Hip and knee joint arthroplasty wait list has been getting outrageously long in South Africa with some tertiary hospital reporting more than 5 years of waiting time. This has been further compounded by covid 19 pandemic. There is plateau of ideas on how best to address the backlogs in high volume tertiary centers, with catchup list, out reach program, private partnership seeming unsustainable. We sought to look for sustainable solution to the problem and we looked not far but inside the system. Triggered by the fire that engulfed part of the hospital, we found ourself refuged at the sister tertiary hospital with no access to theatre time. We visited districts hospitals within the cluster and discovered state of the art facility underutilized. We presented a plan to establish a satellite arthroplasty center which was greatly embraced by the management. We partnered with the trade to setup an arthroplasty service in this district hospital. Employed 3 retired nurses and 2 parttime anaesthetist all on yearly contract. We developed pathways for patient selection according to American Society of Anaesthesiologist(ASA). 232 total joint arthroplasties were performed in 15-month, 33%Hips and 67%Knees. The average hospital stay was 2,3± 2days. We had 1 mortality(# NOF) and 2 cases of PJI treated successfully with debridement antibiotic and implant retention. We had 5 cases of intraoperative calcar femur fracture managed with cables and all stable at 6weeksand 3month. Over 76% of the cases were performed by fellows as the primary surgeons. Primary hip and knee total joint replacement can be safely performed in a district hospital. Employing motivated retired staff was key to the success of this project. Fellowship trainees performed most of the operations. We suggest that other academic hospitals with long waiting list can look at emulating this model within their district.Method
Total Joint Arthroplasty (TJA) is a successful orthopaedic procedure allowing dramatic clinical and functional improvements. Globally, there's been an increase in demand and performed cases associated with an increase in complications. Subsequently, focus on the prevention of complications has become important worldwide. The incidence of venous-thrombolic events (VTE) despite great attention has not diminished despite much investigation. A balance between efficacy and safety from the available agents is essential. Low molecular weight heparin (LMWH) has been commonly used, but oral anti-coagulants have become more popular. The aim of this study was to assess the adherence LMWH and the effectiveness and safety of preventing VTE in post-operative arthroplasty patients in a South African setting. We conducted a prospective cohort study that included hip and knee, primary and revision, arthroplasty patients who received thromboprophylaxis with one daily injection of LMWH for 14 days post discharge. Patients who omitted 1 or more doses during the follow up period were classified as “non adherent”. A questionnaire was used at follow up visits at least 6 weeks post-operatively. 100 consecutive patients were followed up. The mean age of patients was 63.45 years. There were 68 % female patients. There was a 92% compliance rate. 60 % of patients had the injection administered by a family member, 38 % administered it themselves and 2 % had the injection administered by health professionals. Venous thromboembolic events were confirmed in 5 % at 7.86 days after surgery. Three patients had persistent wound drainage after surgery, however, none required reoperation or readmission. Compliance with LMWH is high and is comparable with oral agents. It is effective in preventing VTE and safe with regards to bleeding and wound complications in a South African setting. Patient education regarding medications may improve compliance of the medication.
Depression is a common co-morbidity in Total Hip Arthroplasty (THA). Chronic pain and depression influence one another. Postoperative outcomes and satisfaction rates are affected by depression. The aim of the study was to determine the impact of pre-operative depression on patient functional outcomes and satisfaction rates after THA. A secondary objective was to assess potential change in the incidence of depression at mid-term post-operative follow-up.Introduction
Objectives
The prevalence of immunocompromised patients undergoing Total Hip Arthroplasty (THA) is increasing worldwide as a consequence of advances in treatment. HIV is presenting in an older population group and concerns of higher rates of infection, early failures and dangers posed to healthcare workers exist. This study is imperative to predict future burden of THA and make subsequent provisions The objective was to determine the seroprevalence of HIV in patients presenting for THA in an academic institution in a developing country. Secondarily, the aim was to determine if there is any difference in the seroprevalence of patients undergoing THA and TKA and finally to assess the status of disease control in seropositive patients eligible for TJA on pre-existing HAART.Background
Objectives
A longitudinal study was done assessing the latest radiographs available in a series of collarless Corail uncemented stems which have reported survival rates of 95% at 20 years. Parameters scored included the degree of “Ghosting” or delamination, the Gruen, the stem fit in the femoral canal and the degree of calcar resorption. Patient and implant demographics were noted. At 3 years the loosening rate was 23% reaching 64% at 6 years after the index procedure. It was present in all age groups, with a peak in the 24 to 49 year age group. Males and females had the same occurrence. When it was present this was always in zone 1. It was present in 6% of patients in zone 7, but then always associated with zone 1 changes. High and standard off-set stems had the same loosening rates. The looser fit of the stem the higher the incidence of loosening. There was no correlation to the type of bearing surface or the degree of calcar resorption. Those patients with a BMI of 25 – 35 had lower loosening rates compared to those with higher or lower BMI's. We postulate that cancellous bone on-growth onto the hydroxyapatite coating associated with loading flexural micro-motion leads to hydroxyapatite being pulled off the smooth stem substrate in zone 1. Progressive delamination of the hydroxyapatite then occurs. The triple-tapered design though imparts continued stability. We report high loosening rates in the Corail stem and suggest a mechanism for its development.
Total Hip Replacement (THR) is a proven and effective surgical procedure. One of the main limiting factors of the longevity of THR is the performance of the bearing surface. The optimum bearing surface choice, however, remains controversial. We wanted to understand what influenced the choice of bearing surfaces amongst South African orthopaedic surgeons. We also wanted to know if there was any consensus between surgeons and the orthopaedic trade. There is no epidemiological registry-based data available in South Africa in respect of bearing surfaces used in hip replacements. We sent out an electronic survey to all members of the South African Orthopaedic Association as well as to trade representatives. Patient parameters influencing the choice of bearing surfaces were surveyed and these included age, gender, level of activity and diagnosis. We used a regressional and tree analysis methodology to interpret the results.Introduction:
Aims, material and methods:
Antibiotic prophylaxis prior to dental and other procedures when patients have joint replacements in situ remains controversial. Recommendations seem to generally be intuitive and not based on any sound scientific evidence. Recently, the American Academy of Orthopaedic Surgeons altered their previous standpoint and suggested that orthopaedic surgeons review their current practice of routine prescription of antibiotic prophylaxis. We conducted an electronic survey of members of the South African Orthopaedic Association to determine the opinion of the average orthopaedic surgeon in South Africa in respect of this prophylaxis. 111 surgeons responded.Background:
Method:
Massive acetabular defects remain an unresolved challenge in revision arthroplasty surgery of the hip. We report on 7 patients treated with custom made acetabular components to manage these massive boney defects. After high resolution CT scans were done, custom made implants were designed in collaboration between the surgeons and the manufacturer. All implants matched the bony defects as designed.Background:
Methods:
Metal ion levels are used to track the performance of metal containing bearings in hip replacement patients. Changes in whole blood metal ion levels are indicators of wear rates in these bearings. Normal metal ion levels are variable, and range widely. Changes in these “non-bearing” levels over a period of time may influence the monitoring of these bearings. As part of a prospective randomised trial of different bearing surfaces, whole blood metal ion levels were monitored. This included four cohorts of patients, namely ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoP), ceramic-on-ceramic (CoC) and ceramic-on-metal (CoM). Serial whole blood metal ion levels in the non-metal bearings, namely CoC and CoP, were analyzed. There was no consistency in these whole blood metal ion levels. Intra-patient variations in these levels over a period of time could not be due to bearing-produced metal ions as these were all metal free, and thus not the source of any endogenous ions. These intra-patient variations may reflect changes in exogenous exposure to these metal ions, fluctuations in these patient's metabolic functions or production of metal ions from non-bearing prosthetic sources.Methods.
Results.
The advantages of computer navigated total knee replacement are well documented in the literature, however, increased surgical time and cost issues remain the major deterrent for the wide use of this technology. Placement of cutting jigs under computer guidance forms a major aspect of computer assisted knee replacement surgery. The use of a motorized mini-robotic cutting jig allows for a more precise and time efficient execution of the femoral cuts under computer guidance. We present a preliminary report on our experience using standard computer assisted surgery (CAS) jigs and mini robotic motorized jigs in computer navigated knee replacement We compared our experience using standard jigs and mini-robotic jigs in knee replacement. A cohort of patients involved in a study comparing navigated and standard total knee replacements received TKA using a Bi-Cruciate Stabilised Knee System. A pilot cohort of patients received total knee replacement using standard computer navigation by the pi galileo system without the mini-robots while awaiting acquisition of the mini robot system. We compared our experience using the same pi galileo system with mini robotic cutting jigs to the cohort without the mini-robotic cutting guides. Reduction in surgical time was statistically significant when using the motorized mini robotic jigs. Blood loss was identical in both cohorts, and cut precision was better in the cohort with the motorized mini robotic jigs.Methods:
Results:
Monitoring the performance of hip replacements post-operatively is tedious and costly, necessitating radiological examinations as well as other specialized examinations such as whole blood metal ion levels. In an effort to control escalating costs, we conducted an ethically approved clinical trial to assess the efficacy of basic acoustic monitoring equipment to asses these implants. An electronic stethoscope was successfully used to record sounds from the hips of participants with different bearing surfaces. The sounds were recorded while conducting a standardized movement sequence. A 5th order Savitzky-Golay filter with a window width of 21 points was used to remove background noise. The recordings were also listened to by ear and three primary classes of sounds were identified. Frequency components contained in the classes were identified using spectrograms and Welch power density spectra. The sounds were correlated with different patient factors including component positioning, BMI and length of time that the implant was in situ. The skewness and kurtosis of the power spectra were calculated and found to be different for each class. Further frequency analysis was conducted with the aid of the discrete wavelet transform. This met with some success as different frequency levels were found in each sound class. All bearing surfaces produced some noise. The most sounds were produced by the ceramic-on-metal group, even though not in the audible range, and those participants with a body mass index in the obese range. Sounds were also detected in the ceramic-on-polyethylene implants. However, no consistent links between these factors and the sounds produced could be identified. Specifically, the lack of correlation between sound occurrence and length of implantation indicates that this technique is not useful in predicting possible failures or future complications in real time.Method.
Results.
There has been much controversy around metal on metal hip replacements of late due to adverse metal reactions. There is evidence implicating lymphocyte mediated response (type IV delayed-hypersensitivity) to metal debris generated by the implants as one of the main factors responsible for the reactions. Our understanding of these adverse reactions continues to improve but we also recognize that the majority of patients with MOM implants are asymptomatic with well functioning implants. Studies have shown up to 16% allergy to metal ions on pre-operative allergy patch testing. We set out to determine the incidence of hypersensitivity to Cobalt, Chromium and Molybdenum in a arthroplasty population. We assayed whole blood using a validated optimized lymphocyte transformation test, MELISA as part of a prospective randomized study on large diameter bearing surfaces. We recruited 47 subjects, 19 males, 28 females (35–75 yrs). Specific exclusions included presence of metal implants in the body and industrial exposure to metals.Introduction
Method
Maximizing efficiency in total knee replacement surgery is desirable and one of the key aspects is optimum utilization of available theatre time allocation. The level of complexity of the pathology is often one of the determinants of the length of operative time. Body mass index (BMI) has also been positively correlated with operative time. However, two patients with the same BMI but different body habitus (central obesity vs generalized obesity) may present different challenges during surgery. An index focusing on the anthropometry of the lower limb (supra-patella index SPI) has been proposed and we hypothesize that it correlates more closely with operative time than BMI. BMI and SPI were determined in all patients recruited into a prospective trial of a specific knee implant. All patients were operated on by one of two surgeons in a standardized manner. Data including operative time and tourniquet time were determined.Introduction
Method
