Aims

The place of thromboprophylaxis in arthroplasty surgery remains controversial, with a challenging requirement to balance prevention of potentially fatal venous thrombo-embolism with minimising wound-related complications leading to deep infection. We compared the incidence of fatal pulmonary embolism in patients undergoing elective primary total hip arthroplasty (THA) between those receiving aspirin, warfarin and low molecular weight heparin (LMWH) for the chemical component of a multi-modal thromboprophylaxis regime.

Background

The available treatments for NSLBP (Non-Specific Low Back Pain) provide, typically, small to moderate average benefits to patients. The aim of this pilot cluster RCT was to test the hypothesis that the use of a patient decision aid together with an informed shared decision making consultation would produce better outcomes in satisfaction with treatment at four month follow-up.

Early detection of Developmental Dysplasia of the Hip (DDH), and treatment, may prevent the need for surgical correction following late presentation. Neonatal examination, and ultrasound screening of at risk groups, does not detect all cases. Most neonates treated in the Intensive Care Unit (NICU) have abdominal radiographs performed during their stay. These include the hips but DDH is not routinely looked for.

50 neonatal abdominal films (five from patients who subsequently were found to have DDH, 45 from patients without this condition) were randomly shown to three paediatric orthopaedic surgeons and three paediatric radiologists on two separate occasions. Each was asked whether they would refer the patient for further investigation.

An overall sensitivity of 25.5% (Range 0–60%) and specificity of 93.2% (Range 87–97%) was found with a positive predictive value (PPV) of 14.0% (Range 0–37%) and negative predictive value (NPV)of 96.3% (Range 95–98%).

Although the low sensitivity and PPV make interpretation of these films a poor way to diagnose DDH, the high specificity and NPV suggest that they may be used as a prompt to further investigation. Therefore, we propose that DDH should be looked for on these films and, where there is radiological suspicion, ultrasound examination should be advised.

Aim

To assess the incidence of fatal pulmonary embolism (PE) following elective total knee replacement (TKR) with a standardised multi-modal prophylaxis regime in a large teaching DGH over a 10 year period.

The aim of this prospective randomised study was to compare the clinical and radiological results of a cemented all-polyethylene Ultima acetabular component with those of a cementless porous-coated acetabular component (PFC) following total hip replacement (THR). A total of 287 patients received either a polyethylene acetabular component (group A) or a cobalt–chromium porous-coated component (group B) with an identical cemented femoral component and 28 mm cobalt-chromium head, thus making it the largest study of its type. Patients were evaluated radiologically and clinically using the Harris hip score (HHS). Group A comprised 183 patients (73 male, 110 female) with a mean age of 71.3 years (55 to 89). Group B comprised 104 patients (48 male, 56 female) with a mean age of 69.8 years (56 to 89). A total of 16 patients (13 in Group A, three in Group B) did not have post-operative data for analysis. The mean follow-up in group A was 7.52 years (0.4 to 15.0) and in Group B 7.87 years (0.5 to 14.0).

At final follow-up the mean HHS was similar between groups A and B (74.5 (25 to 100) and 78.0 (37 to 100), respectively; p = 0.068). The total number of revisions for any cause was 28, 17 of which were in group A and 11 in group B. The ten-year survivorship was 86.8% (95% confidence interval (CI) 78.4 to 92.1) and 89.2% (95% CI 78.3 to 94.8) for groups A and B, respectively (log-rank p-value = 0.938). A total of 20 cemented and two cementless acetabular components had evidence of acetabular radiolucencies or acetabular component migration at last follow-up (p = 0.001).

These results indicate that patients with a cemented all-polyethylene and cementless porous-coated polyethylene lined acetabular component have similar long-term clinical outcomes.

Method

286 patients underwent total hip arthroplasty with a cemented titanium femoral implant (Ultima, Johnson & Johnson) between July 1995 and July 2001. The acetabular component was either a porous coated cup or a cemented all-polyethylene cup. A 28mm cobalt chromium head was used in all patients. Patients were prospectively evaluated with clinical examination, Harris hip scores and radiographic assessment. Analysis of the data was performed.

Summary

We report a large study of 331 patients at two years post operation who were prospectively randomised to receive either a rotating platform or a fixed bearing knee replacement of an otherwise identical design.

Introduction

Previous studies comparing cruciate retaining (CR) and cruciate sacrificing - posterior stabilised (PS) TKRs have failed to demonstrate a difference in outcomes based on numbers of patients recruited.

This large study compares clinical outcomes in groups having PS and CR TKR and reports the results at 1 and 2 years post-operatively.

Summary: This study compares the outcomes of a large series of 683 cruciate sacrificing (PS) and cruciate retaining (CR) TKRs at minimum 2 years follow-up. Patients with a PS component showed a greater improvement in the pain and knee components of the American Knee Society Score at both 1 and 2 years post-operatively and also demonstrated a greater improvement in knee flex-ion at both time points.

Introduction: Excellent clinical results have been reported with both PS and CR TKR designs. A number of randomised trials comparing the two techniques have failed to demonstrate a difference in outcomes based on the numbers of patients recruited.

It is hypothesised that cruciate retention in total knee arthroplasty may result in improved kinematics of the knee by maintaining the femoral rollback seen in the normal knee, resulting in improved function. This study compares clinical outcomes in groups having PS and CR total knee arthroplasty and report the results at 1 and 2 years post-operatively.

Methods: A total of 683 patients undergoing TKR surgery were consecutively enrolled in a prospective multi-centre study with 2 arms. In the first arm patients receiving a PS component were randomised to receive either a mobile bearing (176 patients) or fixed bearing (176 patients) implant. In the second arm, patients receiving a CR component were randomised to receive either a mobile bearing (161 patients) or fixed bearing (170 patients) implant. All patients were assessed pre-operatively and at one and two years postoperatively using standard tools (Oxford, AKSS, Patellar Score) by independent nurse specialists. The data from the 2 arms of the trial were then analysed to compare differences between PS and CR implants.

Results: Patients with a PS component showed a greater improvement in the pain component of the AKSS at 1 year (p=0.0003) and at 2 years (p=0.0085) post-op.

Patients with a PS also showed a greater improvement in the AKSS knee score at 1 (p=0.0001) and 2 (p=0.001) years.

Knee flexion improvement was also greater in the PS group at 1 (p=0< 0.0001) and 2 (p=0.0035) years.

PS knees also achieved better outcomes in these variables in the mobile and fixed subgroups.

There were no other significant differences in the scores between the two groups at any stage.

Conclusion: This study reports on a large prospective multi-centre series of PS and CR TKRs. Improvements in pain and knee components of the AKSS score and knee flexion at both 1 and 2 years follow-up were greater in PS knees. Although this difference was statistically significant, differences in real terms were relatively small.

Background: Cemented and cementless fixations of acetabular components in total hip arthroplasty are routine practice with inherent advantages and disadvantages. The aim of our prospective randomized study was to compare the clinical and radiographic results of cementless porous-coated cobalt chromium acetabular component with cemented all-polyethylene acetabular component in total hip arthroplasty.

Methods: Three hundred patients were randomized to receive a cementless hemispherical cobalt chromium porous-coated no-hole acetabular component (group 1) or cemented all-polyethylene acetabular component (group 2) with an identical cemented femoral stem and 28mm cobalt-chromium head. Patients were evaluated clinically with Harris Hip Scores (HHS) and radiographically. Analysis of both intention-to-treat groups was performed.

Results: Group 1 had 128 patients (55 male, 73 female) with average age of 70.3 years. Group 2 had 147 patients (63 male, 84 female) with average age of 71.2 years. Average follow-up was 9.5 years (1.03–13.23). The median follow-up was 10 years. 25 patients were excluded from analysis for reasons including unfit for surgery (2), operation cancelled (2), missing data (8) and non-study device (10). Average preoperative HHS improved from 34.4 and 34.5 to 80 and 82.5 postoperatively in group 1 and 2 respectively. There was no statistically significant difference between the average HHS of the two groups (p=0.449) at last follow-up. There were 7 revisions in group 1 [infection (2), cup migration (2), aseptic loosening (1), slipped cup (1) and fractured liner (1)]. 11 patients had revision in group 2 [aseptic loosening (8) and recurrent dislocations (3)]. Revision rate between the two groups was not statistically significant (p=0.465). 10-year survivorship was 93.8%; and 86.6%; for group 1 and 2 respectively. No statistically significant difference was noted for prognostic factors like gender (p=0.006), body mass index (p=0.433), age (p=0.657) and surgical approach (p=0.004) for the two groups. Prognostic factors like gender (male, p=0.006) and surgical approach (posterior, p=0.004) were noted to be significant but body mass index (p=0.433) and age (p=0.657) had no statistical significance. Bootstrapping analysis for the two groups (p-value calculations N=3000) showed a significant p-value for 19 and not significant p-value for 2981 calculations. 4 porous coated cups and 29 all-polyethylene cups had radiolucencies. None of the porous-coated cups had expansile osteolysis.

Conclusions: The results from our study indicate that patients with a cemented all-polyethylene cup and cementless porous coated cup have similar long term outcomes. In patients over 75 years cemented cups have excellent results (100% survivorship at 10 years).

Background: Lenke 1 curves can be treated by a selective thoracic fusion. The lumbar curve, if flexible, can spontaneously correct itself in terms of the Cobb angle and the apical vertebral translation. De-rotation of the thoracic spine with current instrumentation systems has been reported. However, it is unclear what effect this would have on the un-instrumented lumbar curve.

Objective: We report on the changes in the apical rotation (AVR) of the un-instrumented lumbar curve following selective thoracic fusion in Lenke 1B and 1C curves.

Methods and patients: 32 patients with idiopathic scoliosis underwent a selective thoracic fusion for a Lenke 1B or 1C curves. We assessed the apical vertebral rotation of the lumbar curve before and after the selective thoracic fusion. This was measured by the Pedriolle method on the pre-, and post-operative erect radiographs. Cobb angle of the thoracic and lumbar curves before and after the fusion were also measured.

Results: The apical lumbar rotation changed form a mean of 10.7 deg (pre-op) to 7.33 deg (post-op), with a correction index of 19.8 %. The Cobb angle of the instrumented thoracic curve changed from a mean of 54.4 deg (pre-op) to a mean 24.9 deg (postop), the mean correction index was 52.9 %. The mean Cobb angle of the un-instrumented lumbar curve changed from 29.36 deg (pre-op) to 17.76 deg (post-op), with a correction index of 38.8 %.

Conclusion: Selective thoracic fusion of Lenke 1B and 1C leads to an improvement of the rotation un-instrumented lumbar curve.

Patients with severe haemophilia have a tendency towards recurrent haemarthroses resulting in chronic synovitis and leading to end stage haemophilic arthropathy. From 1997 to 2001 five patients underwent sequential bilateral total knee replacement. We compared these patients with 13 haemophilic patients undergoing primary unilateral total knee replacement. One senior surgeon performed all surgery using an identical prosthesis under similar surgical and haematological conditions.

We reviewed information regarding pre-operative medical condition, antibiotic prophylaxis, blood replacement requirement and tourniquet time were all recorded. The rate of post-operative complications and economic evaluation between the two cohorts was calculated. Functional results were assessed using the Hospital for Special Surgery knee scoring system both pre and postoperatively.

We have shown that complication rates following bilateral and unilateral total knee replacements are comparable and that there are no differences in the functional outcomes or complication rates between the two groups. Furthermore, we found that bilateral procedures were advantageous with respect to total rehabilitation times, length of in-patient stay clotting factor usage and cost efficiency.