Background

Patients who undergo elective hip and knee arthroplasty often have multiple risk factors increasing their likelihood of suffering from hyponatraemia post operatively. Consequently suffering from hyponatraemia post elective hip and knee arthroplasty is common. Consequently we wanted to assess the occurrence of hyponatraemia in our elective arthroplasty unit, assess our effectiveness in managing this and importantly assess how its occurrence impacted on length of patient stay.

MHRA guidance for patients with metal on metal hip replacements (MOM) was provided in 2012 and updated in 2017 to assist in the early detection of soft tissue reactions due to metal wear debris. A large number of metal on metal hip replacements were undertaken at our trust. A program of recall for all patients with metal on metal hip replacements was undertaken and MHRA guidelines implemented.

Identification and recall of all patients from 2001 with MOM hip replacements using theatre logs, patient records and consultant log books. Two consultant review of X-rays and patient records. Postal questionnaires and GP requests for cobalt & chromium blood tests. Two consultant led MOM review clinics undertaken with metal artefact reduction scans (MARS) performed following consultation in 2017.

674 patients, 297 available for review. 59 refused follow up. 87 moved out of area, 36 untraceable, 26 not MOM, 147 RIP, 22 already revised. From 297 patients 126 female, 171 male, age range 39 – 95 yrs. 126 resurfacing, 171 MOM THR. 26 patients with elevated metal ions, MARS performed of which 17 positive, 9 negative. Of 17 positive scans 10 patients asymptomatic, 7 waiting revision.

A time consuming effort and additional resource was needed and supported by the trust. From 297 hips 17 positive MARs were identified (5.7%). A new database registry has been developed to track MOM patients, clinics set up for ongoing follow up with radiological protocols for imaging. An arthroplasty advanced nurse practitioner (ANP) is now trained reviewing patients independently.

Purpose

There is concern that the positive predictive value (PPV) of neonatal screening for instability may have deteriorated over recent years, this study aims to evaluate this.

Summary

The 80% porous structure of trabecular metal allows for bone ingrowth in more than 90% of the available surface. The Nexgen LPS Uncemented Knee using a trabecular metal tibial component has performed well at minimum of 5 years’ follow-up.

Aim:

An assessment of the relationship between pathological Developmental Dysplasia of the Hip (DDH) and Congenital Talipes Equinovarus (CTEV).

Outcome studies of the Ponseti method from various centres have reported success rates ranging from 85–95%. The vast majority of patients can expect a supple, functional and pain free foot. The small percentage of feet that are resistant to Ponseti treatment often require open surgical correction, leading to scarring and stiffness. We present a method of correcting resistant equinus by a tenotomy and calcaneal pulldown technique. This method is complimentary to the Ponseti technique.

An 11 year prospective longitudinal study assessed the relationship between major neonatal foot deformities and developmental dysplasia of the hip (DDH). From 41,474 infants born between 01/01/1996 and 31/12/2006 with 614 foot deformities were referred as ‘risk factors’ in a screening/surveillance programme for DDH. All hips were clinically examined and sonographically imaged in a specialist Paediatric Orthopaedic clinic.

The 614 cases were subdivided into: 436 postural equinovarus deformities (TEV), 60 fixed congenital talipes equinovarus (CTEV), 93 congenital talipes calcaneovalgus (CTCV) & 25 metatarsus adductus. The overall risk of sonographic dysplasia/instability was as follows: TEV 1:27, CTEV 1:8.6, CTCV 1:5.2, Metatarsus adductus 1:25

The Relative Risk (RR) of sonographic dysplasia/instability in TEV vs CTEV was 0.31 (95% CI 0.12–0.80; p=0.0057; OR=0.29). The Relative Risk of dysplasia/instability in CTCV vs. Postural TEV is 5.27 (95% CI 2.57–10.8; p< 0.0001; OR=6.30).

The risk of Type IV hip instability or irreducible dislocation in CTCV was 1:15.4 (6.5%), 1:25 (4%) in metatarsus adductus and 1:436 (0.2%) in TEV. There were no cases of hip instability (Type IV) or irreducible dislocation in the CTEV cases.

The routine screening for DDH in cases of postural TEV and fixed CTEV is no longer advocated. Postural TEV is poorly defined as a deformity in the literature leading to the over diagnosis of a possibly spurious condition. Sonographic imaging and surveillance of the hips in cases of CTCV and metatarsus adductus should continue.

Advances in implant design and instrumentation have led to total ankle replacement (TAR) becoming an attractive alternative to ankle fusion in selected cases. We present the short-term results for Mobility TAR with clinical and radiological findings.

Methods: Prospective study from Dec 2004 to Dec 2007. Single surgeon, anterior approach to the ankle. Patients assessed clinically, radiologically and with pre and postoperative visual analogue (VAS) and American orthopaedic foot and ankle society (AOFAS) hindfoot score.

Results: 34 patients, 36 TAR, 2 bilateral. Male 25, female nine. Mean age 66.9 years, range 43 to 89 years. 26 osteoarthritis, four rheumatoid arthritis, four post-traumatic osteoarthritis. Follow up 6 months to 3.5 yrs, mean 22 months. VAS pre-operative mean 8, postoperative mean 1.5. AOFAS score mean pre-operative 30, post-operative mean 85. No deep infections, 3 superficial infections, which settled with antibiotics. No nerve damage. Two medial malleolar fractures. Two lateral malleolar fractures. One talar malposition – one of first six cases, no surgery required outcome not affected. Three unexplained painful TAR. No revisions. 90% patients satisfied and would have operation again

Conclusion: Short-term results for TAR are encouraging. Implants and instrumentation are improving and patients are satisfied with the results. There is a steep learning curve of at least six cases. Surgical skill, technique and careful patient selection are paramount in achieving satisfactory results. With patient demands increasing TAR is a realistic alternative to ankle fusion.

In a prospective study over 11 years we assessed the relationship between neonatal deformities of the foot and the presence of ultrasonographic developmental dysplasia of the hip (DDH). Between 1 January 1996 and 31 December 2006, 614 infants with deformities of the foot were referred for clinical and ultrasonographic evaluation. There were 436 cases of postural talipes equinovarus deformity (TEV), 60 of fixed congenital talipes equinovarus (CTEV), 93 of congenital talipes calcaneovalgus (CTCV) and 25 of metatarsus adductus.

The overall risk of ultrasonographic dysplasia or instability was 1:27 in postural TEV, 1:8.6 in CTEV, 1:5.2 in CTCV and 1:25 in metatarsus adductus.

The risk of type-IV instability of the hip or irreducible dislocation was 1:436 (0.2%) in postural TEV, 1:15.4 (6.5%) in CTCV and 1:25 (4%) in metatarsus adductus. There were no cases of hip instability (type IV) or of irreducible dislocation in the CTEV group.

Routine screening for DDH in cases of postural TEV and CTEV is no longer advocated. The former is poorly defined, leading to the over-diagnosis of a possibly spurious condition. Ultrasonographic imaging and surveillance of hips in infants with CTCV and possibly those with metatarsus adductus should continue.

Aim: To assess the relationship between different types of foot deformity as risk factors in developmental dysplasia of the hip.

Methods: In the Blackburn district foot deformities were referred as risk factors in a screening programme for DDH. All hips were imaged ultrasonographically using a modified Graf morphological and Harcke dynamic method: type I, II, III and IV.

Statistical analysis compared relative risks, odds ratios, 95% confidence intervals for relative risk and P values using Chi the squared test.

Results: Total 585 cases, 432 postural equinovarus deformities (TEV), 60 fixed congenital talipes equinovarus (CTEV), 93 congenital talipes calcaneovalgus (CTCV) & 25 metatarsus adductus.

Conclusion: Routine screening for DDH in cases of postural TEV & fixed CTEV is no longer advocated. The deformity of postural TEV is poorly defined in the literature leading to over diagnosis. The screening of CTCV & metatarsus adductus should continue.

Introduction: The popularity of hip arthroscopy has lagged behind that of other joints. However surgeons are increasingly using hip arthroscopy to investigate and treat disorders such as early osteoarthritis, inflammatory arthritis, labral tears, loose bodies and paediatric hip disease.

We present the indications, intra operative findings and outcomes of patients undergoing hip arthroscopy.

Methods: Prospective study of 43 patients from 2000 to 2005 undergone hip arthroscopy performed by the senior author. Pre & post operative visual analogue scores and oxford hip scores were recorded.

CT or MRI was performed were clinically indicated. Mean follow up 4 months, range(2– 10).

Results: 45 hips. 20 right. 21 left. 2 bilateral. 22 females. 21 males. Mean age 39.6yrs, Range 20–65yrs

Symptoms: Pain, Clicking, Giving way.

History: Idiopathic pain 30, DDH 5, Perthes 3, Trauma acetabulum fracture 2, RT A Dislocation 1, SUFE 1, Non union 1.

6 patients had pre-op CT scans and 22 had MRI.

MRI Findings: 3 loose bodies, 14 labral tears, 2 large filling defects, 3 normal MRI

42 Arthroscopic debridement and wash outs, 3 failed scopes.

Intra operative findings: 5 loose bodies, 4 degenerate labrum’s, 10 labral tears, 14 Grade 3–4 Osteoarthritic changes, 7 Torn ligament Teres,1 normal joint.

3 normal MRI findings had labral tears and articular cartilage defects.

Mean Pre-op VAS- 7.9 Range(5– 10). Mean Post-op VAS- 4.7 Range(1– 10)

Discussion: Hip arthroscopy is of value in assessing and treating patients with hip pain of uncertain cause. Our results indicated good patient satisfaction and outcomes with improved pain and Oxford hip scores. However patient selection and diagnostic expertise are critical to successful outcomes.

The contribution of incorrectly fitting footwear to the development of foot pain and deformity has been citied as an etiologic factor but is something that has not been fully evaluated. We examined the relationship between footwear characteristics and the prevalence of common forefoot problems in patients attending foot clinic.

Methods: Prospective study measuring shoe size (width & Length) and foot measurements in 50 patients attending foot clinic with foot problems. Comparison made with 50 random people with no foot complaints. Deformities, medical histories and pain scores were documented.

Results: Clinic patients: Mean age 49 range(19–68). 12 male 38 female. 21 out of 50 wearing shoes half a shoe size too small, 7 patients wearing shoes half a shoe size larger. 32 patients wearing shoes narrower than feet mean 6mm (range 2–9mm.) Deformities: 27 hallux valgus, 3 bunionette, 6 hammertoes, 5 callosities. Mean pain VAS 5 range (3–10). 11 patients were diabetic, 6 had peripheral vascular disease.

Random patients: Mean age 41 range(19–65). 19 male 31 female. 7 out of 50 wearing shoes half a size smaller, 13 wearing shoes half a size larger, 15 wearing shoes narrower than feet mean 4 mm (range 2–7mm). Deformities: 6 hallux valgus, 3 hammer toes, 8 callosities. Mean pain VAS 1 (1–3). 8 people were diabetic.

Conclusion: A large proportion of patients attending foot clinic wore ill-fitting shoes. Women wore shoes that were shorter and narrower compared to their feet than men. Wearing shoes smaller and narrower than the feet was associated with hammer toes, hallux valgus deformity and foot pain. Incorrectly fitting footwear may be a significant contributing factor associated with forefoot pathology and foot pain. These findings highlight the need for footwear assessment in the management of foot problems.

Introduction: Blood conservation has rapidly moved into political and medical agendas. The ongoing shortage of blood in blood banks and the discovery of vCJD pose a threat to UK blood supply with ever rising costs. The use of blood conservation techniques is increasingly being used in surgery to help reduce the need for homologous blood.

We studied the use of Autologous blood transfusion drains (Bellovac ABT) in lower limb arthroplasty compared with standard closed suction drains. We studied 123 lower limb arthroplasty (61 TKR & 62 THR) to see if there was a significant reduction in the need for homologous blood transfusion when using re-transfusion drains and its cost effectiveness.

Methods: Retrospective analysis of 123 patients undergone lower limb arthroplasty from March 2002 to Dec 2004 under one surgeon using the same technique for TKR and THR. 61 TKR (30 ABT drains v 31 standard drain) and 62 THR (30 ABT drains v 32 standard drain). Data was collected on sex, age, pre & post op Hb, volumes drained, volumes re-transfused and the number of homologous blood transfusions.

Results: 30 THR with ABT drains: 14 male, 16 female, mean age 68.7, mean pre op Hb 13.67, mean post op Hb 10.55,mean volume re-transfused 324ml, mean volume drained 466ml. 7 patients(23%) required additional homologous blood transfusion.

32 THR with standard drains: 14 male, 18 female, mean age 68.4, mean pre op Hb 12.96, mean post op Hb 9.36, mean volume drained 579.5ml. 24 patients (75%) required homologous blood transfusion.

30 TKR with ABT drains: 14 male, 16 female, mean age 69.8, mean pre-op Hb13.4, mean post-op Hb 11.03, mean volume re-transfused 415ml, mean volume drained 580ml. 4 patients (13%) required additional homologous blood transfusion.

31 TKR with Standard drains: 13 male, 18 female. Mean age72.1, mean pre-op Hb13.33, mean post-op Hb10.4, mean volume drained 711.5ml. 14 patients (45%) required homologous blood transfusion.

No re-transfusion complications occurred in the ABT group. 2 patients requiring homologous blood had increasing pyrexia and transfusion hence stopped.

Discussion: 11 out of 60 patients (18%) using ABT drains required additional homologous blood compared with 38 out of 63 patients (60%) requiring homologous blood using standard drains. Pvalue< 0.001. We show a stastically significant reduction in the need for homologous blood transfusion using an autologous blood re-transfusion drain. One unit of blood costs approximately £120 the ABT drain less than half of this amount, there is a significant cost saving in using autologous blood re-transfusion drains. We conclude that using Autologous blood Re-transfusion drains is safe, cost effective and reduces the need for homologous blood transfusion. If drains are to be used then Re-transfusion drains should be used.