Background

An increased incidence of periprosthetic osteolysis, resulting in loss of biologic fixation, has been recently reported in contemporary THAs with low-carbide metal-on-metal compared to metal-on-polyethylene couple bearings. A hypersensitivity reaction due to Co and Cr debris is reported as a potential cause for failure of THAs with high-carbide bearings, but there are no evidence-based data for this reaction in low-carbide metal-on-metal bearings.

Aim. The present study was designed to evaluate the implantation of alginate beads containing human mature allogenic chondrocytes for the treatment of symptomatic cartilage defects in the knee. Methods. A biodegradable, alginate-based biocompatible scaffold containing human mature allogenic chondrocytes was used for the treatment of chondral and osteochondral lesions in the knee. Twenty-one patients were clinically prospectively evaluated with use of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and a Visual Analogue Scale (VAS) for pain preoperatively and at 3, 6, 9, 12, 24 and 36 months of follow-up. Results. A statistically significant clinical improvement became apparent after 6 months and patients continued to improve during the 36 months of follow-up. Adverse reactions to the alginate/fibrin matrix seeded with the allogenic cartilage cells were not observed. Two of the procedures failed. One of the patients had loosening of the periosteal flap, which was attributed to a failure of the surgical procedure. The other failure case was the result of the poor quality and quantity of the repair tissue itself. Discussion. The results of this pilot study show that the alginate-based scaffold containing human mature allogenic chondrocytes is feasible for the treatment of symptomatic cartilage defects in the knee. The described technique provides clinical outcomes equal to those of other cartilage repair techniques

Aims

Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections.

Purpose. To evaluate the long term results of the use of a postoperative autologous blood reinfusion system in total knee arthroplasty. Material and method. In a prospective study, 176 patients who underwent unilateral total knee replacement, during the period 2004–2008, were evaluated (study group or group A). In all these patients a reinfusion system of unwashed blood salvaged was applied, while supplementary homologous blood transfusion was performed when required. The admission of banked blood transfusion determined by haemoglobin value (<9mg/dL) and/or clinical signs (blood pressure, pulses, etc). The value of haemoglobin, haematocrite and platelets recorded preoperatively and the 1st, 5th and 15th day after operation. Results were compared with the material of our previous prospective randomized controlled study (control groups B and C), where in 60 patients, between the years 2002–2004, the effectiveness of postoperative autologous blood reinfusion had been proved. Results. 19 patients of group A required postoperatively 23 units of homologous blood (total study group requirements23 blood units or 0.13 units per patient) while in group B required 1.5 units/patient and in group C 0.3 units/patient. In the study group the total homologous blood requirements reduced by 91% compared with group B (patients without autotransfusion system applied) and by 47% compared with group C (patients with autotransfusion system applied). There was no statistically significant difference in the postoperative values of Hb and Ht between the groups. None of the patients developed any adverse reactions after reinfusion. The cost of blood management was reduced in study group by 76%. Conclusions. The use of an autotransfusion system postoperatively minimizes practically the demands for homologous banked blood transfusion in total knee arthroplasty

INTRODUCTION. A detailed clinical examination and investigations are required to evaluate the cause of persisting groin pain following a metal on metal (MoM) hip replacement. Adverse reaction to metallic debris (ARMD) is an emerging problem with MoM hip replacements. It is an umbrella term encompassing metallosis, pseudo-tumors and aseptic lymphocytic vasculitis associated lesions (ALVAL). The role of imaging in the diagnosis of this complex problem is still unclear. A study was undertaken to evaluate the efficacy of ultrasound in diagnosis of ARMD following a MoM hip replacement. METHODS. The study group included 35 patients with a clinical and histological diagnosis of ARMD, who had a preoperative ultrasound. All ultrasound procedures were performed on the anterior and lateral aspects of the painful hip with a high frequency probe of 9–13 MHz (Sonoline Antares – Siemens). RESULTS. All patients diagnosed with ARMD had abnormalities identified on ultrasound. Fluid inside the joint was noted in 30 out of 35 procedures (85.7 %). Fluid outside the joint was noted in 33 procedures (94.3 %). Amongst the patients with fluid outside the joint, 32 had iliopsoas and 30 had trochanteric bursitis. Echogenic reflections were noted in 31 out of 35 procedures (88.6 %). Considerable attenuation or absence of iliopsoas and gluteus tendon reflection was seen in many patients with echogenic fluid collections on the anterior and trochanteric aspects of hip. Progression of such changes was noted on further 5 patients, who had a repeat ultrasound within an interval of 3–6 months. 1 patient had a progression from anechogenic to echogenic joint effusion. DISCUSSION. Different radiological investigations including MRI scan have been used for evaluation of painful MoM hip arthroplasty. To our knowledge, this is the first study to demonstrate the efficacy of ultrasound in diagnosis of ARMD. Floating echogenic reflections and fluid collections around iliopsoas and gluteus medius/minimus tendons is highly suggestive of ARMD. Ultrasound is a cheap, non-invasive and dynamic investigation and has been shown to be reliable in diagnosis of ARMD

Introduction. The advantages of metal on metal (MOM) hip replacement are decreased wear rate, preservation of bone stock, anatomical restoration and enhanced stability. Large amounts of metal wear particles and metal ions are released which may induce adverse reactions including local soft tissue toxicity, hypersensitivity reactions, bone loss and risk of carcinogenesis. Aseptic loosening can be the result of a peri prosthetic osteolysis generated as a result of a biological response to particulate wear debris. Our aim in this study was to determine whether a steeply inclined acetabular component would give rise to a higher concentration of metal ions. Patients and methods. Between April 2003 and June 2006, 22 patients had MOM hip replacement for osteoarthritis by a single Surgeon. There were 12 male and 10 female patients. The average age at the time of surgery was 56 years (Range: 44–69 years). We divided the 22 patients into 2 groups, one group (A) of 11 patients with the acetabular inclination angle more than 50 degrees and the other group (B) of 11 patients with the angle less than 50 degrees. The inclination of the acetabular cup was measured using a standard AP radiograph of the pelvis. The patients had metal ion levels (blood chromium and serum cobalt) measured at an average follow up of 3.2 years (Range 2.4 to 5 years). Results. Mean blood chromium level in the group A (146 nM/L) was significantly higher (p=0.005) than in Group B (92 nM/L). Mean serum cobalt level in the group A (245 nM/L) was significantly higher (p=0.002) than in Group B (110 nM/L). Discussion. The early to mid term published results of MOM hip replacements have been encouraging. There are, however, a number of concerns about the MOM bearing. Although its wear rate is low, it still releases metal ions into the body particularly cobalt and chromium since most metal on metal bearings are made of a cobalt chromium alloy. The long-term consequences of increased levels of these ions in the body are not known. High concentrations of Co and Cr are toxic and are known to interfere with a number of biological functions. There also have been recent reports of soft tissue reactions with MOM hip replacement. In the light of these concerns, it is important to examine factors which may influence the release of metal ions after MOM hip replacement. It has been reported in the recent literature that the position of the acetabular component will influence the bearing wear inturn leading to the release of metal ions after MOM hip replacement. Our findings indicate that steeply inclined acetabular components with an inclination angle greater than 50 degrees gives rise to higher concentration of metal ions

INTRODUCTION. The advantages of large diameter metal on metal total hip arthroplasty (MoM THA) and hip resurfacing arthroplasty are decreased wear rate, preservation of bone stock, anatomical restoration and enhanced stability. Large amounts of metal wear particles and metal ions are released which may induce adverse reactions including local soft tissue toxicity, hypersensitivity reactions, bone loss and risk of carcinogenesis. Aseptic loosening can be the result of a peri-prosthetic osteolysis generated as a result of a biological response to particulate wear debris. No reports in the literature exist as to whether circulating levels of Chromium (Cr) and Cobalt (Co) decrease upon removal of a symptomatic large diameter MoM implant or whether levels remain high due to the effect of metal ions debris left behind in the soft tissues after revision surgery. PATIENTS AND METHODS. Between June 2006 and June 2009 we undertook 44 revision surgeries of both large head MoM THAs (femoral head diameter 38mm) and metal-on-metal hip resurfacings for suspected metallosis. Mean time from original implant to revision was 4 years, 8 months (1yr 4mo–7yr 9mo). The mean follow up evaluation was 2 years and 2 months (1yr 2mo–4 years). Blood samples were taken for whole blood Cr and serum Co according to a recognised protocol and compared with reference levels indicated by the Medicines and Healthcare Regulatory Agency recommendation of less than 7ppb for Cr (130nM/L) and Co (119nM/L). RESULTS. 42 patients were found to have histological evidence of either metal allergy, metal toxicity or foreign body reaction. 2 patients had evidence of infection with no features of metal reaction. 3 patients suffered early dislocation requiring closed reduction. 1 patient had infective complications necessitating Girdlestones. 11 patients were lost to follow up, 8 patients were diagnosed pre operatively on Co and Cr levels in urine or synovial fluid aspirate alone. 23 patients had pre revision blood or serum metal ion level results available for direct comparison. Median serum Co level pre revision was 176.6nM/L, falling post revision to 5.1nM/L (p=<0.001∗). The median whole blood Cr level pre revision was 117nM/L and 19nm/L post revision (p=<0.001∗). Mean Oxford Hip Score was 23.7. DISCUSSION. This study demonstrates that at greater than one year post removal of a large diameter MoM hip implant for the indication of symptomatic metallosis or metal hypersensitivity, metal ion levels fall to almost normal levels and that outcome of revision surgery in terms of patient satisfaction is not adversely affected

Background. It is an accepted fact that Ilizarov frames are difficult to live with. Professionals advise patients that things get easier over time, but, there is little evidence to support this. This study examined the course of patient's self-reported anxiety and depression during treatment with an Ilizarov frame. Method. Over 12 months, 66 trauma and elective patients were prospectively recruited to the study. Patients completed validated questionnaires measuring anxiety and depression (GAD-7 and PHQ-9) at set time points through their treatment ranging from before the frame was fitted through to after it was removed. Results. Complete data sets were collected for sixty patients. Two patients were unable to be included and four have yet to complete treatment. There is a trend towards decreasing anxiety and depression throughout the period evaluated. However, of seven patients who scored within the ‘severe’ range (PHQ/GAD = 15+) before the Ilizarov frame was applied, four remained in the ‘severe’ range at the treatment end. Conclusion. We have shown that psychological screening can be easily incorporated into standard practise, and found that early screening of psychological distress can identify the small but significant group of patients who go on to have prolonged adverse psychological reactions

Aims

To assess the safety of tranexamic acid (TXA) in a large cohort of patients aged over 65 years who have sustained a hip fracture, with a focus on transfusion rates, mortality, and thromboembolic events.

Aims

The Intraosseous Transcutaneous Amputation Prosthesis (ITAP) may improve quality of life for amputees by avoiding soft-tissue complications associated with socket prostheses and by improving sensory feedback and function. It relies on the formation of a seal between the soft tissues and the implant and currently has a flange with drilled holes to promote dermal attachment. Despite this, infection remains a significant risk. This study explored alternative strategies to enhance soft-tissue integration.

This multicentre prospective clinical trial aimed to determine whether early administration of alendronate (ALN) delays fracture healing after surgical treatment of fractures of the distal radius. The study population comprised 80 patients (four men and 76 women) with a mean age of 70 years (52 to 86) with acute fragility fractures of the distal radius requiring open reduction and internal fixation with a volar locking plate and screws. Two groups of 40 patients each were randomly allocated either to receive once weekly oral ALN administration (35 mg) within a few days after surgery and continued for six months, or oral ALN administration delayed until four months after surgery. Postero-anterior and lateral radiographs of the affected wrist were taken monthly for six months after surgery. No differences between groups was observed with regard to gender (p = 1.0), age (p = 0.916), fracture classification (p = 0.274) or bone mineral density measured at the spine (p = 0.714). The radiographs were assessed by three independent assessors. There were no significant differences in the mean time to complete cortical bridging observed between the ALN group (3.5 months (se 0.16)) and the no-ALN group (3.1 months (se 0.15)) (p = 0.068). All the fractures healed in the both groups by the last follow-up. Improvement of the Quick-Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, grip strength, wrist range of movement, and tenderness over the fracture site did not differ between the groups over the six-month period. Based on our results, early administration of ALN after surgery for distal radius fracture did not appear to delay fracture healing times either radiologically or clinically.

Cite this article: Bone Joint J 2013;95-B:1544–50.

Using data from the Norwegian Hip Fracture Register, 8639 cemented and 2477 uncemented primary hemiarthroplasties for displaced fractures of the femoral neck in patients aged > 70 years were included in a prospective observational study. A total of 218 re-operations were performed after cemented and 128 after uncemented procedures. Survival of the hemiarthroplasties was calculated using the Kaplan-Meier method and hazard rate ratios (HRR) for revision were calculated using Cox regression analyses. At five years the implant survival was 97% (95% confidence interval (CI) 97 to 97) for cemented and 91% (95% CI 87 to 94) for uncemented hemiarthroplasties. Uncemented hemiarthroplasties had a 2.1 times increased risk of revision compared with cemented prostheses (95% confidence interval 1.7 to 2.6, p < 0.001). The increased risk was mainly caused by revisions for peri-prosthetic fracture (HRR = 17), aseptic loosening (HRR = 17), haematoma formation (HRR = 5.3), superficial infection (HRR = 4.6) and dislocation (HRR = 1.8). More intra-operative complications, including intra-operative death, were reported for the cemented hemiarthroplasties. However, in a time-dependent analysis, the HRR for re-operation in both groups increased as follow-up increased.

This study showed that the risk for revision was higher for uncemented than for cemented hemiarthroplasties.

The incidence of deep-vein thrombosis and the need for thromboprophylaxis following isolated trauma below the knee is uncertain. We have investigated this with a prospective randomised double-blind controlled trial using low molecular weight heparin with saline injection as placebo in patients aged between 18 and 75 years who had sustained an isolated fracture below the knee which required operative fixation. All patients had surgery within 48 hours of injury and were randomised to receive either the placebo or low molecular weight heparin for 14 days, after which they underwent bilateral lower limb venography, interpreted by three independent radiologists. Further follow-up was undertaken at two, six, eight and 12 weeks.

A total of 238 patients fulfilled all the inclusion criteria, with 127 in the low molecular weight heparin group and 111 in the placebo group, all of whom underwent bilateral venography. There was no statistically significant difference in the incidence of deep-vein thrombosis between those patients treated with low molecular weight heparin or the placebo (p = 0.22). The number of deep-vein thromboses in the two groups was 11 (8.7%) and 14 (12.6%), respectively. Age and the type of fracture were significantly associated with the rate of deep-vein thrombosis (p = 0.001 and p = 0.009, respectively) but gender, comorbidities and the body mass index were not.

The overall incidence of deep-vein thrombosis in this series was 11%. There was no clinical or statistical significant reduction in the incidence of deep-vein thrombosis with the use of thromboprophylaxis. However, we accept that owing to a cessation of funding, recruitment to this trial had to be ended prior to establishing the necessary sample size. Our results cannot, therefore, categorically exclude the possibility that low molecular weight heparin treatment could be beneficial. We recommend a further multicentre trial be undertaken to resolve this matter.