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Introduction: Non-traumatic pseudoaneurysms are very rare but should be considered as a differential diagnosis on patients presenting with a thigh mass. Case Presentation: We present an extremely unusual case of a 70-year-old patient who presented with clinical features of a soft-tissue sarcoma of the thigh that instead was proven to be a non-traumatic pseudoaneurysm. There was also incidental finding of bilateral leg non-traumatic pseudoaneurysms. Conclusion: Medical practitioners must consider the possibility of non-traumatic pseudoaneurysm in patients that present with a thigh mass. Keywords: Pseudoaneurysm, non-traumatic, thigh, sarcoma.

Aναφέρουμε την εμπειρία μας σε ασθενείς με σάρκωμα Ewing πυέλου που έλαβαν θεραπεία στην Ογκολογική Μονάδα στο Βασιλικό Ορθοπεδικό Νοσοκομειο. Εξετασαμε αναδρομικά μια σειρά ασθενών με σάρκωμα μη μεταστατικόυ πυέλου του Ewing που αντιμετωπιστηκαν μεταξύ 1977 και 2009. Οι ασθενείς ταξινομήθηκαν σε τρεις ομάδες ανάλογα με την τοπική αγωγή που έλαβε: Ομάδα 1: Ακτινοθεραπεία- χημειοθεραπεία, Ομάδα 2: Χειρουργική-χημειοθεραπεία και Ομάδα 3: Ακτινοθεραπεία-χειρουργική-χημειοθεραπεία. Τα ποσοστα υποτροπής και τα συνολικά ποσοστά επιβίωσης υπολογίστηκαν χρησιμοποιώντας τη μέθοδο Kaplan-Meier. Επίδραση διαφόρων παραγόντων (ηλικία κατά τη διάγνωση, το φύλο, την περιοχή του όγκου και του μεγέθους, επιδραση της χημειοθεραπείας, χειρουργικά όρια και το είδος της θεραπείας) στην επιβίωση αξιολογήθηκε με ένα μοντέλο λογιστικής παλινδρόμησης. Συνολικά 85 ασθενείς υποβλήθηκαν σε θεραπεία με μέσο ορο παρακολούθηση 65,8 μηνών και ο μέσος όγκος του όγκου των 435ml. Η 5-ετή επιβίωση για όλους τους ασθενείς ήταν 40,7% και μειώθηκε σε 36,2% στα 10 χρόνια. Ένας σημαντικός προγνωστικός παράγοντας ήταν η επιδραση της χημειοθεραπείας. Υπήρχε μια τάση για βελτιωμένα ποσοστα επιβίωσης και ελέγχου τοπικα για τους ασθενείς που είχαν χημειοθεραπεία και χειρουργική επέμβαση και τα αποτελέσματα ήταν εμφανή για όλους τους όγκους ανεξάρτητα από το μέγεθος, αλλά όχι στατιστικά σημαντική. Επί του παρόντος, η βέλτιστη διαχείριση του σαρκώματος Ewing πυέλου είναι αμφιλεγόμενη, αλλά η μελέτη μας δείχνει μια τάση για βελτιωμένη επιβίωση για τους ασθενείς που έλαβαν θεραπεία με χημειοθεραπεία και χειρουργική επέμβαση.

Summary Background Patients with Achilles tendon rupture who have non-operative treatment have traditionally been treated with immobilisation of the tendon in plaster casts for several weeks. Functional bracing is an alternative non-operative treatment that allows earlier mobilisation, but evidence on its effectiveness and safety is scarce. The aim of the UKSTAR trial was to compare functional and quality-of-life outcomes and resource use in patients treated non-operatively with plaster cast versus functional brace. Methods UKSTAR was a pragmatic, superiority, multicentre, randomised controlled trial done at 39 hospitals in the UK. Patients (aged ≥16 years) who were being treated non-operatively for a primary Achilles tendon rupture at the participating centres were potentially eligible. The exclusion criteria were presenting more than 14 days after injury, previous rupture of the same Achilles tendon, or being unable to complete the questionnaires. Eligible participants were randomly assigned (1:1) to receive a plaster cast or functional brace using a centralised web-based system. Because the interventions were clearly visible, neither patients nor clinicians could be masked. Participants wore the intervention for 8 weeks. The primary outcome was patient-reported Achilles tendon rupture score (ATRS) at 9 months, analysed in the modified intention-to-treat population (all patients in the groups to which they were allocated, excluding participants who withdrew or died before providing any outcome data). The main safety outcome was the incidence of tendon re-rupture. Resource use was recorded from a health and personal social care perspective. The trial is registered with ISRCTN, ISRCTN62639639. Findings Between Aug 15, 2016, and May 31, 2018, 1451 patients were screened, of whom 540 participants (mean age 48·7 years, 79% male) were randomly allocated to receive plaster cast (n=266) or functional brace (n=274). 527 (98%) of 540 were included in the modified intention-to-treat population, and 13 (2%) were excluded because they withdrew or died before providing any outcome data. There was no difference in ATRS at 9 months post injury (cast group n=244, mean ATRS 74∙4 [SD 19∙8]; functional brace group n=259, ATRS 72∙8 [20∙4]; adjusted mean difference –1∙38 [95% CI –4∙9 to 2∙1], p=0·44). There was no difference in the rate of re-rupture of the tendon (17 [6%] of 266 in the plaster cast group vs 13 [5%] of 274 in the functional brace group, p=0·40). The mean total health and personal social care cost was £1181 for the plaster cast group and £1078 for the functional bract group (mean between-group difference –£103 [95% CI –289 to 84]). Interpretation Traditional plaster casting was not found to be superior to early weight-bearing in a functional brace, as measured by ATRS, in the management of patients treated non-surgically for Achilles tendon rupture. Clinicians may consider the use of early weight-bearing in a functional brace as a safe and cost-effective alternative to plaster casting. Funding UK National Institute for Health Research Health Technology Assessment Programme.

With restructuring within the NHS, there is increased public and media interest in surgical outcomes. The Nottingham Hip Fracture Score (NHFS) is a well-validated tool in predicting 30-day mortality in hip fractures. VLAD provides a visual plot in real time of the difference between the cumulative expected mortality and the actual death occurring. Survivors are incorporated as a positive value equal to 1 minus the probability of survival and deaths as a negative value equal to the probability of survival. Downward deflections indicate mortality and potentially suboptimal care. We prospectively included every hip fracture admitted to UHW that underwent surgery from January–August 2014. NHFS was then calculated and predicted survival identified. A VLAD plot was then produced comparing the predicted with the actual 30-day mortality. Two hundred and seventy-seven patients have completed the 30-day follow-up, and initial results showed that the actual 30-day mortality (7.2 %) was much lower than that predicted by the NHFS (8.0 %). This was reflected by a positive trend on the VLAD plot. Variable life-adjusted display provides an easy-to-use graphical representation of risk-adjusted survival over time and can act as an “early warning” system to identify trends in mortality for hip fractures.

Stiffness following total knee arthroplasty is a disabling complication. One of the management options of stiffness includes manipulation under anaesthesia, but no real consensus exist on appropriate timing of intervention, and the timing and results of the manipulation under anaesthesia (MUA) are under debate in the literature. Our aim was to determine the efficacy of single and multiple manipulations under anaesthesia following total knee arthroplasty and to determine the most appropriate timing for manipulation. We retrospectively reviewed 86 patients who underwent manipulation for stiffness following primary total knee replacement with at least 1-year follow-up. Range of motion before surgery, at the time of the MUA, immediately after MUA and at 6 weeks and 1 year post-MUA were recorded. At the end of 1 year post-manipulation, manipulations performed at less than 20 weeks, following primary total knee arthroplasty, showed 31° of flexion gain as compared to only 1.5° of flexion gain when manipulation was undertaken after 20 weeks. Of the 86 patients, 21 had multiple manipulations with no significant difference in flexion gain after the second manipulation. Patients on warfarin (26%) had an increased incidence of stiffness and poor flexion gain. This study showed that better results were achieved when manipulation was performed at less than 20 weeks (particularly between 12 and 14 weeks) from primary surgery with no added benefit from re-manipulations.

IntroductionFailure of acetabular components frequently leads to bone loss with extensive elongated defects in the surrounding bone. In these cases the use of an oblong cup has been described as an option for acetabular reconstruction. We report the longest follow up results obtained with this implant to date.Materials and MethodsA prospective study was conducted to evaluate the results of the BOFOR oblong revision cup. Between 2001 and 2006, 15 acetabular revisions were performed for aseptic loosening of the acetabular cup. The acetabular defects were classified as type 2A to 3A, according to Paprosky's criteria. No allografts were used in any of the cases. The mean follow-up was 90 months (range 60–120 months).ResultsClinical assessment at follow-up showed a significantly improved mean Harris Hip Score from 39 points preoperatively to 84 points postoperatively and a mean Oxford Hip Score from 55 points preoperatively to 22 points postoperatively. Only one case underwent re-revision due to aseptic loosening in a patient with severe ankylosing spondylitis. There were no cases of dislocation or infection. One patient had a sciatic nerve neurapraxia. After an average follow up of 7.5 years, 93% of the investigated implants remained in-situ without further revision.ConclusionThis study shows that the BOFOR cup provided good clinical results and showed satisfactory stability at early to midterm follow-up.

In this article, we present a review of the current practice regarding computer-assisted navigation in total knee replacement together with the bearing on cost-effectiveness and clinical outcome.

INTRODUCTION Objective measures can be impractical in some settings, because they are time consuming and require face-to-face contact. More recently, there is an increasing trend towards the use of subjective outcome measures. Hence, in this article, five common subjective shoulder outcome measures are critically appraised in terms of their development, validity, relia-lity, responsiveness and clinical application. MATERIALS AND METHODS Following an extensive literature search, five common shoulder patient-based scores were identified: Disability of Arm, Shoulder and Hand (DASH), Oxford Shoulder Score (OSS), Shoulder Disability Questionnaire (SDQ-UK), Shoulder Pain and Disability Index (SPADI), and the Shoulder Rating Questionnaire (SRQ). These questionnaires were then critically appraised in terms of their development process, validity, reliability, responsiveness, and clinical application. RESULTS The SDQ-UK has shown good construct validity but there is no data available regarding internal consistency, reliability and responsiveness. The SPADI has good internal consistency, fair reliability with adequate criterion and construct validity. The DASH has shown to have good construct validity, excellent test–re-test reliability and responsiveness to change. The OSS has good sensitivity, validity and responsiveness. Though SRQ has good internal consistency, its reproducibility and responsiveness are poor. CONCLUSIONS Based on this critical appraisal, the DASH received the best ratings for its clinimetric properties followed by the OSS.

Background This was a retrospective study presenting our results and survivorship of the Acclaim total elbow when used as a revision implant. Methods Between May 2001 and July 2005, 29 revision elbow replacements were carried out on 28 patients in our institution. Five were redo revisions and one received the fourth sequential implant. A variety of implants were removed for aseptic loosening (17), periprosthetic fracture (7), dislocation (3) and infection (2). Two patients had died and one was unavailable for follow-up. Results At a mean follow-up of 50 months (12 to 80 months) pain, functional assessment scores and radiographs were assessed and a Kaplan-Meier survival curve created. Symptoms were reliably relieved with 72% reporting no pain. Mean flexion was 128° with loss of full extension of 34°. Complications were noted in six cases of which three patients underwent further surgery. None of the 29 revisions has been re-revised till date. Conclusion The medium term results for this implant suggest it is an effective revision prosthesis.

The majority of proximal humerus fractures are low-energy osteoporotic injuries in the elderly and their incidence is increasing in the light of an ageing population. The diversity of fracture patterns encountered renders objective classification of prognostic value challenging. Non-operative management has been associated with good functional outcomes in stable, minimally displaced and certain types of displaced fractures. Absolute indications for surgery are infrequent and comprise compound, pathological, multi-fragmentary head-splitting fractures and fracture dislocations, as well as those associated with neurovascular injury. A constantly expanding range of reconstructive and replacement options however has been extending the indications for surgical management of complex proximal humerus fractures. As a result, management decisions are becoming increasingly complicated, in an attempt to provide the best possible treatment for each individual patient, that will successfully address their specific fracture configuration, comorbidities and functional expectations. Our aim was to review the management options available for the full range of proximal humerus fractures in adults, along with their specific advantages, disadvantages and outcomes.

Discrepancy of leg length is often considered to be a problem after total hip replacement and can adversely affect an otherwise excellent outcome. Furthermore, it has been associated with patient dissatisfaction and remains one of the most common reasons for litigation against the orthopedic community. As a consequence of the need to equalize leg length, several authors have sought to validate methods of minimizing limb length discrepancy based on preoperative planning with preoperative radiological templates or intraoperative methods of measurement. In this article, we present a review of the limb length discrepancy in total hip arthroplasty, its implications and several techniques to avoid it. We recommend that a combination of the above mentioned methods will give the best chance for the surgeon to minimise the risk of leg length discrepancy following total hip replacement.

Introduction Intertrochanteric fractures of the femur are common fractures in the elderly, and management includes operative fixation after patient positioning on the fracture table. Patients with bilateral above-knee amputations are challenging in terms of positioning on the table. We describe a simple technique to overcome this special problem. Case presentation A 75-year-old wheelchair-bound Caucasian man with bilateral above-knee amputations presented to our hospital after a fall. Plain radiographs showed an intertrochanteric fracture of the femur, and operative fixation with a dynamic hip screw was planned. His positioning on the table posed a particular problem, and therefore we developed a technique to overcome this problem. Conclusion Positioning of patients for fixation of intertrochanteric fractures of the femur poses a particular problem that can be solved by using our simple technique.

Lightning risk assessment of a 170 kV GIS substation connected to the Hellenic transmission system through underground cables has been performed. Fast-front overvoltages impinging on the substation due to shielding failure and backflashover of the incoming overhead transmission lines have been computed with the aid of ATPEMTP simulations and evaluated with respect to the insulation level of the substation equipment. The mean time between failures of the substation is greatly reduced for higher tower grounding resistance and varies significantly among lightning attachment models employed for the evaluation of the lightning performance of the incoming overhead transmission lines. Implementation of the IEEE Std 1243:1997 in lightning risk assessment of substations imposes high requirements on protection against incoming fast-front overvoltage surges. (5 pages)

The aim of this study was to find out whether discharging pin sites following Kirschner-wire fixation of distal radial fractures warrant early wire removal. In a prospective study of 50 patients with a closed distal radial fracture treated by manipulation and either percutaneous or mini-incision Kirschner-wiring, we identified 14 patients (28%) with discharging pin sites. All of the cases were observed within the first two weeks following surgery. Of the 14 cases, only 2 patients had a positive swab culture and were treated with systemic antibiotics. In all cases the Kirschner wires were left in situ until serial radiographs demonstrated satisfactory union. Three patients (8.6%) in the percutaneous group had superficial radial nerve irritation, which settled following wire removal. Deep soft tissue infection, pyoarthrosis, osteomyelitis, and extensor tendon rupture were not encountered. We conclude that pin site discharge, whether sterile or infected, is in general not an indication for early wire removal.

Introduction and aims. It is well established that soft tissue sarcomas (STSs) are more effectively treated in a specialist centre. However, delays in time taken for a patient to be referred to a specialist centre may lead to a poorer prognosis. This study aims to identify the length of these delays and where they occur.Patients and methods. Patients with a proven STS were included. They were recruited from both outpatient clinics and from the surgical ward of the Royal Orthopaedic Hospital (Birmingham, UK). A structured interview was used to take a detailed history of the patients' treatment pathway, before arriving at the specialist centre. Dates given were validated using the case notes.Results. The median time for the patient to present to a specialist centre from the onset of symptoms was 40.4 weeks. The median delay until presentation to a medical professional (patient delay) was 1.3 weeks. Median delay in referral to a specialist centre (service delay) was 25.0 weeks.Discussion. Medical professionals rather than patients contribute the greatest source of delay in patients reaching a specialist centre for treatment of STS. Adherence to previously published guidelines could decrease this delay for diagnosis of possible sarcoma. Steps should be taken to refer patients directly to a diagnostic centre if they have symptoms or signs suggestive of STS.

The purpose of this study was to show the significance of a positive Propionibacterium acnes sample around a joint replacement. Records from the microbiology laboratory data over a 3-year period were reviewed to identify patients with prosthetic joints from whom Propionibacterium acnes was isolated at least once. The medical records of all those patients were retrieved and the demographic, clinical, microbiological and haematological data were collected and examined. The preoperative values of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were recorded. Fifty patients underwent a routine revision of a joint arthroplasty; six patients had a joint aspiration. Only one patient had further revision surgery for infection. The preoperative values of ESR and CRP were very variable. The presence of a positive sample around a joint arthroplasty is of uncertain significance. Further studies are needed in order to establish uniform criteria for the diagnosis of infection caused by Propionibacterium acnes.

A prospective study was undertaken to assess the efficacy and financial cost of the use of an autologous blood transfusion device in the reduction of allogeneic blood requirements of patients undergoing primary unilateral total knee arthroplasty. Forty-nine consecutive patients received either the CellTrans blood salvage device (group A of 32 patients) or the Redivac high vacuum drainage system (group B of 17 patients). The preoperative and postoperative haemoglobin levels were recorded at 72 or 96 hours. Nine percent of group A patients received an allogeneic blood transfusion compared to 59% in group B. There was an average saving of 1.1 unit of allogeneic blood per patient in group A (p0.001). The total cost per patient was about Euro 111 less for the group A patients. Autologous re-infusion was found in this study to be an effective method of reducing allogeneic blood requirements and to afford significant cost savings in primary unilateral knee arthroplasty.

In this article, we provide an account of two rare cases of Stewart-Treves syndrome, that is, cutaneous angiosarcoma secondary to lymphedema, treated at our center. Unusually, both occurred in the lower extremity. The first case was treated initially with a wide local excision, followed by a further re-excision, and eventually an above-the-knee amputation because of recurrence. In the second case, a hindquarter amputation was undertaken after a positron emission tomographic scan, which revealed the extent and spread of the lesions. In cases of cutaneous angiosarcoma, a positron emission tomographic scan can be extremely helpful in demonstrating the extent of subcutaneous spread and planning surgical management.

Dans cet article, nous rapportons deux rares cas de syndrome de Stewart-Treves, c.-a-d. d’angiosarcome cutane secondaire a un lymphoedeme, traites dans notre centre. Exceptionnellement, les deux cas interessaient les membres inferieurs. Le premier cas a d’abord ete traite par excision locale large, suivi d’une autre excision, et d'une amputation au-dessus du genou en raison d’une recidive. Dans le deuxieme cas, une hemipelvectomie a ete faite apres une tomographie par emission de positrons, qui montrait l'ampleur et la diffusion des lesions. Dans les cas d'angiosarcome cutane, une tomographie par emission de positrons peut etre extremement utile en montrant l'ampleur de la diffusion sous-cutanee et pour prevoir le traitement chirurgical.

Failure of total hip arthroplasty through septic or aseptic loosening, periprosthetic fracture, or recurrent dislocation is well recognized and understood. We present an unusual cause of failure of total hip replacement which occurred on a 79 year old gentleman: that of prosthetic loosening secondary to malignant infiltration around components. Our aim is to highlight the fact that malignant infiltration should be considered as part of the differential diagnosis in aseptic and septic loosening of prosthetic implants.