A comparison of mortality rates following revision hip arthroplasty for periprosthetic fracture, infection or aseptic loosening.

BACKGROUND: Mortality following revision hip surgery for periprosthetic fracture (PPF) is comparable to neck of femur fractures. Our institution provides a regional "PPF Service". The aim of this study was to determine the time to surgery and mortality rate for PPF, compared to revision for infection or aseptic loosening. METHODS: Revision arthroplasty procedures performed for PPF, infection or aseptic loosening between January 2014 and December 2015 were identified. Comparisons were made between the 3 groups for baseline demographics, admission to higher-level care, length of stay, complications and mortality. RESULTS: There were 37 PPF, 71 infected and 221 aseptic revisions. PPF had a higher proportion of females (65% vs. 39% in infection and 53% in aseptic; p = 0.031) and grade 3 and 4 ASA patients (p = 0.006). Median time to surgery for PPF was 8 days (95% CI, 6-16). Single-stage procedures were performed in 84% of PPF, 42% of infections and 99% of aseptic revisions (p < 0.001). 19% of PPF revisions required HDU admission, 1% in the aseptic group and none in the infection group. Median length of stay was significantly different (PPF 10; infection 14; aseptic 8 days (p < 0.001). The 1-year mortality rate for PPF was 0%, 2.8% for infection and 0.9% in the aseptic group (p = 0.342). CONCLUSIONS: Despite the PPF group having higher ASA grades and more HDU admissions, our 1-year mortality rate was 0% and not significantly different to infection or aseptic loosening. Our low complication and 1-year mortality rate is encouraging and supports the safety of a regional "Periprosthetic Fracture Service".

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.

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.

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.

Raised serum lactate in a cirrhotic patient presenting after a trivial fall.

We present the case of a pelvic fracture in a 69-year-old man with Child-Pugh class C cirrhosis who presented to the Accident and Emergency department after a slip on wet grass. After initially being systemically well, he became haemodynamically unstable in the Emergency department requiring resuscitation via the massive transfusion pathway. He was admitted to intensive care unit for resuscitation following a CT angiogram which showed no arterial bleed, but significant retroperitoneal haematoma. He received a prophylactic embolization of the internal iliac artery 2 days later and his acetabular fracture was managed with skeletal traction. He died 7 weeks later as a result of his liver failure. We propose that a high index of suspicion would have led to an earlier diagnosis of his venous bleed and earlier transfusion.

The in vitro and in vivo effects of nicotine on bone, bone cells and fracture repair.

INTRODUCTION: Cigarette smoke has negative effects on bone metabolism and fracture repair. However, no study has reviewed effects of nicotine on bone and fracture repair independent of other constituents of cigarette smoke. The authors review the existing evidence of the effect of nicotine on 'bone' and 'bone cells' and fracture repair, drawing conclusions relevant to clinical practice and future research. AREAS COVERED: A literature review was conducted using PRISMA guidelines and PubMed, Cochrane, MEDLINE/OVID, EMBASE, NHS Evidence and Google scholar databases. Articles were included if they specifically investigated the effects of nicotine on 'bone' or fracture repair in animal or human models or in vitro effects on 'bone cells'. A total of 64 papers were included in this review, of which 15 were human in vitro studies and 49 animal studies wherein 9 were in vitro and 40 in vivo. In vivo studies of the effects of nicotine in animals demonstrated widespread effects on bone including osteoneogenesis, osseointegration, steady-state skeletal bone and genes and cytokines relevant to bone cell physiology and bone homeostasis. In these studies, nicotine's effects are predominately negative, inhibiting bone cell metabolism and fracture repair, whereas most in vitro studies reported biphasic responses in all bone cells except osteoclastic cells. EXPERT OPINION: The review suggests that nicotine has effects on osteoneogenesis, osseointegration and steady-state skeletal bone in animal in vivo models, as well as effects on all 'bone cells', via several mechanisms in both animal and human cell in vitro studies. The effect of nicotine is dose-dependent, with higher concentrations having predominantly negative effects, whereas at low concentrations a stimulatory effect is seen. Stimulatory effects on certain cells may indicate a possible, limited therapeutic role; advice regarding smoking cessation perioperatively should remain due to the other harmful components of cigarette smoke, but there may be scope for allowing the use of nicotine patches instead of complete abstention. Further research into clinical outcomes is required before the exact response of bone and fracture repair in humans to nicotine is known.