Peri-operative Morbidity Associated with Bilateral Hip Arthroplasty for Inflammatory Arthritis: Results from a Consecutive Series of 168 Hips.

AIM: This study aims to assess the risks and peri-operative morbidity associated with a single-stage sequential bilateral hip arthroplasty (SBHA) when performed in patients with arthritis secondary to inflammatory arthropathy. METHODS: Data of patients who underwent SBHA between 2012 and 2018 for inflammatory arthritis were extracted from a database, for peri-operative complications and functional improvement. SBHA for other causes was excluded. RESULTS: Data of 84 consecutive patients with a mean age of 34.5 years were analyzed. The mean follow-up was 2.4 years. 66% had ankylosing spondylitis, while 14% had rheumatoid arthritis. 50% of the patients had bilateral fusion of the hips, and 34% had flexion deformity > 30°.None of the patients had peri-operative cardiac or pulmonary complications. 2.4% had per-operative hypotension (MAP < 50 mmHg) and 1.2% had desaturation (SpO2 < 90%). The mean drop in hematocrit was 9.3%. While 31% did not require blood transfusion, 35% required more than 1 unit of blood. Patients with pre-operative PCV of > 36% had a significantly lower risk of being transfused > 1 unit of blood (p = 0.02). ICU admission was 6%-mostly for post-operative monitoring. While one patient had a local hematoma that needed a wash-out, there were no infections, dislocations, or mortality in these patients. The modified Harris hip score improved from a mean of 26.5-85. The mean hip flexion improved post-operatively from 32° to 92°. CONCLUSIONS: SBHA for inflammatory arthritis can be performed with minimum complications in a multidisciplinary setting. Pre-operatively, PCV of > 36 is advised to reduce transfusion rates.

Subtrochanteric femoral shortening for hip centre restoration in complex total hip arthroplasty with functional outcome.

AIMS: Complex total hip arthroplasty (THA) with subtrochanteric shortening osteotomy is necessary in conditions other than developmental dysplasia of the hip (DDH) and septic arthritis sequelae with significant proximal femur migration. Our aim was to evaluate the hip centre restoration with THAs in these hips. METHODS: In all, 27 THAs in 25 patients requiring THA with femoral shortening between 2012 and 2019 were assessed. Bilateral shortening was required in two patients. Subtrochanteric shortening was required in 14 out of 27 hips (51.9%) with aetiology other than DDH or septic arthritis. Vertical centre of rotation (VCOR), horizontal centre of rotation, offset, and functional outcome was calculated. The mean followup was 24.4 months (5 to 92 months). RESULTS: The mean VCOR was 17.43 mm (9.5 to 27 mm) and horizontal centre of rotation (HCOR) was 24.79 mm (17.2 to 37.6 mm). Dislocation at three months following acetabulum reconstruction required femoral shortening for offset correction and hip centre restoration in one hip. Mean horizontal offset was 39.72 (32.7 to 48.2 mm) compared to 42.89 (26.7 to 50.6 mm) on the normal side. Mean Harris Hip Score (HHS) of 22.64 (14 to 35) improved to 79.43 (68 to 92). Mean pre-operative shortening was 3.95 cm (2 to 8 cm). Residual limb length discrepancy was 1.5 cm (0 to 2 cm). Sciatic neuropraxia in two patients recovered by six months, and femoral neuropraxia in one hip recovered by 12 months. Mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was 13.92 (9 to 19). Mean 12-item short form survey (SF-12) physical scores of 50.6 and mental of 60.12 were obtained. CONCLUSION: THA with subtrochanteric shortening is valuable in complex hips with high dislocation. The restoration of the hip centre of rotation and offset is important in these hips. LEVEL OF EVIDENCE IV: Femoral shortening useful in conditions other than DDH and septic sequelae.Restoration of hip centre combined with offset to be planned and ensured.

Is it safe to do a single-stage implant exit and primary hip replacement? clinical and microbiological profiling.

Background: A single-stage implant revision for failed fixation of proximal femoral fractures is performed only when there is no evidence of infection. Else, a two-staged revision is preferred - where the definitive revision surgery is done a few months after the implant exit. This study aims to audit the safety and incidence of culture positivity in single-stage revisions. Materials and Methods: Forty one of 284 patients that presented over the last 12 years for implant exchange of the hip, had a single stage revision surgery for failed fixation of a fracture of the hip, as there was no obvious evidence of infection at the time of implant exit. Results: Micro-organisms were grown in 51% of the 41 hips. 76% were gram positive, of which 63% were Coagulase negative staphylococci (CoNS). 50% of CoNS and 75% of S. aureus were resistant to oxacillin, but susceptible to Vancomycin. Of the gram negative organisms, 2 (Enterobacter sp) were resistant to carbapenam, while others were susceptible. Preoperative ESR and CRP, individually, had low specificity - 50% for ESR >30mm at 1 hour and 62% for CRP>10. The combined use of ESR > 30mm and CRP>10 increased the specificity to 90%. 12% of the patients had immediate postoperative complications that required a wash out in theatre. The long term clinical follow up of these patients is limited. Conclusion: This study suggests that implant exit and simultaneous arthroplasty for failed fracture fixation should be done with caution due to the high possibility of infection. It may be prudent to opt for a 2 stage revision.

Proprioceptive changes in the contralateral knee joint following anterior cruciate injury.

Loss of proprioception following an anterior cruciate ligament (ACL) injury has been well documented. We evaluated proprioception in both the injured and the uninjured limb in 25 patients with ACL injury and in 25 healthy controls, as assessed by joint position sense (JPS), the threshold for the detection of passive movement (TDPM) and postural sway during single-limb stance on a force plate. There were significant proprioceptive deficits in both ACL-deficient and uninjured knees compared with control knees, as assessed by the angle reproduction test (on JPS) and postural sway on single limb stance. The degree of loss of proprioception in the ACL-deficient knee and the unaffected contralateral knee joint in the same patient was similar. The TDPM in the injured knee was significantly higher than that of controls at 30° and 70° of flexion. The TDPM of the contralateral knee joint was not significantly different from that in controls. Based on these findings, the effect of proprioceptive training of the contralateral uninjured knee should be explored.

Benign tumors and tumor-like lesions of the calcaneum: a study of 12 cases.

UNLABELLED: Benign tumors of the calcaneum are rare. Cystic lesions such as simple bone cysts and aneurysmal bone cysts are commonly seen. AIMS AND OBJECTIVES: To evaluate tumors of the calcaneum, which were seen over a 12-year period. MATERIALS AND METHODS: We analyzed noninfectious, noninflammatory, benign lesions of the calcaneum seen in the Orthopedic Out Patient Department from 1991 to 2003. Twelve such tumors were encountered. There were 11 males and one female and their ages varied from 18 to 53 years with a median of 31. Data was collected from the histopathology reports, radiographs, and inpatient and outpatient records. One of the coauthors reviewed the histopathologic findings of all the tumors. RESULTS: Twelve benign lesions were seen in 12 patients. In our series, cysts predominated, with three aneurysmal bone cysts and five simple bone cysts. The other benign tumors were: one fibrous dysplasia, one vascular hamartoma, one osteoblastoma, and one chondromyxoid fibroma. The bone cysts were treated by curettage, with or without bone grafting, except for one large aneurysmal bone cyst, which was treated by excision of the calcaneum. The postoperative function in this patient was good, with modified footwear. CONCLUSION: The calcaneum is an uncommon site for most bone tumors, and in our series, bone cysts were the most common benign lesions. Curettage and bone grafting or the use of bone substitutes can be effectively used in the treatment of symptomatic bone cysts of the calcaneum.

Slipped upper femoral epiphysis in Hashimoto's thyroiditis in a 29-year-old man.

Slipped upper femoral epiphysis (SUFE) with an open physis is rare in an adult and the condition may present without prior diagnosis of an underlying medical condition. We have treated a 29-year-old man with bilateral SUFE associated with autoimmune hypothyroidism. The management was delayed and complicated by co-existing autoimmune chronic active hepatitis. He underwent thyroxine therapy and bilateral pinning in situ with a single ASNIS screw. Closure of the physis occurred after five months on the right side. The left side required a further corrective intertrochanteric osteotomy, and it was only after 13 months that complete fusion of this physis was seen. The case highlights the need to consider endocrine and metabolic conditions in atypical presentation of SUFE.

The "dot-in-circle" sign -- a characteristic MRI finding in mycetoma foot: a report of three cases.

Three patients referred for MRI of the foot were found to have imaging features characteristic of mycetoma. Two patients presented with recurrent soft tissue masses, which were operated on several times and not suspected to be of infective aetiology. The third patient had typical clinical features with a history of blackish granule discharge. In all three patients, MRI showed conglomerate areas of small round discrete T(2) weighted hyperintense lesions, representing granulation tissue surrounded by a low-signal-intensity rim representing intervening fibrous septa. Within many of these hyperintense lesions, there was a central low-signal-intensity dot, which gives rise to the "dot-in-circle" sign that has been very rarely described in the literature. This sign is an easily recognisable and unique appearance that is highly suggestive of mycetoma.

Chronic rupture of the extensor apparatus of the knee joint.

Chronic ruptures of the extensor mechanism of the knee are uncommon injuries, and previously reported literature assumes the presence of an intact patella for repair. We present a case of chronic rupture following patellectomy done twelve years previously. The defect in the extensor apparatus was extensive (18cm), and this was bridged using a large fascia lata graft from the opposite thigh, with reasonably successful results.