The purpose of this study was to identify changing trends in the pattern of distribution of the type and demographics of fractures of the hip in the elderly between 2001 and 2010. A retrospective cross-sectional comparison was conducted between 179 fractures of the hip treated in 2001, 357 treated in 2006 and 454 treated in 2010. Patients aged < 60 years and those with pathological and peri-prosthetic fractures were excluded. Fractures were classified as stable extracapsular, unstable extracapsular or intracapsular fractures.

The mean age of the 179 patients (132 women (73.7%)) treated in 2001 was 80.8 years (60 to 96), 81.8 years (61 to 101) in the 357 patients (251 women (70.3%)) treated in 2006 and 82.0 years (61 to 102) in the 454 patients (321 women (70.1%)) treated in 2010 (p = 0.17). There was no difference in the gender distribution between the three study years (p = 0.68).

The main finding was a steep rise in the proportion of unstable peritrochanteric fractures. The proportion of unstable extracapsular fractures was 32% (n = 57) in 2001, 35% (n = 125) in 2006 and 45% (n = 204) in 2010 (p < 0.001). This increase was not significant in patients aged between 60 and 69 years (p = 0.84), marginally significant in those aged between 70 and 79 years (p = 0.04) and very significant in those aged > 80 years (p < 0.001). The proportion of intracapsular fractures did not change (p = 0.94).

At present, we face not only an increasing number of fractures of the hip, but more demanding and complex fractures in older patients than a decade ago. This study does not provide an explanation for this change.

Cite this article: Bone Joint J 2013;95-B:1250–4.

Background: The embryology of the cruciate ligaments of the knee had received scant attention in the orthopaedic and embryologic literature. Understanding the embryonic development of the blood supply to criciate ligaments (CL) may help to comprehend the mechanisms of pathology leading to failure of these structures and of the revascularization process after reconstruction injured of cruciate ligaments or implantation of grafts.

Aim: To describe the anatomy and spatial relationships of the cruciate ligaments and their blood supply in the developing fetus.

Method: Knees from one leg of 48 normal human embryos from abortion material were examined, gestational age varying from early as the 8^th week and up to the 20^th week. Microscopic semi serial consequent sections of the knees were examined under light microscope and spatial changes within the cruciate ligaments were noted. The contra-lateral knees of some of the embryos were dissected to confirm the three dimensional picture. This gave us the possibility to follow the developmental changes of the spatial orientation of the cruciate ligaments and the blood vessels within them.

Results: The anterior and posterior cruciate ligaments are formed from a single mass of cells, divided by a sinovial septum. Folds within the septum partially divide the ligaments into bundles and carry within them the vasculature needed to sustain the ligaments. We show that the blood supply of the growing CL arises from the middle genicular artery and enters the ligaments from the poster-superiolateral corner (P.S.L.C.) of the inter-condylar notch, passes between the ACL and PCL and descends along he posterior aspect of the ACL.

These findings can explain why injury involving the P.S.L.C. in the adult has a worse prognosis for rehabilitation.

Proximal Metatarsal osteotomies are used for larger deformities, generally those with an intermetatarsal angle greater than 15°. These osteotomies usually are combined with a Distal Soft Tissue Release, which is necessary to correct metatarsophalangeal (MTP) sub-luxation with a Hallux Valgus Angle greater than 35°. Many types of osteotomies have been described. These include a medial opening wedge, a lateral closing wedge, proximal chevron, and a crescentic. Additional osteotomies include the Scarf, Ludloff, and Mao osteotomies. Presently, the proximal chevon and crescentic osteotomies are widely used.

In our study we used the proximal chevon osteotomy combined with Distal Soft Tissue Release and approximation of the 1^st and 2^nd metatarsus using a string to further decrease the intermetatarsal angle.

From January 2000 to June 2005 the basal chevon osteotomy was selected in 44 patients (37 female and seven male patients, ages 14 to 80, mean: 54.97 years) total of 49 feet with moderate metatarsus primus varus (IMA 13 to 20 degrees) and hallux valgus deformities (less than 50 degrees). The AOFAS Hallux Metatarsopha-langeal-Interphalangeal Scale and patient satisfaction were monitored prior to surgery, and postoperatively. Changes in the IMA and HV angle were measured in the conventional method and documented. All patients were treated in a Darco Post operative splint.

Results: Multiple complications were encountered. The most common is transfer metatarsalgia. This occurred in 10 patients (20%). Other complications include delayed union (4%), increase in the height of the first metatarsus (10%), floating toe (6%), superficial infection (15%), local parenthesis and early recurrence of deformity in 3%. 38 patients were available for follow-up. The hallux valgus angle improved significantly more than 20 degrees on average postoperatively. The intermeta-tarsal angle also improved significantly (more than 10 degrees on average) postoperatively. The position of the sesamoids was realigned to beneath the first metatarsal head and the metatarsal length remained essentially unchanged. The AOFAS score preoperatively was a mean of 75.64 with respect to pain, deformity, motion, disability, and cosmetic. The AOFAS score postoperatively was a mean of 94.55. The mean improvement was 18.91. About 95.45 percent (42/44) were satisfied and would recommend the surgery to a friend.

Conclusions: The basal chevron osteotomy combined with Distal Soft Tissue Release and realignment using a string is a technically demanding procedure and has multiple potential complications but provdes a reliable method with respect to stability, technical ease and satisfactory surgical outcome for correction of moderate and severe bunion deformity, both as a primary and revision procedure.

Objective: The purpose of this study was to survey and to evaluate our early results with the cementless ZMR hip prosthesis.

Methods and Patients: This modular system is designed to address the challenges and design goals of hip revision with off-the-shelf flexibility, proximal-distal extensive fixation and restoration of hip kinematics (offset, lengths and anteversion). The Taper femoral component is designed for distal fixation using a distal stem that is tapered to help obtain secure, consistent seating in the femoral canal, and splints that engage bone to provide rotational stability. The porous stem is designed to provide proximal or extensive (both proximal and distal) fixation. The geometry of the modular proximal body is designed to help preserve bone. The taper junction between the proximal body and distal stem allows for control of version of the implant. Eighteen ZMR taper hip prostheses were implanted between January 2004 and August 2005. The mean age of the 18 patients (13 females, 5 males) was 72 and the mean follow-up period was 10 months.

Results: Out of these 18 patients, 4 interventions were primary (DDH or pathological fractures) and 14 were revision procedures. In most (16) cases a taper stem was used. In 14 cases a total hip revision was performed, in 2 cases only the femoral stem was revised and in 2 cases a bipolar Hemiarthroplasty was done. Operative time averaged 187±33 minutes.

The stem displayed an excellent distal fixation, clinically and radiologically. Much less complications were noted, compared to earlier series. Three patients had postoperative infections – one case was after a 2 stage revision of an infected implant, one case was associated with a large hematoma due to excessive anticoagulation and another case was a superficial infection that resolved. Other complications included 2 (11%) early dislocations and one femoral nerve palsy. There were no intraoperative fractures of perforations and none of these complications necessitated implant removal.

Conclusion: The excellent distal fixation, simplicity of the operative technique and modularity of stem length and diameter, body size and offset, and anteversion, makes this system an attractive solutions for a wide variety of difficult femoral revisions. The high rate (11%) of early dislocations is still lower than other series with this system.

Purpose: Numerous implants used in repairing a trochanteric fracture of the hip are currently available. The purpose of this prospective study was to determine the complications and results of the percutaneous compression plate (PCCP), a relatively new device versus the conventional dynamic hip screw (DHS).

Materials and Methods: Between 2001–2003, 110 consecutive patients with trochanteric fractures were treated in our department. Fifty-five fractures were stabilized using the PCCP and 55 fractures were treated with the DHS. Results were analyzed according to fracture pattern, type of implant, quality of fracture reduction and position of implant. Function was assessed on the basis of pain, walking aids and walking capability.

Results: Forty-seven (85%) of 55 hips treated with PCCP healed without additional treatment and complications. Forty-three (78%) treated with DHS healed without additional treatment and complications. Complications among 8 patients (15%) of the PCCP group were: deep vein thrombosis, cardiac complication, chest infection and pressure sores. Complications among 12 patients (22%) of the DHS group were: implant failure (7%), deep wound infection, deep vein thrombosis and pressure sores.

Conclusions: Use of the PCCP implant provides similar and occasionally better results compared to those obtained with the conventional DHS device. The most outstanding advantage of the PCCP device was no implant failure or implant cut out.

Osteoarthritis (OA) is associated with biochemical and mechanical processes that release different wear particles into the synovial fluid. Unfortunately, symptoms such as pain, swelling and limited range of motion often do not correlate with the level of OA as observed by X-ray. In addition, the mechanisms of OA and the processes involved are still not clearly understood. Therefore, there is much interest in developing new diagnostic techniques that would provide means to both sensitive, objective determination of joint damage and studying the underlying mechanisms. Such a technique may also aid in evaluating the efficiency of drugs under development objectively and relatively quickly.

Bio-ferrography (BF) is a method for magnetic isolation of target cells or particles in a fluid. The current project was aimed at evaluating the applicability of BF for isolation and analysis of specific wear particles in human joints. Synovial fluid aspirates were drawn during either arthroscopy or total joint replacement from 14 patients with either OA or other types of chondropathy. Target components of bone and cartilage (collagen type I and type II, respectively) were labeled with monoclonal antibodies coupled to magnetic beads. The captured particles were isolated on microscope slides by means of BF and characterized by several optical and scanning electron microscopy techniques combined with chemical analysis. The number, size and shape of particles were quantified by image analysis.

Results showed that specific labeling of target collagens enables capture of a much higher number of particles in comparison to previous reports. A variety of particles with different morphologies and sizes were documented. The number of captured particles changed in different patients. In addition to bone and cartilage fragments, particles of repaired cartilage that contained collagen I, meniscus particles containing collagens I and II, and magnesium-rich particles that could form during biochemical dissolution of hydroxyapatite or precipitation from body fluids, were identified. Further in-depth characterization of these particles would shade more light on the mechanisms and processes involved in joint degradation. The evaluation of joint damage by BF was found to correlate with clinical observations.

It was concluded that BF has the potential of becoming a powerful tool in the study of human joint diseases. Future studies may use even more specific labeling of joint components. BF may become a routine diagnostic technique, aiding the orthopedist in determination of OA level in an objective manner. The ability to draw samples quickly during arthroscopy with little discomfort to the patient could facilitate routine serial assessment of particular joints.

Bio-ferrography (BF) is a method for magnetic isolation of particles suspended in liquid on a glass slide. The objective of the current research was to evaluate the potential use of BF in determining the wear level of artificial hip and knee joints based on analysis of aspirated synovial fluids.

Synovial fluid aspirates and prosthesis compartments removed by revision surgery from 14 patients were analyzed. The synovial fluid was centrifuged to separate the wear particles from the hyaluronic acid. The failed prostheses were washed in the lab with either saline or distilled water to remove and capture unbound wear particles. An erbium chloride (ErCl₃) solution was added in some cases to induce increased magnetization. The wear particles were isolated by means of a Bio-Ferrograph 2100 system, and characterized by means of several optical and scanning electron microscopy techniques as well as energy dispersive spectroscopy. The number and size of particles were quantified by image analysis. The failed prostheses were also characterized in order to determine whether BF can monitor the wear of artificial joints.

Results showed that metallic (namely, Ti-, Co- and Fe-based alloys), polymeric (namely, UHMWPE, POM and PMMA) and bone particles could be isolated on slides by BF. The isolated particles exhibited a variety of shapes and surface morphologies that were dependent on the process by which they had been formed. No other technique allows retrieval and isolation of so many tiny particles, either metallic or non-metallic, while preserving their shape for microscopic examination and chemical analysis. A correlation existed between the level of prosthesis degradation, as inspected during failure analysis, and the number and size of isolated particles; namely, an increase in number and size of particles represented increased prosthesis wear. When the prosthesis was visually in good condition, very few small particles were retrieved from the synovial fluid. The formation of metal and bone particles in several cases accelerated further wear of these prostheses.

On the basis of the good correlation between the classification of damage by BF and the level of artificial joint degradation as evaluated during failure analysis, it was concluded that BF of synovial fluids may be used in the study of artificial joints failure. In addition to monitoring the level of wear, it allows determination of the mechanism and cause of failure, thus providing feedback on problems associated with design, manufacturing and installation of artificial joints. The ability to draw samples quickly during joint aspiration with little discomfort to the patient could facilitate periodic ferrographic evaluation of specific joints. Such information may also prove invaluable in the design of improved prostheses. In these cases, the atlas of wear particles that was constructed in this project for the first time may be used as a reference.

Approximately 700 TKRs (Total Knee Arthroplasty) were performed in our department from 1992–2000. In 13 cases, patellar dislocation occurred post-operation - 12 with no trauma and one following a fall and trauma to the medial aspect of the knee. Dislocation occurred from 2 months following the operation until 1 year postoperative (average 4.5 months). None of the patients had malalignment of the components. The average femorotibial angle was 5° (range 8° valgus to 3° varus). No patient had preoperative valgus deformity. Postoperative range of motion was 105° (range 90–125°). All dislocations were treated by operative lateral relapse and medial capsular implication followed by 6 weeks of immobilization with a brace in full extension and then physiotherapy, range of motion, patellar taping and Vastus medialis strengthening.

The patella stabilized in 11 cases following the operation. In 2 cases, dislocation recurred following the operation and they were operated on again where medialization of the tibial tubercle was performed. Both cases stabilized following the second operation. One case developed a stress fracture of the tibia at the end of the tubercle osteotomy which healed conservatively. All dislocations occurred in the IBII prosthesis.

During the past 3 years since using the PFC Sigma and Legacy prosthesis, we have had no dislocations of the patella, probably for the following reasons:

Use of the mid vastus exposure.

Forty-two revision knee replacements were performed in our department between 1992–2000. We report our experience in 18 cases of stiff knees with a range of motion from −5° – 75° (average 50°) where an oblique incision through the quadriceps tendon combined with medial capsular incision (the “wandering resident” incision) was used for exposure. This exposure allowed us to expose the stiff knee with no hazard of avulsion of the patellar tendon and with easy removal of the old prosthesis and implantation of the new one. In 5 of these cases, this exposure was used twice in two stage revisions of a septic prosthesis.

Post-operative rehabilitation was slower, a knee brace was used in extension for 6 weeks and daily physiotherapy and CPM from 0°–70° only. Full range of motion was started after 6 weeks. Follow-up in 1–8 years (average 3.5 years).

All patients had good clinical results with range of motion from 0°–110° (average 86°). One patient had a lag of 10° in active extension. The knee score of the American Knee Society ranged from 35–52 (average 40) and improved to 72–89 (average 84).

In 3 cases, we used a non-constrained prosthesis (PCL) sacrificing condylar prosthesis), in 11 cases a constrained prosthesis (CCK type) and in 4 cases a rotating hinge prosthesis.

The residual shortening of the affected limbs in 55 patients treated by subtrochanteric varus derotation osteotomy was compared with that in 71 patients treated with weight-relieving calipers. When last examined, 43 of the former group and 47 of the latter had reached complete or near-complete skeletal maturity. The average follow-up was 9.1 years in the osteotomised patients and 5.25 years in the conservatively treated group. The average residual shortening (0.9 cm) was identical in both groups. In most patients the initial shortening caused by the osteotomy gradually corrected as, over a period of several years, the postosteotomy angle gradually became less varus. Any residual shortening depended principally on the severity of inhibition of endochondral ossification at the proximal femoral growth plate. Less residual shortening was seen in children who were under seven years of age at the onset of symptoms (under eight at operation) in whom the open-wedge technique of osteotomy was employed and who had good anatomical results.

Disruption of the major ligaments of the knee was seen in six young men, five parachutists and a house painter, after what we have termed abduction-traction injury. This unusual complaint results from the application of a sudden block to the ankle while falling head first, leading to traction and abduction of the knee. All the patients underwent operations, generally with unsatisfactory results. At operation tears of the anterior cruciate ligament, medial collateral ligament and posterior oblique ligament were seen in each case; in four patients the posterior capsule and in three the posterior cruciate ligament also were torn. In one patient the lateral collateral ligament was torn and the lateral meniscotibial ligament was avulsed. The compression component is absent in this type of injury and consequently the menisci and the osteochondral surfaces of the tibia and femur remained intact in each case.