Radiation exposure remains a significant occupational hazard for Orthopaedic surgeons. There are no references values for trauma procedures performed with Image Intensifier (II). We aimed to determine and compare reference values for patient radiation exposure for common trauma operations, and to analyse the effect of surgeon grade on II usage. Data collected prospectively from 849 cases between 01/05/2013 and 01/10/2014 were analysed. Statistical analysis was performed to calculate reference values for dose area product (DAP), screening time (ST), and number of II images taken for common trauma procedures where n>9 (n=808).Background
Methods
Salter’s innominate osteotomy predisposes the hip to acetabular retroversion as it hinges upon the symphysis pubis. Retroversion is a recognised cause of osteoarthritis, hip pain and clinical signs of impingement, but there is uncertainty as to whether this over cover persists with growth and development. We reviewed the long-term follow up of twenty patients that had undergone a Salter’s osteotomy between 1985 to 1993 at The Royal Orthopaedic Hospital Birmingham or New Cross Hospital Wolverhampton. Sixteen skeletally mature patients were available for review that had previously had the pelvic osteotomy performed at a mean five years of age with a contralateral normal hip. Salter’s osteotomy had been performed for developmental dysplasia of the hip in 13 patients and for Perthes’ disease in three patients. Follow up was performed at an average age of 20 years. Outcome was assessed using the Harris Hip Score and a clinical examination for signs of impingement and by a measurement of acetabular version, on well centered pelvic radiograph. Acetabular version was evaluated by the relationship between anterior and posterior walls of both the normal and Salter acetabulum, using radiographic templates as described by Hefti. Mean acetabular version averaged 16.9 degrees (95% CI 7.6 to 26.1) of anteversion on the Salter side and 17.6 degrees (95% CI 10.4 to 24.8) anteversion on the contralateral normal hip. There was no statistical difference between the version on operated and normal hips, paired t test (p = 0.83). Harris Hip Score averaged 85, indicating a good outcome at long-term follow up. Two patients (12%) demonstrated retroversion, however neither of these had signs of impingement on clinical examination. After a Salter innominate osteotomy in childhood, we believe there is remodelling of acetabular version by skeletal maturity.
Unicompartmental knee replacement (UKR) is an increasingly popular alternative to total knee replacement in medial compartment disease. Early problems include unexplained pain, stiffness, infection and technical errors leading to dislocation of bearing or fracture. This study is the first to highlight re-intervention as an outcome measure when assessing the success of a partial joint replacement. All Oxford UKRs undertaken at ROH during November 2002 and December 2007 were reviewed to identify patients who required a further procedure. 383 UKRs were implanted. 21 (5.5%) patients underwent further re-intervention. Twelve (3.1%) were for persistent post-operative pain, three (0.8%) for stiffness and six (1.6%) had a combination of symptoms. one re-intervention was for a tibial plateau fracture. Initial re-interventions included eleven arthroscopies and three manipulations. Nine (2.4%) patients subsequently underwent revision procedures, eight to a total knee replacement with one revision to a fixed bearing unicompartmental prosthesis. There were no revisions for infection. Manipulation improved stiffness in all the patients. Outcome following re-interventions for persistent pain were less predictable. Arthroscopy improved symptoms in only 36% of patients but eight of the nine (88.9%) patients that were formally revised had an improvement in symptoms. Our early re-intervention rate of 5.5% and the out-come of subsequent surgery provides a valuable evidence based resource to discuss potential post operative expectations and complications with patients awaiting an Oxford UKR.
Between January 1996 and July 2002, 60 patients (65 hips) were treated in our unit by 5 consultant surgeons using the Corin Cobalt-Chrome metal-on-metal hip resurfacing. 41 procedures were performed on male patients and 24 female. All 65 cases used the Cormet Hip resurfacing (Corin, UK). Of these, 12 cases (18.5%) have required revision for mechanical failure. 5 of these patients were male and 7 female. The time to failure was defined as the interval between the date of primary and the date of revision surgery. The mean time to failure was 10.2 months (range 48 hours to 53 months). 8 out of 12 patients required revision within 6 months of the primary procedure. The mean age at the time of revision was 56 years (range 22–71 years). The commonest mechanism of failure in our series is fractured neck of femur and 4 out of the 6 fractured neck of femur occurred in females over the age of 60. Only 12 of our primary hip resurfacings were women over 60 with the result that 33% of this group were complicated by fractured neck of femur. In 4 cases, the indication for revision was acetabular loosening. One patient underwent revision surgery for chronic pain of unknown aetiology and one developed progressive avascular necrosis of the femoral head. Our early results suggest that the procedure is operator-dependent and associated with a steep learning curve. The procedure would appear to be contraindicated in women over 60 and others at risk of osteoporosis.
Deep infection complicating arthroplasty surgery carries a heavy fnancial and emotional burden on any orthopaedic service. The cost of hospital acquired infection is estimated at £1 billion per year 1 by the National Audit Office. Healthcare associated infection is an area currently under great scrutiny. Each NHS trust will have an Inspector of Microbiology, who will ensure the co-ordination of information required to diagnose healthcare associated infection. The Alexandra Hospital, Redditch has developed a dedicated elective orthopaedic ward free from multi resistant staphylococcus aureus (MRSA). that delivers high quality and high volume major joint replacement surgery through rigorous infection control. Between October 2001 and December 2002, the Alexandra hospital had an infection rate of 0.21% for total knee replacements compared to the national rate of 2.1% p= 0.002 (CI 0.00005–0.01) The infection rate for total hip replacements was 1.31% compared to 3.8% nationwide. p = 0.01 (CI 0.004–0.03). The total number of joint replacements performed per year increased from 256 in 2000 to 629 in 2002. We have developed a safe, effective and efficient orthopaedic unit within the framework of an NHS trust for a relatively modest investment. We believe the practical changes that have been made within our department can be repeated in other units around the country with relative ease.
One of the most commonly cited advantages of hip resurfacing is the technical ease of revision surgery on the femoral side of the joint. It is therefore reasonable to suggest that such surgery ought to be associated with reduced operative times, reduced blood loss and more rapid mobilisation than conventional hip revision. However, there is little objective evidence in the literature to support this view. In our own unit, 6 consultants have now revised 15 hip resurfacings (13 Corins and 2 MMT Birmingham Hip Resurfacings). A retrospective study of the hospital records was performed to compare three well recorded parameters 1) On table operative times 2) Post Operative blood transfusion requirement 3) In patient length of stay. Average on table time was 195 minutes for conventional THR revision and 120 minutes for revision of resurfacing i.e. a 1 third reduction in theatre time for resurfacing with attendant advantages in costs and risks. However, post operative length of stay was little different between the two groups. Average blood transfusion requirement was 4.6 units for conventional THR revision (n=190) and 0.9 units for revision of resurfacing. However, these crude figures do not take into account the difference in physiological state between the two groups of patients. A more complex comparison of age matched revision THR patients shows and average transfusion requirement of 1.8 to 2.2 units for revision of THR versus 0.9 units for revision resurfacing. In conclusion, there is now objective evidence of the advantages of resurfacing in the revision situation but that these advantages are more modest than those anticipated.
In recent years there has been a resurgence of interest in the concept of hip resurfacing. Since 1996, we have treated 60 patients (65 hips) with the Corin Hip Resurfacing. Of the 65 primary procedures, 13 have now required revision. 1 case was complicated by early deep infection and 12 (17%) for mechanical failure. 5 of these patients were male and 8 female. Mean time to failure was 11 months (range 48 hours to 53 months). 8 out of the 12 mechanical failures required revision within 6 months of the primary procedure. Mean age of the revision patients was 57 years (range 22 – 71 years). The most common failure modality (6 cases) was fractured neck of femur. 4 out of 6 of these cases occurred in women over 60 years of age. All of these fractures occurred without a specific history of trauma. Since only 12 patients were women over 60, 1 in 3 women over 60 years of age in our series were complicated by fractured neck of femur. In 4 cases, the indication for revision was acetabular loosening. One patient had ongoing pain of unknown aetiology and one developed progressive avascular necorsis of the femoral head with subsequent collapse. Of the 12 cases requiring revision for mechanical failure, two cases required revision of the femoral component only and this was performed using the stemmed modular CTI prosthesis produced by Corin for this purpose. Three cases required revision of the socket only and the others were revised to total joint replacement. The one case of early deep infection was treated by two stage revision. There were no dislocations in our series and there was no evidence of metallosis. Not for the first time in the history of orthopaedics, a DGH has been unable to repeat the excellent results reported by a specialist centre with a new technique. However, analysis of the above data has led us to believe that our results may be much improved by careful patient selection. It is also apparent that formal revision strategies need to be developed for hips resurfacing.
The best management of displaced intracapsular femoral neck fractures in the elderly remains undecided. Most are treated by hemiarthroplasty. The aim of this study was to establish whether the advantages of cement outweigh the disadvantages. All patients with displaced intracapsular femoral neck fractures treated with herniarthroplasty between January 1997 and May 1998, in 2 hospitals within the same Deanery, were reviewed. The same prosthesis was used, but in hospital A they were uncemented, and in B cemented. There were 122 patients in hospital A and 123 in B. We conducted a detailed retrospective analysis of hospital notes. All surviving patients (50 and 56 respectively) were interviewed to obtain pre-fracture and current scores of pain, walking ability, use of walking aids, activities of daily living (ADL) and accommodation status, using validated scoring systems. The relative deterioration over the follow-up period (32–36 months) was determined and the groups compared. Patient demographics confirmed comparability of groups. There was no greater incidence of intra-operative fall in diastolic blood pressure, or oxygen saturation in the cemented group. Cemented procedures were on average 15 minutes longer. Median in-patient stay was the same. Significantly fewer of the cemented group had been revised or were awaiting revision (p=0. 036). There was no difference in mortality rates at any point between surgery and follow-up. Prospective assessment of surviving patients revealed highly statistically significant greater deterioration in pain (p=0. 003), walking ability (p=0. 002), use of walking aids (p=0. 003) and ADL (p=0. 009) in the uncemented group. The trend for more dependent accommodation in the uncemented group failed to reach statistical significance (p=0. 14). In conclusion, the cemented group faired significantly better than the uncemented group. Our findings suggest the advantages of cement outweigh the disadvantages, and we support the use of cemented hemiarthroplasty for the displaced intracapsular femoral neck fracture in the elderly patient.
