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Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_II | Pages 149 - 149
1 Apr 2005
Malik M Chougle A Pradhan N Gambhir A Porter M
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In 1999 a statement of best practice in primary total hip replacement was approved by the Council of the British Orthopaedic Association (BOA) and by the British Association for Surgery of the Knee (BASK) to provide a basis for regional and national auditable standards: we have compared practice in the North West of England to this document to ascertain adherence to this guide to best practice.

A direct comparison of data held on the North West Hip Arthroplasty Register for 2001/2002 and BASK/BOA guidelines was performed. 86 surgeons from 26 hospitals were included in the study. A mean of 93.3% of operations were performed in the surgeon’s usual theatre. All of these theatres had vertical laminar air flow systems. 42.2% of respondents routinely used exhaust suits. 68.1% of respondents routinely used impermeable disposable gowns. All surgeons use some form of anti-thromboembolic prophylaxis. 66.2% use a combination of both mechanical and chemical means. All surgeons used antibiotic prophylaxis. The most popular choice of antibiotic was a cephalosporin. 93.7% of surgeons routinely use antibiotic-loaded cement. The PFC and Kinemax prostheses were the most commonly used pros-theses. Interestingly, 97.7% of all first choice implants were cemented. Only 2 surgeons used uncemented TKR. 69.8% of surgeons used a posterior cruciate retaining design. A midline longitudinal skin incision is used by 87.2% of surgeons, a medial longitudinal skin incision by 7.0% and a lateral longitudinal skin incision by 5.8% 0f surgeons. A medial parapatellar capsular incision is preferred by 91.9% with the remainder using mid vastus or trivector retaining capsulotomy. Closure of capsulotomies is performed in flexion by 65.1% and in extension by 34.9%. In patients with osteoarthritis 38.4% routinely resurfaced the patella, 34.9% never resurfaced the patella and 26.7% selectively resurfaced. This was in direct contrast to practice for patients with rheumatoid arthritis in whom 66.3% routinely resurfaced the patella, 22.1% never resurfaced the patella and 11.6% selectively resurfaced.

This study has demonstrated considerable variation of practice in hip arthroplasty across the North West region and significant divergence from the BASK/BOA statement of best practice. The introduction of a properly funded national arthroplasty register will surely help to clarify the effect of such diverse practice on patient outcome.


Orthopaedic Proceedings
Vol. 86-B, Issue SUPP_IV | Pages 478 - 478
1 Apr 2004
Porter M Shadbolt B
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Introduction Plantar fasciitis is a common presenting problem and there are multiple treatments available. There is little scientific data to assist in the selection of the most efficacious or cost-effective treatment. This study compared the efficacy of corticosteroid injection and low-dose ESWT for the treatment of chronic proximal plantar fasciitis.

Methods One hundred and thirty-two cases of plantar fasciitis were enrolled into this prospective study over five years. Eligible patients performed a stretching program for the gastrocsoleus. In addition, patients randomized to group A received an intralesional corticosteroid injection, while group B received low dose ESWT (3 x 1000 pulses, energy flux density 0.08/mm2). Nineteen patients were not randomized and comprised a control group C. Patients were assessed before, and then three and 12 months post treatment using a VAS, and algometer (tenderness threshold, TT). The groups were compared using generalized linear models for repeated measures of VAS and TT scores, with orthogonal contrasts.

Results The three groups were significantly different in their VAS scores post treatment. Over the 12 months, pain levels reduced for all groups, but the trends between them differed significantly. The corticosteroid (CSI) group, had significantly lower levels of pain than the ESWT or controls. At 12 months, the CSI and ESWT had similar levels of pain, both significantly lower than that in the controls. Similar trends were found for TT. Threshold levels increased for all three groups post treatment but the trends between the groups were significantly different. At three months, the CSI group had significantly higher TTs than both the ESWT and control groups. By 12 months, all groups had higher TTs but they were similar. The TT of the CSI group had plateaued by three months. Of the 64 heels that received CSI, there were no infections and no cases of rupture of the plantar fascia. There were eight cases of post-injection pain. All patients found the injection unpleasant. Of the 61 heels treated with ESWT, six reported throbbing pain and erythema. Four reported a severe headache. All patients found the procedure unpleasant.

Conclusions Intralesional corticosteroid injection is more efficacious, and much more cost-effective, than ESWT, in the treatment of plantar fasciitis present for at least six weeks. The injection achieves a significant and lasting reduction in pain and tenderness within three months. Correctly used, this treatment has a low incidence of complications.


Orthopaedic Proceedings
Vol. 86-B, Issue SUPP_III | Pages 368 - 368
1 Mar 2004
Gambhir A Pradham N Bale L Gregori A Porter M
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Restoration of the mechanical axis is thought to be a critical factor in determining the outcome of knee replacement surgery. There is strong theoretical evidence that reproduction of this axis improves mechanical loading and hence longevity of the implant. Per operative use alignment jigs help to determine the bony cuts. Studies have shown large margins of error using the standard jigs. On this basis computer navigation systems are being introduced. No study has shown conclusively that accurately reproducing the mechanical axis of the lower limb improves survivorship of the implant. Prior to investing in these systems we felt it would be prudent to investigate how critical reproduction of the mechanical axis was in the primary total knee replacement.

We assessed 100 primary total knee replacements performed in 1990. All case notes were reviewed looking for basic demographics, pathology, and clinical outcome. All cases had a long leg þlm weight bearing alignment þlm taken post operatively. These were digitised and then analysed using CAD software. From this the mechanical axis calculated.

Using this data the patients were divided into two groups. The þrst were within 3 degrees varus/valgus of the mechanical axis. The second were outside this range. These two groups were then correlated to clinical outcome.

Our results suggest that accurate reproduction of the mechanical axis improves clinical outcome and survi-vorship of the implant. Our data would support the use of intra operative computer navigation systems


Orthopaedic Proceedings
Vol. 86-B, Issue SUPP_III | Pages 277 - 278
1 Mar 2004
Emyr AC Porter M
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Aims: Should the tibial tray be rotated about the femoral component of a total knee arthroplasty? Literature review provides evidence commending rotation and neutral alignment. We wanted to provide evidence to help this debate.

Method: We developed a knee jig allowing full range of movement of a knee arthoplasty. Under compression, we studied the isolated effect of tibial tray rotation about the femoral prosthesis in þxed and mobile bearing prostheses. We photographed the tibio-femoral and patello-femoral articulations.

Results: A mobile bearing prosthesis at 15 degrees of tray rotation suffered posteromedial and anterolateral polyethylene impingement. At 25 degrees, the medial femoral component lifted off. The þxed bearing prosthesis showed similar polyethylene impingement, but no femoral condyle lift off. In both prostheses, tray rotation increased lateral patella facet loading, which increased with knee ßexion.

Conclusion: Mobile bearing prosthesis was less tolerant than þxed bearing prosthesis to tibial tray rotation. Rotation caused polyethylene impingement, which would generate wear debris. Patella tracking was not improved by tibial tray rotation. The mobile bearing prosthesis is less congruent at the tibio-femoral articulation. Therefore there is less Òdriving forceÒ to rotate the polyethylene to align it to the femoral component, when the tray is rotated. We recommend the tibial tray be aligned to the femoral prosthesis in neutral.


Orthopaedic Proceedings
Vol. 84-B, Issue SUPP_III | Pages 319 - 320
1 Nov 2002
Pradhan N Borrill J Blan J Porter M
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The aim of this study was to ascertain if a correlation exists between the indication for revision and the clinical outcome in revision total knee replacement.

Methods: We analysed the data of 81 revision knee arthroplasty patients performed at Wrightington Hospital with an average follow-up of 31 months (1yr – 6yrs). All patients had semi-constrained prosthesis implanted (PS-PFC or TC3, Depuy). The indications for revising the total knee arthroplasty in each patient were noted and the clinical outcome was determined using a patient satisfaction questionnaire.

Results: Of the 81 patients, 18 were enthusiastic with the clinical outcome, 38 were satisfied, eight were non-committal and 17 were disappointed. Indications for revision in our series were aseptic loosening (31 patients), implant failure (21 patients), instability (14 patients), pain (eight patients) and infection (seven patients). Correlation between the indication for revision and the clinical outcome are detailed in the table below.

Sixteen per cent of patients revised for aseptic loosening were non-committal or disappointed with the outcome in comparison with 33.3% revised for implant failure, 21.4% revised for instability, 62.5% revised for pain and 71.4% revised for infection.

Conclusion: The indication for revision does affect the clinical outcome in revision knee arthroplasty. Patients undergoing revision knee arthroplasty for infection and pain are less likely to be satisfied with the clinical outcome of revision surgery.


Orthopaedic Proceedings
Vol. 84-B, Issue SUPP_III | Pages 319 - 319
1 Nov 2002
Pradhan N Borrill J Blan J Porter M
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It is usually assumed that there is a correlation between the number of previous operations and the clinical outcome of revision knee arthroplasty though it has not been studied and published. We reviewed our series of 81 revision knee arthroplasty patients to ascertain if a correlation exists. All patients had a semi-constrained prosthesis implanted.

Methods: We analysed the data of 81 revision knee arthroplasty patients performed at Wrightington Hospital with an average follow-up of 31 months (1yr – 6yrs). The number of previous operations on each knee were noted and the clinical outcome was determined using a patient satisfaction questionnaire.

Results: Of the 81 patients; 18 were enthusiastic with the clinical outcome; 38 were satisfied; eight were non-committal; 17 were disappointed. Seventy four per cent of patients with one previous operation were enthusiastic or satisfied with the revision surgery outcome in comparison to 55.5% and 0% of patients with two and three previous surgery respectively.

Conclusion: The trend from the above figures suggests that as the number of previous operations increases the likelihood of satisfactory clinical outcome decreases, in revision total knee replacement using semi-constrained prosthesis.


Orthopaedic Proceedings
Vol. 84-B, Issue SUPP_II | Pages 115 - 115
1 Jul 2002
Porter M
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The clinical results of cemented hip arthroplasty in patients with DDH are excellent in terms of pain relief and implant longevity. The survivorship of the femoral stem in young patients less than 40 years of age is 97% at ten years and falls to 89% at 25 years. In comparison, survivorship of the acetabular component is 97% at ten years but falls to 58% at 25 years. The excellent survivorship of the femoral stem can be explained by a favourable canal flair index, competent cancellous bone, and secure fixation with acrylic cement. The inferior results of the acetabular component are explained by the distorted pelvic anatomy and lack of bone support for the acetabular component. We continue to recommend cemented hip arthroplasty in this cohort of patients. Our current practice is to use fourth generation cementing techniques and to employ autografting of the acetabulum to address some of the anatomical deficiencies of the original anatomy.


Orthopaedic Proceedings
Vol. 84-B, Issue SUPP_II | Pages 159 - 159
1 Jul 2002
Pradhan NR Porter M
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Background: The risks associated with homologous blood transfusion and the increasing shortage of banked blood have brought the need for blood salvage procedures to the forefront.

Post operative blood salvage and autologous blood transfusion have been used though the financial implications of their use has not been assessed in the UK.

Methods: We carried out a retrospective study of 98 consecutive unilateral Total Knee Replacements performed in 96/97, under the care of one consultant, of these 55 had non-autologous drains and 43 had autologous drains after surgery.

Results:

Mean blood loss (non-autologous system) – 778mls

Mean blood loss ( autologous system) – 633mls

Mean autologous blood reinfused – 360mls

- (autologous drainage system)

Mean homologous blood transfused – 179mls

- autologous drainage system)

Mean homologous blood transfused – 590mls

- (non autologous drainage system)

Total cost for use of autologous drainage system and associated transfusion – 6,226.00

Total cost for use of non-autologous drainage system and associated transfusion – 8,346.00

Conclusions: Autologous drains decreased the need for homologous blood transfusion by 69% and brought about a financial saving of 26%. There were no complications arising from the use of autologous drains. There was less blood loss with the use of autologous drains than non-autologous drains in our study.


Orthopaedic Proceedings
Vol. 84-B, Issue SUPP_II | Pages 163 - 164
1 Jul 2002
Borrill J Pradhan N Blan J Porter M
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Background: Opinions about hinged knee prostheses vary a lot in different studies. We wanted to examine our series to ascertain their continued need in treating severely unstable knee joints and look at the early results.

Methods: 30 rotating hinged knee prostheses were implanted in Wrightington Hospital by the senior author. 4 patients deceased and the remaining knees were retrospectively followed up for an average of 16 months and examined for clinical or radiological factors indicating the overall outcome.

Results: Preoperative diagnosis: Gross instability associated with 12 – aseptic loosening; 18 – infection (15 pseudarthrosis, 1 failed arthrodesis) 19

Preoperatively, 16 patients were wheelchair bound and using a frame as a walking aid and 10 used two crutches for ambulation. 5 patients needed plastic surgical input and 5 needed a whiteside’s osteotomy for exposure. Previous surgery on the knee:

2 patients – 1 surgery

13 patients – 2 surgeries

8 patients – 3 surgeries

5 patients – 4 surgeries

2 patients – more than 4 surgeries

In the latest review, excluding the deceased patients, there were 24 patients (89%) regarded as having satisfactory and 3 patients (11%) unsatisfactory results. 89% of the patients were subjectively satisfied with the operation, mostly because of a stable, mobile knee with minimal pain, in comparison to their pre-operative debilitating condition.

Conclusions: Apart from clinical and radiological examination, preoperative diagnosis, pain, mobility, the number of previous surgeries and need for plastic surgery can be used as factors to assess the preoperative severity/morbidity of the case. Taking into account the very poor initial status of these patients, we recommend the rotating hinged prostheses still to be used in severely unstable knees.