(v) Computer assisted navigation in primary total hip arthroplasty

Computer Assisted Surgery (CAS) is an important development in orthopaedic surgery. While its use in total hip arthroplasty is recent, it has led to significant changes in the surgeon's perception of the procedure, allowing visualization of stages of the operation that previously had to be inferred, such as cup position during acetabular reaming and femoral stem orientation, making surgery more accurate and reproducible.     

Leg length inequality after primary total hip arthroplasty

This paper presents an overview of our current understanding of the problem of leg length inequality after primary total hip replacement. We discuss the definition, explore why some patients are affected by this condition and others are not, and review the techniques of measurement on X-ray. We review three key papers from the literature, techniques available for the surgeon to prevent this problem, describe the clinical assessment of a patient with LLI, and their conservative or surgical management. We report on our lessons learnt from the management of these patients and give some thought to the future.     

(iii) Surgical tactics in the difficult primary hip replacement

The term complex primary total hip arthroplasty (THA) is used when THA is performed on patients with any combination of abnormal anatomy, bone loss and compromised soft tissues. This is often as a result of the development of secondary osteoarthritis complicating an underlying primary pathology. Those most commonly associated are developmental hip dysplasia, protrusio acetabuli, skeletal dysplasias, previous fractures or surgical procedures about the hip and neuromuscular conditions, but this is by no means an exhaustive list. The importance of preoperative planning and the use of reconstructive techniques including bone grafting, as well as the use of modular and customized implants to overcome these significant surgical challenges, are discussed.     

(i) Planning and consent for primary total knee replacement

The aim of primary total knee replacement is to decrease pain, restore function and reduce disability. This is achieved by correct patient selection and adequate planning so that the appropriate prosthesis can be implanted in the appropriate manner. The technical goal of total knee arthroplasty is to implant a well-aligned prosthesis in a well-balanced knee, with linear patellar tracking and achieve infection-free healing.Weight bearing anteroposterior, lateral and patellofemoral joint radiographs are mandatory and standing long leg views help determine alignment. CT and MRI scans may be of value in assessing bone stock and ligamentous deficiency. If there is a lack of bone stock a stemmed prosthesis or augmentation wedges may be required, whilst a ligamentous deficiency may necessitate a stabilized or constrained prosthesis.The consent process for TKR commences at the outpatient consultation and must consider the reason for operation, alternative treatments, all common and serious risks and the rehabilitation protocol. There is an increasing use of multimedia tools (e.g. www.orthoconsent.com) in the consent process.     

Double anterior (anterolateral and anteromedial) thigh flap for oral perforated defect reconstruction

ObjectiveThe purpose of this study was to assess the therapeutic efficacy of oral perforated defect reconstruction with a double anterior (anterolateral and anteromedial) thigh flap through the modified lateral lip-submandibular approach.Materials and methodsFrom July 2010 to August 2013, eight patients with oral perforated defects secondary to oral cancer ablation involving the superior partial mandible or the posterior partial maxilla, with immediate reconstruction by double anterior (anterolateral and anteromedial) thigh flaps, were retrospectively enrolled into this study.ResultsAll double anterior flaps were musculocutaneous flaps. Seven double flaps resulted in good functional and aesthetic outcomes with complete flap survival. One patient required operative exploration in the postoperative period due to thrombosis in the external jugular vein. After the salvage, one of the double flaps in the intraoral region resulted in partial failure of the superficial skin of the flap. No functional impairment at the donor sites occurred in any of the cases.ConclusionThe double anterior (anterolateral and anteromedial) thigh flap is a feasible and acceptable technique for reconstruction of an oral perforated defect involving the mandible or the maxilla through the modified lateral lip-submandibular approach. It presents a very acceptable aesthetic and functional result with the additional advantage of low morbidity at the donor site.