Cementless femoral stems are currently preferred for total hip replacement (THR) in the United States. Improvements in stem design, instrumentation and surgical technique have made this technology highly successful, reproducible, and applicable to the vast majority of patients requiring a THR. However, there are ongoing developments in some aspects of stem design that influence clinical results, the incidence of complications and their inherent adaptability in accommodating the needs of individual patients. Here we examine some of these design features.

Cite this article: Bone Joint J 2013;95-B, Supple A:53–6.

Satisfactory primary wound healing following total joint replacement is essential. Wound healing problems can have devastating consequences for patients. Assessment of their healing capacity is useful in predicting complications. Local factors that influence wound healing include multiple previous incisions, extensive scarring, lymphoedema, and poor vascular perfusion. Systemic factors include diabetes mellitus, inflammatory arthropathy, renal or liver disease, immune compromise, corticosteroid therapy, smoking, and poor nutrition. Modifications in the surgical technique are necessary in selected cases to minimise potential wound complications. Prompt and systematic intervention is necessary to address any wound healing problems to reduce the risks of infection and other potential complications.

Cite this article: Bone Joint J 2013;95-B, Supple A:144–7.

The treatment of hip dysplasia should be customised for patients individually based on radiographic findings, patient age, and the patient’s overall articular cartilage status. In many patients, restoration of hip anatomy as close to normal as possible with a PAO is the treatment of choice.

Cite this article: Bone Joint J 2013;95-B, Supple A:21–5.

Hip replacement is a very successful operation and the outcome is usually excellent. There are recognised complications that seem increasingly to give rise to litigation. This paper briefly examines some common scenarios where litigation may be pursued against hip surgeons. With appropriate record keeping, consenting and surgical care, the claim can be successfully defended if not avoided. We hope this short summary will help to highlight some common pitfalls. There is extensive literature available for detailed study.

Symptomatic and asymptomatic deep-vein thrombosis (DVT) is a common complication of knee replacement, with an incidence of up to 85% in the absence of prophylaxis. National guidelines for thromboprophylaxis in knee replacement are derived from total knee replacement (TKR) data. No guidelines exist specific to unicompartmental knee replacement (UKR). We investigated whether the type of knee arthroplasty (TKR or UKR) was related to the incidence of DVT and discuss the applicability of existing national guidelines for prophylaxis following UKR.

Data were collected prospectively on 3449 knee replacements, including procedure type, tourniquet time, surgeon, patient age, use of drains and gender. These variables were related to the incidence of symptomatic DVT.

The overall DVT rate was 1.6%. The only variable that had an association with DVT was operation type, with TKR having a higher incidence than UKR (2.2% versus 0.3%, p < 0.001). These data show that the incidence of DVT after UKR is both clinically and statistically significantly lower than that after TKR.

TKR and UKR patients have different risk profiles for symptomatic DVT. The risk-benefit ratio for TKR that has been used to produce national guidelines may not be applicable to UKR. Further research is required to establish the most appropriate form of prophylaxis for UKR.

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: Bone Joint J 2013;95-B, Supple A:70–3.

Popliteal artery injury (PAI) is a feared complication during knee replacement. Our aim was to investigate those injuries that occurred in association with knee replacement in terms of the type of injury, treatment and outcomes.

From our national vascular registry (Swedvasc) and the Swedish Patient Insurance databases a total of 32 cases were identified. Prospective data from the registries was supplemented with case-records, including long-term follow-up.

We estimated the incidence during 1998 to 2010 to be 0.017%. In our series of 32 patients with PAI occurring between 1987 and 2011, 25 (78%) were due to penetrating trauma and seven were caused by blunt trauma. The patients presented in three ways: bleeding (14), ischaemia (7) and false aneurysm formation (11), and five occurred during revision surgery. A total of 12 injuries were detected intra-operatively, eight within 24 hours (3 to 24) and 12 at more than 24 hours post-operatively (2 to 90 days). Treatment comprised open surgery in 28 patients. Patency of the vascular repair at 30 days was 97% (31 of 32, one amputation). At the time of follow-up (median 546 days, mean 677 days (24 to 1251)), 25 patients had residual symptoms. Of seven patients with a complete recovery, six had had an early diagnosis of the PAI during the procedure, and were treated by a vascular surgeon in the same hospital.

PAI is a rare adverse event during knee replacement surgery. The outcome following such events is often adversely affected by diagnostic and therapeutic delay. Bleeding and false aneurysm were the most common clinical presentations.

Cite this article: Bone Joint J 2013;95-B:1645–9.

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 report the long-term results of the management of neglected chronically infected total knee replacements with a two-stage re-implantation protocol. In 18 of 34 patients (53%) a resistant organism was isolated. All cases were treated by the same surgical team in a specialist centre and had a mean follow-up of 12.1 years (10 to 14). They were evaluated clinically and radiologically using the Knee Society Score (KSS) and the American Knee Society Roentgenographic scoring system, respectively. One patient died after eight years from an unrelated cause and two were lost to follow-up. Three patients (8.8%) developed a recurrent infection for which further surgery was required. The infection was eradicated successfully in 31 patients (91.1%). There was one case of aseptic loosening after 13 years. We found a significant improvement in the KSS at final follow-up (p < 0.001).

Our objective was to examine the rate of revision and its predictive factors in patients undergoing total shoulder arthroplasty (TSA). We used prospectively collected data from the Mayo Clinic Total Joint Registry to examine five-, ten- and 20-year revision-free survival following TSA and the predictive factors. We examined patient characteristics (age, gender, body mass index, comorbidity), implant fixation (cemented versus uncemented), American Society of Anesthesiologists class and underlying diagnosis. Univariate and multivariable adjusted hazard rates were calculated using Cox regression analysis. A total of 2207 patients underwent 2588 TSAs. Their mean age was 65.0 years (19 to 91) and 1163 (53%) were women; osteoarthritis was the underlying diagnosis in 1640 shoulders (63%). In all, 212 TSAs (8.2%) were revised during the follow-up period. At five, ten and 20 years, survival rates were 94.2% (95% confidence interval (CI) 93.2 to 95.3), 90.2% (95% CI 88.7 to 91.7) and 81.4% (95% CI 78.4 to 84.5), respectively. In multivariable analyses men had a higher hazard ratio of revision of 1.72 (95% CI 1.28 to 2.31) (p < 0.01) compared with women, and those with rotator cuff disease had a hazard ratio of 4.71 (95% CI 2.09 to 10.59) (p < 0.001) compared with patients with rheumatoid arthritis. We concluded that male gender and rotator cuff disease are independent risk factors for revision after TSA. Future studies are needed to understand the biological rationale for these differences.

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° (sd 6.46) and the mean CT measurement was 12.35° (sd 6.39) (p = 0.096). The intra- and interobserver reliabilities were excellent for both measurements. The radiological measurements correlated well with the CT measurements (p = 0.001, r = 0.877). The modified Budin method appears reliable and valid for the measurement of femoral stem anteversion.

Cite this article: Bone Joint J 2013;95-B:877–80.

Using the United States Nationwide Inpatient Sample, we identified national trends in revision spinal fusion along with a comprehensive comparison of comorbidities, inpatient complications and surgical factors of revision spinal fusion compared to primary spinal fusion.

In 2009, there were 410 158 primary spinal fusion discharges and 22 128 revision spinal fusion discharges. Between 2002 and 2009, primary fusion increased at a higher rate compared with revision fusion (56.4% vs 51.0%; p < 0.001). In 2009, the mean length of stay and hospital charges were higher for revision fusion discharges than for primary fusion discharges (4.2 days vs 3.8 days, p < 0.001; USD $91 909 vs. $87 161, p < 0.001). In 2009, recombinant human bone morphogenetic protein (BMP) was used more in revision fusion than in primary fusion (39.6% vs 27.6%, p < 0.001), whereas interbody devices were used less in revision fusion (41.8% vs 56.6%, p < 0.001).

In the multivariable logistic regression model for all spinal fusions, depression (odds ratio (OR) 1.53, p < 0.001), psychotic disorders (OR 1.49, p < 0.001), deficiency anaemias (OR 1.35, p < 0.001) and smoking (OR 1.10, p = 0.006) had a greater chance of occurrence in revision spinal fusion discharges than in primary fusion discharges, adjusting for other variables. In terms of complications, after adjusting for all significant comorbidities, this study found that dural tears (OR 1.41; p < 0.001) and surgical site infections (OR 3.40; p < 0.001) had a greater chance of occurrence in revision spinal fusion discharges than in primary fusion discharges (p < 0.001). A p-value < 0.01 was considered significant in all final analyses.

Cite this article: Bone Joint J 2014;96-B:807–16.

With the development of systems of trauma care the management of pelvic disruption has evolved and has become increasingly refined. The goal is to achieve an anatomical reduction and stable fixation of the fracture. This requires adequate visualisation for reduction of the fracture and the placement of fixation. Despite the advances in surgical approach and technique, the functional outcomes do not always produce the desired result. New methods of percutaneous treatment in conjunction with innovative computer-based imaging have evolved in an attempt to overcome the existing difficulties. This paper presents an overview of the technical aspects of percutaneous surgery of the pelvis and acetabulum.

The outcome of total knee replacement (TKR) using components designed to increase the range of flexion is not fully understood. The short- to mid-term risk of aseptic revision in high flexion TKR was evaluated. The endpoint of the study was aseptic revision and the following variables were investigated: implant design (high flexion vs non-high flexion), the thickness of the tibial insert (≤ 14 mm vs > 14 mm), cruciate ligament (posterior stabilised (PS) vs cruciate retaining), mobility (fixed vs rotating), and the manufacturer (Zimmer, Smith & Nephew and DePuy). Covariates included patient, implant, surgeon and hospital factors. Marginal Cox proportional hazard models were used.

In a cohort of 64 000 TKRs, high flexion components were used in 8035 (12.5%). The high flexion knees with tibial liners of thickness > 14 mm had a density of revision of 1.45/100 years of observation, compared with 0.37/100 in non-high flexion TKR with liners ≤ 14 mm thick. Relative to a standard fixed PS TKR, the NexGen (Zimmer, Warsaw, Indiana) Gender Specific Female high flexion fixed PS TKR had an increased risk of revision (hazard ratio (HR) 2.27 (95% confidence interval (CI) 1.48 to 3.50)), an effect that was magnified when a thicker tibial insert was used (HR 8.10 (95% CI 4.41 to 14.89)).

Surgeons should be cautious when choosing high flexion TKRs, particularly when thicker tibial liners might be required.

Cite this article: Bone Joint J 2014;96-B:217–23.

We investigated the capacity of patient warming devices to disrupt the ultra-clean airflow system. We compared the effects of two patient warming technologies, forced-air and conductive fabric, on operating theatre ventilation during simulated hip replacement and lumbar spinal procedures using a mannequin as a patient. Infection data were reviewed to determine whether joint infection rates were associated with the type of patient warming device that was used.

Neutral-buoyancy detergent bubbles were released adjacent to the mannequin’s head and at floor level to assess the movement of non-sterile air into the clean airflow over the surgical site. During simulated hip replacement, bubble counts over the surgical site were greater for forced-air than for conductive fabric warming when the anaesthesia/surgery drape was laid down (p = 0.010) and at half-height (p < 0.001). For lumbar surgery, forced-air warming generated convection currents that mobilised floor air into the surgical site area. Conductive fabric warming had no such effect.

A significant increase in deep joint infection, as demonstrated by an elevated infection odds ratio (3.8, p = 0.024), was identified during a period when forced-air warming was used compared to a period when conductive fabric warming was used. Air-free warming is, therefore, recommended over forced-air warming for orthopaedic procedures.

The presacral retroperitoneal approach for axial lumbar interbody fusion (presacral ALIF) is not widely reported, particularly with regard to the mid-term outcome. This prospective study describes the clinical outcomes, complications and rates of fusion at a follow-up of two years for 26 patients who underwent this minimally invasive technique along with further stabilisation using pedicle screws. The fusion was single-level at the L5-S1 spinal segment in 17 patients and two-level at L4–5 and L5-S1 in the other nine. The visual analogue scale for pain and Oswestry Disability Index scores were recorded pre-operatively and during the 24-month study period. The evaluation of fusion was by thin-cut CT scans at six and 12 months, and flexion-extension plain radiographs at six, 12 and 24 months. Significant reductions in pain and disability occurred as early as three weeks postoperatively and were maintained. Fusion was achieved in 22 of 24 patients (92%) at 12 months and in 23 patients (96%) at 24 months. One patient (4%) with a pseudarthrosis underwent successful revision by augmentation of the posterolateral fusion mass through a standard open midline approach.

There were no severe adverse events associated with presacral ALIF, which in this series demonstrated clinical outcomes and fusion rates comparable with those of reports of other methods of interbody fusion.

We carried out an audit on the result of achieving early walking in total knee replacement after instituting a new rehabilitation protocol, and assessed its influence on the development of deep-vein thrombosis as determined by Doppler ultrasound scanning on the fifth post-operative day. Early mobilisation was defined as beginning to walk less than 24 hours after knee replacement.

Between April 1997 and July 2002, 98 patients underwent a total of 125 total knee replacements. They began walking on the second post-operative day unless there was a medical contraindication. They formed a retrospective control group. A protocol which allowed patients to start walking at less than 24 hours after surgery was instituted in August 2002. Between August 2002 and November 2004, 97 patients underwent a total of 122 total knee replacements. They formed the early mobilisation group, in which data were prospectively gathered. The two groups were of similar age, gender and had similar medical comorbidities. The surgical technique and tourniquet times were similar and the same instrumentation was used in nearly all cases. All the patients received low-molecular-weight heparin thromboprophylaxis and wore compression stockings post-operatively.

In the early mobilisation group 90 patients (92.8%) began walking successfully within 24 hours of their operation. The incidence of deep-vein thrombosis fell from 27.6% in the control group to 1.0% in the early mobilisation group (chi-squared test, p < 0.001). There was a difference in the incidence of risk factors for deep-vein thrombosis between the two groups. However, multiple logistic regression analysis showed that the institution of an early mobilisation protocol resulted in a 30-fold reduction in the risk of post-operative deep-vein thrombosis when we adjusted for other risk factors.

The June 2013 Foot & Ankle Roundup³⁶⁰ looks at: soft-tissue pain following arthroplasty; pigmented villonodular synovitis of the foot and ankle; ankles, allograft and arthritis; open calcaneal fracture; osteochondral lesions in the longer term; severe infections in diabetic feet; absorbable first ray fixation; and showering after foot surgery.

We describe three cases of fracture of the titanium JRI-Furlong hydroxyapatite-ceramic (HAC)-coated femoral component. We have examined previous case reports of failure of this stem and conclude that fracture may occur in two places, namely at the neck-shoulder junction and at the conical-distal cylindrical junction. These breakages are the result of fatigue in a metallurgically-proven normal femoral component. All the cases of failure of the femoral component have occurred in patients with a body mass index of more than 25 in whom a small component, either size 9 or 10, had been used.

In patients with a body mass index above normal size 9 components should be avoided and the femoral canal should be reamed sufficiently to accept a large femoral component to ensure that there is adequate metaphyseal fixation.