Introduction

Total hip arthroplasty (THR) is one of the most successful procedures performed today. Uncemented acetabular components have by and large replaced cemented cups. As such, optimal fixation, bony ingrowth with longevity, and safety is highly demanded. In this study, we look at the safety and efficacy of the Stryker® Trident PSL™ acetabular component based on radiographic and clinical analysis.

Femoral component fracture is a rarely reported but devastating complication of total knee arthroplasty. It has occurred most frequently with Whiteside Ortholoc II replacements uncemented knee replacements. Presentation may be with acute pain, progressive pain or returning deformity. It occurs more commonly in the medial condyle of the femoral component. It is rarely seen in cemented replacements.

All currently available literature describing fractures of condylar replacements, both cemented and uncemented. Predisposing factors include varus deformity either pre or post operatively. The mechanism of failure is thought to be failure of the infiltration of bone into the replacement. This is often due to polyethylene wear or metallosis causing abnormal tissue reaction with or without osteolysis.

We present the case of a fractured Press Fit Condylar (PFC) cemented implant (DePuy, Johnson&Johnson, Raynham, Massachusettes, USA) affecting the medial condyle. To our knowledge this is only the third reported case of fracture in a PFC implant, and the first in a cemented PFC implant.

Our patient was a 64 year old male who presented with unresolving knee pain post total knee arthroplasty, caused by fatigue fracture of the medial condyle of the femoral component. This was identified as loosening on plain radiographs and replaced with a revision prosthesis with a good post operative result. Given our aging population and with the increase of joint arthroplasty, this case sheds light on a potentially under recognised and increasingly important cause of knee pain following arthroplasty.

Introduction: Serum inflammatory markers are routinely used as pre assessment investigation before the revision hip surgery. Various investigations are used to aid in diagnosis of infection in the revision prosthetic hip replacement including aspiration, broad range PCR, bone scan and serum interleukin- 6.

Materials and Methods: 256 consecutive revision total hip replacements were assessed for the value of pre operative ESR and c-reactive proteins (CRP) in predicting the deep infections.

All patients were evaluated prior to surgery. The patients with coexisting inflammatory disease or peri-prosthetic fracture were also evaluated.

A hip was diagnosed as infected on the basis of positive intra operative microbiology samples three or more out of five and or histological evidence.

Results: Using the values of ESR > 35 mm/1st hour and CRP> 10mg/l, the positive predictive value (either/or) was 56% and the negative predictive value was 96%.

14 patients had an underlying inflammatory arthritis and 5 were peri prosthetic fractures. The inflammatory markers tended to be elevated in these patients. Excluding these 19 patients and using the same criteria, the positive predictive value was 65% and the negative predictive value was 97%

Discussion: We conclude that a CRP< 10 mg/l and ESR < 35 mm/1st hour are very useful in excluding infection(negative predictive value of 97%, excluding peri-prosthetic fractures and inflammatory joint disease). But raised inflammatory markers are less accurate in predicting infection.

Introduction: Hip resurfacing has been increasingly used procedure for physiologically young and active patients. Wear properties of the implants are considered to be excellent. We present a case of tumor like swelling of the thigh following metal on metal hip resurfacing.

Case report: 56 year old lady underwent metal on metal hip resurfacing for idiopathic osteoarthritis of right hip. Implant size: 38 mm head with 44 mm cup.

After 18 months of successful surgery she presented with short duration (2 weeks) history of thigh swelling with pain and stiffness in hip and knee. Clinically gross circumferential swelling of right thigh from inguinal ligament to the knee joint. She had increased serum cobalt chromium levels. Aspiration of hip revealed high levels of cobalt and chromium. Biopsy and intra operative samples at revision revealed “no infection or tumor but non specific inflammatory reaction.”

The patient underwent revision surgery to ceramic-plastic bearing.(THR).

12 months post operative, the swelling has reduced with painless mobile hip and knee joints.

Discussion: The metal on metal hip resurfacing could have produced high metal ion wear reaction leading to swelling. Which could be because of small diameter prosthesis with valgus position of femoral component with open cup angle of 49 degrees.

Introduction: Metal on metal hip resurfacing is a bone conserving procedure with excellent medium term results. A retrospective audit of 150 consecutive Birmingham Hip resurfacings, performed by a single surgeon at a DGH was carried out.

Materials and Methods: We report 150 hip resurfacings implanted between June 2001 to June 2004. There were 99 male and 51 female hips. The mean age was 50.7 years (38–75years). Range of follow up was 6 months to 45 months (average 20.1 months)

Pre operative diagnosis was Osteoarthritis (n=135), osteonecrosis(n=8),traumatic(n=2),dysplasia(n=3),Slipped capital femoral epiphysis (n=1) and ankylosing spondylitis (n=1). Al hips were implanted via the posterior approach. Clinical assessment, by postal questionnaire, was by pre and post-operative Oxford Hip scores (OHS) and X-rays were reviewed.

Results: Range of follow up was 6 months to 42 months (average 20.1 months). No patient was lost to follow up. The mean pre operative Oxford hip score was 41 (r=27–56). The score was 15.1 (r=12–29) at the time of questionnaire.

Complications included: One femoral neck fracture at 3 months requiring revision to a stemmed “big ball” THR, one deep infection requiring early wash out with salvage of the hip prosthesis, (both the patients are now doing well. OHS 13 and 15 respectively) and one asymptomatic stress fracture of femoral neck, which healed without intervention (OHS 12).

There was one dislocation in a neuropathic hip requiring bracing. (OHS 29). There was one retained alignment pin needing removal. Otherwise patients were highly satisfied with the operation with excellent function and Hip scores.

Conclusion: Our study has demonstrated that, in the short term and in young age group, this prosthesis gives excellent functional results, with an acceptably low complication rate. Long term surveillance of these patients will provide further data to compare our results with specialist centres.

Introduction: Rat-bite fever is an uncommon illness caused by Streptobacillus moniliformis or Spirillum minor. We present an unusual case of rat bite fever involving a left cemented total hip replacement after a rodent bite.

Case report: A 38-year-old lady, presented with poly arthralgia, who had Total Hip replacement for arthritis secondary to developmental dysplasia of Hip(one year ago), presented with signs & symptoms suggestive of infective joint pathology. Examination revealed painful restricted joint movements.

Initial blood tests revealed very high ESR, c-reactive proteins with leucocytosis. Blood cultures were negative. X-rays revealed dislocation of Total hip replacement Ultrasound scan and CT scan revealed a large collection of fluid in the Left Total Hip Replacement.

Aspirate from the affected joints revealed gram negative bacilli, Streptobacillus moniliformis. The joints were all washed out arthroscopically. She was put on intravenous antibiotics and continued for six weeks. The inflammatory markers normalised after six weeks. Follow up x-rays of the left hip prosthesis do reveal some signs of osteolysis and surveillance is ongoing.

Discussion: Prosthetic replacements are now commonplace, with large number of patients keeping pets. Septic arthritis following the rat bite has been reported. As far as we can tell from the available literature that it has not been reported in a joint prosthesis. The long- term outcome is unknown. The possibility of low grade infection involving the joint prosthesis and the association of this organism with endocarditis is a cause for concern.

Arthrodesis of 1st MTP joint is a reliable procedure for hallux rigidus. We have studied the effects of first MTP joint arthrodesis on activities of daily living and leisure activities

Methods: We retrospectively evaluated 103 1st MTP fusion, done by a single orthopaedic surgeon with special interest in foot surgery over seven years period. All patient underwent two cross screw fixation for primary operation. Same operative technique was used in all patients.

We evaluated pre op scoring for pain, walking distance, walking up hill – stairs, foot wear, return to leisure activity and work, chronicity of symptoms, associated symptoms, radiological appearance pre op, post op and at radiological fusion and complication rate.

All patients were followed up.

The patients were contacted with questionnaire to evaluate the function after the fusion.

The patients were asked whether they would participate in the foot pressure study; which was done with the help of podiatrist at same trust.

We have tried to correlate the functional outcome and its relation to foot pressure.

Results: Fusion was achieved in all patients. (three after revision). Pain scores evaluated using the visual analogue scale, indicated effective pain relief. High levels of return to functions were noted. The pressure (under 1st or 2nd Metatarsal heads or laterally) study has revealed a pattern of changes with various symptoms.

Conclusion: Arthrodesis of first MTP joint, using two cross screws, is a successful surgical technique for Hallux rigidus and also allows high level of function in daily activities of living and leisure activities.

Does the type of implant have any correlation with critical fusion time of hallux metatarsophalangeal joint? There are few cadaveric biomechanical studies published in the literature assessing the strength and rigidity of different fixation methods. Although it is still unclear whether the amount of metal affects the fusion rate, the aim of this study was to assess whether using a supplementary dorsal ¼ tubular plate in addition to a compression screw gives any added rigidity to the fusion area leading to an earlier fusion.

A retrospective analysis was conducted on the first metatarsophalangeal joint fusion in 26 consecutive patients (34 feet) between April 1998 to February 2002 comparing using single screw versus a screw supplemented with a dorsal ¼ tubular plate. There were 18 females and 8 males with a mean age of 51.5 years and a mean follow-up of 2.9 years. The final fusion was assessed clinically and radiologically by trans-articular trabeculation.

There was a fusion rate of 97%. All patients except one had solid fusion. One case had non-union. Four cases had superficial wound infection, which settled down with appropriate antibiotic therapy. Paraesthesia over the dorso-medial aspect of the big toe in three patients and transfer metatarsalgia in two patients were documented.

The type of implant did not show any direct correlation with the complication rate. There is no evidence to suggest in this study relating the amount of implant to final outcome. Therefore the choice of implant fixation can be at the discretion of the operating surgeon.