Aims

Due to widespread cancellations in elective orthopaedic procedures, the number of patients on waiting list for surgery is rising. We aim to determine and quantify if disparities exist between inpatient and day-case orthopaedic waiting list numbers; we also aim to determine if there is a ‘hidden burden’ that already exists due to reductions in elective secondary care referrals.

Patellar resurfacing in total knee arthroplasty remains controversial. We report the medium term results of patients who had Scorpio total knee replacement for osteoarthritis between January 2002 and September 2004. A retrospective review of 118 patients was undertaken. All patients during the first half of this time period had no resurfacing of the patella, and all patients in the later half of this period underwent resurfacing of the patella. The mean follow-up in the non-resurfaced group was 30 months and the mean follow-up in the resurfaced group was 17 months. The two groups were similar in age, gender and the grade of the surgeon. Knee society clinical rating score, patient satisfaction, anterior knee pain, patellofemoral questionnaires, patellofemoral revision rates and success in returning to normal daily activities were noted.

There was a significant difference between the two groups in the patellar revision rates, anterior knee pain and Euroquol scores. The incidence of anterior knee pain in the patella non-resurfaced group was 23%, compared to 6% in the resurfaced group [p<0.05]. The rate of revision in the non-resurfaced group was 11% compared to 0% in the resurfaced group [p=0.03]. The mean Euroquol score in the resurfaced group was 86.44 compared to 80.35 [p=0.04]. Knee Society score, patient satisfaction, symptoms of patellar apprehension and knee instability, return to pre-op functional level, ability to kneel, use of a walking aid, presence of limp and satisfaction with operation as not statistically different between the two groups.

In view of the statistically significant difference in the incidence of anterior knee pain and the rate of revision in the group of patients without patellar resurfacing, the authors suggest that retaining the patellar surface may not be a viable option. Although an appropriate design for the femoral prosthetic trochlea is an important factor, a good surgical technique with patellar resurfacing is more likely to result in predictable satisfactory results. We feel that high contact pressures between the non-resurfaced patellae and the prosthetic femoral trochlea can be generated after a total knee replacement when the patella is not resurfaced, and can thus result in patients having anterior knee pain.

We compared revision and mortality rates of 4668 patients undergoing primary total hip and knee replacement between 1989 and 2007 at a University Hospital in New Zealand. The mean age at the time of surgery was 69 years (16 to 100). A total of 1175 patients (25%) had died at follow-up at a mean of ten years post-operatively. The mean age of those who died within ten years of surgery was 74.4 years (29 to 97) at time of surgery. No change in comorbidity score or age of the patients receiving joint replacement was noted during the study period. No association of revision or death could be proven with higher comorbidity scoring, grade of surgeon, or patient gender.

We found that patients younger than 50 years at the time of surgery have a greater chance of requiring a revision than of dying, those around 58 years of age have a 50:50 chance of needing a revision, and in those older than 62 years the prosthesis will normally outlast the patient. Patients over 77 years old have a greater than 90% chance of dying than requiring a revision whereas those around 47 years are on average twice as likely to require a revision than die. This information can be used to rationalise the need for long-term surveillance and during the informed consent process.

We determined the survival of primary total hip and knee replacements and patients who had undergone surgery between 1989 and 2007 in Dunedin with the aim to using these figures to provide information on

whether our arthroplasty population is changing,

The initial search using records held by the audit department at Dunedin Hospital returned 6,328 patient records with total hip and knee arthroplasty between 1988 and 2007. These reports however, included many procedures which were neither hip/knee nor primary/revision total joint arthroplasty. The data was filtered, resulting in 4,773 hip and knee arthroplasties. The final data included 3194 primary total hip replacements and 1579 primary total knee replacements. Comorbidity scoring of these patients was also undertaken.

The mean age of patients who underwent primary hip replacement was 67.6 yrs (SD 12.4) and the mean age of patients who underwent a primary knee replacement was 70.8 yrs (SD 9.8). Around 25% of patients who have had a primary joint replacement died after a mean of 10 yrs after the operation. In the group of patients who died after 10 years, the mean age at surgery was around 74 years. The mean age at the time of death was around 80 years. No difference was found in the death rate, revision rate, and the combined outcomes with death or revision as the end point with respect to the following-THRs. TKR, the grade of the surgeon, the comorbidity score or in men vs. women as compared to the general population.

Patients over 59 years of age at time of primary arthroplasty have a > 90% chance of dying before the need for revision surgery. Patients of less than 51 years of age have a > 90% chance of requiring revision surgery. Patients of 55 years of age have a 50% chance of requiring revision surgery. In a setting of ongoing scarce resources symptomatic/questionnaire targeted follow-up with radiology may be the only long term viable solution.

We reviewed the results at nine to 13 years of 125 total hip replacements in 113 patients using the monoblock uncemented Morscher press-fit acetabular component. The mean age at the time of operation was 56.9 years (36 to 74). The mean clinical follow-up was 11 years (9.7 to 13.5) and the mean radiological follow-up was 9.4 years (7.7 to 13.1). Three hips were revised, one immediately for instability, one for excessive wear and one for deep infection.

No revisions were required for aseptic loosening. A total of eight hips (7.0%) had osteolytic lesions greater than 1 cm, in four around the acetabular component (3.5%). One required bone grafting behind a well-fixed implant. The mean wear rate was 0.11 mm/year (0.06 to 0.78) and was significantly higher in components with a steeper abduction angle.

Kaplan-Meier survival curves at 13 years showed survival of 96.8% (95% confidence interval 90.2 to 99.0) for revision for any cause and of 95.7% (95% confidence interval 88.6 to 98.4) for any acetabular re-operation.

Non-operative treatment is usually employed in the treatment of femoral fractures in young individuals. Malunion, delayed union, joint stiffness, limb length discrepancy, psychological problems and delay in functional recovery are well known complications of conservative treatment. The length of hospital stay that will be a part of non-operative treatment will add to the cost of the treatment.

We report our experience with intramedullary nailing of closed femoral shaft fractures with a new femoral nail in adolescent patients with an open physis. We treated 13 patients between 1995 and 2004 aged between 8–16 years (8 males and 5 females) with a new femoral nail for closed femoral shaft fractures using the tip of the greater trochanter as the entry point. 11 of the 13 patients had removal of the femoral nail.

The mechanism of injury, length of hospital stay, patient mental well-being, surgical technique, requirement of secondary surgical procedures, associated complications, post-operative mobility, return to pre-injury status, range of movement at the hip and knee are discussed

At follow up ranging from few months to 7 years, we found no leg length discrepancy, rotational deformity, limp, problems with physis and all patients had a full range of movement at the hip and knee.

External fixation, elastic intramedullary nails, plate and screw fixation are other surgical options available to treat femoral shaft fractures. Children poorly tolerate external fixators and plate fixation can be associated with a high incidence of complications. Flexible intramedullary fixation of femoral shaft fractures is an attractive option, but is technically difficult and is associated with a learning curve. In our view, intramedullary nailing is a simple, safe, efficient and effective method of treatment of femoral shaft fractures in adolescent patients with open physis.

Aims: Irradiated allograft bone may help to reduce the risk of transmission of infectious agents from donor to recipient. The purpose of this study was to establish the results of impaction bone grafting of acetabular defects with froze, irradiated allograft bone. Methods: All patients treated by a single surgeon with impaction bone grafting of acetabular defects at revision total hip replacement were reviewed retrospectively. All operations were performed during the period 1994–2000. The mean follow-up was 50 months (range 30–96 months). Case notes and X rays were reviewed and analysed. The Paprosky grade of acetabular defects was determined from the pre-operative X rays and the surgeonñs operation note. Post-operative X rays were reviewed to establish the extent and rate of new bone in-growth. Functional outcomes were determined by way of self-administered questionnaires. Results: Complete records and X rays were obtained for 33 patients who underwent revision hip arthroplasty with impaction bone grafting of the acetabulum using frozen, irradiated allograft bone. There were no complications associated with the bone grafts and no patient required a re-operation. Review of serial X rays conþrmed in-growth of host bone and the functional outcome was satisfactory. Overall 29 patients (88%) declared themselves satis-þed with the outcome of their operation and 32 patients (97%) improved functionally after the operation. Conclusions: These results indicate that satisfactory results can be achieved with impaction bone grafting using frozen, irradiated allograft bone. The use of irradiated bone graft can potentially reduce the risk of disease transmission from donor to recipient without compromising the surgical results.

Irradiated allograft bone may help to reduce the risk of transmission of infectious agents from donor to recipient. The purpose of this study was to establish the results of impaction bone grafting of acetabular defects using irradiated allograft bone.

Patients treated with impaction bone grafting of ace-tabular defects between 1994 and 2000 were reviewed retrospectively. The mean follow-up was 50months (range 30–96months). Case notes and Xrays were reviewed and analysed. The Paprosky grade of acetabular defects was determined. Functional outcomes were determined by way of self-administered questionnaires.

Complete records and Xrays were obtained for 33 patients who underwent impaction bone grafting of the acetabulum using freeze-dried, irradiated bone. The Paprosky classifications of the defects were as follows: 3 type 1, 10 type 2A, 4 type 2B, 4 type 2C, 10 type 3A and 2 type 3B.

There were no complications associated with the bone grafts and no patient required reoperation. Review of serial Xrays confirmed ingrowth of host bone. The functional results obtained were as follows: 17 patients (52%) could walk an unlimited distance. 11 patients (33%) required no walking aids whilst a further 17 (52%) required a single cane to mobilise. 21 patients (64%) were able to use public transport after the operation. 20 patients (61%) reported little or no pain. 9 patients (28%) had no limp and 14 patients (42%) had a slight limp. Overall 29 patients (88%) declared themselves to be satisfied with the outcome of their surgery. 32 patients (97%) improved functionally after their operation.

These results indicate that satisfactory results can be achieved with impaction bone grafting using irradiated, frozen allograft bone. The use of irradiated bone graft can potentially reduce the risks of disease transmission from donor to recipient without compromising the surgical results.

The rate of deep infection following primary joint replacement has reduced to below 1%, but the cost remains high. The surgical team is the most important source of bacteria causing infection. All surgical gowns are susceptible to penetration by these organisms, which may then spread to the wound via the surgeon’s hands or contact with wet drapes without ever being airborne.

There is insufficient clinical data on the penetration of bacteria through surgical gowns, in part due to the difficulty of in vivo measurement. A simple new method was developed, using petri dishes filled with horse blood agar that were attached to the outside of the gown material. This was used to assess bacterial penetration through disposable spun-bonded polyester gowns and re-usable woven polyester gowns during normal use.

There was a significant difference between the two gown types when tested in the axilla (p < 0. 05), the groin (p < 0. 05) and the peri-anal region (p < 0. 01), with the disposable gowns performing to a higher standard.

Re-usable gowns demonstrated significant variation in penetrability. This is most likely to be due to the number of laundering and sterilisation cycles that they had undergone. Unless the continued satisfactory performance of multiple-use gowns can be guaranteed, they may be unsuitable for use in orthopaedic implant surgery.

Twelve patients undergoing total hip replacements were given 600mg linezolid as a 20min intravenous infusion along with conventional prophylaxis of 1gm cefamandole immediately before surgery. Routine total hip arthroplasty was performed and at timed intervals during surgery, samples of bone, fat, muscle and blood were collected for assay by HPLC analysis. Samples of haematoma fluid that formed around the operation site and further blood samples were also collected at timed intervals following the operation for assay. The penetration of linezolid into bone was rapid with mean levels of 9.1mg/L (95% CI: 7.7–10.6mg/L) achieved at 10min after the infusion, decreasing to 6.3mg/L (95% CI: 3.9–8.6mg/L) at 30min. Correcting for the simultaneous blood concentrations gave values for bone penetration of 51% at 10min, 60% at 20min and 47% at 30min. although the penetration of linezolid into fat was also rapid, mean levels and degree of penetration were approximately 60% of those seen in bone at 10min: 4.5mg/L (95%CI:3–6.1mg/L; penetration 27%) 20min: 5.2mg/L (95% CI:4–6.4mg/L; penetration 37%) and 30min:4.1mg/L (95% CI:3.3–4.8mg/L; penetration 31%). For muscle, the corresponding values were 10min: 10.4mg/L (95%CI:8.1–12.7mg/L; penetration 58%), 20min 13.4mg/L (95%:10.2–16.5mg/L; penetration 94%) and 30min 12mg/L (95% CI:9.2–14.8mg/L; penetration 93%). Mean concentration of linezolid in the haematoma around the operation site were 8.2mg/L at 6–8h and 5.6mg/L at 8–10h after the infusion and 7mg/L at 2–4h following a second 600mg infusion given 12h postoperatively.

We conclude that linezolid exhibits rapid penetration in bone, fat and muscle of patients undergoing hip arthroplasty to achieve levels in excess of the MIC for sensitive organisms (MIC of < _ 4mg/L); with therapeutic levels maintained in the drainage which surrounds the operation site for more than 16h. This pharmaco-kinetic profile is similar to those of agents currently used for the treatment of bone and associated soft tissue infections and suggests a role for linezolid in the management of such patients