Introduction

Knee arthroscopy can be used for ligamentous repair, reconstruction and to reduce burden of infection. Understanding and feeling confident with knee arthroscopy is therefore a highly important skillset for the orthopaedic surgeon. However, with limited training or experience, furthered by reduced practical education due to COVID-19, this skill can be under-developed amongst trainee surgeons.

Abstract

Background

Joint replacement surgery has been shown to be successful in post solid organ transplantation patients. However, complication rates, revision rates, and overall mortality can be higher in this population compared to patients who have not undergone solid organ transplantation. Many transplant patients have a decreased life expectancy. Therefore, literature suggests that joint replacement surgery be offered to qualifying patients early on when symptomatic. This study compares the outcomes of patients who have undergone solid organ transplantation as well as a joint replacement to patients that have only undergone joint replacement surgery.

Fascia iliaca compartment block (FIB), performed in the Emergency Department (A&E) in patients presenting with femoral neck fracture, has gained increasing recognition as an adjunctive analgesic. The purpose of this study was to investigate whether FIB significantly reduced the requirement for systemic opiates in the pre-operative setting. Analgesia requirements for all patients admitted with fractured neck of femur to one unit over a four month period were gathered prospectively. 33% patients had received FIB at diagnosis in ED, dependant on the expertise of the attending physician. Morphine requirements on arrival on the ward between groups were analysed. Over a four month period 144 patients were admitted with fractured neck of femur. Over this time period, introduction of an informal educational programme in A&E increased the incidence of FIB provision at diagnosis and reduced the average amount of morphine administered. Administration of FIB reduced the average morphine requirement in A&E by 56%, when compared with those who received systemic analgesia alone (CI 0.4–3.5, p=0.014). No adverse effects were reported with FIB. Fascia Iliaca Compartment Block is a safe and effective method of providing analgesia to patients with fractured neck of femur and reduces morphine requirement.

Introduction: Osteoarthritis of the first metatarsopha-langeal joint (MTPJ) is common. A range of surgical treatment options is described, including different designs of total arthroplasty. The MOJE is a ceramic-on-ceramic press fit arthroplasty. We present a maximum 8 year follow up of 32 procedures.

Methods: 32 MOJE arthroplasties were undertaken by the senior author (MF) in 30 patients (9 male, 21 female; mean age 61.9, range 37–76) over six years. Patients were followed up in special clinics where symptoms, levels of function and radiographs were subjectively and objectively scored using the SF-36, modified Kitaoka and AOFAS systems.

Results: 100% follow-up was achieved, with mean time since surgery 58 months (range 25–97). Mean scores were: Kitaoka 53.8 (15–75, maximum possible 75), AOFAS score was 61.3/100 (range 18–100, maximum 100), SF-36 physical score 48.6 (27.6–58.7) SF-36 mental score 52.2 (19.5–62.2). Eight implants had required revision; two for component fracture.

Radiologically, 15 showed component subsidence, 9 demonstrating radiolucency around one or both components. In one case where the patient had not undergone reoperation component fracture was seen on x-ray. Clinically, in patients who had not undergone subsequent fusion, 15 had less than 36 degrees of movement, 9 had between 36–45 degrees, 4 were in the 46–60 range and only one had more than 60 degrees. There were no cases of infection.

Discussion: Although several previous studies have suggested favourable initial outcomes with this implant, all focus only on early results. The longest follow-up we found was 29 months; these authors quote excellent early outcomes but acknowledge the need for longer-term follow-up. In our series, the reoperation rate of 25% up to 8 years is worryingly high. Whilst a cohort of patients clearly have satisfactory results with the MOJE, we would suggest that surgeons contemplating its use give due consideration to these outcomes before proceeding.

Introduction: In this study, we report interobserver reliability of X-ray for the interpretation of pedicle screw osteointegration based on the diagnosis of “Halo zone” surrounding the screw.

Dynamic stabilisation system for the spine relies on titanium screw purchase within the pedicle. Decision on osteointegration is important especially when the patient becomes symptomatic following initial good outcome. From our cohort of 420 Dynesys patients, over all incidence of screw loosening was 17%. Only 35% were symptomatic.

Method: Lumbar spine X-ray images of 50 patients in two views (AP and lateral) randomly selected from our cohort of 420 Dynesys patients. The images were deployed in a CD-ROM. The authors were asked to review the images and state whether or not each pedicle screw is loose (total of 258 pedicle screws).

Seven observers composed of two expert orthopaedic spine consultant surgeons and one spine expert consultant radiologist and four Specialist Registrars in orthopaedics and radiology.

Data gathered were distributed and presented in tables in the form of descriptive statistics. The evaluation of interobserver agreement was performed by obtaining a Kappa (K) index. For continuous variables comparison, the t test was employed, with a significance level of 0.05.

Results: Kappa Index among three experts was 0.2198 at 95% CI (−0.0520, 0.4916) while for all 7 assessors (3 Experts & 4 SpR), KI was 0.1462 at 95% CI (0.0332, 0.2592)

Discussion & Conclusion: Kappa Index among expert assessors was 0.2 which means X-ray is unreliable for the assessment of pedicle screw osteointegration. Validity of X-ray is not applicable as it is unreliable.

We are planning to evaluate a 3D computer reconstruction model based on 2 X-ray views at 45 degree angle to each other which might be sensitive to detect screw loosening.

Introduction: In this study, we report interobserver reliability of X-ray for the interpretation of pedicle screw osteointegration based on the diagnosis of “Halo zone” surrounding the screw.

Dynamic stabilisation system for the spine relies on titanium screw purchase within the pedicle. Decision on osteointegration is important especially when the patient becomes symptomatic following initial good outcome. From our cohort of 420 Dynesys patients, over all incidence of screw loosening was 17%. Only 35% were symptomatic.

Method: Lumbar spine X-ray images of 50 patients in two views (AP and lateral) randomly selected from our cohort of 420 Dynesys patients. The images were deployed in a CD-ROM. The authors were asked to review the images and state whether or not each pedicle screw is loose (total of 258 pedicle screws).

Seven observers composed of two expert orthopaedic spine consultant surgeons and one spine expert consultant radiologist and four Specialist Registrars in orthopaedics and radiology.

Data gathered were distributed and presented in tables in the form of descriptive statistics. The evaluation of interobserver agreement was performed by obtaining a Kappa (K) index. For continuous variables comparison, the t test was employed, with a significance level of 0.05.

Results: Kappa Index among three experts was 0.2198 at 95% CI (−0.0520, 0.4916) while for all 7 assessors (3 Experts & 4 SpR), KI was 0.1462 at 95% CI (0.0332, 0.2592)

Discussion & Conclusion: Kappa Index among expert assessors was 0.2 which means X-ray is unreliable for the assessment of pedicle screw osteointegration. Validity of X-ray is not applicable as it is unreliable.

We are planning to evaluate a 3D computer reconstruction model based on 2 X-ray views at 45 degree angle to each other which might be sensitive to detect screw loosening.

Introduction: Pharmacological and mechanical methods are recommended to prevent venous thromboembolism (VTE) following hip replacement (THR). However, data on mechanical methods such as graduated compressive stockings (GCS) are limited. This study examined the efficacy and safety of GCS when added to fondaparinux.

Methods: The randomised treatments were 2.5 mg fondaparinux for 5–9 days starting postoperatively alone or with GCS for 42±7 days. The primary efficacy outcome was VTE or sudden death prior to Day 42±7. All patients were to have duplex USS at day 42 + 7. VTE was defined by verified symptomatic VTE or asymptomatic proximal DVT. The main safety outcomes were major and minor bleeding and VTE death.

Results: 856 patients were randomised, of which 799 were THR patients. Of these 756 (95%) were evaluable, 377 in the fondaparinux and 379 in the fondaparinux plus GCS groups. Risk factors for thrombosis were recorded (age > 75 in 20%, history of obesity in 21%, cancer in 6% and VTE in 3%). Compliance with GCS was high, with 85% wearing them continuously. The primary efficacy outcome of VTE or sudden death in THR patients was similar in each treatment group, the results were 5.5% in the fondaparinux only group and 5.3% in the fondaparinux with GCS group; odds ratio was 0.96, 95% confidence interval 0.50–1.83, p=0.91. Outcomes were not different for long-length and short-length stockings. Major bleeding occurred in one patient (< 1%), minor bleeding in 6.7%. No VTE deaths were reported.

Discussion: The addition of GCS to fondaparinux showed no benefit in thromboprophylaxis over fondaparinux alone in this large study of THR patients. Therefore GCS may not be indicated in patients receiving fondaparinux. Graduated compression stockings are time consuming to measure and fit, inconvenient and expensive; therefore we recommend a reconsideration of this current and commonly used practice in THR.

Aim: This retrospective study was undertaken to establish the accuracy of magnetic resonance imaging (MRI) in diagnosing medial meniscal, lateral meniscal and anterior cruciate ligament (ACL) tears.

Materials and methods: Sixty patients who had arthroscopic knee surgery following MRI scans were included in the study. MRI findings were then compared with the pathologies noted at subsequent arthroscopy.

Results: In this study, the sensitivity of MRI in diagnosing tears was 67% (ACL), 100% (medial meniscus) and 57% (lateral meniscus) whereas the specificity was 91%(ACL), 46 %(medial meniscus) and 77 % (lateral meniscus).The positive predictive values were 29% (ACL), 68% (medial meniscus) and 57% (lateral meniscus). The negative predictive values were 98% (ACL), 100% (medial meniscus) and 76% (lateral meniscus).

Conclusion: In contrast to some studies, these findings indicate a lower accuracy for MRI scanning in detecting tears of, in particular of the ACL and lateral meniscus. We suggest that where symptoms and clinical findings support one of these diagnoses and arthroscopic therapeutic intervention is contemplated, that MRI scanning is not beneficial. The additional expense and delay in management seems inappropriate given the findings we have demonstrated.

Purpose: The purpose of this study was to use the thromboelastogram to determine whether autologous blood transfusion following primary total knee replacement surgery results in an alteration to systemic coagulation.

Methods: 44 patients were randomised to receive either Hartmann’s solution alone postoperatively (control group), or Hartmann’s solution and autologous blood at six hours (ABT group). Thromboelastogram measurements of systemic blood clotting were performed pre-operatively, and post operatively at 6h just prior to the commencement of the ABT, 6h 30mins, and 8h.

Results: At 8h post operation (2h post ABT), the ABT group when compared with the control group showed an earlier onset of coagulation (3.83 minutes versus 4.49 minutes, p=0.003) and the formation of a stronger clot as assessed by the TEG maximum amplitude (maximum clot strength 83.9mm versus 75.9mm, p< 0.001).

Conclusion: The transfusion of drained autologous blood following total knee replacement may lead to an exaggerated hypercoagulable postoperative state. Further investigation of this potentially serious consequence of autologous blood transfusion is required.

Aims: To investigate the efficacy and safety of a new dosage regimen of the oral direct thrombin inhibitor ximelagatran, and its subcutaneous (sc) form melagatran, started in close proximity to surgery. Methods: In a randomised, double-blind, parallel-group study, duration 8–11 days, patients undergoing total hip or knee replacement (THR, n= 1856; TKR, n= 908) received either sc melagatran 2 mg immediately before surgery followed by sc 3 mg in the evening after surgery, and then by oral ximelagatran 24 mg bid as a fixed dose (the ximelagatran group), or sc enoxaparin 40 mg od, started the evening before surgery. Bilateral venography was performed on the final day of treatment. Results: The rate of proximal deep vein thrombosis plus pulmonary embolism was 2.3% in the ximelagatran group vs. 6.3% in the enoxaparin group (p< 0.000002; RRR 63.2%). The total rates of venous thromboembolism (VTE) were 20.3% vs. 26.6%, respectively (p< 0.0003; RRR 23.6%). Cases with symptomatic VTE were rare: 8 in the ximelagatran group and 12 in the enoxaparin group. Bleeding events were more common in the ximelagatran group compared with the enoxaparin group (3.3% vs. 1.2%) as were the transfusion rates (66.8% vs. 61.7%). Importantly, there were no differences in fatal bleeding, critical organ bleeding or bleeding requiring re-operation. Conclusion: Pre-operatively initiated sc melagatran followed by oral ximelagatran was superior in efficacy to enoxaparin in preventing VTE in patients undergoing THR or TKR.

Aims: To determine the usefulness of isotope bone scintography in investigating skeletal pain in children. Methods: We reviewed bone scans, notes and radiographs requested for children under 16 years presenting to two teaching hospitals in the city. Results: There were 229 patients with and average age of 11 years.

139 were investigated for back pain and 90 for skeletal pain in the appendicular skeleton.

There were positive scans in 13 patients with back pain and 22 with pain elsewhere.

The management was altered in only 3 children with back pain and 6 with other skeletal pain. Conclusions: Isotope bone scintigraphy is a low yield, and non-speciþc investigation that imparts a signiþcant dose of radiation. Its role in the investigation of skeletal pain should be re-evaluated.

Ximelagatran is an oral direct thrombin inhibitor intended for the prophylaxis and treatment of thrombo-embolic complications. Purpose: The efficacy and safety of ximelagatran, and its subcutaneous (sc) form melagatran, were evaluated in patients undergoing total hip or knee replacement (THR, TKR). Study 1 was a randomised, double-blind, controlled, dose–response study in which patients received 2-6 doses of sc melagatran (1, 1.5, 2.25, or 3 mg bid) followed by oral ximelagatran (8, 12, 18, or 24 mg bid), or sc dalteparin (5000 IU od). Melagatran treatment was initiated immediately before surgery. Study 2 was a randomized, double-blind, controlled study in which patients received 1–5 doses of sc melagatran (3 mg bid) initiated 4–12 h after surgery followed by oral ximelagatran (24 mg bid), or sc enoxaparin (40 mg od). In both studies, low-molecular-weight heparin (LMWH) was started the evening before surgery, and all treatment regimens were continued for 8–11 days. Bilateral venography was performed on the final day of treatment.

Results: In Study 1, 1876 patients underwent THR (n=1270) or TKR (n=606). A significant dose-dependent reduction in venous thromboembolism (VTE) was seen with melagatran + ximelagatran for both THR (P< 0.0001) and TKR (P=0.0014). The rate of VTE was significantly lower with the highest dose of melagatran + ximelagatran (15.1%) when compared with dalteparin (28.2%) (P< 0.0001). In Study 2, 2788 patients underwent THR (n=1923) or TKR (n=865). The VTE rate was 31% in the melagatran + ximelagatran group and 27% in the enoxaparin group (P=0.053). Total bleeding volume was not significantly different between treatment groups. Conclusion: Fixed-dose sc melagatran followed by oral ximelagatran are efficacious and well tolerated for the prophylaxis of VTE following THR or TKR.

To determine the usefulness of isotope bone scintigraphy in investigating skeletal pain in children, we reviewed the bone scans, plain radiographs and clinical notes of consecutive children under 16 years of age presenting to children’s orthopaedic surgeons at two teaching hospitals in one city.

There were 229 patients, of which 87 were boys and 142 girls. They had an average age of 11 years. 139 were investigated for back pain and 90 for skeletal pain in the appendicular skeleton. They were investigated for a variety of conditions including idiopathic back and skeletal pain, scoliosis, Scheuermann’s disease, spondylolysis, osteomyelitis and postoperative pain.

There were positive scans in 4 out of 78 patients with idiopathic back pain, and 13 out of 64 with idiopathic skeletal pain.

Overall the positive scan rate for all conditions was 10% for back conditions and 22% for pain in the appendicular skeleton.

Of all patients with back pain the management was altered in only 3 children. Of all those investigated for appendicular skeletal pain, the management was altered in 6 children. Isotope bone scanning is a low yield and non-specific investigation that imparts a significant dose of radiation to the patient.

It should not be used as a first line investigation for idiopathic back or skeletal pain in children. Other tools such as MRI should be considered initially.

It still has a role in the investigation of children with obvious abnormality on radiographs, with spondylolysis and probably where there are worrying clinical features to the pain such as night pain and recent onset.

The role of bone scanning in the investigation of skeletal pain should be re-evaluated in the investigation of skeletal pain.

We undertook a review of bone scans requested for children to determine the usefulness of isotope bone scintigraphy in investigating skeletal pain in this population.

We reviewed the bone scans, plain radiographs and clinical notes of consecutive children under 16 years of age presenting to children’s orthopaedic surgeons at two teaching hospitals in one city.

There were 229 patients, of which 40% were boys and 60% girls. They had and average age of 11 years. 139 were investigated for back pain and 90 for skeletal pain in the appendicular skeleton. They were investigated for a variety of conditions including idiopathic back and skeletal pain, scoliosis, Scheuermann’s disease, spondylolysis and stress fractures, osteomyelitis and post-operative pain.

There were positive scans in 4 out of 78 patients with idiopathic back pain, 1 of 25 patients with scoliosis and 1 out of 5 with spondylolysis and 11 out of 70 with idiopathic skeletal pain.

Of all patients with back pain the management was altered in only 3 children. Of all those investigated for appendicular skeletal pain the management was altered in 6 children.

Conclusion: Isotope bone scanning is a low yield, and non-specific investigation that imparts a significant dose of radiation to the patient. It should not be used as a first line investigation for idiopathic back or skeletal pain in children. Other tools such as MRI should be considered initially.

The role of isotope bone scanning in the investigation of skeletal and joint pain in children should be reevaluated.