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Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_6 | Pages 13 - 13
2 May 2024
Wijesekera M East J Chan CD Hadfield J As-Sultany M Kassam A Petheram T Jones HW Palan J Jain S
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This large UK multicentre study evaluates clinical outcomes and identifies factors associated with local complication following PFR for non-oncological conditions.

132 patients across four UK centres underwent PFR from 01/08/2004-28/03/2023 with median follow-up of 1.9 (Q10.5-Q34.2) years. 75 (56.8%) patients were female and the mean age was 74.0 (SD 11.7) years. 103 (78%) patients had Charleston Comorbidity Index ≥3. ASA class was III or IV in 66.6%. Indications were infected revision (39, 29.5%), periprosthetic fracture (36, 27.3%), acute trauma (30, 22.7%), aseptic revision (17, 12.9%), failed trauma (nine, 6.8%) and complex primary arthroplasty (one, 0.8%). The primary outcome was the local complication rate. Secondary outcomes were systemic complications, reoperation and mortality rates. Comparisons were made with t-tests and Chi2 tests to investigate patient and surgical factors associated with local complication. Statistical significance was p<0.05.

There were 37(28.0%) local complications. These were 18 (13.6%) dislocations, eight (6.1%) prosthetic joint infections, four (3.0%) haematomas, three (2.3%) superficial infections, one (0.8%) wound dehiscence, one (0.8%) sciatic nerve palsy and one (0.8%) femoral perforation. Dislocation mostly occurred in conventional articulations (12, 9.1%) followed by dual-mobility cups (three, 2.3%), constrained cups (two, 1.5%) and hemiarthroplasty (one, 0.8%). Median time to local complication was 30 (Q14-Q3 133) days. Seven (5.3%) patients developed a systemic complication. Thirty-three (25.0%) patients underwent reoperation. Thirty-day and one-year mortality rates were 3.8% and 12.1%, respectively. Longer surgical waiting times (7.9 \[SD 16.9) versus 2.6 \[SD 4.4\] days, p<0.001) and longer operating times (212.5 \[SD 71.8\] versus 189.4 \[SD 59.3\] mins, p=0.0450) were associated with local complication.

Due to its high complication rate, PFR should be a salvage option when performed for non-oncological indications. Conventional articulations should be avoided. PFR should be delivered in a timely manner and ideally as dual-consultant cases to reduce operating time.


Bone & Joint Open
Vol. 4, Issue 10 | Pages 742 - 749
6 Oct 2023
Mabrouk A Abouharb A Stewart G Palan J Pandit H

Aims

Prophylactic antibiotic regimens for elective primary total hip and knee arthroplasty vary widely across hospitals and trusts in the UK. This study aimed to identify antibiotic prophylaxis regimens currently in use for elective primary arthroplasty across the UK, establish variations in antibiotic prophylaxis regimens and their impact on the risk of periprosthetic joint infection (PJI) in the first-year post-index procedure, and evaluate adherence to current international consensus guidance.

Methods

The guidelines for the primary and alternative recommended prophylactic antibiotic regimens in clean orthopaedic surgery (primary arthroplasty) for 109 hospitals and trusts across the UK were sought by searching each trust and hospital’s website (intranet webpages), and by using the MicroGuide app. The mean cost of each antibiotic regimen was calculated using price data from the British National Formulary (BNF). Regimens were then compared to the 2018 Philadelphia Consensus Guidance, to evaluate adherence to international guidance.


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_10 | Pages 3 - 3
1 Aug 2021
Wignall A Giannoudis V Jimenez A De C Sturdee S Giannoudis P Pandit H Gulati A Palan J
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In March 2020, the World Health Organisation declared the COVID-19 outbreak a pandemic. Multiple new guidelines were proposed and existing models of social, domestic and hospital care altered. Most healthcare systems were largely unprepared for this and this pandemic has tested their adaptability. This study is aimed at assessing the impact of covid-19 on the demographics, presentation and clinical management of patients with proximal femoral (hip) fractures.

This retrospective multi-centre cohort study compared all patients admitted with hip fractures, between 1st March and 30th May 2019 (Group PC: Pre-Covid) with hip fracture patients admitted over the same time period during the pandemic in 2020 (Group C: Covid). The data was obtained from the hospitals' local and National Hip Fracture Databases. Mortality data was checked with the Office for National Statistics (ONS). Primary outcomes were time to theatre, in-patient length of stay and 30-day mortality.

580 patients were included (304 PC, 276 C). Patient Charlson comorbidity index and Nottingham Hip Fracture scores were broadly similar across the two cohorts. There was a significant reduction in percentage of total hip replacements in Group C (11% to 5%, p=0.006). There was an increase in conservative management in group C (1% to 5%, p=0.002). The time to theatre was significantly delayed in Group C (43.7 hours C versus 34.6 hours PC, p<0.001). Overall length of hospital stay was similar in both groups (16.6 days PC versus 15 days C, p=0.089). 30-day mortality rate in Group C was 9.8% compared to 8.2% in Group PC (p=0.431), but for covid (+) patients it was significantly higher at 38.2% versus 5.8% in covid (−) patients (p<0.001).

This is one of the largest multi-centre comparative cohort study in the literature to date, examining the impact of the covid-19 pandemic on the management of hip fracture patients. Whilst mortality rates were similar in both groups, covid patients were almost seven times more likely to die, reflecting the seriousness of the covid-19 infection and its sequelae in such elderly, vulnerable patients.


Bone & Joint 360
Vol. 7, Issue 5 | Pages 2 - 7
1 Oct 2018
Palan J Bloch BV Shannak O James P


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_12 | Pages 2 - 2
1 Oct 2018
Dodd CAF Kennedy J Palan J Mellon SJ Pandit H Murray DW
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Introduction

The revision rate of unicompartmental knee replacement (UKR) in national joint registries is much higher than that of total knee replacements and that of UKR in cohort studies from multiple high-volume centres. The reasons for this are unclear but may be due to incorrect patient selection, inadequate surgical technique, and inappropriate indications for revision. Meniscal bearing UKR has well defined evidence based indications based on preoperative radiographs, the surgical technique can be assessed from post-operative radiographs and the reason for revision from pre-revision radiographs. However, for an accurate assessment aligned radiographs are required. The aim of the study was to determine why the revision rate of UKR in registries is so high by undertaking a radiographic review of revised UKR identified by the United Kingdom's (UK) National Joint Registry (NJR).

Methods

A novel cross-sectional study was designed. Revised medial meniscal bearing UKR with primary operation registered with the NJR between 2006 and 2010 were identified. Participating centres from all over the country provided blinded pre-operative, post-operative, and pre-revision radiographs. Two observers reviewed the radiographs.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 77 - 77
1 Jan 2013
Isaac S Shyamsunder S Palan J Esler C
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Introduction

The optimal treatment for isolated patello-femoral arthritis is unclear. Patello-femoral arthroplasty (PFA) may offer superior knee function in isolated patello-femoral osteoarthritis compare to TKA. The literature is controversial for patient outcomes in PFA. Some reports showed improved outcomes while others were disappointing. We assessed our outcomes to try to identify causes for poor outcomes.

Methods

The Trent Arthroplasty was established in 1990 to collect prospective data on knee arthroplasty surgery. Data is entered by surgeons at the time of surgery, with patient consent. PFA constitute less than 1% of the arthroplasties performed in this region. Patients were sent self-administered outcome forms 1 year post-op. Re-operation and revision procedures were reported. 334 PFA have been registered from 17 hospitals. 79% were female patients with 43% of the patients aged 55 years or less, suggesting dysplasia as the cause of their osteoarthritis. Age range 28–94 yrs (SD 11.8 yrs). The implants were Stryker Avon 236, Corin Leicester 47, Link Lubinus 24, Smith & Nephew Journey 10, DePuy LCS 7, Wright FPV 2, other 8.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXIX | Pages 3 - 3
1 Jul 2012
Palan J Taub N Esler C
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Purpose of the Study

To identify trends in patient satisfaction of their knee arthroplasty, total and unicompartmental, one year post primary knee arthroplasty surgery, with reference to age, gender and primary diagnosis, from 1990 to 2008.

Methods & Results

The Trent Arthroplasty Register was established in 1990 to collect prospective data on knee arthroplasty surgery Data has been recorded relating to 48,929 knee arthroplasties in the period 1990-2008. Self-administered questionnaires were mailed to patients 1 year after their surgery. This PROMS data has been analysed to identify trends in 25,521 patients

62% (24,648) of knee arthroplasties were performed for osteoarthritis and 32% (1,233) for rheumatoid arthritis. 83.6% of osteoarthritic patients (20,244) were satisfied with their knee 1 yr post surgery, 8.5% (2055) unsure and 7.9% dissatisfied. Comparable figures for patients with rheumatoid arthritis were 81.3% (1,028) satisfied, 10.3% (130) unsure and 8.4% dissatisfied. Overall, there was no significant difference in satisfaction rates between different diagnostic groups of patients. In osteoarthritic patients, satisfaction rates have remained the same throughout the last 18 years, in different time periods. The satisfaction rate was 83.2% for the period 1990-1994, 80.9% for 1995-1999, 86.5% for 2000-2004 and 84.1% for 2005-2007. There was no statistically significant difference between the levels of satisfaction for these time periods. The age of the patient did not affect the satisfaction rate.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXIX | Pages 31 - 31
1 Jul 2012
Palan J Taub N Esler C
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Purpose

To identify if the age of the patient was related to satisfaction rates 1 year following unicompartmental knee replacement, in a generalist setting in the U.K.

Methods & Results

Unicompartmental knee replacement (UKR) is a treatment option for patients presenting with isolated medial compartmental osteoarthritis. In many cases, such patients are aged 65 years or younger. The Trent Arthroplasty Register was established in 1990 collecting prospective data on knee arthroplasties performed in this region of the U.K. Self completed questionnaires were sent to 1081 patients who had had a unicompartmental knee arthroplasty 1 year post surgery.

Completed questionnaires were received from 648 patients (60% return rate). Of these patients, 80.2% (451) reported being satisfied, 6.6% (37) unsure of their satisfaction and 13.2% (74) dissatisfied. 78% of those in the 55 or under group (n=92) were satisfied relative to 77.6% in 56-65 yr group (n=264), 90.6% for 66-75 yrs (n=202) and 87.6% for 75+ yrs (73).

Increasing age appears to correlate with increased satisfaction rates. Of those who were dissatisfied, severe pain was the primary reason given as a cause for dissatisfaction. In comparison, patients undergoing total knee arthroplasty (TKA), who were sent identical questionnaires, demonstrated no difference in satisfaction rates in each of the different age groups. The overall satisfaction rate in such patients was 90%.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 26 - 26
1 Jan 2011
Gulati A Glyn-Jones S Simpson D Palan J Beard D Gill H McLardy-Smith P Gundle R Murray D
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Roentgen Stereophotogrammetric Analysis (RSA) can predict long-term outcome of prostheses by measuring migration over time. The Exeter femoral stem is a double-tapered highly polished implant and has been shown to subside within the cement mantle in 2 year RSA studies. It has a proven track record in terms of long-term survivorship and low revision rates. Several studies have demonstrated excellent clinical outcomes following its implantation but this is the first study to assess stem migration at 10 years, using RSA.

This is a single-centre study involving 20 patients (mean age: 63 years, SD=7) undergoing primary total hip replacement for degenerative osteoarthritis using the lateral (Hardinge) approach. RSA radiographs were taken with the patient bearing full weight post-operatively, at 3, 6, 12 months and at 2, 5 and 10 years follow-up. The three-dimensional migration of the Exeter femoral stem was determined.

The mean Oxford Hip Score at 10 years was 43.4 (SD=4.6) and there were no revisions. The stems subsided and rotated internally during a 10-year period. The mean migrations of the head and tip of the femoral stem in all three anatomic directions (antero-posterior, medio-lateral & supero-distal) were 0.69 mm posterior, 0.04 mm lateral and 1.67 mm distal for the head and 0.20 mm anterior, 0.02 mm lateral and 1.23 mm distal for the tip. The total migration at 10 years was 1.81 mm for the head and 1.25 mm for the tip.

The Exeter femoral stem exhibits migration which is a complex combination of translation and rotation in three dimensions. Comparing our 10 year with our previous 2 year migration results, the Exeter stems show continued, but slow distal migration and internal rotation. The subsidence continues to compress the cement and bone-cement interface which maintains secure fixation in the long term.


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 422 - 422
1 Sep 2009
Gulati A Chau R Palan J Rout R Dodd C Price A Gill H Murray D
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Purpose: To compare the site of lesions in medial and lateral unicompartmental osteoarthritis (OA) of the knee.

Methods: Patients with medial (n=35) and lateral (n=15) OA, having unicompartmental knee arthroplasty, were recruited. Intra-operatively, the distance between the anterior, posterior, medial and lateral margins of the full-thickness lesion and reference lines dividing the condyles was measured. The midpoints of lesions were calculated and groups were compared. Lateral radiographs were used to determine the relationship between the lesion site and knee flexion angle (KFA).

Results: Femoral lesion: In lateral OA, the midpoint of lesions was 25.0mm (SD:8.8) posterior to the reference line passing transversely through the apex of the inter-condylar notch. This was significantly different (p< 0.001) from midpoint in medial OA, which was 10.7mm (SD:9.4) posterior to the reference line.

Tibial lesion: In lateral OA, the midpoint of lesions was 2.0mm (SD:6.5) posterior to the reference line passing through the mid-coronal plane of the resected tibia. This was located significantly more posterior (p=0.038) than midpoint in medial OA, which was 2.2mm (SD:5.7) anterior to the reference line.

Knee Flexion Angle: In lateral OA, the midpoint of lesions was on average at 40° flexion and sites of smaller lesions were very variable. The lesion expanded both anteriorly and posteriorly. In medial OA, smaller femoral lesions occurred in full extension and extended further posteriorly with disease progression.

No significant difference was demonstrated in medial and lateral localisation of the lesions.

Conclusion: Medial OA begins near full extension, progresses in a predictable manner and is perhaps initiated by events occurring at heel strike. Lateral OA begins in flexion in a less predictable manner, at KFA above that seen during the gait cycle. The different sites of lesions in medial and lateral OA suggest different aetiology and pathophysiology. Therefore, prevention and treatment strategies should be different.


Introduction: Approximately 60000 patients are admitted each year in the UK with neck of femur fractures, the vast majority of whom are elderly presenting with multiple medical comorbidities, including a history of ischaemic heart disease and stroke. They are often on a number of regular medications which may include aspirin, warfarin and more recently, clopidogrel. Clopidogrel and aspirin are associated with an increased bleeding time especially if present as a combined therapy. As such, they can lead to bleeding complications in patients undergoing surgery, increasing the need to transfuse such patients and increasing the risk of cardiovascular events as a result of anaemia. Although clopidogrel is often stopped for patients undergoing elective surgery for a period of 7–10 days, to our knowledge, no such guidelines are available regarding the discontinuation of clopidogrel in patients undergoing surgery for femoral neck fractures. The aim of conducting this survey was to investigate the current practice of various orthopaedic units in the UK with regards to stopping clopidogrel in such patients.

Methods: A telephone questionnaire survey was conducted on junior doctors (House officers, Senior House Officers and Registrars) in orthopaedic departments in the UK which routinely admit and treat patients with fractured neck of femurs.

Does your trust/department have a policy on discontinuing clopidogrel in patients who are due to have emergency trauma surgery such as operative fixation for femoral neck fractures?

If yes: how many days prior to surgery is the clopidogrel discontinued?

If no: are any precautions undertaken?

Clotting function checked:

Platelet cover/other blood products:

Increased X matching of packed red cells:

Other precautions?

Any complications as a result of clopidogrel?

Results: 184 NHS trusts in the UK were involved. 45% of trusts stop clopidogrel routinely prior to performing surgery on patients with femoral neck fractures. The number of days clopidogrel is stopped prior to surgery varied from 1 – 7 days. 55% of trusts did not routinely stop aspirin prior to surgery. 97% of trusts routinely stopped warfarin prior to surgery and the target INR varied from < 1.0 – < 3.2.

Conclusions: It is clear from this study that a wide range of policies exists amongst orthopaedic departments in the UK regarding the routine discontinuation of clopidogrel, aspirin and warfarin in patients with femoral neck surgery who are awaiting surgery. This highlights the need for further debate and guidelines regarding the routine discontinuation of clopidogrel.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 478 - 478
1 Aug 2008
McErlain M Palan J Nelson I Hutchinson M
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Introduction: L5/S1 injuries can be associated with pelvic fracture but unfortunately they are often missed. Left untreated these patients may suffer disabling lower back pain. Our goal is to study the frequency of these injuries in pelvic fractures treated at this institution, thereupon to determine how many are missed and the outcome if this injury is treated conservatively. We will describe the radiological findings, anatomical features and possible surgical treatments.

Materials and Methods: A retrospective analysis was undertaken of pelvic fractures treated at this institution from 2000 onward. Outcome scores were taken from the patient records. All CT scans and x-rays were scru-tinised for a Lumbosacral Junction Injury(LJI). Numbers missed were tallied against numbers diagnosed and treated. Patient outcome measures were compared using the Matta Hip Scores. It was noted whether low back or hip pain contributed to their symptoms most.

Results: The incidence of lumbar sacral injuries associated with vertical shear pelvic fractures was 20%. Of these, 75% had not been identified as a specific lumbar-sacral injury. The remaining 25% which were identified and treated with fixation of the lumbar sacral junction had an excellent result. We have identified specific morphology patterns and propose a CT based grading system.

Discussion: We suggest that a heightened level of awareness is needed for these important injuries in pelvic trauma as their occurrence changes the management. The incidence appears to be higher than that reported by Isler and suggest our CT based classification be used to grade these injuries.