The link between squeaking and ceramic on ceramic (CoC) bearings has been widely reported in orthopaedic literature and is described as a hard bearing phenomenon. We aim to look at the incidence of noise in CoC bearings compared to Metal on Polyethylene (MoP) bearing, which have yet to be linked to squeaking. We developed a noise characterizing hip questionnaire and sent that along with the Oxford Hip Score (OHS) to 1000 patients; 3:2 ratio of CoC to MoP. 282 CoC patients and 227 MoP patients returned the questions: 509 patients in total. Our patient database provided details on femoral head size and the acetabular inclination angle, for each respondent 47 (17%) of the CoC hip patients reported noise compared to 19 (8%) of the MoP hip patients (P=0.054). 9 CoC patients and 4 MoP patients reported squeaking, while clicking was the most frequent answer in both groups. 27% patients with noise reported avoiding recreational activities because of it. Patient's with noisy hips scored on average, 5 points worse in the OHS (CoC: P = 0.04 and MoP: P = 0.007) and were on average 5 years younger (CoC: P<0.001 and MoP: P=0.007). No correlation was found between noisy hips and femoral head size or inclination angle. The squeaking hip phenomenon is not exclusive to hard bearing THA. Noise from patient's hips may have social implications and this should be highlighted when consenting a patient for either of these hip procedures. In both implants, we showed there to be a correlation between noise production and a lower OHS. However, longer follow up studies are needed to link noise to a poorly functioning implant
We compared the postoperative wound discharge rates and 3 months clinical results of three types of wound closure and dressing – 2-octylcyanoacrylate with Opstie (G+O), 2-octylcyanoacrylate with Tegaderm (G+T), and Opsite without 2-octylcyanoacrylate (O) in patients having primary total hip arthroplasty. We randomised 141 patients scheduled for primary total hip arthroplasty into 3 arms of this study- G+O, G+T, or O. The extent of wound discharge was recorded on a diagrammatic representation of the dressing in situ on paper and graded each day. Dressings were left in-situ provided the extent of wound discharge allowed for this. The patient was clinically reviewed at 3 months to assess their scar length, cosmesis, scar discomfort, and evidence of superficial or deep wound sepsis. A greater number of patients dressings remained dry on day 1 postoperatively in the two groups with 2-octylcyanoacrylate compared to the no glue group In patients who have had primary total hip arthroplasty, usage of 2-octylcyanoacrylate for wound closure along with Tegaderm dressing reduces wound discharge. The same effect is not noted in glue with Opsite group. Whilst dressing changes required in the non-glue group compared from the two glue groups did not reach statistical significance, this may have clinical relevance for patients and nursing staff. No effect on postoperative length of stay, or wound complications was noted.
The aim of this study was to characterise noise associated with ceramic-on-ceramic total hip arthroplasty (THA). A questionnaire was constructed to assess noise associated with THA. 116 patients responded. All had ceramic-on-ceramic hybrid THA at Glasgow Royal Infirmary between 2005 and 2007 using a Trident prosthesis and Exeter stem. Oxford Hip Questionnaires (OHS) were also completed by the patients. 16.4% of respondents reported noise associated with their ceramic hip. The vast majority reported onset at least 1 year after implantation. The most common noise types were ‘clicking’ (47%) or ‘grinding’ (42%), while ‘squeaking’ was least frequently reported (11%). Noise was most commonly brought on by bending and during sit to stand movements. No correlation was identified between the incidence of noise and any patient specific factor or demographic variable. The mean OHS at questionnaire follow-up was 39 and there was no significant difference in OHS when comparing noisy and silent hips (p=0.65). Only 1 patient limited social or recreational activities and overall patients felt the noise had minimal effect on their quality of life. Acetabular component inclination angles were compared on post-operative x-rays. There was no significant difference (p=0.51) in inclination angles of the noisy (47.1°±6.3°, range 30–57°) and silent hips (47.8°±6.1°, range 35–68°). The groups were further analysed for deviation out with the desirable inclination range of 40–45°. Of the noisy hips, a total of 73% were out with this range compared to 63% in the silent hip group. The incidence of noise within this ceramic-on-ceramic THA group did not appear to be related to patient specific factors, patient reported outcome (OHS) or acetabular inclination angles. Subjective appraisal of the noise revealed that ‘squeaking’ was not common but patients tended to report ‘clicking’ and ‘grinding’ more. The precipitation of noise with bending activities reinforces a possible mechanical cause.
The Trident acetabular system is the second most common cementless cup implanted in the UK. Recent studies have shown that malseating of the liner can be as high as 16.4%. We felt this was very high and were prompted to review our series and early clinical outcomes. We reviewed 118 hips in 110 patients, implanted between from 2005-2007. We reviewed initial post operative X-rays using the technique described by Howcroft to identify malseating. The posterior approach was used in all cases. All cups were Trident PSL and all 85 Patients had OA, 10 RA, 8 AVN, 5 DDH, 3 OA post trauma, 2 Perthes, 2 Psoriatic Arthritis, 3 other. We only identified 3 malseated cups in 118 hips. 2 were in patients with OA secondary to trauma and 1 in primary OA. The rate of malseating for trainees operating was 5 % and only 1% when consultants were operating. There were no adverse events in these patients. No-one required revision. Oxford Hip Score (OHS) improved from 47 pre-op to 20 post op. This was compared to 47 and 22 in the correctly seated group (115 cases). Surprisingly the subgroup with the poorest OHS at 1 year had surgery for DDH, with a mean OHS of 31. The reasons for this are unclear. Contrary to other studies our malseating rate is very low. We do not feel that malseating is a problem with Trident if adequate exposure is obtained. In those patients with sclerotic bone, we suggest over reaming the rim of the acetabulum by 1mm to avoid excess deformation of the shell which may lead to difficulty with seating the liner. We suggest trainees are supervised closely when using Trident.
Exeter Trauma Stem (ETS) is one of the most common implants used for treating displaced intracapsular hip fractures in the UK. We previously performed a radiographic audit of these implants which showed good placement was difficult. This was in particular relation to leg length discrepancy (LLD). This study reviewed the clinical outcomes of these patients, in particular looking at the relation of leg length discrepancy to outcome. We performed a clinical review of patients at 3 months and 1 year post ETS for hip fracture. Oxford hip score (OHS), Trendelenberg test, Visual Analogue Score (VAS) and walking aids required were recorded. Leg length discrepancy was determined radiographically on initial post op X-ray. This was recorded as Even (+/− 5mm), 6-10mm Long and >10mm long. Seventy-two patients were reviewed at 3 months and 21 at 1 year. Mean VAS was 1.6. At 3 months 66% were Trendelenberg positive. Of those Trendelenberg positive at 3 months only 42% remained positive at 1 year. Mean OHS at 3months and 1 year was 30.8 and 32.1 respectively. On radiographic review 38 implants were Even, 24 were 6-10mm Long and 10 implants were >10mm Long. There was no correlation between leg length discrepancy and either VAS or Trendelenberg test. 45 patients ambulated independently pre-op. Of these only 8 ambulated independently post-op, 18 used a stick and 11 a Zimmer frame. There was no correlation between post operative leg length discrepancy and either Visual Analogue Score, OHS or Trendelenberg test. Mean pain score was very low. There was however almost 10% of patients with a VAS greater than 6. 80% of patients dropped one ambulatory level post-op, this is consistent with previous studies. The ETS provides good pain relief with a low complication rate in the vast majority of patients.
Post-operative check radiographs following Total Hip Replacements (THR) are routine practice in most orthopaedic units. In our unit an Anteroposterior and Turned Lateral View (TLV) radiograph was used routinely in this assessment, but the TLV method has anecdotally been reported as painful by patients. We undertook a study to evaluate patients' experiences of pain using this technique and to consider if a change to a Horizontal Beam Lateral View (HBLV) radiograph method would result in a reduction in pain. The study was conducted in two phases. Patients who underwent a primary THR and subsequent post-operative TLV over 3months (n=46) were contacted by telephone and asked to grade their experience using a numerical and descriptive pain scale. After a change in practice to HBLV, the study was repeated (n=53) to identify any difference in pain. Ten radiographs were randomly selected from each group and assessed for radiation exposure and quality by two independent assessors. 87.0% of patients who underwent the TLV radiograph described the post-operative radiograph as painful, with a mean pain score of 7.44+1.5. After a change in practice to the HBLV radiograph, only 28.4% of patients experienced any pain, with a significantly lower mean pain score of 1.00+1.89 (p< 0.001). There was a significant increase in radiation dose in the HBLV vs. TLV method (62.4mAs vs. 25.8mAs, p< 0.001). HBLV X-ray quality was only slightly inferior to TLV when evaluating stem alignment and cement mantle quality. There was a dramatic reduction in both number of patients experiencing pain and level of pain experienced when switching from TLV to HBLV radiographs; this is most likely due to reduced direct pressure on the wound post-operatively. X-ray quality was not compromised, and whilst there was increased radiation exposure, the benefits in patient experience were felt to outweigh this. We recommend the HBLV radiograph method when performing a lateral post-operative check x-ray following THR.
