Aims

Medial unicompartmental knee arthroplasty (mUKA) is an advised treatment for anteromedial knee osteoarthritis. While long-term survival after mUKA is well described, reported incidences of short-term surgical complications vary and the effect of surgical usage on complications is less established. We aimed to describe the overall occurrence and treatment of surgical complications within 90 days of mUKA, as well as occurrence in high-usage centres compared to low-usage centres.

Aims

The most frequent indication for revision surgery in total hip arthroplasty (THA) is aseptic loosening. Aseptic loosening is associated with polyethylene liner wear, and wear may be reduced by using vitamin E-doped liners. The primary objective of this study was to compare proximal femoral head penetration into the liner between a) two cross-linked polyethylene (XLPE) liners (vitamin E-doped (vE-PE)) versus standard XLPE liners, and b) two modular femoral head diameters (32 mm and 36 mm).

Aims

Surgical site infection (SSI) is a common complication of surgery with an incidence of about 1% in the United Kingdom. Sutures can lead to the development of a SSI, as micro-organisms can colonize the suture as it is implanted. Triclosan-coated sutures, being antimicrobical, were developed to reduce the rate of SSI. Our aim was to assess whether triclosan-coated sutures cause a reduction in SSIs following arthroplasty of the hip and knee.

Aims

A fracture of the hip is the most common serious orthopaedic injury, and surgical site infection (SSI) is one of the most significant complications, resulting in increased mortality, prolonged hospital stay and often the need for further surgery. Our aim was to determine whether high dose dual antibiotic impregnated bone cement decreases the rate of infection.

To report our experience with the use of local antibiotic co-delivery with a synthetic bone graft substitute during a second stage re-implantation of an infected proximal humeral replacement.

A 72 year old man was admitted to our department with a pathological fracture through an osteolytic lesion in the left proximal humerus, due to IgG Myelomatosis. He was initially treated with a cemented proximal humerus replacement hemiarthroplasty. Peri-prosthetic joint infection (PJI) with significant joint distention was evident three weeks post operatively. Revision surgery confirmed presence of a large collection of pus and revealed disruption of the soft tissue reattachment tube, as well as complete retraction of rotator cuff and residual capsule. All modular components were removed and an antibiotic-laden cement spacer (1.8g of Clindamycin and Gentamycin, respectively) was implanted onto the well-fixed cemented humeral stem. Initial treatment with i.v. Amoxicillin/Clavulanic acid was changed to Rifampicin and Fusidic Acid during a further 8 weeks after cultures revealed growth of S. epidermidis. During second stage revision, a hybrid inverse prosthesis with silver coating was implanted, with a total of 20 ml Cerament ™G (injected into the glenoid cavity prior to insertion of the base plate and around the humeral implant-bone interface) and again stabilized with a Trevira tube. Unfortunately, this prosthesis remained unstable, ultimately requiring re-revision to a completely new constrained reverse prosthesis with a custom glenoid shell and silver-coated proximal humeral component.

18 months postoperatively, the patient's shoulder remains pain free and stable, without signs of persistent or reinfection since the initial second stage revision. The function however, unfortunately remains poor.

This case report illustrates the application of an antibiotic-eluting bone graft substitute in a specific clinical situation, where co-delivery of an antibiotic together with a bone remodeling agent may be beneficial to simultaneously address PJI as well as poor residual bone quality.

The cement used for hemiarthroplasties by the authors and many other surgeons in the UK is Palacos® (containing 0.5g Gentamicin). Similar cement, Copal® (containing 1g Gentamicin and 1g Clindamycin) has been used in revision arthroplasties. We aim to investigate the effect on SSI rates of doubling the gentamicin dose and adding a second antibiotic (clindamycin) to the bone cement in hip hemiarthroplasty.

We randomised 848 consecutive patients undergoing cemented hip hemiarthroplasty for fractured NOF into two groups: Group I, 464 patients, received standard cement (Palacos®) and Group II, 384 patients, received high dose, double antibiotic-impregnated cement (Copal®). We calculated the SSI rate for each group at 30 days post-surgery. The patients, reviewers and statistician were blinded as to treatment group.

The demographics and co-morbid conditions were statistically similar between the groups. The combined superficial and deep SSI rates were 5 % (20/394) and 1.7% (6/344) for groups I and II respectively (p=0.01). Group I had a deep infection rate 3.3 %(13/394) compared to 1.16% (4/344) in group II (p=0.082). Group I had a superficial infection rate 1.7 % (7/394) compared to 0.58% (2/344) in group II (p=0.1861). 33(4%) patients were lost to follow up, and 77 (9%) patients were deceased at the 30 day end point.

Using high dose double antibiotic-impregnated cement rather than standard low dose antibiotic-impregnated cement significantly reduced the SSI rate (1.7% vs 5%; p=0.01) after hip hemiarthroplasty for fractured neck of femur in this prospective randomised controlled trial.

Currently, the cement being used for hemiarthroplasties and total hip replacements by the authors and many other surgeons in the UK is Palacos® (containing 0.5g Gentamicin). Similar cement, Copal® (containing 1g Gentamicin and 1g Clindamycin) has been used in revision arthroplasties, and has shown to be better at inhibiting bacterial growth and biofilm formation. We aim to investigate the effect on SSI rates of doubling the gentamicin dose and adding a second antibiotic (clindamycin) to the bone cement in hip hemiarthroplasty.

We randomised 848 consecutive patients undergoing cemented hip hemiarthroplasty for fractured NOF at one NHS trust (two sites) into two groups: Group I, 464 patients, received standard cement (Palacos®) and Group II, 384 patients, received high dose, double antibiotic-impregnated cement (Copal®). We calculated the SSI rate for each group at 30 days post-surgery. The patients, reviewers and statistician were blinded as to treatment group.

The demographics and co-morbid conditions (known to increase risk of infection) were statistically similar between the groups. The combined superficial and deep SSI rates were 5 % (20/394) and 1.7% (6/344) for groups I and II respectively (p=0.01). Group I had a deep infection rate 3.3 %(13/394) compared to 1.16% (4/344) in group II (p=0.082). Group I had a superficial infection rate 1.7 % (7/394) compared to 0.58% (2/344) in group II (p=0.1861). 33(4%) patients were lost to follow up, and 77 (9%) patients were deceased at the 30 day end point. There was no statistical difference in the 30 day mortality, C. difficile infection, or the renal failure rates between the two groups.

Using high dose double antibiotic-impregnated cement rather than standard low dose antibiotic-impregnated cement significantly reduced the SSI rate (1.7% vs 5%; p=0.01) after hip hemiarthroplasty for fractured neck of femur in this prospective randomised controlled trial.

Introduction

Total leg muscle function in hip OA patients is not well studied. We used a test-retest protocol to evaluate the reproducibility of single- and multi-joint peak muscle torque and rapid torque development in a group of 40–65 yr old hip patients. Both peak torque and torque development are outcome measures associated with functional performance during activities of daily living.

Introduction

Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower limb arthroplasty. Trials supporting its use have not fully evaluated the risks of wound complications related to rivaroxaban.

Background and purpose

The prevalence of back pain has remained relatively constant in the population in spite of previous interventions. Persons with sub-acute back pain are assumed to benefit from extended multidisciplinary, interdisciplinary or transdiciplinary and multisectorial, intersectorial or trans-sectorial interventions as an alternative to traditional mono-professional interventions. The purpose of this health technology assessment (HTA) was to document the possible effect of such interventions in patients suffering from back pain of 4-12 weeks duration.

Introduction: Prophylactic systemic antibiotics are commonly used peri-operatively in primary hip and knee arthroplasty in the UK. ‘Fast-Track’ (FT) peri-operative care – a multimodal concept aiming to accelerate postoperative rehabilitation and reduce general morbidity – is also becoming more common in arthroplasty surgery. There are no published reports of acute kidney injury (AKI) as a result of a single-dose prophylactic Gentamicin. The renal impact of hypotensive anaesthesia and reduced routine post-operative intravenous fluid therapy, both features of FT protocol, has not yet been reported. Aim: To evaluate the renal impact of prophylactic Gentamicin and FT perioperative care in hip and knee arthroplasty surgery.

Methods: Four hundred and eighty-four total hip/knee arthroplasty patients had their pre-operative, first and third post-operative day serum creatinine concentration measured and recorded. The first 180 patients (group A) received 1.5g Cefuroxime at induction and two further doses of 750mg at 8 hours and 16 hours post-operatively as antibiotic prophylaxis. The next 160 patients (Group B) received 5mg/kg single-dose Gentamicin at induction instead of Cefuroxime. These patients (Group A and B) were not treated as per FT protocol. The final 144 patients (Group C) received the same Gentamicin as Group B and were treated as per FT protocol. Outcome measures were overall change and an increase of > 30 μmol/L, the latter signifying an AKI.

Results: Mean creatinine change at day 1 was −4.63 in Group A, −3.95 in Group B and 4.19 in Group C. Mean creatinine change by day 3 was −5.28 in Group A, −2.53 in Group B and 8.89 in Group C. No patients in Group A, 4 patients (2.56%) in Group B and 9 patients (6.66%) in Group C had a rise of > 30 μmol/L in day 1 creatinine concentrations.

Conclusions: Comparing the groups, there was no statistically significance change in the day 1 creatinine when Gentamicin replaced Cefuroxime (p=0.625,) however this became significant once FT was also introduced (p=0.001.) In terms of an important creatinine rise (AKI,) the change to Gentamicin produced a statistically significant rise in the number of patients with a day 1 creatinine rise > 30 μmol/L (p=0.048.) By day 3 there is no significant difference in the number of patients with a creatinine rise > 30 μmol/L.

Discussion: FT protocol aims to encourage haemostatic surgery and early ambulant patients (free from drip stands) at the expense of mild hypovolaemia. When these patients are also receiving Gentamicin, the kidneys are concentrating urine and Gentamicin in the tubules thus causing and AKI in some cases. It appears that Gentamicin and FT are cumulative in their effect on renal function.

Background: Ankle fractures are the second commonest lower limb fractures after hip fractures and as opposed to the latter occur commonly in younger population of working age. Due to a host of different factors including the state of soft tissues and delayed presentation, there is often a delay of several days between fracture and operation, resulting in longer admissions. It is hypothesised that early intervention may shorten hospital stay and hence save on hospital resources.

Aims: To ascertain the impact of timing of ankle fracture surgery on length of post operative and total hospital stay and its implication on resources.

Methodology: Consecutive ankle fractures that underwent open reduction and internal fixation at Newcastle General Hospital over a 4-year period were studied as a retrospective cohort. Data collection from Theatre records, PAS system, case notes and radiographs was undertaken and entered in SPSS database.

Results: 431 cases of ankle fracture open reduction and internal fixation were included in the study. 41% were female and 59% were male patients, with a mean age of 39.1 years (SD±17.8), with age range from 16 to 89 years.

298 patients were operated within 48 hours of admission (early surgery group), and 136 patients after 48 hours (delayed surgery group). The mean hospital stay in the early operation group was mean 5.3 days (SD±4.9) and in the delayed surgery group it was 12.2 days (SD±8.4). The patients who were operated early had shorter total hospital stay (p< 0.001) and also had shorter post-operative stay (p< 0.05). Increasing age and female gender appeared to predispose to longer hospital stay but this was not statistically significant. Mean age, gender and ASA grade, fracture class and operating surgeon’s grade distribution were not significantly different in the early and late surgery groups.

Each patient in delayed surgery group spent an extra 6.9 days in hospital stay compared to the early surgery group, translating into an extra 937 hospital bed days. The average extra cost of hospital stay per case in the delayed surgery group (£1414) exceeds the average expense of surgery per case in that group. The delayed surgery group resulted in added expenditure of £192085 to the trauma division solely for extra hospital stay.

Conclusion: Timing of surgery in ankle fracture appears to be the most significant determinant affecting the hospital stay. This has a significant resource implication, financially and in freeing up of hospital resources, as well as impacting on the lives of this large group of patients.

A dorsal incision is made over the metatarso-phalangeal joint (MTPJ) extending 2cm proximally and distally from the joint line. A routine cheilectomy of the MTPJ is performed. The Extensor digitorum longus (EDL) tendon is identified and divided through a separate incision 5 cm proximal to the MTPJ at the mid-foot level. A 3/0 vicryl stay suture is placed in the divided tendon. The tendon is retrieved from the distal wound and mobilised along with the extensor expansion and the dorsal capsule to expose the proximal half of the proximal phalanx. The transverse fibres of the extensor expansion and the MTPJ capsule are divided medially and laterally with preservation of the collateral ligaments. Extensor digitorum brevis is identified and protected. A groove is created on the dorsum of the proximal phalanx at the centre of the articular surface to stabilise the EDL tendon in its final position. A 3.2mm tunnel is then created at a 45 degree angle through the metatarsal neck beginning dorsally 2.5cm from the metatarsal articular surface and exiting just proximal to the plantar plate. The mobilised EDL tendon, expansion and capsule are then passed down through the MTPJ via a perforation in the plantar plate. The EDL tendon is then passed through the tunnel from plantar to dorsal where it is sutured to the periosteum of the metatarsal using a 3/0 vicryl suture. Hence the EDL tendon, expansion and dorsal capsule form an interposition arthroplasty.

Eleven patients with an average age of 37 years underwent the above procedure for Freiberg’s Disease or osteoarthritis of the second or third MTPJ. There were no intra-operative complications and at an average 31 month follow up 70% were pain free. We recommend the Cobb II procedure as a primary management option for MTPJ Freiberg’s Disease/osteoarthritis.