Background

Previously, the Coonrad-Morrey elbow system has typically been performed using linked-type total elbow arthroplasty (TEA) implants. However, this implant have been reported to be associated with some problems, such as wearing down, loosening, the complexity of the necessary surgical techniques and inappropriate implant size for Asian people.

The Discovery elbow system (Biomet Inc., Warsaw, US) has recently been developed and it has many advantages when compared to Coonrad-Morrey implant, but the treatment outcome for this system is unclear in patients with rheumatoid arthritis (RA).

Salter innominate osteotomy is an effective reconstructive procedure for the treatment of developmental dysplasia of the hip (DDH), but some children have a poor outcome at skeletal maturity. In order to investigate factors associated with an unfavourable outcome, we assessed the development of the contralateral hip. We retrospectively reviewed 46 patients who underwent a unilateral Salter osteotomy at between five and seven years of age, with a mean follow-up of 10.3 years (7 to 20). The patients were divided into three groups according to the centre–edge angle (CEA) of the contralateral hip at skeletal maturity: normal (> 25°, 22 patients), borderline (20° to 25°, 17 patients) and dysplastic (<  20°, 7 patients). The CEA of the affected hip was measured pre-operatively, at eight to nine years of age, at 11 to 12 years of age and at skeletal maturity. The CEA of the affected hip was significantly smaller in the borderline and dysplastic groups at 11 and 12 years of age (p = 0.012) and at skeletal maturity (p = 0.017) than in the normal group. Severin group III was seen in two (11.8%) and four hips (57.1%) of the borderline and dysplastic groups, respectively (p < 0.001).

Limited individual development of the acetabulum was associated with an unfavourable outcome following Salter osteotomy.

Cite this article: Bone Joint J 2014;96-B:1419–23.

When total ankle arthroplasty (TAA) is performed, although tibial osteotomy is instructed to be perpendicular to long axis of tibia, there is no established index for the talar bone corrective osteotomy. Then, we have been deciding the correction angle at the plan for adjustment of the loading axis through whole lower extremities. We studied 17 TAA cases with rheumatoid arthritis (RA). X-ray picture of hip to calcaneus view (hip joint to tip of the calcaneus) defined to show more approximated loading axis has been referred for the preoperative planning. Furthermore, the data of correction angle has been reflected to pre-designed custom-made surgical guide. If soft tissue balance was not acceptable, malleolar sliding osteotomy was added. The distance between the centre of ankle joint and the axis (preD) was measured (mm) preoperatively, and the distance between the centre of prosthesis and the axis (postD) was measured postoperatively. Next, the tilting angle between tibial and talar components (defined as the index of prosthesis edge loading) were measured with X-rays during standing. Tibio Calcaneal (TC) angle was also measured pre and postoperatively.

TC angle was significantly improved from 8.3±6.0° to 3.5±3.6° postoperatively (P=0.028). PreD was 12.9±9.6mm, and that was significantly improved to 4.8±6.3mm (postD) (P=0.006). Within 17 cases, 8 cases showed 0–1mm of postD, 4 cases showed 1–5mm of postD, remaining 5 cases concomitant subtalar fusion with severe valgus and varus hindfoot deformity showed over 8mm of postD. All of the 12 cases showing within 5mm of postD indicated within 13mm of preD. The tilting angle between components was 0.17±0.37° postoperatively.

Taken together, pre-designed corrective talar osteotomy based on preoperative planning using hip to calcaneus view was useful to adjust the mechanical axis for replaced ankle joint in RA cases. Furthermore, after surgery, the hip to calcaneus view was useful to evaluate post-operative mechanical axis of whole lower extremities.

Two types of fracture, early and late, have been reported following limb lengthening in patients with achondroplasia (ACH) and hypochondroplasia (HCH).

We reviewed 25 patients with these conditions who underwent 72 segmental limb lengthening procedures involving the femur and/or tibia, between 2003 and 2011. Gender, age at surgery, lengthened segment, body mass index, the shape of the callus, the amount and percentage of lengthening and the healing index were evaluated to determine predictive factors for the occurrence of early (within three weeks after removal of the fixation pins) and late fracture (> three weeks after removal of the pins). The Mann‑Whitney U test and Pearson’s chi-squared test for univariate analysis and stepwise regression model for multivariate analysis were used to identify the predictive factor for each fracture. Only one patient (two tibiae) was excluded from the analysis due to excessively slow formation of the regenerate, which required supplementary measures. A total of 24 patients with 70 limbs were included in the study.

There were 11 early fractures in eight patients. The shape of the callus (lateral or central callus) was the only statistical variable related to the occurrence of early fracture in univariate and multivariate analyses. Late fracture was observed in six limbs and the mean time between removal of the fixation pins and fracture was 18.3 weeks (3.3 to 38.4). Lengthening of the tibia, larger healing index, and lateral or central callus were related to the occurrence of a late fracture in univariate analysis. A multivariate analysis demonstrated that the shape of the callus was the strongest predictor for late fracture (odds ratio: 19.3, 95% confidence interval: 2.91 to 128). Lateral or central callus had a significantly larger risk of fracture than fusiform, cylindrical, or concave callus.

Radiological monitoring of the shape of the callus during distraction is important to prevent early and late fracture of lengthened limbs in patients with ACH or HCH. In patients with thin callus formation, some measures to stimulate bone formation should be considered as early as possible.

Cite this article: Bone Joint J 2014;96-B:1269–73.

Acetabular component malposition during total hip Arthroplasty (THA) increases the risk of dislocation, reduces the range of motion, and can be the cause of early wear and loosening. Variability in implant alignment also affects the result of THA. The purpose of this study was to compare acetabular cup positioning of three different approaches in THA.

Three different approaches for cementless THA were studied in 108 operations.

The direct anterior approach was used in 56, the anterolateral approach in 32 and the posterolateral approach in 50. The same cementless cup was used in all cases. The same surgeon performed all procedures with mini-incision surgery, using different approaches. To determine the accuracy of the cups, the inclination and anteversion angles were measured with a CT-investigation of the pelvis.

There were no statistical differences between the three groups regarding means of the inclination and anteversion angles. But a significant range of variance, the lowest variations being in the group of the direct anterior approach, the highest in the group of the anterolateral approach.

Purpose: The interest in minimally invasive surgery (MIS) for total hip arthroplasty has not waned in anyway (THA). Different surgical approaches have been used to do MIS-THA. The purpose of this study was to compare the outcome of the THA using the minimally invasive postero-lateral approach (MIS-PL) and minimally invasive antero-lateral approach (MIS-AL).

Patients and Methods: Fifty randomly assigned patients with MIS-PL and 32 patients with MIS-AL were included in the study. There were no significant differences in age, sex, diagnosis, JOA score or body mass index in each group. The operation time, length of incision, blood loss, implant position, muscle recovery and complication were observed.

Results: Total blood loss and pain was significantly less in patients undergoing THA via MIS postero-lateral approach. In addition, the MIS-PL had improved recovery of muscle strength (hip flexion and abduction) which was statistically significant. Median cup inclination was 42.3 degrees (MIS-AL) and 41.7 degrees (MIS-PL). Median cup anteversion was 18.3 degrees (MIS-AL) and 15.9 degrees (MIS-PL), respectively. Roentgenographic evaluation of femoral component positioning showed no significant difference. Other postoperative data (length of hospital stay, operation time, complication) were comparable.

Conclusion: The MIS antero-lateral approach have often been selected to decrease the risk of dislocation, but this approach needs to release the one third of the gluteus medius from the greater trochanter. MIS postero-lateral approach caused less pain and improve recovery time, postero-lateral approach is more suitable for minimally invasive total hip arthroplasty.