The aim of this study was to understand the experience of mature patients who undergo a periacetabular osteotomy (PAO), a major hip-preserving surgical procedure that treats symptomatic hip dysplasia by realigning the acetabulum. Our aim was to improve our understanding of how the operation affected the lives of patients and their families, with a long-term goal of improving their experience. We used a phenomenological approach with in-depth, semi-structured interviews to investigate the experience of seven female patients, aged between 25 and 40 years, who underwent a PAO. A modified homogeneity sampling approach coupled with criterion sampling was used. Inclusion criteria involved having at least one child at home and being in a committed relationship with a spouse or partner.Aims
Methods
Current treatments of prosthetic joint infection (PJI) are minimally effective against The ability of PlySs2 and vancomycin to kill biofilm and colony-forming units (CFUs) on orthopaedic implants were compared using in vitro models. An in vivo murine PJI model of DAIR was used to assess the efficacy of a combination of PlySs2 and vancomycin on periprosthetic bacterial load.Aims
Methods
Of growing concern in arthroplasty is the emergence of atypical infections, particularly For this non-randomized non-blinded study, 101 adult patients scheduled for hip or knee surgery were recruited. For each, four 3 mm dermal punch biopsies were collected after administration of anaesthesia, but prior to antibiotics. Prebiopsy skin preparation consisted of a standardized preoperative 2% chlorhexidine skin cleansing protocol and an additional 70% isopropyl alcohol mechanical skin scrub immediately prior to biopsy collection. Two skin samples 10 cm apart were collected from a location approximating a standard direct anterior skin incision, and two samples 10 cm apart were collected from a lateral skin incision (suitable for posterior, direct-lateral, or anterolateral approaches). Samples were cultured for two weeks using a protocol optimized for 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 practice of overlapping surgery has been increasing in the delivery of orthopaedic surgery, aiming to provide efficient, high-quality care. However, there are concerns about the safety of this practice. The purpose of this study was to examine the safety and efficacy of a model of partially overlapping surgery that we termed ‘swing room’ in the practice of primary total hip (THA) and knee arthroplasty (TKA). A retrospective review of prospectively collected data was carried out on patients who underwent primary THA and TKA between 2006 and 2017 in two academic centres. Cases were stratified as partially overlapping (swing room), in which the surgeon is in one operating room (OR) while the next patient is being prepared in another, or nonoverlapping surgery. The demographic details of the patients which were collected included operating time, length of stay (LOS), postoperative complications within six weeks of the procedure, unplanned hospital readmissions, and unplanned reoperations. Fisher's exact, Wilcoxon rank-sum tests, chi-squared tests, and logistic regression analysis were used for statistical analysis.Aims
Methods
The purpose of this study was to evaluate the biological fixation of a 3D printed porous implant, with and without different hydroxyapatite (HA) coatings, in a canine model. A canine transcortical model was used to evaluate the characteristics of bone ingrowth of Ti6Al4V cylindrical implants fabricated using laser rapid manufacturing (LRM). At four and 12 weeks post-implantation, we performed histological analysis and mechanical push-out testing on three groups of implants: a HA-free control (LRM), LRM with precipitated HA (LRM-PA), and LRM with plasma-sprayed HA (LRM-PSHA).Aims
Materials and Methods
Adverse reaction to wear and corrosion debris
is a cause for concern in total hip arthroplasty (THA). Modular junctions
are a potential source of such wear products and are associated
with secondary pseudotumour formation. We present a consecutive series of 17 patients treated at our
unit for this complication following metal-on-highly cross-linked
polyethylene (MoP) THA. We emphasise the risk of misdiagnosis as
infection, and present the aggregate laboratory results and pathological
findings in this series. The clinical presentation was pain, swelling or instability.
Solid, cystic and mixed soft-tissue lesions were noted on imaging
and confirmed intra-operatively. Corrosion at the head–neck junction
was noted in all cases. No bacteria were isolated on multiple pre-
and intra-operative samples yet the mean erythrocyte sedimentation
rate was 49 (9 to 100) and C-reactive protein 32 (0.6 to 106) and
stromal polymorphonuclear cell counts were noted in nine cases. Adverse soft–tissue reactions can occur in MoP THA owing to corrosion
products released from the head–neck junction. The diagnosis should
be carefully considered when investigating pain after THA. This
may avoid the misdiagnosis of periprosthetic infection with an unidentified
organism and mitigate the unnecessary management of these cases
with complete single- or two-stage exchange. Cite this article:
Joint-preserving surgery of the hip (JPSH) has evolved considerably
and now includes a number of procedures, including arthroscopy,
surgical dislocation, and redirectional osteotomies of the femur
and acetabulum. There are a number of different factors which lead
to failure of JPSH. Consequently, it is of interest to assess the
various modes of failure in order to continue to identify best practice
and the indications for these procedures. Using a retrospective observational study design, we reviewed
1013 patients who had undergone JPSH by a single surgeon between
2005 and 2015. There were 509 men and 504 women with a mean age
of 39 years (16 to 78). Of the 1013 operations, 783 were arthroscopies,
122 surgical dislocations, and 108 peri-acetabular osteotomies (PAO).
We analysed the overall failure rates and modes of failure. Re-operations
were categorised into four groups: Mode 1 was arthritis progression
or organ failure leading to total hip arthroplasty (THA); Mode 2
was an Incorrect diagnosis/procedure; Mode 3 resulted from malcorrection
of femur (type A), acetabulum (type B), or labrum (type C) and Mode 4
resulted from an unintended consequence of the initial surgical
intervention.Aims
Patients and Methods
The peri-prosthetic tissue response to wear debris
is complex and influenced by various factors including the size, area
and number of particles. We hypothesised that the ‘biologically
active area’ of all metal wear particles may predict the type of
peri-prosthetic tissue response. Peri-prosthetic tissue was sampled from 21 patients undergoing
revision of a small diameter metal-on-metal (MoM) total hip arthroplasty
(THA) for aseptic loosening. An enzymatic protocol was used for
tissue digestion and scanning electron microscope was used to characterise
particles. Equivalent circle diameters and particle areas were calculated.
Histomorphometric analyses were performed on all tissue specimens.
Aspirates of synovial fluid were collected for analysis of the cytokine
profile analysis, and compared with a control group of patients
undergoing primary THA (n = 11) and revision of a failed ceramic-on-polyethylene
arthroplasty (n = 6). The overall distribution of the size and area of the particles
in both lymphocyte and
non-lymphocyte-dominated responses were similar; however, the subgroup
with lymphocyte-dominated peri-prosthetic tissue responses had a
significantly larger total number of particles. 14 cytokines (interleukin (IL)-1ß, IL-2, IL-4, IL-5, IL-6, IL-10,
IL-13, IL-17, interferon (IFN)-γ, and IFN-gamma-inducible protein
10), chemokines (macrophage inflammatory protein (MIP)-1α and MIP-1ß),
and growth factors (granulocyte macrophage colony stimulating factor
(GM-CSF) and platelet derived growth factor) were detected at significantly higher
levels in patients with metal wear debris compared with the control
group. Significantly higher levels for IL-1ß, IL-5, IL-10 and GM-CSF
were found in the subgroup of tissues from failed MoM THAs with
a lymphocyte-dominated peri-prosthetic response compared with those
without this response. These results suggest that the ‘biologically active area’ predicts
the type of
peri-prosthetic tissue response. The cytokines IL-1ß, IL-5, IL-10,
and GM-CSF are associated with lymphocyte-dominated tissue responses
from failed small-diameter MoM THA. Cite this article:
Total hip replacement (THR) is a very common
procedure undertaken in up to 285 000 Americans each year. Patient
satisfaction with THR is very high, with improvements in general
health, quality of life, and function while at the same time very
cost effective. Although the majority of patients have a high degree
of satisfaction with their THR, 27% experience some discomfort,
and up to 6% experience severe chronic pain. Although it can be
difficult to diagnose the cause of the pain in these patients, this
clinical issue should be approached systematically and thoroughly.
A detailed history and clinical examination can often provide the
correct diagnosis and guide the appropriate selection of investigations, which
will then serve to confirm the clinical diagnosis made. Cite this article:
Squeaking arising from a ceramic-on-ceramic (CoC)
total hip replacement (THR) may cause patient concern and in some
cases causes patients to seek revision surgery. We performed a meta-analysis
to determine the incidence of squeaking and the incidence of revision
surgery for squeaking. A total of 43 studies including 16 828 CoC
THR that reported squeaking, or revision for squeaking, were entered
into the analysis. The incidence of squeaking was 4.2% and the incidence
of revision for squeaking was 0.2%. The incidence of squeaking in
patients receiving the Accolade femoral stem was 8.3%, and the incidence
of revision for squeaking in these patients was 1.3%. 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.
This conversation represents an attempt by several
arthroplasty surgeons to critique several abstracts presented over
the last year as well as to use them as a jumping off point for trying
to figure out where they fit in into our current understanding of
multiple issues in modern hip and knee arthroplasty.
Two Durasul highly crosslinked polyethylene liners were exchanged during revision surgery four and five years after implantation, respectively. The retrieved liners were evaluated macroscopically and surface analysis was performed using optical and electron microscopy. A sample of each liner was used to determine the oxidation of the material by Fourier transform infrared spectroscopy. Samples of the capsule were examined histologically. The annual wear rate was found to be 0.010 and 0.015 mm/year, respectively. Surface analysis showed very little loss of material caused by wear. Histological evaluation revealed a continuous neosynovial lining with single multinucleated foreign-body giant cells. Our findings showed no unexpected patterns of wear on the articulating surfaces up to five years after implantation and no obvious failure of material.
In a randomised study, 28 patients with a mean age of 62.2 years (32 to 81) with osteoarthritis or avascular necrosis of the hip received either a ceramic-on-ceramic or a metal-on-metal total hip replacement. Apart from the liners the acetabular and femoral components were made of Ti-Al-Nb alloy. The serum aluminium and cobalt levels were measured before, and at one year after surgery. The 15 patients in the ceramic-on-ceramic group had a median pre-operative aluminium level of 1.3 μg/l (0.25 to 8.4) and a cobalt level below the detection limit. At one year the aluminium level was 1.1 μg/l (0.25 to 2.3) and the cobalt level was 0.4 μg/l (0.15 to 0.7). The 13 patients in the metal-on-metal group had a median pre-operative aluminium level of 1.9 μg/l (0.25 to 4.4) and a cobalt level below the detection limit. At one year the median aluminium level was 0.9 μg/l (0.25 to 3.9) whereas the cobalt level was 1.4 μg/l (0.5 to 10.5). This increase in the cobalt level at one year was significant (p <
0.001). Our findings indicate that ceramic-on-ceramic bearings do not cause elevated levels of serum aluminium in the first post-operative year.
A prospective, multi-centre study was carried out on 1421 total hip replacements between January 1999 and July 2007 to examine if obesity has an effect on clinical outcomes. The patients were categorised into three groups: non-obese (body mass index (BMI) <
30 kg/m2), obese (BMI 30 to 40 kg/m2) and morbidly obese (BMI >
40 kg/m2). The primary outcome measure was the change in Oxford hip score at five years. Secondary outcome measures included dislocation and revision rates, increased haemorrhage, deep infection, deep-vein thrombosis and pulmonary embolism, mean operating time and length of hospital stay. Radiological analysis assessing heterotopic ossification, femoral osteolysis and femoral stem positioning was performed. Data were incomplete for 362 hips (25.5%) There was no difference in the change in the Oxford hip score, complication rates or radiological changes at five years between the groups. The morbidly obese group was significantly younger and required a significantly longer operating time. Obese and morbidly obese patients have as much to gain from total hip replacement as non-obese patients.
Neurogenic myositis ossificans is a disabling condition affecting the large joints of patients with severe post-traumatic impairment of the central nervous system. It can result in ankylosis of the joint and vascular or neural compression. Surgery may be hazardous with potential haemorrhage, neurovascular injury, iatrogenic fracture and osteochondral injury. We undertook pre-operative volumetric CT assessment of 45 ankylosed hips with neurogenic myositis ossificans which required surgery. Helical CT with intravenous contrast, combined with two- and three-dimensional surface reconstructions, was the only pre-operative imaging procedure. This gave good differentiation of the heterotopic bone from the adjacent vessels. We established that early surgery, within 24 months of injury, was neither complicated by peri-operative fracture nor by the early recurrence of neurogenic myositis ossificans. Surgical delay was associated with a loss of joint space and a greater degree of bone demineralisation. Enhanced volumetric CT is an excellent method for the pre-operative assessment of neurogenic myositis ossificans and correlates well with the operative findings.
In this meta-analysis we included 32 English-language articles published between January 1975 and June 2004 on the diagnostic performance of plain radiography, subtraction arthrography, nuclear arthrography and bone scintigraphy in detecting aseptic loosening of the femoral component, using criteria based on the Cochrane systematic review of screening and diagnostic tests. The mean sensitivity and specificity were, respectively, 82% (95% confidence interval (CI) 76 to 87) and 81% (95% CI 73 to 87) for plain radiography and 85% (95% CI 75 to 91) and 83% (95% CI 75 to 89) for nuclear arthrography. Pooled sensitivity and specificity were, respectively, 86% (95% CI 74 to 93) and 85% (95% CI 77 to 91) for subtraction arthrography and 85% (95% CI 79 to 89) and 72% (95% CI 64 to 79) for bone scintigraphy. Although the diagnostic performance of the imaging techniques was not significantly different, plain radiography and bone scintigraphy are preferred for the assessment of a femoral component because of their efficacy and lower risk of patient morbidity.
We evaluated the concentrations of chromium and cobalt ions in blood after metal-on-metal surface replacement arthroplasty using a wrought-forged, high carbon content chromium-cobalt alloy implant in 64 patients. At one year, mean whole blood ion levels were 1.61 μg/L (0.4 to 5.5) for chromium and 0.67 μg/L (0.23 to 2.09) for cobalt. The pre-operative ion levels, component size, female gender and the inclination of the acetabular component were inversely proportional to the values of chromium and/or cobalt ions at one year postoperatively. Other factors, such as age and level of activity, did not correlate with the levels of metal ions. We found that the levels of the ions in the serum were 1.39 and 1.37 times higher for chromium and cobalt respectively than those in the whole blood. The levels of metal ions obtained may be specific to the hip resurfacing implant and reflect its manufacturing process.
