2-Year Radiostereometric Analysis Evaluation of a Short, Proximally Coated, Triple-Taper Blade Femoral Stem Versus a Quadrangular-Taper Stem With Reinforced Proximal Body: A Randomized Controlled Trial.

BACKGROUND: Cementless stem designs with proximal metaphyseal fixation aim to achieve better load distribution, reduce stress shielding, and improve primary stability. The purpose of this prospective, randomized controlled trial was to evaluate the 2-year migration and clinical outcomes of two cementless femoral stems. METHODS: A total of 60 participants undergoing primary total hip arthroplasty for any cause were randomly allocated to receiving either a proximally coated, short blade stem or a quadrangular-taper stem with a reinforced proximal body. Radiostereometric analysis radiographs were performed postoperatively and at 6 weeks, 6 months, 1 year and 2 years. The Harris Hip Score, Oxford Hip Score and the EuroQol five-dimension were also collected. RESULTS: At two years, the median subsidence of the short-blade stem was 0.097 millimeters (mm) [Interquartile range (IQR) -0.67 to 0.08)] versus 0.086 mm(IQR, -0.29 to 0.005, P = .683); medial translation 0.023 mm (IQR 0.08 to 0.12) versus 0.029 mm(IQR -0.07 to 0.10, P = .907); anterior translation 0.035 mm (IQR -0.23 to 0.33) versus 0.07 mm (IQR -0.13 to 0.08, P = .268). At 24 months postoperatively, there were no stem revisions and Patient-Reported Outcome Measures (PROMs) were comparable between groups. CONCLUSION: Both cementless stems exhibited a predictable migration pattern and achieved initial stability. There was no difference in migration across the three Cartesian axes at any time point. Clinical outcomes and PROMs were also comparable. Biological fixation of both implants evidenced by the radiostereometric analysis and excellent PROMs are likely to translate to longer-term stability, which would need to be corroborated by longer-term outcome studies.

Tibial derotation osteotomies are effective in improving pain and function and avoiding hip arthroscopy in patients with hip pain-a short-term follow-up.

The primary objective was to determine short-term clinical outcomes following distal tibial derotation osteotomy (DTDO) performed to manage hip pain in the presence of tibial maltorsion and to review how co-existing pathomorphology affected the management. All patients undergoing DTDO for hip pain with tibial rotational deformities recognized as the predominant aetiology were included. Normal tibial torsion range was assumed as 0-40°, measured by trans-malleolar line relative to femoral posterior condyles. All patients had a positive hip impingement test Flexion Adduction Internal Rotation test (FADIR). The patients older than 50 years or presenting with degenerative joint changes and neuromuscular conditions were excluded. Associated ipsilateral MRI-defined intra-articular pathomorphology (cam/pincer), non-cam/pincer-related labral tears and abnormal combined femoral/acetabular version (McKibbin index) were noted. Pre-operative and post-operative functional outcomes were analysed. Thirty-two patients underwent DTDO. Mean tibial torsion was 48.8° (41-63°), average age was 27 years (18-44), and average follow-up was 30 months (16-45). Nine patients (28%) had a co-existing cam/pincer, and eight patients (25%) had an excessive McKibbin index (51-76°). Overall, 63% of all patients (including 54% of patients with co-existing pathology) experienced significant hip functional improvement following DTDO alone. Pre-operative vs 12 months post-operative scores were calculated as follows: International Hip Outcome Tool-12-41 vs 67 (P < 0.01); Hip Outcome Score Activities of Daily Living Scale-47 vs 70 (P < 0.05); and Hip Outcome Score Sport Scale-36 vs 64 (P < 0.05). Patients with hip pain frequently present with a combination of tibial and/or femoral rotational deformity and cam/pincer lesions. It is important to consider tibial maltorsion as an aetiology of hip pain. Tibial derotation with DTDO results in significant clinical and functional recovery within 12 months in symptomatic hip impingement patients even in the presence of co-existing pathomorphology.

Early to medium-term outcomes of uncemented ceramic-bearing total hip arthroplasty in teenagers for paediatric hip conditions.

AIMS: Despite advances in the treatment of paediatric hip disease, adolescent and young adult patients can develop early onset end-stage osteoarthritis. The aims of this study were to address the indications and medium-term outcomes for total hip arthroplasty (THA) with ceramic bearings for teenage patients. METHODS: Surgery was performed by a single surgeon working in the paediatric orthopaedic unit of a tertiary referral hospital. Databases were interrogated from 2003 to 2017 for all teenage patients undergoing THA with a minimum 2.3 year follow-up. Data capture included patient demographics, the underlying hip pathology, number of previous surgeries, and THA prostheses used. Institutional ethical approval was granted to contact patients for prospective clinical outcomes and obtain up-to-date radiographs. In total, 60 primary hips were implanted in 51 patients (35 female, 16 male) with nine bilateral cases. The mean age was 16.7 years (12 to 19) and mean follow-up was 9.3 years (2.3 to 16.8). RESULTS: The most common indication for teenage hip arthroplasty was avascular necrosis secondary to slipped upper femoral epiphysis (31%; n = 16). Overall, 64% of patients (n = 33) had undergone multiple previous operations. The survival at follow-up was 97%; two patients required revision for aseptic loosening (one femoral stem, one acetabular component). Both patients had fused hips noted at the time of arthroplasty. A further two patients had radiolucent lines but were asymptomatic. At latest follow-up the mean Oxford Hip Score was 44 (31 to 48) and a Visual Analogue Scale measurement of 1.5, indicating satisfactory function. CONCLUSION: Operating on this cohort can be complicated by multiple previous surgeries and distorted anatomy, which in some cases require custom-made prostheses. We have demonstrated a good outcome with low revision rate in this complex group of patients. Cite this article: Bone Joint J 2020;102-B(11):1491-1496.

Trust compliance with best practice tariff criteria for total hip and knee replacement.

BACKGROUND: Satisfaction of the best practice tariff criteria for primary hip and knee replacement enables on average an additional £560 of reimbursement per case. The Getting it Right First Time report highlighted poor awareness of these criteria among orthopaedic departments. METHODS: The authors investigated the reasons for non-compliance with the best practice tariff criteria at their trust and implemented a quality improvement approach to ensure successful adherence to the standards (a minimum National Joint Registry compliance rate of 85%, a National Joint Registry unknown consent rate below 15%, a patient-reported outcome measure participation rate of ≥50%, and an average health gain not significantly below the national average). This was investigated using quarterly online reports from the National Joint Registry and NHS Digital. RESULTS: Initially, the trust had a 31% patient-reported outcome measures participation rate arising from a systematic error in the submission of preoperative patient-reported outcome measure scores. Re-audit following the resubmission of patient-reported outcome measure data under the trust's correct organization data service code confirmed an improvement in patient-reported outcome measure compliance to 90% and satisfaction of all criteria resulting in over £450 000 of additional reimbursement to the trust. CONCLUSIONS: The authors would urge others to review their compliance with these four best practice tariff criteria to ensure that they too are not missing out on this significant reimbursement sum.

Hip hemiarthroplasty for fractured neck of femur; a freedom of information study to assess national variation in implant selection and procurement.

INTRODUCTION: During 2016, according to the National Hip Fracture Database (NHFD), over 65,000 patients suffered a hip fracture of which approximately half underwent hemiarthroplasty. Clear guidelines exist on the usage of proven cemented implants. The Getting It Right First Time (GIRFT) Report highlighted the financial implications of 'unwarranted variation' and stressed the importance of rationalising and standardising service provision, in particular implant usage. The primary aims of this study were to investigate the variation in hip hemiarthroplasty implant usage and associated costs. We hypothesised there to be large variation in implants used and procurement costs. METHODS: Freedom of Information Requests (FOI) were sent to all 177 hospitals listed in the 2017 NHFD Report as treating hip fracture patients. All hospitals were asked for their most commonly used hemiarthroplasty implant and the cost of this, per patient. RESULTS: One hundred sixty six (94%) responses were received. Eighty four (51%) provided implant name and cost, 78 (47%) provided implant name but refused costs and 4 (3%) refused to provide any details. Nineteen different prostheses were used nationally with 20 hospitals using a non-ODEP (Orthopaedic Data Evaluation Panel) 10A implant. Average total cost was £725.00 (range £71-£1378). Significant cost variation was demonstrated for the same implants; one implant was £978.19 at it's most costly and £285.59 at it's cheapest. DISCUSSION: The aims of this study have been met. We have demonstrated huge variation in the implants used for hip hemiarthroplasty and their costs. Notwithstanding the nuances of departmental procurement processes, the financial implications for this variation are significant. CONCLUSIONS: This article demonstrates a requirement for rationalisation of implant usage and procurement in order to potentially improve patient outcomes and provide opportunities for significant cost saving in an already overstretched health service.

Diagnosis, management and complications of distal humerus lateral condyle fractures in children.

We review the diagnosis, evaluation and management of paediatric lateral condylar fractures. The complications of these fractures are also discussed, including the management of fracture non-union.

An In Vitro Comparison of the Primary Stability of 2 Tapered Fluted Femoral Stem Designs.

BACKGROUND: Proximal bony deficiencies present a biomechanical challenge to achieving primary stability in revision hip arthroplasty. Long tapered fluted stems have been engineered to span these defects but concerns of early subsidence are well documented. This work aimed primarily to investigate the issue of subsidence with this design using a cadaveric model. A secondary aim was to compare the stability of 2 versions of this design. METHODS: Seven pairs of cadaveric femora were obtained, dual emission x-ray absorpitometry scanned, with calibration radiographs taken for digital templating. Each bone was potted according to the ISO standard for fatigue testing and a Paprosky type 3 defect was simulated. The established cone-conical Restoration Modular (Stryker) system and a novel design with a chamfered tip and flute configuration (Redapt, Smith & Nephew) were examined. Movement at the stem-bone interface was measured using radiostereometric analysis and micromotion transducers. RESULTS: All restoration stems and 85% of the Redapt stems achieved stability by recognized criteria, micromotion < 150 µm and migration less than 2 mm. A Fisher exact test comparing the proportion of stems which were stable or unstable was not significant, P = .055. Mean axial subsidence (SD) was 0.17 mm (0.32) and 0.1 mm (0.131) for the Restoration and Redapt stems respectively. CONCLUSION: This study has demonstrated minimal subsidence in the immediate post-operative period using tapered fluted stems. Both designs achieved excellent stability despite simulation of Paprosky type 3 bony defects in the cadaveric model. This geometry appears satisfactory for use in revision surgery in the presence of significant proximal bony deficiencies.

A rare Lisfranc-type injury involving dorsal dislocation of the intermediate cuneiform.

Lisfranc injuries occur at the tarsometatarsal joint resulting from direct or indirect force to the midfoot. They account for only 0.2% of all fractures, with diagnoses easily missed on presentation. The resultant instability is often associated with significant morbidity to the patient. This report describes a Lisfranc injury sustained by a healthy gentleman who suffered indirect trauma to the foot when he fell from a standing height. Plain film radiographs and CT revealed dorsal dislocation of the intermediate cuneiform associated with fractures at the base of the third and fourth metatarsals. He underwent open reduction and internal fixation the following day. His Foot and Ankle Disability Index (FADI) score improved from 16.3 1 week postoperatively to 58.7 6 months postoperatively. This report describes a rare injury pattern resulting from indirect, low-energy trauma. We provide a guide to appropriate radiological imaging and evaluation in the assessment of these complex injuries.

Management of acute anterior shoulder dislocation.

Shoulder dislocation is the most common large joint dislocation in the body. Recent advances in radiological imaging and shoulder surgery have shown the potential dangers of traditional reduction techniques such as the Kocher's and the Hippocratic methods, which are still advocated by many textbooks. Many non-specialists continue to use these techniques, unaware of their potential risks. This article reviews the clinical and radiographic presentation of dislocation; some common reduction techniques; their risks and success rate; analgesia methods to facilitate the reduction; and postreduction management. Many textbooks advocate methods that have been superceded by safer alternatives. Trainees should learn better and safer relocation methods backed up by the current evidence available.

Elbow injuries at the London 2012 Summer Olympic Games: demographics and pictorial imaging review.

OBJECTIVE: Elbow injuries in Olympic sports and their imaging findings have not been described previously. The main objective of this article is to analyze the demographic data on imaging of elbow injuries at the London 2012 Summer Olympic Games and to review the spectrum of imaging findings. CONCLUSION: Elbow injuries were seen in a wide variety of sports. Judo and weight-lifting contributed nearly half of all injuries, with only a surprisingly small number of injuries seen in throwing athletes. Knowledge of elbow anatomy coupled with awareness of types of elbow injuries and their prevalence in various sports will contribute toward improving diagnostic accuracy, handling of workload, and overall provision of services at similar major international sporting events in the future.

The London 2012 Summer Olympic Games: an analysis of usage of the Olympic Village 'Polyclinic' by competing athletes.

BACKGROUND: The London 2012 Summer Olympic Games involved 10 568 elite athletes representing 204 competing nations. To manage the varied healthcare needs of this diverse population, a Polyclinic was constructed in the athletes' village. AIM: This work aims to summarise the usage of the Polyclinic by competing athletes and the facilities available to them. METHODS: All Polyclinic encounters were entered into a database from which data were exported for the time frame 28 July-12 August 2012, inclusive to cover the first to last full day of competition. Only Polyclinic data involving accredited athletes were analysed. All types of encounters were collected for analysis, not just sports-related issues. RESULTS: There were a total of 3220 encounters within the Polyclinic. This figure combines medical consultations, radiology/pathology investigations and prescriptions dispensed. Of these 3220 encounters, there were 2105 medical consultations; musculoskeletal comprised the greatest number (52%), followed by dental (30%) and ophthalmic (9%). The most frequently used imaging modality was MRI and diagnostic CT was used the least. After correction for multiple entries, Africa provided the largest proportion of athletes attending the Polyclinic (44%) and Europe the least (9%). Peak usage of all facilities was seen around days 9 and 10 of competition, reflecting the busiest time of the competition and the largest number of athletes in the village. CONCLUSIONS: The Polyclinic managed a wide variety of both sports-related and non-sports-related injuries and illnesses. The breadth of specialists available for consultation was appropriate as was the ease of access to them. The radiology department was able to satisfy the demand, as were the pharmacy and pathology services. We would recommend a similar structure of facilities and available expertise in one clinic when planning future mass participation sporting events.

Sports injuries and illnesses during the London Summer Olympic Games 2012.

BACKGROUND: The Olympic Movement Medical Code encourages all stakeholders to ensure that sport is practised without danger to the health of the athletes. Systematic surveillance of injuries and illnesses is the foundation for developing preventive measures in sport. AIM: To analyse the injuries and illnesses that occurred during the Games of the XXX Olympiad, held in London in 2012. METHODS: We recorded the daily occurrence (or non-occurrence) of injuries and illnesses (1) through the reporting of all National Olympic Committee (NOC) medical teams and (2) in the polyclinic and medical venues by the London Organising Committee of the Olympic and Paralympic Games' (LOCOG) medical staff. RESULTS: In total, 10 568 athletes (4676 women and 5892 men) from 204 NOCs participated in the study. NOC and LOCOG medical staff reported 1361 injuries and 758 illnesses, equalling incidences of 128.8 injuries and 71.7 illnesses per 1000 athletes. Altogether, 11% and 7% of the athletes incurred at least one injury or illness, respectively. The risk of an athlete being injured was the highest in taekwondo, football, BMX, handball, mountain bike, athletics, weightlifting, hockey and badminton, and the lowest in archery, canoe slalom and sprint, track cycling, rowing, shooting and equestrian. 35% of the injuries were expected to prevent the athlete from participating during competition or training. Women suffered 60% more illnesses than men (86.0 vs 53.3 illnesses per 1000 athletes). The rate of illness was the highest in athletics, beach volleyball, football, sailing, synchronised swimming and taekwondo. A total of 310 illnesses (41%) affected the respiratory system and the most common cause of illness was infection (n=347, 46%). CONCLUSIONS: At least 11% of the athletes incurred an injury during the games and 7% of the athletes' an illness. The incidence of injuries and illnesses varied substantially among sports. Future initiatives should include the development of preventive measures tailored for each specific sport and the continued focus among sport bodies to institute and further develop scientific injury and illness surveillance systems.

Revising the well-fixed, painful resurfacing using a double-mobility head: a new strategy to address metal-on-metal complications.

Isolated revision of the femoral component of hip resurfacings to metal-on-metal (MoM) total hip arthroplasties has shown inferior results. We present a case series of well-fixed, painful MoM hips with elevated chromium and cobalt levels. An isolated femoral revision using a noncemented femoral component and a double-mobility head was performed. Patients were followed up for 6 months and showed excellent improvements in visual analog score and Hip dysfunction and Osteoarthritis Outcome Score (HOOS). Cobalt and chromium levels dropped at 6 weeks and were normal at 6 months. Although our follow-up is short, we feel that it is important to highlight this as a potential treatment strategy. This revision is less aggressive than traditional methods, eliminates the concerns from MoM bearings, and results in a stable construct.

The morel-lavallée lesion as a rare differential diagnosis for recalcitrant bursitis of the knee: case report and literature review.

A 72 year-old-male was referred to our institution with recalcitrant prepatellar bursitis. The injury was sustained after striking his right knee against a post whilst horse riding 9 months ago. Previous treatments included repeated aspiration and excision of the bursa with elastic compression bandaging. A diagnosis of a Morel-Lavallée internal degloving injury was made, and the lesion was satisfactorily managed by an internal quilting procedure to eliminate the potential dead space. A review of the literature reveals 29 published reports of Morel-Lavallée lesions with sufficient information for inclusion. These came from 14 separate countries with a total of 204 lesions in 195 patients. The most common anatomical location was the greater trochanter/hip (36%), followed by the thigh (24%) and the pelvis (19%). Most were managed surgically with evacuation of the haematoma and necrotic tissue followed by debridement, which was often repeated (36%). Conservative treatment with percutaneous aspiration and compression bandaging was the next most common treatment (23%). The knee was the fourth most common region affected (16%), and only 3 other lesions in the literature have been managed with a quilting procedure.

A rare patella anatomical abnormality causing locking in an adolescent girl.

UNLABELLED: Locking is an inability to fully extend the knee and is most commonly associated with meniscal pathology and loose bodies. The locked knee is an infrequent presentation in paediatric orthopaedics, and the presence of a patella protuberance as a cause has never been reported in children or adults. An adolescent female presented with a 4-year history of intermittent locking of the right knee associated with a painful audible 'clunk' on full extension. Plain film radiographs and computed tomography showed a posteriorly projecting bony protuberance over the inferior aspect of the patella. The protuberance was removed via an arthrotomy, and the patient made significant improvement in pain and function with no further locking episodes experienced. LEVEL OF EVIDENCE: IV.

The use of a novel "conservative hip replacement" to reconstruct an osteoarthritic hip with an occluded femoral canal.

This case report describes the successful use of a novel "conservative hip replacement" in conditions precluding the use of a standard total hip arthroplasty in a 70-year-old man. The femoral canal was occluded because of previous surgery for a bone tumor in the subtrochanteric region. The patient continues to do well at 4 years with minimal discomfort. At this interval, the Oxford Hip Score was 35. This conservative hip replacement has been developed to preserve bone stock and produce more physiologic loading of the proximal femur. Its design has been produced, using plain radiographs and computed tomography, to maximize "fit and fill" of the femur. The neck supports standard modular heads, allowing the use of any bearing surface. The prosthesis has been rigorously laboratory tested.