Haemorrhagic Pseudotumour Following Metal-on-Metal Hip Replacement.

We present a unique report of a spontaneous haemorrhage into a pseudotumour five years following revision surgery for failed metal-on-metal hip arthroplasty. The patient sustained no trauma, was not taking anticoagulants and had no bleeding disorder. Rapid progression in the size of the pseudotumour caused significant symptoms and functional impairment. Surgical excision was recommended by a national specialist centre, but with conservative management, significant regression of the pseudotumour was noted, with complete resolution of symptoms. This case is the first report of haemorrhage into a pseudotumour, which is an important differential and can be managed non-operatively.

A review of outcomes and modes of presentation following liner dissociation from Harris-Galante uncemented acetabular components.

PURPOSE: Dissociation of the polyethylene liner is a known failure mechanism of the Harris Galante I and II uncemented acetabular components. The outcomes of revision surgery for this indication and the influence of time to diagnosis are not well described. METHODS: We report a series of 29 cases revised due to this failure mechanism. The median time from primary to revision surgery was 13 years. RESULTS: At a median of 4 years follow-up, the mean OHS was 34 (range 6-48) but results were poorer (mean 29; range 6-45) when the diagnosis and revision was delayed compared to when it was not (mean 39; range 20-48). A large proportion of our patients (n = 14) presented with sudden onset of symptoms with or without trauma. Osteolysis was common in this series but the cup was well fixed in 20/29 cases. There was macroscopic damage to the shell in all cases. CONCLUSIONS: In our experience, prompt revision of liner dissociation optimises outcomes in this group of patients and radiology reporting alone is not sufficient to identify these cases.

A novel technique for identification of fractured ceramic acetabular liner in total hip arthroplasty: a case report.

In total hip arthroplasty ceramic bearings are liable to fracture. We present the case of an 82-year-old male with groin pain and an audible squeak 6 months post ceramic on ceramic hip arthroplasty. Initial plain radiography and examination under anaesthetic (EUA) were normal. Fluoroscopy with normal image exposure was also unremarkable. Over penetration of the image intensifier film demonstrated a fracture of the ceramic acetabular liner. The patient subsequently underwent a revision of both acetabular and femoral bearing surfaces.Displaced ceramic liner fractures are easy to identify with plain radiographs. We recommend the use of over penetration using image intensification as a technique to help identify subtle ceramic liner fractures. To our knowledge this has not been previously reported in the literature.

The development and nature of femoral head cam lesions following acetabular fractures.

The aim of acetabular fracture fixation is to restore joint congruity with restoration of the articular surface. Poor outcomes are seen where this has not been achieved. Letournel reported a collarette osteophyte seen postoperatively in a proportion of patients, which he suggested was an early precursor to the development of osteoarthritis. This is a retrospective study of patients treated at a tertiary referral unit who developed this lesion. The triangular index was measured in 48 of these patients and then correlated with their clinical findings, Oxford Hip Score and the presence of osteoarthritis. Length of follow-up, fracture classification, and joint congruency were also recorded. Results showed a statistically significant relationship between cam lesion size and the development of osteoarthritis (P = 0.008), cam lesion size and length of follow-up (P = 0.01), and between groin pain and postoperative joint congruency (LR = 0.035). These findings suggest that the appearance of a cam lesion is a poor long-term prognostic marker for the development of osteoarthritis in patients with an acetabular fracture.

Surgeon administered regional blocks for day case forefoot surgery.

INTRODUCTION: The aim was to see if as surgeons we were providing safe, efficient and effective, regional blocks for patients undergoing day case, forefoot surgery. We also assessed the costs of, providing this service. METHODS: 63 consecutive patients were recruited prospectively for local anaesthetic block. Blocks were, performed by the orthopaedic team. Efficacy of block was assessed intra-operatively with a visual, analogue score (VAS) of 0-10. Satisfaction with the anaesthetic procedure was also assessed. RESULTS: Average time to perform the block was 6 min. Mean VAS for knife to skin was 0.44 (95%, confidence 0.07-0.81) and for ankle tourniquet was 1.39 (95% confidence 0.85-1.39). Patients were, highly satisfied with the blocks. No complications were reported. CONCLUSIONS: These blocks are quick and easy to perform by orthopaedic surgeons. They are well, tolerated and effective. They result in considerable cost savings to the Hospital.

Prospective review of medium term outcomes following interpositional arthroplasty for hammer toe deformity correction.

BACKGROUND: Hammer toe is a common lesser toe deformity that is usually found to affect the second toe. A number of procedures have been applied in its surgical management with varying results but there is still no consensus on the best technique. MATERIALS AND METHOD: We prospectively reviewed a consecutive series of patients treated with interpositional arthroplasty, early mobilisation and with a minimal follow up of 6 months. We measured outcome using the Manchester Oxford foot and ankle questionnaire and a global impression of change score. RESULTS: There was a high level of satisfaction with the resulting pain relief and the type of footwear worn thereafter. We had no complications in terms of infection or chronic pain. There were no early recurrences within our follow up period. CONCLUSIONS: Overall we demonstrate good to excellent results with this surgical tactic allowing pain relief, early mobilisation and a low risk of infection.

Outcomes after the Stainsby procedure in the lesser toes: an alternative procedure for the correction of rigid claw toe deformity.

Clawing of the digits is a deformity seen both in patients with and without rheumatoid arthritis, resulting in pain and deformity in the forefoot. After failure of conservative treatment, the Stainsby procedure is one surgical option for severe clawing and metatarsalgia in both rheumatoid and nonrheumatoid feet. Results from the originating authors (G.D. Stainsby and P.J. Briggs) are consistent and reliable; however, there is little material outside of the originating center. This article reviews our experience in the Western Sussex Hospitals NHS Trust. Sixteen consecutive patients who underwent Stainsby procedure between 2006 and 2009 were reviewed. All operations were performed by a single consultant surgeon, the senior author (S.P.). All patients were scored using the Manchester Oxford Foot and Ankle score preoperatively and postoperatively. Minimum follow-up was 6 months, with a mean follow-up of 14 months. Significant improvements in all scores were seen postoperatively. Walking scores dropped from a mean of 22 preoperatively to 12.7 postoperatively (p = 0.007). Pain scores dropped from a mean of 13.3 to 7.1 (p = 0.001). Social scores dropped from a mean 11 to 6 (p = 0.001). Overall patient satisfaction was high. The Stainsby procedure has been shown to improve function and reduce pain in patients from its originating center in both rheumatoid and nonrheumatoid feet. This study demonstrates this simple technique is reproducible and effective in reducing morbidity.

Length of stay following primary total hip replacement.

INTRODUCTION: Much of the cost of primary total hip arthroplasty (THA) comprises the length of stay in hospital. Given the increasing drive for cost-effective surgery in today's National Health Service, the aim of this investigation was to determine the patient and surgical factors that most influence the length of stay following surgery. PATIENTS AND METHODS: A large, population-based study of 675 consecutive patients in a regional orthopaedic centre in the South West of Britain. RESULTS: The median length of stay was 8 days. The majority of patients (81.5%) left hospital within 2 weeks, 13.6% within 2-4 weeks and 4.9% after 4 weeks. On multivariate analysis, age above 70 years, ASA grades 3 and 4, prolonged operations and long incisions were highly significantly associated with hospital stay of over 2 weeks. CONCLUSIONS: Prolonged stay after THA is largely predetermined by case mix and this should be taken into account when units are compared for performance and in the remuneration they receive for providing this service. Slick surgery through limited incisions may reduce the length of stay.

Assessing the clinical significance of change scores following carpal tunnel surgery.

This article presents a prospective longitudinal study to determine the cut-off values for change scores of DASH, Levine, and Kamath questionnaires to distinguish clinical improvement following carpal tunnel surgery. Fifty-four patients (40 female, 14 male), with positive nerve conduction studies, were prospectively followed up. Three questionnaires (DASH, Levine, and Kamath) were posted to patients at four and two weeks prior to their operation and then six weeks following surgery. A patient global impression of change (PGIC) score was completed for patients to rate the overall change in their symptoms. According to the PGIC, 93% of patients improved. The cut-off values for raw change scores that best define clinically significant improvement following carpal tunnel release were 20.9 for DASH, 0.47 for Levine, and 1.97 for the Kamath questionnaire. This study provides a methodological framework for identifying clinically significant changes following treatment. A questionnaire follow-up of patients is now possible using the data provided.