Total hip arthroplasty is well established as a successful treatment modality for end stage arthritis, with a variety of components currently available. However, utilising traditional stemmed implants in patients with distorted proximal femoral geometry can be technically challenging with increased risk of complications. We present seven patients with distorted proximal femoral anatomy or failed hip arthroplasty in whom a technically challenging primary or revision operation was simplified by use of a Proxima stem. This is a short, stemless, metaphyseal loading implant with a pronounced lateral flare. At twelve months follow up there have been no complications with average improvement in Oxford and Harris scores of forty and forty-nine respectively. Radiological analysis shows all stems to be stable and well fixed. Designed primarily as a bone conserving implant for primary hip arthroplasty we propose that the Proxima prosthesis also be considered in cases where a conventional stemmed implant may not be suitable due to challenging proximal femoral anatomy. The use of the stemless Proxima implant provided a simple solution in seven difficult and potentially lengthy complex primary and revision hip arthroplasties with gratifying clinical and radiological outcomes.
Joint line elevation >
8mm has been associated with inferior clinical outcome, and depression associated with retropatellar pain and increased risk of patella subluxation. Recently, modifications have been made to the Kine-max-Plus Total Knee System instrumentation, theoretically providing better internal fixation to prevent a varus cut and a 12 mm measured resection from the “normal” tibial plateau. This study aims to examine whether these changes result in an improvement in alignment, and a more reliable restoration of joint line.
In the future, registration with a surgical speciality may require no more than the demonstration of core knowledge in the generality of that speciality and in the diagnosis and management of the related acute conditions. Sub-speciality training will be recognised separately. Rationalisation of referral patterns would then require that primary care practitioners are aware of these special abilities. A questionnaire was sent to 1207 General Practitioners in the Avon, Leicestershire and Central London regions. The response rate was 86.2% (n = 1040). Views were sought on the management and referral of patients experiencing problems with existing hip replacements. These included the use of pre referral radiographs, whether practitioners would preferentially refer to a specialist hip surgeon and whether they believed that referral to a generalist could compromise patient care. The majority GP’s arranged pre referral radiographs (84.2%). A third (34.2%) indicated that they would refer to any orthopaedic surgeon. 50.0% felt that outcome could be compromised if the patient was seen by an orthopaedic surgeon without a special interest in hip surgery. There appears to be a need for more scientific information for GP’s and an agreed referral protocol. It is expected that rationalisation the referral system would lead to closer matching of patients needs with specialists’ abilities.
Guidelines from the National Institute of Clinical Excellence (NICE) recommend comparative clinical evaluation for prostheses without long-term follow-up data and set an initial ‘benchmark’ for performance at 3 years. Data collection for the CPS-Plus stem is on-going as part of a multi-centre prospective clinical trial. 227 patients have been recruited to the trial and 70 of these have reached 3 years follow-up.
We hypothesise that patients are unable to recall much of the information imparted during the informed consent procedure. This may have important medico-legal consequences and increase patient anxiety. Receiving the information in a written format may improve patient recall. There have been no previous studies testing recall or information sheets for British orthopaedic patients. We performed a randomised controlled trial of consent for total hip arthroplasty, with one group of patients receiving a written information sheet with explanation as necessary, and the control group receiving the same information verbally. The consent was obtained at a pre-operative assessment clinic approximately three weeks before admission. On admission, a questionnaire was filled in both groups of patients to assess recall. There were no significant differences between the two groups with regard to type of arthroplasty (revision or primary), age, or days from consent to admission. The group receiving written information performed better in the recall questionnaire. This group were pleased to have received the information sheet, there were no negative comments about the sheet. In the group who received verbal information, most expressed a desire to receive a written information sheet. One patient stated that she would rather know nothing about the operation and would have refused a sheet. We conclude that patient information sheets are an acceptable and appropriate method of imparting the necessary information for informed consent for total hip arthroplasty, and are more effective than standard verbal informed consent. Medico-legally, the sheet could be a permanent record of what was discussed. This should prevent disputes and claims due to poor recall of the consent procedure.
