Introduction. We report a case which total knee arthroplasty (TKA) was able to be performed on schedule for the patient with occult fracture of proximal tibia which seemed to have occurred three months prior to the surgery, and has healed in short period of time by the use of Teriparatide. Case report. The patient is 84-year-old female, having right knee pain for past 7 years. Her knee pain increased by passive extension maneuver that was done by a bonesetter 3 months prior to the surgery. On her initial visit, the X-ray finding was severe medial osteoarthritis, and femorotibial angle (FTA) in the upright film was 197°, but there was no other disorder including fracture. Since the bone mineral density (BMD) of affected femoral neck was 62%YAM, and affected lateral femoral condyle as well as lateral tibial condyle seemed very porotic, we started using daily 20μg Teriparatide injection from 3 months prior to the surgery. Proximal tibial fracture was presented in the X-ray taken on the day before surgery, but since adequate bone union has already been formed, surgery was performed on schedule. Tibial implant with long stem was used for just to be certain. Thanks to the Teriparatide, the condition of cancellous bone in cut surface was excellent, and reaming of the tibia through fracture area felt very solid. Discussion. Proximal tibial fracture that occurred just before TKA is very rare. The fracture in this case was probably due to the maneuver done by the bonesetter. Teriparatide is indicated when osteoporosis is severe and the patient is at risk for fracture. We also indicate Teriparatide for the patients whose femoral neck BMD is very low and severe valgus knee or varus knee is present. Unloaded side of femoral or tibial condyle is usually very porotic in such a case. In our case, the fracture was so called fragility fracture which was found incidentally the day before surgery, but TKA could be done on schedule since adequate callus has been formed by the use of Teriparatide which started 3 months prior to the surgery

Background. High velocity vertical aircraft ejection seat systems are credited with aircrew survival of 80-95% in modern times. Use of these systems is associated with exposure of the aircrew to vertical acceleration forces in the order of 15-25G. The rate of application of these forces may be up to 250G per sceond. Up to 85% of crew ejecting suffer skeletal injury and vertebral fracture is relatively common (20-30%) when diagnosed by plain radiograph. The incidence of subtle spinal injury may not be as apparent. Aim. A prospective study to evaluate spinal injury following high velocity aircraft ejection. Methods. A prospective case series from 1996 to 2006 was evaluated. During this interval 26 ejectees from 20 aircraft were admitted to the spinal studies unit for comprehensive examination, evaluation and management. The investigations included radiographs of the whole spine and Magnetic Resonance Imaging (incorporating T1, T2 weighted and STIR sagittal sequences). All ejections occurred within the ejection envelope and occurred at an altitude under 2000 feet (mean 460 feet) and at an airspeed less than 500 knots (mean 275 knots). Results. in this series 6 ejectees (24%) had clinical and radiographic evidence of vetebral compression fractures. These injuries were located in the thoracic and thoracolumbar spine. 4 cases required surgery (indicated for angular kyphosis greater than 30 degrees, significant spinal canal compromise, greater than 50% or neurological injury. 1 patient had significant neurological compromise, following an AO A3.3 injury involving the L2 vertebra. 11 ejectees (45 %) had MRI evidence of a combined total of 22 occult thoracic and lumbar fractures. The majority of these ejectees with occult injury had multilevel injuries. Conclusion. This study confirms a high incidence of spinal fracture and particularly occult spinal injury

The amount of bone loss due to implant failure, loosening, or osteolysis can vary greatly and can have a major impact on reconstructive options during revision total knee arthroplasty (TKA). Massive bone loss can threaten ligamentous attachments in the vicinity of the knee and may require use of components with additional constraint to compensate for associated ligamentous instability. Classification of bone defects can be helpful in predicting the complexity of the reconstruction required and in facilitating preoperative planning and implant selection. One very helpful classification of bone loss associated with TKA is the Anderson Orthopaedic Research Institute (AORI) Bone Defect Classification System as it provides the means to compare the location and extent of femoral and tibial bone loss encountered during revision surgery. In general, the higher grade defects (Type IIb or III) on both the femoral and tibial sides are more likely to require stemmed components, and may require the use of either structural graft or large augments to restore support for currently available modular revision components. Custom prostheses were previously utilised for massive defects of this sort, but more recently have been supplanted by revision TKA component systems with or without special metal augments or structural allograft. Options for bone defect management are: 1) Fill with cement; 2) Fill with cement supplemented by screws or K-wires; 3) Morselised bone grafting (for smaller, especially contained cavitary defects); 4) Small segment structural bone graft; 5) Impaction grafting; 6) Porous metal cones or sleeves 7) Massive structural allograft-prosthetic composites; 8) Custom implants. Of these, use of uncemented highly porous metal metaphyseal cones in combination with an initial cemented or partially cemented implant has been shown to provide versatile and highly durable results for a range of bone defects including those previously requiring structural bone graft. The hybrid fixation combination of both cement and cementless fixation of an individual tibial or femoral component has emerged as a frequent and often preferred technique. Initial secure and motionless interfaces are provided by the cemented portions of the construct, while subsequent bone ingrowth to the cementless porous metal portions is the key to long term stable fixation. As bone grows into the porous portions there is off loading and protection of the cemented interfaces from mechanical stresses. While maximizing support on intact host bone has been a longstanding fundamental principle of revision arthroplasty, this is facilitated by the use of metaphyseal cones or sleeves in combination with initial fixation into the adjacent diaphysis. Preoperative planning is facilitated by good quality radiographs, supplemented on occasion by additional imaging such as CT. Fluoroscopically controlled x-ray views may assist in diagnosing the loose implant by better revealing the interface between the implant and bone and can facilitate accurate delineation of the extent of bone deficiency present. Part of the preoperative plan is to ensure adequate range and variety of implant choices and bone graft resources for the planned reconstruction allowing for the potential for unexpected intraoperative findings such as occult fracture through deficient periprosthetic bone. While massive bone loss may compromise ligamentous attachment to bone, in the majority of reconstructions, the degree of revision implant constraint needed for proper balancing and restoration of stability is independent of the bone defect. Thus, some knees with minimal bone deficiency may require increased constraint due to the status of the soft tissues while others involving very large bone defects, especially of the cavitary sort, may be well managed with minimal constraint

Introduction. When performing a total hip arthroplasty (THA), some surgeons routinely perform an intraoperative anteroposterior (AP) pelvis radiograph to assess components. The purpose of this study was to evaluate the reliability of the intraoperative radiograph to accurately reflect acetabular inclination, leg length, and femoral offset as compared to the immediate postoperative supine AP radiograph. Methods. The intraoperative (lateral decubitus position) and immediate postoperative (supine position) AP pelvis x-rays of 100 consecutive patients undergoing primary THA were retrospectively reviewed. Acetabular inclination, leg length, and femoral offset were measured on both radiographs. We analyzed the correlation coefficient of the recorded measurements between the two films as well as the interobserver reliability of each measurement obtained. Results. Our data demonstrated a high positive correlation between the intraoperative and postoperative acetabular inclination measurements of both reviewers (r=.886 and .896). In addition, no significant difference was observed between the inclination measurements (p= .06 and .37). There was a moderate correlation among the leg length (r= .58 and .66) and poor correlation among the offset (r= .29 and .25) between the two radiographs. One observer generated a significant difference between leg length measurements while both reviewers generated a significant difference between offset measurements. Interobserver reliability was high for all measurements. Conclusion. Intraoperative AP radiographs are commonly obtained during THA to aid in evaluation of component position and size, femoral neck cut, femoral canal fill, and detection of occult fractures. Results from this study suggest that this film could also be used to accurately measure acetabular inclination, but is a less reliable indicator of femoral offset and leg length when compared to the immediate postoperative film. In addition, the high interobserver correlation illustrates the high reproducibility of the measurement methods utilized

A retrospective review of 57 military patients undergoing ankle arthroscopy between 1999 and 2011 was performed. A case-note review of medical records was undertaken pertaining to military role, ankle injury sustained, mechanism, presenting symptoms and their duration. Arthroscopic findings were compared to findings on radiographs and MRI scans. At first presentation 23 patients had features of arthritis on radiographs. We found MRI was both highly sensitive (97.7%) and specific (93.4%) in detecting osteochondral defects (OCD). 16 of the patients had evidence of osteochondral injury. All OCDs picked up on MRI were confirmed at arthroscopy. Ankle injury may not be a benign injury in military personnel, with over half of these young patients having radiological features of osteoarthritis at presentation. We found MRI an effective tool for identifying occult injuries not seen on radiographs. Lateral ligament injury with associated gutter scarring can be successfully treated with arthroscopic debridement. This suggests pseudoinstability rather than a true mechanical instability as the main cause for patient's symptoms in this cohort

The amount of bone loss due to implant failure, loosening, or osteolysis can vary greatly and can have a major impact on reconstructive options during revision total knee arthroplasty (TKA). Massive bone loss can threaten ligamentous attachments in the vicinity of the knee and may require use of components with additional constraint to compensate for associated ligamentous instability. Classification of bone defects can be helpful in predicting the complexity of the reconstruction required and in facilitating pre-operative planning and implant selection. One very helpful classification of bone loss associated with TKA is the Anderson Orthopaedic Research Institute (AORI) Bone Defect Classification System as it provides the means to compare the location and extent of femoral and tibial bone loss encountered during revision surgery. In general, the higher grade defects (Type IIb or III) on both the femoral and tibial sides are more likely to require stemmed components, and may require the use of either structural graft or large augments to restore support for currently available modular revision components. Custom prostheses were previously utilised for massive defects of this sort, but more recently have been supplanted by revision TKA component systems with or without special metal augments or structural allograft. Options for bone defect management are: 1) Fill with cement; 2) Fill with cement supplemented by screws or K-wires; 3) Morselised bone grafting (for smaller, especially contained cavitary defects); 4) Small segment structural bone graft; 5) Impaction grafting; 6) Large prosthetic augments (cones); 7) Massive structural allograft-prosthetic composites (APC); 8) Custom implants. Maximizing support on intact host bone is a fundamental principle to successful reconstruction and frequently requires extending fixation to the adjacent diaphysis. Pre-operative planning is facilitated by good quality radiographs, supplemented on occasion by additional imaging such as CT. Fluoroscopically controlled x-ray views may assist in diagnosing the loose implant by better revealing the interface between the implant and bone and can facilitate accurate delineation of the extent of bone deficiency present. Part of the pre-operative plan is to ensure adequate range and variety of implant choices and bone graft resources for the planned reconstruction allowing for the potential for unexpected intra-operative findings such as occult fracture through deficient periprosthetic bone. Reconstruction of bone deficiency following removal of the failed implant is largely dictated by the location and extent of bone loss and the quality of bone that remains. While massive bone loss may compromise ligamentous attachment to bone, in the majority of reconstructions the degree of implant constraint needed for proper balancing and restoration of stability is independent of the bone defect. Thus some knees with minimal bone deficiency may require increased constraint due to the status of the soft tissues while others involving very large bone defects especially of the cavitary sort may be well managed with minimal constraint

The amount of bone loss due to implant failure, loosening, or osteolysis can vary greatly and can have a major impact on reconstructive options during revision total knee arthroplasty (TKA). Massive bone loss can threaten ligamentous attachments in the vicinity of the knee and may require use of components with additional constraint to compensate for associated ligamentous instability. Classification of bone defects can be helpful in predicting the complexity of the reconstruction required and in facilitating pre-operative planning and implant selection. One very helpful classification of bone loss associated with TKA is the Anderson Orthopaedic Research Institute (AORI) Bone Defect Classification System as it provides the means to compare the location and extent of femoral and tibial bone loss encountered during revision surgery. In general, the higher grade defects (Type IIb or III) on both the femoral and tibial sides are more likely to require stemmed components, and may require the use of either structural graft or large augments to restore support for currently available modular revision components. Custom prostheses were previously utilised for massive defects of this sort, but more recently have been supplanted by revision TKA component systems with or without special metal augments or structural allograft. Options for bone defect management are: 1) Fill with cement; 2) Fill with cement supplemented by screws or K-wires; 3) Morselised bone grafting (for smaller, especially contained cavitary defects); 4) Small segment structural bone graft; 5) Impaction grafting; 6) Large prosthetic augments (cones); 7) Massive structural allograft-prosthetic composites (APC); 8) Custom implants. Maximizing support on intact host bone is a fundamental principle to successful reconstruction and frequently requires extending fixation to the adjacent diaphysis. Pre-operative planning is facilitated by good quality radiographs, supplemented on occasion by additional imaging such as CT. Fluoroscopically controlled x-ray views may assist in diagnosing the loose implant by better revealing the interface between the implant and bone and can facilitate accurate delineation of the extent of bone deficiency present. Part of the pre-operative plan is to ensure adequate range and variety of implant choices and bone graft resources for the planned reconstruction allowing for the potential for unexpected intra-operative findings such as occult fracture through deficient periprosthetic bone. Reconstruction of bone deficiency following removal of the failed implant is largely dictated by the location and extent of bone loss and the quality of bone that remains. While massive bone loss may compromise ligamentous attachment to bone, in the majority of reconstructions the degree of implant constraint needed for proper balancing and restoration of stability is independent of the bone defect. Thus some knees with minimal bone deficiency may require increased constraint due to the status of the soft tissues while others involving very large bone defects especially of the cavitary sort may be well managed with minimal constraint. Highly porous metal augments designed to reestablish metaphyseal support and function in the manner of a prosthetic structural graft have been introduced or are under development by several manufacturers. Published reports of short term experiences have been encouraging for both the tibial side and for femoral augmentation. It remains to be seen whether these implants will provide the desired longer term durability

Introduction. Up to 16% of scaphoid fractures are radiologically occult; failure to diagnose scaphoid fractures may lead to delayed union, nonunion or avascular necrosis. Fractures may take weeks to be excluded and many patients are unnecessarily immobilised increasing work absence, clinical reviews and cost. The use of CT early in the management of suspected occult scaphoid fractures has been evaluated. Methods. The radiology and clinical notes of all patients that had scaphoid CT scans over the preceding 3 years were retrospectively reviewed. 84 patients that had CT scans within 14 days from injury were identified. Results. 64% of CTs excluded fracture (N=54) and these patients were mobilised promptly and reviewed within six weeks. No patients returned with any complications, such as carpal instability, from this management strategy. Mean number of clinic appointments for this group was 2.34 (range 2–6). 36% of CTs were abnormal (N=30). 7% revealed occult scaphoid fractures; 18% revealed occult carpal fractures of the triquetrum, capitate and lunate respectively and 5% distal radius fractures. All patients diagnosed with fractures were successfully managed with plaster immobilisation, with one case of regional pain syndrome. Conclusions. Early CT immediately alters therapeutic decision making in suspected occult fractures preventing unnecessary immobilisation. Early CT also reduces clinic attendances for clinical and radiological review without increase in cost

The amount of bone loss due to implant failure, loosening, or osteolysis can vary greatly and can have a major impact on reconstructive options during revision total knee arthroplasty (TKA). Massive bone loss can threaten ligamentous attachments in the vicinity of the knee and may require use of components with additional constraint to compensate for associated ligamentous instability. Classification of bone defects can be helpful in predicting the complexity of the reconstruction required and in facilitating pre-operative planning and implant selection. One very helpful classification of bone loss associated with TKA is the Anderson Orthopaedic Research Institute (AORI) Bone Defect Classification System as it provides the means to compare the location and extent of femoral and tibial bone loss encountered during revision surgery. In general, the higher grade defects (Type IIb or III) on both the femoral and tibial sides are more likely to require stemmed components, and may require the use of either structural graft or large augments to restore support for currently available modular revision components. Custom prostheses were previously utilised for massive defects of this sort, but more recently have been supplanted by revision TKA component systems with or without special metal augments or structural allograft. Options for bone defect management are: 1) Fill with cement; 2) Fill with cement supplemented by screws or K-wires; 3) Morselised bone grafting (for smaller, especially contained cavitary defects); 4) Small segment structural bone graft; 5) Impaction grafting; 6) Large prosthetic augments (cones); 7) Massive structural allograft-prosthetic composites (APC); 8) Custom implants. Maximizing support on intact host bone is a fundamental principle to successful reconstruction and frequently requires extending fixation to the adjacent diaphysis. Pre-operative planning is facilitated by good quality radiographs, supplemented on occasion by additional imaging such as CT. Fluoroscopically controlled x-ray views may assist in diagnosing the loose implant by better revealing the interface between the implant and bone and can facilitate accurate delineation of the extent of bone deficiency present. Part of the pre-operative plan is to ensure adequate range and variety of implant choices and bone graft resources for the planned reconstruction allowing for the potential for unexpected intra-operative findings such as occult fracture through deficient periprosthetic bone. Reconstruction of bone deficiency following removal of the failed implant is largely dictated by the location and extent of bone loss and the quality of bone that remains. While massive bone loss may compromise ligamentous attachment to bone, in the majority of reconstructions the degree of implant constraint needed for proper balancing and restoration of stability is independent of the bone defect. Thus some knees with minimal bone deficiency may require increased constraint due to the status of the soft tissues while others involving very large bone defects especially of the cavitary sort may be well managed with minimal constraint

The amount of bone loss due to implant failure, loosening, or osteolysis can vary greatly and can have a major impact on reconstructive options during revision total knee arthroplasty (TKA). Massive bone loss can threaten ligamentous attachments in the vicinity of the knee and may require use of components with additional constraint to compensate for associated ligamentous instability. Classification of bone defects can be helpful in predicting the complexity of the reconstruction required and in facilitating preoperative planning and implant selection. One very helpful classification of bone loss associated with TKA is the Anderson Orthopaedic Research Institute (AORI) Bone Defect Classification System as it provides the means to compare the location and extent of femoral and tibial bone loss encountered during revision surgery. In general, the higher grade defects (Type IIb or III) on both the femoral and tibial sides are more likely to require stemmed components, and may require the use of either structural graft or large augments to restore support for currently available modular revision components. Custom prostheses were previously utilised for massive defects of this sort, but more recently have been supplanted by revision TKA component systems with or without special metal augments or structural allograft. Options for bone defect management are: 1) Fill with cement; 2) Fill with cement supplemented by screws or K-wires; 3) Morselised bone grafting (for smaller, especially contained cavitary defects); 4) Small segment structural bone graft; 5) Impaction grafting; 6) Large prosthetic augments (cones); 7) Massive structural allograft-prosthetic composites (APC); 8) Custom implants. Maximising support on intact host bone is a fundamental principle to successful reconstruction and frequently requires extending fixation to the adjacent diaphysis. Preoperative planning is facilitated by good quality radiographs, supplemented on occasion by additional imaging such as CT. Fluoroscopically controlled x-ray views may assist in diagnosing the loose implant by better revealing the interface between the implant and bone and can facilitate accurate delineation of the extent of bone deficiency present. Part of the preoperative plan is to ensure adequate range and variety of implant choices and bone graft resources for the planned reconstruction allowing for the potential for unexpected intraoperative findings such as occult fracture through deficient periprosthetic bone. Reconstruction of bone deficiency following removal of the failed implant is largely dictated by the location and extent of bone loss and the quality of bone that remains. While massive bone loss may compromise ligamentous attachment to bone, in the majority of reconstructions the degree of implant constraint needed for proper balancing and restoration of stability is independent of the bone defect. Thus some knees with minimal bone deficiency may require increased constraint due to the status of the soft tissues while others involving very large bone defects especially of the cavitary sort may be well managed with minimal constraint

Hip fractures accounts to about 86000 cases per annum in UK. AP and Lateral radiographs form an essential investigation in planning the management of these fractures. Recently it has been suggested that lateral view doesn't provide any additional information in majority of the cases. We looked retrospectively at 25 consecutive radiographs with intracapsular and extracapsular fracture neck of femur each presenting to our department between May 2010 and January 2011. These radiographs were put on the CD in 2 folders as AP and Lateral. It was reviewed by 2 Observers who suggested their preferred treatment. The results were compared for the intra observer agreement to assess the necessity of the lateral view of the radiographs. We also compared the treatment options with the gold standard and looked at the interobserver agreement. Of the 50 set of radiographs that were reviewed, Observer 1 had disagreed with himself on one occasion (98%agreement) compared to the Observer 2 who had two disagreements (96% agreement). When analyzing the intracapsular fractures, we found 100% agreement of OBSERVER 1 with himself when proposing treatment on AP and Lateral View. Whereas, OBSERVER 2 had only one disagreement. It gave us a Free marginal kappa value of more than 0.70 indicating excellent agreement. One difference doesn't have any statistical significance. In the extracapsular fractures, Kappa values ranged from 0.413 to 0.88. OBSERVER 1 did change his opinion after reviewing the lateral view but generally had good outcome (K=0.88). Whereas, the opinion of OBSERVER 2 was unaffected by the Lateral view. The X-ray diagnoses by OBSERVER 1 and OBSERVER 2 had only moderate agreement (K=0.52 (AP) and 0.57 (Lat). Comparing the observer opinion to the gold standard (operation performed) showed moderate agreement both on AP and Lateral view (OBSERVER 1 AP and Lat both K=0.64, OBSERVER 2 AP and Lat both K=0.41). The Lateral view failed to change the opinion of the observers (K > 0.7) but there was moderate to excellent agreement between the observers and observer vs operation (The Gold Standard) with kappa value of more than 0.52. We feel that the Lateral view doesn't make any difference in most of the cases as shown by a good intra-observer agreement. However, we cannot completely rule out their importance and they should be performed in occult fractures, pathological fractures, fractures extending into the shaft, young patients, and on the request of physician