International Delphi Study on Wound Closure and Incision Management in Joint Arthroplasty Part 2: Total Hip Arthroplasty.

BACKGROUND: This modified Delphi study aimed to develop a consensus on optimal wound closure and incision management strategies for total hip arthroplasty (THA). Given the critical nature of wound care and incision management in influencing patient outcomes, this study sought to synthesize evidence-based best practices for wound care in THA procedures. METHODS: An international panel of 20 orthopedic surgeons from Europe, Canada, and the United States evaluated a targeted literature review of 18 statements (14 specific to THA and 4 related to both THA and total knee arthroplasty). There were 3 rounds of anonymous voting per topic using a modified 5-point Likert scale with a predetermined consensus threshold of ≥ 75% agreement necessary for a statement to be accepted. RESULTS: After 3 rounds of voting, consensus was achieved for all 18 statements. Notable recommendations for THA wound management included (1) the use of barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); (2) the use of subcuticular sutures over skin staples (lower risk of superficial infections and higher patient preferences, but longer closing times); (3) the use of mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); (4) for at-risk patients, the use of negative pressure wound therapy over other dressings (lower wound complications and reoperations, as well as fewer dressing changes); and (5) the use of triclosan-coated sutures (lower risk of surgical site infection) over standard sutures. CONCLUSIONS: Through a structured modified Delphi approach, a panel of 20 orthopedic surgeons reached consensus on all 18 statements pertaining to wound closure and incision management in THA. This study provides a foundational framework for establishing evidence-based best practices, aiming to reduce variability in patient outcomes and to enhance the overall quality of care in THA procedures.

Identifying Critical Evidence Gaps in Wound Closure and Incision Management After Total Knee Arthroplasty: Delphi Panel Insights.

INTRODUCTION: In orthopaedic surgery, particularly total knee arthroplasty (TKA), the management of surgical wounds is critical for optimal wound healing and successful patient outcomes. Despite advances in surgical techniques, challenges persist in effectively managing surgical wounds to prevent complications and infections. This study aimed to identify and address the critical evidence gaps in wound management in TKA, including preoperative optimization, intraoperative options, and for the avoidance of postoperative complications. These are important issues surrounding wound management, which is essential for improving patient recovery and the overall success of the surgery. METHODS: Utilizing the Delphi method, this study brought together 20 experienced orthopaedic surgeons from Europe and North America. Conducted from April to September 2023, the process involved three stages: an initial electronic survey, a virtual meeting, and a concluding electronic survey. The panel reviewed and reached a consensus on 26 specific statements about wound management in TKA based on a comprehensive literature review. During these three stages and after further panel review, an alternative goal of the Delphi panel was to also identify critical evidence gaps in the current understanding of wound management practices for TKA. RESULTS: While the panel reached consensus on various wound management practices, they highlighted several major evidence gaps. Also, there was general consensus on issues such as wound closure methods including the use of mesh-adhesive dressings, skin glue, staples, sutures (including barbed sutures),and negative-pressure wound therapy (NPWT). However, it was deemed necessary that further evidence needs to be generated to address the cost-effectiveness of each and develop best practices for promoting patient outcomes. The identification of these gaps points to areas requiring more in-depth research and improvements to enhance wound care in TKA. DISCUSSION: The identification of these major evidence gaps underscores the need for targeted research in wound management surrounding TKA. Addressing these evidence gaps is crucial for the future development of more effective, efficient, and patient-friendly wound care strategies. Future research should prioritize these areas, focusing on comparative effectiveness studies and further developing clear guidelines for the use of emerging technologies. Bridging these gaps has the potential to improve patient outcomes, reduce complications, and elevate the overall success rate of TKA surgeries.

International Delphi Study on Wound Closure and Dressing Management in Joint Arthroplasty: Part 1: Total Knee Arthroplasty.

BACKGROUND: The purpose of this modified Delphi study was to obtain consensus on wound closure and dressing management in total knee arthroplasty (TKA). METHODS: The Delphi panel included 20 orthopaedic surgeons from Europe and North America. There were 26 statements identified using a targeted literature review. Consensus was developed for the statements with up to three rounds of anonymous voting per topic. Panelists ranked their agreement with each statement on a five-point Likert scale. An a priori threshold of ≥ 75% was required for consensus. RESULTS: All 26 statements achieved consensus after three rounds of anonymous voting. Wound closure-related interventions that were recommended for use in TKA included: 1) closing in semi-flexion versus extension (superior range of motion); 2) using aspirin for venous thromboembolism prophylaxis over other agents (reduces wound complications); 3) barbed sutures over non-barbed sutures (lower wound complications, better cosmetic appearances, shorter closing times, and overall cost savings); 4) mesh-adhesives over other skin closure methods (lower wound complications, higher patient satisfaction scores, lower rates of readmission); 5) silver-impregnated dressings over standard dressings (lower wound complications, decreased infections, fewer dressing changes); 6) in high-risk patients, negative pressure wound therapy over other dressings (lower wound complications, decreased reoperations, fewer dressing changes); and 7) using triclosan-coated over non-antimicrobial-coated sutures (lower risks of surgical site infection). CONCLUSIONS: Using a modified Delphi approach, the panel achieved consensus on 26 statements pertaining to wound closure and dressing management in TKA. This study forms the basis for identifying critical evidence supported by clinical practice for wound management to help reduce variability, advance standardization, and ultimately improve outcomes during TKA. The results presented here can serve as the foundation for knowledge, education, and improved clinical outcomes for surgeons performing TKAs.

Inertial Tracking System for Monitoring Dual Mobility Hip Implants In Vitro.

Dual mobility (DM) implants are being increasingly used for total hip arthroplasties due to the additional range of motion and joint stability they afford over more traditional implant types. Currently, there are no reported methods for monitoring their motions under realistic operating conditions while in vitro and, therefore, it is challenging to predict how they will function under clinically relevant conditions and what failure modes may exist. This study reports the development, calibration, and validation of a novel inertial tracking system that directly mounts to the mobile liner of DM implants. The tracker was custom built and based on a miniaturized, off-the-shelf inertial measurement unit (IMU) and employed a gradient-decent sensor fusion algorithm for amalgamating nine degree-of-freedom IMU readings into three-axis orientation estimates. Additionally, a novel approach to magnetic interference mitigation using a fixed solenoid and magnetic field simulation was evaluated. The system produced orientation measurements to within 1.0° of the true value under ideal conditions and 3.9° with a negligible drift while in vitro, submerged in lubricant, and without a line of sight.

Effect of Various Ancillary Operating Room Techniques on Wound Healing Outcomes After Total Knee Arthroplasty.

INTRODUCTION: The successful management of wound healing after total knee arthroplasty (TKA) depends on several aspects of ancillary intraoperative techniques and surgical variables. Many of these have been evaluated in a few recent reports. The prior reviews studied many aspects of wound healing and, for example, found lower risks of wound complications with barbed sutures compared with interrupted closure with non-barbed sutures, no differences in wound complications between adhesives, subcuticular sutures, staples, glue, or mesh adhesives for the closure of the skin layer, and that mesh adhesives may be associated with faster closing times compared to subcuticular sutures or staples in TKA. However, some topics that can be influenced by the surgeon were not covered in these previous reviews. Namely, the use of deep vein thrombosis (DVT) prophylaxis, tourniquet application, management of intraoperative drains, surgical approach selection, and patellar handling techniques can all potentially influence wound healing. Therefore, in this comprehensive systematic review of the literature, we focused on these five factors that may influence wound healing. Specifically, we evaluated: (1) the impact of different DVT prophylaxis methods on wound healing and infection rates; (2) the role of tourniquet application on wound closure and potential infection risks; (3) the effects of intraoperative drain usage on wound healing; (4) the influence of different surgical approaches on wound closure and postoperative infection rates; and (5) the effects of varying patellar handling strategies on wound healing and infection rates. MATERIALS AND METHODS: A systematic search of electronic databases, including PubMed, Cochrane Library, Medline, and Embase, was conducted to identify studies assessing auxiliary surgical techniques and their impact on wound healing in total knee arthroplasty (TKA). Relevant terms like "knee," "arthroplasty," and "wound healing" refined the search, which included English language publications until May 1, 2023. Independent screening by two authors and a third mediator facilitated the selection process, with 24 studies meeting the criteria. Assessment of these studies involved evaluating their evidence level and methodological quality using the Modified Coleman Methodology Score (MCMS). A comparison was made on wound healing outcomes in TKA, which included evaluating methodological quality parameters like sample sizes, follow-up durations, and clinical effect measurements. Data synthesis for the studies provided a comprehensive summary, categorizing them by evidence level. RESULTS: There were seven reports on DVT prophylaxis that showed no statistically significant differences in wound complications among various treatment methods and medications in patients undergoing total knee arthroplasty (TKA), with wound complication rates ranging from 0.25 to 1%, except that aspirin appeared to have lower wound complications rates in three recent studies than other methods. There were five reports on tourniquet application that showed a generally increased rate of wound complications, but no increase in deep infections. The five reports on intraoperative drain use showed that while there is an increase in total blood loss in the group with drains, ranging from 568ml to 1,856ml, compared to 119ml to 535ml in the no-drain group, there are no significant differences in wound complications, infection rates, or other postoperative outcomes such as swelling, deep vein thrombosis, and range of motion between the drain and no-drain groups. There were three studies on surgical approaches revealing no differences in wound complication rates between the mini-subvastus and medial parapatellar incisions. Also, the surgical variables of patella eversion and anterior tibial translation were only studied in one report. CONCLUSION: The current literature highlights the importance of using aspirin when possible for DVT prophylaxis and the possibility that tourniquets may lead to increased superficial wound complications. Drains or surgical approach do not appear to lead to wound problems. Surgical variables, such as patella eversion and anterior tibial translation, need more study.

Effect of Various Ancillary Operating Room Techniques on Wound Healing Outcomes After Total Hip Arthroplasty.

INTRODUCTION: The successful management of wound healing following total hip arthroplasty (THA) is multifaceted, relying on various intraoperative techniques and surgical variables. Recent reviews have evaluated many of these factors, including the comparison between mesh-adhesive dressings and other skin closure methods, the closing time of different suture techniques, and the four aspects of closure for THA (deep fascial layer; subdermal layer; intradermal layer). However, previous articles did not cover certain topics that can be directly influenced by the surgeon. Specifically, these include the use of deep vein thrombosis (DVT) prophylaxis, the management of intraoperative drains, and the selection of surgical approaches. Therefore, in this comprehensive systematic review of the literature, we have focused on three factors that may influence wound healing. We evaluated the following: (1) the impact of different DVT prophylaxis methods on wound healing and infection rates; (2) the effects of intraoperative drain use on wound healing; (3) the influence of various surgical approaches on wound closure, and postoperative infection rates. By concentrating on these areas, this review aims to provide a more complete understanding of the factors that contribute to successful wound management after THA. MATERIALS AND METHODS: A systematic search of electronic databases, including PubMed, Cochrane Library, Medline, and Embase, was conducted to identify studies assessing surgical variables and techniques, specifically focusing on DVT prophylaxis, intraoperative drain use, and surgical approaches and their impact on wound healing in THA. Relevant terms like "hip," "arthroplasty," "wound healing," "DVT prophylaxis," and "surgical approaches" refined the search, which included English language publications until May 1, 2023. Independent screening by two authors and a third mediator facilitated the selection process, with 13 studies meeting the criteria. Assessment of these studies involved evaluating their evidence level and methodological quality using the Modified Coleman Methodology Score (MCMS). A comparison was made on wound healing outcomes in THA, specifically focusing on the three factors outlined in the introduction: (1) the impact of different DVT prophylaxis methods on wound healing and infection rates; (2) the effects of intraoperative drain use on wound healing; and (3) the influence of various surgical approaches on wound closure and postoperative infection rates. Data synthesis for the studies provided a comprehensive summary, categorizing them by evidence level, and aimed to contribute to a more complete understanding of the factors that influence successful wound management after THA. RESULTS: In studies examining DVT prophylaxis for total knee arthroplasties (TKA), three reports found that both rivaroxaban and enoxaparin had similar wound infection rates at 0.36%. However, one study segment suggested a slightly higher infection rate for rivaroxaban at 0.71% compared to enoxaparin's 0.49%. Despite this difference, it was not statistically significant (odds ratio [OR] 1.34, 95% confidence interval [CI] 0.46 to 3.86). In recent research, a low dose of aspirin has been observed to yield fewer wound complications when contrasted with other techniques. Five studies on intraoperative drain use revealed mixed outcomes. A total of five studies were identified that evaluated wound complications with drains following THA, comprising two randomized controlled trials (RCTs) and three observational cohort studies, with a combined sample size of 765. Among these, four studies specifically compared the use of closed suction drains to no drains. Half of these studies (two out of four) reported no significant differences in wound complications between the two groups, while the other half presented mixed findings. In surgical approach comparisons by Jin et al., meta-analysis between the direct anterior approach (DAA) and posterolateral approach (PLA) showed no significant difference in complications (OR 0.57, p=0.952). Two studies analyzed bikini incision DAA versus PLA or conventional DAA, indicating comparable outcomes with no significant differences in wound complications between the approaches and no major variations in healing, acute PJI, or dysesthesia when comparing bikini incision DAA to conventional DAA. CONCLUSION: Wound healing post THA is a complex process, influenced by various surgical techniques and intraoperative decisions. This systematic review meticulously examined three critical factors: the role of DVT prophylaxis, the implications of intraoperative drain usage, and the impact of different surgical approaches. Our analysis revealed that rivaroxaban and enoxaparin exhibit similar wound infection rates in THA. The decision to use intraoperative drains in the current literature indicates no definite advantage or disadvantage regarding wound problems with the use of closed-suction drainage in THA. In exploring surgical methodologies, the DAA and the PLA showed comparable complication rates. Yet, specific techniques within the DAA category demonstrated variations in delayed wound healing, particularly among obese patients. These findings emphasize the nuanced role of surgical choices in determining wound healing outcomes. As the field of THA continues to evolve, it becomes important for surgeons to be well-informed, ensuring optimal patient outcomes.

Pathogenic variants in GNPTAB and GNPTG encoding distinct subunits of GlcNAc-1-phosphotransferase differentially impact bone resorption in patients with mucolipidosis type II and III.

PURPOSE: Pathogenic variants in GNPTAB and GNPTG, encoding different subunits of GlcNAc-1-phosphotransferase, cause mucolipidosis (ML) II, MLIII alpha/beta, and MLIII gamma. This study aimed to investigate the cellular and molecular bases underlying skeletal abnormalities in patients with MLII and MLIII. METHODS: We analyzed bone biopsies from patients with MLIII alpha/beta or MLIII gamma by undecalcified histology and histomorphometry. The skeletal status of Gnptgko and Gnptab-deficient mice was determined and complemented by biochemical analysis of primary Gnptgko bone cells. The clinical relevance of the mouse data was underscored by systematic urinary collagen crosslinks quantification in patients with MLII, MLIII alpha/beta, and MLIII gamma. RESULTS: The analysis of iliac crest biopsies revealed that bone remodeling is impaired in patients with GNPTAB-associated MLIII alpha/beta but not with GNPTG-associated MLIII gamma. Opposed to Gnptab-deficient mice, skeletal remodeling is not affected in Gnptgko mice. Most importantly, patients with variants in GNPTAB but not in GNPTG exhibited increased bone resorption. CONCLUSION: The gene-specific impact on bone remodeling in human individuals and in mice proposes distinct molecular functions of the GlcNAc-1-phosphotransferase subunits in bone cells. We therefore appeal for the necessity to classify MLIII based on genetic in addition to clinical criteria to ensure appropriate therapy.

Is Preoperative Identification of the Infecting Organism Essential Before Single-Stage Revision Hip Arthroplasty for Periprosthetic Infection?

BACKGROUND: It is commonly stated that identification of the infecting organism is a prerequisite to single-stage revision arthroplasty of the hip for deep infection. We have performed single-stage revision in a series of patients where the organism was not identified preoperatively. The aim of this study is to investigate whether the rate of infection eradication following single-stage revision was affected by preoperative knowledge of the infecting organism. METHODS: We identified all patients who had undergone a single-stage revision for a deep infection at our hospital between 2006 and 2015. One hundred five patients were assigned into 2 groups based upon whether the infecting organism had been identified preoperatively (group A = 28) or not (group B = 77). RESULTS: The reinfection rates were 3.6% in group A and 9.1% for group B (P = .679). Re-revision rates were 7.1% and 9.1%, respectively (P = 1.00). Overall, the implant survival rate at 6 years was 87.9% (95% confidence interval, 97.4-78.4). In group B, preoperative aspiration was performed in 36.4% (28/77) of cases. Staphylococci species were the predominant causative organisms, with gram-negative involvement in 19.0% (20/105) of cases. CONCLUSION: The rate of infection eradication and overall survivorship with single-stage revision was similar in our series to that reported in the literature. While desirable, we did not find identification of the infecting organism before surgery influenced the outcome. Given the functional and economic benefits of single-stage revision, we suggest that failure to identify an organism is not an absolute contraindication to this approach.

Survivorship and Radiological Analysis of a Monoblock, Hydroxyapatite-Coated Titanium Stem in Revision Hip Arthroplasty.

BACKGROUND: We evaluated the survivorship, incidence of complications, radiological subsidence, proximal stress shielding, and patient-reported outcomes of a conservative, monoblock, hydroxyapatite-coated femoral stem. METHODS: This retrospective cohort study reports on 254 revision hip arthroplasties between January 2006 and June 2016. The mean age of patients was 71 years. The mean length of follow-up was 62 months (range 12-152). RESULTS: There were 13 stem re-revisions: infection (4), periprosthetic fracture (4), aseptic stem loosening (3), stem fracture (1), and extended trochanteric osteotomy nonunion (1). Kaplan-Meier aseptic stem survivorship was 97.33% (confidence interval 94-100) at 6 years. There were 29 intraoperative fractures. There were 6 cases of subsidence greater than 10 mm; however, none required revision. Ninety-six percent of cases showed no proximal stress shielding. Thigh pain was reported in 3% of cases. CONCLUSION: This study confirms that this stem provides good survivorship at 6 years, acceptable complication rates, adequate proximal bone loading, low incidences of thigh pain, and reliable clinical performance in revision hip arthroplasty. KEY MESSAGE: A monoblock, fully hydroxyapatite-coated titanium stem is reliable in revision arthroplasty with mild-moderate femur deficiencies.

Fractured Femoral Stems in Primary and Revision Hip Arthroplasties Revisited: Wrightington Experience.

BACKGROUND: The aim of this study is to present our experience in managing fractured femoral stems over the last 10 years for both primary and revision stems at our tertiary unit focusing on modes of failure and operative techniques. METHODS: This is a retrospective consecutive study of all patients with fractured femoral stems that were operatively managed in our unit between 2008 and 2018. Detailed radiographic evaluation (Paprosky classification) was undertaken and data collected on operative techniques used to extract distal fractured stem fragments. RESULTS: Thirty-five patients (35 hips) were included (25 men/10 women) with average age at time of presentation of 68 years (range, 29-93). Average body mass index was 30 (standard deviation, 3.8; range, 22.5-39). There were variety of stems both contemporary and historical, primary and revision cases (15 hips polished tapered cemented stems, 10 hips composite beam and miscellaneous stems, and 10 revision hip stems). The predominant mechanism of failure was fatigue due to cantilever bending in distally fixed stems. Surgical techniques used to extract distal fragment were drilling technique in 2 hips, cortical window in 13 hips, extended trochanteric osteotomy (ETO) in 5 hips, and proximal extraction in 15 hips. CONCLUSION: When faced with a contemporary fractured stem, drilling techniques into the distal fragment are unlikely to succeed. If a trochanteric osteotomy had been used at time of index surgery, this could be used again to aid proximal extraction with conventional revision instrumentations. The cortical window technique is useful but surgically demanding technique that is most successful in extracting polished tapered fractured stems particularly when an ETO is not planned for femoral reconstruction. Use of trephines can be useful for removal of longer, uncemented stems. Finally, an ETO might be necessary when other techniques have failed.

Total hip arthroplasty in patients with Trisomy 21: Systematic review and exploratory patient level analysis.

INTRODUCTION: Trisomy 21 is the most common chromosomal disorders in humans; it is caused by an extra copy of chromosome number 21. This extra chromosomal material causes widespread abnormalities involving nearly every part of human body. Hip disorders are the second most serious musculoskeletal disorder in patients with T21 with a reported incidence between 2 and 28%. The outcomes of these hip disorders in patients with T21 are much less favorable than similar hip diagnoses in normal patients and a substantive number of these patients develop severe osteoarthritis that require total hip arthroplasty (THA). The outcome of THA in this cohort of patient is not well studied. METHODS: A modified Cochrane review methodology has been utilized in this review. An extended literature search was performed of the medical databases. A hierarchical approach was used to include relevant studies. Search, published papers and extracted data were checked by authors independently then jointly to ensure accuracy. RESULTS: Nine studies (321 patients with Trisomy 21) who underwent total hip arthroplasty (THA) were included. The functional hip scores (Harris and WOMAC hip scores) improved substantively after hip arthroplasty. The 5-year cumulative revision rate was 7.5%; twice as high as age matched control. Medical and surgical complications were 3 times higher than matched controls. CONCLUSION: Total hip arthroplasty can be offered to patients with T21 and severe arthritis although the increased revision and complication rates must be appreciated by patients and care givers.

Does oversizing an uncemented cup increase post-operative pain in primary total hip arthroplasty?

INTRODUCTION: It has been suggested that one of the factors related to persistent post-operative pain following total hip arthroplasty (THA) is to over sizing of the acetabular component. In order to investigate this potential issue, we retrospectively analysed a series of consecutive uncemented THA. We assessed the incidence of persistent post-operative pain and the size difference between the implanted acetabular component and the native femoral head. METHODS: A total of 265 consecutive THAs were retrospectively identified. Standardised pre-operative radiographs were analysed using validated techniques to determine the native femoral head diameter. Post-operative standardised radiographs were reviewed and the acetabular orientation determined. Patients were sent postal questionnaires regarding their outcome and level of pain. RESULTS: Questionnaires were returned by 169 patients (189 hips, 71% response rate). A total of 17 were excluded due to inadequate radiographs., leaving 172 THA in the study group. The mean native femoral head (NFH) size was 47 mm. The most common implanted acetabular component size was 52 mm. The mean difference in cup to NFH diameter (delta) was 5.7 mm (range - 6.1 to 15.4 mm; 95% CI 5.3-6.2 mm). A delta of > 6 mm was found to be significant for predicting persistent post-operative pain (RR = 1.81; 95% CI 1.1-3.1; P = 0.027). CONCLUSION: Our study confirms that a delta of > 6 mm is associated with an increased risk of persistent post-operative pain following THA. We recommend pre-operative templating in all uncemented THA to ensure the planned acetabular component is no more than 6 mm larger than the NFH diameter.

Is patient satisfaction related to patient reported sounds from ceramic on ceramic total hip arthroplasty? A study of 265 hips.

INTRODUCTION: The ideal method and implant to perform total hip arthroplasty (THA) is still a debated topic. Ceramic on ceramic (CoC) bearings have favourable wear properties, but squeaking has been reported as an unwanted side effect. We aimed to determine the rate of noise generation from CoC hips and investigate whether there is a relationship with patient satisfaction. METHODS: A total of 246 consecutive CoC bearing uncemented THA were retrospectively identified in a single institution. Post-operatively patients were sent a postal questionnaire to evaluate their reported sounds and satisfaction with their THA. Uni- and multi-variate analyses were performed to identify potential predictor variables for reported post-operative sounds. RESULTS: Questionnaires were returned by 172 patients (70% return rate). 24% reported sounds from their hips with 11% reporting a squeak. Median satisfaction levels were minimally, but significantly less for "noisy" (9/10) than "quiet" hips (10/10) (median difference = - 1, 95% CI - 2 to 0, p < 0.001). Compared to those with "noisy" hips, patients with "quiet" hips were 1.7 times (95% CI 1.3-2.5, p = 0.0002) more likely to report a "forgotten" hip. Younger age (p < 0.043) and increased anteversion (p < 0.021) were predictors for reported sounds. CONCLUSION: We have identified a high rate of "noisy" hips in this series of CoC THA with a significant inverse relationship between "noisy" hips and patient satisfaction levels. In our unit, we are moving towards the use of ceramic on cross-linked polyethylene bearings as a result of these findings and the excellent survivorship of this bearing combination.

One- and two-stage surgical revision of peri-prosthetic joint infection of the hip: a pooled individual participant data analysis of 44 cohort studies.

One-stage and two-stage revision strategies are the two main options for treating established chronic peri-prosthetic joint infection (PJI) of the hip; however, there is uncertainty regarding which is the best treatment option. We aimed to compare the risk of re-infection between the two revision strategies using pooled individual participant data (IPD). Observational cohort studies with PJI of the hip treated exclusively by one- or two-stage revision and reporting re-infection outcomes were retrieved by searching MEDLINE, EMBASE, Web of Science, The Cochrane Library, and the WHO International Clinical Trials Registry Platform; as well as email contact with investigators. We analysed IPD of 1856 participants with PJI of the hip from 44 cohorts across four continents. The primary outcome was re-infection (recurrence of infection by the same organism(s) and/or re-infection with a new organism(s)). Hazard ratios (HRs) for re-infection were calculated using Cox proportional frailty hazards models. After a median follow-up of 3.7 years, 222 re-infections were recorded. Re-infection rates per 1000 person-years of follow-up were 16.8 (95% CI 13.6-20.7) and 32.3 (95% CI 27.3-38.3) for one-stage and two-stage strategies respectively. The age- and sex-adjusted HR of re-infection for two-stage revision was 1.70 (0.58-5.00) when compared with one-stage revision. The association remained consistently absent after further adjustment for potential confounders. The HRs did not vary importantly in clinically relevant subgroups. Analysis of pooled individual patient data suggest that a one-stage revision strategy may be as effective as a two-stage revision strategy in treating PJI of the hip.

Skin closure in arthroplasty surgery: Current practice.

The study by Smith et al. (2010) concluded that clips are associated with 3 times the infection rate compared with subcuticular sutures in orthopaedic surgery (P = .01).For hip surgery, there was a 4-fold increase. We aimed to determine the trends and influences in skin closure and wound care for hip and knee arthroplasty in the northwest region as well as what would change surgeons' current practice. A short online survey was emailed to consultants in the northwest of England enquiring about their current practice in superficial skin closure, what has influenced this, and finally what would change their practice. Returned surveys were then analysed. A total of 45 consultants responded (response rate of 40.2%). In both hip and knee arthroplasty, clips were the most commonly used superficial skin closure material (53% and 63%, respectively). Personal experience was the greatest influence on the choice of closure material in both hip and knees (84% and 93% respectively). A total of 66% of hip and 76% of knee surgeons would change their closure material if there was evidence to support this. Hip and knee arthroplasty surgeons are influenced by their personal experience, and most use clips as their skin closure method. Most would change their practice with evidence of one material over another. We conclude that there is need for a prospective, well-powered, multi-centre randomised control trial to determine the skin closure material that has the lowest return-to-theatre rate in arthroplasty surgery.

Management of symptomatic knee osteoarthritis in obesity: a survey of general practitioners' opinions and practice.

INTRODUCTION: The aim of this survey was to explore general practitioners' opinions and practices regarding the management of symptomatic knee osteoarthritis in obesity. METHODS: Questionnaires were sent electronically to members of the Royal College of General Practitioners specialty interest groups: GPs with an Interest in Nutrition Group and the Physical Activity and Life Style group. RESULTS: The response rate was 75% (142/190). The majority stated weight loss should be the first-line treatment. Half stated that community interventions were effective, and three quarters stated that bariatric surgery should be available to these patients. Two-thirds reported that their knowledge and training around obesity management was insufficient. CONCLUSION: Our survey has shown a variation in the opinions and practices amongst respondents on the management of symptomatic knee osteoarthritis in obesity. Given the projected obesity epidemic, greater training and resources are required in the community setting to enable effective management. There is support for the creation of combined ortho-bariatric services.

Management of symptomatic knee osteoarthritis in obesity: a survey of orthopaedic surgeons' opinions and practice.

INTRODUCTION: The aim of this survey was to explore knee surgeons' opinions and practices regarding the management of symptomatic knee osteoarthritis in obesity. METHODS: Questionnaires were sent electronically to all consultant members of the British Association for Surgery of the Knee. RESULTS: The response rate was 52%. The survey showed considerable practice variation and divided opinion on the evidence base. The majority stated that weight loss should be the first-line treatment. 53% (91/172) stated that such cases should ideally be assessed by a specialist multidisciplinary service; however, only 24% (41/169) would be interested in being the orthopaedic surgeon in such a service. DISCUSSION: The optimal pathway of care for the obese patient with symptomatic knee osteoarthritis remains unclear. Given recent debate around the rationing of knee arthroplasty surgery in obesity, we felt it was timely to survey knee surgeons' current practice. CONCLUSION: Our survey has shown considerable variation in the opinions and practice of surgeons on the management of symptomatic knee osteoarthritis in obesity, together with divided views on current literature.

Correction to: Management of symptomatic knee osteoarthritis in obesity: a survey of orthopaedic surgeons' opinions and practice.

The corresponding author would like to state a different e-mail address: drdanielhill@icloud.com.

Manipulation for stiffness following total knee arthroplasty: when and how often to do it?

Stiffness following total knee arthroplasty is a disabling complication. One of the management options of stiffness includes manipulation under anaesthesia, but no real consensus exist on appropriate timing of intervention, and the timing and results of the manipulation under anaesthesia (MUA) are under debate in the literature. Our aim was to determine the efficacy of single and multiple manipulations under anaesthesia following total knee arthroplasty and to determine the most appropriate timing for manipulation. We retrospectively reviewed 86 patients who underwent manipulation for stiffness following primary total knee replacement with at least 1-year follow-up. Range of motion before surgery, at the time of the MUA, immediately after MUA and at 6 weeks and 1 year post-MUA were recorded. At the end of 1 year post-manipulation, manipulations performed at less than 20 weeks, following primary total knee arthroplasty, showed 31° of flexion gain as compared to only 1.5° of flexion gain when manipulation was undertaken after 20 weeks. Of the 86 patients, 21 had multiple manipulations with no significant difference in flexion gain after the second manipulation. Patients on warfarin (26%) had an increased incidence of stiffness and poor flexion gain. This study showed that better results were achieved when manipulation was performed at less than 20 weeks (particularly between 12 and 14 weeks) from primary surgery with no added benefit from re-manipulations.

Which factors are associated with a successful outcome following total hip arthroplasty in patients with early radiographic osteoarthritis?

BACKGROUND: It is unclear which factors are associated with a successful total hip arthroplasty (THA) in patients with early radiographic osteoarthritis (OA). METHODS: 70 patients with early OA (Kellgren and Lawrence [KL] grades 0-2) who underwent THA were compared with 200 patients with advanced OA (KL grades 3-4). Outcomes were Oxford Hip Scores (OHS), EQ-5D and EQ-VAS scores; compared preoperatively with 1 year postoperatively. We investigated which clinical and radiographic (plain x-ray, CT, MRI) features predicted successful THA (postoperative OHS ⩾42). RESULTS: The early OA group were significantly younger (61 vs. 66 years; [p = 0.0035). There were no significant differences in BMI, ASA grade or gender. After adjusting for confounders, the advanced OA group had a significantly greater percentage of possible change (PoPC) in OHS (75.8% vs. 50.4%; p < 0.0001) and improvement in EQ-5D (0.151 vs. 0.002; p < 0.0001). There were no significant differences in complication, revision or readmission rates. In the early OA group, 16/70 (22.9%) patients had a 'successful' THA. Patients who had a 'successful' THA were significantly more likely to have subchondral cysts on CT/MRI (91.7% vs. 57.7%; p = 0.0362). The presence of cysts on CT/MRI was associated with a significantly greater PoPC in OHS (61.6% vs. 38.2%; p = 0.0353). The combination of cysts and joint space width <1 mm was associated with a PoPC of 68%. CONCLUSIONS: THA in patients with early OA (KL grades 0-2) on plain radiographs should be indicated with caution. We advocate preoperative cross-sectional imaging in these patients. In the absence of cysts on CT/MRI, a THA seems unlikely to provide a satisfactory outcome.