Dual mobility total hip replacement in a high risk population.

OBJECTIVE: The purpose of the study was to evaluate results of dual mobility total replacement in a high risk population who take hip into hyperflexed position while sitting and praying on the floor. METHOD: The study included 65 (35 primary total replacement and 30 complex total hip replacement) cases of total hip replacement using avantage privilege dual mobility cup system from biomet. A cemented acetabular component and on femoral side a bimetric stem, either cemented or uncemented used depending on the canal type. Ten cases were examined fluoroscopically in follow up. RESULT: There was dislocation in one patient undergoing complex hip replacement. Fluoroscopy study showed no impingement between the neck of prosthesis and acetabular shell at extremes of all movements. CONCLUSION: The prevalence of dislocation is low in our high risk population and we consider it preferred concept for patients undergoing complex total hip replacement.

Minimally invasive exchange tibial nailing for a broken solid nail: case report and description of a new technique.

We present a minimally invasive technique for the removal of a broken solid tibial nail. A special device was invented that minimizes the extraction difficulties. After minimal over-reaming, the device is slid in an antegrade fashion over the nail and locked. Retraction is safe and easy. This article is an illustrative case-presentation describing the device and the surgical technique.

A comparison of plates with and without locking screws in a calcaneal fracture model.

BACKGROUND: We compared different plates in an experimental calcaneal fracture model under biocompatible loading. METHODS: Four plates were tested: a plate without locked screws (Synthes), and three different plates with locked screws (Newdeal, Darco, Synthes). Synthetic calcanei (Sawbone) were osteotomized to create a fracture model, and the plates were fixed onto them. Seven specimens for each plate model were subjected to cyclic loading (preload 20 N, 1,000 cycles with 800 N, 0.75 mm/s), and load to failure (0.75 mm/s). Motion, forces, plastic deformation of the plate, and consequent depression of the posterior joint facet were analyzed. RESULTS: During cyclic loading, all plates with locked screws showed statistically significant lower displacement in the primary loading direction than the plates without locked screws. Mean values (mm) of maximal displacements for each plate during cyclic loading were as follows: Synthes, 3.5; Darco, 4.5; Newdeal, 5.0; Synthes without locked screws, 7.5; (p < 0.001). No statistically significant differences between the plates were found in relation to loads to failure and corresponding displacement. CONCLUSION: This is the first biomechanical study to assess the stability of different plates currently in use in our practice for the fixation of calcaneal fractures. Our results showed that plates with locked screws provided greater stability during cyclic loading than the plate without locked screws.

Long-term quality of life in trauma patients following the full spectrum of tibial injury (fasciotomy, closed fracture, grade IIIB/IIIC open fracture and amputation).

AIMS AND OBJECTIVES: To measure long-term functional outcome and health-related quality of life following tibial fracture in association with the full spectrum of soft tissue injury. METHODS: One hundred and thirty patients with different types of tibial injury were selected from our trauma database. This included 33 patients with compartment syndrome (no underlying fracture), 30 with closed diaphyseal tibial fractures, 45 with grade IIIB/IIIC open fractures and 22 requiring below knee amputation. Mean time to final follow-up was 37.4 months. The EQ-5D (EuroQol) questionnaire was used to assess these patients at this point. Patients had been treated according to standard unit protocols. Open fractures were jointly managed under the care of local plastic and orthopaedic surgeons using a policy of obtaining early soft tissue cover. RESULTS: Patients with reconstructed IIIB fractures reported problems with pain and carrying out their normal activities more frequently than amputees whilst still reporting problems with mobility just as frequently. Anxiety and depression were more common in the patients with open fractures and amputees as were problems with self-care, though the latter were unusual overall. Stepwise logistic regression revealed that tibial injury type was significantly predictive of all measured outcomes except self-care (p<0.0001). Age, ISS, sex and time to follow-up were not significant predictors of response. CONCLUSIONS: These results show that patients with these injuries still report long-term problems with their health-related quality of life, though to varying degrees. This information is useful when determining the treatment options for these patients and it is important that it is shared with the patient prior to surgery where possible.

Screw placement in slipped upper femoral epiphysis: is good the enemy of better?

Introduction and aims A single hip screw is the recommended method of fixation for slipped upper femoral epiphysis (SUFE). Current practice favours the placement of the screw in the centre of the femoral head on both anteroposterior and lateral planes to avoid the risks of chondrolysis and avascular necrosis (AVN). We investigated the correlation between different positions of the screw in the femoral head and the prevalence of AVN, chondrolysis, late slippage and the time to epiphyseal closure. Methods The clinical notes and radiographs of 38 consecutive patients (61 hips) who underwent single screw fixation for SUFE were evaluated retrospectively with a mean follow-up of 36 months. Two-way ANOVA and the post hoc test was performed to analyse the correlation between the different variables and the outcome at the 5% level of significance. Results There were 16 acute slips, 18 chronic slips and ten acute-on-chronic slips. Seventeen slips were treated prophylactically. Mild slip was encountered in 39 hips, moderate slip in four and severe slip in one. The central-central position was only achieved in 51% of cases. The most significant results of the study were as follows: (1) no significant difference between the time to epiphyseal closure and the position of the screw, and (2) no late slippage or chondrolysis was observed in our series. Conclusion Our results showed that the positioning of the screw other than in the centre of the femoral head has the ability to provide physeal stability and has no correlation with the timing to closure of the epiphysis and the risk of avascular necrosis or chondrolysis. We therefore recommend that other positions be considered if the "optimal central-central position" is not initially achieved - specifically for the treatment of mild slip - as the potential hazards from several attempts to achieve the optimum position outweigh the benefits.

Staged management and outcome of combined pelvic and liver trauma. An international experience of the deadly duo.

Pelvic fracture associated with liver trauma is not an uncommon injury combination in multiple trauma and is associated with high morbidity and mortality. The aim of this study was to examine the characteristics of this specific patient group, to describe the diagnostic and treatment protocols and finally to analyse risk factors associated with mortality. Data were collected over a 6-year period, ending in 2001. The pelvic injury was graded according to the Tile classification system and the hepatic injury was scored using the organ injury scale (OIS). Treatment protocol, associated injuries, complications, length of ICU/Hospital stay and mortality were recorded and analysed. A total of 140 patients (40% female) with a mean age of 35.1+/-15.9 years and a median ISS of 41 were included in this study. The overall mortality rate was 40.7%. Binomial logistic regression analysis revealed age, initial blood pressure, transfusion requirement as well as the severity of head, chest, spleen and liver injury as independent parameters predicting reduced survival rates. This deadly duo of injuries presents a challenge to the trauma surgeon. Rapid assessment and treatment is required to prevent death by haemorrhage. The presence of concomitant injuries renders the patient very sensitive to ongoing or additional physiological disturbance. The principles of 'damage control surgery' must be applied to avoid complications such as acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS).