Patellofemoral arthroplasty (PFA) has experienced significant
improvements in implant survivorship with second generation designs.
This has renewed interest in PFA as an alternative to total knee
arthroplasty (TKA) for younger active patients with isolated patellofemoral
osteoarthritis (PF OA). We analysed the cost-effectiveness of PFA We used a Markov transition state model to compare cost-effectiveness
between PFA and TKA. Simulated patients were aged 60 (base case)
and 50 years. Lifetime costs (2015 United States dollars), quality-adjusted
life year (QALY) gains and incremental cost-effectiveness ratio
(ICER) were calculated from a healthcare payer perspective. Annual rates
of revision were derived from the National Joint Registry for England,
Wales, Northern Ireland and the Isle of Man. Deterministic and probabilistic
sensitivity analysis was performed for all parameters against a
$50 000/QALY willingness to pay. Aims
Patients and Methods
The best time for definitive orthopaedic care is often unclear
in patients with multiple injuries. The objective of this study
was make a prospective assessment of the safety of our early appropriate
care (EAC) strategy and to evaluate the potential benefit of additional
laboratory data to determine readiness for surgery. A cohort of 335 patients with fractures of the pelvis, acetabulum,
femur, or spine were included. Patients underwent definitive fixation
within 36 hours if one of the following three parameters were met:
lactate <
4.0 mmol/L; pH ≥ 7.25; or base excess (BE) ≥ -5.5 mmol/L.
If all three parameters were met, resuscitation was designated full
protocol resuscitation (FPR). If less than all three parameters
were met, it was designated an incomplete protocol resuscitation
(IPR). Complications were assessed by an independent adjudication
committee and included infection; sepsis; PE/DVT; organ failure;
pneumonia, and acute respiratory distress syndrome (ARDS). Aims
Patients and Methods
Compartment syndrome results from increased intra-compartmental
pressure (ICP) causing local tissue ischaemia and cell death, but
the systemic effects are not well described. We hypothesised that
compartment syndrome would have a profound effect not only on the affected
limb, but also on remote organs. Using a rat model of compartment syndrome, its systemic effects
on the viability of hepatocytes and on inflammation and circulation
were directly visualised using intravital video microscopy.Aims
Methods
A fracture of the hip is the most common serious orthopaedic
injury, and surgical site infection (SSI) is one of the most significant
complications, resulting in increased mortality, prolonged hospital
stay and often the need for further surgery. Our aim was to determine
whether high dose dual antibiotic impregnated bone cement decreases the
rate of infection. A quasi-randomised study of 848 patients with an intracapsular
fracture of the hip was conducted in one large teaching hospital
on two sites. All were treated with a hemiarthroplasty. A total
of 448 patients received low dose single-antibiotic impregnated
cement (control group) and 400 patients received high dose dual-antibiotic impregnated
cement (intervention group). The primary outcome measure was deep
SSI at one year after surgery.Aims
Patients and Methods
Depression can significantly affect quality of life and is associated
with higher rates of medical comorbidities and increased mortality
following surgery. Although depression has been linked to poorer
outcomes following orthopaedic trauma, total joint arthroplasty
and spinal surgery, we wished to examine the impact of depression
in elective total shoulder arthroplasty (TSA) as this has not been
previously explored. The United States Nationwide Inpatient Sample (NIS) was used
to identify patients undergoing elective TSA over a ten-year period.
Between 2002 and 2012, 224 060 patients underwent elective TSA.Aims
Patients and Methods
Despite the increasing prevalence of sleep apnoea,
little information is available regarding its impact on the peri-operative
outcome of patients undergoing posterior lumbar fusion. Using a
national database, patients who underwent lumbar fusion between
2006 and 2010 were identified, sub-grouped by diagnosis of sleep
apnoea and compared. The impact of sleep apnoea on various outcome
measures was assessed by regression analysis. The records of 84
655 patients undergoing posterior lumbar fusion were identified
and 7.28% (n = 6163) also had a diagnostic code for sleep apnoea.
Compared with patients without sleep apnoea, these patients were
older, more frequently female, had a higher comorbidity burden and
higher rates of peri-operative complications, post-operative mechanical
ventilation, blood product transfusion and intensive care. Patients
with sleep apnoea also had longer and more costly periods of hospitalisation. In the regression analysis, sleep apnoea emerged as an independent
risk factor for the development of peri-operative complications
(odds ratio (OR) 1.50, confidence interval (CI) 1.38;1.62), blood
product transfusions (OR 1.12, CI 1.03;1.23), mechanical ventilation
(OR 6.97, CI 5.90;8.23), critical care services (OR 1.86, CI 1.71;2.03), prolonged
hospitalisation and increased cost (OR 1.28, CI 1.19;1.37; OR 1.10,
CI 1.03;1.18). Patients with sleep apnoea who undergo posterior lumbar fusion
pose significant challenges to clinicians. Cite this article:
Autologous retransfusion and no-drainage are
both blood-saving measures in total hip replacement (THR). A new combined
intra- and post-operative autotransfusion filter system has been
developed especially for primary THR, and we conducted a randomised
controlled blinded study comparing this with no-drainage. A total of 204 THR patients were randomised to autologous blood
transfusion (ABT)
(n = 102) or no-drainage (n = 102). In the ABT group, a mean of
488 ml ( The use of a new intra- and post-operative autologous blood transfusion
filter system results in less total blood loss and a smaller maximum
decrease in haemoglobin levels than no-drainage following primary
THR. Cite this article:
The aim of this randomised controlled study was
to compare functional and radiological outcomes between modern cemented
and uncemented hydroxyapatite coated stems after one year in patients
treated surgically for a fracture of the femoral neck. A total of
141 patients aged >
65 years were included. Patients were randomised
to be treated with a cemented Exeter stem or an uncemented Bimetric
stem. The patients were reviewed at four and 12 months. The cemented group performed better than the uncemented group
for the Harris hip score (78 In conclusion, our data do not support the use of an uncemented
hydroxyapatite coated stem for the treatment of displaced fractures
of the femoral neck in the elderly. Cite this article:
The June 2015 Trauma Roundup360 looks at: HIV-related implant surgery in trauma; Major transfusion under the spotlight; Surgery and mortality in elderly acetabular fractures; Traction pin safety; Obesity and trauma; Salvage of acetabular fixation in the longer term
Systemic capillary leak syndrome, or the Clarkson syndrome, is an extremely rare condition in which increased capillary permeability results in a massive shift of fluid into the extravascular space. This is followed rapidly by hypotensive shock, haemoconcentration, and, potentially, substantial oedema of the limbs resulting in an acute compartment syndrome. It is important for orthopaedic surgeons to be aware of this syndrome as our medical colleagues, who initially care for these patients, are less familiar with the diagnosis and the need for emergency management of the associated compartment syndrome should it develop. There have been fewer than 100 cases of this entity reported. This case report is the first to describe the subsequent development of a compartment syndrome in all four limbs. Clinical vigilance and continuous monitoring of intracompartmental pressure is necessary in these patients in order to help reduce limb-threatening complications.
Little information is available about several
important aspects of the treatment of melioidosis osteomyelitis
and septic arthritis. We undertook a retrospective review of 50 patients with these
conditions in an attempt to determine the effect of location of
the disease, type of surgical intervention and duration of antibiotic
treatment on outcome, particularly complications and relapse. We found that there was a 27.5% risk of osteomyelitis of the
adjacent bone in patients with septic arthritis in the lower limb.
Patients with septic arthritis and osteomyelitis of an adjacent
bone were in hospital significantly longer (p = 0.001), needed more
operations (p = 0.031) and had a significantly higher rate of complications
and re-presentation (p = 0.048). More than half the patients (61%), most particularly those with
multifocal bone and joint involvement, and those with septic arthritis
and osteomyelitis of an adjacent bone who were treated operatively,
needed more visits to theatre. Cite this article:
The aim of this study was to compare the operating
time, length of stay (LOS), adverse events and rate of re-admission
for elderly patients with a fracture of the hip treated using either
general or spinal anaesthesia. Patients aged ≥ 70 years who underwent
surgery for a fracture of the hip between 2010 and 2012 were identified
from the American College of Surgeons National Surgical Quality
Improvement Program (ACS-NSQIP) database. Of the 9842 patients who
met the inclusion criteria, 7253 (73.7%) were treated with general
anaesthesia and 2589 (26.3%) with spinal anaesthesia. On propensity-adjusted
multivariate analysis, general anaesthesia was associated with slightly increased
operating time (+5 minutes, 95% confidence interval (CI) +4 to +6,
p <
0.001) and post-operative time in the operating room (+5
minutes, 95% CI +2 to +8, p <
0.001) compared with spinal anaesthesia.
General anaesthesia was associated with a shorter LOS (hazard ratio
(HR) 1.28, 95% CI 1.22 to 1.34, p <
0.001). Any adverse event
(odds ratio (OR) 1.21, 95% CI 1.10 to 1.32, p <
0.001), thromboembolic
events (OR 1.90, 95% CI 1.24 to 2.89, p = 0.003), any minor adverse
event (OR 1.19, 95% CI 1.09 to 1.32, p <
0.001), and blood transfusion
(OR 1.34, 95% CI 1.22 to 1.49, p <
0.001) were associated with
general anaesthesia. General anaesthesia was associated with decreased
rates of urinary tract infection (OR 0.73, 95% CI 0.62 to 0.87,
p <
0.001). There was no clear overall advantage of one type
of anaesthesia over the other, and surgeons should be aware of the
specific risks and benefits associated with each type. Cite this article:
We present the results of 13 patients who suffered severe injuries to the lower leg. Five sustained a traumatic amputation and eight a Gustilo-Anderson type IIIC open fracture. All were treated with debridement, acute shortening and stabilisation of the fracture and vascular reconstruction. Further treatment involved restoration of tibial length by callus distraction through the distal or proximal metaphysis, which was commenced soon after the soft tissues had healed (n = 8) or delayed until union of the fracture (n = 5). All patients were male with a mean age of 28.4 years (17 to 44), and had sustained injury to the leg only. Chen grade II functional status was achieved in all patients. Although the number of patients treated with each strategy was limited, there was no obvious disadvantage in the early lengthening programme, which was completed more quickly.
Several studies have reported the rate of post-operative
mortality after the surgical treatment of a fracture of the hip,
but few data are available regarding the delayed morbidity. In this
prospective study, we identified 568 patients who underwent surgery
for a fracture of the hip and who were followed for one year. Multivariate
analysis was carried out to identify possible predictors of mortality
and morbidity. The 30-day, four-month and one-year rates of mortality
were 4.3%, 11.4%, and 18.8%, respectively. General complications
and pre-operative comorbidities represented the basic predictors
of mortality at any time interval (p <
0.01). In-hospital, four-month
and one-year general complications occurred in 29.4%, 18.6% and
6.7% of patients, respectively. After adjusting for confounding variables,
comorbidities and poor cognitive status determined the likelihood
of early and delayed general complications, respectively (p <
0.001). Operative delay was the main predictor of the length of
hospital stay (p <
0.001) and was directly related to in-hospital
(p = 0.017) and four-month complications (p = 0.008). Cite this article:
This review of the literature presents the current understanding of Scheuermann’s kyphosis and investigates the controversies concerning conservative and surgical treatment. There is considerable debate regarding the pathogenesis, natural history and treatment of this condition. A benign prognosis with settling of symptoms and stabilisation of the deformity at skeletal maturity is expected in most patients. Observation and programmes of exercise are appropriate for mild, flexible, non-progressive deformities. Bracing is indicated for a moderate deformity which spans several levels and retains flexibility in motivated patients who have significant remaining spinal growth. The loss of some correction after the completion of bracing with recurrent anterior vertebral wedging has been reported in approximately one-third of patients. Surgical correction with instrumented spinal fusion is indicated for a severe kyphosis which carries a risk of progression beyond the end of growth causing cosmetic deformity, back pain and neurological complications. There is no consensus on the effectiveness of different techniques and types of instrumentation. Techniques include posterior-only and combined anteroposterior spinal fusion with or without posterior osteotomies across the apex of the deformity. Current instrumented techniques include hybrid and all-pedicle screw constructs.
We hypothesised there was no clinical value in
using an autologous blood transfusion (ABT) drain in either primary total
hip (THR) or total knee replacement (TKR) in terms of limiting allogeneic
blood transfusions when a modern restrictive blood management regime
was followed. A total of 575 patients (65.2% men), with a mean age
of 68.9 years (36 to 94) were randomised in this three-arm study
to no drainage (group A), or to wound drainage with an ABT drain
for either six hours (group B) or 24 hours (group C). The primary
outcome was the number of patients receiving allogeneic blood transfusion.
Secondary outcomes were post-operative haemoglobin (Hb) levels,
length of hospital stay and adverse events. This study identified only 41 transfused patients, with no significant
difference in distribution between the three groups (p = 0.857).
The mean pre-operative haemoglobin (Hb) value in the transfused
group was 12.8 g/dL (9.8 to 15.5) Cite this article:
The December 2013 Hip &
Pelvis Roundup360 looks at: Enhanced recovery works; Acetabular placement; Exercise better than rest in osteoarthritis patients; if Birmingham hip resurfacing is immune from pseudotumour; HIV and arthroplasty; Labral tears revisited; Prophylactic surgery for FAI; and Ceramics and impaction grafting
We retrospectively reviewed 30 two-stage revision
procedures in 28 patients performed for fungal peri-prosthetic joint
infection (PJI) after a primary total knee replacement. Patients were
followed for at least two years or until the infection recurred.
The mean follow-up for patients who remained free of infection was
4.3 years (2.3 to 6.1). Overall, 17 patients were assessed as American
Society of Anesthesiologists grade 3 or 4. The surgical protocol included
removal of the infected implant, vigorous debridement and insertion
of an articulating cement spacer. This was followed by at least
six weeks of antimicrobial treatment and delayed reimplantation
in all patients. The mean interval between removal of the prosthesis
and reimplantation was 9.5 weeks (6 to 24). After reimplantation,
patients took antifungal agents orally for a maximum of six months. Fungal PJIs can be treated successfully by removal of all infected
material, appropriate antimicrobial treatment and delayed reimplantation.