The Revision Hip Complexity Classification (RHCC) was developed by modified Delphi system in 2022 to provide a comprehensive, reproducible framework for the multidisciplinary discussion of complex revision hip surgery. The aim of this study was to assess the validity, intra-relater and inter-relater reliability of the RHCC.

Radiographs and clinical vignettes of 20 consecutive patients who had undergone revision of Total Hip Arthroplasty (THA) at our unit during the previous 12-month period were provided to observers. Five observers, comprising 3 revision hip consultants, 1 hip fellow and 1 ST3-8 registrar were familiarised with the RHCC. Each revision THA case was classified on two separate occasions by each observer, with a mean time between assessments of 42.6 days (24–57). Inter-observer reliability was assessed using the Fleiss™ Kappa statistic and percentage agreement. Intra-observer reliability was assessed using the Cohen Kappa statistic. Validity was assessed using percentage agreement and Cohen Kappa comparing observers to the RHCC web-based application result.

All observers were blinded to patient notes, operation notes and post-operative radiographs throughout the process.

Inter-observer reliability showed fair agreement in both rounds 1 and 2 of the survey (0.296 and 0.353 respectively), with a percentage agreement of 69% and 75%.

Inter-observer reliability was highest in H3-type revisions with kappa values of 0.577 and 0.441.

Mean intra-observer reliability showed moderate agreement with a kappa value of 0.446 (0.369 to 0.773).

Validity percentage agreement was 44% and 39% respectively, with mean kappa values of 0.125 and 0.046 representing only slight agreement.

This study demonstrates that classification using the RHCC without utilisation of the web-based application is unsatisfactory, showing low validity and reliability. Reliability was higher for more complex H3-type cases. The use of the RHCC web app is recommended to ensure the accurate and reliable classification of revision THA cases.

Abstract

Background

The cemented mobile bearing metal backed low contact stress patellofemoral arthroplasty (LCS PFA) is a newer design belonging to the second generation of inlay type implant, based on the more successful knee arthroplasty model. The advantage is the patella can articulate with the trochlear implant as well as the femoral component of a total knee replacement (TKR).

A retrospective review of 51 consecutive patients undergoing fixation of Scaphoid fractures by two surgeons in a single institution was conducted. Twenty-four patients were treated with a Herbert screw and twenty-seven with an Acutrak screw. This included six patients who underwent acute fixation, three in each group. The remaining cases were for the treatment of non-union and delayed union.

There were no significant differences between the two groups in terms of age, side of injury, and mechanism of injury. Fractures were classified as proximal, middle and distal thirds of the Scaphoid and there was no significant difference between the groups regarding the types of fractures treated. The only significant difference between the groups was the time from injury to fixation when considering the cases of delayed union and non union which was greater in the Herbert screw group (7.5 months vs 4 months p=<0.05).

There was no significant difference in outcome between the two methods of fixation. Union rates for all cases were 79% for Herbert screws and 81% for Acutrak screws and 82% and 83% respectively when only considering the delayed union/non-union procedures. There was no difference in terms of time to union, further surgery or clinical outcome between the two groups. The Acutrak screw required removal in five patients and the Herbert screw in two due to symptoms from screw prominence. This was not statistically significant.

In conclusion there is no significant difference in surgical outcome between these two methods of fixation for Scaphoid fractures. The authors feel that this supports the view that biological factors are more important than the method of fixation in obtaining union of Scaphoid fractures.

Gentamicin is one of the most widely used antibiotics in Orthopaedic practice. It is commonly used as prophylaxis either through intravenous route, incorporated into bone cement or topical intraoperative irrigation. The former two are well studied. However, there is limited study on the therapeutic efficacy and safety of topical Gentamicin irrigation.

To assess the safety and infection rate of joint replacement surgery when topical gentamicin irrigation was used. This is a non-randomised, prospective study whereby patients undergoing joint replacement surgery were treated with gentamicin irrigation intra-operatively.

A total of 138 patients were divided into two groups in this study. Group A (98 patients) were patients with Total Joint Replacement and group B (40 patients) were patients with hemi arthroplasty of the hips and shoulders. Patients with pre-existing renal impairment were excluded. Two ampoules of Gentamicin (160mg) were irrigated into the wound before implants insertion and wound closure respectively. Intravenous Cefuroxime was also given prophylactically to all patients but none of them had intravenous gentamicin. Plasma Gentamicin level was assayed 4 hours and 24 hours post-operatively.

There were 16 patients in group A (16%; p< 0.001) and 12 patients in group B (30%; p< 0.001)) found to have plasma Gentamicin level > 2mcg/ml. All but 6 had plasma gentamicin level dropped to < 2mcg/ml at 24 hours. Although none of them developed systemic complications, the raise in plasma gentamicin was alarming. The incidence of infection was 6.1% (6 patients) in group A. These were superficial wound infection responded to antibiotics. No infection was reported in group B.

This study did not show apparent reduction in infection rate as compared to the reported literatures. Nevertheless, there was significant systemic absorption of topical gentamicin irrigation. Therefore, monitoring of post-operative plasma gentamicin levels is mandatory to avoid unforseen toxicity.

Previous studies have demonstrated higher infection rates following elective procedures on the foot and ankle as compared with procedures involving other area of the body. Previous studies also have documented the difficulty of eliminating bacteria from the forefoot prior to surgery. The purpose of the present study was to ascertain that preoperative chlorhexidine bathing provide significant local flora reduction than placebo in elective foot and ankle surgery.

From October 2005 to October 2006, a prospective study was undertaken to evaluate 50 consecutive patients undergoing planned, elective surgery of the foot and ankle. 50 patients were prospectively enrolled and randomly assigned to have preoperative footbath with Chlorhexidine Gluconate (Hibitane) (Group 1) or placebo (Group 2). Culture swabs were taken from all web spaces, nail folds, toe surfaces and proposed surgical incision sites before the preoperative antiseptics bath, during the procedures and immediately completion of surgery.

50 patients were enrolled (mean age: 42.6 years; range: 19–85; F: M = 29:21). 25 patients are assigned to each groups. 100% bacterial isolation preoperatively in both groups prior to antiseptics bathing. In group1, bacteria grew on intraoperative culture in 60% cases and 0% in immediate post-operative culture. In group 2, 96% in intraoperative swab culture and 16% in postoperative swab culture. The intraoperative swab culture bacterial count is statistically significant (p= 0.002). The postoperative swab culture bacterial count is marginally significant (p=0.055) when comparing 2 groups. No complications were recorded in both groups.

These data indicate that chlorhexidine provides better reduction in skin flora than placebo. Based of these data, we recommend the use of chlorhexidine footbath as well as the surgical preparatory agent for the foot and ankle surgery.

Introduction: Gentamicin is one of the most commonly used antibiotics in orthopaedic practice. It is mostly used as prophylaxis either through intravenous route, incorporated into bone cement or as local irrigation intra-operatively. The former two have been well studied. However, the literature on the therapeutic efficacy and safety of gentamicin irrigation is sparse. The objective of this study is to assess the safety of gentamicin irrigation in joint replacement surgery and associated infection rate.

Methods: This is a non-randomized, prospective study whereby patients undergoing joint replacement surgery were treated with gentamicin irrigation intra-operatively. Patients with pre-existing renal impairment were excluded. Two ampoules of Gentamicin (160mg) were irrigated into the wound before implants insertion and wound closure respectively. Cefuroxime was given pro-phylactically for all patients but none of them had intravenous gentamicin. Gentamicin level in the blood was assayed at 4 hours and 24 hours post-operation.

Results: A total of 138 patients were divided into two groups in this study. Group A (98 patients) consisted of patients with Total Joint Replacement and group B (40 patients) consisted of patients with hemi- arthroplasty of the hips and shoulders. There were 16 patients in group A (16%) and 12 patients in group B (30%) found to have plasma gentamicin level above 2mcg/ml. All but 6 of them had their gentamicin level dropped to below 2mcg/ml after 24 hours. The incidence of superficial wound infection was 6.1% (6 patients) in group A. No infection was reported for group B.

Discussion: Although none of them developed systemic complications, the plasma gentamicin level is high enough to raise an alarm. In this study, there was no apparent reduction in infection rate as compared to literatures reported. However, there was significant systemic blood gentamicin absorption.

Background: Previous studies have demonstrated higher infection rates following elective procedures on the foot and ankle as compared with procedures involving other area of the body. Previous studies also have documented the difficulty of eliminating bacteria from the forefoot prior to surgery. The purpose of the present study was to ascertain that preoperative chlorhexidine bathing provide significant local flora reduction than placebo in elective foot and ankle surgery.

Methods: From October 2005 to October 2006, a prospective study was undertaken to evaluate 50 consecutive patients undergoing planned, elective surgery of the foot and ankle. 50 patients were prospectively enrolled and randomly assigned to have preoperative footbath with Chlorhexidine Gluconate (Hibitane) (Group 1) or placebo (Group 2). Culture swabs were taken from all web spaces, nail folds, toe surfaces and proposed surgical incision sites before the preoperative antiseptics bath, during the procedures and immediately completion of surgery.

Results: 50 patients were enrolled (mean age: 42.6 years; range: 19 –85; F: M = 29:21). 25 patients are assigned to each groups. 100% bacterial isolation preoperatively in both groups prior to antiseptics bathing. In group 1, bacteria grew on intraoperative culture in 60% cases and 0% in immediate post-operative culture. In group 2, 96% in intraoperative swab culture and 16% in postoperative swab culture. The intraoperative swab culture bacterial count is statistically significant (p= 0.002). The postoperative swab culture bacterial count is marginally significant (p=0.055) when comparing 2 groups. No complications were recorded in both groups.

Conclusions: These data indicate that chlorhexidine provides better reduction in skin flora than placebo. Based of these data, we recommend the use of chlorhexidine footbath as well as the surgical preparatory agent for the foot and ankle surgery.

Introduction: The tribiological properties of bearing surfaces are one of the main topics in discussion in the orthopaedic research. Hard-on-hard bearings are one of the ways to reduce wear rates. Modern hard-on-hard bearing low wear rates depend on the correct pairing of bearing surfaces and strict manufacturing tolerances in surface roughness, clearance, and roundness.

There have been some concerns in using ceramic bearings, particularly regarding the fracture rate and their subsequent management. Hence, we present here 2 similar cases that highlight the catastrophic failure of metal head when used subsequently to treat the complication of ceramic fractures in Total Hip Arthroplasty (THA).

Case Details: Two patients underwent primary THA at different centres with ceramic-on-ceramic bearing. After an initial asymptomatic period of 2 years, ceramic fracture occurred in both the cases, which were subsequently replaced by metal-on-polyethylene bearings by the primary surgeons. One year after the revision of bearings, both the patients developed severe pain and discomfort, which on further investigation revealed massive metallosis, wear of the metal head and aseptic loosening of the acetabular components with cavitation in acetabulum.

Both the patients underwent revision THA under the senior author at our tertiary centre-Wrightington Hospital. Intraoperatively near total erosion of the metal head was noted with more than one litre of black, dense material collection in and around the hip joint revealing extensive metallosis. The acetabular cup was grossly loose and significant loss of bone stock was noted due to metallosis.

Single stage revision surgery was performed with impaction bone grafting for deficient acetabulum and cemented components were used. At one-year follow-up none of the cases have shown any further wear or complications.

Conclusion: One of the main objectives of successful THA is to improve implant longevity. To achieve this understanding the mechanisms of wear between the interacting surfaces is extremely important. The use of ceramic head is good, but there is always a risk of fracture. We do not recommend using metal heads in cases with prior ceramic fractures, as the wear of metal is most likely to occur as it is an ongoing process due to the residual ceramic debris. Hence in these difficult scenarios we recommend usage of ceramic-on-polyethylene as a safe option to prevent catastrophic erosion of metal head and improve implant longevity.

Background: To look into the incidence of lymphatic spread in Soft Tissue Sarcomas (STS) of the extremities and its relevance to the patient’s prognosis.

Patients & Methods: Retrospective review of 96 patients over a period of 5 years from 1999 to 2004 with a minimum follow up of 8 months. Complete data of every patient was reviewed with particular emphasis on lymph node and distant metastasis. All the patients were seen by one consultant and the histology reports were given by one Pathologist. 2 consultant radiologists were also involved in giving reports.

Results: There were 39 males and 57 females with an average age of 51 years. The average duration of swelling at presentation was 6 months. There was a strong family history of cancer in first degree relatives in 23 patients (24%). Liposarcoma was the commonest tumour (22) followed by Leiomyosarcoma (19), Fibro sarcoma (14), Synovial Sarcoma (12), Rhabdomyosarcoma (10), Histiocytoma (9) and other rare sarcomas. The Trojani grade of the tumours was Grade 1 = 36, Grade 2 = 39 & Grade 3 = 21. No metastasis (mets) were found during pre op. screening in 71 patients (74%) while 11 (12%) had lung mets, 9 (10 %) had lymph node involvement and 5 had liver involvement (4 %). 4 had multiple organ involvement on presentation. All except 6 patients had either wide local or radical excision of the tumour. The average interval between presentation and definitive treatment was 28 days. 9 of the patients with lymph node mets underwent nodal clearance during primary surgery. 2 turned out to be reactive hyperplasia while 7 proved to be malignant. 22 of the 71 patients (31 %) with no mets pre op. developed mets during follow up at an average duration of 11 months (11 to lungs, 8 to regional lymph nodes, 2 to liver and one to bone. 4 patients had multiple mets) In addition to this, there was local recurrence in 12 patients of whom 9 had incomplete excision during primary surgery. Of the total 15 patients who had proven lymph node mets, 5 came from Rhabdomyosarcoma, 4 from Leiomyosarcoma, 3 each from Lipo & Synovial sarcoma. The average life span in patients with lymph node involvement was 13 months in total when compared to 31 months for others. As on 31-3-2005, 39 were dead and the rest were alive. The average life span of the patients who died from the time of confirmed diagnosis was 23 months. The average life span for Rhabdomyosarcoma was 8 months, Histiocytoma was 12 months, Liposarcoma was 19 months, Leiomyosarcoma was 28 months and Synovial sarcoma was 36 months. Patients with Trojani grade 3 STS died at an average of 9 months when compared to 38 months for grade 1.

Discussion: There is a 16% spread to regional lymph nodes. It appears that lymph node involvement is indicative of micrometastatic disease elsewhere. Excision of the lymph nodes during primary surgery did not improve the life expectancy.

Conclusion:

Lymph node involvement is a poor prognostic sign

The AO, Frykman, Mayo and Fernandez classification system for distal radius fractures were evaluated for interobserver reliability and intraobserver reproducibility using plain radiographs. Five orthopaedic consultants, five orthopaedic registras and five orthopaedic senior house officers classified 20 sets of distal radius fractures on two seperate occasions. There were 2400 induvidual observations. Kappa statistics were used to establish a relative level of agreement between observers for the two readings and between seperate readings by the same observer. Our results for intraobserver reproducibility showed Fernandez Kappa value of 0.49, Frykman 0.47, Mayo 0.45 and AO 0.33. A 0.4 result shows good consistecy accorcing to well reconised staistical boundries and is significant. That is reproducibility happened at a level greater than by chance. Interobserver Kappa values were poor in all classification systems. We also sought to look at varibles within grade of surgeon and developed Kappa values for these also.

Introduction and Aims: Prospective review of the patients who underwent stabilisation of displaced acetabular fractures in our unit in order to evaluate the presence of neurological lesions and functional outcome.

Method: Out of 136 patients operated over six years we identified 27 patients with neurological lesions. A standard protocol was followed for the clinical and neurophysiological evaluation of nerve injuries. Electromyography (EMG) was used to determine the anatomical location of the neurological lesions and the type of lesion, which act as a valuable tool in the diagnosis of double crush lesion in the sciatic nerve. Neurological recovery was evaluated with EMG studies and clinically rated as described by Clawson et al. Functional outcome was graded by the system proposed by Fassler and Swiontkowski.

Results: EMG studies revealed sciatic nerve lesions in all the cases. Additionally, in nine patients with a dropped foot there was evidence of a proximal (sciatic notch) and distal (neck of fibula) lesion – ‘double crush syndrome’. At final follow-up, clinical examination and associated EMG studies revealed full recovery in five cases with initial muscle weakness, and complete resolution of sensory symptoms (burning pain, hyposthesia) in four cases. There was improvement of functional capacity (motor and sensory) in two cases with initial complete drop foot and in four cases with muscle foot weakness. In 11 of the cases with dropped foot (all nine with double crush) at presentation, there was no improvement in function. Functional outcome was unsatisfactory in all patients with double crush injury.

Conclusion: In cases where there is evidence of ‘double crush lesions’ the prospect of functional recovery is low as seen in this group of patients. The patients with double crush syndrome are not expected to recover and could be considered as a sign of unfavourable outcome following neurological impairment after acetabular fractures. Single lesions appear to be associated with a more favourable prognosis.

Purpose: We carried out a questionnaire survey amongst all the members of the British Association for surgery of the Knee (BASK) to provide us with a guide to the current practice and opinions on cementing techniques in Knee replacement.

Materials & Methods: Between January and February 2003, all the three hundred members of the BASk were mailed a thirteen-question survey regarding the current practice of TKR with specific emphasis on the cementing techniques.

Conclusion: Our study shows the wide variation in current practice and attitudes towards cementing in Total Knee replacement amongst the specialist Knee surgeons of Britain, but the practice of the majority is in accordance with the guidelines issued by the BOA & BASK.

Aim: To assess the intra- and inter-observer reliability of using pre-operative templates in selecting the appropriate prosthetic size of the unicompartmental knee system (Oxford Phase3, Biomet Merck, Bridgend) Methods: Ten observers estimated the size of the unicondylar knee prosthesis required for thirty randomly selected patients with osteoarthritis. Estimation of the size was gauged using templates pre-operatively. AP and lateral radiographs were taken of each patient. All observers were orthopaedic surgeons with a minimum of þve years experience in orthopaedic surgery and with a general interest in joint arthroplasty. The observations were recorded independently and repeated measurements were taken two weeks later. Results: Intra- and inter-observer discrepancies were evaluated using the weighted kappa (κ) coefþcient with signiþcant intra- and inter-observer variations. The results are shown in the table.

Conclusions: Pre-operative radiological templating is of questionable beneþt in patients undergoing Oxford Phase 3 knee arthroplasty.