Introduction

The pelvis moves in the sagittal plane during functional activity. These movements can have a detrimental effect on functional cup orientation. The authors previously reported that 17% of total hip replacement (THR) patients have excessive pelvic rotation preoperatively. This increased pelvic rotation could be a risk factor for instability and edge-loading in both flexion and/or extension. The aim of this study was to investigate how gender, age and lumbar spine stiffness affects the number of patients at risk of excessive sagittal pelvic rotation.

Introduction: Femoro-acetabular impingement (FAI) is a common source of impaired motion of the hip, often attributed to the presence of an aspherical femoral head and reduced concavity of the anterior head/neck junction. However, other types of femoral deformity, including posterior slip, retroversion, and neck enlargement, can also limit hip motion. This study was performed to establish whether the “cam” impinging femur is a unique entity with a single deformity of the head/neck junction or is part of a multi-component continuum of femoral dysmorphia.

Materials and Methods: Computer models of 71 femora (28 normal and 43 “cam” impinging) were prepared from CT scans. Morphologic parameters describing the shape and dimensions of the head, neck, and medullary canal were calculated for each specimen. The anteversion angle, alpha angle of Notzli, beta angle of Beaulé, and normalized anterior heads offset were also calculated. Average dimensions were compared between the normal and impinging femora. A dimensionless model of the femoral neck was also generated to determine whether there is an inherent difference in the shape of the femoral neck in cam impinging and normal femora, independent of any differences in specimen size.

Results: Compared to the normal controls, the impinging femora had wider necks (AP: 15.2 vs 13.3 mm, p< 0.0001), larger heads (diameter: 48.3mm vs 46.0mm, p=0.032) and decreased head/neck ratios (1.60 vs 1.74, p=0.0002). However, there was no difference in neck/shaft angle (125.7° vs 126.5°, p=0.582) or anteversion angle (8.70 vs 8.44°, p=0.866). Most significantly, 53% of impinging femora also had a significant posterior slip (> 2mm), compared to only 14% of normal controls. Average head displacements for the two groups were: FAI: 1.93mm vs Normals: 0.78mm (p< 0.0001). Shape indices derived from individual dimensionless models showed slight AP widening of the abnormal femora (ap/ml ratio: 1.10 abnormal vs. 1.07 normal).

Conclusions: The CAM impinging femur has many abnormalities apart from the morphology of the head/neck junction. These femora have increased neck width and head/neck ratio, a smaller spherical bearing surface, and reduced neck offset from the medullary canal. Moreover, the presence of posterior head displacement and reduced anteversion should be appreciated when assessing treatment options, as surgical treatment limited to localized re-contouring of the head–neck profile may fail to address significant components of the underlying abnormality.

Introduction and Aims: The role of tendon transfer in progressive hereditary motor sensory neuropathy (CMT) is controversial. This paper examines a large single surgeon cohort and reviews the surgical outcome of tendon transfers against a large group of CMT patients represented by the Australian CMT Health Survey 2001.

Method: A retrospective review was carried out in 19 patients (36 feet) with CMT, managed surgically by a single author (GW). Functional outcomes were measured using standard tools such as SF36, American Orthopaedic Foot and Ankle Score (AOFAS) rating scale, and a clinical review including a specially designed questionnaire. Quality of life and functional outcome has been compared with the Australian CMT Health Survey 2001 in 324 patients.

Results: Nineteen patients were managed with tendon transfers, typically by flexor to extensor transfer of toes, combined with peroneus longus release and transfer, and tibialis posterior transfer. The Levitt classification of the objective results of surgery rates 79% of patients as having good-excellent outcomes. Eighty-nine percent of patients report an improvement overall with surgery, specifically 53% report improvement in pain, 79% feel their gait has benefited, and 58% report an improvement in the appearance of their foot deformity, as a direct result of their surgery. All patients reviewed would recommend similar surgery to others, and 95% of those surveyed wished they had their surgery much earlier (months to years). The AOFAS clinical rating system for ankle-hindfoot showed an average improvement of 39.7 points out of 100. In general patients treated by this method were improved when considered against a larger cohort both in quality of life measures and functional outcome. This combination was not always successful and a small number of disappointed patients were identified.

Conclusion: Tendon transfer in the younger patient has a role in treating flexible deformity in CMT and improving quality of life. Traditionally surgery has been advised by means of arthrodesis in patients with more advanced fixed deformity and pain due to secondary osteoarthritis. This paper study shows that patients may benefit at an earlier stage in the progression of their disease by tendon transfer.

Introduction and Aims: This study was designed to assess the impact of lower limb arthroplasty on performance and other outcome measures in active golfers. The aim was to obtain justification data prior to proceeding with a much larger prospective study.

Method: Subjects were selected for inclusion in the study on the basis of having undergone lower limb arthroplasty surgery and actively playing golf at a social or competitive level at least fortnightly. Data was collected retrospectively by the use of a self-administered, patient-orientated questionnaire. Pre- and post-joint replacement data was obtained for: Australian Golf Union (AGU) handicap; driving and longest iron distances; frequency and duration of golf rounds played; use of motorised assistance; and pain, stiffness, swelling and subjective performance scores. Demographics, length of time to return to playing golf post-operatively and post-operative complications were also recorded.

Results: Results were obtained from 25 subjects with 33 joints in total replaced, 24 male and one female, mean age 70.6 years (range 53–81 years) and average time to survey post-arthroplasty was five years and 10 months. The right knee was replaced in 30.3% of subjects, left knee 27.3%, right hip 24.2% and left hip 18.2%. Eight of the 25 subjects reported complications with three requiring further surgery. There were no reports of dislocation. The average time taken to resume golfing activity post-arthroplasty was 15.4 weeks (range 5–52 weeks). Subjects demonstrated a mean increase in their AGU handicap of 1.6 strokes (p< 0.05). Average drive distance off the tee shortened by 8.6 metres (p< 0.05), with a similar change for average longest iron length, in the magnitude of 7.4 metres (p< 0.05). There was no significant change in the numbers of rounds played per month, with a mean of 8.9 pre-joint replacement and 8.3 after surgery. Wilcoxon signed-ranks test values were significant (p < 0.05) for comparison of pre to post-joint replacement, showing a decrease in reported symptoms of pain, stiffness and swelling following joint replacement. A highly significant (p< 0.001) finding was a reduction in the subjective impact of joint symptoms on golf performance post-arthroplasty.

Conclusion: Although subjects seem to be more satisfied with their golf by playing with less joint pain, stiffness and swelling, they appear to do so with an actual decrease in objective performance. These significant findings support conducting a much larger prospective study looking at the impact of arthroplasty on golf activity, and vice versa.

Introduction The role of tendon transfer in progressive hereditary motor sensory neuropathy (CMT) is controversial. This paper examines a large single surgeon cohort and reviews the surgical outcome of tendon transfers against a large group of CMT patients represented by the Australian CMT Health Survey 2001.

Methods A retrospective review was carried out in 29 patients (57 feet) with CMT, managed surgically by a single author (GW). Functional outcomes were measured using standard tools such as SF-36, AOFAS ankle hindfoot clinical rating scale, and a clinical review including a specially designed questionairre. Quality of life and functional outcome has been compared with the Australian CMT Health Survey 2001 in 324 patients. Twenty-nine patients were managed with tendon transfers, typically by flexor to extensor transfer of toes, combined with peroneus longus release and transfer, and tibialis posterior transfer.

Results The Levitt classification rated 80% of patients as having good-excellent outcomes. Ninety-two percent of patients reported an improvement overall with surgery, specifically 52% reported improvement in pain, 85% felt their gait had benefited, and 74% reported an improvement in the appearance of their foot deformity, as a direct result of their surgery. All patients reviewed would recommend similar surgery to others, and 92% of those surveyed wished they had their surgery much earlier (months to years). The AOFAS clinical rating system for ankle-hindfoot showed an average improvement of 36 points out of 100. In general, patients treated by this method were improved when considered against a larger cohort both in quality of life measures and functional outcome. This combination was not always successful, and a small number of disappointed patients were identified.

Conclusions Tendon transfers in the younger patient has a role in the treatment of flexible deformities in CMT, and improving quality of life. This paper shows that patients benefit at an earlier stage of their disease by tendon transfers. Indications for tendon transfers have been refined by this study and lessons learned recognised.

The aim of this study was to determine the medium term survivorship and function of the cemented Exeter Universal Hip Replacement when used in younger patients.

Since 1988 The Exeter Hip Research Unit has prospectively gathered data on all patients who have had total hip replacements at the Princess Elizabeth Orthopaedic Hospital.

There were 88 Exeter Universal total hip replacements (THR) in 71 patients who were 50 years or younger at the time of surgery and whose surgery was performed at least 10 years before. 25 surgeons performed the surgery. Mean age at surgery was 43 years (range 24 to 50 years. ) 5 patients who had 7 THRs had died leaving 81 THRs for review. Patients were reviewed in clinic at an average of 11. 4 years (10 – 13 years). No patient was lost to follow up.

At review, 8 hips had been revised. 5 cases were for loose cemented metal backed acetabular prosthesis. Two femoral components were revised for infection and one for aseptic loosening. Radiographs showed that a further 10 (13%) acetabular prosthesis were loose and that 3 femurs showed significant osteolysis. Overall 10-year survivorship of stem and cup from all causes was 93%. The 10-year survivorship of stem only from all causes was 98% and from aseptic loosening was 99%.

The Exeter Universal Stem performs extremely well in the younger patient. However the high failure rate of the cemented metal backed Exeter acetabular component has compromised the overall results in this series.

Total hip arthroplasty (THA) using modular components offers many advantages such as a reduction in the implant inventory required and increased intra-operative flexibility with component sizing and selection. However, it also comes at the price of the additional complication of component dissociation, in particular at the non-fixed interface between the polyethylene cup and the acetabular metal backing.

A review of 110 patients requiring revision THA from June 1993 to December 2000 performed by the senior authors revealed seven patients presenting with the triad of signs suggestive of this complication – a previously successful, painless THA that had become acutely painful and with radiographic evidence of femoral head asymmetry in the acetabular cup. Each of these patients had Harris - Galante II porous acetabular cups. At the time of the revision, these patients were found to have dissociated polyethylene cup liners and several with broken locking mechanisms warranting replacement of the acetabular cups, the liners and the worn femoral heads.

This is an uncommon complication of THA, with characteristic presenting symptoms and signs. The importance of comparison of previous radiographs with those at presentation and the postulated mechanisms for dissociation is stressed. Certain precautions are imperative when using modular implants and the pitfalls of the Harris - Galante II porous acetabular component locking mechanism should be acknowledged.

Equinus deformity of the ankle is one of the serious orthopaedic problems associated with Duchenne muscular dystrophy. Sixty-nine patients (age range 4 to 17 years) were treated, 43 conservatively and 26 operatively. They were followed up at six-monthly intervals for a minimum of two years and a maximum of six years. The patients were divided into three groups: independently mobile, mobile in calipers, and wheelchair-bound. It was found that conservative treatment could at best only minimise progression of the deformity. The indications for surgery, the operative procedure and the postoperative management are described; all varied according to the stage of the disease. The postoperative follow-up suggests that, though the deformity recurs, the patients have several years of benefit from the procedure.