Introduction.
To describe the impact of a failed DAIR in the further prognosis of the prosthesis after a PJI A retrospective multicentrically study was conducted, including 10 institutions from all over the country. PJI-confirmed patients who underwent DAIR clinical records were revised. Age, sex, relevant previous conditions, Charlson comorbidity score, previous surgery, PJI diagnosis and surgical and antibiotic treatment, from the index surgery onwards. DAIR failure was defined as the removal of the prosthesis and/or an antibiotic suppressive treatment.Aim
Method
Same day home (SDH) discharge in total joint arthroplasty (TJA) has increased in popularity in recent years. The objective of this study was to evaluate the causes and predictors of failed discharges in planned SDH patients. A consecutive cohort of patients who underwent total knee (TKA) or total hip arthroplasty (THA) that were scheduled for SDH discharge between April 1, 2019 to March 31, 2021 were retrospectively reviewed. Patient demographics, causes of failed discharge, perioperative variables, 30-day readmissions and 6-month reoperation rates were collected. Multivariate regression analysis was undertaken to identify independent predictors of failed discharge. The cohort consisted of 527 consecutive patients. One hundred and one (19%) patients failed SDH discharge. The leading causes were postoperative hypotension (20%) and patients who were ineligible for the SDH pathway (19%). Two individual surgeons, later operative start time (OR 1.3, 95% CI, 1.15-1.55, p=0.001), ASA class IV (OR 3.4, 95% CI, 1.4-8.2; p=0.006) and undergoing a THA (OR 2.0, 95% CI, 1.2-3.1, p=0.004) were independent predictors of failed SDH discharge. No differences in age, BMI, gender, surgical approach or type of anesthetic were found (p>0.05). The 30-day readmission or 6-month reoperation were similar between groups (p>0.05). Hypotension and inappropriate patient selection were the leading causes of failed SDH discharge. Significant variability existed between individual surgeons failed discharge rates. Patients undergoing a THA, classified as ASA IV or had a later operative start time were all more likely to fail SDH discharge.
Metal-on-metal total hip replacements (MoM THRs) are frequently revised. However, there is a paucity of data on clinical outcomes following revision surgery in this cohort. We report on outcomes from the largest consecutive series of revisions from MoM THRs and consider pre-revision factors which were prognostic for functional outcome. A single-centre consecutive series of revisions from MoM THRs performed during 2006–2015 was identified through a prospectively maintained, purpose-built joint registry. The cohort was subsequently divided by the presence or absence of symptoms prior to revision. The primary outcome was functional outcome (Oxford Hip Score (OHS)). Secondary outcomes were complication data, pre- and post-revision serum metal ions and modified Oxford classification of pre-revision magnetic resonance imaging (MRI). In addition, the study data along with demographic data was interrogated for prognostic factors informing on post-revision functional outcome.Aims
Materials and Methods
External fixator knee arthrodesis is a salvage procedure mainly used in cases of end-stage infected total knee replacement (iTKR). A stable fixation combined with bone-ends compression is basic to achieve knee fusion in such a scenario but providing enough stability can be challenging in the presence of severe bone loss after multiple previous procedures. Compared with monoplanar configuration, a biplanar frame achieves improved coronal stiffness, while providing the advantages of good access to the wound and allowance of early ambulation. Our primary hypothesis stated that a biplanar frame would achieve higher and quicker fusion rate than a monolateral configuration. We conducted a retrospective cohort study examining patients managed with biplanar external fixator knee fusion due to non-revisable iTKR between 2014 and 2018. We compared this group of patients with a historical cohort-control patient who had been previously published by our unit in 2013, since we switched from a monoplanar to a biplanar configuration for the management of this kind of complex end-stage iTKR. Primary end-points were fusion rate, time to achieve bone fusion and infection eradication rate. Limb-length discrepancy, pain level, patient satisfaction, and health-related quality of life were also evaluated.Aim
Method
Patients presenting with arthrosis following high tibial osteotomy (HTO) pose a technical challenge to the surgeon. Slight overcorrection during osteotomy sometimes results in persisting medial unicompartmental arthrosis, but with a valgus knee. A medial UKA is desirable, but will result in further valgus deformity, while a TKA in someone with deformity but intact cruciates may be a disappointment as it is technically challenging. The problem is similar to that of patients with a femoral malunion and arthrosis. The surgeon has to choose where to make the correction. An ‘all inside’ approach is perhaps the simplest. However, this often means extensive release of ligaments to enable ‘balancing’ of the joint, with significant compromise of the soft tissues and reduced range of motion as a consequence. As patients having HTO in the first place are relatively high demand, we have explored a more conservative option, based upon our experience with patient matched guides. We have been performing combined deformity correction and conservative arthroplasty for 5 years, using PSI developed in the MSk Lab. We have now adapted this approach to the failed HTO. By reversing the osteotomy, closing the opening wedge, or opening the closing wedge, we can restore the obliquity of the joint, and preserve the cruciate ligaments. Technique: CT based plans are used, combined with static imaging and on occasion gait data. Planning software is then used to undertake the arthroplasty, and corrective osteotomy. In the planning software, both tibial and femoral sides of the UKA are performed with minimal bone resection. The tibial osteotomy is then reversed to restore joint line obliquity. The placing of osteotomy, and the angling and positioning in relation to the tibial component are crucial. This is more important in the opening of a closing wedge, where the bone but is close to the keel cut. The tibial component is then readjusted to the final ‘Cartier’ angle. Patient guides are then made. These include a tibial cutting guide which locates both the osteotomy and the arthroplasty. At operation, the bone cuts for the arthroplasty are made first, so that these cuts are not performed on stressed bone. The cuts are not in the classical alignment as they are based upon deformed bone so the use of patient specific guides is a real help. The corrective osteotomy is then performed. If a closing wedge is being opened, then a further fibular osteotomy is needed, while the closing of an opening wedge is an easier undertaking. Six cases of corrective osteotomy and partial knee replacement are presented. In all cases, the cruciates have been preserved, together with normal patello-femoral joints. Patient satisfaction is high, because the deformity has been addressed, restoring body image. Gait characteristics are those of UKA, as the ACL has been preserved and joint line obliquity restored.
Osteosynthesis to conserve femoral head following neck of femur (NOF) fractures has reported failure rates of 36 to 47% at 2 years. However, the long-term outcomes of THAs performed for failed osteosynthesis is yet to be elucidated. This study aims to report on long term outcome of primary THAs post failed osteosynthesis for NOF fracture. Consecutive patients with THA for failed NOF osteosynthesis managed by a single unit between January 1974 and December 2009 were included. Clinical and radiological outcomes of all 72 patients were analysed. Patients with minimum follow-up of 5 years were included. Those with less than 5 years of follow-up were reviewed for failures.Introduction
Methods
Fifteen percent of the primary total knee arthroplasties (TKA) fails within 20 years. Among the main causes for revision surgery are instability and patellofemoral pain. Currently, the diagnostic pathway requires various diagnostic techniques to reveal the original cause for the failed knee prosthesis and is therefore time consuming and inefficient. Accordingly, there is a growing demand for a diagnostic tool that is able to simultaneously visualize soft tissue structures, bone and TKA. Magnetic resonance imaging (MRI) is capable of visualising all the structures in the knee although a trade- off needs to be made between metal artefact reducing capacities and image quality. Low-field MRI (0.25T) results in less metal artefacts and a lower image quality compared with high-field MRI (1.5T). The aim of this study is to develop a MRI imaging guide to image the problematic TKA and to evaluate this guide by comparing low-field and high-field MRI on a case study. Based on literature and current differential diagnostic pathways a guide to diagnose patellofemoral pain, instability, malposition and signs of infection or fracture with MRI was developed. Therefore, methods as Insall Salvati, patellar tilt angle and visibility of fluid and soft tissues were chosen. Visibility was scored on a VAS scale from 0 to 100mm (0mm zero visibility, 100mm excellent visibility). Subsequently, this guide is used to analyse MRI scans made of a volunteer (female, 61 years, right knee) with primary TKA (Biomet, Zimmer) in sagittal, coronal and transversal direction with a FSE PD metal artefact reducing (MAR) sequence (TE/TR 12/1030ms, slice thickness 4.0mm, FOV 260×260×120mm3, matrix size 224×216) on low-field MRI (Esaote G-scan Brio, 0.25T) and with a FSE T1-weighted high bandwidth MAR sequence (TE/TR 6/500ms, slice thickness 3.0mm, FOV 195×195×100mm3, matrix size 320×224) on high-field MRI (Avanto 1.5T, Siemens). Scans were analysed three times by one observer and the intra observer reliability was calculated with a two-way random effects model intra class correlation coefficient (ICC).Introduction
Method
Arthrodesis is usually offered to patients in whom a two stage exchange arthroplasty has already failed or is likely to fail because of local factors (such as soft tissue damage, bone loss or poor perfusion), or because of systemic conditions which categorise the patient as a C-host (e.g. immune deficiency, diabetes and malnutrition). In other words arthrodesis is selected for patients with the worst prognosis. I use an intramedullary nail extending from trochanter to just above the ankle which is locked distally only. The nail is curved with an arc of a 2 meter radius. This conforms to the shape of the femur and when passed through to the straight tibia it ends against the posterior cortex of the distal tibia where the bone is thickest. It creates an angle of between 9° and 11° of flexion at the knee. The nail is bent into 5° of valgus at the point where the femur and tibia meet. This allows the two bones to coapt, dynamise and unite. The procedure is performed in two stages. At the first every effort is made to eradicate the infection by debridement and appropriate local and systemic antibiotics. The nail is inserted at the second procedure and again every effort is made to deal with infection. If infection persists one can easily remove the nail when the knee has fused, and repeat the attempt to eradicate the infection in better circumstances. I have devised a scoring system in order to evaluate the eradication of infection based on clinical grounds, laboratory investigations and radiological examination. This allows for the fact that cure of an infection is not based on any one parameterIntroduction
Method
Total hip arthroplasty (THA) is the most common surgery performed for complications of bipolar arthroplasty. The present study evaluated the functional results and complications associated with this surgery. Forty eight hips (48 patients) who had conversion of bipolar arthroplasty to THA between 1998 June and 2013 June, and who were followed-up for more than one year were evaluated. Twenty one hips had conversion surgery to THA using a Fitmore cup with metal-on-metal articulation (28 mm head). Six hips had surgery using the SecurFit cup and three hips, using the Lima LTO cup with ceramic-on-ceramic articulation (28 mm or 32 mm head). Eighteen hips had surgery using a large head metal-on-metal bearing: –MMC (seven hips), ACCIS (six hips) and Magnum (five hips). The average time of follow-up duration was 3.9 years (range, 1.0–11.3). There were 22 men and 26 women between the ages of 28 and 80 years (average, 68.9 years) at the time of conversion surgery. Conversion arthroplasty was performed for acetabular erosion without femoral stem loosening in 19 hips, acetabular cartilage erosion with femoral stem loosening in 13 hips, periprosthetic fracture in 12 hips, and recurrent dislocation in four hips. Results were evaluated using Harris hip score (HHS) and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) score. The radiographs were analyzed for evidence of acetabular and femoral osteolysis or loosening. The complications were evaluated.Introduction
Patients and Methods
To identify the causes of failure after unicompartmental knee arthroplasty (UKA), and to evaluate considerations for surgical procedures and the results of revision total knee arthroplasty (TKA) performed after failure of UKA. Eight hundreds and fifty-two cases of UKA were performed from January 2002 to June 2011. Forty-seven cases of failures after UKA were analyzed for the cause of the failures, and thirty-five cases of revision TKA after failure were analyzed for the operative findings and surgical technique. The clinical results were measured for thirty cases which were followed-up on at least two years after TKA. The mean duration of follow-up was four years and one month after revision TKA and the mean patient age at the time of surgery was sixty-five years.Purpose
Materials and Methods
Multiple reports suggest good outcome results following unicompartmental knee replacement (UKR). However, several authors report technically difficult revision surgery secondary to osseous defects. We reviewed clinical outcomes following revision total knee replacement for failed UKR and analysed the reasons for failure and the technical aspects of the revision surgery. Between 2003 and 2009, thirty three revisions from unicompartmental knee replacement to total knee replacement were performed in thirty two patients at a single centre. Demographics, indications for the primary and revision procedures, details of the revised prosthesis including augments and any technical difficulties or complications were noted. Patient assessment included range of motion and the functional status of the affected knee in the form of the Oxford knee score questionnaire. Statistical analysis was performed with the Student t test. All 33 revision knees were available for prospective clinical and radiological follow-up. The minimum duration of follow-up after revision surgery was 1 year (mean 3 years, range 1 – 7 years). The median interval between the original unicompartmental knee replacements to revision surgery was 19 months (range 2 – 159 months). The predominant cause of failure was aseptic loosening (50%). Other reasons included persistent pain (21%), dislocated meniscus (18%), mal-alignment (7%) and progression of symptomatic osteoarthritis in another compartment (4%). 18 of the 33 revision procedures required additional augments. During the revision surgery, 11 knees required a long tibial stem while 1 required a long femoral stem. 10 knees required medial tibial wedge augmentation; bone graft was used in 6 knees while a metal wedge augment was used in 4 to fill significant osseous defects. At the time of follow-up, range of movement averaged 103 degrees (range 70 – 120). The mean one year Oxford knee score, was 29 compared to 39 for primary total knee replacements performed during the same period in a comparable sample group of patients at our institute (p < 0.001). Three patients continued to have pain and two required re-revision; one for infection and one for loosening. Aseptic loosening was the commonest mode of failure. Of the UKRs revised to TKRs, 90% were revised within 5 years. The majority of revisions required additional constructs. Oxford Knee Scores after revision surgery were inferior to those for primary TKR. The role of UKR needs to be more clearly defined.
Failure of intertrochanteric fracture fixation often occurs in patients, who have poor bone quality, severe osteoporosis, or unstable fracture patterns. Hip arthroplasty is a good replacement procedure even though it involves technical issues such as implant removal, bone loss, poor bone quality, trochanteric nonunion and difficulty of surgical exposure. The purpose of this study is to evaluate the outcomes of total hip arthroplasty (THA) as the replacement for failed fixation of intertrochanteric fractures of the femur. 203 patients of failed intertrochanteric fractures between April 2009 and October 2014 were included in the study. All of them underwent total hip arthroplasty through direct lateral approach. 150 patients were male (73.8%) and 53 patients (26.1%) were female and the mean of age was 59.02±10.34 years old (range: 56–90 years). The indications of the failure were nail cut out in 174 (85.7%), non-union in 15 (7.3%), plate failure in 14 cases (6.8%). One patient underwent two-stage protocol due to infection. We evaluated the possible clinical and radiological complications and measured functional outcome with modified Harris hip score (MHHS). We used cementless cup in nearly all of patients (95.2%), cementless long stem in 88.1% of patients.Introduction
Patients and Methods
Proximal femur fractures are increasing in prevalence, with femoral neck (FN) and intertrochanteric (IT) fractures representing the majority of these injuries. The salvage procedure for failed open reduction internal fixation (ORIF) is often a conversion to total hip arthroplasty (THA). The use of THA for failed ORIF improves pain and function, however the procedure is more challenging. The aim of this study was to investigate the clinical and radiographic outcomes in patients who have undergone THA after ORIF. This retrospective case-control study compared patients who underwent THA after failed ORIF to a matched cohort undergoing primary THA for non-traumatic osteoarthritis. From 2004 to 2014, 40 patients were identified. The matched cohort was matched for date of operation, age, gender, and type of implant. Preoperative, intraoperative, and postoperative data were collected and statistical analysis was performed. The cohort of patients with a salvage THA included 18 male and 22 female patients with a mean age of 73 years and mean follow up of 3.1 years. Those with failed fixation included 12 IT fractures and 28 FN fractures. The mean time between ORIF and THA was 2.1 years for IT fractures and 8.5 years for FN fractures (p=0.03). The failed fixation group had longer procedures, greater drop in hemoglobin, and greater blood transfusion rate (p<0.05). There was one revision and one dislocation in the failed fixation group with no revisions or dislocations in the primary THA group. Length of admission, medical complications, and functional outcome as assessed with a standardised hip score and were found not to be statistically different between the groups. Salvage THA for failed initial fixation of proximal femur fractures yields comparable clinical results to primary THA with an increased operative time, blood loss, and blood transfusion rate.
Hemiarthroplasty of the hip involves the replacement of the femoral side of the joint with a metal prosthesis, resulting in metal-on-cartilage articulation. The two most common types of hemiarthroplasty used are the Austin Moore and the Thomson, both of which are available in either Titanium (Ti) or cobalt chromium (CoCr). Hemiarthroplasty may be more cost effective in elderly patients who have lower life expectancy and are less active. Three Ti and two CoCr hemiarthroplasty components were obtained following revision surgery. Four had an articulating diameter of 44mm and the other was 46mm diameter. These five hemiarthroplasties were analysed using a Mitutoyo LEGEX322 co-ordinate measuring machine (CMM) (manufacturer's claimed scanning accuracy of 0.8μm). In each case a wear map was generated and the wear volume from the articulating surface was calculated using a bespoke MATLAB program.Background
Materials and Methods
We present a series of 16 patients who have had a failed ankle arthroplasty converted to an ankle arthrodesis using a surgical technique of bone grafting with internal fixation. We describe our technique using tricortical autograft from the iliac crest to preserve length and an emphasis is placed on maintaining the malleoli and subtalar joint. A successful fusion was achieved in all cases with few complications. Our post operative AOFAS improved to a mean of 70 with good patient satisfaction and compares well to other published series. From this series and an extensive review of the literature we have found fusion rates following failed arthroplasty in patients with degenerative arthritis to be very high. In this group of patients a high fusion rate and good clinical result can be achieved when the principles of this surgical technique are adhered to. It would appear that a distinction should be made between treating patients with poor quality bone and more extensive bone loss, as is often the case with rheumatoid patients; and the patients with a non inflammatory arthropathy and better bone quality. The intramedullary nail would appear to be the preferred option in patients with inflammatory polyarthropathy where preservation of the subtalar joint is probably not of relevance as it is usually extensively involved in the disease process, and a higher rate of complications can be anticipated with internal fixation.
Revision surgery for a failed metal on metal (MoM) hip arthroplasty is often unpredictable and challenging due to associated massive soft tissue and bony lesions. We present the analysis and early outcomes of revision surgery in failed MoM hip arthroplasties at our institution. We have retrospectively analysed the findings and outcomes of revision surgery in 61 failed MoM hip arthroplasties performed between 2009 and 2014. These patients were identified in the special MoM hip surveillance pathway. All these patients underwent clinical assessment and relevant investigations. Intra-operative and histopathological findings were analysed.Background
Methods
Aseptic loosening of the glenoid after total shoulder replacement is a challenging problem to manage clinically. In the right circumstances, arthroscopic retrieval of loose polyethylene glenoids can be a valuable tool in the shoulder surgeon's repertoire for dealing with this uncommon problem. The purpose of this talk is to demonstrate the technique for arthroscopic removal of a loose glenoid and review the clinical circumstances where this procedure may play a valuable role.
Coracoid fractures during screw insertion and graft osteolysis are serious concerns with standard screw fixation techniques in Latarjet procedure. This study tends to evaluate the outcome of mini open Latarjet using Arthrex mini-plate for coracoids graft fixation. We did retrospective analysis of 30 patients with recurrent anterior shoulder instability after arthroscopic Bankart's repair. A low profile wedge plate (Arthrex) with two low profile screws was used for fixation of the coracoid graft. CT analysis was performed at final follow up to see graft union and results were evaluated using American shoulder and elbow score (ASES) and Western Ontario shoulder instability score (WOSIS). Mean follow up time was 24 months. Postoperatively, mean forward elevation was 162.8 degrees and external rotation was 44.6 degrees. All patients returned to their previous occupation. None reported to be having any recurrent subluxation post-surgery. The mean ASES score was 92.5 while the mean WOSIS score was 76.84%. Only one patient had screw backing out from the plate. There was no case of coracoid graft osteolysis. The mini-open Latarjet procedure with graft fixation with Arthrex mini-plate provides satisfactory outcome and stabilization in patients who present with dramatic bone loss and failed soft tissue reconstruction. It not only ensures early rehabilitation but also minimum loss of external rotation. The only drawback is the relatively high cost of the implant.
