An enhanced recovery programme for knee arthroplasty was introduced two years ago to our orthopaedic department. It involved the setting up of an educational programme for patients along with an extensive rehabilitation programme. The main aim of the programme is to provide an efficient and personalised service that results in an improved patient experience and fewer bed days following surgery. We carried out a retrospective study, randomly selecting 100 patients over a period of a year who were enrolled in the enhanced recovery programme. We analysed three main areas involving the pre-, peri- and post-operative period. We looked for any key factors that led to an increase or decrease in bed days. The re-admissions were analysed and the cost benefit was calculated. 99 patients were randomly selected and satisfied the inclusion criteria. We found that with the enhanced recovery programme the average length of stay for a knee arthroplasty was four days. There were no re-admissions within the population. We would like to share our enhanced recovery programme model as we feel it is a robust and effective way of providing a high level of care and decreasing the length of stay post-operatively.
The design of hip replacements is based on the morphology of the proximal femur. Populations living in hard water regions have higher levels of serum calcium and magnesium which promote bone mineralization. A case control study was performed comparing proximal femoral morphology in patients living in soft and hard water regions to determine whether the effect of water hardness had an implication in the future design of hip-prostheses. The proximal femoral morphology of 2 groups of 70 aged and sex matched patients living in hard and soft water regions at mean age 72.24 (range, 50 to 87 years) were measured using an antero-posterior radiograph of the non-operated hip with magnification adjusted. The medullary canal diameter at the level of the lesser trochanter was significantly wider in patients living in the hard water region (mean width 1.9 mm wider; p=0.003). No difference was found at the isthmus, Dorr index, or cortical bone ratio. In conclusion proximal femoral morphology does differ: a wider medullary canal at the level of the lesser trochanter in hard water regions. This size difference is relatively small and is unlikely therefore to affect the mechanics of the current femoral stem prostheses components.
We investigated the role of Plasma Viscosity (PV), C-reactive protein (CRP) and Frozen Section (FS) in diagnosing prosthetic joint infection. We compared these results with microbiological diagnosis of infection of the tissue samples (three or more samples grown same organisms in culture). 53 patients, average age 67 years (37 – 89) underwent joint revision surgery. 34 patients had hip and 19 patients had knee joint revision arthroplasty, this includes single and multiple stage revision surgeries and excision arthroplasty. Nine (17%) patients had microbiologically proven joint infection. PV had sensitivity of 100%, specificity of 43% and negative predictive value of 100%. CRP had sensitivity of 89 %, specificity of 75% and negative predictive value of 97%. FS (presence of infection being more than 5 neutrophils/hpf) had sensitivity of 56% and specificity of 84%. We recommend PV and CRP to be used in the investigation of prosthetic joint infection. If both CRP and PV are normal the chance of infection is very low (negative predictive value of 100%). In our series an elevated PV and CRP represented a 50% chance of having a joint infection. The role of frozen section does not appear to be beneficial in the diagnosis of joint
The role of magnetic resonance arthrography (MRA) in the evaluation of patients with femeroacetabular impingement (FAI) to assess femoral head-neck junction asphericity and labral pathology is well established. However, in our experience the presence of acetabular cysts on MRA, which may signify underlying full thickness articular cartilage delamination and progression towards arthropathy, is also an important feature. We retrospectively reviewed 142 hips (mean age 32 years, 47 men, 95 women), correlating the findings on MRA with those found at the time of open surgical hip debridement to ascertain the prevalence of acetabular cysts and the association with underlying acetabular changes. Fifteen MRA's demonstrated features consistent with underlying acetabular cystic change. At the time of surgery, this was confirmed in eleven cases that demonstrated a full thickness articular chondral flap (carpet lesion) and an underlying acetabular cyst. The sensitivity, specificity, positive predictive value and negative predictive value of MRA in relation to acetabular cysts was 55%, 96.7%, 73.3% and 92.9% respectively. We believe acetabular cysts on MRA to be a significant finding. Such patients are likely to have an associated full thickness chondral lesion and features of early degenerative change, influencing outcome and prognosis. Our clinical practise has changed to reflect this finding. For those patients with cysts on MRA, we are less likely to offer open debridement and favour arthroscopic intervention followed by arthroplasty when symptoms dictate. We believe hip preservation surgeons should be aware of the significance of acetabular cysts and be prepared to adjust treatment options accordingly.
Femoroacetabular impingement (FAI) causes anterior hip pain, labral tears and damage to the articular cartilage leading to early osteoarthritis of the hip. Surgical hip dislocation and osteoplasty of the femoral neck and acetabular rim is a technique pioneered by the Bernese group for the treatment of FAI. We present and discuss our results of this technique. Functional outcome was measured in hips with over 12 month follow-up using the Oxford hip and McCarthy non-arthritic hip scores pre- and post-operatively.Introduction
Methods
We describe our technique and the early results of compaction morselised bone grafting (CMBG) for displaced tibial plateau fractures using fresh frozen allograft. This technique has been performed by the senior author since July 2006 on eight patients. Clinical and radiological follow-up was performed on seven remaining patients at an average 12 months (range 4–19) following surgery. One patient died of an unrelated cause three months following surgery. One patient underwent a manipulation under anaesthesia at three months for knee stiffness. One patient developed a painless valgus deformity and underwent corrective osteotomy at 15 months. The height of the tibial plateau on radiographs has been maintained to an excellent grade (less than 2 mm depression) in all but one patient. CMBG using fresh frozen allograft in depressed tibial plateau fractures provides structural support sufficient to maintain the height of the tibial plateau, is associated with few complications in complex patients with large bone loss and has theoretical advantages of graft incorporation and remodelling.
The review of the first 325 Exeter Universal hips reported good long term survivorship despite the majority of cups being metal backed. We have reviewed the long term performance of the concentric all-polyethylene Exeter cups used with the Universal Exeter stem. Clinical and radiographic outcomes of 263 consecutive primary hip arthroplasties in 242 patients with mean age 66 years (range, 18 to 89) were reviewed. 118 cases subsequently died none of whom underwent a revision. Eighteen hips have been revised; thirteen for aseptic cup loosening, three for recurrent dislocation and two for deep infection. Three patients (four hips) were lost to follow-up. The minimum follow-up of the remaining 123 hips was 10 years (mean 13.3 years, range 10–17). Radiographs demonstrated 4 (4%) of the remaining acetabular prostheses were loose. The Kaplan Meier survivorship at 14.5 years with endpoint revision for all causes is 91.5% (95% CI 86.6 to 96.2%). With endpoint revision for aseptic cup loosening, survivorship is 93.3% (CI 88.8 to 97.8%). This series included a number of complex cases requiring bone blocks and/or chip autograft for acetabular deficiencies. The concentric all polythene Exeter cup and Exeter stem has excellent long term results particularly when factoring in the complexity of cases in this series.
Of the 27 hips preserved, 14 had chondral ‘carpet’ flaps debrided, 17 underwent recession of the acetabular rim at the site of impingement, 6 had removal of medial osteophytes, 6 had labral and/or bony cysts excised and grafted and 1 underwent an osteochondral graft. Oxford Hip Score improved from an average 36 (range 17–59) to 23 (12–45) and McCarthy hip score from 43 (9–74) to 62 (36–72) in the preserved hips at an average 15 months following surgery (range 6–33 months).
Of the 27 hips preserved, 14 had chondral ‘carpet’ flaps debrided, 17 underwent recession of the acetabular rim at the site of impingement, 6 had removal of medial osteophytes, 6 had labral and/or bony cysts excised and grafted and 1 underwent an osteochondral graft. In 3 hips (12%) osteoarthritis progressed requiring hip resurfacing within the first year. Oxford Hip Score improved from an average 36 (range 17–59) to 23 (12–45) and McCarthy hip score from 43 (9–74) to 62 (36–72) in the preserved hips at an average 15 months following surgery (range 6–33 months).
