We compared the long-term clinical and radiological results of hybrid total hip replacement (THR) with metal-on-metal Birmingham hip resurfacing (BHR) in two groups of 54 young patients matched for age, gender, body mass index and pre-operative levels of activity. The clinical outcome was assessed by the University of California, Los Angeles (UCLA) activity score, the Oxford Hip Score (OHS) and the EuroQol scores. Radiologically, all hips were assessed for migration and osteolysis, the hybrid THRs for polyethylene wear and the BHRs for a pedestal sign. The mean follow-up of the patients with a hybrid THR was 16 years and for those with a BHR, 15 years. 12 patients with a hybrid THR and 6 with a BHR had died. 2 patients with a BHR refused follow up but remain unrevised and 5 were lost to follow-up, as was 1 with a hybrid THR. The revision rate of the hybrid THRs was 28% (15 of 54) and of the BHRs 11% (6 of 54) (p = 0.029). Radiographs of a further 13 hybrid THRs demonstrated wear and osteolysis but are functioning well and are under observation. Of the unrevised BHRs 96% had radiological changes, of which approximately 17% had progressed over the previous 6 years. All hybrid THRs demonstrated linear polyethylene wear with a mean of 1.84mm (0.06 to 2.6). The BHRs recorded superior OHS (p = 0.03), UCLA (p = 0.0096), and EuroQol visual analogue scores (p = 0.03). After 15 years, patients with BHRs remained more active and had a lower rate of revision and death than those with hybrid THRs. Both groups demonstrated progressive radiological changes at long-term follow-up.
Post-traumatic immunosuppression (PTI) after surgery increases vulnerability to nosocomial infections, sepsis, and death. Knee arthroplasty offers a sterile clinical model to characterise PTI and explore its underlying mechanisms. This prospective non-randomised cohort study of primary total knee arthroplasty was approved by the Local Ethics Committee. Exclusion criteria included revision-arthroplasty, pre-existing infections, blood-transfusions, malignancy, and auto-immune disease. 48 recruited patients fell into two groups, the first received unwashed anti-coagulated autologous salvaged blood transfusions after surgery (ASBT cohort, n=25). The second received no salvaged blood transfusions (NSBT cohort, n=18). Venous blood was sampled pre-operatively and within 3–7 days post-operatively. Salvaged blood was sampled at one and six hours post-operatively. Biomarkers of immune status included: interleukins (IL) or cytokines (x15), chemokines (x3), Damage-Associated-Molecular-Patterns (DAMPS) (x5), anti-microbial proteins (x3), CD24, and Sialic-acid-binding-Immunoglobulin-type-Lectin-10 (Siglec-10). Results were expressed as fold-change over pre-operative values. Only significant changes are described.Background
Methods
We have prospectively followed up 191 consecutive primary total hip replacements utilising a collarless polished tapered (CPT) femoral stem, implanted in 175 patients between November 1992 and November 1995. At a mean follow-up of 15.9 years (range 14 – 17.5) 86 patients (95 hips) were still alive (25 men and 61 women) and available for routine follow up. Clinical outcome was determined from a combination of the Harris (HHS) and Oxford (OHS) hip scores. Radiological assessment was with antero-posterior radiographs of both hips and a lateral radiograph of the operated hip. The radiographs were evaluated using well-recognised assessment techniques. There was no loss to follow up, with clinical data available on all 95 hips. Five patients were too frail to undergo radiographic assessment, therefore radiological assessment was performed on 90 hips (95%). At the latest follow-up, the mean HHS was 78 (range 28 – 100) and the mean OHS was 36 (range 15 – 48). Stems subsided within the cement mantle, with a mean total subsidence of 2.1mm (range 0.4 – 24). Higher grades of heterotopic bone formation were significantly associated with males (p<0.001) and hypertrophic osteoarthritis (p<0.001). Acetabular wear was associated with increased weight (p<0.001) and male sex (p=0.005). Amongst the cohort, only 1 stem (1.1%) has been revised due to aseptic loosening. This patient required reaming of their canal prior to implantation, as a result of a previous femoral osteotomy. The rate of stem revision for any cause was 7.4% (7 stems), of which 4.2% (4 stems) resulted from infection following revision of the acetabular component. Twenty patients (21.1%) required some sort of revision procedure; all except 3 of these resulted from failure of the acetabular component. Cemented cups had a significantly lower revision burden (2.7%) than Harris Galante uncemented components (21.8%) (p<0.001). The CPT stem continues to provide excellent radiological and clinical outcomes at 15 years following implantation. Its results are consistent with other polished tapered stem designs. Cup failure remains a problem and is related in part to inadequate bearings and biological abnormalities.
Wound ooze is common following Total Knee Arthroplasty and persistent wound ooze is a risk factor for infection, increased length and cost of hospitalisation. We undertook a prospective study to assess the effect of tourniquet time, periarticular local anaesthesia and surgical approach on wound oozing after TKA. The medial parapatellar approach was used in 59 patients (77%) and subvastus in 18 patients (23%). Periarticular local anaesthesia (0.25% Bupivacaine with 1:1000000 adrenalin) was used in 34 patients (44%). The mean tourniquet time was 83 minutes (range 38 to 125 minutes). We found a significant association between cessation of oozing and periarticular local anaesthesia (P = 0.003), length of the tourniquet time (P = 0.03) and the subvastus approach (P = 0.01). Periarticular local anaesthesia, the subvastus approach and shorter tourniquet time were all associated with less wound oozing after total knee arthroplasty.
Last minute cancellations of operations are a major waste of NHS resources. This study identifies the number of late cancellations at our elective orthopaedic centre, the reasons for them, the costs involved, and whether they are avoidable. Last minute cancellations of operations in a 7-month period from January to July 2009 were examined. 172 cases out of 3330 scheduled operations were cancelled at the last minute (5.2%). Significantly more cancellations occurred during the winter months due to seasonal illness. The commonest causes for cancellation in descending order of frequency were patient unfit/unwell (n=76, 44.2%), lack of theatre time (n=32, 18.6%), patient self cancelled/DNA (n=20, 11.6%), staff unavailable or sick (n=9, 5.2%), theatre or equipment problem (n=8, 4.7%), operation no longer required (n=8, 4.7%), administrative error (n=7, 4.1%) or no bed available (n=5, 2.9%). In 7 out of the 172 cancelled cases (4.1%) no cause was identified. 59.7% of the cases were potentially avoidable. 3.2% of Patients seen in the specialist pre-operative anaesthetic clinic (POAC) were cancelled at the last minute for being unfit or unwell, compared to 2.2% seen in the routine nurse led clinic. Last minute cancellations cost the hospital over £700,000 in 7 months.
Long-term prospective RCT comparing hemiarthroplasty (HEMI) and total hip arthroplasty (THA) for the treatment of intracapsular neck of femur fracture. 81 previously mobile, independent, orientated patients were randomised to receive THA or HEMI after sustaining a displaced neck of femur fracture. Patients were followed up with radiographs, Oxford hip score (OHS), SF-36 scores and their walking distance. At a mean follow up of 8.7 years, overall mortality following THA was 32.5% compared to 51.2% following HEMI (p=0.09). Following THA, patients died after a mean of 63.6 months compared to 45 months following HEMI (p=0.093). Patients with THA walked further and had better physical function. No HEMIs dislocated but three (7.5%) THAs did. Four (9.8%) HEMI patients were revised to THA, but only one (2.5%) THA required revision. All surviving HEMI patients had acetabular erosion and all surviving THA patients had wear of the cemented polyethylene cup. Patients with THA have better function in the medium-term and survive longer.
We compared the early complication rates of total hip (THA) and total knee (TKA) arthroplasty carried out at a regional orthopaedic hospital (AOC) and two Independent Sector Treatment Units (ISTUs) (WGH and CNH). After THA, reoperation rates were higher at CNH (9%) than AOC (0.6%) or WGH (1.4%). After TKA, reoperation rates at CNH were (8%) higher than AOC (1%) and WGH (1.9%). 5% of patients undergoing TKR at CNH underwent 2 stage revision for deep infection. After THA, dislocation rates at CNH (6%) were higher than AOC and WGH (1.8%). Readmission from CNH (13%) was higher than AOC (1.2%) and WGH (0.6%). Major wound problems at CNH (20%) were higher than WGH (3.8%) and AOC (0.4%). After TKA, major wound problems were higher at CNH (19%) compared to WGH (1.9%) and AOC (1.1%). Readmission rates not requiring surgery from CNH (13%) were higher than AOC. (1.1%) and WGH (1%). AOC and WGH audited their outcomes. None were available from CNH. WGH initially missed many of their complications because they presented at base hospitals elsewhere. ISTUs performed approximately 2/3rds of procedures for which patients had been referred from base hospitals. At CNH, 23% were rejected on grounds of potential co-morbidity. Audit from ISTUs is inferior to NHS hospitals and the results in one of those audited significantly worse. Patients offered surgery at ISTUs should be told that the audited outcome of the surgeon who will be treating them is not known and that, in some, results are inferior to surgery in the NHS.
We reviewed 142 consecutive primary hip arthroplasties using the Exeter Universal femoral stem implanted between 1988 and 1993 into 123 patients. 74 patients with 88 hips survived to 10 years or more and were reviewed with a mean 12 years 8 months. There was no loss to follow-up and the fate of all stems is known. Our stem revision rate for aseptic loosening and osteolysis was 1.1% (1 stem); stem revision for any cause was 2.2% (2 stems); and re-operation for any cause was 21.6% (19 hips), all but 2 of which were due to cup failure. All but one stem subsided within the cement mantle to an average of 1.5mm at final follow-up (0 to 8mm). One stem was revised for deep infection and one was revised for excessive periarticular osteolysis. One further stem had subsided excessively (8mm) and demonstrated lucent lines at the stem-cement and cement-bone interfaces. This was classified as a radiological failure and is awaiting revision. 28% of stems had cement mantle defects, which were associated with increased subsidence (p=0.01), but were not associated with endosteal lysis or stem failure. Periarticular osteolysis was significantly related with the degree of polyethylene wear (p<0.001), which was in turn associated with younger age patients (p=0.01) and males (p<0.001). The Exeter metal backed cups were a catastrophic failure with 34% revised (11 cups) for loosening. The Harris Galante cups failed with excessive wear and osteolysis, with failure to revision of 18%. Only 1 cemented Elite cup was revised for loosening and osteolysis (4%). The Exeter Universal stem implanted outside the originator centre has excellent medium term results.
The success of total hip replacement in the young has consistently been worse both radiologically and clinically when compared to the standard hip replacement population. We describe the clinical and radiological outcome of 58 consecutive polished tapered stems (PTS) in 47 patients with a minimum of 10 years follow-up (mean 12 years 6 months) and compared this to our cohort of standard patients. There were 22 CPT stems and 36 Exeter stems.Introduction
Methods
Metal-on-metal resurfacing offers an alternative strategy to hip replacement in the young active patient with severe osteoarthritis of the hip. The aim of this study was to compare functional outcomes, failure rates and impending revisions in hybrid total hip arthroplasties (THAs) and Birmingham Hip Resurfacings (BHRs) in young active patients. We compared the 5-7 year clinical and radiological results of the metal-on-metal BHR with hybrid THA in two groups of 54 hips each, matched for sex, age, body mass index and activity. Function was excellent in both groups as measured by the Oxford hip score (median 13 in the BHRs and 14 in the THAs, p=0.14), but the resurfacings had higher UCLA activity scores (median 9 v 7, p=0.001) and better EuroQol quality of life scores (0.90 v 0.78, p=0.003). The THAs had a revision or intention to revise rate of 8% and the BHRs 6%. Both groups demonstrated impending failure on surrogate end-points. 12% of THAs had polyethylene wear and osteolysis under observation, and there was femoral component migration in 8% of resurfacings. Polyethylene wear was present in 48% of hybrid hips without osteolysis. Of the femoral components in the resurfacing group which had not migrated, 66% had radiological changes of unknown significance (classification proposed). In conclusion, the early to mid-term results of resurfacing with the BHR appear at least as good as those of hybrid THA. Only by longer term follow-up will we establish whether the change of practice recorded here represents a true advance.
Nationwide, proximal femoral fractures contribute a significant workload for the NHS and are the commonest trauma admission. Timely discharge from the acute hospital setting is beneficial to both patient and orthopaedic team. The Community Care Act 2003 formed part of Governmental strategy to reduce ‘bed blocking’. Introduced on 5 January 2004, the scheme enabled Trusts to charge Local Authorities £100 a day where there was delayed transfer of care due to lack of Social Service [SS] provision. The Act brought with it a £250 million package of funding over three years. We looked at patients admitted to Weston Area Healthcare Trust [WAHT] sustaining fractured neck of femur. These were pre-scheme group A, admitted 08/09/2003-06/10/2003 and post scheme group B, 08/03/2004 – 05/04/2003. Patient numbers, group ‘A’ 33 patients, group ‘B’ 28 patients. Average length of stay, ‘A’ 22.3 days, ‘B’ 16.1 days. The average time spent in hospital after being declared ‘medically fit’, ‘A’ 6.6 days, ‘B’ 2.3 days. Only 13 patients were referred to SS post scheme, with combined delayed discharge of 116 days. The impact of the scheme in reducing length of stay has not been proven. Few patients were referred to SS even after the implementation of the scheme; however, the delay in discharge for these patients would have amounted to £11600 of funding. To date, WAHT have not received any funds for patients in whom discharge was delayed. The Act states that lack of SS input must be the ‘sole reason’ for delay in discharge. The scheme is not applicable if delay is due to family choice, lack of equipment or lack of intermediate care package and for these reasons transfer of funds from SS to Trusts has become a multidisciplinary minefield. The impact of the reimbursement scheme will only become apparent if the Act is enforced.
Of the survivors four of the HEMI group were revised to total hip arthroplasty. One patient had been revised in the THA group. Radiographically six of seven patients in the HEMI group had evidence of acetabular erosion and 13 of 15 patients in the THA group had a lucency around their acetabular component.
Satisfactory function was shown in both groups. There was no significant difference between groups with respect to the OHS but the UCLA score was superior in the BHR group (p=0.008). There was no significant difference for Euroqol visual analogue score. 56% of hybrids were delighted with their hip replacement verses 65% of BHR patients.
Clinician expectation and anatomical studies suggest that the distribution of sensory dysfunction in carpal tunnel syndrome (CTS) should be confined to the thumb, index, middle and half of the ring fingers. We mapped the distribution of disturbance to evaluate the accuracy of these assumptions. We evaluated 64 wrists in 64 patients with nerve conduction study confirmed CTS. Each patient filled out a Katz hand diagram and we collated the distribution of pain and non-painful (tingling, numbness &
decreased sensation) sensory disturbance. Frequency of reporting was analysed; dividing symptoms into thenar and hypo-thenar eminence, distal palm, each digit, posterior hand and forearm. Non-painful sensory disturbance occurred in all patients. The index finger was the most common location (94%) followed by the middle finger (91%), the distal palm (84%), the ring finger (72%), the thumb (69%), the thenar eminence (63%), the little finger (39%), the dorsal hand (31%), the hypothenar eminence (25%) and the forearm (13%). Pain was less common, reported in 59% of cases. Pain occurred most frequently over the wrist crease (33%) followed by thenar eminence (27%), the forearm (20%), the middle finger (23%), the index finger (22%), the ring finger (19%), the distal palm (16%), the thumb (14%), the dorsal hand (11%), the little finger (11%) and least frequently the hypothenar eminence (6%) In CTS sensory disturbance occurs most frequently in the median nerve distribution; however it occurs almost as often elsewhere. An atypical distribution of symptoms should not discourage diagnosis of CTS.
Dysplastic acetabuli are associated with a higher incidence of zone 1 radiolucency. Retroverted acetabuli are associated with a higher risk of zone 1 radiolucency. Radiolucencies progress in the early post operative period.
Stable fixation with macro and micro interlock prevents early migration and therefore early failure of cemented acetabular cups. The authors describe a cementation technique in an in-vitro model that increases the interossoeous pressure by a factor of 3.5 in the ishium, 4.5 in the ilium and 5.1 in the pubis by the injection of the cement directly into the 10 mm key holes prior to insertion of the cement bolus and cup.
21 patients described difficulty reaching and lifting (36%), 11/36 (31%) digging the garden, 13/58 (22%) were unable to reach between their shoulder blades. Over 90% had no difficulty with feeding (55/58), dressing (50/58), personal toilet (56/58), brushing hair (41/46), hanging up clothes (52/56) or ironing (37/41) but overall 23/58 patients (40%) had some functional restriction 1–2 years after injury. 18/48 patients (38%) returned to work within one month, 39 (81%) by three, and all by six. 28/30 (93%) clerical workers had returned within three months compared with 11/18 (61%) of manual (p <
0.05) 36/42 (86%) sportsmen returned. High impact sportsmen were less likely to resume than low impact or overhead. 38/46 (83%) of drivers returned by three months and all by six. 40/58 (69%) patients noted cosmetic deformity the severity of which was associated with worse functional outcome (p = 0.002). The degree of displacement of the fracture was associated with cosmetic deformity (p = 0.015) and functional outcome (p = 0.025), but the Robinson classification8 alone was not.
Tibial shaft fracture occurs commonly in the young active population with high demands. Tibial fracture is potentially life changing. There are no published studies with long-term follow-up to provide accurate prognostic information regarding return to leisure activities, employment and driving. We aim to define the patient demographic and mechanism of injury and quantify the time period following tibial shaft fracture to return to sport and sporting level achieved at long-term follow-up. A retrospective multi-centre study was performed. Data collection was by questionnaire including Tegner activity scale score for sporting level and closed questioning on employment and driving. Ninety-three patients were recruited with an average 46 month (18–64mo) follow-up period. Patients were predominantly male (77%) with a median age at injury of 37 years. Road traffic accidents were responsible for 43% of injuries; sport 31%; falls 25% and assault 1%. High energy mechanisms accounted for 49% of injuries Seventy-eight percent of patients felt that prognostic information given at the time of injury was inaccurate. At follow-up, only 31% had regained their original level of sporting ability. Median Tegner score prior to injury score was 5 and at 18 months the mean score fell by 1.85. Patients sustaining high energy injuries were worst affected, dropping an average of 2.13 compared to low energy mechanisms with an average fall of 1.35 on the Tegner scale (p=0.503). High demand patients had a greater reduction in functional outcome, with a fall of 0.8 for patients with pre-injury activity level of 1–3 compared to the fall of 2.6 on the scale for more active patients scoring 7–9 pre-injury. Tibial fracture can result in significant long-term morbidity. Patients sustaining high energy injuries and high demand patients have significantly worse outcome. Patients are unlikely to achieve their pre-injury level of sporting activity at 2 years.
The comparison between the CROM and universal goniometer demonstrated that the majority of goniometer readings were within 5° of the CROM result; however, this was not consistently the case. Given that the CROM is a valid and reliable method of measuring neck movement, the inconsistency between the goniometer and CROM can be taken as inaccuracy on the part of the universal goniometer. As the interobserver variance is excellent one can assume that these results are reproducible and that the errors observed are a true reflection of the limitations of the device.
At the end of the follow up period, 11 of the 70 acetabular components (polyethylene liner or the acetabular shell) had been revised. The cumulative survival was 94.0% (95% confidence interval 88.4–99.7) with revision of the metal shell as the end point, and 84.0% (95% confidence interval 74.5–93.5) with revision surgery of the acetabular shell or liner due to any reason as an end point. Radiologically, 4 patients require acetabular revision and 22 patients had femoral osteolysis in gruen zone 7, indicative of polyethylene failure. This gave a combined revision, impending revision and zone 7 osteolysis cumulative survival of 55.3% (95% confidence interval 40.6–70.0).
We examined the effect of age, gender, body mass index (BMI), medical co-morbidity as represented by the American Society of Anaesthesiologists (ASA) grade, social deprivation, nursing practice, surgical approach, length of incision, type of prosthesis and duration of surgery on length of stay after primary total hip arthroplasty (THA). Data was collected on 675 consecutive patients in a regional orthopaedic centre in South West England. The length of stay varied from 2 to 196 days and was heavily skewed. Data were therefore analysed by non parametric methods. To permit comparison of short with protracted length of stay, data were arbitrarily reduced to 2 groups comprising 2 to 14 days for short stays and 15 to 196 for long. These data were analysed by Chi-squared and Fisher’s exact test in univariate and by Logistic regression for multivariate analysis The mean length of stay was 11.4 days, an over-estimate compared to the median length of stay of 8 days which more correctly reflects the skewed nature of the distribution. 81.5% of patients left hospital within 2 weeks, 13.6% within 2 and 4 and 4.9% after 4. On univariate analysis age above 80 years, age between 70 and 79 years, Body Mass Index >
35, ASA grades 3 and 4, transgluteal approaches, long incisions, cemented cups and prolonged operations were associated with longer stays. On multivariate analysis, age above 80, age between 70 and 80, ASA grades 3 and 4, prolonged operations and long incisions were highly significantly associated with hospital stay of over 2 weeks. This is the first study to record all the published variables associated with length of stay prospectively and to subject the data to multivariate analysis. Prolonged stay after THA is pre-determined by case mix but slick surgery through limited incisions may reduce the length of admission.
Metal-on-metal resurfacing offers an alternative strategy to hip replacement in the young active patient with severe osteoarthritis of the hip. The functional outcomes, failure rates and impending revisions in hybrid total hip arthroplasties (THAs) and Birmingham hip resurfacings (BHRs) were compared after 5–7 years. We studied the clinical and radiological results of the BHR with THA in two groups of 54 hips each, matched for sex, age, BMI and activity. Function was excellent in both groups as measured by the Oxford hip score (median 13 in the BHRs and 14 in the THAs, p=0.14), but the resurfacings had higher UCLA activity scores (median 9 v 7, p=0.001) and better EuroQol quality of life scores (0.90 v 0.78, p=0.003). The THAs had a revision or intention to revise rate of 8% and the BHRs 6%. Both groups demonstrated impending failure on surrogate end-points. 12% of THAs had polyethylene wear and osteolysis and there was femoral component migration in 8% of resurfacings. Polyethylene wear was present in 48% of hybrid hips without osteolysis. Of the femoral components in the resurfacing group which had not migrated, 66% had radiological changes of unknown significance. In conclusion, the early to mid-term results of resurfacing with the BHR appear at least as good as those of hybrid THA.
We investigated the effect of neck dimension upon cervical range of movement. Data relating to 100 subjects healthy subjects aged between 20 and 40yrs was recorded with respect to age, gender and ranges of movement in three planes. Additionally two commonly used methods of measuring neck motion, chin-sternal distance and uniplanar goniometer, were assessed against a validated measurement tool the CROM goniometer (Performance Attainment Associates, Roseville, MN). Using multiple linear regression analysis it was determined that sagittal flexion (P= 0.0021) and lateral rotation (P<
0.0001) were most closely related to neck circumference alone whereas lateral flexion (P<
0.0001) was most closely related to a ratio of circumference and length. The uniplanar goniometer has some usefulness when assessing neck motion, comparing favourably to chin-sternal distance that has almost no role. Neck dimension should be incorporated into cervical functional assessment. One should be wary about recorded values for neck motion from non-validated measurement tools.
The success of total hip replacement in the young has consistently been worse both radiologically and clinically when compared to the standard hip replacement population. Methods: We describe the clinical and radiological outcome of 58 consecutive polished tapered stems (PTS) in 47 patients with a minimum of 10 years follow up (mean 12 years 6 months) and compared this to our cohort of standard patients. There were 22 CPT stems and 36 Exeter stems. Results: Three patients with 4 hips died before 10 years and one hip was removed as part of a hindquarter amputation due to vascular disease. None of these stems had been revised or shown any signs of failure at their last follow-up. No stems were lost to follow up and the fate of all stems is known. Survivorship with revision of the femoral component for aseptic loosening as the endpoint was zero and 4% (2 stems) for potential revision. The Harris hip scores were good or excellent in 81% of the patients (mean score 86). All the stems subsided within the cement to a mean total of 1.8mm (0.2–8) at final review. There was excellent preservation of proximal bone and an extremely low incidence of loosening at the cement bone interface. Cup failure and cup wear with an associated periarticular osteolysis was a serious problem. 19% of the cups (10) were revised and 25% of the hips (13) had significant periarticular osteolysis associated with excessive polyethylene wear. Discussion: The outcome of polished tapered stems in this age group is as good as in the standard age group and superior to other non PTS designs in young patients. This is despite higher weight and frequent previous surgery. Cup wear and cup failure were significantly worse in this group, with a higher incidence of periarticular osteolysis.
We examined the effect of age, gender, body mass index (BMI), medical comorbidity as represented by the American Society of Anaesthesiologists (ASA) grade, social deprivation, nursing practice, surgical approach, length of incision, type of prosthesis and duration of surgery on length of stay after primary total hip arthroplasty (THA). Data was collected on 675 consecutive patients in a regional orthopaedic centre in South West England. The length of stay varied from 2 to 196 days and was heavily skewed. Data were therefore analysed by non parametric methods. To permit comparison of short with protracted length of stay, data were arbitrarily reduced to 2 groups comprising 2 to 14 days for short stays and 15 to 196 for long. These data were analysed by Chi-squared and Fisher’s exact test in univarate and by Logistic regression for multivariate analysis. The mean length of stay was 11.4 days, an over-estimate compared to the median length of stay of 8 days which more correctly reflects the skewed nature of the distribution. 81.5% of patients left hospital within 2 weeks, 13.6% within 2 and 4 and 4.9% after 4. On univarate analysis age above 80 years, age between 70 and 79 years, Body Mass Index >
35, ASA grades 3 and 4, transgluteal approaches, long incisions, cemented cups and prolonged operations were associated with longer stays. On multivariate analysis, age above 80, age between 70 and 80, ASA grades 3 and 4, prolonged operations and long incisions were highly significantly associated with hospital stay of over 2 weeks. This is the first study to record all the published variables associated with length of stay prospectively and to subject the data to multivariate analysis. Prolonged stay after THA is pre-determined by case mix but slick surgery through limited incisions may reduce the length of admission.
The collarless polished tapered stem (CPT) is a double tapered, cemented femoral component designed for primary hip replacement and as a revision stem for impaction bone grafting. We report outcome at a minimum of 10 years (mean 11 years 1 month). Of 191 consecutive primary hip replacements in 174 patients, implanted using contemporary cementing techniques, 63 patients died before 10 years (68 hips). None of these stems had been revised or had radiological signs of failure at their last follow-up. Only one patient (two hips) was lost to radiological follow-up, hence complete radiological data was available on 121 hips and clinical follow-up on 123 hips. The fate of all the hips is known. Survivorship with revision of the femoral component for aseptic loosening as the endpoint was 100%. The Harris hip scores were good or excellent in 75% of the patients with a mean of 86. All the stems subsided vertically within the cement mantle at a mean rate of 0.18mm per year, stabilising to a mean total of 1.95 mm (0.21–24 mm) after a mean of 11 years 1 month. Unlike Exeter stems there was no change in the alignment of the stems. There was excellent preservation of proximal bone and an extremely low (<
2%) incidence of loosening at the cement bone interface. The study confirms that the CPT subsides within the cement mantle, but without failing. It performs at-least as well as the best stems currently available.
Intramedullary pressures were better in all zones, for all cement modes, with proximal occlusion. The highest pressures were seen with Palacos-R at 4 minutes 30 seconds with proximal thumb occlusion. Stem insertion into Palacos-R at 4 minutes or 4 minutes 30 seconds, gave higher pressures than Simplex-P, with or without any form of occlusion. With Simplex-P, intramedullary pressures were higher, with Collar rather than thumb occlusion.
53 patients underwent closed reduction and longitudinal k-wiring of displaced Colles’ fractures and were reviewed after a mean of 26 months. Radiographs taken at the time of injury, after reduction and k-wiring, and at fracture union were compared for radial shortening and dorsal angulation. Manipulation significantly improved fracture position (p<
0.001). Dorsal angulation was successfully corrected by manipulation in 98%, and this position was maintained to fracture union in all cases. 73% of fractures manipulated for radial shortening >
2mm were adequately reduced, but 41% of these fractures subsequently lost position to malunite. The mean shortening between reduction and fracture union was 1.6mm. This did not correlate with Frykman Class or radial shortening at injury. Closed Reduction and k-wire stabilisation is an attractive technique because it is relatively non-invasive compared with plating or external fixation. However, a degree of radial shortening between reduction and fracture union must be anticipated. Fractures reduced inadequately to allow for this loss of radial length, are more likely to malunite. This may compromise functional outcome.
Arthroplasty is the most effective management of displaced intracapsular femoral neck fracture. Hemiarthroplasty (HEMI) is associated with acetabular erosion and loosening in mobile patients and total hip arthroplasty (THA) with instability. We sought to establish whether HEMI or THA gave better results in independent mobile patients with displaced intracapsular femoral neck fracture. Eighty-two patients were randomised into two groups. One arm received a modular HEMI, the second a THA using the same femoral stem. Patients were followed for a mean of three years after surgery. After HEMI, eight patients died, two were revised to THA and there is intention to revise three. One patient had a periprosthetic fracture. Mean walking distance was 1.08 miles and Oxford Hip Score (OHS) 22.5. Twenty patients (64.5% of survivors) had radiological evidence of acetabular erosion. After THA, four patients died, three dislocated, one required revision. Mean walking distance was 2.23 miles and OHS was 18.8. HEMI is associated with a higher rate of revision than THA and potential revision because of acetabular erosion. THA after three years displayed superior walking distances (p=0.039) and lower OHS (p=0.033). THA is a preferable option to HEMI in independent mobile elderly patients with displaced intracapsular femoral neck fracture.
65 hips were assessed clinically and radiologically. Our aim was to establish whether results from the inventing centre for the Exeter Universal stem were reproducible and to identify the features of cementing technique associated with survival of this prosthesis.
Poor proximal femoral pressures obtained during a cemented, primary hip replacement may lead to poor fixation of the stem to the cement and cement to bone, contributing to early aseptic loosening of the prosthesis. Occlusion of the proximal femoral area during stem insertion, especially in the region of the calcar, may help in achieving a uniform and sustained rise distally and proximally. An In-vitro analysis of femoral pressures was performed. Dental plaster was used to prepare femoral moulds in aluminium cylinders and the stem insertion phase of a cemented hip replacement was simulated with a number 3 Exeter stem, with no proximal occlusion, with thumb occlusion over the calcar and with the Exeter Horse collar. Pressure transducers were attached to the moulds. 54 experiments were performed. Of these 18 experiments were done with Palacos R cement, with the stem inserted at the recommended time of insertion and 18 with a delayed time of insertion. The last 18 experiments were performed with low viscosity Simplex P cement. Good distal pressures were obtained in all cases. However, digital occlusion helped achieve sustained, high proximal pressures as well as early, high distal pressures. The Horse collar did achieve high pressures, but only towards the end of the stem insertion phase. This was much more appreciable with low viscosity cement, where peak pressures obtained with the collar were higher than with digital occlusion. Our results show that occluding the medial cal car area is an effective way of achieving and sustaining high-pressures in the proximal and distal femur, during a hip replacement. The Exeter Horse collar is an effective means of increasing the pressure, towards the end of stem insertion, especially with low viscosity cement. Animal or cadaveric bone studies are required to show the actual penetration of cement in bone, achieved with these high pressures.
Trochanteric bursitis is initially treated with local anaesthetic and corticosteroid injections but when this fails there are few interventions that relieve the symptoms. We report a new surgical technique for refractory trochanteric bursitis in 43 patients. Fourteen patients had developed trochanteric bursitis after primary total hip arthroplasty (THA), 6 after revision THA, 17 for no definable reason (idiopathic) and 7 after trauma. Follow up ranged from six months to 15 years (mean five years). Outcome was measured by pre and post operative Oxford Hip Scores. The mean post operative decreases were 23 points in traumatic cases, 13 in idiopathic and 13 for patients after primary THA. A mean increase of 3 was observed in patients after revision THA. The operation relieved symptoms in 75%. The outcome depended on aetiology. 100% of traumatic, 88% of idiopathic and 64% after primary THA were successful. All operations after revision THA were unsuccessful. This is the largest series of a single surgical technique for refractory trochanteric bursitis and the only one to subdivide the outcome by aetiology. Transposition of the gluteal fascia is indicated in patients with idiopathic, traumatic and post primary THA trochanteric bursitis, but not after revision THA.
Personal injury claims following whiplash injury currently cost the British economy more than £3 billion a year, yet only a minority of patients have radiologically demonstrable pathology. Patients sustaining fractures of the cervical spine have been subjected to greater force and might reasonably be expected to have worse symptoms than those with whiplash injuries. Using the Neck Disability Index, we compared pain and functional disability in four groups of patients who had suffered cervical spine injuries. The four groups were: patients with stable cervical fractures treated conservatively, patients with unstable cervical fractures treated by internal fixation, patients with whiplash injuries seeking compensation, and patients with whiplash injuries not involved in litigation. After a mean follow-up of 3½ years, patients who had sustained cervical spine fractures had significantly lower levels of pain and disability than those who suffered whiplash injuries and were pursuing compensation (p<
0.01), but had similar level to those whiplash sufferers who had settled litigation or had never sought compensation. Functional recovery following neck injury is unrelated to the physical insult. The increased morbidity in whiplash patients is likely to be psychological and is associated with litigation.
The purpose of the study was to objectively compare the effects of the scaphoid and Colles’ type casts on hand function. Currently there is no such published study. Both casts are commonly used to immobilise suspected and radiologically proven undisplaced scaphoid fractures. There is no difference in non-union rates. The scaphoid incorporates the thumb in palmar abduction, whereas the Colles’ type cast leaves the thumb free. Although necessary for bone healing, immobilisation disrupts function and may require intensive corrective physiotherapy. Unnecessary immobilisation of uninvolved joints should be avoided when use does not compromise fracture stability. We compared the effect of the two casts on hand function in 20 healthy right hand dominant volunteers using the Jebsen-Taylor Hand Function Test, which uses seven subtests designed to test tasks representative of everyday functional activities. Data were obtained through a mixed between and within subject design. Using the Jebsen-Taylor Hand Function Test, median overall scoring in the Colles’ type cast was 2.5 times that obtained in the scaphoid. In timing individual subtests, the analyses show significant differences (p<
0001) between the presence and absence of a cast. When comparing the two cast types, mean times for all subtests are less in the Colles’ than in the scaphoid, with the difference reaching statistical significance in five out of seven subtests. Having either type of cast significantly impairs handling and finger dexterity, and so affects activities of daily living. A scaphoid, however, is much more limiting than a Colles’ type cast. This makes it clearly more inconvenient for the patient with socioeconomic implications and occasionally issues of compliance during a long period of immobilisation.
In 90 patients undergoing primary THA, leg length discrepancy (LLD) and hip function were assessed pre-operatively and 3 and 12 months postoperatively. Hip function was measured by the Oxford hip score (OHS). Postoperatively the mean OHS improved by 26 points out of a possible 48 at 3 months and by 30 points at 12 months. Postoperatively 62% of patients’ limbs were lengthened by a mean of 9 mm. The LLD was perceived by 43% of the affected patients at 3 months and by 33% at 12 months. The OHS in patients who perceived true lengthening was 27% worse than in the other patients at 3 months and 18% worse at 12 months. In 98%, lengthening occurred in the femoral component. The problem of LLD after THA is lengthening. Appropriate placement of the femoral component could reduce patients’ perception of this.