We hypothesised that the removal of the subchondral
bone plate (SCBP) for cemented acetabular component fixation in
total hip arthroplasty (THA) offers advantages over retention by
improving the cement-bone interface, without jeopardising implant
stability. We have previously published two-year follow-up data
of a randomised controlled trial (RCT), in which 50 patients with
primary osteoarthritis were randomised to either retention or removal
of the SCBP. The mean age of the retention group (n = 25, 13 males)
was 70.0 years ( Cite this article:
The April 2013 Spine Roundup360 looks at: smuggling spinal implants; local bone graft and PLIF; predicting disability with slipped discs; mortality and spinal surgery; spondyloarthropathy; brachytherapy; and fibrin mesh and BMP.
Total knee replacement (TKR) smart tibial trials
have load-bearing sensors which will show quantitative compartment
pressure values and femoral-tibial tracking patterns. Without smart
trials, surgeons rely on feel and visual estimation of imbalance
to determine if the knee is optimally balanced. Corrective soft-tissue
releases are performed with minimal feedback as to what and how
much should be released. The smart tibial trials demonstrate graphically
where and how much imbalance is present, so that incremental releases
can be performed. The smart tibial trials now also incorporate accelerometers
which demonstrate the axial alignment. This now allows the surgeon
the option to perform a slight recut of the tibia or femur to provide
soft-tissue balance without performing soft-tissue releases. Using
a smart tibial trial to assist with soft-tissue releases or bone
re-cuts, improved patient outcomes have been demonstrated at one
year in a multicentre study of 135 patients (135 knees). Cite this article:
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 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:
The aim of this study was to define return to
theatre (RTT) rates for elective hip and knee replacement (HR and
KR), to describe the predictors and to show the variations in risk-adjusted
rates by surgical team and hospital using national English hospital
administrative data. We examined information on 260 206 HRs and 315 249 KRs undertaken
between April 2007 and March 2012. The 90-day RTT rates were 2.1%
for HR and 1.8% for KR. Male gender, obesity, diabetes and several
other comorbidities were associated with higher odds for both index
procedures. For HR, hip resurfacing had half the odds of cement fixation
(OR = 0.58, 95% confidence intervals (CI) 0.47 to 0.71). For KR,
unicondylar KR had half the odds of total replacement (OR = 0.49,
95% CI 0.42 to 0.56), and younger ages had higher odds (OR = 2.23,
95% CI 1.65 to 3.01) for ages <
40 years compared with ages 60
to 69 years). There were more funnel plot outliers at three standard deviations
than would be expected if variation occurred on a random basis. Hierarchical modelling showed that three-quarters of the variation
between surgeons for HR and over half the variation between surgeons
for KR are not explained by the hospital they operated at or by
available patient factors. We conclude that 90-day RTT rate may
be a useful quality indicator for orthopaedics. Cite this article:
In a randomised controlled pragmatic trial we
investigated whether local infiltration analgesia would result in earlier
readiness for discharge from hospital after total knee replacement
(TKR) than patient-controlled epidural analgesia (PCEA) plus femoral
nerve block. A total of 45 patients with a mean age of 65 years
(49 to 81) received a local infiltration with a peri-articular injection
of bupivacaine, morphine and methylprednisolone, as well as adjuvant
analgesics. In 45 PCEA+femoral nerve blockade patients with a mean
age of 67 years (50 to 84), analgesia included a bupivacaine nerve
block, bupivacaine/hydromorphone PCEA, and adjuvant analgesics.
The mean time until ready for discharge was 3.2 days (1 to 14) in
the local infiltration group and 3.2 days (1.8 to 7.0) in the PCEA+femoral
nerve blockade group. The mean pain scores for patients receiving
local infiltration were higher when walking (p = 0.0084), but there
were no statistically significant differences at rest. The mean
opioid consumption was higher in those receiving local infiltration. The choice between these two analgesic pathways should not be
made on the basis of time to discharge after surgery. Most secondary
outcomes were similar, but PCEA+femoral nerve blockade patients
had lower pain scores when walking and during continuous passive
movement. If PCEA+femoral nerve blockade is not readily available, local
infiltration provides similar length of stay and similar pain scores
at rest following TKR. Cite this article:
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
The October 2014 Oncology Roundup360 looks at: how best to reconstruct humeral tumours; not everything is better via the arthroscope; obesity and sarcoma; frozen autograft;
The purpose of this study was to compare the
amount of acetabular bone removed during hip resurfacing (HR) and cementless
total hip replacement (THR), after controlling for the diameter
of the patient’s native femoral head. Based on a power analysis,
64 consecutive patients (68 hips) undergoing HR or THR were prospectively
enrolled in the study. The following data were recorded intra-operatively:
the diameter of the native femoral head, the largest reamer used,
the final size of the acetabular component, the size of the prosthetic
femoral head and whether a decision was made to increase the size
of the acetabular component in order to accommodate a larger prosthetic femoral
head. Results were compared using two-sided, independent samples
Student’s
The strain on clinic and surgeon resources resulting
from a rise in demand for total knee replacement (TKR) requires reconsideration
of when and how often patients need to be seen for follow-up. Surgeons
will otherwise require increased paramedical staff or need to limit
the number of TKRs they undertake. We reviewed the outcome data
of 16 414 primary TKRs undertaken at our centre to determine the
time to re-operation for any reason and for specific failure mechanisms.
Peak risk years for failure were determined by comparing the conditional
probability of failure, the number of failures divided by the total
number of TKRs cases, for each year. The median times to failure
for the most common failure mechanisms were 4.9 years (interquartile
range (IQR) 1.7 to 10.7) for femoral and tibial loosening, 1.9 years
(IQR 0.8 to 3.9) for infection, 3.1 years (IQR 1.6 to 5.5) for tibial
collapse and 5.6 years (IQR 3.4 to 9.3) for instability. The median
time to failure for all revisions was 3.3 years (IQR 1.2 to 8.5),
with an overall revision rate of 1.7% (n = 282). Results from our
patient population suggest that patients be seen for follow-up at
six months, one year, three years, eight years, 12 years, and every
five years thereafter. Patients with higher pain in the early post-operative
period or high body mass index (≥ 41 kg/m2) should be
monitored more closely. Cite this article:
In this prospective study a total of 80 consecutive
Chinese patients with Crowe type I or II developmental dysplasia of
the hip were randomly assigned for hip resurfacing arthroplasty
(HRA) or total hip replacement (THR). Three patients assigned to HRA were converted to THR, and three
HRA patients and two THR patients were lost to follow-up. This left
a total of 34 patients (37 hips) who underwent HRA and 38 (39 hips)
who underwent THR. The mean follow-up was 59.4 months (52 to 70)
in the HRA group and 60.6 months (50 to 72) in the THR group. There was
no failure of the prosthesis in either group. Flexion of the hip
was significantly better after HRA, but there was no difference
in the mean post-operative Harris hip scores between the groups.
The mean size of the acetabular component in the HRA group was significantly
larger than in the THR group (49.5 mm vs 46.1 mm, p = 0.001). There was
no difference in the mean abduction angle of the acetabular component
between the two groups. Although the patients in this series had risk factors for failure
after HRA, such as low body weight, small femoral heads and dysplasia,
the clinical results of resurfacing in those with Crowe type I or
II hip dysplasia were satisfactory. Patients in the HRA group had
a better range of movement, although neck-cup impingement was observed.
However, more acetabular bone was sacrificed in HRA patients, and
it is unclear whether this will have an adverse effect in the long
term.
Early and accurate prediction of hospital length-of-stay
(LOS) in patients undergoing knee replacement is important for economic
and operational reasons. Few studies have systematically developed
a multivariable model to predict LOS. We performed a retrospective
cohort study of 1609 patients aged ≥ 50 years who underwent elective,
primary total or unicompartmental knee replacements. Pre-operative
candidate predictors included patient demographics, knee function,
self-reported measures, surgical factors and discharge plans. In
order to develop the model, multivariable regression with bootstrap
internal validation was used. The median LOS for the sample was
four days (interquartile range 4 to 5). Statistically significant
predictors of longer stay included older age, greater number of comorbidities,
less knee flexion range of movement, frequent feelings of being
down and depressed, greater walking aid support required, total
( Cite this article:
We conducted a retrospective study to assess
the prevalence of adverse reactions to metal debris (ARMD) in patients
operated on at our institution with metal-on-metal (MoM) total hip
replacements with 36 mm heads using a Pinnacle acetabular shell.
A total of 326 patients (150 males, 175 hips; 176 females, 203 hips)
with a mean age of 62.7 years (28 to 85) and mean follow-up of 7.5
years (0.1 to 10.8) participating in our in-depth modern MoM follow-up
programme were included in the study, which involved recording whole
blood cobalt and chromium ion measurements, Oxford hip scores (OHS)
and plain radiographs of the hip and targeted cross-sectional imaging. Elevated
blood metal ion levels (>
5 parts per billion) were seen in 32 (16.1%)
of the 199 patients who underwent unilateral replacement. At 23
months after the start of our modern MoM follow-up programme, 29
new cases of ARMD had been revealed. Hence, the nine-year survival
of this cohort declined from 96% (95% CI 95 to 98) with the old
surveillance routine to 86% (95% CI 82 to 90) following the new
protocol. Although ARMD may not be as common in 36 mm MoM THRs as
in those with larger heads, these results support the Medicines
and Healthcare Products Regulatory Agency guidelines on regular
reviews and further investigations, and emphasise the need for specific
a follow-up programme for patients with MoM THRs. Cite this article:
Despite the worldwide usage of the cemented Contemporary
acetabular component (Stryker), no published data are available
regarding its use in patients aged <
50 years. We undertook a
mid- to long-term follow-up study, including all consecutive patients
aged
<
50 years who underwent a primary total hip replacement using
the Contemporary acetabular component with the Exeter cemented stem
between January 1999 and January 2006. There were 152 hips in 126
patients, 61 men and 65 women, mean age at surgery 37.6 years (16
to 49 yrs). One patient was lost to follow-up. Mean clinical follow-up of all implants was 7.6 years (0.9 to
12.0). All clinical questionnaire scores, including Harris hip score,
Oxford hip score and several visual analogue scales, were found
to have improved. The eight year survivorship of all acetabular
components for the endpoints revision for any reason or revision
for aseptic loosening was 94.4% (95% confidence interval (CI) 89.2
to 97.2) and 96.4% (95% CI 91.6 to 98.5), respectively. Radiological follow-up
was complete for 146 implants. The eight year survival for the endpoint
radiological loosening was 93.1% (95% CI 86.2 to 96.6). Three surviving
implants were considered radiologically loose but were asymptomatic.
The presence of acetabular osteolysis (n = 17, 11.8%) and radiolucent
lines (n = 20, 13.9%) in the 144 surviving cups indicates a need
for continued observation in the second decade of follow-up in order
to observe their influence on long-term survival. The clinical and radiological data resulting in a ten-year survival
rate >
90% in young patients support the use of the Contemporary
acetabular component in this specific patient group. Cite this article:
We evaluated the clinical results and complications
after extra-articular resection of the distal femur and/or proximal
tibia and reconstruction with a tumour endoprosthesis (MUTARS) in
59 patients (mean age 33 years (11 to 74)) with malignant bone or
soft-tissue tumours. According to a Kaplan–Meier analysis, limb
survival was 76% (95% confidence interval (CI) 64.1 to 88.5) after
a mean follow-up of 4.7 years (one month to 17 years). Peri-prosthetic infection
was the most common indication for subsequent amputation (eight
patients). Survival of the prosthesis without revision was 48% (95%
CI 34.8 to 62.0) at two years and 25% (95% CI 11.1 to 39.9) at five years
post-operatively. Failure of the prosthesis was due to deep infection
in 22 patients (37%), aseptic loosening in ten patients (17%), and
peri-prosthetic fracture in six patients (10%). Wear of the bearings
made a minor revision necessary in 12 patients (20%). The mean Musculoskeletal
Tumor Society score was 23 (10 to 29). An extensor lag >
10° was
noted in ten patients (17%). These results suggest that limb salvage after extra-articular
resection with a tumour prosthesis can achieve good functional results
in most patients, although the rates of complications and subsequent
amputation are higher than in patients treated with intra-articular
resection. 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 August 2014 Shoulder &
Elbow Roundup360 looks at: Myofibroblasts perhaps not implicated in post-traumatic elbow stiffness; olecranon tip biomechanically sound for coranoid reconstruction; obesity and elbow replacement don’t mix; single column plating successful for extra-articular distal humeral fractures; satisfaction not predictable in frozen shoulder; tenodesis and repair both acceptable in Grade II SLAP tears; glenoid bone grafting is effective and glenohumeral articular lesions best seen with an arthroscope.
Pre-operative variables are increasingly being
used to determine eligibility for total knee replacement (TKR).
This study was undertaken to evaluate the relationships, interactions
and predictive capacity of variables available pre- and post-operatively
on patient satisfaction following TKR. Using nationally collected
patient reported outcome measures and data from the National Joint
Registry for England and Wales, we identified
22 798 patients who underwent TKR for osteoarthritis between August
2008 and September 2010. The ability of specific covariates to predict
satisfaction was assessed using ordinal logistic regression and
structural equational modelling. Only 4959 (22%) of 22 278 patients
rated the results of their TKR as ‘excellent’, despite the majority
(71%, n = 15 882) perceiving their knee symptoms to be much improved.
The strongest predictors of satisfaction were post-operative variables.
Satisfaction was significantly and positively related to the perception
of symptom improvement (operative success) and the post-operative
EuroQol-5D score. While also significant within the models pre-operative
variables were less important and had a minimal influence upon post-operative
satisfaction. The most robust predictions of satisfaction occurred
only when both pre- and post-operative variables were considered
together. These findings question the appropriateness of restricting
access to care based on arbitrary pre-operative thresholds as these
factors have little bearing on post-operative satisfaction. Cite this article:
The aim of this study was to identify the incidence of post-operative symptomatic deep-vein thrombosis (DVT), as well as the risk factors for and location of DVT, in 665 patients (701 ankles) who underwent primary total ankle replacement. All patients received low-molecular-weight heparin prophylaxis. A total of 26 patients (3.9%, 26 ankles) had a symptomatic DVT, diagnosed by experienced radiologists using colour Doppler ultrasound. Most thrombi (22 patients, 84.6%) were localised distally in the operated limb. Using a logistic multiple regression model we identified obesity, a previous venous thromboembolic event and the absence of full post-operative weight-bearing as independent risk factors for developing a symptomatic DVT. The incidence of symptomatic DVT after total ankle replacement and use of low-molecular-weight heparin is comparable with that in patients undergoing total knee or hip replacement.
In this prospective study we studied the effect
of the inclination angle of the acetabular component on polyethylene wear
and component migration in cemented acetabular sockets using radiostereometric
analysis. A total of 120 patients received either a cemented Reflection
All-Poly ultra-high-molecular-weight polyethylene or a cemented
Reflection All-Poly highly cross-linked polyethylene acetabular
component, combined with either cobalt–chrome or Oxinium femoral
heads. Femoral head penetration and migration of the acetabular
component were assessed with repeated radiostereometric analysis
for two years. The inclination angle was measured on a standard
post-operative anteroposterior pelvic radiograph. Linear regression
analysis was used to determine the relationship between the inclination
angle and femoral head penetration and migration of the acetabular component. We found no relationship between the inclination angle and penetration
of the femoral head at two years’ follow-up (p = 0.9). Similarly,
our data failed to reveal any statistically significant correlation
between inclination angle and migration of these cemented acetabular
components (p = 0.07 to p = 0.9).