Intravenous tranexamic acid (TXA) has been shown
to be effective in reducing blood loss and the need for transfusion
after joint replacement. Recently, there has been interest in applying
it topically before the closure of surgical wounds. This has the
advantages of ease of application, maximum concentration at the
site of bleeding, minimising its systemic absorption and, consequently,
concerns about possible side-effects. We conducted a systematic review and meta-analysis which included
14 randomised controlled trials (11 in knee replacement, two in
hip replacement and one in both) which investigated the effect of
topical TXA on blood loss and rates of transfusion. Topical TXA
significantly reduced the rate of blood transfusion (total knee
replacement: risk ratio (RR) 4.51; 95% confidence interval (CI):
3.02 to 6.72; p <
0.001 (nine trials, I2 = 0%); total
hip replacement: RR 2.56; 95% CI: 1.32 to 4.97, p = 0.004 (one trial)).
The rate of thromboembolic events with topical TXA were similar
to those found with a placebo. Indirect comparison of placebo-controlled
trials of topical and intravenous TXA indicates that topical administration
is superior to the intravenous route. In conclusion, topical TXA is an effective and safe method of
reducing the need for blood transfusion after total knee and hip
replacement. Further research is required to find its optimum dose
for topical use. Cite this article:
In this systematic review, our aim was to explore
whether or not patients are able to return to athletic activity
following lower limb joint replacement. We also investigated any evidence
as to whether participation in athletic activity post-joint replacement
increases complications and reduces implant survival. A PubMed, Embase and Sports Discus search was performed using
the MeSH terms ‘Sport’, ‘Athletic’, ‘Athlete’, ‘Physical’, ‘Activity’,
‘Arthroplasty’, ‘Total Hip Replacement’, ‘Hip Resurfacing’, ‘Total
Knee Replacement’, ‘Unicompartmental Knee Replacement’ and ‘Unicondylar
Knee Replacement’. From this search, duplications were excluded,
the remaining abstracts were reviewed and any unrelated to the search
terms were excluded. The remaining abstracts had their full papers
reviewed. Following joint replacement, participation in sporting activity
is common principally determined by pre-operative patient activity
levels, BMI and patient age. The type of joint replaced is of less
significance. Total time spent performing activity does not change
but tends to be at a lower intensity. There is little evidence in
the literature of an association between high activity levels and
early implant failure. Cite this article:
Substantial healthcare resources have been devoted
to computer navigation and patient-specific instrumentation systems
that improve the reproducibility with which neutral mechanical alignment
can be achieved following total knee replacement (TKR). This choice of
alignment is based on the long-held tenet that the alignment of
the limb post-operatively should be within 3° of a neutral mechanical
axis. Several recent studies have demonstrated no significant difference
in survivorship when comparing well aligned Review of the literature suggests that a neutral mechanical axis
remains the optimal guide to alignment. Cite this article:
Periprosthetic fractures are an increasingly
common complication following joint replacement. The principles
which underpin their evaluation and treatment are common across
the musculoskeletal system. The Unified Classification System proposes
a rational approach to treatment, regardless of the bone that is
broken or the joint involved. Cite this article:
We have reviewed the current literature to compare
the results of surgery aimed to repair or debride a damaged acetabular
labrum. We identified 28 studies to be included in the review containing
a total of 1631 hips in 1609 patients. Of these studies 12 reported
a mean rate of good results of 82% (from 67% to 100%) for labral debridement.
Of the 16 studies that reported a combination of debridement and
re-attachment, five reported a comparative outcome for the two methods,
four reported better results with re-attachment and one study did
not find any significant difference in outcomes. Due to the heterogeneity
of the studies it was not possible to perform a meta-analysis or
draw accurate conclusions. Confounding factors in the studies include
selection bias, use of historical controls and high rates of loss
of follow-up. It seems logical to repair an unstable tear in a good quality
labrum with good potential to heal in order potentially to preserve
its physiological function. A degenerative labrum on the other hand
may be the source of discomfort and its preservation may result
in persistent pain and the added risk of failure of re-attachment.
The results of the present study do not support routine refixation
for all labral tears. Cite this article:
The outcome after total hip replacement has improved
with the development of surgical techniques, better pain management
and the introduction of enhanced recovery pathways. These pathways
require a multidisciplinary team to manage pre-operative education,
multimodal pain control and accelerated rehabilitation. The current economic
climate and restricted budgets favour brief hospitalisation while
minimising costs. This has put considerable pressure on hospitals
to combine excellent results, early functional recovery and shorter
admissions. In this review we present an evidence-based summary of some common
interventions and methods, including pre-operative patient education,
pre-emptive analgesia, local infiltration analgesia, pre-operative
nutrition, the use of pulsed electromagnetic fields, peri-operative
rehabilitation, wound dressings, different surgical techniques, minimally
invasive surgery and fast-track joint replacement units. Cite this article:
The increasing need for total hip replacement
(THR) in an ageing population will inevitably generate a larger number
of revision procedures. The difficulties encountered in dealing
with the bone deficient acetabulum are amongst the greatest challenges
in hip surgery. The failed acetabular component requires reconstruction
to restore the hip centre and improve joint biomechanics. Impaction
bone grafting is successful in achieving acetabular reconstruction
using both cemented and cementless techniques. Bone graft incorporation
restores bone stock whilst providing good component stability. We
provide a summary of the evidence and current literature regarding impaction
bone grafting using both cemented and cementless techniques in revision
THR. Cite this article:
Young adults with hip pain secondary to femoroacetabular
impingement (FAI) are rapidly being recognised as an important cohort
of orthopaedic patients. Interest in FAI has intensified over the
last decade since its recognition as a precursor to arthritis of
the hip and the number of publications related to the topic has
increased exponentially in the last decade. Although not all patients
with abnormal hip morphology develop osteoarthritis (OA), those
with FAI-related joint damage rapidly develop premature OA. There
are no explicit diagnostic criteria or definitive indications for
surgical intervention in FAI. Surgery for symptomatic FAI appears
to be most effective in younger individuals who have not yet developed
irreversible OA. The difficulty in predicting prognosis in FAI means
that avoiding unnecessary surgery in asymptomatic individuals, while
undertaking intervention in those that are likely to develop premature
OA poses a considerable dilemma. FAI treatment in the past has focused
on open procedures that carry a potential risk of complications. Recent developments in hip arthroscopy have facilitated a minimally
invasive approach to the management of FAI with few complications
in expert hands. Acetabular labral preservation and repair appears
to provide superior results when compared with debridement alone.
Arthroscopic correction of structural abnormalities is increasingly becoming
the standard treatment for FAI, however there is a paucity of high-level
evidence comparing open and arthroscopic techniques in patients
with similar FAI morphology and degree of associated articular cartilage damage.
Further research is needed to develop an understanding of the natural
course of FAI, the definitive indications for surgery and the long-term
outcomes. Cite this article:
In a time of limited resources, the debate continues
over which types of hip prosthesis are clinically superior and more
cost-effective. Orthopaedic surgeons increasingly need robust economic
evidence to understand the full value of the operation, and to aid
decision making on the ‘package’ of procedures that are available
and to justify their practice beyond traditional clinical preference. In this paper we explore the current economic debate about the
merits of cemented and cementless total hip replacement, an issue
that continues to divide the orthopaedic community. Cite this article:
In this paper, we will consider the current role
of metal-on-metal bearings by looking at three subtypes of MoM hip
arthroplasty separately: Hip resurfacing, large head (>
36 mm) MoM
THA and MoM THA with traditional femoral head sizes.
Peri-prosthetic infection remains a leading cause
of revision surgery. Recent publications from the American Musculoskeletal
Infection Society have sought to establish a definition of peri-prosthetic
infection based on clinical findings and laboratory investigations.
The limitations of their approach are discussed and an alternative
definition is proposed, which it is felt may better reflect the
uncertainties encountered in clinical practice.
In this paper we make the case for the use of
single-stage revision for infected knee arthroplasty.
Radiological assessment of total and unicompartmental
knee replacement remains an essential part of routine care and follow-up.
Appreciation of the various measurements that can be identified
radiologically is important. It is likely that routine plain radiographs
will continue to be used, although there has been a trend towards
using newer technologies such as CT, especially in a failing knee,
where it provides more detailed information, albeit with a higher
radiation exposure. The purpose of this paper is to outline the radiological parameters
used to evaluate knee replacements, describe how these are measured
or classified, and review the current literature to determine their
efficacy where possible.
This review summarises the opinions and conclusions
reached from a symposium on infected total knee replacement (TKR)
held at the British Association of Surgery of the Knee (BASK) annual
meeting in 2011. The National Joint Registry for England and Wales
reported 5082 revision TKRs in 2010, of which 1157 (23%) were caused
by infection. The diagnosis of infection beyond the acute post-operative
stage relies on the identification of the causative organism by
aspiration and analysis of material obtained at arthroscopy. Ideal
treatment then involves a two-stage surgical procedure with extensive
debridement and washout, followed by antibiotics. An articulating
or non-articulating drug-eluting cement spacer is used prior to
implantation of the revision prosthesis, guided by the serum level
of inflammatory markers. The use of a single-stage revision is gaining popularity
and we would advocate its use in certain patients where the causative
organism is known, no sinuses are present, the patient is not immunocompromised,
and there is no radiological evidence of component loosening or
osteitis. It is our opinion that single-stage revision produces high-quality
reproducible results and will soon achieve the same widespread acceptance
as it does in infected hip arthroplasty.
Revision arthroplasty of the hip is expensive
owing to the increased cost of pre-operative investigations, surgical implants
and instrumentation, protracted hospital stay and drugs. We compared
the costs of performing this surgery for aseptic loosening, dislocation,
deep infection and peri-prosthetic fracture. Clinical, demographic
and economic data were obtained for 305 consecutive revision total
hip replacements in 286 patients performed at a tertiary referral
centre between 1999 and 2008. The mean total costs for revision
surgery in aseptic cases (n = 194) were £11 897 (
An international faculty of orthopaedic surgeons
presented their work on the current challenges in hip surgery at
the London Hip Meeting which was attended by over
400 delegates. The topics covered included femoroacetabular impingement, thromboembolic
phenomena associated with hip surgery, bearing surfaces (including metal-on-metal
articulations), outcomes of hip replacement surgery and revision
hip replacement. We present a concise report of the current opinions
on hip surgery from this meeting with appropriate references to
the current literature.
Lately, concerns have arisen following the use of large metal-on-metal bearings in hip replacements owing to reports of catastrophic soft-tissue reactions resulting in implant failure and associated complications. This review examines the literature and contemporary presentations on current clinical dilemmas in metal-on-metal hip replacement.
There have been considerable recent advances in the understanding and management of femoroacetabular impingement and associated labral and chondral pathology. We have developed a classification system for acetabular chondral lesions. In our system, we use the six acetabular zones previously described by Ilizaliturri et al. The cartilage is then graded on a scale of 0 to 4 as follows: grade 0, normal articular cartilage lesions; grade 1, softening or wave sign; grade 2, cleavage lesion; grade 3, delamination; and grade 4, exposed bone. The site of the lesion is further classed as A, B or C based on whether the lesion is less than one-third of the distance from the acetabular rim to the cotyloid fossa, one-third to two-thirds of the same distance and greater than two-thirds of the distance, respectively. In order to validate the classification system, six surgeons graded ten video recordings of hip arthroscopy. Our findings showed a high intra-observer reliability of the classification system with an intraclass correlation coefficient of 0.81 and a high interobserver reliability with an intraclass correlation coefficient of 0.88. We have developed a simple reproducible classification system for lesions of the acetabular cartilage, which it is hoped will allow standardised documentation to be made of damage to the articular cartilage, particularly that associated with femoroacetabular impingement.
Bacterial infection in orthopaedic surgery can be devastating, and is associated with significant morbidity and poor functional outcomes, which may be improved if high concentrations of antibiotics can be delivered locally over a prolonged period of time. The two most widely used methods of doing this involve antibiotic-loaded polymethylmethacrylate or collagen fleece. The former is not biodegradable and is a surface upon which secondary bacterial infection may occur. Consequently, it has to be removed once treatment has finished. The latter has been used successfully as an adjunct to systemic antibiotics, but cannot effect a sustained release that would allow it to be used on its own, thereby avoiding systemic toxicity. This review explores the newer biodegradable carrier systems which are currently in the experimental phase of development and which may prove to be more effective in the treatment of osteomyelitis.
We report a systematic review and meta-analysis of published randomised controlled trials evaluating the efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion in total hip replacement (THR). The data were evaluated using the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. We identified 11 clinical trials which were suitable for detailed extraction of data. There were no trials that used TXA in revision THR. A total of seven studies (comprising 350 patients) were eligible for the blood loss outcome data. The use of TXA reduced intra-operative blood loss by a mean of 104 ml (95% confidence interval (CI) −164 to −44, p = 0.0006, heterogeneity I2 0%), postoperative blood loss by a mean of 172 ml (95% CI −263 to −81, p = 0.0002, heterogeneity I2 63%) and total blood loss by a mean of 289 ml (95% CI −440 to −138, p <
0.0002, heterogeneity I2 54%). TXA led to a significant reduction in the proportion of patients requiring allogeneic blood transfusion (risk difference −0.20, 95% CI −0.29 to −0.11, p <
0.00001, I2 15%). There were no significant differences in deep-vein thrombosis, pulmonary embolism, infection rates or other complications among the study groups.
Fibrin glue, also known as fibrin sealant, is now established as a haemostatic agent in surgery, but its role in orthopaedic surgery is neither well known nor clearly defined. Although it was originally used over 100 years ago, concerns about transmission of disease meant that it fell from favour. It is also available as a slow-release drug delivery system and as a substrate for cellular growth and tissue engineering. Consequently, it has the potential to be used in a number of ways in orthopaedic surgery. The purpose of this review is to address its use in surgery of the knee in which it appears to offer great promise.
Periprosthetic infection following total hip replacement can be a catastrophic complication for the patient. The treatments available include single-stage exchange, and two-stage exchange. We present a series of 50 consecutive patients with a diagnosis of infected total hip replacement who were assessed according to a standardised protocol. Of these, 11 underwent single-stage revision arthroplasty with no recurrence of infection at a mean of 6.8 years follow-up (5.5 to 8.8). The remaining 39 underwent two-stage revision, with two recurrences of infection successfully treated by a second two-stage procedure. At five years, significant differences were found in the mean Harris Hip Scores (single-stage 87.8; two-stage 75.5; p = 0.0003) and in a visual analogue score for satisfaction (8.6; 6.9; p = 0.001) between the single- and two-stage groups. Single-stage exchange is successful in eradicating periprosthetic infection and results in excellent functional and satisfaction scores. Identification of patients suitable for the single-stage procedure allows individualisation of care and provides as many as possible with the correct strategy in successfully tackling their periprosthetic infection
As of April 2010 all NHS institutions in the United Kingdom are required to publish data on surgical site infection, but the method for collecting this has not been decided. We examined 7448 trauma and orthopaedic surgical wounds made in patients staying for at least two nights between 2000 and 2008 at our institution and calculated the rate of surgical site infection using three definitions: the US Centers for Disease Control, the United Kingdom Nosocomial Infection National Surveillance Scheme and the ASEPSIS system. On the same series of wounds, the infection rate with outpatient follow-up according to Centre for Disease Control was 15.45%, according to the UK Nosocomial infection surveillance was 11.32%, and according to ASEPSIS was 8.79%. These figures highlight the necessity for all institutions to use the same method for diagnosing surgical site infection. If different methods are used, direct comparisons will be invalid and published rates of infection will be misleading.
We measured the plasma 25-hydroxyvitamin D3 (25(OH)D3) levels in 62 consecutive Caucasian patients undergoing total hip replacement for osteoarthritis. The patients were divided into two groups based on whether they were vitamin D sufficient or deficient. The groups were matched for age, gender and the American Society of Anaesthesiologists (ASA) grade. The prevalence of vitamin D deficiency in our patients was comparable with recent population-based studies performed in the United Kingdom. Patients with vitamin D deficiency had lower pre-operative Harris hip scores (Mann-Whitney test, p = 0.018) and were significantly less likely to attain an excellent outcome from total hip replacement (chi-squared test, p = 0.038). Vitamin D levels were found to positively correlate with both pre- and post-operative Harris hip scores. These results warrant further study of vitamin D deficiency in patients undergoing joint replacement as it is a risk factor for a suboptimal outcome which is relatively simple and cheap to correct.
The radiological evaluation of the anterolateral femoral head is an essential tool for the assessment of the cam type of femoroacetabular impingement. CT, MRI and frog lateral plain radiographs have all been suggested as imaging options for this type of lesion. The alpha angle is accepted as a reliable indicator of the cam type of impingement and may also be used as an assessment for the successful operative correction of the cam lesion. We studied the alpha angles of 32 consecutive patients with femoroacetabular impingement. The angle measured on frog lateral radiographs using templating tools was compared with that measured on CT scans in order to assess the reliability of the frog lateral view in analysing the alpha angle in cam impingement. A high interobserver reliability was noted for the assessment of the alpha angle on the frog lateral view with an intraclass correlation coefficient of 0.83. The mean alpha angle measured on the frog lateral view was 58.71° (32° to 83.3°) and that by CT was 65.11° (30° to 102°). A poor intraclass correlation coefficient (0.08) was noted between the measurements using the two systems. The frog lateral plain radiograph is not reliable for measuring the alpha angle. Various factors may be responsible for this such as the projection of the radiograph, the positioning of the patient and the quality of the image. CT may be necessary for accurate measurement of the alpha angle.
The Vancouver classification has been shown by its developers to be a valid and reliable method for categorising the configuration of periprosthetic proximal femoral fractures and for planning their management. We have re-validated this classification system independently using the radiographs of 30 patients with periprosthetic fractures. These were reviewed by six experienced consultant orthopaedic surgeons, six trainee surgeons and six medical students in order to assess intra- and interobserver reliability and reproducibility. Each observer read the radiographs on two separate occasions. The results were subjected to weighted kappa statistical analysis. The respective kappa values for interobserver agreement were 0.72 and 0.74 for consultants, 0.68 and 0.70 for trainees on the first and second readings of the radiographs and 0.61 for medical students. The intra-observer agreement for the consultants was 0.64 and 0.67, for the trainees 0.61 and 0.64, and for the medical students 0.59 and 0.60 for the first and second readings, respectively. The validity of the classification was studied by comparing the pre-operative radiological findings within B subgroups with the operative findings. This revealed agreement for 77% of these type-B fractures, with a kappa value of 0.67. Our data confirm the reliability and reproducibility of this classification system in a European setting and for inexperienced staff. This is a reliable system which can be used by non-experts, between centres and across continents.
Orthopaedic outcome measures are used to evaluate the effect of operative interventions. They are used for audit and research. Knowledge of these measures is becoming increasingly important with league tables comparing surgeons and hospitals being made accessible to the profession and the general public. Several types of tool are available to describe outcome after hip surgery such as generic quality-of-life questionnaires, disease-specific quality-of-life questionnaires, hip-specific outcome measures and general short-term clinical measures. We provide an overview of the outcome measures commonly used to evaluate hip interventions.