The Bimetric cementless total hip replacement: 7-18 year follow-up assessing the influence of acetabular design on survivorship.

The purpose of this study was to evaluate the mid- to long-term survivorship of Bimetric cementless total hip replacement and assess how it is affected by the acetabular design. This was a retrospective analysis of 127 Bimetric cementless total hip replacements in 110 patients with a follow-up of 7-18 years. A single design stem and three different cementless metal-backed acetabular designs were used. Patients were assessed clinically using the Harris hip score and radiologically by independent review of current hip radiographs. There was only one case of aseptic loosening of the femoral stem. The earliest acetabular design showed a high failure rate whilst the latter two designs showed a 96% survivorship at a mean of 9.5 years. We conclude that a combination of the bimetric stem with either of the latter acetabular cup designs has a good mid- to long-term performance.

The torn acetabular labrum.

Eleven patients with tears of the acetabular labrum are discussed and the syndrome of the torn labrum is defined. In all cases the lesion was associated with acetabular dysplasia, and a constant early radiological sign was a cyst in the lateral aspect of the acetabulum. The diagnosis was confirmed by arthrography. It is suggested that these tears are degenerative, occurring as a consequence of abnormal stresses imposed by the uncovered lateral portion of the femoral head. Once a tear is present a localised stress point occurs on the femoral head, leading rapidly to degenerative arthritis.

Arteriovenous fistula after fibular osteotomy leading to recurrent haemarthroses in a total knee replacement.

We present a patient with an arteriovenous fistula of the peroneal artery acquired after a left dome tibial osteotomy with midshaft fibular osteotomy. He had subsequently had a total knee replacement on that side. The arteriovenous malformation was only diagnosed when he represented with symptoms and signs of venous hypertension with sterile recurrent haemarthroses in the left knee. Percutaneous obliteration of the fistula, by a combination of coil embolisation and balloon occlusion, cured the symptoms.

Closing the audit circle: effect of continuing audit on arthroscopic practice.

A prospective study in a single orthopaedic unit for one calendar year was carried out to examine the effect of continuing audit on arthroscopic practice. A standard proforma was introduced to record information and results were analysed using a system of audit codes. Two audit periods were examined, the first 3 months and the subsequent 9 months. Results after audit of the first period were compared with the second period; diagnostic accuracy and clarity had improved as had the accuracy of audit coding. The subset of patients with a preoperative diagnosis of a meniscal tear was analysed and the diagnostic accuracy for this group improved over the year. We found that the Audit Circle had been closed in the areas of diagnostic clarity, diagnostic accuracy of meniscal tears and the accuracy of audit coding.

Percutaneous dynamic hip screw.

We present the results of a technique of dynamic hip screw insertion through a very small incision, typically 2-2.5 cm. The technique is performed using a standard dynamic hip screw set and requires no additional equipment. We compared the results to those of an age and sex-matched group who had undergone the operation through a traditional approach. We compared the time spent in theatre, the pre- and post-operative haemoglobin concentration, haematocrit and prevalence of wound infection. Thirteen consecutive cases were performed by one surgeon using the percutaneous technique. There were nine females and four males with a mean age of 84 years (range 62-96 years). Each had a 135 degrees four-hole plate. The mean post-operative drop in haemoglobin concentration in the percutaneous group was 2.2 g/dl (range 0-4.4 g/dl) compared to 3.5 g/dl (range 1.2-5.4 g/dl) in the control group (p = 0.014). The mean haematocrit drop was 0.07 (range 0-0.12) in the percutaneous group compared to 0.10 (range 0.03-0.17) in the control group (p = 0.017). The mean theatre time with the percutaneous technique was 57 min (range 40-75 min) and in the control group, 60 min (range 30-95 min). There were no wound problems. It is likely that this minimally invasive technique offers a better clinical outcome at no extra expense and warrants further evaluation in a larger study.

The AO unreamed nail: friend or foe.

Twenty-nine tibial shaft fractures were stabilized with the AO unreamed tibial nail. These included 13 type A fractures, 11 type B fractures and five type C injuries. Fourteen of the fractures were open. The AO unreamed tibial nail was the primary device used in all cases. Our series suggests that this is an easy device to insert and that its multiple locking options confer an advantage for the management of distal fractures. It also has a low soft-tissue complication rate. There was a delay in full patient mobilization and in the progression to fracture union. There was also a significant degree of implant failure with screw breakage in 21 per cent. This necessitated a high rate of secondary operative intervention. The high incidence (55 per cent) of anterior knee pain was also worrying and frequently necessitated nail removal. We feel that this implant may still have a role for distal fractures and in the multiply injured patient but do not feel that, in its current form, it is the ideal implant for the majority of tibial shaft fractures.