We report the use of the reverse shoulder prosthesis in the revision of a failed shoulder hemiarthroplasty in 19 shoulders in 18 patients (7 men, 11 women) with severe pain and loss of function. The primary procedure had been undertaken for glenohumeral arthritis associated with severe rotator cuff deficiency. Statistically significant improvements were seen in pain and functional outcome. After a mean follow-up of 44 months (24 to 89), mean forward flexion improved by 26.4° and mean abduction improved by 35°. There were six prosthesis-related complications in six shoulders (32%), five of which had severe bone loss of the glenoid, proximal humerus or both. Three shoulders (16%) had non-prosthesis related complications. The use of the reverse shoulder prosthesis provides improvement in pain and function for patients with failure of a hemiarthroplasty for glenohumeral arthritis and rotator cuff deficiency. However, high rates of complications were associated with glenoid and proximal humeral bone loss

Five children with congenital pseudarthrosis of the tibia treated by free vascularised fibular grafts were followed up until skeletal maturity. The ipsilateral fibula was used in four cases, the contralateral fibula in one. All our cases achieved bone union, but leg length discrepancy, atrophy of the foot and ankle stiffness were frequent complications, due perhaps to the many previous operations. Vascularised fibular grafting might achieve better results if it were done as the primary procedure

Aims

To report mid- to long-term results of Oxford mobile bearing domed lateral unicompartmental knee arthroplasty (UKA), and determine the effect of potential contraindications on outcome.

Introduction

The primary aim of this study was to describe a baseline comparison of early knee-specific functional outcomes following revision total knee arthroplasty (TKA) using metaphyseal sleeves with a matched cohort of patients undergoing primary TKA. The secondary aim was to compare incidence of complications and length of stay (LOS) between the two groups.

Aims

To investigate the experience and emotional impact of prosthetic joint infection (PJI) on orthopaedic surgeons and identify holistic strategies to improve the management of PJI and protect surgeons’ wellbeing.

The results of excision arthroplasty on forty hips in thirty-two patients have been studied by personal review. The mean follow-up was ten years and the results were graded in the Lazansky system. The outcome was fairly predictable, most patients achieving a fair to good result. The patients were satisfied with the operation in unilateral cases as a secondary operation, but it was generally unsatisfactory as a primary procedure or when performed bilaterally. Pain relief was satisfactory, and previously infected hips achieved sound wound and bone healing. Half could walk with no aid or one stick. No correlation could be found between the radiological appearances and the quality of the result

We reviewed retrospectively 25 hip arthroplasties in 25 patients with sickle-cell haemoglobinopathy and osteonecrosis. The mean age of the ten women and 15 men at the onset of hip symptoms was 25 years, and at surgery 30 years (16 to 45); 66% had either SS or S-thal disease, 20% sickle-cell trait, and the remainder SC disease. The mean follow-up was 8.6 years (two to 18). Fourteen (40%) of the arthroplasties had been revised at a mean of 7.5 years after the primary procedure and nine other hips were either radiographically and/or symptomatically loose. The overall complication rate was 49% and the infection rate 20%. The risk-to-benefit ratio of hip arthroplasty in sickle-cell haemoglobinopathy is high

We have treated 11 patients aged three days to 15 years with bladder exstrophy by horizontal osteotomies of the innominate bones. The operation was originally used for older patients with severe deformity or failed previous surgery but is now applied as a primary procedure in the first week of life. The osteotomies enable the complex malformations to be corrected in a single operation without turning the patient: the pubic bones can be brought together, the abdominal wall repaired and the bladder closed with reconstruction of the urethra and external genitalia. The early results have been very satisfactory in all cases with only minor complications; we felt that a preliminary report should be made, despite a mean follow-up of only seven months

Aims

Limb salvage in bone tumour patients replaces the bone with massive segmental prostheses where achieving bone integration at the shoulder of the implant through extracortical bone growth has been shown to prevent loosening. This study investigates the effect of multidrug chemotherapy on extracortical bone growth and early radiological signs of aseptic loosening in patients with massive distal femoral prostheses.

Aim

There has been a significant reduction in unicompartmental knee arthroplasty (UKA) procedures recorded in Australia. This follows several national joint registry studies documenting high UKA revision rates when compared to total knee arthroplasty (TKA). With the recent introduction of robotically assisted UKA procedures, it is hoped that outcomes improve. This study examines the cumulative revision rate of UKA procedures implanted with a newly introduced robotic system and compares the results to one of the best performing non-robotically assisted UKA prostheses, as well as all other non-robotically assisted UKA procedures.

We studied the rate of revision in 84 consecutive total hip replacements performed for failed osteosynthesis of femoral neck fractures and compared it with that for primary arthroplasty for osteoarthritis. The age and sex adjusted risk of prosthetic failure was 2.5 times higher after failure of fixation, but all the excess risk was in patients over 70 years of age. There were radiographic signs of loosening of the femoral component at five to 12 years after secondary arthroplasty in six of 33 survivors. In general, the results of secondary replacement were no worse than those obtained after primary arthroplasty for femoral neck fracture. We consider that internal fixation should be the primary procedure: total hip replacement is a safe secondary procedure when osteosynthesis fails

We have compared the survival of 67 revision arthroplasties of the knee undertaken for aseptic loosening with and without the retention of a secure, cemented femoral component. All the patients had undergone a single primary procedure at a mean of nine years previously. In group I (25 knees) the original femoral component was secure and was retained. There were no abrasions or osteolysis. The knees were stable, normally aligned, with minimal bone loss. In group II 42 knees did not fulfil these criteria and underwent revision of both components. The mean follow-up was four years. Re-revision for loosening was required in seven knees (28%) in group I and three (7%) in group II (p < 0.01). The remaining knees function well with Knee Society scores averaging 84/69 and no radiological evidence of osteolysis. When revising cemented implants, retention of a secure femoral component cannot be recommended even when conditions appear to be suitable

We have reviewed the results of amputation through the ankle in the management of 37 children with congenital leg-length discrepancy, followed up for a mean of 7.6 years after operation. In general good function was achieved and 18 patients considered their activities to be unrestricted. The main factor affecting the functional result was the underlying condition for which operation had been performed. Although heel pad migration, scar rotation and os calcis remnants were seen, these could be accommodated by the prosthesis. Syme's amputation is tolerated well in the younger child and, in patients with a predicted leg-length discrepancy of over 15 cm associated with an abnormal foot, we recommend the operation as a primary procedure between the ages of 18 months and two years

We undertook a radiological analysis of 186 standard Souter implants to determine survivorship and to analyse the pattern of failure in those needing revision. The implants had been inserted as a primary procedure in patients with rheumatoid arthritis of the elbow at our hospital over the last 12 years. Taking revision as an endpoint, the survivorship after 12 years was 87%. If, however, revision and loosening, defined as the Hindex value equivalent to demarcation of 1 mm around the whole implant, are also included, the survivorship falls to 80%. Of the 24 implants revised, 18 (75%) were for problems with the humeral component, three (12.5%) with the ulnar component and three (12.5%) for instability. Loosening of the humeral component occurred when the implant extended into the humerus, with the tip moving anteriorly on to the anterior humeral cortex. Our study indicates that loosening can be predicted by the rate of change in this angle of extension of the prosthesis

We describe 11 patients with congenital pseudarthrosis of the tibia treated by a free vascularised fibular graft (FVFG) and followed up from 10 to 64 months (mean 38). Bony union was achieved in nine of the 11 cases: two failures required amputation. The mean time for union in the successful cases was five months. Nine of the 11 patients had had an average of four surgical procedures before the FVFG, so the graft was a salvage procedure for which the only alternative was amputation. FVFG is recommended as a primary procedure for the treatment of congenital pseudarthrosis of the tibia if there is a large tibial defect (over 3 cm) or shortening of more than 5 cm. The primary use of this operation is not advised for cases in which standard orthopaedic procedures are expected to succeed. For a small defect with a favourable prognosis (Boyd and Sage 1958), we recommend conventional bone grafting, intramedullary nailing and electrical stimulation

1. Fifty-eight adult patients who had been treated for radial head fractures by excision of the head of the radius have been reviewed at periods varying between two and nineteen years after operation. 2. Symptoms referable to the inferior radio-ulnar joint were present in half of the patients and the mechanisms of the disorder in these patients are discussed in the light of a radiographic study. 3. We feel it justifiable to conclude from our observations that this complication of surgical treatment of radial head fractures deserves greater attention than has been given to it in the past, and that it is of sufficient importance to be taken into consideration when planning the management of these fractures, especially the less severe injuries. 4. Prosthetic replacement of the proximal end of the radius is the logical and, indeed, the only way in which the distal radio-ulnar joint subluxation can be avoided, but no clearly defined indications for the routine use of a prosthesis as a primary procedure can be suggested on the basis of this investigation

Bone cement containing gentamicin may release antibiotic when fractured during revision operations. Tissue samples taken during surgery may be contaminated by gentamicin and give inaccurate microbiological assessment. We studied five patients in whom cement containing gentamicin had been used in the primary procedure. During revision hip replacement, samples of joint fluid, tissues and cement were taken both before and after disruption of the cement. With the exception of one sample of joint fluid, low concentrations of gentamicin were recorded in the samples taken before the cement was disrupted, but after disruption the specimens contained gentamicin at concentrations high enough to inhibit or prevent growth of sensitive organisms. The cement contained very high levels up to ten years after insertion. Our findings suggest that no reliance can be placed on the microbiological assessment of specimens taken once cement splitting has started and that specimens should therefore be taken as early as possible

Aims

Heterotopic ossification (HO) is a potentially devastating complication of the surgical treatment of a proximal humeral fracture. The literature on the rate and risk factors for the development of HO under these circumstances is lacking. The aim of this study was to determine the incidence and risk factors for the development of HO in these patients.

We compared 74 total hip arthroplasties (THAs) carried out after previous proximal femoral osteotomy with a diagnosis-matched control group of 74 primary procedures performed during the same period. We report the perioperative results and the clinical and radiological outcome at five to ten years. We anticipated a higher rate of complications in the group with previous osteotomy, but found no significant difference in the rate of perioperative complications (11% each) or in the septic (8% v 3%) and aseptic (4% each) revision rates. There was a trend towards improved survival in the group without previous osteotomy (90% v 82%), but this difference was not statistically significant. The only significant differences were a higher rate of trochanteric osteotomy (88% v 14%) and a longer operating time in the osteotomy group. Our study indicates that THA after previous osteotomy is technically more demanding but not necessarily associated with a higher rate of complications. Furthermore, proximal femoral osteotomy does not jeopardise the clinical and radiological outcome of future THA enough to exclude the use of osteotomy as a therapeutic alternative in younger patients

We have implanted 76 biaxial total wrist prostheses as a primary procedure in patients with rheumatoid arthritis of the wrist. A total of 66 was reviewed at a mean follow-up time of 52 months. Pain was relieved in 67% of the surviving wrist replacements. On the basis of the Hospital for Special Surgery scoring system, 49 wrists (74%) were graded as fair to excellent. More than half of the 27 patients who had an arthrodesis on the contralateral wrist would have preferred a second arthroplasty. Five replacements were revised or fused because of loosening and a further nine showed signs of radiological loosening, three of which were asymptomatic. The probability of survival of the biaxial total wrist replacement at eight years was 83% with revision surgery as the terminal event, 78% with radiological loosening as the endpoint and 82% with dorsal migration and displacement from the metacarpal as the terminal event. There was a linear relationship between subsidence of the component and distal loosening. There was no evidence that the length of the stem of the carpal component, within the third metacarpal, affected any of the terminal events. The position and alignment of the carpal component within the bone at the time of surgery significantly affect the outcome and can be used to predict failure