Aim. Treatment recommendations for periprosthetic joint infections (PJI) include surgical debridement, antibiotic therapy or staged revision. In surgical related foot and ankle infections (SR-FAI), implant removal will lead to instability. Debridement is difficult because the implant is outside the joint. Recommendations regarding PJI treatment can therefore not be extrapolated to the treatment of SR-FAI. Method. We searched PubMed for the etiology and treatment of SR-FAI, taken into account the time of occurrence, causative microorganisms and surgical treatment options. We integrated this knowledge into a treatment algorithm for SR-FAI. Results. Within the first 6 weeks after surgery, it is difficult to distinguish acute osteomyelitis from surgical site infection in which infection is limited to the soft tissue. The predominantly causative microorganism is Staphylococcus aureus. No debridement can be performed, because of the diffuse soft tissue inflammation and the absence of a joint space. If early SR- FAI is suspected without signs of systemic symptoms, fistula or abscess, empirical antibiotic treatment covering Staphylococcus aureus is recommended. If there is suspicion of ongoing SR-FAI after 2 weeks of empirical treatment, samples for culture after an antibiotic free window should be obtained to identify the causative microorganisms. If SR-FAI is confirmed, but there is no consolidation yet, targeted antibiotic treatment is given for 12 weeks without initial implant removal. In all other cases, debridement and samples for culture should be obtained after an antibiotic free window. Staged revision surgery will be performed if there is still a nonunion. Conclusions. Treatment algorithm regarding PJI cannot be extrapolated to the treatment of SR-FAI. Until now, no treatment guideline for SR-FAI is available. We have introduced a treatment algorithm for the treatment of SR-FAI. The guideline will be validated during the next 2 years

Aims. There remains a lack of consensus regarding the management of chronic anterior sternoclavicular joint (SCJ) instability. This study aimed to assess whether a standardized treatment algorithm (incorporating physiotherapy and surgery and based on the presence of trauma) could successfully guide management and reduce the number needing surgery. Methods. Patients with chronic anterior SCJ instability managed between April 2007 and April 2019 with a standardized treatment algorithm were divided into non-traumatic (offered physiotherapy) and traumatic (offered surgery) groups and evaluated at discharge. Subsequently, midterm outcomes were assessed via a postal questionnaire with a subjective SCJ stability score, Oxford Shoulder Instability Score (OSIS, adapted for the SCJ), and pain visual analogue scale (VAS), with analysis on an intention-to-treat basis. Results. A total of 47 patients (50 SCJs, three bilateral) responded for 75% return rate. Of these, 31 SCJs were treated with physiotherapy and 19 with surgery. Overall, 96% (48/50) achieved a stable SCJ, with 60% (30/50) achieving unrestricted function. In terms of outcomes, 82% (41/50) recorded good-to-excellent OSIS scores (84% (26/31) physiotherapy, 79% (15/19) surgery), and 76% (38/50) reported low pain VAS scores at final follow-up. Complications of the total surgical cohort included a 19% (5/27) revision rate, 11% (3/27) frozen shoulder, and 4% (1/27) scar sensitivity. Conclusion. This is the largest midterm series reporting chronic anterior SCJ instability outcomes when managed according to a standardized treatment algorithm that emphasizes the importance of appropriate patient selection for either physiotherapy or surgery, based on a history of trauma. All but two patients achieved a stable SCJ, with stability maintained at a median of 70 months (11 to 116) for the physiotherapy group and 87 months (6 to 144) for the surgery group. Cite this article: Bone Jt Open 2022;3(10):815–825

Muller-Weiss disease is an uncommon condition with unclear etiology and no gold standard treatment. The question arises; which joints to fuse? Although no consensuses prevail, one must postulate fusion should include those affected. Consequently, to establish an algorithm for its surgical management we set out to study clinical and radiographic features with use of SPECT-CT and a literature review. 57 consecutive feet presenting with Muller-Weiss disease analysed; 15 men, 25 women, age 22–84. Condition bilateral in 17, left side 16, right in 7 patients. Specific history and examination by senior author. Radiographic series and SPECT-CT obtained with surgery performed on significantly symptomatic feet. Measurements of Meary-Tomeno angles, anteroposterior thickness of navicular at the midpoint of each naviculo-cuneiform, alongside the medial extrusion distance and percentage of compression in each case performed. Poor correlation between Meary's angle and 1) degree of compression at naviculo-cuneiform joints, 2) degree of extrusion 3) compression vs extrusion using R. 2. coefficient of determination (invalidating Maceira et al. classification). In unilateral cases, extrusion significantly greater on affected side 94.7% (P< 0.001 Fisher exact test). Degree of extrusion significantly greater in bilateral than unilateral cases (p=0.004 unpaired T test). Valgus hindfoot and Meary's negative most common pattern with no correlation between heel alignment and Meary's R. 2. = 0.003. SPECT-CT useful to determine subtalar involvement in ‘stage 2 disease.’. Following review of cases and published literature we propose the following classification for Muller-Weiss disease with treatment algorithm. 3 Stage delineation; Stage 1 (Normal hindfoot alignment); 1A. Talonavicular disease only - Isolated Talonavicular arthrodesis 1B. Talonavicular + Subtalar; double medial or triple arthrodesis. Stage 2. Talonavicular + Naviculocuneiform; 2A. Adequate bone stock - Talo-naviculo-cuneiform arthrodesis, 2B. Inadequate bone stock +- subtalar disease; Talo-naviculo-cuneiform arthrodesis with tricortical bone graft (Mayich). Stage 3; Asymmetric ankle varus. Pantalar arthrodesis Double/triple/TNC/TAR arthrodesis with hindfoot re-alignment

Introduction and Objective. Despite the low incidence of pilon fractures among lower limb injuries, their high-impact nature presents difficulties in surgical management and recovery. Current literature includes a wide range of different management strategies, however there is no universal treatment algorithm. We aim to determine clinical outcomes in patients with open and closed pilon fractures, managed using a treatment algorithm that was applied consistently over the span of this study. Materials and Methods. This retrospective study was conducted at a single institution, including 141 pilon fractures in 135 patients, from August 2014 to January 2021. AO/OTA classification was used to classify fractures. Among closed fractures, 12 had type 43A, 18 had type 43B, 61 had type 43C. Among open fractures, 11 had type 43A, 12 had type 43B, 27 had type 43C. Open fractures were further classified with Gustilo-Anderson (GA); type 1: n=8, type 2: n=10, type 3A: n=12, type 3B: n=20. Our treatment algorithm consisted of fine wire fixator (FWF) for severely comminuted closed fractures (AO/OTA type 43C3), or open fractures with severe soft tissue injury (GA type 3). Otherwise, open reduction internal fixation (ORIF) was performed. When required, minimally invasive osteosynthesis (MIO) was performed in combination with FWF to improve joint congruency. All open fractures, and closed fractures with severe soft tissue injury (skin contusion, fracture blister, severe oedema) were initially treated with temporary ankle-spanning external fixation. For all open fracture patients, surgical debridement, soft tissue cover with a free or pedicled flap were performed. For GA types 1 and 2, this was done with ORIF in the same operating session. Those with severe soft tissue injury (GA type 3) were treated with FWF four to six weeks after soft tissue management was completed. Primary outcome was AOFAS Ankle-Hindfoot score at 3, 6 and 12-months post-treatment. Secondary outcomes include time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time. All complications were recorded. Results. Mean AOFAS score 3, 6, and 12 months post-treatment for open and closed fracture patients were 44.12 and 53.99 (p=0.007), 62.38 and 67.68 (p=0.203), 78.44 and 84.06 (p=0.256), respectively. 119 of the 141 fractures healed without further intervention (84.4%). Average time to bone union was 51.46 and 36.48 weeks for open and closed fractures, respectively (p=0.019). Union took longer in closed fracture patients treated with FWF than ORIF (p=0.025). On average, open and closed fracture patients took 12.29 and 10.76 weeks to PWB (p=0.361); 24.04 and 20.31 weeks to FWB (p=0.235), respectively. Common complications for open fractures were non-union (24%), post-traumatic arthritis (16%); for closed fractures they were post-traumatic arthritis (25%), superficial infection (22%). Open fracture was a risk factor for non-union (p=0.042; OR=2.558, 95% CI 1.016–6.441), bone defect (p=0.001; OR=5.973, 95% CI 1.986–17.967), and superficial infection (p<0.001; OR=4.167, 95% CI 1.978–8.781). Conclusions. The use of a two-staged approach involving temporary external fixation followed by definitive fixation, provides a stable milieu for soft tissue recovery. FWF combined with MIO, where required for severely comminuted closed fractures, and FWF for open fractures with severe soft tissue injury, are safe methods achieving low complication rates and good functional recovery

Partial meniscectomy patients have a greater likelihood for the development of early osteoarthritis (OA). To prevent the onset of early OA, patient-specific treatment algorithms need to be created that predict patient risk to early OA after meniscectomy. The aim of this work was to identify patient-specific risk factors in partial meniscectomy patients that could potentially lead to early OA. Partial meniscectomy patients operated between 01/2017 and 12/2019 were evaluated in the study (n=317). Exclusion criteria were other pathologies or surgeries for the evaluated knee and meniscus (n = 114). Following informed consent, an online questionnaire containing demographics and the “Knee Injury and Osteoarthritis Outcome Score” (KOOS) questionnaire was sent to the patient. Based on the KOOS pain score, patients were classified into “low” (> 75) and “high” (< 75) risk patients, indicating risk to symptomatic OA. The “high risk” patients also underwent a follow-up including an MRI scan to understand whether they have developed early OA. From 203 participants, 96 patients responded to the questionnaire (116 did not respond) with 61 patients considered “low-risk” and 35 “high-risk” patients. Groups that showed a significant increased risk for OA were patients aged > 40 years, females, overweight (BMI >25 kg/m2 ≤ 30 kg/m2), and smokers (*p < 0.05). The “high-risk”-follow-up revealed a progression of early osteoarthritic cartilage changes in seven patients, with the remaining nineteen patients showing no changes in cartilage status or pain since time of operation. Additionally, eighteen patients in the high-risk group showed a varus or valgus axis deviation. Patient-specific factors for worse postoperative outcomes after partial meniscectomy and indicators for an “early OA” development were identified, providing the basis for a patient-specific treatment approach. Further analysis in a multicentre study and computational analysis of MRI scans is ongoing to develop a patient-specific treatment algorithm for meniscectomy patients

Aims. Fungal periprosthetic joint infections (fPJIs) are rare complications, constituting only 1% of all PJIs. Neither a uniform definition for fPJI has been established, nor a standardized treatment regimen. Compared to bacterial PJI, there is little evidence for fPJI in the literature with divergent results. Hence, we implemented a novel treatment algorithm based on three-stage revision arthroplasty, with local and systemic antifungal therapy to optimize treatment for fPJI. Methods. From 2015 to 2018, a total of 18 patients with fPJI were included in a prospective, single-centre study (DKRS-ID 00020409). The diagnosis of PJI is based on the European Bone and Joint Infection Society definition of periprosthetic joint infections. The baseline parameters (age, sex, and BMI) and additional data (previous surgeries, pathogen spectrum, and Charlson Comorbidity Index) were recorded. A therapy protocol with three-stage revision, including a scheduled spacer exchange, was implemented. Systemic antifungal medication was administered throughout the entire treatment period and continued for six months after reimplantation. A minimum follow-up of 24 months was defined. Results. Eradication of infection was achieved in 16 out of 18 patients (88.8%), with a mean follow-up of 35 months (25 to 54). Mixed bacterial and fungal infections were present in seven cases (39%). The interval period, defined as the period of time from explantation to reimplantation, was 119 days (55 to 202). In five patients, a salvage procedure was performed (three cementless modular knee arthrodesis, and two Girdlestone procedures). Conclusion. Therapy for fPJI is complex, with low cure rates according to the literature. No uniform treatment recommendations presently exist for fPJI. Three-stage revision arthroplasty with prolonged systemic antifungal therapy showed promising results. Cite this article: Bone Jt Open 2021;2(8):671–678

The most common classification of periprosthetic femoral fractures is the Vancouver classification. The classification has been validated by multiple centers. Fractures are distinguished by location, stability of the femoral component, and bone quality. Although postoperative and intraoperative fractures are classified using the same three regions, the treatment algorithm is slightly different. Type A fractures involve the greater and lesser trochanter. Fractures around the stem or just distal to the stem are Type B and subcategorised depending on stem stability and bone quality. Type C fractures are well distal to the stem and are treated independent of the stem with standard fixation techniques. The majority of fractures are either B1 (stable stem) or B2 (unstable stem). The stem is retained and ORIF of the fracture performed for B1 fractures. B2 and B3 fractures require stem revision with primary stem fixation distal to the fracture. Intraoperative fractures use the same A, B, C regions but are subtyped 1–3 as cortical perforations, nondisplaced, and displaced unstable fractures, respectively. With the exception of A1 intraoperative fractures all other intraoperative fractures require surgical treatment. A recent publication utilizing a New York state registry highlighted the patient risk of mortality associated with periprosthetic hip fractures. One month, 6 month and 1 year mortality was 3.2%, 3.8% and 9.7%, respectively. The mortality risk was lower for periprosthetic fractures treated with ORIF at 1 and 6 months compared to fractures requiring revision total hip

Purpose: Spontaneous osteonecrosis of the knee is a potentially greatly debilitating condition. While success has been reported with non-operative treatment of this disorder in its earliest stages, knee arthroplasty is the only viable modality if allowed to progress to condylar collapse. The purpose of this report is to review the etiologic and pathophysiologic principles of spontaneous osteonecrosis of the knee, to present our experience with joint-preserving surgical treatment of this condition, and finally to introduce a treatment algorithm developed based on this knowledge. Method: Seventeen patients with a clinical and/or radiographic a diagnosis of spontaneous osteonecrosis of the knee, and exclusion of secondary osteonecrosis, who failed non-operative modalities were treated with joint-preserving surgery at a single center between January 2000 and December 2006. Treatment modalities included arthroscopy, and either percutaneous core decompression and/or osteochondral autograft transfer. Three knees were lost to follow-up, leaving 14 knees with a mean follow-up of 37 months (range, 11 to 84 months). Results: Twelve of 14 knees (86%) had knee joint survival with a mean Knee Society Score of 80 points (range, 45 to 100 points) at final follow-up. One patient was treated with serial core decompression followed by osteochondral transfer, and was included in both groups. Six of 7 patients (86%) treated with core decompression alone had a successful clinical outcome, as did 7 of 8 patients (87%) treated with osteochondral autograft transfers. Two patients (14%) progressed to condylar collapse, and were treated with total knee arthroplasty with successful results. Conclusion: Based on these results, we propose a treatment algorithm that begins with non-operative treatment, followed by joint-preserving surgery consisting of arthroscopy, core decompression, and/or osteochondral autograft transfer. Although our sample size is small, the results suggest that this proposed treatment algorithm can successfully postpone the need for knee arthroplasty in selected patients with pre-collapse spontaneous osteonecrosis of the knee

The patho-anatomy of a valgus knee could be divide into two categories as bony hypolasia and/or deficiency and soft tissue imbalance. The soft tissue in the lateral side of the knee (Including illio-tial band, lateral collateral ligament, poplitious tendon, posterior-lateral ligament, and hamstrings etc) is contracted with or without medial soft tissue attenuation. There are many reasons explain why dealing with a valgus knee is much more difficult than dealing with a varus knee. The most important three factors are:. There is much less room or space to release a LCL,. The MCL could be attenuated,. A fixed valgus deformity is always associated with bone deficiency or hypoplasia. However, it is arbitrary, and in many times, it is wrong to take it for granted that a valgus knee is always associated with a tight LCL. In this article, the author mainly introduce the rationale and clinical application of a LCL tension based classification and treatment algorithm of a valgus knee. The details of how to judge if the LCL is tight, loose or normally tensioned; Is the valgus knee purely or associated with an extra-articular deformity will also be discussed. JST Classification of a Valgus Knee. Femoral deformity. Type F1 Valgus in Extension only. F1a Intra-articular deformity, LCL is loose when the knee extends, while LCL maintains normal tension when the knee flexes. F1b Extra-articular deformity which is close to knee joint(supra-condylar deformity), LCL remains normal length and tension through all the range of motion. Type F2 Valgus in both extension and flexion. Intra-articular deformity, LCL is tight through all the range of motion, hypoplasia or bone deficiency in both distal and posterior lateral femoral condyle. Tibial deformity. Type T1 Intra-articular deformity, lateral tibial plateau deficiency. Type T2 Extra-articular deformity, tibial metaphyseal orshaft deformity. Treatment algorithm of a valgus knee. Type F1a. This type valgus knee is the easiest to deal with. The LCL length is well maintained, and LCL is loose when knee extends. What is tight and restrains the deformity as a fixed valgus one is: ITB and posterior-lateral capsule instead of LCL and poplitous tendon. The deformity is corrected simply by releasing ITB & posterior-lateral capsule and bony graft or using a metal block to augment the deficient or hypoplastic lateral distal femoral condyle. At the same time, the loose LCL is properly tensioned by bone graft of metal augmentation. Since both ITB & posterior capsule are secondary stabilizers, the LCL and poplitous tendon is properly tensioned, the knee is pretty stable. Type F1b. This type of valgus deformity actually comes from juxta supera-condylar area, the deformity is very close to the joint, or in other words, close to the collateral ligament frame, this type deformity is also regard as a type of valgus knee. According to severity of the deformity, patient’s age, and surgeon’s preference, the following methods are commonly used. Method A: lateral condyle distal sliding osteotomy The essence of a sliding osteotomy is converting a F1b deformity into a F1a deformity. By distally sliding osteotomy, the LCL becomes loose when the knee extends, and the valgus deformity is shifted into the collateral ligament frame. Method B: Soft tissue releasing + constrained total knee The LCL of a F1b valgus knee is normal tensioned with normal length, over releasing lateral soft tissue will lead to imbalanced flexion gap, in this meaning, it may not possible to balance a F1b valgus knee properly in both flexion and extension. In such a knee, if the patient is old and is not going to lead an active life, a constrained prosthesis such as CCK or TC III can be used. Method C: One stage or two stage supera-condylar osteotomy+TKA. Since a F1b valgus knee is actually a normal knee combined with a supera-condylar deformity, it is understandable to correct deformity by an supera-condylar osteotomy. The osteotomy can be done in one stage or two stage style. Theoretically, a supera-condylar osteotomy is done in the most deformed region, and is done within cancellous bone, bone union can be predictably expected. But if a total knee and osteotomy is performed in one stage, the operator could encounter the following difficulties:. Conventional instruments can not guarantee correct bone cut because a supera-condylar deformity deviates intramedullary guiding rod;. the canal in distal femoral metaphyseal part is quite expended, it is difficult to achieve solid fixation either by a stem extension or retrograde intramedullary nailing. Total knee replacement, supera-condylar osteotomy and intramedullary could severely damage blood supply to osteotomy line leading to nonunion. The author prefer a two stage TKA and osteotomy for a F1b valgus knee. In one stage TKA and osteotomy, the author will use frontal epicondyle axis instead of intra-medullary rod to guide distal femoral cut. TypeF2. This type knee is consistently valgus no matter the knee extends of flexes, indicating both distal distal and posterior part of lateral femoral condyle is deficient of dysplastic and LCL is contracted. Lateral soft tissue, including LCL and some times popolitous tendon, is inevitable in managing type F2 valgus knee. If soft tissue releasing alone can’t balance medial and lateral part of the knee, a bidirectional sliding osteotomy can be done to shift proximal insertion of LCL both distally and posteriorly, releasing the LCL. Type T deformity. Type T deformity is sparse, Type T1 is typically seen in a rheumatoid arthritis, and Type T2 is usually iatrogenic(over corrected high tibia osteotomy) or after malunion of a tibia metapyseal or proximal shaft fracture. It is possible try to augament the lateral tibial plateau deficiency and release the lateral soft tissue for a Type T1 valgus knee. But for a Type T2 knee, a correctional osteotomy concomitant to a total knee is usually needed

Introduction. Metatarsus adductus (MA) increases the risk of recurrence following surgery for hallux valgus (HV). The goal of this study was to analyze patients with severe MA and identify clinical/surgical factors that are associated with a lower rate of recurrent deformity. Methods. 587 patients underwent correction of HV deformity. The rate of recurrence of HV was 15% (63 out of 414 patients) in patients without MA (MA angle < 20°) and 29.6% (50 out of 173 patients) in patients with MA. 19 patients with severe MA (>31°) were identified; 8 of 19 had associated tarsometatarsal arthritis, and two patients had a skew foot deformity. Ten patients had severe valgus lesser toe deformities. Clinical information collected included associated diagnoses, the presence of arthritis of the tarsometatarsal joints, the presence and degree of lesser toe valgus deformities and surgical procedures performed. Radiographic recurrence was defined as a postoperative HVA > 20°. Results. 9/19 patients were treated with a modified Lapidus procedure and 10 patients underwent a distal first metatarsal osteotomy. Of the 9 patients who were treated with a modified Lapidus procedure, 6 patients underwent simultaneous realignment lesser metatarsal osteotomy or arthrodesis of the 2. nd. /3. rd. TMT joints. 1/9 of these patients had radiographic recurrence of deformity. Of the 10 patients who underwent a distal first metatarsal osteotomy without realignment proximal osteotomy or arthrodesis, 5 had recurrence of deformity. Of the 11 patients with severe valgus lesser toe deformity, those who were treated with simultaneous additional distal lesser metatarsal osteotomies, did not have recurrence of hallux valgus. Conclusion. The use of a modified Lapidus procedure led to a lower rate of HV deformity recurrence in comparison to isolated distal first metatarsal osteotomies. Treatment of lesser toe deformity with distal osteotomy should be included as part of the treatment algorithm

Purpose of the study: To develop a new treatment algorithm for patients with chronic anterior knee pain based on kinematic patella tracking MR imaging. Methods and Results: Patients with anterior knee pain of more than one year duration and not responding to non-operative treatment, underwent kinematic MRI study. The provocative test was performed with the conventional MRI scanner and the patient extending the knee against resistance, the resistance provided by inflated beach ball. A retrospective analysis was done of first seventy patients, who had undergone this scanning technique. On the imaging films, four measurements were made. They were patella subluxation, tilt, cartilage thickness and the Tibial Tubercle Trochlear distance (TTD). Patellar subluxation was classified as mild, moderate and severe. We found that a Tibial Tubercle Trochlea distance of 18mm had a specifity of 100% and a sensitivity of 89% for severe maltracking. Conclusion: Kinematic MR Imaging is a useful investigation before considering operative treatment for patients with chronic anterior knee pain. Based on our study, we conclude that those patients with moderate lateral maltracking with a TTD< 18 mm should be offered lateral release and those with severe maltracking and TTD> 18mm should have a tibial tubercle transfer, in addition to lateral release

Purpose of the study: To develop a new treatment algorithm for patients with chronic anterior knee pain based on kinematic patella tracking MR imaging. Methods and Results: Patients with anterior knee pain of more than one year duration and not responding to non-operative treatment, underwent kinematic MRI study. The provocative test was performed with the conventional MRI scanner and the patient extending the knee against resistance, the resistance provided by inflated beach ball. A retrospective analysis was done of first seventy patients, who had undergone this scanning technique. On the imaging films, four measurements were made. They were patella subluxation, tilt, cartilage thickness and the Tibial Tubercle Trochlear distance (TTD). Patellar subluxation was classified as mild, moderate and severe. We found that a Tibial Tubercle Trochlea distance of 18mm had a specifity of 100% and a sensitivity of 89% for severe maltracking. Conclusion: Kinematic MR Imaging is a useful investigation before considering operative treatment for patients with chronic anterior knee pain. Based on our study, we conclude that those patients with moderate lateral maltracking with a TTD< 18 mm should be offered lateral release and those with severe maltracking and TTD> 18mm should have a tibial tubercle transfer, in addition to lateral release

Important issues related to total hip replacement for dysplasia are: placement of the cup and bone stock; the role of femoral osteotomy, and the choice of acetabular and femoral components.

The cup can be placed at the correct or near correct anatomical level with or without a bone graft, in a high position (high hip center) or at the right level in a protruded position. All three techniques can provide adequate coverage of the cup. In the high hip position bone graft is not usually necessary to obtain cup coverage. There is, however, a higher rate of component loosening, a higher dislocation rate, and lengthening is limited to the femoral side. Placing the cup in a protruded position to obtain coverage does not restore bone stock for future surgery, but it does place the hip at the correct level. Placing the cup in the correct anatomical position (i.e., at the right level and not protruded) may require a structural autograft which adds to the complexity of the case. However, bone stock is restored for future surgery.

Femoral osteotomy may be used as part of the exposure for diaphyseal shortening or for derotation of excessive anteversion. The osteotomy is carried out in the sub-trochanteric region and may be oblique, step-cut or transverse. Fixation of the osteotomy is achieved via the stem, a plate, or a cortical strut.

Cementless components are usually used because of the relatively young age of this patient population. Small components may be necessary. On the femoral side, the stem should be straight or modular so excessive anteversion can be neutralised.

To examine the impact of a structured rehabilitation programme as part of an integrated multidisciplinary treatment algorithm for adult spinal deformity patients. A prospective cohort study was performed over a 2-year period at a major tertiary referral centre for adult spinal deformity surgery. All consecutive patients requiring 2-stage corrective surgery for sagittal malalignment were included (n=32). Details of physiotherapy initial evaluation, inpatient rehabilitation progress, details of bracing treatment and time to discharge were collected. Clinical outcome scores were measured preoperatively and at 6 weeks, 6 months and 1 year postoperatively. After second stage corrective surgery, the mean time to standing without assistance was 2.1 days, mean time to independent ambulation was 4.2 days, mean time to competent ascending and descending stairs was 5.6 days and mean time to moulded orthosis application 7.1 days. Successful progression through the structured rehabilitation programme was associated with high clinical outcome scores and improved health related quality of life (HRQOL). The introduction of this programme contributed to the development of an enhanced recovery pathway for patients having adult spinal deformity surgery, reducing inpatient length of stay and optimising clinical outcomes

At our institution, periprosthetic hip joint infections are treated according to a previously defined treatment algorithm. Each patient is evaluated regarding risk factors such as duration of clinical signs and symptoms, stability of the implant, condition of the soft tissue, and antimicrobial susceptibility of the microorganism. Depending on these factors, either debridement with retention, one-stage exchange, or two-stage exchange with spacer (short interval, 2–4 weeks), or without spacer (long interval, 8 weeks) is performed. Very rarely, resection arthroplasty or lifetime suppression is necessary. All surgical procedures are combined with an antimicrobial therapy for 6 or 12 weeks, depending on the surgical pathway. For infection due to staphylococci, whenever possible, rifampicin is used in combination with a fluoroquinolone. From 2002–2006, 89 patients with 95 episodes (3 patients with 2 independent episodes, 3 patients with bilateral infection) of periprosthetic hip joint infection have been treated at our hospital. Five patients died within 2 years after revision, one of them with septic shock related to the periprosthetic hip joint infection. One patient is living abroad. All other patients (n=83) had consecutive follow-up visits at least until 2 years after infection treatment without recurrence. Debridement with retention has been performed in 18 episodes, one-stage exchange in 25 episodes, two-stage exchange with temporary spacer for 2–4 weeks has been performed in 26 episodes, and two-stage exchange without spacer and an interval of 8 weeks in 19 episodes. In 4 cases, immediate resection arthroplasty was performed and 3 patients received long-term suppression therapy. After debridement with retention, 3 recurrences and one event of death occurred (4/18=22.2%), 3 of them did not fulfil the criteria of the algorithm. No failure was observed after one-stage exchange (0/25). Treatment with two-stage exchange was followed by one failure in the group with spacer and short interval (1/26=3.8%), as well as one in the group without spacer and long interval (1/19=5.3%). No recurrence occurred after resection arthroplasty or suppression therapy. All 5 patients with relapse could be cured with a one- or two-stage exchange and remained without recurrence. Comparing one-stage versus two-stage exchange, one-stage exchange is known to have better functional results. It is associated with better patient acceptance, shorter hospital stay, and therefore lower economic burden. In conclusion, one-stage exchange implies no increasing risk of recurrence provided that the standards of our algorithm are considered

Background: Pelvic fractures are frecuently associated with massive intrapelvic bleeding from venous or arterial sources. Different treatment algorithms has been proposed in order to stablish early control of haemorragic sites, mostly based on external fixation/angiography. The aim of present study was to evaluate the clinical evolution of 70 pelvic fractures with uncontrolled hypotension treated with combined ex fix/angio based on fracture pattern. Materials and methods: Case serie . We analyzed a serie of patients admitted at our center between 1994 and 2004 with pelvic fracture and haemodinamic instability , treated by the same algorithm. Decision-making for the first treatment(angio vs external fixation) were based on the type of pelvic fracture. Patients was considered unstable if PAS was less than 90mmHg or the patients needs more than two blood products replacement in first 24 hours. Results: External fixation was used in 45 patients(64%) and 37 patients were treated by angio. We found active arterial bleeding in 31 cases (44%). The combination of both treatment was used in 20 patients. Laparotomy was performed in 21 patients. Incidence of sistemic complications were high . Mortality was 26% . Mortality were higher in two groups: patients with TBI and those treated by laparotomy. Conclusions: Arterial lesions demostrated by angio were high in our study(44%). In our experience a combined algorithm using both external fixation or angio based on type fracture control intrapelvic bleeding in most cases , although mortality in patients with pelvic fractre and haemodinamic instabilty remains high

Treatment of Tendo Achilles (TA) ruptures can result in considerable morbidity and has significant socio-economic implications. The ideal management of these injuries has yet to be defined. Recent studies have demonstrated that non-surgical treatment with accelerated rehabilitation may have comparable outcomes to surgery. The aim of this study was to evaluate current management and outcomes of TA ruptures at a tertiary referral centre, with a view to developing contemporary treatment guidelines.

A retrospective review of TA ruptures over a 12-month period was undertaken. Patients were managed on an individual based approach with no strict management algorithm followed. Data collection included pre-injury activity level, ultrasound findings and treatment methodology. Outcome data collected included return to activity, incidence of DVT and re-rupture. Patients were followed up for an average of 2 years.

Data was collected in 49 patients. 31 (63%) of these were managed non-surgically. Ruptures were most common in men (65%) at an average age of 44 yrs. Ultrasound scan at initial diagnosis was performed in 28 patients. There was an average gap in equinus of 34mm in the surgical group, while the average gap within the non-surgical group was 24mm (p=0.23). There was no association between the gap observed on ultrasound and re-rupture rate.

At a median of 2 year follow up, there was no significant reduction in average time spent immobilised in a below knee splint in the surgically treated group (10.2 weeks) compared to non-surgical group (10.9 weeks, p=0.35). 86.3% of patients returned to pre-injury level of activity in the non-surgical group and 86.7% in the surgery group (p=1.0). Complications within this patient cohort consisted of one superficial wound infection and one re-rupture, both occurring within the surgical group. Within the surgical group patients were treated with direct primary repair or primary reconstruction using FHL augmentation in cases of delayed presentation. DVT was not observed in either group. Only 22.6% received thromboprophylaxis in non-surgical group compared to 61.1% in surgical group.

We observed that patients within the non-surgical group demonstrated the same return to pre-injury activity as the surgically treated group and had fewer complications. The time spent immobilised was also comparable. Based on these findings, we modified guidelines and now recommend that surgery should be limited to patients with gap of greater than 20 mm in full equinus on ultrasound and in those with delayed diagnosis. We also recommend thromboprophylaxis for 2 weeks in non-surgical group.

The Vancouver classification separates periprosthetic femur fractures after THA into three regions (A - trochanteric, B - around or just below the stem, and C - well below the stem), with fractures around or just below the stem further separated into those with a well-fixed (B1) or loose stem and good (B2) or poor (B3) bone stock. Trochanteric fractures may be associated with osteolysis and require treatment that addresses osteolysis as well as ORIF of displaced fractures. Fractures around a well-fixed stem can be treated with ORIF using cerclage or cable plating, while those around a loose stem require implant revision usually to a longer cementless tapered or distally porous coated cementless stem. Fractures around a loose stem with poor bone stock in which salvage of the proximal femur is not possible require replacement of the proximal femur with an allograft prosthetic composite or proximal femoral replacement. Fractures well below the stem can be treated with conventional plating methods.

Periprosthetic acetabular fractures are rare and usually occur in the early post-operative period or late as a result of osteolysis or trauma. These can generally be separated into those with a stable acetabular component which can be treated non-operatively, and those with an unstable component often with discontinuity or posterior column instability which require complex acetabular reconstruction utilizing plating or revision to a cup-cage.

To assess the reliability of the pre-operative measurement methods used in the management of the hallux valgus deformity, five observers assessed 50 pre-operative standing foot radiographs on two occasions in order to assess the reliability of radiological hallux valgus assessment using the inter-metatarsal angle (IMA), hallux valgus angle (HVA) and joint congruency. Five published methods of angle measurements described by Hawkins, Venning and Hardy, Mitchell, Miller and Nestor were used.

Kappa statistics were used to assess the reliability of the diagnosis of congruency. Regarding IMA and HVA, mean values between the methods were assessed by one-way ANOVA. The differences between the methods and observers were assessed by two-way ANOVA.

Results: Diagnosis of congruency showed good agreement (k=0.608) over two occasions, although this did vary by observer.

The mean IMA and HVA measurements varied significantly between methods on both occasions (p< 0.0001). Mitchell’s method had the lowest and Miller’s the highest mean values.

Analysis of variance showed both method and observer variations were significant for IMA. But HVA measurements differed significantly only by observers.

Conclusion: The reliability of IMA and HVA measurements is poor whichever measuring method is used and these methods are not interchangeable. Study papers should state the measurement method used. For the pre- and post-operative assessment the same method should be used.

Introduction

We propose that Total Hip Replacement with correction of fixed flexion deformity of the hip and exaggerated lumbar lordosis will result in relief of symptoms from spinal stenosis, possibly avoiding a spinal surgery. A sequence of patients with this dual pathology has been assessed to examine this and suggest a possible management algorithm.