Aims. Our aim in this study was to describe the long-term survival of the native hip joint after open reduction and internal fixation of a displaced fracture of the acetabulum. We also present long-term clinical outcomes and risk factors associated with a poor outcome. Patients and Methods. A total of 285 patients underwent surgery for a displaced acetabular fracture between 1993 and 2005. For the survival analysis 253 were included, there were 197 men and 56 women with a mean age of 42 years (12 to 78). The mean follow-up of 11 years (1 to 20) was identified from our pelvic fracture registry. There were 99 elementary and 154 associated fracture types. For the long-term clinical follow-up, 192 patients with complete data were included. Their mean age was 40 years (13 to 78) with a mean follow-up of 12 years (5 to 20). Injury to the femoral head and acetabular impaction were assessed with CT scans and patients with an ipsilateral fracture of the femoral head were excluded. Results. A total of 36 patients underwent total hip arthroplasty (THA). The overall ten-year survival of the hip joint was 86% (95% confidence interval (CI) 81% to 90%) and the 20-year survival was 82% (95% CI 76% to 87%). Injury to the femoral head and acetabular impaction were the strongest predictors of failure, with the long-term survival rate falling towards 50% in these patients. The survival fell to 0% at three years when both these risk factors were present in patients aged > 60 years. Conclusion. The long-term survival of the native hip joint after acetabular fractures was good, but the presence of injury to the femoral head and acetabular impaction proved to be strong predictors of failure, especially in patients aged > 60 years. These patients may be better treated with a combination of open reduction and internal fixation and primary arthroplasty. Cite this article: Bone Joint J 2017;99-B:834–40

Introduction

Total Hip Arthroplasty (THA) in patients after proximal femoral osteotomy remains a major challenge. Inferior survival for both cementless and cemented THA has been reported in this subgroup of patients.

Aims

The aim of this study was to report the three-year follow-up for a series of 400 patients with a displaced intracapsular fracture of the hip, who were randomized to be treated with either a cemented polished tapered hemiarthroplasty or an uncemented hydroxyapatite-coated hemiarthroplasty.

Quality of cementation in the early postoperative period has been proven to be an indicator of long-term survival of the total hip arthroplasty. Cementation grading described by Barrack et al is widely used but has certain limitations. It is based upon second-generation cementation technique and has unacceptably high inter- and intra-observer variability due to its subjective evaluation method. We are introducing a new grading system of quality of femoral cementation. It is based upon the ratio of the length of radiological lucency to the total length of cement-bone interface on both antero-posterior and lateral views. Because of its objective nature, it is likely to show reproducible results. We recruited five observers of various grades of surgical experience (trainees to consultant). Each observer graded the quality of femoral cementation on immediate postop xrays twice (gap of atleast two weeks) of 30 primary hip arthroplasties, using Barrack's grading and a new cementation index measured by dividing the ength of Radiolucency along CBI by the total Length of CBI. Statistical analysis was performed by SPSS v17.0. Inter-observer and Intra-observer variability was determined by Intraclass Correlation Coefficient for a two way mixed model. New cementation index showed excellent agreement for both inter and intra-observer reliability with intraclass correlation coefficient of 0.79 and 0.82 respectively. On contrary, results of inter-observer reliability for Barrack's grading were poor with value of 0.20. intra-observer reliability was found to be fair with 0.55. As evident from this study, it is a more reliable way of assessing the quality of cementation, with excellent agreement in both inter and intra-observer categories

Aims

Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited.

Sacral tumours are rare and can present difficult diagnostic and therapeutic challenges even at an early diagnosis. Surgical resection margins have a reported prognostic role in local recurrence and improved survival. Successful management is achieved within a specialist multidisciplinary service and involves combination chemotherapy, radiotherapy and surgery. We present our experience of patients with sacral tumours referred to our unit, who underwent total and subtotal sacrectomy procedures. Materials and Methods. Between 1995 and 2010, we identified twenty-six patients who underwent a total or subtotal sacrectomy operation. Patients were referred from around the United Kingdom to our services. We reviewed all case notes, operative records, radiological investigations and histopathology, resection margins, post operative complications, functional outcomes and we recorded long-term survival outcomes. Patients who were discharged to local services for continued follow up or further oncological treatment were identified and information was obtained from their general practitioner or oncologist. We reviewed the literature available on total sacrectomy case series, functional outcomes and soft tissue reconstruction. Results. We reviewed 26 patients, 16 male and 10 female, with a mean age at presentation of 53.4 years (range 11–80 years). Duration of symptoms ranged from 2 weeks to 6 years; lower back pain and sciatica were amongst the most common presenting features. Histological diagnoses included chordoma, Ewing's, malignant peripheral nerve sheath tumour, chondromyxoid fibroma, spindle cell sarcoma, synovial sarcoma, chondrosarcoma. A combined approach was used in two-thirds of patients and most of these patients had a soft tissue reconstruction with pedicled vertical rectus myocutaneous flap. Complications were categorised into major and minor and subdivided into wound, bladder and bowel symptoms. Wound complications and need for further intervention were more common amongst the patient group who did not have simultaneous soft tissue reconstruction at operation. All patients had a degree of bladder dysfunction in the early postoperative period. We present survivorship curves including recurrence and development of metastases. Conclusion. Total sacrectomy procedures carry a high risk of associated morbidity but can improve survival amongst specific groups of patients. They present challenges in diagnosis and management, but must be referred to a specialist service, that will instigate appropriate investigations and treatment regimes within a multidisciplinary setting. The expansion of services from other specialties required for the postoperative and ongoing rehabilitation plays an important role in overall management and appropriate pathways to coordinate these services are necessary

Aims

Hospital case volume is shown to be associated with postoperative outcomes in various types of surgery. However, conflicting results of volume-outcome relationship have been reported in hip fracture surgery. This retrospective cohort study aimed to evaluate the association between hospital case volume and postoperative outcomes in patients who had hip fracture surgery. We hypothesized that higher case volume would be associated with lower risk of in-hospital and one-year mortality after hip fracture surgery.

Aims

The aim of this study was to describe implant and patient-reported outcome in patients with a unilateral transfemoral amputation (TFA) treated with a bone-anchored, transcutaneous prosthesis.

Background. Both from experimental studies and the large arthroplasty registries there is evidence that bacteria are more often involved in implant loosening then is currently reported. To further elucidate this potential problem, the current study investigated the hypothesis that many total hip arthroplasty revisions, classified as aseptic, are in fact low-grade infections missed with routine diagnostics. Methods. In 7 Dutch hospitals, 176 patients with the preoperative diagnosis of aseptic loosening of their total hip arthroplasty were enrolled. From each patient, the preoperative history was obtained. During surgery, between 14 and 20 tissue samples were obtained for routine culture, pathology analysis and broad range 16S rRNA PCR with reverse line blot hybridization (PCR-RLB). Samples were taken from the (neo-) capsule and acetabular and femoral interface tissue. Cultures were performed locally according to similar protocols. One specialized pathologist, blinded for all other results, analyzed all pathology samples. The PCR-RLB analysis was performed centrally, using a technique previously validated for orthopedic use. Patients were classified as not infected, suspect for infection or infected, according to strict, predefined criteria. Each patient had a follow-up visit after 1 year. Results. Seven patients were classified as infected, of whom 4 were not identified by routine culture. In these patients, positive PCR-RLB results were supported by pathology analyses suspect for infection as well. An additional 15 patients were suspect for infection as well. The microorganisms identified were low virulent bacteria, like coagulase negative staphylococci and Proprionibacterium acnes, in most cases. Twenty of these 22 patients received a cemented prosthesis, fixated with antibiotic-loaded bone cement. All patients received prophylactic systemic antibiotics, after obtaining the tissue samples. Seven of the 22 patients reported complaints one year post-surgery, only one showing signs of early loosening. However, in none of the patients additional surgery was performed. Discussion. Although percentages were not as high as previously reported in literature, between 4 and 13 percent of patients with the preoperative diagnosis of aseptic loosening were infected. However, as thorough debridement was performed during surgery and prophylactic antibiotics were used, it did not have many clinical consequences, as most patients performed well at the 1-year follow-up. Whether it has implications for long-term implant survival remains to be seen

Aims

To evaluate the outcomes of cemented total hip arthroplasty (THA) following a fracture of the acetabulum, with evaluation of risk factors and comparison with a patient group with no history of fracture.

This retrospective cohort study was conducted to investigate whether operative treatment of patients with a pertrochanteric femoral fracture outside working hours is associated with an increased risk of complications and higher mortality. During the study period 165 patients were operated on outside working hours and 123 were operated on during working hours (08.00 to 17.00). There was no difference in the rate of early complications (outside working hours 33% versus working hours 33%, p = 0.91) or total complications during follow-up (outside working hours 40% versus working hours 41%, p = 0.91). Both in-hospital mortality (outside working hours 12% versus working hours 11%, p = 0.97) and mortality after one year (outside working hours 29% versus working hours 27%, p = 0.67) were comparable. Adjustment for possible confounders by multivariate logistic regression analysis revealed no increased risk of complications when patients were operated on outside working hours.

On the basis of these data, there is no medical reason to postpone operative reduction and fixation in patients with a proximal femoral fracture until working hours.

Endoprosthetic replacement of the proximal femur may be required to treat primary bone tumours or destructive metastases either with impending or established pathological fracture. Modular prostheses are available off the shelf and can be adapted to most reconstructive situations for this purpose. We have assessed the clinical and functional outcome of using the METS (Stanmore Implants Worldwide) modular tumour prosthesis to reconstruct the proximal femur in 100 consecutive patients between 2001 and 2006. We compared the results with the published series for patients managed with modular and custom-made endoprosthetic replacements for the same conditions.

There were 52 males and 48 females with a mean age of 56.3 years (16 to 84) and a mean follow-up of 24.6 months (0 to 60). In 65 patients the procedure was undertaken for metastases, in 25 for a primary bone tumour, and in ten for other malignant conditions. A total of 46 patients presented with a pathological fracture, and 19 presented with failed fixation of a previous pathological fracture. The overall patient survival was 63.6% at one year and 23.1% at five years, and was significantly better for patients with a primary bone tumour than for those with metastatic tumour (82.3% vs 53.3%, respectively at one year (p = 0.003)). There were six early dislocations of which five could be treated by closed reduction. No patient needed revision surgery for dislocation. Revision surgery was required by six (6%) patients, five for pain caused by acetabular wear and one for tumour progression. Amputation was needed in four patients for local recurrence or infection.

The estimated five-year implant survival with revision as the endpoint was 90.7%. The mean Toronto Extremity Salvage score was 61% (51% to 95%). The implant survival and complications resulting from the use of the modular system were comparable to the published series of both custom-made and other modular proximal femoral implants.

We conclude that at intermediate follow-up the modular tumour prosthesis for proximal femur replacement provides versatility, a low incidence of implant-related complications and acceptable function for patients with metastatic tumours, pathological fractures and failed fixation of the proximal femur. It also functions as well as a custom-made endoprosthetic replacement.