The accuracy of restoration of femoral head centre of rotation in the anteroposterior plane after uncemented total hip arthroplasty : a CT-based study.

AIMS: Hip arthroplasty aims to accurately recreate joint biomechanics. Considerable attention has been paid to vertical and horizontal offset, but femoral head centre in the anteroposterior (AP) plane has received little attention. This study investigates the accuracy of restoration of joint centre of rotation in the AP plane. METHODS: Postoperative CT scans of 40 patients who underwent unilateral uncemented total hip arthroplasty were analyzed. Anteroposterior offset (APO) and femoral anteversion were measured on both the operated and non-operated sides. Sagittal tilt of the femoral stem was also measured. APO measured on axial slices was defined as the perpendicular distance between a line drawn from the anterior most point of the proximal femur (anterior reference line) to the centre of the femoral head. The anterior reference line was made parallel to the posterior condylar axis of the knee to correct for rotation. RESULTS: Overall, 26/40 hips had a centre of rotation displaced posteriorly compared to the contralateral hip, increasing to 33/40 once corrected for sagittal tilt, with a mean posterior displacement of 7 mm. Linear regression analysis indicated that stem anteversion needed to be increased by 10.8° to recreate the head centre in the AP plane. Merely matching the native version would result in a 12 mm posterior displacement. CONCLUSION: This study demonstrates the significant incidence of posterior displacement of the head centre in uncemented hip arthroplasty. Effects of such displacement include a reduction in impingement free range of motion, potential alterations in muscle force vectors and lever arms, and impaired proprioception due to muscle fibre reorientation. Cite this article: Bone Joint Res 2022;11(3):180-188.

Management of neck of femur fracture in an adult with short stature and learning disability.

Neck of femur fractures (NOFF) are one of the major health concerns, with their incidence and the cost of care rising each year. Though a plethora of literature remains available on NOFF and its management, we found very little evidence for management of NOFF in patients with short stature and learning disability. Because of this unique combination of conditions in our patient, we had to deviate from the standard practice in terms of the implant choice. The usage of cemented Asian C stem AMT with a 36 mm metallic head which is normally reserved for total hip replacements, helped us obtain the desired hip joint stability. This was supplemented by early involvement of the learning disability physiotherapy team and eventually the patient had a satisfactory outcome at 8 months of follow-up. This rare amalgamation of NOFF, short stature and learning disability deserves more attention which our case report hopes to achieve.

Role of preoperative magnetic resonance imaging in patients with quiescent septic arthritis undergoing primary total hip arthroplasty.

AIM: to evaluate the role of preoperative magnetic resonance imaging (MRI) in assessing patients with a history of quiescent hip septic arthritis undergoing total hip arthroplasty. MATERIALS AND METHODS: retrospective consecutive study of patients with previous history of septic arthritis who underwent MRI scans of their hips prior to primary hip arthroplasty surgery and who also had minimum 2 years follow up postoperatively. Detailed radiographic examinations were obtained, demographic and microbiological data collected. The primary outcome measure was whether a preoperative MRI scan had influenced the surgical decision-making and planning. Rate of recurrence of infection and complications was also collected at final follow up. RESULTS: sixteen patients with quiescent hip septic arthritis were included. There were 4 males and 12 females with average age at time of primary hip arthroplasty 51.7 years (range 22-75). Five patients had childhood septic arthritis with no documented microbiology data. Eleven patients had adult onset septic arthritis. In patients with childhood septic arthritis the MRI findings were similar to those with degenerative joint disease and had no added value to the routine surgical work up. MRIs of patients with adult onset septic arthritis showed persistent findings of effusion, marrow oedema and soft tissue oedema and had no added value to the surgical planning. All but one underwent single stage total hip arthroplasty. At final follow up, with average 4.6 years (range 2-8), none had a recurrence of infection. CONCLUSION: In our experience, preoperative MRI scans did not influence the surgical decision making and are not recommended for routine practice in the surgical work up of quiescent septic arthritis prior to total hip arthroplasty.

Femoroacetabular impingement in young adults: assessment and management.

Femoroacetabular impingement is a cause of hip pain in young adults as a result of premature dynamic contact between the femur and acetabulum that occurs within the physiological range of hip motion. Diagnosis is made by patient history, clinical examination and radiographic findings. Cross-sectional imaging with computed tomography and magnetic resonance arthrography may be necessary in selected patients. Femoroacetabular impingement can be treated non-operatively with physiotherapist-led conservative care including analgesia and intra-articular steroid injections. Arthroscopic hip surgery aiming to restore pain-free functional range of movement and repair damaged labrum can help in selected patients with no pre-existing osteoarthritis. This review outlines the clinical assessment, investigations and management of femoroacetabular impingement in young adults.

Functional outcome of total hip arthroplasty after a previous hip arthroscopy: a retrospective comparative cohort study.

BACKGROUND: Despite patients demonstrating significant short-term clinical improvement from a hip arthroscopy (HA), a number of patients progress to significant osteoarthritis of the hip requiring total hip arthroplasty (THA). This study aims to evaluate if there is any difference in the functional outcome of patients undergoing THA after a previous hip arthroscopy compared to patients undergoing THA for primary osteoarthritis of the hip. METHODS: Between 2010 and 2013, in a group of 414 patients who underwent hip arthroscopy, we identified 18 patients who underwent a subsequent uncemented THA. These formed the study group. During the same period, 625 patients underwent an uncemented THA performed for primary OA, of which 63 patients were matched to the study group for age, follow-up and implants used. These formed the control group. Pre-op and post-op Oxford Hip Scores (OHS) were recorded for all patients. RESULTS: A mean follow-up of 26.5 and 26.3 months was observed in the study and control groups respectively. The median (interquartile ranges) preoperative OHS were 14 (8.25, 17.0) and 18.5 (13.25, 24.75) in the 2 groups. Corresponding postoperative scores were 40 (31.25, 45) and 46 (43, 48). Median difference between the preoperative and postoperative OHS was 27 (19, 31) and 25 (18.25, 31). Adjusting for the pre-treatment scores, the postoperative scores in the study arm were significantly lower than for the control arm with an estimate (SE) of -0.464 (p = 0.012). Post-hoc power analysis showed that the study was sufficiently powered to detect a meaningful difference in scores. CONCLUSION: Total hip arthroplasty after hip arthroscopy leads to satisfactory functional outcomes. However, the functional outcome in this group is significantly worse than in a matched cohort of patients undergoing THA for osteoarthritis. There was no difference in the rate of complications between the 2 groups.

Finkelstein's Test Is Superior to Eichhoff's Test in the Investigation of de Quervain's Disease.

Introduction de Quervain's tenosynovitis is a common pathologic condition of the hand. Finkelstein's test has long been considered to be a pathognomonic sign of this diagnosis, yet most clinicians and instruction manuals erroneously describe what is in fact the Eichhoff's test, which is thought to produce similar pain by tendon stretching in a normal wrist. The purpose of this study was to compare Finkelstein's test with Eichhoff's test in asymptomatic individuals. Materials and Methods Thirty-six asymptomatic participants (72 wrists) were examined using both Finkelstein's and Eichhoff's tests with a minimum interval of 24 hours between the tests. Results The results showed that Finkelstein's test was more accurate than Eichhoff's test. It demonstrated higher specificity, produced significantly fewer numbers of false-positive results, and also caused significantly less discomfort to patients. Conclusion This study recommends Finkelstein's test as the clinical examination of choice for the diagnosis of de Quervain's disease.

Current Concepts in Acetabular Positioning in Total Hip Arthroplasty.

Being one of the most successful surgeries in the history of medicine, the indications for total hip arthroplasty have widened and are increasingly being offered to younger and fitter patients. This has also led to high expectations for longevity and outcomes. Acetabular cup position has a significant impact on the results of hip arthroplasty as it affects dislocation, abductor muscle strength, gait, limb lengths, impingement, noise generation, range of motion (ROM), wear, loosening, and cup failure. The variables in cup position are depth, height, and angular position (anteversion and inclination). The implications of change in depth of center of rotation (COR) are medialized versus anatomical positioning. As opposed to traditional medialization with beneficial effects on joint reaction force, the advantages of an anatomical position are increasingly recognized. The maintained acetabular offset offers advantages in terms of ROM, impingement, cortical rim press fit, and maintaining medial bone stock. The height of COR influences muscle activity and limb lengths and available bone stock for cup support. On the other hand, ideal angular position remains a matter of much debate and reliably achieving a target angular position remains elusive. This is not helped by variations in the way we describe angular position, with operative, radiologic, or anatomic definitions being used variably to describe anteversion and inclination. Furthermore, pelvic tilt plays a major role in functional positions of the acetabulum. In addition, commonly used techniques of positioning often do not inform us of the real orientation of the pelvis on operating table, with possibility of significant adduction, flexion, and external rotation of the pelvis being possibilities. This review article brings together the evidence on cup positioning and aims to provide a systematic and pragmatic approach in achieving the best position in individual cases.

Hip arthroscopy: a focus on the future.

The indications for hip arthroscopy over the last decade have increased rapidly, driven by technical and technological advances aimed at hip joint preservation. This article reviews the current indications and supporting evidence for hip arthroscopy, explores some newer techniques/technologies and discusses the future directions in this rapidly evolving and expanding field.

The evolution of the trunnion.

Implant modularity has recently come under increasing scrutiny due to concerns regarding wear, corrosion and potential adverse reactions to metal debris. This review outlines the evolution and development of the femoral stem trunnion and relates this to contemporary issues now encountered.Despite different manufacturers producing what appear to be similar trunnion designs, there is still a lack of standardisation, with small but significant design variations. Wear and corrosion is certainly not a new phenomenon, but recent changes in design and the use of larger metal head sizes has potentially made the problem more prevalent. These issues along with steps to avoid these problems are discussed.

First metatarsophalangeal joint arthrodesis versus proximal phalanx hemiarthroplasty for hallux rigidus: feasibility study for a randomised controlled trial.

BACKGROUND: Osteoarthritis of the first metatarsophalangeal joint (hallux rigidus) leads to pain and poor function and mobility. Arthrodesis is the gold standard treatment for end-stage disease. Total joint arthroplasties have been attempted, but early loosening has been attributed to dorsally directed shear forces on the metatarsal component. Metallic proximal phalangeal hemiarthroplasty theoretically avoids this. Whilst early results are promising, no comparative trials exist comparing this to arthrodesis. METHODS/DESIGN: The primary objectives are to determine the range of outcome scores between the two treatment arms (to inform a power calculation). Outcome measures will include the MOXFQ, AOFAS-Hallux and EuroQol EQ-5D-5 L. Secondary objectives are to determine the accrual rate, dropout rate and trial acceptability to both patients and surgeons. These data will allow the development of a larger trial with longer follow-up.This is a prospective randomised controlled single-centre study comparing proximal phalanx hemiarthroplasty (AnaToemic, Arthrex Ltd., Sheffield, UK) with arthrodesis (15 patients in each arm). Randomisation will be performed using a 1:1 allocation ratio in blocks of six.Patients meeting the eligibility criteria will be recruited from three foot and ankle consultant surgeon's clinics (East Lancashire Hospitals NHS Trust). If agreeable, informed consent will be obtained before patients are randomised.The outcome measure scores will be completed pre-operatively and repeated at 6 weeks, 3 months and 12 months. A radiological review will be performed at 6 weeks and 12 months to determine rates of loosening (hemiarthroplasty) and union (arthrodesis). Data on length of stay, return to work, complications and re-operation rates will also be collected.The analysis will compare the change in outcome scores between treatment groups at all follow-up time points. Scores will be compared using a Student t-test, adjusting for scores at baseline.This study will be conducted in accordance with the current revision of the Declaration of Helsinki (1996) and the ICH-GCP Guideline (International Conference on Harmonisation, Good Clinical Practice, E6(R1), 1996). This study has been approved by the sponsor, the Trust Research & Development office. Ethical approval has been received from the National Research Ethics Service (North East: 12/NE/0385 for protocol version 5.3 dated 3 June 2013). TRIAL REGISTRATION: Current Controlled Trials ISRCTN88273654.

An Unrecognised Case of a Scapula Fracture Sustained through an Unusual Indirect Mechanism.

Scapula fractures following low-velocity injuries are extremely rare but can be a missed associated fracture of other upper limb injuries. We describe the case of a patient who sustained a fracture of the scapula through an unusual and hitherto unreported indirect mechanism. The injury was associated with a radial head fracture and initially missed on presentation. This case highlights the need for increased vigilance when diagnosing injuries with unusual mechanisms.

Medical management of osteonecrosis of the hip: a review.

Osteonecrosis or avascular necrosis (AVN) of the hip is a progressive disease mainly affecting adults in their third, fourth or fifth decade of life. Studies into the natural history of the disease suggest that femoral head collapse occurs within 2-3 yrs with associated degenerative changes and at that stage arthroplasty is the most reliable treatment option. Therefore prevention of femoral head collapse is highly desirable in this young patient group. In early stage disease, before femoral head collapse (Ficat and Arlet stage 1-3) core decompression of the femoral head is currently the most widely used procedure to try to relieve intraosseous pressure in the femoral head and restore blood supply.Greater understanding of the pathogenesis of osteonecrosis has led to research into non-surgical management of early stages of the disease, including pharmacological and biophysical treatments.There may be a reduction in symptoms and evidence of prevention of disease progression following some non-surgical treatments. Further studies are needed, including trials comparing medical management with surgical intervention.

Clinical experience of revision of metal on metal hip arthroplasty for aseptic lymphocyte dominated vasculitis associated lesions (ALVAL).

There has been growing concern regarding the systemic and local effects of metal ions released from metal-on-metal hip resurfacings and total hip replacements, including the development of aseptic lymphocyte dominated vasculitis associated lesions (ALVAL). We describe our experience of treating 13 patients with failed metal on metal bearing hip prostheses secondary to this condition. Hip revision occurred at mean of 45 months following primary surgery. Groin pain was present in all patients. Other common features included large bursal swelling and mechanical symptoms. 3 patients developed their symptoms immediately postoperatively. The mean time to presentation was 21 months. Radiographic abnormalities noted included 3 patients with cup loosening and 2 patients with neck thinning. The mean cup inclination was 52 degrees. Surgical findings included bursal swellings and creamy brown fluid. Osteolysis was rarely seen. 12 revisions were achieved with primary implants and all patients had immediate symptomatic improvement. One patient was left with a pseudoarthrosis due to extensive soft tissue destruction. Diagnosis of ALVAL was confirmed histologically. The diagnosis of ALVAL should be considered in patients with unexplained pain from a metal on metal bearing hip arthroplasty. Surgical findings are typical and symptoms tend to resolve reliably following conversion to an alternative bearing surface.

Pakistan earthquake: experiences of a multidisciplinary surgical team.

INTRODUCTION: Four weeks after the earthquake in Kashmir, Pakistan, multidisciplinary surgical teams were organized within the United Kingdom to help treat disaster victims who had been transferred to Rawalpindi. The work of these teams between 05-17 November 2005 is reviewed, and experiences and lessons learned are presented. METHODS: Two self-sufficient teams consisting of orthopedic, plastic surgical, anesthetic, and theatre staff were deployed consecutively over a two-week period. A trauma unit was set up in a donated ward within a private ophthalmological hospital in Rawalpindi. RESULTS: Seventy-eight patients with a mean age of 23 years were treated: more than half (40) were <16 years of age. Fifty-two patients only had lower limb injuries, 18 upper limb injuries, and eight combined lower and upper limb. The most common types of injuries were: (1) tibial fractures (n=24), with the majority being open grade 3B injuries (n=22); (2) femoral fractures (n=11); and (3) forearm fractures (n=9). Almost half (n=34) of the fractures were open injuries requiring soft tissue cover. Over 12 days, 293 operations were performed (average 24.4 per day). A total of 202 examinations under anesthesia, washouts, and debridements were performed. The majority of wounds required multiple washouts prior to definitive procedures. Thirty-four definitive orthopedic procedures (fixations) and 57 definitive plastic procedures were performed. Definitive orthopedic procedures included 15 circular frame fixations of long bones, nine of which required acute shortening and five open reduction and internal fixation of long bones. Definitive plastic procedures included 21 skin grafts, four amputations, 11 revisions of amputations, 20 regional flaps, and one free flap. CONCLUSIONS: A joint ortho-plastic approach was key to the treatment of the spectrum of injuries encountered. Only four patients required fresh amputations. Twenty patients may have required amputation without the use of ring fixators and soft tissue reconstruction. Having self-sufficient teams along with their own equipment and supplies also was mandatory in order not to put further demand on already scarce resources. However, mobilizing such teams logistically was difficult, and therefore, an organization consisting of willing volunteers for future efforts has been established.