We report our experience of performing an elbow hemiarthroplasty in the treatment of comminuted distal humeral fractures in the elderly patients.

A cohort of 42 patients (three men and 39 women, mean age 72; 56 to 84) were reviewed at a mean of 34.3 months (24 to 61) after surgery. Functional outcome was measured with the Mayo Elbow Performance Score (MEPS) and range of movement. The disabilities of the arm, shoulder and hand questionnaire (DASH) was used as a patient rated evaluation. Complications and ulnar nerve function were recorded. Plain radiographs were obtained to assess prosthetic loosening, olecranon wear and heterotopic bone formation.

The mean extension deficit was 23.5° (0° to 60°) and mean flexion was 126.8° (90° to 145°) giving a mean arc of 105.5° (60° to 145°). The mean MEPS was 90 (50 to 100) and a mean DASH score of 20 (0 to 63). Four patients had additional surgery for limited range of movement and one for partial instability. One elbow was revised due to loosening, two patients had sensory ulnar nerve symptoms, and radiographic signs of mild olecranon wear was noted in five patients.

Elbow hemiarthroplasty for comminuted intra-articular distal humeral fractures produces reliable medium-term results with functional outcome and complication rates, comparable with open reduction and internal fixation and total elbow arthroplasty.

Cite this article: Bone Joint J 2015;97-B:1377–84.

The aims of this study were to determine the functional impact and financial burden of isolated and recurrent dislocation after total hip arthroplasty (THA). Our secondary goal was to determine whether there was a difference between patients who were treated non-operatively and those who were treated operatively.

We retrospectively reviewed 71 patients who had suffered dislocation of a primary THA. Their mean age was 67 years (41 to 92) and the mean follow-up was 3.8 years (2.1 to 8.2).

Because patients with recurrent dislocation were three times more likely to undergo operative treatment (p < 0.0001), they ultimately had a significantly higher mean Harris Hip Score (HHS) (p = 0.0001), lower mean Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores (p = 0.001) and a higher mean SF-12 score (p < 0.0001) than patients with a single dislocation. Likewise, those who underwent operative treatment had a higher mean HHS (p < 0.0001), lower mean WOMAC score (p < 0.0001) and a higher mean SF-12 score (p < 0.0001) than those who were treated non-operatively.

Recurrent dislocation and operative treatment increased costs by 300% (£11 456; p < 0.0001) and 40% (£5217; p < 0.0001), respectively.

The operative treatment of recurrent dislocation results in significantly better function than non-operative management. Moreover, the increase in costs for operative treatment is modest compared with that of non-operative measures.

Cite this article: Bone Joint J 2015; 97-B:1046–9.

The April 2014 Foot & Ankle Roundup³⁶⁰ looks at: Hawkins fractures revisited; arthrodesis compared with ankle replacement in osteoarthritis; mobile bearing ankle replacement successful in the longer-term; osteolysis is an increasing worry in ankle replacement; ankle synostosis post-fracture is not important; radiofrequency ablation for plantar fasciitis; and the right approach for tibiotalocalcaneal fusion.

We compared a new fixation system, the Targon Femoral Neck (TFN) hip screw, with the current standard treatment of cannulated screw fixation. This was a single-centre, participant-blinded, randomised controlled trial. Patients aged 65 years and over with either a displaced or undisplaced intracapsular fracture of the hip were eligible. The primary outcome was the risk of revision surgery within one year of fixation.

A total of 174 participants were included in the trial. The absolute reduction in risk of revision was of 4.7% (95% CI 14.2 to 22.5) in favour of the TFN hip screw (chi-squared test, p = 0.741), which was less than the pre-specified level of minimum clinically important difference. There were no significant differences in any of the secondary outcome measures.

We found no evidence of a clinical difference in the risk of revision surgery between the TFN hip screw and cannulated screw fixation for patients with an intracapsular fracture of the hip.

Cite this article: Bone Joint J 2014;96-B:652–7.

This prospective study reports the 15-year survival and ten-year functional outcome of a consecutive series of 1000 minimally invasive Phase 3 Oxford medial UKAs (818 patients, 393 men, 48%, 425 women, 52%, mean age 66 years; 32 to 88). These were implanted by two surgeons involved with the design of the prosthesis to treat anteromedial osteoarthritis and spontaneous osteonecrosis of the knee, which are recommended indications. Patients were prospectively identified and followed up independently for a mean of 10.3 years (5.3 to 16.6).

At ten years, the mean Oxford Knee Score was 40 (standard deviation (sd) 9; 2 to 48): 79% of knees (349) had an excellent or good outcome. There were 52 implant-related re-operations at a mean of 5.5 years (0.2 to 14.7). The most common reasons for re-operation were arthritis in the lateral compartment (2.5%, 25 knees), bearing dislocation (0.7%, seven knees) and unexplained pain (0.7%, seven knees). When all implant-related re-operations were considered as failures, the ten-year rate of survival was 94% (95% confidence interval (CI) 92 to 96) and the 15-year survival rate 91% (CI 83 to 98). When failure of the implant was the endpoint the 15-year survival was 99% (CI 96 to 100).

This is the only large series of minimally invasive UKAs with 15-year survival data. The results support the continued use of minimally invasive UKA for the recommended indications.

Cite this article: Bone Joint J 2015;97-B:1493–99.

Objectives

The purpose of this study was to compare the results and complications of tibial lengthening over an intramedullary nail with treatment using the traditional Ilizarov method.

A number of studies have reported satisfactory results from the isolated revision of an acetabular component. However, many of these studies reported only the short- to intermediate-term results of heterogeneous bearing surfaces in a mixed age group.

We present our experience of using a ceramic-on-ceramic (CoC) bearing for isolated revision of an uncemented acetabular component in 166 patients (187 hips) who were under the age of 50 years at the time of revision. There were 78 men and 88 women with a mean age of 47.4 years (28 to 49). The most common reason for revision was polyethylene wear and acetabular osteolysis in 123 hips (66%), followed by aseptic loosening in 49 hips (26%).

We report the clinical and radiological outcome, complication rate, and survivorship of this group. The mean duration of follow-up was 15.6 years (11 to 19).

The mean pre-operative Harris hip score was 33 points (1 to 58), and improved to a mean of 88 points (51 to 100) at follow-up. The mean pre-operative total Western Ontario and McMaster Universities Osteoarthritis Index score was 63.2 (43 to 91) and improved to 19.8 points (9 to 61) post-operatively. Overall, 153 of 166 patients (92%) were satisfied with their outcome. Kaplan–Meier survivorship analysis, with revision or radiological evidence of implant failure (13 patients, 8%) as end-points, was 92% at 15 years (95% confidence interval 0.89 to 0.97).

Isolated revision of a cementless acetabular component using a CoC bearing gives good results in patients under 50 years of age.

Cite this article: Bone Joint J 2015;97-B:1197–1203.

Our understanding of the origin of hip pain in degenerative disorders of the hip, including primary osteoarthritis, avascular necrosis and femoroacetabular impingement (FAI), is limited. We undertook a histological investigation of the nociceptive innervation of the acetabular labrum, ligamentum teres and capsule of the hip, in order to prove pain- and proprioceptive-associated marker expression. These structures were isolated from 57 patients who had undergone elective hip surgery (44 labral samples, 33 ligamentum teres specimens, 34 capsular samples; in 19 patients all three structures were harvested). A total of 15 000 histological sections were prepared that were investigated immunohistochemically for the presence of protein S-100, 68 kDa neurofilament, neuropeptide Y, nociceptin and substance P. The tissues were evaluated in six representative areas.

Within the labrum, pain-associated free nerve ending expression was located predominantly at its base, decreasing in the periphery. In contrast, the distribution within the ligamentum teres showed a high local concentration in the centre. The hip capsule had an almost homogeneous marker expression in all investigated areas.

This study showed characteristic distribution profiles of nociceptive and pain-related nerve fibres, which may help in understanding the origin of hip pain.

Cite this article: Bone Joint J 2013;95-B:770–6.

Tranexamic acid (TXA), an inhibitor of fibrinolysis, reduces blood loss after total knee arthroplasty. However, its effect on minimally invasive total hip arthroplasty (THA) is not clear. We performed a prospective, randomised double-blind study to evaluate the effect of two intravenous injections of TXA on blood loss in patients undergoing minimally invasive THA.

In total, 60 patients (35 women and 25 men with a mean age of 58.1 years; 17 to 84) who underwent unilateral minimally invasive uncemented THA were randomly divided into the study group (30 patients, 20 women and ten men with a mean age of 56.5 years; 17 to 79) that received two intravenous injections 1 g of TXA pre- and post-operatively (TXA group), and a placebo group (30 patients, 15 women and 15 men with a mean age of 59.5 years; 23 to 84). We compared the peri-operative blood loss of the two groups. Actual blood loss was calculated from the maximum reduction in the level of haemoglobin. All patients were followed clinically for the presence of venous thromboembolism.

The TXA group had a lower mean intra-operative blood loss of 441 ml (150 to 800) versus 615 ml (50 to 1580) in the placebo (p = 0.044), lower mean post-operative blood loss (285 ml (120 to 570) versus 392 ml (126 to 660) (p = 0.002), lower mean total blood loss (1070 ml (688 to 1478) versus 1337 ml (495 to 2238) (p = 0.004) and lower requirement for transfusion (p = 0.021). No patients in either group had symptoms of venous thromboembolism or wound complications.

This prospective, randomised controlled study showed that a regimen of two intravenous injections of 1 g TXA is effective for blood conservation after minimally invasive THA.

Cite this article: Bone Joint J 2015;97-B:905–10.

Oxidised zirconium (OxZi) has been developed as an alternative bearing surface for femoral heads in total hip arthroplasty (THA). This study has investigated polyethylene wear, functional outcomes and complications, comparing OxZi and cobalt–chrome (CoCr) as part of a three-arm, multicentre randomised controlled trial. Patients undergoing THA from four institutions were prospectively randomised into three groups. Group A received a CoCr femoral head and highly cross-linked polyethylene (XLPE) liner; Group B received an OxZi femoral head and XLPE liner; Group C received an OxZi femoral head and ultra-high molecular weight polyethylene (UHMWPE) liner. At five years, 368 patients had no statistically significant differences in short-form-36 (p = 0.176 mental, p = 0.756 physical), Western Ontario and McMaster Universities Osteoarthritis Index (p = 0.847), pain scores (p = 0.458) or complications. The mean rate of linear wear was 0.028 mm/year (standard deviation (sd) 0.010) for Group A, 0.023 mm/year (sd 0.010) for Group B, and 0.09 mm/year (sd 0.045) for Group C. Penetration was significantly higher in the UHMWPE liner group compared with both XLPE liner groups (p < 0.001) but no significant difference was noted between CoCr and OxZi when articulating with XLPE (p = 0.153). In this, the largest randomised study of this bearing surface, it appears that using a XLPE acetabular liner is more important in reducing THA component wear than the choice of femoral head bearing, at mid-term follow-up. There is a non-significant trend towards lower wear, coupling OxZi rather than CoCr with XLPE but long-term analysis is required to see if this observation changes with time and becomes significant.

Cite this article: Bone Joint J 2015;97-B:883–9.

The aim of our study was to describe the characteristics, treatment, and outcomes of patients with periprosthetic joint infection (PJI) and normal inflammatory markers after total knee arthroplasty (TKA) and total hip arthroplasty (THA).

In total 538 TKAs and 414 THAs underwent surgical treatment for PJI and met the inclusion criteria. Pre-operative erythrocyte sedimentation rate (ESR) and C-reactive protein level (CRP) were reviewed to identify the seronegative cohort. An age- and gender-matched cohort was identified from the remaining patients for comparison. Overall, 4% of confirmed infections were seronegative (21 TKA and 17 THA). Of those who underwent pre-operative aspiration, cultures were positive in 76% of TKAs (n = 13) and 64% of THAs (n = 7). Cell count and differential were suggestive of infection in 85% of TKA (n = 11) and all THA aspirates (n = 5). The most common organism was coagulase-negative Staphylococcus. Seronegative infections were associated with a lower aspirate cell count and a lower incidence of Staphylococcus aureus infection. Two-stage revision was performed in 35 cases (95%). At a mean of five years (14 to 162 months) following revision, re-operation for infection occurred in two TKAs, and one THA. From our study we estimate around 4% of patients with PJI may present with normal ESR and CRP. When performed, pre-operative aspirate is useful in delivering a definitive diagnosis. When treated, similar outcomes can be obtained compared with patients with positive serology.

Cite this article: Bone Joint J 2015;97-B:939–44.

Young adults with hip pain secondary to femoroacetabular impingement (FAI) are rapidly being recognised as an important cohort of orthopaedic patients. Interest in FAI has intensified over the last decade since its recognition as a precursor to arthritis of the hip and the number of publications related to the topic has increased exponentially in the last decade. Although not all patients with abnormal hip morphology develop osteoarthritis (OA), those with FAI-related joint damage rapidly develop premature OA. There are no explicit diagnostic criteria or definitive indications for surgical intervention in FAI. Surgery for symptomatic FAI appears to be most effective in younger individuals who have not yet developed irreversible OA. The difficulty in predicting prognosis in FAI means that avoiding unnecessary surgery in asymptomatic individuals, while undertaking intervention in those that are likely to develop premature OA poses a considerable dilemma. FAI treatment in the past has focused on open procedures that carry a potential risk of complications.

Recent developments in hip arthroscopy have facilitated a minimally invasive approach to the management of FAI with few complications in expert hands. Acetabular labral preservation and repair appears to provide superior results when compared with debridement alone. Arthroscopic correction of structural abnormalities is increasingly becoming the standard treatment for FAI, however there is a paucity of high-level evidence comparing open and arthroscopic techniques in patients with similar FAI morphology and degree of associated articular cartilage damage. Further research is needed to develop an understanding of the natural course of FAI, the definitive indications for surgery and the long-term outcomes.

Cite this article: Bone Joint J 2013;95-B, Supple A:26–30.

We evaluated the accuracy with which a custom-made acetabular component could be positioned at revision arthroplasty of the hip in patients with a Paprosky type 3 acetabular defect.

A total of 16 patients with a Paprosky type 3 defect underwent revision surgery using a custom-made trabecular titanium implant. There were four men and 12 women with a median age of 67 years (48 to 79). The planned inclination (INCL), anteversion (AV), rotation and centre of rotation (COR) of the implant were compared with the post-operative position using CT scans.

A total of seven implants were malpositioned in one or more parameters: one with respect to INCL, three with respect to AV, four with respect to rotation and five with respect to the COR.

To the best of our knowledge, this is the first study in which CT data acquired for the pre-operative planning of a custom-made revision acetabular implant have been compared with CT data on the post-operative position. The results are encouraging.

Cite this article: Bone Joint J 2015; 97-B:780–5.

The aim of this study was to evaluate the ten-year clinical and functional outcome of hip resurfacing and to compare it with that of cementless hip arthroplasty in patients under the age of 55 years.

Between 1999 and 2002, 80 patients were enrolled into the study: 24 were randomised (11 to hip resurfacing, 13 to total hip arthroplasty), 18 refused hip resurfacing and chose cementless total hip arthroplasty with a 32 mm bearing, and 38 insisted on resurfacing. The mean follow-up for all patients was 12.1 years (10 to 14).

Patients were assessed clinically and radiologically at one year, five years and ten years. Outcome measures included EuroQol EQ5D, Oxford, Harris hip, University of California Los Angeles and University College Hospital functional scores.

No differences were seen between the two groups in the Oxford or Harris hip scores or in the quality of life scores. Despite a similar aspiration to activity pre-operatively, a higher proportion of patients with a hip resurfacing were running and involved in sport and heavy manual labour after ten years.

We found significantly higher function scores in patients who had undergone hip resurfacing than in those with a cementless hip arthroplasty at ten years. This suggests a functional advantage for hip resurfacing. There were no other attendant problems.

Cite this article: Bone Joint J 2015; 97-B:617–22.

The long-term survival of the cementless Spotorno CLS femoral component in patients aged > 50 years at the time of arthroplasty was investigated. Survivorship analysis of a consecutive series of 85 patients (100 hips; under 50 years of age at a mean follow-up of 18.4 years (16.3 to 20.8)) was performed. The clinical and radiographic outcomes were satisfactory. The overall rate of survival of the femoral component was 93.5% (95% confidence interval (CI), 90.9 to 96.1) after 19 years. Survival with revision for aseptic loosening as the end point was 95.7% (95% CI 93.6 to 97.8%) at 19 years.

This study demonstrates an excellent long-term survival of the Spotorno CLS femoral component after 16 to 20 years in young patients undergoing total hip arthroplasty.

Cite this article: Bone Joint J 2015;97-B:160–3.

End caps are intended to prevent nail migration (push-out) in elastic stable intramedullary nailing. The aim of this study was to investigate the force at failure with and without end caps, and whether different insertion angles of nails and end caps would alter that force at failure.

Simulated oblique fractures of the diaphysis were created in 15 artificial paediatric femurs. Titanium Elastic Nails with end caps were inserted at angles of 45°, 55° and 65° in five specimens for each angle to create three study groups. Biomechanical testing was performed with axial compression until failure. An identical fracture was created in four small adult cadaveric femurs harvested from two donors (both female, aged 81 and 85 years, height 149 cm and 156 cm, respectively). All femurs were tested without and subsequently with end caps inserted at 45°.

In the artificial femurs, maximum force was not significantly different between the three groups (p = 0.613). Push-out force was significantly higher in the cadaveric specimens with the use of end caps by an up to sixfold load increase (830 N, standard deviation (SD) 280 vs 150 N, SD 120, respectively; p = 0.007).

These results indicate that the nail and end cap insertion angle can be varied within 20° without altering construct stability and that the risk of elastic stable intramedullary nailing push–out can be effectively reduced by the use of end caps.

Cite this article: Bone Joint J 2015;97-B:558–63.

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.

The October 2013 Children’s orthopaedics Roundup³⁶⁰ looks at: Half a century of Pavlik treatment; Step away from the child!: trends in fracture management; Posterolateral rotatory elbow instability in children; Osteochondral lesions undiagnosed in patellar dislocations; Oral bisphosphonates in osteogenesis imperfecta; Crossed or parallel pins in supracondylar fractures?; Not too late nor too early: getting epiphysiodesis right; Fixation of supramalleolar osteotomies.

Most proximal humeral fractures are stable injuries of the ageing population, and can be successfully treated non-operatively. The management of the smaller number of more complex displaced fractures is more controversial and new fixation techniques have greatly increased the range of fractures that may benefit from surgery.

This article explores current concepts in the classification and clinical aspects of these injuries, reviewing the indications, innovations and outcomes for the most common methods of treatment.

The management of children’s fractures has evolved as a result of better health education, changes in lifestyle, improved implant technology and the changing expectations of society. This review focuses on the changes seen in paediatric fractures, including epidemiology, the increasing problems of obesity, the mechanisms of injury, non-accidental injuries and litigation. We also examine the changes in the management of fractures at three specific sites: the supracondylar humerus, femoral shaft and forearm. There has been an increasing trend towards surgical stabilisation of these fractures. The reasons for this are multifactorial, including societal expectations of a perfect result and reduced hospital stay. Reduced hospital stay is beneficial to the social, educational and psychological needs of the child and beneficial to society as a whole, due to reduced costs.

Cite this article: Bone Joint J 2015; 97-B:442–8.