Only limited data are available regarding the infiltration of local anaesthetic for total hip arthroplasty (THA), and no studies were performed for THA using the anterior approach.

In this prospective, randomised placebo-controlled study we investigated the effect of both standard and reverse infiltration of local anaesthetic in combination with the anterior approach for THA. The primary endpoint was the mean numeric rating score for pain four hours post-operatively. In addition, we recorded the length of hospital stay, the operating time, the destination of the patient at discharge, the use of pain medication, the occurrence of side effects and pain scores at various times post-operatively.

Between November 2012 and January 2014, 75 patients were included in the study. They were randomised into three groups: standard infiltration of local anaesthetic, reversed infiltration of local anaesthetic, and placebo. There was no difference in mean numeric rating score for pain four hours post-operatively (p = 0.87). There were significantly more side effects at one and eight hours post-operatively in the placebo group (p = 0.02; p = 0.03), but this did not influence the mobilisation of the patients. There were no differences in all other outcomes between the groups.

We found no clinically relevant effect when the infiltration of local anaesthetic with ropivacaine and epinephrine was used in a multimodal pain protocol for THA using the anterior approach.

Cite this article: Bone Joint J 2015; 97-B:734–40.

The aim of this study was to compare the maximum laxity conferred by the cruciate-retaining (CR) and posterior-stabilised (PS) Triathlon single-radius total knee arthroplasty (TKA) for anterior drawer, varus–valgus opening and rotation in eight cadaver knees through a defined arc of flexion (0º to 110º). The null hypothesis was that the limits of laxity of CR- and PS-TKAs are not significantly different.

The investigation was undertaken in eight loaded cadaver knees undergoing subjective stress testing using a measurement rig. Firstly the native knee was tested prior to preparation for CR-TKA and subsequently for PS-TKA implantation. Surgical navigation was used to track maximal displacements/rotations at 0º, 30º, 60º, 90º and 110° of flexion. Mixed-effects modelling was used to define the behaviour of the TKAs.

The laxity measured for the CR- and PS-TKAs revealed no statistically significant differences over the studied flexion arc for the two versions of TKA. Compared with the native knee both TKAs exhibited slightly increased anterior drawer and decreased varus-valgus and internal-external roational laxities. We believe further study is required to define the clinical states for which the additional constraint offered by a PS-TKA implant may be beneficial.

Cite this article: Bone Joint J 2015; 97-B:642–8.

In this study we evaluated whether pre-operative Western Ontario and McMaster Universities (WOMAC) osteoarthritis scores can predict satisfaction following total hip arthroplasty (THA). Prospective data for a cohort of patients undergoing THA from two large academic centres were collected, and pre-operative and one-year post-operative WOMAC scores and a 25-point satisfaction questionnaire were obtained for 446 patients. Satisfaction scores were dichotomised into either improvement or deterioration. Scatter plots and Spearman’s rank correlation coefficient were used to describe the association between pre-operative WOMAC and one-year post-operative WOMAC scores and patient satisfaction. Satisfaction was compared using receiver operating characteristic (ROC) analysis against pre-operative, post-operative and δ WOMAC scores.

We found no relationship between pre-operative WOMAC scores and one-year post-operative WOMAC or satisfaction scores, with Spearman’s rank correlation coefficients of 0.16 and –0.05, respectively. The ROC analysis showed areas under the curve (AUC) of 0.54 (pre-operative WOMAC), 0.67 (post-operative WOMAC) and 0.43 (δ WOMAC), respectively, for an improvement in satisfaction.

We conclude that the pre-operative WOMAC score does not predict the post-operative WOMAC score or patient satisfaction after THA, and that WOMAC scores can therefore not be used to prioritise patient care.

Cite this article: Bone Joint J 2015;97-B:150–3.

We examined the risk of thrombotic and major bleeding events in patients undergoing total hip and knee replacement (THR and TKR) treated with thromboprophylaxis, using nationwide population-based databases. We identified 83 756 primary procedures performed between 1997 and 2011. The outcomes were symptomatic venous thromboembolism (VTE), myocardial infarction (MI), stroke, death and major bleeding requiring hospitalisation within 90 days of surgery.

A total of 1114 (1.3%) and 483 (0.6%) patients experienced VTE and bleeding, respectively. The annual risk of VTE varied between 0.9% and 1.6%, and of bleeding between 0.4% and 0.8%. The risk of VTE and bleeding was unchanged over a 15-year period. A total of 0.7% of patients died within 90 days, with a decrease from 1% in 1997 to 0.6% in 2011 (p < 0.001). A high level of comorbidity and general anaesthesia were strong risk factors for both VTE and bleeding, with no difference between THR and TKR patients. The risk of both MI and stroke was 0.5%, which remained unchanged during the study period.

In this cohort study of patients undergoing THR and TKR patients in routine clinical practice, approximately 3% experienced VTE, MI, stroke or bleeding. These risks did not decline during the 15-year study period, but the risk of dying fell substantially.

Cite this article: Bone Joint J 2014;96-B:479–85.

The February 2015 Hip & Pelvis Roundup³⁶⁰ looks at: Hip arthroplasty in Down syndrome; Bulk femoral autograft successful in acetabular reconstruction; Arthroplasty follow-up: is the internet the solution?; Total hip arthroplasty following acetabular fracture; Salvage arthroplasty following failed hip internal fixation; Bone banking sensible financially and clinically; Allogenic blood transfusion in arthroplasty.

The February 2015 Knee Roundup³⁶⁰ looks at: Intra-operative sensors for knee balance; Mobile bearing no advantage; Death and knee replacement: a falling phenomenon; The swings and roundabouts of unicompartmental arthroplasty; Regulation, implants and innovation; The weight of arthroplasty responsibility!; BMI in arthroplasty

Surface hip replacement (SHR) is generally used in younger, active patients as an alternative conventional total hip replacement in part because of the ability to preserve femoral bone. This major benefit of surface replacement will only hold true if revision procedures of SHRs are found to provide good clinical results.

A retrospective review of SHR revisions between 2007 and 2012 was presented, and the type of revision and aetiologies were recorded. There were 55 SHR revisions, of which 27 were in women. At a mean follow-up of 2.3 years (0.72 to 6.4), the mean post-operative Harris hip score (HHS) was 94.8 (66 to 100). Overall 23 were revised for mechanical reasons, nine for impingement, 13 for metallosis, nine for unexplained pain and one for sepsis. Of the type of revision surgery performed, 14 were femoral-only revisions; four were acetabular-only revisions, and 37 were complete revisions.

We did not find that clinical scores were significantly different between gender or different types of revisions. However, the mean post-operative HHS was significantly lower in patients revised for unexplained pain compared with patients revised for mechanical reasons (86.9 (66 to 100) versus 99 (96 to 100); p = 0.029). There were two re-revisions for infection in the entire cohort.

Based on the overall clinical results, we believe that revision of SHR can have good or excellent results and warrants a continued use of the procedure in selected patients. Close monitoring of these patients facilitates early intervention, as we believe that tissue damage may be related to the duration of an ongoing problem. There should be a low threshold to revise a surface replacement if there is component malposition, rising metal ion levels, or evidence of soft-tissue abnormalities.

Cite this article: Bone Joint J 2013;95-B, Supple A:88–91.

There is little information about the management of peri-prosthetic fracture of the humerus after total shoulder replacement (TSR). This is a retrospective review of 22 patients who underwent a revision of their original shoulder replacement for peri-prosthetic fracture of the humerus with bone loss and/or loose components. There were 20 women and two men with a mean age of 75 years (61 to 90) and a mean follow-up 42 months (12 to 91): 16 of these had undergone a previous revision TSR. Of the 22 patients, 12 were treated with a long-stemmed humeral component that bypassed the fracture. All their fractures united after a mean of 27 weeks (13 to 94). Eight patients underwent resection of the proximal humerus with endoprosthetic replacement to the level of the fracture. Two patients were managed with a clam-shell prosthesis that retained the original components. The mean Oxford shoulder score (OSS) of the original TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean OSS after revision for fracture was 25 (9 to 31). Kaplan-Meier survival using re-intervention for any reason as the endpoint was 91% (95% confidence interval (CI) 68 to 98) and 60% (95% CI 30 to 80) at one and five years, respectively.

There were two revisions for dislocation of the humeral head, one open reduction for modular humeral component dissociation, one internal fixation for nonunion, one trimming of a prominent screw and one re-cementation for aseptic loosening complicated by infection, ultimately requiring excision arthroplasty. Two patients sustained nerve palsies.

Revision TSR after a peri-prosthetic humeral fracture associated with bone loss and/or loose components is a salvage procedure that can provide a stable platform for elbow and hand function. Good rates of union can be achieved using a stem that bypasses the fracture. There is a high rate of complications and function is not as good as with the original replacement.

A high radiographic inclination angle (RI) contributes to accelerated wear and has been associated with dislocation after total hip arthroplasty (THA). With freehand positioning of the acetabular component there is a lack of accuracy, with a trend towards a high radiographic inclination angle. The aim of this study was to investigate whether the use of a digital protractor to measure the operative inclination angle (OI) could improve the positioning of the acetabular component in relation to a ‘safe zone’.

We measured the radiographic inclination angles of 200 consecutive uncemented primary THAs. In the first 100 the component was introduced freehand and in the second 100 a digital protractor was used to measure the operative inclination angle.

The mean difference between the operative and the radiographic inclination angles (∆RI–OI) in the second cohort was 12.3° (3.8° to 19.8°). There was a strong correlation between the circumference of the hip and ∆RI–OI. The number of RI outliers was significantly reduced in the protractor group (p = 0.002).

Adjusting the OI, using a digital protractor and taking into account the circumference of the patient’s hip, improves the RI significantly (p < 0.001) and does not require additional operating time.

Cite this article: Bone Joint J 2015; 97-B:603–610.

Total hip replacement (THR) after acetabular fracture presents unique challenges to the orthopaedic surgeon. The majority of patients can be treated with a standard THR, resulting in a very reasonable outcome. Technical challenges however include infection, residual pelvic deformity, acetabular bone loss with ununited fractures, osteonecrosis of bone fragments, retained metalwork, heterotopic ossification, dealing with the sciatic nerve, and the difficulties of obtaining long-term acetabular component fixation. Indications for an acute THR include young patients with both femoral head and acetabular involvement with severe comminution that cannot be reconstructed, and the elderly, with severe bony comminution. The outcomes of THR for established post-traumatic arthritis include excellent pain relief and functional improvements. The use of modern implants and alternative bearing surfaces should improve outcomes further.

Cite this article: Bone Joint J 2013;95-B, Supple A:11–16.

We prospectively followed 191 consecutive collarless polished tapered (CPT) femoral stems, implanted in 175 patients who had a mean age at operation of 64.5 years (21 to 85). At a mean follow-up of 15.9 years (14 to 17.5), 86 patients (95 hips) were still alive. The fate of all original stems is known. The 16-year survivorship with re-operation for any reason was 80.7% (95% confidence interval 72 to 89.4). There was no loss to follow-up, with clinical data available on all 95 hips and radiological assessment performed on 90 hips (95%). At latest follow-up, the mean Harris hip score was 78 (28 to 100) and the mean Oxford hip score was 36 (15 to 48). Stems subsided within the cement mantle, with a mean subsidence of 2.1 mm (0.4 to 19.2). Among the original cohort, only one stem (0.5%) has been revised due to aseptic loosening. In total seven stems were revised for any cause, of which four revisions were required for infection following revision of the acetabular component. A total of 21 patients (11%) required some sort of revision procedure; all except three of these resulted from failure of the acetabular component. Cemented acetabular components had a significantly lower revision burden (three hips, 2.7%) than Harris Galante uncemented components (17 hips, 21.8%) (p < 0.001).

The CPT stem continues to provide excellent radiological and clinical outcomes at 15 years following implantation. Its results are consistent with other polished tapered stem designs.

Persistent groin pain after seemingly successful total hip replacement (THR) appears to have become more common. Recent studies have indicated a high incidence after metal-on-polyethylene and metal-on-metal conventional THR and it has been documented in up to 18% of patients after metal-on-metal resurfacing. There are many causes, including acetabular loosening, stress fracture, and iliopsoas tendonitis and impingement. The evaluation of this problem requires a careful history and examination, plain radiographs and an algorithmic approach to special diagnostic imaging and tests. Non-operative treatment is not usually successful. Specific operative treatment depending on the cause of the pain usually involves revision of the acetabular component, iliopsoas tenotomy or other procedures, and is usually successful. Here, an appropriate algorithm is described.

The April 2012 Hip & Pelvis Roundup³⁶⁰ looks at osteoporotic hip fractures, retrotrochanteric pain, fibrin adhesive and reattachment of articular cartilage, autologous bone marrow mononuclear cells and avascular necrosis, bearing surfaces, stability after THR, digital templating, pelvic tilt after THR, custom-made sockets for DDH, and dogs and THR

Impaction bone grafting for the reconstitution of bone stock in revision hip surgery has been used for nearly 30 years. Between 1995 and 2001 we used this technique in acetabular reconstruction, in combination with a cemented component, in 304 hips in 292 patients revised for aseptic loosening. The only additional supports used were stainless steel meshes placed against the medial wall or laterally around the acetabular rim to contain the graft. All Paprosky grades of defect were included. Clinical and radiographic outcomes were collected in surviving patients at a minimum of ten years after the index operation. Mean follow-up was 12.4 years (sd 1.5) (10.0 to 16.0). Kaplan–Meier survival with revision for aseptic loosening as the endpoint was 85.9% (95% CI 81.0 to 90.8) at 13.5 years. Clinical scores for pain relief remained satisfactory, and there was no difference in clinical scores between cups that appeared stable and those that appeared radiologically loose.

Cite this article: Bone Joint J 2014;96-B:188–94.

Revision total knee arthroplasty (TKA) is a complex procedure which carries both a greater risk for patients and greater cost for the treating hospital than does a primary TKA. As well as the increased cost of peri-operative investigations, blood transfusions, surgical instrumentation, implants and operating time, there is a well-documented increased length of stay which accounts for most of the actual costs associated with surgery.

We compared revision surgery for infection with revision for other causes (pain, instability, aseptic loosening and fracture). Complete clinical, demographic and economic data were obtained for 168 consecutive revision TKAs performed at a tertiary referral centre between 2005 and 2012.

Revision surgery for infection was associated with a mean length of stay more than double that of aseptic cases (21.5 vs 9.5 days, p < 0.0001). The mean cost of a revision for infection was more than three times that of an aseptic revision (£30 011 (sd 4514) vs £9655 (sd 599.7), p < 0.0001).

Current NHS tariffs do not fully reimburse the increased costs of providing a revision knee surgery service. Moreover, especially as greater costs are incurred for infected cases. These losses may adversely affect the provision of revision surgery in the NHS.

Cite this article: Bone Joint J 2015;97-B:197–201.

We hypothesised that the use of tantalum (Ta) acetabular components in revision total hip arthroplasty (THA) was protective against subsequent failure due to infection. We identified 966 patients (421 men, 545 women and 990 hips) who had undergone revision THA between 2000 and 2013. The mean follow up was 40.2 months (3 months to 13.1 years). The mean age of the men and women was 62.3 years (31 to 90) and 65.1 years (25 to 92), respectively.

Titanium (Ti) acetabular components were used in 536 hips while Ta components were used in 454 hips. In total, 73 (7.3%) hips experienced subsequent acetabular failure. The incidence of failure was lower in the Ta group at 4.4% (20/454) compared with 9.9% (53/536) in the Ti group (p < 0.001, odds ratio 2.38; 95% CI 1.37 to 4.27). Among the 144 hips (64 Ta, 80 Ti) for which revision had been performed because of infection, failure due to a subsequent infection was lower in the Ta group at 3.1% (2/64) compared with 17.5% (14/80) for the Ti group (p = 0.006).

Thus, the use of Ta acetabular components during revision THA was associated with a lower incidence of failure from all causes and Ta components were associated with a lower incidence of subsequent infection when used in patients with periprosthetic joint infection.

Cite this article: Bone Joint J 2015;97-B:45–9.

The October 2013 Knee Roundup³⁶⁰ looks at: Make it easy, release the MCL; Do patients remember clinical information in day surgery?; Osteoarthritis and arthroscopy?; How best to double your bundles; When to operate for infection; Cementless unicompartment knee replacement?; Tibial tubercle-trochlear groove confusion; Tarts, cherries and osteoarthritis

Pelvic discontinuity with associated bone loss is a complex challenge in acetabular revision surgery. Reconstruction using ilio-ischial cages combined with trabecular metal acetabular components and morsellised bone (the component-cage technique) is a relatively new method of treatment.

We reviewed a consecutive series of 26 cases of acetabular revision reconstructions in 24 patients with pelvic discontinuity who had been treated by the component-cage technique. The mean follow-up was 44.6 months (24 to 68). Failure was defined as migration of a component of > 5 mm.

In 23 hips (88.5%) there was no clinical or radiological evidence of loosening at the last follow-up. The mean Harris hip score improved significantly from 46.6 points (29.5 to 68.5) to 76.6 points (55.5 to 92.0) at two years (p < 0.001). In three hips (11.5%) the construct had migrated at one year after operation. The complications included two dislocations, one infection and one partial palsy of the peroneal nerve.

Our findings indicate that treatment of pelvic discontinuity using the component-cage construct is a reliable option.

Objectives

We aimed to determine the effect of surgical approach on the histology of the femoral head following resurfacing of the hip.