Ensuring correct rotation of the femoral component
is a challenging aspect of patellofemoral replacement surgery. Rotation
equal to the epicondylar axis or marginally more external rotation
is acceptable. Internal rotation is associated with poor outcomes.
This paper comprises two studies evaluating the use of the medial
malleolus as a landmark to guide rotation. We used 100 lower-leg anteroposterior radiographs to evaluate
the reliability of the medial malleolus as a landmark. Assessment
was made of the angle between the tibial shaft and a line from the
intramedullary rod entry site to the medial malleolus. The femoral
cut was made in ten cadaver knees using the inferior tip of the
medial malleolus as a landmark for rotation. Rotation of the cut
relative to the anatomical epicondylar axis was assessed using CT.
The study of radiographs found the position of the medial malleolus
relative to the tibial axis is consistent. Using the inferior tip
of the medial malleolus in the cadaver study produced a mean external
rotation of 1.6° (0.1° to 3.7°) from the anatomical epicondylar
axis. Using the inferior tip of the medial malleolus to guide the
femoral cutting jig avoids internal rotation and introduces an acceptable
amount of external rotation of the femoral component.
The aim of this study was to investigate the use of large diameter head THR to treat fractured neck of femur, and to demonstrate if this conferred greater stability. Forty-six (46) independent, mentally alert patients with displaced intracapsular fractures underwent THR. Mean age was 72.1 years. Outcome measures were dislocation, reoperation/ revision rate, Oxford hip score (OHS), Euroqol (EQ-5D) and residential status. Data was collected prospectively, with review being carried out at 3 months and 1 year. At mean follow-up (12.5 months) there were no dislocations. Reoperation, revision and infection rate were all 0%. Two patients died (4.3%). Mean pre-injury and postoperative OHS were 12.1 and 17.9 respectively. Mean pre-injury and postoperative EQ-5D index scores were 0.97 and 0.83 respectively. Mean postoperative walking distance was 2.5 miles. There were no changes in residential status. This is the first published series utilizing 36-mm diameter metal-on-metal THR for the treatment of fractured neck of femur. We have demonstrated that it affords patients excellent stability with no recorded dislocations.
The aim of this study was to investigate the use of large diameter head THR to treat fractured neck of femur, and to demonstrate if this conferred greater stability. 46 independent, mentally alert patients with displaced intracapsular fractures underwent THR. Mean age was 72.1 years. Outcome measures were dislocation, reoperation/ revision rate, Oxford hip score (OHS), Euroqol (EQ-5D) and residential status. Data was collected prospectively, with review being carried out at 3 months and 1 year. At mean follow-up (12.5 months) there were no dislocations. Reoperation, revision and infection rate were all 0%. Two patients died (4.3%). Mean pre-injury and postoperative OHS were 12.1 and 17.9 respectively. Mean pre-injury and postoperative EQ-5D index scores were 0.97 and 0.83 respectively. Mean postoperative walking distance was 2.5 miles. There were no changes in residential status. This is the first published series utilising 36-mm diameter metal-on-metal THR for the treatment of fractured neck of femur. We have demonstrated that it affords patients excellent stability with no recorded dislocations.
Dislocation is a major concern following total hip replacement (THR) for fractured neck of femur. The aim of this prospective study was to investigate the use of large diameter femoral head uncemented THR to treat fractured neck of femur, and to demonstrate if the improved stability seen in previous clinical situations with these designs, can be used to benefit this difficult subgroup of patients that are particularly prone to dislocation. Forty-six consecutive independent, active and mentally alert patients with displaced intracapsular fractured neck of femur underwent large diameter head uncemented THR. The mean age of patients was 72.1 years. The outcome measures used were the dislocation rate, reoperation and revision rate, Oxford hip score (OHS), Euroqol (EQ-5D) and residential status. Clinical and radiological data were available on all 46 patients. At a mean follow-up of 12.5 months there were no dislocations. The reoperation, revision and infection rate were all 0%. Two patients died (4.3%) from unrelated causes. Mean pre- and postoperative OHS were 12.1 and 17.9 respectively. The mean pre- and postoperative EQ-5D index scores were 0.97 and 0.83 respectively. The mean postoperative walking distance was 2.5 miles and there were no changes in residential status. This is the first published series utilising a 36-mm diameter metal-on-metal THR for the treatment of fractured neck of femur in mobile, independent patients. We have demonstrated that it affords patients excellent stability with no recorded dislocations.
Dislocation is a major concern following THR for fractured neck of femur. The aim of this prospective study was to investigate the use of large diameter femoral head uncemented THR to treat fractured neck of femur, and to demonstrate if the improved stability seen in previous clinical situations with these designs, can be used to benefit this difficult subgroup of patients that are particularly prone to dislocation. Forty-six consecutive independent, active and mentally alert patients with displaced intracapsular fractured neck of femur underwent large diameter head uncemented THR. The mean age of patients was 72.1 years. The outcome measures used were the dislocation rate, reoperation and revision rate, Oxford hip score (OHS), EuroQol (EQ-5D) and residential status. Clinical and radiological data were available on all 46 patients. At a mean follow-up of 12.5 months there were no dislocations. There were no reoperations, revisions or infections. Two patients died (4.3%) from unrelated causes. Mean pre- and postoperative OHS were 12.1 and 17.9 respectively. The mean pre- and postoperative EQ-5D index scores were 0.97 and 0.83 respectively. The mean postoperative walking distance was 2.5 miles and there were no changes in residential status. This is the first published series utilising a 36-mm diameter metal-on-metal THR for the treatment of fractured neck of femur in mobile, independent patients. We have demonstrated that it affords patients excellent stability with no recorded dislocations.
The aim of this study was to measure intra-articular gentamicin levels at the 2nd stage revision following the use of an antibiotic impregnated articulating spacer. Infected total knee replacements are a cause of considerable morbidity often requiring revision in two stages. Rings of bone cement, cement moulds and spacer devices are available for use following the initial debridement and removal of infected metalwork. The availability of antibiotic impregnated articulating spacers are potentially attractive to achieve a high local dose of antibiotic and to maintain a good range of movement. Seven patients underwent a two stage revision of their total knee replacements. Following the initial debridement an antibiotic impregnated articulating spacer was cemented in place. At the 2nd stage revision a perioperative joint aspirate and blood sample was taken and gentamicin levels measured. The range of movement was assessed. The average gentamicin levels were 0.72mg/l (0.24 – 2.36mg/l). A good range of movement was maintained in all cases. At these levels the gentamicin would be therapeutic. Antibiotic impregnated articulating spacers possess several potential advantages to the revision knee surgeon by helping maintain the range of movement and provide local release of antibiotics. Their use should be considered in such cases.
Proximal humeral fractures are common and often occur in osteoporotic bone. Suture fixation utilises the rotator cuff tendons as well as bone providing adequate stability and avoids complications associated with metalwork insertion. Surgical exposure was via a delto-pectoral approach with minimal dissection of the fracture site. Initially a 2 suture technique was utilized with heavy ethibond sutures passed through drill holes either side of the bicipital groove; however, because of concerns about varus instability the technique now uses a third suture placed laterally acting as a tension band to prevent varus collapse. Patients with Neer 2 and 3 part fractures treated with suture fixation were assessed clinically (using the Constant score) and radiologically at a mean of 27 months post fracture. To date 24 patients have been studied. The average age of the patients in our series was 70.2. All fractures progressed to union with no cases of radiological avascular necrosis. We had 2 cases of mal-union (-one varus and one valgus-), both with a 2-suture technique. One patient had early loss of fixation; re-exploration was performed with stability conferred by a third lateral suture. Active abduction >
120o was achieved in 9 patients with a mean Constant score of 72 compared to 89 on the un-injured contra-lateral side. We have demonstrated that suture fixation of displaced proximal humeral fractures is an effective alternative to fixation using metalwork. The advantages are that minimal soft tissue stripping of the fracture site is required and the potential problems associated with metalwork insertion into osteoporotic bone are avoided. Following one case of varus mal-union with a 2-suture technique we now routinely use a third suture to act as a lateral tension band.
A previous study done in our unit showed good results in terms of union, stability and function following 2-suture repair of proximal humeral fractures. Healing took place usually with a mild degree of varus angulation but one failure of this technique when the fracture slipped into varus prompted us to re-evaluate our technique. The addition of a third (lateral) suture to the repair has been used as routine following this. A prospective series of 24 patients with displaced Neer 2 and 3 part proximal humeral fractures was studied. The patients were reviewed at a mean of 22.5 months post fixation. The patients were reviewed clinically and graded according to the Constant Shoulder Score to assess range of movement, power, function and pain. This was compared to the contralateral uninjured shoulder. Radiographic evaluation of fracture union, avascular necrosis and malunion was performed, and any complications of treatment were noted. There were 24 2- and 3-part fractures. All the fractures united with no radiological evidence of avascular necrosis. At follow-up there was a mean Constant Score of 71.05 compared with a mean score of 84.5 on the uninjured contralateral shoulder. Active abduction of >
120° was achieved in 9 patients. Intraoperative stability in the varus/valgus plane was noted to be better. All patients were satisfied with the results; the problem of instability in the coronal plane has not been a problem and the fractures have healed with no varus mal-union. There have been no additional complications with this technique compared to the 2-suture method. We have successfully achieved stability after open reduction and suture fixation of 2- and 3-oart fractures of the proximal humerus. Following one case of varus instability using a 2 suture technique, We have routinely supplemented this with a third (lateral) suture. There have been no additional complications using this method, the angulation of the fractures once healed are improved and none of the repairs have had a problem with varus slip.
