Aims

Return to sport following undergoing total (TKA) and unicompartmental knee arthroplasty (UKA) has been researched with meta-analyses and systematic reviews of varying quality. The aim of this study is to create an umbrella review to consolidate the data into consensus guidelines for returning to sports following TKA and UKA.

There is growing interest in the peri-operative management of patients with indications for hip and knee arthroplasty in the setting of modifiable risk factors such as morbid obesity, type 2 diabetes mellitus, and smoking. A recent survey of the American Association of Hip and Knee Surgeons (AAHKS) found that 95% of respondents address modifiable risk factors prior to surgery. The aim of this study was to poll Australian arthroplasty surgeons regarding their approach to patients with modifiable risk factors. The survey tool used in the AAHKS study was adapted for use in the Australian context and distributed to the membership of the Arthroplasty Society of Australia via Survey Monkey. Seventy-seven survey responses were received, representing a response rate of 64%. The majority of respondents were experienced, high volume arthroplasty surgeons. Overall, 91% of respondents restricted access to arthroplasty for patients with modifiable risk factors. Seventy-two percent of surgeons restricted access for excessive body mass index, 85% for poor diabetic control, and 46% for smoking. Most respondents made decisions based on personal experience or literature review rather than hospital or departmental pressures. Despite differences in healthcare systems, our findings were similar to those of the AAHKS survey, although their responses were more restrictive in all domains. Differences were noted in responses concerning financial considerations for potentially underprivileged populations. The survey is currently being administered by arthroplasty societies in six other countries, allowing comparison of orthopaedic practice across different healthcare systems around the world. In conclusion, over 90% of Australian arthroplasty surgeons who responded to the survey address modifiable risk factors prior to surgery

In his classic monograph entitled Low Friction Arthroplasty of the Hip, which was published in 1979, John Charnley dedicated a chapter to thromboembolic complications. The overall incidence of pulmonary embolism (PE) was approximately 8% and the incidence of death from PE approximately 1%. Surveys of orthopaedic surgeons who undertake total joint replacement conducted by The American Association of Hip and Knee Surgeons (AAHKS), 30 years later, showed that there was still no consensus as to the best form of prophylaxis with a wide variation of methods being used. In the past 3 years, for the first time there is uniformity in the recommendations of the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP). Both groups have reached an agreement that the rate of DVT formation is not the ideal endpoint to use when assessing the efficacy of thromboprophylaxis after joint replacement, as had been done in previous drug trials. Most of these DVTs are asymptomatic and of questionable clinical significance. At least one recent study brings into question the association between the rate of DVT formation and that of subsequent symptomatic events. Both groups also focus on minimizing iatrogenic bleeding complications, which can lead to compromised clinical results, including limited movement and pain in the case of knee replacement and increased risk of infection in both knee and hip replacement. To further complete the uniformity of approach in the United States, the Center for Medicare and Medicaid Services (CMS), which administers the Surgical Care Improvement Program (SCIP) that monitors hospital compliance with VTE prophylaxis of hospitalised patients, has also changed their policy. Beginning January 2014, either aspirin or a compression device has been considered as acceptable measures for THR, TKR and hip fracture. The remarkable success reported from many centers with the use of aspirin and/or the use of a mobile compression device in patients without major risk factors, such as a prior history of symptomatic VTE, clearly indicate that aggressive pharmacoprophylaxis is not necessary for the vast majority of patients who undergo joint replacement

There is continuing debate among orthopedists regarding the appropriate treatment of femoral neck fractures, open reduction internal fixation (ORIF), Total hip arthroplasty (THA) or hemiarthroplasty. In 2003 310,000 patients were hospitalized for hip fracture in the United States and about one-third were treated with total hip arthroplasty. Worldwide, the total number of hip fractures is expected to surpass 6 million by the year 2050. In a survey distributed by the American Association of Hip and Knee Surgeons, and of the 381 members who responded, 85% preferred hemiarthroplasty, 2% preferred ORIF and 13% preferred THA. The decision to perform internal fixation, hemiarthroplasty, or THA is based on comminution of the fracture activity level and independence, bone quality, presence of rheumatoid or degenerative arthritis, and mental status. Evidence based practice indicates that in a young patient with good bone stock and a fracture with relatively low comminution an ORIF is the treatment of choice. If the patient has a comminuted fracture with poor bone quality, minimal DJD, no RA, and low activity demand a hemiarthroplasty is a reasonable choice. If the patient has a comminuted fracture with poor bone quality, DJD and high activity demand a total hip replacement is a reasonable choice

Total hip and knee arthroplasty is known to have a significant blood loss averaging 3–4 g/dL. Historically, transfusion rates have been as high as 70%. Despite years of work to optimise blood management, some published data suggests that transfusion rates (especially with allogeneic blood) are rising. There is wide variability between surgeons as well, suggesting that varying protocols can influence transfusion rates. Multiple studies now associate blood transfusions with negative outcomes including increased surgical site infection, costs, and length of stay. Preoperative measures can be employed. Identify patients that are at increased risk of blood transfusion. Smaller stature female patients, have pre-operative anemia (Hgb less than 13.0 gm/dl), or are undergoing revision or bilateral surgery are at high risk. We identify these patients and check a hemoglobin preoperatively, using a non-invasive finger monitor for screening. For anemic patients, iron administration (oral or IV) can be given, along with Procrit/Epogen in select cases. Insurance coverage for that medication has been challenging. Intraoperative measures that have been linked to reduced postoperative transfusions include regional anesthesia and intraoperative hypotension (mean arterial pressure <60mm/hg). Lowering the surgical time by practicing efficient, organised, and quality surgery, along with leaving a dry field at the completion of surgery can reduce blood loss. Tranexemic acid (TXA) is an antifibrinolytic agent that has been shown to be effective, reducing average blood loss by 300 cc per case. There are multiple different administration protocols: IV using either a weight-based dosing 10–20 mg/kg or standardised dosing for all patients. Our current regimen is 1 gm IV preoperatively, 1 gm IV in PACU. Topical TXA can be used, usually 2–3 gm mixed in 50–100 cc of saline, sprayed in wound and allow to soak for 3–5 minutes. Oral administration is attractive for ease of use and reduced cost, standard oral dosing is 1950 mg PO 2 hours prior to surgery. The American Association of Hip and Knee Surgeons, in collaboration with the American Association of Orthopedic Surgeons, American Society of Regional Anesthesiologists, and the Hip & Knee Society have developed a Clinical Practice Guideline with 8 recommendations for TXA as follows: All individual formulations are effective at reducing blood loss – strong; No method of administration is clearly superior at reducing blood loss and the risk of transfusion; The dose of IV or topical TXA does not significantly affect the drug's ability to reduce blood loss and risk of transfusion; Multiple doses of IV or oral TXA compared to a single dose does not significantly alter the risk of blood transfusion; Pre-incision IV TXA administration potentially reduces blood loss and risk of transfusion compared to post-incision administration; Administration of all TXA formulations in patients without history of VTE does not increase the risk of VTE; Administration of all TXA formulations in patients with a history of VTE, MI, CVA, TIA, or vascular stent does not appear to increase the risk of VTE; Administration of all TXA formulations does not appear to increase the risk of arterial thrombotic events; Postoperative measures to reduce transfusion rates include changing transfusion triggers. Instead of treating a “number”, use lower thresholds and employ safe algorithms established. In conclusion, a comprehensive blood management program can reduce transfusion rates to less than 3% for THA and 1% for TKA and facilitate outpatient total joint arthroplasty

Purpose. Conflict of interest reporting at annual orthopaedic surgical meetings aims to ensure transparency of surgeon-industry relationships. Increasing rigor in the reporting guidelines provides a unique opportunity to understand the impact of industry relationships in the conduct of orthopaedic research. We examined self-reported conflicts by surgeons presenting original research in arthroplasty and trauma meetings. Method. We reviewed the proceedings of the 2009 Annual American Association of Hip and Knee Surgeons (AAHKS) and Orthopaedic Trauma Association (OTA). Information including the number of studies, self-reported conflicts, nature of conflicts, and direction of study results were extracted. Conflicts were compared between arthroplasty and trauma meetings. Results. A total of 85 AAHKS abstracts (45 presentations and 40 posters) and 201 OTA abstracts (88 presentations and 113 posters) were included. Abstracts presented at the AAHKS revealed significantly more conflicts than those presented at the OTA (84/85 presentations, 98.8%, versus 156/201 presentations, 77.6%, respectively, p value < 0.0001). On average, papers at the AAHKS and OTA meetings had similar numbers of conflicts per paper (9.5 versus 9.8, respectively). 213 (52.6%) of authors at the AAHKS revealed at least one conflict compared to 364 (40.6%) of authors at the OTA (p value < 0.0001). The most common conflicts included research, institutional, fellowship, and grant support (48.3%) and paid consultant, salary or staff (20.2%). Conclusion. Our findings suggest that surgeon-industry relationships are critical to the conduct of research. The high proportion of papers with self-reported conflicts of interest supports increasing transparency and rigor in reporting guidelines at orthopaedic meetings

Introduction: The Durom hip acetabular component is a large diameter metal on metal (MoM) implant that has recently been the subject of much controversy. Dr. Lawrence Dorr, reported in a letter in April 2008 to the American Association of Hip and Knee Surgeons a worryingly high number of early revisions, as many as 8%, within the first 2 years as a result of a loose acetabular component. Following a Zimmer investigation an early revision rate of 5.7% in the US, but not in Europe, was revealed and this has resulted in the withdrawal of the implant from the market in the US and justifiable concern with regards to its usage resulting in decreased implantation within the UK. Surgical technique in the US has been sited as the main reason for failure as a result of low volume centres not performing crucial steps in the technique which include, but are not limited to, line-to-line reaming, use of trials in every case, proper cup position for this device, appropriate impaction techniques and no repositioning. We present the short term results and our experience of the Durom Acetabular component in our centre in the UK. Method: We reviewed all patients that had a Durom Acetabular component implanted since its usage began in our unit in 2003. No patients were excluded and the end point being revision surgery of the Durom acetabular component. In addition we analysed the plain radiographs of a random selection of 50 patients to assess component integration. Results: 260 patients had undergone primary hip surgery with the implantation of the Durom Acetabular component. 108 as part of a hip resurfacing and 152 as a large bearing MoM THR. Their follow up ranged from 1 to 7 years. 1 had undergone revision for thigh pain with aseptic failure of the acetabular component, 1 for ALVAL, 3 had undergone revison for infection and 1 for peri-prosthetic fracture. Analysis of the radiographs revealed a number of acetabulae with a lucent line visible around the implant. None of the implants had migrated from their original position at implantation. Conclusions: At present their appears to be no evidence in our unit that the Durom Acetabular component has a higher than expected rate of early revision. However, a number of patients do appear to have lucency around the component on radiographs raising the possibility of questionable bony integration and on growth. Reports from the United States have suggested that the cup will “spin out” easily at revision showing no signs of bony integration. This may result in an increased revision rate in the future and we suggest that all patients that have a Durom acetabular component in situ be followed up with yearly clinical assesment and radiographs to assess the longevity of this component

Background: Implant fractures are complications that have a great impact on the patient’s quality of life after total hip arthroplasty. Nevertheless their occurrence is often considered as rare in clinical practice. We compared incidences of implant fractures in various datasets in order to calculate the risk of a fracture and assess the quality of these datasets for such evaluations. Methods: In a structured literature analysis based on a standardised methodology the incidence of reoperations was evaluated comparing clinical studies published in Medline-listed journals and annual reports of National Arthroplasty Registers worldwide. Case reports and experimental studies were not considered. Results: The majority of clinical studies are monocentre trials. The publications comprise a cumulative number of 72,571 stems with 234 stem fractures, 73,743 cups with 191 component fractures, and 16,381 ceramic heads with 44 fractures. A survey among the members of the American Association of Hip and Knee Surgeons covered 64,483 primary operations, hence including a similar number of primary cases as all monocentre studies together. This dataset involves 355 implant fractures. By contrast, worldwide Register data refer to 733,000 primary operations, i.e. approximately 10 times as many as sample-based datasets. In general, sample-based datasets present higher revision rates than register data. The deviations are high, with a maximum factor of 64 for hip stems. Whereas the AAHKS survey exhibits lower deviations than the monocentre trials, they are still too high for this data collection tool being considered as reliable and safe to provide valid data for general conclusions. The incidence of implant fractures after total hip arthroplasty in pooled worldwide arthroplasty register datasets is 304 fractures per 100.000 implants. In other words, one out of 323 patients has to undergo revision surgery due to an implant fracture after THA in their lifetime. Conclusion: For general assessments in the context of implant fractures, register data have the highest value. Clinical studies, which often focus on a particular implant, are of very limited value for global conclusions. Structured surveys produce more reliable data than clinical studies and are superior to monocentre trials. However, the AAHKS survey presents data that also show considerable differences to data from registers. For the detection of rare, but severe complications like implant fractures sample-based studies achieve the goal of providing accurate figures only to a very limited extent, even if the samples are large. Here, too, comprehensive national arthroplasty registers are the most suitable tool to identify such incidents and calculate reliable figures. Contrary to the prevalent opinion, implant fractures still are a relevant problem in arthroplasty

Over the past 40 years information from large institutional total joint registries have aided in patient clinical care and follow-up efforts, have helped drive improvements in clinical practice, and have been a powerful tool for generating research studies on large well documented populations of patients. Still, these efforts are limited in that they are expensive, usually reflect a single institutional experience, and results can be biased by the larger volumes or experience at the typically large academic centers which have such registries in place. National registry efforts in other countries including Scandinavia, Australia, and the UK have resulted in improved outcomes and a decreased number of revision procedures by a combination of early identification and withdrawal of poorly performing implants, altered surgical techniques, implant choices and behaviors by surgeons, changes in practices by hospitals, and modification in requirements and incentives by payors and regulatory agencies. The American Joint Replacement Registry (AJRR) is a collaborative multi-stakeholder, independent, not-for-profit 501 c3 organisation established in 2009 for data collection and quality improvement initiatives relating to total hip and knee arthroplasty. AJRR is a national registry effort with the goal of enrolling more than 90% of the over 5,000 hospitals performing nearly 1 million hip and knee arthroplasties each year in the US. AJRR is supported by contributions from the American Academy of Orthopedic Surgeons (AAOS), the American Association of Hip and Knee Surgeons (AAHKS), the Hip Society, the Knee Society, Health Insurers, Medical Device Manufacturers, and individual orthopaedic surgeons via designated contributions through the Orthopedic Research and Education Foundation (OREF). The overarching goal of AJRR is to improve arthroplasty care for patients through the collection and sharing of data on all primary and revision total joint replacement procedures in the U.S. The mission of the registry is to enhance patient safety, and improve the value of arthroplasty care. This will be accomplished by providing national benchmarks for implant, surgeon and hospital performance which serves to modify behaviors thereby decreasing the revision burden, improving outcomes and reducing costs. From the time of incorporation in 2009 up to October 2013 the AJRR has secured the participation of 218 hospitals in 47 different states in the formal enrollment process, and have level one data submission from more than 100 institutions on over 63,000 hip and knee procedures. In addition to publicly available annual reports, confidential specific individual reports for hospitals, surgeons and manufacturers will be available by subscription with an option for future confidential online direct data queries by an individual or entity regarding their own individual performance compared to national benchmark values. In summary, registry studies have provided a rich source of information for improving arthroplasty care over the past four decades, with the emergence and increasing interaction of national registries a major factor in current efforts to increase both the quality and value of the health care of entire populations. The development, support and continued expansion of a national registry in the US must remain a central focus if we wish to improve as much as possible the arthroplasty care provided to all patients in our country

Aims

Obesity is associated with an increased risk of hip osteoarthritis, resulting in an increased number of total hip arthroplasties (THAs) performed annually. This study examines the peri- and postoperative outcomes of morbidly obese (MO) patients (BMI ≥ 40 kg/m²) compared to healthy weight (HW) patients (BMI 18.5 to < 25 kg/m²) who underwent a THA using the anterior-based muscle-sparing (ABMS) approach.

Aims

To investigate the optimal thresholds and diagnostic efficacy of commonly used serological and synovial fluid detection indexes for diagnosing periprosthetic joint infection (PJI) in patients who have rheumatoid arthritis (RA).

Aims

This study investigates head-neck taper corrosion with varying head size in a novel hip simulator instrumented to measure corrosion related electrical activity under torsional loads.

Obesity is a global epidemic of 2.1 billion people and a well known cause of osteoarthritis. Joint replacement in the obese attracts more complications, poorer outcomes and higher revision rates. It is a reversible condition and the fundamental principles of dealing with reversible medical conditions prior to elective total joint replacement should apply to obesity. The dilemma for orthopaedic surgeons is when to offer surgery in the face of a reversible condition, which if treated may obviate joint replacement and reduce the risk and severity of obesity related disease in both the medical arena and the field of orthopaedics.