Following review of data regarding the preoperative distribution of pain in 2000 patients attending for hip replacement, it was noted that 40% of these patients had complained of pain at or below the knee. We proposed to prospectively investigate the severity and location of pain in patients attending for THR and assessed how this distribution of pain altered following surgery. We also proposed to examine the distribution of radiological wear preoperatively and assess if there is any relationship between localisation of pain, and the severity or distribution of the radiological wear pattern.
All patients underwent a standardised preoperative AP and Lateral x-ray. The AP film was divided into three areas, and the lateral film was divided into 5 areas. Each zone was assessed as to the severity of wear pattern and graded from 1–3 (no change in joint space, decreased joint space, femoral or acetabular destruction).
With regard to the frequencies and severity of x-ray changes, zone-1 (34%) was most commonly severely damaged with femoral and/or acetabular destruction in the AP film, with the anterior and anterolateral areas being most commonly affected areas in the lateral film (20% and 19% respectively). When the distributions and severities of x-ray changes were correlated with the distribution of pain localised pre and postoperatively we were unable to show any association between the degree of radiological wear in any one zone and the locatin of pain identified by the patient. In fact, there was a normal distribution to the severity of radiological damage between each of the zones and localisation of pain in any of the 9 areas.
We retrospectively audited outcomes from 97 patients aged over 40 who had undergone arthroscopy in the last 4 years in this orthopaedic unit. The audit was carried out by way of questionnaires which were sent out to patients with the results inputted to a database combined with a review of patients charts, in particular the operative note from the arthroscopy. A standardised proforma was used to record both patient’s details and operative findings. The questionnaires were sent out to 165 patients. Of that number 102 were returned, five of which were excluded due to inadequate information. The average wait for surgery was 10 months and 6 patients noticed an improvement in symptoms while waiting for surgery. 80% of those waiting less than 1 year experienced an improvement compared to 73% of those waiting more than 1 year. The results showed that post-operative symptoms in 74 out of the 97 (77%) patients were improved, 12 (12%) remained unchanged with 11 (11%) experiencing a worsening in symptoms. The age group 60+ had the best outcomes with 23 out of 26 (89%) experiencing some improvement in symptoms; males also experienced a better outcome with 51 out of 63 (81 %) achieving some improvement, compared to females where only 23 out of 34 (67%) showed improvement. We did not have routine access to an MRI scanner so only 23 of the patients had a pre-operative scan. We have insufficient numbers to comment on the accuracy or otherwise of positive MRI findings. Pre-operative symptoms of pain, swelling, locking and instability were recorded and their correlation to successful outcome analysed. This showed that the presence of these symptoms did not predict a post-operative improvement in symptoms as an equal number of those with any of these symptoms compared to those without derived benefit from the procedure. This finding is significant in that these symptoms are commonly used in clinical practice to predict the likely benefit from arthroscopy. A pre-operative history of locking was a specific predictive symptom for meniscal injury in that 27 out of 33 (82%) patients with true locking as a symptom had a meniscal injury but only 27 out of 58 (47%) patients with a meniscal injury experienced locking as a symptom implying that it is not a sensitive indicator of meniscal damage. We also enquired about the presence of a definite acute injury associated with the onset of symptoms. This also had no predictive value as to the potential benefit of surgery. A significant negative from the study was the fact that a history of an acute injury gave no indication as to the presence of a meniscal injury and even if a meniscal injury was present the patient’s outcomes were not significantly better than if no injury was present. In conclusion 77% of patients aged 40+ derived benefit from arthroscopy, possibly due to the effects of washing out the knee rather than any active intervention. A history of locking, pain swelling or an acute injury did not offer an accurate prediction of benefit from arthroscopy, therefore the elderly and those without a history of locking or acute injury should not be dissuaded from undergoing this procedure. This study is confined to those over 40 years of age and the findings are quite different to the findings in younger patients. These findings surprised the surgeons at our unit and therefore we feel may be an interesting and stimulating presentation at the B.A.S.K. meeting.