Aims

To our knowledge, no study has compared the long-term results of cemented and hybrid total hip arthroplasty (THA) in patients with osteoarthritis (OA) secondary to congenital hip disease (CHD). This is a demanding procedure that may require special techniques and implants. Our aim was to compare the long-term outcome of cemented low-friction arthroplasty (LFA) and hybrid THA performed by one surgeon.

Aims

This study presents the long-term survivorship, risk factors for prosthesis survival, and an assessment of the long-term effects of changes in surgical technique in a large series of patients treated by metal-on-metal (MoM) hip resurfacing arthroplasty (HRA).

We have reviewed 29 patients (30 hips) who had undergone revision total hip arthroplasty using a Freeman metal-backed acetabular component and acetabular impaction allografting. The mean follow-up was for 15.3 years (12 to 17). Five patients (5 hips) died with the prosthesis in situ and four (4 hips) were lost to follow-up. Twelve hips had failed and in the remaining nine there were minor symptoms. The mean time to failure requiring further surgery was nine years. Excluding patients who were lost to follow-up or had died, 72% of the hips were radiologically loose at the last review. The commonest pattern in those requiring revision was failure of the reinforcement ring in adduction with remodelling of the medial wall. Of the nine patients who had not undergone revision, one with bilateral replacements had no current radiographs and only three of the remaining seven replacements had no radiological signs of loosening. The short-term results for this technique have been reported to be satisfactory, but in the long term they are not. The factors associated with failure include the design of the prosthesis, which has been implicated in disappointing long-term results when used in primary arthroplasty, but not with the frequency of failure found in this series. It seems that the reliance on peripheral screw fixation over a bed of allograft without bridging the graft does not provide sufficient stability to allow incorporation of the graft

A prospective study involving 500 consecutive patients undergoing hip replacement was performed to find out whether a combination of heparin and dihydroergotamine was effective in preventing postoperative fatal and non-fatal emboli. Deep-vein thrombosis was demonstrated in 131 cases (26.2%), in 99 of whom thrombi were confined to the ipsilateral (operated) limb and in 13 to the contralateral limb; 19 patients developed bilateral thrombi. Nine patients (1.8%) died during the first four weeks after operation, before they were discharged from hospital; in one, major emboli were demonstrated in the right pulmonary artery. Three of the 500 patients developed non-fatal pulmonary emboli. Excessive bleeding occurred in 21 (4.2%) and in 19 of these prophylaxis was discontinued. Wound haematomas developed in 25 patients (5.0%); only six required evacuation but in none of these six did deep infection occur while in hospital; in three patients, however, the wound haematoma prolonged the stay in hospital. Thus the combination of heparin and dihydroergotamine proved an effective prophylaxis against pulmonary embolism in patients undergoing total hip replacement. The risk of bleeding complications is wholly acceptable when balanced against the advantages of the therapy

This investigation examined the validity of the hypothesis that the acetabulum in congenital dislocation of the hip will develop satisfactorily provided accurate congruous and concentric reduction is obtained as early as possible, and is maintained throughout growth. Seventy-two patients with eighty-five hips were studied. The children were more than one year old on admission and over ten years at the time of review. Acetabular development was assessed radiologically by measurement of the acetabular angle. Angles of less than 21 degrees were regarded as normal, and more than 21 degrees as indicating some failure of development. Satisfactory acetabular development occurred in 80 per cent (angles 24 degrees or below), and was unsatisfactory in 20 per cent (angles above 24 degrees). If three errors in management, namely failure to obtain congruity, failure to maintain congruity and ischaemic necrosis secondary to manipulative reductions, are excluded from the analysis, it is found that 95 per cent of acetabula develop satisfactorily. The outcome is largely independent of the age on admission up to four years old, and of bilateral involvement. It is concluded that acetabuloplasty should not be necessary if the patient is admitted under the age of four or congruity is obtained in the functional position under four and a half years

Club foot can be diagnosed by ultrasound of the fetus in more than 60% of cases. We have correlated the accuracy of the prenatal findings in 281 ultrasound surveys with the physical findings after birth and the subsequent treatment in 147 children who were born with club foot. The earliest week of gestation in which the condition was diagnosed with a high degree of confidence was the 12th and the latest was the 32nd. Not all patients were diagnosed at an early stage. In 29% of fetuses the first ultrasound examination failed to detect the deformity which subsequently became obvious at a later examination. Club foot was diagnosed between 12 and 23 weeks of gestation in 86% of children and between 24 and 32 weeks of gestation in the remaining 14%. Therefore it can be considered to be an early event in gestation (45% identified by the 17th week), a late event (45% detected between 18th and 24th weeks) or a very late event (10% recognised between 25th and 32nd weeks). We cannot exclude, however, the possibility that the late-onset groups may have been diagnosed late because earlier scans were false-negative results. The prenatal ultrasonographic findings were correlated with the physical findings after birth and showed that bilateral involvement was more common than unilateral. There was no significant relationship between the prenatal diagnosis and the postnatal therapeutic approach (i.e., conservative or surgical), or the degree of rigidity of the affected foot

Congenital talipes equinovarus is a common anomaly which can now be diagnosed prenatally on a routine ultrasound scan at 20 weeks of gestation. Prenatal counselling is increasingly offered to parents with affected fetuses, but it is difficult to counsel parents if there is a chance that the fetus may not have talipes. Our study correlates the prenatal ultrasound findings of 14 infants diagnosed as having unilateral or bilateral talipes during their routine 20-week ultrasound scan with their clinical findings at birth and the treatment received. No feet diagnosed as talipes on the ultrasound scan were completely normal at birth and therefore there were no true false-positive results. One foot graded as normal at 20 weeks was found to have a mild grade-1 talipes at birth, but did not require treatment other than simple stretches. A total of 32% of feet required no treatment and so could be considered functional false-positive results on the scan. Serial casting was required by 13% of feet and surgical treatment by 55%. The severity of the talipes is difficult to establish before birth. A number of patients are likely to need surgical treatment, but a proportion will have talipes so mildly that no treatment will be required. In counselling parents at 20 weeks, orthopaedic surgeons need to know whether or not there is a small chance that the ultrasound diagnosis could be wrong and also that the talipes may be so mild that the foot will not require treatment

We report the treatment in 17 patients of 27 angular deformities of the long bones by progressive opening-wedge osteotomy. The technique consists of percutaneous osteotomy and progressive angular correction using a modified Wagner distractor. Ten patients (20 bone segments) had adolescent bilateral idiopathic tibia vara with a mean angular deformity of 12 degrees varus (10 to 16). Seven other adolescent patients had secondary angular deformities either at the distal femur or the distal tibia. One of the femoral deformities had an associated 5.5 cm of shortening which was treated simultaneously. The patients with idiopathic tibia vara achieved a final mean angular correction of 15 degrees (mechanical axis from 12 degrees varus to 3 degrees valgus). In patients with secondary angular deformities the mean angular correction was 17 degrees. The Wagner device was removed in an average period of 12 weeks (9 to 27), and no major complications were observed. Progressive opening-wedge osteotomy is an alternative to conventional osteotomies for the treatment of angular deformities of the long bones in adolescent patients, and has the advantage of requiring less invasive surgery, allowing progressive and adjustable correction with bone lengthening if needed

1. The histories of 149 patients, coming to the Hospital for Sick Children within the first three years of life with congenital dislocation of the hip (191 dislocated hips), and treated by conservative methods, have been reviewed. 2. The patients with unilateral dislocations (107) have been divided into three groups, according to the angle of slope of the opposite acetabulum. This angle was measured on the first radiograph and related to the mean value for age and sex. 3. The opposite hip was classed as "normal" if the acetabular angle was below or within one standard deviation above the mean for sex and age; as "moderately shallow" if it was between one and two standard deviations above the mean; and as "shallow" if it was over two standard deviations above the mean. This grouping was found to have a direct bearing on the results of conservative treatment in unilateral cases. a) Those with "normal" opposite acetabula–accounting for most of the unilateral cases–responded well. b) Those with "moderately shallow" opposite acetabula responded variably. c) The group with "shallow" opposite acetabula usually failed to respond. 4. Most bilateral dislocations behaved as unilateral dislocations with shallow opposite hips. 5. Additional factors influencing the response to conservative treatment–sex, age at first attendance, family history, fragmentation of the femoral epiphysis and eccentric reduction–are discussed

1. A study of 2,200 patients receiving electro-convulsive therapy showed that fifty-three sustained fractures or dislocations—an incidence of 2·4 per cent. Of the fifty-three injuries, twenty-one occurred in the spine, fifteen in the neck of femur, fifteen in the upper end of humerus, one in the coracoid process; one dislocated jaw required anaesthesia for its reduction (other cases of transient dislocation of the jaw are excluded). 2. The incidence, site, and type of spinal fractures are recorded, and the relation of the fracture to the first convulsion is noted. No late changes were found in the spines of patients examined two years or more after treatment. A neutral position of the spine during the convulsion is believed to diminish the risk of fracture. 3. Fracture of the neck of the femur is a serious injury in these patients. In one case the injury was bilateral. 4. The fifteen cases of fracture-dislocation of the upper humerus are analysed. They included two cases of posterior dislocation of the humeral head; the possible mechanism of this is explained and a method of prevention suggested. 5. Fifty-three patients with chronic epilepsy with psychosis were examined. Four cases of fractured spine were discovered. The site of fracture was different from that of fractures caused by convulsive therapy and a reason for this is suggested. The type and mechanism of the fracture are similar in the two groups

Aims

There has been a recent resurgence in interest in combined partial knee arthroplasty (PKA) as an alternative to total knee arthroplasty (TKA). The varied terminology used to describe these procedures leads to confusion and ambiguity in communication between surgeons, allied health professionals, and patients. A standardized classification system is required for patient safety, accurate clinical record-keeping, clear communication, correct coding for appropriate remuneration, and joint registry data collection.

From 1982 to 1987, we randomised prospectively 413 patients requiring primary total hip replacements to receive either a Stanmore or Charnley prosthesis. They were reviewed by an independent observer in an attempt to correlate a number of factors including femoral head size with longevity. There were 213 Stanmore hips and 200 Charnley prostheses. At five to ten years (mean 6.5) 76 patients had died and 16 arthroplasties had required revision. Seven were radiologically loose in asymptomatic patients. There was only one case of deep infection. We found no difference statistically in the clinical outcome or in the revision rate of 4% in the two types of prosthesis. The revision rate was greater for trainees than for senior operating surgeons, and there were recognisable technical errors in seven of the nine Stanmore, and four of the seven Charnley replacements which required revision. Retrospective radiological analysis of a random subset of 51 Charnley and 57 Stanmore femoral components showed no difference in femoral subsidence, but in 14 patients who had had bilateral replacements with one femoral component of each type, there was greater early subsidence of the Stanmore prosthesis. Our results confirm that conventional cemented total hip replacements give acceptable results in a general teaching unit, and we found no evidence of any effect of the size of the femoral head on wear or loosening at five to ten years

Between 1978 and 1986, 59 patients received a GSB III elbow prosthesis, six of them in both elbows. Rheumatoid arthritis (RA) was the underlying cause in 51 of the patients and post-traumatic osteoarthritis (PTOA) in eight. Of these, 24 patients (28 prostheses) have since died; two, both operated on bilaterally, had had their implants for more than ten years and had already been assessed for inclusion in the long-term follow-up. Two patients, each with one elbow prosthesis, have been lost to follow-up and three males who are still living (two with PTOA, one with juvenile RA) had their prosthesis removed before ten years had elapsed. The remaining 32 patients (28 RA, 4 PTOA) with 36 GSB III elbows were examined clinically and radiologically after a mean period of 13.5 years. Pain was considerably reduced in 91.6%. Mobility was increased by 37° in those with RA and by 67° in those with PTOA. There were three cases of aseptic loosening and three of deep infection. The main complication was disassembly of the prosthetic component in nine elbows (13.8%). This last group included two patients with postoperative fractures unrelated to the operative technique and one with neuropathic arthritis. Ulnar neuritis occurred in two patients. Since 87.7% of all the GSB III prostheses implanted in this period remained in situ, our results are comparable with those for hip and knee arthroplasty

We assigned 67 patients with central lumbar stenosis alternately to either multiple laminotomy or total laminectomy. The protocol, however, allowed multiple laminotomy to be changed to total laminectomy if it was thought that the former procedure might not give adequate neural decompression. There were therefore three treatment groups: group I consisting of 26 patients submitted to multiple laminotomy; group II, 9 patients scheduled for laminotomy but submitted to laminectomy; and group III, 32 patients scheduled for, and submitted to, laminectomy. The mean follow-up was 3.7 years. Bilateral laminotomy at two or three levels required a longer mean operating time than total laminectomy at an equal number of levels. The mean blood loss at surgery and the clinical results did not differ in the three groups. The mean subjective improvement score for low back pain was higher in group I but there was also a higher incidence of neural complications in this group. No patient in group I had postoperative vertebral instability, whereas this occurred in three patients in groups II and III, who had lumbar scoliosis or degenerative spondylolisthesis preoperatively. Multiple laminotomy is recommended for all patients with developmental stenosis and for those with mild to moderate degenerative stenosis or degenerative spondylolisthesis. Total laminectomy is to be preferred for patients with severe degenerative stenosis or marked degenerative spondylolisthesis

We reviewed 40 patients treated surgically for lumbar stenosis at an average time of 8.6 years after operation. In 32, total laminectomy had been performed and in eight bilateral laminotomy, both at one or more levels. Of the 16 patients with degenerative spondylolisthesis, ten had had a concomitant spinal fusion. Patients were assigned to one of four groups according to the amount of bone regrowth: group 0 had no regrowth and groups I, II, and III, had mild, moderate or marked regrowth, respectively. Only 12% of the patients showed no bone regrowth; 48% were assigned to group I, 28% to group II and 12% to group III. Imaging studies showed varying degrees of recurrent stenosis in patients with moderate or marked bone regrowth. All patients with degenerative spondylolisthesis showed bone regrowth, which was more severe in those who had not had a fusion. The clinical results were satisfactory in most of the patients with mild or no bone regrowth and significantly less good in those with moderate or marked regrowth. In the group with degenerative spondylolisthesis, the proportion of satisfactory results was significantly higher in patients who had had spinal fusion. The long-term results of surgery for lumbar stenosis depend both upon the amount of bone regrowth and the degree of postoperative vertebral stability

We reviewed the results of reconstruction of 97 upper limbs in a consecutive series of 57 tetraplegic patients, treated from 1982 to 1990. Of these, 49 had functional and eight had cosmetic reconstructions. The principal functional objectives were to provide active elbow extension, hook grip, and key pinch. Elbow extension was provided in 34 limbs, using deltoid-to-triceps transfer. Hook grip was provided in 58 limbs, mostly using extensor carpi radialis longus to flexor pollicis longus transfer, and key pinch in 68, mostly using brachioradialis to flexor pollicis longus transfer. Many other procedures were employed. At an average follow-up of 37 months, 70% had good or excellent subjective results, and objective measurements of function compared favourably with other series. Revisions were required for 11 active transfers and three tenodeses, while complications included rupture of anastomoses and problems with thumb interphalangeal joint stabilisation and wound healing. We report a reliable clinical method for differentiating between the activity of extensor carpi radialis longus and brevis and describe a successful new split flexor pollicis longus tenodesis for stabilising the thumb interphalangeal joint. Bilateral simultaneous surgery gave generally better results than did unilateral surgery

We describe the results of a prospective study of 28 children with spastic diplegia and in-toed gait, who had bilateral femoral derotation osteotomies undertaken at either the proximal intertrochanteric or the distal supracondylar level of the femur. Preoperative clinical evaluation and three-dimensional movement analysis determined any additional soft-tissue surgery. Distal osteotomy was faster with significantly lower blood loss than proximal osteotomy. The children in the distal group achieved independent walking earlier than those in the proximal group (6.9 ± 1.3 v 10.7 ± 1.7 weeks; p < 0.001). Transverse plane kinematics demonstrated clinically significant improvements in rotation of the hip and the foot progression angle in both groups. Correction of rotation of the hip was from 17 ± 11° internal to 3 ± 9.5° external in the proximal group and from 9 ± 14° internal to 4 ± 12.4° external in the distal group. Correction of the foot progression angle was from a mean of 10.0 ± 17.3° internal to 13.0 ± 11.8° external in the proximal group (p < 0.001) compared with a mean of 7.0 ± 19.4° internal to 10.0 ± 12.2° external in the distal group (p < 0.001). Femoral derotation osteotomy at both levels gives comparable excellent correction of rotation of the hip and foot progression angles in children with spastic diplegia