Reverse shoulder arthroplasty (RSA) has become the most common type of shoulder arthroplasty used in the UK, and a better understanding of the outcomes after revision of a failed RSA is needed. The aim of this study was to review the current evidence systematically to determine patient-reported outcome measures and the rates of re-revision and complications for patients undergoing revision of a RSA. MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews were searched. Studies involving adult patients who underwent revision of a primary RSA for any indication were included. Those who underwent a RSA for failure of a total shoulder arthroplasty or hemiarthroplasty were excluded. Pre- and postoperative shoulder scores were evaluated in a random effects meta-analysis to determine the mean difference. The rates of re-revision and complications were also calculated.Aims
Methods
Metal and ceramic humeral head bearing surfaces are available choices in anatomical shoulder arthroplasties. Wear studies have shown superior performance of ceramic heads, however comparison of clinical outcomes according to bearing surface in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) is limited. This study aimed to compare the rates of revision and reoperation following metal and ceramic humeral head TSA and HA using data from the National Joint Registry (NJR), which collects data from England, Wales, Northern Ireland, Isle of Man and the States of Guernsey. NJR shoulder arthroplasty records were linked to Hospital Episode Statistics and the National Mortality Register. TSA and HA performed for osteoarthritis (OA) in patients with an intact rotator cuff were included. Metal and ceramic humeral head prostheses were matched within separate TSA and HA groups using propensity scores based on 12 and 11 characteristics, respectively. The primary outcome was time to first revision and the secondary outcome was non-revision reoperation.Aims
Methods
With up to 40% of patients having patellofemoral joint osteoarthritis (PFJ OA), the two arthroplasty options are to replace solely the patellofemoral joint via patellofemoral arthroplasty (PFA), or the entire knee via total knee arthroplasty (TKA). The aim of this study was to assess postoperative success of second-generation PFAs compared to TKAs for patients treated for PFJ OA using patient-reported outcome measures (PROMs) and domains deemed important by patients following a patient and public involvement meeting. MEDLINE, EMBASE via OVID, CINAHL, and EBSCO were searched from inception to January 2022. Any study addressing surgical treatment of primary patellofemoral joint OA using second generation PFA and TKA in patients aged above 18 years with follow-up data of 30 days were included. Studies relating to OA secondary to trauma were excluded. ROB-2 and ROBINS-I bias tools were used.Aims
Methods
A lipohaemarthrosis seen on Horizontal beam lateral X-ray in acute knee injury is often considered predictive of an intra-articular fracture requiring further urgent imaging. We retrospectively searched a five-year X-ray database for the term “lipohaemarthrosis”. We excluded cases if the report concluded “no lipohaemarthrosis” or “lipohaemarthrosis” AND “fracture”. All remaining cases were reviewed by an Orthopaedic Consultant with a special interest in knee injuries (AD) blinded to the report. X-rays were excluded if a fracture was seen, established osteoarthritic change was present, a pre-existing arthroplasty present or no lipohaemarthrosis present. Remaining cases were then studied for any subsequent Radiological or Orthopaedic surgical procedures.Abstract
Introduction
Methodology
Studies have shown that 10–30% patients do not achieve optimal function outcomes after total hip replacement (THR). High quality randomised controlled trials (RCTs) evaluating the clinical and cost-effectiveness of techniques to improve functional outcomes after THR are lacking. We performed this study to evaluate the feasibility of a RCT comparing patient-reported functional outcomes after hybrid or fully cemented THR (ISRCTN11097021). Patients were recruited from two centres and randomised to receive either a fully cemented or hybrid THR. Data collection included Patient Reported Outcome Measures (PROMs), non-serious adverse events of special interest (AESI), serious adverse device effects (SADE) and NHS resource use. Qualitative interviews were undertaken to understand a) patient experiences of study processes and their reasons for taking part or not, and b) to understand surgeons’ perceptions of the study, factors affecting willingness to participate, and barriers to implementation of the future RCT findings. The target of 40 patients were successfully recruited for the feasibility RCT; the ratio of successful recruitment to eligible patients was 0.61 across both sites. Treatment crossovers occurred in four patients, all related to bone quality. Four patients were withdrawn due to not undergoing surgery within the study window because of the pandemic. Follow-up was 100% and PROMs were completed by all patients at all time points. The feasibility of conducting a within-trial cost-utility analysis was demonstrated. Interviews were conducted with 27 patients and 16 surgeons. Patients and surgeons generally found the study procedures acceptable and workable. Some declined participation because they did not want treatment allocated at random, or because blinding was off-putting. Surgeons’ perceptions of equipoise varied, and implementation of findings from the future RCT would need to recognise the ‘craft’ nature of surgery and the issue of training. We conclude that a full RCT with economic analysis will be both feasible and practicable, although mechanisms to safely implement potential changes to practice because of RCT findings may need consideration by the wider arthroplasty community.
Patella Baja is a known complication of TKR. In this study, we report the effect of the senior author's change of practice from total excision to minimal resection of Hoffa's fat pad on patellar height. Retrospective analysis of a prospective series of TKRs performed or directly supervised by the senior author. Group 1 included 72 patients performed before April 2011 who had complete excision of Hoffa's fat pad to improve exposure during their TKR procedures. Group 2 included 138 patients performed after April 2011 who had the minimum excision of Hoffa's fat pad to allow exposure. There were no other changes in surgical technique, implant choice or rehabilitation protocol during this time. Patellar height was measured using the Caton–Deschamps Index (CDI) on standard lateral radiographs immediately postoperative and at a minimum follow up of 1 year.Abstract
Introduction
Methods
The Coronavirus pandemic mandated an immediate and dramatic change in the delivery of acute trauma services to minimise face-to-face contact. In our hospital, patients presenting to the Emergency Department with a knee injury and no fracture seen on Xrays were referred to a “Virtual Fracture Clinic” (VFC) where Xrays and clinical notes were reviewed by the duty Trauma and Orthopaedic Consultant the following working day. We present the outcomes of 101 consecutive patients managed through this process and deemed to have a “Soft Tissue Knee Injury” with a minimum follow-up of six months. All Xrays were reviewed by a sub-specialist knee surgeon blinded to notes or clinical outcomes. Electronic clinical records were reviewed to determine further clinical appointments, surgical treatment and pending interventions. Of 101 patients, the knee surgeon diagnosed 1 Fracture, 4 Lipo-haemarthroses, 41 significant effusions and 55 patients with normal Xrays. Correlation to urgent surgery was 100% for fracture (1/1), 25% for Lipo-haemarthrosis (1/4), 7.3% for significant effusion (3/41) and 9.1% for normal Xrays (5/55). A further 9.8% (4/41) of the “effusion” group and 7.3% (4/55) of the “normal” group were subsequently listed for non-urgent surgery. Overall 17% (7/41) of “effusion” patients and 16% (9/55) of “normal” patients required surgery. Management plans from VFC varied within groups. Acute “soft-tissue” injuries of the knee in adults cannot be reliably managed via VFC based on X-ray findings. A staged review by an appropriately trained health professional could reduce demand on acute knee surgical clinics and may enhance patient outcomes.Abstract
The ODEP (Orthopaedic Data Evaluation Panel) rating system should offer a surgeon and patient extra information when making a choice on which implant to use. However, in the current economic environment, ratings may also influence implant choice by contracting bodies. Our aim was to determine the performance of commonly used Acetabular and femoral components in our unit and compare these to their published ODEP ratings (or absence of rating). We analysed all of the following primary THR components (12,792) for revision for any reason, using same date ranges as ODEP where more than 100 implantations had occurred. Hip components: Trinity (3A in 2013), Trilogy (10A* in 2016), Atlas (10A in 2013), Trilogy TMT (10A 2010) Durom (not rated), BHR (10A, 2010), ACCIS (not rated); Femoral components: Taperfit (10A in 2013), Taperloc (10A* in 2016), Metafix (3A in 2013), CPT (10A in 2012), Ecofit (not Rated), ESOP (not rated), Minihip (3A 2013), Durom (not rated), BHR (10A 2010), ACCIS (not rated). Analysis of Kaplan Meier survival curves was undertaken for all components. The rated components and non-rated components were compared using HR and logrank tests for all time groups when ratings were introduced. No statistical difference was observed in any group except for the Trinity cup which had a 98.2% (1344 cups) survival at 6 years. Component survival in our unit was better than ODEP suggested failure for A category of not more than 1% per year, for all components. Whilst we applaud the intention to improve data available for prostheses, the present ODEP system does not distinguish between performances of different implants in our unit. We therefore recommend care when relying upon ODEP ratings to make clinical or contracting decisions.
There is little information available to surgeons regarding how the lateral soft-tissue structures prevent instability in knees implanted with total knee arthroplasty (TKA). The aim of this study was to quantify the lateral soft-tissue contributions to stability following cruciate retaining (CR) TKA. Nine cadaveric knees with CR TKA implants (PFC Sigma; DePuy Synthes Joint Reconstruction) were tested in a robotic system (Fig. 1) at full extension, 30°, 60°, and 90° flexion angles. ±90 N anterior-posterior force, ±8 Nm varus-valgus and ±5 Nm internal-external torque were applied at each flexion angle. The anterolateral structures (ALS, including the iliotibial band, anterolateral ligament and anterolateral capsule), the lateral collateral ligament (LCL), the popliteus tendon complex (Pop T) and the posterior cruciate ligament (PCL) were then sequentially transected. After each transection the kinematics obtained from the original loads were replayed, and the decrease in force / moment equated to the relative contributions of each soft-tissue to stabilising the applied loads.Introduction
Methods
The purpose of this study was to quantify the number of children treated with ESIN (elastic stable intra-medullary nails) at our institution and to determine what proportion of these nails have been removed and the time and difficulty taken to do so. Patients treated with ESIN between 2000 and 2005 were identified by database search. Their notes were reviewed to record patient and initial nailing details, and timing, difficulty and length of metalwork removal procedures. Complications leading to premature removal or following nail extraction were noted.Aim
Methods
A study to assess the clinical importance of asymmetric thigh creases as the sole clinical sign in the diagnosis of developmental dysplasia of the hip. All consultant clinic letters have been saved on a hospital hard drive since 1999. This drive was searched for the terms “thigh crease” and “skin crease”. Irrelevant letters and referral letters describing factors that would indicate screening in our unit were excluded leaving those with the sole referral complaint of asymmetric thigh creases (ATC). We also reviewed the original referrals of developmental dysplasia of the hip (DDH) patients managed by open or closed reduction. These patients were identified through operative coding. All available hard copy notes were reviewed and patients with neuromuscular conditions or longitudinal deficiency were excluded. Results were inputted into an Excel spreadsheet and analysed by a statistician at the University of Sheffield assuming a background population incidence for DDH of 1 in 1000. 399 computer files containing the search terms were identified. Many contained whole clinics of patient letters. After exclusions we identified 229 patients with the sole referral complaint of ATC. Three of the 229 patients had DDH, which was not statistically significant (p=0.107). The majority of the normal patients had radiological investigations. Hard copy notes were available and relevant for 130 of the 289 operatively managed patients, of whom one was initially referred with the sole complaint of ATC. Orthopaedic specialist examination demonstrated all four patients initially referred with only ATC had decreased abduction and shortening.METHOD
RESULTS
To evaluate the influence of arthrodiatasis in the natural history of the stages of the disease radiologically and also the timing of arthrodiatasis. 44 patients with Perthes' disease that had articulated hip distraction were radiologically evaluated. We assessed these based on Joseph's modified Elizabethtown classification before, during and soon after distraction. Other parameters used were the application of common radiological grading systems and other features.Aim
Materials and methods
The advent of double bundle ACL (Anterior Cruciate Ligament) reconstruction had been hailed as potentially allowing for more anatomically and physiologically functioning graft, however until recently there had been little evidence of enhanced functional outcomes. The aim of this study is to explore whether the dimensions of hamstring two strand single bundle grafts, are predictive of the combined four strand single bundle graft that results from combining the single bundle grafts, as well as the impact of double bundle grafts upon the available healing and attachment area within the bony tunnels. Grafts of all likely two strand single bundle graft sizes, measured to the nearest 0.5mm in diameter using unslotted sizing block, were prepared using porcine flexor tendons,. These two strand single bundles were then systematically combined, and re-measured. By geometrical calculation, the sum of the circumferences of the two, two strand double bundle grafts were compared to the combined four strand single bundle graft formed by combining the two smaller bundles.Introduction
Methods
Subtalar dislocation of the hindfoot is a rare injury and can be associated with poor functional outcomes. We report a case of an irreducible subtalar dislocation in an elite athlete, who returned to elite sport. A 28 year old competitor in the world mountain bike championships was injured in a high speed fall from his mountain bike during a competitive downhill run in July 2007. He had an obvious deformity at the scene and a fracture dislocation of the ankle was suspected. The injury was closed and neuro-vascular status was intact. Radiographs revealed the ankle mortise was intact with the talus anatomical, but a subtalar dislocation was present which proved irreducible in the emergency department. The patient was taken to the operating theatre and the dislocation was reduced through a short antero-medial arthrotomy using a blunt lever and traction. Post- reduction, the joint was stable and was supported in a below knee cast. He was kept partial weight bearing for 6 weeks and then had an intensive physiotherapy rehabilitation regime. Serial radiology showed no evidence of avascular necrosis or other skeletal abnormalities. Our patient has since returned to elite Mountain Biking and won the British National Championships in 2008 and the World Championships in Canberra in 2009.
The aim of this study was to assess the increase in the anterior diameter of the knee and the impact of this increase on the range of motion and function of the knee. Twenty-eight patients (34 knees) who underwent Patello-femoral replacement with FPV (Wright Medical) prosthesis between 2005 and 2009 who were identified retrospectively and analyzed using chart and radiological review. Oxford and AKSS knee-scores were gathered prospectively pre-operative and at follow-up. Trochlear height was measured using lateral radiograph. Trochlear height was compared pre and postoperatively. Patellar height was also measured in preoperative and postoperative skyline view and was compared. The range of movement at six weeks and the Oxford and American knee society knee scores at six months postoperatively were noted. Association between increased anterior height and improved range of motion was studied. All but three-knees regained full knee extension. Postoperative mean range of flexion of the knee joint was 116 degrees. The mean Oxford knee and the mean American Knee Society Knee Scores significantly improved post-operatively The trochlear height was increased by 4mms. Patellar height was also increased by 3 mms resulting in average total increase of 7 mms in the anterior-posterior diameter of the knee. We found no relationship between range of motion of the knee and the increase in the anterior-posterior diameter. We found a negative correlation between increase in the antero-posterior and preoperative trochlear and patellar height. We conclude that FPV Patello-femoral replacement results in correct anatomical reconstruction of the trochlear height rather than ‘overstuffing’ of the patellofemoral joint which can lead to stiffness and failure of resolution of pain post-operatively. This should in turn result in durable improvements in pain and function.
Patellofemoral unicompartmental joint replacement is a controversial subject with a relatively small evidence base. Of the 50,000 total knee arthroplasties performed each year in the UK, approximately 10% are performed for predominantly patellofemoral arthritis. There are several patellofemoral unicompartmental prostheses on the market with the National Joint Registry recording 745 such prostheses used in 2007. Most evidence in favour of this procedure comes from experience with the Avon prosthesis (Stryker) predominantly from designer-surgeons. The FPV patellofemoral joint replacement (Wright Medical) has been in use in Europe for several years. The instruments have recently been redesigned and the device marketed in the UK. In 2007 the FPV had 5.9% market share (n=44). We present our early experience with the FPV patellofemoral joint replacement, which to our knowledge, is the first clinical outcome series for this prosthesis. 33 consecutive FPV joint replacements in 29 patients were performed between April 2007 and September 2009 for unicompartmental patellofemoral OA. All cases were performed or directly supervised by the senior author. Results are presented with a minimum follow-up of six months. Oxford and American Knee Society scores (AKSS) were obtained on all patients preoperatively and at subsequent outpatient visits. Mean preoperative AKSS knee score was 49.7 points and postoperative scores at 6 months and 1 year were 82.5 and 86.4 respectively. Mean Oxford score preoperatively was 30.4 (37%) and at 6 months and 1 year were 21.3 (56%) and 11.2 (77%) respectively. There were no complications related to the implant. One knee required a secondary open lateral release due to inadequate balancing at the index procedure. Further medium to long-term follow up data are required, but our initial experience with this device is encouraging.
Patellofemoral unicompartmental joint replacement is a controversial subject with a relatively small evidence base. Of the 50,000 total knee arthroplasties performed each year in the UK, approximately 10% are performed for predominantly patellofemoral arthritis. There are several patellofemoral unicompartmental prostheses on the market with the National Joint Registry recording 745 such prostheses used in 2007. Most evidence in favour of this procedure comes from experience with the Avon prosthesis (Stryker) predominantly from designer-surgeons. The FPV patellofemoral joint replacement (Wright Medical) has been in use in Europe for several years. The instruments have recently been redesigned and the device marketed in the UK. In 2007 the FPV had 5.9% market share (n=44). We present our early experience with the FPV patellofemoral joint replacement, which to our knowledge, is the first clinical outcome series for this prosthesis. 33 consecutive FPV joint replacements in 29 patients were performed between April 2007 and September 2009 for unicompartmental patellofemoral OA. All cases were performed or directly supervised by the senior author. Results are presented with a minimum follow-up of six months. Oxford and American Knee Society scores (AKSS) were obtained on all patients preoperatively and at subsequent outpatient visits. Mean preoperative AKSS knee score was 49.7 points and postoperative scores at 6 months and 1 year were 82.5 and 86.4 respectively. Mean Oxford score preoperatively was 30.4 (37%) and at 6 months and 1 year were 21.3 (56%) and 11.2 (77%) respectively. There were no complications related to the implant. One knee required a secondary open lateral release due to inadequate balancing at the index procedure. Further medium to long-term follow up data are required, but our initial experience with this device is encouraging.
We report the clinical results of seven consecutive allograft knee ligament reconstructions using Achilles tendon prepared using a chemical treatment process. Results have been disappointing with six clinical failures at short durations of follow-up. All allografts are not the same and the method of tissue preparation may have important consequences for clinical outcomes. Debate regarding the use of allograft or autograft tissue for knee ligament reconstruction continues. A variety of allograft tissues are available from commercial and NHS sources: fresh frozen, freeze dried, irradiated or chemically prepared. There are gaps in the literature with respect to clinical outcomes for these various methods of graft preparation. A recent systematic review indicated similar short-term clinical outcomes for fresh frozen allografts and autografts. The senior author began using allograft Achilles tendon for revision ACL reconstruction or primary multiple ligament reconstruction in 2007. Tissues were obtained from a commercial supplier. These tissues had been harvested in Eastern Europe, transported to the USA and sterilised using a patented “Biocleanse” chemical treatment process. This involves sequential ultrasonic baths of detergent, peroxide and alcohol for fixed periods of time along with pressure and vacuum cycles. Between April 2007 and April 2009, 7 allograft ligament reconstructions were performed in 5 knees. These comprised 5 ACL and 2 LCL reconstructions. At follow up of between 4 months and 2 years, clinical failure of 6 grafts has been observed. We are aware of one previous series of results for ACL reconstructions using chemically sterilised and irradiated allograft tissues. A 45% graft failure rate was reported. We have not been able to identify any clinical outcome studies for grafts prepared using the “Biocleanse” process. Our results have prompted us to change to UK sourced, donor screened allografts, which are fresh frozen after decontamination with 70% ethanol.
