hip. Our series agrees with the results of those authors. These similar results from 2 centres confirm that arthroscopic microfracture is an effective treatment for acetabular chondral lesions in carefully selected patients.

Introduction: Accurate templating prior to hip replacement requires that the magnification of the radiograph is known. This magnification is usually measured using a scale marker ball or disc of known diameter, but this method is inaccurate when the marker is not precisely positioned in the coronal plane of the hips.

Our aims were to design a novel scale marker which does not require such precise positioning, and to compare the accuracy of this new marker with a standard single ball marker.

Methods: The new marker consists of two separate markers: one behind the patient’s pelvis, the other at the front. It can be shown that the radiographic magnification of such markers is consistently related to the magnification of the hips.

The posterior marker consists of a 75x75cm square foam mat, incorporating multiple 25.4mm metal rods arranged in series down the centre. The anterior marker is made from five 25.4mm steel balls, linked in series at 20mm intervals. The mat is positioned just underneath the patient’s pelvis as they lie supine for their radiograph. The five balls are placed in the midline over the patient’s suprapubic region, and the x-ray is then taken. The radiographic dimensions of the ball and rod which are located between the hips are then measured. The magnification of the hips may then be calculated from these dimensions using a simple equation.

To validate the new “double” marker, it was compared with a conventional single marker ball. 74 hip arthroplasty patients undergoing routine radiographic follow up were recruited. Both the new double marker and the single marker were applied at the time of x-ray, the magnification according to each was calculated, and these were compared to the true radiographic magnification as determined from the known dimensions of the prosthesis. All markers were positioned by independent radiographers trained in their use.

Results: The correlation between true and predicted magnification was excellent using the double marker (r=0.90), but only moderate for the single marker (r=0.50). The median error of the single marker was 4.8%, but only 1.1% for the double marker (p< 0.001). The reliability of the double marker as a predictor of true magnification was very good (intraclass correlation coefficient, ICC=0.89), but was poor for the single marker (ICC=0.32). The accuracy of the double marker was unaffected by the patient’s body mass index. The inter and intraobserver variability of the new method were both excellent (ICC> 0.94).

Discussion: The double marker method is significantly more accurate and reliable than the single marker method when used in a clinical setting, as it does not rely on precise positioning of the marker by the user. We believe that this technique may become the gold standard method of calculating radiographic hip magnification in clinical practice.

Introduction: Clinical communication and research across centres will be facilitated by an easy to use and reliable method to describe lesions within the hip. This requires a system for describing location and a system for describing pathology. We present a hip mapping system for describing location, which has been used to map more than 2000 therapeutic hip arthroscopies to date and tested for ease of use and inter-observer reliability.

Method: The articular surfaces of acetabulum and femoral head are divided into zones. The femoral head has a medial zone around the fovea (A) approximately 2.5 cm in diameter. Lines radiating from the fovea at 90-degree intervals divide the remaining head into equally sized posterior, superior, anterior and inferior zones (B, C, D, E respectively).

The acetabular surface is divided radially into five zones (A, B, C, D, E) starting postero-inferior (A) and ending antero-inferior (E). Each zone is further divided in half into an outer and inner zone, forming ten zones in total i.e Ai, Ao, Bi, Bo.etc.

This study was performed during therapeutic hip arthroscopy of 41 patients. Five surgeons took part in the study. After gaining access into the hip joint one of the surgeons identified three small intra-articular features (marks, small defects or blood clots) as X, Y and Z to some or all of the other 4 surgeons. Each of the other surgeons examined the hip independently without Discussion: and recorded the location on a hip map. If two surgeons had observed a point, this provided one pair to assess agreement; three or four surgeons provided three or six pairs respectively. Each observation of a point by a pair of surgeons (a point-pair) provided one opportunity for assessment of agreement.

Results: In total 103 points were mapped by two, three or four surgeons giving 286 point-pairs for assessment. In 263 cases (92%), the pair of surgeons were in agreement, designating the point as within the same zone. On 23 (8%) occasions, there was disagreement but always across a boundary between adjacent zones. Disagreements were more common about points on the femoral head (12) than on the acetabulum (11). Seven of these were the boundary between femoral zone A and one of the other zones (B, C, D). Disagreements in acetabulum occurred equally at each radial boundary (A/B-2, B/C-3, C/D-2, D/E-2) but only rarely between inner and outer acetabular zones (2 point-pairs).

All surgeons reported that they found the system easy to use. There was no difference in the level of disagreement between more and less experienced surgeons or a learning effect with time.

Conclusion: Inter-observer reliability of this mapping system was 92%. Disagreements all occurred at boundaries between zones especially on the femoral head where zones are difficult to define in the absence of landmarks. This study supports the use of a zone based mapping system in clinical practice.

Introduction: Chondral lesions are the second most common pathology encountered during hip arthroscopy and can cause substantial morbidity and functional limitation. Microfracture is a simple and effective technique to treat chondral lesions. Studies have shown good long term results in the knee. However there is little evidence to confirm the ability of microfracture to produce repair tissue in hip joint

Methods: Patients aged 18 years or older who had a full thickness acetabular chondral defect treated with microfracture during primary arthroscopy and who had a subsequent hip arthroscopy enabling visualisation of the treated chondral defect were included in the study. Over a three year period 185 patients had microfracture for treatment of full thickness chondral defect. 11 patients (8 males and 3 females) with a mean age of 35 years (range 17–54 years) who had revision hip arthroscopy for various reasons form the study population. The size of chondral defect was measured at the time of primary arthroscopy. Microfracture was performed using arthroscopic awls with a standard technique. Postoperatively a strict rehabilitation protocol was followed with no weight bearing allowed for six weeks. The extent and quality of repair tissue was assessed by visual inspection at second look arthroscopy

Results: All acetabular chondral lesions were identified in the antero-superior quadrant at primary arthroscopy. The average defect after debridement measured 180 mm2 (range 50–300 mm2). 10 patients had chondral lesions confined to the acetabulum. 1 patient had a large femoral head defect in addition, due to Avascular Necrosis. None of the patients had diffuse osteoarthritis. All patients had an associated labral tear. The mean time interval between the primary and revision arthroscopy was 12 months. Excluding 1 failure the overall percent fill of the defects was 95% (range 75 – 100%) with good quality (Grade 1) cartilage. There was one failure with only a 25% fill. In that particular patient a large flap of delaminated cartilage was not resected at primary arthroscopy. Instead microfracture was done under the flap in the hope of encouraging the cartilage to stick to the underlying bone. Unfortunately the cartilage continued to remain delaminated and also hindered the formation of new repair tissue.

Conclusion: Only one other series of second look arthroscopy after microfracture has been reported. Our series agrees with the results of those authors. These similar results from 2 centres confirm that arthroscopic microfracture is an effective treatment for acetabular chondral lesions in carefully selected patients.

Randomised controlled clinical trials (RCTs) produce the most reliable evidence about the effects of clinical care. In surgical trials, lack of surgeons’ individual equipoise (state of genuine uncertainty about treatment arms) appears to be one of the greatest obstacles. Collective equipoise based on present or imminent controversy in the expert medical community has been proposed as a solution (Freedman, 1987), but could be applied only at the beginning of a trial to a general trial question.

We developed a system that quantifies collective uncertainty among a group of surgeons for an individual clinical case. After a successful pilot study the system was introduced as an independent project within the UK Heel Fracture Trial. The expert panel included 10 surgeons from 8 hospitals. Anonymous clinical data of potentially eligible consecutive cases including CT and X-ray images was published on a secure online forum after 6 weeks follow up clinic to avoid interference with clinical course. Surgeons registered in the panel estimated the probability that the patient would be better or worse by various degrees with operative treatment.

30 clinical cases have been analysed, including 6 bilateral fractures (otherwise excluded). 86.7% could be recommended for inclusion in the trial, compared to 43.3% recruited out of this series in the actual trial. Lack of individual uncertainty within the panel was present in every case.

The system not only has a potential to improve recruitment in surgical RCTs, but provides ethically sound grounds to offer or otherwise a patient participation in a trial. Surgeon’s individual equipoise dilemma and responsibility is shared with colleagues. Cases that otherwise will be excluded can be evaluated with broader inclusion criteria. The system is easy to use, cheap and reliable. Limitations include surgeons’ compliance and time lapse (at least 48 hours) for voting to be completed.

Background: Acetabular labral tears are increasingly recognised as a cause of hip pain in young adults and middle aged patients. Degenerative acetabular conditions and sporting activities can cause labral injury. Recent interest has focussed on anterior femoroacetabular impingement as a cause of labral injury, progressive articular cartilage damage and secondary osteoarthritis. Labral tears are difficult to diagnose clinically or with conventional radiographic techniques.

Aim: The purpose of this study was to assess the accuracy of MR arthrography in locating labral tears and articular cartilage defects compared with hip arthroscopy.

Materials and Methods: 200 consecutive patients with a diagnosis of acetabular labral tear underwent hip arthroscopy. All of them had a preoperative Magnetic Resonance Arthrogram done by a single musculoskeletal radiologist using a standard protocol. The labrum was assessed for abnormalities of morphology and signal intensity. Acetabular articular cartilage defects were expressed as a reduction in joint space. All hip arthroscopies were done by a single surgeon after a trial period of conservative therapy consisting of activity modification, physiotherapy and non-steroidal anti-inflammatory medications. All procedures were recorded digitally and documented in an operative report. Labral tears and acetabular cartilage abnormalities were described by location and appearance.

Results: Comparison of MRA and hip arthroscopy findings demonstrate MRA to have a sensitivity of 100%, positive predictive value of 99%, negative predictive value of 100% and accuracy of 99% in predicting labral tears. MRA correctly identified the location of labral tears in 90% of cases. Acetabular cartilage abnormalities were under recognised by MRA (43 hips on MRA vs 54 hips on arthroscopy). MRA was not sensitive enough to pick up early delamination of cartilage adjacent to labral tear in 6 hips.

Conclusion: Hip MRA with radial reformatting has high accuracy rates in diagnosing and localising hip labral lesions.

Background: Femoro-acetabular impingement (FAI) is increasingly recognised as a cause of mechanical hip symptoms in sportspersons. In femoro-acetabular impingement abnormal contact occurs between the proximal femur and the acetabular rim during terminal motion of the hip as a result of abnormal morphologic features involving the proximal femur (CAM) or the acetabulum (Pincer) or both (Mixed) leading to lesions of acetabular labrum and the adjacent acetabular cartilage. It is likely that it is a cause of early hip degeneration. Ganz developed a therapeutic procedure involving trochanteric flip osteotomy and dislocation of the hip, and have reported good results. We have developed an arthroscopic technique to reshape the proximal femur and remove prominent antero-superior acetabular rim thereby relieving impingement.

Methods: Twelve patients presented with mechanical hip symptoms and had demonstrable cam-type (eight patients) or mixed (four patients) FAI on radially-reconstructed MR arthrography, were treated by arthroscopic femoral osteochondroplasty and acetabular rim resection if indicated. All patients were competing at the highest level in their respective sport (football, rugby and athletics). All patients were followed up and post-operative Non-Arthritic Hip Scores (NAHS, maximum possible score 100) compared with pre-operative NAHS.

Results: There were no complications. All patients were asked to be partially weight-bearing with crutches for four weeks and most returned to training within six weeks. All of them returned to competitive sports by 14 weeks. Symptoms improved in all patients, with mean NAHS improving from 72 preoperatively to 97 at 3 months.

Conclusion: Arthroscopic reshaping to relieve FAI is feasible, safe and reliable. However it is technically difficult and time-consuming. The results are comparable to open dislocation and debridement, but avoid the prolonged disability and the complications associated with trochanteric flip osteotomy. This is important in elite athletes as they can return to training and competitive sports much quicker with less morbidity.

Introduction: Multiple scoring systems are available to evaluate arthritic hip pain and to assess outcome after arthroplasty. These scores focus on evaluating hip pain and function in elderly patients with degenerative joint disease. They are not specific for sports-related or mechanical hip symptoms in young people, or sensitive to change after new treatments such as arthroscopic hip surgery.

Methods: We systematically reviewed the literature since 1980, searching for systems used to measure severity of symptoms and outcome of treatment in these patients. We collected reports of performance of these systems. We then used the best of them to collect symptom scores from 200 patients, and measured the agreement of systems. We performed an item reduction process to identify the question items most associated with overall scores.

Results: Systematic review yielded 4 scoring systems which have been used to evaluate sports-related or mechanical hip symptoms: the Non-arthritic Hip Score (NHS), Hip Outcome Score (HOS), Hip disability and Osteoarthritis Outcome Score (HOOS)and a modified Harris Hip Score (mHHS). All scores are self administered and symptom related, requiring no physical examination. All but the mHHS have some evidence of reliability and validity. There is a great deal of overlap among the variables selected by the authors and agreement between the various scoring systems is surprisingly good. Most of the variability of all of the systems could be captured with ten simple questions.

Conclusion: We have developed a simple set of ten questions which capture outcome information as well as existing more complex systems. This will be useful is assessing outcome after new treatments such as hip arthroscopy in young active people.

We have carried out a prospective double-blind randomised controlled trial to compare the efficacy of a single subacromial injection of the non-steroidal anti-inflammatory drug, tenoxicam, with a single injection of methylprednisolone in patients with subacromial impingement. A total of 58 patients were randomly allocated into two groups. Group A received 40 mg of methylprednisolone and group B 20 mg of tenoxicam as a subacromial injection along with lignocaine. The Constant-Murley shoulder score was used as the primary outcome measure and the Disability of Arm, Shoulder and Hand (DASH) and the Oxford Shoulder Score (OSS) as secondary measures. Six weeks after injection the improvement in the Constant-Murley score was significantly greater in the methylprednisolone group (p = 0.003) than in the tenoxicam group. The improvement in the DASH score was greater in the steroid group and the difference was statistically significant and consistent two (p < 0.01), four (p < 0.01) and six weeks (p < 0.020) after the injection. The improvement in the OSS was consistently greater in the steroid group than in the tenoxicam group. Although the difference was statistically significant at two (p < 0.001) and four (p = 0.003) weeks after the injection, it was not at six weeks (p = 0.055). Subacromial injection of tenoxicam does not offer an equivalent outcome to subacromial injection of corticosteroid at six weeks. Corticosteroid is significantly better than tenoxicam for improving shoulder function in tendonitis of the rotator cuff after six weeks.

Introduction: Hip resurfacing has become re-established in recent years as a viable option in younger, active individuals. The results of a multi-centre evaluation of the Cormet resurfacing device are presented.

Materials and Methods: Data has been entered from 1997 onwards from 5 centres, patients being selected as suitable by 8 individual surgeons. Pre and intraoperative details recorded including indications, patient details, implant used, Harris Hip Score (HHS) and surgical approach.

Results: A total of 781 procedures in 676 patients have been recorded (54% posterior approach, 40% antero-lateral, 6% Ganz approach). The mean follow-up is 2.5 years (0.1–9.7 yrs) and the mean postoperative HHS is 85.9 (range 25–100). The mean age at surgery was 54.2 years. 60% of implantations were on male patients. The principal diagnosis was; OA 87%, RA 5%, AVN, post-traumatic OA and DDH 2% each, Perthes 1% and the remainder 1%. It is thought likely that many cases of OA had many of the above-named pathologies as a precursor. The mean maximum flexion postoperatively was 98.6 degrees. Uncemented heads (a recent innovation) were used in 7%. Kaplan-Meier survivorship is 93% at 9 years. In the OA subgroup 3.3% have been revised, approximately equal numbers for femoral head collapse, dislocation and cup loosening, but the vast majority due to femoral neck fracture, which in turn was generally associated with the posterior approach.

Conclusions: The results of this cohort (which includes the learning period of the contributing surgeons) indicate highly satisfactory outcomes in terms of HHS and implant longevity. Sub-classification of cases into those presenting abnormal anatomy and those with ‘ordinary’ OA indicates better survivorship still in the latter group. The surgical challenge varies more with hip resurfacing than with standard hip arthroplasty and this should be considered when results of surgery are reviewed. The revision options are generally much simpler than after standard THR.

Introduction: Two major complications of hip resurfacing arthroplasty are avascular necrosis of the femoral head and femoral neck fracture. Both are thought to be precipitated by disruption of the blood supply to the femoral head and neck during the approach to the hip joint. Ganz et al have described their technique of approaching the hip joint using a “trochanteric flip” osteotomy. This has the theoretical advantage of preserving the medial femoral circumflex artery to the femoral head. The aim of this study was to compare the intra-operative femoral head blood flow during the Ganz flip osteotomy to the blood flow during a posterior approach for resurfacing arthroplasty of the hip.

Methods: The intra-operative measurements of blood flow were performed using a DRT laser Doppler flow-meter with a 20 mW laser and a fibreoptic probe. The probe was introduced into the lateral femoral cortex and threaded into the femoral head under image intensifier control. Measurements were recorded before the approach to the hip was performed, after the approach was performed but before the head was dislocated, and after the head was dislocated.

Results: Our initial results indicate that there is on average a 50% drop in the blood flow to the femoral head after a posterior approach to the hip joint. In contrast, the trochanteric flip osteotomy produces a much smaller fall of around 18%. We have used these results to inform a sample size calculation, and are currently recruiting further patients to achieve a total of 42 in order to confirm a statistically significant effect.

Conclusion: The Ganz trochanteric flip osteotomy appears to produce less damage to the blood supply to the femoral head during resurfacing arthroplasty than the posterior approach. This study will inform surgeons in deciding on their preference for a routine approach for hip resurfacing.

Background: High doses of local antibiotics are used to treat infected acute fractures or chronic osteomyelitis. In the U.S.A., tobramycin is one of the most commonly used antibiotics in trauma surgery. It is an aminoglycoside antibiotic with a broad spectrum of action. However, its effect on the osteogenic potential of bone marrow derived mesenchymal stem cells (MSC’s) is unknown. We hypothesised that high concentrations of tobramycin would be detrimental to the osteogenic potential of multipotent stem cells derived from the bone marrow.

Methods: MSC’s were derived in vitro from reamings obtained in patients undergoing hip hemiarthroplasties. Following subculture, these cells were exposed to various concentrations of tobramycin for 15 days, with a change of media every other day.

The amount of bone formed under each condition was assessed by solubilising the mineral content in hydrochloric acid overnight and then measuring the change in colour induced by Calcium exposed to a commercial reagent. The amount of calcium detected was then determined using a standard curve.

This experiment was repeated in cells from 3 patients.

Results: The amount of calcium formed was as follows Tobramycin concentration of 0 microg/ml

There was a statistically significant impairment in osteogenesis at a concentration of tobramycin of 400 microg/ml and above.

Conclusion: A high local dose of tobramycin affects negatively the osteogenic potential of stem cells derived from the bone marrow.

Subacromial corticosteroid injection has been shown to be effective in treating impingement syndrome. The exact mechanism of action is not clear but it may be due to its anti-inflammatory properties. However, there are potential side effects of steroid injection including tendon weakening, dermal atrophy and infection. NSAIDs may offer similar anti-inflammatory properties but without the side effects of corticosteroids. Tenoxicam is a long-acting water soluble NSAID and is available without irritant preservatives. Studies have shown that peri-articular Tenocixam injection was useful in treating painful shoulders and local tolerability was good.

The aim of this study is to carry out a blinded ran-domised controlled study comparing subacromial Tenoxicam injection (NSAID) against methylprednisolone (steroid) injection in patients with clinical subacromial impingement syndrome.

The study protocol was approved by local research ethics committee. Patients over 18 with a clinical diagnosis of subacromial impingement syndrome were considered eligible to this study. Patients with other known causes of shoulder pain, contraindication or sensitivity to NSAID and pregnant patients were excluded.

Three functional outcome measures were used – Constant-Murley Shoulder Score, DASH and the Oxford Shoulder Score. The patients completed all three outcome measures before and 2, 4 and 6 weeks after the subacromial injection. Simple randomisation method was used and blinded to both researcher and the patient.

58 patients randomised into two groups were reviewed at the end of six weeks. Patients treated with subacromial steroid injection had a much better outcome compared to patients treated with subacromial tenoxicam injection and this difference was highly significant (p< .003)

In conclusion, patients with subacromial impingement syndrome have a better clinical outcome when treated with subacromial steroid injection than NSAID injection.

Introduction: Hip resurfacing has become re-established in recent years as a viable option in younger, active individuals. The results of a multi-centre evaluation of the Cormet resurfacing device are presented.

Methods: Data has been entered from 1997 onwards from 5 centres, patients being selected as suitable by 8 individual surgeons. Pre and intraoperative details recorded including indications, patient details, implant used, Harris Hip Score (HHS) and surgical approach.

Results: A total of 905 procedures in 782 patients have been recorded (52% posterior approach, 39% anterolateral 9% Ganz approach). The mean follow-up is 2.8 years (0.1–9.5 yrs) and the mean postoperative HHS is 86.1 (range 25–100). The mean age at surgery was 54.4 years. 61% of patients were male. The principal diagnosis was; OA 88.3%, RA 4.3%, AVN 2.1%, posttraumatic OA 1.1%, DDH 2.1%, Perthes 0.7% and the remainder 1.4%. It is thought likely that many cases of OA had many of the above-named pathologies as a precursor. The mean maximum flexion postoperatively was 98.7 degrees. Uncemented heads (a recent innovation) were used in 10%. Kaplan-Meier survivorship is 93% at 9 to 10 years. Survivorship in the OA subgroup was 96.7% with approximately equal numbers for femoral head collapse, dislocation and cup loosening, but the vast majority due to femoral neck fracture, which in turn was generally associated with the posterior approach.

Discussion: The results of this cohort (including all contributors’ learning curves) indicate highly satisfactory outcomes in terms of HHS and implant longevity. Subclassification of cases into those presenting abnormal anatomy and those with ‘ordinary’ OA indicates better survivorship still in the latter group. The surgical challenge varies more with hip resurfacing than with standard hip arthroplasty and this should be considered when results of surgery are reviewed. The revision options are generally much simpler than after standard THR.

We applied the technique of path analysis to investigate the effect of potential prognostic factors, including injury characteristics and treatment choices, on the risk of delayed healing or non-union after operative treatment of tibial shaft fractures.

Data were collected in a prospective observational study of 41 Swiss hospitals over two years, and analysed by regression models and path analysis. Path analysis is a technique to visualize the most important associations between clinical factors and outcome in a ‘causal path diagram’ that summarises the most likely cause and effect relationships.

Factors having a direct relationship with the occurrence of delayed healing or non-union included open fracture (RR 6.7), distal shaft location (RR 2.2), and initial treatment with an external fixator (RR 2.8). There were many other significant inter-relationships within the final diagram. For example, the choice of treatment was related to factors such as fracture aetiology, AO classification, location and skin injury. Fracture classification was not associated with delayed healing and non-union after adjustment for other factors including treatment choice.

The association of hypothesised risk factors, such as soft tissue injury and fracture location, with delayed healing or non-union was confirmed and measured. This study suggested that the use of an external fixator had a direct, negative effect on outcome, and that the use of nails or plates might contribute to delayed healing or non-union by their association with post-operative diastasis. These observations support this first use of path analysis in orthopaedics as a powerful technique to interpret data from an observational study.

To assess whether epidural steroid injection [ESI] is effective in the treatment of nerve root pathology caused by compression in the lumbar spine secondary to either spinal stenosis or disc prolapse, we carried out a prospective randomised controlled trial; patients were randomised either to ESI or Intramuscular steroid injection, with minimum two year follow-up.

Ninety two patients with symptoms, signs and radiological findings consistent with lumbar nerve root compression suitable for surgical decompression.

The main outcome measures were the Oxford Pain Chart over the first month, Oswestry Disability Index, and the need for surgery.

There was a significant reduction in pain early on after ESI compared with controls [p=< 0.004] between 10 and 35 days. There was no difference in the long term between the two groups and the rate of surgery in the two groups was not significantly different. Indeed the rate of surgery was higher in the ESI group than the control group [41% vs.31%] but this was not significant. A second ESI did not change the likelihood that surgery would be required.

Conclusion: ESI is effective for early pain relief for lumbar nerve root compression. However it does not change the natural history of the condition and does not reduce the ultimate need for surgery. It is probably effect to “buy time” in acute sciatica until improvement occurs naturally.

Hip and knee arthroplasty has been associated with relatively high rates of thromboembolic events and the majority of UK orthopaedic surgeons use at least one form of prophylaxis. Of the many different subgroups of thromboembolic rates that are commonly presented in the literature, symptomatic proximal deep vein thrombosis (spDVT) and fatal pulmonary embolism (fPE) are perhaps the most important clinical outcomes.

To determine the effectiveness of common chemical and mechanical prophylactic methods in preventing spDVT and fPE in patients undergoing primary hip and knee arthroplasty. A systematic review of the literature from 1981 to December 2002 was performed. Predetermined inclusion and exclusion criteria were applied. Studies where more than one method of prophylaxis was used were excluded from analysis. For each individual method of prophylaxis, data was extracted, combined and converted to give estimates of the rates of spDVT, fPE and major bleeding events. Absolute risk reduction estimates for spDVT, fPE and major bleeding events were calculated by comparing the thromboembolic rates for each method of prophylaxis with using no prophylaxis of any kind.

992 studies were identified of which 162 met the inclusion criteria. No method of prophylaxis was statistically significantly more effective at preventing spDVT and fPE than using nothing. There were at least as many major bleeding complications as spDVTs. The number of fPEs prevented was very small.

When complications such as major bleeding are considered, the evidence behind the use of any prophylaxis is unconvincing.

A systematic search of the literature published between January 1985 and February 2006 identified 62 studies which reported the results of arthroscopic procedures for chronic anterior shoulder instability or comparisons between arthroscopic and open surgery. These studies were classified by surgical technique and research methodology, and when appropriate, were included in a meta-analysis.

The failure rate of arthroscopic shoulder stabilisation using staples or transglenoid suture techniques appeared to be significantly higher than that of either open surgery or arthroscopic stabilisation using suture anchors or bio-absorbable tacks. Arthroscopic anterior stabilisation using the most effective techniques has a similar rate of failure to open stabilisation after two years.

Aims: The re-dislocation rates in adults (< 30 years) in the initial 12 months after FAT (first,anterior,traumatic) shoulder dislocations treated non-operatively vary from 25% to 95%. Some surgeons advocate early arthroscopic surgery following such dislocations as this appears to reduce recurrent instability. The purpose of this study was to establish if arthroscopic surgery reduces the incidence of recurrent instability after such dislocations when compared to non-operative treatment.

Material and Methods: Specific search terms were used to retrieve relevant studies from MEDLINE, EMBASE, and CINAHL extending from 1966 to October 2003. Guidelines for reporting of meta-analysis, adapted from QUOROM statement were followed. Adults under 30 years of age, with clinical and radiological confirmation of anterior dislocation following trauma with a minimum follow-up of 12 months were included. Patients with previous shoulder problems, generalised joint laxity, neurological injury, impingement and a history of substance abuse were excluded.

Results: 13 studies involving 433 shoulders were reviewed.

Group A included 84 shoulders treated by arthroscopic lavage without stabilisation. There were no subluxations. The re-dislocation rate was 14.3% (12/84).

Group B had 179 shoulders treated by arthroscopic stabilisation. The incidence of subluxation was 5.02% (9/179) and dislocation was 6.14% (11/179).

Recurrent instability (subluxation /dislocation) following arthroscopic lavage (12/84 – 14.3%) was significantly higher than after arthroscopic stabilisation (20/179 – 11.2%). [p= 0.04, Relative risk = 2.32, 95% CI: 1.07 to 5.05]

Group C involved 170 shoulders treated non-operatively. The incidence of subluxation was 8% (12/150) and dislocation was 62% (93/150). The overall incidence of recurrent instability was 70% (119/170).

Recurrent instability following arthroscopic intervention (32/263 – 12.2%) was significantly lower than following non-operative treatment (119/170 – 70%) [p< 0.0001, Relative risk = 0.17, 95% CI: 0.12 to 0.24].

Conclusion: Early arthroscopic surgery reduces recurrent instability during the initial 12 months after FAT shoulder dislocation in young adults (< 30 years) when compared to non-operative treatment. Arthroscopic treatment should be offered to young, athletic patients especially those involved in contact sports or defence personnel, who are at a high risk of recurrent instability after initial shoulder dislocation. Further randomised control trials reporting on a larger number of patients with a minimum follow-up of 5 years are required before one can draw firm conclusions on the ability of arthroscopic intervention to influence the natural history of FAT shoulder dislocation.

Aim: The re-dislocation rates in adults (< 30 years) in the initial 12 months after first, anterior, traumatic (FAT) shoulder dislocations treated non-operatively vary from 25% to 95%. The purpose of this study was to establish if arthroscopic surgery reduces the incidence of recurrent instability (failure) after such dislocations when compared to non-operative treatment.

Material and Methods: Specific search terms were used to retrieve relevant studies from various databases extending from 1966 to May 2004. Guidelines for reporting of meta-analysis, adapted from QUOROM statement were followed.

Results: 13 studies involving 433 shoulders were reviewed. Group A included 84 shoulders treated by arthroscopic lavage without stabilisation. There were no subluxations. The re-dislocation rate was 14.3% (12/84). Group B had 179 shoulders treated by arthroscopic stabilisation. The incidence of subluxation was 5.02% (9/179) and dislocation was 6.14% (11/179). Failure following arthroscopic lavage (12/84 – 14.3%) was significantly higher than after arthroscopic stabilisation (20/179 – 11.2%). [p= 0.04, Relative risk = 2.32, 95% CI: 1.07 to 5.05]. Group C involved 170 shoulders treated non-operatively. The incidence of subluxation was 8% (12/150) and dislocation was 62% (93/150). The overall incidence of failure was 70% (119/170). Failure following arthroscopic intervention (32/263 – 12.2%) was significantly lower than following non-operative treatment (119/170 – 70%) [p< 0.0001, Relative risk = 0.17, 95% CI: 0.12 to 0.24].

Conclusion: Early arthroscopic surgery appears to reduce recurrent instability during the initial 12 months after FAT shoulder dislocation in young adults (< 30 years) when compared to non-operative treatment. Arthroscopic stabilisation may be considered for young, athletic patients and those involved in contact sports or defence personnel, who are at a high risk of recurrent instability after FAT shoulder dislocation. RCTs reporting on a larger number of patients with a minimum follow-up of 5 years are required before one can draw firm conclusions on the ability of arthroscopic intervention to influence the natural history of traumatic anterior shoulder dislocation.

Introduction and Aims: Randomised controlled trials (RCTs) are frequently presented as the best design for studies of treatment effect because they minimise bias from unknown confounders. But, very few have been performed in orthopaedic and trauma surgery in comparison to other areas of medicine. This study investigated the perceived obstacles to performing RCTs, in order to identify areas where novel aspects of study design may facilitate randomisation in orthopaedic research.

Method: A qualitative study was performed using a deliberate maximum variation sample of 24 orthopaedic surgeons from four countries, involved in all aspects of practice, teaching, research, research funding, ethical approval and publication. A semi-structured interview was used to explore surgeons’ perceptions of obstacles to performing RCTs. A computer-assisted framework approach was used to analyse transcripts of these interviews, and to identify consistent themes and connections between them.

Results: Thirty-four discrete obstacles to performing RCTs in trauma and orthopaedic surgery were identified and classified. Many of these fell into six main themes:

A non-evaluative culture;

Conclusion: A complex set of perceived problems were identified. None of these problems is insurmountable. The performance of RCTs would be encouraged by development of a more evaluative culture, collaboration between surgeons and epidemiologists, and greater resources for, and commitment to, clinical research. Novel study designs to address lack of individual equipoise are possible and offer the prospect of much greater use of randomisation.

We have assessed whether an epidural steroid injection is effective in the treatment of symptoms due to compression of a nerve root in the lumbar spine by carrying out a prospective, randomised, controlled trial in which patients received either an epidural steroid injection or an intramuscular injection of local anaesthetic and steroid. We assessed a total of 93 patients according to the Oxford pain chart and the Oswestry disability index and followed up for a minimum of two years. All the patients had been categorised as potential candidates for surgery.

There was a significant reduction in pain early on in those having an epidural steroid injection but no difference in the long term between the two groups. The rate of subsequent operation in the groups was similar.

Rheumatoid arthritis results in pain and loss of function due to gradual destruction of articular cartilage. The shoulder joint is frequently involved and a prosthetic replacement of the humeral head can restore function and relieve pain. Deficiency of the rotator cuff is common in patients with rheumatoid arthritis. Longevity of movement at the intraprosthetic interface of the bipolar shoulder prosthesis is debatable and has not previously been studied in rheumatoid arthritis.

We report a radiological study of the intraprosthetic movements of a bipolar shoulder replacement in 25 shoulders in 20 patients with rheumatoid arthritis of mean age 66 years (SD 10 years). Shoulders were X-rayed at a minimum of 3 and a maximum of 10 years from surgery. Measurements were repeated in 12 shoulders 3 years later. The patient was positioned in the scapular plane. An initial X-ray was taken with the arm in neutral and a further X-ray taken with the arm in full active abduction. Measurements were taken to determine the movement at the intraprosthetic interface and at the prosthesis/glenoid interface. Interobserver error and intraobserver error were determined using an intraclass correlation coefficient (ICC). A paired T-test and Pearson Correlation Coefficient were used to compare intraprosthetic movement with prosthesis/glenoid movement.

We found that intraprosthetic movement was preserved up to 10 years from surgery. However, there was no significant difference between intraprosthetic movement and shell/glenoid movement, with some shoulders exhibiting paradoxical movement at the intraprosthetic interface. Repeating the measurements after a 3 year interval in a subgroup of 12 shoulders showed a significant difference in intraprosthetic movement. Interobserver and intraobserver reliability for measurements of the movement at the intraprosthetic interface were excellent with a Kappa value of 0.92 for intraobserver error and a Kappa value of 0.94 for interobserver error.

We conclude that movement of the bipolar shoulder prosthesis in rheumatoid shoulders at the intraprosthetic interface is preserved up to 10 years from operation but is not related to or significantly different from prosthesis/glenoid movement and requires further investigation.

Purpose: Diverse extended approaches have been described for the treatment of complex acetabular fractues. Little data is however available concerning the results, morbidity, and complications of acetabular fractures treated with this approach. The purpose of this work was to assess outcome in procedures performed by a single operator using the extended iliofemoral approach as described by Letournel for the treatment of acetabular fractures.

Material and methods: The database of the senior author included 833 acetabular fractures, 156 of which were operated via the extended iliofemoral approach in 109 patients who had a minimal two years follow-up. The series included 69 women and 40 men, mean age 34 years (11–93). Fracture type was: BC 64; TR+PW 15; T 12; ACH: 3; PW: 2; AC: 2. Delay before surgery was less than 21 days for 76 patients, between 21 days and three months for 22 and greater than three months for 11. There was a femoral head injury in 21% of the cases and 6% had had an earlier operation.

Results: At mean follow-up of 5.4 years (2–12), all fractures had healed. Reduction was anatomic in 69% of the cases, imperfect in 13ù and fair (interfragment gap > 3 mm) in 18%. The mean Postel Merle d’Aubigné score was 15 (5–18) with 63% excellent or good results. Complications were observed in 9% of the cases: seven infections, two serous discharges, and one necrosis of the scar borders. Ectopic ossifications were noted in 56% of the patients, 16% required surgical resection. Total arthroplasty was performed for 7% of the patients, arthrodesis for 4% and haematoma evacuation for 8%. The arthroplasty was revised two years after recurrent dislocation in one patient.

Discussion: This work allows us to conclude that the extended iliofemoral approach is safe and effective for the treatment of complex acetabular fractures. The percentage of excellent and good results is closely related to the quality of the reduction, and can be considered satisfactory known that the extended iliofemoral approach is used for more complex fractures less susceptible of healing. We recommend this approach for experimented operators well trained in the use of the iliofemoral approach.