We compared 5341 patients with an initial fracture of the hip with 633 patients who sustained a second fracture of the contralateral hip. Patients presenting with a second fracture were more likely to be institutionalised, female, older, and have lower mobility and mental test scores. There was no significant difference between the two groups with regards to the change in the level of mobility or return to their original residence at one year follow-up. However, the mortality rate in the second fracture group was significantly higher at one year (31.6% vs 27.3%, p = 0.024). In two thirds of patients, the second fracture was in the same anatomical location as the first. In an analysis of 293 patients, approximately 70% of second fractures occurred within three years of the first. This is the largest study to investigate the outcome of patients who sustain a second contralateral hip fracture. Despite the higher mortality rate at one year, the outcome for surviving patients is not significantly different from those after initial hip fractures

It is anecdotally thought that a good outcome from the first of staged total hip arthroplasties (THAs) is predictive of benefit on the contralateral side. The objective was to determine whether outcome from the first THA could be used to predict outcome from the second, contralateral THA. A retrospective cohort study of consecutive patients undergoing staged THAs at a UK arthroplasty centre over 25-years (1995–2020). A control THA group was identified and matched for age, gender, BMI, implant and diagnosis. One-year patient-reported outcome data was available for 91% 1543/1700. 1700 patients who underwent staged THA were compared to 1700 matched controls. Preoperative status was comparable for pain, function, and modified Harris hip score (mHHS, mean 41 SD 13 for both groups). At one year, there was a 2% dissatisfaction rate in all groups (first of staged THAs, second of staged THAs and controls). Groups were similar in terms of pain, function and mHHS (mean 88 SD 11 for all groups). For every 100 patients undergoing staged THAs, 87 had a bilateral good outcome (mHHS >70 both), 11 had unilateral poor outcome (mHHS >70 one, <70 other) and 2 had bilateral poor outcome (mHHS <70 both). If the first THA had a good outcome, the relative risk of a bad outcome was 20% less than for controls (RR 0.8 95% CI 0.6–1.1). If the first THA had a poor outcome, the risk of a second poor outcome was 4.5 times higher (RR 4.5 95% CI 3.2–6.4), increasing from 6% to 29% (absolute risk). Patients undergoing staged THAs with a good outcome from the first THA were less likely to have a bad outcome with the second. Risk of a poor outcome after a previous successful THA was 6% but rose to almost 30% with a previous poor outcome. This remained after correcting for patient variables including gender, age, BMI and diagnosis, indicating a potentially novel independent risk factor for poor outcome from staged THA

Aims. The aim of this study was to describe and compare joint-specific and generic health-related quality of life outcomes of the first versus second knee in patients undergoing staged bilateral total knee arthroplasty (BTKA) for osteoarthritis. Methods. This retrospective cohort study used Australian national arthroplasty registry data from January 2013 to January 2021 to identify participants who underwent elective staged BTKA with six to 24 months between procedures. The primary outcome was Oxford Knee Score (OKS) at six months postoperatively for the first TKA compared to the second TKA, adjusted for age and sex. Secondary outcomes compared six-month EuroQol five-dimension five-level (EQ-5D-5L) domain scores, EQ-5D index scores, and the EQ visual analogue scale (EQ-VAS) between knees at six months postoperatively. Results. The cohort included 635 participants (1,270 primary procedures). Preoperative scores were worse in the first knee compared to the second for all instruments; however, comparing the first knee at six months postoperatively with the second knee at six months postoperatively, the mean between-knee difference was minimal for OKS (-0.8 points; 95% confidence interval (CI) -1.4 to -0.2), EQ-VAS (3.3; 95% CI 1.9 to 4.7), and EQ-5D index (0.09 points; 95% CI 0.07 to 0.12). Outcomes for the EQ-5D-5L domains ‘mobility’, ‘usual activities’, and ‘pain/discomfort’ were better following the second TKA. Conclusion. At six months postoperatively, there were no clinically meaningful differences between the first and second TKA in either the joint-specific or overall generic health-related quality of life outcomes. However, individual domain scores assessing mobility, pain, and usual activities were notably higher after the second TKA, likely reflecting the cumulative improvement in quality of life after both knees have been replaced. Cite this article: Bone Jt Open 2024;5(3):202–209

Aim. Two-stage replacement is a frequent procedure in patients with chronic PJI. However, results in the literature after this procedure differ, ranging from 54% to 100% of infection eradication. Positive cultures at reimplantation, when performing the second stage, are perceived as a risk factor for reinfection. This study aims to determine the impact of positive cultures during the second stage on the outcome of patients undergoing a 2-stage septic replacement and the impact of antibiotic holidays between the first and the second stage. Method. We systematically searched four databases from inception to May 31, 2022. We combined terms related to PJI, joint replacement and culture results. We analysed the risk of failure when positive cultures at second stage and performed a subgroup analysis by antibiotic holiday period. Results. We included 24 studies with 2387 patients of which 432 had positive cultures during second stage (18.09%). Global failure rate was 18.01% (430 patients). When dividing failure by culture results during second stage, we found that failure in positive group was 37.01% (161/432 patients) and failure in negative group was 13.7% (269/1953 patients). In the meta-analysis (MA) the odds ratio (OR) was 4.047 (95% CI: 2.954–5.544). When performing the subgroup analysis by antibiotic holidays we found that the rate of positive cultures without and with holidays was 21.3% and 16.05%, respectively. Failure rate without holidays was 15% (90/600 patients) and with holidays was 17.3% (202/1165 patients) (p=0.21). Failure in each group was higher when cultures were positive (without holidays, 25% vs 12.2%, p=0.0003, and with holidays 41.1% vs 12.7%, p<0.0001). In the MA we found that those studies in which antibiotic holiday was reported had higher risk of failure when cultures were positive during second stage (OR 4.798 95%IC 3.142–7.325). When studies reported no antibiotic holidays also had a higher risk of failure when cultures where positive (OR 2.225 95%CI 1.103–4.489), though it was lower. Conclusions. There exists a higher risk of failure after a two-stage septic replacement when cultures are positive during reimplantation. Patients who followed no antibiotic holidays or antibiotic holidays before reimplantation have similar failure rate when cultures are negative. In both groups they have a higher risk of failure when cultures are positive, having higher risk those positive patients in the antibiotic holidays group. Therefore, importance in detecting these patients before reimplantation is crucial to ensure higher survival rates

Limb symmetry on a battery of functional tests is becoming more common as a clinical rehabilitation tool serving as a proxy assessment for readiness to return to sport following anterior cruciate ligament reconstruction (ACLR). The predictive capability of each included test for determining the likelihood of a second ACL injury is not well known. This study combines 14 established functional tests into a comprehensive return-to-sport assessment (RTSA). Study purpose: to determine if any of the functional tests were independently related to a second ACL injury occurring after the patient was cleared for return to sport. The RTSA was administered to 226 individuals after primary, unilateral ACLR who were followed for at least 24 months (51% female; mean ± SD age, 18.9 ± 4.0 years at RTSA, 9.4 ± 2.4 months post-surgery). The RTSA included 14 tests that involved calculation of Limb Symmetry Indices (LSI): leg press [LP], eccentric hamstring strength [HS], hip adductor strength [HA], Y Balance Test (anterior [YANT], posteromedial [YPM], posterolateral [YPL]), single hop [SH], triple hop [TH], crossover hop [CH], 6 meter timed hop [TiH], lateral hop [LH], medial hop [MH], vertical jump [VJ], single leg squat [SLS]. LSI averaged values of three trials for each leg for LP, HS, HA, SH, TH, CH, TiH, LH, MH, VJ, and SLS. The lowest bilateral difference across three trials was used for YANT, YPM, and YPL. Logistic regression using backward elimination was used to predict the odds of a second non-contact ACL injury using the RTSA, sex, age, and months post-surgery at RTSA as the independent variables. Twenty-five (11%) patients returned to have a subsequent ACL surgery. Twenty of the 25 experienced a second non-contact ACL injury (70% female; 10 ipsilateral, 10 contralateral). Of the 14 female athletes, there were eight contralateral and six ipsilateral tears. In males, there were two contralateral and four ipsilateral tears. The mean time from surgery to injury was 20.5 ± 9.8 months. Age (OR; 95%CI: 0.75; 0.58, 0.92), LP (0.97; 0.93, 0.99), YANT (1.21; 1.02, 1.43), and TiH (1.10; 1.01, 1.20) were found to be significantly associated with the odds of re-injury. Age, YANT, and the LSI of LP and TiH have a statistically significant impact on the odds of a second ACL injury after ACL reconstruction. YANT has an OR of 1.21, indicating that a 1cm increase in asymmetry will increase the likelihood of re-injury by 21%, holding all else constant. A 1% increase in the TiH LSI results in a 10% increase in the odds of re-injury. The risk of re-injury decreases as age increases. The OR for LP symmetry was near 1.0 and therefore may not have a clinically relevant effect on re-injury risk. Although LSI is a straightforward, quantitative measure, clinicians should not solely rely on it as a proxy for recovery of knee function. Many tests are available for clinical assessments, but this study found only a few of the tests to have significant associations with a subsequent ACL injury following return to play after ACL reconstruction

The second wave of COVID-19 infections in 2021 resulting from the delta strain had a significantly larger impact on the state of New South Wales, Australia and with it the government implemented harsher restrictions. This retrospective cohort study aims to explore how the increased restrictions affected hand trauma presentations and their treatment. Retrospective analysis was performed on patients who underwent hand surgery from the period of June 23 – August 31 in 2020 and 2021 at a level one trauma centre in Western Sydney. During the second-wave lockdown there was an 18.9% decrease in all hand trauma presentations. Despite widespread restrictions placed on the manufacturing, wholesale, retail and construction industries, there was an insignificant difference in work injuries. Stay-at-home orders and reduced availability of professional tradespersons likely contributed to an increase in DIY injuries. Significant reductions in metacarpal and phalangeal fractures coincided with significantly curtailed sporting seasons. The findings from this study can assist in predicting the case-mix of hand trauma presentations and resource allocation in the setting of future waves of COVID-19 and other infectious diseases

Aims. The new COVID-19 variant was reported by the authorities of the UK to the World Health Organization (WHO) on 14 December 2020. We aim to describe the clinical characteristics and nosocomial infection rates in major trauma and orthopaedic patients comparing the first and second wave of COVID-19 infection. Methods. A retrospective analysis of a prospectively collected trauma database was reviewed at a level 1 major trauma centre from 1 December 2020 to 18 February 2021 looking at demographics, clinical characteristics, and nosocomial infections and compared to our previously published first wave data (26 January 2020 to 14 April 2020). Results. From 1 December 2020 to 18 February 2021, 522 major trauma patients were identified with a mean age of 54.6 years, and 53.4% (n = 279) were male. Common admissions were falls (318; 60.9%) and road traffic accidents (RTAs; 71 (13.6%); 262 of these patients (50.2%) had surgery. In all, 75 patients (14.4%) tested positive for COVID-19, of which 51 (68%) were nosocomial. Surgery on COVID-19 patients increased to 46 (61.3%) in the second wave compared to 13 (33.3%) in the first wave (p = 0.005). ICU admissions of patients with COVID-19 infection increased from two (5.1%) to 16 (20.5%), respectively (p = 0.024). Second wave mortality was 6.1% (n = 32) compared to first wave of 4.7% (n = 31). Cardiovascular (CV) disease (35.9%; n = 14); p = 0.027) and dementia (17.9%; n = 7); p = 0.030) were less in second wave than the first. Overall, 13 patients (25.5%) were Black, Asian and Minority ethnic (BAME), and five (9.8%) had a BMI > 30 kg/m. 2. The mean time from admission to diagnosis of COVID-19 was 13.9 days (3 to 44). Overall, 12/75 (16%) of all COVID-19 patients died. Conclusion. During the second wave, COVID-19 infected three-times more patients. There were double the number of operative cases, and quadruple the cases of ICU admissions. The patients were younger with less dementia and CV disease with lower mortality. Concomitant COVID-19 and the necessity of major trauma surgery showed 13% mortality in the second wave compared with 15.4% in the first wave. In contrast to the literature, we showed a high percentage of nosocomial infection, normal BMI, and limited BAME infections. Cite this article: Bone Jt Open 2021;2(8):661–670

INTRODUCTION. In recent years the age of world's population has risen and with it there has been a significant increase in the frequency of hip fractures in the elderly. These fractures are known to increase morbidity and mortality. However, little is known about the frequency and characteristics of patients who sustain a second hip fracture. We examined the incidence and the underlying associated medical disorders of patients with a second fracture in the other hip. MATERIAL & METHODS. This study consists of 132/1208 Pts. (10.9%) treated in our department between 1998–2006 that had a secondary hip fracture 1–9 years following the first hip fracture. We examined the most common complications following surgery of this type, the most common related illnesses among these patients, and the influence of post-surgical rehabilitative care on the patients' return to daily functioning. RESULTS. 132 Pts (10.9%) of this series (34 M, 98 F; 64–101 year old; mean 81Y) had a second hip fracture. Most of them (82%) had chronic associated disorders such as heart problems, dementia, old CVA, sight problems and renal failure. Of those with a second hip fracture- 9/132 (6.8%) had the second hip fracture within the first year following surgery, 35/132 (26.5.3%) after 2 years and the remaining 102/132 (66.7%) after 3–6 years. 70.8% of the second hip fracture were of the same type and location of the first hip fracture. 65% of the single hip-fracture patients returned to the same type of daily functioning that they had had prior to injury within one year following surgery. 52% of the patients with the second hip fracture returned to the same level of daily functioning they had had during the period between the first and the second hip fracture Furthermore, we also found that sub-capital fractures are more characteristic of a younger population than are intertrochanteric fractures. DISCUSSION. Based on this study it seems that the frequency of a second fracture in the other hip was 10.9%. The length of time between occurrence of the first and second fractures ranged from one to six years, a third of them within the first 2 years and two thirds of them after 3–6 years. Age and medical status of the patient may be important predictors of a second hip fracture. It is therefore imperative to improve bone quality, medical and functional status of the patients following the first hip fractures in order to reduce the risk of the second hip fractures

Introduction:. Unicompartmental knee arthroplasty (UKA) is becoming an increasingly popular option in single compartment osteoarthritis. As a result, diverse second operations including revisions to total knee arthroplasty (TKA) will also increase. The objective of this study is to investigate the distribution of causes of second operations after UKA. Methods:. We retrospectively reviewed 695 UKAs performed on 597 patients between January 2003 and December 2011. Except in one case, all UKAs were replaced at the medial compartment of the knee. The UKAs were performed on 559 (80.4%) women's knees and 136 (19.6%) men's knees. The mean age at the time of UKA was 61.5 years. The mobile-bearing designs were those that were predominantly implanted (n = 628 mobile, 90.2%; n = 67 fixed). The mean interval between UKA and second operation was 14.1 months. Results:. In our study, the burden of a second operation after the initial UKA was 7.3%, and the total number of second operations was 51 (n = 45 mobile, n = 6 fixed). The most common cause of a second operation after a mobile-bearing UKA was the dislocation of the meniscal bearing (34.8%), followed by component loosening (21.7%), the formation of a cement loose body (15.2%), unexplained pain (13%), infection (6.5%), periprosthetic fracture (4.3%), and others (4.4%). For the fixed-bearing UKA, the causes of a second operation were loosening (n = 2), unexplained pain (n = 2), and bearing wear (n = 1). The main causes of either a revision UKA or a conversion to TKA were multiform operations that included bricement, internal fixation for a periprosthetic fracture, isolated bearing changes, open debridement with bearing changes, or implant removal due to early infection. Conversions to TKA during the second operation were performed in 17 cases. Discussion and conclusion:. The most common cause of a second operation after a mobile-bearing UKA was the dislocation of the bearing, followed by component loosening and the formation of a cement loose body. After a fixed-bearing UKA, component loosening and unexplained pain were the most common. A cause-based approach to the primary and failed UKA may be helpful to minimize the possibility of a second operation and to give rise to a successful outcome of a revision TKA

Introduction. A large proportion of patients with osteoarthritis of the knee, present with bilateral symptoms at the outpatient department. A simultaneous total knee arthroplasty (TKA) procedure is available for such patients. The first operation in a simultaneous surgery may provide information to the operator to determine component size, soft tissue balancing, and estimate gap size for the second operation, while the second team usually conducts an operation in a confined space on the contralateral side during closure for the first operation, which can disturb cooperation during the second operation and may lead to more intra-operative surgical errors. We hypothesized that the circumstances of the two consecutive operations of a simultaneous bilateral TKA are different, could lead to different outcomes of overlapping bilateral TKAs. We therefore addressed the following research questions to determine whether there would be differences in short-term clinical outcomes, radiographic results, and implanted component size between the two sides. Methods. A retrospective review of 451 consecutive patients, who underwent simultaneous bilateral TKA between January 2011 and April 2012, was conducted. Bilateral TKAs were performed with the senior surgeon conducting the main procedure (from skin incision to implantation of first prosthesis until prior closure of the first knee) on the right side first and subsequently the left side with a second team. At 1 year after surgery, clinical outcome scores (the Knee Society Knee and Function scores, WOMAC score), radiologic findings were evaluated and clinical results as postoperative blood loss, operation time were compared between bilateral sides. Results. A greater incidence (16.1%) of outliers during postoperative coronal limb alignment (>±3o) were identified in the second TKA than those in the first TKA (9.0%) (p =0.003). Multivariate analysis for the association of outlier rates in the second TKA relative to the first revealed a significance for severity of the preoperative deformity (pre-op. coronal limb alignment, p = 0.002) and decreased ROM (p = 0.042) from the GEE analysis. The second knee also showed more blood loss (735 vs. 656mL), and longer operation time (61, 58 minutes respectively), as compared to the first TKA, while no significant differences in clinical outcomes. Discussion and Conclusion. There were no significant differences in the clinical outcomes even though few distinct outcomes due to different circumstances of the surgery. Awareness of these findings can help the continued success of bilateral TKA in an increasing patient population

We determined the age-specific incidence of a second fracture of the hip and compared it with that of a primary fracture in a study population drawn from 6331 patients admitted to Nottingham University Hospital with a primary fracture of the hip over a period of 8.5 years. The incidence of a second fracture was determined using survival analysis. The mean age-specific incidence rates of primary hip fracture were calculated using census data. The overall incidence of a second fracture was 2.7% at one year and 7.8% at 8.5 years. That of a primary fracture was 50 per 100 000 in women aged 55 to 64 years rising to 3760 in those aged 84 years and over. The incidence of a second fracture in women aged 55 to 64 years was 2344 per 100 000. Patients of this age had a relative risk of 45 (95% confidence interval 13 to 155) for further fracture when compared with the population at risk of a first fracture. The incidence of a second fracture in women aged > 84 years was 2451 per 100 000 (relative risk 0.7, 95% confidence interval 0.5 to 0.9). A similar trend was seen in men. Patients sustaining a primary fracture of the hip between the ages of 55 and 64 years have a much greater risk of further fracture than the normal population, whereas those over 84 years have a similar risk. These findings have important implications for the provision of fracture prevention services in primary and secondary care

Hallux valgus deformity may cause overriding of the second toe. Hallux valgus correction surgery in the elderly can be debilitating and patients may suffer a long period of morbidity. We show the outcomes of amputation of over-riding second toe caused by gross hallux valgus in the elderly. Eight patients underwent amputation of their overriding second toe, one of these patients underwent bilateral second toe amputations. All surgery was performed as a day case. Six patients had surgery under a local anaesthetic, two patients had surgery under a general anaesthetic. Patients selected had asymptomatic or minimally symptomatic hallux valgus with an overriding second toe and did not want hallux valgus correction surgery. A disease specific questionnaire using a Visual Analogue Scale (VAS) was implemented measuring pain, discomfort, deformity and walking distance. Patients were followed up for a minimum nine of months. Eight patients (nine feet) underwent amputation of their second toe. There were seven females and one male. The age range was 63–90 years (median 83 years). All patients had a painful second toe on wearing footwear. Skin ulceration occurred on the dorsum of second toe in two patients. The mean VAS for pain, deformity, discomfort and walking distance before and after surgery are:- (before/after); pain = (7.00/0.94), deformity = (7.44/2.78), discomfort = (7.78/1.22) and walking distance = (6.89/6.44). There were no cases of post-operative infection, wound dehiscence, bleeding or deep vein thrombosis. One patient complained of a painful neuroma after one year. Amputation of the second toe significantly reduces pain, discomfort and the appearance of deformity (p< 0.01), there was no difference in the patient’s walking distance after surgery. We recommend this type of surgery as an alternative to hallux valgus correction surgery in the elderly if the first ray is not causing significant symptoms

Background: Although hip fracture is often the first presentation of osteoporosis, prophylactic measures are not routinely prescribed. Aims: To investigate whether the second hip fracture has a significant further impact on walking and social independence and to identify which patients are most likely to benefit from currently available prophylactic measures. Method: Information on walking ability and social independence was obtained approximately 3 months following discharge for 49 consecutive patients admitted with a second hip fracture. Results: Fewer patients maintained their ability to walk without the help of an able-bodied assistant after the second fracture compared with the first fracture (53% and 91% respectively p< 0.0005). A similar proportion of patients admitted from their own homes remained socially independent after the first and second fractures (64% and 54% respectively). Social independence was determined by mental status after the first fracture but by ability to walk unassisted after the second fracture. The median time to second fracture was 31 months (3–302). The median time to second fracture for patients aged 80 and below and patients without a history of recurrent falls was more than 2 years. Conclusion: The second fracture had a significant further impact on patients. Bisphosphonates given over a 2 year period can decrease the rate of hip fracture and should be given to patients who sustain a hip fracture aged 80 or less and patients who do not have a history of multiple falls. Hip protectors should be considered in other patients

Aim. Antibiotic loaded spacers are often used during a two-stage exchange for periprosthetic joint infections (PJI) both for its mechanical properties and as a means for local antibiotic delivery. The main goal of this study is to compare the rate of positive cultures during reimplantation with the use of different antibiotic loaded spacers: aminoglycoside only vs. combined glycopeptide/aminoglycoside vs. combined glycopeptide/carbapenem/aminoglycoside. Method. We retrospectively evaluated every two-stage exchange procedures for infected hip/knee arthroplasty between 2012–2018. Microbiological findings in the first and second stage were registered as well as the type of spacer and antibiotic(s) used. Cases in whom no cultures were obtained during reimplantation and cases without sufficient data on antibiotic(s) used in cement spacers were excluded. Results. Fifty-four cases were included (20THA and 34TKA), with an overall rate of positive cultures during reimplantation of 18.5% (10/54). The rate of positive cultures was statistically significant higher among spacers with monotherapy with aminoglycoside compared to spacers with combined antibiotic therapy- 35.7% (5/14) vs. 12.5% (5/40) respectively(p<0.05). Comparing those with combined glycopeptide/aminoglycoside (2/19) with triple glycopeptide/carbapenem/aminoglycoside therapy (3/21) there was no significant difference. Microorganisms present during the second stage were mostly staphylococci (coagulase-negative in four cases, S.aureus in three), Corynebacterium striatum, Enterococcus faecalis, C.albicans in one case each. In most cases (8/10), the isolated microorganism was the same as the first stage and was resistant to the antibiotic(s) used in the spacer in seven cases. Failure rate with the need for subsequent surgery was significantly higher at 60% (6/10) in cases with positive cultures at reimplantation compared to 4.5% (2/44) for those with negative cultures during reimplantation(p=0.0005). Conclusions. It has recently been suggested that adding a glycopeptide to the spacer may be advantageous when compared to spacers with aminoglycoside monotherapy, as it will produce significantly lower rates of positive cultures during reimplantation which have been shown to increase the risk of subsequent failure as is the case in our study. Local unavailability of obtaining powder aminoglycosides has driven us to manually add high doses of vancomycin and meropenem to commercially available low-dose gentamicin cement in many of our spacers and they seem to to perform just as well as commercially available vancomycin/gentamicin combination. Although many other variables not considered in this study may influence the rate of positive cultures during the second stage (quality of initial debridement, systemic antibiotic therapy, etc.), we believe these results portrait a sufficiently accurate picture of clinical results with the use of different spacers

The aim of this study was to determine the incidence of second hip fracture. A prospective cohort study include 2682 patients aged 50 years or more admitted with a hip fracture over a 4 year period. Mortality data were available for all patients and survival analysis was performed to determine the incidence of second hip fracture. The mean age-specific incidence rates of primary hip fracture in the population were calculated to serve as a baseline. 95 patients (3.5%) sustained a sequential, contralateral hip fracture within the study period. The mean age at first hip fracture was 82 years and the mean interval between fractures was 316 days. Fracture morphology was similar on both sides in 69% of cases. Survival analysis demonstrated that the incidence of second hip fracture at 1 year was 2.8% (95% CI: 2.0–3.6), 2 years was 5.7% (95% CI: 4.3–7.1) and 3 years was 7.3% (95% CI: 5.4–9.2). The relative risk of hip fracture in patients who had already sustained one hip fracture was 2.4 times above that of matched controls. Assistance with activities of daily living was identified as a risk for second hip fracture (p=0.026, 95% CI: 1.058, 2.466). The odds ratio for sustaining a second hip fracture compared with the incidence of primary hip fracture in the normal population aged 55–64 years was 47.5 xs; 65–74 years was 15 xs; 75–84 years was 3.7x and 85+ years was 1x. The risk of sustaining a second contralateral hip fracture is substantial. In younger patients preventative measures can be targeted at the individual who has sustained a fracture whereas in more elderly patients, preventative measures need to address the population as a whole

Staged bilateral total knee arthroplasty is performed increasingly frequently but no data has been published comparing the specific outcome for the first knee replacement to that of the second. Pre-operative and post-operative Oxford Knee Scores (/ 48) were reviewed for each knee in a series of 91 patients undergoing staged bilateral total knee arthroplasty over a 5-year period. Pre-operative scores for the first total knee arthroplasty were significantly worse with a mean of 14.9 in comparison to 17.0 for the second knee (P=0.0083). While there was no significant difference between the mean post-operative scores for the first knee (37.4) and the second knee (36.6) (P=0.195), the mean improvement was significantly less for the second knee (22.6 points versus 19.6 points) (P=0.0045). Our results demonstrate that in patients undergoing staged bilateral knee arthroplasty, the second knee replacement is commonly performed at a lower threshold and functional improvement is less than for the first knee. This data will be important to inform the expectations of patients considering proceeding to bilateral knee arthroplasty after previously having undergone a primary total knee replacement

Ligamentous injury of the tarsometatarsal joint complex is uncommon but disabling. Injuries to individual ligaments can be visualised with MRI. The relative mechanical contribution of the three ligaments of the second TMTJ is unknown. Methods. The second and third metatarsals and the first cuneiform were dissected from twenty pairs of cadaveric feet. In group I, seven pairs were submaximally loaded to determine stiffness with the dorsal, plantar, and Lisfranc ligaments intact. One of each pair underwent sectioning of the dorsal ligament and was then loaded to failure. In the contralateral specimen both plantar and Lisfranc ligaments were divided before retesting. In group II all 13 pairs underwent dorsal ligament excision and stiffness determination. One of each pair was randomly assigned to undergo sectioning of the plantar ligament, the other sectioning of the Lisfranc ligament, before retesting. Results and Conclusions. The Lisfranc ligament is stronger and stiffer than the plantar ligament. The dorsal ligament is weaker than the Lisfranc/plantar complex. This suggests that ligamentous injuries of the second tarsometatarsal joint may be considered stable if the Lisfranc ligament is intact – even if the other two ligaments are disrupted. If the Lis-franc ligament is injured then the complex is less stiff and may be unstable

Study Design: A retrospective review of case notes and histology reports. Summary of Background Data: Up to 8% of cancer patients develop second malignancies. The vertebral column is frequently involved in metastatic disease and may represent the first manifestation of malignancy in up to 40% of patients. The rate of vertebral metastasis from a second tumour in patients with a known primary is not well known. Objective: We sought to identify the incidence of a second primary in patients referred to our unit with spinal malignancy and a previously diagnosed primary tumour. Subjects: 222 patients underwent definitive surgery for spinal metastatic disease of whom 135 had a prior history of malignancy. Outcome measures: Histological tissue of origin of spinal metastasis in light of previous known malignancy. Results: In 16 patients (11.9%) the vertebral histology differed from the initial primary. The period between first and second malignancies varied widely (19 months – 22 years). Thirteen patients (9.6%) had identifiable tissue origins for the metastasis that was not in keeping with the previous malignancy. Three further patients showed sufficient histological and imunohistochemical differences such that a further tumour of unknown origin and not de-differentiation of the previous tumour was suspected. Three previously unrecognised tumours were diagnosed on biopsy and eight on tissue obtained at definitive surgery. Conclusion: The incidence of second primaries, in particular myeloma, presenting with vertebral metastases is significant and should always be borne in mind when assessing patients and planning treatment. Biopsy should be performed when possible. Comparison needs to be made between the histological features of the previous primary and metastasis

Introduction. Technological advances in the processing of polyethylene have led to improved survivorship of total hip arthroplasty. The purpose of this study was to determine if a second generation highly cross-linked polyethylene could improve upon wear rates compared to conventional and first generation cross-linked polyethylene in patients undergoing primary total hip arthroplasty. Methods. Linear and volumetric wear rates of a second generation highly cross-linked polyethylene were evaluated following primary total hip arthroplasty. There were 44 patients with an average age of 68.6 years and mean follow-up of 5.3 years. Patients were evaluated at six weeks, one, two and five years. Wear rates were determined from digitized AP Pelvis radiograph by an independent observer using Martell's software. Acetabular inclination and femoral head size were also evaluated to determine variability in wear rates. Results. The mean linear wear rate for the entire group was 0.015mm/year (±0.055). There was a 64% decrease in linear wear rate when compared to a first generation highly cross-linked polyethylene from the same institution. There was a 90% decrease in wear rate compared to conventional polyethylene. There were no differences in the linear wear rate between the 32mm vs. larger head sizes (36mm and 40mm). However, there was a 30% increase in volumetric wear rate with larger head sizes. The mean wear rate in patients with cup inclination less than 45 degrees was 0.006mm/year compared with 0.024mm/year for those with an inclination greater than 45 degrees. The amount of linear wear was increased by 4 times in patients with a cup inclination of greater than 45 degrees. There was no evidence of any osteolysis in this group of patients. Conclusion. Our data with a mean follow-up of 5.3 years, using a second generation highly cross-linked polyethylene, demonstrates a dramatic decrease in incidents of linear wear compared to conventional polyethylene and first generation highly cross-linked polyethylene (Figure 1). Of concern is the higher volumetric wear rate noted with larger head sizes and increased linear wear rates with cup inclination angles of greater than 45 degrees. Despite improvements in wear rates using a second generation highly cross-linked polyethylene, cup orientation and choice of head size play significant roles in implant survivorship

One of the major long term problems of total shoulder replacement is loosening of the glenoid component. Since 1997 we have been using atmospheric pressure to drive cement into the interstices of the glenoid trabecular bone by lowering the intraosseous pressure. This is achieved by introducing a wide bore needle into the base of the coracoid process and attaching it to surgical suction. During this period approximately 200 Tornier Aequalis shoulder replacements were performed by the senior author. For the purpose of this detailed study 20 consecutive cases were studied. Good exposure of the glenoid is achieved using an extended approach and aggressive surgical releases. The surface is prepared according to the manufacturers recommendation. The base of the coracoid is now exposed and drilled with a 3.5mm AO drill bit, angled so as not to collide with the keel of the glenoid component. A Verres needle is hammered into the glenoid at this point and connected to a separate, second suction apparatus, placed on high suction during final lavage, cement insertion and cement curing. Blood and lavage fluid can be seen to be sucked from the glenoid during preparation and cementation. Standard true antero-posterior radiographs were taken by the same experienced radiographer in the plane of the glenoid face two days following surgery, and at 3 months and one year. A Mitotoyu digital microcalliper with a resolution of 0.1mm was used to determine the depth of cement intrusion and presence of lucent lines. Three independent observers measured each radiograph. Analysis of interobserver error shows agreement between observers. For assessment the glenoid was divided into five zones – Superior flange; superior slope of keel; base of keel; inferior slope of keel; inferior flange. No patient had a complete lucent line around the glenoid component. Four patients had a single zone lucent line (ranging from 1.1mm to 1.7mm) None of these patients had a lucent line around the keel, and those four areas of lucency under the superior or inferior flange were more likely due to incomplete removal of articular cartilage than a failure of cement technique. The reported prevalence of glenoid lucent lines varies from 22% to 89%. The significance of glenoid lucent lines is controversial but several studies have reported a direct relationship between the presence of radiolucent lines and the development of loosening of cemented components. Secure cement technique is more difficult in the shoulder than in the knee or hip. Access is tighter, bleeding more difficult to control and peroxide should not be contemplated because of close proximity of the axillary nerve to the glenoid. Classic socket pressurisers can not fit into such a small space. We have found that the second sucker technique is extremely effective in establishing a secure cement-bone interface during glenoid replacement