Medial patellofemoral ligament (MPFL) reconstruction is an effective procedure to address patellofemoral instability, however there remains no clear consensus on the optimum technique. Variations in patella tunnel and the use of patella fixation devices are reported in the literature, as are the associated complications of patella fracture and hardware irritation. We present the early results using a two tunnel, Endobutton free technique. 24 MPFL reconstructions (14 female, 10 male) were performed by a single surgeon, using two 3.5mm medial patellar tunnels exiting anteriorly and a looped, extra-synovial hamstring autograft. Femoral fixation was achieved using an non-absorbable interference screw. Mean age was 25.5 years, with a mean follow-up of 21.7 months. Mean Kujala scores were 60.8 preoperatively and 87.9 postoperatively (p<0.0001). No patient experienced further dislocation or patella fracture post-operatively. One patient required interference screw removal. The surgical technique presented has outcomes comparable with the literature. It requires a shorter tendon graft, and removes the need for a patellar fixation device, reducing potential irritation and cost.
In September 2011 our departmental protocol for peri-operative prophylactic antibiotic administration was altered from cefuroxime to gentamicin/flucloxacillin, in response to reported links between cephalosporin use and Clostridium difficile (C. diff) infection. As both gentamicin and flucloxacillin are known to be nephrotoxic in some patients, we investigated whether the new regimen increases the risk of Acute Kidney Injury (AKI) in patients undergoing elective and trauma hip and knee surgery, classified by severity (AKI Network criteria). The incidence of C. diff was noted. 10 out of 202 (5%) patients receiving cefuroxime (group A) developed AKI, compared with 23 of 210 (11%) patients receiving gentamicin and flucloxacillin (group B) (p=0.012). The severity of the renal injury was higher in the group B patients with 16 sustaining stage II/III AKI, whereas in Group A only one patient sustained a stage II injury and none stage III. The increased AKI rate in group B was observed equally in hip fracture patients and elective hip/knee replacement patients. However, 3 of 80 (4%) patients with hip fractures who received doses of cefuroxime developed C. diff, with none in the other groups (p=0.04). The choice of prophylactic antibiotics depends on a careful assessment of benefits and risks. Our data suggests that whereas hip fracture patients may have benefitted from the protocol change with reduced C. diff incidence, elective hip and knee replacement patients sustained additional harm. Different antibiotic regimens may be appropriate for these two groups.
The introduction of direct thrombin inhibitors in arthroplasty surgery has reignited the debate on the risk of wound complications when using chemical thromboprophylaxis. It has been suggested that direct thrombin inhibitors might lead to an increased risk of systemic and operative site bleeding and wound sepsis when compared to low molecular weight heparin. In July 2009, departmental thromboprophylaxis policy for patients undergoing hip and knee replacement surgery (including revision) was changed from subcutaneous enoxaparin for the duration of inpatient stay to dabigatran for 10 days (knees) or 28 days (hips) unless contraindicated. In the 2 years prior to policy change, 1091 patients underwent hip or knee arthroplasty (Group A), with1150 patients undergoing the same procedures in the 2 years following July 2009 (Group B). A minority of patients were already on warfarin (2% in group 1, 3% in group 2). This study presents a retrospective analysis of all patients who returned to theatre within 30 days of joint replacement surgery to assess whether the change in unit policy caused any discernible increase in bleeding-related complications. In group A, 20/1091 patients (1.8%) returned to theatre within 30 days. 9 were for reasons unrelated to thromboprophylaxis (mainly dislocated hips), 4 for gastrointestinal bleeding and 7 for wound complications (haematoma, wound breakdown, or infection). In group B, 22/1150 patients (1.9%) returned to theatre within 30 days. 13 were for unrelated reasons, 4 for gastrointestinal bleeding, and 5 for wound complications. One patient with a wound complication was on warfarin and therefore did not receive dabigatran. The lower wound complication rate in group B was not statistically different. This study, in a large heterogeneous group of patients, suggests that a change from enoxaparin to dabigatran does not increase the incidence of local or systemic complications of sufficient severity to warrant return to theatre.
The introduction of direct thrombin inhibitors in arthroplasty surgery has reignited the debate on the risk of wound complications when using chemical thromboprophylaxis. It has been suggested that direct thrombin inhibitors might lead to an increased risk of systemic and operative site bleeding and wound sepsis when compared to low molecular weight heparin. In July 2009, departmental thromboprophylaxis policy for patients undergoing hip and knee replacement surgery (including revision) was changed from subcutaneous enoxaparin for the duration of inpatient stay to dabigatran for 10 days (knees) or 28 days (hips) unless contraindidated. In the 2 years prior to policy change, 1091 patients underwent hip or knee arthroplasty (Group 1), with1150 patients undergoing the same procedures in the 2 years following July 2009 (Group 2). A minority of patients were already on warfarin (2% in group 1, 3% in group 2). This study presents a retrospective analysis of all patients who returned to theatre within 30 days of joint replacement surgery to assess whether the change in unit policy caused any discernible increase in bleeding-related complications. In group 1, 23/1091 patients (2.1%) returned to theatre within 30 days. 8 were for reasons unrelated to thromboprophylaxis (mainly dislocated hips), 5 for gastrointestinal bleeding (mainly upper GI endoscopy) and 10 for wound complications (haematoma, wound breakdown, or washout of early infection). In group 2, 22 / 1150 patients (1.9%) returned to theatre within 30 days. 12 were for unrelated reasons, 5 for GI bleeding, and 5 for wound complications. The lower return to theatre rate in the second group was not statistically different. This study, in a large heterogeneous group of patients, suggests that a change from enoxaparin to dabigatran does not increase the incidence of early infection, or the risk of bleeding at the operative site or the gastrointestinal tract.
