We report the five year outcomes of a two-stage approach for infected total hip replacement. This is a single-surgeon experience at a tertiary centre where the more straightforward cases are treated using single-stage exchange. This study highlights the vital role of the multidisciplinary team in managing these cases.

A total of 125 patients (51 male, 74 female) with a mean age of 68 years (42 to 78) were reviewed prospectively. Functional status was assessed using the Harris hip score (HHS). The mean HHS improved from 38 (6 to 78.5) pre-operatively to 81.2 (33 to 98) post-operatively. Staphylococcus species were isolated in 85 patients (68%).

The rate of control of infection was 96% at five years. In all, 19 patients died during the period of the study. This represented a one year mortality of 0.8% and an overall mortality of 15.2% at five years. No patients were lost to follow-up.

We report excellent control of infection in a series of complex patients and infections using a two-stage revision protocol supported by a multidisciplinary approach. The reason for the high rate of mortality in these patients is not known.

Cite this article: Bone Joint J 2014;96-B:1312–18

The increasing need for total hip replacement (THR) in an ageing population will inevitably generate a larger number of revision procedures. The difficulties encountered in dealing with the bone deficient acetabulum are amongst the greatest challenges in hip surgery. The failed acetabular component requires reconstruction to restore the hip centre and improve joint biomechanics. Impaction bone grafting is successful in achieving acetabular reconstruction using both cemented and cementless techniques. Bone graft incorporation restores bone stock whilst providing good component stability. We provide a summary of the evidence and current literature regarding impaction bone grafting using both cemented and cementless techniques in revision THR.

Cite this article: Bone Joint J 2013;95-B, Supple A:98–102.

Introduction: There are a number of classification systems for inter trochanteric fractures of the proximal femur but none that have been universally accepted. For a classification to be successful, it should have excellent reliability and reproducibility among all reviewers in the interpretation of the radiographs. Although the Tronzo classification system is used for inter trochanteric fractures, its reliability had not been tested yet.

Aims: The purpose of this paper is to present the interobserver and intraobserver reliability of the Tronzo classification for intertrochanteric fractures of the femur.

Methods: The radiographs of 50 patients with inter trochanteric fractures were classified by seven observers according to Tronzo’s classification. Three observers were consultant orthopaedic surgeons with a minimum 12 years orthopaedic experience and four were orthopaedic residents. All observers worked independently. The observers repeated the measurements three weeks later without reference to the previous assessments. Intra- and inter-observer agreement was evaluated using the weighted kappa (k) coefficient of Cohen as calculated by the Stata computer package.

Results: For time1, the inter-observer is 0.19 (95% CI 0.05 to 0.43) and for time 2 it is 0.20 (95% CI 0.06 to 0.44): jointly the kappa estimate is 0.20 (95% CI 0.09 to 0.36).

For the intra-observer reliability, the kappa is sightly higher, as one would expect, although it is still only 0.41 (95% CI 0.25 to 0.55).

Overall, the inter-observer reliability is slight (and at best, fair) and the intra-observer reliability is moderate. For clinical use a kappa of 0.8 is strongly recommended and clearly this was not achieved.

Discussion: Tronzo’s classification is simple, easy to use and is predictive of the method of reduction unlike the AO/ASIF classification that is more complicated with several groups and subgroups. However there is poor interobsever reliability as shown in our study. This suggests that comparison of results between studies using the Tronzo classification is not reliable enough to be of use. It should be stressed that reliability studies are not a measure of the accuracy of the classification. There is no right or wrong response in grading each radiograph. The analysis purely measures the reproducibility of the response between several observers.

Intraobserver reliability was moderate in our series, which suggest that individuals could use the Tronzo classification to document their results over a period of time to monitor long-term outcomes and to compare treatment modalities in the same studies.

Background: Extra skeletal osteosarcomas are rare malignancies that account for less than 1% of all soft tissue sarcomas. We describe this tumour arising in the belly of vastus medialis muscle in a 56-year-old woman.

Case report: A 56 year old, otherwise healthy teacher was referred to this regional soft tissue sarcoma unit regarding a progressively enlarging mass in her right thigh. She had noticed this swelling 12 months ago, which remained pain free. On examination there was a firm swelling on the medial side of the thigh measuring 6 cm in diameter. There was no regional lymphadinopathy. MRI scan was reported as a probable soft tissue sarcoma arising from vastus medialis. An open biopsy was reported as a sarcoma of chondroid differentiation but a specific diagnosis of extraskeletal osteosarcoma was reached only after definitive tumour resection. She was treated by wide resection, post operative radiotherapy and combined chemotherapy. At 24 months of follow up she remained tumour free.

Relevant literature is reviewed.

Background: Adult rhabdomyosarcoma is a relatively rare tumour. Good prognosis has been reported in children with multimodality of management. Because of its rarity, very little has been written about this tumour in adults especially on extremities.

Aim- To analyse the results of multimodality treatment of rhabdomyosarcoma of extremities in adults treated over a period of ten years in a UK regional centre.

Material and Methods – Between 1991 and 2002, eight patients underwent enbloc resection for rhabdomyosarcoma of extremities. There were four men and four women. Age of these patients ranged from 21 to 78years. Locations of these tumours were thigh in 5 patients, legs in 2 patients and shoulder in one. Treatment consisted of surgical resection in all patients combined with radiotherapy or chemotherapy or both. These patients were studied retrospectively for surgical and treatment details, tumour recurrence, secondary and mortality. Results are analysed in relation to histological subtype, size of the tumour (less or more than 5cm) and stage of the disease.

Conclusion: Our experience shows a significant incidence of metastatic recurrence and mortality in these patients. Major determinant of disease control (local and distant) seems to be the size of the tumour at presentation. Treatment must be individualized, but complete local excision with a tumour-free margin should be the goal. Major ablative amputation surgery was not performed.

In the National Health Service although some units perform ACL reconstruction as a day case, others continue to admit patient’s overnight due to a possible medicolegal implication of complication including postoperative pain, nausea and vomiting and urinary retention. The aim of this study is to assess the safety, efficacy of post operative pain control, cost effectiveness of the day case procedure and the role of extended acute ‘hospitalcare in the community’ by a Rapid Response Team.

We carried out a retrospective review of data of fifty-seven patients who underwent day case ACL reconstruction with pre-emptive analgesia and postoperative pain control with analgesics and non-steroidal anti-inflammatory drugs. Rapid Response Team consisting of qualified nurses who provide intensive level of nursing cares in-patients home provided the postoperative community care. Aim of this team is to reduce the pressure of acute hospital beds.

Out of fifty-seven patients, adequate pain relief was achieved in 92.8%. One patient needed admission for pain relief, one patient needed admission for excessive bleeding and five patients had nausea and vomiting. Cost analysis showed that ACL reconstruction is cost effective. We conclude that ACL reconstruction is a safe procedure provided attention is given to patient selection, preadmission screening, patient education, preemptive analgesia with appropriate pain management and post operative community care.

Aims: The aim of this study was to compare the efþcacy of plastic and bone block cement restrictor as a medullary plug in total hip replacement. Methods: In this pro- spective study all patients undergoing a primary charnley total hip replacement were randomised to receive either a Hardinge cement restrictor or a Bone block. The medullary plug was inserted to a constant distance. Postoperative standardised radiographs were assessed. The length of the distal mantle was compared between the two groups. Results: 119 hips with a bone block (BB) and 85 hips with a Hardinge plastic cement restrictor (CR) were analysed over a period of 4 years. Analysis of the data by the application of the Two-sample t Ð test, ANOVA and Mann Ð Whitney test revealed a statistically signiþcant difference between the two groups (p < 0.0001). 95% CI limits for BB (a) & CR (a)(t Ð test) = (−12.9, −6.6); 95% CI (Mann-Whitney test) = (−13.002, −8.001). Results show that the plastic cement restrictor migrates distally to a greater degree than the bone plug. Conclusion: Interdigitation of cement into the cancellous endosteal bed depends on intramedullary pressure. The depth of the cement mantle is a measure of the intramedullary pressure and the function of the cement restrictor. We conclude that the bone plug is better in primary hip replacements.

Aims: Necrosis of fingers secondary to the use of digital tourniquet has been reported. Harmful effects of tourniquet are due to the high pressures generated beneath the tourniquet.

The aim of this study is to compare the pressures beneath the three different types of digital tourniquet namely rolled rubber glove, commercially available band and urinary catheter on human volunteers using a standardised device which directly measures the pressure and to assess pain score using visual analogue scale. Methods: Twenty healthy volunteers with eighty fingers in total were blinded and the pressures were measured for the three different types of tourniquet in a random fashion. Standard technique of tourniquet application was used. Result and Conclusion: The variation in pressures for each finger and between three different types of tourniquet was examined using the standard analysis of variance. This showed that there was no statistically significant variation between the fingers (F=1.87, 3,234 df) for one type of tourniquet. However the pressures in the catheter tourniquet group was significantly higher (F=53.59, 2,237 df). Analysis of pain perception showed that the catheter tourniquet led to substantially higher pain. We conclude that the catheter tourniquet generates high pressures and thereby increasing the potential risk of neurovascular complications.

Introduction

Mallet toe is a flexion deformity of the distal interphalangeal joint of the lesser toe. It causes pain and callosity in the toe tip and the dorsum of the distal interphalangeal joint. Campbell refers to the “terminal Syme’s amputation” for this condition but the results of this have not previously been reported.

Material and Methods

This is a retrospective review of 35 toes in 22 patients that underwent distal phalangectomy. Sixteen patients were aged over 70. Patients were interviewed by an independent observer regarding the pain relief, cosmetic acceptability and satisfaction with the procedure and were examined for callosity, stump tenderness, sensitivity and neuroma.

Results

All patients were satisfied including pain relief and cosmetic acceptability at an average follow up of 4.6 years. One patient had mild wound infection. One patient had asymptomatic nail growth. No stump tenderness, sensitivity or neuroma was noted.

Discussion and Conclusion

Coughlin reported a satisfaction rate of 89% and 86% following successful fusion and excision arthroplasty respectively. In this series all patients were satisfied. We feel that distal phalangectomy is an option in a selected group of elderly patients where pain relief and functional outcome is the priority.

Displaced supracondylar fracture in adults often require internal fixation. Plate fixation, requires soft tissue stripping resulting in devitalisation of bony fragments and this predisposes to risk of non union, infection and nerve injuries. This is the first report of a new technique, locked intramedullary transolecranon fossa nailing.

In this technique the fracture is exposed through a limited posterior triceps splitting incision, keeping the soft tissue stripping to the minimum. The medullary canal is entered proximally through an anterior shoulder incision. A guide wire is inserted in an antegrade manner to enter the fracture site. The distal fragment is predrilled to create a tract with 3.2mm drill from proximal to distal, in such a way that the drill enters the olecranon fossa and then the proximal part of trochlea avoiding penetration of the elbow joint. The guide wire is then advanced into the tract in the distal segment. The medullary canal is reamed over the guide wire in anti-grade fashion with flexireamer. Utilising the standard antegrade technique, the nail is inserted and advanced under direct vision until tip of the nail is firmly seated in the trochlea. The proximal and distal locking are done in standard fashion. Postoperatively active mobilisation is encouraged. Four patients underwent this procedure. All the fractures healed in 3 months and at one year follow up the average arc of elbow motion is 120 degrees. There are no complications.

Transolecranon fossa locked nailing is an available option to treat the displaced supracondylar fracture of humerus in adults.