Older patients with multiple medical co-morbidities
are increasingly being offered and undergoing total joint arthroplasty
(TJA). These patients are more likely to require intensive care
support, following surgery. We prospectively evaluated the need
for intensive care admission and intervention in a consecutive series
of 738 patients undergoing elective hip and knee arthroplasty procedures.
The mean age was 60.6 years (18 to 91; 440 women, 298 men. Risk
factors, correlating with the need for critical care intervention,
according to published guidelines, were analysed to identify high-risk
patients who would benefit from post-operative critical care monitoring.
A total of 50 patients (6.7%) in our series required critical care
level interventions during their hospital stay. Six independent
multivariate clinical predictors were identified (p <
0.001)
including a history of congestive heart failure (odds ratio (OR)
24.26, 95% confidence interval (CI) 9.51 to 61.91), estimated blood
loss >
1000 mL (OR 17.36, 95% CI 5.36 to 56.19), chronic obstructive
pulmonary disease (13.90, 95% CI 4.78 to 40.36), intra-operative
use of vasopressors (OR 8.10, 95% CI 3.23 to 20.27), revision hip
arthroplasty (OR 2.71, 95% CI 1.04 to 7.04) and body mass index
>
35 kg/m2 (OR 2.70, 95% CI 123 to 5.94). The model was
then validated against an independent, previously published data
set of 1594 consecutive patients. The use of this risk stratification
model can be helpful in predicting which high-risk patients would
benefit from a higher level of monitoring and care after elective
TJA and aid hospitals in allocating precious critical care resources. Cite this article:
Partial knee arthroplasty (PKA), either medial
or lateral unicompartmental knee artroplasty (UKA) or patellofemoral arthroplasty
(PFA) are a good option in suitable patients and have the advantages
of reduced operative trauma, preservation of both cruciate ligaments
and bone stock, and restoration of normal kinematics within the
knee joint. However, questions remain concerning long-term survival.
The goal of this review article was to present the long-term results
of medial and lateral UKA, PFA and combined compartmental arthroplasty
for multicompartmental disease. Medium- and long-term studies suggest
reasonable outcomes at ten years with survival greater than 95% in
UKA performed for medial osteoarthritis or osteonecrosis, and similarly
for lateral Cite this article:
The August 2015 Trauma Roundup360 looks at: Thromboprophylaxis not required in lower limb fractures; Subclinical thyroid dysfunction and fracture risk: moving the boundaries in fracture; Posterior wall fractures refined; Neurological injury and acetabular fracture surgery; Posterior tibial plateau fixation; Tibial plateau fractures in the longer term; Comprehensive orthogeriatric care and hip fracture; Compartment syndrome: in the eye of the beholder?
The purpose of this study was to compare the results and complications of tibial lengthening over an intramedullary nail with treatment using the traditional Ilizarov method. In this matched case study, 16 adult patients underwent 19 tibial lengthening over nails (LON) procedures. For the matched case group, 17 patients who underwent 19 Ilizarov tibial lengthenings were retrospectively matched to the LON group.Objectives
Methods
This prospective study reports the 15-year survival and ten-year
functional outcome of a consecutive series of 1000 minimally invasive
Phase 3 Oxford medial UKAs (818 patients, 393 men, 48%, 425 women,
52%, mean age 66 years; 32 to 88). These were implanted by two surgeons
involved with the design of the prosthesis to treat anteromedial
osteoarthritis and spontaneous osteonecrosis of the knee, which
are recommended indications. Patients were prospectively identified
and followed up independently for a mean of 10.3 years (5.3 to 16.6). At ten years, the mean Oxford Knee Score was 40 (standard deviation
( This is the only large series of minimally invasive UKAs with
15-year survival data. The results support the continued use of
minimally invasive UKA for the recommended indications. Cite this article:
The early failure and revision of bimodular primary
total hip arthroplasty prostheses requires the identification of the
risk factors for material loss and wear at the taper junctions through
taper wear analysis. Deviations in taper geometries between revised
and pristine modular neck tapers were determined using high resolution
tactile measurements. A new algorithm was developed and validated
to allow the quantitative analysis of material loss, complementing
the standard visual inspection currently used. The algorithm was applied to a sample of 27 retrievals ( Cite this article:
We prospectively assessed the diagnostic accuracy
of the gravity stress test and clinical findings to evaluate the stability
of the ankle mortise in patients with supination–external rotation-type
fractures of the lateral malleolus without widening of the medial
clear space. The cohort included 79 patients with a mean age of
44 years (16 to 82). Two surgeons assessed medial tenderness, swelling
and ecchymosis and performed the external rotation (ER) stress test
(a reference standard). A diagnostic radiographer performed the
gravity stress test. For the gravity stress test, the positive likelihood ratio (LR)
was 5.80 with a 95% confidence interval (CI) of 2.75 to 12.27, and
the negative LR was 0.15 (95% CI 0.07 to 0.35), suggesting a moderate
change from the pre-test probability. Medial tenderness, both alone
and in combination with swelling and/or ecchymosis, indicated a
small change (positive LR, 2.74 to 3.25; negative LR, 0.38 to 0.47),
whereas swelling and ecchymosis indicated only minimal changes (positive
LR, 1.41 to 1.65; negative LR, 0.38 to 0.47). In conclusion, when gravity stress test results are in agreement
with clinical findings, the result is likely to predict stability
of the ankle mortise with an accuracy equivalent to ER stress test
results. When clinical examination suggests a medial-side injury,
however, the gravity stress test may give a false negative result. Cite this article:
C5 nerve root palsy is a rare and potentially
debilitating complication of cervical spine surgery. Currently,
however, there are no guidelines to help surgeons to prevent or
treat this complication. We carried out a systematic review of the literature to identify
the causes of this complication and options for its prevention and
treatment. Searches of PubMed, Embase and Medline yielded 60 articles
for inclusion, most of which addressed C5 palsy as a complication
of surgery. Although many possible causes were given, most authors supported
posterior migration of the spinal cord with tethering of the nerve
root as being the most likely. Early detection and prevention of a C5 nerve root palsy using
neurophysiological monitoring and variations in surgical technique
show promise by allowing surgeons to minimise or prevent the incidence
of C5 palsy. Conservative treatment is the current treatment of
choice; most patients make a full recovery within two years. Cite this article:
Patient function after arthroplasty should ideally quickly improve.
It is not known which peri-operative function assessments predict
length of stay (LOS) and short-term functional recovery. The objective
of this study was to identify peri-operative functions assessments
predictive of hospital LOS and short-term function after hospital discharge
in hip or knee arthroplasty patients. In total, 108 patients were assessed peri-operatively with the
timed-up-and-go (TUG), Iowa level of assistance scale, post-operative
quality of recovery scale, readiness for hospital discharge scale,
and the Western Ontario and McMaster Osteoarthritis Index (WOMAC).
The older Americans resources and services activities of daily living
(ADL) questionnaire (OARS) was used to assess function two weeks
after discharge. Objectives
Methods
In this paper, we will consider the current role
of simultaneous-bilateral TKA. Based on available evidence, it is
our opinion that simultaneous bilateral TKA carries a higher risk
of morbidity and mortality and should be reserved for select few.
Transarticular screw fixation with autograft
is an established procedure for the surgical treatment of atlantoaxial instability.
Removal of the posterior arch of C1 may affect the rate of fusion.
This study assessed the rate of atlantoaxial fusion using transarticular
screws with or without removal of the posterior arch of C1. We reviewed
30 consecutive patients who underwent atlantoaxial fusion with a
minimum follow-up of two years. In 25 patients (group A) the posterior
arch of C1 was not excised (group A) and in five it was (group B).
Fusion was assessed on static and dynamic radiographs. In selected
patients CT imaging was also used to assess fusion and the position
of the screws. There were 15 men and 15 women with a mean age of
51.2 years (23 to 77) and a mean follow-up of 7.7 years (2 to 11.6).
Stable union with a solid fusion or a stable fibrous union was achieved
in 29 patients (97%). In Group A, 20 patients (80%) achieved a solid
fusion, four (16%) a stable fibrous union and one (4%) a nonunion.
In Group B, stable union was achieved in all patients, three having
a solid fusion and two a stable fibrous union. There was no statistically
significant difference between the status of fusion in the two groups.
Complications were noted in 12 patients (40%); these were mainly
related to the screws, and included malpositioning and breakage.
The presence of an intact or removed posterior arch of C1 did not
affect the rate of fusion in patients with atlantoaxial instability
undergoing C1/C2 fusion using transarticular screws and autograft. Cite this article:
We analysed the incidence of slipped capital
femoral epiphysis (SCFE) in South Australia, investigating possible associations
between an increased incidence of SCFE, the local indigenous population
and the Australian obesity epidemic during the last 20 years. Data
including race, age and gender were collected to obtain a profile
of the South Australian SCFE patient, and were then compared with
epidemiological data for South Australian adolescents. We concluded
that the incidence of both obesity and SCFE is increasing. We also
noted that the median weight of SCFE patients has increased and
the mean age at diagnosis has decreased. Despite weight profiles
comparable with those of the general population, we noted that an
indigenous child was three times more likely to develop SCFE than
a non-indigenous child. As far as we know there is no published
literature on the predisposition of Aboriginal Australians to SCFE.
We continued a prospective longitudinal follow-up
study of 53 remaining patients who underwent open total meniscectomy
as adolescents and who at that time had no other intra-articular
pathology of the knee. Their clinical, radiological and patient-reported
outcomes are described at a mean follow-up of 40 years (33 to 50).
The cohort of patients who had undergone radiological evaluation
previously after 30 years were invited for clinical examination,
radiological evaluation and review using two patient-reported outcome
measures. A total of seven patients (13.2%) had already undergone total
knee replacement at the time of follow-up. A significant difference
was observed between the operated and non-operated knee in terms
of range of movement and osteoarthritis of the tibiofemoral joint,
indicating a greater than fourfold relative risk of osteoarthritis
at 40 years post-operatively. All patients were symptomatic as defined
by the Knee Injury and Osteoarthritis Outcome Score. This study represents the longest follow-up to date and it can
be concluded that meniscectomy leads to symptomatic osteoarthritis
of the knee later in life, with a resultant 132-fold increase in
the rate of total knee replacement in comparison to their geographical
and age-matched peers.
Rebound growth after hemiepiphysiodesis may be
a normal event, but little is known about its causes, incidence
or factors related to its intensity. The aim of this study was to
evaluate rebound growth under controlled experimental conditions. A total of 22 six-week-old rabbits underwent a medial proximal
tibial hemiepiphysiodesis using a two-hole plate and screws. Temporal
growth plate arrest was maintained for three weeks, and animals
were killed at intervals ranging between three days and three weeks
after removal of the device. The radiological angulation of the proximal
tibia was studied at weekly intervals during and after hemiepiphysiodesis.
A histological study of the retrieved proximal physis of the tibia
was performed. The mean angulation achieved at three weeks was 34.7° (standard
deviation ( In our rabbit model, rebound was an event of variable incidence
and intensity and, when present, did not appear immediately after
restoration of growth, but took some time to appear. Cite this article:
The April 2015 Hip &
Pelvis Roundup360 looks at: Goal-directed fluid therapy in hip fracture; Liberal blood transfusion no benefit in the longer term; Repeated measures: increased accuracy or compounded errors?; Peri-acetabular osteotomy safer than perhaps thought?; Obesity and peri-acetabular osteotomy: poor bedfellows; Stress fracture in peri-acetabular osteotomy; Infection and tantalum implants; Highly crosslinked polyethylene really does work
Deep vein thrombosis is a common complication
of immobilising the lower limb after surgery. We hypothesised that
intermittent pneumatic compression (IPC) therapy in outpatients
who had undergone surgical repair of acute ruptures of the Achilles
tendon could reduce the incidence of this problem. A total of 150 patients who had undergone surgical repair of
the Achilles tendon were randomised to either treatment with IPC
for six hours per day (n = 74) under an orthosis or treatment as
usual (n = 74) in a plaster cast without IPC. At two weeks post-operatively,
the incidence of deep vein thrombosis was assessed using blinded, double-reported
compression duplex ultrasound. At this point, IPC was discontinued
and all patients were immobilised in an orthosis for a further four
weeks. At six weeks post-operatively, a second compression duplex ultrasound
scan was performed. At two weeks, the incidence of deep vein thrombosis was 21% in
the treated group and 37% in the control group (p = 0.042). Age
over 39 years was found to be a strong risk factor for deep vein
thrombosis (odds ratio (OR) = 4.84, 95% confidence interval (CI)
2.14 to 10.96). Treatment with IPC, corrected for age differences
between groups, reduced the risk of deep vein thrombosis at the
two-week point (OR = 2.60; 95% CI 1.15 to 5.91; p =0.022). At six weeks,
the incidence of deep vein thrombosis was 52% in the treated group
and 48% in the control group (OR 0.94, 95% CI 0.49 to 1.83). IPC
appears to be an effective method of reducing the risk of deep vein
thrombosis in the early stages of post-operative immobilisation
of outpatients. Further research is necessary to elucidate whether
it can confer similar benefits over longer periods of immobilisation
and in a more heterogeneous group of patients. Cite this article:
The aims of this piece of work were to: 1) record the background
concentrations of blood chromium (Cr) and cobalt (Co) concentrations
in a large group of subjects; 2) to compare blood/serum Cr and Co
concentrations with retrieved metal-on-metal (MoM) hip resurfacings;
3) to examine the distribution of Co and Cr in the serum and whole
blood of patients with MoM hip arthroplasties; and 4) to further
understand the partitioning of metal ions between the serum and
whole blood fractions. A total of 3042 blood samples donated to the local transfusion
centre were analysed to record Co and Cr concentrations. Also, 91
hip resurfacing devices from patients who had given pre-revision
blood/serum samples for metal ion analysis underwent volumetric
wear assessment using a coordinate measuring machine. Linear regression analysis
was carried out and receiver operating characteristic curves were
constructed to assess the reliability of metal ions to identify
abnormally wearing implants. The relationship between serum and
whole blood concentrations of Cr and Co in 1048 patients was analysed
using Bland-Altman charts. This relationship was further investigated
in an Objectives
Methods
Tranexamic acid (TXA) has been used to reduce
blood loss during total hip arthroplasty (THA), but its use could increase
the risk of venous thromboembolic disease (VTE). Several studies
have reported that TXA does not increase the prevalence of deep
vein thrombosis (DVT), but most of those used routine chemical thromboprophylaxis,
thereby masking the potential increased risk of TXA on VTE. We wished
to ascertain whether TXA increases the prevalence of VTE in patients
undergoing THA without routine chemical thromboprophylaxis. We carried
out a retrospective case-control study in 254 patients who underwent
a primary THA, 127 of whom received TXA (1 g given pre-operatively)
and a control group of 127 who did not. All patients had mechanical
but no chemical thomboprophylaxis. Each patient was examined for
DVT by bilateral ultrasonography pre-operatively and on post-operative
days 1 and 7. TXA was found to statistically significantly increase
the incidence of total DVT on post-operative day 7 compared with
the control group (24 (18.9%) and 12 (9.4%), respectively; p <
0.05) but most cases of DVT were isolated distal DVT, with the exception
of one patient with proximal DVT in each group. One patient in the control
group developed a non-fatal symptomatic pulmonary embolism (PE).
The use of TXA did not appear to affect the prevalence of either
proximal DVT or PE. Cite this article:
In this paper, we will consider the current role
of simultaneous-bilateral TKA. Based on available evidence, it is
our opinion that bilateral one stage TKR is a safe and efficacious treatment
for patients with severe bilateral arthritic knee disease but should
be reserved for selected patients without significant medical comorbidities.