Venous thromboembolism (VTE) is a preventable cause of morbidity and mortality in patients undergoing elective hip arthroplasty surgery. The balance of post-operative VTE prophylaxis and risk of post-operative haemorrhage remains at the forefront of surgeon's mind. The National Institute for Clinical Excellence (NICE) has altered their prophylaxis guidance in the setting of total hip arthroplasty (THA). The aim of this study was to present the VTE incidence in 8,890 patients who underwent total hip arthroplasty between January 1997 and March 2018 with Aspirin as the primary agent for pharmacological thromboprophylaxis.

Analysis of prospective data collection from consecutive patients undergoing THA was performed with the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) occurring within 6 months of the index operation as the primary outcome measure. 90-day all-cause mortality of this cohort of patients was also analysed.

8890 patients were reviewed. This included 7235 primary, 224 complex primary and 1431 revision cases. The incidence of DVT was 0.64% after elective THA and the incidence of PE was 0.54%. There was no difference in the incidence between primary and revision cases. The 90-day all-cause mortality was 0.88%. Cardiovascular and respiratory disease were the main causes of death following surgery. Only 0.03% of deaths (n= 3) within 90 days of index surgery were due to VTE.

Our results support the use of aspirin as an effective form of prophylaxis against VTE following THA. It is not associated with an increased incidence in symptomatic DVT, PE or death compared to other published studies. The fact that it is inexpensive, readily available, requires no monitoring and does not pose an increased risk of bleeding are other attractive advantages of using aspirin for VTE prophylaxis.

To investigate the utility of virtual reality (VR) simulators in improving surgical proficiency in Orthopaedic trainees for complex procedures and techniques.

Fifteen specialty surgeons attending a London Orthopaedic training course were randomised to either the VR (n = 7) or control group (n = 8). All participants were provided a study pack comprising an application manual and instructional video for the Trochanteric Femoral Nail Advanced (TFNA) procedure. The VR group underwent additional training for TFNA using the DePuy Synthes (Johnson and Johnson) VR simulator. All surgeons were then observed applying the TFNA in a Sawbones model and assessed by a blinded senior consultant using three metrics: time to completion, 22-item procedure checklist and 5-point global assessment scale.

Participant demographics for the VR and control groups were similar in context of age (mean [SD]: VR group, 31.0 [2.38] years; control group, 30.6 [2.39] years), gender (VR group, 5 [71%] men; control group, 8 [100%] men) and prior experience with TFNA (had applied TFNA as primary surgeon: VR group, 6 [86%]; control group, 7 [88%]). Although statistical significance was not reached, the VR group, on average, outperformed the control group on all three metrics. They completed the TFNA procedure faster (mean [SD]: 18.2 [2.16] minutes versus 19.78 [1.32] minutes; p<0.189), performed a greater percentage of steps correctly (79% versus 66%; p<0.189) and scored a higher percentage on the global assessment scale (75% versus 65%; p<0.232).

VR simulators offer a safe and accessible means for Orthopaedic trainees to prepare for and supplement their theatre-based experience. It is vital, therefore, to review and validate novel simulation-based systems and in turn facilitate their improvement. We intend to increase our sample size and expand this preliminary study through a second upcoming surgical course for Orthopaedic trainees in London.

In Canada, hip and knee replacements are each among the top three surgeries performed annually. In 2020, surgeries across the country were cancelled in response to the COVID-19 pandemic. We examined the impact on these joint replacement surgeries throughout the year.

Using the Discharge Abstract Database and National Ambulatory Care Reporting System, we developed a dataset of all 208,041 hip and knee replacements performed in Canada (except from Quebec) between January 1, 2019 to December 31, 2020. We compared patient and surgical characteristics (including sex, age, main diagnosis, and type of surgery (planned/urgent, primary/revision, inpatient/day surgery) in 2020 to 2019.

In 2020, hip and knee replacements volumes decreased by 18.8% compared to 2019. In April and May 2020, hip and knee replacements fell by 69.4% and 93.8%, respectively, compared to the same period in 2019. During those months, 66.5% of hip replacements were performed to treat hip fracture versus 20.2% in April and May 2019, and 64.5% of knee replacements were primaries versus 93.0% in April and May 2019. Patterns by patient age group and sex were similar compared to 2019. These patterns were similar across all provinces. By the summer, planned surgeries resumed across the country and volumes mostly returned to pre-pandemic monthly levels by the end of the year. We also found that there was an increase in the proportion of hip and knee replacements done as day surgery, with 4% in 2020 versus 1% in 2019, and patients undergoing day surgery replacement for osteoarthritis were older, with a median age of 64 for hip patients and 65 for knee patients, versus 63 for both joints the previous year.

As a result of the COVID-19 pandemic, there was a notable drop in 2020 of hip and knee replacements performed in Canada. With the demand for joint replacements continuing to grow, the resulting backlog will have an immediate, significant impact on wait lists and patient quality of life. The shift to a greater proportion of joint replacements performed as day surgeries may have an effect on patient outcomes as well shifts in access to care. It will be important to continue monitor patient outcomes following day surgery and the impact on patients for which day surgery was not an option.

Background

Tourniquets and tranexamic acid (TXA) are commonly used in total knee arthroplasty (TKA), but there is not consensus on how these interventions affect blood transfusion rates and total blood loss. Few studies examine the combined use of both interventions. We compared outcome measures and transfusion rates following TKA, with and without the use of tourniquet and TXA.

Clavicle fractures account for 44–66% of shoulder fractures. Evaluating degree of shortening is important when deciding between operative and non-operative treatment. The clavicle of a skeleton was marked at midpoint and junctions of the thirds along its superior surface. Antero-posterior (AP) and 30-degree upshot radiographs were taken. Images were analysed measuring distance between markers. In both AP and upshot images there were apparent discrepancies between lengths of each third and half. The main differences in apparent length appear in the measurement of the thirds of the clavicle. The AP made the medial third shorter compared to the middle and lateral third, whereas the upshot appeared to make the medial third shorter than the middle third with the lateral third shorter again. This study supports the theory that there is parallax error created by the shape of the clavicle. Middle third fractures account for 80% of fractures and both our AP and upshot images make the middle third appear longer in relation to lateral and medial thirds. This leads us to believe that shortening may be overestimated when measured using AP or upshot images. This leads us to advise caution when using WebPacs tools to measure shortening in clinical decision making.

Background

Best practice tariff (BPT) for hip fracture was introduced in April 2010, offering financial incentive to encourage trusts to implement best practice and improve quality of care. This equates to £1335. An early indicator of a patient's outcome is the time to operation from admission, with best practice targets of <36hours as a key marker of quality. As well as being detrimental to patient experience, delays in the time to operation have clear links to increased mortality rates.

In bone and joint infections, several materials can be used for local antibiotic elution at site of infection. Polymethylmethacrylate (PMMA) cement is often used. Recently the use of antibiotic impregnated dissolvable synthetic pure calcium sulphate beads [Stimulan R]1 has been used as an alternative, due to several perceived advantages.

We present our experience of using Calcium sulphate beads in infections involving the upper limb.

From Jan 2012 to Jan 2015, we used Calcium sulphate beads in 7 complex upper limb infections including 1 elbow replacement, 2 infected non unions, 2 shoulder replacement, 1 wrist fusion and I ORIF elbow.

We used combination of Vancomycin and Gentamicin in the beads, using manufacturer's mixing guide for optimum setting.

Arthroplasty infections underwent explantation, addition of antibiotic impregnated calcium sulphate beads in the joint space, followed by a second stage, and systemic antibiotics. Fracture non-union cases had surgical debridement, calcium sulphate beads and systemic antibiotics

Follow up (6months to 2 years) indicate no recurrence of infection in any case.

The most common organisms isolated were Coagulase negative staphylococcus and Staphylococcus aureus. Others included Group B Streptococcus, Serratia marscesens and Corynebacterium spp.

In 2 of 7 cases there was significant drainage from the wound. This settled without further input.

For fracture non-union fixation, there was no need to do second procedure to remove beads as they dissolve. In cases of staged revisions, the beads were inserted at first stage with microbiological clearance at 2nd stage

At present there are no reports in the literature of the use of this product in the upper limb. Our experience suggests use of dissolvable pure Calcium sulphate beads impregnated with selected antibiotics, is an effective adjunct to current treatments.

Aseptic drainage has been reported and this was seen in some of our cases. It is postulated that the use of Calcium sulphate beads in more superficial joints may lead to more drainage. It may be necessary to avoid packing any beads in the subcutaneous spaces and using lower volumes in upper limb.

Further work will include long-term follow up and any evidence of relapse or recurrence of infection.

Introduction:

Percutaneous fixation of intraarticular calcaneal fractures adequately restore the subtalar joint with lower soft tissue complications and equivalent short-term results compared to open fixation. However, studies have largely focused on less severe fracture types (Sanders types 2/3). We report our initial experience of this relatively new Mini-open Arthroscopic-assisted Calcaneal Osteosynthesis (MACO) technique for more comminuted calcaneal fractures (Sanders types 3/4).

Total hip arthroplasty (THA) in teenagers is uncommon and previously associated with poor survival rates. However it is sometimes the only option remaining to relieve pain and improve function in patients with advanced hip disease. We report on the clinical and radiological outcomes of THA in teenage patients. Medical records and radiographs of all consecutive teenage patients undergoing THA at a tertiary referral centre between 2006–2011 were reviewed. Mean follow-up was 3.4 years (range 0.6–6.8) with 9 patients having at least 5 years follow-up. Post-operative Harris hip, Oxford hip (OHS) and University of California Los Angeles (UCLA) activity scores were recorded. 51 THAs were performed in 43 patients (21 male, 22 female) with a mean age of 17 years (range 12–19). The 5 most common indications were slipped upper femoral epiphysis osteonecrosis 15 (29.4%), developmental hip dysplasia osteonecrosis 5 (9.8%), multiple/spondylo-epiphyseal dysplasia 5 (9.8%), chemotherapy-induced osteonecrosis 4 (7.8%) and idiopathic osteonecrosis 4 (8.2%). 46 (90%) were uncemented THAs and 5 (10%) were reverse hybrid THAs with 7 computer assisted design/manufacture (CADCAM) femoral implants. Articular bearings were ceramic/ceramic in 40 (78.4%), metal/metal 6 (11.8%), metal/polyethylene 3 (5.9%) and ceramic/polyethylene 2 (3.9%). The survival rate was 96% with 2 acute head revisions for 1 sciatic nerve palsy and 1 instability. Other complications (8.2%) included 1 dislocation, 1 sciatic nerve palsy that resolved, 1 surgical site infection and 1 unexplained pain. At latest follow-up, the mean Harris hip score was 90 (68–99), OHS was 42 (32–48) and UCLA activity score was 6 (4–9). Radiological analysis showed 2 patients with lucent lines around the acetabular component, but no signs of osteolysis or wear. As one of the largest studies on teenagers undergoing THA, we report good clinical and radiological outcomes at short to intermediate term follow-up.

Background

There is much research on metal on metal hip resurfacing arthroplasty (HRA) but few studies have reported the outcome with respect to implant characteristics from non-specialist centres.

Hamstring tendons are commonly used for Anterior Cruciate Ligament (ACL) reconstruction. In our series of 100 consecutive Hamstring ACL reconstructions, a four-strand graft was less than 7.0 mm in 5 patients. The aim of this study was to develop a screening test to assess the size of the hamstring tendon and so aid in the pre operative planning and patient counselling especially if hamstring size was deemed to be inadequate. A retrospective study of 100 consecutive hamstring ACL reconstructions analysed the correlation of the tendon size to height, weight and body mass index. A prospective double blind study was also set up involving independent observations by a musculoskeletal radiologist and the lead Orthopaedic surgeon.

A child with traumatic laceration of the tendo Achillis developed secondary infection after primary repair. This resulted in the loss of 5 cm of the distal part of the tendon and overlying soft tissue. The patient was treated with a free skin flap to cover the wound and to control the infection leaving reconstruction for a second-stage procedure.

However, when he was assessed two years after the skin-flap, delayed reconstruction proved to be unnecessary since he had regained normal ankle function spontaneously and could demonstrate equal function in both tendons.

The purpose of this study is to evaluate the clinical outcomes between a bipolar prosthesis and a hemiprosthesis (unipolar) in the treatment of displaced intracapsular femoral neck fractures. The theoretical advantage of a bipolar prosthesis is a reduction of acetabular erosion. Movement within the prosthesis may also reduce the pain caused by movement in the acetabulum.

A prospective randomised study was conducted evaluating 40 patients over the age of 70 years, who presented with intracapsular hip fractures Garden 3 or 4, treated either with a bipolar prosthesis (medical international) or a Thompsons hemiarthroplasty. There were 20 patients in each group, and the operation was performed through a Hardinge approach by the same surgical team. All prostheses were uncemented. All patients were rehabilitated by the same Physiotherapist using the same routine. An out-patient assessment was performed at 6 weeks, checking the wound, the clinical result and doing an AP x-ray of the pelvis.

39 Patients were followed for a median period of 13 months. 1 Patient who received a Thompsons prosthesis died in hospital. The average hospital stay in patients receiving a bipolar prosthesis was 7 days, and 13 days for those who were treated with a Thompsons prosthesis. There were 2 deep infections and 1 peri prosthetic fracture in the hemiarthroplasty (Thompsons) group. 15 Of the 20 patients treated with a bipolar prosthesis returned to their pre-injury state with mild pain, and were satisfied with the procedure. Only 9 of the 19 patients in the Thompsons group returned to their pre-injury level, with 12 complaining of pain and only 4 satisfied with the procedure.

The early subjective outcome in elderly patients is difficult to assess, and the optimum realistic outcome should be a return to pre-injury function and the presence or absence of pain. This review was not blinded, and hence the assessment of results could be biased towards certain prostheses. The findings suggest that a bipolar prosthesis may give a better short term result in the elderly. The bipolar prosthesis used in this series is inexpensive, and we felt its use justified.

Anterior Cruciate Ligament (ACL) reconstruction is performed widely across the United Kingdom by orthopaedic surgeons many of whom are members of the British Association for Surgery to the Knee (BASK), The choice of graft and fixation devices varies, based on surgeon’s preference, experience and patient needs. No data has been published with regards to choice of graft material or fixation devices in primary ACL reconstruction within the United Kingdom (UK).

To find out what current practice is, we undertook a postal questionnaire of BASK members. 62% responded. Of these, 55% of surgeons have been undertaking ACL reconstruction for more than 10 years. Only 39% are performing over 50 ACL reconstructions per year. 71% of surgeons have read the Good Practice for ACL reconstruction booklet published by the British Orthopaedic Association (BOA).

For the femur, the most popular devices used were metal screws (49%), rigidfix (17%), endobutton (14%), transfix (8%) and bioscrews (6%). For the tibia it was metal screws (57%), bioscrews (25%) and intrafix (14%)

16% use bone patellar tendon bone graft (BPTB), 18% use hamstrings, while 66% use either. Overall the most popular method seems to be the use of hamstrings or BPTB secured at both ends with metal interference screws without the use of a tensioner.

Whether the variation alters clinical result is difficult to prove. With no national registry, comparison of outcomes becomes impossible. Our survey should serve as a baseline for any future research in this area.

Introduction; In contrast to hydroxyapatite (HA), carbonate substituted hydroxyapatite (CHA) is resorbed by osteoclasts, and is more osteoconductive in vivo. On bone, osteoclastic resorption results not only in topographical changes, but also changes in the proteinaceous matrix within the resorption pit to which osteoblasts respond [1]. This study sought to investigate a possible link between the different bioresorptive properties of these biomaterials and subsequent bone formation on their surfaces, analogous to the coupling seen in normal bone remodelling.

Methods; Phase-pure HA and 2.7wt% CHA were prepared by aqueous precipitation methods [2] and processed into dense sintered discs for cell culture. Human osteoclasts derived from CD14+ precursors were cultured for 21 days on discs of HA and CHA; subsequently, cells and the proteinaceous layer were removed from some discs leaving a topographically altered surface (assessed by SEM and profilometry), whilst in others the proteinaceous layer was left intact. Control (unresorbed) discs were also prepared. The discs were then seeded with human osteoblasts (HOBs) which were cultured for up to 28 days, in some cases in the presence of hydrocortisone and â-glycerophosphate. Proliferation (MTS assay), collagen synthesis (3-H Proline incorporation), and the formation of mineralised nodules (tetra-cycline labelling [3] and SEM) were assessed.

Results; Osteoclasts altered the ceramic surfaces. Large pits were seen on CHA in contrast to limited erosion of the HA surface, accompanied by a greater increase surface roughness (Ra) (p< 0.05). After 6 days of culture, proliferation of HOBs was increased on resorbed discs provided the proteinaceous layer resulting from osteoclastic activity was left intact. At 28 days, cells had formed confluent sheets and there were no significant differences in their number. At 6 days, collagen synthesis by HOBs on CHA was increased on resorbed surfaces, and further increased if the proteinaceous layer was left intact. A similar response was seen on HA, but not until 28 days. Mineralised nodules formed after 28 days of culture in the presence of hydrocortisone and â-glycerophosphate on tissue culture plastic, but not in their absence. By contrast on the ceramics there was no evidence of mineralised nodule formation on any of the discs, although globular accretions were present in small amounts throughout the collagenous matrix regardless of the presence or absence of supplements.

Conclusion; Prior osteoclastic activity on HA and CHA affects subsequent proliferation and collagen production by HOBs. The effects of topographical alteration and matrix conditioning appear synergistic, and are apparent at an earlier time-point on a more resorbable ceramic. Osteoclastic activity may be important in the osteoconductive properties of biomaterials.

Objective: Spontaneous spinal subdural haematoma is a rare cause of spinal cord compression usually confined to a few vertebral levels. When the haematoma extends over several spinal segments, surgical decompression is a major undertaking. A minimally invasive technique of decompression, using topical recombinant tissue plasminogen activator (rt-PA), is presented in two patients with extensive spinal intradural haematoma.

Clinical Presentation: Two patients, receiving long-term anticoagulation therapy, presented with acute-onset back pain progressing to paraparesis. MRI of the spine demonstrated spinal subdural haematomas extending over fifteen vertebral levels in one and twelve in the other patient.

Intervention: An angiography catheter was introduced into the subdural space through a limited laminectomy. Thrombolysis and evacuation of haematoma was then achieved by intermittent irrigation of the subdural space with recombinant tissue plasminogen activator (rt-PA), followed by saline lavage. Post-operative imaging demonstrated satisfactory decompression in both patients. There was significant improvement of neurological function in one patient.

Conclusion: Topical application of rt-PA for spinal sub-dural haematoma allows evacuation of the haematoma through a limited surgical exposure. Decompression of the subdural space by this minimally invasive technique may be advantageous over extensive surgery by minimizing surgical exposure, reducing postoperative pain and risk of neuronal injury. This technique may be useful in patients presenting with compression extending over several vertebral levels or poor surgical candidates.