Arthroplasty registries are important for the
surveillance of joint replacements and the evaluation of outcome. Independent
validation of registry data ensures high quality. The ability for
orthopaedic implant retrieval centres to validate registry data
is not known. We analysed data from the National Joint Registry
for England, Wales and Northern Ireland (NJR) for primary metal-on-metal
hip arthroplasties performed between 2003 and 2013. Records were
linked to the London Implant Retrieval Centre (RC) for validation.
A total of 67 045 procedures on the NJR and 782 revised pairs of
components from the RC were included. We were able to link 476 procedures
(60.9%) recorded with the RC to the NJR successfully. However, 306
procedures (39.1%) could not be linked. The outcome recorded by the
NJR (as either revised, unrevised or death) for a primary procedure
was incorrect in 79 linked cases (16.6%). The rate of registry-retrieval
linkage and correct assignment of outcome code improved over time.
The rates of error for component reference numbers on the NJR were
as follows: femoral head category number 14/229 (5.0%); femoral head
batch number 13/232 (5.3%); acetabular component category number
2/293 (0.7%) and acetabular component batch number 24/347 (6.5%). Registry-retrieval linkage provided a novel means for the validation
of data, particularly for component fields. This study suggests
that NJR reports may underestimate rates of revision for many types
of metal-on-metal hip replacement. This is topical given the increasing
scope for NJR data. We recommend a system for continuous independent
evaluation of the quality and validity of NJR data. Cite this article:
Whether patients with asymptomatic bacteriuria
should be investigated and treated before elective hip and knee replacement
is controversial, although it is a widespread practice. We conducted
a prospective observational cohort study with urine analyses before
surgery and three days post-operatively. Patients with symptomatic
urinary infections or an indwelling catheter were excluded. Post-discharge
surveillance included questionnaires to patients and general practitioners
at three months. Among 510 patients (309 women and 201 men), with
a median age of 69 years (16 to 97) undergoing lower limb joint
replacements (290 hips and 220 knees), 182 (36%) had pre-operative asymptomatic
bacteriuria, mostly due to We conclude that testing and treating asymptomatic urinary tract
colonisation before joint replacement is unnecessary. Cite this article:
We report our experience with glenohumeral arthrodesis
as a salvage procedure for epilepsy-related recurrent shoulder instability.
A total of six patients with epilepsy underwent shoulder fusion
for recurrent instability and were followed up for a mean of 39 months
(12 to 79). The mean age at the time of surgery was 31 years (22
to 38). Arthrodesis was performed after a mean of four previous
stabilisation attempts (0 to 11) in all but one patient in whom
the procedure was used as a primary treatment. All patients achieved
bony union, with a mean time to fusion of 2.8 months (2 to 7). There
were no cases of re-dislocation. One revision was undertaken for
loosening of the metalwork, and then healed satisfactorily. An increase
was noted in the mean subjective shoulder value, which improved
from 37 (5 to 50) pre-operatively to 42 (20 to 70) post-operatively
although it decreased in two patients. The mean Oxford shoulder
instability score improved from 13 pre-operatively (7 to 21) to
24 post-operatively (13 to 36). In our series, glenohumeral arthrodesis
eliminated recurrent instability and improved functional outcome. Fusion
surgery should therefore be considered in this patient population.
However, since the majority of patients are young and active, they
should be comprehensively counselled pre-operatively given the functional
deficit that results from the procedure. Cite this article:
Previous classification systems of failure of
limb salvage focused primarily on endoprosthetic failures and lacked sufficient
depth for the effective study of the causes of failure. In order
to address these inadequacies, the International Society of Limb
Salvage (ISOLS) formed a committee to recommend revisions of the
previous systems. The purpose of this study was to report on their
recommendations. The modifications were prepared using an earlier,
evidence-based model with subclassification based on the existing
medical literature. Subclassification for all five primary types
of failure of limb salvage following endoprosthetic reconstruction
were formulated and a complementary system was derived for the failure
of biological reconstruction. An additional classification of failure
in paediatric patients was also described. Limb salvage surgery presents a complex array of potential mechanisms
of failure, and a complete and precise classification of types of
failure is required. Earlier classification systems lacked specificity,
and the evidence-based system outlined here is designed to correct
these weaknesses and to provide a means of reporting failures of
limb salvage in order to allow the interpretation of outcome following
reconstructive surgery. 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:
A national, multi-centre study was designed in
which a questionnaire quantifying the degree of patient satisfaction
and residual symptoms in patients following total knee replacement
(TKR) was administered by an independent, blinded third party survey
centre. A total of 90% of patients reported satisfaction with the
overall functioning of their knee, but 66% felt their knee to be
‘normal’, with the reported incidence of residual symptoms and functional
problems ranging from 33% to 54%. Female patients and patients from
low-income households had increased odds of reporting dissatisfaction.
Neither the use of contemporary implant designs (gender-specific,
high-flex, rotating platform) or custom cutting guides (CCG) with
a neutral mechanical axis target improved patient-perceived outcomes.
However, use of a CCG to perform a so-called kinematically aligned
TKR showed a trend towards more patients reporting their knee to
feel ‘normal’ when compared with a so called mechanically aligned
TKR This data shows a degree of dissatisfaction and residual symptoms
following TKR, and that several recent modifications in implant
design and surgical technique have not improved the current situation. Cite this article:
Cartilage defects of the hip cause significant
pain and may lead to arthritic changes that necessitate hip replacement.
We propose the use of fresh osteochondral allografts as an option
for the treatment of such defects in young patients. Here we present
the results of fresh osteochondral allografts for cartilage defects
in 17 patients in a prospective study. The underlying diagnoses
for the cartilage defects were osteochondritis dissecans in eight
and avascular necrosis in six. Two had Legg-Calve-Perthes and one
a femoral head fracture. Pre-operatively, an MRI was used to determine
the size of the cartilage defect and the femoral head diameter.
All patients underwent surgical hip dislocation with a trochanteric
slide osteotomy for placement of the allograft. The mean age at
surgery was 25.9 years (17 to 44) and mean follow-up was 41.6 months
(3 to 74). The mean Harris hip score was significantly better after
surgery (p <
0.01) and 13 patients had fair to good outcomes.
One patient required a repeat allograft, one patient underwent hip
replacement and two patients are awaiting hip replacement. Fresh
osteochondral allograft is a reasonable treatment option for hip
cartilage defects in young patients. Cite this article:
Femoroacetabular Junction Impingement (FAI) describes abnormalities
in the shape of the femoral head–neck junction, or abnormalities
in the orientation of the acetabulum. In the short term, FAI can
give rise to pain and disability, and in the long-term it significantly increases
the risk of developing osteoarthritis. The Femoroacetabular Impingement
Trial (FAIT) aims to determine whether operative or non-operative
intervention is more effective at improving symptoms and preventing
the development and progression of osteoarthritis. FAIT is a multicentre superiority parallel two-arm randomised
controlled trial comparing physiotherapy and activity modification
with arthroscopic surgery for the treatment of symptomatic FAI.
Patients aged 18 to 60 with clinical and radiological evidence of
FAI are eligible. Principal exclusion criteria include previous
surgery to the index hip, established osteoarthritis (Kellgren–Lawrence
≥ 2), hip dysplasia (centre-edge angle <
20°), and completion
of a physiotherapy programme targeting FAI within the previous 12
months. Recruitment will take place over 24 months and 120 patients
will be randomised in a 1:1 ratio and followed up for three years.
The two primary outcome measures are change in hip outcome score
eight months post-randomisation (approximately six-months post-intervention
initiation) and change in radiographic minimum joint space width
38 months post-randomisation. ClinicalTrials.gov: NCT01893034. Cite this article: Aims
Methods
In patients with a tumour affecting the distal
ulna it is difficult to preserve the function of the wrist following extensive
local resection. We report the outcome of 12 patients (nine female,
three male) who underwent excision of the distal ulna without local
soft-tissue reconstruction. In six patients, an aggressive benign
tumour was present and six had a malignant tumour. At a mean follow-up
of 64 months (15 to 132) the mean Musculoskeletal Tumour score was
64% (40% to 93%) and the mean DASH score was 35 (10 to 80). The
radiological appearances were satisfactory in most patients. Local
recurrence occurred in one patient with benign disease and two with
malignant disease. The functional outcome was thus satisfactory
at a mean follow-up in excess of five years, with a relatively low
rate of complications. The authors conclude that complex reconstructive
soft-tissue procedures may not be needed in these patients. Cite this article:
Our aim was to compare the outcome of arthroscopic
release for frozen shoulder in patients with and without diabetes.
We prospectively compared the outcome in 21 patients with and 21
patients without diabetes, two years post-operatively. The modified
Constant score was used as the outcome measure. The mean age of
the patients was 54.5 years (48 to 65; male:female ratio: 18:24),
the mean pre-operative duration of symptoms was 8.3 months (6 to
13) and the mean pre-operative modified Constant scores were 36.6
(standard deviation ( Cite this article:
There have been several studies examining the
association between the morphological characteristics seen in acetabular
dysplasia and the incidence of the osteoarthritis (OA). However, most studies focus mainly on acetabular morphological
analysis, and few studies have scrutinised the effect of femoral
morphology. In this study we enrolled 36 patients with bilateral
acetabular dysplasia and early or mid-stage OA in one hip and no
OA in the contralateral hip. CT scans were performed from the iliac
crest to 2 cm inferior to the tibial tuberosity, and the morphological
characteristics of both acetabulum and femur were studied. In addition, 200 hips in 100 healthy volunteer Chinese adults
formed a control group. The results showed that the dysplastic group
with OA had a significantly larger femoral neck anteversion and
a significantly shorter abductor lever arm than both the dysplastic
group without OA and the controls. Femoral neck anteversion had
a significant negative correlation with the length of the abductor
lever arm and we conclude that it may contribute to the development
of OA in dysplastic hips. 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:
We report the clinical and radiological outcome
of subcapital osteotomy of the femoral neck in the management of symptomatic
femoroacetabular impingement (FAI) resulting from a healed slipped
capital femoral epiphysis (SCFE). We believe this is only the second
such study in the literature. We studied eight patients (eight hips) with symptomatic FAI after
a moderate to severe healed SCFE. There were six male and two female
patients, with a mean age of 17.8 years (13 to 29). All patients underwent a subcapital intracapsular osteotomy of
the femoral neck after surgical hip dislocation and creation of
an extended retinacular soft-tissue flap. The mean follow-up was
41 months (20 to 84). Clinical assessment included measurement of
range of movement, Harris Hip Score (HHS) and Western Ontario and McMaster
Universities Osteoarthritis score (WOMAC). Radiological assessment
included pre- and post-operative calculation of the anterior slip
angle (ASA) and lateral slip angle (LSA), the anterior offset angle
(AOA) and centre head–trochanteric distance (CTD). The mean HHS
at final follow-up was 92.5 (85 to 100), and the mean WOMAC scores
for pain, stiffness and function were 1.3 (0 to 4), 1.4 (0 to 6)
and 3.6 (0 to 19) respectively. There was a statistically significant
improvement in all the radiological measurements post-operatively.
The mean ASA improved from 36.6° (29° to 44°) to 10.3° (5° to 17°)
(p <
0.01). The mean LSA improved from 36.6° (31° to 43°) to 15.4°
(8° to 21°) (p <
0.01). The mean AOA decreased from 64.4° (50°
to 78°) 32.0° (25° to 39°) post-operatively (p <
0.01). The mean
CTD improved from -8.2 mm (-13.8 to +3.1) to +2.8 mm (-7.6 to +11.0)
(p <
0.01). Two patients underwent further surgery for nonunion.
No patient suffered avascular necrosis of the femoral head. Subcapital osteotomy for patients with a healed SCFE is more
challenging than subcapital re-orientation in those with an acute
or sub-acute SCFE and an open physis. An effective correction of
the deformity, however, can be achieved with relief of symptoms
related to impingement. Cite this article:
The October 2014 Wrist &
Hand Roundup360 looks at: pulsed electromagnetic field of no use in acute scaphoid fractures; proximal interphalangeal joint replacement: one at a time or both at once; trapeziometacarpal arthrodesis in the young patient; Tamoxifen and Dupytren’s disease; and endoscopic or open for de Quervain’s syndrome?
Although it has been suggested that the outcome
after revision of a unicondylar knee replacement (UKR) to total knee
replacement (TKR) is better when the mechanism of failure is understood,
a comparative study on this subject has not been undertaken. A total of 30 patients (30 knees) who underwent revision of their
unsatisfactory UKR to TKR were included in the study: 15 patients
with unexplained pain comprised group A and 15 patients with a defined
cause for pain formed group B. The Oxford knee score (OKS), visual
analogue scale for pain (VAS) and patient satisfaction were assessed before
revision and at one year after revision, and compared between the
groups. The mean OKS improved from 19 (10 to 30) to 25 (11 to 41) in
group A and from 23 (11 to 45) to 38 (20 to 48) in group B. The
mean VAS improved from 7.7 (5 to 10) to 5.4 (1 to 8) in group A
and from 7.4 (2 to 9) to 1.7 (0 to 8) in group B. There was a statistically
significant difference between the mean improvements in each group
for both OKS (p = 0.022) and VAS (p = 0.002). Subgroup analysis
in group A, performed in order to define a patient factor that predicts
outcome of revision surgery in patients with unexplained pain, showed
no pre-operative differences between both subgroups. These results may be used to inform patients about what to expect
from revision surgery, highlighting that revision of UKR to TKR
for unexplained pain generally results in a less favourable outcome
than revision for a known cause of pain. Cite this article:
Patient-centred medicine is an approach to medical care that emphasises the patient experience. Treatment outcome measures reflect this experience, and outcomes are measured by obtaining patient feedback. Central to this type of care is the patient-physician relationship. Communication, physician empathy, and shared decision making are key components of this relationship. Patient-centred care is correlated with better patient outcomes across medical specialties and higher patient perceived quality of care. Payors are now using patient-centred quality measures in their physician reimbursement schedules.
A total of 219 hips in 192 patients aged between
18 and 65 years were randomised to 28-mm metal-on-metal uncemented
total hip replacements (THRs, 107 hips) or hybrid hip resurfacing
(HR, 112 hips). At a mean follow-up of eight years (6.6 to 9.3)
there was no significant difference between the THR and HR groups
regarding rate of revision (4.0% (4 of 99) Cite this article:
The outcome of surgery for recurrent lumbar disc
herniation is debatable. Some studies show results that are comparable
with those of primary discectomy, whereas others report worse outcomes.
The purpose of this study was to compare the outcome of revision
lumbar discectomy with that of primary discectomy in the same cohort
of patients who had both the primary and the recurrent herniation
at the same level and side. A retrospective analysis of prospectively gathered data was undertaken
in 30 patients who had undergone both primary and revision surgery
for late recurrent lumbar disc herniation. The outcome measures
used were visual analogue scales for lower limb (VAL) and back (VAB)
pain and the Oswestry Disability Index (ODI). There was a significant improvement in the mean VAL and ODI scores
(both p <
0.001) after primary discectomy. Revision surgery also
resulted in improvements in the mean VAL (p <
0.001), VAB (p
= 0.030) and ODI scores (p <
0.001). The changes were similar
in the two groups (all p >
0.05). Revision discectomy can give results that are as good as those
seen after primary surgery. Cite this article:
The February 2013 Wrist &
Hand Roundup360 looks at: to splint or not to splint; salvage of the unsalvageable; a close shave for malunions; a classic approach to malunion; diabetic carpal tunnel; capsulodesis; a wrist from a fibula; thumb-based osteoarthritis - a further opinion from the Editor-in-Chief.