Abstract. Background. Multiple devices can stabilise the MTP joint for arthrodesis. The ideal implant should be easy to use, provide reproducible and high quality results, and ideally enable early rehabilitation to enable faster return to function, whilst lessening soft tissue irritation. We prospectively evaluated the combination of the IO-Fix (Extremity Medical, NJ, USA) device which consists of an intra-osseous post and lag screw that offers these features with full bearing of weight after surgery. Methods. 67 feet in 65 patients were treated over 31 months. After excluding patients lost to follow-up, undergoing revision arthrodesis, or concomitant first ray procedures, there were 54 feet in 52 patients available with a minimum 12 month follow-up with clinical and radiographic outcomes. All patients were treated using a similar operative technique with immediate bearing of weight in a rigid soled shoe. Results. The mean MOXFQ score improved from 46.4 (range 18 – 64) before surgery to 30.2 (range 0 – 54) at 6 months after surgery (p=0.02), and 18.4 (range 0 – 36) (p< 0.001) at latest follow-up. Arthrodesis across the MTP joint was achieved in 52 feet (96%), at a mean of 61 days (range 39–201). Non-union was observed in two feet;
In 2020, the COVID-19 pandemic meant that proceeding with elective surgery was restricted to minimise exposure on the wards. In order to maintain throughput of elective cases, our hospital was forced to convert as many cases as possible to same day procedures rather than overnight admission. In this retrospective analysis we review the cases performed as same day arthroplasty surgeries compared to the same period 12 months previous. We conducted a retrospective analysis of patients undergoing total hip and knee arthroplasties in a three month period between October and December in 2019 and again in 2020, in the middle of the SARS-CoV-2 pandemic. Patient demographics, number of out-patient primary arthroplasty cases, length of stay for admissions, 30-day readmission and complications were collated. In total, 428 patient charts were reviewed for the months of October-December of 2019 (n=195) and 2020 (n=233). Of those, total hip arthroplasties comprised 60% and 58.8% for 2019 and 2020, respectively. Demographic data was comparable with no statistical difference for age, gender contralateral joint replacement or BMI. ASA grade I was more highly prevalent in the 2020 cohort (5.1x increase, n=13 vs n=1). Degenerative disc disease and fibromyalgia were less significantly prevalent in the 2020 cohort. There was a significant increase in same day discharges for non-DAA THAs (2x increase) and TKA (10x increase), with a reciprocal decrease in next day discharges. There were significantly fewer reported
Purpose. Recently many authors have questioned the role of tourniquets in primary knee arthroplasty (TKA). Meanwhile, whether the use of an intra-articular wound drainage is an advance over the lack of a drain in TKA is controversial in the literature. This study aimed to investigate the efficacy and safety of drainage or not in TKA without a tourniquet. Methods. Eighty participants who underwent primary unilateral TKA were prospectively enrolled and were randomized to one of two techniques during surgery without a tourniquet: drainage (Group A) or non-drainage (Group B). Blood loss was monitored perioperatively. The operating time, allogeneic blood transfusion rate, thigh pain, knee pain, limb swelling, clinical outcome as measured by the hospital for special surgery (HSS) score, the ability to straight-leg raise, visual analog scale (VAS) in pain, length of stay and knee active range of motion (ROM) were also recorded. The digital radiographs taken at 6 months postoperatively were assessed for cement mantle thickness and radiolucency using the Knee Society radiographic zones. Results. The mean Haemoglobin levels on day one and three postoperative were significantly higher in Group B (112.1±10.6 mg/dL, 99.5±9.6 mg/dL) than in Group A (106.1±12.4 mg/dL, 92.7±13.1 mg/dL) (P=0.026, P=0.011). Blood or blood product transfusion was necessary for thirteen patients in Group A (33.3%) whereas five patients of Group B (13.1%) were in need of blood products, the difference was significant (P=0.036). The total blood loss in Group A was significant more than Group B (597.7 ± 331.6ml vs. 496.1 ± 260.8ml, P=0.012). Among the patients in Group B, haemarthrosis developed in 3 knees (7.9%, P=0.23). Calf circumference measurements of both groups showed a significant difference at postoperative day one (3.2% vs. 5.6%, P = 0.012) as well as day two (4.9% vs. 7.1%, P = 0.07). A
Our study sought to establish the necessity of prolonged pre-operative antibiotic prophylaxis in patients presenting with zone II and zone V acute flexor tendon injuries (FTI). We hypothesized that a single dose of prophylactic antibiotic was adequate in prevention of post-operative wound infection in acute zone II and V FTI. This was a prospective study of 116 patients who presented with zone II and zone V acute FTI. The study included patients who were 18 years and older. Those with macroscopic contamination, immunocompromised, open fractures, bite injuries, and crush injuries were excluded. Patients were randomised into a group receiving a single dose of prophylactic antibiotic and another group receiving a continuous 8 hourly antibiotic doses until the day of surgery. Each group was subdivided into occupational and non-occupational injuries. Their post-operative wound outcomes were documented 10 – 14 days after surgery. The wound outcome was reported as no infection, superficial infection (treated with wound dressings), and deep infection (requiring surgical debridement). There was 0.9% rate of deep post-operative wound infections, which was a single zone V acute FTI case in a single dose prophylactic antibiotic group. There was a 7.8%
To identify the incidence of sequential slip of the unaffected hips in patients presenting with unilateral SCFE managed with prophylactic fixation or observation. A retrospective review of all unilateral SCFE treated during 1998 to 2012 was undertaken. The study compares the incidence of sequential slip of the initially unaffected hip in patients managed with prophylactic fixation or observation. The study also reports the incidence avascular necrosis, chondrolysis, and metal-work related problem in this group of patients. All patients included in this current work have at least 12 months of follow-up from the index slip. A total of 44 cases had prophylactic fixation of the unaffected hip (mean age 12.6 years,) and 36 patients managed with regular observation (mean age 13.4 years). Sequential slip of the unaffected hip was noted in a total of 10 patients (28 %) managed with regular observation and only in 1 patient (2%) managed with prophylactic fixation. A Fishers exact test showed significantly high incidence of sequential slip in unaffected hips when managed by regular observation (p-value-0.002). There is no evidence of avascular necrosis or chondrolysis in the unaffected hip in both groups, 3 patients had metalwork related problem and one had
Treatment of Tendo Achilles (TA) ruptures can result in considerable morbidity and has significant socio-economic implications. The ideal management of these injuries has yet to be defined. Recent studies have demonstrated that non-surgical treatment with accelerated rehabilitation may have comparable outcomes to surgery. The aim of this study was to evaluate current management and outcomes of TA ruptures at a tertiary referral centre, with a view to developing contemporary treatment guidelines. A retrospective review of TA ruptures over a 12-month period was undertaken. Patients were managed on an individual based approach with no strict management algorithm followed. Data collection included pre-injury activity level, ultrasound findings and treatment methodology. Outcome data collected included return to activity, incidence of DVT and re-rupture. Patients were followed up for an average of 2 years. Data was collected in 49 patients. 31 (63%) of these were managed non-surgically. Ruptures were most common in men (65%) at an average age of 44 yrs. Ultrasound scan at initial diagnosis was performed in 28 patients. There was an average gap in equinus of 34mm in the surgical group, while the average gap within the non-surgical group was 24mm (p=0.23). There was no association between the gap observed on ultrasound and re-rupture rate. At a median of 2 year follow up, there was no significant reduction in average time spent immobilised in a below knee splint in the surgically treated group (10.2 weeks) compared to non-surgical group (10.9 weeks, p=0.35). 86.3% of patients returned to pre-injury level of activity in the non-surgical group and 86.7% in the surgery group (p=1.0). Complications within this patient cohort consisted of one
Presence of
Infection is a complication in hip arthroplasty. It increases mortality and morbidity and is a cause for patient's dissatisfaction. Previous Works report an infection rate between 0,4% e 1,5% in primary hip replacement and between 3,2% in revision hip replacement. The aim of this work was to access the infection rates in one hospital, compare them with the reported rates and investigate possible risk factors for infection. Electronic clinical records were consulted. Patients who underwent total hip arthroplasty (primary or revision) or hemiarthroplasty in one hospital, between the 1st February 2011 and 31st February 2013, were included. Two hundred and sixty one patients (267 surgeries) were included. Demographically, 57,5% were female patients and 42,5% were male patients with an average age of 77,1 years (± 12,3 years). Infection rate for hemiarthroplasty 3,1%, for primary total hip arthroplasty was 1,4% and for revision procedures 4,8%. A statistically significant relation was found between arthroplasty
Hemorrhage and transfusion requirements in spine surgery are common. This is especially true for thoracic and lumbar fusion surgeries. The purpose of this papersi to determine predictive factors for transfusion and their effect on short-term post-operative outcomes for thoracic and lumbar fusions. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients that underwent lumbar or thoracic fusion surgery from 2010 to 2013. Univariate and multivariate regression analysis was used to determine predictive factors and post-operative complications associated with transfusion. A total of 14,249 patients were included in this study; 13,586 had lumbar fusion and 663 had thoracic fusion surgery. The prevalence of transfusion was 35% for thoracic fusion and 17.5% for lumbar fusion. The multivariate analysis showed that age between 50–60 (OR 1.38, CI: 1.23–1.54), age between 61–70 (OR 1.65, CI: 1.40–1.95), dyspnea (OR 1.11, CI: 1.02–1.23), hypertension (OR 1.14, CI: 1.02–1.27), ASA class (OR 1.73, 1.18–1.45), pre-operative blood transfusion (OR 1.91, CI: 1.04–3.49), and extended surgical time (OR 4.51, CI: 4.09–4.98) were predictors of blood transfusion requirements for lumbar fusion. While only pre-operative BUN (OR 1.04, CI: 1.01–1.06) and extended surgical time (OR 4.70, CI: 3.12–6.96) were predictors of transfusion for thoracic fusion. In contrast, higher pre-operative hematocrit was protective against transfusion. Patients transfused who underwent lumbar fusion had an increased risk to develop
Computer assisted surgery (CAS) has gained popularity in orthopaedics for both total knee (TKA) and total hip arthroplasty (THA) in the past decades as a stereotactic device that provides the surgeon with real-time feedback on implant position based on electromagnetic or infrared based instruments. The purpose of this study was to assess the effect of CAS on 30-day complication rates following THA and TKA. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify all patients that underwent THA and TKA from 2011 to 2013, as well as any complication they had within 30-days of their surgery. Univariate and multivariate regression analysis was used to compare the post-operative complications in patients whose surgery involved the use of CAS with those by conventional surgical techniques. We identified 104,550 patients who had THA (42,275 patients) and TKA (62,275 patients) procedures in the database between 2011 and 2013. Computer Assisted Surgery was used in 1,120 THA and 2,173 TKA procedures. There were higher overall adverse events (OR 1.40, CI: 1.22–1.59) in the Conventional group when compared to CAS for TKA. The rate of overall minor events (OR 1.38, CI: 1.21–1.58) and requirements for blood transfusion (OR 1.44, CI: 1.25–1.67) were higher in the Conventional group compared to the CAS group for TKA. However, rate of re-operation was significantly higher in the CAS group for TKA (OR 1.60, CI: 1.15–2.25). The results also showed higher overall adverse events (OR 2.61, CI: 2.09–3.26) in the Conventional group when compared to CAS for THA. The rate of overall minor events (OR 2.72, CI: 2.16–3.42) and requirements for blood transfusion (OR 3.27, CI: 2.52–4.25) was higher in the Conventional group whereas
Because life expectancy is increasing, the number of primary knee arthroplasties performed is projected to increase 673% by 2030, according to Westrich et al. Also, Toulson et al. in a recent study predict that the incidence of deep infection associated with primary total knee arthroplasty ranges from 1% to 2%. Periprosthetic knee infection is one of the most dramatic and difficult to manage complications following total knee arthroplasty. Therefore, periprosthetic knee infection will continue to be a significant complication and an economic burden in the future. Our objective was to identify the risk factors that may provide greater likelihood of infection and thus select high-risk patients and to take maximum prevention strategies. Case-control study, between infected and non infected patients, undergoing primary total knee arthroplasty between January 2008 and January 2013. The risk factors evaluated were: duration of hospital stay, surgery duration, prophylactic antibiotics and timing for administration, volume of blood transfusion, autologous blood recovery system use, anesthetic technique, ASA classification, Diabetes Mellitus, Obesity (BMI>30), immunosuppression and history of any infection in the month preceding surgery. The presence of infection was defined by the criteria of the Center for Disease Control for Nosocomial Surgical Site Infections1. Statistical analysis IBM SPSS Statistics 20 (Fisher's exact test, Mann-Whitney U test and Student's t-test). Statistical significance for p ≤ 0.05. We evaluated 540 patients with a mean follow-up of 56 months. We identified 21 deep infections (3,8%), and 35
Introduction. Anterior cruciate ligament (ACL) reconstructive surgery is one of the most commonly performed surgical procedures. Synthetic ACL repair surgery with the Lars ligament is designed to repair, rather than replace, the torn ACL. Once the ACL is repaired, the level of function, biomechanical attributes and proprioception should be similar to the pre-injury state. All patients in this cohort have undergone surgical repair of the torn ACL with synthetic Lars ligament augmentation. The indications and surgical technique will be outlined. Patients have been assessed at follow-up with KOOS and Marx scores, which reflect the surgical outcome. The preliminary results with a six-month minimum follow-up will be presented. The results reflect previous published studies that show that surgical repair of the torn ACL with Lars ligament augmentation, can reliably and reproducibly stabilise the knee and allow an early return to sport. Complications include one septic arthritis,
Background. Revision THA presents significant challenges for the surgeon when the proximal femur is deficient or mechanically unreliable. The aim of this study is to assess the clinical and functional results of the use of tumor enndoprosthesis to reconstruct the proximal femur when there is massive bone loss. Patients and Methods. A prospective study was conducted involving 10 cases. The follow up of the cases ranged from 12 months to 30 months with a mean period of an average of 23months. The indications for revision surgery were aseptic loosening in 9 cases and septic loosening in one case Harris hip score was used for pre and postoperative clinical evaluation of the patients. Results. At the latest follow up the Harris Hip scores improved from a preoperative average of 16 (range, 3-47), to a postoperative average of 75.6 (range, 66-94). The complications that we encountered in the study included one case of
Innominate Osteotomy first described by Salter is one of the commonest procedures performed for treatment of Developmental Dysplasia of the Hip (DDH) in children. We recently described a less invasive technique for Innominate Osteotomy, which significantly reduces the operation time without compromising outcome (J Pediatr Orthop B. 2010 Jul;19(4):318–22). As part of the evolution of this procedure we now routinely use bioabsorbable pins (INION OTPS PIN, made from co-polymers of L-lactic acid, D-lactic acid and trimethylene carbonate) instead of K-wires to secure the graft. We prospectively followed-up 120 consecutive cases done using bioabsorbale pins over a 2 year period. The surgical technique was as described in our less invasive innominate osteotomy paper. Average age at surgery was 24 months (18–52) with mean follow-up period of 15 months (6–24 months). The mean preoperative acetabular index was 36.2. o. Our results show a mean acetabular index of 18.7. o. (P< 0.0001) at latest follow-up with no loss of correction. We recorded three
Background. Adductor muscle and tendon injuries are commonly seen in sport. Complete adductor avulsions have been described and can be managed non-operatively or operatively. A rare variant of this injury is the complete avulsion of the adductor complex with the pectineus and rectus abdominus amounting to a complete sleeve avulsion from the pubis. This is a severe injury that is increasingly recognised due to improved imaging and lower diagnostic threshold. Purpose. We describe the surgical management of twelve athletes with this severe injury. Study design. Prospective case series - Level of evidence, 4. Methods. All the injuries were prospectively collected onto our institutional pelvic sports injury database. This series summarises the outcome in twelve consecutive cases where surgery was undertaken after presentation with an acute avulsion (6–34 days) in athletes. The procedure comprised anatomical reattachment of the avulsed tissues with mesh reinforcement of the inguinal wall in seven patients. An independent physiotherapist reviewed all patients. Results. One patient developed a
Aim:. To review the short to medium term radiological, clinical and functional outcomes of reconstructive surgery for severe forefoot deformities in patients with Rheumatoid arthritis. Methods:. We conducted a review of prospectively collected data of patients with Rheumatoid arthritis who received reconstructive surgery for forefoot deformities. Patients requiring metatarso-phalangeal joint arthrodesis and excision of the lesser metatarsals for hallux valgus, dislocation of the lesser metatarso-phalangeal joints and intractable plantar keratosis were included. The patients were followed up at 2 weeks, 6 weeks, 3 months and 6 months. X-Rays were performed preoperatively, postoperatively, at 6 weeks, 3 months and 6 months follow-up. Patients completed a SF36, and AOFAS (American Orthopaedic Foot and ankle Score) forefoot score preoperatively and at 6 months postoperatively. Results:. Ten feet in eight patients were included in the study. Follow-up was for a minimum of 6 months. All patients were female, with an average age of 58 years (34–69 years). Radiologically there was an average correction in the hallux valgus angle from 48 degrees to 15 degrees. The inter-metatarsal angle improved from 14 to 9 degrees. Objective scores were significantly improved. The mean SF36 score pre-operatively was 36 (24–54) and 67 (54–82) post operatively (P < 0.05). The AOFAS score improved from a mean of 32 (28–50) pre operatively to 74 (64–78) post-operatively (p < 0.05). One patient required re-operation for further metatarsal shortening due to ongoing pain and two patients required oral antibiotics for minor
Background. Intravenous and topical tranexamic acid (TXA) has become increasingly popular in total joint arthroplasty to decrease perioperative blood loss. In direct comparison, the outcomes and risks of either modality have been found to be equivalent. In addition, current literature has also demonstrated that topical TXA is safe and effective in the healthy population. To our knowledge, there is a scarcity of studies demonstrating the safety of topical TXA in high risk patient populations undergoing total joint arthroplasty or revision joint arthroplasty. The purpose of this study is to determine the safety of topical TXA in patients undergoing total or revision arthroplasty that are also on chronic anticoagulant or anti-platelet therapy. Methods. We performeded a retrospective review of patients undergoing primary and revision total hip or knee arthroplasties that received topical TXA (3g/100mL NS) from November 2012 to March 2015. All patients, regardless of co-morbidities, were included in the study population. Patients were divided into 3 groups:. Group 1: Patients without any antiplatelet or anticoagulant therapy within 90 days of surgery. Group 2: Patients receiving antiplatelet therapy (Aspirin and/or Plavix) within 90 days of surgery. Group 3: Patients receiving anti-coagulant therapy within 90 days of surgery (low molecular weight heparin, unfractionated heparin, warfarin, dabigatran, rivaroxaban, apixaban). Chart review analyzing ICD-9 and ICD-10 coding was then utilized to establish any peri-operative complications within the 30 day post-operative period in all groups. Complications amongst the groups were evaluated via chi-squared testing as well as multivariate linear regression. Review of current literature and CMS protocols were used to establish reportable peri-operative complications. Wound infections, thromboembolic events and vascular complications such as myocardial infarction, pulmonary embolism, deep venous thrombosis, stroke, aortic dissection were included. Results. During the study period, a total 1471 total joint arthroplasties were performed on 1324 patients (88.7% knee arthroplasty, 11.3% hip arthroplasty). Group 1 included 1033 patients who were not on any prior anti-platelet or anticoagulant therapy. Group 2 included 254 patients receiving chronic antiplatelet therapy 90 days prior to surgery. Group 3 included 184 patients receiving chronic anticoagulant therapy 90 days prior to surgery. No statistically significant differences were found between the groups for any of the included peri-operative complications. The most common complication occurring amongst all the groups was
Introduction. Growing evidence in the literature suggests better clinical and functional outcomes and lower re-rupture rates with repair compared to non-operative treatment of ruptured Achilles tendon. There are however, concerns of wound infection, nerve injury and scar tenderness with the standard open and percutaneous techniques of repair. We aim to evaluate clinical and functional outcomes and complications in patients treated with minimally invasive Achillon device. Materials and Methods. Prospectively collected clinical data was reviewed of all consecutive patients who underwent repair of the ruptured Achilles tendon using the Achillon device. Patients were contacted using a postal questionnaire for assessment of their functional status using the validated Achilles Tendon Total Rupture Score (ATRS) and compared with their uninjured side. The outcomes were compared to the published results. Results. We present patient demographics; and clinical and functional outcomes of 140 consecutive patients who underwent repair of ruptured Achilles tendon using the minimally invasive technique between June 2007 to August 2010. Our complication rate was of two-three percent each of proximal DVT, scar sensitivity,
Introduction. Extensor digitorum brevis (EDB) transfer is a useful method for treating chronic ankle instability in selected patients. It adds strength to the anterolateral capsule and provides proprioceptive feedback to functionally unstable ankles. Method. A single surgeon of case series of patients undergoing EDB transfer for chronic ankle instability following sporting injuries between January 2003 and July 2011 was reviewed. All patients underwent arthroscopic procedures in a day case setting. Outcomes were measured using return to sporting activity and the Karlsson functional scoring system. Results. 67 patients underwent unilateral EDB transfer over the 102 month period. 49 patients were male and all patients were aged less than 45. Minimum follow up was 6 months and all patients were discharged by 15 months (median follow up 9 months). Post operative assessment demonstrated normal range of ankle movements in all cases. At 6 months all patients had returned to sporting activity, achieving pre injury activity by 9 months. Karlsson scores were above 85.3 minor complications were seen - a
The aim of this study was to investigate the risk factors, financial costs and outcomes associated with infection after hip fracture surgery. Prospective hip fracture data from the University Hospital, Nottingham, was analysed, assessing patients with either deep or