Necrotizing soft tissue infection (NSTI) is a rapidly progressive infection that typically starts in the dermis and epidermis and spreads along soft tissue planes, penetrating subdermal layers and can lead to massive tissue necrosis resulting in severe morbidity and mortality. The aim of this case series was to describe the epidemiology and burden of NSTI's at a District Hospital servicing a South African urban settlement. This retrospective case series was performed at a single centre. Consecutive patients were identified following a clinical diagnosis for NSTI. Further laboratory pre-operative work up was standardized including: use of validated Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC scores) and Human Immunodeficiency Virus (HIV) status. All patients who underwent surgical debridement were captured on the Theatre Database (. www.medwebtools.org™. ). All patients received standardized perioperative, intra-operative and post-operative protocols for antibiotics, debridement and soft tissue closure or cover based on the severity of disease. Medical records, theatre notes, National Health Laboratory Service (NHLS) results and radiological results were captured for every patient. 28 patients (14 male, 14 female) presented with NSTI over a 3 year period (2021–2023). The mean age was 39.5 years. The most common organisms cultured were Streptococcus pyogenes (10 patients), Staphylococcus aureus (9 patients), Bacillus cereus (3 patients). This retrospective case series is an important study because it demonstrates some of the highest incidence of NSTI globally; however, the cause of this is yet to be determined. Our results show that having a high clinical index of suspicion; using the LRINEC score to assess severity and using a standardized antibiotic and peri-operative protocol with early soft tissue cover that NSTI's can be managed effectively with a reduction in patient morbidity and overall length of hospital stay

Introduction. Bone transport and distraction osteogenesis have been shown to be an effective treatment for significant bone loss in the tibia. However, traditional methods of transport are often associated with high patient morbidity due to the pain and scarring caused by the external frame components transporting the bone segment. Prolonged time in frame is also common as large sections of regenerate need significant time to consolidate before the external fixator can be removed. Cable transport has had a resurgence with the description of the balanced cable transport system. However, this introduced increasingly complex surgery along with the risk of cable weave fracture. This method also requires frame removal and intramedullary nailing, with a modified nail, to be performed in a single sitting, which raised concern regarding potential deep infection. An alternative to this method is our modified cable transport system with early intramedullary nail fixation. Internal cables reduce pain and scarring of the skin during transport and allow for well controlled transport segment alignment. The cable system is facilitated through an endosteal plate that reduces complications and removes the need for a single-stage frame removal and nailing procedure. Instead, the patients can undergo a pin-site holiday before nailing is performed using a standard tibial nail. Early intramedullary nailing once transport is complete reduces overall time in frame and allows full weight bearing as the regenerate consolidates. We present our case series of patients treated with this modified cable transport technique. Methodolgy. Patients were identified through our limb reconstruction database and clinic notes, operative records and radiographs were reviewed. Since 2019, 8 patients (5 male : 3 female) have undergone bone transport via our modified balanced cable transport technique. Average age at time of transport was 39.6 years (range 21–58 years) with all surgeries performed by the senior author. Patients were followed up until radiological union. We recorded the length of bone transport achieved as well as any problems, obstacles or complications encountered during treatment. We evaluated outcomes of full weight bearing and return to function as well as radiological union. Results. 4/8 bone defects were due to severely comminuted open fractures requiring extensive debridement. All other cases had previously undergone fixation of tibial fractures which had failed due to infection, soft tissue defects or mal-reduction. The mean tibial defect treated with bone transport was 41mm (range 37–78mm). From the start of cable transport to removal of external fixator our patients spent an average of 201 days in frame. 7/8 patients underwent a 2-week pin-site holiday and subsequent insertion of intramedullary nail 2 weeks later. One patient had sufficient bony union to not require further internal fixation after frame removal. 10 problems were identified during treatment. These included 4 superficial infections treated with antibiotics alone and 5 issues with hardware, which could be resolved in the outpatient clinic. 1 patient had their rate of transport slowed due to poor skin quality over the site of the regenerate. 4 obstacles resulted in a return to theatre for additional procedures. 1 patient had a re-do corticotomy and 3 had revision of their internal cable transport constructs due to decoupling or screw pull out. 1 patient had residual ankle joint equinus following treatment which required an Achilles tendon lengthening procedure. Another patient underwent treatment for DVT. There were no deep infections identified and no significant limb length discrepancies or deformities. Conclusions. Overall, we have found that our modified balanced cable transport technique has allowed for successful bone transport for significant defects of the tibia. We have learned from the obstacles encountered during this case series to avoid unnecessary return trips to theatre for our future transport patients. The internal cable system allowed all patients to complete their planned transport without excessive pin tract scarring or pain. Early conversion to intramedullary nail allowed for a shorter time in frame with continued full weight bearing as the regenerate consolidated. No metalwork failure or deformity has occurred in relation to docking site union. All patients have made a good return to pre-operative function during their follow-up period with no evidence of late complications such as deep infection

Introduction. We have previously published limb lengthening using external fixation in pathological bone diseases. We would like to report a case series of femoral lengthening using the PRECICE system in a similar pathological group especially looking at it's feasibility and complications. Materials and Methods. This is a case series of four patients, two patients with osteogenesis imperfecta and two with Ollier's disease, who underwent femoral lengthening via distraction osteogenesis using the PRECICE intramedullary nail system. It was a retrospective study from a prospective database from clinical records and radiographs. Results. The mean age at the time of surgery was 15.5 years, the mean preoperative leg length discrepancy was 30mm, and the mean distraction distance achieved was 28.75mm. Since these patients were of shorter heigh, limb lengthening was considered. All 4 patients had successful insertion of the nail. The outcomes noted from the 4 patients are collated, with several complications occurring including delayed femoral union, fixed flexion deformity of the hip, persisting pain and quadriceps weakness. Those with Ollier's disease underwent an increased rate of distraction to prevent premature healing. The implications of long-term bisphosphonate therapy in OI are discussed with regards to the risk of delayed femoral union and intra-operative fracture. Conclusions. Intramedullary femoral lengthening in pathological bone disease is possible, but the surgeon needs to give attention to certain details. The regenerate formation is based on the background pathology irrespective of the hardware used. There is much more compliance with the nail technique

Acromioclavicular joint injuries are one of the most common injuries in the shoulder girdle complex. Surgical management is considered based on patient profile, level of activity, pain, and classification of injury. To date, a vast array of surgical techniques have been proposed and described in the literature, a possible reason being that the optimal solution is still uncertain. The aim of this study is to determine the efficacy of an alternative surgical technique. This study is a retrospective case series of 80 patients that have been operated by a single surgeon over a period of 6 years. A novel surgical technique, the ‘BiPOD method’, was applied where a synthetic artificial ligament (LARS®) is used to reconstruct and reduce the acromioclavicular joint. The technique is done in a reproducible manner, where a single continuous artificial ligament is used to reduce and reconstruct both, the coracoclavicular and acromioclavicular ligament complexes to achieve bidirectional stability. Patients were followed-up postoperatively, either clinically where possible or telephonically. The Acromioclavicular Joint Instability Score (ACJI) and radiographic measurements were used to determine the clinical and surgical outcome of the surgery. Radiographic parameters, measuring the reduction of the coracoclavicular- and acromioclavicular joint, were analysed and documented. The results showed marked improvement in both, the coracoclavicular distance and acromioclavicular distance. Clinically, using the ACJI scoring system, the patients reported substantial improvement in pain and function. Complications were recorded but were insignificant. The BiPOD surgical technique, making use of an artificial LARS® ligament, has proven acceptable outcomes in the surgical management of acromioclavicular joint dislocations

Abstract. Background. Traumatic knee dislocations are devastating injuries and there is no single best accepted treatment. Treatment needs to be customised to the patient taking into consideration injury to the knee; associated neurovascular and systemic injuries. Objective. This study looked at functional outcome of a single surgeon case series of patients who underwent surgical management of their knee dislocation. Methods. Seventy patients with knee dislocation were treated with multi-ligament reconstruction at a major trauma centre. Acute surgical repair and reconstruction with fracture fixation within 3 weeks was preferred unless the patient was too unstable (Injury severity score>16). PCL was primarily braced and reconstructed subsequently, if required. Outcome was collected prospectively using IKDC score, KOOS and Tegner score. Results. The mean age of the patients was 35yrs (17–74), 53 males and 17 females. 5 patients had CPN injury (7%), 3 had vascular injury (4.2%), 2 had combined CPN and vascular injury (2.8%). Acute surgical treatment was done in 48 patients while 10 had staged reconstruction. 22 patients had delayed reconstruction. The mean follow-up period was 4.8 years (1–12 yrs). According to the IKDC score 67% of the patients had near-normal knee function. The mean Tegner activity scale postoperatively was 4.5 (preinjury 6.5) and the mean KOOS score was 75.3. Four patients had stiffness and needed arthroscopic arthrolysis, two patients had a residual foot drop from the original injury and needed tendon transfer. Conclusion. Traumatic knee dislocation is a challenging problem but good outcomes can be achieved by surgical management

Thoracic hyperkyphosis (TH – Cobb angle >40°) is correlated with rotator cuff arthropathy and associated with anterior tilting and protraction of scapula, impacting the glenoid orientation and the surrounding musculature. Reverse total shoulder arthroplasty (RTSA) is a reliable surgical treatment for patients with rotator cuff arthropathy and recent literature suggests that patients with TH may have comparable range of motion after RTSA. However, there exists no study reporting the possible link between patient-reported outcomes, humeral retroversion and TH after RTSA. While the risk of post-operative complications such as instability, hardware loosening, scapular notching, and prosthetic infection are low, we hypothesize that it is critical to optimize the biomechanical parameters through proper implant positioning and understanding patient-specific scapular and thoracic anatomy to improve surgical outcomes in this subset of patients with TH. Patients treated with primary RTSA at an academic hospital in 2018 were reviewed for a two-year follow-up. Exclusion criteria were as follows: no pre-existing chest radiographs for Cobb angle measurement, change in post-operative functional status as a result of trauma or medical comorbidities, and missing component placement and parameter information in the operative note. As most patients did not have a pre-operative chest radiograph, only seven patients with a Cobb angle equal to or greater than 40° were eligible. Chart reviews were completed to determine indications for RTSA, hardware positioning parameters such as inferior tilting, humeral stem retroversion, glenosphere size/location, and baseplate size. Clinical data following surgery included review of radiographs and complications. Follow-up in all patients were to a period of two years. The American Shoulder and Elbow Surgeons (ASES) Shoulder Score was used for patient-reported functional and pain outcomes. The average age of the patients at the time of RTSA was 71 years old, with six female patients and one male patient. The indication for RTSA was primarily rotator cuff arthropathy. Possible correlation between Cobb angle and humeral retroversion was noted, whereby, Cobb angle greater than 40° matched with humeral retroversion greater than 30°, and resulted in significantly higher ASES scores. Two patients with mean Cobb angle of 50° and mean humeral retroversion 37.5° had mean ASES scores of 92.5. Five patients who received mean humeral retroversion of 30° had mean lower ASES scores of 63.7 (p < 0 .05). There was no significant correlation with glenosphere size or position, baseplate size, degree of inferior tilting or lateralization. Patient-reported outcomes have not been reported in RTSA patients with TH. In this case series, we observed that humeral stem retroversion greater than 30° may be correlated with less post-operative pain and greater patient satisfaction in patients with TH. Further clinical studies are needed to understanding the biomechanical relationship between RTSA, humeral retroversion and TH to optimize patient outcomes

Malalignment is a common complication following tibial surgery, occurring in 10% of fractures. This is associated with prolonged healing time and non-union. It occurs due to inability to maintain a satisfactory reduction. A reduction device, such as the Staffordshire Orthopaedic Reduction Machine (STORM), permits the surgeon to manipulate the fracture and hold it reduced. A retrospective parallel case series was undertaken of all patients undergoing tibial nails over a six-year period from 2014 to 2021. Patient demographics were obtained from medical records. Operative times obtained from the theatre IT system and included the time patient entered theatre and surgical start and finish times for each case. Anteroposterior and lateral long leg post-operative radiographs were reviewed. Angulation was measured in both coronal and sagittal planes, by two separate orthopaedic surgeons. A reduction was classified to be ‘mal-aligned’ if the angle measured was greater than 5 degrees. One tailed unpaired t-test was used to compare alignment in each plane. Bony union was assessed on subsequent radiographs and was determined according to the Radiographic Union Score for Tibial Fractures. 31 patients underwent tibial nail during the time period. 8 patients were lost to follow up and were excluded. Of the remaining 23 patients, the STORM device was utilised in 11. The overall mean alignment was acceptable across all groups at 2.17° in the coronal plane and 2.56° in the saggital plane. Analysing each group individually demonstrated an improved alignment when STORM was utilised: 1.7° (1°–3°) vs 2.54° (0°–5°) for the coronal plane and 1.6° (0°–3°) vs 3.31° (0°–9°) in the saggital plane. This difference was significant in saggital alignment (p=0.03) and showed a positive trend in coronal alignment, although was not significant (p=0.08). The time in theatre was shorter in the control group with a mean of 113 minutes (65 to 219) in comparison to STORM with a mean of 140 minutes (105 to 180), an increased theatre time of 27 minutes (p=0.04). This study demonstrates that STORM can be used in the surgical treatment of tibial fractures resulting in improved fracture alignment with a modest increase in theatre time

Aim. Optimal strategies for surgical and antimicrobial management of Candida periprosthetic joint infections (PJI) are unclear. We present a retrospective case series of patients diagnosed with PJI caused by Candida spp. Method. Patients treated at our institution with Candida PJI from 01/2017 to 04/2018 were retrospectively included with isolation of Candida spp. in synovial fluid, intraoperative tissue or sonication fluid culture. PJI was defined by the proposed European Bone and Joint Infection Society (EBJIS) criteria. Treatment failure was defined as relapse or persistence of infection. Results. We included 9 patients (4 men and 5 women, mean age 75 years) involving 4 knee and 5 hip joint prosthesis. Risk factors for Candida PJI were prior PJI (n=4), diabetes mellitus (n=3), chronic kidney disease (n=3), obesity (n=3), negative-pressure wound therapy (n=3), rheumatoid arthritis (n=1) and chronic decubitus (n=1). Two patients had no risk factors for Candida PJI identified. Infection was acquired postoperatively (n=7), hematogenously (n=1) or contiguously through communicating vesico-articular sinus (n=1). The causative pathogen was C. albicans in 5, C. parapsilosis in 3, C. tropicalis in 1 patient, isolated from periprosthetic tissue samples (n=7), sonication fluid (n=3) and blood cultures (n=2); bacterial co-pathogens were isolated in 8 patients. Histopathological analysis revealed low-grade inflammation in all 6 patients, in whom it was performed. All patients were treated with oral fluconazole for 3 months, two initially received intravenous caspofungin and three received suppression with oral fluconazole for additional 9 months (total treatment 12 months). Liposomal amphotericin B (300–700 mg per 40 g bone cement) was admixed to spacer cement in 3 patients. Debridement and prosthesis retention was performed in one patient with tumor prosthesis after bone resection due to osteochondrosarcoma. In the remaining 8 patients the prosthesis was removed, with one-stage reimplantation in 1 patient and two-stage reimplantation in 3 patients (after 6 weeks, 3 months and 7 months); two patients are currently awaiting reimplantation, one died due to reason not related to PJI and another underwent knee arthrodesis. Among 5 patients with prosthesis in place, relapse occurred in one patient with prosthesis retention. Another patient experienced new PJI of the exchanged prosthesis caused by Staphylococcus aureus. Conclusions. All Candida PJI presented as chronic infection with low-grade inflammation. Treatment with prostheses retention failed, whereas in 4 patients who underwent two-stage exchange and long-term antifungal suppression, no relapse or persistence of infection was observed. All patients received oral fluconazole for ≥3 months

The Masquelet technique, also known as the ‘induced membrane technique’ has been utilised in adult reconstruction with varied success. However, there is limited literature on its use in children and this study aims to share our experience.

Introduction. Knee osteoarthritis is a leading cause of disability around the world. Traditionally, total knee arthroplasty (TKA) is the gold standard treatment; however, unicompartmental knee arthroplasty (UKA) has emerged as a less-invasive alternative to TKA. Patients with UKAs participate earlier with physical therapy (PT), have decreased complications, and faster discharges (1, 2). As UKA has evolved, so has computer navigation and robotic technology. The Robotic Assisted UKA combines the less invasive approach of the UKA with accurate and reproducible alignment offered by a robotic interface (3)(Figure1). A key part of a patient's satisfaction is perioperative pain control. Femoral nerve blocks (FNB) are commonly performed to provide analgesia, though they cause quadriceps weakness which limits PT (4). An alternative is the adductor canal block (ACB) which provides analgesia while limiting quadriceps weakness (4). The adductor canal is an aponeurotic structure in the middle third of the thigh containing the femoral artery and vein, and several nerves innervating the knee joint including the saphenous nerve, nerve to the vastus medialis, medial femoral cutaneous nerve, posterior branch and occasionally the anterior branch of the obturator nerve (5). In a multi-modal approach with Orthopedic Surgery, Regional Anesthesia, and PT departments, an early goal directed plan of care was developed to study ACB in UKA with a focus on analgesia effectiveness and PT compliance rates. Methods. Following IRB approval, we performed a case series including 29 patients who received a single shot ACB. Primary outcomes were distance walked with PT on postoperative day (POD) 0 and 1 and discharge day. Our secondary outcomes included Visual Analog Scale (VAS) scores in the post-anesthesia care unit (PACU), 8 and 24 hours postoperatively and oral morphine equivalents required for breakthrough pain. Results. All patients received PT prior to discharge. With respect to distance walked, the median distance on POD 0 was 26 feet (IQR 9–66), and on POD 1 was 128 feet (IQR of 80–200), and the median day of discharge was POD 1 (IQR 0–2). In this study, the patients’ median age was 64 (IQR 59–69) and the median BMI was 31 kg/m2 (IQR 22–41). The median VAS score in the PACU was 1 (IQR 0–7). The VAS scores for 8 and 24 hours were 5 (IQR 2–7) and 5 (IQR 2.7–7). Median oral morphine equivalents required for breakthrough pain were 99.5 mg (IQR 67.5–150.5 mg) (Figure 3). Conclusion. This case series supports that a single shot ACB facilitates early PT and hospital discharge in patients post UKA

Background:. Glomus tumours of the hand are rare benign vascular tumours. The literature shows a limited number of case series with few patients treated over several years. Methods:. Patient records and the literature were reviewed. Case Series:. We present a series of 5 patients with glomus tumour treated over a period of 1 year. All 5 patients presented with a similar history. They were all seen by various medical practitioners for an extended period of time before presenting to the Hand Unit of our institution. All 5 patients had classical symptoms and signs of glomus tumour i.e. pain, cold intolerance and pin-point tenderness over the nail bed, while 4 of the 5 had a purplish spot seen through the nail plate. All 5 tumours were excised and the histology confirmed our pre-operative diagnosis of glomus tumour. In all of them, complete resolution of symptoms was the final outcome and there was no reported recurrence of symptoms in the short period of follow-up. Discussion and conclusion:. Glomus tumours are rare benign vascular tumours. The limited number of case series in the literature report small numbers of patients treated at institutions over long periods of time. It can occur anywhere in the body, but up to three quarters of them are found in the hand. It arises from the neuromyoarterial glomus cells of the nailbed dermis. The triad of pain, cold intolerance and pin-point tenderness is highly suggestive of the condition. Subjective symptoms typically exceed clinical signs for which the diagnosis is delayed for months. Sometimes the tumour is visible through the nail plate appearing as reddish or purplish spot of few millimeters or as longitudinal streaks. Imaging studies except MRI are not very helpful and one must rely on a history of cold intolerance and clinical findings like pin-point tenderness for diagnosis

Background

In recent years, ‘Get It Right First Time (GIRFT)’ have advocated cemented replacements in femoral part of Total hip arthroplasty (THA) especially in older patients. However, many studies were unable to show any difference in outcomes and although cemented prostheses may be associated with better short-term pain outcomes there is no clear advantage in the longer term. It is not clear when and why to do cemented instead of cementless.

Acromioclavicular joint (ACJ) dislocations is a common disorder amongst our population for which numerous techniques have been described. It is thought that by using this novel technique combining a CC and AC repair with a reconstruction will result in high maintenance of anatomical reduction and functional results.

12 consecutive patients ACJ dislocations were included. An open superior clavicular approach is used. Firstly, the CC ligaments are repaired after which a CC reconstruction is performed using a tendon allograft. Secondly, the AC ligaments are repaired using an internal brace construct combined with a tendon allograft reconstruction (Figure 1).

The acute:chronic ratio was 6:6. Only IIIB, IV and V AC-joint dislocations were included. The Constant-Murley Score improved from 27.6 (8.0 – 56.5) up to 61.5 (42.0 – 92.0) at 12 months of follow up. Besides one frozen shoulder from which the patient recovered spontaneously no complications were observed with this technique. The CCD was reduced from 18.7 mm (13.0 – 24.0) to 10.0 mm (6.0 – 16.0) and 10.5 mm (8.0 – 14.0) respectively 12 weeks and 12 months postoperatively.

There is some evidence, suggesting to address as well as the vertical (coracoclavicular (CC) ligaments) as the horizontal (acromioclavicular (AC) ligaments) direction of instability. This study supports addressing both entities however comparative studies discriminating chronic as acute cases should be conducted to further clarify this ongoing debate on treating ACJ instability.

This study describes a novel technique to treat acute and chronic Rockwood stage IIIB – IV ACJ dislocations with promising short-term clinical and radiological results. This suggests that the combined repair and reconstruction of the AC and CC ligaments is a safe procedure with low complication risk in experienced hands. Addressing the vertical as well as horizontal stability in ACJ dislocation is considered key to accomplish optimal long-term results.

Aim

Squamous cell carcinoma (SCC) is a rare but often devastating complication of chronic osteomyelitis. Optimum diagnosis and management are not well established. This paper aimed to develop a definitive, evidence-based approach to its diagnosis and management.

Aim. Spinal infection is the most frequent complication of spine surgery. Its incidence varies between 1% and 14% in the literature, depending on various studied populations and surgical procedures. The aim of this study was to describe a consecutive 2706 case series. Method. We analyzed a prospective cohort of 2706 patients operated for spine disease between 2013 and 2016 in a University Hospital. The infection rates, germs, time between surgery and infection and outcomes after surgical revision were assessed with a minimum follow-up of 7 months. We developed a mathematical model to analyze risk factors in this difficult-to-treat population. Results. Among 2706 patient who underwent spinal surgery during the three-year study period, 106 developed a postoperative spine infection. Clinical indicators for infection were the sudden onset of local pain and swelling without fever after an initial pain-free interval. We observed a masculine predominance (68%); the median age was 56 years. The rate of infection was comprised between 0,3% (discal herniation surgery) to over 20% in posterior cervical instrumented surgery (acute cervical fractures), with a global rate of 4%. Polymicrobial infections with more than 3 germs were found in only 2 case, with 3 germs in 8 cases, 2 germs in 27 cases and 1 germ in 69 cases. Staphylococcus aureus, Propionibacterium acnes and Staphylococcus epidermidis were the three main germs identified (53, 36 and 22 respectively). Propionibacterium acnes was involved with a higher rate in instrumented surgery but also in 8% of conventional non-instrumented surgery, with a median relapse time of 24 days (12 days to 4 years). Staphylococcus aureus was involved at a higher rate in posterior non-instrumented surgery with a median relapse time of 18 days (8–66 days). The rate of infection per month was globally stable along the year except an increased rate in February-March. All patients with a suspicion of post-op infection were initially treated with wound/deep tissues revision within the first month after surgery and associated with implant removal after one-month post-op. Pejorative outcomes were associated with incomplete revision surgery, several surgeries and polymicrobial infection. Conclusions. In this study, the rate of postoperative infection is comparable to the literature. In contrast, Propionibacterium incidence is high, especially for acute infections. This unexpected rate can be linked to technical improvements in culture detection but this should also lead us to further discuss the natural process of spine/disk colonization of this germ

Abstract

Squamous Cell Carcinoma (SCC) is a rare complication of chronic osteomyelitis (OM), arising in a sinus tract (Marjolin's Ulcer). We routinely send samples for histological analysis for all longstanding sinus tracts in patients with chronic osteomyelitis. We reviewed the clinical features and outcomes of patients with SCC arising from chronic osteomyellitis. A retrospective study was performed of patients with osteomyelitis between January 2004 and December 2014 in a single tertiary referral centre. Clinical notes, microbiology and histo-pathological records were reviewed for patients who had squamous cell carcinoma associated with OM. We treated 9 patients with chronic osteomyelitis related squamous cell carcinoma. The mean age at time of diagnosis was 51 years (range 41–81 years) with 4 females and 5 males. The mean duration of osteomyelitis was 16.5 years (3–30 years) before diagnosis of SCC. SCC arose in osteomyelitis of the ischium in 5 patients, sacrum in 1 patient, femur in 1 patient and tibia in 2 patients. Osteomyelitis was due to pressure ulceration in 7 patients and post-traumatic infection in 2 patients. The histology showed well differentiated SCC in 4 cases and moderately differentiated SCC in 2 cases with invasion. Two patients had SCC with involvement of bone. One patient had metastatic SCC to bowel. All patients had polymicrobial or Gram-negative cultures from microbiology samples. Four patients (57%) in our series died as result of their cancer despite wide resection. The mean survival after diagnosis of SCC was 1.3 years and mean age at time of death was 44.7 years. Two of these patients had ischial disease and were treated with hip disarticulation, hemi-pelvectomy and iliac node clearance. Five patients remain disease free at a mean of 3.4 years (range 0.1 – 7yrs) after excision surgery. One patient in this group underwent a through-hip amputation, one underwent an above knee amputation and one underwent excision of ischium and surrounding sinuses. Of note, all these patients had clear staging scans at time of diagnosis. This case series demonstrates the consequences of an uncommon complication of osteomyelitis. In our series only 3 patients underwent biopsy for suspected SCC due to clinical appearances. The other cases were all identified incidentally after routine histological sampling, demonstrating the importance of this practice

We present a case series of patients who underwent 3 or 4 part proximal humerus fracture fixation using an intra-osseous suture technique. 18 patients are included in the study with follow up data obtained ranging from 1 to 4 years. Oxford Shoulder Scores (OSS) and range of movement measurements were taken for all patients. The mean OSS for the group was 50/60 with a mean forward flexion of 140°, abduction of 132°, external rotation of 48° and internal rotation to the level 10. th. thoracic vertebra. Three patients developed adhesive capsulitis, 2 requiring subsequent arthroscopic release. This data compares favourably to outcomes reported in the literature with hemiarthroplasty or locking plate fixation. An activity based costing analysis estimated that the treatment costs for proximal humerus fractures was approximately £2,055 when performing a soft tissue reconstruction, £3,114 when using a locking plate and £4,679 when performing a hemiarthroplasty. This demonstrates a significant financial saving when using intra-osseous fixation compared to other fixation techniques. We advocate the use of the intra-osseous suture fixation technique for certain 3 and 4 part fractures. It gives good functional outcomes, significant cost savings and potentially makes revision procedures easier when compared to other fixation techniques

Introduction

Revision total hip arthroplasty is a complex procedure and becoming more common. Acetabular implant loosening or fracture has previously been treated with a cup and cage construct. Recent studies have shown significant failure rates with Cup Cage constructs in more complex 3B and 3C Acetabular revisions. As a result the use of 3D printed custom made acetabular components has become more common.

The shoulder is the least constrained of all joints of the body and is more susceptible to injury including dislocation. The rate of recurrent instability following primary stabilization procedure at 10 years of follow-up ranged from 3.4 to 35 %. We describe the outcomes of 74 patients who underwent knotless arthroscopic anterior stabilisation using 1.5 mm Labral Tape with 2.9mm Pushlock anchors for primary anterior instability. We performed a retrospective analysis of patients who underwent surgery for post-traumatic recurrent anterior instability for 2 years by a single surgeon. Patients with glenoid bone loss, >25% Hill Sachs lesion, posterior dislocation, paediatric age group and multidirectional instability were excluded from this study. Over 90% of our case mix underwent the procedure under regional block anaesthesia and was discharged on the same day. The surgical technique and post-operative physiotherapy was as per standard protocol. Outcomes were measured at 6 months and 12 months. Of the 74 patients in our study, we lost 5 patients to follow up. Outcomes were measured using the Oxford Shoulder Score apart from clinical assessment including the range of motion. We noted good to excellent outcomes in 66 cases using the Oxford Instability Scores. All patients achieved almost full range of motion at the end of one year. Our cumulative Oxford Instability Score (OIS) preoperatively was 24.72 and postoperatively was 43.09. The Pearson correlation was .28. The t Critical two-tail was 2.07 observing the difference between the means of the OIS. Complications included recurrent dislocation in 2 patients following re-injury and failure of procedure due to recurrent instability requiring an open bone block procedure in one case. We had no reported failures due to knot slippage or anchor pull-out. We publish the largest case series using this implant with distinct advantages of combining a small bio absorbable implant with flat braided, and high-strength polyethylene tape to diminish the concern for knot migration and abrasive chondral injury with the potential for earlier rehabilitation and a wider footprint of labral compression with comparative outcomes using standard techniques. Our results demonstrate comparable and superior results to conventional suture knot techniques for labral stabilization