There are well-established guidelines for musculoskeletal and connective tissue disorders in the assessment of potential recruits. There have been no critical appraisals of the application of these guidelines since their recent revision. The aim of this study was to examine whether common presenting conditions are covered by the guidelines and whether there was adherence by the assessor to the recommended outcome. We reviewed 110 potential recruits presenting to an Orthopaedic Consultant. There were a number of conditions not covered and a few occasions when the decision seemed contrary to the guidelines. In particular we think more consideration is needed of congenital deformities.

Objective: The purpose of this study was to evaluate the type and the dosage regimer the antibiotics administered prophylactically or curatively in six orthopaedic departments of «KAT» hospital.

Material-Method: Our study group consisted of 1231 patients who were hospitalized between September and November 2003. 1002 patients were treated surgically whilst 229 patients were managed conservatively. Among the patients who were operated 270 underwent THR or TKR, 306 patients were operated for NOF fracture, 195 patients were admitted because of long-bone fractures, 30 patients were operated for fracture or chronic deformity of the hand or the foot, 26 patients for open fractures, 52 patients underwent spine surgery and finally 53 patients were admitted for metal work removal.

Results: All patients were given antibiotics as prophylaxis for a period of 1–7 days 8 patients received antibiotics based on the cultures whilst 113 patients received empiric chemotherapy for some kind of infection. The microbiology lab recorded the microflora in every department and the percentage of resistance of the most important pathogens. Those were: 47% Gram(+) (45% staphylococcus) and 53% Gram(−). Of the identified staphylococci 44% were MR. MRSA-CNS was detected to be completely resistant to b-lactams and at a percentage up to 80% to amynoglycosides. The percentage of resistance of Pseudomonas was 55% to quinolones, 48% to aminoglycosides and 90% to b-lactams. We did notice that the use of the antibiotics was not based on a specific antibiotic policy and in a high percentage; the empirical use of chemotherapy was not documented on the laboratory data.

Conclusion: Taking into consideration the modern scientific data regarding the antibiotic treatment; the rational use of antibiotics in clinical practice requires the implementation of policies, the continuous education of the doctors as well as the intervention for proper prescriptions.

3D imaging is commonly employed in the surgical planning and management of bony deformity. The advent of desktop 3D printing now allows rapid in-house production of specific anatomical models to facilitate surgical planning. The aim of this pilot study was to evaluate the feasibility of creating 3D printed models in a university hospital setting.

For requested cases of interest, CT DICOM images on the local NHS Picture Archive System were anonymised and transferred. Images were then segmented into 3D models of the bones, cleaned to remove artefacts, and orientated for printing with preservation of the regions of interest. The models were printed in polylactic acid (PLA), a biodegradable thermoplastic, on the CubeX Duo 3D printer.

PLA models were produced for 4 clinical cases; a complex forearm deformity as a result of malunited childhood fracture, a pelvic discontinuity with severe acetabular deficiency following explantation of an infected total hip replacement, a chronically dislocated radial head causing complex elbow deformity as a result of a severe skeletal dysplasia, and a preoperative model of a deficient proximal tibia as a result of a severe tibia fracture. The models materially influenced clinical decision making, surgical intervention planning and required equipment. In the case of forearm an articulating model was constructed allowing the site of impingement between radius and ulnar to be identified, an osteotomy was practiced on multiple models allowing elimination of the block to supination. This has not previously been described in literature. The acetabulum model allowed pre-contouring of a posterior column plate which was then sterilised and eliminated a time consuming intraoperative step.

While once specialist and expensive, in house 3D printing is now economically viable and a helpful tool in the management of complex patients.

Cite this article: Bone Joint Res 2025;14(1):16–19.

Introduction. With advances in artificial intelligence, the use of computer-aided detection and diagnosis in clinical imaging is gaining traction. Typically, very large datasets are required to train machine-learning models, potentially limiting use of this technology when only small datasets are available. This study investigated whether pretraining of fracture detection models on large, existing datasets could improve the performance of the model when locating and classifying wrist fractures in a small X-ray image dataset. This concept is termed “transfer learning”. Method. Firstly, three detection models, namely, the faster region-based convolutional neural network (faster R-CNN), you only look once version eight (YOLOv8), and RetinaNet, were pretrained using the large, freely available dataset, common objects in context (COCO) (330000 images). Secondly, these models were pretrained using an open-source wrist X-ray dataset called “Graz Paediatric Wrist Digital X-rays” (GRAZPEDWRI-DX) on a (1) fracture detection dataset (20327 images) and (2) fracture location and classification dataset (14390 images). An orthopaedic surgeon classified the small available dataset of 776 distal radius X-rays (Arbeidsgmeischaft für Osteosynthesefragen Foundation / Orthopaedic Trauma Association; AO/OTA), on which the models were tested. Result. Detection models without pre-training on the large datasets were the least precise when tested on the small distal radius dataset. The model with the best accuracy to detect and classify wrist fractures was the YOLOv8 model pretrained on the GRAZPEDWRI-DX fracture detection dataset (mean average precision at intersection over union of 50=59.7%). This model showed up to 33.6% improved detection precision compared to the same models with no pre-training. Conclusion. Optimisation of machine-learning models can be challenging when only relatively small datasets are available. The findings of this study support the potential of transfer learning from large datasets to improve model performance in smaller datasets. This is encouraging for wider application of machine-learning technology in medical imaging evaluation, including less common orthopaedic pathologies

Introduction. Acetabular bone defects are still challenging to quantify. Numerous classification schemes have been proposed to categorize the diverse kinds of defects. However, these classification schemes are mainly descriptive and hence it remains difficult to apply them in pre-clinical testing, implant development and pre-operative planning. By reconstructing the native situation of a defect pelvis using a Statistical Shape Model (SSM), a more quantitative analysis of the bone defects could be performed. The aim of this study is to develop such a SSM and to validate its accuracy using relevant clinical scenarios and parameters. Methods. An SSM was built on the basis of segmented 66 CT dataset of the pelvis showing no orthopedic pathology. By adjusting the SSM's so called modes of shape variation it is possible to synthetize new 3D pelvis shapes. By fitting the SSM to intact normal parts of an anatomical structure, missing or pathological regions can be extrapolated plausibly. The validity of the SSM was tested by a Leave-one-out study, whereby one pelvis at a time was removed from the 66 pelvises and was reconstructed using a SSM of the remaining 65 pelvises. The reconstruction accuracy was assessed by comparing each original pelvis with its reconstruction based on the root-mean-square (RMS) surface error and five clinical parameters (center of rotation, acetabulum diameter, inclination, anteversion, and volume). The influence of six different numbers of shape variation modes (reflecting the degrees of freedom of the SSM) and four different mask sizes (reflecting different clinical scenarios) was analyzed. Results. The Leave-one-out study showed that the reconstruction errors decreased when the number of shape variation modes included in the SSM increased from 0 to 20, but remained almost constant for higher numbers of shape variation modes. For the SSM with 20 shape variation modes, the RMS of the reconstruction error increased with increasing mask size, whereas the other parameters only increased from Mask_0 to Mask_1, but remained almost constant for Mask_1, Mask_2 and Mask_3. Median reconstruction errors for Mask_1, Mask_2, and Mask_3 were approximately 3 mm in Center of Rotation (CoR) position, 2 mm in Diameter, 3° in inclination and anteversion, as well as 5 ml in volume. Discussion. This is the first study analyzing and showing the feasibility of a quantitative analysis of acetabular bone defects using a SSM-based reconstruction method in the clinical scenario of a defect or implant in both acetabuli and incomplete CT-scans. Validation results showed acceptable reconstruction accuracy, also for clinical scenarios in which less healthy bone remains. Further studies could apply this method on a larger number of defect pelvises to obtain quantitative measures of acetabular bone defects

A commonly misunderstood principle in medical literature is statistical significance. Often, statistically non-significant or negative results are thought to be evidence for equivalence; mistakenly validating treatment modalities and putting patients at risk. This study examines the prevalence of misinterpretation of negative results of superiority trials in orthopaedic literature and outlines the need for a non-inferiority or equivalence research design. Four orthopaedic journals – Journal of Paediatric Orthopaedics A, Journal of Bone and Joint Surgery American Volume, Journal of Arthroplasty and Journal of Shoulder and Elbow Surgery – were hand searched to identify all randomised control trials (RCTs) published within the time periods 2002–2003, 2007–2008 and 2012–2013. The identified RCTs were read and classified by study methodology, results obtained, and interpretation of results. A total of 237 RCTs were identified. When analysing the primary outcomes, 117 (49.4%) studies yielded negative results and 120 (50.8%) yielded positive results. Out of the 237 articles, 231 (97.5%) used superiority methodology and 6 (2.5%) used non-inferiority or equivalence methodology. Of the 231 studies that used superiority methodology, 115 (49.8%) obtained negative results; and 45 (39.1%) of those misinterpreted the negative results for equivalence. While no statistical differences were seen, there was an upward trend in utilising non-inferiority and equivalence methodologies over time. Given the frequency of misinterpreted negative results, there is an evident need for a more appropriate research methodology that shows equivalence of treatment methods. A non-inferiority or equivalence study design can address orthopaedic clinical dilemmas more suitably when trying to show one treatment is no worse or is equal to another treatment. Regarding orthopaedic treatment modalities as equivalent when studies show negative statistical results can be detrimental to patients and their clinical outcomes. A non-inferiority methodology can be used to accurately depict no difference between treatment methods rather than attempting to show one treatment method as superior

Purpose: This research project compared the accuracy of 3 methods of meniscal injury diagnosis that are commonly employed in a clinical orthopaedics: Clinical examination, MRI and Arthroscopic surgery. Method: A retrospective review of charting was used to collect meniscal injury assessment data for 116 patients that had sustained an acute anterior cruciate ligament injury to one knee. Sixty-eight of the 116 patients had the presence of a meniscal lesion confirmed via surgery. Sensitivity and specificity of “hands on” clinical examination and MRI interpretation were determined using the results of arthroscopic surgery as the gold standard. Sensitivity and specificity of “hands on” clinical examination relative to MRI interpretation was also calculated. Finally, the findings of all three methods of meniscal evaluation were compared. Results: Accuracy testing demonstrated that the sensitivity and specificity of clinical examinations (0.54 / 0.81) was comparable to levels observed for MRI (0.69 / 0.70), and when directly comparing the findings of clinical examination against MRI, that there was a high level of agreement when a meniscal lesion was not present (specificity: 0.91), but a much lower level of agreement when a meniscal lesion was suspected (sensitivity: 0.54). In general, when comparing the findings from clinical examination, MRI, and arthroscopic surgery, complete agreement among all 3 methods of evaluation occurred in only 51% of the patients. Conclusion: Our results serve to highlight the inaccuracies associated with meniscal injury assessment when evaluating an acutely traumatized knee joint, and suggest that the incidence of secondary joint trauma following ligament injury may be under predicted

With the increasing availability of magnetic resonance imaging, there is potentially less emphasis being placed on making a definitive clinical diagnosis. Changes in the undergraduate curriculum have also reduced the emphasis on orthopaedic clinical evaluation. This aim of this study was to evaluate the predictability of clinical examination alone in comparison with arthroscopic findings in 50 consecutive patients presenting for arthroscopy to our service. Four trainees examined each patient; each examiner was blinded to the clinical diagnosis made by their colleagues. All patients were examined in the ward and subsequently underwent examination under anaesthesia and arthroscopy. Of the tests for meniscal injuries joint line tenderness was the most sensitive (77%) and specific (68%). Apley’s and McMurray’s test while specific (92%, 98%) lacked sensitivity (9%, 30%). Overall the tests for anterior cruciate ligament (ACL) disruption were more reliable than the tests for meniscal injuries. The anterior drawer and Lachmann tests had high specificity (90%, 75%) and sensitivity. The pivot shift test also had very high specificity (75%) and sensitivity (98%) for detecting ACL injuries. These data demonstrate that joint line tenderness is the most reliable sign of menis-cal injury. In the absence of joint line tenderness Apley & McMurray’s tests have little role in routine clinical examination. Clinical tests and signs of ACL deficiency are consistently reliable in diagnosing ACL rupture

Introduction. The National Institute for Health and Clinical Effectiveness recommends both low molecular weight heparin (LMWH) and Rivaroxaban for venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. Despite evidence in the literature that suggests Rivaroxaban reduces VTE events, there are emerging concerns from the orthopaedic community regarding an increase in wound complications following its use. Methods. Through the orthopaedic clinical directors forum, Trusts replacing LMWH with Rivaroxaban for lower limb arthroplasty thromboprophylaxis during 2009 were identified. Prospectively collected Hospital episode statistics (HES) data was then analysed for these units so as to determine rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary thromboembolism (PTE), major bleed (cerebrovascular accident or gastrointestinal haemorrhage), all-cause mortality, and 30-day wound infection and readmission rates before and after the change to Rivaroxaban. 2752 patients prescribed Rivaroxaban following TKR or THR were compared to 10358 patients prescribed LMWH. Data was analysed using odds ratios (OR). Results. There were significantly more wound infections in the Rivaroxaban group (3.85% vs. 2.81%, OR=0.72; 95% CI 0.58-0.90). There were no significant differences between the two groups for PTE (OR=1.52; 0.77-2.97), major bleed (OR=0.73; 0.48-1.12), all-cause mortality (OR=0.93; 0.46-1.87) and re-admission rate (OR=1.21; 0.88-1.67). There were significantly fewer symptomatic DVTs in the Rivaroxaban group (0.91% vs. 0.36%, OR=2.51; 1.30-4.82). Conclusion. This study is the first to describe the real impact of the use of Rivaroxaban in the NHS. When compared with LMWH in lower limb arthroplasty patients, wound infection rates were significantly higher following Rivaroxaban use whilst providing no reduction in symptomatic PTE or all-cause mortality

The Orthopaedic National Programme aims to co-ordinate the provision of efficient orthopaedic and trauma service to central, provincial and rural hospitals. The country is divided into southern, central and northern regions, each with a central hospital with orthopaedic surgeons. The 1 500-bed Central Hospital in Maputo is the national referral centre and the teaching hospital for Eduardo Mondlane University. The orthopaedic department has 200 beds and 12 orthopaedic surgeons. In each provincial hospital an orthopaedic surgeon provides specialist care and supports and supervises the surgical paramedical staff at district and rural hospitals. The referring hospitals have been equipped to provide conservative treatment. The types of fractures that should be treated surgically have been clearly defined. In some rural hospitals with surgical facilities, there are well-trained surgical paramedics, but where possible patients are treated conservatively. We guarantee the supply of equipment and material and provide regular refresher training. In Mozambique fractures constitute more than 70% of the orthopaedic pathology. In adults the most common are fractures of the femur, tibia, forearm and arm. In children under 16 years, 60% of hospital admissions are for trauma, usually sustained in falls from trees or vehicle accidents. Infections account for 30% of admissions, and other causes for the remainder. In contrast with developed countries, we have few patients with fractures due to osteoporosis

Background. The National Institute for Health and Clinical Effectiveness recommends both low molecular weight heparin (LMWH) and Rivaroxaban for venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. Despite evidence in the literature that suggests Rivaroxaban reduces VTE events, there are emerging concerns from the orthopaedic community regarding an increase in wound complications following its use. Methods. Through the orthopaedic clinical directors forum, Trusts replacing LMWH with Rivaroxaban for lower limb arthroplasty thromboprophylaxis during 2009 were identified. Prospectively collected Hospital episode statistics (HES) data was then analysed for these units so as to determine rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary embolism (PE), major bleed (cerebrovascular accident or gastrointestinal haemorrhage), all-cause mortality, and 30-day wound infection and readmission rates before and after the change to Rivaroxaban. 2752 patients prescribed Rivaroxaban following TKR or THR were compared to 10358 patients prescribed LMWH. Data was analysed using odds ratios (OR). Results. There were significantly more wound infections in the Rivaroxaban group (3.85% vs. 2.81%, OR=0.72; 95% CI 0.58–0.90). There were no significant differences between the two groups for PE (OR=1.52; 0.77–2.97), major bleed (OR=0.73; 0.48–1.12), all-cause mortality (OR=0.93; 0.46–1.87) and re-admission rate (OR=1.21; 0.88–1.67). There were significantly fewer symptomatic DVTs in the Rivaroxaban group (0.91% vs. 0.36%, OR=2.51; 1.30–4.82). Discussion. This study is the first to describe the real impact of the use of Rivaroxaban in the NHS. When compared with LMWH in lower limb arthroplasty patients, there were fewer DVTs in the Rivaroxaban group. However, wound infection rates were significantly higher following Rivaroxaban use whilst providing no reduction in symptomatic PE or all-cause mortality

To clinically diagnose and postoperatively monitor the younger or more demanding orthopaedic patients it becomes increasingly important to measure function beyond the capacity of classic scores suffering from subjectivity, pain dominance and ceiling effects. This study investigates whether a stair climbing test with accelerometer derived motion parameters in a group of healthy subjects is clinically feasible and valid to distinguish between demographic differences. The ascending and descending of stairs (preferred speed, no handrails) was measured in 46 healthy subjects (19m/27f, no orthopaedic pathology) using a triaxial accelerometer attached with a belt to the sacrum. The study group was divided in two age groups: young group (15m/16f; age: 25 [21–38]) and old group (4m/11f; age: 67 [54–74]). Motion parameters were derived by acceleration peak detection algorithms based on step times: tup, tdown, tup-tdown,, step irregularity: irrup, irrdown and asymmetry: asymup, asymdown. Step times were slightly higher ascending (tup=606ms) than descending (tdown=575ms, p< 0.05). The step time difference between ascending and descending (tup-tdown=31ms) showed a significant difference between the young (47ms) and elderly (−7ms). All subjects with descending times ≥20ms slower than ascending (6/46) were elderly. Irregularity and asymmetry were similar between stepping direction and age groups. Asymmetry identified the dominant leg with equal or faster steps than the non-dominant leg in 43/46 cases. Motion parameters were not correlated to gender, height or BMI. Slower step times down than up seem a promising parameter to detect general or bilateral orthopaedic pathologies. Asymmetry identifying the dominant leg shall detect unilateral pathologies. The accelerometer assessed stair test seems suitable for routine clinical follow-up complementing classic scores

The study aimed to determine how well recorded pain levels and range of motion relate to patients' reported levels of functional ability/disability pre- and post- total hip arthroplasty. Range of motion (ROM), Oxford Hip Score (OHS) and Self-Report Harris Hip Score (HHS) were recorded pre-operatively and 3 months post-total hip arthroplasty. Pearson's correlation coefficients were calculated to determine the strength of the relationships both pre- and post-operatively between ROM (calculated using the HHS scoring system) and scores on OHS and HHS and response relating to pain from the questionnaires (question 1 HHS and questions 1, 6, 8, 10, 11 and 12 of OHS) and overall scores. Only weak relationships were found between ROM and HHS pre- (r = 0.061, n = 99, p = 0.548) and post-operatively (r = 0.373, n = 66, p = 0.002). Similar results were found for OHS, and when ROM was substituted for flexion range. In contrast, strong correlations were found between OHS pain component and HHS pre- (r = -0.753, n = 107, p<0.001) and post-operatively (r = -0.836, n = 87, p<0.001). Strong correlations were also found between the OHS pain component correlated with the HHS functional component only (HHS with score for questions relating to pain deducted) pre- (r = -0.665, n = 107, p<0.001) and post-operatively (r = -0.688, n = 87, p<0.001). Similar results were found when the HHS pain component was correlated with OHS. In orthopaedic clinical practice ROM is routinely used to assess the success or failure of arthroplasty surgery. These results suggest that this should not be done. Instead, asking the patient the level of pain that they are experiencing may be a good determinant of level of function. The results of this study may aid the development of arthroplasty scoring systems which better assess patients' functional ability

Objectives: Ischaemia reperfusion injury (IRI) is one of the most common metabolic insults in orthopaedic clinical practice. Oral ascorbate and both oral and intravenous n-acetylcysteine (NAC) have shown definitive beneficial effects in animal skeletal muscle IRI models. The authors hypothesized that a similar protective effect could be demonstrated in a well designed clinical trial. Materials and Methods: A EudraCT registered, prospective, randomized, controlled, double blind trial was performed to assess the hypothesis. Ethical approval was obtained from the competent authority. Patients (n=18) undergoing elective knee arthroscopy were randomised to one of 3 groups. The NAC group received IV NAC and preoperative oral placebo. The ascorbate group received oral ascorbate and IV placebo. The placebo group received both oral and IV placebo. Anaesthetic protocols were standardized across all groups. Phlebotomy was performed preoperatively and at 3 post-operative time points. IL-1, 2, 6 and 10, ICAM, VCAM, Selectins, TNF-alpha and malondialdehyde (MDA) were measured in systemic and local blood samples. Physiological parameters were recorded in the peri-operative period. Post-operative analgesic requirements and visual analogue scores were recorded. Leg oedema was measured using volumetric analysis and figure-of-eight tape measurement. Results: There were no differences between the groups pre-operatively. In the post-operative period the analgesic requirements were lower in the NAC group compared to ascorbate and placebo groups. CRP and d-dimers were found to peak in the early post operative period. White cell counts decreased in all groups in the early post-operative period, with a lesser reduction in the NAC and ascorbate groups. Elevation of MDA was noted in all groups but was significantly less in the NAC group. There was a trend towards increasing IL-6 and IL-8. There was a trend towards decreasing TNF-alpha and IL-1. Conclusions: Ascorbate and NAC appear to attenuate the inflammatory response to IRI in a clinical model. These cheap, readily available medications which are acceptable to patients and doctors alike appear offer a potential benefit to patients. Further studies are required to clarify the extent of the benefit and to examine the role of these medications in trauma and in the setting of more extensive ischaemic insults

Modern orthopaedics increasingly demands objective functional outcome assessment beyond classic scores and tests suffering from subjectivity, pain dominance and ceiling effects. Inertia based motion analysis (IMA) is a simple method and validated for gait in knee arthroplasty patients. This study investigates whether IMA assessed stair climbing can distinguish between healthy and pathological subjects and is able to diagnose a meniscal tear (MT). Following standard physical examination (McMurray, rotation pain), 37 patients (18–72yrs) received arthroscopy suspecting a meniscal tear resulting from trauma, degeneration or both. Arthroscopy identified the presence or absence of MT and the osteoarthritis level (Outerbridge). Prior to arthroscopy, the ascending and descending five stairs twice at preferred speed and without the use of handrails was measured using a triaxial accelerometer (62×41×18mm; m=53g; f=100Hz) taped to the sacrum. Based on peak detection algorithms, temporal motion parameters were derived such as step time up and down (Tup, Tdown), the difference between step time up and down (Tup-down), step irregularity (step time difference of subsequent steps) and step asymmetry (step time difference between affected and non-affected leg). Patients were compared to a control group of 100 healthy subjects (17–81yrs) without any known orthopaedic pathology. Using the results of arthroscopy, test sensitivity and specificity for differentiating healthy and pathologic subjects and for diagnosing MT were calculated based on threshold values. Sensitivity and specificity for detecting pathological motion was 0.68 (CI 0.50–0.81) and 0.92 for the most sensitive parameter (Tdown). Sensitivity and specificity to detect MT was 0.74 and 0.25 percent overall compared to 0.53 and 0.50 for the McMurray. Sensitivity increased to 1.00 when MT was combined with a chondropathy scale III or IV (McMurray 0.33). IMA assessed stair climbing can distinguish healthy and pathological subjects and detect the presence of MT with better sensitivity than classic scores especially when combined with severe chondropathy. IMA is a simple and fast clinical outcome measure suitable for routine follow-up and may support the diagnosis of meniscal tears prior to arthroscopy

Orthopaedic pathology at the craniocervical junction (CCJ) is uncommon. This is a retrospective analysis of 37 patients who underwent transoral surgery. The indications were fixed rotatory subluxation in 12 patients, myelopathy following nonunion of the dens in 15, tuberculous abscesses in seven, congenital anomalies in two and chordoma in one. There were 29 males and the mean age was 24 years (3 to 57). Neurological deficit was present in 19 patients. Other symptoms included hoarseness, difficulty swallowing, neck pain and limitation of movement. All patients had a CT scan, MR angiography, MRI and dental consultation to exclude oral sepsis. After the transoral release, 29 patients underwent atlanto-axial fusion and two occipito-axial fusion. Following nasal intubation the skull was immobilised in tongs with 2-kg traction. A Jacques catheter was used to retract the uvula. The CCJ was located with an image intensifier and the posterior pharyngeal wall was infiltrated with 5 cc of local anaesthetic and Por-8. The atlanto-axial joints (AAJ) were released and in children with fixed rotatory subluxation the atlantodentate interval was cleared of fibrous tissue. The 15 patients with non-union of the dens underwent anterior release of the AAJs and the fracture site. The seven patients with abscesses had incision and drainage. Two patients with basilar invagination required excision of the dens. The chordoma was partially excised. One patient required a partial excision of the dens to reduce a posterior dislocation of the AAJ. A patient with chronic atlanto-axial subluxation owing to a type-I fracture required a partial excision of the superior part of atlas. Two patients with CSF leaks were treated successfully. There were cases of sepsis. Two patients developed occipital pressure sores. One patient died 5 days after surgery because of pulmonary embolus. The transoral approach is safe and effective in treating pathology at the CCJ

Introduction: Arterial bleeding following pelvic fractures is widely recognized as an indication for angiography and embolization although controversy persists as to the timing of this procedure in the treatment algorithm. Less well appreciated is its application in similar circumstances following blunt injury to the pelvic arteries and limb injuries. We describe our experience in a variety of haemorrhagic orthopaedic pathologies. Patients and Methods: Angiography was performed in 29 patients- 16 with pelvic fractures, 9 with extremity injuries, and 4 with tumors. Seldinger technique was used for angiographic access, usually from the groin although on occasion extensive local injury required use of the brachial approach. Following the initial diagnostic study the a selective catheter was placed at the target, appropriate embolic material was selected and the source of haemorrhage was closed off. Results: In our experience of pelvic traumatic bleeding (14 associated with fracture, 2 without) embolization was successful in promptly arresting hemorrhage in all but one case of advanced DIC. Mortality was confined to this last case and two others, all of whom were referred for embolization following prolonged hypotension and commenced angiographic intervention with blood pressure unmeasureable or of the order of 30mm systolic. With 9 cases of extremity injury, 1 iatrogenic, 5 penetrating, 2 blunt and one following fracture of the femur, embolization successfully treated the hemorrhage. Finally we present our experience in preventing hemorrhage in 4 cases, 3 of which were vertebral body tumours and 1 pathological fracture of the humerus due to RCC. At surgery following embolization none bled significantly. Conclusions: The present study describes our experience in various orthopedic conditions. Less well recognized is its role in preventing hemorrhage; as a prelude to bloody operations on vertebral body metastases, aneurysmal bone cysts and hemangiomata as well as open reduction and internal fixation of pathological extremity fractures. We conclude that this technique is a valuable addition to the tools available to the orthopedic surgeon and whose application is not necessarily limited to the examples quoted, but should be applied in any case where the direct surgical approach is considered hazardous or ineffective

Material of 3.468 (6.936 hips) randomized cases of newborns, was sonographically and clinically examined during the two first days after birth with the aid of a 7,5 MHz linear transducer and a 5 MHz one for older babies in reexaminations. A standard plane of section was recorded by scanning (scale 1:1) and with this procedure documented a total number of 480 dysplastic hips (belonging to 395 newborns) indicating an incidence of 114 0/00. There is a difference of 64 0/00 between our findings (114 0/00) and the highest clinically diagnosed incidence (50 0/00), which has appeared in the international literature so far. This 64 0/00 theoretically indicates the cases with dysplastic hips that would go unnoticed without the help of sonography. These 480 dysplastic hips were classified (according to Graf) as following: IIa+ 328 (47,280/00), IIa- 6 (0,850/00), IIc 60 (8,650/00), D 38 (5,470/00), III 40 (5,750/00) and IV 10 (1,500/00). Pediatric clinical examination of hips revealed 10%, 12%, 5% and 50% dysplastic cases for the types IIc, D, III and IV respectively as expected. However orthopedic clinical examination revealed 40%, 60%, 70% and 100% dysplastic cases for each of the above mentioned types. It is obvious that the orthopedic examination with the aid of sonography is by far more reliable as regards DDH diagnosis and there is also a decrease in the frequencies of types that presented severe dysplasia when the newborns reexamined after treatment. At the end of the first trimester of life only six cases remained pathological (type II 5 cases and III one case). Conclusions: Sonography is a simple and reliable method, easy to use, free from the harmful effects of radiation and most effective in the early diagnosis of DDH

The use of neck modular adapter is a relative new solution for hip revision arthroplasty. This device assure a lot of advantages for the orthopaedic surgeon because Bioball can be use in different situations in order to solve different complications: hip prosthesis dislocation, correction of length (up to +21mm), save an old stem not mobilized, reduction of operation length. The hip prosthesis dislocation, in spite of the continuous progress of implants’ materials and design, is still an actual event in the orthopaedic clinical practice, both after total hip replacement or a endoprosthesis. Furthermore, dislocation has an important social-economic impact because of a protracted hospitalization and rehabilitation and elevated costs of an eventual revision. Although using heads with a diameter larger than 28 mm we obtain virtually a greater range of motion, with a contemporary increase of degree necessary to cause the head-neck impingement, the risck of dislocation hasn’t a significant increase using head with a diameter of 22 mm. Neck modular adapters (Bioball) allow to correct easily the biomechanics parameters of the dislocated prosthesic joint, avoiding the revision of the stem. Other indications for the use of the neck modular adapter are total hip replacement and intraoperatory correction of the limb length. Vantages are the possibilty to obtain a great range of motion through a small thickness of the 12/14 adapter, the possibility to extend the limb length up to 21 mm and to use ceramic heads during revisions, because the combination head/neck has a tribological unweared surface. In fact, in normal conditions, if the stem is not mobilizated, the use of ceramic head is rash; the Bioball adapter, instead, can be used with a old stem, so we can set a ceramic head. Every stem with a Biolox cone can be combined with a metal or ceramic head up to the 5XL size (+21 mm) through a Bioball adapter; in this way the cup is not removed. We have two kinds of neck modular adapters: 12/14 allow both to extend the neck and to correct the offset, and 14/16 that allow to extend only the neck, because of the largest diameter of the prosthesic neck and the small thickness of the adapter. For these neck modular adapters exist different sizes, from M to 5XL (+21mm). Recently to these two types of Bioball were introduced also solutions for special stems (like for Exeter, ABG I, ABGII, PCA and others) We have also proving heads and necks. The proving and definitive heads have to be of the Bioball system because these are inserted on a modular neck with a no-standard diameter. In the common practice the use of these adaptors has not to be considered as a routinary procedure, but have to be taken in consideration as a valid aid for orthopaedic surgeon to quickly and less invasively, solve technically demanding procedures with a real benefit for high-surgical risk patients