The Olympia anatomic polished cemented stem is associated with a high survivorship, excellent hip-specific functional outcome, and high satisfaction levels: follow-up of 239 consecutive patients beyond 15 years.

INTRODUCTION: The Olympia femoral stem is a stainless steel, anatomically shaped, polished and three-dimensionally tapered implant designed for use in cemented total hip arthroplasty (THA). The primary aim of this study was to determine the long-term survivorship, radiographic outcome, and patient-reported outcome measures (PROMs) of the Olympia stem. PATIENTS AND METHODS: Between May 2003 and December 2005, 239 patients (264 THAs) underwent a THA with an Olympia stem in our institution. Patient-reported outcome measures were assessed using the Oxford Hip Score (OHS), EuroQol-5 dimensions (EQ-5D) score, and patient satisfaction at mean 10 years following THA. Patient records and radiographs were then reviewed at a mean of 16.5 years (SD 0.7, 15.3-17.8) following THA to identify occurrence of complications or revision surgery for any cause following surgery. Radiographs were assessed for lucent lines and lysis according to Gruen's zones RESULTS: Mean patient age at surgery was 68.0 years (SD 10.9, 31-93 years). There were 156 women (65%, 176 THAs). Osteoarthritis was the indication for THA in 204 patients (85%). All cause stem survivorship at 10 years was 99.2% (95% confidence interval [CI], 97.9%-100%) and at 15 years was 97.5% (94.6%-100%). The 15-year stem survival for aseptic loosening was 100%. Analysis of all-cause THA failure demonstrated a survivorship of 98.5% (96.3%-100%) at 10 years and 95.9% (92.4%-99.4%) at 15 years. There were 9 THAs with non-progressive lucent lines in a single Gruen zone and 3 had lines in two zones, and no patient demonstrated signs for lysis. At a mean of 10-year (SD 0.8, 8.7-11.3) follow-up, mean OHS was 39 (SD 10.3, range 7-48) and 94% of patients reported being very satisfied or satisfied with their THA. CONCLUSIONS: The Olympia stem demonstrated excellent 10-year PROMs and very high rates of stem survivorship at final follow-up beyond 15 years.

Return to Work Following Total Knee and Hip Arthroplasty: The Effect of Patient Intent and Preoperative Work Status.

BACKGROUND: The ability of total knee and hip arthroplasty (TKA/THA) to facilitate return to work (RTW) when it is the patient's preoperative intent to do so remains unclear. We aimed at determining whether TKA/THA facilitated RTW in patients of working age who intended to return. METHODS: This is a prospective cohort study of 173 consecutive patients <65 years of age, undergoing unilateral TKA (n = 82: median age 58; range, 39-65; 36 [43.9%] male) or THA (n = 91: median age 59; range, 34-65; 42 [46.2%] male) during 2018. Oxford knee/hip scores, Oxford-Activity and Participation Questionnaire, and EuroQol-5 dimension (EQ-5D) scores were measured preoperatively and at 1 year when an employment questionnaire was also completed. RESULTS: Of patients who intended to RTW, 44 of 52 (84.6%) RTW by 1 year following TKA (at mean 14.8 ± 8.4 weeks) and 53 of 60 (88.3%) following THA (at mean 13.6 ± 7.5 weeks). Failure to RTW despite intent was associated with job physicality for TKA (P = .004) and negative preoperative EQ-5D for THA (P = .01). In patients unable to work before surgery due to joint disease, fewer RTW: 4 of 21 (19.0%) after TKA; and 6 of 17 (35.3%) after THA. Preoperative Oxford knee score >18.5 predicted RTW with 74% sensitivity (P < .001); preoperative Oxford hip score >19.5 predicted RTW with 75% sensitivity (P < .001). Preoperative EQ-5D indices were similarly predictive (P < .001). CONCLUSION: In this United Kingdom study, preoperative intent to RTW was the most powerful predictor of actual RTW following TKA/THA. Where patients intend to RTW following TKA/THA, 85% RTW following TKA and 88% following THA.

Gender and Preoperative Function Predict Physical Activity Levels After Revision Total Knee Arthroplasty.

BACKGROUND: The incidence of revision total knee arthroplasty (TKA) is projected to increase 6-fold worldwide by 2030. As the number of younger, physically active revision TKA patients increases in future, understanding factors influencing postoperative function will be increasingly important to help counsel patients. The primary aim of this study was to examine factors influencing return to physical activity following revision TKA. METHODS: Patients who had undergone tibiofemoral revision between 2003 and 2013 at a single UK teaching hospital were retrospectively identified from a prospectively collected arthroplasty database. Preoperative activity level (University of California, Los Angeles [UCLA] score), patient demographics, indication, implant used, and Oxford Knee Scores (OKSs) were recorded in the database. At a mean follow-up of 3.9 years (standard deviation, 2.2), UCLA score, OKS, EuroQol-5 Dimension Score (EQ-5D), satisfaction, complications, and WORQ scores (Work, Osteoarthritis and Joint-Replacement Questionnaire) were sampled via postal questionnaire. Patient experience of complications and related surgery was also identified from healthcare records. Univariate and multivariate analyses were performed. RESULTS: Responses were received from 112 revision TKAs (112 patients; mean age, 71 years). Mean UCLA activity scores improved from preoperative levels (P < .001): activity levels improved in 47% of patients with 58% engaging in moderate or more intensive activities (UCLA score ≥5). Postoperative activity level was independently predicted by male gender (P = .042) and preoperative UCLA score (P < .001). Increasing social deprivation was associated with inferior UCLA (P = .005), EQ-5D (P < .005), and OKS (P = .006) scores. Indication, implant type, and patient body mass index did not affect functional outcome or satisfaction (P > .05). Patients <65 years old were more likely to be dissatisfied (P = .009), and patients aged ≤55 years were more likely to report difficulties with WORQ criteria (P < .05). CONCLUSION: Although 90% of patients maintain activity levels following revision TKA, less than half increase levels and this is predicted by male sex and pre-revision activity level.

The survivorship of the link endo-rotational hinge total knee arthroplasty: 5-12-year follow-up of 100 patients.

INTRODUCTION: There is a paucity of survival data reporting the medium to long-term outcome of the LINK® Endo-Model® rotational hinge total knee arthroplasty (ERH-TKA). Such information is essential when counselling patients and predictors of survival would help inform patients of their likely outcome. MATERIALS AND METHODS: A series of patients, who received an ERH-TKA, with a minimum follow-up of 5 years, were retrospectively identified from an established arthroplasty database. Data were collected from paper and electronic patient records. This included patient demographics, indication for surgery, complication rates and revision status. Our primary outcome of interest was joint implant survival. RESULTS: One hundred patients underwent an ERH-TKA over an 11-year period. There were 66 females and 34 males, with a mean age of 73.8 years and 67.6 years, respectively. Indications were classified into primary (n = 41), aseptic revision (n = 47) and two-stage infective revision (n = 12). The median follow-up was 8.2 (range 5-12) years. One-year implant survival amongst the cohort was 99%, falling to 95% at 5 years. Overall, there were eight revisions during the follow-up period. Considering only cases of aseptic failure, survival was 97% at 5 years and all failures occurred amongst revision cases. Implant failure was greater following revision arthroplasty but this was not statistically significant (p = 0.97). Cox regression analysis identified male sex to be the only independent predictor of failure (hazard ratio 1.75, 95% CI 1.04-31.82, p = 0.04) after adjusting for confounding variables. CONCLUSIONS: The ERH-TKA has a good medium- to long-term survival rate but male patients are nearly twice as likely to undergo revision, compared to females, and should be made aware of this preoperatively.

Return to activity following revision total hip arthroplasty.

BACKGROUND: Demand for revision total hip arthroplasty (RTHA) continues to grow worldwide and is expected to more than double within the next 1-2 decades. The primary aim of this study was to examine return to function following revision THA in a UK population. PATIENTS AND METHODS: We assessed 118 patients (132 RTHAs, mean age 65 years SD 13, range 23-88) at a mean follow-up of 7.9 years (SD 4.4) postoperatively. Preoperative age, gender, BMI, social deprivation, operative indication, comorbidities, activity level (UCLA score) and Oxford Hip Scores (OHS) were recorded. Postoperative UCLA score, OHS, EQ-5D, satisfaction levels and performance in activities of daily living (ADLs) were obtained and univariate and multivariate analysis performed. RESULTS: Mean UCLA activity score improved following RTHA (p < 0.001): UCLA activity score improved in 37% and was unchanged in 50%; 49% of patients engaged in at least moderate level activities (UCLA score ≥ 6). Patient BMI, gender, age and reason for revision did not influence levels of pain, stiffness or activity at follow-up. Preoperative UCLA activity scores (p < 0.001) independently predicted long-term UCLA scores. Independent predictors (p < 0.05) of poor hip-specific function (OHS) following revision included social deprivation, revision for periprosthetic fracture and lower preoperative OHS. Difficulties with ADLs were associated with increasing deprivation, ≥ 3 comorbidities, and revision for periprosthetic fracture or infection (p < 0.05). Overall, 79% of patients remained satisfied or very satisfied following revision THA. Following RTHA, 10% suffered a dislocation and 13% required reoperation for complications. CONCLUSION: Revision THA facilitates long-term return to preoperative levels of physical activity in the majority of patients, though activity levels increase in one-third only. Overall over three-quarters are satisfied with their outcome, but revision for periprosthetic fracture or dislocation gives the worse overall outcomes and lower satisfaction levels.

Functional and patient-reported outcomes of the Swanson metacarpo-phalangeal arthroplasty in the rheumatoid hand.

INTRODUCTION: Replacement of the metacarpo-phalangeal joints (MCPJ) with silastic Swanson's implants can help decrease pain, stiffness and allow for improved function in rheumatoid arthritis (RA). There is a lack of patient reported outcome measure (PROM) studies assessing the efficacy of this procedure in RA. The aim of this study was to report any change in function, pain, stiffness and satisfaction following the Swanson MCPJ replacement using patient reported outcomes in a rheumatoid population. METHODS: The combined results of 64 RA patients (71 hands) with 284 Swanson MCPJ arthroplasties (mean follow-up: 75.85 months) were assessed using the validated M-SACRAH questionnaire and a separate satisfaction questionnaire. Radiographic evaluation was performed to insure correct alignment of the hinged prosthesis postoperatively. No attempt was made to identify other predictors, radiologically or clinically. Data analysed in the study was interpreted in the context of the number of hands and survivorship was defined as implant fracture, loosening or revision. RESULTS: The mean total functional outcome score improved by 46.2% and the total pain outcome improved by 60.2%. The total stiffness outcome improved by 56.9% postoperatively and the results obtained from the satisfaction questions revealed that 73.2% of patients would retrospectively elect to have the procedure again. We report two postoperative complications in this group of superficial wound infections. Radiographically, all MCPJs showed improved alignment, however five patients reported worsening pain, four patients reported increased stiffness and four reported reduced function postoperatively. There was one re-operation of a 5th MCPJ Swanson's, which did not require implant exchange and one implant was revised. Implant survivorship was 98.6%. CONCLUSIONS: Patient satisfaction and functional surrogate markers were overall favourable. Our results support the continued use of Swanson silastic arthoplasty in advanced RA.

Patient rated outcomes study into the surgical interventions available for the rheumatoid hand and wrist.

INTRODUCTION: A multitude of surgical interventions are recognised for the treatment of the rheumatoid hand and wrist, however there seems to be a distinct lack of patient rated outcome measures (PROMs) studies reporting on the efficacy of these procedures. The aim of this study was to assess the PROMs related to hand and wrist surgery in patients with rheumatoid arthritis (RA). MATERIALS AND METHODS: A single surgeon series identified 94 patients (133 hands) with RA who had undergone one of eight surgical procedures (Swanson's arthroplasty, finger joint or wrist arthrodesis, carpal tunnel decompression, posterior interosseous nerve denervation, RA nodule excision, synovectomy/tenosynovectomy and tendon repair/release) with a mean follow-up period of 3 years. The primary outcome measures were the same for all patients and comprised the validated modified score for the assessment and quantification of chronic rheumatoid affections of the hand (M-SACRAH) and a separate satisfaction questionnaire. RESULTS: Highly significant improvements in both function and pain scores are reported across the cohort as a whole following hand surgery, with this pattern replicated within all of the operative subgroups. In keeping with these favourable results very high levels of overall satisfaction were reported with 93 % of patients reporting themselves to be very or fairly satisfied with their procedure. CONCLUSIONS: Overall, patient reported outcomes in functional, stiffness and pain domains of the M-SACRAH questionnaire appear very favourable across the range of surgical procedures that can be performed in the rheumatoid hand. We believe this data supports the use of all the procedures explored, and will be helpful in patient guidance.

Triple arthrodesis of the foot with allograft through a lateral incision in planovalgus deformity.

BACKGROUND: Triple arthrodesis may be performed using various surgical approaches, most typically through two incisions and without structural bone graft. We have found that a single lateral incision allows adequate surgical exposure and structural bone graft facilitates lateral column reconstruction. METHODS: A consecutive series of 30 triple arthrodeses with additive bone graft using a single lateral incision. Outcome measures were SF12 score, Manchester-Oxford Foot Questionnaire index score, visual analogue pain score and satisfaction scores, and radiographic assessment at 3, 6 and 12 months post-operatively. RESULTS: Statistically significant improvements were seen in all measured outcomes, except the SF12 mental component score. The union rate was 100% with no loss of correction at 12 months. Twenty-nine out of 30 patients were satisfied. CONCLUSIONS: In this series, triple arthrodesis using structural allograft through a single lateral incision was safe and effective, with restoration and maintenance of surgical deformity correction and foot length.

Risk factors for venous thromboembolism after total hip and total knee arthroplasty: a meta-analysis.

INTRODUCTION: Venous thromboembolism (VTE) is a common complication after total hip arthroplasty (THA) or total knee arthroplasty (TKA) and may be the cause for a secondary PE and associated morbidity/mortality. We performed a systematic literature review of risk factors and risk reduction of VTE after THA or TKA. MATERIALS AND METHODS: A systematic search of PubMed database, the Cochrane Library, OVID MEDLINE and American Academy of Orthopaedic Surgeons (AAOS), without restriction of publication data and language, was conducted. We performed a meta-analysis of ten factors for VTE after THA or TKA. Four authors independently assessed data extraction and quality of the studies using the Newcastle-Ottawa Scale (NOS) as quality assessment tool. Assessment of heterogeneity and analysis of data were operated by Review Manager 5.2.9. RESULTS: Fourteen retrospective case-control or prospective cohort studies, which included 18,075 patients who developed VTE after THA or TKA of a total of 1,723,350 cases, were selected. Our results demonstrated that, among all ten factors investigated, 3 main risk factors were significantly associated with VTE after THA or TKA: history of VTE (RR > 10.6), varicose vein (RR > 2.7) and congestive cardiac failure (RR 2). There was also an increase of VTE risk ranging from 8 to 30 % for female gender < age (≥80) < hypertension < (active) cancer < obesity (BMI ≥ 30) < (black) race. Data analysis revealed that diabetes mellitus had no significant relationship with VTE after THA or TKA. CONCLUSIONS: This study highlighted the role of nine significant risk factors in the development of VTE after THA or TKA. Among all risk factors, history of VTE seems the one main indication for more potent anticoagulation. All other risk factors need to be considered and discussed with patients individually and balanced against the risk of bleeding and infection. Individual patient risk assessment, rather than a "blanket policy", is considered the best management strategy before deciding on the type of chemical prophylaxis.

Functional and patient-reported outcome of partial wrist denervation versus the Mannerfelt wrist arthrodesis in the rheumatoid wrist.

INTRODUCTION: Wrist arthrodesis offers high success rates in patients with rheumatoid arthritis; however, loss of residual mobility may cause unnecessary disability. This makes wrist denervation an appealing alternative. However, there is a distinct lack of patient-reported outcome measure studies comparing these two procedures. The aim of this study was to report any change in function, pain and satisfaction following wrist arthrodesis compared to denervation in a single surgeon series of rheumatoid patients. PATIENTS AND METHODS: The results of 16 wrist arthrodesis in 15 patients and 14 partial (PIN) wrist denervations in 13 patients were compared with a mean follow-up period of 39 and 22 months, respectively. The primary outcome measures were the same for both groups and included the validated patient-rated wrist evaluation questionnaire and a satisfaction questionnaire. RESULTS: Wrist arthrodesis significantly improved the mean total pain and functional outcome scores by 54 and 36 %, respectively, at the time of follow-up. Wrist denervation patients also reported significant improvements of 44 and 42 % in total pain and functional outcomes, respectively; 87 % reported being very satisfied with their wrist arthrodesis procedure compared to 78 % in the denervation group. No statistically significant difference in response between the groups was observed in this series of patients. CONCLUSIONS: Both procedures enjoyed favourable results amongst patients with excellent satisfaction outcomes. PIN denervation is a simple procedure with low complication rates and we therefore consider it a valid alternative to more difficult treatment options, such as partial or total wrist arthrodesis.

No effect of subperiosteal growth factor application on periosteal neo-chondrogenesis in osteoperiosteal bone grafts for osteochondral defect repair.

PURPOSE: The purpose of this study was to examine the effect of subperiosteal injection of chondroinductive growth factors on the histological and biomechanical outcome of autologous osteoperiosteal grafts. METHODS: Thirty six standardised osteochondral defects were created in the trochlear groove of 18 Göttinger Minipigs and evaluated after six, 12 and 52 weeks. Defects were treated with press-fit implantation of autologous osteoperiosteal cylindrical block-grafts with or without subperiosteal injection of a chondroinductive growth factor mixture (GFM). RESULTS: Histomorphological analysis showed complete osseointegration of all grafts from six weeks. The periosteum remained in place in 35 of 36 cases. Fibrocartilagineous repair tissue formation occurred at the cambium layer with a maximum at 12 weeks in both groups. Histomorphological grading and biomechanical testing showed highest values at 12 weeks, with signs of tissue degradation at one year. There was no significant difference between both groups. CONCLUSION: Transplantation of autologous osteoperiosteal grafts is an effective method to restore subchondral bone defects, but not the overlying cartilage as the repair tissue deteriorates in the long term. Subperiosteal growth factors injection did not stimulate tissue differentiation on a biomechanical and histomorphological level.

Preoperative predictors for allogenic blood transfusion in hip and knee arthroplasty for rheumatoid arthritis.

INTRODUCTION: To identify the preoperative predictors of requirement for postoperative allogenic blood transfusion following hip and knee joint arthroplasty. MATERIALS AND METHODS: We analysed the retrospective data on patients with rheumatoid arthritis who had undergone either total hip or knee arthroplasty at a single university teaching hospital. Factors of age, sex, procedure type, preoperative haemoglobin, blood transfusion data, comorbidities and body mass index were investigated for association with postoperative allogenic blood after hip or knee arthroplasty. RESULTS: Three hundred and forty nine cases of patients with rheumatoid arthritis were reviewed. 21 % (n = 72) required allogenic blood transfusion. The only significant predictive preoperative factors associated with postoperative blood transfusion were a low preoperative haemoglobin (Hb) level (p < 0.001), procedure of total hip arthroplasty (p = 0.008), a previous history of myocardial infarction (p = 0.038) and previous allogenic blood transfusion (p = 0.03). A preoperative haemoglobin <120 g/l was associated with a tenfold increase in transfusion requirement. All patients with a preoperative Hb level <90 g/l were transfused. CONCLUSIONS: The ability to identify those within this high-risk group who are likely to receive blood transfusion allows for an informed, appropriate and cost effective approach to blood management strategies.

The use of enhanced recovery after surgery (ERAS) principles in Scottish orthopaedic units--an implementation and follow-up at 1 year, 2010-2011: a report from the Musculoskeletal Audit, Scotland.

OBJECTIVE: To establish whether a nationally guided programme can lead to more widespread implementation of enhanced recovery after surgery (ERAS), a well-established optimised care pathway for lower limb arthroplasty. DESIGN: In 2010, National Services Scotland's Musculoskeletal Audit was asked to perform a 'snapshot' audit of the current peri-operative management of patients undergoing total hip and knee arthroplasty in all 22 Scottish orthopaedic units with an identical follow-up audit in 2011 after input and support from the national steering group. POPULATION: Audit 1 and audit 2 involved 1,345 and 1,278 patients, respectively. RESULTS: The number of Scottish units that developed an ERAS programme increased from 8 (36 %) to 15 (68 %). Units that included more ERAS patients had earlier mobilisation rates (146/474, 36 % ERAS patients mobilised same day vs. 34/873, 4 % non-ERAS; n = 22 units, r = 0.55, p = 0.008) and shorter post-operative length of stay (median 4 days vs. ERAS, 5 days non-ERAS, n = 22 units, r = -0.64, p = 0.001). ERAS knee arthroplasty patients had lower blood transfusion rates (5/205, 2 % vs. 51/399, 13 %, n = 22 units, r = -0.62, p = 0.002). Units that restricted the use of IV fluids post-operatively had higher early mobilisation rates (n = 22 units, r = 0.48, p = 0.03) and shorter post-operative length of stay (n = 22 units, r = -0.56, p = 0.007). Reduced use of patient-controlled analgesia was also associated with earlier mobilisation (n = 22 units, r = 0.49, p = 0.02) and shorter length of stay (n = 22 units, r = -0.39, p = 0.07). Urinary catheterisation rates also dropped from 468/1,345 (35 %) in 2010 to 337/1,278 (26 %) in 2011 (n = 22 units, z = 2.19, p = 0.03). CONCLUSION: A clinically guided and nationally supported process has proven highly successful in achieving a further uptake of enhanced recovery principles after lower limb arthroplasty in Scotland, which has resulted in clinical benefits to patients and reduced length of hospital stay.

Survivorship and functional outcome of a cemented acetabular component with bulk roof autograft for severe acetabular dysplasia: 12- to 23-year follow-up.

AIMS: Primary aim was to determine survival of a cemented acetabular component with bulk roof autograft with a minimum of 12 years follow-up. The secondary aim was to determine the clinical outcome. METHODS: A cohort of 62 consecutive patients (74 hips) undergoing cemented total hip arthroplasty with acetabular bulk roof autograft for acetabular dysplasia were retrospectively identified. The group consisted of 57 female patients (67 hips) and 5 male patients (7 hips) with a mean age at operation of 45 years. No patient was lost to follow-up, however 9 patients died had during the study period. The Oxford Hip Score (OHS), Forgotten Joint Score (FJS), EuroQol 5-Dimensional Score (EQ-5D), Short Form (SF-12) physical score and patient satisfaction were used to assess clinical outcome for patients with a surviving prosthesis. RESULTS: The median follow-up was 16.6 (13.4-19.1) years. 6 revisions were performed during the follow-up period, all of which were due to aseptic loosening of the acetabular component. The all-cause Kaplan Meier survival rate for the acetabular component was 99% at 10 years, 95% at 15 years and 83% at 20 years. Neither age, gender, femoral osteotomy or polyethylene (UHMW vs. cross-linked) were significant predictors of aseptic revision of the acetabular component. There were no case of graft resorption and all grafts were radiologically incorporated. 45 patients were available for functional assessment at a mean follow-up of 18.2 years. The mean OHS was 37.8, FJS was 55.7, EQ5D was 0.73, and SF-12 physical component was 43.2. No patient was dissatisfied, with 2 patients reporting a neutral satisfaction, 7 stating they were satisfied and the remaining 36 were very satisfied. CONCLUSIONS: A cemented acetabular component with bulk roof autograft for dysplasia offers excellent survival with good to excellent functional outcome with high patient satisfaction in the medium- to long-term.

High survivorship of cemented sockets with roof graft for severe acetabular dysplasia.

BACKGROUND: Socket fixation in patients with acetabular dysplasia can be technically demanding but the use of structural grafts can help to reconstruct the original center of hip rotation. Because reported survival rates differ, construct survival seems to depend on the technique of graft preparation and fixation. QUESTIONS/PURPOSES: What is the survivorship of cemented sockets with acetabular roof graft in patients with severe acetabular dysplasia? Do clinical scores equal those of patients without acetabular grafting? METHODS: We retrospectively reviewed 62 patients (74 hips) who had undergone cemented THA with acetabular roof graft. Mean age at surgery was 45 years (range, 19-71 years). Revisions and radiographic failures were determined and clinical scores (Oxford, SF-12) were obtained and matched to a control group. Kaplan-Meier analysis was used to determine survivorship at a minimum followup of 5 years (mean, 10.4 years; range, 5-16 years). RESULTS: Survivorship for all-cause revision was 98% (95% CI, 92.5%-100.0%) at 10 years followup. Two hips were revised for aseptic acetabular loosening and one hip for polyethylene wear. All grafts incorporated and no additional radiographic loosenings were seen. Patients with grafting had higher Oxford scores compared with the control group but other scores were equal. CONCLUSIONS: In contrast to reported series and the common use of cementless cups in patients with developmental dysplasia of the hip, we found high survivorship of cemented sockets with roof graft in severe acetabular dysplasia at a mean followup of more than 10 years. These patients showed higher Oxford scores than patients in a control group. This technique that restores bone stock is a reasonable solution for often young patients with dysplasia. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Periarticular infiltration in total hip replacement: effect on heterotopic ossification, analgesic requirements and outcome.

BACKGROUND: Up to 80% of patients develop heterotopic ossification (HO) following total hip replacement (THR) and high grades may adversely affect outcome. This study investigated the influence of local infiltration of a NSAID (Ketorolac) and local anaesthetic on the incidence and grade of HO following THR, the effect on post-operative opiate analgesic requirement and on patient reported outcome score. METHODS: A retrospective study was performed on 118 THRs performed without periarticular infiltration from 2003 to 2005, and on 211 performed with infiltration from 2005 to 2008. Pre-operative and 12-month radiographs were examined and HO graded according to the Brooker classification. Peri-operative analgesic requirements and NSAID use were noted and outcome was measured at 1 year with the Oxford Hip Score. RESULTS: Univariate and multivariate analysis indicated that single-dose periarticular NSAID infiltration did not reduce the incidence or grade of HO. Preoperative HO (p = 0.005) and enthesopathy (p = 0.027) were significant predictors of post-operative HO. The use of post-operative oral NSAID (except aspirin) significantly reduced HO (p = 0.001). Periarticular infiltration significantly reduced opiate analgesia use in the first 24 h (p < 0.001) and length of inpatient stay (p < 0.001). There was no difference in Oxford Hip Score at 1 year. CONCLUSION: Preoperative enthesopathies are a risk factor for postoperative HO. Periarticular infiltration of NSAID and local anaesthetic does not reduce HO incidence or grade in THR, but does reduce perioperative opiate requirements and length of hospital stay.

Outcomes following pantalar arthrodesis in rheumatoid arthritis.

BACKGROUND: We report a consecutive series of pantalar arthrodeses in patients with rheumatoid arthritis, using a single laterally based incision and autologous bone graft. MATERIALS AND METHODS: All operations were performed by a single surgeon and were assessed preoperatively and at 6 and 12 months postoperatively. The levels of patient satisfaction, functional improvement and pain scores of the foot following surgery were recorded along with radiological parameters. Seventeen patients (two male and 15 female) underwent 18 hindfoot surgeries and were assessed preoperatively using the SF-12 General Health survey questionnaire, Manchester-Oxford Foot Survey and pain scores. RESULTS: We found a significant improvement in pain levels and SF-12 scores. In addition the patients reported a high level of satisfaction with the outcome of surgery and improvement in function. CONCLUSION: The results show that pantalar arthrodesis is a very effective operative treatment for severe ankle and concomitant hindfoot disease. The treatment period is prolonged and patients should be counselled appropriately. LEVEL OF EVIDENCE: IV, Retrospective Case Series

Metal-on-metal hip resurfacing: a critical review.

In this article, a concise review of the current literature on metal-on-metal hip resurfacing (MoMHR) is given. In contrast to conventional total hip arthroplasty, older age, female sex and small femoral head sizes predispose to failure. Neck fracture and metal wear-related complications account for the most frequent reasons for re-operations. Although the long-term consequences of metal ion release remain unknown, the increasing prevalence of soft tissue related problems with potentially devastating functional consequences in this younger patient group are of concern. Outcome after revision for metal wear related failure of MoMHR is poor. In our opinion, patients with this device should be managed in dedicated centers with facilities for data collection and monitoring. The majority of proposed advantages of MoMHR cannot be supported by the published evidence.

Pre-packed vacuum bone cement mixing systems. A further step in reducing methylmethacrylate exposure in surgery.

OBJECTIVES: Polymethylmethacrylate bone cements are widely used in orthopaedic and trauma surgery as well as in dentistry. The toxic side effects of inhaled methylmethacrylate (MMA) fumes generated during mixing have been well studied. Vacuum cement mixing systems have been shown to reduce the risk of airborne MMA significantly compared to handmixing. In an effort to further reduce MMA exposure, the latest generation of mixing devices are pre-packed with the ingredients and thus allow preparation in nearly closed circuits. Until now, there has been no study proofing the efficacy of those systems in protecting theatre staff from MMA vapours. METHODS: A pre-packed vacuum mixing system (Optipac®) was compared with two standard systems (Palamix® and Easymix®) regarding MMA emission. The latter systems require loading with the bone cement compounds prior to mixing. Following a standardized procedure, 10 mixes were performed with each system and the emission of MMA vapours in the breathing zone was recorded using photoionization detection over a period of 3 min. RESULTS: The mean MMA exposure was reduced when using the pre-packed system compared to the devices that require filling with the components. The highest emission peaks were recorded during the mixing and preparation steps in all systems. CONCLUSIONS: Modern pre-packed vacuum mixing systems further help to reduce the occupational hazards created by bone cement preparation. However, MMA fumes can still be detected using this technique. Although this is an important step in reducing MMA exposure in the operating theatre, further technical effort has to be taken to eliminate the continuous leakage of monomer from the devices while mixing and to minimize necessary manipulation for final delivery.

Anatomic stem design reduces risk of thin cement mantles in primary hip replacement.

PURPOSE: To analyse the influence of femoral stem design in the lateral plane (anatomic vs. straight) on the cement mantle quality. METHOD: In this consecutive multi-surgeon radiographic study we determined, Dorr grading, cement mantle quality (Barrack) and mantle thickness using Gruen zones 1­14 in 280 primary cemented total hip replacements, divided into two groups (140 anatomic Biomet Olympia, 140 straight Exeter Universal Series). RESULTS: Twenty-three per cent of the straight Exeter Universal stems had a cement mantle of <2 mm thickness in Gruen zone 8 and 25% in Gruen zone 9, compared to 0.7% of the anatomical Olympia stems in Gruen zone 8 and 1.4% in Gruen zone 9. The difference between the two groups was statistically significant (P < 0.001). In all other zones no significant differences were found. CONCLUSION: This radiological study confirms that femoral stems with an anatomical curve in the lateral plane carry a lower risk of thin cement mantles (especially in Gruen zones 8 and 9) than straight stems. Cement mantle analysis in one radiographic plane only is insufficient.