Valenzuela GA, Jacobson NA, Buzas D, Koreckij TD, Valenzuela RG, Teitge RA. Unicompartmental knee replacement after high tibial osteotomy: Invalidating a contraindication. Bone Joint J 2013;95-B:1348–1353.

Batta V, Coathup MJ, Parratt MT, et al. Uncemented, custom-made, hydroxyapatite-coated collared distal femoral endoprostheses: Up to 18 years’ follow-up. Bone Joint J 2014;96-B:263–269.

Brånemark R, Berlin Ö, Hagberg K, Bergh P, Gunterberg B, Rydevik B. A novel osseointegrated percutaneous prosthetic system for the treatment of patients with transfemoral amputation: A prospective study of 51 patients. Bone Joint J 2014;96-B:106–113.

Canadian Arthroplasty Society. The Canadian Arthroplasty Society’s experience with hip resurfacing arthroplasty: an analysis of 2773 hips. Bone Joint J 2013;95-B:1045–1051.

We have reviewed the current literature to compare the results of surgery aimed to repair or debride a damaged acetabular labrum. We identified 28 studies to be included in the review containing a total of 1631 hips in 1609 patients. Of these studies 12 reported a mean rate of good results of 82% (from 67% to 100%) for labral debridement. Of the 16 studies that reported a combination of debridement and re-attachment, five reported a comparative outcome for the two methods, four reported better results with re-attachment and one study did not find any significant difference in outcomes. Due to the heterogeneity of the studies it was not possible to perform a meta-analysis or draw accurate conclusions. Confounding factors in the studies include selection bias, use of historical controls and high rates of loss of follow-up.

It seems logical to repair an unstable tear in a good quality labrum with good potential to heal in order potentially to preserve its physiological function. A degenerative labrum on the other hand may be the source of discomfort and its preservation may result in persistent pain and the added risk of failure of re-attachment. The results of the present study do not support routine refixation for all labral tears.

Cite this article: Bone Joint J 2014;96-B:24–30.

The outcome after total hip replacement has improved with the development of surgical techniques, better pain management and the introduction of enhanced recovery pathways. These pathways require a multidisciplinary team to manage pre-operative education, multimodal pain control and accelerated rehabilitation. The current economic climate and restricted budgets favour brief hospitalisation while minimising costs. This has put considerable pressure on hospitals to combine excellent results, early functional recovery and shorter admissions.

In this review we present an evidence-based summary of some common interventions and methods, including pre-operative patient education, pre-emptive analgesia, local infiltration analgesia, pre-operative nutrition, the use of pulsed electromagnetic fields, peri-operative rehabilitation, wound dressings, different surgical techniques, minimally invasive surgery and fast-track joint replacement units.

Cite this article: Bone Joint J 2013;95-B:1587–94.

The increasing need for total hip replacement (THR) in an ageing population will inevitably generate a larger number of revision procedures. The difficulties encountered in dealing with the bone deficient acetabulum are amongst the greatest challenges in hip surgery. The failed acetabular component requires reconstruction to restore the hip centre and improve joint biomechanics. Impaction bone grafting is successful in achieving acetabular reconstruction using both cemented and cementless techniques. Bone graft incorporation restores bone stock whilst providing good component stability. We provide a summary of the evidence and current literature regarding impaction bone grafting using both cemented and cementless techniques in revision THR.

Cite this article: Bone Joint J 2013;95-B, Supple A:98–102.

Cavaignac E, Lafontan V, Reina N, Pailhé R, Wargny M, Laffosse JM, Chiron P. Obesity has no adverse effect on the outcome of unicompartmental knee replacement at a minimum follow-up of seven years. Bone Joint J 2013;95-B:1064-1068.

Young adults with hip pain secondary to femoroacetabular impingement (FAI) are rapidly being recognised as an important cohort of orthopaedic patients. Interest in FAI has intensified over the last decade since its recognition as a precursor to arthritis of the hip and the number of publications related to the topic has increased exponentially in the last decade. Although not all patients with abnormal hip morphology develop osteoarthritis (OA), those with FAI-related joint damage rapidly develop premature OA. There are no explicit diagnostic criteria or definitive indications for surgical intervention in FAI. Surgery for symptomatic FAI appears to be most effective in younger individuals who have not yet developed irreversible OA. The difficulty in predicting prognosis in FAI means that avoiding unnecessary surgery in asymptomatic individuals, while undertaking intervention in those that are likely to develop premature OA poses a considerable dilemma. FAI treatment in the past has focused on open procedures that carry a potential risk of complications.

Recent developments in hip arthroscopy have facilitated a minimally invasive approach to the management of FAI with few complications in expert hands. Acetabular labral preservation and repair appears to provide superior results when compared with debridement alone. Arthroscopic correction of structural abnormalities is increasingly becoming the standard treatment for FAI, however there is a paucity of high-level evidence comparing open and arthroscopic techniques in patients with similar FAI morphology and degree of associated articular cartilage damage. Further research is needed to develop an understanding of the natural course of FAI, the definitive indications for surgery and the long-term outcomes.

Cite this article: Bone Joint J 2013;95-B, Supple A:26–30.

Kazi HA, Perera JR, Gillott E, Carroll FA, Briggs TW. A prospective study of a ceramic-on-metal bearing in total hip arthroplasty: Clinical results, metal ion levels and chromosome analysis at two years. Bone Joint J 2013;95-B:1040-1044.

Gordon M, Stark A, Sköldenberg OG, Kärrholm J, Garellick G. The influence of comorbidity scores on re-operations following primary total hip replacement: Comparison and validation of three comorbidity measures. Bone Joint J 2013;95-B:1184-1191.

Cadossi M, Chiarello E, Savarino L, Tedesco G, Baldini N, Faldini C, Giannini S. A comparison of hemiarthroplasty with a novel polycarbonate-urethane acetabular component for displaced intracapsular fractures of the femoral neck: a randomised controlled trial in elderly patients. Bone Joint J 2013;95-B:609-615.

Canadian Arthroplasty Society. The Canadian Arthroplasty Society’s experience with hip resurfacing arthroplasty: an analysis of 2773 hips. Bone Joint J 2013;95-B:1045-1051.

In a time of limited resources, the debate continues over which types of hip prosthesis are clinically superior and more cost-effective. Orthopaedic surgeons increasingly need robust economic evidence to understand the full value of the operation, and to aid decision making on the ‘package’ of procedures that are available and to justify their practice beyond traditional clinical preference.

In this paper we explore the current economic debate about the merits of cemented and cementless total hip replacement, an issue that continues to divide the orthopaedic community.

Cite this article: Bone Joint J 2013;95-B:874–6.

Infected periprosthetic fractures around total hip arthroplasties are increasingly common and extremely challenging problem. The purpose of the study was to review the experience of two tertiary referral units managing infected periprosthetic femoral fractures using interlocking long-stem femoral prostheses either as temporary functional spacers or as definitive implants.

In this paper, we will consider the current role of metal-on-metal bearings by looking at three subtypes of MoM hip arthroplasty separately: Hip resurfacing, large head (> 36 mm) MoM THA and MoM THA with traditional femoral head sizes.

Peri-prosthetic infection remains a leading cause of revision surgery. Recent publications from the American Musculoskeletal Infection Society have sought to establish a definition of peri-prosthetic infection based on clinical findings and laboratory investigations. The limitations of their approach are discussed and an alternative definition is proposed, which it is felt may better reflect the uncertainties encountered in clinical practice.

In this paper we make the case for the use of single-stage revision for infected knee arthroplasty.

Radiological assessment of total and unicompartmental knee replacement remains an essential part of routine care and follow-up. Appreciation of the various measurements that can be identified radiologically is important. It is likely that routine plain radiographs will continue to be used, although there has been a trend towards using newer technologies such as CT, especially in a failing knee, where it provides more detailed information, albeit with a higher radiation exposure.

The purpose of this paper is to outline the radiological parameters used to evaluate knee replacements, describe how these are measured or classified, and review the current literature to determine their efficacy where possible.

This review summarises the opinions and conclusions reached from a symposium on infected total knee replacement (TKR) held at the British Association of Surgery of the Knee (BASK) annual meeting in 2011. The National Joint Registry for England and Wales reported 5082 revision TKRs in 2010, of which 1157 (23%) were caused by infection. The diagnosis of infection beyond the acute post-operative stage relies on the identification of the causative organism by aspiration and analysis of material obtained at arthroscopy. Ideal treatment then involves a two-stage surgical procedure with extensive debridement and washout, followed by antibiotics. An articulating or non-articulating drug-eluting cement spacer is used prior to implantation of the revision prosthesis, guided by the serum level of inflammatory markers. The use of a single-stage revision is gaining popularity and we would advocate its use in certain patients where the causative organism is known, no sinuses are present, the patient is not immunocompromised, and there is no radiological evidence of component loosening or osteitis.

It is our opinion that single-stage revision produces high-quality reproducible results and will soon achieve the same widespread acceptance as it does in infected hip arthroplasty.

Introduction

Up to 2% of total hip arthroplasties (THA) are still complicated by infection. This leads to dissatisfied patients with poor function, and has far-reaching social and economic consequences. The challenge in these cases is the eradication of infection, the restoration of full function and the prevention of recurrence. We report the outcome of early aggressive debridement in the acutely infected THA.

Introduction

There have been concerns regarding the quality of training received by Orthopaedic trainees. There has been a reduction in working hours according to the European working times directive. National targets to reduce surgical waiting lists has increased the workload of consultants, further reducing the trainees' surgical experience. Navigation assisted procedures are successfully used in orthopaedics and provides useful feedback to the surgeon regarding precision of implant placement. We investigated the use of navigation aids as an alternative source of training surgical trainees.

Introduction

In recent years, there has been a significant advancement in our understanding of femoro-acetabular impingement and associated labral and chondral pathology. Surgeons worldwide have demonstrated the successful treatment of these lesions via arthroscopic and open techniques. The aim of this study is to validate a simple and reproducible classification system for acetabular chondral lesions.

Revision arthroplasty of the hip is expensive owing to the increased cost of pre-operative investigations, surgical implants and instrumentation, protracted hospital stay and drugs. We compared the costs of performing this surgery for aseptic loosening, dislocation, deep infection and peri-prosthetic fracture. Clinical, demographic and economic data were obtained for 305 consecutive revision total hip replacements in 286 patients performed at a tertiary referral centre between 1999 and 2008. The mean total costs for revision surgery in aseptic cases (n = 194) were £11 897 (sd 4629), for septic revision (n = 76) £21 937 (sd 10 965), for peri-prosthetic fracture (n = 24) £18 185 (sd 9124), and for dislocation (n = 11) £10 893 (sd 5476). Surgery for deep infection and peri-prosthetic fracture was associated with longer operating times, increased blood loss and an increase in complications compared to revisions for aseptic loosening. Total inpatient stay was also significantly longer on average (p < 0.001). Financial costs vary significantly by indication, which is not reflected in current National Health Service tariffs.

Introduction

Up to 2% of total knee arthroplasties (TKA) are still complicated by infection. This leads to dissatisfied patients with poor function, and has far-reaching social and economic consequences. The challenge in these cases is the eradication of infection, the restoration of full function and the prevention of recurrence.

We report the outcome of prosthesis sparing early aggressive debridement in the acutely infected TKA.

An international faculty of orthopaedic surgeons presented their work on the current challenges in hip surgery at the London Hip Meeting which was attended by over 400 delegates. The topics covered included femoroacetabular impingement, thromboembolic phenomena associated with hip surgery, bearing surfaces (including metal-on-metal articulations), outcomes of hip replacement surgery and revision hip replacement. We present a concise report of the current opinions on hip surgery from this meeting with appropriate references to the current literature.

Introduction

Unicondylar knee replacements (UKR) may be more effective compared to Total knee replacements (TKR) in unicompartmental arthritis. We report patient outcomes & satisfaction data in an age matched cohort of patients with either a UKR or TKR.

Lately, concerns have arisen following the use of large metal-on-metal bearings in hip replacements owing to reports of catastrophic soft-tissue reactions resulting in implant failure and associated complications. This review examines the literature and contemporary presentations on current clinical dilemmas in metal-on-metal hip replacement.

There have been considerable recent advances in the understanding and management of femoroacetabular impingement and associated labral and chondral pathology. We have developed a classification system for acetabular chondral lesions. In our system, we use the six acetabular zones previously described by Ilizaliturri et al. The cartilage is then graded on a scale of 0 to 4 as follows: grade 0, normal articular cartilage lesions; grade 1, softening or wave sign; grade 2, cleavage lesion; grade 3, delamination; and grade 4, exposed bone. The site of the lesion is further classed as A, B or C based on whether the lesion is less than one-third of the distance from the acetabular rim to the cotyloid fossa, one-third to two-thirds of the same distance and greater than two-thirds of the distance, respectively. In order to validate the classification system, six surgeons graded ten video recordings of hip arthroscopy.

Our findings showed a high intra-observer reliability of the classification system with an intraclass correlation coefficient of 0.81 and a high interobserver reliability with an intraclass correlation coefficient of 0.88.

We have developed a simple reproducible classification system for lesions of the acetabular cartilage, which it is hoped will allow standardised documentation to be made of damage to the articular cartilage, particularly that associated with femoroacetabular impingement.

Bacterial infection in orthopaedic surgery can be devastating, and is associated with significant morbidity and poor functional outcomes, which may be improved if high concentrations of antibiotics can be delivered locally over a prolonged period of time. The two most widely used methods of doing this involve antibiotic-loaded polymethylmethacrylate or collagen fleece. The former is not biodegradable and is a surface upon which secondary bacterial infection may occur. Consequently, it has to be removed once treatment has finished. The latter has been used successfully as an adjunct to systemic antibiotics, but cannot effect a sustained release that would allow it to be used on its own, thereby avoiding systemic toxicity.

This review explores the newer biodegradable carrier systems which are currently in the experimental phase of development and which may prove to be more effective in the treatment of osteomyelitis.

We report a systematic review and meta-analysis of published randomised controlled trials evaluating the efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion in total hip replacement (THR). The data were evaluated using the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. We identified 11 clinical trials which were suitable for detailed extraction of data. There were no trials that used TXA in revision THR. A total of seven studies (comprising 350 patients) were eligible for the blood loss outcome data. The use of TXA reduced intra-operative blood loss by a mean of 104 ml (95% confidence interval (CI) −164 to −44, p = 0.0006, heterogeneity I² 0%), postoperative blood loss by a mean of 172 ml (95% CI −263 to −81, p = 0.0002, heterogeneity I² 63%) and total blood loss by a mean of 289 ml (95% CI −440 to −138, p < 0.0002, heterogeneity I² 54%).

TXA led to a significant reduction in the proportion of patients requiring allogeneic blood transfusion (risk difference −0.20, 95% CI −0.29 to −0.11, p < 0.00001, I² 15%). There were no significant differences in deep-vein thrombosis, pulmonary embolism, infection rates or other complications among the study groups.

Fibrin glue, also known as fibrin sealant, is now established as a haemostatic agent in surgery, but its role in orthopaedic surgery is neither well known nor clearly defined. Although it was originally used over 100 years ago, concerns about transmission of disease meant that it fell from favour. It is also available as a slow-release drug delivery system and as a substrate for cellular growth and tissue engineering. Consequently, it has the potential to be used in a number of ways in orthopaedic surgery. The purpose of this review is to address its use in surgery of the knee in which it appears to offer great promise.

Periprosthetic infection following total hip replacement can be a catastrophic complication for the patient. The treatments available include single-stage exchange, and two-stage exchange. We present a series of 50 consecutive patients with a diagnosis of infected total hip replacement who were assessed according to a standardised protocol. Of these, 11 underwent single-stage revision arthroplasty with no recurrence of infection at a mean of 6.8 years follow-up (5.5 to 8.8). The remaining 39 underwent two-stage revision, with two recurrences of infection successfully treated by a second two-stage procedure. At five years, significant differences were found in the mean Harris Hip Scores (single-stage 87.8; two-stage 75.5; p = 0.0003) and in a visual analogue score for satisfaction (8.6; 6.9; p = 0.001) between the single- and two-stage groups. Single-stage exchange is successful in eradicating periprosthetic infection and results in excellent functional and satisfaction scores.

Identification of patients suitable for the single-stage procedure allows individualisation of care and provides as many as possible with the correct strategy in successfully tackling their periprosthetic infection

As of April 2010 all NHS institutions in the United Kingdom are required to publish data on surgical site infection, but the method for collecting this has not been decided. We examined 7448 trauma and orthopaedic surgical wounds made in patients staying for at least two nights between 2000 and 2008 at our institution and calculated the rate of surgical site infection using three definitions: the US Centers for Disease Control, the United Kingdom Nosocomial Infection National Surveillance Scheme and the ASEPSIS system. On the same series of wounds, the infection rate with outpatient follow-up according to Centre for Disease Control was 15.45%, according to the UK Nosocomial infection surveillance was 11.32%, and according to ASEPSIS was 8.79%. These figures highlight the necessity for all institutions to use the same method for diagnosing surgical site infection.

If different methods are used, direct comparisons will be invalid and published rates of infection will be misleading.

Purpose: To determine if a multi-modal programme including non-operative measures of physiotherapy and education can improve the symptoms of osteoarthritis of the knee.

Methods/Results: 72 patients with osteoarthritis of the knee confirmed on radiographic or arthroscopic evidence were referred over a 13 month period (April 2007 – May 2008) for a lower limb programme. The programme consisted of 12 classes over 6 weeks of group physiotherapy and included education on osteoarthritis, diet and exercise.

The total number of knees affected was 98. The mean number of compartments affected was 1.2 with the medial and patellofemoral compartment most affected. The mean number of classes attended was 8.3. Pre-intervention, the mean WOMAC score was 64.7 and the mean Oxford knee score was 31.9. Post-intervention at a mean follow up of 12 months (range 7 – 22 months), the mean WOMAC score was 29.4 and the mean Oxford knee score 22.4. The change in scores following intervention was statistically significant (p < 0.05). Of the cohort, 9 patients were subsequently offered or went on to have knee joint arthroplasty.

Conclusions: At 12 months, a multi-modal programme consisting of non-operative interventions has an excellent impact upon osteoarthritis of the knee with improved patient reported scores. This modality should be considered for all patients with mild to moderate osteoarthritis in whom surgical options are not otherwise indicated. Further work is required to see which components most influenced patients’ outcomes, the impact of education and group classes on maintaining physiotherapy exercises in the long term, the benefits conferred even for those patients who subsequently undergo joint arthroplasty, and whether referral to the programme from a primary care setting will lower the number of referrals of knee osteoarthritis to orthopaedic units which are ultimately managed without surgical intervention.

Aim: To ascertain if a medial rotation platform knee replacement design (MRK; Finsbury Orthopaedics) exhibits improved range of motion (ROM) and functional outcome compared to a conventional single radius condylar knee replacement system (PFC Sigma; Depuy) at one year.

Methods: Eighty patients undergoing total knee arthroplasty(TKA) were prospectively randomised and allocated to either receive the MRK or PFC Sigma pros-thesis. Patients were blinded to the choice of implant. Follow-up clinical and radiological evaluations were carried out by a single clinician so as to avoid interob-server error. Validated patient based scores including the Total Knee Function Questionnaire (TKFQ) were used to assess patient function.

Results: The average ROM in the MRK group was 108.53°. In the PFC Sigma group it was 94.16°. Statistical significance was demonstrated between the two groups.

The MRK group showed superior results in the TKFQ score which assesses activities of daily living as well as recreational and sporting activities. The movement and lifestyle component of the TKFQ, and the Knee Society Score were better in the MRK group with statistical significance.

No difference was demonstrated between the two groups with respect to radiological analysis, WOMAC Knee, Oxford Knee and SF-36 scores.

6 out of 40 patients in the MRK group compared to 5 out of 40 patients in the PFC group said that they had forgotten about their TKA at one year.

Conclusions: The medial rotation platform design confers increased ROM at one year with an associated benefit in movement and lifestyle and resultant patient satisfaction.

We measured the plasma 25-hydroxyvitamin D₃ (25(OH)D₃) levels in 62 consecutive Caucasian patients undergoing total hip replacement for osteoarthritis. The patients were divided into two groups based on whether they were vitamin D sufficient or deficient. The groups were matched for age, gender and the American Society of Anaesthesiologists (ASA) grade. The prevalence of vitamin D deficiency in our patients was comparable with recent population-based studies performed in the United Kingdom. Patients with vitamin D deficiency had lower pre-operative Harris hip scores (Mann-Whitney test, p = 0.018) and were significantly less likely to attain an excellent outcome from total hip replacement (chi-squared test, p = 0.038). Vitamin D levels were found to positively correlate with both pre- and post-operative Harris hip scores.

These results warrant further study of vitamin D deficiency in patients undergoing joint replacement as it is a risk factor for a suboptimal outcome which is relatively simple and cheap to correct.

The radiological evaluation of the anterolateral femoral head is an essential tool for the assessment of the cam type of femoroacetabular impingement. CT, MRI and frog lateral plain radiographs have all been suggested as imaging options for this type of lesion. The alpha angle is accepted as a reliable indicator of the cam type of impingement and may also be used as an assessment for the successful operative correction of the cam lesion.

We studied the alpha angles of 32 consecutive patients with femoroacetabular impingement. The angle measured on frog lateral radiographs using templating tools was compared with that measured on CT scans in order to assess the reliability of the frog lateral view in analysing the alpha angle in cam impingement.

A high interobserver reliability was noted for the assessment of the alpha angle on the frog lateral view with an intraclass correlation coefficient of 0.83. The mean alpha angle measured on the frog lateral view was 58.71° (32° to 83.3°) and that by CT was 65.11° (30° to 102°). A poor intraclass correlation coefficient (0.08) was noted between the measurements using the two systems.

The frog lateral plain radiograph is not reliable for measuring the alpha angle. Various factors may be responsible for this such as the projection of the radiograph, the positioning of the patient and the quality of the image. CT may be necessary for accurate measurement of the alpha angle.

The Vancouver classification has been shown by its developers to be a valid and reliable method for categorising the configuration of periprosthetic proximal femoral fractures and for planning their management. We have re-validated this classification system independently using the radiographs of 30 patients with periprosthetic fractures. These were reviewed by six experienced consultant orthopaedic surgeons, six trainee surgeons and six medical students in order to assess intra- and interobserver reliability and reproducibility. Each observer read the radiographs on two separate occasions. The results were subjected to weighted kappa statistical analysis.

The respective kappa values for interobserver agreement were 0.72 and 0.74 for consultants, 0.68 and 0.70 for trainees on the first and second readings of the radiographs and 0.61 for medical students. The intra-observer agreement for the consultants was 0.64 and 0.67, for the trainees 0.61 and 0.64, and for the medical students 0.59 and 0.60 for the first and second readings, respectively. The validity of the classification was studied by comparing the pre-operative radiological findings within B subgroups with the operative findings. This revealed agreement for 77% of these type-B fractures, with a kappa value of 0.67.

Our data confirm the reliability and reproducibility of this classification system in a European setting and for inexperienced staff. This is a reliable system which can be used by non-experts, between centres and across continents.

Introduction: The incidence of post-operative peri-prosthetic fractures is increasing. This is a consequence of the larger number of revision cases being undertaken, the increase in the use of cementless implants and a number of patients who develop undetected osteolysis as a result of poor follow up. The Vancouver classification has been shown to be a valid and reliable method for determining the configuration of periprosthetic fractures. This is essential in directing the further management of periprosthetic fractures appropriately.

Methods: We have revalidated this classification system independently from the original authors at our institution. The radiographs from 30 patients with peri-prosthetic fractures were reviewed by 6 expert consultant surgeons, 6 non-experts at registrar level and 6 medical students, who had received no specialist training in this area, in order to assess intra and inter-observer reliability and reproducibility. Each observer read the radiographs on 2 separate occasions and classified the fracture according to its type (A, B1, B2, B3, and C).

Results: The results were subjected to weighted κ analysis and were: Intraobserver agreement 0.72 for experts,0.68 for non experts and 0.61 for medical students. Interobserver agreement was 0.63 for the first reading and 0.67 for the second reading. Validity analysis showed a κ value of 0.79 (substantial agreement).

Discussion: Our results confirm the reliability and reproducibility of this classification system. In addition we have shown that substantial agreement can even be found between individuals with no specialist training. This is a classification system that can be used by non-experts, between centres and across continents.

Orthopaedic outcome measures are used to evaluate the effect of operative interventions. They are used for audit and research. Knowledge of these measures is becoming increasingly important with league tables comparing surgeons and hospitals being made accessible to the profession and the general public.

Several types of tool are available to describe outcome after hip surgery such as generic quality-of-life questionnaires, disease-specific quality-of-life questionnaires, hip-specific outcome measures and general short-term clinical measures. We provide an overview of the outcome measures commonly used to evaluate hip interventions.

Due to economic constraints, it has been suggested that joint replacement patients can be followed up in primary care. There are clinical, ethical and academic reasons why we must ensure that our joint replacements are appropriately clinically and radiologically followed up to minimise complications. This Editorial discusses this.

Background And Aims: Total knee replacements provide a cost effective treatment for painful joint conditions such as osteoarthritis. Their long term performance is governed by ultra-high molecular weight polyethylene (UHMWPE) wear which produces wear debris and leads to osteolysis and aseptic loosening of the implant. Using a new material which is more scratch resistant than cobalt chrome it is hoped to reduce wear of UHMWPE and its subsequent complications.

Methods: Two total knee replacements made from cobalt chrome and two of oxidised zirconium were wear tested in a knee simulator. Surface roughness data from the femoral components was collected. Gravimetric and volumetric wear of the polyethylene inserts was measured. SEM analysis of the surfaces was also performed.

Results: Oxidised zirconium is significantly more scratch resistant than CoCr; Ra (mean average roughness) of 0.7μm compared to 0.43μm (p< < 0.01) at end of test, and confirmed by SEM analysis. This was accompanied by a 4 fold reduction in wear of UHMWPE 49.60mg to 12.48mg (p=0.02). Barium sulphate particles were found to be embedded in the surface of the CoCr implants.

Summary And Conclusions: Oxidised zirconium leads to a reduction in wear of UHMWPE due to its increased resistance to third body wear. It has the potential to increase the longevity of total knee replacements by reducing UHMWPE related complications.

The Kent hip is a distally-locked femoral stem which was developed to address severe proximal bone loss, severe bony deformity and peri-prosthetic fracture.

We reviewed the results of 145 consecutive Kent hips implanted into 141 patients between 1987 and 2000. The indications for implantation were aseptic loosening (75 hips), septic loosening (two), peri-prosthetic and prosthetic fracture (37), severe bony deformity (24), and fracture through a proximal femoral metastasis (seven).

The median time to full weight-bearing after surgery was two days and the mean length of follow-up was 5.1 years (2 to 15). Further revisions were required for 13 femoral stems. With removal of the stem for any reason as an end-point, the cumulative survival at five, ten and 15 years was 93%, 89% and 77%, respectively. In patients aged ≥ 70 years, the cumulative survival at 15 years was 92%, compared with 68% in those aged < 70 years. Because of these findings, we recommend the use of interlocking stems in patients aged ≥ 70 years, particularly in those with a peri-prosthetic fracture, for whom alternative methods are limited. Outcome scores and survival data, compared with other systems, indicate that the Kent hip should be used with caution in younger patients.

We reviewed retrospectively the outcome of the treatment by impaction grafting of periprosthetic femoral fractures around loose stems in 106 patients with Vancouver type-B2 and type-B3 fractures. Eighty-nine patients had a cemented revision with impaction grafting and a long or short stem. The remaining 17 had cemented revision without impaction grafting.

Fractures treated by impaction grafting and a long stem were more than five times likely to unite than those treated by impaction grafting and a short stem (odds ratio = 5.5, 95% confidence interval (CI) 1.54 to 19.6; p = 0.009). Furthermore, those with impaction grafting and a long stem were significantly more likely to unite than those with a long stem without impaction grafting (odds ratio = 4.07, 95% CI 1.10 to 15.0; p = 0.035).

There was also a trend towards a higher rate of union in those treated by impaction grafting than in those without (odds ratio = 2.69, 95% CI 0.86 to 8.45; p = 0.090).

Impaction grafting is being increasingly widely used for the restoration of femoral bone stock. It can be successfully applied to periprosthetic femoral fractures but a long stem should be used to bypass the distal fracture line.

Aims: To quantify the intraoperative cerebral microemboli load during primary total hip arthroplasty (THA) using transcranial Doppler ultrasound and to investigate whether a patent foramen ovale influences cerebral embolic load in general. The timing of the microemboli will be related to certain surgical activities to determine if a specific relationship exists.

Methods: Patients undergoing primary THA, with no history of stroke, TIA, ongoing CNS disease or alcoholism were included. All operations were carried out under a standardised general anaesthetic and performed by two consultant orthopaedic surgeons. Microemboli load was recorded, using transcranial Doppler ultrasound (TCD), onto VHS tape for subsequent playback and analysis. Patent foramen ovale detection was performed using bolus intravenous injection of agitated saline followed by valsalva manoeuvre technique and TCD. Timing of specific surgical steps was recorded for each operation and emboli load calculated for that period.

Results: 25 THA patients were studied (18 females, 7 males) 16 right and 9 left THA’s were performed. Cerebral microembolisation occurred in 10 patients (40%). Mean microembolic load was 5.52 per patient (range = 0–83). PFO was detected in 8 patients (32%). 37.5% of PFO positive patients displayed cerebral microemboli. However, 41.1% of PFO negative patients also displayed microemboli intraoperatively.

Insertion of the femoral component was associated with generating a larger microembolic load than the other phases of the operation.

Conclusion: Intraoperative cerebral microembolisation occurs in a significant proportion of patients during total hip arthroplasty. The presence of a patent foramen ovale does not appear to influence the incidence microemboli intraoperatively. Specific surgical activities are associated with generating greater embolic loads. These questions will be comprehensively assessed in the larger study currently underway..

Introduction: An increasing number of patients present for revision hip replacement with severe bone loss. The results of cemented revision in these cases are poor. This study was conducted to determine the medium term clinical and radiological outcome of 50 consecutive revision hip replacements performed using custom femoral stems.

Materials and Method: 50 consecutive hips (49 patients) performed by the senior author between 1992 and 1995 were identified. The indications for revision were aseptic loosening in 42 cases, infection in 7 cases (6 of which were revised using a two-stage technique), and dislocation in one case. The stems are manufactured on the basis of standardised measurement films using specially developed software. The design includes proximal macrogrooves with hydroxyapatite coating, an anterior flare, a lateral flare and a collar. The average follow up was 88.4 months (range 12–111 months). All patients were evaluated radiologically and using Harris, Oxford and WOMAC hip scores.

Results: The patients were assessed by an independent observer. All had severe bone loss according to AAOS and Paprosky classifications. 5 patients died due to causes unrelated to their hip replacement, 5 were lost to follow up or did not respond to questionnaires sent. The remaining patients had average preoperative scores of HHS 40.8 (range 8–87), Oxford 43.5 (range18–56) and WOMAC 82.5 (range 40–120) and had improved to HHS 74.4 (range 19–99), Oxford 25.5(range 12–51) and WOMAC 43.8 (range 13–89).

Conclusions: The use of customised revision stems allows the implant to be tailored to the patient’s bone stock and femoral anatomy. This technique avoids the massive inventory of implants and trials needed for highly modular revision systems, but nevertheless leads to excellent bone implant apposition and interface stability. The clinical results are excellent at medium term review, and the survivorship compares very favourably with other revision series.

There are few medium- and long-term data on the outcome of the use of proximal femoral structural allografts in revision hip arthroplasty. This is a study of a consecutive series of 40 proximal femoral allografts performed for failed total hip replacements using the same technique with a minimum follow-up of five years (mean 8.8 years; range 5 to 11.5 years). In all cases the stem was cemented into both the allograft and the host femur. The proximal femur of the host was resected in 37 cases.

There were four early revisions (10%), two for infection, one for nonunion of the allograft-host junction, and one for allograft resorption noted at the time of revision of a failed acetabular reconstruction. Junctional nonunion was seen in three patients (8%), two of whom were managed successfully by bone grafting, and bone grafting and plating respectively. Instability was observed in four (10%). Trochanteric nonunion was seen in 18 patients (46%) and trochanteric escape in ten of these (27%). The mean Harris hip score improved from 39 to 79. Severe resorption involving the full thickness of the allograft was seen in seven patients (17.5%). This progressed rapidly and silently, but has yet to cause failure of any of the reconstructions.

Profound resorption of the allograft may be related to a combination of factors, including a slow form of immune rejection, stress shielding and resorption due to mechanical disuse with solid cemented distal fixation, and the absence of any masking or protective effect which may be provided by the retention of the bivalved host bone as a vascularised onlay autograft. Although continued surveillance is warranted, the very good medium-term clinical results justify the continued use of structural allografts for failed total hip replacements with severe loss of proximal femoral bone.

The PROSTALAC functional spacer is made of antibiotic-loaded acrylic cement but has a small metal-on-polythene articular surface. We have used it as an interim spacer in two-stage exchange arthroplasty for infected total knee replacement. PROSTALAC allows continuous rehabilitation between stages as it maintains good alignment and stability of the knee and a reasonable range of movement. It also helps to maintain the soft-tissue planes, which facilitates the second-stage procedure.

We reviewed 45 consecutive patients, treated over a period of nine years. The mean follow-up was for 48 months (20 to 112). At final review, there was no evidence of infection in 41 patients (91%); only one had a recurrent infection with the same organism. There was improvement in the Hospital for Special Surgery knee score between stages and at final review. The range of movement was maintained between stages. Complications were primarily related to the extensor mechanism and stability of the knee between stages. Both of these problems decreased with refinement of the design of the implant.

The rate of cure of the infection in our patients was similar to that using other methods. Movement of the knee does not appear to hinder control of infection.

We treated 50 consecutive patients with infected total hip arthroplasties according to a standard protocol. Previous surgery to eradicate the infection had been attempted in 13 patients and discharging sinuses were present in 20. Aspiration arthrography was routinely carried out before our interventions.

The first stage was a meticulous removal of all foreign and potentially infected material. Samples were taken for culture and a thorough lavage carried out. Antibiotic-loaded beads were placed in the femoral shaft and an antibiotic-loaded cement ball in the acetabulum. At the second stage an uncemented arthroplasty was introduced. Bone allograft was used in 18 patients. The interval between procedures was usually three weeks, but this was extended if the wound was slow to heal or there was extensive bony destruction. Appropriate antibiotics were given for three months.

At a mean follow-up of 5.8 years the rate of reinfection was 8% (4 patients). Two of these patients have had another, successful, two-stage revision. At this medium-term review, a satisfactory clinical and radiological outcome was obtained in all except two patients.

We have previously described a simple and reproducible three-dimensional technique of CT for the measurement of the cover of the femoral head in acetabular dysplasia in adults. We now describe the application of this technique in ten patients with symptomatic dysplasia to assess the degree and direction of dysplasia and to measure the cover obtained at acetabular osteotomy.

The indices obtained gave a useful indication of the degree and direction of the dysplasia and confirmed which components had been used most efficiently to achieve cover. The information is easily presented in graphical form and gives a clearer indication of the cover obtained than the indices derived from plain radiographs.

Fractures of the scaphoid are most common in young men; immobilisation in a cast usually means a long period away from work and athletic activities. Early rigid fixation has been shown to promote a rapid functional recovery, but open reduction and internal fixation is technically demanding with the dangers of damage to the radiocarpal ligaments, the scaphotrapezial joint, and the blood supply of the scaphoid. For minimally displaced or undisplaced B1 or B2 fractures, these problems can be overcome by percutaneous fixation.

We report our technique and the results of a pilot study in 15 patients. There was no immobilisation; patients were allowed movement soon after operation, but union was obtained in all at a mean of 57 days (38 to 71). The range of movement after union was equal to that of the contralateral limb and grip strength was 98% of the contralateral side at three months. Patients were able to return to sedentary work within four days and to manual work within five weeks.

Our initial results show that percutaneous scaphoid fixation for acute fractures is satisfactory and gives rapid functional recovery.

We performed intraoperative arthrography of the knee in 12 children with congenital short femur, Blount’s disease or Ollier’s disease in whom the Ilizarov technique was used for correction of deformity, leg lengthening or both.

In each case, arthrography revealed a joint surface considerably different from that assumed from plain radiographs, and resulted in a change in the placement of our reference wires before application of the frame. This gave significant improvement in the mechanical axis obtained at the time of removal of the frame. The technique is safe, cheap and easy to perform. It is a useful adjunct to the application of the Ilizarov frame when used for complex lengthening and correction of deformity in the leg.

Children with a mucopolysaccharidosis or mucolipidosis suffer progressive disability of the hands, particularly in relation to dysfunction of the median nerve. This is an increasing problem because bone-marrow transplantation has dramatically improved survival without apparently changing the musculoskeletal manifestations. We have reviewed 48 children with these syndromes who required carpal tunnel decompression, recording symptoms, signs, radiological, electrophysiological and operative findings, histology and upper-limb function. In these children the carpal tunnel syndrome differs from that seen in adults. Symptoms are rare but signs such as decreased sweating, pulp atrophy, thenar wasting and manual clumsiness are much more common. At operation, the flexor retinaculum was thickened and a mass of white tenosynovium engulfed the flexor tendons. Most patients had some definite nerve constriction with a thickened epineurium.

Functional improvement was seen after early decompression, with some benefit from simultaneous tendon release. Regular physiotherapy helped to maintain increased hand movement.

We describe our assessment protocol, the physiotherapy and operative regime and the standard functional review which helps to maximise function in the hands and upper limbs of these children.

We report six caucasian patients who had acute pain in the hip and marked limitation of all movements of the joint. Plain radiographs and CT of the pelvis showed calcification within the reflected head of rectus femoris. All six responded to accurate CT-controlled injections of corticosteroid and local anaesthetic with dramatic and prolonged pain relief, although one required a second injection for recurrence of symptoms after two months.

Aseptic loosening is seen in a significant proportion of cemented total hip replacements (THR). In a small subgroup of patients who suffer early loosening polyethylene debris is unlikely to be responsible. We recently reported one case of allergic contact dermatitis to N,N-dimethylparatoluidine (DMT), an accelerator used in bone cement. We have therefore investigated this using skin-patch tests to a variety of substances including metals, polyethylene and the separated individual components of Simplex cement.

We studied 70 patients, 15 with aseptic loosening less than two years after THR, 25 with satisfactory long-term cemented fixation, five with infected loosening of cemented THRs and 25 awaiting hip arthroplasty. We found seven positive reactions to DMT, all of them in patients with the rapid onset of aseptic loosening.

Allergy to DMT is recognised in the dental profession in respect of the ‘denture sore mouth’ syndrome, and could also be an occupational hazard since some industrial glues contain DMT. Our results suggest the need for awareness of possible previous dental or occupational exposure to the constituents of bone cement. We recommend the use of skin-patch testing in high-risk cases.

We present a patient with an arteriovenous fistula of the peroneal artery acquired after a left dome tibial osteotomy with midshaft fibular osteotomy. He had subsequently had a total knee replacement on that side. The arteriovenous malformation was only diagnosed when he represented with symptoms and signs of venous hypertension with sterile recurrent haemarthroses in the left knee. Percutaneous obliteration of the fistula, by a combination of coil embolisation and balloon occlusion, cured the symptoms.