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OBJECTIVES: Rib fractures present a heavy pain and functional burden in trauma. Our primary aim was to determine return to work in patients with acute rib fractures requiring surgical stabilization of rib fractures. Our secondary outcomes were pain and quality of life. We also document the first application of the Work Productivity and Activity Impairment Instrument, a validated injury-specific patient-reported outcome measure, for chest wall injury in the literature. METHODS: A retrospective review was conducted on patients with rib fractures requiring surgical fixation in a single centre between 2008 and 2020. After applying inclusion and exclusion criteria to ensure relevance, all eligible patients were asked to complete patient-reported outcome measure questionnaires. RESULTS: Of 1841 trauma patients with rib fractures, 66 underwent surgical fixation. Thirty-nine patients were eligible and 31 completed the questionnaires. Pre-injury and post-injury answers were compared. The number of patients in employment decreased postoperatively from 22 to 16 (P = 0.006). For those who returned to work, there was no difference in hours missed but reduced weekly hours and productivity scores. There were significantly more patients with pain and on pain relief. There was a lower quality of life score postoperatively. CONCLUSIONS: Approximately 1 in 5 patients who require surgical fixation for rib fractures will not return to work. This is the first chest wall trauma study that uses the Work Productivity and Activity Impairment Instrument, a validated tool for work productivity outcomes. We recommend this instrument as a reliable tool for investigating return-to-work outcomes in trauma patients.
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Medidas de Resultados Relatados pelo Paciente , Qualidade de Vida , Retorno ao Trabalho , Fraturas das Costelas , Humanos , Fraturas das Costelas/cirurgia , Retorno ao Trabalho/estatística & dados numéricos , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Adulto , Traumatismos Torácicos/cirurgia , Idoso , Inquéritos e Questionários , Fixação Interna de Fraturas/métodosRESUMO
OBJECTIVES: Treatment of 5th metatarsal fractures via direct discharge from virtual fracture clinic (VFC) has become common practice in the NHS. We aim to assess the functional outcome and incidence of non-union in a series of 5th metatarsal base fractures, exposed to 1-year of follow-up. METHODS: 194 patients who sustained a fracture between the period February 2019 to April 2020 were included, referred via the VFC pathway. Radiographs were reviewed to classify in which zone, the fracture occurred along with union on subsequent follow-up. Telephone follow-up was used to measure patient functional outcomes (EQ-5D & FAAM survey) and satisfaction with the VFC service. RESULTS: Off 194 patients, 53 (27.3%) had zone 1, 99 (51%) had zone 2, and 42 (21.6%) had zone 3 fractures. 80 were discharged directly from VFC, with 114 patients being offered at least one face to face clinic follow-up. Six (3.1%) patients had clinical and radiological evidence of non-union; 4 in zone 2, and 2 in zone 3. No zone 1 injuries were identified as a non-union. Only 2 patients had surgery, 1 of which was for symptomatic non-union. Of the 6 non-union patients, 1 had surgery, 4 did not wish to have surgery and the final non-union patient was deemed unsuitable for surgery. CONCLUSION: The VFC is an effective way of managing 5th metatarsal fractures, with high patient satisfaction. Conservative management has excellent outcomes, with a low percentage of zone 2 and 3 injuries developing a symptomatic non-union. Functional outcome surveys provide further reassurance.
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Fraturas Ósseas , Fraturas não Consolidadas , Ossos do Metatarso , Humanos , Ossos do Metatarso/lesões , Ossos do Metatarso/diagnóstico por imagem , Fraturas não Consolidadas/cirurgia , Masculino , Feminino , Fraturas Ósseas/cirurgia , Adulto , Pessoa de Meia-Idade , Satisfação do Paciente , Idoso , Consolidação da Fratura , Adulto Jovem , Radiografia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Aims: The aim of this study was to determine both the incidence of, and the reoperation rate for, postoperative periprosthetic femoral fracture (POPFF) after total hip arthroplasty (THA) with either a collared cementless (CC) femoral component or a cemented polished taper-slip (PTS) femoral component. Methods: We performed a retrospective review of a consecutive series of 11,018 THAs over a ten-year period. All POPFFs were identified using regional radiograph archiving and electronic care systems. Results: A total of 11,018 THAs were implanted: 4,952 CC femoral components and 6,066 cemented PTS femoral components. Between groups, age, sex, and BMI did not differ. Overall, 91 patients (0.8%) sustained a POPFF. For all patients with a POPFF, 16.5% (15/91) were managed conservatively, 67.0% (61/91) underwent open reduction and internal fixation (ORIF), and 16.5% (15/91) underwent revision. The CC group had a lower POPFF rate compared to the PTS group (0.7% (36/4,952) vs 0.9% (55/6,066); p = 0.345). Fewer POPFFs in the CC group required surgery (0.4% (22/4,952) vs 0.9% (54/6,066); p = 0.005). Fewer POPFFs required surgery in males with a CC than males with a PTS (0.3% (7/2,121) vs 1.3% (36/2,674); p < 0.001). Conclusion: Male patients with a PTS femoral component were five times more likely to have a reoperation for POPFF. Female patients had the same incidence of reoperation with either component type. Of those having a reoperation, 80.3% (61/76) had an ORIF, which could greatly mask the size of this problem in many registries.
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Artroplastia de Quadril , Prótese de Quadril , Fraturas Periprotéticas , Humanos , Masculino , Feminino , Artroplastia de Quadril/efeitos adversos , Fraturas Periprotéticas/epidemiologia , Fraturas Periprotéticas/etiologia , Fraturas Periprotéticas/cirurgia , Prótese de Quadril/efeitos adversos , Reoperação/efeitos adversos , Fatores de Risco , Desenho de Prótese , Cimentos Ósseos , Estudos RetrospectivosRESUMO
AIMS: Fragility fractures are a growing global healthcare burden; fragility fractures of the femur have been shown to occur in a highly comorbid patient group, with parallels to hip fracture patients. This study aimed to investigate if early surgery for femoral fractures, distal to the hip, resulted in a reduction in mortality in patients over 65 years of age. METHODS: A retrospective review of prospectively collected data for all consecutive femoral fractures in patients aged over 65 years who underwent surgical management between January 2000 and December 2018. Data was extracted from the Fracture Outcomes Research Database (FORD) and analysed to assess if early surgery, defined as occurring within 48 h of hospital admission with a fragility femur fracture, had an effect on 30 day and 1 year mortality. RESULTS: 502 eligible patients were included; median follow up time was 57 months. 24 patients (4.7%) died within 30 days of surgery and 105 patients (20.9%) had died within 1 year of surgery. Patients who underwent surgery within 48 h of admission had a significantly reduced chance of mortality within 1 year of surgery compared to patients who had surgery more than 48 h after admission (OR = 0.401, 95% CI 0.25-0.65, p<0.001). Following Multivariate Cox Regression analysis the hazard ratio of 1 year mortality following early surgery remained significantly reduced (HR = 0.57, 95% CI 0.36-0.92, p = 0.020). CONCLUSIONS: This study demonstrates that fragility femoral fracture patients represent a similar cohort to hip fracture patients, with high mortality rates. We recommend that hip fracture management principles are also employed for fragility femoral fractures in patients over 65 years, with rapid pre-operative optimisation to ensure these patients undergo early surgical intervention.
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Fraturas do Fêmur , Fraturas do Quadril , Idoso , Humanos , Estudos Retrospectivos , Fraturas do Fêmur/cirurgia , Fraturas do Quadril/cirurgia , Fêmur , ComorbidadeRESUMO
INTRODUCTION: The incidence of acetabular fractures in older patients is increasing. The management of these patients is evolving due to the recognition of risks associated with prolonged immobility with conservative treatment. MATERIALS AND METHODS: Consecutive patients undergoing fixation and total hip replacement (THR) for displaced acetabular fractures undergoing single operation with acetabular fixation and THR were identified. Outcomes were assessed using radiographs, clinical notes, Oxford Hip Score and EuroQol-5L. RESULTS: 77 patients were identified with 51 completing outcome scores. Mean age 68 years at time of injury. Mean follow-up 5 (2-12) years, OHS 40, EQ-5D 0.78. Revision surgery performed in 7 patients (9%). DISCUSSION: Acute fixation combined with THR for acetabular fractures in the elderly patient, offers good functional outcomes and a low complication rate in the mid-term.
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Artroplastia de Quadril , Fraturas Ósseas , Fraturas do Quadril , Humanos , Idoso , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/métodos , Resultado do Tratamento , Fraturas do Quadril/cirurgia , Acetábulo/diagnóstico por imagem , Acetábulo/cirurgia , Acetábulo/lesões , Fixação Interna de Fraturas/efeitos adversos , Fixação Interna de Fraturas/métodos , Fraturas Ósseas/cirurgia , Estudos RetrospectivosRESUMO
Femoral de-rotational osteotomies are a safe and effective treatment for symptomatic excessive femoral anteversion or retroversion. The author's preferred technique for performing a de-rotational osteotomy is via a subtrochanteric transverse osteotomy with intramedullary nail fixation. We describe a method for guiding femoral de-rotation correction intra-operatively using a bubble inclinometer.
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OBJECTIVES: To examine outcome for patients with hip fracture treated by a hemiarthroplasty (HA) but who actually met the United Kingdom, National Institute for Health and Care Excellence (NICE) criteria for receiving a total hip arthroplasty (THA). DESIGN: Match cohort study. SETTING: Level 1, Academic Trauma Centre (UK Major Trauma Centre). PATIENTS/PARTICIPANTS: Three hundred ninety-eight patients underwent either a HA or THA for a nonpathological displaced intracapsular fractured neck of the femur [OTA/AO 31 B3 (garden 3-4)], having met the NICE criteria for THA. INTERVENTION: HA versus THA. Two analyses were performed, the first comparing the outcome in a cohort of patients who either received a THA or HA but who all had met the NICE criteria to receive a THA (n = 398). The second analysis assessed the outcome of THA versus HA, in a matched cohort of patients who all met the NICE criteria for a THA (n = 44 matched pairs). All patients in the matched cohort were able to walk independently outdoors (WIOs) before injury. MAIN OUTCOME: Mobility and functional outcome, 1 year after surgery. RESULTS: Of the 398 patients who met the criteria for THA, only 78 (19.6%) patients actually received a THA. Within the matched cohort, significantly more THA patients (92.9%, 39/42) maintained the ability to WIOs at 1-year compared with patients with HA (56.4%, 22/39; P = 0.001). There was no difference in mortality, reoperation, or complication rates for our matched population at 1 year. CONCLUSIONS: Patients who meet the NICE criteria for THA and are able to WIOs preinjury are more likely to have a higher level of independent mobility and a better functional outcome at 1-year if they receive a THA, as opposed to receiving a HA. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Artroplastia de Quadril , Fraturas do Colo Femoral , Hemiartroplastia , Estudos de Coortes , Fraturas do Colo Femoral/cirurgia , Humanos , ReoperaçãoRESUMO
Acetabular fractures in the elderly are challenging. Management is complicated by patients' poor physiological status and osteoporotic bone. Analysis of the management of these patients must be separated from the treatment of younger patients. Conservative management continues to have a role in patients who sustain fractures that are non-displaced and are considered stable with weight bearing mobilisation, and in those patients considered too medically frail to undergo surgical intervention. The mainstay of current surgical intervention is open reduction and internal fixation (ORIF) and variations of ORIF and total hip arthroplasty (THA), or fix and replace. Fix and replace is being increasingly favoured in those patients who display poor prognostic factors for long term joint survival after ORIF. Percutaneous fixation has the theoretical benefits of minimally invasive surgery and the potential to make any subsequent THA less complicated. However, it requires specialised fluoroscopic skills and is not suitable for all fracture patterns. There are a number of developments being reported. The use of a reinforcement ring and THA in has been reported in a number of centres, as has the use of trabecular metal acetabular implants. A coned hemi pelvic prosthesis and THA has been described in our centre, with promising early results. The potential for 3D printing to improve preoperative planning and reduce intra-operative time is also being explored. The aim of this review is to provide a summary of the literature supporting current and future treatment methods, tips on reduction techniques and an overview of the treatment algorithm of these patients in our unit.
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Artroplastia de Quadril , Fraturas Ósseas , Fraturas do Quadril , Acetábulo/cirurgia , Idoso , Fixação Interna de Fraturas , Fraturas Ósseas/cirurgia , Fraturas do Quadril/cirurgia , Humanos , Redução Aberta , Estudos Retrospectivos , Resultado do TratamentoRESUMO
AIMS: Now that we are in the deceleration phase of the COVID-19 pandemic, the focus has shifted to how to safely reinstate elective operating. Regional and speciality specific data is important to guide this decision-making process. This study aimed to review 30-day mortality for all patients undergoing orthopaedic surgery during the peak of the pandemic within our region. METHODS: This multicentre study reviewed data on all patients undergoing trauma and orthopaedic surgery in a region from 18 March 2020 to 27 April 2020. Information was collated from regional databases. Patients were COVID-19-positive if they had positive laboratory testing and/or imaging consistent with the infection. 30-day mortality was assessed for all patients. Secondly, 30-day mortality in fracture neck of femur patients was compared to the same time period in 2019. RESULTS: Overall, 496 operations were carried out in 484 patients. The overall 30-day mortality was 1.9%. Seven out of nine deceased patients underwent surgery for a fractured neck of femur. In all, 27 patients contracted COVID-19 in the peri-operative period; of these, four patients died within 30 days (14.8%). In addition, 21 of the 27 patients in this group had a fractured neck of femur, 22 were over the age of 70 years (81.5%). Patients with American Society of Anesthesiologists (ASA) grade > 3 and/or age > 75 years were at significantly higher risk of death if they contracted COVID-19 within the study period. CONCLUSION: Overall 30-day postoperative mortality in trauma and orthopaedic surgery patients remains low at 1.9%. There was no 30-day mortality in patients ASA 1 or 2. Patients with significant comorbidities, increasing age, and ASA 3 or above remain at the highest risk. For patients with COVID-19 infection, postoperative 30-day mortality was 14.8%. The reintroduction of elective services should consider individual patient risk profile (including for ASA grade). Effective postoperative strategies should also be employed to try and reduce postoperative exposure to the virus.Cite this article: Bone Joint Open 2020;1-7:392-397.
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INTRODUCTION: The enhanced recovery after surgery (ERAS) concept in arthroplasty surgery has led to a reduction in postoperative length of stay in recent years. Patients with prolonged length of stay (PLOS) add to the burden of a strained NHS. Our aim was to identify the main reasons. METHODS: A PLOS was arbitrarily defined as an inpatient hospital stay of four days or longer from admission date. A total of 2,000 consecutive arthroplasty patients between September 2017 and July 2018 were reviewed. Of these, 1,878 patients were included after exclusion criteria were applied. Notes for 524 PLOS patients were audited to determine predominant reasons for PLOS. RESULTS: The mean total length of stay was 4 days (1 to 42). The top three reasons for PLOS were social services, day-before-surgery admission, and slow to mobilize. Social services accounted for 1,224 excess bed days, almost half (49.2%, 1,224/2,489) of the sum of excess bed days. CONCLUSION: A preadmission discharge plan, plus day of surgery admission and mobilization on the day of surgery, would have the potential to significantly reduce length of stay without compromising patient care.Cite this article: Bone Joint Open 2020;1-8:488-493.
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AIMS: Previous research has demonstrated increased early complication rates following total hip arthroplasty (THA) in obese patients, as defined by body mass index (BMI). Subcutaneous fat depth (FD) has been shown to be an independent risk factor for wound infection in cervical and lumbar spine surgery, as well as after abdominal laparotomy. The aim of this study was to investigate whether increased peritrochanteric FD was associated with an increased risk of complications in the first year following THA. METHODS: We analyzed prospectively collected data on a consecutive series of 1,220 primary THAs from June 2013 until May 2018. The vertical soft tissue depth from the most prominent part of the greater trochanter to the skin was measured intraoperatively using a sterile ruler and recorded to the nearest millimetre. BMI was calculated at the patient's preoperative assessment. All surgical complications occuring within the initial 12 months of follow-up were identified. RESULTS: Females had a significantly greater FD at the greater trochanter in comparison to males (median 3.0 cm (interquartile range (IQR) 2.3 to 4.0) vs 2.0 cm (IQR 1.7 to 3.0); p < 0.001) despite equivalent BMI between sexes (male median BMI 30.0 kg/m2 (IQR 27.0 to 33.0); female median 29.0 kg/m2 (IQR 25.0 to 33.0)). FD showed a weak correlation with BMI (R² 0.41 males and R² 0.43 females). Patients with the greatest FD (upper quartile) were at no greater risk of complications compared with patients with the lowest FD (lower quartile); 7/311 (2.3%) vs 9/439 (2.1%); p = 0.820 . Conversely, patients with the highest BMI (≥ 40 kg/m2) had a significantly increased risk of complications compared with patients with lower BMI (< 40 kg/m2); 5/60 (8.3% vs 18/1,160 (1.6%), odds ratio (OR) 5.77 (95% confidence interval (CI) 2.1 to 16.1; p = 0.001)). CONCLUSION: We found no relationship between peritrochanteric FD and the risk of surgical complications following primary THA. Cite this article: Bone Joint J 2020;102-B(9):1146-1150.
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Artroplastia de Quadril , Complicações Pós-Operatórias/epidemiologia , Gordura Subcutânea/anatomia & histologia , Idoso , Feminino , Humanos , Masculino , Estudos Prospectivos , Medição de Risco , Fatores de RiscoRESUMO
AIMS: Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort. METHODS: We have prospectively monitored a series of 22 cases (21 patients) with a mean follow-up of 32 months (13 to 59). RESULTS: The mean patient age was 79 years (67 to 87), and the mean ASA score was 3.3 (3 to 5). Three patients had high-energy injuries and 18 had low-energy injuries. All cases were associated fractures (Letournel classification: anterior column posterior hemitransverse, n = 13; associated both column, n = 6; transverse posterior wall, n = 3) with medialization of the femoral head. Mean operative time was 93 minutes (61 to 135). There have been no revisions to date. Of the 21 patients, 20 were full weight-bearing on day 1 postoperatively. Mean length of hospital stay was 12 days (5 to 27). Preoperative mobility status was maintained in 13 patients. At one year, mean Merle d'Aubigné score was 13.1 (10 to 18), mean Oxford Hip Score was 38.5 (24 to 44), mean EuroQol five-dimension five-level (EQ-5D-5L) health score was 68 (30 to 92), and mean EQ-5D-5L index score was 0.68 (0.335 to 0.837); data from 14 patients. Mortality was 9.5% (2/21) at one year. There have been no thromboembolic events, deep infections, or revisions. CONCLUSION: The coned hemipelvis reconstruction bypasses the fracture, creating an immediately stable construct that allows immediate full weight-bearing. The posterior approach minimizes the operative time and physiological insult in this vulnerable patient population. Early results suggest this to be a safe addition to current surgical options, targeted at the most medically frail elderly patient with a complex displaced acetabular fracture. Cite this article: Bone Joint J 2020;102-B(2):155-161.
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Acetábulo/cirurgia , Fraturas Ósseas/cirurgia , Idoso Fragilizado , Fraturas por Osteoporose/cirurgia , Ossos Pélvicos/cirurgia , Acetábulo/lesões , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/métodos , Comores , Feminino , Fixação Interna de Fraturas/métodos , Humanos , Masculino , Procedimentos de Cirurgia Plástica/métodos , Suporte de CargaRESUMO
BACKGROUND: Fracture of a polyethylene tibial post after a posterior stabilized total knee arthroplasty (PS-TKA) is an uncommon but severe complication. We report five cases of non-traumatic fracture of a tibial polyethylene post that occurred with Prolong highly cross-linked polyethylene with the NexGen LPS-Flex total knee prosthesis. METHODS: A Joint Reconstruction database for a high volume arthroplasty unit was used to identify all cases of revision of Prolong polyethylene used in PS-TKA. Five cases were identified as being revised because of a broken tibial post. RESULTS: All five cases presented with a combination of sudden and increasing pain, instability and giving way, in previously well-functioning TKAs. There was no history of trauma or precipitating incident. Mean time from primary TKA to presentation and diagnosis of post fracture was 67.7â¯months (range 24-108). All five cases were successfully treated by revision, in the form of a liner exchange to a standard ultra-high molecular weight polyethylene (UHMWPE) bearing of the same thickness. The five cases occurred from a consecutive series of 955 total PS-TKAs with Prolong. This gives a conservative estimate of the frequency of this complication of 0.52%. This would give a risk of a tibial post fracture in approximately one in every 200 TKAs with this specific implant and bearing combination. CONCLUSIONS: To our knowledge, this is the first report of a non-traumatic fracture to the tibial post with this bearing type. We would advocate against the routine use of Prolong highly crosslinked polyethylene in PS-TKA.
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Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/instrumentação , Prótese do Joelho , Polietileno , Falha de Prótese , Fraturas da Tíbia/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polietilenos , Desenho de Prótese , Reoperação , Estudos Retrospectivos , Fraturas da Tíbia/cirurgiaRESUMO
BACKGROUND: Instability remains one of the main problems after revision hip surgery. The aim of this study was to review the clinical, radiological, and patient-reported outcomes with the use of modular dual-mobility articulation for revision acetabular reconstruction and investigate the risk of fretting corrosion by measuring serum trace metal ion levels. METHODS: Sixty consecutive patients with a minimum of 24-month follow-up after the insertion of a modular dual-mobility (Stryker, Mahwah, NJ) cup at the time of revision hip surgery were identified. Follow-up included clinical and radiological patient review and functional outcome measures, and a subset of patients had their metal ion (cobalt and chromium) levels checked. RESULTS: At the most recent follow-up, 5 patients had died, 3 patients have been revised because of ongoing instability, and 3 patients have had revision surgery due to infection. Overall functional outcome (mean Western Ontario and McMaster Universities Osteoarthritis Indexfunction 76, University of California, Los Angeles 5.6, mean Oxford 74.7, Short Form-12 physical 41.6/mental 53.3) and overall pain relief (mean Western Ontario and McMaster Universities Osteoarthritis Index pain score 78.3) scores were good. The mean satisfaction score was 78 of 100. The median serum trace metal chromium and cobalt levels at the most recent follow-up were 0.4 µg/L (range 0.1-6.1 µg/L) and 0.42 µg/L (range 0.21-9.42 µg/L), respectively. The survival with revision as the end point was 90%. CONCLUSIONS: Dual-mobility cups with modularity represent an excellent option for the patient having revision hip surgery at high risk of instability. This series presents good patient-reported outcome measures and a low complication and revision rate.
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Acetábulo/cirurgia , Artroplastia de Quadril/efeitos adversos , Prótese de Quadril/efeitos adversos , Reoperação/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Cromo/sangue , Cobalto/sangue , Corrosão , Feminino , Seguimentos , Humanos , Íons/sangue , Estudos Longitudinais , Masculino , Metais/sangue , Pessoa de Meia-Idade , Osteoartrite/diagnóstico , Osteoartrite/cirurgia , Desenho de Prótese , Amplitude de Movimento Articular , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
Peri-prosthetic joint infection remains one of the most difficult and challenging complications following hip and knee arthroplasty for both patients and surgeons. Two-stage revision arthroplasty for infection remains the most popular option for the majority of patients and arguably the only option for some. The use antibiotic spacers and in particular articulating spacers has improved the quality of life for patients between stages. The spacers provides local delivery of high concentration antibiotics and provides many benefits to the soft tissues including maintaining soft tissue tension and range of movement. This benefit to the soft tissues also translates into reducing the difficulty and time spent doing the exposure during the second stage procedure. It is generally accepted that peri-prosthetic joint infection should be dealt with my specialist centers who deal with high volumes of patients with this diagnosis in a multidisciplinary approach.
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Antibacterianos/administração & dosagem , Artroplastia/efeitos adversos , Bombas de Infusão Implantáveis , Prótese Articular/efeitos adversos , Infecções Relacionadas à Prótese/tratamento farmacológico , Idoso , Artroplastia/métodos , Artroplastia do Joelho/efeitos adversos , Feminino , Articulação do Quadril/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/etiologia , Qualidade de Vida , Reoperação/métodosRESUMO
BACKGROUND: Excellent medium-term to long-term results for function and survivorship have been shown with mobile-bearing (MB) total knee arthroplasty (TKA). One of the key arguments against its use is the risk of "spinout" or dislocation of the MB. The aim of this study is to discuss the etiology, prevention, incidence, management, and outcome of spinout. METHODS: Between October 1993 and February 2016, 8373 consecutive primary MB TKAs were performed irrespective of preoperative deformity. Before 2001, soft-tissue knee balancing was achieved by release of collateral ligaments and all spinouts were treated by open reduction. Thereafter, soft-tissue balancing was achieved without ligament release and with the use of a higher conformity MB and all spinouts were reduced closed, giving 2 comparative cohorts. RESULTS: Twenty-six spinouts occurred in 8373 (0.31%) patients. In the first cohort up until May 2001, there were 14 spinouts of 2379 (0.58%) cases. There were 12 in cohort 2, in those patients having surgery after May 2001, thus giving an incidence of 12 of 5994 (0.2%), which was significantly lower than in cohort 1 (P < .01). Spinout was associated with the valgus knee (P < .01) and most (73%) occurred within the first 6 months. There was 1 arthrodesis in cohort 1 and 1 both-component revision in cohort 2. CONCLUSION: The etiology of spinout is flexion gap instability. It can normally be reduced closed with recurrence being uncommon. Focus on soft-tissue balance necessary with an MB TKA can reduce the incidence of revision for instability as compared to a fixed-bearing TKA. Therefore, the risk of spinout should not be used as an argument against the MB TKA.
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Artroplastia do Joelho/métodos , Luxações Articulares/cirurgia , Articulação do Joelho/cirurgia , Prótese do Joelho , Osteoartrite do Joelho/cirurgia , Amplitude de Movimento Articular , Adulto , Idoso , Idoso de 80 Anos ou mais , Ligamentos Colaterais/cirurgia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Recidiva , Resultado do Tratamento , Suporte de CargaRESUMO
INTRODUCTION: Acetabular liner dissociation is a complication exclusive to modular designs. We present a single surgeon series of 8 polyethylene liner dissociations with the Pinnacle Acetabular System (DePuy Orthopaedics) from over 4,750 cases. We also present a review of the literature and data from the UK National Joint Registry (NJR) on dissociation in total hip arthroplasty (THA). METHODS: The Pinnacle Acetabular System has been used exclusively by the senior author since April 2003, and to date 5,882 have been implanted (837 ceramic liners, 4,751 polyethylene liners (1,606 Enduron/3,145 Marathon) and 294 metal liners). We reviewed all cases of liner dissociation from this cohort to determine an overall incidence with polyethylene liners, identify associated risk factors, and report the outcome following revision surgery. RESULTS: Our incidence of this complication is 8 out of 4,751 cases (0.17%). Review of these cases and the literature suggests that femoral neck impingement against the polyethylene liner and/or edge loading may produce fatigue failure of the locking mechanism and subsequent dissociation. CONCLUSIONS: Ensuring correct liner seating/locking, minimising impingement, achieving appropriate component version and avoiding radiographic cup inclinations >50° should minimise the risk of liner dissociation. Any new noise or squeaking from a polyethylene liner should undergo radiographic investigation to exclude dissociation. We recommend managing late cases of liner dissociation with revision of the acetabular shell if the cup orientation could be improved or if there is any damage to the liner-locking groove, to reduce the risk of recurrence.
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Acetábulo/cirurgia , Artroplastia de Quadril/efeitos adversos , Migração de Corpo Estranho/epidemiologia , Prótese de Quadril/efeitos adversos , Polietileno , Sistema de Registros , Acetábulo/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Feminino , Migração de Corpo Estranho/diagnóstico , Humanos , Incidência , Masculino , Desenho de Prótese , Falha de Prótese , Radiografia , Reoperação , Fatores de Risco , Reino Unido/epidemiologiaRESUMO
Acetabular liner dissociation is a rare complication of Total Hip Arthroplasty (THA) which requires urgent revision surgery. A case is presented in which the correct diagnosis was not appreciated on two separate Emergency Department attendances. The typical symptoms, signs, and radiological features are outlined and the importance of considering a rare complication following a commonly performed procedure is highlighted.
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The aim of this study is to evaluate the efficacy of bilateral thoracoscopic sympathectomy in alleviating symptoms and improving quality of life in patients with hyperhidrosis or facial blushing and to investigate the occurrence, severity and possible underlying factors to compensatory sweating after surgery. One hundred and sixty-three patients in a single institution underwent bilateral thoracoscopic sympathectomy with a mean follow-up period of 51 (5-140) months. Indications were for palmar hyperhidrosis (41%), axillary hyperhidrosis (17%), combined palmar and axillary hyperhidrosis (27%) and facial blushing+/-facial hyperhidrosis (15%). Success rates were palmar 98.5%, axillary 96.4%, palmar and axillary 97.7% and facial blushing+/-facial hyperhidrosis 84%. Compensatory sweating occurred in 77% of patients and its severity was related to the severity of the primary complaint. Recurrence rates were palmar 4.6%, axillary 7.4%, palmar and axillary 9.3% and facial blushing+/-facial hyperhidrosis 4.7% at a mean of 22 (3-72) months. An improvement in quality of life was seen in 85% and a diminution of quality of life was noted in 5% due to compensatory sweating. This large mature series demonstrates that bilateral thoracoscopic division of the sympathetic chain as opposed to resection can be performed effectively in patients with success rates higher than 90% and low recurrence rates.