A prospective clinical audit of a new dressing design for lower limb arthroplasty wounds.

An audit of wound healing in patients undergoing total hip or knee arthroplasty in a Scottish hospital found that use of a barrier film made no difference to the effectiveness of a new Hydrofiber/hydrocolloid dressing combination.

Long-term results of the modified Hoffman procedure in the rheumatoid forefoot. Surgical technique.

BACKGROUND: Rheumatoid arthritis commonly affects the forefoot, causing metatarsalgia, hallux valgus, and deformities of the lesser toes. Various types of surgical correction have been described, including resection of the lesser-toe metatarsal heads coupled with arthrodesis of the great toe, resection arthroplasty of the proximal phalanx or metatarsal head, and metatarsal osteotomy. We report the results at an average of five and a half years following thirty-seven consecutive forefoot arthroplasties performed in twenty patients by one surgeon using a technique involving resection of all five metatarsal heads. METHODS: All patients were treated with the same technique of resection of all five metatarsal heads through three dorsal incisions. All surviving patients were asked to return for follow-up, which included subjective assessment (with use of visual analogue pain scores, AOFAS [American Orthopaedic Foot and Ankle Society] foot scores, and SF-12 [Short Form-12] mental and physical disability scores), physical examination, and radiographic evaluation. RESULTS: All results were satisfactory to excellent in the short term (six weeks postoperatively), and no patient sought additional surgical treatment for the feet. A superficial infection subsequently developed in two feet, and two feet had delayed wound-healing. At an average of 64.9 months postoperatively, the average AOFAS forefoot score was 64.5 points and the average hallux valgus angle was 22.3 degrees. There were no reoperations. CONCLUSIONS: Resection of all five metatarsal heads in patients with metatarsalgia and hallux valgus associated with rheumatoid arthritis can be a safe procedure that provides reasonable, if rarely complete, relief of symptoms.

The efficacy and safety of epidural filter catheters when used for post-operative intra-articular anaesthesia.

UNLABELLED: There are concerns about the risk of iatrogenic infection when employing local anaesthetic techniques with post-operative intra-articular infusions in total knee arthroplasty. This study aimed to determine the efficacy of intact epidural filters in preventing transit of bacteria and to develop a technique of administration which would prevent membrane rupture. Filter efficacy was assessed using a standardised test suspension of Pseudomonas aeruginosa. Twenty millilitres of suspension was injected through isolated epidural filters (n=10) or filters with 40cm of catheter tubing attached (n=30). For each filter, injections were carried out at 0, 8 and 24h. Filtrates were collected, incubated, sub-cultured onto Columbia horse blood agar and examined for bacterial growth. Three delivery techniques were tested: manually controlled syringe with 5ml of water at 20ml/min, forced administration syringe with 5ml of water at >240ml/min and an automated syringe driver delivering 40ml of water at 6.7ml/min. For the two techniques using syringes, three syringe sizes, 5ml, 10ml and 20ml, were tested. Each test condition was carried out on 10 filters (total n=70). Filters were examined for rupture. Intact epidural filters prevented bacterial transit in all cases. Manual controlled and automated syringe driver administration generated no filter ruptures. Manual forced administration generated 93% filter rupture. Ruptures occurred at peak pressures of approximately 620kPa. Epidural filters can be used to prevent bacterial transit. These results suggest automated devices remove the risk of filter rupture. This study is relevant to all specialties that utilise these filters during infiltration such as epidurals or other regional anaesthetic techniques. CLINICAL RELEVANCE: This study identified that filters are prone to rupture with high infusion rates and that manual techniques are particularly vulnerable. From these results, it is recommended that pumps are used to minimise risk of filter rupture.

The technique of delivery of peri-operative analgesia does not affect the rehabilitation or outcomes following total knee arthroplasty.

AIMS: This non-blinded randomised controlled trial compared the effect of patient-controlled epidural analgesia (PCEA) versus local infiltration analgesia (LIA) within an established enhanced recovery programme on the attainment of discharge criteria and recovery one year after total knee arthroplasty (TKA). The hypothesis was that LIA would increase the proportion of patients discharged from rehabilitation by the fourth post-operative day but would not affect outcomes at one year. PATIENTS AND METHODS: A total of 242 patients were randomised; 20 were excluded due to failure of spinal anaesthesia leaving 109 patients in the PCEA group and 113 in the LIA group. Patients were reviewed at six weeks and one year post-operatively. RESULTS: There was no difference in the proportion of patients discharged from rehabilitation by the fourth post-operative day, (77% in the PCEA group, 82% in the LIA group, p = 0.33), mean length of stay (four days in each group, p = 0.540), day of first mobilisation (p = 0.013) or pain (p = 0.278). There was no difference in mean Oxford Knee Scores (41 points in each group, p = 0.915) or the rate of complications in the two groups. CONCLUSION: Both techniques provided adequate pain relief, enabled early mobilisation and accelerated rehabilitation and good patient-reported outcomes up to one year post-operatively. PCEA and LIA are associated with similar clinical outcomes following TKA. Cite this article: Bone Joint J 2016;98-B1189-96.

Long-term results of the modified Hoffman procedure in the rheumatoid forefoot.

BACKGROUND: Rheumatoid arthritis commonly affects the forefoot, causing metatarsalgia, hallux valgus, and deformities of the lesser toes. Various types of surgical correction have been described, including resection of the lesser-toe metatarsal heads coupled with arthrodesis of the great toe, resection arthroplasty of the proximal phalanx or metatarsal head, and metatarsal osteotomy. We report the results at an average of five and a half years following thirty-seven consecutive forefoot arthroplasties performed in twenty patients by one surgeon using a technique involving resection of all five metatarsal heads. METHODS: All patients were treated with the same technique of resection of all five metatarsal heads through three dorsal incisions. All surviving patients were asked to return for follow-up, which included subjective assessment (with use of visual analogue pain scores, AOFAS [American Orthopaedic Foot and Ankle Society] foot scores, and SF-12 [Short Form-12] mental and physical disability scores), physical examination, and radiographic evaluation. RESULTS: All results were satisfactory to excellent in the short term (six weeks postoperatively), and no patient sought additional surgical treatment for the feet. A superficial infection subsequently developed in two feet, and two feet had delayed wound-healing. At an average of 64.9 months postoperatively, the average AOFAS forefoot score was 64.5 points and the average hallux valgus angle was 22.3 degrees . There were no reoperations. CONCLUSIONS: Resection of all five metatarsal heads in patients with metatarsalgia and hallux valgus associated with rheumatoid arthritis can be a safe procedure that provides reasonable, if rarely complete, relief of symptoms.

Intra-operative deviation in limb alignment occurring at implantation in total knee arthroplasty.

BACKGROUND: Long-term survival of knee replacement depends on accurate alignment. Despite improvements in cut accuracy mal-alignment of 3° or more is still seen. All methods share common implantation techniques. This study examines the effect of implantation on overall limb alignment relating it to cut alignment and trial alignment. METHODS: A retrospective review of navigated primary knee replacements was undertaken (n=113). Overall coronal limb alignments for the aggregated cuts, trial and final implanted components were examined. RESULTS: All 113 knees had coronal aggregated cut alignment within 2° of neutral (range: 2° varus to 2° valgus). With trial components 99 knees (88%) had an overall coronal limb alignment within 2° of neutral (range: 3° varus to 4° valgus). After final implantation 106 knees (94%) were within 2° of neutral (range: 4° varus to 4° valgus). Forty eight knees (42%) showed no alignment deviation occurring between trial and the final implanted prostheses and 16 knees (14%) shoed a deviation of 2° or more. There was a correlation of both aggregated cut (r=0.284, p=0.002) and trial (r=0.794, p<0.001) with final alignment. There was no significant difference between the final alignment and the aggregated cut alignment(mean difference=-0.15°, p=0.254) or trial alignment (mean difference -0.13°, p=0.155). CONCLUSIONS: Even when the aggregated alignment produced by the bone cuts is accurate, inaccuracy in final alignment can result from the implantation process. It may be productive for surgeons to concentrate on the implantation process to improve alignment and reduce outliers.

The role of retraction in direct nerve injury in total hip replacement: an anatomical study.

OBJECTIVES: Acetabular retractors have been implicated in damage to the femoral and obturator nerves during total hip replacement. The aim of this study was to determine the anatomical relationship between retractor placement and these nerves. METHODS: A posterior approach to the hip was carried out in six fresh cadaveric half pelves. Large Hohmann acetabular retractors were placed anteriorly, over the acetabular lip, and inferiorly, and their relationship to the femoral and obturator nerves was examined. RESULTS: If contact with bone was not maintained during retractor placement, the tip of the anterior retractor had the potential to compress the femoral nerve by passing superficial to the iliopsoas. If pressure was removed from the anterior retractor, the tip pivoted on the anterior acetabular lip, and passed superficial to the iliopsoas, overlying and compressing the femoral nerve, when pressure was reapplied. The inferior retractor pierced the obturator membrane in all specimens medial to the obturator nerve, with subsequent retraction causing the tip to move laterally, making contact with the nerve. CONCLUSION: Iliopsoas can only offer protection to the femoral nerve if the retractor passes deep to the muscle bulk. The anterior retractor should be reinserted if pressure is removed intra-operatively. Vigorous movement of the inferior retractor should be avoided. Cite this article: Bone Joint Res 2014;3:212-6.

An enhanced recovery programme for primary total knee arthroplasty in the United Kingdom--follow up at one year.

The concepts of Enhanced Recovery Programmes (ERP) are to reduce peri-operative morbidity whilst accelerating patient's rehabilitation resulting in a shortened hospital stay following primary joint arthroplasty. These programmes should include all patients undergoing surgery and should not be selective. We report a consecutive series of 1081 primary total knee arthroplasties undergoing an enhanced recovery programme with a one year follow up period. A comparative cohort of 735 patients from immediately prior to the enhanced recovery programme implementation was also reviewed. The median day of discharge home was reduced from post-operative day six to day four (p<0.001) for the ERP group. Post-operative urinary catheterisation (35% vs. 6.9%) and blood transfusion (3.7% vs. 0.6%) rates were significantly reduced (p<0.001). Within the ERP group median pain scores (0 = no pain, 10 = maximal pain) on mobilisation were three throughout hospital stay with 95% of patients ambulating within 24h. No statistical difference was found in post-operative thrombolytic events (p=0.35 and 0.5), infection (p=0.86), mortality rates (p=0.8) and Oxford Knee Scores (p=0.99) at follow up. This multidisciplinary approach provided satisfactory post-operative analgesia allowing early safe ambulation and expedited discharge to home with no detriment to continuing rehabilitation, infection or complication rates at one year.

Iatrogenic nerve injury with the Russell-Taylor humeral nail.

The first consecutive 51 humeral shaft fractures treated with the Russell-Taylor intramedullary nail at Glasgow Royal Infirmary were reviewed in a retrospective study. There were eight iatrogenic nerve injuries- three to the radial nerve which settled spontaneously and five to the lateral cutaneous nerve of forearm of which three have failed to recover completely. The authors feel that the insertion of the distal interlocking screw in the antero-posterior direction puts this nerve at risk. We believe that iatrogenic injury to the lateral cutaneous nerve of forearm during humeral nailing has not been previously reported.