Revision of a fractured uncemented revision stem using a custom designed punch and retrograde through-knee approach.

We report a unique case of a fractured modular cobalt chromium connection taper Revitan (Zimmer, Warsaw, IN) revision prosthesis. Macroscopic examination revealed a fracture at the diaphyseal-metaphyseal junction of this modular component. This report highlights that fractures can still occur with modern modular prostheses. We are not aware of any published failures of the Revitan revision prosthesis. We also describe a unique method of retrieval for a broken well fixed uncemented femoral stem, using a custom designed extraction instrument via a through-knee approach.

Cemented or uncemented hemiarthroplasty for displaced intracapsular femoral neck fractures.

The aim of this study was to establish whether or not to cement the hemiarthroplasty for displaced intracapsular femoral neck fractures in the elderly. Consecutive patients treated by hemiarthroplasty in adjacent hospitals were reviewed. The same monoblock prosthesis was used; in hospital A they were uncemented (121 patients), and in hospital B they were cemented (123 patients). Notes were reviewed retrospectively. Surviving patients (50 and 56 respectively) were assessed prospectively for pain and functional ability using validated scoring systems. Follow-up was 32-36 months. Patient demographics were similar. Fewer of the cemented group had been revised or were awaiting revision ( P=0.036). There was no difference in general complication or mortality rates. There was a highly statistically significant greater deterioration in pain ( P=0.003), walking ability ( P=0.002), use of walking aids ( P=0.003) and activities of daily living ( P=0.009) in the uncemented group. Our findings support the use of cemented hemiarthroplasty in the elderly.

A survey of the treatment of displaced intracapsular femoral neck fractures in the UK.

A survey was undertaken to investigate the treatment of displaced intracapsular femoral neck fractures across the UK. The usual practice at 223 hospitals was recorded for two groups of patients, active and frail. Management of stereotyped fractures, in similar patients, varied between hospitals. There was also variation between specialists within some hospitals: two or more of the alternative methods of treatment were in routine use for active patients at 22% of hospitals and for frail patients at 27%. Overall, for active patients, bipolar hemiarthroplasty was undertaken at 41% of hospitals, internal fixation at 37%, unipolar hemiarthroplasty at 32% and total hip replacement at 16%. Cemented prostheses were used in 74% of arthroplasties for active patients. For frail patients, hemiarthroplasty with an Austin Moore or Thompson prostheses was undertaken at 94% of hospitals; bipolar prostheses were used at 8%; internal fixation was undertaken at 1%. Cement was used in 46% of hemiarthroplasties. These findings indicate a lack of consensus in aspects of the treatment of displaced intracapsular femoral neck fractures and are likely to reflect difficulties in determining "best practice."

Cemented or uncemented hemiarthroplasty for displaced intracapsular fractures of the hip--a systematic review.

Displaced intracapsular hip fractures are often treated by hemiarthroplasty, with or without cement. The aim of this study is to perform a systematic review of the literature to establish whether this influences the outcome. A comprehensive search of the English language world literature of all studies comparing cemented with uncemented hemiarthroplasty was performed. Eighteen publications addressing this issue were identified. Three were excluded from review because of poor study design and non-comparability of groups. Of the remainder, few were suitable for statistical analysis, therefore a qualitative comparison of results was carried out. The majority of studies suggested a lower revision rate, less thigh pain and better mobility in-patients in whom the prosthesis was cemented. Cemented hemiarthroplasty may be associated with increased operative time and blood loss. There appears to be no difference in general complication, or mortality rates after 3 months, between the two groups. Radiographic differences were variable and did not correlate with clinical findings. We conclude, the literature tends to support the use of cement in hemiarthroplasty for displaced intracapsular femoral neck fractures. Further prospective randomised studies are required to resolve the issue.

Magnetic resonance imaging of the knee: assessment of effectiveness.

OBJECTIVES: To quantify how magnetic resonance imaging (MRI) influences clinicians' diagnoses, diagnostic confidence and management plans in patients with knee problems. To investigate whether these changes can bring about an improvement in health. METHODS: This was a prospective observational study on all patients referred to a regional unit for MRI of the knee over a 6-month-period. Data on diagnosis, diagnostic confidence and proposed management before MRI was compared with diagnoses and actual management after MRI. In addition, short form 36 item (SF-36) health survey data was collected at referral and again 6 months later. RESULTS: Three hundred and thirty-two patients were entered into the study. MRI led to previously unsuspected diagnosis in 69 of 269 patients with available data. When MRI confirmed the clinical diagnosis, significant improvements in clinicians' diagnostic confidence were found (P < 0.01 for medical meniscus, P < 0.05 lateral meniscus, P < 0.05 anterior cruciate). MRI led to a change in management in 180 (63%) of 288 patients (where data available). There was a significant shift away from surgical management after MRI (P < 0.01). SF-36 results were available in 206 patients. There was a significant improvement over time in five of the eight SF-36 scales (four at P < 0.001, one at P < 0.01). CONCLUSIONS: Magnetic resonance imaging significantly influences clinicians' diagnoses and management plans. These patients, examined by MRI, also recorded an improvement in health related quality of life.

Comparative audit of blood transfusion during war and peace in Sarajevo.

A comparative study was made between 146 patients receiving blood transfusion at the State Hospital, Sarajevo, in a 3-month period of peace (group 1) and 250 patients receiving transfusions in a 3-month period of war (group 2). In group 1, trauma accounted for only 7% of transfusions while it accounted for 99% in group 2. The threshold for transfusion was increased in war and the mean pretransfusion haematocrit in group 2 was 21%, compared with 27% in group 1 (P < 0.001). Less blood was also transfused per patient in war with a mean transfusion volume of 1.1 units in group 2 compared with 2.6 units in group 1 (P < 0.001). The reasons and justification for such a conservative transfusion practice in a besieged city are discussed.

Errors at knee magnetic resonance imaging: true or false?

Amongst a series of 332 patients undergoing a prospective evaluation of the influence of magnetic resonance imaging (MRI) on diagnosis and outcome, arthroscopic correlation became available in 92 knees (91 patients). The MRI report, the arthroscopic findings and the patient's case notes were reviewed by a consensus panel. With respect to the menisci and cruciate ligaments, the formal radiological report was at variance with the arthroscopic findings in 22/349 sites where there had been no previous surgery (10 medial meniscus, six lateral meniscus and six anterior cruciate ligament). 12 of these 22 errors were considered, on review, to be genuine MRI errors. However, considerable controversy remains as to whether the other 10 "errors" were true or false. There are several factors which contribute to such controversy. These include technically difficult arthroscopies, delays between MRI and arthroscopy, and ambiguities in the wording of both the referral letter and the radiological report. These factors should be considered when evaluating the diagnostic performance of both MRI and arthroscopy.

Haemophilus aphrophilus discitis and vertebral osteomyelitis.

An unusual case of discitis and vertebral osteomyelitis due to Haemophilus aphrophilus is described. Infections due to this organism have usually responded to treatment with beta-lactam antibiotics. However, our isolate was resistant to third-generation cephalosporins which has not been reported previously in the world literature. The patient made a good clinical response to ciprofloxacin treatment.

Arthroscopic loose body retrieval following traumatic hip dislocation.

Traumatic dislocation of the hip is associated with considerable morbidity due to the risk of aseptic necrosis and post-injury arthritis, which is greater in the presence of an associated fracture. Computed tomography after a traumatic dislocation may reveal loose bone fragments within the weight-bearing area of the joint. We advocate the early arthroscopic retrieval of loose bone fragments to preserve the articular surface, as the retention of such fragments may lead to a less satisfactory long-term result. Arthroscopic surgery is associated with less morbidity than open arthrotomy.

Arthroscopic anatomy of the hip: an in vivo study.

Hip arthroscopy is an exciting, new, and expanding field of orthopaedic surgery. The anatomy seen arthroscopically is considerably enlarged and more extensive than described in the classical anatomy texts. Orthopaedic surgeons must be familiar with the normal arthroscopic anatomy before embarking on hip arthroscopy.

Direct anatomical-MRI correlation: the knee.

Cadaveric material is often used to guide and validate the interpretation of magnetic resonance imaging (MRI) studies. Direct correlation is achieved when the cadaver material is imaged and then directly sectioned in the plane of the image. Indirect correlation, where the cadaveric sections are compared with unrelated in-vivo images, is easier and more commonly used. Technical difficulties associated with the direct method include preservation of form and composition of the tissues, and the choice of the correct location and plane in which to section the cadaver. Using an MRI compatible ruler, designed to assist the direct correlation of MRI and cadaveric sections, we have examined 10 preserved (embalmed) cadaveric knees using different MRI sequences on several occasions. Despite these variations, subsequent sectioning of the cadaveric knees has shown good correlation with the MR images. Of 54 MR images compared with cadaveric sections, anatomical correlation was rated by independent observers as good or perfect in 47 (87%). This new, versatile and simple method can make better use of our preserved human cadaveric material and has potentially wide application; we are now developing it further to assess the technical capabilities of novel imaging sequences.

Mortality and morbidity after hip fractures.

OBJECTIVE: To study the mortality and morbidity associated with proximal femoral fractures with reference to fracture type (intracapsular and extracapsular). DESIGN: Consecutive prospective study with 12 month follow ups. SETTING: Two British trauma receiving centres. PATIENTS: 1000 consecutive acute proximal femoral fractures (fractured necks of femur) in 972 patients. RESULTS: Significantly higher mortality at one year was seen in patients with extracapsular fractures (188/490; 38%) than in those with intracapsular fractures (147/510; 29%; p < 0.01). Greater morbidity was experienced during the study period by patients with extracapsular fractures, who were less mobile and less independent at the time of their injury. CONCLUSIONS: The rise in average age of presentation with proximal femoral fracture is associated with a persistently high mortality (33%) and morbidity, greater in patients with an extracapsular fracture. Comparison with other studies, principally from outside Britain, is difficult, but despite advancing standards of care the mortality and morbidity of femoral neck fractures remains high, placing an ever increasing burden on the health service.

Hemiarthroplasty of the hip--the anterior or posterior approach? A comparison of surgical approaches.

A series of 531 patients presenting with a displaced subcapital femoral fracture treated by hemiarthroplasty, were studied prospectively to determine the optimal approach for surgery. A total of 302 prostheses were inserted by an anterolateral approach and 229 by a posterolateral approach. Complications in these two broadly comparable groups are discussed. Dislocation and thrombosis were more common after a posterior approach. Operative time, blood loss, and infection, were greater after an anterior approach. There was no significant difference in the length of hospital stay or mortality. Our findings suggest that favoured approach should be that at which the surgeon feels more competent.