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.

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.

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.