Aim

Our aim was to evaluate cementless one-stage revision in chronic periprosthetic hip joint infection.

We present detailed information about early morbidity after aseptic revision knee replacement from a nationwide study. All aseptic revision knee replacements undertaken between 1st October 2009 and 30th September 2011 were analysed using the Danish National Patient Registry with additional information from the Danish Knee Arthroplasty Registry. The 1218 revisions involving 1165 patients were subdivided into total revisions, large partial revisions, partial revisions and revisions of unicondylar replacements (UKR revisions). The mean age was 65.0 years (27 to 94) and the median length of hospital stay was four days (interquartile range: 3 to 5), with a 90 days re-admission rate of 9.9%, re-operation rate of 3.5% and mortality rate of 0.2%. The age ranges of 51 to 55 years (p = 0.018), 76 to 80 years (p < 0.001) and ≥ 81 years (p < 0.001) were related to an increased risk of re-admission. The age ranges of 76 to 80 years (p = 0.018) and the large partial revision subgroup (p = 0.073) were related to an increased risk of re-operation. The ages from 76 to 80 years (p < 0.001), age ≥ 81 years (p < 0.001) and surgical time > 120 min (p <  0.001) were related to increased length of hospital stay, whereas the use of a tourniquet (p = 0.008) and surgery in a low volume centre (p = 0.013) were related to shorter length of stay.

In conclusion, we found a similar incidence of early post-operative morbidity after aseptic knee revisions as has been reported after primary procedures. This suggests that a length of hospital stay ≤ four days and discharge home at that time is safe following aseptic knee revision surgery in Denmark.

Cite this article: Bone Joint J 2014;96-B:1649–56.

Data on early morbidity and complications after revision total hip replacement (THR) are limited. The aim of this nationwide study was to describe and quantify early morbidity after aseptic revision THR and relate the morbidity to the extent of the revision surgical procedure. We analysed all aseptic revision THRs from 1st October 2009 to 30th September 2011 using the Danish National Patient Registry, with additional information from the Danish Hip Arthroplasty Registry. There were 1553 procedures (1490 patients) performed in 40 centres and we divided them into total revisions, acetabular component revisions, femoral stem revisions and partial revisions. The mean age of the patients was 70.4 years (25 to 98) and the median hospital stay was five days (interquartile range 3 to 7). Within 90 days of surgery, the readmission rate was 18.3%, mortality rate 1.4%, re-operation rate 6.1%, dislocation rate 7.0% and infection rate 3.0%. There were no differences in these outcomes between high- and low-volume centres. Of all readmissions, 255 (63.9%) were due to ‘surgical’ complications versus 144 (36.1%) ‘medical’ complications. Importantly, we found no differences in early morbidity across the surgical subgroups, despite major differences in the extent and complexity of operations. However, dislocations and the resulting morbidity represent the major challenge for improvement in aseptic revision THR.

Cite this article: Bone Joint J 2014; 96-B:1464–71.

Introduction

The postoperative management of patients after total hip replacement traditionally includes restrictions of movements and the use of aids (toiletelevation, sleeping pillow, a.o.) in the first 3 months after operation. Few studies have investigated the benefit of such restrictions. The aim of the present study was to evaluate how patients with total hip replacements (THR) are doing with and without restrictions in the first 3 months after surgery, and if walking ability and patients satisfaction was influenced by the postoperative regime.

Introduction: Since 2000 all total hip replacements have been subjected to a continuous quality control. We report an increasing rate of postoperative fractures around uncemented femoral components after minimal or no trauma.

Methods: Four to 6 weeks after the THR all patient files and radiographs are evaluated and demographic data, complications and radiographic position of the implant registered. Surgery was performed according to the manufacturer’s instructions, and full weight bearing was allowed. If a fracture occurred during the first postoperative weeks a further analysis of the case was performed.

Results: During the 9 years 3.295 primary total hip replacements were performed. In the period the use of uncemented THR increased from 41% to 99%. Totally 69 fractures in 2.408 uncemented THR’s (2.9%) were registered, and 28 of these were of the proksimal split fracture type occurring without any previous trauma. The fractures occurred after a few days up to 4 weeks after surgery and were characterised by a vertical femoral fracture from the calcar to the medial femoral region 5 to 7 cm below the lesser trochanter. All cases were seen in women, but were not correlated to age, BMI or previous femoral neck fracture. In most cases treatment was internal fixation with a trochanteric grip and cables and insertion of a new uncemented femoral component.

Conclusion: The increased use of uncemented femoral components implies a substantial risk of subtrochanteric femoral fracture. The cause of these fractures is unknown, but probably multifactorial. It could be due to a mismatch between the instruments and the prosthesis, to undiagnosed weakness of the bone, or to the vigorous mobilisation made possible by the effective modern treatment of postoperative pain.

Background and Aim: SF-36 has been used frequently as a measurement tool to evaluate the effect of total hip arthroplasty (THA) operation on the patient’s quality of life (QoL). There is though a lack of data describing how QoL is affected if the patients have medical co-morbidities before the operation or if they suffer postoperative complications after THA. With this study we wanted to describe the effect on QoL of pre-operative co-morbidity and post-operative surgical and thromboembolic complications after THA.

Material and methods: This study was part of the ESMOS study where 500 consecutive THA patients (both primary and revision THA) were followed prospectively for one year, with the purpose to collect all surgical and thromboembolic events that these patients experienced. The patients were asked to fill in a SF-36 form the day before the operation and one year after the operation. 397 (79.4%) of the patients had two forms sufficient for further data analysis in this study. Co-morbidity data was measured before the operation. Complications were measured with structured interviews by two study persons the fifth postoperative day and at telephone interviews after 3 and 12 month. All reported events were verified according to predefined criteria in the patient’s medical journal.

Results: The majority of the THA patients experienced a gain in their quality of life one year after THA. One year after THA the co-morbid patients had a significantly lower QoL score in all scales, but they still gained from the operation. Patients that experienced either a surgical or a thromboembolic complication had lower SF-36 score one year post-operatively compared to patients without complications. Subgroup analysis revealed that the small group of patients with deep infection, aseptic loosening or re-operation because of malfunction of the prosthesis had a fall in QoL compared to the pre-operative value and scored significantly worse than all other patient groups.

Conclusion: THA is a successful operation when QoL is measured one year postoperatively. Pre-operative co-morbidity and postoperative surgical or thrombo-embolic complications does give a smaller gain in QoL compared to patients without co-morbidity and patients without complications. The small but important group of patients with deep infection, aseptic loosening and malfunction re-operation, were the only to loose QoL one year after THA in this study.

Background: Results after Total Hip Replacement (THR) including prosthetic design, surgical complications and prosthetic survival are frequently reported – however, information on the rate of complications in general is sparse.

Aim and Methods: The aim was to collect information on all complications after THR within the first year after surgery. This study consisted of 500 consecutive patients (386 with primary THR operated due to degenerative osteoarthritis (OA) and 112 with primary THR due to secondary OA or revision THR). These patients were followed by structured interviews at surgery and 3 and 12 months after discharge. Surgical and cardiovascular complications were registered. No interventions related to this study were done. The patients followed the standard care of departments.

Results: 500 patients were included; two withdrew their consent, leaving 498 for the follow up one year after surgery or until death. Of the 498 patients 103 (20.6%) experienced at least one complication related to the operation within the one year observation period. Among the 386 primary THR with degenerative OA the complicationrate was 17.9%.

Of the 498 patients 6.6% experienced one or more symptomatic cardiovascular complications (deep vein thrombosis, pulmonary embolism (PE), myocardial infarction, and stroke, transient ischemic attack or retinal vein thrombosis). In the degenerative OA group 4.7% (95% Cl: 2.6–6.8%) had a cardiovascular event and in the secondary OA + revision group the rate was 13.4% (95% Cl: 10.2–16.6). The rate of complications directly related to the surgery (dislocation, perioperative fracture, bleeding, aseptic loosening, deep infection, peroneal palsy or superficial wound infection) was 15.4% (95% Cl: 12.3–18.6). In the degenerative OA and secondary OA/revision group the rates were: 14.2% and 19.6% respectively. Nine (1.8%) patients died, five of cardiovascular reasons (disseminated intravascular coagulation, PE followed by renal failure, PE followed by cerebral ischemia and stroke), the first three in close relation to the operation.

Discussion: A complication-rate of 20.6% as found in the present study seems to be very high. There is no reason to think that these numbers are not correct. To our knowledge, only one other study has been published with data about complications in general (Williams O., J Arthroplasty17:165–171, 2002). Their results are based on a mix of hospital file data, patient and general practitioner questionnaires with varying response rates – and their findings, although a bit lower in number, support the data from this study. The present study indicates, that there is a need for continuous registration of these common complications– even in the group of primary THR due to degenerative osteoarthritis, usually thought of as being the least complicated. The complication rate must be included in the information given to patients offered THR.

Background: Data on thromboembolic complications (TEC) following major orthopaedic surgery are generally obtained retrospectively from registries or prospectively from large industry-sponsored international multicentre trials. However, the results may differ from those observed in unselected patients in routine operations performed by orthopaedic surgeons. The purpose of the ESMOS study was to describe the number and time of onset of serious symptomatic arterial and venous TEC within 90 days after surgery in an unselected population of patients undergoing total hip replacement (THR).

Patients and methods: A total of 500 (430 primary THR and 70 revision THR) consecutive patients were included in the study performed between January 2004 and May 2005 in Frederiksborg County (Denmark). They were to be followed for 90 days after surgery. Patients were interviewed before surgery for medical history and on days 5 (while in hospital) and 90 (by telephone call) for signs and symptoms of acute myocardial infarction (AMI), pulmonary embolism (PE), deep-vein thrombosis (DVT), transitory cerebral ischemia (TCI)/stroke and retinal vein thrombosis (RVT). The validity of the events was confirmed using files from hospital, general practitioner and international criteria.

Results: Overall, 498 patients were followed-up for 90 days, 2 patients having withdrawn consent. In-hospital pharmacological thromboprophylaxis was performed in 499 patients. Twenty-four patients (4.8%) experienced at least one serious TEC up to day 90: 2 (0.4%) patients died from surgical-related complications (no autopsy was performed); 1 (0.2%) patient experienced AMI, 5 (1.0%) had PE, 10 (2.0%) DVT, 4 (0.8%) TCI, and 2 (0.4%) RVT. Moreover, 2 patients experienced two TEC: AMI followed by TCI in a first patient, PE and TCI in a second patient. The first event occurred up to day 5 in 9 patients (38%) and after day 5 in 15 patients (62%). Five patients (1%) had clinically relevant bleeding complications: 3 patients had a single, minor, upper gastrointestinal bleeding episode while in hospital, one patient developed a huge expanding haematoma at the operation site treated with hip spica and another patient a peritoneal haematoma leading to re-operation.

Conclusion: This study performed in an unselected population clearly shows that THR still results in serious TEC in spite of a wide use of modern anaesthesia techniques, thrombosis prophylaxis and early mobilisation. In the future, we need to better identify at-risk patients in order to optimise their management, in particular post-discharge care, and reduce the risk of serious TEC.