Functional scores are used to clinically assess total hip arthroplasty (THA) and for comparative purposes in the orthopaedic literature. Previous research has highlighted patient age, gender and underlying diagnosis as potential sources of bias but comorbidity has not been considered. The Functional Comorbidity Index (FCI) is a published epidemiological tool which correlates disease with associated physical function deficit. It scores 18 conditions: one point for each, total score 0–18. We analysed 41 fully cemented primary THAs in patients ≤55 years at time of surgery with a minimum 10 years follow up. Past medical history was collected via thorough case note review. Patients were assessed using the SF-12 questionnaire, Harris Hip and WOMAC indexes. The study population consisted of 29 patients: 12 women, 17 men. Mean age: 45 years (range 22–53). All patients received cemented polished Corin TaperFit stem with polyethylene Ogee cup. Mean follow up 13.4 years (range 10.2–17.7). FCI scores ranged 0–3 (12 hips=0; 19 hips=1, 5 hips=2, 5 hips=4). A Pearson's product-moment correlation coefficient was calculated to assess the relationship between co-morbidity and hip function score using all three indexes.
Mean by FCI subgroup: 0=91, 1=96, 2=76.8, 3=68.6 (r=−0.407)
Mean by FCI subgroup: 0=94.7; 1=88.2, 2=63.5, 3=54.6 (r= −0.813)
Mean by FCI subgroup: 0=94.4, 1=91.72, 2=48.8, 3=37.4 (r=−0.812)Introduction
Method & Results
Radiation exposure is a hazard to orthopaedic surgeons, theatre staff and patients intra-operatively. Obesity is becoming a more prevalent problem worldwide and there is little evidence how a patient's body habitus correlates with the radiation doses required to penetrate the soft tissues for adequate imaging. We aimed to identify if there was a correlation between Body Mass Index (BMI) and radiation exposure intra-operatively. We performed a retrospective review of 75 patients who underwent sliding hip screw fixation for femoral neck fractures in one year. We recorded Body Mass Index (BMI), screening time, dose area product (DAP), American Society of Anesthesiologists (ASA) grade, seniority of surgeon and complexity of the fracture configuration. We analysed the data using statistical tests. We found that there was a statistically significant correlation between dose area product and patient's BMI. There was no statistically significant relationship between screening time and BMI. There was no statistical difference between ASA grade, seniority of surgeon, or complexity of fracture configuration and dose area product. Obese patients are exposed to increased doses of radiation regardless of length of screening time. Surgeons and theatre staff should be aware of the increased radiation exposure during fixation of fractures in obese patients and, along with radiographers, ensure steps are taken to minimise these risks.
BOA Guidelines recommend clinical and radiological follow-up after primary total hip arthroplasty (THA) at 1 and 5 years, and every 5 years thereafter to detect asymptomatic failure and allow early intervention. As revision surgery in asymptomatic patients is rare the need for routine follow-up in well-functioning individuals has recently been questioned. To evaluate the role of routine follow-up out-patient appointments (OPA) in identifying failing implants the modes of presentation for patients undergoing revision THA were reviewed. 176 patients who received 183 revision THAs (2003–2010) were identified from an arthroplasty database. 124 patients who received 131 first time revision THAs after primary cemented total hip arthroplasty met inclusion criteria. Retrospective notes review was performed to investigate symptoms at failure and mode of presentation.Background
Methods
The incidence of anterior knee pain following
total knee replacement (TKR) is reported to be as high as 49%. The source
of the pain is poorly understood but the soft tissues around the
patella have been implicated. In theory circumferential electrocautery denervates the patella
thereby reducing efferent pain signals. However, there is mixed
evidence that this practice translates into improved outcomes. We aimed to investigate the clinical effect of intra-operative
circumpatellar electrocautery in patients undergoing TKR using the
LCS mobile bearing or Kinemax fixed bearing TKR. A total of 200
patients were randomised to receive either circumpatellar electrocautery
(diathermy) or not (control). Patients were assessed by visual analogue
scale (VAS) for anterior knee pain and Oxford knee score (OKS) pre-operatively
and three months, six months and one year post-operatively. Patients
and assessors were blinded. There were 91 patients in the diathermy group and 94 in the control.
The mean VAS improvement at one year was 3.9 in both groups (control;
-10 to 6, diathermy; We found no relevant effect of patellar electrocautery on either
VAS anterior knee pain or OKS for patients undergoing LCS and Kinemax
TKR.
Current evidence suggests that we should be moving away from Thompson's hemiarthroplasties for patients with intracapsular hip fractures. Furthermore, the use of cement when inserting these prostheses is controversial. This study aims to show the Inverness experience. We performed a retrospective review of all NHS Highland patients who underwent a hemiarthroplasty for an intracapsular neck of femur fracture over the last 15 years. Demographics and the use of cement were documented. Further analysis of this group was performed to identify any of these patients who required revision of their prosthesis. Patients requiring revision had their case-notes reviewed to identify the cause for further surgery. From 1996 until present 2221 patients from the Highland area had a hemiarthroplasty for an intracapsular neck of femur fracture. 1708 where female (77%) and 513 male (23%). The ages ranged from 28 years to 104 years (mean 80 years, median 81). 2180 of this group had their operations in Raigmore Hospital with the remaining 41 at various centres throughout Scotland. 623 (28%)had a cemented hemiarthroplasty, with the remaining 1578 (72%) having an uncemented Thompson's hemiarthroplasty. The revision rate for the cemented group was 2% (13 of 623 patients). In the uncemented group it was 0.4% (6 of 1578). Reasons from revision included dislocation, periprosthetic fracture, infection and pain. Current evidence from some joint registers regarding the use of Thompson's hemiarthroplasty in the elderly is discouraging. The use of bone cement in this group with multiple co-morbidities is not without it's risks. Our data suggests that uncemented Thompson's hemiarthroplasties in low demand elderly patients with multiple co-morbidities can yield excellent results with less risk to the patients.
British Orthopaedic Association (BOA) Guidelines recommend clinical and radiological follow-up after Total Hip Arthroplasty (THA) at 1 year, 5 years and every 5 years thereafter to detect asymptomatic failure. To evaluate the importance of routine follow-up appointments (OPAs) in detecting failing implants the presentation of patients undergoing revision THA was reviewed. 176 patients who received 183 first-time revision THAs over a seven-year period (2003-2010) were identified from an arthroplasty database. A preliminary study sampled 46 THAs in 45 patients. Retrospective chart review recorded symptoms and mode of presentation. Follow-up OPA costs were calculated to estimate savings. All patients had symptoms at the time of revision (pain 96%, decreased mobility 76%, limp 35%, stiffness 26%, night pain 24%). Route of presentation was 80% new referrals (GP 63%, in-patient 9%, A&E 4%, Rheumatology 4%) vs 20% routine orthopaedic follow-up. The minimum cost for a routine follow-up OPA was £35. Assuming discharge after the earliest review when the patient has returned to full normal activities the estimated saving for the 2009 cohort of 377 primary THAs performed in our hospital is £13195 at 1 year and £52780 over the lifespan of the implants (assuming average 15 year survival). Following uncomplicated primary cemented THA in our hospital asymptomatic implant failure is unlikely. Symptomatic patients tend to present mainly to their GP and other specialities, rather than orthopaedic follow-up OPAs. Early discharge after return to full normal activities would be safe and lead to significant financial savings.
Anterior knee pain post Total knee Replacement (TKR) has been reported to be as high as 49%. The source is poorly understood; both the peripatellar soft tissues and the infrapatellar fat pad have been implicated. Immunohistochemical studies demonstrate hyperinnervation of the peripatellar soft tissues. In theory circumferential electrocautery denervates the patella. However there is little evidence that this practice translates into improved clinical outcomes This study aimed to find the effect on clinical outcome, of intraoperative circumpatellar electrocautery in patients undergoing TKR. 200 patients undergoing primary TKR were randomised to circumferential circumpatellar electrocautery or nothing. Patients were assessed for Visual (VAS) for anterior knee pain and Oxford Knee Score (OKS) preoperatively, 3 months, 6 months and 1 year post-procedure. Patients and assessors were blinded to treatment allocation until the end of the study. There were 91 patients in the electrocautery group and 94 controls. The mean VAS improvement from pre-op to one year was 3.8 in both groups. The mean improvement in OKS was 16.6 points in the control and 17.7 in the electrocautery group (p= 0.40). There were no significant differences between the two groups in terms of VAS or OKS at any other time. Although previous studies have conflicting outcomes, to our knowledge this is the first prospective randomised controlled blinded trial of significant power, to evaluate the effect of peripatellar diathermy in TKR. We conclude that denervation electrocautery of the patella makes no difference to the clinical outcomes of TKR.
The survivorship of the Corin femoral stem component for primary hip arthroplasty is described. The Corin Taper-Fit Femoral System was designed on the same biomechanical principles as the Exeter femoral stem but with an introducer designed to improve accuracy of insertion. Between 1995 and 1999, 246 Corin Taper-Fit stems were implanted in 222 patients. All procedures were performed in a Distrtict General Hospital. The Elite/Ogee acetabular component was used in all but 2 of the hips. Seven patients were lost to follow-up during the period of this study and 68 patients (71 hips) died. No femoral component was revised for aseptic loosening. Three hips were classified as failures of the acetabular component, two of these were for recurrent dislocation, and the other is not recorded. No hip was revised for deep infection. The ‘worst case’ scenario, including the patients lost to follow up, is a survival rate of 97% for the femoral component at 14years. These results show that the medium term outcome for this implant, used in a district general hospital, are excellent. This supports other studies which show impressive medium term results with cemented tapered polished stems.
Total hip replacement using components from different manufactures is common and has been known as cross-breed arthroplasty. The implant industry clearly advises against it for primary arthroplasty, even though this has been the accepted practice in revision hip surgery. The response of the Medicine and Healthcare products Regulatory Agency is to agree with the manufacturers. Thus this advice has been implemented in National Institute of Clinical Excellence guidelines without any supportive clinical data. A consecutive series of 206 crossbreed total hip arthroplasties were performed in 192 patients by a single surgeon between 1990 and 1993. These were observed for an average 11.5 years (range, 10–13years). There were 126 women and 80 men with an average age of 69 (range, 41–89) at the time of surgery. There were 9 failures defined as reoperation. Of these, 5 were for aseptic loosening of cup, 2 for deep infection, 1 for recurrent dislocation and 1 for revision of stem for Periprosthetic fracture following a fall. There was no aseptic loosening of stem. With survivorship to date of 94% these data suggest that it is safe to continue using at least one of the common combinations in primary hip arthroplasty.
Cement pressurisation is recognised as critical to achieving optimal results in cemented arthroplasty of the hip, but relatively little data exists on the pressures generated by different cement introduction systems. An Plastic femoral models (Sawbones Europe) were prepared as for hip arthroplasty, and had a series of three transducers attached to their medial wall. Pressure was recorded continuously during cement introduction and pressurisation, before implanting a hip prosthesis and allowing the cement to cure. The experiment was repeated on ten models for each of the three systems. After cement curing, the femora were split in the coronal plane and examined for air-bubble defects in 7 zones analogous to Gruen’s radiographic zones. Mean pressure was significantly higher for the syringe system (161.45 ± 28.9 kPa) than the Mark 1 (103.51 ± 22.0 kPa) or Cemvac (92.65 ± 30.7 kPa) systems ( These results have relevance for clinical practice and cement system design, and the various design features of the different systems are discussed.
The Scottish Hip Fracture Audit started in four hospitals in 1993. To date, all except two, hospitals doing hip fractures have been involved in the audit. Participation has been intermittent due to a lack of funds to pay for the audit staff. Nonetheless there are now 19,000 patients recorded on the database. This allows individual hospitals to compare their workload over time and to compare local data with national comparators. Unfortunately many of the outcome parameters involve soft end points such as the delay in operation or the proportion of patients who are sent for formal rehabilitation. Much of the data has simply confirmed what surgeons have always suspected. The injury is becoming more common, the patients are getting older and the patients are becoming less fit. Co-morbidities are frequent and the strongest predictor of mortality is the age of the patient at presentation. What the audit has done from a surgeon’s viewpoint is to define the general lack of resources devoted to this injury and to provide evidence which has been used in many hospitals particularly to increase the availability of operating time. Equally as no surprise comes the realisation that surgery is often the least part of the care of these patients. Evidence from the audit has allowed many hospitals to encourage greater participation by geriatricians in the overall care of these patients. The use of the specialist nurse in hip fractures who has responsibility for all aspects of care including follow up has been particularly useful and is recommended in all units. There are however, two huge problems arising from this data. The first, is that the existence of the data means there is something which can be measured and in consequence this has been used as a management tool to measure performance yet where hospitals have been found lacking, resources have not always been made available to improve performance. The second and newer problem relates to the existing anonymity of data. At present the system is very much like critical incident reporting in the airline industry and no surgeon, anaesthetist or hospital is individually identified in any of the published data. The Freedom of Information Act, which has recently come into force in the UK, may now make is possible for anyone to obtain individual named data on both doctors and hospitals. While threatening, this development now seems inevitable but may discourage full participation in future audit. In spite of these concerns individual clinicians remain enthusiastic about the audit and England, Wales and Northern Ireland have shown considerable interest in developing the audit into a UK wide system.
Cement pressurisation is recognised as critical to achieving optimal results in cemented arthroplasty of the hip, but relatively little data exists on the pressures generated by different cement introduction systems. An in vitro experiment was consequently undertaken to measure the mean pressures developed by three such systems: the Howmedica Mark 1 and DePuy Cemvac retrograde cementation systems, and a novel antegrade system consisting of a simple 60ml catheter-tipped syringe and a Miller proximal femoral seal (Zimmer Ltd). Plastic femoral models (Sawbones Europe) were prepared as for hip arthroplasty, and had a series of three transducers attached to their medial wall. Pressure was recorded continuously during cement introduction and pressurisation, before implanting a hip prosthesis and allowing the cement to cure. The experiment was repeated on ten models for each of the three systems. After cement curing, the femora were split in the coronal plane and examined for air-bubble defects in 7 zones analogous to Gruen’s radiographic zones. Mean pressure was significantly higher for the syringe system (161.45 28.9 kPa) than the Mark 1 (103.51 22.0 kPa) or Cemvac (92.65 30.7 kPa) systems (p=0.0001, ANOVA). The antegrade syringe system also generated a statistically different distribution of pressure in comparison to the two retrograde systems, with particularly high proximal pressurisation in the former. The median number of zones with defects was 1 (interquartile range 1,2) using the syringe system, 3 (IQR 2,4) with the Mark 1 system, and 3 (IQR1,3) using the Cemvac system. These differences were also statistically significant (p=0.0256, Kruskal-Wallis). These results have relevance for clinical practice and cement system design, and the various design features of the different systems are discussed.
This study reports the outcome of using the Posterior Lip Augmentation Device (PLAD) for recurrent dislocation of total hip replacement. Twenty-seven patients (16 in Inverness, 11 in Leeds) were treated with the device. The indication for its use was recurrent dislocation of the hip in a patient who had a well-orientated and well-fixed cemented acetabular component. The patients had had between 2 and 14 dislocations before using the PLAD. 24 of the 27 patients had satisfactory control of the dislocations after surgery. The operation was found to be straightforward in most cases with few complications, although one case in the Inverness series has a partial sciatic nerve palsy which is recovering. Of the three failures, two had recurrent dislocation after the use of the PLAD. In one of these, in whom the dislocation followed acetabular reconstruction with impaction grafting, the cup also pulled out due to the semi-captive state after use of the PLAD. Both of these cases were treated by a Girdlestone excision arthroplasty. There was one final failure in whom there has been no further dislocation but following an abduction injury some four months after surgery, progressive cup loosening developed and he awaits revision of the cup. One patient complains of an occasional click in the hip joint and a broken screw is visible on x-ray but there has been no loss of position of the device and no further evidence of dislocation. Overall, we have found that this device gives satisfactory control of recurrent dislocations of the hip but the failures have stressed the need to ensure that the cup fixation is sound before inserting the device.
We report the results of acetabular reconstruction using a bipolar prosthesis bearing on cancellous bone graft in 37 patients after a minimum of five years. There was a satisfactory clinical outcome in 58% when assessed by pain, range of movement and stability, with greater improvement in the pain score than of the other parameters. Radiological migration of the prosthesis was a frequent finding although this did not always correlate with symptoms. Better results were obtained in cases of primary or secondary protrusio acetabuli than after the revision of previous total arthroplasties.
We aimed to develop a better understanding and method of rating the success or failure of low back surgery by studying 185 patients prospectively. Identical pre-operative and postoperative assessment by an independent observer included pain, disability, physical impairment, psychological distress and illness behaviour. Outcome was assessed by the patient, by the observer and by return to work. There was 96% follow-up at two years. Correlation co-efficients varied considerably between the various measures of outcome, both patient and observer appearing to base their assessment mainly on postoperative status rather than on any change produced by surgery. The observer was influenced most by postoperative pain, disability and physical impairment. Patients were influenced most by residual physical impairment, type of surgery and proportional change in disability. Return to work was moderately influenced by postoperative disability and to a larger extent by social and work-related factors. We developed a simple formula to judge overall success or failure which accurately reproduced the combined assessment of patient and observer. If surgical audit is to be meaningful it must be based on an improved understanding of how the outcome of surgery should be assessed.
We present the results of 506 consecutive Howse hip arthroplasties with a minimum follow-up of 10 years. The mortality within one month of surgery was 0.79%. The early dislocation rate was 1.38%, two hips requiring revision. Nine hips developed deep sepsis (1.78%), eight of which required revision. At 10 years 42 hips (8.3%) had required revision, including 14 with aseptic acetabular loosening and 11 with femoral stem fractures. We feel that as judged by the dislocation rate and the need for subsequent revision, the Howse arthroplasty is an acceptable form of total hip replacement, particularly in the older patient and in those requiring total replacement for femoral neck fractures.
