Hip bearing surfaces materials are typically broadly reported in national registry (metal-on-polyethylene, ceramic-on-ceramic etc). We investigated the revision rates of primary total hip replacement (THR) reported in the National Joint Registry (NJR) by detailed types of bearing surfaces used.

We analysed THR procedures across all orthopaedic units in England and Wales. Our analyses estimated all-cause and cause-specific revision rates. We identified primary THRs with heads and monobloc cups or modular acetabular component THRs with detailed head and shell/liner bearing material combinations. We used flexible parametric survival models to estimate adjusted hazard ratios (HR).

A total of 1,026,481 primary THRs performed between 2003–2019 were included in the primary analysis (Monobloc cups: n=378,979 and Modular cups: n=647,502) with 20,869 (2%) of these primary THRs subsequently undergoing a revision episode (Monobloc: n=7,381 and Modular: n=13,488).

Compared to implants with a cobalt chrome head and highly crosslinked polyethylene (HCLPE) cup, the overall risk of revision for monobloc acetabular implant was higher for patients with cobalt chrome or stainless steel head and non-HCLPE cup. The risk of revision was lower for patients with a delta ceramic head and HCLPE cup implant, at any post-operative period.

Compared to patients with a cobalt chrome head and HCLPE liner primary THR, the overall risk of revision for modular acetabular implant varied non-constantly. THRs with a delta ceramic or oxidised zirconium head and HCLPE liner had a lower risk of revision throughout the entire post-operative period.

The overall and indication-specific risk of prosthesis revision, at different time points following the initial implantation, is reduced for implants with a delta ceramic or oxidised zirconium head and a HCLPE liner/cup in reference to THRs with a cobalt chrome head and HCLPE liner/cup.

Hip prosthetic joint infection (PJI) is a debilitating complication following joint replacement surgery, with significant impact on patients and healthcare systems. The INFection ORthopaedic Management: Evidence into Practice (INFORM:EP) study, builds upon the 6-year INFORM programme by developing evidence-based guidelines for the identification and management of hip PJI.

A panel of 21 expert stakeholders collaborated to develop best practice guidelines based on evidence from INFORM \[1\]. An expert consensus process was used to refine guidelines using RAND/UCLA criteria. The guidelines were then implemented over a 12-month period through a Learning Collaborative of 24 healthcare professionals from 12 orthopaedic centres in England. Qualitative interviews were conducted with 17 members of the collaborative and findings used to inform the development of an implementation support toolkit. Patient and public involvement contextualised the implementation of the guidelines. The study is registered with the ISCRTN (34710385).

The INFORM guidelines, structured around the stages of PJI management, were largely supported by surgeons, although barriers included limited awareness among non-surgical team members, lack of job planning for multidisciplinary teams, and challenges in ensuring timely referrals from primary care. Psychological support for patients was identified as a critical gap. Advanced Nurse Practitioners and multidisciplinary team (MDT) coordinators were seen as potential bridges to address these knowledge gaps. The guidelines were also viewed as a useful tool for service development.

This study presents the first evidence-based guidelines for hip PJI management, offering a comprehensive approach to prevention, treatment, and postoperative care. Effective implementation is crucial, involving wider dissemination amongst primary and community care, as well as non-specialist treatment centres. Further resources are needed to ensure job planning for MDTs and psychological support for patients. Overall, this study lays the foundation for improved PJI management, benefiting patients and healthcare systems.

Implants in total hip replacement (THR) are associated with different clinical and cost-effectiveness profiles,. We estimate the costs and outcomes for NHS patients in the year after THR associated with implant bearing materials using linked routinely collected data.

We linked NJR primary elective THR patients for osteoarthritis to HES and National PROMs. We estimated health care costs, health-related quality of life indices, and revision risks, in the year after primary and revision THRs overall. We used generalised linear models adjusting for patient and hospital characteristics and estimated 10-year cumulative probability of revision. We imputed utilities using chained equations for half the sample with missing PROMS.

We linked 577,973 elective primary THRs and 11,812 subsequent revisions. One year after primary THR, patients with the cemented THRs using cobalt chrome or stainless steel head with HCLPE liner/cup cost the NHS, on average, £13,101 (95%CI £13,080,£13,122), had an average quality-of-life score of 0.788 (95%CI 0.787,0.788), and a 10-year revision probability of 1.9% (95%CI 1.6,2.3). Compared to the reference, patients receiving a cemented THR with delta ceramic head and HCLPE liner/cup, hybrid THR with delta ceramic head and HCLPE liner/cup, and hybrid THR with alumina head and HCLPE liner/cup had lower 1-year costs (-£572 \[95% CI -£775,-£385\], -£346 \[-£501,-£192\], -£371 \[-£574,-£168\] respectively), better quality of life (0.007 \[95% CI 0.003,0.011\], 0.013 \[0.010,0.016\], 0.009 \[0.005,0.013\] respectively), and lower 10-year revision probabilities (1.4% \[1.03,2.0\], 1.5 \[1.3,1.7\], 1.6%\[1.2,2.1\] respectively).

Implant bearing materials are associated with varying mean costs and health outcomes after primary THR. Ours is the first study to derive costs and health outcomes from large, linked databases using multiple imputation methods to deal with bias. Our findings are useful for commissioning and procurement decisions and to inform a subsequent cost-effectiveness model with more granular detail on THR implant types.

Abstract

There is paucity of reliable data examining the treatment pathway for hip replacements over the life of the patient in terms of risk of revision and re-revisions.

We did a retrospective observational registry-based study of the National Joint Registry, using data on hip replacements from all participating hospitals in England and Wales, UK. We included data on all first revisions, with an identifiable primary procedure, with osteoarthritis as the sole indication for the original primary procedure. Kaplan-Meier estimates were used to determine the cumulative probability of revision and subsequent re-revision after primary hip replacement. Analyses were stratified by age and gender, and the influence of time from first to second revision on the risk of further revision was explored.

Between 2003, and 2019, there were 29 010 revision hip replacements with a linked primary episode. Revision rates of revision hip replacements were higher in patients younger than 55 years than in older age groups. After revision of primary total hip replacement, 21·3% (95% CI 18·6–24·4) of first revisions were revised again within 15 years, 22·3% (20·3–24·4) of second revisions were revised again within 7 years, and 22·3% (18·3–27·0) of third revisions were revised again within 3 years. After revision of hip resurfacing, 23·7% (95% CI 19·6–28·5) of these revisions were revised again within 15 years, 21·0% (17·0–25·8) of second revisions were revised again within 7 years, and 19·3% (11·9–30·4) of third revisions were revised again within 3 years. A shorter time between revision episodes was associated with earlier subsequent revision.

Younger patients are at an increased risk of multiple revisions. Patients who undergo a revision have a steadily increasing risk of further revision the more procedures they undergo, and each subsequent revision lasts for approximately half the time of the previous one.

Introduction and Objective

An important subset of patients is dissatisfied after total joint arthroplasty (TJA) due to residual functional impairment. This study investigated the assessment of objectively measured step-up performance following TJA, to identify patients with poor functional improvement after surgery, and to predict residual functional impairment during early postoperative rehabilitation. Secondary, longitudinal changes of block step-up (BS) transfers were compared with functional changes of subjective patient reported outcome measures (PROMs) following TJA.

A recent French report suggested that cobalt metal ions released from total hip replacements (THRs) were associated with an increased risk of dilated cardiomyopathy and heart failure. If the association is causal the consequences would be significant given the millions of Orthopaedic procedures in which cobalt-chrome is used annually. We examined whether cobalt-chrome containing THRs were associated with an increased risk of all-cause mortality, heart failure, cancer, and neurodegenerative disorders.

Data from the National Joint Registry was linked to NHS English hospital inpatient episodes for 375,067 primary THRs with up to 14·5 years follow-up. Implants were grouped as either containing cobalt-chrome or not containing cobalt-chrome. The association between implant construct and the risk of all-cause mortality and incident heart failure, cancer, and neurodegenerative disorders was examined.

There were 132,119 individuals (35·2%) with an implant containing cobalt-chrome. There were 48,106 deaths, 27,406 heart outcomes, 35,823 cancers, and 22,097 neurodegenerative disorders. There was no evidence of an association that patients with cobalt-chrome implants had higher rates of any of the outcomes. For all-cause mortality there was a very small survival advantage for patients having a cobalt-chrome implant (restricted mean survival time 13·8=days, 95% CI=6·8-20·9).

Cobalt-chrome containing THRs did not have an increased risk of all-cause mortality, heart failure, cancer, and neurodegenerative disorders into the second decade post-implantation. Our findings will reassure clinicians and patients that primary THR is not associated with systemic implant effects.

Total hip replacement (THR) for end-stage osteoarthritis is a commonly performed cost-effective procedure, which provides patients with significant clinical improvement. Estimating the future demand for joint replacement is important to identify the healthcare resources needed. We estimated the number of primary THRs that will need to be performed up to the year 2060.

We used data from The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man on the current volume of primary THR (n=94,936) performed in 2018. We projected future numbers of THR using a static estimated rate from 2018 applied to population growth forecast data from the UK Office for National Statistics up to 2060.

By 2060, primary THR volume would increase from 2018 levels by an estimated 37.7% (n=130,766). For both males and females demand for surgery was also higher for patients aged 70 and over, with older patients having the biggest relative increase in volume over time: 70–79 years (144.6% males, 141.2% females); 80–89 years (212.4% males, 185.6% females); 90 years and older (448.0% males, 298.2% females).

By 2060 demand for THR is estimated to increase by almost 40%. Demand will be greatest in older patients (70 years+), which will have significant implications for the health service that requires forward planning given morbidity and resource use is higher in this population. There is a backlog of current demand with cancellation of elective surgery due to seasonal flu pressures in 2017 and now Covid-19 in 2020. Orthopaedics already has the largest waiting list of any speciality. These issues will negatively impact the health services ability to deliver timely joint replacement to many patients for a number of years and require urgent planning.

Total hip replacements (THRs) are performed by surgeons at various stages in their training, with varying levels of senior supervision. There is a balance between protecting training opportunities for the next generation of surgeons, while limiting the exposure of patients to unnecessary risk during the training process. The aim of this study was to examine the association between surgeon grade, the senior supervision of trainees, and the risk of revision following THR.

We included 603 474 primary THRs recorded in the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man (NJR) between 2003 and 2016 for an indication of osteoarthritis. Exposures were the grade of the surgeon (consultant or trainee), and whether trainees were supervised by a scrubbed consultant or not. Outcomes were all-cause revision, the indication for revision, and the temporal variation in risk of revision (all up to 10 years). Net failure was calculated using Kaplan-Meier analysis and adjusted analyses used Cox regression and flexible parametric survival analysis (adjusted for patient, operative, and unit level factors).

There was no association between surgeon grade and all-cause revision up to 10 years (crude hazard ratio (HR) 0·999, 95% confidence interval (CI) 0.936–1.065; p=0.966); a finding which persisted with adjusted analysis. Adjusted analysis demonstrated an association between trainees operating without supervision by a scrubbed consultant and an increase in all-cause revision (HR 1.100, 95% CI 1.002–1.207; p=0.045). There was an association between the trainee-performed THRs and revision due to instability (crude HR 1.143, 95% CI, 1.007–1.298; p=0.039). However, this was not observed in fully adjusted models, or when trainees were supervised by a scrubbed consultant.

Within the current training system in the United Kingdom, trainees achieve comparable outcomes to consultant surgeons when supervised by a scrubbed consultant. Revision rates are higher when trainees are not supervised by a scrubbed consultant but remain within internationally recognised acceptable limits.

Considerable debate exists regarding which agent(s) should be preferred for venous thromboembolism (VTE) chemical prophylaxis following joint replacement. We assessed the practice of surgeons regarding VTE chemical prophylaxis for primary THR and TKR, pre and post issuing of updated NICE guidance in 2018.

A survey, circulated through the British Hip Society and regional trainee networks/collaboratives, was completed by 306 UK surgeons at 187 units. VTE chemical prophylaxis prescribing patterns for surgeons carrying out primary THR (n=258) and TKR (n=253) in low-risk patients were assessed post publication of 2018 NICE recommendations. Prescribing patterns before and after the NICE publication were subsequently explored. Questions were also asked about surgeon equipoise for participation in future RCTs.

Following the new guidance, 34% (n=87) used low-molecular weight heparin (LMWH) alone, 33% (n=85) aspirin (commonly preceded by LMWH), and 31% (n=81) direct oral anticoagulants (DOACs: with/without preceding LMWH) for THR. For TKR, 42% (n=105) used aspirin (usually monotherapy), 31% (n=78) LMWH alone, and 27% (n=68) DOAC (with/without preceding LMWH). NICE guidance changed the practice of 34% of hip and 41% of knee surgeons, with significantly increased use of aspirin preceded by LMWH for THR (before=25% vs. after=73%;p<0.001), and aspirin for TKR (before=18% vs. after=84%;p<0.001). Significantly more regimens were NICE guidance compliant after the 2018 update for THR (before=85.7% vs. after=92.6%;p=0.011) and TKR (before=87.0% vs. after=98.8%;p<0.001). Support from surgeons for future RCTs was dependent on the clinical question, ranging from 48% participation in trials (effectiveness of aspirin vs. a DOAC) to 79% (effectiveness of 14 days LMWH vs. 28 days LMWH).

Over one-third of surveyed surgeons changed their VTE chemical prophylaxis in response to 2018 NICE recommendations, with more THR and TKR surgeons now compliant with latest NICE guidance. The major change in practice was an increased use of aspirin for VTE chemical prophylaxis. Furthermore, there is an appetite amongst UK surgeons for participating in future RCTs, with a trial comparing standard versus extended duration LMWH likely feasible in current practice.

Aims

To develop and externally validate a parsimonious statistical prediction model of 90-day mortality after elective total hip arthroplasty (THA), and to provide a web calculator for clinical usage.

Total hip replacements (THRs) provide pain relief and improved function to thousands of patients suffering from end-stage osteoarthritis, every year. Over 800 different THR constructs were implanted in the UK in 2017. To ensure reliable implants are used, a NICE revision benchmark of 5% after 10 years exists. Given the 10-year cumulative mortality of patients under 55 years of age receiving THRs is only 5% and that a recent study suggests 25-year THR survival of 58%, we aim to produce revision estimates out to 30 years that may guide future long-term benchmarks.

The local database of the Princess Elizabeth Orthopaedic Centre (PEOC), Exeter, holds data on over 20,000 patients with nearly 30-years follow-up with contemporary prostheses. A previous study suggests that the results of this centre are generalisable if comparisons restricted to the same prostheses. Via flexible parametric survival analysis, we created an algorithm using this database, for revision of any part of the construct for any reason, controlling for age and gender. This algorithm was applied to 664,761 patients in the NJR who have undergone THR, producing a revision prediction for patients with the same prostheses as those used at this centre.

Using our algorithm, the 10-year predicted revision rate of THRs in the NJR was 2.2% (95% CI 1.8, 2.7) based on a 68-year-old female patient; well below the current NICE benchmark. Our predictions were validated by comparison to the maximum observed survival in the NJR (14.2 years) using restricted mean survival time (P=0.32). Our predicted cumulative revision estimate after 30 years is 6.5% (95% CI 4.5, 9.4). The low observed and predicted revision rate with the prosthesis combinations studied, suggest current benchmarks may be lowered and new ones introduced at 15 and 20 years to encourage the use of prostheses with high survival.

Over 800 total hip replacement (THR) constructs were implanted in the UK in 2017. To ensure reliable implants are used, a NICE revision benchmark of 5% after 10 years exists. Surgeons are guided in choice by organisations such as the Orthopaedic Data Evaluation Panel (ODEP). Currently, ODEP publishes ratings for stem and cup separately and not for constructs. We used NJR data to investigate whether revision estimates of an individual stem (with all cups) is an accurate indicator of survival of all constructs using that stem.

The dataset comprised 234,289 THRs using the most frequently implanted stem between 2004 and 2017. Crude ten-year revision estimates were calculated using Kaplan-Meier for all THRs and for the five most implanted constructs. Adjusted comparisons between individual constructs and the overall stem revision estimate were made using flexible parametric survival analysis.

The 10-year crude, revision estimate for all THRs was 2.3% (95% CI 2.2, 2.4). Only four of the most frequently used constructs had long enough follow-up to analyse. 10-year estimates for these constructs ranged from 1.8% (95% CI 1.5, 2.1) to 3.7% (95% CI 3.2, 4.1), a log-rank test revealed strong evidence against the null hypothesis that revision estimates were the same for all constructs (p<0.001). Adjusted for age, sex and ASA, three of the four constructs showed a difference in 10-year revision estimates compared to this stem with all cups (P=0.03, P<0.001, P<0.001).

This study suggests 10-year revision estimates for all THRs using the most implanted stem in the NJR are not representative of all constructs involving that stem in crude or adjusted analyses. Current benchmarking systems report survival for the stem in combination with all cups and not for constructs. We suggest that benchmarking ratings basing on revision estimates for THR constructs would provide more accurate information, enabling informed construct decisions.

Aims

The aim of this study was to conduct evidence synthesis on the available published literature of the impact of the training status of the operating surgeon (trainee vs. consultant) on the survival and revision rate of primary hip and knee replacements.

Aims

To calculate how the likelihood of obtaining measurable benefit from hip or knee arthroplasty varies with preoperative patient-reported scores.

Background

Total hip replacement (THR) is clinically and cost-effective. The surgical approach influences outcomes, however there is little generalisable and robust evidence to guide practice. We assessed the effect of surgical approach on THR outcomes.

Introduction

Analysis of registry data shows that few units achieve results better than 99·98% control limits. Implant selection is considered a predictor of outcome variation in joint replacement. We analysed the outcomes of a unit with statistically “better than expected” results and compared to all other units within the National Joint Registry for England, Wales, Northern Ireland and Isle of Man (NJR). We sought to determine whether improved implant survival following primary total hip replacement (THR) is a centre effect or mediated by implant selection.

Introduction

Total hip arthroplasty (THA) is indicated in independently mobile patients sustaining displaced intracapsular hip fractures. Studies presently suggest that the anterolateral approach is preferable to the posterior approach due to a perceived reduced risk of reoperations and dislocations. However, these observations come from small studies with short follow-up. We assessed whether surgical approach in THA performed for hip fractures effects outcomes.

Periprosthetic joint infections (PJIs) are uncommon but are devastating complications of total knee replacement (TKR). We analysed the risk factors of revision for PJI following primary TKR and their association with PJI at different post-operative periods. Primary TKRs and subsequent revision surgeries performed for PJI from 2003–2014 were identified from the National Joint Registry (NJR). Multilevel piece-wise exponential non-proportional hazards models were used to estimate the effect of the investigated factors at different post-operative periods. Patient, perioperative and healthcare system characteristics were investigated and data from the Hospital Episode Statistics for England were linked to obtain information on specific comorbidities. The index TKRs consisted of 679,010 primaries with 3,659 subsequently revised for PJI, 7% within 3 months, 6% between 3–6months, 17% between 6–12months, 27% between 1–2years and 43% ≥2 years from the index procedure. Risk factors for revision for PJI included male sex, high BMI, high ASA grade and young age. Patients with chronic pulmonary disease, diabetes and liver disease had higher risk of revision for PJI, as had patients who had a primary TKR for an indication of trauma or inflammatory arthropathy. Surgical procedure, fixation method, constraint and bearing type influenced the risk of revision for PJI. Their effects were period-specific. No or small associations were found with the operating surgeon grade, surgical volume and hospital surgical volume. These findings from the world's largest joint replacement registry show a more complex picture than the meta-analyses published to date with specific time-dependent effects for the identified risk factors.

The aim of this study was to determine the outcomes and survivorship of the Triathlon knee replacement at 7 years after surgery. A cohort of 266 patients receiving a Triathlon knee replacement were assessed before surgery and at 3 months, 1 year, 2 years, 3 years, 5 years and 7 years post-operation. Patient-reported outcomes were assessed using the WOMAC, KOOS Knee-Related Quality of Life scale, Satisfaction Scale and questions on kneeling ability and whether they regretted having the operation. Data on survivorship was collected from self-report and medical records. At 7 years after surgery, 32 patients were deceased, and 17 patients were withdrawn. Of the 217 patients remaining in the study, 164 (76%) returned a completed study questionnaire. At 7 years after surgery, 92% of patients reported an improvement in their WOMAC Pain score greater than the minimally clinically important improvement (defined as improvement of ≥9 points from before surgery) and 82% reported this in their WOMAC Function score (defined as improvement of ≥12 points). Knee-related quality of life was good, with a mean score of 66.8 (SD 26.0) (0–100 scale, worst to best). A high percentage of patients (89%) were somewhat or very satisfied with their outcome at 7 years. Survivorship with revision as the endpoint was 96.4% (95% CI 93.2–98.1%) at 7 years post-operation. Five percent of patients regretted having their operation and 68% reported much difficulty or an inability to kneel. In conclusion, this study observed good long-term patient outcomes and survivorship of the Triathlon knee replacement.

Administration of perioperative antibiotic prophylaxis (AP) reduces the risk of prosthetic joint infection (PJI) following primary total hip (THA) and knee (TKA) arthroplasty. The optimal type of antibiotic used, and duration of prophylaxis are subject to debate. We compared the risk of revision surgery for PJI in the first year following THA and TKA by AP regimen. A national survey collecting information on hospital-level AP regimen policy was conducted across the Netherlands and linked to data from the LROI arthroplasty registry for 2011–2015. PJI status was defined using the surgical indication reported at revision by surgeons in the registry form. Restricted cubic splines Poisson model adjusted for hospital clustering were used to conduct the comparisons on 130,712 THAs and 111,467 TKAs performed across 99 institutions. These included 399 THAs and 303 TKAs revised for an indication of PJI. Multiple shot of Cefazolin (MCZ), of cefuroxime (MCX) and single shot of Cefazolin (SCZ) were respectively administrated to 87%, 4% and 9% of patients. For THA, the rates of revision for PJI were respectively 31/10,000 person-years 95%CI[28, 35], 39[25, 59] and 23[15, 34] in the groups which received MCZ, MCX and SCZ; respectively, the rates for TKA were 27[24, 31], 40[24, 62] and 24[16, 36]. No evidence of difference between AP regimens was found in the unadjusted and adjusted model (age, gender, BMI and ASA grade). Further work is advocated to confirm whether there is an association between AP regimen collected at patient-level and the risk of subsequent revision for PJI.

Introduction

The development of an algorithm that provides accurate individualised estimates of revision risk could help patients make informed surgical treatment choices. This requires building a survival model based on fixed and modifiable risk factors that predict outcome at the individual level. Here we compare different survival models for predicting prosthesis survivorship after hip replacement for osteoarthritis using data from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR).

Osteoarthritis of the hip is common and the mainstay of surgical treatment for end-stage disease is total hip replacement. There are few RCTs comparing long-term outcomes between prostheses; therefore, surgeons and patients are reliant on single-centre case-series and recently, analysis of joint registries, when making evidence-based implant choices.

We conducted a systematic review, conforming to PRISMA, of Medline and Embase in September 2017. Single-centre case-series and papers analysing registries were included. Series looking at disease-specific cohorts (other than OA), under 15 years follow-up or lacking survival analyses were excluded. Resurfacings, revisions and complex-primaries were also excluded. 2750 abstracts were screened, resulting in 299 full-text articles. Following full review 124 articles were excluded and 21 series added from references, resulting in 150 analyses of individual prostheses/constructs and 12 papers from registries. We also analysed annual reports of registries.

Registry data indicated cemented prostheses tended to better outcomes at late follow-ups, whereas case-series showed cementless prostheses tended to have better survival past 15 years with revision for any reason (of stem, cup or either component) as the end-point.

The discrepancy between results from registry data and single-centre case series is stark, and whilst the reasons for these differences may be multifactorial, single-centre case-series included in this review often lacked sufficient power to provide precise estimates of survival. This is contrasted to data from registries, which tended to have far greater numbers from multiple centres, allowing results to be generalised to the population.

The difference between these two modes of analysis suggests bias exists in selection and outcomes from single-centre series. The varied quality of reporting in case-series make it difficult for a reader to adequately assess bias, and accurately inform contemporary decision making.

Surgeons and patients should be cautious when interpreting single-centre case series and systems relying on data generated from them.

Introduction

Prosthetic joint infection (PJI) is an uncommon but serious complication of hip replacement.

A recent systematic review of patient risk factors for PJI identified male gender, smoking status, increasing BMI, steroid use, previous joint surgery and comorbidities of diabetes, rheumatoid arthritis and depression as risk factors for developing PJI. Limitations of the current literature include the short term follow up of most published studies.

We investigated the role of patient, surgical and healthcare factors on the risk of revision of a primary hip replacement for PJI at different time-points in the post-operative follow-up. It is important that those risk factors are identified so that patients can be appropriately counselled according to their individual risk profile prior to surgery and modifiable factors can be addressed to reduce the risk of PJI at an individual and healthcare system level.

Background

To aid recovery, rehabilitation is an important adjunct to surgery. Acknowledging the MRC framework for complex interventions we assessed the evidence-base for components of comprehensive rehabilitation in total hip (THR) and total knee replacement (TKR) pathways.

Background

Inpatient physiotherapy is routinely provided after total knee replacement (TKR) surgery to enhance recovery prior to discharge. However, the provision of outpatient physiotherapy is variable in the UK, and the longer-term benefits of outpatient physiotherapy are unclear. This study aimed to evaluate the feasibility of conducting a randomised controlled trial (RCT) to assess the effectiveness and cost-effectiveness of group-based outpatient physiotherapy after TKR.

Background

Total knee replacement (TKR) is an effective operation for many patients, however approximately 20% of patients experience chronic pain and functional limitations in the months and years following their TKR. If modifiable pre-operative risk factors could be identified, this would allow patients to be targeted with individualised care to optimise these factors prior to surgery and potentially improve outcomes. Psychosocial factors have also been found to be important in predicting outcomes in the first 12 months after TKR, however their impact on long-term outcomes is unknown. This study aimed to identify pre-operative psychosocial predictors of patient-reported and clinician-assessed outcomes at one year and five years after primary TKR.

With the increasing demand for hip and knee replacement and move towards seven-day services, we examined whether this planned, elective surgery performed at the weekend is associated with a different 30-day mortality versus that performed between Monday and Friday.

The study dataset comprised 118,096 joint replacement episodes performed at the weekend and 1,233,882 episodes done on a weekday. We used a Kaplan-Meier framework to examine the 30-day cumulative mortality rate for all elective hip and knee replacements performed in England and Wales and recorded in the NJR between 1st April 2003 and 31st December 2014, with Cox proportional-hazards regression models to assess for time-dependent variation and adjust for identified risk factors for mortality.

For hip replacement the cumulative 30-day mortality was 0.15% (95%CI: 0.12–0.19) for patients operated on at the weekend versus 0.20% (0.19–0.21) for patients undergoing surgery during the normal working week. For knee replacement the cumulative 30-day mortality was 0.14% (0.11–0.17) for patients operated on at the weekend versus 0.18% (0.17–0.19) for patients undergoing surgery during the normal working week. The lower mortality associated with weekend operating was most apparent in the later years of the audit (2009 to 2014) and remained after adjustment for any differences in patient age, gender, American Society of Anaesthesiologist grade, surgeon seniority, surgical and anaesthetic practices, and thrombo-prophylaxis choice in weekend versus weekday operated patients.

Routine hip and knee replacements performed at the weekend in England and Wales and are not associated with an increased risk of post-operative mortality.

Aims

To investigate whether elective joint arthroplasty performed at the weekend is associated with a different 30-day mortality versus that performed between Monday and Friday.

With the increasing demand for hip and knee replacement, and the increasing pressure to move towards routine seven-day services within the National Health Service, the trend towards weekend operating is set to increase. We aimed to determine whether planned, elective total hip and total knee replacement performed at the weekend is associated with a different 30-day mortality versus those performed between Monday and Friday.

We used National Joint Registry of England, Wales, Northern Ireland and Isle of Man (NJR) linked to Office for National Statistics (ONS) data. The study dataset comprised 118,096 joint replacement episodes performed at the weekend and 1,233,882 episodes done on a weekday. The main outcome measure was 30-day all-causes mortality. We applied a survivorship analysis using a Kaplan-Meier framework to examine the 30-day cumulative mortality rate for all elective hip and knee replacements performed in England and Wales between 1st April 2003 and 31st December 2014, with Cox proportional-hazards regression models to assess for time-dependent variation and adjust for identified risk factors for mortality.

For hip replacement the cumulative 30-day mortality was 0.15% (95%CI: 0.12–0.19) for patients operated on at the weekend versus 0.20% (0.19–0.21) for patients undergoing surgery during the normal working week. For knee replacement the cumulative 30-day mortality was 0.14% (0.11–0.17) for patients operated on at the weekend versus 0.18% (0.17–0.19) for patients undergoing surgery during the normal working week. The lower mortality associated with weekend operating was most apparent in the later years of the audit (2009 to 2014) and remained after adjustment for any differences in patient age, gender, American Society of Anaesthesiologist grade, surgeon seniority, surgical and anaesthetic practices, and thrombo-prophylaxis choice in weekend versus weekday operated patients.

Hip and knee replacements are routinely performed on Saturdays, and to a lesser extent on Sundays, in England and Wales and are not associated with an increased risk of post-operative mortality.

Background

To investigate whether the interaction between pre-operative widespread hyperalgesia and radiographic osteoarthritis (OA) was associated with pain severity before and after total hip replacement (THR) and total knee replacement (TKR).

Background

There is a paucity of long term data concerning the pre and postoperative patient reported function of total knee replacement. The aim of this study was to determine the mortality, implant survivorship, patient reported function and satisfaction in a cohort of 114 patients, from a single centre, who received a Kinemax total knee replacement more than 15 years ago.

Background

Chronic pain after joint replacement is common, affecting approximately 10% of patients after total hip replacement (THR) and 20% of patients after total knee replacement (TKR). Heightened generalised sensitivity to nociceptive input could be a risk factor for the development of this pain. The primary aim of this study was to investigate whether preoperative widespread pain sensitivity was associated with chronic pain after joint replacement.

Background

In the UK, over 160,000 total joint replacements are performed annually. About 1% of patients subsequently develop a deep bacterial infection and, if untreated, this can result in severe pain, disability, and death. Costs to the NHS are substantial. The INFORM (Infection Orthopaedic Management) programme aims to address gaps in knowledge relating to treatment of deep prosthetic joint infection through six work packages. The programme is supported by a patient forum and patient-partners working on oversight groups.

Background

Assessment of functional outcome after total hip arthroplasty (THA) often involves subjective patient-reported outcome measures (PROMs) whereas analysis of gait allows more objective assessment. The aims of the study were to compare longitudinal changes of WOMAC function score and ambulatory gait analysis after THA, between patients with low and high self-reported levels of physical function.

Background

Frequency of primary total hip (THA) and total knee (TKA) arthroplasty procedures is increasing, with a subsequent rise in revision procedures. This study aims to describe timing and excess surgical mortality associated with revision THA and TKA compared to those on the waiting list.

Background

Post-traumatic immunosuppression (PTI) after surgery increases vulnerability to nosocomial infections, sepsis, and death. Knee arthroplasty offers a sterile clinical model to characterise PTI and explore its underlying mechanisms.

Background

Total hip replacement (THR) and total knee replacement (TKR) are usually effective at relieving pain; however, 7–23% of patients experience chronic post-surgical pain. These trials aimed to investigate the effect of local anaesthetic wound infiltration on pain severity at 12 months after primary THR or TKR for osteoarthritis.

Background

Over 96% of primary total hip replacements (THR) recorded in the National Joint Registry (NJR) are performed through a posterior or lateral surgical approach. There is no high quality evidence available to support the use of one approach over the other in primary THR and even less evidence when the outcome of revision THR is considered.

Background

Dissociation of the polyethylene liner is a known failure mechanism of the Harris Galante I and II uncemented acetabular components. The outcomes of revision surgery for this indication and the influence of time to diagnosis are not well described.

Objective

There is limited information about the extent to which the association between pre-operative and chronic post-operative pain is mediated via pain-on-movement or pain-at-rest. We explored these associations in patients undergoing total hip (THR) and total knee (TKR) replacement.

Background

This article reviews four commonly used approaches to assess patient responsiveness to a treatment or therapy [Return To Normal (RTN), Minimal Important Difference (MID), Minimal Clinically Important Difference (MCID), OMERACT-OARSI (OO)], and demonstrates how each of the methods can be formulated in a multi-level modelling (MLM) framework.

Background

The two-stage revision strategy has been claimed as being the “gold standard” for treating prosthetic joint infection. The one-stage revision strategy remains an attractive alternative option, however, its effectiveness in comparison to the two-stage strategy remains uncertain. A systematic review and meta-analysis was conducted to compare the effectiveness of one- and two-stage revision strategies to prevent re-infection after prosthetic hip infection.

Physical functioning in patients undergoing hip surgery is commonly assessed in three ways: patient-reported outcome measure (PROM), performance test, or clinician-administered measure. It is recommended that several types of measures are used concurrently to capture an extended picture of function. Patient fatigue and burden, time, resources and logistical constraints of clinic and research appointments mean that collecting multiple measures is seldom feasible, leading to focus on a limited number of measures, if not a single one. While there is evidence that performance-tests and PROMs do not fully correlate, correlations between PROMs, performance tests and clinician-administrated measures are yet to be evaluated. It is also not known if the associations between function and patient characteristics depend on how function is measured. The aim of our study was to use different measures to assess function in the same group of patients before their hip surgery to determine 1. how well PROMs, performance tests and clinician-administrated measures correlate with one another and 2. Whether these measures are associated with the same patient characteristics.

We conducted a cross-sectional analysis of the pre-operative information of 125 participants listed for hip replacement. The WOMAC function subscale, Harris Hip Score (HHS) and walk-, step- and balance-tests were assessed by questionnaire or during a clinic visit. Participant socio-demographics and medical characteristics were also collected. Correlations between functional measures were investigated with correlation coefficients (r). Regression models were used to test the association between the patient's characteristics and each of the three types of functional measures.

None of the correlations between the PROM, clinician-administrated measure and performance tests were very high (r<0.90). The highest correlations were found between the WOMAC-function and the HHS (r=0.7) or the Walk-test (r=0.6), and between the HHS and the walk-test(r=0.7). All the other performance-tests had low correlations with the other measures(r ranging between 0.3 and 0.5).

The associations between patient characteristics and functional scores varied by type of measure. Psychological status was associated with the WOMAC function (p-value<0.0001) but not with the other measures. Age was associated with the performance test measures (p-value ranging from ≤0.01 to <0.0001) but not with the WOMAC function. The clinician-administered (HHS) measure was not associated with age or psychological status.

When evaluating function prior to hip replacement clinicians and researchers should be aware that each assessment tool captures different aspects of function and that patient characteristics should be taken into account. Psychological status influences the perception of function; patients may be able to do more than they think they can do, and may need encouragement to overcome anxiety. A performance test like a walk-test would provide a more comprehensive assessment of function limitations than a step or balance test, although performance tests are influenced by age.

For the most precise description of functional status a combination of measures should be used. Clinicians should supplement their pre-surgery assessment of function with patient-reported measure to include the patient's perspective.

Joint arthroplasty is a common surgical procedure, with over 185,000 primary hip and knee arthroplasties performed in England, Wales and Northern Ireland in 2014. After total hip or knee arthroplasty, about 1% of patients develop deep prosthetic joint infection (PJI), which usually requires further major operations to clear the infection. Although PJI affects only a small percentage of patients it is one of the most devastating complications associated with this procedure. Research evidence has focussed on clinical effectiveness of revision surgery while there has been less focus on the impact on patients and support needs. Using a systematic review approach, the aim of this study was to assess support needs and evaluate what interventions are routinely offered to support patients undergoing treatment for PJI following hip or knee arthroplasty.

We systematically searched MEDLINE, Embase, Web of Science, PsycINFO, Cinahl, Social Science Citation Index, and The Cochrane Library from 1980 to February 15, 2015 for observational (prospective cohort, nested case-control, case-control, and retrospective cohort) studies, qualitative studies, and clinical trials that report on the support needs and interventions for patients being treated for PJI or other major adverse occurrences following joint arthroplasty. Data were extracted by two independent investigators and consensus reached with involvement of a third.

Of 4,161 potentially relevant citations, we identified one case-control, one prospective cohort and two qualitative studies for inclusion in the synthesis. Patients report that PJI and treatment had a profoundly negative impact affecting physical, emotional, social and economic aspects of their lives. No study evaluated support interventions for PJI or other major adverse occurrences following hip and knee arthroplasty.

The interpretation of study results is limited by variation in study design, outcome measures and the small number of relevant eligible studies. Findings show that patients undergoing treatment for PJI have extensive physical, psychological, social and economic support needs. Our review highlights a lack of evidence about support strategies for patients undergoing treatment for PJI and other adverse occurrences. There is a need to design, implement and evaluate interventions to support these patients.

Prosthetic joint infection (PJI) is an uncommon but serious complication of hip and knee replacement. We investigated the rates of revision surgery for the treatment of PJI following primary and revision hip and knee replacement, explored time trends, and estimated the overall surgical burden created by PJI.

We analysed the National Joint Registry for England and Wales for revision hip and knee replacements performed for a diagnosis of PJI and their index procedures from 2003–2014. The index hip replacements consisted of 623,253 primary and 63,222 aseptic revision hip replacements with 7,642 revisions subsequently performed for PJI; for knee replacements the figures were 679,010 primary and 33,920 aseptic revision knee replacements with 8,031 revisions subsequently performed for PJI. Cumulative incidence functions, prevalence rates and the burden of PJI in terms of total procedures performed as a result of PJI were calculated.

Revision rates for PJI equated to 43 out of every 10,000 primary hip replacements (2,705/623,253), i.e. 0.43%(95%CI 0.42–0.45), subsequently being revised due to PJI. Around 158 out of every 10,000 aseptic revision hip replacements performed were subsequently revised for PJI (997/63,222), i.e. 1.58%(1.48–1.67). For knees, the respective rates were 0.54%(0.52–0.56) for primary replacements, i.e. 54 out of every 10,000 primary replacements performed (3,659/679,010) and 2.11%(1.96–2.23) for aseptic revision replacements, i.e. 211 out of every 10,000 aseptic revision replacements performed (717/33,920). Between 2005 and 2013, the risk of revision for PJI in the 3 months following primary hip replacement rose by 2.29 fold (1.28–4.08) and after aseptic revision by 3.00 fold (1.06–8.51); for knees, it rose by 2.46 fold (1.15–5.25) after primary replacement and 7.47 fold (1.00–56.12) after aseptic revision. The rates of revision for PJI performed at any time beyond 3 months from the index surgery remained stable or decreased over time.

From a patient perspective, after accounting for the competing risk of revision for an aseptic indication and death, the 10-year cumulative incidence of revision hip replacement for PJI was 0.62%(95%CI 0.59–0.65) following primary and 2.25%(2.08–2.43) following aseptic revision; for knees, the figures were 0.75%(0.72–0.78) following primary replacement and 3.13%(2.81–3.49) following aseptic revision.

At a health service level, the absolute number of procedures performed as a consequence of hip PJI increased from 387 in 2005 to 1,013 in 2014, i.e. a relative increase of 2.6 fold. While 70% of those revisions were two-stage, the use of single stage revision increased from 17.6% in 2005 to 38.5% in 2014. For knees, the burden of PJI increased by 2.8 fold between 2005 and 2014. Overall, 74% of revisions were two-stage with an increase in use of single stage from 10.0% in 2005 to 29.0% in 2014.

Although the risk of revision due to PJI following hip or knee replacement is low, it is rising. Given the burden and costs associated with performing revision joint replacement for prosthetic joint infection and the predicted increased incidence of both primary and revision hip replacement, this has substantial implications for service delivery.

Around 20% of patients who have total knee replacement find that they experience long-term pain afterwards. There is a pressing need for better treatment and management for patients who have this kind of pain but there is little evidence about how to improve care. To address this gap we are developing a complex intervention comprising a clinic to assess potential causes of a patient's long-term pain after knee replacement and onwards referral to appropriate, existing services. The Medical Research Council recommends that development of complex interventions include several stages of development and refinement and involvement of stakeholders. This study comprises the penultimate stage in the comprehensive development of this intervention. Earlier stages included a survey of current practice, focus groups with healthcare professionals, a systematic review of the literature and expert deliberation.

Healthcare professionals from diverse clinical backgrounds with experience of caring for patients with long-term pain after knee replacement were sent a study information pack. Professionals who wished to participate were asked to return their signed consent form and completed study questionnaire to the research team. Participants rated the appropriateness of different aspects of the assessment process and care pathway from 1–9 (not appropriate to very appropriate). Data were collated and a document prepared, consisting of anonymised mean appropriateness ratings and summaries of free-text comments. This document was then discussed in 4 facilitated meetings with healthcare professional held at the future trial centres. A summary report and revised care pathway was then prepared and sent to participants for further comments.

28 professionals completed the questionnaire and/or attended a meeting. Participants included surgeons, physiotherapists, nurses, pain specialists and rheumatologists. Mean appropriateness scores ranged from 6.9 to 8.4. Taking a score of 7–9 as agreement, consensus was achieved that the assessment should be performed at 3 months post-operative by an extended scope practitioner/nurse, treatment be guided by a standardised assessment of pain, and treatment individualised. There was also agreement that referrals in the care pathway to surgical review, GP and pain clinics were appropriate. Nurse-led/self-monitoring was rated lower (6.9) because of considerations about the need to ensure that patients receive appropriate support, follow-up and referral to other services.

This work demonstrates the research methods that can be used to refine the design of a complex intervention. The process and findings enable refinement of an intervention for patients with long-term pain after knee replacement. The next stage of intervention development will assess the acceptability and reliability of the assessment process, and the usability of the intervention's standard operating procedures. The intervention will then be evaluated by a larger research team in a multi-centre randomised controlled trial, starting in late 2016.

Patients report similar or better pain and function before revision hip arthroplasty than before primary arthroplasty but poorer outcomes after revision surgery. The trajectory of post-operative recovery during the first 12 months and any differences by type of surgery have received little attention. We explored the trajectories of change in pain and function after revision hip arthroplasty to 12-months post-operatively and compared them with those observed after primary hip arthroplasty.

We conducted a single-centre UK cohort study of patients undergoing primary (n = 80) or revision (n = 43) hip arthroplasty. WOMAC pain and function scores and 20-metres walking time were collected pre-operatively, at 3 and 12-months post-operatively. Multilevel regression models were used to chart and compare the trajectories of post-operative change (0–3 months and 3–12 months) between the types of surgery.

Patients undergoing primary arthroplasty had a total hip replacement (n=74) or hip resurfacing (n=6). Osteoarthritis was the indication for surgery in 92% of primary cases. Patients undergoing revision arthroplasty had revision of a total hip arthroplasty (n=37), hemiarthroplasty (n=2) or hip resurfacing (n=4). The most common indication for revision arthroplasty was aseptic loosening (n=29); the remaining indications were pain (n=4), aseptic lymphocyte-dominated vasculitis-associated lesion (n=4) or other reasons (n=6). Primary (87%) and revision arthroplasties (98%) were mostly commonly performed via a posterior surgical approach.

The improvements in pain and function following revision arthroplasty occurred within the first 3-months following operation (WOMAC-pain, p<0.0001; WOMAC-function, p<0.0001; timed 20-metres walk, p<0.0001) with no evidence of further change beyond this initial period (p>0.05)

While the pattern of recovery after revision arthroplasty was similar to that observed after primary arthroplasty, improvements in the first 3-months were smaller after revision compared to primary arthroplasty (p<0.0001). Patients listed for revision surgery reported lower pre-operative pain levels (p=0.03) but similar post-operative levels (p=0.268) compared to those undergoing primary surgery. At 12-months post-operation patients who underwent a revision arthroplasty had not reached the same level of function achieved by those who underwent primary arthroplasty (WOMAC-function p=0.015; Time walk p=0.004).

Patients undergoing revision hip arthroplasty should be informed that the majority of their improvement will occur in the first 3-months following surgery and that the expected improvement will be less marked than that experienced following primary surgery. More research is now required to 1.) identify whether specific in-patient and post-discharge rehabilitation tailored towards patients undergoing revision arthroplasty would improve or achieve equivalent outcomes to primary surgery and 2.) whether patients who are achieving limited improvements at 3-months post-operative would benefit from more intensive rehabilitation. This will become all the more important with the increasing volume of revision surgery and the high expectations of patients who aspire to a disease-free and active life.

Total hip replacement (THR) is a common elective surgical procedure and can be effective for reducing chronic pain. However, waiting times for THR can be considerable, and patients often experience significant pain during this time. A pain self-management intervention may provide patients with the skills to enable them to manage their pain and its impact more effectively before surgery. However, studies of arthritis self-management programmes have faced challenges because of low recruitment rates, poor intervention uptake, and high attrition rates. This study aimed to evaluate the feasibility of a randomised controlled trial (RCT) to assess the effectiveness and cost-effectiveness of a group-based pain self-management course for patients undergoing THR. Specific objectives were to assess trial design, ascertain recruitment and retention rates, identify barriers to participation, refine data collection methods, and evaluate uptake and patient satisfaction with the course.

Patients listed for THR in an elective orthopaedic centre Bristol, UK were sent a postal invitation about the study. Participants were randomised to attend a pain self-management course plus standard care or standard care only using a computer-generated randomisation system. The pain self-management course was delivered by Arthritis Care and consisted of two half-day group sessions prior to surgery and one full-day group session 2–4 months after surgery. A structured course evaluation questionnaire was completed by participants.

Outcomes assessment was by postal questionnaire prior to surgery and 1-month, 3-months and 6-months after surgery. Self-report resource use data were collected using a diary prior to surgery and inclusion of resource use questions in the 3-month and 6-month post-operative questionnaires. Brief telephone interviews were conducted with non-participants to explore barriers to participation.

Postal invitations were sent to 385 eligible patients and 88 patients consented to participate (23% recruitment rate). Participants had a mean age of 66 years and 65% were female. Brief interviews with 57 non-participants revealed the most common reasons for non-participation were perceptions about the intervention and difficulties in getting to the hospital for the course.

Of the 43 patients randomised to the intervention group, 28 attended the pre-operative pain self-management sessions and 11 attended the post-operative sessions. Participant satisfaction with the course was high, and patients enjoyed the group format.

Retention of participants was acceptable, with 83% completing follow-up. Questionnaire return rates were high (76–93%), with the exception of the pre-operative resource use diary (35%). Completion rates for the resource use questions varied by category and allowed for an economic perspective from the health and social care payer to be taken.

Undertaking feasibility work for a RCT is labour-intensive; however this study highlights the importance of conducting such work. Postal recruitment resulted in a low recruitment rate and brief interviews with non-participants provided valuable information on barriers to participation. Embedding collection of resource use data within questionnaires resulted in higher completion rates than using resource use diaries. While patients who attended the course gave positive feedback, attendance was low. Findings from this feasibility study enable us to design successful definitive group-based RCTs in the future.

Around 1% of the 185,000 primary hip and knee arthroplasties performed in the UK are followed by prosthetic joint infection (PJI). Although PJI affects a small percentage of patients, it is one of the most devastating complications associated with this procedure. Treatment usually involves further major surgery which can adversely affect patients' quality of life. Understanding current service provision provides valuable information needed to design and evaluate support interventions for patients. The aim of this survey was to identify usual care pathways and support in UK NHS orthopaedic centres for this population.

The 20 highestvolume UK NHS orthopaedic centresfor hip and knee arthroplasty account for 33–50% of all cases treated for prosthetic joint infection. Infection leads at each centre were invited to participate in a survey about usual care provision and support for PJI. Questions exploredfollow up time-points; use of standard outcome measures; multidisciplinary care plans; supportive in-patient care and care after treatment; and onward referrals. Survey responses were recorded on a standardised proforma. Data were entered into Excel for analysis, then reviewed and coded into categories and frequency statistics to describe categorical data. A descriptive summary was developed based on these categories.

Eleven of the highestvolume orthopaedic centres completed the survey. Follow-up of patients varied greatly across centres; some centres reviewed patients at weekly or 2 week intervals, while all centres saw patients at 6 weeks. Long-term follow-up varied across centres from 3–4 monthsto 12 monthly. Length of follow-up period varied from until the infection had cleared toindefinitely. Follow-up timepoints were only standardised in 4 out of 11 centres. Only 1 centre had a dedicated infection clinic. Advice on who patients should contact if they had concerns included the consultant, community nurse, extended scope practitioner or the ward, while 3 centres told patients to avoid calling their GP. Only half of the centres routinely used standardised outcome measures with patients with PJI. The majority of centres provided standard physiotherapy and occupational therapy (OT) to in-patients while approximately half also offered social support. Only one centre provided dedicated physiotherapy and OT on a separate infection ward. Three centres provided hospital at home or community services to patients in-between operative stages. Only 3 out of 11 centres stated they had specific multidisciplinary care plans in place for patients. Once discharged most patients were provided with physiotherapy, OT and social services if needed. Common barriersto referral included complexities of referring patients outside the hospital catchment area;lack of availability of community services, and shortage of staff including physiotherapists. Delays in rehab and social services could also be problematic.

Findings show wide variation intreatment pathways and support for patients treated for PJI, both as inpatients and in the community. Only one of the 11 centreswho participated had a dedicated infection clinic. Only one centre suggested they individualised their physiotherapy support. A number of barriers exist to referring patients on to other support services after revision surgery.

Around 1% of total hip replacements are follow by prosthetic joint infection (PJI). There is uncertainty about best treatment method for PJI, and the most recent high quality systematic reviews in unselected patients indicates that re-infection rates following one-stage and two-stage revision arthroplasty are relatively similar. In the absence of evidence randomised controlled trials will help to identify the most clinically and cost-effective treatment for PJI. Before such trials are conducted, there is a need to establish reasons for current practice and to identify whether trials are feasible. This study aimed to deliver research that would inform trial design. Specifically, we aimed to characterise consultant orthopaedic surgeons' decisions about performing either one-stage or two-stage exchange arthroplasty for patients with PJI after hip replacement and to identify whether a randomised trial comparing one-stage with two-stage revision would be possible.

Semi-structured interviews were conducted with 12 consultant surgeons from 5 high-volume National Health Service (NHS) orthopaedic departments in the UK. Surgeons were sampled on the basis that they perform revision surgery for PJI after hip arthroplasty and final sample size was justified on the basis of thematic saturation. Surgeons were interviewed face-to-face (n=2) or via telephone (n=10). The interview study took place before design of a multicentre prospective randomised controlled trial comparing patient and clinical outcomes after one-stage or two-stage revision arthroplasty. Data were audio-recorded, transcribed, anonymised and analysed using a thematic approach, with 25% of transcripts independently double-coded.

Results: There is no standard surgical response to the treatment of PJI and surgeons manage a complex balance of factors when choosing a surgical strategy. These include multiple patient-related factors, their own knowledge and expertise, available infrastructure and the infecting organism. Surgeons questioned whether evidence supports the emergence of two-stage revision as a method. They described the use of loosely cemented articulating spacers as a way of managing uncertainty about best treatment method. All surgeons were supportive of a randomised trial to compare one-stage and two-stage revision surgery for PJI after hip replacement. Surgeons reported that they would put patients forward for randomisation when there was uncertainty about best treatment.

Surgeons highlighted the need for evidence to support their choice of revision. Some surgeons now use revision methods that can better address both clinical outcomes and patients' quality of life, such as loosely cemented articulating spacers. Surgeons thought that a randomised controlled trial comparing one-stage and two-stage exchange joint replacement is needed and that randomisation would be feasible. The next stage of the work was to design a multi-centre randomised controlled trial, this has been achieved and the trial is now ongoing in the UK.

Robust evidence on the effectiveness of peri-operative local anaesthetic infiltration (LAI) is required before it is incorporated into the pain management regimen for patients receiving total knee replacement (TKR). To assess the effectiveness of peri-operative LAI for pain management in patients receiving TKR we conducted a systematic review, fully powered randomised controlled trial (RCT) and economic evaluation.

We searched MEDLINE, Embase and Cochrane databases for RCTs of peri-operative LAI in patients receiving TKR. Two reviewers screened abstracts and extracted data. Outcomes were pain, opioid use, mobilisation, hospital stay and complications. Authors were contacted if required. When feasible, we conducted meta-analysis with studies analysed separately if a femoral nerve block (FNB) was provided.

In the APEX RCT, we randomised 316 patients awaiting TKR to standard anaesthesia which included FNB, or to the same regimen with additional peri-operative LAI (60mls 0.25% bupivacaine plus adrenaline). Post-operatively, all patients received patient-controlled morphine. The primary outcome was joint pain severity (WOMAC-Pain) at 12 months. Patients and outcome assessors were blinded to allocation.

Within APEX, cost-effectiveness was assessed from the health and social-care perspective in relation to quality adjusted life years (QALYs) and WOMAC-Pain at 12-months. Resource use was collected from hospital records and patient questionnaires.

In the systematic review, 23 studies including 1,439 patients were identified. Compared with patients receiving no intervention, LAI reduced WOMAC-Pain by standardised mean difference (SMD) −0.40 (95%CI −0.58, −0.22; p<0.001) at 24 hours at rest and by SMD −0.27 (95%CI −0.50, −0.05; p=0.018) at 48 hours during activity. In three studies there was no difference in pain at any time point between randomised groups where all patients received FNB. Patients receiving LAI spent fewer days in hospital, used less opioids and mobilised earlier. Complications were similar between groups. Few studies reported long-term outcomes.

In the APEX RCT, pain levels in hospital were broadly similar between groups. Overall opioid use was similar between groups. Time to mobilisation and discharge were largely dependent on local protocols and did not differ between groups. There were no differences in pain outcomes between groups at 12 months.

In the economic evaluation, LAI was marginally associated with lower costs. Using the NICE £20,000 per QALY threshold, the incremental net monetary benefit was £264 (95%CI, −£710, £1,238) and the probability of being cost-effective was 62%.

Although LAI appeared to have some benefit for reduced pain in hospital after TKR there was no evidence of pain control additional to that provided by femoral nerve block, however it would be cost-effective at the current NICE thresholds.

Robust evidence on the effectiveness of peri-operative local anaesthetic infiltration (LAI) is required before it is incorporated into the pain management regimen for patients receiving total hip replacement (THR). We assessed the effectiveness of LAI using a systematic review and a fully powered randomised controlled trial (RCT) with economic evaluation.

We searched MEDLINE, Embase and Cochrane databases for RCTs of peri-operative LAI in patients receiving THR. Two reviewers screened abstracts, extracted data, and liaised with authors. Outcomes were pain, opioid use, mobilisation, hospital stay and complications. If feasible, we conducted meta-analysis.

In the APEX RCT, we randomised 322 patients awaiting THR to receive additional peri-operative LAI (60mls 0.25% bupivacaine plus adrenaline) or standard anaesthesia alone. Post-operatively, all patients received patient-controlled morphine. The primary outcome was joint pain severity (WOMAC-Pain) at 12 months. Patients and outcome assessors were blinded to allocation.

Within APEX, cost-effectiveness was assessed from the health and social-care perspective in relation to quality adjusted life years (QALYs) and WOMAC-Pain at 12-months. Resource use was collected from hospital records and patient questionnaires.

In the systematic review, we identified 13 studies (909 patients). Patients undergoing THR receiving LAI experienced greater pain reduction at 24 hours at rest, standardised mean difference (SMD) −0.61 (95%CI −1.05, −0.16; p=0.008) and at 48 hours during activity, SMD −0.43 (95%CI −0.78, −0.09; p=0.014). Patients receiving LAI spent fewer days in hospital, used less opioids and mobilised earlier. Complications were similar between groups. Long-term outcomes were not a focus of these studies.

In the APEX RCT, pain levels in hospital were broadly similar between groups, probably due to patient-controlled analgesia. Opioid use was similar between groups. Time to mobilisation and discharge were largely dependent on local protocols and did not differ between groups. Patients receiving LAI were less likely to report severe pain at 12 months than those receiving standard care, odds ratio 10.2 (95%CI 2.1, 49.6; p=0.004). Complications were similar between groups.

In the economic evaluation, LAI was associated with lower costs and greater cost-effectiveness than standard care. Using a £20,000 per QALY threshold, the incremental net monetary benefit was £1,125 (95%CI £183, £2,067) and the probability of being cost-effective was greater than 98 %.

The evidence suggests that peri-operative LAI is a cost-effective intervention for reducing acute and chronic post-surgical pain after THR.

Aim

To evaluate the ability of different combinations of antibiotic loaded cement to inhibit bacteria growth and biofilm formation.

In England and Wales in 2012 over 160,000 primary total hip and knee replacements were performed with 57% of hip replacements utilising uncemented prostheses. The main cause of failure, affecting approximately 10% of patients, is aseptic loosening. Previous research has found that functionalising titanium with lysophosphatidic acid (LPA) induces an increase in human osteoblast maturation on the implant surface through co-operation with active metabolites of vitamin D3. This feature, the small size of the LPS molecule and its affinity to readily bind to titanium and hydroxylapatite makes it an especially desirable molecule for bone biomaterials. Nevertheless biomaterials that also demonstrate anti-microbial properties are highly desirable.

To test the antimicrobial efficacy of the LPA-functionalised titanium, a clinical isolate of Staphylococcus aureus, obtained from an infected revision surgery, was cultured on the surface of titanium discs functionalised with 0, 0.1. 0.5, 1, 2 and 5μM LPA. Bacterial adhesion was quantified at 1, 2, 6, 12 and 24 hours by live/dead counts and biofilm mass quantified by crystal violet staining after 24, 48, 72 and 96 hours culture. To elucidate the mechanisms of action of LPA, proteomic analysis of adhered bacteria was performed using SDS-PAGE and Western blots.

500nM to 1μM LPA were the optimum concentrations to significantly inhibit bacterial adhesion (ANOVA, p<0.001). These concentrations also reduced biofilm mass on the surface of the titanium. Proteomic analysis highlighted an increase in low molecular weight proteins as a result of optimal LPA surface concentrations. Fatty acid chains as found in LPA have previously been associated with causing leakage of low molecular weight proteins through increased cell membrane permeability.

LPA coatings have the potential to enhance implant osseointegration whilst simultaneously reducing bacterial attachment. This technology may reduce both septic and aseptic failure of cementless joint prostheses, ultimately prolonging implant longevity and patient quality of life.

The mini-incision posterior approach may appeal to surgeons comfortable with the standard posterior approach to the hip. We present the first systematic review and meta-analysis of these two approaches. Twelve randomised controlled trials and four non-randomised trials comprising of 1498 total hip arthroplasties were included.

The mini-incision posterior approach was associated with an early improvement in Harris hip score of 1.8 points (P < 0.001), reduced operating time (5 minutes, P < 0.001), length of hospital stay (14 hours, P < 0.001), intraoperative and total blood loss (63 ml, P < 0.001 and 119 ml, P < 0.001 respectively). There were no statistically significant differences on the incidence of dislocation, nerve injury, infection or venous thromboembolic events.

The minimally invasive posterior approach appears to provide a safe and acceptable alternative to the standard incision posterior approach.

The subvastus approach has potential early advantages over the medial parapatellar approach because it avoids disruption of the quadriceps tendon. We present a systematic review and meta-analysis of the functional outcomes and complications associated with these two approaches.

Following an extensive search of prospective trials published in any language before 1st August 2014, studies were screened in duplicate according to pre-defined inclusion and exclusion criteria. Sixteen randomised controlled trials were included in the meta-analysis comprising of 1,711 total knee replacements.

Knee society score and range of movement were significantly superior in the subvastus group at early and one-year follow up. The subvastus approach was also associated with a statistically significant reduction in the requirement for intraoperative lateral release, perioperative blood loss, visual analogue score for pain on day 1 post operatively, and the number of days to achieve active straight leg raising. Both tourniquet time and total operative time were increased for the subvastus approach. There was no statistically significant difference in complications such as stiffness requiring MUA, superficial and deep infection and deep vein thrombosis.

The subvastus approach confers a functional advantage over the medial parapatellar approach to the knee which lasts for a minimum of one year postoperatively.

The physiological effects of 1,25 vitamin D3 (1,25D) are well known and the previously held dogma was that this was the only active vitamin D metabolite.

A number of methods have been employed to demonstrate the effects of 24,25-dihydroxyvitamin D3 (24,25D) on osteoblast maturation responses, in the presence of FHBP, ((3S) 1-Fluoro-3-hydroxy-4-(oleoyloxy)butyl-1-phosphonate), an agonist of lysophosphatidic acid (LPA). These include alkaline phosphatase (ALP) expression and investigation of the role of CYP27B1, which is the enzyme responsible for converting 24,25D to 1,24,25D. Ketoconazole, which inhibits the actions of CYP27B1, as well as an enzyme-linked immunosorbant assay (ELISA) for CYP27B1 were used.

The results clearly demonstrate that 24,25D stimulates maturation of MG63 cells when combined with FHBP. It has also been shown that the metabolite is not converted to another active form (for example, 1,24,25D) within osteoblasts, due to the absence of CYP27B1.

24,25D is an active vitamin D metabolite and exerts its effects in a bone fide manner, rather than following conversion to another active metabolite in osteoblasts. Given it is non-calcaemic, this metabolite has the exciting potential of being used in a bone regenerative setting in orthopaedic applications.

Triple-tapered cemented stems were developed in the hope that they would reduce aseptic loosening and prevent calcar bone loss.

Between March 2005 and April 2008, a consecutive series of 415 primary C-stem AMT hip arthroplasties in 386 patients were performed under the care of three surgeons at our institution. When all the patients had reached the 5-year anniversary of surgery, functional questionnaires were sent out by mail. In the event of non-response, reminders were sent by post before the patients were contacted by telephone. Postoperative radiographs were also reviewed.

Follow-up ranges from 60 to 99 months, with a mean of 76 months. 32 hips (8%) were lost to follow-up. The median OHS was 40, median SF-12 mental component score (MCS) was 50, and median SF-12 physical component score (PCS) was 39. Radiographic review showed that aseptic femoral component loosening has yet to be observed. At 99 months follow up, stem survivorship is 96.9% (95% confidence interval (CI) 82.5 to 99.5). Adverse events such as calcar fracture, greater trochanter fracture and dislocation were rare at <1%.

The C-stem AMT demonstrates excellent implant survivorship at 5–8 year follow-up, as well as good midterm functional outcome.

Summary Statement

Developing titanium (Ti) surfaces that are biocompatible yet serve as deterrents for bacterial attachment and growth are particularly appealing in tackling the ongoing problem of sepsis-induced implant failures. Realising this could include coating Ti with the bioactive lipid, lysophosphatidic acid.

Summary

A single 3D accelerometer is accurate in measuring upper-extremity activity durations, rest periods and intensities, suggesting its feasibility for daily life measurements with patients. Further enhancements are feasible to reduce residual false classifications of intensity from certain activities.

Prosthetic joint infection(PJI) still remains a concern in orthopaedic practice. Antibiotic-loaded acrylic-cement(ALAC) is a proven means of lowering the incidence of PJI. However, increasing antimicrobial resistance has complicated both prophylaxis and treatment, prompting the use of combination antimicrobial therapy, with the addition of vancomycin to gentamicin-containing ALAC commonly used. The new antimicrobial, daptomycin, has better activity than vancomycin and we studied its elution from ALAC in comparison with vancomycin, along with its impact on the co-elution of gentamicin.

Cement beads were prepared from PalacosRG containing, 1g/2g daptomycin, 1g/2g vancomycin and without additional antibiotics. Six replicates of each combination were eluted in PBS at 37oC, at timed intervals, for up to 90days, the antibiotic loss was assessed using validated assays.

The mean recovery of gentamicin after 90days was 1.1mg with half eluted within the first 6 hours. Recovery was significantly increased by 60% and 40% with addition of 1g&2g of daptomycin(two-tail t-test: p=0.004 and p=0.02), respectively. Although there was a slight increase in gentamicin recovery in vancomycin loaded samples, this was not statistically significant(p>0.05).

The significant increases in gentamicin elution from Palacos RG when supplemented with daptomycin, along with a superior activity, may provide a better synergistic effect than PalacosRG supplemented with vancomycin in the management of PJI.

Cyanoacrylate tissue compounds are marketed as a surgical wound dressing with a variety of properties including microbiological impermeability. This study compares the bacteriological impermeability of cyanoacrylates and a commonly used occlusive adhesive dressing using a technique established in several other studies. Cyanoacrylate compound and an occlusive dressing were applied to both CLED and CROM agar plates. S. Aureus and E. Coli was then applied in a range of concentrations. The work demonstrated that cyanoacrylate compound provides as occlusive a barrier to microbiological penetration as adhesive dressings.

Orthopaedic cobalt chromium particles and ions can induce indirect DNA damage and chromosome aberrations in human cells on the other side of a cellular barrier in tissue culture. This occurs by intercellular signalling across the barrier. We now show that the threshold for this effect depends on the metal form and the particle composition.

Ionic cobalt and chromium induced single strand breaks at concentrations equivalent to those found in the blood of patients with well functioning metal on metal hip prostheses. However, they only caused double strand breaks if the chromium was present as chromium (VI), and did not induce chromosome aberrations. Nanoparticles of cobalt chromium alloy caused DNA double strand breaks and chromosome aberrations, of which the majority were tetraploidy. Ceramic nanoparticles induced only single strand breaks and/or alkaline labile sites when indirectly exposed to human fibroblasts.

The assessment of reproductive risk from maternal exposure to biomaterials, especially those liberated by orthopaedic implants, is not yet possible with epidemiology. Whilst the barrier model used here differs from the in vivo situation in several respects, it may be useful as a framework to evaluate biomaterial induced damage across physiological barriers.

Accelerometer based gait analysis (AGA) is a potential alternative to the more commonly used skin marker based optical motion analysis system(OMAS). The use of gyroscopes in conjunction with accelerometers (i.e. inertial sensors), enables the assessment of position and angular movements of body segments and provides ambulatory kinematic characterisation of gait.

We investigated commonly used gait parameters and also a novel parameter, Pelvic obliquity (PO) and whether they can be used as a parameter of physical function and correlate with classic clinical outcome scores

Gait was studied in healthy subjects (n=20), in patients with end stage hip OA (n=20) and in patients with end stage knee OA (n=20). Subjects walked 20 metres in an indoor environment along a straight flat corridor at their own preferred speed. A 3D inertial sensor was positioned centrally between the posterior superior iliac spines (PSIS) overlying S1.

Comparing gait parameters of end stage hip OA patients with an age and gender matched healthy control group, significantly lower walking speed, longer step duration and shorter step length was observed. After correcting for walking speed between groups, significantly less average range of motion of PO (RoM_po) was observed for patients with end stage hip OA compared to healthy subjects and patients with end stage knee OA.

IGA allows objective assessment of physical function for everyday clinical practice and allows assessment of functional parameters beyond time only. IGA measures another dimension of physical function and could be used supplementary to monitor recovery of OA patients after TJR.

Successful osseointegration requires the production of a mechanically competent collagenous matrix, by osteoblasts, at the implant site. Lysophosphatidic acid (LPA) is a bioactive lipid which we discovered interacts with vitamin D3 (D3) to secure human osteoblast (hOB) maturation on both titanium (Ti) and hydroxyapatite.

We therefore covalently attached LPA and a related compound, (3S) 1-fluoro-3-hydroxy-4-butyl-1-phosphate (FHBP), to both solid and porous Ti discs and seeded them with hOBs to assess their ability to support D3-induced cell maturation. Solid functionalised discs were washed and reused a further two times, whilst other discs were stored for 6 months.

Increased alkaline phosphatase (ALP) activity indicated that both LPA and FHBP-modified Ti serve as superior substrates for securing D3-induced hOB maturation compared to unmodified metal (p < 0.001). Although total ALP activity was less for cells on recycled discs and after storage, enzyme levels were still significantly greater compared to hOBs grown on control Ti. LPA and D3 co-treatment also resulted in an increase in osteocalcin (∼17ng/ml versus 6ng/ml for D3 alone, P < 0.001) and collagen synthesis (∼310pg/ml versus <10pg/ml for D3 alone, P < 0.001).

Research is ongoing to evaluate the efficacy of our modified Ti surfaces to secure hOB formation from their stem cell progenitors.

Total Shoulder Resurfacing (TSR) provides a reliable solution for the treatment of glenohumeral arthritis. It confers a number of advantages over traditional joint replacement with stemmed humeral components, in terms of bone preservation and improved joint kinematics.

This study aimed to determine if humeral reaming instruments produce a thermal insult to subchondral bone during TSR. This was tested in vivo on 13 patients (8 with rheumatoid arthritis and 5 with osteoarthritis) with a single reaming system and in vitro with three different humeral reaming systems on saw bone models. Real-time infrared thermal video imaging was used to assess the temperatures generated.

Synthes Epoca instruments generated average temperatures of 40.7°^C (SD 0.9°^C) in the rheumatoid group and 56.5°^C (SD 0.87°^C) in the osteoarthritis group (p = 0.001). Irrigation with room temperature saline cooled the humeral head to 30°^C (SD 1.2°^C). Saw bone analysis generated temperatures of 58.2°^C (SD 0.79°^C) in the Synthes (Epoca) 59.9°^C (SD 0.81°^C) in Biomet (Copeland) and 58.4°^C (SD 0.88°^C) in the Depuy (CAP) reamers (p=0.12).

Humeral reaming with power driven instruments generates considerable temperatures both in vivo and in vitro. This paper demonstrates that a significant thermal effect beyond the 47°^C threshold needed to induce osteonecrosis is observed with humeral reamers, with little variation seen between manufacturers. Irrigation with room temperature saline cools the reamed bone to physiological levels, and should be performed regularly during this step in TSR.

Total knee arthroplasty (TKA) remains a safe and effective intervention for the treatment of arthritis of the knee. It does, however, carry risks including death. Studies have compared the incidence of death following TKA to standardised mortality ratios of matched populations. This often suggests that TKA is protective to health in the immediate post operative phase, attributed to the lower incidence of co-morbidities in patients undergoing surgery.

In an attempt to remove this “well patient effect”, we compared the incidence of death in the first 30 and 90 days following primary TKA to that of a comparable population added to a waiting list for the same procedure.

All primary TKAs undertaken, and all patients added to a waiting list for the same procedure, in a single unit between 2000 and 2007 were recorded. Death rates at 30 and 90 days were compared in each group.

The 30 and 90 day mortality following primary TKA were 0.295% and 0.565% respectively, compared to a 30 and 90 day mortality of 0.055% and 0.316% seen in a population of patients awaiting operation. When stratified for age, surgery conferred an excess surgical mortality in all age groups over the age of 60. Factors associated with an increased mortality following operation include male gender and increasing age.

Previous studies have suggested that TKA is associated with a decreased risk of death. This study demonstrates an increased risk of death associated with surgery in comparison to a similar population deemed fit enough to undergo operation. Primary TKA carries an excess surgical mortality of 0.24% at 30 days and 0.25% at 90 days, a 5.36 and 1.79 times greater risk of death when compared to patients awaiting the same procedure.

This information will greatly assist orthopaedic surgeons when counselling patients as to the risks of surgery.

Introduction: The principal aim of total knee replacement (TKR) surgery is to relieve chronic knee pain. However, following recuperation from surgery, 10–30% of patients report chronic pain in the replaced joint. There has been little research investigating the impact of this continuing pain on patients’ lives or exploring the way in which individuals adjust to this pain. Therefore, the aim of this study is to explore, from their own perspectives, patients’ experiences of chronic pain following this end-stage treatment of TKR.

Participants and Methods: Participants were twenty-eight patients who had undergone a TKR with the National Health Service at Bristol, Southwest UK, and who reported chronic pain in the replaced knee joint at least one year post-operatively. Purposive sampling was used in order to recruit participants both of a range of ages and with moderate to severe chronic pain. In-depth, semi-structured interviews were conducted with participants. Interviews explored individuals’ perceptions of the identity of their condition, its cause, duration and consequences and whether they had any control over it. Data was analysed using thematic analysis.

Results: Analysis revealed that, while all participants experienced chronic pain which necessitated the use of pain relief medication, there was great variation among individuals in terms of their adjustment to their condition: while some were well adjusted and accepting of their pain, for others the pain constituted a source of ongoing distress.

Regardless of their expectations concerning level of pain following TKR, those participants who perceived an improvement in pain as a result of their TKR were less likely to expect a cure for their residual pain and were either very well or reasonably well adjusted to the pain. Nevertheless, those who had moderate expectations of outcome were more likely to perceive an improvement than those with high expectations. Those individuals who reported having held high expectations of TKR outcome and subsequently experienced increased pain were likely to experience distress in relation to their pain; those who also felt that a cure for their current pain may be possible experienced particularly high levels of distress.

Discussion: The findings show the significance of cognitions, beliefs and expectations to individuals’ adjustment to chronic pain following TKR. They highlight a group of patients for whom adjustment may be problematic, which could indicate the need for assessment and intervention. There could be potential for surgeons to influence their patients’ adjustment positively by attempting to instil realistic expectations both prior to surgery and when chronic pain is experienced after recovery from TKR.

Total knee arthroplasty represents one of the greatest advances in modern orthopaedic surgery and remains one of the safest and most effective interventions for the treatment of crippling arthritis of the knee. It does, however, carry significant risk including death. Conventional studies have compared the incidence of death following knee arthroplasty to standardised mortality ratios of age and sex matched populations. This often raises aberrant results suggesting that knee arthroplasty is protective to health in the immediate post operative phase, attributed to the observation that patients undergoing surgery suffer fewer co morbidities than the population in general.

In an attempt to remove this “well patient effect”, we compared the incidence of death in the first 30 and 90 days following primary total knee arthroplasty to the incidence of death in a comparable population added to a waiting list for the same procedure.

All primary total knee arthroplasties undertaken, and all patients added to a waiting list for the same procedure, in a single unit between 2000 and 2007 were recorded. Death rates at 30 and 90 days of those on the waiting list were compared to death rates after surgery.

The 30 and 90 day mortality following primary total knee arthroplasty were 0.295% and 0.565% respectively. This compares to a 30 and 90 day mortality of 0.055% and 0.316% seen in a population of patients awaiting operation. When stratified for age, surgery conferred an excess surgical mortality in all age groups over the age of 60. Factors associated with an increased mortality following operation include male gender and increasing age.

Previous studies, where incidence of death is compared to standardised mortality ratios, have erroneously suggested that arthroplasty is associated with a decreased risk of death. This study demonstrates an increased risk of death associated with surgery in comparison to a similar population deemed fit enough to undergo operation. Primary total knee arthroplasty carries an excess surgical mortality of 0.24% at 30 days and 0.25% at 90 days, a 5.36 and 1.79 times greater risk of death respectively when compared to patients awaiting the same procedure.

This information will greatly assist orthopaedic surgeons when counselling patients as to the risks of surgery.

Introduction: Patient satisfaction with the outcome of elective surgery is increasingly used as a measure of the patient’s perception of the success of an operation. Satisfaction is an individualistic complex of factors and measuring satisfaction can add another valuable dimension to outcomes assessment after arthroplasty. The aim of this study was to explore patient satisfaction after lower limb arthroplasty.

Patients and Methods: All patients who had a primary joint replacement at the Avon Orthopaedic Centre over a 3-year period were invited to participate in the study. Participants completed a questionnaire which consisted of the WOMAC, the Joint-Related Quality of Life Scale from the KOOS/HOOS, SF-12 and a validated satisfaction scale. The satisfaction questionnaire measures patient satisfaction with four domains of outcome: overall outcome, pain relief, ability to perform ADLs and ability to participate in leisure activites. Responses are on a 4-point Likert scale which ranges from very satisfied to very dissatisfied. A global satisfaction score was calculated from these responses and then transformed onto a 0–100 scale (100 being best).

Results: Completed questionnaires were received from 2085/3125 patients (67% response rate). 911 respondents had a THR, 866 had a TKR, 157 had a hip resurfacing, 100 had a UKR and 51 had a patellar resurfacing. The mean age of respondents was 70 years and 58% were female. The mean length of follow-up was 28 months.

The median satisfaction score was 100 (interquartile range 75–100). However, within the individual outcome domains dissatisfaction rates were: 9% for pain; 12% for overall outcome; 14% for ADLs; and 17% for leisure activities. To explore differences in satisfaction with age, patients were divided into 3 age groups: < 60 years, 60–80 years and > 80 years. The respective rates of dissatisfaction among the age groups were 13%, 11% and 14%, which were not significantly different (p=0.33). In an analysis of gender and satisfaction, significantly more females were dissatisfied than men (14% vs 10%, p=0.01). When pain, function, quality of life, mental health and physical health were compared between patients who were satisfied (n=1834) and dissatisfied (n=251) with their overall outcome, all outcomes were significantly worse in the dis-satisfied patient group (p< 0.001 for all outcomes).

Discussion: Although the median satisfaction score in this study was 100, there was a group of patients who were not satisfied with their outcome. As well as having worse joint pain and function, dissatisfied patients also have significantly worse quality of life, physical health and mental health compared to satisfied patients. In conclusion, patient satisfaction is one of the key outcomes that should be strived for after an elective intervention, and these results indicate that joint replacement is failing to fully satisfy a proportion of patients.

Introduction: Radiolucency in the DeLee and Charnley zone 1 of the acetabulum in the early post operative period is a strong predictor of long-term failure of the cemented acetabulum. There is a wide variety in the acetabular anatomy of patients presenting for total hip replacement. Zone 1 radiolucency is an indicator of the failure of penetration of cement into the relatively hard cortical bone encountered in zone 1. Cement penetration is achieved by adequate preparation, achieving containment and effective pressurisation.

Aim: To use pre operative radiological measurements to predict the risk of radiolucency around the cemented acetabular component post operation.

Hypotheses:

Dysplastic acetabuli are associated with a higher incidence of zone 1 radiolucency.

Materials and Methods: A cohort of 300 patients undergoing cemented THR in our institution was identified. Radiographs performed on the patients pre operatively, post operatively, at first follow up (6 weeks to 3months) and follow up at 1 year were analysed. The following measurements of the native acetabulum were performed: Tonnis grade of osteoarthritis, Crowe grade of dysplasia, acetabular index of depth to width, ACM angle, peak to edge distance, acetabular index of weight bearing zone, centre-edge angle of Widberg, acetabular angle of Sharp, cross over sign and posterior wall sign to assess retroversion, acetabular inclination and anteversion angle. Post operative films were then assessed for the presence of zone 1 keyholes, incidence and degree of radiolucency, cup inclination and anteversion.

Results: Patients with an acetabulum outside the normal range were more likely to have a post operative radiolucency. Radiolucency tended to progress with time. Zone 1 keyholes appeared to terminate this progression. Retroverted and steeply inclined acetabuli demonstrated a higher incidence of radiolucency. A large change in version from the native to prosthetic acetabulum was associated with an increased risk of radiolucency.

Conclusion: Thorough pre operative radiological assessment of the acetabular anatomy allows us to predict patients at high risk of post operative radiolucency. Patients with unsuitable anatomy may be more appropriate for an alternative method of fixation or require different techniques of acetabular preparation or augmentation in order to reduce their risk of loosening of the acetabular component in the long term.

Resurfacing hip arthroplasty is a successful option for the treatment of the young and active patient with hip arthritis. However, it is complicated by femoral neck fracture and avascular necrosis, which result from devascularisation during surgery. Devascularisation maybe caused by thermal necrosis. Thermal necrosis of bone has been shown to occur in temperatures of 47°C and above. We investigated the temperatures generated during femoral head preparation to see if the temperatures reached were great enough to induce osteonecrosis.

Method: Eight patients with osteoarthritis underwent standard resurfacing hip arthroplasty through the posterior approach. From the first over-drilling of the femoral heads until the prosthesis was cemented in place the temperatures generated at the bone surface were recorded using an infra-red thermal imaging camera. Images were captured every 4 seconds as the operation was performed with no interference to the surgeon

Results: The maximum temperatures generated occurred during sleeve reaming at 88.4°C. Seven patients had a temperature recorded greater than 47°C. Removing the femoral caput with an oscillating saw had the highest mean temperature 62.2°C, followed by sleeve reaming (mean 48.7°C). Female patients had the lowest temperature rises and patients receiving the larger femoral prosthesis the greatest temperatures at the bone surface.

Conclusions: Heat generated during femoral head preparation exceeded 47°C in all but one case. Osteonecrosis secondary to thermal insult is likely to occur during femoral head preparation. Strategies need to be devised to decrease the temperatures generated during femoral head preparation.

Study Design: This is a retrospective study evaluating the use of BoneSave (Stryker, UK) in posterolateral inter-transverse spinal fusion.

Objectives. To evaluate the clinical outcomes and fusion success rates associated with the use of BoneSave in posterolateral spinal fusion.

Summary of Background Data: Achieving spinal fusion is the guiding principle behind surgical treatment for a range of pathologies of the spine. The use of a substantial amount of bonegraft is often required and autograft, commonly harvested from the iliac crest, represents the gold standard. Morbidities associated with graft harvest and a limited supply of graft material have led to the development of alternatives. BoneSave, a porous tricalcium phosphate-hydroxyapatite ceramic, is one such alternative which has been employed in spinal fusion over the past few years. Despite this the outcomes associated with its use lack research.

Methods: Clinical data was collected retrospectively from the case notes of all patients who underwent posterolateral inter-transverse spinal fusion at any level, involving the application of BoneSave, between June 2003 and January 2005 at Frenchay hospital, Bristol, UK. A postal questionnaire was used to collect the latest follow-up information, with an average follow-up of 46 months. Validated outcome instruments employed included the Short Form 36 and Oswestry Low Back Pain Disability Index. In addition visual analogue scales for both back and leg pain, Patient Global Impression of Change data, work status, persisting symptoms, and patient satisfaction data was collected. Radiological evaluation of fusion was carried out from the most recent spinal radiographs available for each patient.

Results: There were 45 patients in the study group. Qualitative post-operative data was available in 96% and response rate to the follow-up questionnaire was 68.4%. Radiographical evaluation was possible in 67%. Significant post-operative improvements were seen across all outcome measures in the large majority of cases. Successful fusion was achieved in 56.7% of cases.

Conclusion: The clinical outcomes associated with the use of BoneSave are comparable to those available in the literature for more conventional techniques of spinal fusion. The fusion rate was not significantly lower than achieved with other techniques.

Stable fixation with macro and micro interlock prevents early migration and therefore early failure of cemented acetabular cups.

The authors describe a cementation technique in an in-vitro model that increases the interossoeous pressure by a factor of 3.5 in the ishium, 4.5 in the ilium and 5.1 in the pubis by the injection of the cement directly into the 10 mm key holes prior to insertion of the cement bolus and cup.

Introduction: Joint replacement has a low mortality rate, few adverse occurrences, excellent survivorship and is considered a cost-effective intervention to reduce disability in the community. However, the assessment of complications and survivorship fail to measure the success of joint replacement in achieving pain relief and restoration of functional ability. The aim of this large cross-sectional postal survey was to provide information on the prevalence of pain, disability, poor quality of life and patient dissatisfaction at 1–3 years after a range of lower limb orthopaedic surgeries in the UK.

Patient and Methods: A questionnaire was posted to all 3,125 consecutive alive patients who underwent a primary THR, hip resurfacing, TKR, UKR or patellar resurfacing at the Avon Orthopaedic Centre between January 2004 – April 2006. The questionnaire included the WOMAC, HOOS/KOOS quality of life scale and a validated satisfaction scale. All questionnaires are scored on a 0–100 scale (worst-best) and a poor outcome was defined as a score of ≤ 50 on the outcome measure.

Results: Completed questionnaires were received from 2,085 patients (response rate of 67%). Patients had a mean age of 67 years and 42% were male. The mean length of follow-up was 28 months (range 14–44 months). 911 patients had a THR, 157 patients had a hip resurfacing, 866 patients had a TKR, 100 patients had a UKR and 51 patients had a patellar resurfacing.

Pain: the prevalence of poor outcomes were 6% of patients with a THR, 4% with a hip resurfacing, 12% with a TKR, 9% with a UKR and 31% with a patellar resurfacing.

Conclusion: This survey has provided descriptive data on the prevalence of patient-reported levels of pain, disability, poor joint-related quality of life and dissatisfaction after lower limb arthroplasty. It is important that patient-reported outcomes after joint replacement are rigorously assessed in order to provide information on which patients do poorly after surgery, with the aim of targeting these patients with an intervention to improve their outcome.

North Bristol Trust Small Grants Scheme provided funding for the consumables for this study.

Background: Because of the changing demographics of the population and improvements in prosthesis design and surgical technique, ever-increasing numbers of younger patients are undergoing joint replacement. Younger patients often receive hip resurfacing rather than conventional THR because of the preservation of bone stock and the lower risk of dislocation. However, pain relief and restoration of function for younger patients is particularly important to continue with a normal, active life. Yet there is little existing research to establish if hip resurfacing results in better patient-reported outcomes than conventional total hip replacement (THR). Therefore, the aim of this study was to compare patient-reported outcomes after hip resurfacing and THR, after controlling for age, gender, general health and length of follow-up.

Methods: A postal survey was sent to all patients who had a hip resurfacing or primary THR between April 2004 - April 2006 at the Avon Orthopaedic Centre. To assess hip pain and function, quality of life, general health and satisfaction with the outcome of surgery, the questionnaire included the WOMAC, HOOS Quality of Life Scale, SF-12 and a validated satisfaction scale. The continuous outcome scores were compared for those who had a THR and those who had hip resurfacing, after adjusting for age, sex, general health and length of follow-up, using Analysis of Variance.

Results: Completed questionnaires were received from 911 THR patients and 157 hip resurfacing patients (response rate of 68% and 71%). Hip resurfacing patients had a mean age of 52 years and 71% were male. THR patients had a mean age of 68 years and 37% were male. After controlling for the effects of age, gender, general health and follow-up length, there was no significant difference in pain (p=0.70), function (0.85), hip-related quality of life (p=0.66) or satisfaction (0.09) between hip resurfacing patients and THR patients at 1–3 years post-operative.

Conclusions: The findings from this study suggest that hip resurfacing has no short-term clinical advantage over conventional THR. A prospective randomised controlled trial is necessary to further compare patient outcomes after hip resurfacing and THR.

Background: The principal cause of late failure of the cemented acetabular component is aseptic loosening. The acetabulum is a horse shoe of cortico-cancellous bone surrounding a cortical fovea. The cancellous bone becomes denser and less porous peripherally, limiting cement penetration. A radiolucent line in the DeLee and Charnley zone 1 of the acetabulum increases the risk of loosening of the acetabular component by 38.8 times. We propose that the use of 0.5cm keyholes in zone 1 decreases the incidence of zone 1 radiolucency.

Materials and Methods: Two contemporous cohorts of 100 patients were analysed for the incidence of zone 1 radiolucency on the first post operative film. In one cohort, zone 1 keyholes were used and in the other they were not. The films were analysed independently by two blinded investigators. The incidence, length and thickness of any radiolucency were recorded.

Results: The cohort of patients in which zone 1 keyholes were used demonstrated a 9% incidence of any zone 1 radiolucency, 8% were of 1mm width or greater and 2% involved 50% or more of the zone. In the cohort of patients in which zone 1 keyholes were not used the incidence of zone 1 radiolucency was 40% with 29% demonstrating a width of 1mm or greater and 12% affecting 50% or more of the zone.

Conclusions: The use of peripheral keyholes aids penetration of cement into the denser peripheral acetabular bone as demonstrated by decreased rates of post operative zone 1 radiolucency. This decrease in the incidence of early radiolucency should result in lower rates of subsequent loosening of the acetabular component.

Introduction: Total hip replacement (THR) and total knee replacement (TKR) are widely accepted as effective surgical procedures to alleviate chronic joint pain and improve functional ability. Clinical evidence suggests that joint replacement results in excellent outcomes. Traditionally, reporting of outcomes has been focused on implant survivorship and surgeon based assessment of objective outcomes, such as range of motion, knee stability and radiographic results. However, because there is a discrepancy between patient and clinician ratings of health, patient-reported outcome measures have been validated to allow patients to rate their own health, thereby placing them at the centre of outcome assessment. The aim of this study was to compare the mid-term functional outcomes of TKR and THR using validated patient-reported outcome measures.

Methods: A cross-sectional postal audit survey of all consecutive patients who had a primary, unilateral THR or TKR at the Avon Orthopaedic Centre 5–8 years previously was conducted. Participants completed an Oxford hip score (OHS) or Oxford knee score (OKS). The Oxford questionnaires are self-report joint-specific measures that assess functional ability and pain from the patient’s perspective. They consist of 12 questions about pain and physical limitations experienced over the past four weeks because of the hip or knee.

Results: 1112 THR patients and 613 TKR patients returned a completed questionnaire, giving a response rate of 72%. The median OKS of 26 was significantly worse than the median OHS of 19 (p< 0.001). TKR patients experienced a poorer functional outcome than THR patients on all domains assessed by the Oxford questionnaire, independent of age. The percentage of patients reporting moderate-severe pain was two-fold greater for TKR than THR patients (26% vs 13%, respectively).

Conclusion: This survey found that TKR patients report more pain and functional limitations than THR patients at 5–8 years post-operatively, independent of age. The finding that over a quarter of TKR patients reported moderate-severe pain at 5–8 years post-operative indicates that a large proportion of people are undergoing major knee surgery that is failing to achieve its primary aim of pain relief. This raises questions about whether patient selection for TKR is appropriate. To improve patient selection, it may be necessary to have a preoperative screening protocol to identify patient factors predictive of a poor outcome after TKR. Currently, no such protocol exists and this is an area of orthopaedics requiring further research.

Introduction: Although THR can provide excellent pain relief and restore functional ability for most patients, there is a proportion of patients who experience a poor functional outcome after THR. One factor that could contribute to a poor outcome after THR is leg length discrepancy (LLD). Restoration of leg length is important in optimising hip biomechanics and LLD has several consequences for the patient, including back pain and a limp. Assessment of LLD using radiographs is time consuming and labour intensive, and therefore limits large scale studies of LLD. However, patients self-report of perceived LLD may be a useful tool to study LLD on a large scale. Therefore, the aim of this postal audit survey was to determine the prevalence of patient-perceived LLD after primary THR and its impact on mid-term functional outcomes.

Methods: A cross-sectional postal audit survey of all consecutive patients who had a primary, unilateral THR at the Avon Orthopaedic Centre 5–8 years previously was conducted. Several questions about LLD were included on the questionnaire. Firstly, patients were asked if they thought that their legs were the same length. For those who thought their legs were different lengths, they were asked if the difference bothered them, whether the difference in length leg was enough to comment upon, and whether they used a shoe raise. Participants also completed an Oxford hip score (OHS), which is a self-report measure that assesses functional ability and pain after THR, including limping

Results: 1,114 THR patients returned a completed questionnaire, giving a response rate of 73%. 329 patients (30%) reported that they thought their legs were different lengths. The median OHS for patients with a perceived LLD was 22, which was significantly worse than the OHS of 18 for patients who thought their legs were the same length (p< 0.001). Of the 329 patients with a perceived LLD, 161 patients (51%) were bothered by the difference, 65 patients (20%) thought the discrepancy was sufficient to comment upon and 101 patients (31%) used a shoe raise. 31% of patients with LLD limped most or all of the time compared to only 9% of patients without LLD.

Conclusion: In conclusion, this study found that the prevalence of perceived LLD at 5–8 years after THR was 30%. Of the patients with LLD, over 50% were bothered by the LLD and over a third used a shoe raise to equalise leg lengths. Patients with perceived LLD have a significantly poorer self-report functional outcome than those patients without LLD. It is therefore important that patients are informed pre-operatively of the high risk of LLD after THR and the associated negative impact this may have on their outcome.

Introduction: Venous thromboembolism is a major cause of morbidity and mortality in hospitalised patients and patients undergoing major orthopaedic surgery are at high risk from venous thromboembolism. Thromboprophylaxis, both mechanical and chemical, is commonly administrated to reduce fatality from thromboembolism after surgery. However, there is no convincing evidence in the literature demonstrating that routine chemothromboprophylaxis reduces death rates from pulmonary embolus. Furthermore, it is unclear from the literature which thromboprophylactic agent, if any, should be used.

Recent NICE guidelines have recommended that heparin should be routinely administered to patients under-going THR to prevent thromboembolism, although it is unclear from the existing evidence if heparin is the most effective. However, research has suggested that aspirin, which is a low cost prophylactic agent, is effective in preventing DVT and PE after orthopaedic surgery. The aim of this study was to determine the 90-day mortality rate after THR using aspirin as a prophylactic agent.

Patients and Methods: Between 2003–2006, 2,286 patients underwent primary THR and 372 patients underwent revision hip replacement (RHR). Routine chemothromboprophylaxis consisting of aspirin 75mg daily for 6 weeks. In addition all patients were treated with anti-thromboembolic stockings. 40mg of subcutaneous clexane, in lieu of aspirin, was given daily to all patients who had previously suffered from a pulmonary embolus or deep venous thrombosis. Patients who died within 90 days of surgery had their death certificates examined. Retrieval at 90 days with regard to death was 100%.

Results:

Primary THR

One patient (0.04%) died within 30 days of surgery and a further 3 (0.13%) died between day 30 and day 90, giving a total mortality at 90 days of 0.17% (4/2,286). One patient (0.04%) died from PE and the other 3 patients (0.13%) died from non-vascular causes.

Discussion: This study found that the 30-day mortality rate for primary THR and RHR was 0.08% and the 90-day mortality rate was 0.23%. In this study, there was only one death from PE and no deaths from arterial complications. Therefore, although NICE guidelines suggest the use of heparin, this study found that routine aspirin administration is beneficial in protecting against early death after THR because of both thromboembolism and adverse arterial events.

Introduction: The long-term results of 70 Harris-Galante I uncemented acetabular components implanted in 53 patients who were under 50 years of age at the time of their hip arthroplasty are presented.

Methods: Follow up was both clinical, using Oxford and Harris Hip scores, and radiological. Kaplan-Meier survivorship analysis was performed to calculate the survivorship of the acetabular components. Failure was defined as either liner exchange or acetabular component revision due to aseptic loosening, osteolysis, infection or dislocation.

Results: The mean age of the patients at the time of surgery was 40 years (range 19–49 years), with follow up of between 12 and 16 (mean 13.6) years. All patients’ acetabular components were implanted primarily with cemented femoral components. The mean Oxford Hip Score at the end of the follow-up period was 20 out of 60 (range 12–46) and Harris Hip Score 81 (range 37–100).

At the end of the follow up period, 11 of the 70 acetabular components (polyethylene liner or the acetabular shell) had been revised. The cumulative survival was 94.0% (95% confidence interval 88.4–99.7) with revision of the metal shell as the end point, and 84.0% (95% confidence interval 74.5–93.5) with revision surgery of the acetabular shell or liner due to any reason as an end point. Radiologically, 4 patients require acetabular revision and 22 patients had femoral osteolysis in gruen zone 7, indicative of polyethylene failure. This gave a combined revision, impending revision and zone 7 osteolysis cumulative survival of 55.3% (95% confidence interval 40.6–70.0).

Discussion: In contrast to cemented acetabular components which undergo aseptic loosening and give groin pain, high density polyethylene lined metal shells do not give groin pain but cause silent acetabular and femoral osteolysis. The danger time for osteolysis is between 10–20 years, therefore follow up at that time is essential.

Introduction: Resurfacing hip arthroplasty is a successful option for the treatment of the young and active patient with hip arthritis. However, it is complicated by femoral neck fracture and avascular necrosis, which may result from devascularisation during surgery. Devascularisation maybe caused by thermal necrosis. Thermal necrosis of bone has been shown to occur in temperatures of 47°C and above. We investigated the temperatures generated during femoral head preparation to see if the temperatures reached were great enough to induce osteonecrosis.

Method: Eight patients with osteoarthritis underwent standard resurfacing hip arthroplasty through the posterior approach. From the first over-drilling of the femoral heads until the prosthesis was cemented in place the temperatures generated at the bone surface were recorded using an infra-red thermal imaging camera. Images were captured every 4 seconds as the operation was performed with no interference to the surgeon

Results: The maximum temperatures generated occurred during sleeve reaming at 88.4°C. Seven patients had a temperature recorded greater than 47°C. Removing the femoral caput with an oscillating saw had the highest mean temperature 62.2°C, followed by sleeve reaming (mean 48.7°C). Female patients had the lowest temperature rises and patients receiving the larger femoral prosthesis the greatest temperatures at the bone surface.

Conclusions: Heat generated during femoral head preparation exceeded 47°C in all but one case. Osteonecrosis secondary to thermal insult is likely to occur during femoral head preparation. Strategies need to be devised to decrease the temperatures generated during femoral head preparation.

Our aim was to determine the pre-operative sporting profiles of patients undergoing primary joint replacement and to establish if they were able to return to sport after surgery. A postal survey was completed by 2085 patients between one and three years after operation. They had undergone one of five operations, namely total hip replacement, hip resurfacing, total knee replacement, unicompartmental knee replacement or patellar resurfacing. In the three years before operation 726 (34.8%) patients were participating in sport, the most common being swimming, walking and golf. A total of 446 (61.4%) had returned to their sporting activities by one to three years after operation and 192 (26.4%) were unable to do so because of their joint replacement, with the most common reason being pain. The largest decline was in high-impact sports including badminton, tennis and dancing. After controlling for the influence of age and gender, there was no significant difference in the rate of return to sport according to the type of operation.

Restoration of bone stock is the single greatest challenge facing the revision hip surgeon today. This has been dealt with by means of impaction grafting with morsellised allograft from donor femoral heads.

Alternatives to allograft have been sought. This study investigates the use of a porous biphasic ceramic in impaction grafting of the femur.

Impaction grafting of the femur was performed in four groups of sheep. Group one received pure allograft, group two 50% allograft and 50% BoneSave, group three 50% allograft and 50% BoneSave 2 and group four 10% allograft and 90% BoneSave as the graft material.

Function was assessed by measuring peak vertical reaction forces. Changes in bone mineral density were measured by DEXA scanning. Loosening and subsidence were assessed radiographically and by examination of explanted specimens.

All outcome measures showed no statistically significant difference between the four groups after eighteen months of full function.

Conclusion: When used as allograft expanders, Bone-Save and similar porous biphasic ceramics perform as well as pure allograft in impaction grafting of the femur.

Objective: To critically appraise the use of hindfoot nailing as an alternative treatment for fragility fractures of the ankle.

Summary of background data: Ankle fractures are common. The peak incidence now lies in women between the ages of 75 and 84. These fractures are inherently unstable and it is known that anatomical reduction and stable fixation leads to a rapid return of function. Although this is usually achieved by open reduction and plate and screw fixation, in older patients poor bone quality and compromised wound healing can lead to unacceptably high complication rates. Conservative management of these patients also has its problems with anatomical congruity being difficult to achieve and maintain.

Method: We reviewed 13 patients who underwent minimally invasive intramedullary nailing to fuse the tibiotalocalcaneal joint as primary or revision treatment for an ankle fracture. Olerud and Molander Scale, and SF36 were used as outcome measures.

Results: There were 12 females and 1 male with a mean age of 81.5 (range 64 to 93). One nail was revised after 22 days due to valgus deformity and one patient suffered a minor wound (breakdown / infection). Half of the patients were discharged in the first two weeks after the operation. They all achieved pain free full weight bearing on the fractured ankle and gained a comparable function to their pre-operative state. The mean follow up period was 9 months (range of 2 – 62 months).

Conclusion: Minimally invasive tibiotalocalcaneal fusion is a very useful and successful way of restoring function following a fragility fracture of the ankle. We recommend its use in the cases of fragility fracture of the ankle with poor soft tissue.

Polyethylene liners of modular acetabular components wear and sometimes need to be replaced, despite the metal shell being well fixed. Replacing the liner is a relatively simple procedure, but very little is known of the outcome of liner revision. We prospectively followed up 1126 Harris-Gallante 1 metal backed, uncemented cups for between 9 and 19 years. 38 (3.4%) liners out of 1126 acetabular components wore and required revision. These revisions were then followed up for a mean of 4.8 years. The rate of dislocation was 28.9%. Nine of the dislocations were single dislocations and 2 were recurrent.

The overall re-revision rate was 3 out of 38 total hip replacements (7.9%) at a mean follow up of 4.8 years. This gives a 92.1% survivorship at just under 5 years. In isolated liner revision we had a complication rate of 23%. In liner revision combined with stem revision we had a complication rate of 48%. Possible reasons for high dislocation rates are discussed.

Leaving the well fixed acetabular shell in-situ leads to an increased risk of instability. However, this needs to be balanced against the otherwise low complication rate for liner revision. Patients should be consented accordingly

Dissociation of the polyethylene liner of modular acetabular components is a rare occurrence, and previous reports have commented on the difficulty in diagnosis from plain radiographs. The radiograph is often incorrectly reported by radiologists as showing advanced polyethylene wear, causing delay in referral and increasing the complexity of treatment required.

We report 9 cases of late polyethylene liner dissociation of the cementless Harris-Galante II porous-coated acetabular component (Zimmer Inc, Warsaw, IN) which occurred without trauma or injury. This is the largest reported series to date.

In all cases, there was a common pattern of clinical symptoms and signs which is described.

Radiographs showed a distinct appearance with a radiolucency medial to the femoral neck in association with an eccentrically placed femoral head lying in contact with the acetabular metal shell. We have termed this the ‘crescent sign’.

We believe that the diagnosis can be made from a single antero-posterior pelvic radiograph without the need for previous films for comparison, or the need for arthrography. Clinicians should look specifically for the crescent sign when an eccentrically placed femoral head has been noted, in order to differentiate the more unusual diagnosis of dissociation from that of polyethylene wear. Early diagnosis and prompt referral prevents further damage to the femoral head and metal acetabular shell, thus reducing the complexity of revision surgery.