Aims

Now that we are in the deceleration phase of the COVID-19 pandemic, the focus has shifted to how to safely reinstate elective operating. Regional and speciality specific data is important to guide this decision-making process. This study aimed to review 30-day mortality for all patients undergoing orthopaedic surgery during the peak of the pandemic within our region.

Introduction

We performed a longitudinal outcome study involving the operative management of ankle fractures at two university teaching hospitals. This was a retrospective review of the quality of reduction and a prospective study into the functional outcome.

Osseous first ray surgery is a common day case procedure. Patients are often given regional blocks. We sought to find if there is a difference between ankle block and metatarsal block in this group of patients. After ethical approval was granted and power analysis performed, 25 patients were recruited into each arm of the study. These patients were having either an osteotomy or arthrodesis.

All patients had standardised general anaesthesia and received 20mls of 0.5% chirocaine for the blockade. The cohort having the ankle block had infiltration under ultrasound guidance in the anaesthetic room; and the cohort receiving the metatarsal block had infiltration at the end of the procedure. The timings of both the anaesthesia and the operation were recorded for each patient.

Patients scored their pain level at 2, 6 and 24 hours. The amount of post-operative analgesia used in the first 24 hours was also recorded by the research nurse. All patients were discharged home with a standardised prescription of analgesia.

Analysis of the pain scores showed that there was no difference between the two blocks at any measured time period. Nor was there a difference in the analgesic requirement in the first 24 hours. There was, however, a difference in the time taken for the whole procedure: with the ankle block taking an average of ten minutes more.

We conclude that metatarsal blocks are as effective as ankle blocks in providing pain relief after osseous first ray surgery, and may be a more efficient use of time.

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.

Treatment of the rheumatoid forefoot involves resection arthroplasty of the MTP joints of the lesser toes. This can either involve resection of the metatarsal heads or, as described by Stainsby: resection of the proximal phalanx. The Stainsby procedure is a well accepted technique, however despite this there is very little information on the outcome of this procedure.

NICE published the guidelines ‘Selection of prostheses for primary hip replacement’ in 2000. Essentially these guidelines made two recommendations: firstly to use prostheses which had attained the ‘10 year benchmark’ of a revision rate of 10% or less at 10 years, or had a minimum of three years revision rate experience that was on target to reach this benchmark; and secondly to use cemented hip prostheses to the exclusion of uncemented and hybrid prostheses.

The information from the Trent Regional Arthroplasty Study (TRAS) has been used to retrospectively examine the types of hip prostheses used from 1990 – 2005, and assess the impact that the NICE guidelines have had on orthopaedic practice.

This study revealed that the percentage of prostheses used which attained the ‘ten year benchmark’ has increased since the guidelines were published. In 2001, of the ten cups, which constituted 80% of the acetabular components used, only three attained this NICE benchmark, but by 2005 this number had risen to eight. Similarly in 2001, of the eight stems, which constituted almost 80% of the femoral components used, only five attained this NICE benchmark. In 2005 seven out of these eight stems had attained the minimum standard.

However contrary to the recommendation made by NICE in 2000, to use cemented prostheses, the results indicate the use of uncemented prostheses has trebled (from 6.7% to 19.2%, n= 137 and 632 respectively), and the use of hybrid prostheses has more than doubled (from 8.8% to 22% of all prostheses, n= 181 and 722 respectively) since the guidelines were published.

Therefore the recommendations made by NICE are not being followed, which calls the value of NICE guidelines into question.

Introduction: The technique of quadriceps sparing knee arthroplasty involves a pure capsular incision, without violation of the extensor mechanism. This capsular incision should be placed distal to Vastus Medialis Obliquus (VMO). The termination of VMO is variable and may make the quadriceps sparing approach difficult. We initiated this study based on the hypothesis that quadriceps sparing approach may not be possible in all the patients undergoing total knee arthroplasty. We examined MRI scans of the knee joint to assess the variation in VMO muscle insertion in relation to the patella and variation of VMO muscle insertion in relation to the age.

Material and Methods: Between Jan 2005 and Dec 2005, 262 MRI scans of the knee joint were performed at our institute. We studied MRI scans of the patients aged 16 years and over. The scans with neoplasm or those without complete set of films were excluded from the study. There were 198 scans available for analysis. Our cohort consisted of 106 female patients and 92 male patients with an average age of 43 years (range 16–86 years). One hundred and thirty four patients were aged less than 50 years and 64 patients were 50 years or older.

We measured patellar height, VMO length on the axial views of the scans. The VMO insertion was calculated from the data and we divided the patients into proximal and distal groups in relation to the VMO termination on the patella. The proximal group included patients with VMO termination proximal to the mid-point of the patella and distal group included patients with VMO termination at or distal to the mid-point of the patella.

Results: The median height of the patella in female patients was 32mm (range 24–44mm) and in male patients was 36mm (range 28–48mm). The VMO length from the apex of the patella was 13.5mm (range 4–28mm) in female patients and 16mm (range 8–32mm) in male patients. Overall there were 119 (60%) patients in the proximal group and 79 (40%) in the distal group. In 20% of patients aged more than 50 years, VMO terminated in the distal half of the patella. In patients less than 50 years old, 50% had the VMO termination in the distal half of patella. A statistically significant inverse relationship was noted between the level of insertion of VMO and the age of the patient (p-value > 0.001, Chi-square test). There was no statistically significant relation between the level of insertion of VMO and the sex of the patient, in either age group (p-value 0.339).

Conclusion: Younger patients are statistically more likely to have a VMO which terminated at or more distal to the mid-point of patella. Therefore, the quadriceps sparing approach may not be possible in these subjects, however it is possible in majority of older patients.

Introduction: Between 1% and 5% of joint prostheses will become infected. The main bacteria involved in prosthetic infections are coagulase negative staphylococci, principally Staphylococcus epidermidis.

The introduction of the laminar flow theatre was responsible for a decrease in wound infection four and a half fold. Further research has found that total body exhaust suits were also responsible for a reduction in infection rate.

These exhaust suits include a toga hood, also supplied sterile and attached to the gown. There is no information from the manufacturers regarding microbial penetration of these hoods. Therefore we have performed an experiment to examine the potential for microbial penetration of these toga hoods, both when wet and dry.

Methods: Confluent lawns of Staphylococcus Epidermidis NCTC 11047 (Fig. 2) were created on two isosensitest agar plates by flood seeding the organism onto the plates, followed by incubation overnight at 37°C.

Both wet and dry toga circles were applied to the previously prepared lawns of Staphylococcus epidermidis NCTC 11047, with the internal surface in contact with the lawn. Swabbings were taken from the external surface of both wet and dry toga circles at regular intervals. The timing of the swabbings were: 1 min, 5 mins, 20 mins, and 60 mins. The swabs were then used to inoculate blood agar plates, which were incubated overnight at 37°C, after which they were examined for growth of Staphylococcus epidermidis.

Discussion: The results are conclusive: there is bacterial transmission from one side of the toga hood to the other. Therefore it is possible to transmit bacteria from the surgeon’s face across the toga material and into the operative field.

Introduction: The technique of quadriceps sparing knee arthroplasty involves a pure capsular incision, without violation of the extensor mechanism. This capsular incision should be placed distal to Vastus Medialis Obliquus (VMO). It is well known that the termination of VMO is variable and may make the quadriceps sparing approach difficult. We initiated this study based on the hypothesis that the quadriceps sparing approach is not possible in all patients undergoing total knee arthroplasty.

Methods: We examined the axial MRI images of the knee joint performed over a period of 12 months at our institute. A total of 198 MRI scans were analysed between two observers.

To calculate the patellar height the apex of the patella was considered as ‘Reference Slice 1’. The consecutive slices were followed distally to the last slice in which the patella was visible. From ‘Reference Slice 1’ VMO muscle was followed distally to the slice in which the muscle was last visible. We calculated the patella height and VMO muscle length as the product of the number of MRI slices and MRI slice thickness.

Results: Of the 134 patients aged less than 50 years, 68 patients (50.7%) had a VMO that terminated in the proximal half of the patella. Out of 64 patients aged 50 years or older, 51 patients (79.7%) had a VMO that terminated in the proximal half of the patella.

A statistically significant inverse relationship was noted between the level of insertion of VMO and the age of the patient.

Discussion: Our results will have an implication on the use of the quadriceps sparing approach, as they highlight another possible limitation of this approach. Patients need to be warned before the TKA that the quadriceps sparing approach may not be possible in all, especially if they are younger.

Purpose: To evaluate the fifteen year survivorship of primary Total Knee Replacements in a single UK health region.

Methods: Since the beginning of 1990, and with the agreement of all consultant orthopaedic surgeons in the region, all primary total knee replacements (TKR) performed throughout Trent were recorded prospectively. At the time of operation the surgeon completes a questionnaire, which records demographic, medical and operative details for each patient and implant.

In this study we have traced all the patients, who had a primary total knee replacement between 1990 and 1992. We issued a validated, self administered questionnaire to all surviving patients, at a mean of fifteen years post arthroplasty. This questionnaire examines the patient’s level of expectation and satisfaction with their TKR, and also measures their quality of life (using EQ-5D and visual analogue score). Using a similar register, containing information of all revision TKR in the region, we have measured the survivorship of these primary TKR at 10 and 15 years.

Results: 4,665 primary TKR were performed on 4,448 patients. At fifteen year follow-up 1,408 patients were alive. The questionnaire response rate was 57.1% (n=912). Of our responders, 87.8% were satisfied with the result of their TKR at 15 years post-arthroplasty, and 82% felt their TKR had met their expectations.

Survivorship analysis revealed that 94.7% (+/−0.4%) of implants survive to 10 years, and 92.7% (+/−0.5%) to 15 years. Survivorship was significantly affected by gender of the patient, age at time of primary, and type of prosthesis used. Infection rate at 15 years was 0.9%.

Discussion: This is one of the first long term studies of primary TKR, which assesses survivorship of primary TKR beyond 10 years. This study shows that survivorship at 5 and 10 years compares favourably to the results of similar studies from other countries.