An Analysis of a National Administrative Dataset Demonstrating No Evidence of Increase in Elective Primary Total Hip Arthroplasty Dislocation Rates When Postoperative Hip Precautions are Not Used.

BACKGROUND: The purpose of this study is to determine whether there is a higher dislocation rate when postoperative hip precautions are not used for primary total hip arthroplasty (THA). METHODS: A survey was conducted of the hip precautions used by orthopaedic departments in England performing elective primary THA. From the responses to the survey an interrupted time series analysis was performed using the hospital admissions data from the Hospital Episode Statistics (HES) database during the period April 1, 2011 to December 31, 2019 and subsequent dislocations of these prostheses up to June 30, 2020. These were used to determine dislocations within 180 days of primary surgery and emergency readmissions within 30 days of discharge. RESULTS: Records were reviewed from 229,057 patients receiving primary, elective THA across 114 hospitals. In total, 1,807 (0.8%) dislocations were recorded within 180 days of surgery. There were 12,416 (5.4%) emergency readmissions within 30 days of surgery. Within hospitals where hip precautions were stopped, the proportion of patients having a dislocation was 0.8% both before and after stopping precautions, with a significant postintervention trend towards fewer dislocations (P < .001). There was also a significant immediate change in median length of stay from 4 to 3 days (P < .001) but no significant trend in the proportion of emergency readmissions within 30 days. CONCLUSION: There is no evidence of an increase in early dislocation or 30-day readmission rates after stopping traditional postoperative hip precautions in primary THA. Potential reductions in length of stay will reduce the risks associated with an extended hospital admission, improve service efficiency, and reduce costs.

Correction to: Can spinal surgery in England be saved from litigation: a review of 978 clinical negligence claims against the NHS.

Unfortunately, the first author name was incorrectly published in the original publication. The complete correct name is given as below.

Can spinal surgery in England be saved from litigation: a review of 978 clinical negligence claims against the NHS.

PURPOSE: The aim of this study is to evaluate the true incidence of all clinical negligence claims against spinal surgery performed by orthopaedic spinal surgeons and neurosurgeons in the National Health Service (NHS) in England, including both open and closed claims. METHODS: This study was a retrospective review of 978 clinical negligence claims held by NHS Resolution against spinal surgery cases identified from claims against 'Neurosurgery' and 'Orthopaedic Surgery'. This category included all emergency, trauma and elective work and all open and closed cases without exclusion between April 2012 and April 2017. RESULTS: Clinical negligence claims in spinal surgery were estimated to cost £535.5 million over this five-year period. There is a trend of both increasing volume and estimated costs of claims. The most common causes for claims were 'judgement/timing' (512 claims, 52.35%), 'interpretation of results/clinical picture' (255 claims, 26.07%), 'unsatisfactory outcome to surgery' (192 claims, 19.63%), 'fail to warn/informed consent' (80 claims, 8.13%) and 'never events' including 'wrong site surgery' or 'retained instrument post-operation' (26 claims, 2.66%). A sub-analysis of 3 years including 574 claims revealed the most prevalent pathologies were iatrogenic nerve damage (132 claims, 23.00%), cauda equina syndrome (CES) (131 claims, 22.82%), inadequate decompression (91 claims, 15.85%), iatrogenic cord damage (72 claims, 12.54%), and infection (51 claims, 8.89%). CONCLUSIONS: The volume and costs of clinical negligence claims is threatening the future of spinal surgery. If spinal surgery is to continue to serve the patients who need it, most thorough investigation, implementation and sharing of lessons learned from litigation claims must be systematically carried out. These slides can be retrieved under Electronic Supplementary Material.

Hydroxyapatite-coated collars reduce radiolucent line progression in cemented distal femoral bone tumor implants.

BACKGROUND: Aseptic loosening of massive bone tumor implants is a major cause of prosthesis failure. Evidence suggests that an osteointegrated hydroxyapatite (HA)-coated collar would reduce the incidence of aseptic loosening around the cemented intramedullary stem in distal femoral bone tumor prostheses. Because these implants often are used in young patients with a tumor, such treatment might extend the longevity of tumor implants. Questions/purposes We asked whether (1) HA-coated collars were more likely to osteointegrate; (2) HA collars were associated with fewer progressive radiolucent lines around the stem-cement interface; and (3) HA-coated collars were associated with less bone loss at the bone-shoulder implant junction? METHODS: Twenty-two patients were pair-matched to one of two groups--either (1) implants with a HA-coated ingrowth collar (HA Collar Group); or (2) implants without an ingrowth collar (Noncollar Group). Age, sex, and length of followup were similar in both groups. HA-coated collars were developed and used at our institution from 1992 to address the high failure rate attributable to aseptic loosening in patients with massive bone tumor implants. Before this, smooth titanium shafts were used routinely adjacent to bone at the transection site. The minimum followup was 2 years (mean, 7 years; range, 2-12 years). Radiographs obtained throughout the followup period were analyzed and osteointegration at the shaft of the implant quantified. Radiolucent line progression around the cemented stem was semi-quantitatively assessed and cortical bone loss at the bone-shoulder implant junction was measured during the followup period. RESULTS: Comparison of the most recent radiographs showed nine of 11 patients had osteointegrated HA collars, whereas only one patient in the Noncollar Group had osteointegration (p > 0.001). The radiolucent line score quantified around the cemented stem was lower in the HA Collar Group when compared with the Noncollar Group (p = 0.001). Results showed an increase in cortical bone loss at the bone-shoulder implant junction in the Noncollar Group when compared with the HA Collar Group (p < 0.001). CONCLUSIONS: Osteointegration at the implant collar resulted in fewer radiolucent lines adjacent to the intramedullary cemented stem and decreased cortical bone loss immediately adjacent to the transection site. These results suggest that the HA collar may help reduce the risk of aseptic loosening in patients with this type of implant, but longer followup and a larger prospective comparison series are necessary to prove this more definitively.

Custom-made cement-linked mega prostheses: a salvage solution for complex periprosthetic femoral fractures.

Periprosthetic femoral fractures with long stem implants, poor bone stock and loosening pose a considerable surgical challenge. We describe a reconstruction technique using a custom-made mega-prosthesis, cement-linked to the femoral stem of a well-fixed existing implant. Clinical and radiological outcomes were assessed at our tertiary referral centre. There were 15 patients with a periprosthetic femoral fracture: 5 proximal and 10 distal femoral arthroplasties linked to existing femoral stems. The survival rate was 93.3% at a mean follow-up of 5.3 years (0.5-19.3) with 1 revision. We present a salvage technique with good intermediate-term outcomes for highly selected patients with complex periprosthetic femoral fractures, as another option to conventional fixation methods. Specifically, it allows immediate weight bearing and avoids some of the morbidity of total femoral arthroplasty or amputation.

The impact of a revision arthroplasty network on patient outcomes.

Aims: Revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA) are complex procedures with higher rates of re-revision, complications, and mortality compared to primary TKA and THA. We report the effects of the establishment of a revision arthroplasty network (the East Midlands Specialist Orthopaedic Network; EMSON) on outcomes of rTKA and rTHA. Methods: The revision arthroplasty network was established in January 2015 and covered five hospitals in the Nottinghamshire and Lincolnshire areas of the East Midlands of England. This comprises a collaborative weekly multidisciplinary meeting where upcoming rTKA and rTHA procedures are discussed, and a plan agreed. Using the Hospital Episode Statistics database, revision procedures carried out between April 2011 and March 2018 (allowing two-year follow-up) from the five network hospitals were compared to all other hospitals in England. Age, sex, and mean Hospital Frailty Risk scores were used as covariates. The primary outcome was re-revision surgery within one year of the index revision. Secondary outcomes were re-revision surgery within two years, any complication within one and two years, and median length of hospital stay. Results: A total of 57,621 rTHA and 33,828 rTKA procedures were performed across England, of which 1,485 (2.6%) and 1,028 (3.0%), respectively, were conducted within the network. Re-revision rates within one year for rTHA were 7.3% and 6.0%, and for rTKA were 11.6% and 7.4% pre- and postintervention, respectively, within the network. This compares to a pre-to-post change from 7.4% to 6.8% for rTHA and from 11.7% to 9.7% for rTKA for the rest of England. In comparative interrupted time-series analysis for rTKA there was a significant immediate improvement in one-year re-revision rates for the revision network compared to the rest of England (p = 0.024), but no significant change for rTHA (p = 0.504). For the secondary outcomes studied, there was a significant improvement in trend for one- and two-year complication rates for rTHA for the revision network compared to the rest of England. Conclusion: Re-revision rates for rTKA and complication rates for rTHA improved significantly at one and two years with the introduction of a revision arthroplasty network, when compared to the rest of England. Most of the outcomes studied improved to a greater extent in the network hospitals compared to the rest of England when comparing the pre- and postintervention periods.

Proximal ulna endoprosthetic replacement for bone tumours in young patients.

PURPOSE: The optimal reconstructive method after resection of malignant bone tumours of the proximal ulna is unknown.We report the outcome of endoprosthetic replacement in a young patient population. METHODS: This was a retrospective review of four patients[three males and one female; mean age 17.5 (range 11­31)years] who underwent limb salvage with a proximal ulnar endoprosthetic replacement following excision of malignant bone tumour. Mean follow-up was 85 (range 14­194) months. RESULTS: All patients were alive at final follow-up and reported an improvement in pain. One patient required transhumeral amputation for intralesional excision complicating a local recurrence at one month. Two patients developed fixed flexion deformities of the elbow, one of whom required radial-head excision. Mean Musculoskeletal Tumour Society (MSTS)score and Toronto Extremity Salvage Score (TESS) were 27(range 25­28) and 81 (73­88), respectively. CONCLUSIONS: Custom-made proximal ulna endoprosthetic replacement following resection of malignant bone tumours in young patients provides a stable reconstruction option with satisfactory function and without apparent compromise in patient survival.

Custom cementless THA in patients with skeletal dysplasia results in lower apparent revision rates than other types of femoral fixation.

BACKGROUND: Patients with skeletal dysplasia are prone to degenerative hip disease thus requiring THA at a younger age than the general population. This is a technically demanding procedure with high complication and revision rates. Achieving good femoral fixation can be challenging because of the abnormal features of the hip. QUESTIONS/PURPOSES: We therefore determined: (1) survivorship, (2) function, (3) radiographic findings, and (4) complications associated with a cementless custom-made femoral component used in THAs for patients with skeletal dysplasia and compared these parameters with those from other types of femoral fixation. PATIENTS AND METHODS: Between 1992 and 2005, 40 THAs were performed in 25 patients with skeletal dysplasia using custom-made cementless femoral components. There were 15 men and 10 women with a mean age of 37.5 years (range, 18-61 years) and a mean height of 145 cm (range, 120-173 cm). Patients were followed clinically and radiographically for a minimum of 4.3 years (mean, 10.1 years; range, 4.3-18.2 years). RESULTS: The survivorship rates for the femoral and acetabular components were 92% and 70%, respectively, at 220 months. Revision arthroplasty was performed in four of 40 hips (10%). In two, the acetabular component was revised for aseptic loosening, one had both components revised for aseptic loosening, and one had an isolated femoral component revision for deep infection. The mean Harris hip score improved from 41 (range, 27-57) preoperatively to 80 (range, 51-94) at final followup. There were two intraoperative proximal femoral fractures and one dislocation. CONCLUSIONS: When compared with studies with equal followup, custom-made cementless components in THAs for patients with skeletal dysplasia apparently had lower revision and complication rates with comparable function and higher midterm survival.

Custom endoprosthetic reconstruction for malignant bone disease in the humeral diaphysis.

The optimal reconstructive method following segmental resection of malignant tumours in the humeral diaphysis is unknown as there are no prospective long-term studies comparing biologic with endoprosthetic reconstruction. This is a retrospective review of 13 patients who, between 1995 and 2010, had undergone limb salvage at our institution using a custom-made humeral diaphyseal endoprosthetic replacement following excision of malignant bone disease. There were 9 males and 4 females with a mean age of 35 years at the time of surgery (range: 10 to 78). Mean follow-up was 56.8 months (range: 5 to 148). Cumulative patient survival was 75% at 10 years. Implant survival, with removal of the endoprosthesis or part of it for any reason as an end point, was 47% at 10 years. Seven patients required revision (54%). Complications included metastases in four, aseptic loosening in four, peri-prosthetic fracture in two and local recurrence in two. Mean MSTS and TESS scores were 23 (18 to 27) and 67% (52-80) respectively. Custom-made humeral diaphyseal replacement following resection of malignant bone tumours provided functional results superior to amputation, without an obvious compromise in patient survival. There was a relatively high revision rate for aseptic loosening and peri-prosthetic fracture and patients should be counselled about this preoperatively.

Proximal femoral replacements for metastatic bone disease: financial implications for sarcoma units.

Metastatic pathological fractures of the proximal femur are increasingly treated by endoprosthetic proximal femoral replacement. We report the results and the costs incurred performing these procedures at our supra-regional sarcoma unit. Sixty-two patients underwent 63 proximal femoral replacements for metastatic bone disease over a seven-year period. Breast cancer was the most common primary pathology. One patient underwent a revision procedure for infection. Twenty-two patients suffered dislocations, most commonly those undergoing a conventional arthroplasty articulation. The estimated cost of a proximal femoral replacement is 18,002 pounds at our centre. Less than half of this is reimbursed under Payment by Results. Endoprosthetic replacement of the proximal femur is an effective treatment of metastases, but is poorly reimbursed under current funding arrangements.

Modular proximal femoral replacement in salvage hip surgery for non-neoplastic conditions.

Addressing severe proximal femoral bone loss in revision hip surgery is a challenging reconstructive problem. The use of modular proximal femoral megaprostheses is one of many available options to address this. This is a retrospective review of 15 patients who had undergone limb salvage at our institution using a modular proximal femoral replacement. There were 8 males and 7 females with a mean age of 67 years (34 to 85) and a mean follow-up of 60 months (1 to 99). Indications included re-implantation for deep infection in nine patients, aseptic loosening in three, periprosthetic fracture in two and painful excision arthroplasty in one. Mean Harris hip score increased from 28 (13 to 49) pre-operatively to 69 (39 to 85) at final follow-up (paired t-test, p < 0.0001) and mean Toronto Extremity Salvage score increased from 26% (14 to 40) to 71% (35 to 82) (paired t-test, p < 0.0001). Prosthesis survival with revision as the endpoint was 87% at 5 years. There were two dislocations (14%) and there was failure to eradicate deep infection in two. Modular proximal femoral replacement provided good function and versatility with an acceptable complication rate for patients with severe proximal femoral bone loss with or without infection.

Nonbacterial osteitis: a clinical, histopathological, and imaging study with a proposal for protocol-based management of patients with this diagnosis.

BACKGROUND: Nonbacterial osteitis (NBO), a term referring to sterile bone lesions with nonspecific histopathological features of inflammation, may be either unifocal or multifocal, acute (< or =6 months) or chronic, and recurrent. Only when the condition is chronic, recurrent, and multifocal is it appropriate to use the term chronic recurrent multifocal osteomyelitis (CRMO). We present our clinical experience as the largest reported series of children with NBO to date. METHODS: We report a retrospective clinical, histopathological, and radiological study of 41 children with nonbacterial osteitis. RESULTS: Of 41 children (2-16 years of age) diagnosed with NBO in our institution over the last 6 years, 21 (51%) had recurrent disease and 18 (44%) had multifocal disease. The most common bones affected were the clavicle, femur, and tibia (in order of decreasing prevalence) accounting for 44 (63%) of a total of 70 lesions. Only one individual had SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis) and no other patients had evidence of bowel or skin disease. In the absence of evidence for an infective etiology, we recommend nonsteroidal anti-inflammatory agents as the firstline therapy and bisphosphonates only in cases of resistant disease. CONCLUSIONS: On the basis of our findings, we propose using a patient questionnaire and protocol for investigating and managing patients who present with NBO to orthopedic surgeons. We predict that this will benefit patients with this disorder by improving our knowledge of the presenting signs and symptoms and related disorders, rationalizing the therapeutic approach, and allowing us to learn about the natural history of the disease.

Use of a distal radius endoprosthesis following resection of a bone tumour: a case report.

Limited literature is available on the reconstruction of the distal radius using prosthetic replacement following resection of a bone tumour. We present the first reported case, in the English literature, of the use of an entirely metal endoprosthesis for the reconstruction of the distal radius. This case involves a 66-year-old male who was treated for giant cell tumour of the distal radius with surgical excision of the lesion and replacement of the defect using a predominantly titanium endoprosthesis. He was followed-up for 56 months following surgery and had a good functional outcome with no associated pain or complications. We propose that the use of a primarily titanium endoprosthesis for the reconstruction of a bone defect of the distal radius is a suitable alternative, providing good function of the forearm with satisfactory range of movement at the wrist and adequate pain relief.

Late widespread skeletal metastases from myxoid liposarcoma detected by MRI only.

BACKGROUND: Myxoid liposarcoma is the second most commonly occurring sub-type of liposarcomas. In contrast to other soft tissue sarcomas, it is known to have a tendency to spread toward extrapulmonary sites, such as soft tissues, retroperitoneum, and the peritoneal surface. Bony spread, however, is not as common. CASE PRESENTATION: We report an unusual case of diffuse skeletal metastases from myxoid liposarcoma occurring 13 years after treatment of the primary tumour in the left lower limb. The skeletal spread of the disease was demonstrated on MRI only after other imaging modalities (plain radiography, CT and TC99 bone scans) had failed to detect these metastases. CONCLUSION: MRI is an extremely sensitive and specific screening tool in the detection of skeletal involvement in these types of sarcomas, and therefore, should be a part of the staging process.

Immune responses in patients with metal-on-metal hip articulations: a long-term follow-up.

Metal-on-metal (MoM) hip bearings are being inserted into ever-younger patients. The effects on the immune system of chronic exposure are unknown. We investigated the immune response of patients with MoM hip bearings. In patients with MoM implants, the expression of antigen-presenting cell (APC) surface molecules (CD86 and HLA-DR) was seen to be significantly higher (P < .05) than control group. High levels of APC surface molecules suggest an activated state and attempts to propagate an immune response. However, in the same group, the expression of T-cell markers (CD3 and CD28) was low, indicating a small T-cell population. This suggests, despite the activation of APCs, that T cells down-regulate immune responses in MoM articulations. Conversely, in metal-on-polyethylene articulations, expression of T-cell molecules was elevated and expression of APC molecules lowered.

A Review of the Surgical Management of Extrathoracic Solitary Fibrous Tumors.

OBJECTIVES: Extrathoracic solitary fibrous tumors (ESFTs) are rare low-to-intermediate grade spindle-cell neoplasms of pluripotent fibroblastic or myofibroblastic origin. This review explores prognostic factors in the management of ESFTs and provides guidance on optimal treatment regimens based on the current literature. PATIENTS AND METHODS: Electronic searches were performed using MEDLINE, Embase, and the Cochrane library to identify studies on prognostic factors in the management of ESFTs published between January 1970 and June 2016. The literature search and review process identified 100 articles that were included in this review article. This included both surgical and nonsurgical studies on the management of ESFTs. RESULTS: Surgical excision with wide resection margins forms the mainstay of treatment and provides optimal long-term oncological outcomes. Large tumor size (>5 to 10 cm diameter), inadequate resection margins, malignant histologic features, dedifferentiation, and tumor location within the abdomen/pelvis are associated with adverse oncological outcomes. Radiotherapy may be used for preoperative tumor shrinkage and/or as adjuvant therapy in patients with malignant disease or incomplete surgical margins. Chemotherapy with molecular-targeted therapies has produced promising results and the results of further phase 2 trials are awaited. CONCLUSIONS: Routine long-term follow-up is essential for benign and malignant disease to enable early detection and treatment of recurrent disease.

Use of a novel bone graft substitute in peri-articular bone tumours of the knee.

We treated three patients with aneurysmal bone cysts and seven with giant cell tumours who presented with a large osteolytic lesion in peri-articular areas of the knee. The patients age ranged from 8 to 49 years (mean 25 years). The average tumour volume was measured at 39.8 cm(3) (range 18 to 65 cm(3)). The tumour cavities were treated with curettage, phenolisation and application of a composite bone graft substitute containing 35% calcium-sulphate hemihydrate and 65% hydroxyapatite granules. All patients were followed up for 4.0 to 5.2 years (mean 4.5 years). Tumour recurrence was noted in two cases. In the remaining patients consolidation of the lesion was considered complete at a mean of 4.5 months (3-6.5 months). During follow-up no deformities developed and no radiological signs of joint degeneration were noted. All patients regained close to normal function, with a mean Musculoskeletal Tumour Society Rating Score of 95.1%. Due to their good osteoconductive abilities, composite synthetic bone graft substitute combining porous hydroxyapatite with calcium-sulphate appears to be an effective alternative to autologous cancellous bone graft in the treatment of large osteolytic lesions in peri-articular areas around the knee joint. They bear major advantages through ubiquitous availability and the avoidance of morbidity associated with iliac crest harvest. Concerns remain as the radio-opaque appearance of the bone graft substitute may potentially delay the detection of tumour recurrence.

Orthopaedic manifestations of congenital indifference to pain with anhidrosis (Hereditary Sensory and Autonomic Neuropathy type IV).

BACKGROUND: Congenital indifference to pain with anhidrosis (CIPA) is a rare hereditary neuropathy, which is associated with defective sensation to noxious stimuli and autonomic dysfunction. The objective of the study was to report on the orthopaedic manifestations of this condition and provide an evidence-based approach for management. METHODS: Retrospective review of 14 consecutive patients with CIPA referred to a single tertiary centre. Mean age of diagnosis was 2.5 years (range 0.5 to 11 years). RESULTS: Patients presented with a range of orthopaedic problems including fractures, infections, growth disturbance, joint subluxation and Charcot joints affecting the limbs and spine. Conservative treatment with closed reduction and cast immobilisation was satisfactory for stress fractures of the lower extremity and Charcot joints. Posterior instrumented correction of scoliosis was associated with a high-risk of infection requiring reoperation for debridement and removal of posterior instrumentation. Growth disturbance leading to leg-length discrepancies were managed with shoe raises and corrective osteotomies. Aspiration and cultures may be used to differentiate between acute fracture and infection. CONCLUSIONS: Preventative treatment strategies with appropriately padded shoe-wear, gait and posture modification, parental education regarding environmental thermoregulation, and behavioural support are essential for improving prognosis and reducing long-term complications.

Characterisation of cryopreserved cells freshly isolated from human bone marrow.

Osteoblast progenitor cells (OBPCs) isolated from bone marrow have the ability to differentiate into osteoblasts and thus potential therapeutic use to tissue-engineer bone. In order for OBPCs to be available for clinical use a means of storing viable cells is necessary. The aim of this study was to determine whether a simple method of cryopreservation had an effect on osteogenic differentiation or growth of OBPCs isolated from fresh human bone marrow. Stro-1 was used to identify the isolated OBPCs. The osteoblastic potential of the marrow cells was confirmed as culture with osteogenic supplements (OS) significantly increased osteoblastic protein production (alkaline phosphatase (ALP), osteopontin and osteocalcin) compared with standard conditions (P less than 0.05). Ten further marrow aspirates were harvested; each was halved for either cryopreservation or control culture. Primary cultures from both populations formed colonies with recognised OBPC morphology. OS stimulated both cryopreserved and control populations to produce significantly more osteoblastic proteins (P less than 0.05) and there was no significant difference between the increase in osteogenic proteins when cultured with OS (P great than 0.2). The proliferation rate after 5 days in culture was not significantly affected by cryopreservation (P greater than 0.05). It has been suggested that OBPCs are immuno-privileged; so allogenic cells could be implanted into patients for tissue engineering bone without causing a hypersensitivity reaction. Our study demonstrates a method of storage, which allows OBPCs to be available for use without affecting osteoblastic potential or viability.