We retrospectively reviewed 220 patients following hip hemiarthroplasty, creating 2 demographically matched cohorts; Group 1: 3 doses of Cefuroxime (n=113) and Group 2: single dose Gentamicin and Amoxicillin (n=107). End points were evidence of infection, length of stay and Clostridium difficile (CD) rates. Considering antibiotic therapies administered; significant reductions in group 2 for the number of patients that required post-operative antibiotics (99/113 Vs 73/107 p=0.0005), the median antibiotic DDDs (Defined Daily Doses) in 1st 2 post-operative days (0.25 Vs 0 p=0.0000) and those that received Ciprofloxacin or Cefuroxime post-operatively (82/113 Vs 24/107 p=0.0000). No significant difference was found for median antibiotic DDDs, median antibiotic DDDs from 2nd post-operative day, patients that received Flucloxacillin post-operatively. Measured microbiological outcomes showed a significant reduction in the number of patients with confirmed growth requiring treatment with antibiotics in group 2 (21/23 Vs 12/22 p=0.0053). No difference was found between number patients with operation site swabbed and those with confirmed microbial growth. We demonstrate single dose Gentamicin and Amoxicillin significantly reduces length of stay, CD rates and the number of patients requiring post-operative antibiotics for wound infection, inferring a reduction in the rate of wound infection. We would recommend this as an effective alternative to the 3 dose Cefuroxime regime.
This prospective randomised controlled trial recruited 420 patients into 3 equal groups: extension, 3 &
6 hrs flexion. This trial found a significant reduction in blood loss(12%, p=0.006) and length of stay(1/2 day, p=0.006) in the 6 hour flexion group, compared the extension group. There was no significant difference in pain or complication rates (excluding nerve palsy). 2 patients in the 6 hour group had postoperative nerve palsy, however, this palsy was sensory only and markedly different to that found previously. Although the palsy rate in this study is similar(1.4%) to quoted literature rates (1.3%) for TKA, it is difficult to know if the jig was the cause of palsy as the there was a difference between those caused by the old metal jig (painful) and those in this study (sensory loss only).
56 patients fulfilled the criteria and 50 patients were included in the study between September 2006 – May 2007. Male/female ratio was 18: 32. Mean age was 66.2 years. Procedure included 33 total knees, 13 bilateral and 4 revision knee replacements.
Prior to our study the expenditure on allogenic blood transfusion was £13,230. The estimated cost of using the re-infusion system was £6230 A saving of £ 7500 was achieved as a result of using the drain in the “at risk” patient.
Hip fractures are a major challenge and impose high demand on orthopaedic services. DHS has been proved to be a gold standard method of treatment in uncomplicated extracapsular fractures. The introduction of Intramedullary devices has provided us with a wider choice of construct. Since there was conflicting literature evidence comparing the outcomes of DHS and IMHS, we set out to analyse the same in our practice. Forty patients in each group operated in the year 2000, comparable in fracture pattern, age and sex distribution were studied. The operating time, fluoroscopic exposure, blood loss, complications (Intra-op, Post-op and Deaths), duration of hospital stay and the discharge destinations were studied from the clinical notes and Hospital information system. Statistical analysis was carried out using SPSS for all the available data. Statistically, the DHS has a lesser duration of surgery, lower fluoroscopic exposure and lesser duration of hospital stay. However, clinically it appears that the IMHS is fraught with more complications.
Current methods for restoring or preserving limb length following total hip arthroplasty are anatomically inaccurate, as they do not consider acetabular and femoral height independently. In order to address this, we present and evaluate a technique that uses the transverse acetabular ligament to control the vertical height of the acetabular component and a caliper that controls the vertical placement of the femoral component within the femoral canal. Limb lengths were measured in 200 patients who had undergone primary total hip arthroplasty using this technique. Using this method, 94% had a post-operative limb length inequality that was 6 mm or less when compared to the normal side (average +0.38 mm). The maximum measured limb length inequality was ± 8 mm.
We report a series of 668 patients (699 hips) with an average follow up of 10.5 years (range, 10–11 years) following THR using a cemented custom-made titanium femoral stem and a cemented high-density polyethyl-ene acetabular component. The fate of every implant is known. The mean age at operation was 68 years (24 – 94 years). The indication for THR was as follows: primary OA (629), RA (18), AVN (10), intracapsular femoral neck fracture (5), Perthes disease (3), developmental hip dysplasia (2) and SUFE (1). The mean pre-operative Harris Hip Score was 19 (range 10 – 42). One hundred and seventy-four patients (26%) were deceased at the time of their 10-year review. Four hundred and ninety-four patients were subsequently reviewed of which 88 patients (13%) were assessed by telephone review as they were too frail to attend. The average 10-year Harris Hip Score was 92 (range 43 – 100). The average 10-year Oxford Hip Score was 19 (range 12 – 46). 99.2% reviewed at 10 years stated that they were satisfied with their THR. Revision surgery occurred in 21 cases (3%). Seventeen femoral components were revised for infection, one for recurrent dislocation and one was iatrogenically loosened during socket revision. There were no cases of revision for aseptic loosening of the stem. Dislocation occurred in 18 cases, of which 4 became recurrent (0.6%). Six patients had a postoperative sciatic nerve palsy (0.9%) with 4 making a full recovery. There was one case of femoral nerve palsy. Eleven patients developed a DVT (1.6%). Six patients had a PE (0.9%) all of which were non-fatal. There were 16 deep and 3 superficial wound infections. Thirty-eight patients had symptomatic trochanteric bursitis post-surgery. In conclusion, the 10-years results of the custom femoral stem are encouraging with an overall high level of patient satisfaction.
Polyethylene wear remains an important cause of failure in knee replacements. Retrieval studies, simulators and simple X-ray methods produce wear data that may be inaccurate or unrealistic. We have developed an accurate RSA system for measuring wear in-vivo. Using this system we have found wear rate in a fixed bearing TKR to be about 0.1mm/yr[ Four Oxford uni-compartmental knee replacements, with excellent clinical results were studied ten years after implantation. RSA X-rays were taken in double leg stance with the knee in full extension and 15 and 30 degrees flexion. Following RSA calibration, silhouettes of the components on the stereo X-rays were extracted using a Canny edge detector and were matched to silhouettes projected using CAD models to determine the 3D component position. The average minimum thickness of the bearing was determined and was compared with the measured minimum thickness of 14 unused bearings to calculate linear penetration. The average linear penetration after average 10 years implantation (range 8.5 to 10.25 years) was 0.16 mm (SD 0.13 mm). The average penetration rate was 0.017 mm/year (SD 0.011 mm/year). The maximum linear penetration rate was 0.027 mm/year. The penetration rate is similar to that obtained in a retrieval study [
Leg-length inequality is not uncommon following primary total hip arthroplasty and can be distressing to the patient. An excellent clinical result with respect to pain relief, function, component fixation, range of motion and radiographic appearance can be transformed into a surgical failure because of patient dissatisfaction due to leg-length inequality. Postoperative leg-length discrepancy was determined radiographically for 200 patients who had had a primary custom total hip arthroplasty. In all cases the opposite hip was considered to have a normal joint center. The femoral component was designed and manufactured individually for each patient using screened marker x-rays. A graduated calliper was used at the time of surgery to control depth of femoral component insertion. The transverse acetabular ligament was used to control placement of the acetabular component and therefore restore acetabular joint center. Using this method 94% of subjects had a postoperative leg-length discrepancy that was 6mm or less when compared to the normal side (average, +0.38mm). The maximum value measured for leg-length discrepancy was +/−8mm. We describe a simple technique for controlling leg length during primary total hip arthroplasty and propose an alternative radiographic method for measuring leg-length discrepancy.
In a previous study
To maximise the long-term survivorship of any hip prosthesis it is important to recreate joint centre. Normal joint centre is determined by horizontal offset and vertical height of the acetabular and femoral components. In this study joint centre and horizontal offset were analysed in 200 consecutive patients operated on from October 1998 in whom the opposite hip was normal. Joint centre was defined relative to the acetabulum and femur both pre- and post-operatively. On the acetabular side a horizontal line was drawn across the pelvis immediately below each teardrop. A vertical line was drawn at right angles through the middle of each teardrop. Acetabular offset was defined as the horizontal distance from the vertical trans teardrop line to head centre. For femoral offset a screened x-ray was taken to show maximum offset. The anatomical axis was drawn and the offset was defined as the distance from the anatomical axis to head centre. Our results show on the acetabular side there was an overall tendency to leave the joint centre medial and so decrease acetabular offset. However, we found that 90% of our sockets were placed within 6 mm of normal joint centre. We attribute this accuracy to the principle of visualising the transverse acetabular ligament intra-operatively and using this landmark to control depth of socket insertion. Conversely, on the femoral side there was a slight tendency to increase the offset. Nevertheless, 98% of the custom stems were within 10mm of normal joint centre. When we looked at total horizontal offset i.e. the combination of femoral and acetabular offset we found that joint centre had been restored to within 10mm in 93% of cases. This study confirms the effectiveness of the custom femoral stem and Duraloc socket in restoring joint centre.
Rapidly progressive cases of primary idiopathic hip osteoarthrosis are well known and recognised. The prevalence reported in the literature varies from 4–18%. Three types have been identified- type 1 (rapid), type 2 (moderate) and type 3 (delayed) depending on the duration of chondrolysis and the subsequent rate of bone loss per year. We reviewed the charts of all patients deemed to be RPO type 1 who had underwent hip arthroplasty under the care of the senior author (DEB) over a two-year period in an attempt to identify risk factors, which may have contributed to the rapid progression of their disease. All patients were treated using a custom femoral stem and a spiked Duraloc cementless socket following careful preparation of the acetabulum. We identified 34 patients (40 hips) with type 1 rapidly progressive osteoarthrosis. Over the same time period 991 patients had underwent primary total hip arthroplasty, giving a prevalence of 4%. Of the 34 patients, 29 were female of average age 70.6 years (range, 51–83 years). All of the bilateral cases (6 patients) were female. Body mass index (BMI) for the female group ranged from 20.6 to 41.1Kg/m2 (average, 28.2kg/m2) whilst that for the males was on average 25.8Kg/m2 (range, 23.4–29.7Kg/m2). Preoperative erythrocyte sedimentation rate (ESR) was 18mm/hr on average for the female group (range, 2–65mm/hr) and ranged from 3–52mm/hr (average, 20mm/hr) for the male patients. The preoperative Oxford Hip Score averaged 51 points for the female group and 48 points for the male group. A detailed review of occupational history did not reveal any common occupational hazard. The majority of patients were non-smokers and denied any regular alcohol intake. Twenty-two patients (65%) had a history of hypertension. Twenty-seven patients (79%) had a history of non-steroidal anti-inflammatory use (most common preparation-diclofenac). Twenty-four patients (71%) resided in a rural area. When compared to a cohort of patients undergoing primary total hip arthroplasty over the same time period, the only statistically significant risk factor identified was female gender. We conclude, that patients who develop rapidly progressive osteoarthrosis of the hip are difficult to identify due to the absence of specific clinical features. We also outline our experience in the management of these technically challenging cases.