Introduction

Bundled reimbursement models for total knee arthroplasty (TKA) by the Center for Medicare and Medicaid Services (CMS) have resulted in an effort to decrease the cost of care. However, these models may incentivize bias in patient selection to avoid excess cost of care. We sought to determine the impact of the Comprehensive Care for Joint Replacement (CJR) model at a single center.

Introduction

The Comprehensive Care for Joint Replacement (CJR) model for total hip arthroplasty (THA) involves a target reimbursement set by the Center for Medicare and Medicaid Services (CMS). Many patients exceed these targets, but predicting risk for incurring these excess costs remains challenging, and we hypothesized that select patient characteristics would adequately predict CJR cost overruns.

This is a case series of 25 patients with Multiple Epiphyseal Dysplasia (MED), a genetically determined disorder characterised by abnormal ossification of multiple epiphyses. The Nottingham Skeletal Dysplasia Clinic has run since 1966. In 1994 it combined with the Clinical Genetics Service providing care to patients from throughout the region. We collected data on MED patients with follow up of 1 to 41 years (average 12 years) and described their presenting symptoms, genetic, clinical and radiographic features. We followed the natural history and vast array of treatments.

From the genetic point of view, 90% of patients counselled had typical AD-MED and 10% syndromic MED. Seven families opted to have testing. There were MATN3 mutations in 10% of the cohort, with marked intra-familial variability of phenotype. The average age at presentation was thirteen, with 80% of patients presenting before their sixteenth birthday. A third was seen because of a known family history of MED. Newly diagnosed index patients tended to present later. The most commonly affected joint at presentation was the hip and the most common knee deformity genu valgum. Symptoms progressed with time and joints not clinically affected at presentation became symptomatic later. Sixty percent of patients had further joint involvement within 10 years of diagnosis. Treatment ranged from orthotics to arthroplasty. Half of patients required surgical intervention at least once. Six patients underwent hip arthroplasty at an average age of 37.

MED is a rare diagnosis but has significant impact on the quality of life of those diagnosed, who require the support of a multidisciplinary team from an early age. This is not only to help manage symptoms and preserve function, but also to counsel on the progressive nature and the genetic aspects of the disorder.

Introduction and Aims: This is a prospective randomised trial comparing the ABG uncemented total hip replacement with the Charnley in 243 patients less than 65 years of age. A standardised protocol and anterolateral approach was used.

Method: The ABG I cup was used in combination with a polyethylene liner. All stems were templated and a 28mm cobalt chrome head was used. Early mobilisation with partial weightbearing for six weeks was allowed. In the Charnley group, Elite polyethylene cups were used in conjunction with 22mm monoblock stems. All hips were inserted with pressurised CMW cement. Patients were followed up annually. Standardised radiographs were taken at each visit and the Harris hip score and Merle d’Aubigné outcome measures recorded.

There were 222 hips available for follow-up, 96 ABG hips and 126 Charnley hips (17 died and 10 were lost to follow-up), with the mean age at surgery and mean length of follow-up comparable. Most hips were replaced due to osteoarthritis.

There was no significant difference in the mean Harris hip or Merle d’Aubigné scores at one year and at latest follow-up.

Results: Radiographic results demonstrated accelerated polyethylene wear in the ABG hips with mean polyethylene wear at seven years being 2.1mm compared with 0.9mm for Charnley hips. Wear associated lysis around the ABG cup was the major reason for failure, with a total of eight cups (8.3%) undergoing revision.

Conclusion: There was no evidence of subsidence of the stem or osteolysis around the stem despite the polyethylene wear. Conversely, in the Charnley group the stem was the major reason for failure with 12 stems (9.5%) being revised for aseptic loosening. The Kaplan Meier Survivorship at 10 years was 66.6% ± 19.1% for the ABG and ± 82% for the Charnley group. This was not significant.

We have reviewed the results of 19 ankle arthrodeses in 18 patients by a new technique of posterior internal compression. Sixteen of the ankles fused at a mean time of 14 weeks and the other three after reoperation. Complications included one case each of infection, Sudeck's atrophy and non-fatal pulmonary embolism. Clinical assessment using Mazur's ankle score showed excellent or good results in nine ankles and three painfree ankles in patients who were wheelchair-bound for other reasons. The mean position of fusion was in 1.7 degrees equinus and 0.8 degrees varus, and the mean range of midtarsal movements was 15.8 degrees. Twelve patients showed radiographic signs of talonavicular or subtalar osteoarthritis.

Tricho-rhino-phalangeal syndrome is probably not so much uncommon as unrecognised. Its significance to orthopaedic surgeons, apart from the functionally unimportant minor finger deformities, lies in its mimicking both Perthes' disease and diaphyseal aclasis. The 14 cases analysed in this paper illustrate the wide range of clinical variation.