Background

Current treatments for the prevention of thromboembolism include heparin and low-molecular weight heparins (LMWHs). A number of studies have suggested that long term administration of these drugs may adversely affect osteoblasts and therefore, bone metabolism. Xarelto(tm) (Rivaroxaban) is a new anti-thrombotic drug for the prevention of venous thromboembolism in adult patients undergoing elective hip and knee replacement surgery. The aim of this in vitro study was to investigate the possible effects of rivaroxaban on osteoblast proliferation, function, matrix mineralisation and gene expression compared to enoxaparin, a commonly used LMWH.

Pseudotumours (soft-tissue masses relating to the hip joint) following metal-on-metal hip resurfacing arthroplasty (MoMHRA) have been associated with elevated serum and hip aspirate metal ion levels, suggesting that pseudotumours occur when there is increased wear. This study aimed to quantify the wear of implants revised for pseudotumours and a control group of implants revised for other reasons of failure.

A total of 30 contemporary MoMHRA implants in two groups were investigated: (1) 8 MoMHRA implants revised due to pseudotumour; (2) 22 MoMHRA implants revised due to other reasons of failure. The linear wear of retrieved implants was measured using a Taylor-Hobson Roundness machine. The average linear wear rate was defined as the maximum linear wear depth divided by the duration of the implant in vivo.

In comparison with the non-pseudotumour implant group, the pseudotumour implant group was associated with: (1) significantly higher median linear wear rate of the femoral component: 8.1 um/year (range 2.75-25.4 um/year) vs. 1.97 um/year (range 0.82-13.00 um/year), p=0.002; and (2) significantly higher median linear wear rate of the acetabular component: 7.36 um/year (range 1.61-24.9 um/year) vs. 1.28 um/year (range 0.18-3.33 um/year), p=0.001. Wear on the acetabular cup components in the pseudotumour group always involved the edge, indicating edge-loading of the bearing.

Significantly greater linear wear rates of the MoMHRA implants revised due to pseudotumour support the in vivo elevated metal ion concentrations in patients with pseudotumours. This study is the first to confirm that pseudotumour occurs when there is increased wear at the MoM articulation. Furthermore, edge-loading may be the dominant wear generation mechanism in patients with pseudotumour.

Introduction

Varus positioning of cemented ‘composite beam’ stems is associated with increased risks of aseptic loosening and stem fracture. We investigated whether the incidence of varus malalignment of the Exeter polished, double taper design in a multicentre prospective study adversely affected outcome after total hip replacement (THR).

Patients undergoing total knee arthroplasty (TKA) experience significant post-operative pain. We report the results of a new comprehensive patient care plan to manage peri-operative pain, enable early mobilisation and reduce length of hospital stay in TKA.

A prospective audit of 1081 patients undergoing primary TKA during 2008 and 2009 was completed. All patients followed a planned programme including pre-operative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, post-operative high volume intermittent ropivacaine boluses with an intra-articular catheter and early mobilisation. The primary outcome measure was the day of discharge from hospital. Secondary outcomes were verbal rating pain scores on movement, time to first mobilisation, nausea and vomiting scores, urinary catheterisation for retention, need for rescue analgesia, maximum flexion at discharge and six weeks post-operatively, and Oxford score improvement.

The median day of discharge to home was post-operative day four. Median pain score on mobilisation was three for first post-operative night, day one and two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterisation rate was 6.9%. Rescue analgesia was required in 5% of cases. Median maximum flexion was 85° on discharge and 93° at six weeks post-operatively. Only 6.6% of patients had a reduction in maximum flexion (loss of more than 5°) at six weeks. Median Oxford score had improved from 42 pre-operatively to 27 at six weeks post-operatively. The infection rate was 0.7% and the DVT and PE rates were 0.6% and 0.5% respectively.

This multidisciplinary approach provides satisfactory post-operative analgesia allowing early safe ambulation and discharge from hospital. Anticipated problems did not arise, with early discharge not being detrimental to flexion achieved at six weeks and infection rates not increasing with the use of intra-articular catheters.

Introduction

Rolando type base of thumb metacarpal fractures are potentially debilitating injuries, which can be difficult to manage because of their inherent instability. Malunion is associated with stiffness, pain and weakness of pinch grip. We aimed to assess the outcome of a simple technique for the treatment of this fracture using the principle of ligamentotaxis, with a static, 2-pin external fixator spanning the trapeziometacarpal joint. We present the results and functional outcomes of this technique.