Background

Greater trochanteric pain syndrome (GTPS) is a common problem affecting 10–25% of the population. Physiotherapy, anti-inflammatories, corticosteroid injections and surgery have all been described in the management of GTPS, all with limited, temporal success. Extracorporeal shockwave therapy (ESWT) has been proposed as a potential management option for this difficult presentation.

Frozen section is a recognised technique to assist in the diagnosis of infection and there are standards for reporting. Our aim of this review was to assess the value of frozen section in the diagnosis of infection, as well as other variables.

We performed a retrospective review of all frozen sections for suspected infection in 2016. Patient demographics, histological and microbiological investigations, laboratory and bedside tests were recorded and analysed using statistical software.

46 patients had 55 frozen sections; the majority were for lower limb arthroplasty. No sections were reported as polymorphonuclear neutrophils per high-power field. Three sections showed signs of infection and one without evidence had positive cultures. One uncertain section did not grow organisms. 10 patients had two-stage procedures, four of these were intended to be determined by frozen section but only two had evidence of infection on analysis.

Evidence of infection on frozen section does correlate with microbiological growth but does not relate to intention to stage procedures in half of patients. The effect of new tests such as Synovasure is highlighted by this review.

Frozen section analysis is reported subjectively but is a good predictor of infection. Clinical assessment is accurate in diagnosing infection. Histological, microbiological and additional investigations should be considered in relation to their cost-effectiveness.

Deep infection occurs in 2–4% of lower limb arthroplasty resulting in increasing cost, co-morbidity and challenging revision arthroplasty surgery. Identifying the potential sources of infection helps reduce infection rates. The aim of our study is to identify the impact and potential for contamination of our hands and gowns whilst scrubbing using SSHS.

A colony-forming unit (CFU) is a pathogenic particle of 0.5 micrometers to 5 micrometers. Concurrent particle counts and blood agar exposure settle plates for 3 subjects and 1 alcohol cleaned mannequin; testing a standard arthroplasty hood, a SSHS with and without the fan on for a 2 minute exposure to represent scrubbing time. Microbiological plates were incubated using a standard protocol by our local microbiology department.

All SSHS were positive for gram-positive cocci with a mean colony count of 410cfu/m². Comparing background counts for laminar flow (mean 0.7 particle/m³; 95% CI 0–1.4) versus scrub areas (mean 131.5 particle/m3; 95% CI 123.5–137.9; p=0.0003), however neither grew any CFU's with a 2-minute exposure. For the mannequin, the only significant result was with the fan on with a 1.5× increase in the particle count (p=0.042) and a correlating positive organism (13CFU/m²). With human subjects, however, the particle count increased by 3.75× the background count with the fan on (total p=0.004, CFU p=0.047) and all had positive cultures, mean 36 CFU/m². There were no positive cultures with the standard arthroplasty hood or the SSHS with no fan on. If repeated in laminar flow, there was only a statistically significant increase with the fan on (p=0.049), but with negative cultures following a 2-minute exposure.

Sterile gloves and gowns can be contaminated when scrubbing with the SSHS fan on. We recommend having the fan switched off when scrubbing until the hood and gown is in place, ideally in a laminar flow environment.

The quality of femoral stem cementation has been shown to be a useful indicator of long-term survival of the total hip arthroplasty. Barrack's cementation grading is widely used but has certain limitations. It is based upon second-generation cementation technique and has high inter- and intra-observer variability. We introduce a new femoral cementation index based upon lengths of radiological lucency and cement-bone interface on AP and lateral views.

Five observers graded femoral cementation of radiographs of 30 primary hip arthroplasties using Barrack's grading and the new index on two occasions and Inter- & Intra-observer reliability was assessed. We also assessed the correlation between proximal femoral anatomy (calcar-canal ratio) & structural bone quality (using cortical index) with cementation using the new index in 50 patients.

Inter- and intra-observer reliability of the new index showed intraclass correlation coefficient 0.79 and 0.82 respectively and Barrack's grading system showed Kappa value- 0.20 (inter-observer) and 0.55 (intra-observer) reliability.

There was poor correlation between the calcar-canal ratio and the quality of cementation [Pearson's coefficient −0.04 (p< 0.05)]. There was some correlation between the cortical index and the quality of cementation [Pearson's coefficient 0.46 (p < 0.05)].

Our new index is a reliable method of assessing femoral cementation. The anatomy of femoral canal didn't have any significant influence on the quality of cementation achieved as assessed by our new index. The femoral cortical structural quality seemed to have some positive influence on the quality of cementation.

Quality of cementation in the early postoperative period has been proven to be an indicator of long-term survival of the total hip arthroplasty. Cementation grading described by Barrack et al is widely used but has certain limitations. It is based upon second-generation cementation technique and has unacceptably high inter- and intra-observer variability due to its subjective evaluation method.

We are introducing a new grading system of quality of femoral cementation. It is based upon the ratio of the length of radiological lucency to the total length of cement-bone interface on both antero-posterior and lateral views. Because of its objective nature, it is likely to show reproducible results.

We recruited five observers of various grades of surgical experience (trainees to consultant). Each observer graded the quality of femoral cementation on immediate postop xrays twice (gap of atleast two weeks) of 30 primary hip arthroplasties, using Barrack's grading and a new cementation index measured by dividing the ength of Radiolucency along CBI by the total Length of CBI.

Statistical analysis was performed by SPSS v17.0. Inter-observer and Intra-observer variability was determined by Intraclass Correlation Coefficient for a two way mixed model.

New cementation index showed excellent agreement for both inter and intra-observer reliability with intraclass correlation coefficient of 0.79 and 0.82 respectively. On contrary, results of inter-observer reliability for Barrack's grading were poor with value of 0.20. intra-observer reliability was found to be fair with 0.55.

As evident from this study, it is a more reliable way of assessing the quality of cementation, with excellent agreement in both inter and intra-observer categories.

Aim

The aim of this study was to determine the medium term survivorship and function of the Exeter Universal Hip Replacement when used in younger patients, a group that is deemed to place high demands on their arthroplasties. Since 1988 The Exeter Hip Research Unit has prospectively gathered data on all patients who have had total hip replacements at the Princess Elizabeth Orthopaedic Hospital. There were 130 Exeter Universal total hip replacements (THR) in 107 patients who were 50 years or younger at the time of surgery and whose surgery was performed at least 10 years before. Mean age at surgery was 42 years (range 17-50 years.) Six patients who had 7 THRs had died, leaving 123 THRs for review. Patients were reviewed at an average of 12.5 years (range 10-17 years). No patient was lost to follow-up.

Introduction & methods: The aim of this study was to determine the medium term survivorship and function of the Exeter Universal Hip Replacement when used in younger patients, a group that is deemed to place high demands on their arthroplasties. Since 1988, The Exeter Hip Research Unit has prospectively gathered data on all patients who have had total hip replacements at the Princess Elizabeth Orthopaedic Hospital. There were 130 Exeter Universal total hip replacements (THR) in 107 patients who were 50 years or younger at the time of surgery and whose surgery was performed at least 10 years before. Mean age at surgery was 42y (range 17y to 50y.) Six patients who had 7 THRs had died leaving 123 THRs for review. Patients were reviewed at an average of 12.5 years (range 10 – 17 years). No patient was lost to follow up. Results: At review, 12 hips had been revised. Of these, 9 were for aseptic loosening of the acetabular component and one cup was revised for focal lysis and pain. One hip was revised for recurrent dislocation. One femoral component required revision in 1 case of infection. Radiographs showed that a further 11(10%) of the remaining acetabular prostheses were loose but that no femoral components were loose. Survivorship of stem and cup from all causes was 92.7%, at an average of 12.5 years. Survivorship of stem only from all causes was 99% and from aseptic loosening was 100%.

Conclusion: The Exeter Universal Stem is shown to perform extremely well in the younger patient. No femoral component became loose and only 9 acetabular components were revised for aseptic loosening