Aims. Knee joint distraction (KJD) is a relatively new, knee-joint
preserving procedure with the goal of delaying total knee arthroplasty
(TKA) in young and middle-aged patients. We present a randomised
controlled trial comparing the two. Patients and Methods. The 60 patients ≤ 65 years with end-stage knee osteoarthritis
were randomised to either KJD (n = 20) or TKA (n = 40). Outcomes
were assessed at baseline, three, six, nine, and 12 months. In the
KJD group, the joint space width (JSW) was radiologically assessed,
representing a
The complications of impaction bone grafting in revision hip replacement includes fracture of the femur and subsidence of the prosthesis. In this in vitro study we aimed to investigate whether the use of vibration, combined with a perforated tamp during the compaction of morsellised allograft would reduce peak loads and hoop strains in the femur as a
Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England. We conducted a cohort study of patients with hip fracture recorded in the National Hip Fracture Database between 1 February 2019 and 31 October 2020 in England. Data were linked to Hospital Episode Statistics to quantify patient characteristics and comorbidities, Office for National Statistics mortality data, and Public Health England’s SARS-CoV-2 testing results. Multivariable Cox regression examined determinants of 90-day mortality. Excess mortality attributable to COVID-19 was quantified using Quasi-Poisson models.Aims
Methods
The ‘pink, pulseless hand’ is often used to describe the clinical situation in which a child with a supracondylar fracture of the humerus has normal distal perfusion in the absence of a palpable peripheral pulse. The management guidelines are based on the assessment of perfusion, which is difficult to undertake and poorly evaluated objectively. The aim of this study was to review the available literature in order to explore the techniques available for the preoperative clinical assessment of perfusion in these patients and to evaluate the clinical implications. A systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered prospectively with the International Prospective Register of Systematic Reviews. Databases were explored in June 2022 with the search terms (pulseless OR dysvascular OR ischaemic OR perfused OR vascular injury) AND supracondylar AND (fracture OR fractures).Aims
Methods
The early diagnosis of cauda equina syndrome (CES) is crucial for a favourable outcome. Several studies have reported the use of an ultrasound scan of the bladder as an adjunct to assess the minimum post-void residual volume of urine (mPVR). However, variable mPVR values have been proposed as a threshold without consensus on a value for predicting CES among patients with relevant symptoms and signs. The aim of this study was to perform a meta-analysis and systematic review of the published evidence to identify a threshold mPVR value which would provide the highest diagnostic accuracy in patients in whom the diagnosis of CES is suspected. The search strategy used electronic databases (PubMed, Medline, EMBASE, and AMED) for publications between January 1996 and November 2021. All studies that reported mPVR in patients in whom the diagnosis of CES was suspected, followed by MRI, were included.Aims
Methods
The primary objective of this study was to develop a validated classification system for assessing iatrogenic bone trauma and soft-tissue injury during total hip arthroplasty (THA). The secondary objective was to compare macroscopic bone trauma and soft-tissues injury in conventional THA (CO THA) versus robotic arm-assisted THA (RO THA) using this classification system. This study included 30 CO THAs versus 30 RO THAs performed by a single surgeon. Intraoperative photographs of the osseous acetabulum and periacetabular soft-tissues were obtained prior to implantation of the acetabular component, which were used to develop the proposed classification system. Interobserver and intraobserver variabilities of the proposed classification system were assessed.Aims
Methods
Loosening of components after total knee arthroplasty (TKA) can be associated with the development of radiolucent lines (RLLs). The aim of this study was to assess the rate of formation of RLLs in the cemented original design of the ATTUNE TKA and their relationship to loosening. A systematic search was undertaken using the Cochrane methodology in three online databases: MEDLINE, Embase, and CINAHL. Studies were screened against predetermined criteria, and data were extracted. Available National Joint Registries in the Network of Orthopaedic Registries of Europe were also screened. A random effects model meta-analysis was undertaken.Aims
Methods
This study aimed to identify risk factors (patient, healthcare system, and socioeconomic) for mortality after hip fractures and estimate their relative importance. Further, we aimed to elucidate mortality and survival patterns following fractures and the duration of excess mortality. Data on 37,394 hip fractures in the Norwegian Hip Fracture Register from January 2014 to December 2018 were linked to data from the Norwegian Patient Registry, Statistics Norway, and characteristics of acute care hospitals. Cox regression analysis was performed to estimate risk factors associated with mortality. The Wald statistic was used to estimate and illustrate relative importance of risk factors, which were categorized in modifiable (healthcare-related) and non-modifiable (patient-related and socioeconomic). We calculated standardized mortality ratios (SMRs) comparing deaths among hip fracture patients to expected deaths in a standardized reference population.Aims
Methods
Patients who sustain neck of femur fractures are at high risk of malnutrition. Our intention was to assess to what extent malnutrition was associated with worse patient outcomes. A total of 1,199 patients with femoral neck fractures presented to a large UK teaching hospital over a three-year period. All patients had nutritional assessments performed using the Malnutrition Universal Screening Tool (MUST). Malnutrition risk was compared to mortality, length of hospital stay, and discharge destination using logistic regression. Adjustments were made for covariates to identify whether malnutrition risk independently affected these outcomes.Aims
Methods
The aim of this study was to compare the clinical and radiological outcomes of patients with early-onset scoliosis (EOS), who had undergone spinal fusion after distraction-based spinal growth modulation using either traditional growing rods (TGRs) or magnetically controlled growing rods (MCGRs). We undertook a retrospective review of skeletally mature patients who had undergone fusion for an EOS, which had been previously treated using either TGRs or MCGRs. Measured outcomes included sequential coronal T1 to S1 height and major curve (Cobb) angle on plain radiographs and any complications requiring unplanned surgery before final fusion.Aims
Methods
The aim of this study was to analyze the prevalence of culture-negative periprosthetic joint infections (PJIs) when adequate methods of culture are used, and to evaluate the outcome in patients who were treated with antibiotics for a culture-negative PJI compared with those in whom antibiotics were withheld. A multicentre observational study was undertaken: 1,553 acute and 1,556 chronic PJIs, diagnosed between 2013 and 2018, were retrospectively analyzed. Culture-negative PJIs were diagnosed according to the Muskuloskeletal Infection Society (MSIS), International Consensus Meeting (ICM), and European Bone and Joint Society (EBJIS) definitions. The primary outcome was recurrent infection, and the secondary outcome was removal of the prosthetic components for any indication, both during a follow-up period of two years.Aims
Methods
The modified Glasgow Prognostic Score (mGPS) uses preoperative CRP and albumin to calculate a score from 0 to 2 (2 being associated with poor outcomes). mGPS is validated in multiple carcinomas. To date, its use in soft-tissue sarcoma (STS) is limited, with only small cohorts reporting that increased mGPS scores correlates with decreased survival in STS patients. This retrospective multicentre cohort study identified 493 STS patients using clinical databases from six collaborating hospitals in three countries. Centres performed a retrospective data collection for patient demographics, preoperative blood results (CRP and albumin levels and neutrophil, leucocyte, and platelets counts), and oncological outcomes (disease-free survival, local, or metastatic recurrence) with a minimum of two years' follow-up.Aims
Methods
Many surgeons choose to perform total knee arthroplasty (TKA) surgery with the aid of a tourniquet. A tourniquet is a device that fits around the leg and restricts blood flow to the limb. There is a need to understand whether tourniquets are safe, and if they benefit, or harm, patients. The aim of this study was to determine the benefits and harms of tourniquet use in TKA surgery. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, and trial registries up to 26 March 2020. We included randomized controlled trials (RCTs), comparing TKA with a tourniquet versus without a tourniquet. Outcomes included: pain, function, serious adverse events (SAEs), blood loss, implant stability, duration of surgery, and length of hospital stay.Aims
Methods
The impact of concomitant injuries in patients with proximal femoral fractures has rarely been studied. To date, the few studies published have been mostly single-centre research focusing on the influence of upper limb fractures. A retrospective cohort analysis was, therefore, conducted to identify the impact and distribution of concomitant injuries in patients with proximal femoral fractures. A retrospective, multicentre registry-based study was undertaken. Between 1 January 2016 and 31 December 2019, data for 24,919 patients from 100 hospitals were collected in the Registry for Geriatric Trauma. This information was queried and patient groups with and without concomitant injury were compared using linear and logistic regression models. In addition, we analyzed the influence of the different types of additional injuries.Aims
Methods
The use of tourniquets in lower limb trauma surgery to control bleeding and improve the surgical field is a long established practice. In this article, we review the evidence relating to harms and benefits of tourniquet use in lower limb fracture fixation surgery and report the results of a survey on current tourniquet practice among trauma surgeons in the UK.
Uncemented metal acetabular components show good osseointegration, but material stiffness causes stress shielding and retroacetabular bone loss. Cemented monoblock polyethylene components load more physiologically; however, the cement bone interface can suffer fibrous encapsulation and loosening. It was hypothesized that an uncemented titanium-sintered monoblock polyethylene component may offer the optimum combination of osseointegration and anatomical loading. A total of 38 patients were prospectively enrolled and received an uncemented monoblock polyethylene acetabular (pressfit) component. This single cohort was then retrospectively compared with previously reported randomized cohorts of cemented monoblock (cemented) and trabecular metal (trabecular) acetabular implants. The primary outcome measure was periprosthetic bone density using dual-energy x-ray absorptiometry over two years. Secondary outcomes included radiological and clinical analysis.Aims
Methods
The aim of this study was to identify the minimal clinically important difference (MCID), minimal important change (MIC), minimal detectable change (MDC), and patient-acceptable symptom state (PASS) threshold in the Forgotten Joint Score (FJS) according to patient satisfaction six months following total knee arthroplasty (TKA). During a one-year period 484 patients underwent a primary TKA and completed preoperative and six-month FJS and OKS. At six months patients were asked, “How satisfied are you with your operated knee?” Their response was recorded as: very satisfied, satisfied, neutral, dissatisfied, or very dissatisfied. The difference between patients recording neutral (n = 44) and satisfied (n = 153) was used to define the MCID. MIC for a cohort was defined as the change in the FJS for those patients declaring their outcome as satisfied, whereas receiver operating characteristic curve analysis was used to determine the MIC for an individual and the PASS threshold. Distribution-based methodology was used to calculate the MDC.Aims
Methods
The aim of this study was to measure the effect of hospital case volume on the survival of revision total knee arthroplasty (RTKA). This is a retrospective analysis of Scottish Arthroplasty Project data, a nationwide audit which prospectively collects data on all arthroplasty procedures performed in Scotland. The primary outcome was RTKA survival at ten years. The primary explanatory variable was the effect of hospital case volume per year on RTKA survival. Kaplan-Meier survival curves were plotted with 95% confidence intervals (CIs) to determine the lifespan of RTKA. Multivariate Cox proportional hazards were used to estimate relative revision risks over time. Hazard ratios (HRs) were reported with 95% CI, and p-value < 0.05 was considered statistically significant.Aims
Methods
Anterior cruciate ligament (ACL) surgery in children and the adolescent population has increased steadily over recent years. We used a national database to look at trends in ACL reconstruction and rates of serious complications, growth disturbance, and revision surgery, over 20 years. All hospital episodes for patients undergoing ACL reconstruction, under the age of 20 years, between 1 April 1997 and 31 March 2017, were extracted by procedure code from the national Hospital Episode Statistics (HES). Population standardized rates of intervention were determined by age group and year of treatment. Subsequent rates of serious complications including reoperation for infection, growth disturbance (osteotomy, epiphysiodesis), revision reconstruction, and/or contralateral ACL reconstruction rates were determined.Aims
Methods
Postoperative delirium (POD) and postoperative cognitive decline (POCD) are common surgical complications. In the UK, the Best Practice Tariff incentivizes the screening of delirium in patients with hip fracture. Further, a National Hip Fracture Database (NHFD) performance indicator is the reduction in the incidence of POD. To aid in its recognition, we sought to determine factors associated with POD and POCD in patients with hip fractures. We interrogated the NHFD data on patients presenting with hip fractures to our institution from 2016 to 2018. POD was determined using the 4AT score, as recommended by the NHFD and UK Department of Health. POCD was defined as a decline in Abbreviated Mental Test Score (AMTS) of two or greater. Using logistic regression, we adjusted for covariates to identify factors associated with POD and POCD.Aims
Methods
The aim of this study was to use diffusion tensor imaging (DTI) to investigate changes in diffusion metrics in patients with cervical spondylotic myelopathy (CSM) up to five years after decompressive surgery. We correlated these changes with clinical outcomes as scored by the Modified Japanese Orthopedic Association (mJOA) method, Neck Disability Index (NDI), and Visual Analogue Scale (VAS). We used multi-shot, high-resolution, diffusion tensor imaging (ms-DTI) in patients with cervical spondylotic myelopathy (CSM) to investigate the change in diffusion metrics and clinical outcomes up to five years after anterior cervical interbody discectomy and fusion (ACDF). High signal intensity was identified on T2-weighted imaging, along with DTI metrics such as fractional anisotropy (FA). MJOA, NDI, and VAS scores were also collected and compared at each follow-up point. Spearman correlations identified correspondence between FA and clinical outcome scores.Aims
Methods
Patients with abnormal spinopelvic mobility are at increased risk for instability. Measuring the change in sacral slope (ΔSS) can help determine spinopelvic mobility preoperatively. Sacral slope (SS) should decrease at least 10° to demonstrate adequate posterior pelvic tilt. There is potential for different ΔSS measurements in the same patient based on sitting posture. The purpose of this study was to determine the effect of sitting posture on the ΔSS in patients undergoing total hip arthroplasty (THA). In total, 51 patients undergoing THA were reviewed to quantify the variability in preoperative spinopelvic mobility when measuring two different sitting positions using SS for planning.Aims
Methods
Fracture of the odontoid process (OP) in the elderly is associated with mortality rates similar to those of hip fracture. The aim of this study was to identify variables that predict mortality in patients with a fracture of the OP, and to assess whether established hip fracture scoring systems such as the Nottingham Hip Fracture Score (NHFS) or Sernbo Score might also be used as predictors of mortality in these patients. We conducted a retrospective review of patients aged 65 and over with an acute fracture of the OP from two hospitals. Data collected included demographics, medical history, residence, mobility status, admission blood tests, abbreviated mental test score, presence of other injuries, and head injury. All patients were treated in a semi-rigid cervical orthosis. Univariate and multivariate analysis were undertaken to identify predictors of mortality at 30 days and one year. A total of 82 patients were identified. There were 32 men and 50 women with a mean age of 83.7 years (67 to 100).Aims
Patients and Methods
Intraoperative 3D navigation (ION) allows high accuracy to be achieved in spinal surgery, but poor workflow has prevented its widespread uptake. The technical demands on ION when used in patients with adolescent idiopathic scoliosis (AIS) are higher than for other more established indications. Lean principles have been applied to industry and to health care with good effects. While ensuring optimal accuracy of instrumentation and safety, the implementation of ION and its associated productivity was evaluated in this study for AIS surgery in order to enhance the workflow of this technique. The aim was to optimize the use of ION by the application of lean principles in AIS surgery. A total of 20 consecutive patients with AIS were treated with ION corrective spinal surgery. Both qualitative and quantitative analysis was performed with real-time modifications. Operating time, scan time, dose length product (measure of CT radiation exposure), use of fluoroscopy, the influence of the reference frame, blood loss, and neuromonitoring were assessed.Aims
Methods
The aim of this study was to determine the impact of the severity of anaemia on postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA). A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database. All patients who underwent primary TKA or THA between January 2012 and December 2017 were identified and stratified based upon hematocrit level. In this analysis, we defined anaemia as packed cell volume (Hct) < 36% for women and < 39% for men, and further stratified anaemia as mild anaemia (Hct 33% to 36% for women, Hct 33% to 39% for men), and moderate to severe (Hct < 33% for both men and women). Univariate and multivariate analyses were used to evaluate the incidence of multiple adverse events within 30 days of arthroplasty.Aims
Methods
Arthroplasty skills need to be acquired safely during training, yet operative experience is increasingly hard to acquire by trainees. Virtual reality (VR) training using headsets and motion-tracked controllers can simulate complex open procedures in a fully immersive operating theatre. The present study aimed to determine if trainees trained using VR perform better than those using conventional preparation for performing total hip arthroplasty (THA). A total of 24 surgical trainees (seven female, 17 male; mean age 29 years (28 to 31)) volunteered to participate in this observer-blinded 1:1 randomized controlled trial. They had no prior experience of anterior approach THA. Of these 24 trainees, 12 completed a six-week VR training programme in a simulation laboratory, while the other 12 received only conventional preparatory materials for learning THA. All trainees then performed a cadaveric THA, assessed independently by two hip surgeons. The primary outcome was technical and non-technical surgical performance measured by a THA-specific procedure-based assessment (PBA). Secondary outcomes were step completion measured by a task-specific checklist, error in acetabular component orientation, and procedure duration.Aims
Patients and Methods
The aim of this study was to compare the incidence of anterior knee pain after antegrade tibial nailing using suprapatellar and infrapatellar surgical approaches A total of 95 patients with a tibial fracture requiring an intramedullary nail were randomized to treatment using a supra- or infrapatellar approach. Anterior knee pain was assessed at four and six months, and one year postoperatively, using the Aberdeen Weightbearing Test – Knee (AWT-K) score and a visual analogue scale (VAS) score for pain. The AWT-K is an objective patient-reported outcome measure that uses weight transmitted through the knee when kneeling as a surrogate for anterior knee pain.Aims
Patients and Methods
The aim of this study was to determine the long-term risk of undergoing knee arthroplasty in a cohort of patients with meniscal tears who had undergone arthroscopic partial meniscectomy (APM). A retrospective national cohort of patients with a history of isolated APM was identified over a 20-year period. Patients with prior surgery to the same knee were excluded. The primary outcome was knee arthroplasty. Hazard ratios (HRs) were adjusted by patient age, sex, year of APM, Charlson comorbidity index, regional deprivation, rurality, and ethnicity. Risk of arthroplasty in the index knee was compared with the patient’s contralateral knee (with Aims
Patients and Methods
Aims
Patients and Methods
The primary aim of this study was to determine the surgical team’s
learning curve for introducing robotic-arm assisted unicompartmental
knee arthroplasty (UKA) into routine surgical practice. The secondary
objective was to compare accuracy of implant positioning in conventional
jig-based UKA versus robotic-arm assisted UKA. This prospective single-surgeon cohort study included 60 consecutive
conventional jig-based UKAs compared with 60 consecutive robotic-arm
assisted UKAs for medial compartment knee osteoarthritis. Patients
undergoing conventional UKA and robotic-arm assisted UKA were well-matched
for baseline characteristics including a mean age of 65.5 years
(Aims
Patients and Methods
The aim of this study was to examine the association between
postoperative glycaemic variability and adverse outcomes following
orthopaedic surgery. This retrospective study analyzed data on 12 978 patients (1361
with two operations) who underwent orthopaedic surgery at a single
institution between 2001 and 2017. Patients with a minimum of either
two postoperative measurements of blood glucose levels per day,
or more than three measurements overall, were included in the study.
Glycaemic variability was assessed using a coefficient of variation
(CV). The length of stay (LOS), in-hospital complications, and 90-day
readmission and mortality rates were examined. Data were analyzed
with linear and generalized linear mixed models for linear and binary
outcomes, adjusting for various covariates.Aims
Patients and Methods
This study compared the clinical outcomes following
mini-open rotator cuff repair (MORCR) between early mobilisation
and usual care, involving initial immobilisation. In total, 189
patients with radiologically-confirmed full-thickness rotator cuff
tears underwent MORCR and were randomised to either early mobilisation
(n = 97) or standard rehabilitation (n = 92) groups. Patients were
assessed at six weeks and three, six, 12 and 24 months post-operatively.
Six-week range of movement comparisons demonstrated significantly
increased abduction (p = 0.002) and scapular plane elevation (p
= 0.006) in the early mobilisation group, an effect which was not
detectable at three months (p >
0.51) or afterwards. At 24 months
post-operatively, patients who performed pain-free, early active mobilisation
for activities of daily living showed no difference in clinical
outcomes from patients immobilised for six weeks following MORCR.
We suggest that the choice of rehabilitation regime following MORCR
may be left to the discretion of the patient and the treating surgeon. Cite this article:
Patients with multiple myeloma (MM) develop deposits in the spine
which may lead to vertebral compression fractures (VCFs). Our aim
was to establish which spinopelvic parameters are associated with
the greatest disability in patients with spinal myeloma and VCFs. We performed a retrospective cross-sectional review of 148 consecutive
patients (87 male, 61 female) with spinal myeloma and analysed correlations
between spinopelvic parameters and patient-reported outcome scores.
The mean age of the patients was 65.5 years (37 to 91) and the mean
number of vertebrae involved was 3.7 (1 to 15).Aims
Patients and Methods
There is a high rate of mortality in elderly
patients who sustain a fracture of the hip. We aimed to determine
the rate of preventable mortality and errors during the management
of these patients. A 12 month prospective study was performed on
patients aged >
65 years who had sustained a fracture of the hip.
This was conducted at a Level 1 Trauma Centre with no orthogeriatric
service. A multidisciplinary review of the medical records by four
specialists was performed to analyse errors of management and elements
of preventable mortality. During 2011, there were 437 patients aged
>
65 years admitted with a fracture of the hip (85 years (66 to
99)) and 20 died while in hospital (86.3 years (67 to 96)). A total
of 152 errors were identified in the 80 individual reviews of the
20 deaths. A total of 99 errors (65%) were thought to have at least
a moderate effect on death; 45 reviews considering death (57%) were thought
to have potentially been preventable. Agreement between the panel
of reviewers on the preventability of death was fair. A larger-scale
assessment of preventable mortality in elderly patients who sustain
a fracture of the hip is required. Multidisciplinary review panels
could be considered as part of the quality assurance process in
the management of these patients. Cite this article
We evaluated the top 13 journals in trauma and
orthopaedics by impact factor and looked at the longer-term effect regarding
citations of their papers. All 4951 papers published in these journals during 2007 and 2008
were reviewed and categorised by their type, subspecialty and super-specialty.
All citations indexed through Google Scholar were reviewed to establish
the rate of citation per paper at two, four and five years post-publication.
The top five journals published a total of 1986 papers. Only three
(0.15%) were on operative orthopaedic surgery and none were on trauma.
Most (n = 1084, 54.5%) were about experimental basic science. Surgical
papers had a lower rate of citation (2.18) at two years than basic science
or clinical medical papers (4.68). However, by four years the rates
were similar (26.57 for surgery, 30.35 for basic science/medical),
which suggests that there is a considerable time lag before clinical
surgical research has an impact. We conclude that high impact journals do not address clinical
research in surgery and when they do, there is a delay before such
papers are cited. We suggest that a rate of citation at five years
post-publication might be a more appropriate indicator of importance
for papers in our specialty. Cite this article:
We investigated the role of ion release in the assessment of fixation of the implant after total knee replacement and hypothesised that ion monitoring could be a useful parameter in the diagnosis of prosthetic loosening. We enrolled 59 patients with unilateral procedures and measured their serum aluminium, titanium, chromium and cobalt ion levels, blinded to the clinical and radiological outcome which was considered to be the reference standard. The cut-off levels for detection of the ions were obtained by measuring the levels in 41 healthy blood donors who had no implants. Based on the clinical and radiological evaluation the patients were divided into two groups with either stable (n = 24) or loosened (n = 35) implants. A significant increase in the mean level of Cr ions was seen in the group with failed implants (p = 0.001). The diagnostic accuracy was 71% providing strong evidence of failure when the level of Cr ions exceeded the cut-off value. The possibility of distinguishing loosening from other causes of failure was demonstrated by the higher diagnostic accuracy of 83%, when considering only patients with failure attributable to loosening. Measurement of the serum level of Cr ions may be of value for detecting failure due to loosening when the diagnosis is in doubt. The other metal ions studies did not have any diagnostic value.
Prophylactic antibiotics can decrease the risk
of wound infection and have been routinely employed in orthopaedic surgery
for decades. Despite their widespread use, questions still surround
the selection of antibiotics for prophylaxis, timing and duration
of administration. The health economic costs associated with wound
infections are significant, and the judicious but appropriate use
of antibiotics can reduce this risk. This review examines the evidence behind commonly debated topics
in antibiotic prophylaxis and highlights the uses and advantages
of some commonly used antibiotics. Cite this article:
Periprosthetic fracture (PF) after primary total hip arthroplasty
(THA) is an uncommon but potentially devastating complication. This
study aims to investigate the influence of cemented stem designs
on the risk of needing a revision for a PF. We analysed data on 257 202 primary THAs with cemented stems
and 390 linked first revisions for PF recorded in the National Joint
Registry (NJR) of England, Wales and Northern Ireland to determine
if a cemented femoral stem brand was associated with the risk of
having revision for a PF after primary THA. All cemented femoral
stem brands with more than 10 000 primary operations recorded in
the NJR were identified. The four most commonly used cemented femoral
stems were the Exeter V40 (n = 146 409), CPT (n = 24 300), C-Stem
(n = 15 113) and Charnley (n = 20 182). We compared the revision risk ratios due to PF amongst the stems
using a Poisson regression model adjusting for patient factors.
Compared with the Exeter V40, the age, gender and ASA grade adjusted
revision rate ratio was 3.89 for the cemented CPT stem (95% confidence
interval (CI) 3.07 to 4.93), 0.89 for the C-Stem (95% CI 0.57 to
1.41) and 0.41 for the Charnley stem (95% CI 0.24 to 0.70).Aims
Patients and Methods
The aim of this study was to present data on 11 459 patients
who underwent total hip (THA), total knee (TKA) or unicompartmental
knee arthroplasty (UKA) between November 2002 and April 2014 with
aspirin as the primary agent for pharmacological thromboprophylaxis. We analysed the incidence of deep vein thrombosis (DVT) and pulmonary
embolism (PE) then compared the 90-day all-cause mortality with
the corresponding data in the National Joint Registry for England
and Wales (NJR). Aims
Patients and Methods
Concerns have been raised that deformation of
acetabular shells may disrupt the assembly process of modular prostheses.
In this study we aimed to examine the effect that the strength of
bone has on the amount of deformation of the acetabular shell. The
hypothesis was that stronger bone would result in greater deformation.
A total of 17 acetabular shells were inserted into the acetabula
of eight cadavers, and deformation was measured using an optical
measuring system. Cores of bone from the femoral head were taken
from each cadaver and compressed using a materials testing machine.
The highest peak modulus and yield stress for each cadaver were used
to represent the strength of the bone and compared with the values
for the deformation and the surgeon’s subjective assessment of the
hardness of the bone. The mean deformation of the shell was 129
µm (3 to 340). No correlation was found between deformation and
either the maximum peak modulus (r² = 0.011, t = 0.426, p = 0.676) or
the yield stress (r² = 0.024, t = 0.614, p = 0.549) of the bone.
Although no correlation was found between the strength of the bone
and deformation, the values for the deformation observed could be
sufficient to disrupt the assembly process of modular acetabular
components. Cite this article:
A small proportion of patients have persistent
pain after total knee replacement (TKR). The primary aim of this study
was to record the prevalence of pain after TKR at specific intervals
post-operatively and to ascertain the impact of neuropathic pain.
The secondary aim was to establish any predictive factors that could
be used to identify patients who were likely to have high levels
of pain or neuropathic pain after TKR. A total of 96 patients were included in the study. Their mean
age was 71 years (48 to 89); 54 (56%) were female. The mean follow-up
was 46 months (39 to 51). Pre-operative demographic details were
recorded including a Visual Analogue Score (VAS) for pain, the Hospital
Anxiety and Depression score as well as the painDETECT score for neuropathic
pain. Functional outcome was assessed using the Oxford Knee score. The mean pre-operative VAS was 5.8 (1 to 10); and it improved
significantly at all time periods post-operatively (p <
0.001):
(from 4.5 at day three to five (1 to 10), 3.2 at six weeks (0 to
9), 2.4 at three months (0 to 7), 2.0 at six months (0 to 9), 1.7
at nine months (0 to 9), 1.5 at one year (0 to 8) and 2.0 at mean
46 months (0 to 10)). There was a high correlation (r >
0.7; p <
0.001) between the mean VAS scores for pain and the mean painDETECT
scores at three months, one year and three years post-operatively.
There was no correlation between the pre-operative scores and any
post-operative scores at any time point. We report the prevalence of pain and neuropathic pain at various
intervals up to three years after TKR. Neuropathic pain is an underestimated
problem in patients with pain after TKR. It peaks at between six
weeks and three-months post-operatively. However, from these data
we were unable to predict which patients are most likely to be affected. Cite this article:
We aimed to determine whether cemented hemiarthroplasty
is associated with a higher post-operative mortality and rate of
re-operation when compared with uncemented hemiarthroplasty. Data
on 19 669 patients, who were treated with a hemiarthroplasty following
a fracture of the hip in a nine-year period from 2002 to 2011, were extracted
from NHS Scotland’s acute admission database (Scottish Morbidity
Record, SMR01). We investigated the rate of mortality at day 0,
1, 7, 30, 120 and one-year post-operatively using 12 case-mix variables
to determine the independent effect of the method of fixation. At
day 0, those with a cemented hemiarthroplasty had a higher rate
of mortality (p <
0.001) compared with those with an uncemented
hemiarthroplasty, equivalent to one extra death per 424 procedures.
By day one this had become one extra death per 338 procedures. Increasing
age and the five-year co-morbidity score were noted as independent
risk factors. By day seven, the cumulative rate of mortality was
less for cemented hemiarthroplasty though this did not reach significance
until day 120. The rate of re-operation was significantly higher
for uncemented hemiarthroplasty. Despite adjusting for 12 confounding
variables, these only accounted for 15% of the observed variability. The debate about the choice of the method of fixation for a hemiarthroplasty
with respect to the rate of mortality or the risk of re-operation
may be largely superfluous. Our results suggest that uncemented
hemiarthroplasties may have a role to play in elderly patients with
significant co-morbid disease. Cite this article:
Version of the femoral stem is an important factor
influencing the risk of dislocation after total hip replacement (THR)
as well as the position of the acetabular component. However, there
is no radiological method of measuring stem anteversion described
in the literature. We propose a radiological method to measure stem
version and have assessed its reliability and validity. In 36 patients
who underwent THR, a hip radiograph and CT scan were taken to measure
stem anteversion. The radiograph was a modified Budin view. This
is taken as a posteroanterior radiograph in the sitting position
with 90° hip flexion and 90° knee flexion and 30° hip abduction.
The angle between the stem-neck axis and the posterior intercondylar
line was measured by three independent examiners. The intra- and
interobserver reliabilities of each measurement were examined. The
radiological measurements were compared with the CT measurements
to evaluate their validity. The mean radiological measurement was
13.36° ( Cite this article:
The medial approach for the treatment of children
with developmental dysplasia of the hip (DDH) in whom closed reduction
has failed requires minimal access with negligible blood loss. In
the United Kingdom, there is a preference for these children to
be treated using an anterolateral approach after the appearance
of the ossific nucleus. In this study we compared these two protocols,
primarily for the risk of osteonecrosis. Data were gathered prospectively for protocols involving the
medial approach (26 hips in 22 children) and the anterolateral approach
(22 hips in 21 children) in children aged <
24 months at the
time of surgery. Osteonecrosis of the femoral head was assessed
with validated scores. The acetabular index (AI) and centre–edge
angle (CEA) were also measured. The mean age of the children at the time of surgery was 11 months
(3 to 24) for the medial approach group and 18 months (12 to 24)
for the anterolateral group, and the combined mean follow-up was
70 months (26 to 228). Osteonecrosis of the femoral head was evident
or asphericity predicted in three of 26 hips (12%) in the medial approach
group and four of 22 (18%) in the anterolateral group (p = 0.52).
The mean improvement in AI was 8.8° (4° to 12°) and 7.9° (6° to
10°), respectively, at two years post-operatively (p = 0.18). There
was no significant difference in CEA values of affected hips between
the two groups. Children treated using an early medial approach did not have
a higher risk of developing osteonecrosis at early to mid-term follow-up
than those treated using a delayed anterolateral approach. The rates
of acetabular remodelling were similar for both protocols. Cite this article:
A retrospective study was conducted to investigate
the changes in metal ion levels in a consecutive series of Birmingham
Hip Resurfacings (BHRs) at a minimum ten-year follow-up. We reviewed
250 BHRs implanted in 232 patients between 1998 and 2001. Implant
survival, clinical outcome (Harris hip score), radiographs and serum chromium
(Cr) and cobalt (Co) ion levels were assessed. Of 232 patients, 18 were dead (five bilateral BHRs), 15 lost
to follow-up and ten had been revised. The remaining 202 BHRs in
190 patients (136 men and 54 women; mean age at surgery 50.5 years
(17 to 76)) were evaluated at a minimum follow-up of ten years (mean
10.8 years (10 to 13.6)). The overall implant survival at 13.2 years
was 92.4% (95% confidence interval 90.8 to 94.0). The mean Harris
hip score was 97.7 (median 100; 65 to 100). Median and mean ion
levels were low for unilateral resurfacings (Cr: median 1.3 µg/l,
mean
1.95 µg/l (<
0.5 to 16.2); Co: median 1.0 µg/l, mean 1.62 µg/l
(<
0.5 to 17.3)) and bilateral resurfacings (Cr: median 3.2 µg/l,
mean 3.46 µg/l (<
0.5 to 10.0); Co: median 2.3 µg/l, mean 2.66
µg/l (<
0.5 to 9.5)). In 80 unilateral BHRs with sequential ion
measurements, Cr and Co levels were found to decrease significantly
(p <
0.001) from the initial assessment at a median of six years
(4 to 8) to the last assessment at a median of 11 years (9 to 13),
with a mean reduction of 1.24 µg/l for Cr and 0.88 µg/l for Co.
Three female patients had a >
2.5 µg/l increase of Co ions, associated with
head sizes ≤ 50 mm, clinical symptoms and osteolysis. Overall, there
was no significant difference in change of ion levels between genders
(Cr, p = 0.845; Co, p = 0.310) or component sizes (Cr, p = 0.505;
Co, p = 0.370). Higher acetabular component inclination angles correlated
with greater change in ion levels (Cr, p = 0.013; Co, p = 0.002).
Patients with increased ion levels had lower Harris hip scores (p
= 0.038). In conclusion, in well-functioning BHRs the metal ion levels
decreased significantly at ten years. An increase >
2.5 µg/l was
associated with poor function. Cite this article:
Despite excellent results, the use of cemented
total hip replacement (THR) is declining. This retrospective cohort study
records survival time to revision following primary cemented THR
using the most common combination of components that accounted for
almost a quarter of all cemented THRs, exploring risk factors independently associated
with failure. All patients with osteoarthritis who had an Exeter
V40/Contemporary THR (Stryker) implanted before 31 December 2010
and recorded in the National Joint Registry for England and Wales
were included in the analysis. Cox’s proportional hazard models
were used to analyse the extent to which risk of revision was related
to patient, surgeon and implant covariates, with a significance
threshold of p <
0.01. A total of 34 721 THRs were included in
the study. The overall seven-year rate of revision for any reason
was 1.70% (99% confidence interval (CI) 1.28 to 2.12). In the final
adjusted model the risk of revision was significantly higher in
THRs with the Contemporary hooded component (hazard ratio (HR) 1.88,
p <
0.001) than with the flanged version, and in smaller head
sizes (<
28 mm) compared with 28 mm diameter heads (HR 1.50,
p = 0.005). The seven-year revision rate was 1.16% (99% CI 0.69
to 1.63) with a 28 mm diameter head and flanged component. The overall
risk of revision was independent of age, gender, American Society
of Anesthesiologists grade, body mass index, surgeon volume, surgical
approach, brand of cement/presence of antibiotic, femoral head material
(stainless steel/alumina) and stem taper size/offset. However, the
risk of revision for dislocation was significantly higher with a
‘plus’ offset head (HR 2.05, p = 0.003) and a hooded acetabular component
(HR 2.34, p <
0.001). In summary, we found that there were significant differences
in failure between different designs of acetabular component and
sizes of femoral head after adjustment for a range of covariates.
The popularity of cementless total hip replacement
(THR) has surpassed cemented THR in England and Wales. This retrospective
cohort study records survival time to revision following primary
cementless THR with the most common combination (accounting for
almost a third of all cementless THRs), and explores risk factors independently
associated with failure, using data from the National Joint Registry
for England and Wales. Patients with osteoarthritis who had a DePuy
Corail/Pinnacle THR implanted between the establishment of the registry
in 2003 and 31 December 2010 were included within analyses. There
were 35 386 procedures. Cox proportional hazard models were used
to analyse the extent to which the risk of revision was related
to patient, surgeon and implant covariates. The overall rate of
revision at five years was 2.4% (99% confidence interval 2.02 to
2.79). In the final adjusted model, we found that the risk of revision
was significantly higher in patients receiving metal-on-metal (MoM:
hazard ratio (HR) 1.93, p <
0.001) and ceramic-on-ceramic bearings
(CoC: HR 1.55, p = 0.003) compared with the best performing bearing
(metal-on-polyethylene). The risk of revision was also greater for
smaller femoral stems (sizes 8 to 10: HR 1.82, p <
0.001) compared
with mid-range sizes. In a secondary analysis of only patients where body
mass index (BMI) data were available (n = 17 166), BMI ≥ 30 kg/m2 significantly
increased the risk of revision (HR 1.55, p = 0.002). The influence
of the bearing on the risk of revision remained significant (MoM:
HR 2.19, p <
0.001; CoC: HR 2.09,
p = 0.001). The risk of revision was independent of age, gender,
head size and offset, shell, liner and stem type, and surgeon characteristics. We found significant differences in failure between bearing surfaces
and femoral stem size after adjustment for a range of covariates
in a large cohort of single-brand cementless THRs. In this study
of procedures performed since 2003, hard bearings had significantly
higher rates of revision, but we found no evidence that head size
had an effect. Patient characteristics, such as BMI and American
Society of Anesthesiologists grade, also influence the survival
of cementless components. Cite this article:
