Infection following total knee arthroplasty (TKA) can cause significant morbidity to the patient and be associated with significant costs and burdens to the healthcare system. Wound complications often initiate the cascade that can eventually lead to deep infection and implant failure. Galat et al. reported that wound complications following TKA requiring surgical treatment were associated with 2-year cumulative risks of major reoperation and deep infection of 5.3% and 6.0%, respectively. Consequently, developing a systematic approach to the management of wound problems following TKA can potentially minimise subsequent complications. Unlike the hip, the vascular supply to the soft tissue envelope to the knee is less robust and more sensitive to the trauma of surgery. Therefore, proper soft tissue handling and wound closure at the time of surgery can minimise potential wound drainage and breakdown postoperatively. Kim et al. showed, using a meta-analysis of the literature, that primary skin closure with staples demonstrated lower wound complications, decreased closure times, and lower resource utilization compared to sutures. However, a running subcuticular closure enables the most robust skin perfusion following TKA. Finally, the use of hydrofiber surgical dressings following surgery was associated with increased patient comfort and satisfaction and reduced the incidence of superficial surgical site infection. A wound complication following TKA needs to be managed systematically and aggressively. A determination of whether the extent of the involvement is superficial or deep is critical. Antibiotics should not be started without first excluding the possibility of a deep infection. Weiss and Krackow recommended return to the operating room for wound drainage persisting beyond 7 days. While incisional negative pressure wound therapy can occasionally salvage the “at risk” draining wound following TKA, its utilization should be limited only to the time immediately following surgery and should not delay formal surgical debridement, if indicated. Finally, early wound flap coverage and co-management of wound complications with plastic surgery is associated with increased rates of prosthesis retention and limb salvage

Introduction. Many patients with displaced intracapsular femoral neck fractures (IFNF) are treated with hemiarthroplasty (HA) which has been shown superior to internal fixation(IF) the first year after injury. Long term results, however, are sparse. Methods. A total of 222 consecutive patients above 60 years, including mentally disabled, with IFNF were randomized to either internal fixation with two parallel screws or hemiarthroplasty, and operated by the surgeon on call. After 5 years, 68 of the 70 surviving patients accepted a follow-up visit. The reviewers were blinded for initial treatment. Results. The mean survival of the groups was similar. Only 12 (of 31) patients in the IF group still had their native hip joint at five years. Harris Hips score was 70.0 ± 3.5 and 70.4 ± 3.4 in the IF and hemiarthroplasty group, respectively (p=0.9). Eq5d index was in the IF group 0.56 ±0.08 and in the hemiarthroplasty group 0.45 ± 0.7 (p=0.3). Barthel ADL index was split into good function (score 95 or 100) and reduced function (score below 95). Of the patients in the internal fixation group, 42 % reported good function, corresponding number in the arthroplasty group was 52 % (p=0.4). After two years, there were 44 (42%) hips with a major reoperation in the IF group and 11 (10%) in the hemiarthroplasty group. Between 2 and 5 years, there were two new major reoperations (both in the IF group; avascular necrosis; deep wound infection). Discussion. Hemiarthroplasty has predictable and good long time surgical results. These findings emphasize that arthroplasty is better than IF as treatment for displaced intracapsular femoral neck fractures

Infection following total knee arthroplasty (TKA) can cause significant morbidity to the patient and be associated with significant costs and burdens to the health care system. Wound complications often initiate the cascade that can eventually lead to deep infection and implant failure. Galat et al. reported that wound complications following TKA requiring surgical treatment were associated with a 2-year cumulative risk of major reoperation and deep infection of 5.3% and 6.0%, respectively. Consequently, developing a systematic approach to the management of wound problems following TKA can potentially minimise subsequent complications. Unlike the hip, the vascular supply to the soft tissue envelope to the knee is less robust and more sensitive to the trauma of surgery. Therefore, proper soft tissue handling and wound closure at the time of surgery can minimise potential wound drainage and breakdown post-operatively. Kim et al. showed, using a meta-analysis of the literature, that primary skin closure with staples demonstrated lower wound complications, decreased closure times, and lower resource utilization compared to sutures. However, a running subcuticular closure enables the most robust skin perfusion following TKA. Finally, the use of hydrofiber surgical dressings following surgery was associated with increased patient comfort and satisfaction and reduced the incidence of superficial surgical site infection. A wound complication following TKA needs to be managed systematically and aggressively. A determination of whether the extent of the involvement is superficial or deep is critical. Antibiotics should not be started without first excluding the possibility of a deep infection. Weiss and Krackow recommended return to the operating room for wound drainage persisting beyond 7 days. While incisional negative pressure wound therapy can occasionally salvage the “at risk” draining wound following TKA, its utilization should be limited only to the time immediately following surgery and should not delay formal surgical debridement, if indicated. Finally, early wound flap coverage and co-management of wound complications with plastics surgery is associated with increased rates of prosthesis retention and limb salvage

Aims

Our primary aim was to assess reoperation-free survival at one year after the index injury in patients aged ≥ 75 years treated with internal fixation (IF) or arthroplasty for undisplaced femoral neck fractures (uFNFs). Secondary outcomes were reoperations and mortality analyzed separately.

Purpose: We studied the effect of rhBMP-2 in patients with open leg fractures to determine the impact on the number of revision procedures and on late bone healing or nonunion. Material and method: Four hundred fifty patients with an open tibial shaft fracture that could be treated with a stratified nail (Gustilo-Anderson) were included in the study. Patients were randomly assigned to three treatment arms: control, with rhBMP-2 0.75 mg/ml, and with rhBMP-2 1.5 mg/ml. The proteins were carried on a biodegradable collagen sponge. The rhBMP impregnated sponge was placed on the wound in contact with the fracture after reduction and nailing. A dynamic or locked nail was used, with or without reaming. Results: Follow-up data were available for 93% of the patients at 12 months after nailing. Compared with the control group, the number of reoperations for delayed healing was lower in the rhBMP-2 groups (p = 0.0017). Results were better in the 1.5 mg/ml group (−44%, RR=0.56, 95CI = 0.40-0.78, p=0.0005). The number of major reoperations (bone grafts new nailing) was considerably reduced (−49%, p = 0.0264). Between the 10th and 52nd week, the proportion of patients with a healed bone was significantly higher in the 1.5 mg/ml group than in the control group. At six months, 58% of the patients treated with 1.5 mg/ml had healed, compared with only 38% in the control group. Mean delay to healing was significantly lower in the 1.5 mg/ml group compared with controls (Kaplan Meier, p=0.022) and mean delay to healing in 50% of the patients was 145 days, compared with 184 days. Rate of infection was similar in the three groups, but there were significantly fewer infections in the 1.5 mg/ml group patients with a grade 3 fracture than in controls (p=0.0219). There was also a lower rate of fixation material failure in the 1.5 mg/ml group (p=0.0174). Anti rhBMP-2 antibodies (< 6%) or anti-collagen bovine antibodies (< 20%) were observed without presence of anti-human collagen antibodies and without any clinical expression or apparent effect on the clinical outcome. Conclusion: At the dose of 1.5 mg/ml, rhBMP-2 associated with centromedullary nailing significantly improved outcome, with fewer reoperations for late healing and fewer major reoperations. Fracture healing was accelerated and rate of infection was lower in patients with the most severe fractures

Introduction. The optimal bearing for hip arthroplasty is still a matter of debate. in younger and more active patients ceramic-on-polyethylene (CoP) bearings are frequently chosen over metal-on-polyethylene (MoP) bearings to reduce wear and increase biocompatibility. However, the fracture risk of ceramic heads is higher than that of metal heads. This can cause serious issue, as ceramic fractures pose a serious complication often necessitating major revision surgery – a complication more frequently seen in ceramic-on-ceramic bearings. To date, there are no long-term data (> 20 years of follow-up) reporting fracture rates of the ceramic femoral heads in CoP bearings. Patients and Methods. We retrospectively evaluated the clinical and radiographic results of 348 cementless THAs treated with 2nd generation Biolox® Al2O3 Ceramic-on-Polyethylene (CoP) bearings, which had been consecutively implanted between January 1985 and December 1989. At implantation the mean patient age was 57 years. The cohort was subsequently followed for a minimum of 20 years. At the final follow-up 111 patients had died, and 5 were lost to follow-up (Fig. 1). A Kaplan-Meier survivorship analysis was used to estimate the cumulative incidence of ceramic head fractures over the long-term. Results. (Figs. 2, 3):. After 22-years the cumulative incidence of ceramic head fracture was estimated at 0.3% (95%-CI, 0–2.4%; 38 hips at risk). No impending failures could be noted on radiographic analysis at final follow-up. Discussion. The fracture rate of second-generation ceramic heads using a CoP articulation remains very low into the third decade after cementless THA; ceramic heads appear to be a safe alternative to metal femoral heads. Summary. This study evaluates the long-term (20–25 year) survivorship of cement on polyethylene bearings in uncemented THA

Vancouver B fractures around a cemented polished tapered stem (CTPS) are often treated with revision arthroplasty. Results of osteosynthesis in these fractures are poor as per current literature. However, the available literature does not distinguish between fractures around CTPS from those around other stems. The aim of our study was to assess the clinical and radiological outcome of open reduction and internal fixation in Vancouver B fractures around CTPS using a broad non-locking plate. Patients treated with osteosynthesis between January 1997 and July 2011 were retrospectively reviewed. All underwent direct reduction and stabilisation using cerclage wires before definitive fixation with a broad DCP. Bicortical screw fixation was obtained in the proximal and distal fragments. We defined failure of treatment as revision for any cause. 101 patients (42 men and 59 women, mean age 79) were included. 70 had minimum follow-up of 6 months. 63 of these went on to clinical and radiological union. Three developed infected non-union. 7 had failure of fixation. Lack of anatomical reduction was the commonest predictor of failure followed by inadequate proximal fragment fixation and infection. 14 patients dropped at least 1 mobility grade from their preoperative status. This is the largest series of a very specific group of periprosthetic fractures treated with osteosynthesis. Patients who develop these fractures are often frail and “high risk” for major revision surgery. We recommend osteosynthesis for patients with Vancouver B periprosthetic fractures around CTPS provided these fractures can be anatomically reduced and adequately fixed

Introduction: Periacetabular osteotomy is a complex procedure which is associated with significant complications during the learning period and difficult to maintain such expertise when it is undertaken infrequently. Results were reviewed to determine if this difficult PAO procedure can be safely learnt by a process of mentoring and review. Methods: A structured mentoring program was adopted by the senior author. A double approach was used in the first 11 cases to enhance exposure and minimise the risk of complications. Fifteen osteotomies have subsequently been undertaken using a single approach. The median patient age was 28 years (13–41 years). The median follow-up was 5 years (2–14 years). The clinical and radiographic results were examined. Results: Two cases in the double approach series progressed to total hip replacement and there were two other major reoperations. Two cases in the single approach series had an ischial non-union not requiring reoperation. The median Harris hip score at latest review was 82 (35–100) and 80 (26–100) for the double and single approach series respectively. All radiographic indices indicated correction of the acetabulum for both series. Discussion and Conclusion: A structured program of mentoring and review has allowed a complex surgical procedure to be learnt and surgical expertise maintained at a distant centre while avoiding the complications previously associated with the learning curve and achieving the acetabular correction similar to the originator of the procedure

Introduction: Reported incidence of dislocation following dislocation of hip replacements varies from less than 1% to 8%, the majority (59%) being in the first 3 months and 77% within a year. Recurrent dislocation of total hip arthroplasty is a serious problem for both patient and surgeon. Revision of the components does not guarantee success and there is significant comorbidity associated with major revision surgery. Early techniques of cup augmentation were complicated by screw and augment failure, hence cup augmentation evolved into a low profile polyethylene wedge with a separate metal backing and five screw fixation called the Posterior Lip Augmentation device (PLAD). Methods: 33 patients in Leeds and Inverness underwent PLAD placement between 1995 and 2000. They were followed up at a minimum of 5 years postoperatively (5–9 years). Where patients had died the cause of death and status of the PLAD at time of death was determined from the notes. Results: The mean age at time of PLAD insertion was 73 years(43–94). The longest survival was 102 months, the shortest 8 days. Of the 33 patients undergoing PLAD insertion, 3 were lost to follow up, 13 had died by the time of follow up, 7 had been revised and 10 had survived revision free. Discussion: When considering the revision as an end point, PLAD insertion compares favourably with total revision. As shown by the mortality of the patients in the cohort, a less invasive option for the patient with significant comorbidities is useful to have in the surgical armamentarium

To review the results of periprosthetic femoral fractures treated using Dall-Miles cable and plates. Periprosthetic femoral fractures are increasingly common and their treatment is challanging for Orthopaedic surgeons. Dall-Miles cable and palte system is the current impalnt of choice for periprosthetic femoral fractures following hip arthroplasty. Between January 1999 and December 2001, twenty-two patients with periprosthetic femoral fracture around hip arthroplasty were treated with Dall-Miles system. Thirteen patients required bone grafting (allograft) at time of surgery. The average age of the group was 82 with eighteen females and four men. Thirteen were Vancouver type B2, two type B1, six type C and one type A fracture. All patients were followed up to fracture union. Two patients had fracture of the plate and required further surgery. Two patients had symptomatic loosening even though the fracture had united and underwent revision hip replacement. These four patients were Vancouver type B2. Nine Vancouver B2 patients had fracture union with no need for revision. All other patients had fracture union with no major complications. The Dall-Miles cable and plate system provides an easy to use implant with satisfactory outcome. The simplicity of the system allows widespread acceptance in these increasingly common fractures. It is particularly useful to obtain bony union in elderly patients not fit enough for a major revision surgery

The extraordinary majesty of THR, as it burst onto the scene 60 years ago, both dazzled and blinded. It dazzled patients and surgeons alike and simultaneously obstructed a clear eyed assessment of the human costs. It behooves current practitioners, who have benefited mightily by our progress, to pause and reflect thoughtfully on that progress. Look no further than the fact that the treatment of a benign disease left one patient out of every 50 dead. Dead from a pulmonary embolus and that over 25% of the patients threw pulmonary emboli. What were the big six major disadvantages: 1) Fatal pulmonary emboli; 2) Prosthetic joint infection; 3) Failure of fixation; 4) Dislocation; 5) Periprosthetic osteolysis; 6) Prolonged hospitalization. Start with the observation that THR in the modern era began with Charnley's experiment with Teflon articulations. Of the nearly 300 such operations done, nearly 300 failed. Ultrahigh molecular weight polyethylene was better- much better. But still it produced wear and periprosthetic osteolysis, afflicting an estimated 1 million patients. Periprosthetic osteolysis became the most common reason for failure, the most common reason for reoperation, the most common reason for fracture, and the most common reason for extremely difficult re-operations requiring major grafting. Reoperation rates in certain series were 20 to 30% from loosening and 20 to 40% from osteolysis. Dislocation catapulted the unsuspecting patient to the floor at a rate of one out of 20 patients and the initial rate of prosthetic joint infection was 10%. Most patients were hospitalised in the new neighborhood of 2.5 weeks, at huge expense. Massive progress has been made but forget not that this striking progress was not obsessively linear. Recall the recent, extraordinary and continuing massive failure of metal-on-metal total hip replacements, despite 40 prior years of experience, predicting that metal-on-metal total joints should be ‘just fine’. Over the past six decades every one of the six major disadvantages listed above has been reduced by an order of magnitude. The challenge to you is to continue that progress

Introduction. Total hip arthroplasty (THA) is gaining popularity as a treatment for displaced femoral neck fractures (FNF), especially in physiologically younger patients. While elective THA for primary osteoarthritis (OA) has demonstrated low rates of complications and readmissions, the outcomes of THA for FNF are less predictable. Additionally, these THA procedures are equally included in various alternative payment bundles. Therefore, the aim of this study is to assess postoperative complication rates after THA for primary OA compared with FNF. Methods. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2008 to 2016 was queried. Patients were identified using the Current Procedural Terminology (CPT) code for THA (27130) and divided into groups by diagnosis; OA in one group and FNF in another. Univariate statistics were performed. T-test compared continuous variables between groups, and Chi-square test compared categorical variables. Multivariate and propensity matched logistic regression analyses were performed to control for risk factors of interest. The primary outcomes for this study were death or serious morbidity (surgical site infection (SSI), infection, respiratory complication, cardiac complication, sepsis, or blood loss anemia requiring postoperative transfusion). Additional secondary outcomes included the incidence of specific complications, total operative time (time from incision to closure), length of hospital stay and proportion of patients that were discharged home. Results. Analyses included 139,635 patients undergoing THA. OA was the indication in 135,013 cases and FNF in 4,622 cases. Unadjusted analysis showed a significantly higher rate of mortality when THA was done for hip fracture (2.1% vs. 0.1%; p<0.001). There was also a significantly increased rate of serious morbidity for hip fracture patients; including cardiac complications (3.5% vs 0.96%; p<0.001), respiratory complications (1.3% vs 0.2%; p<0.001), postop transfusion (23.1% vs 9.36%; p<0.001), sepsis (0.95% vs 0.3%; p<0.001). There was a significantly higher percentage of patients requiring reoperation (4.5% vs 2.0%; p<0.001) and readmission (8.0% vs 3.5%; p<0.001) in the hip fracture group. There was a significantly higher percentage of patients in the hip fracture groups having operative time >90min (16.4% vs 10.1%; p<0.001), length of stay longer than 5 days (53.8% vs 7.5%; p<0.001), and a significantly lower percentage of patients who were discharged home (39.0% vs 78.0%; p<0.001). Propensity score matching resulted in a cohort of 6,968 patients; 3,484 in both the hip fracture and osteoarthritis groups. Mortality within 30 days was 530% higher, and major morbidity was 36% higher among FNF patients. Reoperation was 40% higher, readmission was 36% higher, operative length at the 90th percentile was 74% higher, prolonged length of stay was 838% higher, and discharge to home was 62% lower for the FNF group compared with OA patients. Logistic, reverse stepwise regression model () results were consistent with the propensity-matched analysis. Discussion and Conclusion. This large database study showed a higher risk of postoperative complications including mortality, major morbidity, reoperation, readmission, prolonged operative time, increased length of stay, and decreased likelihood of discharge home in patients undergoing THA for FNF compared with OA. Without risk adjustment, the bundled payment methods that are applied to THA procedures including those performed for FNF are at a disadvantage and likely inadequate to cover the more costly episode of care related to treating hip fracture patients

Introduction: Most physicians agree that initial treatment for a newborn child with clubfoot should be nonoperative. Some children with rigid deformities, however, may need a soft tissue release operation at an early age. The optimal timing of such surgery and for whom remain controversial questions. We prospectively followed patients treated in our clinic under temporal protocol and analyzed results in order to answer these questions. Methods: From 1979 to 1989, 132 infants with 185 club-feet visited the Hokkaido Univ. before they were three months old. Eighty eight patients with 124 feet were followed over a 10 year period. The averaged follow-up period was 15.2 years. Corrective casts were applied for no longer than 3 months. If the lateral tibio-calcaneal (TC) angle became less than 90°, a Denis Browne splint was used. If this angle was still larger than 90°, postero-lateral release was performed within a month after casting. Surgery was also performed for children whose deformities continued increasing after conservative treatment. McKay’s scoring system was used to evaluate the final clinical results. The results of patients needing major revision surgery were evaluated “failure”. Results: Forty-nine feet were treated conservatively. Of these 35 were evaluated as good or excellent and seven were evaluated as poor or failure. Forty-three feet were underwent surgery before one year of age; an additional 32 feet underwent surgery after one year of age. Thirty-three feet were evaluated good or excellent and 19 feet were evaluated as poor or failure. At 6 months of age the lateral TC angle of the patients treated non-operatively and evaluated as good or excellent was 68.4 ± 14.3° (Mean ± S.D.), and the lateral TC angle of patients who underwent surgery after one year of age and patients who were treated non-operatively but evaluated as poor or failure was 80.0 ± 9.2°. There are statistically significant difference between these two groups. The age at surgery of patients evaluated as good or excellent was 12.6 ± 12.4 months old, and that of patients evaluated as poor or failure was 5.1 ± 3.0 months old.There are also statistically significant difference between these two groups. Conclusion: Our results suggest that surgery is indicated for patients whose TC angle at 6 months of age is greater than 70°, and that the optimal timing for soft tissue release is later than 8 months of age

In the trend to operate hip fractures with less invasive procedures it is important to realise that the semi-percutaneous approach to make osteosynthesis with two screws or hook pins for femoral neck fractures, actually is a mini invasive procedure. It is well proven since decades. The major question is to select the right patients for osteosynthesis versus arthroplasty (unipolar hemi, bipolar hemi or total hip arthroplasty). It is depending on the damage to the blood supply of the femoral head. There is at the moment no methods for this in routine use, but with the development of MRI techniques it might be possible. The goal is to select the right patients for osteosynthesis to minimise the healing complications and the need for secondary hip arthroplasties. The hook pin procedure has been extensively used in Sweden through decades. Since the last 5 years there is an increasing trend for the most displaced fractures in older patients to be operated with a hemi arthroplasty. Previously a primary osteosynthesis was the first choice in all patients. The results of 10 years use of this procedure in Lund 1988–1997 shows that for the total of femoral neck (cervical) hip fractures the need for a secondary arthroplasty within 2 years was 20%. Previously published need for secondary arthroplasty was 13% when only well trained surgeons operated. There is thus no need to behead all displaces femoral neck fractures because some fail. In Norway the principles of primary osteosynthesis still mostly prevail. In a randomised comparison between hook pins and screws it was found that the rates of early failure of fixation, non-union and need for reoperation did not differ significantly between the two osteosynthesis methods. The use of hook pins was associated with less drill penetrations of the femoral head during surgery (odds ratio 2.6) and a lower incidence of necrosis of the femoral head (odds ratio 3.5). The technique of performance was of significant importance. There was a highly significant relationship between poor reduction and poor fixation of the fracture and subsequent reoperation. Likewise per-operative drill penetration of the femoral head was associated with a greater risk of reoperation. In total 22% of these patients needed a major reoperation (usually hemi arthroplasty). In 7% of the cases the fixation device needed to be removed after a healed fracture. In another randomised study between hook pins and three screws 57% of the patients were operated within 6 hours from admission to hospital and 92% within 24 hours. The mean (median) time for operation was 36 (30) minutes for the hook pins and 40 (35) minutes for the AO screws. After 2 years 77% of the hook pin patients had not needed any reoperation compared to 73% in the AO screw group. In total a secondary hemiarthroplasty had been performed in 7% and a total hip arthroplasty in 12% of the patients. Extraction only of osteosynthesis material had been performed in 5%. Again, healing was much higher if the reposition and positioning of the osteosynthesis material was optimised. Osteosynthesis is a mini invasive procedure. It is indicated for all undisplaced cervical fractures and for less displaced fractures, particularly in younger patients. Attention to the reposition and positioning of the osteosynthesis material is necessary. An image intensifier with large field of view and good resolution facilitates this, preferably a biplanar. The future goal is to select the patients better for the different procedures osteosynthesis or arthroplasty

Objectives

We used the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) to investigate the risk of revision due to prosthetic joint infection (PJI) for patients undergoing primary and revision hip arthroplasty, the changes in risk over time, and the overall burden created by PJI.

The April 2015 Hip & Pelvis Roundup³⁶⁰ looks at: Goal-directed fluid therapy in hip fracture; Liberal blood transfusion no benefit in the longer term; Repeated measures: increased accuracy or compounded errors?; Peri-acetabular osteotomy safer than perhaps thought?; Obesity and peri-acetabular osteotomy: poor bedfellows; Stress fracture in peri-acetabular osteotomy; Infection and tantalum implants; Highly crosslinked polyethylene really does work