We report the management of an adult patient with septic sacroiliitis. This is an uncommon condition. Debridement, decompression and spontaneous fusion are the treatment of choice when symptoms do not resolve with routine initial intravenous antibiotic therapy. A percutaneous technique is described, using the principles of sacroiliac screw insertion commonly used for pelvic reconstruction surgery. After successful evacuation of the infected joint, fusion was observed in our patient.

The purpose of this study was to investigate the development of the osseous acetabular index (OAI) and cartilaginous acetabular index (CAI) using MRI. The OAI and CAI were measured on the coronal MR images of the hip in 81 children with developmental dysplasia of the hip (DDH), with a mean age of 19.6 months (3 to 70), and 241 normal control children with a mean age of 5.1 years (1 month to 12.5 years). Additionally the developmental patterns of the OAI and CAI in normal children were determined by age-based cross-sectional analysis.

Unlike the OAI, the normal CAI decreased rapidly from a mean of 10.17° (sd 1.60) to a mean of 8.25° (sd 1.90) within the first two years of life, and then remained constant at a mean of 8.04° (sd 1.65) until adolescence. Although no difference in OAI was found between the uninvolved hips in children with unilateral DDH and normal hips (p = 0.639), the CAI was significantly different between them both (p < 0.001). The normal CAI has fully formed at birth, and is maintained constantly throughout childhood. The CAI in the unaffected hips in children with unilateral DDH is also mildly dysplastic.

This single-blinded randomised controlled trial investigated whether one design of mobile-bearing (MB) total knee replacement (TKR) has any advantage over a fixed-bearing (FB) design on long-term fixation as measured by radiostereometry. The amount of wear underneath the mobile bearing was also evaluated. A series of 42 knees was randomised to MB or FB tibial components with appropriate polyethylene inserts and followed for between ten and 12 years, or until the death of the patient. The polyethylene in the MB group was superior in that it was gamma-irradiated in inert gas and was calcium-stearate free; the polyethylene in the FB group was gamma-irradiated in air and contained calcium stearate. In theory this should be advantageous to the wear rate of the MB group. At final follow-up the overall mean migration was 0.75 mm (sd 0.76) in the MB group and 0.66 mm (sd 0.4) in the FB group, with the FB group demonstrating more posterior tilt and the MB group more internal rotation. In the FB group there was one revision for aseptic loosening, but none in the MB group. There were no significant differences in clinical or radiological scores.

For the MB group, the mean linear wear rate on the under-surface was 0.026 mm/year (sd 0.014). This was significantly smaller than the wear rate of 0.11 mm/year (sd 0.06) in the MB between femur and polyethylene (p < 0.001). Nevertheless, even in a best-case setting the mobile bearings of this TKR design had no apparent advantage in terms of fixation over the FB knee prosthesis at ten to 12 years. The wear underneath the mobile bearing was small and is unlikely to be clinically relevant.

Using a prospective database of 1309 displaced acetabular fractures gathered between 1980 and 2007, we calculated the annual mean age and annual incidence of elderly patients > 60 years of age presenting with these injuries. We compared the clinical details and patterns of fracture between patients > 60 years of age (study group) with those < 60 years (control group). We performed a detailed evaluation of the radiographs of the older group to determine the incidence of radiological characteristics which have been previously described as being associated with a poor patient outcome.

In all, 235 patients were > 60 years of age and the remaining 1074 were < 60 years. The incidence of elderly patients with acetabular fractures increased by 2.4-fold between the first half of the study period and the second half (10% (62) vs 24% (174), p < 0.001). Fractures characterised by displacement of the anterior column were significantly more common in the elderly compared with the younger patients (64% (150) vs 43% (462), respectively, p < 0.001). Common radiological features of the fractures in the study group included a separate quadrilateral-plate component (50.8% (58)) and roof impaction (40% (46)) in the anterior fractures, and comminution (44% (30)) and marginal impaction (38% (26)) in posterior-wall fractures.

The proportion of elderly patients presenting with acetabular fractures increased during the 27-year period. The older patients had a different distribution of fracture pattern than the younger patients, and often had radiological features which have been shown in other studies to be predictive of a poor outcome.

Glenoid replacement is technically challenging. Removal of a cemented glenoid component often results in a large osseous defect which makes the immediate introduction of a revision prosthesis almost impossible. We describe a two-stage revision procedure using a reversed shoulder prosthesis. Freeze-dried allograft with platelet-derived growth factor was used to fill the glenoid defect. Radiological incorporation of the allograft was seen and its consistency allowed the placement of a screwed glenoid component. There were no signs of new mature bone formation on histological examination.

The addition of platelet-derived growth factor to the allograft seems to contribute to an increase in incorporation and hardness, but does not promote the growth of new bone.

We describe the results of Copeland surface replacement shoulder arthroplasty using the mark III prosthesis in patients over 80 years of age. End-stage arthritis of the shoulder is a source of significant pain and debilitating functional loss in the elderly. An arthroplasty offers good relief of pain and may allow the patient to maintain independence. The risk-benefit ratio of shoulder replacement may be felt to be too high in an elderly age group, but there is no published evidence to support this theory. We have assessed whether the procedure was as reliable and safe as previously seen in a younger cohort of patients. Between 1993 and 2003, 213 Copeland surface replacement arthroplasty procedures were performed in our unit, of which 29 (13.6%) were undertaken in patients over the age of 80. This group of patients was followed up for a mean of 4.5 years (2.1 to 9.3). Their mean age was 84.3 years (81 to 93), the mean operating time was 40 minutes (30 to 45) and the mean in-patient stay was five days (2 to 21). There were no peri-operative deaths or significant complications. The mean Constant score adjusted for age and gender, improved from 15.1% to 77%. Copeland surface replacement shoulder arthroplasty may be performed with minimal morbidity and rapid rehabilitation in the elderly.

We examined the relationships between the serum levels of chromium and cobalt ions and the inclination angle of the acetabular component and the level of activity in 214 patients implanted with a metal-on-metal resurfacing hip replacement. Each patient had a single resurfacing and no other metal in their body. All serum measurements were performed at a minimum of one year after operation. The inclination of the acetabular component was considered to be steep if the abduction angle was greater than 55°.

There were significantly higher levels of metal ions in patients with steeply-inclined components (p = 0.002 for chromium, p = 0.003 for cobalt), but no correlation was found between the level of activity and the concentration of metal ions. A highly significant (p < 0.001) correlation with the arc of cover was found. Arcs of cover of less than 10 mm were correlated with a greater risk of high concentrations of serum metal ions. The arc of coverage was also related to the design of the component and to size as well as to the abduction angle of the acetabular component. Steeply-inclined acetabular components, with abduction angles greater than 55°, combined with a small size of component are likely to give rise to higher serum levels of cobalt and chromium ions. This is probably due to a greater risk of edge-loading.

Loss of bone stock is a major problem in revision surgery of the hip. Impaction bone grafting of the femur is frequently used when dealing with deficient bone stock. In this retrospective study a consecutive series of 68 patients (69 hips) who had revision of a hip replacement with femoral impaction grafting were reviewed. Irradiated bone allograft was used in all hips. Radiological measurement of subsidence of the stem, incorporation of the graft and remodelling was carried out and showed incorporation of the graft in 26 of 69 hips (38%). However, there was no evidence of trabecular remodelling. Moderate subsidence of 5 mm to 10 mm occurred in ten hips (14.5%), and massive subsidence of > 10 mm in five (7.2%).

The results of this study are less favourable than those of others describing studies of revision of the femoral stem using impaction bone grafting. The absence of the characteristic changes of graft remodelling noted in other series raises the question as to whether irradiated bone graft may be a significant factor influencing the post-operative outcome.

The Salter innominate osteotomy has been used successfully for many years in the treatment of developmental dysplasia of the hip. One of its main drawbacks is the need for internal fixation with pins and their subsequent removal. We describe a modification of this osteotomy that does not require pin fixation and secondary removal. We retrospectively reviewed 114 hips in 94 patients who had been operated on by a single surgeon. An oblique rather than the original horizontal osteotomy was used without internal fixation. There were 80 female and 14 male patients. The mean age at operation was 25 months (18 to 84) and the mean follow-up was 30 months (12 to 88). Most patients required additional open reduction and capsuloplasty. The mean pre-operative acetabular index was 37.9° (24° to 54°), which decreased to 19.9° (7° to 29°) in the immediate post-operative period, and improved to 14.6° (5° to 25°) at the final follow-up (student’s t-test, p < 0.0001).

We believe that by changing the direction of the osteotomy line, it is possible to avoid pin fixation. The radiological outcomes are comparable to those of the original technique, but longer follow-up will be necessary.

Osteochondroma is the most common benign bone tumour. The risk of sarcomatous change in an isolated lesion is approximately 1%. We report a case of an isolated osteochondroma which appeared benign on clinical and plain radiographic examination but routine histological analysis revealed non-Hodgkin’s lymphoma in the underlying bone. This association has not previously been reported and the case emphasises the importance of routine histological analysis, even if a lesion appears benign.

There were 47 patients with congenital muscular torticollis who underwent operative release. After a mean follow-up of 74 months (60 to 90), they were divided into two groups, one aged one to four years (group 1) and the other aged five to 16 years (group 2). The outcomes were assessed by evaluating the following parameters: deficits of lateral flexion and rotation, craniofacial asymmetry, surgical scarring, residual contracture, subjective evaluation and degree of head tilt.

The craniofacial asymmetry, residual contracture, subjective evaluation and overall scores were similar in both groups. However, group 2 showed superior results to group 1 in terms of the deficits of movement, surgical scarring and degree of head tilt.

It is recommended that operative treatment for congenital muscular torticollis is postponed until the patient can comply successfully with post-operative bracing and an exercise programme.

The Acclaim total elbow replacement is a modular system which allows implantation in both unlinked and linked modes. The results of the use of this implant in primary total elbow replacement in 36 patients, operated on between July 2000 and August 2002, are presented at a mean follow-up of 36 months (24 to 49). Only one patient did not have good relief of pain, but all had improved movement and function.

No implant showed clinical or radiological loosening, although one had a lucent area in three of seven humeral zones. The short-term results of the Acclaim total elbow replacement are encouraging. However, 11 patients (30.5%) suffered an intra-operative fracture of the humeral condyle. This did not affect the outcome, or the requirement for further surgery, except in one case where the fracture failed to unite. This problem has hopefully been addressed by redesigning the humeral resection guide. Other complications included three cases of ulnar neuropathy (8.3%) and one of deep infection (2.8%).

We describe the medium-term results of a prospective study of 200 total ankle replacements at a single-centre using the Scandinavian Total Ankle Replacement. A total of 24 ankles (12%) have been revised, 20 by fusion and four by further replacement and 27 patients (33 ankles) have died. All the surviving patients were seen at a minimum of five years after operation. The five-year survival was 93.3% (95% confidence interval (CI) 89.8 to 96.8) and the ten-year survival 80.3% (95% CI 71.0 to 89.6).

Anterior subluxation of the talus, often seen on the lateral radiograph in osteoarthritic ankles, was corrected and, in most instances, the anatomical alignment was restored by total ankle replacement. The orientation of the tibial component, as seen on the lateral radiograph, also affects the position of the talus and if not correct can hold the talus in an abnormal anterior position. Subtalar arthritis may continue to progress after total ankle replacement. Our results are similar to those published previously.

We describe three cases of fracture of the titanium JRI-Furlong hydroxyapatite-ceramic (HAC)-coated femoral component. We have examined previous case reports of failure of this stem and conclude that fracture may occur in two places, namely at the neck-shoulder junction and at the conical-distal cylindrical junction. These breakages are the result of fatigue in a metallurgically-proven normal femoral component. All the cases of failure of the femoral component have occurred in patients with a body mass index of more than 25 in whom a small component, either size 9 or 10, had been used.

In patients with a body mass index above normal size 9 components should be avoided and the femoral canal should be reamed sufficiently to accept a large femoral component to ensure that there is adequate metaphyseal fixation.

Despite extensive experience with prosthetic replacement for the reconstruction of limbs following juxta-articular resection of tumours, there are few reports of prosthetic replacement of the distal radius. We present two cases of massive bone defects of the distal radius in which alumina ceramic prosthetic replacements were used. We evaluated the patients more than ten years after the procedure. Both patients had degenerative changes to the wrist. This, however, was not associated with pain or decreased function, and both had returned to their previous occupation after surgery.

When a patient has a massive defect of the distal radius, reconstruction using a ceramic prosthesis is a reasonable alternative to using autograft. This method of treatment results in little pain, a moderate range of movement and satisfactory function.

Our aim in this prospective study was to evaluate the outcome of total shoulder replacement in the treatment of young and middle-aged active patients with primary glenohumeral osteoarthritis. We reviewed 21 patients (21 shoulders) with a mean age of 55 years (37 to 60). The mean follow-up was seven years (5 to 9). The same anatomical, third-generation, cemented implant had been used in all patients. All the patients were evaluated radiologically and clinically using the Constant and Murley score.

No patients required revision. In one a tear of the supraspinatus tendon occurred. Overall, 20 patients (95%) were either very satisfied (n = 18) or satisfied (n = 2) with the outcome. Significant differences (p < 0.0001) were found for all categories of the Constant and Murley score pre- and post-operatively. The mean Constant and Murley score increased from 24.1 points (10 to 45) to 64.5 points (39 to 93), and the relative score from 30.4% (11% to 50%) to 83% (54% to 116%). No clinical or radiological signs of loosening of the implant were seen.

For young and middle-aged patients with osteoarthritis, third-generation total shoulder replacement is a viable method of treatment with a low rate of complications and excellent results in the mid-term.

We report a case of fatal haemorrhage following a low-energy fracture of the pubic ramus in an 85-year-old woman.

We have examined the relief from pain and the functional outcome in 18 patients who underwent resection arthroplasty of the shoulder as a salvage operation between 1988 and 2002. The indications included failed shoulder replacement in 17, with infection in 13, and chronic septic arthritis in one. The mean follow-up was 8.3 years (2.5 to 16.6). Two intra-operative fractures of the humerus occurred, both of which healed.

The level of pain was significantly decreased (t-test, p < 0.001) but five patients continued to have moderate to severe pain. The mean active elevation was 70° (0° to 150°) postoperatively and represented an improvement from 39° (0° to 140°) (t-test, p = 0.003), but internal and external rotation were hardly changed. The mean number of positive answers on the 12-question Simple Shoulder Test was 3.1 (0 to 12) but the shoulder was generally comfortable when the arm was positioned at rest by the side. The mean post-operative American Shoulder and Elbow Surgeon’s score was 36 (8 to 73).

Despite applying this procedure principally to failed shoulder replacements, the results were similar to those reported in the literature for patients after severe fracture-dislocation. Reduction of pain is possible in one half to two-thirds of patients. The outcome of this operation in providing relief from pain cannot be guaranteed, but the shoulder is usually comfortable at rest, albeit with profound functional limitations.

We carried out a prospective study to assess the clinical outcome, complications and survival of the NexGen Legacy posterior-stabilised-Flex total knee replacement (TKR) in a consecutive series of 278 knees between May 2003 and February 2005. Mean follow-up for 259 TKRs (98.2%) was 3.8 years (3.0 to 4.8). Annual follow-up showed improvement in the Knee Society scores (paired t-test, p < 0.05). At the last follow-up, the mean maximum flexion was 135° (110° to 150°). Two knees showed radiolucent lines, but revision was not required because the patients were asymptomatic. Revision was required in one case because of infection, but there were no prosthesis-related revisions. There were no other complications. The estimated survival rate at four years with revision for any reason and prosthesis-related problems was 99.6% and 100%, respectively.

This relatively large study indicates that the legacy posterior stabilised-Flex design provides excellent short-term outcome but warrants ongoing evaluation to confirm the long-term durability and functioning of the implant.

Antegrade intramedullary nailing of fractures of the shaft of the humerus is reported to cause impairment of the shoulder joint. We have reviewed 33 patients with such fractures to assess how many had injuries to the ipsilateral shoulder. All had an MR scan of the shoulder within 11 days of injury. The unaffected shoulder was also scanned as a control. There was evidence of abnormality in 21 of the shoulders (63.6%) on the injured side; ten had bursitis of the subacromial space, five evidence of a partial tear of the rotator cuff, one a complete rupture of the supraspinatus tendon, four inflammatory changes in the acromioclavicular joint and one a fracture of the coracoid process. These injuries may contribute to pain and dysfunction of the shoulder following treatment, and their presence indicates that antegrade nailing is only partly, if at all, responsible for these symptoms.