Introduction

The prevalence of adverse reactions to metal debris (ARMD) associated with metal on metal (MoM) hip arthroplasty has been reported to be as high as 69%. Such findings promoted the development of metal-artefact reducing sequence (MARS)-magnetic resonance imaging (MRI) classifications, with the aim of stratifying soft lesions by severity of disease. The Modified Oxford Classification is a straightforward system that has been shown to correlate with disease progression.

Introduction

Large head total hip arthroplasty (THA) reduces dislocation rates and provides a theooretically larger range of motion. We hypothesised that this would translate into greater improvement in functional scores when compared to 28mm metal-on-polyethylene THA at 5 years. We believe ours to be the first in vivo comparison study.

It is established good practice that hip and knee replacements should have regular follow-up and for the past seven years at the North Hampshire Hospital a local joint register has been used for this purpose and we compare this with results of the Swedish and UK national and the Trent Regional registries.

Since March 1999, all primary and revision hip and knee arthroplasties performed at North Hampshire Hospital, Basingstoke have been prospectively recorded onto a database set up by one of the senior authors (JMB). Data from patients entered in the first five years of the register were analysed. All patients have at least one year clinical and radiological review then a minimum of yearly postal follow-up. 3266 operations (1524 hips and 1742 knees) were performed under the care of 13 consultants. Osteoarthritis was the most common primary diagnosis in over 75% of hips and knees. Our revision burden was 7.5% (10.2% hips and 3.5% knees). As of 31/12/2006 6.2% of patients had died and 5.5% were lost to follow-up.

Revision rates were 1.5% and 1.4% for primary total hip and knee replacements respectively.

Our data analysis of revisions and patello-femoral replacements has allowed us to change our practice following local audit which is ongoing. Oxford scores at 2 years had improved from a mean of 19 and 21 pre-operatively to 40 and 39 for primary hips and knees respectively. Our costs are estimated at approximately £35 per patient for their lifetime on the register.

Compared to other registries:

Our dataset is more complete and comprehensive

Method: This study reports upon 216 patients (97 Minimally invasive and 119 Standard) enrolled into a randomised control trial comparing a standard posterior approach to the hip with a single incision minimally invasive surgery (MIS) posterior approach at 6 weeks and 1 year post-operatively. Primary outcome measures included operative time, blood loss, length of stay and functional hip scores.

Results: The demographics and pre-operative hip scores for both cohorts were statistically similar. Intra-operative blood loss was significantly reduced in the MIS cohort (p=< 0.01). There was no difference in surgical time (p=0.37), time to discharge (p=0.24) or complication rate between the two groups.

Both groups had statistically improved post-operative hip scores, however, at the 1 year follow-up the MIS group were significantly better in terms of WOMAC, Harris Hip, Merle d’Aubigne and SF-12 scores when compared with a standard posterior approach.

Conclusion: This study demonstrates that MIS THA is a safe, reproducible technique in a DGH. We recommend the use of MIS techniques in primary THA and adhere to the principle that an incision need be no longer than necessary to perform the procedure safely.

Introduction: In order to improve the provision of Spinal Surgery in the United Kingdom, the number of Specialist Spinal Surgeons and Surgeons with an Interest in Spinal Surgery needs to increase by 25% from the existing 175 surgeons. There is an expected shortage of Orthopaedic Specialist Registrars (SpRs) planning careers in Spinal Surgery not only to maintain the status quo, with one third of Specialist Spinal Surgeons due to retire in the next three years, but also to provide the needed expansion in numbers.

Methods and results: A postal survey of the 528 SpRs was performed with a response rate fo 71%. The critical question was the post accreditation intention as either a Specialist Spinal Surgeon (greater than 70% of elective work), as a Surgeon with an Interest in Spinal Surgery (more than 30% of elective work), a surgeon doing occasional Spinal Surgery (less than 30% of elective work) or one who avoids all Spinal Surgery. This attitude could then be taken into account when analysing the training provided and the perceptions of Spinal Surgery to identify factors which could be discouraging an interest in Spinal Surgery.

Sixty-nine per cent indicated that they intended to avoid all Spinal Surgery. Thirty-five (9%) intended becoming either Specialist Spinal Surgeons or Surgeons with a Spinal Interest but only nine (2%) are in their final two years of training. The declared intention to avoid Spinal Surgery increases from 54% in the first two years of training, to 70% in the middle two years, and to 75% in the final two years and post C.C.S.T. fellowships. There should be 24 newly accredited Specialist Spinal Surgeons based on a projection of the 4.3% response intending to become Specialist Spinal Surgeons. This leaves a shortfall of 34 Specialist Spinal Surgeons by 2005.

The survey has revealed three main features of Spinal Surgery which appear to have a negative effect on the attitude of the SpRs to Spinal Surgery and overwhelm the potentially attractive features. These are badly organised clinics; the perceived psychological complications of spinal patients; and a perceived inadequate exposure to Spinal Surgery during their training.

Conclusion: It is clear from the response of SpRs that there are important misconceptions concerning Spinal Surgery, together with the shortcomings of training and of the provision of services within the NHS. These have to be addressed urgently if the speciality is to become more attractive to them. Areas where positive action can be taken include the modification of training programmes so that all SpRs are exposed to Spinal Surgery in the formative first three years; properly structured spinal clinics; and above all the need for Spinal Surgeons to be encouraging and enthusiastic about a field of surgery which provides some of the exciting challenges in Orthopaedic Surgery.

12 GPs were invited to take part in a study in which the GPs would undertake training in out-patient techniques, to determine suitability of patients for arthroscopic surgery. The GPs would undertake to counsel the patients regarding the procedure itself and the post operative rehabilitation. They were then referred by means of a set referral form which included specific guidelines which allowed patients to be put directly onto the consultant’s waiting list. The patients would then be sent for surgery directly and be seen immediately pre-operatively by the operating consultant and consented. This group of direct access arthroscopy patients (36) were compared to a contemporaneous consecutive series of patients who had been referred in the normal manner and were undergoing operation at the time of the study period (October 1998 to April 2000.

In the group of patient submitted for direct access arthroscopy three patients had improved such that when they were offered admission dates they declined. A further three patients were deemed unsuitable for direct access arthroscopy and the referral was rejected by the consultant. Two patients declined three separate admission dates and were discharged, and a final patient did not attend his admission date. This left 27 patients who were admitted for direct access arthroscopy service. Of these, one patient was cancelled pre-operatively by the consultant as she had recently been admitted for investigation of cardiac abnormalities procedure and was therefore considered unfit for day case general anaesthetic procedure. Of the 26 patients who underwent arthroscopy all were discharged home the same day, and reviewed in the out-patient clinic at six weeks, and they were asked to complete a Patient Satisfaction Questionnaire, and were discharged from further review at that time.

When compared to a contemporaneous group of patients who had undergone arthroscopic surgery via the routine referral procedure, the group of patients admitted via the direct access route waited on average ten weeks (range 6 – 12) from GP consultation and referral to operation date. This compared to 41 week for the combined total out-patient and in-patient waiting times for the routine access group (range 18 – 132 weeks). Findings at arthroscopy were similar in the two groups with mostly meniscal lesions (18/26 direct access group compared to 15/26 routine access group). The therapeutic operation rate, i.e. procedures beyond simple diagnostic arthroscopy were undertaken, was high in both groups, 68% of the direct access group and 72% of the routine access group. Pre-operative diagnosis accuracy by the GPs was significantly higher in the direct access group of referrals. 65% of direct access referrals had the correct diagnosis made by the GP in the referral compared to 18% of correct diagnosis in the group undergoing routine referrals. Post operative recovery in terms of return to work , return to activities of daily living and discharge from clinic was the same in the two groups. Patient satisfaction was comparable in both groups.

In conclusion direct access arthroscopy reduces significantly the time the surgery and the number of visits by patients to primary or secondary care physicians. GP diagnostic rates were comparable to previously reported figures for registrar/middle grade pre-operative diagnostic rates for patients undergoing knee artrhoscopy. There was a high therapeutic operation rate suggesting few, if any inappropriate procedures were undertaken. The direct access arthroscopy service requires considerable time on the part of the consultant in both setting up the study and training the GPs to a reasonable standard and monitoring referrals and undertaking pre-operative screening of patients awaiting arthroscopy. There was a high inappropriate referral rate in that only 26 patients out of the 36 referred eventually underwent arthroscopic surgery. Although feasible we feel that direct access knee arthroscopy service needs refinement if it is to continue. We intend to introduce an orthopaedic practitioner who will accept referrals from GPs and then screen patients before placing patients on the consultant’s inpatient waiting list. Also the mechanism of extra lists needs to be put in place to ensure direct access patients do not “jump the queue” of patients who are already awaiting arthroscopic surgery.

12 General Practitioners (GP’s) were invited to take part in a study in which the GPs would undertake training in outpatient techniques, to determine suitability of patients for arthroscopic surgery. The GPs would undertake to counsel the patients regarding the procedure itself and the postoperative rehabilitation. They were then referred by means of a set referral form, which included specific guidelines, which allowed patients to be put directly onto the consultant’s waiting list. The patients would then be sent for surgery directly and be seen immediately pre-operatively by the operating consultant and consented. This group of direct access arthroscopy patients (36) were compared to a contemporaneous consecutive series of patients who had been referred in the normal manner and were undergoing operation at the time of the study period (October 1998 to April 2000.

In the group of patient submitted for direct access arthroscopy three patients had improved such that when they were offered admission dates they declined. A further three patients were deemed unsuitable for direct access arthroscopy and the referral was rejected by the consultant. Two patients declined three separate admission dates and were discharged, and a final patient did not attend his admission date. This left 27 patients who were admitted for direct access arthroscopy service. Of these, one patient was cancelled pre-operatively by the consultant as she had recently been admitted for investigation of cardiac abnormalities and was therefore considered unfit for day case general anaesthetic procedure. Of the 26 patients who underwent arthroscopy all were discharged home the same day, and reviewed in the out-patient clinic at six weeks, and they were asked to complete a Patient Satisfaction Questionnaire, and were discharged from further review at that time.

When compared to a contemporaneous group of patients who had undergone arthroscopic surgery via the routine referral procedure, the group of patients admitted via the direct access route waited on average ten weeks (range 6 – 12) from GP consultation and referral to operation date. This compared to 41 weeks for the combined total outpatient and in-patient waiting times for the routine access group (range 18 – 132 weeks). Findings at arthroscopy were similar in the two groups with mostly meniscal lesions (18/26 direct access group compared to 15/26 routine access group). The therapeutic operation rate, i.e. procedures beyond simple diagnostic arthroscopy were undertaken, was high in both groups, 68% of the direct access group and 72% of the routine access group. Pre-operative diagnosis accuracy by the GPs was significantly higher in the direct access group of referrals. 65% of direct access referrals had the correct diagnosis made by the GP in the referral compared to 18% of correct diagnosis in the group undergoing routine referral. Post operative recovery in terms of return to work, return to activities of daily living and discharge from clinic was the same in the two groups. Patient satisfaction was comparable in both groups.

In conclusion direct access arthroscopy reduces significantly the time to surgery and the number of visits by patients to primary or secondary care physicians. GP diagnostic rates were comparable to previously reported figures for registrar/middle grade pre-operative diagnostic rates for patients undergoing knee arthroscopy. There was a high therapeutic operation rate suggesting few, if any inappropriate procedures were undertaken. The direct access arthroscopy service requires considerable time on the part of the consultant in both setting up the study and training the GPs to a reasonable standard and monitoring referrals and undertaking pre-operative screening of patients awaiting arthroscopy. There was a high inappropriate referral rate in that only 26 patients out of the 36 referred eventually underwent arthroscopic surgery. Although feasible we feel that direct access knee arthroscopy service needs refinement if it is to continue. We intend to introduce an orthopaedic practitioner who will accept referrals from GPs and then screen patients before placing patients on the consultant’s inpatient waiting list. Also the mechanism of extra lists needs to be put in place to ensure direct access patients do not “jump the queue” of patients who are already awaiting arthroscopic surgery.