Long term results of the Corin C-Fit uncemented total hip arthroplasty in young patients.

INTRODUCTION: We conducted a prospective study to evaluate the long-term results after Corin C-Fit uncemented total hip arthroplasty in young patients with hydroxyapatite or porous coated components. MATERIALS AND METHODS: We prospectively followed 36 patients (38 hips) who had Corin C-Fit uncemented total hip arthroplasties by eight experienced consultant surgeons at two centres. The acetabular and femoral components were hydroxyapatite or porous coated. RESULTS: The overall 10-year survival rate for the Corin C-Fit arthroplasty was 43%. The 10-year survivorship for the femoral implant was 56% and for the acetabular component 59%. CONCLUSION: The evidence presented in this study suggests that the Corin C-Fit uncemented total hip arthroplasty has one of the highest mid- and long-term failure rates for both femoral and acetabular components in the literature. We believe this implant should not be used and patients who have had this form of total hip arthroplasty should be kept under regular review.

Patellofemoral disorders presenting as bilateral locked knees in achondroplasia.

Patellofemoral disorders in achondroplasia, to our knowledge, have not been reported in the literature. We describe an unusual case of bilateral locked knees in an achondroplastic patient secondary to intra-articular subluxating patellae and symmetrical chondral flap lesions of the femoral trochlea which were treated by arthroscopic resection. We suggest that abnormal kinematics may cause patellofemoral complications in achondroplasia.

Methicillin-resistant Staphylococcus aureus infection following arthroscopy of the knee joint.

Arthroscopic surgery of the knee is considered to be a safe procedure. We had a microbiologically confirmed infection of methicillin-resistant Staphylococcus aureus (MRSA). Although various rare infective cases are reported following arthroscopy of the knee joint, to the best of our knowledge there is no previous report of MRSA infection following arthroscopy of the knee joint.

Reflex hamstring contraction latency in anterior cruciate ligament deficiency.

Decreased dynamic stability of the knee joint associated with functional disability is a feature of anterior cruciate ligament deficiency (ACLD). The purposes of this study were to examine the between-limbs difference in reflex contraction latency of the hamstring muscles in patients with unilateral ACLD and to investigate its relationship with instability and function. Fifty patients with arthroscopically diagnosed unilateral ACLD were measured bilaterally for reflex hamstring contraction latency (RHCL), and 20 normal volunteers were similarly tested. The subjects were measured in a position of single-limb full weight-bearing with the knee flexed 30 degrees. An anteriorly directed shear force was applied to the tibia, and surface electromyographs (EMGs) recorded the activity of the hamstrings in response to the applied force. The latency of contraction was defined as the time from initial tibial movement, identified by accelerometry, to the onset of increased hamstring EMG activity. Both legs were tested and a between-limbs difference was computed. A significant difference in RHCL was found between the limb with ACLD and the control limb. The mean RHCL of the limb with ACLD was nearly double that of the unaffected limb, for a significant mean between-limbs difference (p < 0.05). The mean between-limbs difference for the control subjects was not statistically significant. The conclusion is that patients with ACLD have an increased RHCL of the injured leg. As the RHCL is dependent on proprioceptive activity around the joint, it can be used as a measure of proprioceptive ability. The loss of the neurophysiological protective reflex involving the anterior cruciate ligament and hamstrings in patients with ACLD is likely to be a contributory factor in the decreased joint stability experienced by these patients.

Proprioception after rupture of the anterior cruciate ligament. An objective indication of the need for surgery?

Failure of conservative treatment is the usual indication for the reconstruction of a knee with deficiency of the anterior cruciate ligament (ACL) and this depends on subjective judgement. The ability of muscles to protect the subluxing joint by reflex contraction could provide an objective measurement. We have studied 30 patients with unilateral ACL deficiency by measuring the latency of reflex hamstring contraction. We found that the mean latency in the injured leg was nearly twice that in the unaffected limb (99 ms and 53 ms respectively). There was a significant correlation between the differential latency and the frequency of 'giving way' indicating that functional instability may be due, in part, to loss of proprioception. Measures of proprioception, including reflex hamstring latency, may be useful in providing an objective assessment of the efficacy of conservative treatment and the need for surgery.

Value of radiograph audit in an accident service department.

In our accident service department all trauma radiographs are reported acutely and those misinterpreted by the casualty officers are presented at the daily clinicoradiological conference. We have reviewed this practice over a 6-month period. From over 25,000 patients attending the accident service, 16,246 radiographs were requested and reported. Of these, 456 (2.8 per cent) were considered to have been potentially misinterpreted. The errors included 167 (1 per cent) missed fractures, 55 (0.3 per cent) suspected fractures and 72 (0.4 per cent) false-positive diagnoses of fracture. Subsequently, 114 (0.7 per cent) patients required recall for treatment or further imaging. Incorrect diagnoses were seen most frequently in the more commonly injured anatomical sites--the ankle, wrist, foot, elbow and hand. However, the incidence of misinterpretation was highest in examination of the fingers, especially in children. We believe that these low figures are principally the result of involving both orthopaedic surgeons and radiologists at the formal daily conference. We regard our system of audit as beneficial to patients' care and anticipate reduced litigation which may offset the increased cost of audit.

Allograft versus autograft bone in scoliosis surgery.

The results of a study of the use of autograft versus allograft bone in the surgery of idiopathic adolescent scoliosis are presented. Two groups of patients, matched for age, sex, level and angle of curve, received bone grafts, 20 patients having autogenous bone from the iliac crest and the other 20 having donor bone from a bone bank. Both groups had otherwise identical posterior fusions and Harrington instrumentation. There was no difference between the two groups in a blind, radiographic assessment of bone graft mass at six months, nor in maintenance of the curve correction over the same period. No major operative complications nor failures of instrumentation were encountered. There was, however, a marked reduction in operative time and blood loss in the patients receiving donor bone and also a much lower incidence of late symptoms relating to the operative sites. We conclude that, even in the presence of adequate iliac crest, the use of bank bone is superior for grafting in idiopathic scoliosis surgery.

Early experience with closed interlocking medullary nailing of the femur.

We report on the first 14 patients treated with the Grosse Kempf femoral locking nail in our hospital. As with simple closed nailing of the femur attention to detail in the operating theatre is important. To date there have been only a few minor complications with the procedure, apart from one non-union. It allows stabilization of complicated fractures of the femoral shaft particularly in patients with multiple and often bilateral injuries caused by high velocity. It is concluded that it is an excellent procedure for complicated unstable fractures of the femoral shaft which would otherwise be treated on traction, and that the procedure can be safely performed in any centre where closed intramedullary nailing is commonly practised.

Leg-length inequality in children treated by Syme's amputation.

We have reviewed the results of amputation through the ankle in the management of 37 children with congenital leg-length discrepancy, followed up for a mean of 7.6 years after operation. In general good function was achieved and 18 patients considered their activities to be unrestricted. The main factor affecting the functional result was the underlying condition for which operation had been performed. Although heel pad migration, scar rotation and os calcis remnants were seen, these could be accommodated by the prosthesis. Syme's amputation is tolerated well in the younger child and, in patients with a predicted leg-length discrepancy of over 15 cm associated with an abnormal foot, we recommend the operation as a primary procedure between the ages of 18 months and two years.

Early diagnosis of atlanto-axial rotatory fixation.

Atlanto-axial rotatory fixation is one of a spectrum of rotatory abnormalities of the atlanto-axial joint. Rotatory fixation without anterior displacement of the atlas (Type I) has been reported in only a few cases in which there has been a prolonged interval between injury and diagnosis. The majority of these cases eventually required cervical fusion for persistent deformity or instability. Two cases are presented in which this diagnosis was made early with the aid of rotated odontoid radiographs, tomography and computerised axial tomography. Treatment by a short period of halter traction achieved reduction and early return of function. The authors conclude that early recognition and treatment of this rare condition may prevent the subsequent deformity and instability for which cervical fusion has been required.

Vertebral motion measured using biplanar radiography before and after Harrington rod removal for unstable thoracolumbar fractures of the spine.

The use of Harrington distraction rods for stabilization of fracture dislocation of the thoracolumbar spine is well established. For better initial stabilization and later return of flexibility we routinely use a long rod but fuse over a short segment and then remove the rods at 1 year. A biplanar radiographic technique was used to assess vertebral motion both before and after removal of Harrington rods in five patients. The investigation showed the rod acted to restrict movement and relieved loads on the spine that they spanned. Although all the patients regained considerable spinal flexibility once the rods were removed, none of the intervertebral joints measured could be considered solidly fused. However, the pattern of movement remained abnormal 6 months after rod removal with many intervertebral joints exhibiting lateral flexion and axial rotation during voluntary flexion extension. Despite this, a long rod/short fuse stabilization with routine rod removal after 1 year combines the initial advantage of operative stabilization and is shown to allow a return of spinal flexibility subsequently.

The effect of cephradine prophylaxis on wound infection after arterial surgery through a groin incision.

Cephradine administered prophylactically to a group of 35 patients undergoing reversed saphenous vein femoro-popliteal bypass, iliofemoral endarterectomy or profundaplasty through a groin incision, resulted in a significant reduction in the incidence of wound infection (P = 0.025; exact probability test). One gram of cephradine was given at induction of anaesthesia, followed by three postoperative doses of one gram at 6 hourly intervals. The overall wound infection rate at 7 days, as assessed by frank purulent discharge, was 15%. After cephradine prophylaxis, no infections were noted as judged on this basis, but erythema of the suture line was seen in equal numbers (40% of each group). Where the indication for operative intervention was rest pain or gangrene, the incidence of wound infection was very much increased, 80% of the infected cases being from this group.