Aims

This study describes the variation in the annual volumes of revision hip arthroplasty (RHA) undertaken by consultant surgeons nationally, and the rate of accrual of RHA and corresponding primary hip arthroplasty (PHA) volume for new consultants entering practice.

Aims

Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson’s hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes.

The National Institute for Health and Clinical Excellence (NICE) has thus far relied on historical data and predominantly industry-sponsored trials to provide evidence for venous thromboembolic (VTE) prophylaxis in joint replacement patients. We argue that the NICE guidelines may be reliant on assumptions that are in need of revision. Following the publication of large scale, independent observational studies showing little difference between low-molecular-weight heparins and aspirin, and recent changes to the guidance provided by other international bodies, should NICE reconsider their recommendations?

Cite this article: Bone Joint Res 2014;3:146–9.

Objectives

To review the current best surgical practice and detail a multi-disciplinary approach that could further reduce joint replacement infection.

Background: The painful 1st metatarso-phalangeal joint (MTPJ) is a common presentation in outpatient clinics. Options for treatment include arthroplasty and arthrodesis. Previous MTPJ replacement implant designs have had poor mid-term success. The Moje prosthesis was designed to overcome some of the problems with earlier implants, and employs ceramic bearing surfaces and a press-fit tapered stem design. Previous studies have reported good early results in small numbers of patients.

Methods: Between February 2002 and December 2006 the senior author implanted 55 components in 48 patients. AOFAS hallux scores and satisfaction scores (0 to 10) were recorded at follow-up. Radiographs were analysed for component alignment, implant bone coverage and subsidence. The mean age of patients at implantation was 56 years (34–77). Average follow-up was 42 months (15 to 74).

Results: There were no patients lost to follow-up. Average AOFAS score was 72 (25 to 100) and satisfaction score was 8.2 (range 1 to 10). 82% stated they would have the same procedure again and 82% reported minimal or no pain. There were no deep infections but 35% of patients reported altered sensation. Four implants have been removed (8%) because of worsening pain and implant loosening. 50% of metatarsal implants and 80% of phalangeal implants were implanted within 5 degrees of the long bony axis. Average bony coverage was 80%, resulting in subsidence of 90% of metatarsal and 70% of phalangeal implants at follow-up.

Discussion: Despite the poor radiographic appearance in the majority of cases, this procedure has good clinical outcome at the mid-term stage with 92% implant survival. The long-term clinical significance of the radiographic appearances is currently unknown. Improved surgical technique, including better bony coverage, may reduce the risk of implant subsidence.

Introduction: The return of haemoglobin (Hb) to preoperative levels at 1–6 months following elective lower limb joint arthroplasty is well documented. Previous reports have suggested in healthy, elective patients there is no significant improvement in Hb levels following iron supplementation compared with placebo. There may also be unpleasant side effects. However, there is little published on this topic in the elderly population who suffer a femoral neck fracture and undergo emergency surgery, and often have poorer iron reserves.

Methods: We examined the blood results and discharge prescriptions of consecutive patients who underwent femoral neck fracture surgery at our institute in a 12 month period. Patients who had received a blood transfusion were excluded. 82 patients remained. Normal Hb levels at the time of surgery and 1–6 months post-operatively (late Hb) were collected.

Results: Thirteen patients (16%) were prescribed iron supplementation on discharge. No patients who went on to receive iron had a normal Hb (11.5 – 15.5g/dL in females, 13– 8g/dL in males) immediately following surgery (mean Hb 9.17g/dL) compared with 26% (mean Hb 10.41g/dL) in those who received no iron. At 115.2 days (range 28–284) following surgery 88.9% of patients prescribed iron had a normal Hb compared with only 48.1% of those who received no treatment (P=0.0167).

Discussion: The low level of iron prescribing was surprising, and may be the result of published evidence in elective patients. Our numbers are small, but we show a statistically significant difference which warrants further investigation. We suggest that, unlike the younger, healthier elective arthroplasty patients, femoral neck fracture patients may benefit from dietary iron supplement.

Introduction: Limp in a child is a common presentation to the emergency department. Most patients have no serious pathology. However, it is important not to miss specific problems and delay treatment. We therefore established a limping child protocol in conjunction with the emergency department, which was implemented in 2003. We aimed to assess our performance against agreed standards; 100% investigated as per protocol, and 100% admitted or seen in the next fracture clinic.

Methods: We examined all emergency department case notes of children aged less than 14 years old who presented with a lower limb problem over a 1 year period. Patients diagnosed as having soft tissue injuries or fractures were excluded. We were left with 58 patients. Information concerning investigations and disposal from the emergency department was sought from the case notes and the hospital computer system.

Results: Average age was 5.1 years. The protocol was followed correctly in only 21% of cases. 33% were followed-up incorrectly, and 22% received no documented follow-up.

Discussion: There was poor compliance in the emergency department. Incomplete investigations, follow-up and documentation were the main problems. Up to one quarter of serious pathology may have been missed. We attribute these problems to high staff turn over and poor awareness of the protocol. We have introduced changes to improve our performance.

Introduction: Payment by results was introduced into the NHS in an effort to finance Trusts fairly and reward good performance. Tariffs for a single patient episode are derived from diagnosis and procedure codes, comorbidities, patient age, and length of stay. Poor data collection can result in a lower tariff with subsequent under billing of the Primary Care Trust (PCT). In addition, an individual surgeon’s performance in future comparison league tables will rely on the accuracy of this data. Methods of documentation and data collection vary in different units. We evaluated the methods and the resulting tariffs in 2 units in the Northern Deanery.

Methods: Case notes were examined for 20 consecutive orthopaedic patients discharged from unit A, and 20 from unit B. The case mix in the two groups was similar. A correct tariff based on case notes was compared with the actual tariff used to bill the PCT for each patient. The coding department derived actual tariffs from data in electronic discharge summaries created by ward based junior medical staff in unit A. Accurately completed typed case notes were available to coders in unit B.

Results: Only 3 of the 20 tariffs (15%) were correct for unit A patients. This represented a total financial loss to the trust of £14892 (25% of total revenue). In unit B, 19 of 20 (95%) tariffs were correct. An error in the coding for one procedure resulted in a higher tariff being assigned to a patient (total gain of £486, < 1%).

Discussion: Orthopaedic departments create large Trust revenue. Accurate documentation and information transfer for coding is essential for payment by results to function correctly. Trusts which fail to do this will be financially penalised and surgeon league tables may not adequately reflect individual case complexity. We recommend all Trusts use the model established in unit B.