The accurate reconstruction of hip anatomy and biomechanics is thought to be important in achieveing good clinical outcomes following total hip arthroplasty (THA). To this end some newer hip designs have introduced further modularity into the design of the femoral component such that neck­shaft angle and anteversion, which can be adjusted intra-operatively. The clinical effect of this increased modularity is unknown. We have investigated the changes in these anatomical parameters following conventional THA with a prosthesis of predetermined neck–shaft angle and assessed the effect of changes in the hip anatomy on clinical outcomes.

In total, 44 patients (mean age 65.3 years (standard deviation (sd) 7); 17 male/27 female; mean body mass index 26.9 (kg/m²) (sd 3.1)) underwent a pre- and post-operative three-dimensional CT scanning of the hip. The pre- and post-operative neck–shaft angle, offset, hip centre of rotation, femoral anteversion, and stem alignment were measured. Additionally, a functional assessment and pain score were evaluated before surgery and at one year post-operatively and related to the post-operative anatomical changes.

The mean pre-operative neck–shaft angle was significantly increased by 2.8° from 128° (sd 6.2; 119° to 147°) to 131° (sd 2.1; 127° to 136°) (p = 0.009). The mean pre-operative anteversion was 24.9° (sd 8; 7.9 to 39.1) and reduced to 7.4° (sd 7.3; -11.6° to 25.9°) post-operatively (p < 0.001). The post-operative changes had no influence on function and pain. Using a standard uncemented femoral component, high pre- and post-operative variability of femoral anteversion and neck–shaft angles was found with a significant decrease of the post-operative anteversion and slight increase of the neck–shaft angles, but without any impact on clinical outcome.

Cite this article: Bone Joint J 2015;97-B:1615–22.

Large osteochondral lesions (OCLs) of the shoulder of the talus cannot always be treated by traditional osteochondral autograft techniques because of their size, articular geometry and loss of an articular buttress. We hypothesised that they could be treated by transplantation of a vascularised corticoperiosteal graft from the ipsilateral medial femoral condyle.

Between 2004 and 2011, we carried out a prospective study of a consecutive series of 14 patients (five women, nine men; mean age 34.8 years, 20 to 54) who were treated for an OCL with a vascularised bone graft. Clinical outcome was assessed using a visual analogue scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score. Radiological follow-up used plain radiographs and CT scans to assess graft incorporation and joint deterioration.

At a mean follow-up of 4.1 years (2 to 7), the mean VAS for pain had decreased from 5.8 (5 to 8) to 1.8 (0 to 4) (p = 0.001) and the mean AOFAS hindfoot score had increased from 65 (41 to 70) to 81 (54 to 92) (p = 0.003). Radiologically, the talar contour had been successfully reconstructed with stable incorporation of the vascularised corticoperiosteal graft in all patients. Joint degeneration was only seen in one ankle.

Treatment of a large OCL of the shoulder of the talus with a vascularised corticoperiosteal graft taken from the medial condyle of the femur was found to be a safe, reliable method of restoring the contour of the talus in the early to mid-term.

Cite this article: Bone Joint J 2015;97-B:1242–9.

The purpose of this study was to evaluate the change in sagittal tibiotalar alignment after total ankle arthroplasty (TAA) for osteoarthritis and to investigate factors affecting the restoration of alignment.

This retrospective study included 119 patients (120 ankles) who underwent three component TAA using the Hintegra prosthesis. A total of 63 ankles had anterior displacement of the talus before surgery (group A), 49 had alignment in the normal range (group B), and eight had posterior displacement of the talus (group C). Ankles in group A were further sub-divided into those in whom normal alignment was restored following TAA (41 ankles) and those with persistent displacement (22 ankles). Radiographic and clinical results were assessed.

Pre-operatively, the alignment in group A was significantly more varus than that in group B, and the posterior slope of the tibial plafond was greater (p < 0.01 in both cases). The posterior slope of the tibial component was strongly associated with restoration of alignment: ankles in which the alignment was restored had significantly less posterior slope (p < 0.001).

An anteriorly translated talus was restored to a normal position after TAA in most patients. We suggest that surgeons performing TAA using the Hintegra prosthesis should aim to insert the tibial component at close to 90° relative to the axis of the tibia, hence reducing posterior soft-tissue tension and allowing restoration of normal tibiotalar alignment following surgery.

Cite this article: Bone Joint J 2015;97-B:1525–32.

Worldwide rates of primary and revision total knee arthroplasty (TKA) are rising due to increased longevity of the population and the burden of osteoarthritis.

Revision TKA is a technically demanding procedure generating outcomes which are reported to be inferior to those of primary knee arthroplasty, and with a higher risk of complication. Overall, the rate of revision after primary arthroplasty is low, but the number of patients currently living with a TKA suggests a large potential revision healthcare burden.

Many patients are now outliving their prosthesis, and consideration must be given to how we are to provide the necessary capacity to meet the rising demand for revision surgery and how to maximise patient outcomes.

The purpose of this review was to examine the epidemiology of, and risk factors for, revision knee arthroplasty, and to discuss factors that may enhance patient outcomes.

Cite this article: Bone Joint J 2015; 97-B:723–8.

Successful management of late presenting hip dislocation in childhood is judged by the outcome not just at skeletal maturity but well beyond into adulthood and late middle age. This review considers different methods of treatment and looks critically at the handful of studies reporting long-term follow-up after successful reduction.

Cite this article: Bone Joint J 2015;97-B:729–33.

Tranexamic acid (TXA) has been used to reduce blood loss during total hip arthroplasty (THA), but its use could increase the risk of venous thromboembolic disease (VTE). Several studies have reported that TXA does not increase the prevalence of deep vein thrombosis (DVT), but most of those used routine chemical thromboprophylaxis, thereby masking the potential increased risk of TXA on VTE. We wished to ascertain whether TXA increases the prevalence of VTE in patients undergoing THA without routine chemical thromboprophylaxis. We carried out a retrospective case-control study in 254 patients who underwent a primary THA, 127 of whom received TXA (1 g given pre-operatively) and a control group of 127 who did not. All patients had mechanical but no chemical thomboprophylaxis. Each patient was examined for DVT by bilateral ultrasonography pre-operatively and on post-operative days 1 and 7. TXA was found to statistically significantly increase the incidence of total DVT on post-operative day 7 compared with the control group (24 (18.9%) and 12 (9.4%), respectively; p < 0.05) but most cases of DVT were isolated distal DVT, with the exception of one patient with proximal DVT in each group. One patient in the control group developed a non-fatal symptomatic pulmonary embolism (PE). The use of TXA did not appear to affect the prevalence of either proximal DVT or PE.

Cite this article: Bone Joint J 2015; 97-B:458–62.

In this study we used subject-specific finite element analysis to investigate the mechanical effects of rotational acetabular osteotomy (RAO) on the hip joint and analysed the correlation between various radiological measurements and mechanical stress in the hip joint.

We evaluated 13 hips in 12 patients (two men and ten women, mean age at surgery 32.0 years; 19 to 46) with developmental dysplasia of the hip (DDH) who were treated by RAO.

Subject-specific finite element models were constructed from CT data. The centre–edge (CE) angle, acetabular head index (AHI), acetabular angle and acetabular roof angle (ARA) were measured on anteroposterior pelvic radiographs taken before and after RAO. The relationship between equivalent stress in the hip joint and radiological measurements was analysed.

The equivalent stress in the acetabulum decreased from 4.1 MPa (2.7 to 6.5) pre-operatively to 2.8 MPa (1.8 to 3.6) post-operatively (p < 0.01). There was a moderate correlation between equivalent stress in the acetabulum and the radiological measurements: CE angle (R = –0.645, p < 0.01); AHI (R = –0.603, p < 0.01); acetabular angle (R = 0.484, p = 0.02); and ARA (R = 0.572, p < 0.01).

The equivalent stress in the acetabulum of patients with DDH decreased after RAO. Correction of the CE angle, AHI and ARA was considered to be important in reducing the mechanical stress in the hip joint.

Cite this article: Bone Joint J 2015;97-B:492–7.

This study compared the quality of reduction and complication rate when using a standard ilioinguinal approach and the new pararectus approach when treating acetabular fractures surgically. All acetabular fractures that underwent fixation using either approach between February 2005 and September 2014 were retrospectively reviewed and the demographics of the patients, the surgical details and complications were recorded.

A total of 100 patients (69 men, 31 women; mean age 57 years, 18 to 93) who were consecutively treated were included for analysis. The quality of reduction was assessed using standardised measurement of the gaps and steps in the articular surface on pre- and post-operative CT-scans.

There were no significant differences in the demographics of the patients, the surgical details or the complications between the two approaches. A significantly better reduction of the gap, however, was achieved with the pararectus approach (axial: p = 0.025, coronal: p = 0.013, sagittal: p = 0.001).

These data suggest that the pararectus approach is at least equal to, or in the case of reduction of the articular gap, superior to the ilioinguinal approach.

This approach allows direct buttressing of the dome of the acetabulum and the quadrilateral plate, which is particularly favourable in geriatric fracture patterns.

Cite this article: Bone Joint J 2015;97-B:1271-8.

The long term biological effects of wear products following total hip arthroplasty (THA) are unclear. However, the indications for THA are expanding, with increasingly younger patients undergoing the procedure.

This prospective, randomised study compared two groups of patients undergoing THA after being randomised to receive one of two different bearing surfaces: metal-on-polyethylene (MoP) n = 22 and metal-on-metal (MoM) n = 23. We investigated the relationship between three variables: bearing surface (MoP vs MoM), whole blood levels of chromium (Cr) and cobalt (Co) and chromosomal aberrations in peripheral lymphocyte pre-operatively and at one, two and five years post-surgery.

Our results demonstrated significantly higher mean cobalt and chromium (Co and Cr) blood levels in the MoM group at all follow-up points following surgery (p < 0.01), but there were no significant differences in the chromosomal aberration indices between MoM and MoP at two or five years (two years: p = 0.56, p = 0.08, p = 0.91, p = 0.51 and five years: p = 0.086, p = 0.73, p = 0.06, p = 0.34) for translocations, breaks, loss and gain of chromosomes respectively. Regression analysis showed a strong linear relationship between Cr levels and the total chromosomal aberration indices in the MoM group (R² = 0.90016), but this was not as strong for Co (R² = 0.68991). In the MoP group, the analysis revealed a poor relationship between Cr levels and the total chromosomal aberration indices (R² = 0.23908) but a slightly stronger relationship for Co (R² = 0.64292). Across both groups, Spearman’s correlation detected no overall association between Co and Cr levels and each of the studied chromosomal aberrations. There remains no clear indication which THA bearing couple is the most biocompatible, especially in young active patients. While THA continues to be very successful at alleviating pain and restoring function, the long-term biological implications of the procedure still require further scrutiny.

Cite this article: Bone Joint J 2015;97-B:1183–91.

The repair of chondral lesions associated with femoroacetabular impingement requires specific treatment in addition to that of the impingement. In this single-centre retrospective analysis of a consecutive series of patients we compared treatment with microfracture (MFx) with a technique of enhanced microfracture autologous matrix-induced chondrogenesis (AMIC).

Acetabular grade III and IV chondral lesions measuring between 2 cm² and 8 cm² in 147 patients were treated by MFx in 77 and AMIC in 70. The outcome was assessed using the modified Harris hip score at six months and one, two, three, four and five years post-operatively. The outcome in both groups was significantly improved at six months and one year post-operatively. During the subsequent four years the outcome in the MFx group slowly deteriorated, whereas that in the AMIC group remained stable. Six patients in the MFx group subsequently required total hip arthroplasty, compared with none in the AMIC group

We conclude that the short-term clinical outcome improves in patients with acetabular chondral damage following both MFx and AMIC. However, the AMIC group had better and more durable improvement, particularly in patients with large (≥ 4 cm²) lesions.

Cite this article: Bone Joint J 2015; 97-B:628–35.

The foot and ankle outcome score (FAOS) has been evaluated for many conditions of the foot and ankle. We evaluated its construct validity in 136 patients with osteoarthritis of the ankle, its content validity in 37 patients and its responsiveness in 39. Data were collected prospectively from the registry of patients at our institution.

All FAOS subscales were rated relevant by patients. The Pain, Activities of Daily Living, and Quality of Life subscales showed good correlation with the Physical Component score of the Short-Form-12v2. All subscales except Symptoms were responsive to change after surgery.

We concluded that the FAOS is a weak instrument for evaluating osteoarthritis of the ankle. However, some of the FAOS subscales have relative strengths that allow for its limited use while we continue to seek other satisfactory outcome instruments.

Cite this article: Bone Joint J 2015; 97-B:662–7.

Only limited data are available regarding the infiltration of local anaesthetic for total hip arthroplasty (THA), and no studies were performed for THA using the anterior approach.

In this prospective, randomised placebo-controlled study we investigated the effect of both standard and reverse infiltration of local anaesthetic in combination with the anterior approach for THA. The primary endpoint was the mean numeric rating score for pain four hours post-operatively. In addition, we recorded the length of hospital stay, the operating time, the destination of the patient at discharge, the use of pain medication, the occurrence of side effects and pain scores at various times post-operatively.

Between November 2012 and January 2014, 75 patients were included in the study. They were randomised into three groups: standard infiltration of local anaesthetic, reversed infiltration of local anaesthetic, and placebo. There was no difference in mean numeric rating score for pain four hours post-operatively (p = 0.87). There were significantly more side effects at one and eight hours post-operatively in the placebo group (p = 0.02; p = 0.03), but this did not influence the mobilisation of the patients. There were no differences in all other outcomes between the groups.

We found no clinically relevant effect when the infiltration of local anaesthetic with ropivacaine and epinephrine was used in a multimodal pain protocol for THA using the anterior approach.

Cite this article: Bone Joint J 2015; 97-B:734–40.

A retrospective review was performed of patients undergoing primary cementless total knee replacement (TKR) using porous tantalum performed by a group of surgical trainees. Clinical and radiological follow-up involved 79 females and 26 males encompassing 115 knees. The mean age was 66.9 years (36 to 85). Mean follow-up was 7 years (2 to 11). Tibial and patellar components were porous tantalum monoblock implants, and femoral components were posterior stabilised (PS) in design with cobalt–chromium fibre mesh. Radiological assessments were made for implant positioning, alignment, radiolucencies, lysis, and loosening. There was 95.7% survival of implants. There was no radiological evidence of loosening and no osteolysis found. No revisions were performed for aseptic loosening. Average tibial component alignment was 1.4° of varus (4°of valgus to 9° varus), and 6.2° (3° anterior to 15° posterior) of posterior slope. Mean femoral component alignment was 6.6° (1° to 11°) of valgus. Mean tibiofemoral alignment was 5.6° of valgus (7° varus to 16° valgus). Patellar tilt was a mean of 2.4° lateral (5° medial to 28° lateral). Patient satisfaction with improvement in pain was 91%. Cementless TKR incorporating porous tantalum yielded good clinical and radiological outcomes at a mean of follow-up of seven-years.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):87–92.

Degenerative problems of the hip in patients with childhood and adult onset neuromuscular disorders can be challenging to treat. Many orthopaedic surgeons are reluctant to recommend total hip replacement (THR) for patients with underlying neuromuscular disorders due to the perceived increased risks of dislocation, implant loosening, and lack of information about the functional outcomes and potential benefits of these procedures in these patients. Modular femoral components and alternative bearings which facilitate the use of large femoral heads, constrained acetabular components and perhaps more importantly, a better understanding about the complications and outcomes of THR in the patient with neuromuscular disorders, make this option viable. This paper will review the current literature and our experience with THR in the more frequently encountered neuromuscular disorders.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):27–31.

Drug therapy forms an integral part of the management of many orthopaedic conditions. However, many medicines can produce serious adverse reactions if prescribed inappropriately, either alone or in combination with other drugs. Often these hazards are not appreciated. In response to this, the European Union recently issued legislation regarding safety measures which member states must adopt to minimise the risk of errors of medication.

In March 2014 the Medicines and Healthcare products Regulatory Agency and NHS England released a Patient Safety Alert initiative focussed on errors of medication. There have been similar initiatives in the United States under the auspices of The National Coordinating Council for Medication Error and The Joint Commission on the Accreditation of Healthcare Organizations. These initiatives have highlighted the importance of informing and educating clinicians.

Here, we discuss common drug interactions and contra-indications in orthopaedic practice. This is germane to safe and effective clinical care.

Cite this article: Bone Joint J 2015;97-B:434–41.

Unlinked, linked and convertible total elbow arthroplasties (TEAs) are currently available. This study is the first to report the clinical results of the convertible Latitude TEA. This was a retrospective study of a consecutive cohort of 63 patients (69 primary TEAs) with a mean age of 60 years (23 to 87). Between 2006 and 2008 a total of 19 men and 50 women underwent surgery. The mean follow-up was 43 months (8 to 84). The range of movement, function and pain all improved six months post-operatively and either continued to improve slightly or reached a plateau thereafter. The complication rate is similar to that reported for other TEA systems. No loosening was seen. Remarkable is the disengagement of the radial head component in 13 TEAs (31%) with a radial head component implanted.

Implantation of both the linked and the unlinked versions of the Latitude TEA results in improvement of function and decreased pain, and shows high patient satisfaction at mid-term follow-up.

Cite this article: Bone Joint J 2015; 97-B:681–8.

A high radiographic inclination angle (RI) contributes to accelerated wear and has been associated with dislocation after total hip arthroplasty (THA). With freehand positioning of the acetabular component there is a lack of accuracy, with a trend towards a high radiographic inclination angle. The aim of this study was to investigate whether the use of a digital protractor to measure the operative inclination angle (OI) could improve the positioning of the acetabular component in relation to a ‘safe zone’.

We measured the radiographic inclination angles of 200 consecutive uncemented primary THAs. In the first 100 the component was introduced freehand and in the second 100 a digital protractor was used to measure the operative inclination angle.

The mean difference between the operative and the radiographic inclination angles (∆RI–OI) in the second cohort was 12.3° (3.8° to 19.8°). There was a strong correlation between the circumference of the hip and ∆RI–OI. The number of RI outliers was significantly reduced in the protractor group (p = 0.002).

Adjusting the OI, using a digital protractor and taking into account the circumference of the patient’s hip, improves the RI significantly (p < 0.001) and does not require additional operating time.

Cite this article: Bone Joint J 2015; 97-B:603–610.

The optimal timing of total knee replacement (TKR) in patients with osteoarthritis, in relation to the severity of disease, remains controversial. This prospective study was performed to investigate the effect of the severity of osteoarthritis and other commonly available pre- and post-operative clinical parameters on the clinical outcome in a consecutive series of cemented TKRs. A total of 176 patients who underwent unilateral TKR were included in the study. Their mean age was 68 years (39 to 91), 63 (36%) were male and 131 knees (74%) were classified as grade 4 on the Kellgren–Lawrence osteoarthritis scale. A total of 154 patients (87.5%) returned for clinical review 12 months post-operatively, at which time the outcome was assessed using the Knee Society score.

A low radiological severity of osteoarthritis was not associated with pain 12 months post-operatively. However, it was significantly associated with an inferior level of function (p = 0.007), implying the need for increased focus on all possible reasons for pain in the knee and the forms of conservative treatment which are available for patients with lower radiological severity of osteoarthritis.

Cite this article: Bone Joint J 2014; 96-B:1498–1502.

An increased tibial tubercle–trochlear groove (TT-TG) distance is related to patellar maltracking and instability. Tibial tubercle transfer is a common treatment option for these patients with good short-term results, although the results can deteriorate over time owing to the progression of osteoarthritis. We present a ten-year follow-up study of a self-centring tibial tubercle osteotomy in 60 knees, 30 with maltracking and 30 with patellar instability. Inclusion criteria were a TT-TG ≥ 15 mm and symptoms for > one year. One patient (one knee) was lost to follow-up and one required total knee arthroplasty because of progressive osteoarthritis. Further patellar dislocations occurred in three knees, all in the instability group, one of which required further surgery. The mean visual analogue scores for pain, and Lysholm and Kujala scores improved significantly and were maintained at the final follow-up (repeated measures, p = 0.000, intergroup differences p = 0.449). Signs of maltracking were found in only a minority of patients, with no difference between groups (p > 0.05). An increase in patellofemoral osteoarthritis was seen in 16 knees (31%) with a maximum of grade 2 on the Kellgren–Lawrence scale. The mean increase in grades was 0.31 (0 to 2) and 0.41 (0 to 2) in the maltracking and instability groups respectively (p = 0.2285)

This self-centring tibial tubercle osteotomy provides good results at ten years’ follow-up without inducing progressive osteoarthritis.

Cite this article: Bone Joint J 2015;97-B:329–36.

The aim of this study was to find anatomical landmarks for rotational alignment of the tibial component in total knee replacement (TKR) in a CT-based study. Pre-operative CT scanning was performed on 94 South Korean patients (nine men, 85 women, 188 knees) with osteoarthritis of the knee joint prior to TKR. The tibial anteroposterior (AP) axis was defined as a line perpendicular to the femoral surgical transepicondylar axis and passing through the centre of the posterior cruciate ligament (PCL). The angles between the defined tibial AP axis and anatomical landmarks at various levels of the tibia were measured. The mean values of the angles between the defined tibial AP axis and the line connecting the anterior border of the proximal third of the tibia to the centre of the PCL was -0.2° (-17 to 14.1, sd 4.1). This was very close to the defined tibial axis, and remained so regardless of lower limb alignment and the degree of tibial bowing. Therefore, AP axis defined as described, is a reliable anatomical landmark for rotational alignment of tibial components.

Cite this article: Bone Joint J 2014; 96-B:1485–90.