Treatment for an infected Total Hip replacement (THR) remains controversial with two stage revision surgery traditionally recommended. We describe a series of one stage revisions performed in a District General Hospital to help inform other surgeons and help treatment decisions. 8 patients with a bacteriologically proven infection in their hip underwent single stage revision THR. Cemented Exeter prostheses were used with additional antibiotics added to the cement mixture prior to implantation. Follow-up ranged from 6 to 36 months (average 16.6 months) and there were no re-infections. No radiological changes consistent with re-infection were noted throughout patient follow-up. One patient suffered a periprosthetic fracture (thought to be secondary to myeloma) 3 months post-surgery and underwent further revision surgery. Post-operative antibiotics were given for a minimum of 6 weeks with 2 patients having a 3 month supply after Microbiology advice. Single stage revision THR surgery is a viable and useful option for treatment of infected THR's. Re-infection rates are low. Avoiding the traditional second stage surgery is beneficial to both patients and the NHS trust in terms of health and cost outcomes. We will continue to undertake single stage revisions in this trust and advocate its use by other surgeons.
Removal of well-fixed cement at the time of revision THA for sepsis is time consuming and risks bone stock loss, femoral perforation or fracture. We report our experience of two-stage revision for infection in a series of cases in which we have retained well-fixed femoral cement. All patients underwent two-stage revision for infection. At the first stage the prostheses and acetabular cement were removed but when the femoral cement mantle demonstrated good osseo-integration it was left in-situ. Following Girdlestone excision arthroplasty (GEA), patients received local antibiotics delivered by cement spacers, as well as systemic antibiotics. At the second stage the existing cement mantle was reamed, washed and dried and then a femoral component was cemented into the old mantle. Sixteen patients (M:F 5:11) had at least three years follow-up (mean 80 months – range 43 to 91). One patient died of an unrelated cause at 53 months. Recurrence of infection was not suspected in this case. The mean time to first stage revision was 57 months (3 to 155). The mean time between first and second stages was nine months (1 to 35). Organisms were identified in 14 (87.5%) cases (5 Staphylococcus Aureas, 4 Group B Streptococcus, 2 Coagulase negative Staphylococcus, 2 Enterococcus Faecalis, 1 Escheria Coli). At second stage, five (31.2%) acetabulae were uncemented and 11 (68.8%) were cemented. There were two complications; one patient dislocated 41 days post-operatively and a second patient required an acetabular revision at 44 days for failure of fixation. No evidence of infection was found at re-revision. One patient (1/16, 7%) has been re-revised for recurrent infection. Currently no other patients are suspected of having a recurrence of infection (93%). Retention of a well-fixed femoral cement mantle during two-stage revision for infection and subsequent cement-in-cement reconstruction appears safe with a success rate of 93%. Advantages include a shorter operating time, reduced loss of bone stock, improved component fixation and a technically easier second stage procedure.
It costs the NHS £2billion/year to treat 70000 hip fractures. Following hemiarthroplasty a departmental x-ray is standard practice. During 2009 217 hemiarthroplasties were performed in our unit. 210 had postoperative radiographs (148 departmental, 62 in theatre). All patient demographics were considered and hospital costs accounted for. Mean patient age was 83 (55-100) years. Mean theatre times were 120 (51-213) minutes in the departmental x-ray group and 128 (74-187) minutes in the theatre imaging group. Hospital stay was decreased from 12.8 (3-41) days in the departmental x-ray group to 11.8 (3-32) days in the theatre imaging group. Orthopaedic beds cost £136/day. Departmental x-rays give a radiation dose of ∼12mGy and costs £48.30, theatre imaging gives ∼0.26mGy with no additional cost given the radiographers previous allocation to the list. Changing our practice to intra-theatre imaging has improved patient safety, reduced the average inpatient stay and saves our trust approximately £40,000 annually.
It is difficult to predict the outcome or likely treatment that will be required for an individual child with a rigid clubfoot deformity at an early stage. 32 Dimeglio grade II, III or IV CTEV feet in 24 infants were treated with weekly serial casts according to Ponseti method. Graphical plots of the improvement obtained in Dimeglio scores during serial cast treatment of CTEV were subsequently analysed to identify characteristic features that would help predict the likely success of casting or the need and extent of surgical release. The rate of change in global Dimeglio score, hindfoot (equinus/heel varus) and midfoot (adduction/derotation) components were specifically studied. During casting the rate of change over 4 weeks and a “plateauing” of the global Dimeglio score after 4–6 weeks of casting separated those feet that responded to casting alone from those that required additional surgery. Those with “plateauing” and minimal midfoot deformity by 4 weeks (adduction/derotation score <
=2) required a posterior release. Failure to correct the mid-foot deformity by 4 weeks (adduction/derotation score >
= 3) predicted the need for a combined plantarme-dial and posterolateral release. These parameters were clearly demonstrated by graphical plots that can be easily obtained in a busy clinic setting. Graphical representation of the rate of change in Dimeglio parameters can predict the likely treatment needed for children with CTEV. A graphical algorithm has been developed that can be used during the first 6 weeks of treatment to guide Ponseti method casting and early surgical intervention.
It is difficult to predict the outcome or likely treatment that will be required for an individual child with a rigid clubfoot deformity at an early stage. 32 Dimeglio grade II, III or IV CTEV feet in 24 infants were treated with weekly serial casts according to Ponseti method. Graphical plots of the improvement obtained in Dimeglio scores during serial cast treatment of CTEV were subsequently analysed to identify characteristic features that would help predict the likely success of casting or the need and extent of surgical release. The rate of change in global Dimeglio score, hindfoot (equinus / heel varus) and midfoot (adduction / derotation) components were specifically studied. During casting the rate of change over 4 weeks and a “plateauing” of the global Dimeglio score after 4–6 weeks of casting separated those feet that responded to casting alone from those that required additional surgery. Those with “plateauing” and minimal midfoot deformity by 4 weeks (adduction /derotation score <
=2) required a posterior release. Failure to correct the mid-foot deformity by 4 weeks (adduction /derotation score >
= 3) predicted the need for a combined plantar medial and posterolateral release. These parameters were clearly demonstrated by graphical plots that can be easily obtained in a busy clinic setting. Graphical representation of the rate of change in Dimeglio parameters can predict the likely treatment needed for children with CTEV. A graphical algorithm has been developed that can be used during the first 6 weeks of treatment to guide Ponseti method casting and early surgical intervention.
The management of hip instability in the non-ambulant paediatric cerebral palsy (CP) patient is complex. Subluxations and dislocations arise secondary to muscle imbalance caused by strong hip flexors and adductors overpowering weaker hip abductors and extensors. These conditions give rise to sitting problems and can cause debilitating pain making care difficult. Treatment methods include physiotherapy, abduction bracing, muscle releases and transfers, proximal femoral and pelvic osteotomies, proximal femoral excision +/- interpositional arthroplasty, arthrodesis and total hip arthroplasty (THA). THA in the adult CP patient is not uncommon, however dislocation has remained a concern. THA is rarely used in the paediatric patient and to our knowledge the use of a constrained liner, which should prevent dislocation, has never been described. We present the case of a non-ambulant paediatric CP patient with normal intelligence whom by the age 16 had been successfully managed with staged bilateral uncemented THAs using constrained liner technology.
