This prospective study presents the ten-year (5 to 16) clinical and radiological results of 55 primary total hip replacements (THR) using a cementless modular femoral component (S-ROM). All patients had a significant anatomical abnormality which rendered the primary THR difficult.

The mean Harris hip score was 36 (12 to 72) pre-operatively, 83 (44 to 100) at five years, and 85 (45 to 99) at ten years. The Western Ontario and McMaster Universities osteoarthritis index (WOMAC) and short-form (SF)-12 scores were recorded from the year 2000. The mean SF-12 score at five years after surgery was 45.24 (22.74 to 56.58) for the physical component and 54.14 (29.20 to 66.61) for the mental component. By ten years the SF-12 scores were 42.86 (21.59 to 58.95) and 51.03 (33.78 to 61.40), respectively. The mean WOMAC score at five years post-operatively was 25 (0 to 59), and at ten years was 27 (2 to 70).

No femoral components were radiologically loose, although five had osteolysis in Gruen zone 1, three had osteolysis in zone 7, and two showed osteolysis in both zones 1 and 7. No osteolysis was observed around or distal to the prosthetic sleeve. No femoral components were revised, although three hips underwent an acetabular revision and two required a liner exchange. At a mean of ten years’ follow-up the S-ROM femoral component implanted for an anatomically difficult primary THR has excellent clinical and radiological results.

Panton-Valentine leukocidin secreted by Staphylococcus aureus is known to cause severe skin, soft tissue and lung infections. However, until recently it has not been described as causing life-threatening musculoskeletal infection. We present four patients suffering from osteomyelitis, septic arthritis, widespread intravascular thrombosis and overwhelming sepsis from proven Panton-Valentine leukocidin-secreting Staphylococcus aureus. Aggressive, early and repeated surgical intervention is required in the treatment of these patients.

The Panton-Valentine leukocidin toxin not only destroys host neutrophils, immunocompromising the patient, but also increases the risk of intravascular coagulopathy. This combination leads to widespread involvement of bone with glutinous pus which is difficult to drain, and makes the delivery of antibiotics and eradication of infection very difficult without surgical intervention.

We have managed 27 patients (16 women and 11 men) with a mean age of 68.4 years (50 to 84), with failed total hip replacement and severe proximal femoral bone loss by revision using a distal fix/proximal wrap prosthesis. The mean follow-up was for 55.3 months (25 to 126). The mean number of previous operations was 2.2 (1 to 4). The mean Oxford hip score decreased from 46.2 (38 to 60) to 28.5 (17 to 42) (paired t-test, p < 0.001) and the mean Harris Hip score increased from 30.4 (3 to 57.7) to 71.7 (44 to 99.7) (paired t-test, p < 0.001). There were two dislocations, and in three patients we failed to eradicate previous infection. None required revision of the femoral stem.

This technique allows instant distal fixation while promoting biological integration and restoration of bone stock. In the short term, the functional outcome is encouraging and the complication rates acceptable in this difficult group of patients.

The treatment of developmental dysplasia of the hip diagnosed after the first year of life remains controversial. A series of 36 children (47 hips), aged between one and 4.9 years underwent gradual closed reduction using the Petit-Morel method. A pelvic osteotomy was required in 43 hips (91.5%). The patients whose hips did not require pelvic osteotomy were among the youngest. The mean age at final follow-up was 16.1 years (11.3 to 32). The mean follow-up was 14.3 years (10 to 30).

At the latest follow-up, 44 hips (93.6%) were graded as excellent or good according to the Severin classification. Closed reduction failed in only two hips (4.3%) which then required open reduction. Mild avascular necrosis was observed in one (2.1%).

The accuracy of the reduction and associated low complication rate justify the use of the Petit-Morel technique as the treatment of choice for developmental dysplasia of the hip in patients aged between one and five years.

We have examined the deterioration of implant fixation after withdrawal of parathyroid hormone (PTH) in rats. First, the pull-out force for stainless-steel screws in the proximal tibia was measured at different times after withdrawal. The stimulatory effect of PTH on fixation was lost after 16 days. We then studied whether bisphosphonates could block this withdrawal effect. Mechanical and histomorphometric measurements were conducted for five weeks after implantation. Subcutaneous injections were given daily. Specimens treated with either PTH or saline during the first two weeks showed no difference in the mechanical or histological results (pull-out force 76 N vs 81 N; bone volume density 19% vs 20%). Treatment with PTH for two weeks followed by pamidronate almost doubled the pull-out force (152 N; p < 0.001) and the bone volume density (37%; ANOVA, p < 0.001). Pamidronate alone did not have this effect (89 N and 25%, respectively). Thus, the deterioration can be blocked by bisphosphonates. The clinical implications are discussed.

Osteomyelitis is one of the oldest diseases known. It took many years before the acute infection could be brought under control with antibiotics and chronic osteomyelitis remains difficult to manage. The modern history of the disease is reflected in the pages of the

We analysed the operative technique, morbidity and functional outcome of osteotomy and plate fixation for malunited fractures of the forearm sustained in childhood.

A total of 20 consecutive patients underwent corrective osteotomy of 21 malunited fractures at a mean age of 12 years (4 to 25). The mean time between the injury and the osteotomy was 30 months (2 to 140).

After removal of the plate, one patient suffered transient dysaesthesia of the superficial radial nerve. The mean gain in the range of movement was 85° (20° to 140°). The interval between injury and osteotomy, and the age at osteotomy significantly influenced the functional outcome (p = 0.011 and p = 0.004, respectively).

Malunited fractures of the forearm sustained in childhood can be adequately treated by osteotomy and plate fixation with excellent functional results and minimal complications. In the case of established malunion it is advisable to perform corrective osteotomy without delay.

Deficiencies of acetabular bone stock at revision hip replacement were reconstructed with two different types of allograft using impaction bone grafting and a Burch-Schneider reinforcement ring. We compared a standard frozen non-irradiated bone bank allograft (group A) with a freeze-dried irradiated bone allograft, vitalised with autologous marrow (group B). We studied 78 patients (79 hips), of whom 87% (69 hips) had type III acetabular defects according to the American Academy of Orthopaedic Surgeons classification at a mean of 31.4 months (14 to 51) after surgery. At the latest follow-up, the mean Harris hip score was 69.9 points (13.5 to 97.1) in group A and 71.0 points (11.5 to 96.5) in group B. Each hip showed evidence of trabeculation and incorporation of the allograft with no acetabular loosening.

These results suggest that the use of an acetabular reinforcement ring and a living composite of sterile allograft and autologous marrow appears to be a method of reconstructing acetabular deficiencies which gives comparable results to current forms of treatment.

A giant cell tumour is a primary lesion of bone of intermediate severity. Its histogenesis is unclear. In a few cases pulmonary metastases have been described. Multiple skeletal metastases in the absence of sarcomatous change have been observed.

We present a case report of a 25-year-old woman with a recurrent giant cell tumour of the distal fibula. After a second recurrence and six years after the initial diagnosis, she rapidly developed multiple bony metastases. The outcome was fatal.

The aim of this study was to determine the effectiveness of antibiotic-impregnated implants in the prevention of bone infection. We used a model of contaminated fracture in goats to evaluate four treatment groups: no treatment, hand-made tobramycin-impregnated polymethylmethacrylate beads, commercially-available tobramycin-impregnated calcium sulphate pellets and commercially-available tobramycin-impregnated polymethylmethacrylate beads. Three weeks after intraosseous inoculation with streptomycin-resistant Staphylococcus aureus tissue cultures showed no evidence of infection in any of the antibiotic-treated groups. All of the cultures were positive in the untreated group. These results show that effective local antibiotic delivery can be obtained with both commercially-available products and with hand-made polymethylmethacrylate beads. The calcium sulphate pellets have the advantage of being bioabsorbable, thereby obviating the need for a second procedure to remove them.

Despite advances in reconstructive surgery, salvage of mangled extremities still requires long periods of treatment with many operations that can be taxing both to the surgeon and the patient. Attempts at reconstruction of severely shattered limbs necessitate counselling with regard to the protracted course of treatment and associated morbidity as well as problems which may require abandoning of the procedure and secondary amputation. We report the successful salvage of a severely comminuted and open fracture of the tibia in a 32-year-old man.

Deformity of the forearm due to growth disturbance of the ulna occurs in a number of conditions such as ulnar deficiency, multiple exostoses, and neurofibromatosis. We report a previously unrecognised form, caused by focal cortical indentation.

We have treated five children with this condition, three girls and two boys; the mean age at presentation was 5 years (2 to 8). The deformity was first recognised about the age of two years, and progressed gradually. The radiological findings were the same in all cases. The focal cortical indentation was seen at the distal end of the ulna with anteromedial bowing and dysplasia. The radial head was dislocated posterolaterally. In one patient the histological findings at the site of indentation were of a fold of tissue resembling periosteum, which interfered with enchondral ossification. Treatment by ulnar lengthening using an external fixator and osteotomy which corrected both the ulnar deformity and reduced the dislocated radial head in two cases gave the best results.

We used a knee-sparing distal femoral endoprosthesis in young patients with malignant bone tumours of the distal femur in whom it was possible to resect the tumour and to preserve the distal femoral condyles. The proximal shaft of the endoprosthesis had a coated hydroxyapatite collar, while the distal end had hydroxyapatite-coated extracortical plates to secure it to the small residual femoral condylar fragment. We reviewed the preliminary results of this endoprosthesis in eight patients with primary bone tumours of the distal femur. Their mean age at surgery was 17.years (14 to 21). The mean follow-up was 24 months (20 to 31). At final follow-up the mean flexion at the knee was 102° (20° to 120°) and the mean Musculoskeletal Tumour Society score was 80% (57% to 96.7%).

There was excellent osteointegration at the prosthesis-proximal bone interface with formation of new bone around the hydroxyapatite collar. The prosthesis allowed preservation of the knee and achieved a good functional result. Formation of new bone and remodelling at the interface make the implant more secure. Further follow-up is required to determine the long-term structural integrity of the prosthesis.

We have assessed the proximal capsular extension of the ankle joint in 18 patients who had a contrast-enhanced MRI ankle arthrogram in order to delineate the capsular attachments.

We noted consistent proximal capsular extensions anterior to the distal tibia and in the tibiofibular recess. The mean capsular extension anterior to the distal tibia was 9.6 mm (4.9 to 27.0) proximal to the anteroinferior tibial margin and 3.8 mm (−2.1 to 9.3) proximal to the dome of the tibial plafond. In the tibiofibular recess, the mean capsular extension was 19.2 mm (12.7 to 38.0) proximal to the anteroinferior tibial margin and 13.4 mm (5.8 to 20.5) proximal to the dome of the tibial plafond.

These areas of proximal capsular extensions run the risk of being traversed during the insertion of finewires for the treatment of fractures of the distal tibia. Surgeons using these techniques should be aware of this anatomy in order to minimise the risk of septic arthritis.

Aneurysmal bone cyst is a rare tumour-like lesion which develops during growth. Our aim was to determine the efficacy of the administration of percutaneous intralesional 3% polidocanol (hydroxypolyaethoxydodecan) as sclerotherapy.

Between July 1997 and December 2004 we treated 72 patients (46 males, 26 females) with a histologically-proven diagnosis of aneurysmal bone cyst, at various skeletal sites using this method. The sclerotherapy was performed under fluoroscopic guidance and general anaesthesia or sedation and local anaesthesia. The mean follow-up period was 34 months (26.5 to 80). The patients were evaluated using the Enneking system for functional assessment and all the lesions were radiologically quantified into four grades.

The mean age of patients was 15.6 years (3 to 38) and the mean number of injections was three (1 to 5). Ten patients were cured by a single injection. The mean reduction in size of the lesion (radiological healing) was found to be 76.6% (61.9% to 93.2%) with a mean clinical response of 84.5% (73.4% to 100%). Recurrence was seen in two patients (2.8%) within two years of treatment and both were treated successfully by further sclerotherapy.

Percutaneous sclerotherapy with polidocanol is a safe alternative to conventional surgery for the treatment of an aneurysmal bone cyst. It can be used at surgically-inaccessible sites and treatment can be performed on an out-patient basis.

We evaluated the long-term fixation of 64 press-fit cemented stems of constrained total knee prostheses in 32 young patients with primary malignant bone tumours. Initial stable fixation, especially in rotation, was achieved by precise fit of the stem into the reamed endosteum, before cementation. Complementary fixation, especially in migration and rotation, was obtained by pressurised antibiotic-loaded cement. The mean age at operation was 33 years (13 to 61). No patient was lost to follow-up; 13 patients died and the 19 survivors were examined at a mean follow-up of 12.5 years (4 to 21). Standard revision press-fit cemented stems were used on the side of the joint which was not involved with tumour (26 tibial and six femoral), on this side there was no loosening or osteolysis and stem survival was 100%. On the reconstruction side, custom-made press-fit stems were used and the survival rate, with any cause for revision as an end point, was 88%, but 97% for loosening or osteolysis. This longevity is similar to that achieved at 20 years with the Charnley-Kerboull primary total hip replacement with press-fit cemented femoral components.

We recommend this type of fixation when extensive reconstruction of the knee is required. It may also be suitable for older patients requiring revision of a total knee replacement or in difficult situations such as severe deformity and complex articular fractures.

We retrospectively reviewed 175 patients (191 hips) who had undergone primary cemented total hip replacement between November 1992 and November 1995 using a collarless polished double-tapered femoral component after a minimum of ten years (mean 11.08; 10 to 12.8). All stems were implanted using contemporary cementing techniques with a distal cement restrictor, pressurised lavage, retrograde cementing with a gun and proximal pressurisation. Clinical outcome was assessed using the Harris Hip score. Radiological analysis was performed on calibrated plain radiographs taken in two planes. Complete radiological data on 110 patients (120 hips) and clinical follow-up on all the surviving 111 patients (122 hips) was available. The fate of all the hips was known.

At final follow-up, the mean Harris Hip score was 86 (47 to 100), and 87 of 116 patients (75%) had good or excellent scores. Survival with revision of the stem for aseptic loosening as the endpoint was 100%; and survival with revision of the stem for any reason was 95.9% (95% confidence interval 87.8 to 96.8) at ten years. All the stems subsided vertically at the stem-cement interface in a predictable pattern, at an overall mean rate of 0.18 mm per year (0.02 to 2.16), but with a mean rate of 0.80 mm (0.02 to 2.5) during the first year. The mean total subsidence was 1.95 mm (0.21 to 24). Only three stems loosened at the cement-bone interface. There was excellent preservation of proximal femoral bone stock. There was a high incidence of Brooker III and IV heterotopic ossification affecting 25 patients (22%).

The collarless polished tapered stem has an excellent clinical and radiological outcome at a minimum of ten years’ follow-up. The pattern and magnitude of subsidence of the stem within the cement mantle occurred in a predictable pattern, consistent with the design philosophy.

The outcome of tibial allograft reconstruction after resection of a tumour is inconsistent and has a high rate of failure. There are few reports on the use of tibial allografts in children with open growth plates. We performed 21 allograft reconstructions (16 osteoarticular, five intercalary) in 19 consecutive patients between seven and 17 years of age. Two had Ewing’s sarcoma, one an adamantinoma and 16 osteosarcoma, one with multifocal disease.

Five patients have died; the other 14 were free from disease at the time of follow-up. Six surviving patients (eight allograft reconstructions) continue to have good or excellent function at a mean of 59 months (14 to 132). One patient has poor function at 31 months. The other seven patients have a good or excellent function after additional procedures including exchange of the allograft and resurfacing or revision to an endoprosthesis at a mean of 101 months (43 to 198). The additional operations were performed at a mean of 47 months (20 to 84) after the first reconstruction.

With the use of allograft reconstruction in growing children, joints and growth plates may be preserved, at least partially. Although our results remain inconsistent, tibial allograft reconstruction in selected patients may restore complete and durable function of the limb.

Limb lengthening by callus distraction and external fixation has a high rate of complications. We describe our experience using an intramedullary nail (Fitbone) which contains a motorised and programmable sliding mechanism for limb lengthening and bone transport. Between 2001 and 2004 we lengthened 13 femora and 11 tibiae in ten patients (seven men and three women) with a mean age of 32 years (21 to 47) using this nail. The indications for operation were short stature in six patients and developmental or acquired disorders in the rest.

The mean lengthening achieved was 40 mm (27 to 60). The mean length of stay in hospital was seven days (5 to 9). The mean healing index was 35 days/cm (18.8 to 70.9). There were no cases of implant-related infection or malunion.

We have evaluated the clinical outcomes of simple excision, ulnar lengthening and the Sauvé-Kapandji procedure in the treatment of deformities of the forearm in patients with multiple hereditary osteochondromas. The medical records of 29 patients (33 forearms) were reviewed; 22 patients (22 forearms) underwent simple excision (four with ulnar lengthening) and seven the Sauvé-Kapandji procedure.

Simple excision increased the mean supination of the forearm from 63.2° to 75.0° (p = 0.049). Ulnar lengthening did not significantly affect the clinical outcome. The Sauvé-Kapandji technique improved the mean pronation from 33.6° to 55.0° (p = 0.047) and supination from 70.0° to 81.4° (p = 0.045). Simple excision may improve the range of movement of the forearm but will not halt the progression of disease, particularly in younger patients. No discernable clinical or radiological improvement was noted with ulnar lengthening. The Sauvé-Kapandji procedure combined with simple excision of osteochondromas can improve stability of the wrist, movement of the forearm and the radiological appearance.