Arthroplasty in patients who are intravenous drug abusers presents a complex challenge, frequently requiring intervention at a younger age. The cohort suffer increased complication rates due to significant co-morbidities and poor engagement in medical services, in comparison to other patients undergoing lower limb arthroplasty. Multiple small studies show arthroplasty in this patient cohort is associated with high complication and mortality rates. A search of electronic databases were undertaken with the assistance of the library services from the Rotherham NHS Foundation Trust, including Chocraine, SCOPUS and PubMed. Abstracts were reviewed and relevant studies extracted for full review. Full text articles were reviewed based on strict inclusion and exclusion criteria. Searches identified Two thousand and forty-four papers; twenty-seven studies were identified for full review of the paper based on the inclusion criteria above. From this, nine studies were deemed appropriate to for data extraction. These nine papers present one hundred and thirty-two cases of lower limb arthroplasty, fifty nine Total Knee Arthroplasty and seventy three Total Hip Arthroplasty. From this the authors examined incidences of implant failure due to infection, revision, mortality, dislocation, aseptic loosening, peri-prosthetic fracture, or other causes. Of these, 58% of patients (n = 77) with a history of intravenous drug abuse suffered some form of significant complication; 4% of this cohort (n = 5) were lost to follow up. Infection was reported in 32% of cases and a mortality rate of 4.7%. The rising demand of lower limb arthroplasty for intra-venous drug abusers presents a very real problem for the modern Orthopaedic surgeon. Within the studies examined, more than half report implant failure. This study synthesises the available literature regarding treatment of these patients to help facilitate decision making and informed consent

Elevated synovial leukocyte count is a minor criterion derived from the musculoskeletal infection society (MSIS) widely used in clinical practice for diagnosis of prosthetic joint infection. There is evidence to suggest analysis within 1 hour, preferentially within 30 minutes, of aspiration reduces the risk of ex vivo cell lysis occurring during prolonged transport. Multiple site working is more common practice and the availability of a lab on site to perform these tests is not always possible. We aimed to assess whether we could safely perform synovial leukocyte counts within our cold site in the diagnosis of prosthetic joint infection. We reviewed all orthopaedic synovial fluid aspirates within the lower limb arthroplasty unit from April 2021 – April 2022 performed at South Tees NHS Foundation Trust. We assessed time from aspirate to the lab using electronic data resources. This information was compared with the labs ability to perform a synovial leukocyte count to determine the impact of delays on testing. 110 patients (34.5% hips and 63.6% knees) were identified between two sites. Time from aspirate to lab ranged from 0 mins to 26 hrs 34 mins. Mean time to processing was 3hrs 10 mins. 50% of all samples had a synovial leukocyte count performed. 67% of patients had a cell differential performed. There was no difference in the ability to perform a synovial leukocyte count between samples process in < 2hours vs > 6 hours. We conclude that it is safe practice to perform joint aspirates for the work up of periprosthetic joint infections in sites where no laboratory is immediately available as the delay to processing synovial fluid does not alter the ability to perform a synovial leukocyte count. This study will provide evidence to enable the work up of periprosthetic joint infections in cold centres and therefore reduce the delay in diagnosis and proceeding management

Preoperative anaemia and intraoperative blood loss result in ∼90% of individuals being anaemic following hip and knee arthroplasty. Reducing blood loss offers the opportunity to improve outcomes and reduce the risk of transfusion and costs. This review's aim was to determine the effectiveness of drugs for preventing blood loss, and identify optimal dose, route, and timing of administration. Cochrane network meta-analysis of randomised controlled trials was conducted. Inclusion criteria: adults undergoing primary or revision elective hip or knee arthroplasty. Drugs studied: tranexamic acid (TXA), aprotinin, epsilon-aminocaproic acid, desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants. Primary outcomes: need for allogenic blood transfusion, all• cause mortality (within 30 days). Secondary outcomes: mean number of transfusion episodes, re-operation, length of hospital stay and adverse events (DVT, PE, CVA, MI). 102 studies with 8418 participants. Trials included more women (63%). 47 studies (4398 participants) were included within the blood transfusion NMA. TXA given intra-articularly and orally at a total dose of greater than 3g pre-incision, intraoperatively and postoperatively ranked the highest, with anticipated absolute effect of 147 fewer transfusions per 1000 (53% chance ranking 1st) (relative risk(RR) 0.02, 95% credible interval(CrI) 0–0.31); moderate-certainty). Aprotinin (RR 0.59, 95%:CrI 0.36–0.86; low certainty evidence), fibrin (RR 0.86, CrI 0.25–2.93; very-low certainty) and EACA (RR 0.60, 95%:CrI 0.29–1.27; very-low certainty) were not shown to be as effective as TXA. TXA was the most effective drug for preventing bleeding in lower limb arthroplasty. Aprotinin and EACA were not as effective. Currently, the optimal dose, route and timing of administration of TXA is unclear. However, TXA given at higher doses and via mixed routes ranked higher in the treatment hierarchy. Oral TXA may be as effective as intavenous. There was no evidence of harm associated with higher doses of TXA

Introduction. Prosthetic joint infection (PJI) is the leading cause of failure of primary and revision hip and knee arthroplasty. It is challenging condition which represents a growing burden on hospital resources. In-patient hospital stay for antibiotic therapy post-operatively is costly and access to out-patient IV therapy (OPAT) varies between regions. In a tertiary referral centre for revision and infection, the suitability and cost-effectiveness of Dalbavancin was reviewed as a “single-shot” therapy following DAIR or revision lower limb arthroplasty for PJI. Methods & Materials. A prospective service evaluation was carried out for consecutive patients treated for PJI of the hip or knee who received Dalbavancin. Treatment was indicated by Consultant Microbiologist advice within an MDT setting where clinical or patient factors made alternative therapies eg. OPAT inappropriate. Service-level data was collected to allow calculation of bed-day savings compared to a traditional 14-day course of IV treatment. Readmission rates to the trust within 30 days were reviewed as a marker of clinical efficacy and safety. Results. 12 patients received dalbavancin for PJI. Mean bed-day saving was 6.9 (SD 3.7) per patient. A total of 83 bed days were saved compared to traditional treatment and there was a modest cost-benefit. There were no adverse reactions noted and no readmissions within 30 days. Discussion. The safety and efficacy of dalbavancin has been demonstrated in recent literature, but the impact that it can have on health-care costs and in-patient burden has not been explored. In addition, the success of out-patient therapy relies on patient engagement. In patients with co-existing cognitive difficulty or alcohol/substance use Dalbavancin offers an attractive alternative. Conclusions. The results of our pilot suggest that IV Dalbavancin is cost-effective as part of the treatment strategy for PJI and can lead to significant bed-day savings, which can assist in patient flow and departmental efficiency

Introduction. Body mass index (BMI) is a topical area of interest in the field of lower limb arthroplasty. It has been well established that BMI can influence post-operative outcomes. This study compares post-operative outcomes, including satisfaction rates, length of stay (LOS) and radiographic findings in different BMI groups following total hip arthroplasty (THA). Methods. We retrospectively evaluated all non-navigated THAs performed at our institution from 2006–2016. Case-notes were reviewed for dichotomised satisfaction score, LOS and radiographic parameters including inclination, anteversion, limb length discrepancy (LLD) and offset discrepancy. Patients were classified into 4 groupings based on BMI (underweight (<24.5), healthy (24.5–30), obese (30–40), severely obese (>40)). Appropriate statistical analyses were performed to identify between group differences. Results. A total of 6874 patients were included for analysis, (Male=2807, Female=4067, Age = 68.1, BMI=29.60). Satisfaction rates at 3 months and 1 year and LOS according to BMI are displayed in Table 1. Radiographic findings grouped by BMI are displayed in Table 2. Discussion/Conclusion. Satisfaction rates for all categories of BMI were excellent at 3 months (96.90%-98.02%) and 12 months (95.94%-98.32%), with no clinically significant differences between groups. BMI was associated with a significantly longer LOS for the underweight and the severely obese compared to the healthy group. There was no clinically significant influence of BMI on any of the radiographic findings reported. The obese and severely obese groups were significantly younger than the underweight and healthy groups, indicating BMI does appear to have an effect on the age where THA is considered a suitable treatment option in this patient group. For any figures or tables, please contact the authors directly

Aims

This study evaluates the association between consultant and hospital volume and the risk of re-revision and 90-day mortality following first-time revision of primary hip arthroplasty for aseptic loosening.

Deep infection occurs in 2–4% of lower limb arthroplasty resulting in increasing cost, co-morbidity and challenging revision arthroplasty surgery. Identifying the potential sources of infection helps reduce infection rates. The aim of our study is to identify the impact and potential for contamination of our hands and gowns whilst scrubbing using SSHS. A colony-forming unit (CFU) is a pathogenic particle of 0.5 micrometers to 5 micrometers. Concurrent particle counts and blood agar exposure settle plates for 3 subjects and 1 alcohol cleaned mannequin; testing a standard arthroplasty hood, a SSHS with and without the fan on for a 2 minute exposure to represent scrubbing time. Microbiological plates were incubated using a standard protocol by our local microbiology department. All SSHS were positive for gram-positive cocci with a mean colony count of 410cfu/m. 2. Comparing background counts for laminar flow (mean 0.7 particle/m. 3. ; 95% CI 0–1.4) versus scrub areas (mean 131.5 particle/m3; 95% CI 123.5–137.9; p=0.0003), however neither grew any CFU's with a 2-minute exposure. For the mannequin, the only significant result was with the fan on with a 1.5× increase in the particle count (p=0.042) and a correlating positive organism (13CFU/m. 2. ). With human subjects, however, the particle count increased by 3.75× the background count with the fan on (total p=0.004, CFU p=0.047) and all had positive cultures, mean 36 CFU/m. 2. There were no positive cultures with the standard arthroplasty hood or the SSHS with no fan on. If repeated in laminar flow, there was only a statistically significant increase with the fan on (p=0.049), but with negative cultures following a 2-minute exposure. Sterile gloves and gowns can be contaminated when scrubbing with the SSHS fan on. We recommend having the fan switched off when scrubbing until the hood and gown is in place, ideally in a laminar flow environment

Synovasure has been designed and validated for use in the diagnosis of periprosthetic joint infection (PJI). It has a reported sensitivity of 97.4% (CI 86.1–99.6%) and specificity of 95.8% (CI 90.5–98.6%), higher than the variable results reported for aspiration by most units. At a cost of £500 per test, we aimed to establish cost-effectiveness and diagnostic accuracy, to determine its role in routine practice. We developed a protocol for pre-operative aspiration or intra-operative use. Prerequisites for entry were a high index of clinical suspicion for PJI and equivocal standard investigations. All cases were discussed at the lower limb arthroplasty MDT and approved only if use would change clinical management. Over 15 months, 36 tests were approved for 22 aspirations (5 hip, 17 knee) and 14 intra-operative cases (7 hip, 7 knee). 10/36 had undergone previous revision surgery. 35/36 cases complied with the protocol. All 22 Synovasure aspirations were negative, corresponding to the microbiology in all but one case; thought to be a contaminant. In the intra-operative group there was one true positive and 12 true negative tests, giving a sensitivity of 100% (95% CI 2.5–100%) and a specificity of 100% (95% CI 73.5–100%). Synovasure influenced decision making in 34/36 procedures. One test failed and in another there was evidence of frank infection. In 11 cases no surgery was performed versus a potential two-stage revision and in 21 cases a single rather than two-stage revision was performed. Resulting in estimated savings of £686,690, offset against a cost of £18,000. The Synovasure test was found to be sensitive and specific and can aid decision-making particularly in complex cases with an equivocal diagnosis of PJI. The use of this test through a robust protocol driven peer review MDT process not only reduces patient morbidity but drives significant efficiency savings

Introduction. Data on the outcome of THA in patients under the age of 30 years is sparse. There is a perceived reluctance to offer surgery to young patients on the basis of potential early failure of the implant. We aim to review our experience with THA in this group of patients to establish outcomes in a high volume specialist arthroplasty unit. Material & methods. A retrospective review of prospectively collected data from the Lower Limb Arthroplasty Unit of patients who underwent THA <30 years of age between 1989–2009 was undertaken. Ninety five patients (117 THAs) were identified but 25 patients (27 hips) were excluded for lack of clinical records and 6 patients (9 hips) for follow up of <5 years. Clinical records were reviewed for patients’ age at operation, underlying pathology, details of operation and any failures (revision). Radiographs were reviewed for any evidence of loosening and wear of the components. Functional assessment was also carried out using the modified Hip disability & osteoarthritis outcome score (HOOS), Oxford hip score and EQ5D–5L. Results. The mean age was 25 (16–30) years and 67% patients were females. The underlying pathologies included development dysplasia of the hip (28%), juvenile rheumatoid arthritis (27%), slipped capital femoral epiphyses, avascular necrosis of femoral head, Perthes’ disease and posttraumatic arthritis. Twenty-two patients (28%) have had a revision at 12.6 years (5–26 years), majority of them for aseptic loosening of the acetabular component. Discussion. Higher failure rates has led many to be be very cautious when considering THA in the very young patients despite the significant improvement in function, quality of life and overall health arthroplasty offers. This study provides the mid-long term results of THA which is valuable when advising young patients on the prospects of revision surgery at the time of primary THA

Aims

Golf is a popular pursuit among those requiring total hip arthroplasty (THA). The aim of this study was to determine if participating in golf is associated with greater functional outcomes, satisfaction, or improvement in quality of life (QoL) compared to non-golfers.

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BoneMaster is a thin electrochemically applied hydroxyapatite (HA) coating for orthopaedic implants that is quickly resorbed during osseointegration. Early stabilization is a surrogacy marker of good survival of femoral stems. The hypothesis of this study was that a BoneMaster coating yields a fast early and lasting fixation of stems.

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This study investigates the use of the metabolic equivalent of task (MET) score in a young hip arthroplasty population, and its ability to capture additional benefit beyond the ceiling effect of conventional patient-reported outcome measures.

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The purpose of this study was to determine the access to and ability to use telemedicine technology in adult patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), and to determine associations with the socioeconomic characteristics of the patients, including age, sex, race, and education. We also sought to understand the patients’ perceived benefits, risks, and preferences when dealing with telemedicine.

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In computer simulations, the shape of the range of motion (ROM) of a stem with a cylindrical neck design will be a perfect cone. However, many modern stems have rectangular/oval-shaped necks. We hypothesized that the rectangular/oval stem neck will affect the shape of the ROM and the prosthetic impingement.

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We present the development of a day-case total hip arthroplasty (THA) pathway in a UK National Health Service institution in conjunction with an extensive evidence-based summary of the interventions used to achieve successful day-case THA to which the protocol is founded upon.

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Advances in surgical technique and implant design may influence the incidence and mechanism of failure resulting in revision total hip arthroplasty (rTHA). The purpose of the current study was to characterize aetiologies requiring rTHA, and to determine whether temporal changes existed in these aetiologies over a ten-year period.

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We assessed the difference in hospital based and early clinical outcomes between the direct anterior approach and the posterior approach in patients who undergo total hip arthroplasty (THA).

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The primary aim of this study was to analyse the position of the acetabular and femoral components in total hip arthroplasty undertaken using an anterior surgical approach.

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The primary aim of this study was to investigate the effect of an enhanced recovery program (ERP) on the short-term functional outcome after total hip arthroplasty (THA). Secondary outcomes included its effect on rates of dislocation and mortality.

Thromboprophylaxis after elective orthopaedic surgery remains controversial. Recent guidelines from the National Institute for Clinical Excellence (NICE) have suggested that low molecular weight heparin should be given to all patients undergoing total hip replacement. The British Orthopaedic Association is currently debating this guideline with NICE, as it is not clear whether published evidence supports this view. We present the early mortality in our unit after total hip replacement using aspirin as chemical thromboprophylaxis. The 30-day and 90-day mortality after primary total hip arthroplasty was zero. We compare this with that reported previously from our unit without using chemical thromboprophylaxis. With the introduction of routine aspirin thromboprophylaxis, deaths from cardiovascular causes have dropped from 0.75% to zero.

These results demonstrate that there is a strong argument for the routine administration of aspirin after elective total hip replacement.