This large UK multicentre study evaluates clinical outcomes and identifies factors associated with local complication following PFR for non-oncological conditions.

132 patients across four UK centres underwent PFR from 01/08/2004-28/03/2023 with median follow-up of 1.9 (Q10.5-Q34.2) years. 75 (56.8%) patients were female and the mean age was 74.0 (SD 11.7) years. 103 (78%) patients had Charleston Comorbidity Index ≥3. ASA class was III or IV in 66.6%. Indications were infected revision (39, 29.5%), periprosthetic fracture (36, 27.3%), acute trauma (30, 22.7%), aseptic revision (17, 12.9%), failed trauma (nine, 6.8%) and complex primary arthroplasty (one, 0.8%). The primary outcome was the local complication rate. Secondary outcomes were systemic complications, reoperation and mortality rates. Comparisons were made with t-tests and Chi2 tests to investigate patient and surgical factors associated with local complication. Statistical significance was p<0.05.

There were 37(28.0%) local complications. These were 18 (13.6%) dislocations, eight (6.1%) prosthetic joint infections, four (3.0%) haematomas, three (2.3%) superficial infections, one (0.8%) wound dehiscence, one (0.8%) sciatic nerve palsy and one (0.8%) femoral perforation. Dislocation mostly occurred in conventional articulations (12, 9.1%) followed by dual-mobility cups (three, 2.3%), constrained cups (two, 1.5%) and hemiarthroplasty (one, 0.8%). Median time to local complication was 30 (Q14-Q3 133) days. Seven (5.3%) patients developed a systemic complication. Thirty-three (25.0%) patients underwent reoperation. Thirty-day and one-year mortality rates were 3.8% and 12.1%, respectively. Longer surgical waiting times (7.9 \[SD 16.9) versus 2.6 \[SD 4.4\] days, p<0.001) and longer operating times (212.5 \[SD 71.8\] versus 189.4 \[SD 59.3\] mins, p=0.0450) were associated with local complication.

Due to its high complication rate, PFR should be a salvage option when performed for non-oncological indications. Conventional articulations should be avoided. PFR should be delivered in a timely manner and ideally as dual-consultant cases to reduce operating time.

Aims

Prophylactic antibiotic regimens for elective primary total hip and knee arthroplasty vary widely across hospitals and trusts in the UK. This study aimed to identify antibiotic prophylaxis regimens currently in use for elective primary arthroplasty across the UK, establish variations in antibiotic prophylaxis regimens and their impact on the risk of periprosthetic joint infection (PJI) in the first-year post-index procedure, and evaluate adherence to current international consensus guidance.

In March 2020, the World Health Organisation declared the COVID-19 outbreak a pandemic. Multiple new guidelines were proposed and existing models of social, domestic and hospital care altered. Most healthcare systems were largely unprepared for this and this pandemic has tested their adaptability. This study is aimed at assessing the impact of covid-19 on the demographics, presentation and clinical management of patients with proximal femoral (hip) fractures.

This retrospective multi-centre cohort study compared all patients admitted with hip fractures, between 1^st March and 30th May 2019 (Group PC: Pre-Covid) with hip fracture patients admitted over the same time period during the pandemic in 2020 (Group C: Covid). The data was obtained from the hospitals' local and National Hip Fracture Databases. Mortality data was checked with the Office for National Statistics (ONS). Primary outcomes were time to theatre, in-patient length of stay and 30-day mortality.

580 patients were included (304 PC, 276 C). Patient Charlson comorbidity index and Nottingham Hip Fracture scores were broadly similar across the two cohorts. There was a significant reduction in percentage of total hip replacements in Group C (11% to 5%, p=0.006). There was an increase in conservative management in group C (1% to 5%, p=0.002). The time to theatre was significantly delayed in Group C (43.7 hours C versus 34.6 hours PC, p<0.001). Overall length of hospital stay was similar in both groups (16.6 days PC versus 15 days C, p=0.089). 30-day mortality rate in Group C was 9.8% compared to 8.2% in Group PC (p=0.431), but for covid (+) patients it was significantly higher at 38.2% versus 5.8% in covid (−) patients (p<0.001).

This is one of the largest multi-centre comparative cohort study in the literature to date, examining the impact of the covid-19 pandemic on the management of hip fracture patients. Whilst mortality rates were similar in both groups, covid patients were almost seven times more likely to die, reflecting the seriousness of the covid-19 infection and its sequelae in such elderly, vulnerable patients.

Aims

This aim of this study was to assess the reliability and validity of the Unified Classification System (UCS) for postoperative periprosthetic femoral fractures (PFFs) around cemented polished taper-slip (PTS) stems.

Introduction

The revision rate of unicompartmental knee replacement (UKR) in national joint registries is much higher than that of total knee replacements and that of UKR in cohort studies from multiple high-volume centres. The reasons for this are unclear but may be due to incorrect patient selection, inadequate surgical technique, and inappropriate indications for revision. Meniscal bearing UKR has well defined evidence based indications based on preoperative radiographs, the surgical technique can be assessed from post-operative radiographs and the reason for revision from pre-revision radiographs. However, for an accurate assessment aligned radiographs are required. The aim of the study was to determine why the revision rate of UKR in registries is so high by undertaking a radiographic review of revised UKR identified by the United Kingdom's (UK) National Joint Registry (NJR).

Aims

Periprosthetic fracture (PF) after primary total hip arthroplasty (THA) is an uncommon but potentially devastating complication. This study aims to investigate the influence of cemented stem designs on the risk of needing a revision for a PF.

Introduction

The optimal treatment for isolated patello-femoral arthritis is unclear. Patello-femoral arthroplasty (PFA) may offer superior knee function in isolated patello-femoral osteoarthritis compare to TKA. The literature is controversial for patient outcomes in PFA. Some reports showed improved outcomes while others were disappointing. We assessed our outcomes to try to identify causes for poor outcomes.

The use of journal clubs and, more recently, case-based discussions in order to stimulate debate among orthopaedic surgeons lies at the heart of orthopaedic training and education. A virtual learning environment can be used as a platform to host virtual journal clubs and case-based discussions. This has many advantages in the current climate of constrained time and diminishing trainee and consultant participation in such activities. The virtual environment model opens up participation and improves access to journal clubs and case-based discussions, provides reusable educational content, establishes an electronic record of participation for individuals, makes use of multimedia material (including clinical imaging and photographs) for discussion, and finally, allows participants to link case-based discussions with relevant papers in the journal club.

The Leicester experience highlights the many advantages and some of the potential difficulties in setting up such a virtual system and provides useful guidance for those considering such a system in their own training programme. As a result of the virtual learning environment, trainee participation has increased and there is a trend for increased consultant input in the virtual journal club and case-based discussions.

It is likely that the use of virtual environments will expand to encompass newer technological approaches to personal learning and professional development.

Purpose of the Study

To identify trends in patient satisfaction of their knee arthroplasty, total and unicompartmental, one year post primary knee arthroplasty surgery, with reference to age, gender and primary diagnosis, from 1990 to 2008.

Purpose

To identify if the age of the patient was related to satisfaction rates 1 year following unicompartmental knee replacement, in a generalist setting in the U.K.

Roentgen Stereophotogrammetric Analysis (RSA) can predict long-term outcome of prostheses by measuring migration over time. The Exeter femoral stem is a double-tapered highly polished implant and has been shown to subside within the cement mantle in 2 year RSA studies. It has a proven track record in terms of long-term survivorship and low revision rates. Several studies have demonstrated excellent clinical outcomes following its implantation but this is the first study to assess stem migration at 10 years, using RSA.

This is a single-centre study involving 20 patients (mean age: 63 years, SD=7) undergoing primary total hip replacement for degenerative osteoarthritis using the lateral (Hardinge) approach. RSA radiographs were taken with the patient bearing full weight post-operatively, at 3, 6, 12 months and at 2, 5 and 10 years follow-up. The three-dimensional migration of the Exeter femoral stem was determined.

The mean Oxford Hip Score at 10 years was 43.4 (SD=4.6) and there were no revisions. The stems subsided and rotated internally during a 10-year period. The mean migrations of the head and tip of the femoral stem in all three anatomic directions (antero-posterior, medio-lateral & supero-distal) were 0.69 mm posterior, 0.04 mm lateral and 1.67 mm distal for the head and 0.20 mm anterior, 0.02 mm lateral and 1.23 mm distal for the tip. The total migration at 10 years was 1.81 mm for the head and 1.25 mm for the tip.

The Exeter femoral stem exhibits migration which is a complex combination of translation and rotation in three dimensions. Comparing our 10 year with our previous 2 year migration results, the Exeter stems show continued, but slow distal migration and internal rotation. The subsidence continues to compress the cement and bone-cement interface which maintains secure fixation in the long term.

Purpose: To compare the site of lesions in medial and lateral unicompartmental osteoarthritis (OA) of the knee.

Methods: Patients with medial (n=35) and lateral (n=15) OA, having unicompartmental knee arthroplasty, were recruited. Intra-operatively, the distance between the anterior, posterior, medial and lateral margins of the full-thickness lesion and reference lines dividing the condyles was measured. The midpoints of lesions were calculated and groups were compared. Lateral radiographs were used to determine the relationship between the lesion site and knee flexion angle (KFA).

Results: Femoral lesion: In lateral OA, the midpoint of lesions was 25.0mm (SD:8.8) posterior to the reference line passing transversely through the apex of the inter-condylar notch. This was significantly different (p< 0.001) from midpoint in medial OA, which was 10.7mm (SD:9.4) posterior to the reference line.

Tibial lesion: In lateral OA, the midpoint of lesions was 2.0mm (SD:6.5) posterior to the reference line passing through the mid-coronal plane of the resected tibia. This was located significantly more posterior (p=0.038) than midpoint in medial OA, which was 2.2mm (SD:5.7) anterior to the reference line.

Knee Flexion Angle: In lateral OA, the midpoint of lesions was on average at 40° flexion and sites of smaller lesions were very variable. The lesion expanded both anteriorly and posteriorly. In medial OA, smaller femoral lesions occurred in full extension and extended further posteriorly with disease progression.

No significant difference was demonstrated in medial and lateral localisation of the lesions.

Conclusion: Medial OA begins near full extension, progresses in a predictable manner and is perhaps initiated by events occurring at heel strike. Lateral OA begins in flexion in a less predictable manner, at KFA above that seen during the gait cycle. The different sites of lesions in medial and lateral OA suggest different aetiology and pathophysiology. Therefore, prevention and treatment strategies should be different.

Balancing service provision and surgical training is a challenging issue that affects all healthcare systems. A multicentre prospective study of 1501 total hip replacements was undertaken to investigate whether there is an association between surgical outcome and the grade of the operating surgeon, and whether there is any difference in outcome if surgeons’ assistants assist with the operation, rather than orthopaedic trainees. The primary outcome measure was the change in the Oxford hip score (OHS) at five years. Secondary outcomes included the rate of revision and dislocation, operating time, and length of hospital stay.

There was no significant difference in ΔOHS or complication rates between operations undertaken by trainers and trainees, or those at which surgeons’ assistants and trainees were the assistant. However, there was a significant difference in the duration of surgery, with a mean reduction of 28 minutes in those in which a surgeons’ assistant was the assistant.

This study provides evidence that total hip replacements can be performed safely and effectively by appropriately trained surgeons in training, and that there are potential benefits of using surgeons’ assistants in orthopaedic surgery.

Introduction: Approximately 60000 patients are admitted each year in the UK with neck of femur fractures, the vast majority of whom are elderly presenting with multiple medical comorbidities, including a history of ischaemic heart disease and stroke. They are often on a number of regular medications which may include aspirin, warfarin and more recently, clopidogrel. Clopidogrel and aspirin are associated with an increased bleeding time especially if present as a combined therapy. As such, they can lead to bleeding complications in patients undergoing surgery, increasing the need to transfuse such patients and increasing the risk of cardiovascular events as a result of anaemia. Although clopidogrel is often stopped for patients undergoing elective surgery for a period of 7–10 days, to our knowledge, no such guidelines are available regarding the discontinuation of clopidogrel in patients undergoing surgery for femoral neck fractures. The aim of conducting this survey was to investigate the current practice of various orthopaedic units in the UK with regards to stopping clopidogrel in such patients.

Methods: A telephone questionnaire survey was conducted on junior doctors (House officers, Senior House Officers and Registrars) in orthopaedic departments in the UK which routinely admit and treat patients with fractured neck of femurs.

Does your trust/department have a policy on discontinuing clopidogrel in patients who are due to have emergency trauma surgery such as operative fixation for femoral neck fractures?

Results: 184 NHS trusts in the UK were involved. 45% of trusts stop clopidogrel routinely prior to performing surgery on patients with femoral neck fractures. The number of days clopidogrel is stopped prior to surgery varied from 1 – 7 days. 55% of trusts did not routinely stop aspirin prior to surgery. 97% of trusts routinely stopped warfarin prior to surgery and the target INR varied from < 1.0 – < 3.2.

Conclusions: It is clear from this study that a wide range of policies exists amongst orthopaedic departments in the UK regarding the routine discontinuation of clopidogrel, aspirin and warfarin in patients with femoral neck surgery who are awaiting surgery. This highlights the need for further debate and guidelines regarding the routine discontinuation of clopidogrel.

Introduction: L5/S1 injuries can be associated with pelvic fracture but unfortunately they are often missed. Left untreated these patients may suffer disabling lower back pain. Our goal is to study the frequency of these injuries in pelvic fractures treated at this institution, thereupon to determine how many are missed and the outcome if this injury is treated conservatively. We will describe the radiological findings, anatomical features and possible surgical treatments.

Materials and Methods: A retrospective analysis was undertaken of pelvic fractures treated at this institution from 2000 onward. Outcome scores were taken from the patient records. All CT scans and x-rays were scru-tinised for a Lumbosacral Junction Injury(LJI). Numbers missed were tallied against numbers diagnosed and treated. Patient outcome measures were compared using the Matta Hip Scores. It was noted whether low back or hip pain contributed to their symptoms most.

Results: The incidence of lumbar sacral injuries associated with vertical shear pelvic fractures was 20%. Of these, 75% had not been identified as a specific lumbar-sacral injury. The remaining 25% which were identified and treated with fixation of the lumbar sacral junction had an excellent result. We have identified specific morphology patterns and propose a CT based grading system.

Discussion: We suggest that a heightened level of awareness is needed for these important injuries in pelvic trauma as their occurrence changes the management. The incidence appears to be higher than that reported by Isler and suggest our CT based classification be used to grade these injuries.

A prospective, multi-centre study was carried out on 1421 total hip replacements between January 1999 and July 2007 to examine if obesity has an effect on clinical outcomes.

The patients were categorised into three groups: non-obese (body mass index (BMI) < 30 kg/m²), obese (BMI 30 to 40 kg/m²) and morbidly obese (BMI > 40 kg/m²). The primary outcome measure was the change in Oxford hip score at five years. Secondary outcome measures included dislocation and revision rates, increased haemorrhage, deep infection, deep-vein thrombosis and pulmonary embolism, mean operating time and length of hospital stay. Radiological analysis assessing heterotopic ossification, femoral osteolysis and femoral stem positioning was performed. Data were incomplete for 362 hips (25.5%)

There was no difference in the change in the Oxford hip score, complication rates or radiological changes at five years between the groups. The morbidly obese group was significantly younger and required a significantly longer operating time. Obese and morbidly obese patients have as much to gain from total hip replacement as non-obese patients.

Few independent studies have reported the outcome of resurfacing arthroplasty of the hip. The aim of this study was to report the five-year clinical outcome and seven-year survival of an independent series.

A total of 610 Birmingham Hip Resurfacing arthroplasties were performed in 532 patients with a mean age of 51.8 years (16.5 to 81.6). They were followed for between two and eight years; 107 patients (120 hips) had been followed up for more than five years. Two patients were lost to follow-up. At a minimum of five years’ follow-up, 79 of 85 hips (93%) had an excellent or good outcome according to the Harris hip score. The mean Oxford hip score was 16.1 points (sd 7.7) and the mean University of California Los Angeles activity score was 6.6 points (sd 1.9). There were no patients with definite radiological evidence of loosening or of narrowing of the femoral neck exceeding 10% of its width. There were 23 revisions (3.8%), giving an overall survival of 95% (95% confidence interval 85.3 to 99.2) at seven years. Fractured neck of femur in 12 hips was the most common indication for revision, followed by aseptic loosening in four. In three hips (three patients) (0.5%), failure was possibly related to metal debris.

Considering that these patients are young and active these results are good, and support the use of resurfacing. Further study is needed to address the early failures, particularly those related to fracture and metal debris.