Aims

We present the results, in terms of survival, clinical outcome, and radiological appearance at 20 years, in a cohort of 225 cemented Exeter Universal femoral components (Stryker, Newbury, UK) implanted in 207 patients, at a district general hospital.

Introduction

Assessment for and treatment of osteoporosis is recommended following hip fracture. All forms of osteoporosis treatment require an adequate calcium intake and normal vitamin D levels. This study assesses vitamin D levels in patients with hip fractures and describes guidelines on how to manage low vitamin D levels with high dose oral vitamin D3 (cholecalciferol).

Background

With the recent trend towards enhanced care in joint replacement, it has become increasingly important to identify and address the areas that affect early patient length of stay, while ensuring that practice remains safe. As part of an enhanced care program we conducted two prospective studies of factors delaying discharge following hip replacement in 2006 and 2010.

Awareness that minimising tip apex distance (TAD) when inserting a sliding hip screw reduces the risk of screw cut out is important for orthopaedic trainees. The advent of the Picture Archive and Communication System (PACS) has made the accurate measurement of TAD from x-rays and image intensifier films much easier. This study was to determine whether TAD would be reduced if a surgeon knew that his performance was being continually monitored.

31 consecutive cases of sliding hip screw insertion by a single group of surgeons were identified and the TAD measured. The mean TAD was 16.11mm (8.87mm-25.47mm). The same surgeons were then re-educated as to the importance of the TAD and informed that their results would be monitored and discussed. The next 34 consecutive cases were collected prospectively. The mean TAD in these cases was 13.83mm (6.72mm-21.51mm). There was a significant difference between the TAD for the two groups using the two-tailed t-test (p=0.034). There was one implant failure in the pre education group and none in the post education group.

These results suggest that awareness of surveillance improves surgical performance even if the importance of the variable being assessed is already known.

Introduction. A redesign of a joint replacement service to increase throughput and reduce length of stay despite a reduction in junior doctors hours, recognised that Orthopaedic Nurse Practitioners (ONP) based on the US Surgeons’ +

+ Assistant model would play a pivotal role in managing patient flow efficiently.

Redesigning the Service. The ONP has input at every step of the patient journey. In Outpatient Clinic they see follow-up and selected new patients, commencing the informed consent process if appropriate. They run an information program to patients awaiting surgery, are involved in Pre-Admission clinic, assist in theatre and oversee post-operative care monitoring progress, ensuring earliest possible safe discharge and prescribing as necessary. Continual Audit, Research and development to improve the service are part of the role.

Outcomes. The impact of the introduction of the role after 4 years together with service redesign has been:

An increase in the number of new referrals seen in OPD by 50% from 8 to 12 per clinic.

Conclusion. Based on the US Surgeons’ Assistant model, with involvement at every step of the patient journey, ONPs have been the most important single element in the redesign of the joint replacement service to meet a massive increase in demand. Further ONPs are being recruited to fill the gap envisaged by a reduction in junior doctors hours as a result of the European Working Time Directive.

Introduction: As candidates for arthroplasty become younger and life expectancy increases the required working life of a total hip arthroplasty continues to rise. Hip resurfacing offers potential further advantages in young patients as minimal bone resection makes for easier revision, and the design allows for an increased range of movement. The Birmingham Hip Resurfacing (BHR) is the first of the second generation hip resurfacings.

Reports are beginning to emerge of unexplained failure, pseudotumour formation, individual cases of metallosis. Joint registry data also demonstrates an unexplained high early failure rate for all designs of hip resurfacing. This paper examines the rate and mode of early failures of the BHR in a multi-centre, multi-surgeon series.

Methods: All patients undergoing BHRs in our two centres were recruited prospectively into our arthroplasty follow up programme. Patients have been followed up radiographically and with clinical scores.

Results: Mean radiographic and clinical follow up was to 43 months (range 6 – 90 months). Of the 463 BHRs two have died and three are lost to follow up. Thirteen arthroplasties (2.8%) have been revised. Eight for pain, three for fracture, two for dislocation and one for sepsis. Of these nine were found to have macroscopic and histological evidence of metalloisis. Survival analysis at 5 years is 95.8% (CI 94.1 – 96.8%) for revisions and 96.9% (CI 95.5 – 98.3%) for metallosis.

Discussion: Histopathological examination demonstrated a range of inflammatory changes including necrosis, inflammation, ALVAL and metal containing macrophages. Not all features were associated with each patient and it is likely that these features form part of the spectrum of metal wear debris disease.

The likely rate of metallosis is 3.1% at five years. Risk factors for metallosis in this series are female sex, small femoral component, high abduction angle and obesity. We not advocate use of the BHR in patients with these risk factors.

We report the results of cementless total hip arthroplasty using the Bi-metric titanium femoral stem at a minimum follow up of 10 years and a mean of 12.2 years (range 10–17).

64 hips (43 male/21 female) were implanted consecutively into 54 patients between 1988 and 1995. The mean age at operation was 54.3 years (range 42–65). All patients had a Bi-metric uncemented stem (Biomet UK). The first 13 patients received a metal backed screw in acetabular cup (TTAP-ST, Biomet UK) with the remainder receiving metal backed pressfit cups (Universal, Biomet UK).

All patients were followed up annually and assessed using the Hip Society Score (HSS; max 40 points) to record pain, function and mobility. Survivorship was calculated using the Kaplan-Meier method.

57 hips were followed up for a minimum of ten years. There were 4 deaths (6 hips) before completion of follow up and 1 patient was lost to follow up.

Using revision for any reason as the end point of the study; survivorship for the total hips at 10 years was 89.5% (95% confidence interval: 78.1–96.1%) with a mean Hip Society Score of 34.9 (range 20–40) compared to 14.5 (range 8–24) pre-operatively (p< 0.01 student t test).

Survivorship for the femoral stem in isolation was 100% at 10 years (95% CI 93.7–100%) and there continues to be no revisions to date at a mean follow up of 12.2 years.

The screw fix cup performed poorly with 3 acetabular revisions (including 1 liner change) before the 10 year follow up, a failure rate of 23.1%. There has sub-sequently been a further 4 acetabular revisions.

Ten year survivorship for the pressfit cup is 93.5% (95% CI 82.0–98.8%) with 3 revisions (including 2 liner changes) at ten years. There has subsequently been one further acetabular revision and 9 further liner changes (29.5% failure rate).

There have been no recorded infections and no instances of thigh pain.

Radiographs at ten years showed all the femoral stems were stable with no evidence of migration. Two stems had small radiolucent lines at the bone-implant interface but no signs of loosening. One stem had an area of osteolysis in Gruen zone 7 but didn’t require revision. Rates of osteolysis were extremely low given the large amounts of particulate debris in the hip from the worn acetabular liners.

In conclusion, although neither cup has proved to be particularly successful the Bi-metric stem has performed well at 10 year follow up and continues to do so. This is inspite of the fact they were implanted into a young and active group of patients.

The clinical and radiological results of 50 consecutive acetabular reconstructions in 48 patients using impaction grafting have been retrospectively reviewed. A 1:1 mixture of frozen, ground irradiated bone graft and Apapore 60, a synthetic bone graft substitute, was used in all cases. There were 13 complex primary and 37 revision procedures with a mean follow-up of five years (3.4 to 7.6). The clinical survival rate was 100%, with improvements in the mean Harris Hip Scores for pain and function. Radiologically, 30 acetabular grafts showed evidence of incorporation, ten had radiolucent lines and two acetabular components migrated initially before stabilising.

Acetabular reconstruction in both primary and revision surgery using a 1:1 mixture of frozen, ground, irriadiated bone and Apapore 60 appears to be a reliable method of managing acetabular defects. Longer follow-up will be required to establish whether this technique is as effective as using fresh-frozen allograft.

Introduction: The Birmingham Hip resurfacing was commercially introduced in 1997 and early originating centre series show good functional outcomes. Concerns have been raised over the longevity, functional outcomes and metal ion release from the implants. There are no series of medium term results from an independent district general hospital reported in the literature. We present a prospective series of 100 patients with mean 5 year follow up from a district general hospital. Each patient underwent yearly clinical, hip scoring, and regular radiographic evaluation.

Radiographic analysis was undertaken using Harris’, Hodgkinson’s and Amstutz’s criteria, evaluation of component position, neck narrowing and migration using diagnostic PACS workstations with standardised scaled images.

Results: Between June 2001 and Feb 2004 100 Birmingham Hip replacements were performed by two consultant surgeons (MP, AA). Mean follow up is 61.2 months (range 38–76 months). Harris hip scores (fig 1) improved from 46 pre-operatively to 90 post-operatively and no significant change over the next five years. There were no revisions in this period. Obese patients (BMI> 30) had a significantly (p< 0.03) lower post operative functional score as compared normal patients. No other factors were significant for outcome.

Component position was satisfactory in 93% of cases. Radiographic analysis showed no cups, or stems were definitely loose. Radiolucent lines were present in 8/100 acetabular and 3/100 femoral components, osteolytic lesions were seen in three acetabular components. Mean neck narrowing was 9mm. No patients show any radiographic evidence of avascular necrosis.

Conclusion This independent series shows the results of the Birmingham hip resurfacing are reproducible and comparable to those reported in the originating centre. The Birmingham hip resurfacing gives excellent clinical results, and there is no early evidence of radiographic failure. The high rate of neck narrowing gives us cause for concern and we would recommend regular radiographic follow up.

Aim: We studied the payments received by our hospital for 109 elective lower limb arthroplasty cases to see if this was fair and consistent under Payment by Results.

Methods: A cohort of patients who had Total Hip Replacement (THR), Total Knee Replacement (TKR), Resurfacing Hip Arthroplasty and Unicompartmental Knee Replacements were taken from the departmental database. Their diagnostic codes, operation details and comorbidities were established and compared with the payment the trust received using the Dr Foster database. This was confirmed with their hospital notes and the finance department.

Results: Twenty THRs and twenty TKRs were paid the standard tariff with one exception. Fifteen Hip Resurfacing arthroplasties showed variable payment from £4690 to £6673 per case. Most interesting were the Unicompartmental Knee Replacements. Despite having almost the same operative and diagnostic codes 46 out of 54 cases were significantly underpaid. During one financial year the trust lost more than £70,000 from this operation alone. This does not meet the Department of Health’s stated aim of being fair and consistent. Out of 109 cases reviewed 51 could have been coded differently and 47 of these were “underpaid”.

Conclusion: In an NHS increasingly driven by financial pressures it is vital that surgeons understand how Payment by Results works. There are significant financial gains to be made by those trusts who pay attention to the small print.

Introduction: Primary Care Trusts (PCT) in Suffolk have recently withdrawn funding for hip (THA) or knee replacement (TKA) surgery for obese patients (Body Mass Index (BMI) > 30). We have estimated the number of patients affected by this restriction by reviewing our joint replacement database and have sought evidence for this decision being evidenced based.

Materials and Methods: All patients undergoing joint replacement at our hospital have their BMI recorded prospectively. We have established the number of patients having hip or knee replacements with a BMI of greater than 30. A Medline literature search identified studies that examined the influence of BMI on outcome of joint replacement surgery

Results: 328 (24%) of 1366 people undergoing THA between 2000–2005, and 225 (38.5%) of 567 undergoing TKA between 2003–2005 had a BMI > 30. The difference between these groups is significant (p 0.001 CI 0.095 to 0.191.). There was no difference between the sexes in the hip group, but more women than men were obese in the knee group (p< .001 CI 0.096–0.25). We identified 19 studies that examined the impact of BMI on joint replacement surgery.

Discussion: Based on National joint register figures, a similar policy enacted in England and Wales would affect about 20,000 patients a year.

The literature produces some evidence of a higher early complication rate in obese patients undergoing THA, and operative time seems to be longer and blood loss greater than for matched controls. The only study looking at long-term outcome of THA showed no difference in hip survivorship at 10–18 years between obese and normal weight patients. We conclude that where THA is concerned, the PCT policy has no clinical or evidence based justification.

Delay in the diagnosis of posterior shoulder dislocation is common. We present two such cases treated satisfactorily by rotation osteotomy of the surgical neck of the humerus and discuss the indications for this procedure.