Aims

The purpose of this study was to evaluate whether an innovative templating technique could predict the need for acetabular augmentation during primary total hip arthroplasty for patients with dysplastic hips.

Introduction

Cement in cement revision with preservation of the original cement mantle has become an attractive and commonly practised technique in revision hip surgery. Since introducing this technique to our unit we have used two types of polished tapered stem. We report the clinical and radiological outcomes for cement in cement femoral revisions performed using these prostheses.

When performing total hip replacements in patients with hip dysplasia, acetabular augmentation may be required to prevent early component failure. Preoperative radiographic templating may help estimate acetabularcomponent coverage but has not previously been shown to predict the need for augmentation.

We developed a simple method to estimate the percentage of acetabular component coverage from pre-operative radiographs (True: False cup ratio). We aimed to evaluate whether this couldpredict the need foracetabular augmentation at primary total hip replacement for patients with dysplastic hips.

We reviewed all patients with hip dysplasia who underwent a primary total hip replacement from 2005–2012. Classification of hip dysplasia (Crowe), centre edge angle (CEA), Sharp and Tonnis angles were determined on pre-operative radiographs for each patient. Templating was performed on anteroposteriorand lateral view hip radiographs to determine the likely percentage of acetabular component coverage using the True: False cup ratio. Patients requiring acetabular augmentation at time of primary total hip arthroplasty were noted.

128 cases were reviewed, 31 (24%) required acetabularaugmentation. Comparison between augmented and non-augmented cases revealed no difference in the mean CEA (p = 0.19), Sharp angles (p = 0.76) or Tonnis angles (p = 0.32). A lower True Cup: False Cup ratio was observed in the augmented groupcompared to the non-augmented group(median = 0.68 vs 0.88, p < 0.01).

Preoperative templating can help predict which dysplastic hips are likely to require acetabular augmentation at primary total hip replacement.

Repeat revision hip replacements can lead to severe bone loss necessitating salvage procedures such as proximal or total femoral replacement. We present medium term outcomes from our experience of the Limb Preservation System (LPS) in patients with failed revision hip arthroplasties.

All patients undergoing proximal femoral or total femoral replacement from 2003–2007 at our unit were reviewed. Data was collected preoperatively and at annual assessment post procedure for a minimum of 5 years. This included clinical review, functional outcome scores (WOMAC, Oxford Hip Score, Harris Hip Score) and radiographic evaluation.

A total of 17 patients underwent femoral replacement (13 proximal, 4 total) using the LPS during the study period. Within this cohort there were 13 males and 4 females with a mean age of 64 years (range 47–86). Median follow up was 7 years (range 5–9 years). Primary diagnoses were DDH (7), Primary OA (5), RA (2), proximal femoral fracture (2) and phocomelia (1). Five patients (29%) required further revision surgery for infection (2 patients) or recurrent dislocations (3 patients). No stems required revision due to aseptic loosening or stem failure at 5–9 years. Compared to preoperative assessment, there was significant improvement in median outcome scores at 5 years (WOMAC increased by 33 points, Oxford hip score by16 points and Harris hip score by 43 points). 82% of patients maintained functional independence at latest review.

The Limb Preservation System offers a salvage procedure for failed revision total hip arthroplasty with significant symptom and functional improvement in most patients at medium term follow up.

Background

Venous thromboembolism (VTE) is a common complication of pelvic and acetabular fracture fixation. There is, however, currently limited data to guide clinical decisions on thromboprophylaxis choice in these patients.

Osteoarthritis of the first trapeziometacarpal joint (TMCJ) is a disabling disease which reduces the function of the thumb and the hand. Replacement arthroplasty offers a pain free joint as well as mobility, stability and strength.

This study reviews the results of TMCJ arthroplasty using a cemented metal-on-polyethylene implant (Sr TMC, Avanta®). Between 2001–2005 seventy two (n = 72) TMCJ cemented Arthroplasties were performed by a single surgeon. Patients were followed in the clinics for up to six years (median follow up 36 months, range 24–72). Patients were reviewed clinically and radiologically by two independent assessors. For outcome, Sollerman and Quick-DASH scores were used. A Jamar dynamometer was used to assess the grip and pinch strengths. Thirty six patients (46 joints), were seen at final follow up. There were 13 male and 23 female patients. Ten patients had bilateral TMCJ replaced.

Six patients were revised to trapeziectomy and ligament reconstruction with tendon interposition. Four for aseptic loosening and two for traumatic dislocation. Survival after a median follow up of 36 months was 91%. At final follow up mean Quick DASH score was 29.2 and mean Sollerman Score was 77.1. Radiological review of the surviving joints showed lucencies around trapezial component in 8 joints, 4 of which were loose. However these patients had good hand function and grip strength and therefore declined revision surgery. We found that the radiological findings did not correlate with clinical findings. 83% patients were satisfied with the outcome of their treatment.

Early results of Sr-TMC (Avanta) joint replacement are encouraging. We recommend the use of this prosthesis for osteoarthritis of the trapeziometacarpal joint.

Background: Osteoarthritis of the first trapeziometacarpal (TMC) joint is a disabling disease which reduces the function of the thumb and the hand. Replacement arthroplasty offers good range of joint motion and also maintains thumb length thus improving tip pinch grip.

Aims: This study reviews the results of TMCJ arthroplasty using a cemented metal-on-polyethylene implant (Sr TMC, Avanta^®).

Methods and Results: Between 2001–2005 seventy two (n = 72) TMCJ cemented Arthroplasties were performed by a single surgeon. Patients were followed in the clinics for up to seven years (median follow up 36 months, range 24–84). Patients were reviewed clinically and radiologically by two independent assessors. For outcome, Sollerman and Quick-DASH (Disabilies of the Arm, Shoulder and Hand Score) scores were used. A Jamar dynamometer was used to assess the grip and pinch strengths. Thirty six patients (46 joints, n = 46), were seen at final follow up. There were 13 male and 23 female patients. Ten patients had bilateral TMCJ replaced.

Six patients were revised to trapeziectomy and ligament reconstruction with tendon interposition. Four for aseptic loosening and two for dislocation. With revision as end point the survival rate at median follow up of 36 months was 89%. At final follow up mean Quick DASH score was 29.2 and mean Sollerman Score was 77.1. Radiological review of the surviving joints showed subsidence of trapezial component in 4 joints. However these patients had good hand function and grip strength and therefore declined revision surgery. We found that the radiological findings did not correlate with clinical findings. 83% patients were satisfied with the outcome of their treatment.

Conclusion: Early results of Sr-TMC (Avanta) joint replacement are encouraging. We recommend the use of this prosthesis for osteoarthritis of the trapeziometacarpal joint.

Hallux rigidus is a common condition involving the first Metatarsophalyngeal (MTP) joint. Total joint arthroplasty is an acceptable modality of treatment. A number of different prosthesis have been used. Our study aims to evaluate the outcome of uncemented ceramic on ceramic (MOJE) prosthesis, in the treatment of painful hallux rigidus.

Between March 2000 and June 2005, 38 patients (53 feet) with painful hallux rigidus were treated with uncemented ceramic on ceramic (MOJE) prosthesis. There were 30 female and 8 male patients. The hallux meta-tarsophalangeal-interphalangeal scoring scale, by the American Orthopaedic Foot and Ankle Society, was used to assess these patients, pre-operatively and at follow up. A total score of 100 is possible in a patient with no pain, full range of MTP joint movement and good alignment.

The average follow up was for 34 months (range 12–68 months). Three revisions were carried out in three patients, 2 for deep infection, and 2 for persisting pain. Five patients showed radiological signs of osteolysis but had no symptoms. There was one late subluxation after 32 months. One patient developed a superficial infection, which was treated successfully.

The average AOFAS score pre-operatively was 45, compared to 91 post-operatively (p< 0.05). 23 patients (36 feet) classed the outcome as excellent to good. Ten of the patients subjectively described the out come of the procedure as excellent.

The preop range of movement (combined dorsiflex-ion and plantarflexion) was improved from a mean of 22 degrees to 68 degrees postoperatively.

The ceramic/ceramic (MOJE) total arthroplasty gave excellent results in 77% of patients. The early outcome is encouraging. We ewcommend continued use of this prosthesis for painful hallux rigidus.

Aim:This study was carried out to assess various factors responsible for the development of avascular necrosis and the effect of treatment on clinical outcome.

Methods: We studied the clinical notes and radiographs of patients presenting with SCFE during the period between 1994 and 2003.

Results: Seventy three patients (n=73) with ninety two (n=92) hips were included in the study. There were 16 acute, 43 acute-on-chronic, 29 chronic and 4 preslips. Seventy Seven (n = 77) slips were classified as stable and 15 as unstable slips. Fifty three slips (57.6%) were mild, 34 (37%) were moderate and five (5.4%) were severe slips. Despite no deliberate attempts to reduce the slip at the time of surgery eighteen hips (n=18) showed a median decrease in slip angle of 8 degrees (range 2–36) in acute and acute-on-chronic slips. The mean preoperative slip angle was 32 degrees (range 9–76) compared to postoperative slip angle of 29.9 degrees (range 10–75) (p=0.004). Four patients developed avascular necrosis (AVN). Intraoperative reduction of the slip was significantly related to development of AVN (p< 0.001). According to the criteria of Heyman and Herndon eight patients had functional deficit at the time of final follow up and clinical outcome was fair, poor or failure. All of these patients had a reduction in the angle of slip at the postoperative radiographs compared to their preoperative radiographs.

Conclusion: Reduction of slipped capital femoral epiphysis is responsible for poor outcome and also related to the development of avascular necrosis. We recommend single in situ pinning for these cases regardless of severity of slip.

Background: Subacromial decompression surgery is associated with significant postoperative pain. We compared the effect of intrascalene block (ISB) and sub-acromial bursa block (SBB) with simple opiate based analgesia

Methods: In a prospective, randomised controlled trial, fifty-three (n = 53) patients scheduled for arthroscopic subacromial decompression were randomised into three groups receiving Intrascalene block (n =19), Subacromial Bursa block (n =19) or neither of the two blocks (n =15 controls). Patients with cuff pathology were excluded. ISB was performed preoperatively with 20 mls of 1% Prilocaine and 10 mls of 0.5 % Bupivacaine. SBB was given with 20 mls of 0.5% Bupivacaine postoperatively. All patients received standardised general anaesthetic and postoperative analgesia. Pain, sickness and sedation scores were noted at 1, 2, 4, 8, 12 and 24 hours postoperatively. The postoperative consumption of morphine and the time when the first bolus of morphine was required were also noted.

Results: The visual analogue pain scores in the ISB and SBB group were lower than the control group in the first twelve hours postoperatively achieving statistical significance but there were no significant differences between the SBB and ISB groups. The controls consumed more morphine postoperatively (mean 32.3 mls) than SBB (21.21 mls) and ISB groups (14.00 mls) (p < 0.001). The time for first bolus was earlier in the controls (mean 30.2 mins) as compared to both SBB (72.7 mins) and ISB groups (105.8 mins) (p< 0.001). The oral analgesic intake was less in the SBB and ISB groups than the controls (p = 0.004), but there was no difference between the two treatment groups.

Conclusion: Whilst intrascalene block remains the gold standard where expertise is available for its administration, subacromial bursa block is a safe alternative in patients with intact rotator cuff undergoing arthroscopic subacromial decompression.

Introduction: The Centrament® (Aesculap, Tuttlingen, Germany) is modular hip system combined with a range of modular heads and acetabular components, enabling the system to cover a wide range of applications. We looked at medium term results in a district general hospital.

Methods: This is a retrospective cohort study. Information was obtained from patient notes and radiographs.

Results: One hundred and ninety two (n =192) total hip arthroplasties in 178 patients (14 bilateral) were followed up for at least 5 years (mean: 5.8 years; range: 5–9 years). The mean age of the patients at the time of surgery was 71.8 years (range, 38–91 years). The most frequent indication for surgery was osteoarthritis (94%). One acetabular cup was revised for aseptic loosening, and 2 cups were revised for recurrent dislocation. Two stems have been revised (one for aseptic loosening and one for prosthetic fracture). The dislocation rate was 4.2% during the initial fifty arthroplasties that reduced to 0.9% in the subsequent years. For radiological evaluation Gruen zones for the stem and DeLee and Charnley zones for the cup were used. The acetabular cup was satisfactory in 186 hips radiographs and showed asymptomatic non-progressive osteolysis in three cups. Two stems showed signs of osteolysis at nine years but the patients had no symptoms. Using the recommendation of revision as the endpoint, Kaplan Meier Survival Analysis showed a cumulative survival for the prosthesis as 97.3%, with stem survival of 99% and cup survival of 98.5%.

Discussion: In the medium-term, these results are comparable to other cemented hip prosthesis used in the UK.