Aims

To establish if COVID-19 has worsened outcomes in patients with AO 31 A or B type hip fractures.

Objectives

Tranexamic acid (TXA) is an anti-fibrinolytic medication commonly used to reduce perioperative bleeding. Increasingly, topical administration as an intra-articular injection or perioperative wash is being administered during surgery. Adult soft tissues have a poor regenerative capacity and therefore damage to these tissues can be harmful to the patient. This study investigated the effects of TXA on human periarticular tissues and primary cell cultures using clinically relevant concentrations.

The number of revision knee arthroplasties performed is projected to rise dramatically in the coming years. Primary knee arthroplasties are also being performed in younger patients increasing the likelihood of multiple revision procedures. Reconstruction can be challenging with bone stock deficiencies and ligament incompetence. The aim of this study was to present our results of revision total knee arthroplasty using metaphyseal sleeve components to aid reconstruction.

Sixty seven patients underwent revision total knee arthroplasty between September 2005 and November 2010 using metaphyseal sleeves. There were thirty one male and thirty six female patients. The indication for revision was aseptic loosening in thirty nine, sepsis in fifteen, malalignment in eight and instability in five patients. Thirty four patients had tibial sleeves, thirty patients had both tibial and femoral sleeves and three patients had femoral sleeves during revision.

The patients were followed up for a mean of 32 months (Range 12–60) with outcome data collected prospectively. The mean revised oxford knee scores for the patients improved from 15 (Range 2 to 29) preoperatively to 33 (Range 20 to 45) postoperatively. Mean arc of flexion following revision was 87 degrees (Range 55 to 120). Seventy six percent of patients were satisfied or very satisfied with the result of the revision surgery. There have been no radiographic complications specific to the sleeves and no re-operations. There has been one recurrence of infection in a patient revised for sepsis. This has been managed with suppressive antibiotics due to patient co-morbidities.

Metaphyseal sleeves are an effective adjunct in revision knee arthroplasty. We have had good results with their use. To our knowledge no larger series has been presented or published.

Summary

We report a large study of 331 patients at two years post operation who were prospectively randomised to receive either a rotating platform or a fixed bearing knee replacement of an otherwise identical design.

We undertook a study to determine the rates of infection and revision of total knee replacement (TKR) in patients with renal failure, renal transplantation and those undergoing renal dialysis in Scotland. The overall early and late infection rates were 1.10% and 2.19% compared with 1.06% and 2.01%, respectively, for non-renal patients. Patients with renal failure had a significantly increased risk of early infection (1.6%, relative risk 1.52, p = 0.002) and late infection (4.47%, relative risk 2.22, p < 0.001). Those on renal dialysis had significantly increased risks of late infection (8.03%, relative risk 3.99, p < 0.001) and early revision (3.70%, relative risk 4.40, p < 0.001). Renal transplant patients had a significantly increased risk of late infection, regardless of whether renal transplantation occurred before TKR (9.09%, relative risk 4.517, p = 0.027) or at any time (8.0%, relative risk 3.975, p = 0.047). There were significantly increased rates of comorbidities associated with infection for all the renal patient groups. Logistic regression analysis showed that renal failure and renal dialysis were independent risk factors for early infection and revision, respectively.

Aims: To determine the usefulness of preoperative CRP, ESR, WCC and joint aspirate in the diagnosis of infective loosening before revision TKA.

Methods and Materials: Retrospective review of patients undergoing revision TKA for the period May 1998 to May 2008 was performed, examining the results of preoperative CRP, ESR, WCC, joint aspirate and intra-operative microbiological samples. Positive results were CRP ≥10 mg/dL, ESR ≥ 22mm/hr, WCC ≥11 g/dL and positive growth on culture unless stated as contaminant. The data was analysed to determine sensitivity, specificity, negative and positive predictive values of the tests for single stage and staged revisions.

Results: 51 patients underwent single stage revision with 10 positive cultures. CRP and WCC were highly specific for infection (84%, 98%) with low sensitivities (10%). ESR was 66% specific and 25% sensitive. All had high negative predictive values (76–86%).

23 patients underwent staged revision. 17 cases had positive cultures at 1st stage and 8 at 2nd stage. 1st stage CRP, ESR and WCC had low sensitivity (67%, 59%, 17%). WCC was 80% specific whereas CRP and ESR had low specificity (25%, 20%). All had high positive predictive value (71–80%). 2nd stage CRP and ESR were specific for infection (71%) but had low sensitivities (22 and 44%). WCC was 0% sensitive but 87% specific. Negative predictive values of CRP, ESR and WCC were 63, 71 and 62%.

For both single stage and 1st stage staged revisions, pre-operative joint aspirate was 100% specific with sensitivities of 0% for single stage and 50% in staged revisions.

Conclusion: All patients undergoing both staged and single stage revision arthroplasty should routinely have preoperative inflammatory markers and joint aspirate. However, positive intraoperative cultures may still be obtained despite negative preoperative investigations.

Aims: To determine the rate of early and late infection amongst patients with renal disease undergoing TKA.

Methods and Materials: Review was undertaken of the Scottish National Arthroplasty Project data for the period from April 1985 to March 2008. Data was examined for the rate of infection amongst patients under-going TKA with a diagnosis of renal transplant, renal dialysis or renal failure. Early infection was classed as occurring within 90 days of the index procedure and late infection as occurring after 90 days. Renal failure, dialysis and transplant were identified using ICD 9 and 10 codes. The 4th revision of the OPCS codes was used to search for renal transplant, renal dialysis and knee arthroplasty.

Results: In total, 59288 TKAs were performed in Scotland over the period analysed. There were 651 early infections and 1296 late infections giving overall early and late infection rates of 1.1% and 2.2% respectively. 10 patients had renal transplant prior to TKA with 1 early infection (infection rate 1%) and no late infections. 44 patients had a renal transplant before or after TKA with 1 early and 6 late infections giving an early infection rate of 2.27% and late infection rate of 13.64% for this group. 17 patients undergoing renal dialysis underwent TKA with no early infections but a single late infection, giving a late infection rate of 5.8%. 2920 patients had a diagnosis of renal failure prior to or after TKA with 48 early and 138 late infections. Infection rates for this group were 1.64% early and 4.73% late.

Conclusions: TKA patients with renal transplant, renal failure or undergoing dialysis are at increased risk of infection. In particular, renal transplant patients are most at risk of late infection. Renal patients must be counselled of these increased risks prior to orthopaedic or transplant surgery.

The humerus is a common site for skeletal metastases in the adult. Surgical stabilisation of such lesions is often necessary to relieve pain and restore function. These procedures are essentially palliative and should therefore provide effective relief from pain for the remainder of the patient’s life without the need for further surgical intervention.

We report a retrospective analysis of 35 patients (37 nails) with symptomatic metastases in the shaft of the humerus which were treated by locked, antegrade nailing. There were 27 true fractures (73.0%) and ten painful deposits (27.0%). Relief from pain was excellent in four (11.4%), good in 29 (82.9%) and fair in two (5.7%) on discharge. Function was improved in all but one patient. One case of palsy of the radial nerve was noted. The mean postoperative survival was 7.1 months (0.2 to 45.5) which emphasises the poor prognosis in this group of patients. There were no failures of fixation and no case in which further surgery was required.

Antegrade intramedullary nailing is an effective means of stabilising the humerus for the palliative treatment of metastases. It relieves pain and restores function to the upper limb with low attendant morbidity.

The aim of this work was to compare the oxygen saturations in patients in the early period following total knee joint replacement surgery performed using either computer navigation or conventional intramedullary mechanical jigs.

Between August and November 2007 twelve consecutive patients who had computer navigated total knee joint replacements were prospectively reviewed. A comparison group from the same period was made of twenty patients who had knee replacements performed using conventional jigs. Non-invasive oxygen saturations were measured and recorded as a percentage. Preoperative oxygen saturations measured at the assessment clinic were used a baseline. For the duration of the patients postoperative hospital stay oxygen saturations were measured five times a day as well as their oxygen requirements.

We found that the patients in the computer navigation group on average reached oxygen saturation levels on air equal to those measured in the assessment earlier than the intramedullary jig group. There was also a lower need for oxygen in the computer navigated group during this early post operative period.

Previous studies using transcranial Doppler and transoesophageal echocardiograms have shown a reduction of systemic emboli with computer navigated total knee joint replacements. Using oxygen saturation monitoring we have shown there may be a considerable clinical advantage using computer navigated surgery over conventional intra-medullary rod jigs in knee replacement surgery.

Aim: We have carried out a prospective study to compare duplex ultrasonography and transcutaneous oxygen tension as predictors of wound healing after knee arthroplasty.

Methods and Materials: 53 patients were included in the study. All underwent pre-operative duplex scans of their lower limbs. In addition, transcutaneous oxygen tension measurements were made adjacent to the proposed incision pre-operatively and on days 1, 3 and 7 post knee arthroplasty. Wound healing was assessed using the ASEPSIS wound score.

Results: 4 wounds had evidence of delayed wound healing. Duplex ultrasonography was a poor predictor of such problems; however there was a significant correlation between pre-operative transcutaneous oxygen tension and post-operative wound scores.

Conclusion: Pre-operative transcutaneous oxygen tension measurement is a better predictor of wound healing after knee replacement surgery than duplex ultrasonograph, and may be a useful adjunct to the investigation of patients at risk of wound problems post knee arthroplasty.

Aim: Assessment of the effect of arthrography on the accuracy of MRI studies in the diagnosis of recurrent meniscal tears.

Materials and Methods: A prospective, double blind study was undertaken of 21 patients with a history and clinical examination suggestive of a recurrent meniscal tear. Patients deemed symptomatic enough to justify repeat arthroscopy were also assessed with conventional and contrast enhanced MR imaging. An arthroscopy was performed in order to identify, and where appropriate surgically manage, recurrent meniscal tears. The radiologist performing and reporting the investigations and the surgeons undertaking the arthroscopies were blinded to the results.

Results: 14 patients underwent both the MR scans and the arthroscopies during the period of investigation. An accurate diagnosis of a recurrent meniscal tear was diagnosed in 8 patients on the basis of the conventional MRI, and 7 using MR arthrography. The sensitivity of MRI and MR arthrography in the diagnosis of recurrent meniscal tears was 33%; the specificity of MRI and MR arthrography was 75% and 63% respectively.

Conclusion: Arthrography does not improve the diagnostic accuracy of MRI in assessment for recurrent meniscal tears.

To report the long term outcome of patients with a partial tear of the anterior cruciate ligament (ACL).

We reviewed 26 of 31 athletes who had a diagnosis of acute, incomplete tear of the anterior cruciate ligament (ACL) between November 1986 and December 1991. All patients had arthroscopy and examination under anaesthesia within 8 weeks of acute knee injury, and were included in the study if there were still ACL fibres remaining which resisted anterior tibial translation. We excluded patients with associated major ligamentous lesions. Patients were reviewed by a combination of questionnaire and clinical examination at a mean of 38 months after the index injury (range 18 to 66).

At review, 20 patients (77%) had developed some symptoms of knee instability. The number of patients with a positive Lachman’s test had increased from 17 to 18, and those with a positive pivot shift had increased from 9 to 13. Seven patients (27%) had undergone ACL reconstruction, 7 other patients (27%) had been unable to return to sport, and 6 patients (23%) continued to participate in sport, but at a reduced level. Only 6 patients (23%) were able to continue in sport at their pre-injury level without reconstructive surgery. Patients with a tear of the anteromedial bundle of the ACL were more likely to have signs of instability at review and to require ACL reconstructive surgery than patients with a tear mainly affecting the posterolateral bundle.

Partial lesions of the ACL, especially when involving the AM bundle, should not be regarded as benign injuries. They often result in symptomatic instability necessitating intra-articular reconstruction of the ACL, and, in the long run, in marked decrease in the level of sports participation.

We describe an apparently unreported finding during hip operations: a tear at the insertion of gluteus medius and gluteus minimus. This defect may well be known to many surgeons with experience of hip replacement and hemiarthroplasty for fractures of the neck of the femur, but a Medline search has failed to find a previous description.

We made a prospective study of 50 consecutive patients with fractures of the neck of the femur to quantify the incidence of this condition: 11 (22%) had such a tear.