Introduction

Ashford and St Peter's Hospital (ASPH) is a district general hospital in Chertsey, Surrey. It is a tertiary referral unit offering a circular frame service to manage complex trauma patients in the South East of England.

This study analyses the patient pathway in 66 consecutive tertiary referrals from 2015–2020. All patients were managed with an Ilizarov frame for either a tibial plateau fracture or pilon fracture.

Background

Proximal femoral fracture is a common, major health problem resulting in loss of functional independence and a high cost burden on society. Rehabilitation can potentially maximise functional recovery, but evidence of effectiveness is lacking. An enhanced rehabilitation intervention designed to improve self-efficacy and increase the amount and quality of practice of physical exercise and activities of daily living has been developed consisting of patient held workbooks and extra therapy sessions in the community. This study aims to define characteristics of the cohort of individuals this intervention is targeted to, assess acceptability of the intervention and feasibility of recruiting participants for a larger scale trial.

This aim of this study was to identify common factors in patients with the shortest length of hospital stay following total hip arthroplasty (THA). This would then allow a means of targeting suitable patients to reduce their length of stay.

This was a retrospective cohort study of all patients undergoing primary THA at our institution between September 2013 and August 2014. Demographic data were collected from the patient record. The cohort was divided into those discharged to home within two days of operation and the rest of the THA population. The demographics (age, gender, ASA grade, body mass index (BMI), primary diagnosis, socioeconomic status (Scottish Index of Multiple Deprivation, SIMD and SIMD health domain) were compared between groups. In addition for the early discharge group information on comorbidities, family support at home and independent transport were collected.

The study cohort was 1292 patients. 119 patients were discharged home on the first post-operative day. Those discharged earlier were on average younger (p<0.0001), more likely to be male (p<0.0001) and had a lower ASA grade (p<0.00001). Other demographics did not differ between groups. Patients who were discharged early also appeared to have few comorbidities (Diabetes 5.9%, Cardiac disease 7.6%, Respiratory disease 9%), high levels of family support at home (95%) and high levels of independent transport arrangements (97%).

Factors associated with those patients with the shortest lengths of stay were identified. Such factors could be used to target patients who are suitable for streamlined recovery programmes aimed at early discharge after THA and assist with service planning.

Background-

Health care is best delivered face to face, doctor to patient. However, in some places like Scotland, patients can be in remote areas, far from the nearest health care provider. Medical video conferencing (VC) enables patients and doctors to meet for consultations from wherever they may be without the need for travel, and is already used widely in countries like Australia and Canada.

A tip-apex distance (TAD) greater than 25 mm is a strong predictor of screw cut-out in patients with intertrochanteric femoral fracture treated with a dynamic hip screw (DHS). We aim to show you a simple and reliable way to check this.

By calculating the sum of the distance from the tip of the screw to the apex of the femoral head on anteroposterior and lateral views the TAD is found. X-rays often have magnification errors and therefore measuring tools in digital x-ray systems will be inaccurate. The original method of calculating the TAD uses the known diameter of the screw to avoid magnification errors.

We found that due to the no-cylindrical shape of the screw shaft there is potential of an inaccurate measurement. By using the distance across the highest points of the thread a more accurate TAD can be calculated.

The distance across the highest points of the threads in all three of the most commonly used DHSs in the UK is 13 mm. If the measured distance from the tip of the screw to the apex of the femoral head in both the anteroposterior and lateral views is less than the measured distance across of the treaded diameter of the screw then the surgeon knows the TAD is less than 26 mm. This method can be used intraoperatively to check the TAD by looking at the fluoroscopy images in these two views.

Posterior soft tissue repair is often performed in Total Hip Arthroplasty (THA). Many reports have shown the advantage of posterior soft tissue repair in reducing their prosthetic hip dislocation rates.

We describe an easy and inexpensive way of passing sutures through small drill holes in the Greater Trocanter to re-attach muscle, tendon and capsule in a posterior soft tissue repair.

By using a reversed monofilament suture on a straight needle held in artery forceps and passing this in a retrograde direction through a drill hole, a suture capturing device is produced.

By capturing the long ends of sutures tied in the short external rotators and the posterior capsule of the hip through 2 drill holes in the Greater Trochanter, a posterior soft tissue repair can be performed. We have used this technique successfully in over 100 consecutive THAs.

We conclude that the use of a monofilament suture used in the manner describe is an excellent and inexpensive way to aid in a posterior soft tissue repair in THAs. This is done without the cost of an additional dedicated suture passing device. The suture could also be used in the skin closure if desired.

Early failure of metal-on-metal (MoM) total hip replacements (THR) is now well established. We review 93 consecutive patients with CPT¯ stems MoM THR. Our series demonstrates a new mechanism of failure, which may be implant combination specific.

Between January 2005 and June 2009, 93 consecutive MoM total hip replacements were preformed using CPT stems by 3 surgeons at our unit. 73 CPT¯ stems, Metasul¯ Large Diameter Heads (LDH) with Durom¯ acetabulae and 20 CPT¯ stems, Metasul¯ 28mm diameter heads in Allofit¯ shells (zimmer). Clinical outcomes were collected prospectively before surgery, at 3 months, 1 year, 2 years, 3 years, and at 5 years post surgery. Revision for any cause was taken as the primary endpoint and the roentgenograms and explanted prostheses were analyzed for failure patterns.

In the LDH/Durom¯ group a total of 13 (18%) patients required revision (figs. 1) at a median of 35 months (range 6-44). 6 (8%) for periprosthetic fracture. All 6 periprostethic fractures were associated with minimal or no trauma and all had ALVAL identified histologically.

To date there have been no failures in the CPT¯/28mm head Allofit¯ group. Several failures demonstrated bone loss in Gruen zones 8 ± 9 ± 10 (fig. 2).

We demonstrate an unacceptably high rate of failure in CPT¯ MoM LDH hip replacements, with a high failure secondary to periprosthetic fracture and postulate a mechanism associated with local toxicity to metal ions. We strongly advise against this combination of prosthesis.

Introduction

The Western Infirmary/Gartnavel General Hospital orthopaedic department is geographically located next to the Beatson Oncology Centre, a specialist regional oncology unit. Pathological femoral fractures are the commonest reason for surgical intervention in patients referred from the Beatson and we have used them as a model to establish the demographic data, referral patterns, treatment results, and survival characteristics in such a group of patients.

Purpose: Previous studies have shown the utility of the bisphosphonate zoledronic acid (ZA) by systemic administration and local delivery for enhancing local bone formation with porous implants. The purpose of this study was to quantify the long term effect of local delivery of ZA on bone growth within and around porous tantalum implants one year after surgery.

Method: Hydroxyapatite coated porous tantalum (Trabecular Metal^™, Zimmer Inc) implants measuring 9 mm in diameter and 90 mm in length were used in a canine bilateral femoral intramedullary model. Commercially pure ZA (Novartis Pharma) of either 0.05 mg or 0.20 mg ZA was applied to implants. Bilateral surgery was performed on 10 dogs – all 10 with a control implant on one side and 5 each with either a 0.05 mg or 0.20 mg ZA-dosed implant on the contralateral side. After one year, the femora were harvested and processed for undecalcified thin section histology and backscattered scanning electron microscopy. Statistical analysis was done using the student’s t tests and multiple two-level hierarchical models.

Results: The 160 histologic sections revealed that compared with controls, there was more intramedullary bone around implants dosed with both 0.05 mg ZA (+91%, p< 0.001) and 0.20 mg ZA (+115%, p< 0.001). Bone ingrowth was present in all sections and was more abundant within 1.5mm of the implant periphery. The 0.20 mg ZA dose resulted in more net intramedullary bone formation than the 0.05 mg dose (+41%, p< 0.006). The mean extent of bone ingrowth for implants dosed with 0.20 mg ZA was significantly greater than controls (+32%, p< 0.003) and also greater than for implants dosed with 0.05 mg ZA (+47% for the area within 1.5 mm of the periphery, p< 0.002).

Conclusion: This study demonstrated that the enhanced net bone formation that occurs due to local elution of ZA from porous implants was sustained out to 1 year after surgery. A notable dose response was also demonstrated. The peri-implant response was confined to within a few millimeters of the implant suggesting that ZA elution remains localized. This study supports the concept of using ZA-dosed implants for enhancing net bone formation within and around noncemented implants.

Purpose: The bisphosphonate Zoledronic acid (ZA) is effective for increasing net bone formation within and around implants when directly eluted from implants. The extent to which this occurs or whether ZA is more widely distributed through diffusion into the circulation is unknown. The purpose of this study was to utilize 14C-labeled ZA to quantify the localization and skeletal distribution of ZA in a canine intramedullary implant model.

Method: A solution of 100μg 14C-labeled ZA was evenly distributed onto each implant surface of three hydroxyapatite coated porous tantalum (Trabecular Metal^™, Zimmer Inc) implants measuring 5 mm in diameter and 50 mm in length. The implants were inserted within the left femoral intramedullary canal of an adult mongrel dog and left in situ for 6 weeks. The 3 femora with implants and all the other long bones were harvested, dried, pulverized into a fine powder and disolved in HCl. This solution was then placed in a scintillation cocktail (Ultima Gold AB, Perkin Elmer USA) and analyzed with a Packard Tri-Carb 2100TR liquid scintillator spectrometer. Data were analyzed with student’s t tests and nested analyses of variance with p=0.05.

Results: Very high amounts of ZA were present within the bone samples immediately adjacent to the implants – range 243 – 1487 ng ZA/g of bone, mean of 800 ng ZA/g. By 1 cm proximal or distal to the implant, the values diminished by up to an order of magnitude. All other bone samples contained very low amounts of 14C, (range, 0.8 – 22.6 ng ZA/g; mean 6.5 ng ZA/g), indicating diffusion of ZA into the circulation and a level of systemic distribution. This is about 11-fold less in magnitude (p< 0.0001).

Conclusion: Local elution of ZA directly from an implant results in half of the ZA being distributed locally in the femur with the rest being distributed throughout the skeleton, at levels that are much less than the therapeutic dose required to appreciably affect bone remodeling or cause complications. postoperative time periods.

Introduction: We hypothesised that a stemmed hybrid total hip replacement with a large metal head, (LMOM), with the same bearing technology, would give early functional results as good as hip resurfacing (HR) with fewer contraindications and reduced morbidity due to a less invasive approach.

Methods: We performed a 12 month observational study of consecutive patients undergoing LMOM (n=40) and HR (n=60). Patients’ age, sex, blood loss, hospital stay and early complications were compared as well as pre and post-op Oxford scores and range of movement.

Results: The HR group was younger with more normal hip morphology. Mean age 54years HR/ 59years LMOM, BMI 28 and 29 respectively. Diagnosis of primary osteoarthritis 77% HR compared to 47% in LMOM group. Operation time, blood loss and haemoglobin drop were similar in both groups. The LMOM group achieved an earlier discharge of 5.5 days compared to 6.3 (p< 0.12). Complications included 2 aseptic wound leakages in the LMOM group. In the HR group an aseptic wound leakage, superficial infection and a sciatic nerve palsy was observed. At 6 week and 3 month follow up, the range of moment of both groups was very similar. Mean Oxford hip scores were 44 preoperatively and 22 postoperatively in the HR group and 45 falling to 24 in the LMOM group.

Discussion: LMOM compared to HR is preferable in respect to hospital stay and reduced perioperative complications despite an older cohort with a wider variety of arthritic pathologies. However longer follow up is required to conclude further.

With the advent of the advancement of manufacturing technologies hip resurfacing (HR) has become a serious option for a younger patient with osteoarthritis of the hip. The operation is technically demanding and correct placement of the femoral component is the critical step.

We hypothesised that with computer navigation we can improve the placement of the femoral component and restore the biomechanics of the hip joint compared to currently available mechanical jigs.

We compared the radiological results and operation time in 8 patients undergoing computer navigated hip resurfacings (cnHR) to 30 patients undergoing mechanical jig hip resurfacings (jigHR).

Our results showed the average angle of the central pin in the femoral neck in the jigHR group was 141 degrees on the AP radiographs (range 131 to 154 degrees) and 6 degrees antevertion (range 0 to 8 degrees) on the lateral radiographs compared with 135 degrees (range 134 to 138 degrees)and 5 degrees (range 3 to 8 degrees)in the cnHR group. The position of the central pin in the neck immediately below the head was off-centre in the jigHR group on average by 4mm in both AP and lateral radiographs and never more than 2mm in the cnHR group in either view. Offset was increased on average 5mm in the jigHR group and decreased on average by 3mm in the cnHR group. The average operation time was 107 minutes in the jigHR group and 110 minutes in the cnHR group.

We conclude that despite our relatively small sample group we have showed computer navigation gives consistent optimum positioning of the femoral component and improves the biomechanics of the hip. This was without increasing operating time.

We compared peri-prosthetic bone mineral density between identical cemented and cementless LCS rotating platform total knee arthroplasties. Two matched cohorts had dual energy x-ray absorptiometry scans two years post-operatively using a modified validated densitometric analysis protocol, to assess peri-prosthetic bone mineral density. The knee that was not operated on was also scanned to enable the calculation of a relative bone mineral density difference. Oxford Knee and American Knee Society scores were comparable in the two cohorts.

Statistical analysis revealed no significant difference in absolute, or relative peri-prosthetic bone mineral density with respect to the method of fixation. However, the femoral peri-prosthetic bone mineral density and relative bone mineral density difference were significantly decreased, irrespective of the method of fixation, particularly in the anterior distal portion of the femur, with a mean reduction in relative bone mineral density difference of 27%.

There was no difference in clinical outcome between the cemented and cementless LCS total knee arthroplasty. However, both produce stress-shielding around the femoral implants. This leads us to question the use of more expensive cementless total knee components.

We have reviewed 34 children who had been treated by open reduction through a medial incision and transarticular pinning for a severely displaced supracondylar fracture of the humerus. Follow-up ranging from nine months to 20 years showed that 27 of 34 elbows (79%) had excellent or good results, with satisfactory resolution of neurovascular problems and no complications due to the method of treatment.

We report five examples of physeal widening in four children with myelomeningocele. In all cases there was rapid clinical resolution with the use of the patients' normal orthoses and minor limitation of activity, and there was no evidence of early epiphyseal closure or growth disturbance. We suggest that recognition of the pathological process before fracture occurred may explain the rapid return to normal.

We present the results of 506 consecutive Howse hip arthroplasties with a minimum follow-up of 10 years. The mortality within one month of surgery was 0.79%. The early dislocation rate was 1.38%, two hips requiring revision. Nine hips developed deep sepsis (1.78%), eight of which required revision. At 10 years 42 hips (8.3%) had required revision, including 14 with aseptic acetabular loosening and 11 with femoral stem fractures. We feel that as judged by the dislocation rate and the need for subsequent revision, the Howse arthroplasty is an acceptable form of total hip replacement, particularly in the older patient and in those requiring total replacement for femoral neck fractures.

A study of 79 children with malunion of forearm fractures is presented. Age at the time of injury, the site of the fracture and the degree and direction of angulation at union were correlated with loss of forearm rotation at review 3.5 to 6 years later. Some guidelines are proposed for the acceptability of angular deformity at union, importance being placed on the avoidance of radial deviation of the radius, and the maintenance of the interosseous gap between the shafts of the radius and ulna.

In patients over 60, both Paget's disease and metastatic carcinoma are not uncommon, but it is rare for both to occur in the same patient and in the same bone. One such patient is reported; she had primary carcinoma of the vulva which metastasised to a femur already affected by Paget's disease.