Introduction. Unicompartmental knee arthroplasty (UKA) is becoming an increasingly popular option in single compartment osteoarthritis. As a result, diverse re-operations including revisions to total knee arthroplasty (TKA) has also increase. The objective of this study is to investigate the distribution of causes of re-operations after UKA and to analyze the types of re-operations. Method. We retrospectively reviewed 691 UKAs performed on 595 patients between January 2003 and December 2011. Except in one case, all UKAs were performed for medial compartment osteoarthritis of the knee. The UKAs were performed in 487 (81.8%) women and 108 (18.2%) men. The mean age at the time of UKA was 61.5 years (47 to 88 years). Mobile-bearing designs were implanted in 627 (90.7%) knees (626- Oxford knee and 1- Scorpio knee) and fixed designs were implanted in 64 (9.3%) knees (42- Tornier and 18- Zimmer). The mean interval between UKA and second operation was 15.4 months (10 days to 10 years) and between second and third operation was 7.7 months (5 weeks to 17 months). In the re-operation group, there were 50 knees (48 patients) with 38 female and 10 male patients. Results. In our study, the burden of a re-operation after the initial UKA was 8.7%with, the total number of re-operation of 60. There was 50 cases of second operations (n = 45 mobile, n = 5 fixed), and 10 cases of second re-operation. The most common cause of a second re- operation after a mobile-bearing UKA was the dislocation of the meniscal bearing (32%), followed by component loosening (20%), the formation of a cement loose body (14%), unexplained pain (12%), infection (6%), periprosthetic fracture (4%), and others (2%). For the fixed-bearing UKA, the causes of a second operation were loosening (4%), unexplained pain (4%), and bearing wear (2%). 10 cases required a 3rd operation at mean time interval of 7.7 months, of them 7 cases (70%) had liner exchange at their 2nd operation. Discussion and conclusion. The most common cause of a second re-operation after a mobile-bearing UKA was the dislocation of the bearing, followed by component loosening and the formation of a cement loose body. After a fixed-bearing UKA, component loosening and unexplained pain were the most common causes of re-operation. In cases which underwent a third operation, 70 percent had liner exchange with or without some minor procedure at the time of the 2ndoperation. All were converted to TKA at their 3rd operation at a mean time interval of only 7.7 months. Based on our observations, we recommend a cause-based approach to the management of primary and failed UKA to help minimize the possibility of second and third operations. Furthermore caution should be undertaken when contemplating liner exchange as treatment option in cases involving mobile-bearing UKA

The volume of spinal procedures have increased over the last two decades (220% in lumbar region). A simultaneous increase in re-operation rates (up to 20%) has been reported. Our aim was to compare with literature the reoperation rates and complications for various spinal procedures from a peripheral unit and to provide this information to the patients. This was a retrospective study of all patients who underwent spinal surgery during the period 1995 to 2005 by one surgeon. Using ICDM-9 codes and private notes patients were identified and medical records were used to gather relevant data. The following information was extracted-demographics, diagnosis, ASA criteria, primary procedure, any complication/s, secondary procedures, duration of follow up and to secondary procedure. The index procedures were grouped into regional and according to indication. Both complications and reoperations were grouped into early (within three months) or delayed (after three months) from the index operation. Reoperation rates and complications were calculated and compared with literature. Four hundred and thirty-nine patients formed the study population. Five patients had inadequate data and were excluded. 23 patients have since died. Demographics showed 22% were smokers and 9% were either unemployed or sickness beneficiary. The commonest diagnosis in the lumbar spine was disc herniation (194). Stenosis and disc degeneration were the next most common surgical indications. In the cervical spine 27 patients had disc herniation and 15 patients were operated for trauma. Lumbar discectomy was the commonest procedure-191 patients with one third having microdiscectomy. Instrumented fusion was performed in 97 while 37 patients underwent decompression only. The majority of cervical spine patients (46) had discectomy and fusion. Stabilisation for trauma formed a reasonable workload in both cervical and lumbar regions. Early complications included dural tears (seven), neurological symptoms (eight), wound infections (12) and pulmonary embolism (one) and repeat disc herniation. Delayed problems included repeat disc herniation, pseudoarthrosis and implant related symptoms. Overall re-operation rate was 14.52% with 5.02% early and 9.4%delayed repeat surgery. Repeat discectomy (eight) and decompression and exploration (seven) were the common early reoperation whereas fusion post discectomy (19) and recurrent disc herniation (12) were indications for delayed intervention. Removal of metalware (8) was another large late re-operation group. Our re-operation rates fall within the quoted figures in literature. However our early re-operation rates are somewhat higher. These figures help us to inform patients better at the time of consent for the primary procedure especially lumbar disc surgery as most of the re-operation were required after discectomy

Purpose. Factors that contribute to early and late re-operation after cruciate reconstruction (CR) have not been evaluated on a population level in a public health system. After surgery patients are at risk for knee stiffness, infection or early graft failure prompting revision. Long-term, ipsilateral revision CR, contralateral CR and potentially even joint replacement may occur. Population research in total joint replacement surgery has demonstrated an inverse relationship between complication/failure rates and surgeon procedural volume. We hypothesized that in Ontario, younger patient age and lower surgeon volume would increase the risk of short and long-term re-operation after CR. Method. Billing, procedural and diagnostic coding from administrative databases (Ontario Health Insurance Plan, Canadian Institutes of Health Research) were accessed through the Institute for Clinical Evaluative Sciences to develop the cohort of all Ontario residents aged 14 to 60 who underwent anterior or posterior CR from July 1992 to April 2008. Logistic regression analysis was used to calculate the odds ratio for patient (age, gender, comorbidity, income, concurrent knee surgery) and provider (surgeon volume, teaching hospital status) factors for having a surgical washout of the knee, manipulation for stiffness or repeat of the index event within six months. A cox proportional hazards survivorship model was used to calculate the hazard ratio of the same covariates for repeat CR and partial/total knee arthroplasty from inception until end of 2009. Results. The cohort identified 34,735 CR patients with a median age 28 yrs (IQR 20–36) and 65% male. Re-operation for infection was 0.2% and stiffness 0.5%. The long-term rate of any repeat CR was 7.7% after a mean 4.23.4 years. Female gender (OR=2.8, p<0.0001), overnight hospital stay (OR=2.1, p=0.0005), meniscal repair with CR (OR=1.9, p=0.008) and surgeon volume of 0–12 CR/yr (OR=4.0, p=0.0006), significantly increased the odds of re-operation for stiffness. The odds of re-operation for infection were significantly increased for surgeons performing 0–12 CR/yr (OR=3.8, p=0.007), and for CR performed at a teaching hospital (OR=2.3, p=0.002). Repeat CR was not influenced by surgeon volume at any time-point. Survival analysis demonstrated a long-term repeat CR rate of 13% (HR=1.8, p<0.0001) for age 14–19 yrs compared to the mean cohort age. Late partial or total knee replacement occurred in 0.75% of patients, with increased risk found for patients >30 years (HR=2.5, p=0.002), or who had concurrent surgery for an osteochondral lesion at the index CR (HR=2.3, p=0.001). Conclusion. Although this data is limited by the ability to distinguish between anterior or posterior and revision or contralateral CR, we have demonstrated that lower volume surgeons have higher complication rates (stiffness, infection) after CR surgery. We have also identified at-risk groups, such as females for stiffness post-CR and osteochondral injury + CR for eventual knee replacement

AIM: To investigate the relationship between patient variables and surgeons’ grade and experience on one hand and re-operation and mortality rates at six months on the other hand. Method: Seven hundred and sixty-one patients with proximal femoral fractures (PFF) (463 intracapsular fractures, 286 extracapsular fractures, and 12 subtrochanteric fractures) were treated surgically between April 2005 to October 2007. The level of experience among trainees was quantified as the number of PFF they had fixed or replaced as the first surgeon, from the start of their training at Senior House Officer level to the beginning of the study period. Logistic regression model was used to investigate the relationship between mortality and re-operation at six months and case mix variables (age, ASA grade, fracture types, pre-fracture residence, and mobility and activity level), and management variables (days to operation, the grade of the surgeon and supervision level). Mann-Whitney test was used to compare the level of experience among trainees in the group of patients who died or required re-operation at six months. Results: At six months, the mortality rate was 24.2% (184) and the re-operation rate was 3.8% (29). The logistic regression model used to predict six months mortality was highly significant (X2=166.6 [24df], p< 0.0001). It showed that age, ASA grade and pre-fracture activity level were strongly associated with mortality at six months. Patients operated on by a trainee without the consultant being scrubbed were 1.8 times (p< 0.05) more likely to die at 6 months. (Odds ratio of 1.8 with 95% confidence interval of 1.15 to 2.75). Re-operation at six months could not be predicted by these factors. Regarding patients operated on by trainees, there was no significant difference in the level of experience among trainees who operated on patients who died or who required re-operation at six months compared to those who did not

There has been recent interest in the treatment of Dupuytren's disease by minimally invasive techniques such as needle fasciotomy and collagenase injection, but only few studies have reported the outcomes following open fasciotomy. This study attempts to address this gap, with a retrospective analysis of a large series of patients who underwent an open fasciotomy by a single surgeon over a five-year period. The aim of the study was to determine the requirement for re-operation in the cohort and to analyse the revisionary procedures performed. Theatre coding data was used to identify a consecutive series of patients who underwent open fasciotomy over a five-year period between 2000 and 2005. Within this group medical records were obtained for those patients who underwent a secondary procedure for recurrence. All procedures were carried out by a single surgeon in a regional hand unit using an unmodified open technique. A total of 1077 patients underwent open fasciotomy for Dupuytren's disease. Of these, 865 (80.3%) were male and 212 (19.7%) were female. The mean age at initial surgery was 64.4 years (range 21.7 to 93.7 years) for males and 68.3 (range 43.6 to 89.8 years) for females. Of the 1077 patients who underwent open fasciotomy, 143 patients (13.3%) subsequently underwent a second procedure for recurrence. The medical records were available for 97 patients. The median time to re-operation in this group of patients was 42.0 months (95% CI, 8.3 to 98.0 months). The most common revision procedure being dermofasciectomy (54.2%), followed by fasciectomy (32.6%) and re-do open fasciotomy (13.2%). Mean pre-operative total extension deficit was 88 degrees (range 30–180 degrees) with intra-operative correction to a mean of 9.5 degrees (range 0–45 degrees). There is no standard definition for recurrence after Dupuytren's surgery. We have looked at the rate of revision surgery after open fasciotomy, in a relatively fixed population serviced over a 5-year period by a single hand surgeon. A low re-operation rate has been identified, with good intra-operative correction achieved by secondary surgery

Winner of ISFR Best Paper Award. Introduction: Surgeons agree on the benefits of intramedullary nailing of tibial shaft fractures. We assessed the impact of reamed versus unreamed intramedullary nailing on re-operation rates. Methods: The Study to Prospectively Evaluate Reamed Intamedullary Nails in Tibial Fractures (SPRINT) was a multi-center, randomized trial including 29 clinical sites. 1339 patients with tibial shaft fractures were randomized to either reamed or unreamed intramedullary nail insertion. Re-operations before 6 months were not permitted unless there was critical bone loss. The primary outcome was re-operation to promote healing, treat infection, or preserve the limb. We planned a priori to conduct a subgroup analysis of outcomes in patients with open and closed fractures. Results: Of 1339 enrolled patients, 1226 patients were followed to 1 year. Across treatment groups, patients did not differ in age, gender, and fracture types. The overall event rate was 17.8% (13.7% closed, 27%, open fractures). In 826 patients with closed fractures, patients with a reamed nail had a relative risk reduction of 33% (95%CI: 4–53%, P=0.03). This treatment effect was largely driven by differential autodynamization rates (rel risk: 0.42, p=0.01). Among 400 patients with open fractures, there was a trend towards an increased risk of an event (rel. risk=1.27, p=0.16) for those who received a reamed nail. Conclusions: Our overall incidence of revision surgery was lower than reported in previous studies. Optimizing peri-operative care and avoiding premature re-operation may substantially decrease the need for re-operation in tibial fracture patients

Recent projections expect the number of revision knee replacements performed to grow from 38,000 in 2005 to 270,000 by the year 2030. 1. Although the results of primary total knee arthroplasty are well documented, with overall implant survivorship at 15 years greater than 95%. 2. the results of revision procedures are not as well known. What if the revision TKR fails and what is the prevalence of failure of revision TKRs, the complications and re-operation rates? There are various studies which has either exclusively dealt with the causes or outcomes of revision with a particular prosthesis and survivorship analysis. The effectiveness of revision total knee replacement must be considered in the light of complications rates which could be either medical, orthopaedic surgery related complications or combination of both. The purpose of this study was to evaluate the prevalence of complications, reoperation rates and outcomes in a single surgeon's series between 1984 and 2008. Ninety nine index revision cases were studied. Incidences of surgical complications were 52.5%. The total reoperation rate was 34.3% whilst single re revision accounted for 19.9% whereas multiple re-revision incidences were 4%. The mean outcome in terms of Knee Society Score, Knee Society Function, and Knee society range of motion was statistically and clinically significant between pre operative and posts operative score at one year and remained consistent with time. These results suggest that modern revision total knee replacement are satisfactory operations and the outcomes perhaps can be improved if relatively simple strategies are followed by focusing these operations to specialized that accumulate enough experience from these demanding surgeries. Overall the results asserts that even in the hands of an experienced surgeon the complications do occur which is usually multi factorial, whilst in the light of complications and reoperation incidence the patients can be counselled thoroughly before the procedure

Purpose: Surgeons agree on the benefits of intramedullary nailing of tibial shaft fractures. The SPRINT primary objective aimed to assess the impact of reamed versus unreamed intramedullary nailing on rates of re-operation in patients with tibial shaft fractures. Method: The Study to Prospectively Evaluate Reamed Intramedullary Nails in Tibial Fractures (SPRINT) was a multi-centre, randomized trial including 29 clinical sites. SPRINT enrolled 1319 patients with open or closed tibial shaft fractures. Patients, outcome assessors, and data analysts were blinded to treatment allocation. Peri-operative care was standardized, and re-operations before 6 months were not permitted unless there was critical bone loss. Patients received a statically locked intramedullary nail with either reamed or unreamed insertion. The primary outcome was re-operation to promote healing, treat infection, or preserve the limb. We planned a priori to conduct a subgroup analysis of outcomes in patients with open and closed fractures. Our sample size calculations required 1200 patients followed for 1 year. Results: Of 1319 enrolled patients, 1226 patients were followed to 1 year. Across treatment groups, patients did not differ in age, gender and closed and open fracture types (I-IIIB). The overall event rate was 17.8% (13.7% closed, 26.5%, open fractures). A significant subgroup interaction effect in patients with open versus closed fractures (p=0.01) mandated a separate analysis for each subgroup. In 826 patients with closed fractures, patients with a reamed nail had a relative risk reduction of 33% (95%CI: 4–53%, P=0.03). This treatment effect was largely driven by differential autodynamization rates (rel. risk: 0.42, p=0.01). Among 400 patients with open fractures, there was a trend towards an increased risk of an event (rel. risk=1.27, p=0.16) for those who received a reamed nail. Conclusion: Our overall incidence of revision surgery was lower than reported in previous studies. Possible reasons for the overall lower event rates in SPRINT are:. standardization of surgical and post-surgical care resulted in superior care among the SPRINT centres and surgeons and. proscription of surgery until after 6 months. Optimizing peri-operative care and avoiding premature re-operation may substantially decrease the need for re-operation in tibial fracture patients

To describe complications and reoperation rates associated with degenerative spinal deformity surgery. A retrospective review of prospectively collected data from a single spinal surgeon in the United Kingdom. A total of 107 patients who underwent surgery, of 5 or more levels, for primary degenerative kyphoscoliosis between 2006 and 2012 were identified. Clinical notes were reviewed and post-operative complications, reoperation rates, length of follow up and mortality were analysed. A total of 107 patients, average aged 66.5 years (range 52 – 85), with 80% women. 105 patients underwent posterior surgery, two patients required both anterior and posterior surgery. The average number of instrumented levels was 8.3; 10% 5 levels, 15% 6 levels, 11% 7 levels, 14% 8 levels, 15% 9 levels and 35% had fusions of 10 levels and above. 58% included fixation to sacrum or pelvis. 93% had a decompression performed and 30% had an osteotomy. There were 40 complications recorded within the follow-up period. Infection occurred in 7 patients (6.5%). All were successfully managed with debridement, antibiotic therapy and retention of implants. There were 4 dural tears (3.7%). One patient developed a post-operative DVT (0.9%). No patients sustained cord level deficits. Prevalence of mechanical complications requiring re-operation was 26% (28 patients). 5 patients (4.7) required revision surgery for symptomatic pseudarthrosis, 7 patients (6.5%) underwent revision fixation for metal work failure (broken rods/screw pull-out) and 16 patients (14.9%) underwent revision surgery to extend fixation proximally or distally due to adjacent segment disease (symptomatic proximal junction kyphosis 4.7%; osteoporotic fracture 3.7% and junctional/nerve root pain 6.5%). Overall reoperation rate was 32.5% at an average of 1.9 years following primary surgery (range 1 week–6 years). 37% patients remain on regular outpatient review (average 3.8 years following first surgery; range 2–6 years). 52% have been discharged after a mean follow-up of 2.3 years. 11 patients had died since their surgery (10.2%) at an average 4.1 years following their spinal surgery (range 1 –5.9 years). Overall complication rate was 37.3%. 32.5% of patients were re-operated for infective or mechanical complications. 52% of patients had been discharged at an average of 2.3 years following their surgery. 10.2% of patients had died within 6 years of surgery

Following introduction of the second offer scheme in April 2004, Cardiff and Vale NHS Trust sent 227 patients (254 knees) to the independent sector treatment centre in Weston-Super-Mare for total knee arthroplasty. The Kinemax total knee system was used in all cases. There was a perception that there were a large number of dissatisfied patients, and a previous British Orthopaedic Association report (of a 14 case sample) questioned the quality of the surgery performed. All of the patients concerned were offered a review in order to assess the outcome. Of the 227 patients (254 knees), 77% have been reviewed (167 patients, 190 knees). 23% (59 patients, 64 Knees) have not been seen. Of these, 30 patients (34 knees) declined review on the basis that they were happy with the result of surgery. 14 Patients (15 knees) were unobtainable by post of by phone. A further 12 patients (12 knees) did not attend appointments. 3 Patients (3 Knees) had died. The total number of re-operations was 27/254, giving a re-operation rate of 10.6%. There were 21 revisions, 17 for aseptic causes (oversized components, malalignment, aseptic loosening) and 4 for infection. There were 6 secondary patella resurfacings. A life table survivorship analysis was calculated for the 254 knees. The cumulative survival rate at 3 years was 85.8%. These results are considerably worse than those reported in the current published literature. This has resulted in a significant economic impact on our service

Introduction:. Mayo 2A Olecranon fractures are traditionally managed with a tension band wire device (TBW) but locking plates may also be used to treat these injuries. Objectives:. To compare clinical outcomes and treatment cost between TBW and locking plate fixation in Mayo 2A fractures. Methods:. All olecranon fractures admitted 2008–2013 were identified (n=129). Patient notes and radiographs were studied. Outcomes were recorded with the QuickDASH (Disabilies of Arm, Shoulder and Hand) score. Incidence of infection, hardware irritation, non-union, fixation failure and re-operation rate were recorded. Results:. 89 patients had Mayo 2A fractures (69%). Of these patients 64 underwent TBW (n=48) or locking plate fixation (n=16). The mean age for both groups were 57 (15–93) and 60 (22–80) respectively. In the TBW group, the final follow-up QuickDASH was 12.9, compared with 15.0 for the Locking plate group. There was no statistically significant difference between either group (p = 0.312). 19 of the 48 TBW patients had complications (48%). There was 1 infection (2%). 15 cases of metalwork irritation (31%). 1 non-union (2%). 2 fixation failures (4%). 14 of the 48 TBW patients had re-operations (29%). There were 13 removal of metalwork procedures (27%), 1 washout (2%) and 2 revision fixations (4%). There were 0 complications and 0 re-operations in the 16 patients who underwent locking plate fixation. This was statistically significant, (p = 0.003) and (p= 0.015) respectively. TBW costs £7.00 verses £244.10 for a locking plate. Theatre costs were equivalent. A 30 minute day surgery removal of metalwork or similar case costs £1420. In this cohort, when costs of re-operation were included, locking plates were on average £177 less per patient. Conclusions:. Locking plates are superior to TBW in terms of incidence of post-operative morbidity and re-operation rate. Financial savings may be made by choosing a more expensive initial implant

To assess whether Patients who are clinically Obese are more likely to require further or revision Surgery following One-Level simple Microdiscectomy compared to Non-obese Patients. Retrospective, single centre and single Surgeon review of Patients' Clinical notes of consecutive Patients who underwent primary One-Level Microdiscectomy between December 2007 and July 2009. Background: Obesity in Surgery has become a topical subject given the increasing proportion of Surgical Patients being Obese. This study provides the largest single centre and single Surgeon comparative cohort. All Patients had undergone One-level simple Primary Microdiscectomy Surgery. Data from the Clinical notes included Patient Demographics, level and side of operation, Length of stay and Re-Operation details. A total number of 71 Patients were eligible for inclusion of which 38 were Female and 33 Male with an average age of 41 years. 25 Patients were Clinically Obese (35%). Average LOS was 1.1 days. 8% of the clinically Obese Patients required further Surgery compared to 8.7% in the Non-obese group. Revision surgery for recurrent discs and Surgery for dural tear repair were the main reasons for return to theatre. Revision rates were comparable between the two Patient groups. LOS was no different for Obese Patients. This study concludes that Obese Patients undergoing One-Level simple Microdiscectomy do not face a significantly higher risk of requiring Revision Surgery in the future

The Profix knee replacement arthroplasty manufactured by Smith and Nephew has been in use for the past five years however there are few published outcome data for this prosthesis. The purpose of this study was to provide clinical outcome data for a cohort of patients with a Profix TKR at a minimum 3 years follow up. There were 65 joint replacements in 58 patients all performed by or under the direct supervision of one of two senior consultant Orthopaedic surgeons. There were 34 right and 31 left knees replaced in 31 male and 27 female patients. Mean age of the patients was 69 years (51–84 years) and mean body mass 89Kg (45–140Kg). The femoral component was uncemented in 49 knees and cemented in 16 knees. The tibial component was cemented in all 65 cases. There were 53 mobile bearing polyethylene inserts and 12 fixed bearing knees. The patella was resurfaced primarily in 32 cases. Using the Oxford Knee score, the mean knee score was 20.7 (Range 12–42) where a perfect score is 12 and the worst possible score 60. Mean clinical range of movement was 111 degrees (Range 90–130 degrees). Of the 65 joints, 13 have required or are awaiting some form of re-operation. These included 3 for patellae that were not resurfaced at the index arthroplasty, 6 for secondary insertion or revision of mobile bearing locking-screws and one femoral revision for failure of on-growth of an uncemented femoral component. The finding of loosening of the mobile bearing locking screw in three well functioning knees highlights the importance of Xray follow-up of patients even if their knee scores are entirely satisfactory. Overall, the clinical results of this prosthesis are satisfactory, however these data would support routine patellar resurfacing and use of the cemented fixed bearing option for the Profix arthroplasty

Introduction: We derived an exhaustive operative and supervision guideline for the treatment of hip fractures from the current international and own published literature, and implemented the guidelines in our department. Methods: 1274 unselected consecutive patients admitted with a hip fracture were included, 336 of these prospectively after implementation of the new guideline. Demographic parameters, hospital treatment and re-operations were assessed from patient journals. Re-operations were recorded after six months. Results: 95% (320/336) of operative procedures were found to have followed the new guideline treatment compared to 78% (733/938) prior to its introduction (p< 0.001 X2). Retrospectively we found that only 12% (121/1053) of operative procedures performed as the new guideline prescribes were re-operated compared to 24% (53/221) of operative procedures performed with other methods (p< 0.001 X2). In logistic regression analysis combining sex, age, ASA score, cognitive function, new mobility score, time from admission to operation and level of surgeon’s experience, not following the guideline was the only significant predictor for re-operation (p< 0.001 log. reg.). After implementing the guideline, the rate of unsupervised junior registrars performing operations declined from 20% (188/938) to 6% (21/336, p< 0.001 X2). The rate of reoperations declined from 15% (139/938) to 10% (35/336, p=0.044 X2, p=0.043 log.reg.), with a 20% (85/436) to 13% (23/174) decline for intracapsulary and an 11% (54/502) to 7% (12/162) decline for extracapsulary fractures. Conclusion: An exhaustive operative guideline for hip fracture treatment can be implemented. In our case, the guideline both raised the rate of supervision and reduced the rate of reoperations

Reoperations may be a better way of tracking adverse outcomes than complications. Repeat surgery causes cost to the system, and often indicate failure of the primary procedure resulting in the patient not achieving the expected improvement in pain and function. Understanding the cause of repeat surgery at the primary site may result in design improvements to implants or improvements to fusion techniques resulting in better outcomes in the future. The COFAS group have designed a reoperation classification system. The purpose of this study was to outline the inter and intra observer reliability of this classification scheme.

To verify the inter- and intra-observer reliability of this new coding system, six fellow ship trained practicing foot and ankle Orthopaedic surgeons were asked to classify 62 repeat surgeries from a single surgeons practice. The six surgeons read the operation reports in random order, and reread the reports 2 weeks later in a different order. Reliability was determined using intraclass correlation coefficients (ICC) and proportions of agreement. The agreement between pairs of readings (915 for inter observer for the first and second read – 61 readings with 15 comparisons, observer 1 with observer 2, observer 1 with observer 3, etc) was determined by seeing how often each observer agreed. This was repeated for the 366 ratings for intra observer readings (61 times 6).

The inter-observer reliability on the first read had a mean intra-class correlation coefficient (ICC) of 0.89. The range for the 15 comparisons was 0.81 to 1.0. Amongst all 1830 paired codings between two observers, 1605 (88%) were in agreement. Across the 61 cases, 45 (74%) were given the same code by all six observers. However, the difference when present was larger with more observers not agreeing. The inter-observer reliability test on the second read had a mean ICC of 0.94, with a range of 0.90. There were 43 (72%) observations that were the same across all six observers. Of all pairs (915 in total) there was agreement in 804 pairs for the first reading (88%) and disagreement in 111 (12%). For the second reading there was agreement in 801 pairs (86%) and disagreement in 114 (14%). The intra-observer reliability averaged an ICC value of 0.92, with a range of 0.86 to 0.98. The observers agreed with their own previous observations 324 times out of 366 paired readings (89% agreement of pairs).

The COFAS classification of reoperations for end stage ankle arthritis was reliable. This scheme potentially could be applied to other areas of Orthopaedic surgery and should replace the Claiden Dindo modifications that do not accurately reflect Orthopaedic outcomes. As complications are hard to define and lack consistent terminology reoperations and resource utilisation (extra clinic visits, extra days in hospital and extra hours of surgery) may be more reliable measures of the negative effects of surgery.

Aim: Volar locking plates are increasingly used in the management of distal radius fractures. As with any new implant, understanding the rate and type of potential metalwork related complications is important. The aim of the study was to determine the type and rate of implant related complications that require further surgery when using volar locking plates in the management of distal radius fractures. Methods: In this study, we reviewed 114 distal radius fractures treated with volar locking plating. Patient records were reviewed with regards to demographics, operative details and post-operative outcomes. Fractures were classified as intra-articular or extra-articular. They were further classified using the AO classification system. Results: In our series, 12 cases (10%) underwent further surgery for metal work related complications mainly for screw protrusion into the radiocarpal joint following fracture collapse. Intra-articular fractures had a significantly greater complication rate as compared to extra-articular ones (11 vs. 1, P=0.04). There was no significant difference between the three plating systems used in this series with regards to need of further surgery (P=0.43). There was no significant difference between the grade of the operating surgeon with regards to metal work complications (P=0.9). There was no difference in rate of complications between males and females (P=0.27). Similarly there was no difference in metal work complications between patients aged less than 60 as compared to those aged more than 60 years (P=0.58). Our study has shown that volar locking plates may be associated with up to 10% rate of metalwork complications requiring revision surgery. The most common (8 out of 12) cause of re-operation was to remove the screws protruding into the radio-carpal joint. Discussion: Our results suggest that volar locking plates are associated with a high rate of metal work related complications requiring further surgery. In conclusion our study suggests that volar locking plates are associated with high reoperation rates for implant related complications. Intraoperative screening to ensure that there is no intrarticular penetration is also essential. We favour obtaining intra-operatively a lateral view with the forearm elevated 15–20 degrees to the horizontal plane to allow for the medial-lateral radial inclination and taking the posterior-anterior view at about 20 degrees to the horizontal plane to allow for the normal volar distal radial tilt. We feel that for a common fracture such as distal radial fractures an ideal implant should be easily reproducible with a low complication rate

Osteolysis is one of a major cause of failure that affect long term survival rate in THA. Hard-on-hard bearing surface were developed to reduce wear and osteolysis, such as ceramic-on-ceramic which is the lowest wear rate was introduced but it still has squeaking and ceramic fracture. Metal-on-metal bearing surface significantly reduce wear rate but it still release metal ion which affect local tissue reaction. Then ceramic-on-metal is another choice of bearing with combine the advantage of reduce wear rate, metal ion release, no stripe wear, no squeaking and no ceramic fracture. However after clinical use ALTRs may occur and disturb the longevity of THA.

During January 2009 to December 2009 we performed 98 THR with the same femoral stem and acetabular cup with difference bearing which were 87 cases of metal on cross-linked PE, 8 cases of ceramic on metal and 5 cases of metal on metal. Routinely postoperative care were done with clinical evaluation, plain x-rays and Harris hip score. After 5 years follow up there are clinical problems in ceramic on metal THA with decrease clinical score and progressive osteolysis in radiographic finding in 2 cases then we investigated to find the cause of this problem and revise the components. We preformed magnetic resonance imaging and collect blood sample for ESR, CRP and Cobalt and Chromium level. We revised 2 cases of ceramic on metal THA, during surgery we collected tissue for bacterial and AFB and histopathology. All retrieval components were studied for wear pattern. First patient have thigh pain and progressive osteolysis after year 4^th of follow up. She had normal ESR and CRP with high level of cobalt and chromium level. We revised both components and tissue histopathology showed metallosis with chronic inflammation. Another patient had failure due to ALTRs with mixed solid-cystic mass at trochanteric bursa but component is stable then only bearing surface were change. Wear pattern at femoral head was in weight bearing area with corresponding to apical center wear of metal liner.

Our study showed that only in group of ceramic-on-metal THA that have 5 years follow up have early reoperation due to osteolysis and tissue reaction. We routinely stop to use this bearing since 2010. But we have small number of cases in our study to conclude that is bearing are not suitable for clinical usage.

A retrospective review was conducted of patients undergoing either total hip replacement or hemiarthroplasty for intra-capsular neck of femur fractures between April 2013 and April 2014; identified from entries into the National Hip Fracture Database. PACS and the electronic database encompassing operation notes and discharge summaries were reviewed. 309 patients were identified, 3 of whom fractured both hips during the study period giving a total of 312 operations. The age range was 46 to 102 with a mean age of 82. 59 cemented bipolar hemiarthroplasties, 143 cemented unipolar hemiarthroplasties, 2 uncemented hemiarthroplasties and 108 total hip replacements were performed. 10 patients required further operations. There have been 5 dislocations: 2 underwent MUA only, 2 treated by excision arthroplasty and 1 converted to THR. 1 patient developed a haematoma requiring wound washout. There were 4 wound infections - 1 treated by a washout, 2 by excision arthroplasty and one patient has undergone first stage revision; an overall reoperation rate of 3.2% comparing well with data published elsewhere.

Purpose

Open reduction and plate fixation of displaced mid-shaft clavicle fractures has gained significant popularity following a recent multi-center randomized control trial. The purpose of this study is to describe the incidence of reoperation following plate fixation of displaced mid-shaft clavicle fractures. The secondary objective is to determine if plate design influences the incidence of reoperation.

Introduction: Re-operations after intertrochanteric fractures (ITF) are often caused by fracture displacement following postoperative mobilisation. The biomechanical complexity of the fracture, implant position, and the patient’s characteristics are known to influence postoperative outcome significantly. We investigated the importance of an intact lateral femoral wall (LFW) for the postoperative displacement after fixation by a sliding compression hip screw (SHS).

Methods: Two hundred and fourteen consecutive patients with ITF fixated by 135° SHS mounted on four hole lateral plates were included between 2002 and 2004. The fractures were preoperatively classified according to the AO/OTA classification system. The status of the greater and lesser trochanter, the integrity of the LFW and implant positioning were assessed postoperatively. Re-operations due to technical failure were recorded for six months.

Results: Only three percent of patients (5/168) with postoperatively intact LFW’s were re-operated within six months, while twenty-two percent (10/46) of patients with fractured LFW’s had been re-operated (p < 0.001). In multivariate logistic regression analyses combining demographic and biomechanical parameters, a compromised LFW was a significant predictor for reoperation (p = 0.010). Seventy-four percent (34/46) of the LFW fractures occurred during the operative procedure itself. Peri-operative LFW fractures only occurred in three percent (3/103) of the AO/OTA type 31A1–A2.1 ITF fractures, compared to thirty-one percent (31/99) of the AO/OTA type 31A2.2–A2.3 fractures (p < 0.001).

Conclusions: A postoperative fractured LFW was found to be the main predictor for reoperation after ITF. Consequently we conclude that patients with pre- or potential postoperative LFW fractures are not treated adequately by SHS. ITF should therefore be classified according to the integrity of the LFW, especially in regard to randomized trials comparing fracture implants.