There has been an in increase in the availability
of effective biological agents for the treatment of rheumatoid arthritis
as well as a shift towards early diagnosis and management of the
inflammatory process. This article explores the impact this may
have on the place of orthopaedic surgery in the management of patients
with rheumatoid arthritis. Cite this article:
Although patients with a history of venous thromboembolism
(VTE) who undergo lower limb joint replacement are thought to be
at high risk of further VTE, the actual rate of recurrence has not
been reported. The purpose of this study was to identify the recurrence rate
of VTE in patients who had undergone lower limb joint replacement,
and to compare it with that of patients who had undergone a joint
replacement without a history of VTE. From a pool of 6646 arthroplasty procedures (3344 TKR, 2907 THR,
243 revision THR, 152 revision TKR) in 5967 patients (68% female,
mean age 67.7; 21 to 96) carried out between 2009 and 2011, we retrospectively
identified 118 consecutive treatment episodes in 106 patients (65%
female, mean age 70; 51 to 88,) who had suffered a previous VTE.
Despite mechanical prophylaxis and anticoagulation with warfarin,
we had four recurrences by three months (3.4% of 118) and six by
one year (5.1% of 118). In comparison, in all our other joint replacements
the rate of VTE was 0.54% (35/6528). The relative risk of a VTE by 90 days in patients who had undergone
a joint replacement with a history of VTE compared with those with
a joint replacement and no history of VTE was 6.3 (95% confidence
interval, 2.3 to 17.5). There were five complications in the previous
VTE group related to bleeding or over-anticoagulation. Cite this article:
We compared the clinical and radiographic results
of total ankle replacement (TAR) performed in non-diabetic and diabetic
patients. We identified 173 patients who underwent unilateral TAR
between 2004 and 2011 with a minimum of two years’ follow-up. There
were 88 male (50.9%) and 85 female (49.1%) patients with a mean
age of 66 years ( The mean AOS and AOFAS scores were significantly better in the
non-diabetic group (p = 0.018 and p = 0.038, respectively). In all,
nine TARs (21%) in the diabetic group had clinical failure at a
mean follow-up of five years (24 to 109), which was significantly
higher than the rate of failure of 15 (11.6%) in the non-diabetic
group (p = 0.004). The uncontrolled diabetic subgroup had a significantly
poorer outcome than the non-diabetic group (p = 0.02), and a higher
rate of delayed wound healing. The incidence of early-onset osteolysis was higher in the diabetic
group than in the non-diabetic group (p = 0.02). These results suggest
that diabetes mellitus, especially with poor glycaemic control,
negatively affects the short- to mid-term outcome after TAR. Cite this article:
Valid and reliable techniques for assessing performance
are essential to surgical education, especially with the emergence
of competency-based frameworks. Despite this, there is a paucity
of adequate tools for the evaluation of skills required during joint
replacement surgery. In this scoping review, we examine current
methods for assessing surgeons’ competency in joint replacement
procedures in both simulated and clinical environments. The ability
of many of the tools currently in use to make valid, reliable and
comprehensive assessments of performance is unclear. Furthermore,
many simulation-based assessments have been criticised for a lack
of transferability to the clinical setting. It is imperative that
more effective methods of assessment are developed and implemented
in order to improve our ability to evaluate the performance of skills
relating to total joint replacement. This will enable educators
to provide formative feedback to learners throughout the training
process to ensure that they have attained core competencies upon
completion of their training. This should help ensure positive patient
outcomes as the surgical trainees enter independent practice. Cite this article:
The rate of peri-prosthetic infection following
total joint replacement continues to rise, and attempts to curb
this trend have included the use of antibiotic-loaded bone cement
at the time of primary surgery. We have investigated the clinical-
and cost-effectiveness of the use of antibiotic-loaded cement for
primary total knee replacement (TKR) by comparing the rate of infection
in 3048 TKRs performed without loaded cement over a three-year period The absolute rate of infection increased when antibiotic-loaded
cement was used in TKR. However, this rate of increase was less
than the rate of increase in infection following uncemented THR
during the same period. If the rise in the rate of infection observed
in THR were extrapolated to the TKR cohort, 18 additional cases
of infection would have been expected to occur in the cohort receiving
antibiotic-loaded cement, compared with the number observed. Depending
on the type of antibiotic-loaded cement that is used, its cost in
all primary TKRs ranges between USD $2112.72 and USD $112 606.67
per case of infection that is prevented. Cite this article:
Revision total hip replacement (THR) for young
patients is challenging because of technical complexity and the potential
need for subsequent further revisions. We have assessed the survivorship,
functional outcome and complications of this procedure in patients
aged <
50 years through a large longitudinal series with consistent treatment
algorithms. Of 132 consecutive patients (181 hips) who underwent
revision THR, 102 patients (151 hips) with a mean age of 43 years
(22 to 50) were reviewed at a mean follow-up of 11 years (2 to 26)
post-operatively. We attempted to restore bone stock with allograft
where indicated. Using further revision for any reason as an end point,
the survival of the acetabular component was 71% ( This overall perspective on the mid- to long-term results is
valuable when advising young patients on the prospects of revision
surgery at the time of primary replacement. Cite this article:
Periprosthetic fractures are an increasingly
common complication following joint replacement. The principles
which underpin their evaluation and treatment are common across
the musculoskeletal system. The Unified Classification System proposes
a rational approach to treatment, regardless of the bone that is
broken or the joint involved. Cite this article:
Acetabular retractors have been implicated in damage to the femoral
and obturator nerves during total hip replacement. The aim of this
study was to determine the anatomical relationship between retractor
placement and these nerves. A posterior approach to the hip was carried out in six fresh
cadaveric half pelves. Large Hohmann acetabular retractors were
placed anteriorly, over the acetabular lip, and inferiorly, and
their relationship to the femoral and obturator nerves was examined.Objectives
Methods
To quantify and compare peri-acetabular bone mineral density
(BMD) between a monoblock acetabular component using a metal-on-metal
(MoM) bearing and a modular titanium shell with a polyethylene (PE)
insert. The secondary outcome was to measure patient-reported clinical
function. A total of 50 patients (25 per group) were randomised to MoM
or metal-on-polyethlene (MoP). There were 27 women (11 MoM) and
23 men (14 MoM) with a mean age of 61.6 years (47.7 to 73.2). Measurements
of peri-prosthetic acetabular and contralateral hip (covariate)
BMD were performed at baseline and at one and two years’ follow-up.
The Western Ontario and McMaster Universities osteoarthritis index
(WOMAC), University of California, Los Angeles (UCLA) activity score,
Harris hip score, and RAND-36 were also completed at these intervals.Objectives
Methods
The treatment of peri-prosthetic joint infection
(PJI) of the ankle is not standardised. It is not clear whether
an algorithm developed for hip and knee PJI can be used in the management
of PJI of the ankle. We evaluated the outcome, at two or more years
post-operatively, in 34 patients with PJI of the ankle, identified
from a cohort of 511 patients who had undergone total ankle replacement.
Their median age was 62.1 years (53.3 to 68.2), and 20 patients
were women. Infection was exogenous in 28 (82.4%) and haematogenous
in six (17.6%); 19 (55.9%) were acute infections and 15 (44.1%)
chronic. Staphylococci were the cause of 24 infections (70.6%).
Surgery with retention of one or both components was undertaken
in 21 patients (61.8%), both components were replaced in ten (29.4%),
and arthrodesis was undertaken in three (8.8%). An infection-free
outcome with satisfactory function of the ankle was obtained in
23 patients (67.6%). The best rate of cure followed the exchange
of both components (9/10, 90%). In the 21 patients in whom one or
both components were retained, four had a relapse of the same infecting organism
and three had an infection with another organism. Hence the rate
of cure was 66.7% (14 of 21). In these 21 patients, we compared
the treatment given to an algorithm developed for the treatment
of PJI of the knee and hip. In 17 (80.9%) patients, treatment was
not according to the algorithm. Most (11 of 17) had only one criterion against
retention of one or both components. In all, ten of 11 patients
with severe soft-tissue compromise as a single criterion had a relapse-free
survival. We propose that the treatment concept for PJI of the ankle
requires adaptation of the grading of quality of the soft tissues. Cite this article
The aim of this study was to review the role
of clinical trial networks in orthopaedic surgery. A total of two
electronic databases (MEDLINE and EMBASE) were searched from inception
to September 2013 with no language restrictions. Articles related
to randomised controlled trials (RCTs), research networks and orthopaedic
research, were identified and reviewed. The usefulness of trainee-led
research collaborations is reported and our knowledge of current
clinical trial infrastructure further supplements the review. Searching
yielded 818 titles and abstracts, of which 12 were suitable for
this review. Results are summarised and presented narratively under
the following headings: 1) identifying clinically relevant research
questions; 2) education and training; 3) conduct of multicentre
RCTs and 4) dissemination and adoption of trial results. This review
confirms growing international awareness of the important role research
networks play in supporting trials in orthopaedic surgery. Multidisciplinary
collaboration and adequate investment in trial infrastructure are crucial
for successful delivery of RCTs. Cite this article:
The aim of this study was to define the incidence
of venous thromboembolism (VTE) and risk factors for the development
of deep-vein thrombosis (DVT) after the resection of a musculoskeletal
tumour. A total of 94 patients who underwent resection of a musculoskeletal
tumour between January 2003 and December 2005 were prospectively
studied. There were 42 men and 52 women with a mean age of 54.4
years (18 to 86). All patients wore intermittent pneumatic compression
devices and graduated compression stockings. Ultrasound examination
of the lower limbs was conducted to screen for DVT between the fifth
and ninth post-operative days. DVT was detected in 21 patients (22%). Of these, two were symptomatic
(2%). One patient (1%) had a fatal pulmonary embolism. Patients
aged ≥ 70 years had an increased risk of DVT (p = 0.004). The overall incidence of DVT (both symptomatic and asymptomatic)
after resection of a musculoskeletal tumour with mechanical prophylaxis
was high. It seems that both mechanical and anticoagulant prophylaxis
is needed to prevent VTE in patients who have undergone the resection
of a musculoskeletal tumour. Cite this article:
The effects of surgical approach in total hip
replacement on health-related quality of life and long-term pain
and satisfaction are unknown. From the Swedish Hip Arthroplasty
Register, we extracted data on all patients that had received a
total hip replacement for osteoarthritis through either the posterior
or the direct lateral approach, with complete pre- and one-year
post-operative Patient Reported Outcome Measures (PROMs). A total
of 42 233 patients met the inclusion criteria and of these 4962
also had complete six-year PROM data. The posterior approach resulted in
an increased mean satisfaction score of 15 ( Cite this article:
Satisfaction with care is important to both patients
and to those who pay for it. The Net Promoter Score (NPS), widely
used in the service industries, has been introduced into the NHS
as the ‘friends and family test’; an overarching measure of patient
satisfaction. It assesses the likelihood of the patient recommending
the healthcare received to another, and is seen as a discriminator
of healthcare performance. We prospectively assessed 6186 individuals
undergoing primary lower limb joint replacement at a single university
hospital to determine the Net Promoter Score for joint replacements
and to evaluate which factors contributed to the response. Achieving pain relief (odds ratio (OR) 2.13, confidence interval
(CI) 1.83 to 2.49), the meeting of pre-operative expectation (OR
2.57, CI 2.24 to 2.97), and the hospital experience (OR 2.33, CI
2.03 to 2.68) are the domains that explain whether a patient would
recommend joint replacement services. These three factors, combined
with the type of surgery undertaken (OR 2.31, CI 1.68 to 3.17),
drove a predictive model that was able to explain 95% of the variation
in the patient’s recommendation response. Though intuitively similar,
this ‘recommendation’ metric was found to be materially different
to satisfaction responses. The difference between THR (NPS 71) and
TKR (NPS 49) suggests that no overarching score for a department
should be used without an adjustment for case mix. However, the
Net Promoter Score does measure a further important dimension to
our existing metrics: the patient experience of healthcare delivery. Cite this article:
The April 2014 Trauma Roundup360 looks at: is it safe to primarily close dog bite wounds?; conservative transfusion evidence based in hip fracture surgery; tibial nonunion is devastating to quality of life; sexual dysfunction after traumatic pelvic fracture; hemiarthroplasty versus fixation in displaced femoral neck fractures; silver VAC dressings “Gold Standard” in massive wounds; dual plating for talar neck fracture; syndesmosis and fibular length easiest errors in ankle fracture surgery; and dual mobility: stable as a rock in fracture.
Metal-on-metal hip arthroplasty gained significant
favor in the first decade of the millennium. However, the past several
years have seen increasing reports of failure, pseudotumor and other
adverse reactions. This study presents the results of a single center’s
15-year experience with metal-on-metal total hip arthroplasty as
strong evidence that metal-on-metal is going, going, gone.
The differential diagnosis of the painful total
hip arthroplasty (resurfacing or total hip) includes infection,
failure of fixation (loosening), tendinitis, bursitis, synovitis,
adverse local tissue reaction (ALTR) to cobalt-chromium alloys,
and non-hip issues, such as spinal disorders, hernia, gynecologic,
and other pelvic pain. Assuming that the hip is the source of pain,
the first level question is prosthetic or non-prosthetic pain generator?
The second level prosthetic question is septic or aseptic? The third
level question (aseptic hips) is well-fixed or loose? ALTR is best
diagnosed by cross-sectional imaging. Successful treatment is dependent
on correct identification and elimination of the pain generator.
Treatment recommendations for ALTR and taper corrosion are evolving.
Recent recommendations by the National Institute
for Health and Care Excellence (NICE) suggest that all patients undergoing
elective orthopaedic surgery should be assessed for the risk of
venous thromboembolism (VTE). Little is known about the incidence of symptomatic VTE after
elective external fixation. We studied a consecutive series of adult
patients who had undergone elective Ilizarov surgery without routine
pharmacological prophylaxis to establish the incidence of symptomatic
VTE. A review of a prospectively maintained database of consecutive
patients who were treated between October 1998 and February 2011
identified 457 frames in 442 adults whose mean age was 42.6 years
(16.0 to 84.6). There were 425 lower limb and 32 upper limb frames.
The mean duration of treatment was 25.7 weeks (1.6 to 85.3). According to NICE guidelines all the patients had at least one
risk factor for VTE, 246 had two, 172 had three and 31 had four
or more. One patient (0.23%) developed a pulmonary embolus after surgery
and was later found to have an inherited thrombophilia. There were
27 deaths, all unrelated to VTE. The cost of providing VTE prophylaxis according to NICE guidelines
in this group of patients would be £89 493.40 (£195.80 per patient)
even if the cheapest recommended medication was used. The rate of symptomatic VTE after Ilizarov surgery was low despite
using no pharmacological prophylaxis. This study leads us to question
whether NICE guidelines are applicable to these patients. Cite this article:
Many different lengths of stem are available
for use in primary total hip replacement, and the morphology of
the proximal femur varies greatly. The more recently developed shortened
stems provide a distribution of stress which closely mimics that
of the native femur. Shortening the femoral component potentially
comes at the cost of decreased initial stability. Clinical studies
on the performance of shortened cemented and cementless stems are promising,
although long-term follow-up studies are lacking. We provide an
overview of the current literature on the anatomical features of
the proximal femur and the biomechanical aspects and clinical outcomes
associated with the length of the femoral component in primary hip
replacement, and suggest a classification system for the length
of femoral stems. Cite this article:
Resection of malignant bony tumours of the pelvis
creates large bone and soft-tissue defects, and is frequently associated
with complications such as wound dehiscence and deep infection.
We present the results of six patients in whom a rectus abdominis
myocutaneous (RAM) flap was used following resection of a malignant
tumour of the pelvis. Bony reconstruction was performed using a
constrained hip tumour prosthesis in three patients, vascularised
fibular graft in two and frozen autograft in one. At a mean follow-up
of 63 months (16 to 115), no patients had a problem with the wound. Immediate reconstruction using a RAM flap may be used after resection
of a malignant tumour of the pelvis to provide an adequate volume
of tissue to eliminate the dead space, cover the exposed bone or
implants with well-vascularised soft tissue and to reduce the risk
of complications. Cite this article: