In light of recent regulatory initiatives, medical devices now require additional clinical evidence to prove their safety and efficacy. At the same time, patients' own assessment of their devices' function and performance has gained in importance. The collection of these data allows for a more comprehensive picture of clinical outcomes and complications following total knee arthroplasty (TKA).

These trends have led researchers to search for new methods of acquiring, interpreting and disseminating patient-reported outcome measurements (PROMs). The current study assesses the feasibility of a digital platform for collecting PROMs that was recently adapted for TKA patients. It sought to determine patient engagement, survey completion rates, and satisfaction with this platform.

Eighty-two patients (mean age, 63.7 years, 59% females) scheduled for TKA were enrolled from one US and six UK sites between January 12, 2018 and April 30, 2018. Patients were supplied with a mobile application (app) that collects a variety of PROMs, including four domains based on the Patient-Reported Outcome Information System (PROMIS™): physical function, depression, pain interference and pain behavior. The platform electronically administers questionnaires using computer-adaptive tests (CATs), which reduce the burden on patients by tailoring follow-up questions to account for their previous answers. Satisfaction with the app was assessed in subset of patients who evaluated its ease-of-use (n=45), likelihood that they would recommend it to family/friends (n=35), and whether they successfully used the information it provided during their recovery (n=31). These scores were taken on a 1 to 10 (worst to best) scale.

Patients demonstrated regular engagement with the platform, with 73% using the app at least once a week. Weekly engagement remained high throughout the seven-week post-operative period (Figure 1). There was a 69% completion rate of all PROMIS™ CAT surveys during the study. The four PROMIS™ CAT domains had similar survey completion rates (Figure 2). The subset of patients queried regarding their satisfaction with the app gave it favorable mean scores for ease-of-use (8.8), likelihood to recommend to a family member or friend (8.1), and their success at using its information to improve their recovery (7.4).

Initial results support this digital platform's potential for successfully and efficiently collecting large volumes of PROMs. Patients reported high levels of engagement and satisfaction.

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Introduction

Trabecular titanium implants are 3D printed with a high-friction ingrowth surface that is continuous with the rest of the acetabular shell. The ability to “face-change” following optimum seating of the component allows unprecedented levels of versatility in acetabular orientation. Bolt-on augments enable rapid trialling and definitive insertion of a monobloc construct. The use of these implants has rapidly increased in the National Joint Registry over the last three years with little published outcome data. We present one of the largest studies using this material.

Introduction

Bone loss in the distal femur and proximal tibia is frequently encountered with both complex primary and revision knee replacement surgery. Metaphyseal sleeves provide a good option for enhanced fixation in managing such defects on both the tibia and femur. We present our results in 48 patients (50 knees) with a minimum 12 month follow up (range 12 to 45).

Introduction

Enhanced recovery programmes (ERP) have recently been adopted in the UK, enabling patients to recover quickly and return home sooner. Choice of anaesthetic is an important factor effecting post-operative outcome; studies show regional anaesthesia is more cost-effective, decreasing the incidence of venous thromboembolic events and reducing intra-operative blood loss, the need for transfusion and the length of hospital stay.

Introduction

Rivaroxiban is a direct inhibitor of factor Xa, a licensed oral thromboprophylactic agent that is increasingly being adopted for lower limb arthroplasty. Rivaroxiban has been NICE-approved for use in primary hip and knee arthroplasty following the RECORD 4 trials; proving it more effective in preventing venous thrombo-embolic (VTE) events compared to enoxaparin. Enhanced Recovery Programmes (ERP) are designed to enable patients to recover quickly and return home safely within a few days.

Introduction

Obesity is a direct contributor to degenerative joint disease, and as the prevalence of obesity increases globally it is likely that more overweight patients will present for hip replacement surgery. There are reports that overweight patients in the UK's National Health Service, typically with a Body Mass Index (BMI) over 30 (BMI 30–39 obese, BMI≥40 morbidly obese), are being denied operations on the premise that they are at risk of significant complications. Enhanced Recovery Programmes (ERP) are designed to enable patients to recover quickly and return home safely within a few days. The aim of this study was to compare the outcome of hip replacements in obese and non-obese patients enrolled in our ERP.

The need for hip and knee replacement surgery is increasing. Enhanced recovery programmes, where patients mobilise quickly and safely after surgery, have been adopted now in many hospitals. There are anecdotal reports of Primary Care Trusts raising thresholds for referral for surgery based on patients' Body Mass Index (BMI).

The aim of this study was to evaluate the early outcome of hip and knee arthroplasty in obese patients (BMI>30) enrolled in the enhanced recovery programme.

Between March 2010 and January 2011, 672 patients were enrolled in our enhanced recovery programme. 316 patients (47%) were classified as obese (BMI>30, range 30-39). There was no significant difference in the length of stay: 4.58 days in the obese patients and 4.44 days in the non-obese. There was also no difference in the rates of superficial infections or oozy wounds. Knee replacements was performed more commonly than hip replacements in the obese group

There was no significant difference in the early outcome of hip and knee replacement surgery in patients with a higher Body Mass Index when undergoing lower limb arthroplasty through the enhanced recovery programme. These patients should continue to be offered surgery when clinically indicated.

Introduction

The Stanmore Percentage of Normal Shoulder Assessment (SPONSA) is a simple, fast and reproducible measure of the subjective state of a shoulder. It has been invaluable in our busy clinical practice. This study validates the SPONSA score against the Oxford Shoulder and Constant score and demonstrates a greater sensitivity to change.

Previously ankylosed or surgically arthrodesed hip joints can be converted successfully to a total hip replacement (THR) in order to improve patient mobility and function. We present a long term prospective cohort study of cementless revisions of previously ankylosed hips.

Sixteen hips (15 patients) with a mean age of 52 years (range 16 to 75) had ankylosed hips for a mean of 36 years (range 3.5 to 65 years). They all received a cementless THR between August 1988 and January 2003 and were prospectively followed-up for a mean of 11 years (range 5.0 to 19 years). Two patients died during the study period of unrelated causes and none were lost to follow-up.

All patients showed improved mobility and function following the conversion of their ankylosed hips. The Harris Hip Score improved from a pre-operative mean value of 70 (Standard Error of Mean (SEM) 3.4) to a post-operative value of 83 (SEM 4.4) at the latest review, which was statistically significant (p < 0.05).

There was one acetabular cup revision at 5 years post implantation for aseptic loosening. At a mean of 11 years post THR, all other femoral and acetabular components remained clinically and radiographically well fixed. One patient with systemic ankylosing spondylitis and spontaneous bilateral bony hip ankylosis developed the unusual complication of Paget’s disease of the left hemipelvis and proximal femur two years after successful bilateral THR surgery. His symptoms resolved following medical therapy for Paget’s disease.

We conclude that a previously ankylosed hip can be effectively converted to a cementless total hip replacement with good long term results.

Introduction and Aims: Good clinical outcome can be expected following cementless total knee arthroplasty (TKA) provided there is early stability and bone ingrowth. Screws give excellent initial stability but provide a path for osteolysis. Screws also cause an irregularity of the tibial component surface which limits their use as a mobile bearing component. We hypothesise that early stability can be obtained with four peripheral pegs rather than screws. We present the results of such a tibial component at a minimum of two years in a cementless mobile-bearing TKA.

Materials and Methods: We evaluated 200 knees in 173 patients. The average age at surgery was 72 years (range, 45–91 years) with 61% of cases in women. Patients were followed up for an average of 45.7 months (range 24 to 69 months). All radiographic and clinical scores were performed prospectively and recorded on a relational database. The components used were the cementless Low Contact Stress femoral component with the DuoFix MBT tibial tray (Depuy, Warsaw, Indiana, USA). The tibial tray was manufactured from cobalt-chrome with a central polished stem and four peripheral pegs. The underside, including the pegs, had a porous surface coated with 50 microns of hydroxyapatite.

Results: After excluding patients who had died, or lost to follow up, 164 cases had a minimum 2-year follow-up. None of the tibial components have required revision. One patient (0.6%) required revision of the femoral component at 22 months for failure of bone ingrowth. There was one superficial infection which resolved with intravenous antibiotics. Two patients developed deep infections (1.2%) which resolved with arthroscopic lavage and antibiotics. One patient presented with bearing spin out at 3 months following surgery, and an exchange to a thicker tibial insert was performed. Average flexion at follow up was to 110°. The patients stated that they were satisfied with their knees in 141 out of 155 cases (91%). The mean score for pain at rest was 0.9 (0–10) and for activity related pain was 1.3. The average HSS score was 86/100 with 90% good or excellent results, compared with a preoperative score of 54/100. Lucent lines were seen in one tibial zone in ten knees (7%), and two zones in three knees (2.1%). There were lucent lines in one femoral zone in 13 cases and two zones in two cases. None of the lines were progressive, and all the surviving components were bone ingrown. Osteolysis was present in a single zone around one (0.7%) tibial component. One patient showed some femoral osteolysis in one zone (0.7%) and also had patellar osteolysis in one zone. Two patients had osteolysis in a single zone of the patella.

Conclusion: This study shows that this design of mobile bearing tibial component provides good primary stability and bone ingrowth.

Orthopaedic surgeons vary in their attitude towards resurfacing of the patella in total knee arthroplasty. Few studies are available to assess outcome and patient preference. We evaluated post-operative anterior knee pain and knee preference in patients with bilateral knee replacements and unilateral patellar resurfacing.

We reviewed 30 patients who had undergone bilateral knee replacement with patellar resurfacing on only one side. Follow-up was from five to 12 years and the patients were assessed using the Knee Society rating, an anterior knee pain rating and a satisfaction score. Patients were also asked specifically if they had a preference for either knee. Assessment was performed without knowing which patella had been resurfaced.

Fourteen patients (47%) favoured the resurfaced knee, six (20%) the un-resurfaced knee and 10 (33%) had no particular preference. The overall prevalence of anterior knee pain was 50% in the un-resurfaced cases (six mild, six moderate, three severe) and 20% in the resurfaced knees (four mild, two moderate). No significant difference was found between knee scores. Three un-resurfaced patellae have been secondarily resurfaced.

This study shows a significant preference for the resurfaced side (p< 0.01), with a higher prevalence of anterior knee pain in non-resurfaced patellae (p< 0.05).

We report our results and technique of scapulothoracic fusion. 14 fusions were performed in 10 patients between 2001 and 2005. The underlying diagnosis was fascioscapulohumeral dystrophy in 7 patients (11 cases). The diagnosis in the remaining three patients was failure of scapular suspension due to C4/5 tetraplegia, stroke and cerebral palsy. There were five women and five men with an average age of 35.4 years (range 15–75) In each case the medial scapular border was wired to the ribs with the support of a one-third semi-tubular plate and autologous bone graft. We compared pre and post-operative active forward flexion and abduction. Satisfaction with the procedure was also rated. There was no need for single-lung ventilation or a chest drain and there were no significant post-operative complications. There were two cases of non-union. One patient, a heavy smoker, travelled abroad and has been lost to follow-up, the other aged 76 is awaiting revision surgery. The mean range of preoperative active forward flexion and abduction were 71° (range 30–90°) and 58° (range 40–90°) respectively. The mean post-operative values were 96° (90–120°) and 94° (80–120°) respectively. The remaining 8 patients were enthusiastic or satisfied with the result of the operation. This technique was very successful in 12 out of our 14 cases (85.7%) and is to be recommended. However, union may be unpredictable in older patients

We report 5 cases of linked shoulder and elbow replacement (LSER) following failure of single-joint arthroplasty. Whilst total humeral replacement has been reported for treatment following resection for tumour we know of no reports of linked shoulder and elbow prostheses for arthropathy alone. Between May and December 2005, 2 patients with total elbow arthroplasty and 3 patients with total shoulder arthroplasty were revised to LSER for loosening of the long humeral stems or periprosthetic fracture. Custom-made prostheses were produced using computer-aided design and manufacture technology. There were no early complications including infection. All 5 patients reported early improvement of symptoms, with the ability to bear weight axially through the limb, restored. This technique avoids the problem of a stress riser between the stems of separate shoulder and elbow replacements and solves the problem of salvage of long-stemmed implants where no further humeral fixation is possible.

We present the results of a technique of dynamic hip screw insertion through a very small incision, typically 2.5cm.

Method: The technique is performed using a standard dynamic hip screw set and requires no additional equipment. We compared the results to those of an age and sex matched group who had undergone the operation through a traditional approach. We compared the time spent in theatre, the pre and post-operative haemoglobin concentration, haematocrit, and prevalence of wound infection.

Results: 13 consecutive intertrochanteric hip fractures were treated with a dynamic hip screw and 4-hole plate by one surgeon using the percutaneous technique. There were 9 females and 4 males with a mean age of 84 years (range 62 to 96 years).

The mean post-operative drop in haemoglobin concentration in the percutaneous group was 2.2 g/dl (range 0 to 4.4 g/dl) compared to 3.5 g/dl (range 1.2–5.4) in the control group (p=0.014). The mean haematocrit drop was 0.07 (range 0 to 0.12) in the percutaneous group compared to 0.10 (range 0.03 to 0.17) in the control group (p=0.017)

The mean theatre time with the percutaneous technique was 57 minutes (range 40–75 minutes) and in the control group, 60 minutes (range 30–95). There were no wound problems.

Conclusion: To our knowledge, this technique has not been previously reported. The percutaneous technique offers a better clinical outcome at no extra expense and warrants further evaluation in a larger study

The purpose of this study was to evaluate the role of patellar resurfacing in total knee replacement surgery. We reviewed 48 patients who had undergone bilateral knee replacement with patellar resurfacing on only one side. Follow-up was from 18 months to 9.5 years and the patients were assessed using the Knee Society rating, a clinical anterior knee pain score and BOA patient satisfaction score. Patients were also asked specifically if they had a preference for either knee. Assessment was performed without knowing which patella had been resurfaced.

52.1% of patients favoured the resurfaced knee, 8% the unresurfaced knee and 39.9% had no particular preference. The overall prevalence of anterior knee pain was 8.3% in the resurfaced cases (3 mild, 1 moderate) and 27.1% in the unresurfaced knees (8 mild, 3 moderate, 2 severe). No significant difference was found between knee scores.

This study shows a significantly higher rate of anterior knee pain in unresurfaced patellae and preference for the resurfaced side.