Hip resurfacing arthroplasty and total hip arthroplasty in the same patient: which do they prefer?

INTRODUCTION: Hip resurfacing arthroplasty (HRA) is an alternative to conventional total hip arthroplasty (THA) with potential advantages of preserving femoral bone stock and the ability to participate in higher impact activities. This study compares outcomes, satisfaction and preference in patients who underwent HRA in 1 hip and THA on the contralateral side. METHODS: 62 Patients with an HRA in 1 hip and a contralateral THA were retrospectively identified at 3 centres, consisting of 38 males and 24 females with 53 patients (85.5%) undergoing HRA first. A survey regarding satisfaction and preference for each procedure and outcome scores were obtained. RESULTS: Patients were younger (51.5 vs. 56.6 years, p = 0.002) and had longer follow-up on the HRA hip (11.0 vs. 6.0 years, p < 0.001). HRA was associated with larger increase in Harris Hip Score from preoperative to final follow-up (35.8 vs. 30.6, p = 0.035). 18 Patients (29.0%) preferred HRA, 19 (30.6%) preferred THA and 25 (40.3%) had no preference (p = 0.844). When asked what they would choose if they could only have 1 surgery again, 41 (66.1%, p < 0.001) picked HRA. Overall satisfaction (p = 0.504), willingness to live with their HRA versus THA for the rest of their life (p = 0.295) and recommendation to others (p = 0.097) were similar. CONCLUSIONS: Although HRA is associated with risks related to metal-on-metal bearings, it showed greater increase in patient-reported outcomes and a small subjective preference amongst patients who have undergone both conventional and resurfacing arthroplasty.

Screw fixation for syndesmotic injury is stronger and provides more contact area of the joint surface than TightRope®: A biomechanical study.

BACKGROUND: The rupture of syndesmotic ligaments is treated with a screw fixation as the gold standard. An alternative is the stabilization with a TightRope®. A couple of studies investigated the different clinical outcome and some even looked at the stability in the joint, but none of them examined the occurring pressure after fixation. OBJECTIVE: Is there a difference in pressure inside the distal tibiofibular joint between a screw fixation and a TightRope®? Does the contact area differ in these two treatment options? METHODS: This biomechanical study aimed to investigate the differences in fixation of the injured syndesmotic ligaments by using a fixation with one quadricortical screw versus singular TightRope® both implanted 1 cm above the joint. By using 12 adult lower leg cadaveric specimens and pressure recording sensor, we recorded the pressure across the distal tibiofibular joint. Additionally we measured the contact surface area across the joint. RESULTS: The mean of the pressure across the distal tibiofibular joint from the start of the insertion of the fixation device to the complete fixation was 0.05 Pascal for the TightRope® and 0.1 for the screw (P= 0.016). The mean of the maximum pressure across the joint (after completion of fixation and releasing the reduction clamp) was 1.750 mega Pascal with the screw fixation and 0.540 mega Pascal with TightRope® (P= 0.008). The mean of the measured contact area of the distal tibiofibular joint after fixation was 250 mm2 in the TightRope® group and of 355 mm2 in the screw fixation (P= 0.123). CONCLUSIONS: The screw fixation is stronger and provides a larger surface contact area, which leads us to the conclusion that it provides a better stability in the joint. While previous clinical studies did not show significant clinical difference between the two methods of fixation, the biomechanical construct varied. Long term clinical studies are required to establish whether this biomechanical distinction will contribute to various clinical outcomes.

Noise levels during total hip arthroplasty: the silent health hazard.

BACKGROUND: While there is an enormous amount of data on various surgical aspects of total hip arthroplasty (THA), there is only limited literature on the health hazards incurred by the surgical team. Since THA surgery produces noise, exposure over a long period of time may lead to gradual hearing loss which is known as noise-induced hearing loss. METHODS: We investigated the noise levels during THA and compared it with the maximum allowed limits at the workplace in the United Kingdom. In collaboration with specialised audio engineers, we analysed the noise levels during various steps of performing 7 uncemented THA. RESULTS: The results showed that the noise levels were close to the allowed limits for a workplace in the UK. CONCLUSION: Hospitals and staff who work in orthopaedic operating theatres should be aware of this risk and precautions should be put in place.

Perioperative mortality secondary to a pulmonary embolism during a surgical implantation of the Endo-Exo-Prosthesis: a case report.

We report on a 53-year-old female patient who suffered a perioperative death secondary to a pulmonary embolism (PE) during an implantation of Endo-Exo-Prosthesis. This is a retrospective review of medical case for a patient who had a previous above-the-knee amputation secondary to a failed previous arthroplasty surgery. Our planned surgery was a stage 1 implantation of an Endo-Exo-Prosthesis, and it was performed under general anaesthesia. After 25 min from starting the surgical procedure, the patient sustained a cardiac arrest, and despite an active cardiopulmonary resuscitation for 50 min, the patient did not recover, the ventilator machine was stopped later on, and the patient was declared deceased at that stage. Fatal intraoperative PE is a rare but significant complication during orthopaedic procedures. There are few reports of similar events but include mainly trauma patients with fractured neck of femur. Endo-Exo-Prosthesis is a relatively newly evolved procedure in a unique group of patients. To our knowledge, this is the first case report of such complication during Endo-Exo-Prosthesis implantation. Patient and surgeon should be aware of it, and additional preventive measures like preoperative scoring systems and in special cases using inferior vena cava filter should be considered in patients with high risk of developing venous thromboembolism.

Use of work-based assessments in postgraduate medical education.

Work-based assessments are ubiquitous in postgraduate medical training in the UK. This article discusses the variety of these assessments and explores barriers to their use and solutions for improving the educational value of these tools for adult learners. The focus should be on feedback and learning rather than assessment, and this may promote discussion of more challenging scenarios where the opportunity for learning is greater. Mobile devices may help reduce the administrative, geographical and time constraints of completing work-based assessments.

Paediatric pelvic fractures: A review of 2 cohorts over 22 years.

AIMS: The aim of this retrospective review was to identify all children that presented to our institution with a pelvic or acetabular fracture and to compare these children to a previous cohort of paediatric pelvic fractures that we have reported. PATIENTS: 53 children under the age of 16 were identified over a ten year period. METHODS: We reviewed our trauma database, hospital records and radiological imaging to determine the age, gender, fracture pattern, associated injuries and management of the pelvic fracture. RESULTS: There were 32 boys and 21 girls. Mean age of the boys was 8.8 years and the girls 10.7 years. In seven children the pelvic fracture was an isolated injury and in the remaining 46 children, there were 113 additional injuries. 56% of the additional injuries was either a fracture/dislocation (37%) or a head injury (19%). Compared to our first cohort, we had a larger number of children in the second cohort. Age, sex distribution, mechanism of injury was similar in the two groups. In this current cohort, use of CT scan imaging was more frequent, there were more unstable pelvic fracture patterns identified, ISS scores were higher and mortality was lower. CONCLUSION: We have seen more children with more severe injuries, higher ISS scores but a lower mortality rate.

The Use of Contrast in Caudal Epidural Injections under Image Intensifier Guidance: Is It Necessary?

BACKGROUND: We investigated the value of using contrast as an additional aid to confirm the accuracy of needle placement for caudal epidural injections under intraoperative image intensifier guidance. METHODS: A total of 252 consecutive patients were included in this study. Their mean age was 46.7 years (range, 32 to 76 years). There were 133 males (53%) and 119 females (47%) over a 12-month period. RESULTS: Of the 252 consecutive procedures, the contrast enhanced image intensifier confirmed accurate needle placement on first attempt in 252 cases (100%). Needle resiting following the infiltration of contrast was required in 0 case. CONCLUSIONS: The results from this study demonstrate that a surgeon beyond the learning curve can accurately place caudal epidural injections using image intensification only, without the use of contrast.

Foot and ankle history and clinical examination: A guide to everyday practice.

This review summarises the key points in taking a history and performing a comprehensive clinical examination for patients with foot and/or ankle problems. It is a useful guide for residents who are preparing for their specialty exams, as well as family doctors and any other doctor who has to deal with foot and ankle problems in adults.

A ward round proforma improves documentation and communication.

This article present the results of an audit cycle which evaluated the quality of inpatient ward round documentation in a busy district general hospital before and after the implementation of a standardized proforma which was specifically designed for trauma and orthopaedic patients. In each cycle, 20 case notes were examined and the data analysed to examine three main areas: Diagnosis, management and/or discharge plan Objective assessments including neurovascular status, weight-bearing status, surgical wound review, observations, results of investigations and decision from the daily trauma meeting Logistics of the documentation such as legibility, date and time, name and grade of the doctor and contact number. This audit demonstrated that using a ward round proforma can significantly enhance the quality of documentation and improve communication between multidisciplinary team members.

Management of anterior cruciate ligament injury: pathophysiology and treatment.

Anterior cruciate ligament injury, a common soft tissue injury of the knee joint, is increasing in incidence particularly in young active people. It causes instability of the knee that leads to meniscal tears, cartilage defects and early osteoarthritis. This review summarizes aspects of anterior cruciate ligament injury management.

Surgical treatment of anterior cruciate ligament injury in adults.

Anterior cruciate ligament injury is among the most common soft tissue injuries of the knee joint and reconstruction of the anterior cruciate ligament is the gold standard treatment for young active symptomatic patients. This review summarizes the surgical treatment of anterior cruciate ligament injury.

Salvage Procedures for Management of Prosthetic Joint Infection After Hip and Knee Replacements.

BACKGROUND: The increasing load placed by joint replacement surgery on health care systems makes infection, even with the lowest rates, a serious concern that needs to be thoroughly studied and addressed using all possible measures. METHODS: A comprehensive review of the current literature on salvage procedures for recurrent PJIs using PubMed, EMBASE and CINAHL has been conducted. RESULTS: Prolonged suppressive antibiotic therapy (PSAT), resection arthroplasty and arthrodesis were the most common procedures performed. Suppressive antibiotic therapy is based on the use of well tolerated long term antibiotics in controlling sensitive organisms. Resection arthroplasty which should be reserved as a last resort provided more predictable outcomes in the hip whereas arthrodesis was associated with better outcomes in the knee. Various methods for arthrodesis including internal and external fixation have been described. CONCLUSION: Despite good union and infection control rates, all methods were associated with complications occasionally requiring further surgical interventions.

Aggressive Early Debridement in Treatment of Acute Periprosthetic Joint Infections After Hip and Knee Replacements.

BACKGROUND: Periprosthetic Joint Infection Remains a Dreaded Complication After Hip and Knee Replacement Surgery. Treatment Options for Acute Postoperative and Acute Hematogenous Infections Include Arthroscopic or Open Debridement With Retention or Exchange of the Prostheses. This Review Article Aims to Summarize the Evidence for Management of Acute Postoperative And Acute Hematogenous Infections. METHODS: A Systematic Literature Search Was Performed Using a Computer-based Search Engine Covering Medline (OvidSP), PubMed Database (U.S. National Library of Medicine, National Institutes of Health), Embase, Web of Science, Cochrane and Google Scholar for Relevant Articles. RESULTS: Common Themes Around Treatment of Acute Postoperative and Acute Hematogenous Infections Discussed in this Review Include the Timing of Intervention, Description of the Optimal Procedure and How we Perform it at our Institution, the Role of Arthroscopic Debridement, Most Commonly Isolated Micro-organisms and Prognostic Factors for Infection Control. CONCLUSION: Success in Treating Acute Postoperative and Acute Hematogenous Infections Depends on Early Diagnosis and Aggressive Surgical Debridement Combined With Effective Antibiotic Therapy.

Is single-stage revision according to a strict protocol effective in treatment of chronic knee arthroplasty infections?

BACKGROUND: The increasing number of patients experiencing periprosthetic total knee arthroplasty (TKA) infections and the cost of treating them suggest that we seek alternatives to two-stage revision. Single-stage revision is a potential alternative to the standard two-stage procedure because it involves only one surgical procedure, so if it is comparably effective, it would be associated with less patient morbidity and lower cost. QUESTIONS/PURPOSES: We compared (1) the degree to which our protocol of a highly selective single-stage revision approach achieved infection control compared with a two-stage revision approach to TKA infections; and (2) Knee Society scores and radiographic evidence of implant fixation between the single-stage and two-stage patients who were treated for more complicated infections. METHODS: Between 2004 and 2009, we treated 102 patients for chronic TKA infections, of whom 28 (27%) were treated using a single-stage approach and 74 (73%) were treated using a two-stage approach. All patients were available for followup at a minimum of 3 years (mean, 6.5 years; range, 3-9 years). The indications for using a single-stage approach were minimal/moderate bone loss, the absence of immunocompromise, healthy soft tissues, and a known organism with known sensitivities for which appropriate antibiotics are available. Participants included 38 men and 64 women with a mean age of 65 years (range, 45-87 years). We used the Musculoskeletal Infection Society definition of periprosthetic joint infection to confirm infection control at the last followup appointment. Radiographs were evaluated for signs of loosening, and patients completed Knee Society Scores for clinical evaluation. RESULTS: None of the patients in the single-stage revision group developed recurrence of infection, and five patients (93%) in the two-stage revision group developed reinfection (p=0.16). Patients treated with a single-stage approach had higher Knee Society scores than did patients treated with the two-stage approach (88 versus 76, p<0.001). However, radiographic findings showed a well-fixed prosthesis in all patients with no evidence of loosening at last followup in either group. CONCLUSIONS: Our data provide preliminary support to the use of a single-stage approach in highly selected patients with chronically infected TKAs as an alternative to a two-stage procedure. However, larger, multicenter, prospective trials are called for to validate our findings. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Mortality and re-operation rate after proximal femoral fracture surgery by trainees.

PURPOSE: To review records of 761 patients who underwent surgery for proximal femoral fractures to determine whether surgeon's experience and volume was associated with 6-month mortality and reoperation rates. METHODS: Records of 761 patients who underwent surgery for proximal femoral fractures were reviewed. Patients operated on by a consultant or trainees with supervision of a scrubbed consultant were classified as the consultant group (n=214). Patients operated on by trainees alone (n=516) or trainees with supervision of an unscrubbed consultant (n=31) were classified as the trainee group (n=547). A total of 21 trainees were identified. They had different levels of experience, which was quantified according to the total number of operations performed for proximal femoral fractures from the start of their training to the start of the study. RESULTS: Patients in the trainee group were older (80 ± 12 vs. 77 ± 14 years, p<0.001), and the fractures were more complex in the consultant group. The 6-month mortality rate was 24.2% (n=184). The odds of dying within 6 months after operation was 80% higher in patients operated on by trainees without supervision of a scrubbed consultant (odds ratio, 1.8; 95% confidence interval, 1.1-2.7). Variables associated with the 6-month mortality rate were age (p<0.001), American Society of Anesthesiologists grade (p<0.001), pre-injury activity level (p<0.001), and the surgeon's grade (p<0.05). The 6-month reoperation rate was 3.8% (n=29) and did not differ significantly in the 2 groups. The experience level of the trainees was not associated with the 6-month reoperation rate. CONCLUSION: The odds of dying within 6 months after a surgery for proximal femoral fractures was 80% higher in patients operated on by trainees without supervision of a scrubbed consultant.

Patients undergoing blood tests before minor/moderate trauma surgery: a retrospective review.

OBJECTIVE: The aim of this study was to establish the number of unnecessary preoperative blood tests undertaken on ASA Grade 1 patients undergoing minor/moderate orthopaedic trauma surgery. DESIGN: Review of all ASA1 patients who had been operated on the trauma lists for three consecutive months. SETTING: UK Teaching Hospital. PARTICIPANTS: Patients with ages ranging between 16 and 60 years, and undergoing a minor or moderate trauma operation. MAIN OUTCOME MEASURES: The type and number of blood tests were established and any abnormal results were checked for clinical significance and whether the result altered patients' management. The cost of each blood test was calculated so that potential savings could be identified. RESULTS: A total of 127 patients (60 males, 67 females, average age 34) fulfilled our inclusion criteria. Ninety-five patients (75%) had either one or more preoperative blood tests of which 41% were abnormal but of no clinical significance. CONCLUSION: From the results of our study, we conclude that preoperative blood tests are unnecessary in Grade 1 ASA patients undergoing minor/moderate orthopaedic trauma surgery. Unnecessary blood tests can waste time, money, resources and overburden laboratory staff.

The conversion rate of bipolar hemiarthroplasty after a hip fracture to a total hip arthroplasty.

BACKGROUND: Bipolar hip hemiarthroplasty is used in the management of fractures of the proximal femur. The dual articulation is cited as advantageous in comparison to unipolar prostheses as it decreases acetabular erosion, has a lower dislocation rates and is easier to convert to a total hip arthroplasty (THA) should the need arise. However, these claims are debatable. Our study examines the rate of conversion of the bipolar hemiarthroplasty to THA and the justification for using it on the basis of future conversion to THA. METHODS: All cases of bipolar hemiarthroplasty performed in our unit for hip fractures over a 9-year period (1999-2007) were reviewed. Medical notes and radiographs of all patients were reviewed, and all surviving patients that were contactable received a telephone follow-up. RESULTS: Of all 164 patients reviewed with a minimum of 1 year from date of surgery, 4 patients had undergone a conversion of their bipolar prosthesis to THA. Three conversions were performed for infection, dislocation, and fracture. Only one (0.6%) conversion was performed for groin pain. CONCLUSIONS: Our study show that bipolar hemiarthroplasties for hip fractures have a low conversion rate to THAs and this is comparable to the published conversion rate of unipolar hemiarthroplasties.

The position of the centre of the femoral head relative to the midline of the pelvis: a consistent landmark in total knee replacement surgery.

BACKGROUND: Femoro-tibial malalignment in excess of 3° is a recognised contributor of early mechanical failure in total knee replacement (TKR). Knowledge of the location of the centre of the femoral head is a pre-requisite to identification of the mechanical axis of the femur and can facilitate optimal component orientation. We investigated variation in the location of the centre of the femoral head relative to the midline of the pelvis. METHODS: We analysed the pelvic radiographs of 150 patients with unilateral total hip replacements. The perpendicular distance from the centre of the femoral head of the non-operated hip to the centre of pubic symphysis was measured. RESULTS: The mean distance from the centre of the femoral head to the pubic symphysis was 89.2mm (standard deviation, 5.7 mm). Patient height strongly correlated with this distance (r=0.53, p<0.01), as did the diameter of the femoral head (r=0.59, p<0.01). The latter was significantly larger in men than in women (50.9 mm vs. 44.5mm, p<0.01). CONCLUSION: The results demonstrate that the position of the centre of the femoral head has very little variability, irrespective of patient age or body-mass index. If the gender-specific mean femoral head to midline distance is used to estimate the location of the femoral head centre, a line from this point to the centre of the femoral condyles will deviate from the true mechanical axis by no more than 1.5°, in 98% of cases.

Mortality and morbidity following hip fractures related to hospital thromboprophylaxis policy.

Chemical thromboprophylaxis has been shown to reduce the incidence of venous thromboembolism (VTE) for patients with fractures of the hip, but it is not known with certainty whether it use also reduces mortality. Using postal and telephone questionnaires we collected data from English National Health Service (NHS) hospitals about their thromboprophylaxis policy for hip fractures patients from April 2003 to April 2007. Using Hospital Episode Statistics (HES) we ascertained in-hospital mortality rates at 30 days and at one year following admission to hospital. Unplanned hospital readmission rates for all causes (including episodes of thromboembolism and bleeding) within 30 days (all years) and one year (2003 to 2005) were also established. A total of 150 hospitals were contacted and data gathered from 62 hospitals (response rate 41.3%) There were 255841 patients with neck of femur fractures during this five year period who were assessed for morbidity and mortality, and we correlat these with thromboprophylaxis policy. There was no significant difference in hospital readmission within 30 days, or diagnosis of thromboembolism or haemorrhage among hospitals with different thromboprophylaxis policies. The hospitals using low molecular weight heparin (LMWH) in half the dose recommended by the British National Formulary had significantly reduced mortality in-hospital (odds ratio (OR) 0.79, 95% CI 0.69-0.90, P=0.0006), at 30 days (OR 0.8 (0.70 - 0.92), P=0.001) and at one year (OR 0.89 (0.80 - 1.00), P=0.050), compared with those with no such policy. Our data suggest that the thromboprophylaxis regimen for patients with fracture neck of femur should be half dose LMWH for the duration of the hospital stay.