Aims

Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections.

Introduction

Internal fixation of pertrochanteric fractures is evolving as newer implants are being developed. Proximal Femoral Nail Antirotation (PFNA) is a recently introduced implant from AO/ASIF designed to compact the cancellous bone and may be particularly useful in unstable and osteoporotic hip fractures. This study is a single and independent centre experience of this implant used in management of acute hip fractures.

Background

The failure and subsequent withdrawal of the ASR device in both its resurfacing and THR form has been well documented. The National Joint Registry report of 2010 quoted figures of 12–13% failure at five years. Adverse reaction to metal debris (ARMD) is a poorly understood condition and patients developing severe metal reactions may go unrecognised for sometime.

Introduction

Adverse reaction to metal debris (ARMD) is an increasingly recognised complication of metal-on-metal hip arthroplasty. A previous study described poor results following revision and recommended early intervention¹. We determined the outcome of revision for ARMD and present the largest case series to date.

Introduction

We conducted independent wear analysis of retrieved metal on metal (MoM) hip components from around the world. All patients with resurfaced hips who developed adverse reactions to metal debris (ARMD) were found to have increased wear of the bearing surfaces. This was untrue in patients with large diameter (?36mm) MoM total hip replacements. This led us to search for other factors leading to ARMD.

The aim of this study is to review the functional outcome of the patients treated with Posterior Lumbar Interbody Fusion for FBSS.

This is a retrospective review of prospectively collected data of 39 patients diagnosed with FBSS and treated with PLIF between June 2000 and December 2008 by the senior author in our unit. Pain and function were evaluated by VAS for Back (VAS-BP) & leg pain (VAS-LP), Oswestry disability index (NDI) and SF-36 questionnaires, and were completed pre- & post-operatively.

There were 39 patients (20 women & 19 men) and mean age at operation was 47.3 years (range of 32 to 76.1 years). Mean duration of follow-up was 39.14 months (range 5.21 -73.5 months). Thirty-one patients were diagnosed as Post laminectomy syndrome and 8 patients as post-discectomy syndrome.

The mean pre and post-operative ODI values were 54.13 and 29.14 respectively. The mean pre-operative VAS back and leg pain scores were 7.38 and 6.51 respectively. The mean post-operative VAS for back and leg pain scores were reduced to 4.05 (Pre-op:7.38) and 3.69 (Mean pre-op 6.51)respectively. The mean preoperative SF-36 bodily pain component score was 27.42 and the mean postoperative score was 40.50.

Four patients had uncomplicated dural tears that resolved completely. Two patients had superficial wound infection that resolved with oral antibiotics.

PLIF is one of the safe and effective treatment option for FBSS and it has shown good results in our series.

There is widespread concern regarding the incidence of adverse soft-tissue reactions after metal-on-metal (MoM) hip replacement. Recent National Joint Registry data have shown clear differences in the rates of failure of different designs of hip resurfacing. Our aim was to update the failure rates related to metal debris for the Articular Surface Replacement (ASR). A total of 505 of these were implanted.

Kaplan-Meier analysis showed a failure rate of 25% at six years for the ASR resurfacing and of 48.8% for the ASR total hip replacement (THR). Of 257 patients with a minimum follow-up of two years, 67 (26.1%) had a serum cobalt concentration which was greater than 7 μg/l. Co-ordinate measuring machine analysis of revised components showed that all patients suffering adverse tissue reactions in the resurfacing group had abnormal wear of the bearing surfaces. Six THR patients had relatively low rates of articular wear, but were found to have considerable damage at the trunion-taper interface. Our results suggest that wear at the modular junction is an important factor in the development of adverse tissue reactions after implantation of a large-diameter MoM THR.

Infection in total knee replacement is a devastating complication. Current literature supports two-stage revision as the gold standard treatment. The alternative single stage procedure has been reported to have favourable results. We assessed the early clinical results of single stage revision for infected total knee replacement.

Between February 2005 and August 2007, 12 patients had revision total knee replacement for infection by the senior authors at two centres. In the majority of the patients, the infective organism was isolated by arthroscopic synovial biopsy prior to revision. Standard single stage procedure included the explantation, debridement and re-implantation of the prosthesis. All the patients received intravenous antibiotics for six weeks and oral antibiotics were continued for further 6 weeks. All the patients had the inflammatory markers monitored during follow-up.

Significant improvement was noted in the SF-12 PCS, WOMAC pain and stiffness scores at the latest follow-up. None of these patients required re-revision. Radiological evaluation was done using the Knee Society system. None of the knees showed evidence of progressive loosening. Radio-opaque lines were found around the stems and were present on immediate post-operative radiographs; this did not indicate loosening or infection at a mean follow-up of two years.

Early clinical and radiological results of the single stage revision for infected total knee replacement appear to be promising. One operation, one anaesthetic and quicker recovery are the advantages for the patient and with the reduced hospital stay it is cost-effective. The problems of stiffness in the knee and muscle wasting with cement spacer are avoided.

The principles of revision total knee replacement are to understand the cause of failure, adequate surgical exposure, achieving appropriate soft tissue balance, restoration of limb and joint line alignment, correct implant alignment, and a good range of motion. It is a technically and economically demanding procedure and its successful performance requires thorough preoperative planning, adherence to the principles, availability of diverse implant options and adequate bone graft.

We prospectively assessed the survivorship of Co-ordinate Ultra prosthesis (DePuy, Warsaw, Ind) used for revision knee arthroplasty. Forty-nine patients had 53 revision knee replacements performed by the senior author between April 1999 and September 2001. Seven patients (7 knees) had died. At a mean follow-up of 6 years (range: 5–7 years), 46 knees in 42 patients were available for review. None were lost to follow-up. There were 31 women and 11 men, with a mean age of 74.2 years. The reason for revision was instability in 39 knees, infection in 3 knees, pain in 2 knees and stiffness in 2 knees.

Significant improvement was noted in the SF-12 PCS and WOMAC pain and stiffness scores at the latest follow-up. None of these patients required re-revision. None of the knees showed evidence of progressive loosening. Radio-opaque lines were found around the stems and were present in immediate post-operative radiographs; this did not indicate loosening or infection on further follow-up. Cumulative survival analysis (Kaplan-Meier method) was 100% at 7 years.

Clinical and radiological outcome analysis has revealed that the Co-ordinate Ultra revision knee system continues to function satisfactorily at a mean follow-up of 6 years.

A consecutive group of 150 patients undergoing primary TKA performed by a single surgeon using single prosthesis were studied prospectively. The purpose of this study was to compare the clinical and radiographic results of TKA in obese and non-obese patients.

The patients were categorized into two groups: non-obese (body mass index (BMI < 30 kg/m2) and obese (BMI > 30 to 40 kg/m2). The Primary outcome measures: SF-12 and WOMAC scores were used as generic outcome measures, and the Knee Society scores were used to assess clinical outcome of TKA. The scores were done pre-operatively and at 1, 3 and 5 years post-operatively. Secondary outcome measures included patellar position, anterior knee pain, infections, revision rates, deep-vein thrombosis and pulmonary embolism, length of hospital stay and mortality.

Seventeen patients have died since and none were lost to follow-up. Obese patients had less benefit and overall KSS outcome scores at one year (p-value 0.05) but had similar scores at 3 and 5 years (p-values 0.3 and 0.5). Pre-operative WOMAC and SF-12 scores were significantly worst in obese patients (p-value 0.009 and 0.005) but had the similar outcome at 1, 3 and 5 years. Three patients in the series required revision surgery for infection. One patient had DVT and another had PE post-operatively.

Overall obese patients although had lower KSS scores at one year but had better outcome in SF-12 and WOMAC scores at one year. There was no difference at 3 and 5 years. We found that body weight did not influence adversely the outcome of TKA at medium term.

Introduction: The principles of revision arthroplasty are to understand the cause of failure, adequate surgical exposure, restoration of limb alignment, achieving appropriate soft tissue balance, correct implant alignment, restoration of joint line and a good range of motion. Revision knee Arthroplasty is a technically and economically demanding procedure and its successful performance requires thorough preoperative planning, adherence to the principles, availability of diverse implant options and adequate bone graft.

Aim: We prospectively assessed the survivorship of Coordinate Ultra prosthesis (DePuy, Warsaw, Ind) used for revision knee arthroplasty.

Materials and Methods: Fifty-three patients had revision knee replacement performed by the senior author between April 1999 and September 2001. Seven patients (7 knees) had died. At a mean follow-up of 6 years (range: 5–7years), 46 knees in 42 patients were available for review. None were lost to follow-up. There were 31 women and 11 men, with a mean age of 74.2 years. The reason for revision was instability in 39 knees, infection in 3 knees, pain in 2 knees and stiffness in 2 knees.

Results: Significant improvement was noted in the SF-12 PCS and WOMAC pain and stiffness scores at the latest follow-up. None of these patients required re-revision. Radiological evaluation was done using the Knee Society system. None of the knees showed evidence of progressive loosening. Radiopaque lines were found around the stems and were present in immediate post-operative radiographs; this did not indicated loosening or infection on further follow-up. Cumulative survival analysis (Kaplan Meier method) was 100% at 7 years.

Conclusion: Clinical and radiological outcome analysis has revealed that the Co-ordinate Ultra revision knee system continues to function satisfactorily at a mean follow-up of 6 years.

Background: Tourniquet provides a blood less field for surgery, but it has few complications and contraindications. There are several studies identifying the tourniquet as a factor for increased risk of complications in knee arthroscopy, we reviewed 200 consecutive knee arthroscopies done in our hospital with out tourniquet to analyse the outcome.

Aim: To analyse the out come of 200 knee arthroscopies with out use of tourniquet; with respect to visualisation, time of surgery, bleeding, analgesia and post operative complications.

Materials and methods: We retrospectively analysed 200 consecutive knee arthroscopies with out tourniquet done in our institute. Average age of these patients was 39 (21–81). All patients underwent soft tissue procedures under general anaesthesia, supine, with sole support, no antibiotics and was done by same surgeon as day case. Same arthroscopic kit with pump was used for all patients, using 2 litre saline bag and pump set at 65 mm Hg pressure. First few cases had tourniquet applied but not inflated, but later even this was avoided. Procedures included were diagnostic arthroscopies, arthroscopic debridements, meniscal repairs and partial or complete meniscal resections. Procedures like arthroscopic ACL reconstruction and other bony procedures were excluded. We looked at any visualisation problems, time of surgery, bleeding, analgesia and post operative complications. We also looked weather any of these patients visited the consultant or GP for any wound related problem or pain before the usual review at 2 weeks.

Results: There was no problem with visualisation noted in any of the cases, or any incidence where arthroscopy was unduly prolonged. There was no incidence of bleeding, stiffness or increased need for analgesia in any of these patients. None of the patients had any wound problem or haemathrosis requiring intervention. There was no record of any patients reattending the clinic or their GP for pain or bleeding.

Conclusions: Many orthopaedic units continue to use a tourniquet routinely for soft tissue procedures in knee arthroscopy, probably in the belief that a clear operative view can only be achieved with one. However, the findings in our study indicate that knee arthroscopy for soft tissue procedures may be performed adequately without the use of a tourniquet provided a pump system is used and the pressure maintained above venous pressure. Therefore we recommend that its use for routine soft tissue arthroscopic procedures be discontinued.

Introduction: The technique of quadriceps sparing knee arthroplasty involves a pure capsular incision, without violation of the extensor mechanism. This capsular incision should be placed distal to Vastus Medialis Obliquus (VMO). The termination of VMO is variable and may make the quadriceps sparing approach difficult. We initiated this study based on the hypothesis that quadriceps sparing approach may not be possible in all the patients undergoing total knee arthroplasty. We examined MRI scans of the knee joint to assess the variation in VMO muscle insertion in relation to the patella and variation of VMO muscle insertion in relation to the age.

Material and Methods: Between Jan 2005 and Dec 2005, 262 MRI scans of the knee joint were performed at our institute. We studied MRI scans of the patients aged 16 years and over. The scans with neoplasm or those without complete set of films were excluded from the study. There were 198 scans available for analysis. Our cohort consisted of 106 female patients and 92 male patients with an average age of 43 years (range 16–86 years). One hundred and thirty four patients were aged less than 50 years and 64 patients were 50 years or older.

We measured patellar height, VMO length on the axial views of the scans. The VMO insertion was calculated from the data and we divided the patients into proximal and distal groups in relation to the VMO termination on the patella. The proximal group included patients with VMO termination proximal to the mid-point of the patella and distal group included patients with VMO termination at or distal to the mid-point of the patella.

Results: The median height of the patella in female patients was 32mm (range 24–44mm) and in male patients was 36mm (range 28–48mm). The VMO length from the apex of the patella was 13.5mm (range 4–28mm) in female patients and 16mm (range 8–32mm) in male patients. Overall there were 119 (60%) patients in the proximal group and 79 (40%) in the distal group. In 20% of patients aged more than 50 years, VMO terminated in the distal half of the patella. In patients less than 50 years old, 50% had the VMO termination in the distal half of patella. A statistically significant inverse relationship was noted between the level of insertion of VMO and the age of the patient (p-value > 0.001, Chi-square test). There was no statistically significant relation between the level of insertion of VMO and the sex of the patient, in either age group (p-value 0.339).

Conclusion: Younger patients are statistically more likely to have a VMO which terminated at or more distal to the mid-point of patella. Therefore, the quadriceps sparing approach may not be possible in these subjects, however it is possible in majority of older patients.

Introduction: The technique of quadriceps sparing knee arthroplasty involves a pure capsular incision, without violation of the extensor mechanism. This capsular incision should be placed distal to Vastus Medialis Obliquus (VMO). It is well known that the termination of VMO is variable and may make the quadriceps sparing approach difficult. We initiated this study based on the hypothesis that the quadriceps sparing approach is not possible in all patients undergoing total knee arthroplasty.

Methods: We examined the axial MRI images of the knee joint performed over a period of 12 months at our institute. A total of 198 MRI scans were analysed between two observers.

To calculate the patellar height the apex of the patella was considered as ‘Reference Slice 1’. The consecutive slices were followed distally to the last slice in which the patella was visible. From ‘Reference Slice 1’ VMO muscle was followed distally to the slice in which the muscle was last visible. We calculated the patella height and VMO muscle length as the product of the number of MRI slices and MRI slice thickness.

Results: Of the 134 patients aged less than 50 years, 68 patients (50.7%) had a VMO that terminated in the proximal half of the patella. Out of 64 patients aged 50 years or older, 51 patients (79.7%) had a VMO that terminated in the proximal half of the patella.

A statistically significant inverse relationship was noted between the level of insertion of VMO and the age of the patient.

Discussion: Our results will have an implication on the use of the quadriceps sparing approach, as they highlight another possible limitation of this approach. Patients need to be warned before the TKA that the quadriceps sparing approach may not be possible in all, especially if they are younger.

We reviewed the clinical and radiological outcome of 72 Co-ordinate prostheses (DePuy, Warsaw, Ind) used for revision knee arthroplasty performed by a single surgeon from May 1994 to December 1997. Twenty-three patients (25 knees) since died. Two were lost to follow-up. At a mean follow-up of 10 years (range 9–12years), 45 knees in 43 patients were available for review. There were 12 men and 31 women with a mean age of 71.34 years (range 43 to 87 years). The reason for revision was instability in 38 knees, infection in 5 knees and stiffness in 2 knees.

There was a significant improvement in the SF-12 PCS and WOMAC pain and stiffness scores at the latest follow-up. Five of these knees had to have re-revision surgery. One patient had a re-revision for aseptic loosening, one patient for recurrent dislocation of patella. Three patients underwent repeat procedures for infection.

Radiological evaluation using the Knee Society system revealed well-fixed components in 35 knees (77.78%). The radiolucencies of varying degrees were present in 10 knees (22.22%). Eight had non-progressive radiolu-cencies and did not show any evidence of loosening. 25 (55.5%) knees had halo sign (radiopaque line) present around the prosthesis (7 were femoral side, 4 were tibial side and 14 around both the prosthesis). Using Kaplan Meier method the cumulative survival rate was 88.87% at 12 years, removal of the prosthesis or re-revision were used as end points. An analysis of clinical and standard radiographic outcomes has revealed that the Co-ordinate revision knee system continues to function satisfactorily at a mean of 10 years.

The use of effective pre-operative preparation solution is an important step in limiting surgical wound contamination and preventing infection, particularly in forefoot surgery. The most effective way is unknown. In recent studies, > 70% of aerobic bacterial cultures of specimens taken from the nail folds following skin preparation with povidine iodine were positive. The aim of the study was to determine the effectiveness of pre-operative Triclosan (Aquasept) shower, skin preparation using povidone iodine and ethyl alcohol in reducing post-operative forefoot infection.

Between February 2005 and August 2005, all patients undergoing forefoot surgery under the care of the senior author were followed prospectively. There were 50 women and 10 men with an average age of 55 years (17–92 years), who underwent 92 forefoot procedures. The surgeries included 35 (38%) osteotomies, 31 (34%) arthrodeses, and 9 (10%) Morton’s neuroma excisions and 17 (18%) soft tissue procedures. As a standard protocol, pre-operatively all patients had Triclosan shower on the day of surgery, the foot/feet were painted with povidone iodine and was covered with a sterile towel in the ward. At induction, everyone received cefuroxime 1.5gm (IV); the feet were prepared using povidone iodine and then ethyl alcohol and dried. Patients were followed up in the clinic at 2weeks, 6weeks and 3months, further follow-up if necessary.

None of the patients in the study developed deep infection. Two patients required oral antibiotics for superficial infection (one pin track infection after distal inter-phalangeal joint fusion of second toe, one following scarf osteotomy)

We conclude that the method used in this study was very effective in preventing infection following forefoot surgery.

To assess the outcome and implant removal rate following surgical stabilisation of patella fracture.

Sixty-seven patients who underwent surgical stabilisation of patella fracture between January 1999 and December 2004 were retrospectively reviewed to determine the adequacy of fracture stabilisation, fracture union and implant removal rate.

Forty-three were men and 24 were women with a mean age of 49 years (ranged 14–90 years). Table below demonstrates the injury, fracture patterns and fixation methods. There were 3 open fractures and associated injuries were noted in 22 patients. All fractures united even though the fixation was inadequate in 46 patients. Two superficial infections responded to oral antibiotics. One patient had revision surgery at 6 weeks. Twenty-two patients required implant removal between 2 and 20 months (average 11 months) for implant related symptoms. Of the 22 (32.8%) patients requiring implant removal, 16/40 (40%) were less than 60 years and 6/27 (22.2%) were over 60 years. Mean follow up in asymptomatic patients was 8 months (3 to 18 months) and in patients with implant related problems was 17 months (10 to 36 months). Four patients were lost to follow up.

Surgical stabilisation by current techniques demonstrated satisfactory fracture union. However, one in three required second surgery for implant related symptoms. In the under 60 years group, the implant removal rate increased to 40%. Newer techniques to avoid skin irritation need to be considered.

Background and objectives: Total knee replacement (TKR) produces severe postoperative pain. Peripheral nerve blocks can be used as analgesic adjuncts for TKR, but the efficacy of a sciatic nerve block as an adjunct to a femoral nerve block is controversial. The aim of this study was to compare femoral with femoral and sciatic nerve blocks in postoperative pain management of patients undergoing total knee arthroplasty (TKA).

Methods: 42 patients were involved in the study. 20 patients received only a femoral nerve block, consisting of 20ml of 0.5% Chirocaine and 22 patients received femoral and sciatic nerve blocks, consisting of 20ml of 0.375% Chirocaine for the femoral nerve and 10ml of 0.5% Chirocaine for the sciatic nerve. The primary outcome measures used were visual analogue scale (VAS) scores for pain at 24 hours, 48 hours and 72 hours after the surgery, opiates consumption post-operatively and PCA use. The secondary outcomes were post-operative nausea and vomiting, sensory deficit, quadriceps contraction, straight leg raise, knee flexion, independent mobility and discharge from the hospital.

Results: The results showed no difference in opiate consumption, PCA use, independent mobility and time of discharge from the hospital between the two groups.

Conclusion: The study shows that the addition of a sciatic nerve block to the femoral nerve block does not provide additional benefits.

Introduction: Design of the prosthesis is an important factor in the successful outcome and longevity of total hip replacement. The purpose of the present study is to evaluate the minimum six-year results of primary total hip replacement using LX cemented prosthesis.

Methods: We prospectively studied 177 patients (60 male and 117 female) who underwent 197 hip replacements, between 1996 and 1999, using LX cemented prosthesis comprising a femoral component with cylindrical cross section of the stem and an acetabular component of ultrahigh molecular weight polyethylene. The average follow up was 7.3 years (6.1–9.6years). Clinical (Harris Hip Score) and radiological assessments (Barrack’s grading of cementation, subsidence, debonding, radiolucent lines and osteolysis) were performed.

Results: The average Harris Hip Score is 85.53 (28–99) compared to the preoperative score of 59.28. 28 cases (14.2%) developed progressive radiolucent lines around the stem. Sinking and debonding of the stem was noted in 18 cases (9.1%). 15 hips (7.6%) have dislocated and 11 were recurrent dislocations. Revision hip replacement was carried out in 12 cases (6%) for subsidence and debonding of stem, cement fracture and recurrent dislocation. The femoral stem components were found to be loose at the time of surgery.

Discussion: We believe that design of the prosthesis is an important factor in the high incidence of subsidence and debonding of the femoral stem. Both the geometry (cylindrical shape) and the rough surface finish (Ra value 100 microinches) were responsible for the pattern of progressive loosening. Lack of progressive increase in the offset with increase in the size of femoral component from 1 to 2 is one of the factors which contributed to high incidence of dislocation.

Introduction: The distorted anatomy in Developmental Dysplasia of the Hip (DDH) makes a total hip arthroplasty (THA) a challenging procedure. The purpose of the current study is to report the midterm results after uncemented primary hip arthroplasty using S ROM prosthesis in a prospective series of patients with hip dysplasia.

Methods: We performed 22 uncemented total hip replacements using S ROM prosthesis in 21 (12 female and 9 male) patients with hip dysplasia. The means age at the time of hip surgery was 41.8 (22 to 64) years. The mean follow-up was 6.3 (3.8 to 9.6) years. In 9 (40.9%) patients the operative treatment of DDH was performed during the early childhood (femoral osteotomy in 6 and pelvic osteotomy in 3). All patients were evaluated clinically and radiologically. The femoral head displacement prior to THA surgery was classified according to Crowe at al. classification (4 hips were type1, 2 type2, 10 type3 and 6 type 4).

Results: The average Harris Hip Score improved from 29.48 to 72.76 (44 to 99) and the average Oxford hip score is 31.22 (12 to 47). The range of flexion is 60°–120° (average 83.23) and abduction is 10°–40°(average 22.94). None of the hips has dislocated. Radiolucent lines were noted around the femoral stem in one case. None of the cases have developed osteolysis around femoral prosthesis. In one patient (4.5%), revision hip surgery was done for aseptic loosening of cemented acetabular cup.

Discussion: The midterm results of total hip replacement in DDH using S ROM uncemented prosthesis are promising. We recommend this modular prosthesis for hip replacement in dysplastic hips.