Musculoskeletal disorders have been recognised as common occupational risks for all orthopaedic surgeons. The nature of tasks performed by hip surgeons often requires both forceful and repetitive manoeuvres, potentially putting them at higher risk of musculoskeletal injuries compared to other orthopaedic sub-specialities. This study aimed to investigate the prevalence of musculoskeletal conditions among hip surgeons and evaluate the association between their workplace and lifestyle factors and musculoskeletal health.

An online questionnaire consisting of 22 questions was distributed to UK-based consultant hip surgeons via email and social media platforms. This survey was completed by 105 hip surgeons.

The mean age of the respondents was 49 years (range 35–69), with an average of 12 years (range 1–33) in service. 94% were full-time and 6% worked part-time. 49% worked at a district general hospital, 49% at a tertiary centre and 4% at a private institution. 80% were on the on-call rota and 69% had additional trauma commitments. 91% reported having one or more, 50% with three or more and 13% with five or more musculoskeletal conditions. 64% attributed their musculoskeletal condition to their profession. The most common musculoskeletal conditions were base of thumb arthritis (22%), subacromial impingement (20%), degenerative lumbar spine (18%) and medial or lateral epicondylitis (18%). 60% stated that they experienced lower back pain. Statistical analysis showed that being on the on-call rota was significantly (P<0.001) associated with a higher musculoskeletal burden. Regular resistance and/or endurance training and BMI<30 were statistically significant protective factors (P<0.001).

Over the last few decades, most of the hip-related literature has focused on improving outcomes in patients, yet very little is known about the impact of hip surgery on the musculoskeletal health of hip surgeons. This study highlights a high prevalence of musculoskeletal conditions among UK-based hip surgeons. Hip surgeons have a pivotal role to play in the ongoing recovery of elective orthopaedics services. There is a pressing need for the identification of preventative measures and improvement in the surgical environment of our hip surgeons.

Abstract

Infection is a leading indication for revision arthroplasty. Established criteria used to diagnose prosthetic joint infection (PJI) include a range of laboratory tests. Leucocyte esterase (LE) is widely used on a colorimetric reagent strip for the diagnosis of urinary tract infections. This inexpensive test may be used for the diagnosis or exclusion of PJI. Aspirates from 30 total hip arthroplasties (THAs) and 79 knee arthroplasties (KA) were analysed for LE activity. Semi-quantitative reagent strip readings of 15, 70, 125 and 500 white blood cells (WBC) were validated against a manual synovial white cell count (WCC). A receiver operating characteristic (ROC) curve was constructed to determine the optimal cut-off point for the semi-quantitative results. Based on established criteria, six THAs and 15 KAs were classified as infected. The optimal cut-off point for the diagnosis of PJI was 97 WBC. The closest semi-quantitative reading for a positive result was 125 WBC, achieving a sensitivity of 81% and a specificity of 93%. The positive and negative predictive values of the LE test strip were 74% and 95% respectively.

The LE reagent strip had a high specificity and negative predictive value. A negative result may exclude PJI and negate the need for further diagnostic tests.

Cite this article: Bone Joint J 2015;97-B:1232–6.

The optimum design for the femoral component for cementless Total Hip Replacement is not known. We conducted an ethically approved, randomised and prospective trial to compare two radically different designs of fully hydroxyapatite (HA) coated femoral stems. We compared the original JRI Furlong stem with the Wright Anca fit stem which is more anatomical in design. The paper discusses the merits and disadvantages of these two stems. The same acetabular component was used in both samples. The only variable was the stem shape.

All patients placed on the senior author's waiting list for primary THR were asked if they would enter the trial. There were no restrictions for selection to the sample. Patients were then randomised for one of the two stems. All surgery was performed by or under the direct supervision of the senior author. The periprosthetic and perioperative fracture rates for the two stems were found to be significantly different at three years into the study and the trial was stopped. 337 patients had been entered into the trial, 211 females and 126 males.

191 patients had the JRI furlong hip implanted (57%) and 146 are in the Anca sample (43%).

The number of perioperative fractures in the Furlong group was 13 (6.8%)and in the Anca sample 22 (15.1%). This is statistically significant. The possible reasons for this difference are discussed.

Anatomical fit cementless stems require a more careful technique to avoid fracture during implantation and the shorter stemmed Anca hip proved less stable in the presence of a fracture necessitating further surgical intervention. It is still not certain whether the anatomical shape has long term advantages that may outweigh this initial disadvantage and the cohort of patients continues to be followed up.

Femoro-acetabular impingement (FAI) is an increasingly diagnosed cause of hip pain in young patients. It may progress to cause labral injury and chondral damage within the hip.

Surgery can be undertaken arthroscopically but is not universally available. Open approach to the hip with surgical dislocation, labral surgery and impingement lesion reduction is an acceptable alternative. Described by Ganz in 2001 the approach must conserve the postero-lateral blood supply to the femoral head and neck, to minimize the risk of Avascular Necrosis (AVN). Ganz recommended a sliding trochanteric osteotomy to widen access, and an anterior capsulotomy avoiding dissection postero-lateral to the femoral neck. To date there has been no published support for the Hardinge-type antero-lateral approach.

We describe a series of 26 consecutive patients with FAI, all managed by open osteochondroplasty during 2008 via a modified anterolateral approach and capsule preserving exposure. Trochanteric osteotomy was not undertaken.

The series contained 14 males and 12 females with mean ages of 33 and 29 respectively. Patients were assessed both clinically and using the Non Arthritic Hip Score (NAHS). Assessments were undertaken pre-operatively and at 8 and 16 weeks post-operatively. The mean NAHS pre-op was 54. This improved to 87 at 16 weeks. 77% of our patients achieved a NAHS of 75 or greater indicating a good or excellent result. Three patients had poor outcome and progression of osteoarthritic symptoms. There were no complications from the osteochondroplasty and all patients were Trendelenberg negative by 16 weeks.

We believe hip osteochondroplasty can be safely and effectively undertaken via an anterolateral approach, without a trochanteric osteotomy.

The optimum design for the femoral component for cementless Total Hip Replacement is not known. We conducted an ethically approved, randomized and prospective trial to compare two radically different designs of fully hydroxyapatite (HA) coated femoral stems. We compared the original JRI Furlong stem with the Wright Anca fit stem which is more anatomical in design. The paper discusses the merits and disadvantages of these two stems. The same acetabular component was used in both samples. The only variable was the stem shape.

All patients placed on the senior authors’ waiting list for primary THR were asked if they would enter the trial. There were no restrictions for selection to the sample. Patients were then randomised for one of the two stems. All surgery was performed by or under the direct supervision of the senior author in one center. The surgical approach to the hip, Hardinge antero lateral, was the same in all cases. In all cases the same well-tried JRI CSF acetabular cup and bearings were used. Patients were x-rayed post operatively and reviewed and x-rayed at six weeks and then yearly.

360 patients had been entered into the trial, 219 females and 141 males. 203 patients had the JRI furlong hip implanted (56%) and 157 were in the Anca sample (44%). The periprosthetic and perioperative fracture rates for the two stems were found to be significantly different at three years into the study and the trial was stopped. The number of perioperative fractures in the Furlong group was 17(8.4%)and in the Anca sample 24 (15.3%). This is statistically significant. The possible reasons for this difference are discussed.

Anatomical fit and wedge shaped cementless stems require a more careful technique to avoid fracture during implantation and the shorter stemmed Anca hip proved less stable in the presence of a fracture necessitating further surgical intervention. It is still not certain whether the anatomical shape has long term advantages that may outweigh this initial disadvantage and the cohort of patients continue to be followed up.

Aim: To introduce a new concept of Envelope of Laxity (EoL) in knee arthroplasty surgery for balancing a total knee replacement (TKR).

Methods: Twenty consecutive patients with varus knees undergoing TKR were included in the study. All operations were performed by the senior author using the Stryker Navigation system and the Scorpio cruciate retaining (CR) TKR. After registration with the navigation system initial dynamic varus/valgus curves were recorded from 0–120° flexion to give an EoL of the native knee. Repeated measurements were taken after trial components were initially inserted, then after any soft tissue releases and finally after insertion of actual tibial and femoral components. All measurements were taken with the patellar in situ.

Results: The average deformity in the varus group initially was 6.9° varus at 0°, 8.9° varus at 30°, 6.9° varus at 60° and 5° varus at 90° of knee flexion. Postoperatively values were found to be 0.1°, 0°,0.3°and 0.7°respectively. The initial EoL curves showed a mean increase in laxity of 4° between 30° and 60°compared to 0°–30° and 60°–90° through the range of knee flexion. This was seen less in the outcome curves which tended to show more uniform laxity with only an average of 2° difference throughout flexion.

Conclusions: Traditional balancing devices used in TKR surgery balance knees at 0° and 90°, often with the patellar everted which produces errors. The use of EoL curves allows knees to be balanced throughout the arc of movement from 0–150° with the patellar in situ. This study demonstrates the successful use of the EoL concept and that even when knees are balanced at 0° and 90° they may not be balanced at the mid flexion position where clinical problems often arise. This problem becomes worse with the use of poly radii TKR designs.

The optimum design for the femoral component for cementless Total Hip Replacement is not known. We conducted an ethically approved, randomized and prospective trial to compare two radically different designs of fully hydroxyapatite(HA) coated femoral stems. We compared the original JRI Furlong stem with the Wright Anca fit stem which is more anatomical in design. The paper discusses the merits and disadvantages of these two stems. The same acetabular component was used in both samples. The only variable was the stem shape.

All patients placed on the senior authors’ waiting list for primary THR were asked if they would enter the trial. There were no restrictions for selection to the sample. Patients were then randomised for one of the two stems. The surgery was undertaken by one surgeon, in one centre, in matched patients and using the same well-tried CSF acetabular cup and bearings.

335 patients had been entered into the trial, 228 females and 126 males.

191 patients had the JRI furlong hip implanted (57%) and 146 are in the Anca sample (43%).

The number of perioperative fractures in the Furlong group was 13(6.8%)and in the Anca sample 22 (15.3%).

The periprosthetic and perioperative fracture rates for the two stems were found to be significantly different at three years into the study and the trial was stopped. The possible reasons for this difference are discussed.

Aims: To determine the difference between macroscopic and microscopic appearances of the anterior cruciate ligament (ACL) in patients with osteoarthritis undergoing total knee replacement.

Methods: Patients admitted for routine total knee replacement (TKR) for osteoarthritis were assessed. The integrity of the ACL was noted as normal, moderately damaged (fissured) or complete rupture on a macroscopic level at the time of surgery. The ACL was sacrificed as a normal step in the operation and sent for histological analysis. The macroscopic and microscopic findings of ACL histology were compared using a common grading system (Grade 1 = normal, Grade 2 = moderately diseased, Grade 3 = severely diseased).

Results: The sample contained 48 patients, 17 male and 31 female, age range 55–87 years (mean 73). After exclusions, at surgery 7 ACL ruptures and 8 moderately diseased ligaments (defined by the presence of visible fissuring) were found despite negative pivot shift tests preoperatively. Of the 30 ACL’s that were found to be macroscopically normal, 22 of these (73%) were microscopically moderately or severely diseased.

Conclusion: We have found that a macroscopically normal ACL does not necessarily equate to microscopic integrity in the presence of osteoarthritis. This is an important consideration given the current trend towards unicompartmental knee replacement and highlights the possible need for investigation with appropriate imaging (MRI) and arthroscopy prior to this specific surgery.

The Pipino prosthesis was introduced as an alternative to hip resurfacing because of its bone preserving capability. Preserving the femoral neck to a greater extent saves valuable bonestock for possible revision procedures. The stem (proximal 2/3) and acetabular cup are hydroxyapatite coated. Bearings were all either ceramic or metal on polyethylene. All procedures were performed or directly supervised by the senior author.

Patients in the cohort were assessed pre-operatively, in the short term and the medium term using the Harris Hip Score(HHS). Hip radiographs were performed at medium term follow-up to assess for radiological signs of aseptic loosening.

The study is based on a cohort of 70 patients, 34 male and 36 female with mean age of 52 (range 13-71). Followed up over a mean period of 43 months (range 17-60). 70 patients were contacted and 64 patients were reviewed. Four patients were lost to follow-up. Indications for surgery were Osteoarthritis (56); Rheumatoid arthritis (8); AVN (3); SUFE (2); Perthes (2); DDH (1); Psoriatic Arthropathy (1).

The cohort’s preoperative HHS showed a mean 50.1 (range 25-88). This increased to a mean of 95.9 (range 55-100) in the short term review period, during the medium term review the mean 93.6 (range 63-100). With 82% of patients in the excellent group and 88% good to excellent group.

At the final review there was one case of aseptic loosening (Cup) which required revision surgery. There were 2 dislocations and one intraoperative lateral femoral wall fracture and no cases of superficial or deep infection.

In conclusion we believe that the Pipino collum femo-ris preserving total hip arthroplasty has excellent short and medium term results.