Abstract

Multidisciplinary team (MDT) meetings in orthopaedic surgery are evolving. The goals include patient optimisation, surgical planning and discharge arrangements, individually on a patient specific basis. In line with British Association Surgery of the Knee and GIRFT guidelines, we report our regional experience on the implementation and evolution of our regional Revision Knee Arthroplasty MDT.

We undertook a retrospective review of the process, cases discussed and quality assurance conducted in the weekly MDT.

Since implementation of the MDT meeting in January 2019, 550 patients with painful joint replacements have been discussed. In May 2021, we formalised our ‘terms of reference’ and ‘standard operating procedures’ which are adhered to by the consultants operating within the network, all of whom attend the meeting. A proforma has been developed and is completed for all cases capturing all pertinent information. All cases are graded according to R1, R2, or R3 complexity scale. Since its inception, the MDT has looked at all post-operative imaging, we now describe a new classification system for grading the appearances. Confirmation of the pre-operative plan and actual surgical intervention is reviewed and audited. In addition, confirmation of indication of revision at the time of operation is reviewed and validated for accuracy with benefits to the unit, individual surgeon and the NJR.

In conclusion, the implementation of the revision MDT facilitating pre-operative revision arthroplasty discussion and post-operative quality assurance processes enable surgeons to educate, reflect on their practice and ensure that the highest standards of care are being provided.

Cite this article: Bone Joint J 2023;105-B(6):590–592.

Abstract

Aim

Antibiotic-eluting calcium compounds can be used to deliver antibiotics in the management of prosthetic joint infection (PJI). Described omplications include wound drainage, heterotopic ossification(HO) as well as hypercalcaemia which is potentially life threatening.

The aim of this study is to assess the incidence of hypercalcaemia and other complications between two calcium based antibiotic delivery systems.

Aim

Revision surgery and debridement and implant retention are recognised approaches for managing prosthetic joint infections (PJI) but may not always be indicated. If the patient is unable to have or declines surgery, prolonged suppressive antibiotic therapy (PSAT) is an option. This study aims to define outcomes of PSAT from a single unit.

Introduction

Instability accounts for one third of revision total hip arthroplasty(rTHA) performed in the United Kingdom. Removal of well-fixed femoral stems in rTHA is challenging with a risk of blood loss and iatrogenic damage to the femur. The Bioball Universal Adaptor (BUA) (Merete, Germany), a modular head neck extension adaptor, provides a mechanism for optimisation of femoral offset, leg length and femoral anteversion. This can avoid the need for femoral stem revision in selected cases. There is a relative paucity of clinical data available with the use of this device.

The aim of this study was determine if the detection of pathology in children with a limp can be optimised by screening with blood tests for raised inflammatory markers.

The entry criteria for the study were children (0–15 years) presenting to our hospital Emergency Department from 2012–2015 with a non-traumatic limp or pseudoparalysis of a limb, and no sign of fracture or malignancy on plain radiographs. ESR and CRP blood tests were performed along with other standard investigations. Children with ESR or CRP over 10 underwent MRI scan of their area of pain or tendernesss, with those under 7 years old having general anaesthetic. MRI provided the diagnosis in cases of osteomyelitis, pyomyositis, fasciitis, cellulitis, discitis, as well as non-infective conditions such as malignancy and fracture not visible on plain radiographs. Where a joint effusion was present, the diagnosis of septic arthritis was made from organisms cultured following surgical drainage, or high white cell count in joint fluid if no organisms were cultured. The study was completed once data from 100 consecutive children was available.

64% of children had an infective cause for their symptoms (osteomyelitis, septic arthritis, pyomyositis, fasciitis, cellulitis or discitis). A further 11% had positive findings on MRI from non-infective causes (juvenile idiopathic arthritis, cancer, or occult fracture). The remaining 25% had either a normal scan, or transient synovitis. ESR was a more sensitive marker than CRP, since ESR was raised in 97% of those with abnormal scans, but CRP in only 70%. There were no complications from any of the GA MRI scans. Conclusion: This shows that MRI imaging of all children with a limp and either raised ESR or CRP is a sensitive method to minimise the chance of missing important pathology in this group, and is not wasteful of MRI resources.

Introduction

Surgical simulation and ‘virtual’ surgical tools are becoming recognised as essential aids for speciality training in Trauma & Orthopaedics, as evidenced by the BOA T&O Simulation Curriculum 2013^1,2. The current generation of hip arthroplasty simulators, including cadaveric workshops, offers the trainee limited exposure to reproducible real life bony pathology. We developed and implemented a novel training course using pathological dry bone models generated from real patient cases to support senior orthopaedic trainees and new consultants in developing knowledge and hands on skills in complex total hip arthroplasty.

Several human conditions have a tendency to affect one side of the body over the other. Do lumbar disc prolapses have such a tendency? We sought to answer this question by an analysis of operated cases.

Primary lumbar microdiscectomy cases were identified using the coding system. 1286 cases were identified and in 764 the laterality was not recorded. Electronic records were then examined to establish, where possible, the side of the procedure from the clinic letter or discharge summary. 22 cases were eliminated due to miscoding (laminectomy, instrumentation, revision) and in 24 the side of the operation could not be established. In the remaining 1240 cases (96.4%) the laterality was determined.

Patients who underwent primary lumbar microdiscectomy in a single neurosurgical unit over a 5-year period (2002-2007).

Procedures were bilateral, left or right.

126 cases were bilateral. There were 1114 defined lateral cases. 618 (55.5%) were on the left compared to 496 (44.5%) on the right. The ratio of left to right is close to 5:4. The null hypothesis was that the number of left and right sided operations would be equal. The findings of this study were statistically highly significant (p value < 0.001, binomial test) and the null hypothesis could be rejected.

There is a small but definite preponderance of left sided over right sided cases at a ratio of 5:4. This finding may have implications regarding our understanding of both the epidemiology and biomechanics of lumbar disc prolapse.

Introduction: Numerous studies have been carried out to assess the efficacy of tranexamic acid on intra and post operative blood loss and its implications. Many of these studies conclude that there is a need to study the effects of tranexamic acid on actual post Operative blood transfusion, thromboembolic events and hospital stay.

We analyzed the effects of Tranexamic acid on Intra- operative blood loss, post Operative haemoglobin and haematocrit drop, blood transfusion requirement, incidence of deep vein thrombosis and hospital stay in Patients undergoing Total hip arthroplasty.

Methods: Prospective case control study involving 50 patients (25 in each category, ASA class I to III) operated by a single consultant. Patient were given single dose of Intra venous Tranexamic Acid (10 mg/kg,10 minutes pre-incision) and Intra operative blood loss was compared to control group analyzing dry and wet swab weights and irrigation fluid. The actual haemoglobin drop, blood transfusion requirement, average length of stay in hospital and incidence of DVT were noted.

Results: There was 30% reduction in intra operative blood loss in the study group. None of the other parameters show evidence of a statistically significant difference between the groups. The average hospital stay was 7 days in both the groups.

Discussion: We found out that Tranexamic acid makes little difference in terms of actual haemoglobin and haematocrit drop, blood transfusion requirement and hospital stay. Our study didn’t show any rise in deep vein thrombosis in treatment group. The only difference it made was reduction of intraoperative blood loss by 30%. To the best of our knowledge, ours is the only study which combines all these parameters.

The aim of the study is to highlight the skeletal changes that result from untreated DDH if it is decided to leave the hip unreduced, as may occur if a child presents at a late age. This is of interest today as the data with which we try to determine prognosis in such cases is very old and comprised of small patients numbers. The method used is the study of c.10,000 human skeletons excavated from the medieval cemetery of Spitalfields in London, dating from 1100–1530AD. Diagnosis was made by the presence of an abnormal true acetabulum incompatible with articulation with a femoral head in life, with an associated false acetabulum on the iliac wing. The results demonstrated a range of skeletal consequences in the 13 dislocated hips present. At the hip joint itself, degenerative change was only present in cases with a well developed, cup-shaped false acetabulum. Only 17% of cases had such a cup-shaped false acetabulum. Cases with no such false acetabular cup (83%), presumably with soft tissue articulation, showed no degenerative change. Hip adduction with valgus knee was common, as was femoral neck anteversion with compensatory tibial torsion. Scoliosis in unilateral cases caused lateral wedging of vertebral bodies and markedly asymmetric degenerative change in older individuals. We conclude that the presence or absence of a deep cup-shaped bony acetabulum at late presentation may have prognostic implications as to whether degenerative change in the hip, and so pain, may occur in adulthood. If confirmed by clinical studies, this may influence whether an attempt at reduction should be made. From the viewpoint of the spine, if a hip is reduced late, surgeons should be aware that the scoliosis may not correct as they would expect if the vertebrae are already laterally wedged by the time the child presents.

Introduction: Infection post knee arthroplasty is a catastrophic surgical complication offering a major challenge to the orthopaedic surgeon. We present the outcome of a two-stage revision implantation technique utilizing a rotational hinge prosthesis with an antibiotic impregnated cement spacer in the interim period.

Materials & Method: Since 1995, 38 definitely infected knee replacements were revised. All were followed prospectively over a 10 year period. Initial treatment consisted of thorough debridement, removal of implants and a period of antibiotic administration. Vancomycin impregnated articulating cement spacer was inserted in the interim. C-reactive protein values were monitored periodically. At second stage all patients were clinically and biochemically free of infection.

Results: Second stage revision was performed at an average interval of 9 months (range 4 – 11 months). Average length of hospital stay post 2^nd stage was 19.8 ± 8.2 days. At follow-up (3.5 ± 2.5 years) outcome was poor in 33 % (amputations, arthrodesis, re-infections), good in 49 % (decreased ROM, PFJ pain) and excellent in 13 %. 3, 5% of patients had died with their prostheses in situ. The average pre and post operative Oxford Knee Score were 47.0 ± 7.5 and 21.6 ± 4.3 respectively.

Conclusion: Two-stage re-implantation using a hinge knee prosthesis is a safe and acceptable way of dealing with infected TKRs, conferring a stable reconstruction whilst allowing a through debridement. Thus potentially decreasing failure rates due to recurrence of primary infection. In this challenging group, complication rates were high, but at mid- and long-term review, no prostheses had failed from an aseptic cause. Moreover, this salvage procedure allows a quick rehabilitation and is tolerated well by patients.

Purpose: Periprosthetic fractures around hip prostheses are difficult problems because these fractures range from the very simple (requiring no surgical intervention) to the complex (requiring major surgery). This paper evaluates the primary stability and restoration of femoral bone stock following treatment of Vancouver type B-2 periprosthetic fracture of the femur using an extensively hydroxy-apatite coated revision stem implant.

Methods: We have prospectively reviewed 9 cases with B-2 periprosthetic fracture operated at our centre between 1996 to 2001. Of the nine patients, 4 were male and 5 female. The mean age was 76.7 years (50-92). All patients were treated by femoral revision using an extensively hydroxy-apatite coated titanium revision femoral stem (Restoration HA, Stryker, Rutherford, NJ). Fixation was augmented with a combination of cerclage cables and onlay cortical strut allografts.

Results: There has been no loss to follow-up. 1 patient died, but at most recent follow-up the fracture had united with radiological evidence of bone on-growth to the stem. Mean follow up in the rest of the cohort was 3.3 years. There was radiological evidence of fracture union in all patients. Mean subsidence of the stem was 0.22mm. At most recent follow-up the mean Harris Hip Score had improved to 77.2 (63-93). Favourable bone remodelling was observed in all patients with no evidence of stress shielding so far. At most recent follow-up there have been no cases of mechanical failure, deep infection or dislocations. No patient is awaiting further revision.

Conclusion and Significance: Te Restoration HA stem has produced excellent clinical results in our study. We have observed no intra operative fracture and low postoperative complication rate. We are extremely encouraged by the observed femoral remodelling. There has been no case of mechanical failure as yet and there is no reason to expect, once union and on-growth have occurred, that loosening will be a problem. In treating this challenging and increasingly common complication of total hip replacement, femoral revision using an extensively HA coated revision femoral component offers a reliable method of femoral fixation leading to successful fracture healing and early return to function.

Impaction allografting is increasingly used for the treatment of failed total hip replacements. In six human cadaveric femurs the impaction allografting procedure was performed to comprehensively describe the postoperative morphology of impaction allografting. After the procedure, the specimens were sectioned and prepared for histomorphometric analysis. The graft porosity was lowest in Gruen zone four (52%) and highest in Gruen zone one (76%). At the level of Gruen zone six and two, virtually the entire cross-section was filled with bone cement. The presented data will serve as a baseline for future investigations of the impaction allografting.

Impaction allografting is an attractive procedure for the treatment of failed total hip replacements. The purpose of this study was to comprehensively describe the morphology of impaction allografting post operatively to form a baseline for further investigations.

Three experienced surgeons performed the impaction allografting procedure on six cadaveric femurs. After the procedure, the femurs were cut in 6mm thick transverse sections and processed for histomorphometric analysis.

The porosity of the impacted graft was highest proximally in Gruen zone one (76%) and lowest in Gruen zone four (52%). Below the tip of the stem (Gruen zone four), the mean cement penetration was significantly lower compared to the proximal part of the femur. The averaged residual impacted graft layer in Gruen zone six and two was (0.5mm SD 0.4mm) significantly thinner compared with Gruen zone’s one, 7/1, and four.

In the region of Gruen zone six and two the entire cross-section was penetrated with bone cement with almost no residual graft layer (Figure). Even the simulated lytic defects in this region were filled with the graft cement composite which may not be remodelled by the host bone.

The graft porosity was found to be highest proximally and lowest distally. In the region of Gruen zone six and two the entire cross-section was penetrated with bone cement with almost no residual graft layer.

This investigation will serve as a baseline for future studies of the mechanical and biological processes that make the impaction allografting a successful procedure.

Funding: Stryker Howmedica and DePuy for provided implants and instruments.

Please contact author for figures and/or diagrams.

We describe the clinical and radiological results of 120 consecutive revision hip replacements in 107 patients, using a titanium alloy femoral component fully coated with Hydroxyapatite ceramic (HAC). The mean age at operation was 71 years (range 36 to 92). The average length of follow up was 8.0 years (range 5.0 to 12.4). All patients receiving a JRI Furlong HAC coated femoral component (JRI Instrumentation Ltd, London, UK) with a minimum follow up of 5 years were included. These included patients on whom previous revision hip joint surgery had taken place.

Patients were independently reviewed and scored using the Harris Hip Score (HHS), the Charnley modification of the Merle d’Aubigne and Postel Score (MDP), and The Western Ontario and McMaster Universities Osteoarthritis index (WOMAC). Radiographs were assessed by three reviewers (blinded to clinical details) for new bone formation, osteolysis, osteointegration and radiolucent lines in each Gruen Zone.

The mean Harris hip score was 85.8 (range 42 to 100) at the latest post-operative review. The mean WOMAC and MDP scores were 34.5 and 14.8 respectively. The mean pain visual analogue score (range 0 to 10) was 1.2 overall and 0.5 specifically for mid-thigh pain. There were no revisions of any femoral component for aseptic loosening. There were four stem re-revisions (3 cases of infection, 1 recurrent dislocation). Radiological review of all femoral components, including the four mentioned, revealed stable bone ingrowth with no new radiolucent lines in any zone. Using revision or impending revision for aseptic loosening as the end point, at 10 years the cumulative survival for the stem was 100% (95% CI 94 to 100). We present excellent medium to long term clinical, radiological and survivorship results with the use of a fully HAC coated titanium stem in revision hip surgery.

We studied various aspects of graft impaction and penetration of cement in an experimental model. Cancellous bone was removed proximally and local diaphyseal lytic defects were simulated in six human cadaver femora. After impaction grafting the specimens were sectioned and prepared for histomorphometric analysis.

The porosity of the graft was lowest in Gruen zone 4 (52%) and highest in Gruen zone 1 (76%). At the levels of Gruen zones 6 and 2 the entire cross-section was almost filled with cement. Cement sometimes reached the endosteal surface in other Gruen zones. The mean peak impaction forces exerted with the impactors were negatively correlated with the porosity of the graft.