Hip precautions after primary total hip arthroplasty: a qualitative exploration of clinical reasoning.

PURPOSE: Hip precautions are movement restrictions that are often advised following primary total hip arthroplasty (PTHA) for osteoarthritis (OA), but there is limited evidence supporting their effectiveness in preventing dislocation. This study aimed to explore the clinical reasoning behind the continuation and discontinuation of hip precautions following PTHA for OA. MATERIALS AND METHODS: Semi-structured interviews were conducted with therapists and surgeons at six centres using precautions and six centres not using precautions across secondary or tertiary NHS sites in England. Interviews were transcribed verbatim and thematically analysed. RESULTS: Interviews were conducted with fourteen surgeons and eighteen therapists. Of these clinicians, eight surgeons and ten therapists routinely advised precautions. Clinicians continued to use precautions to avoid dislocation by creating a boundary to movement, particularly important when dealing with patients who "push" these boundaries. Clinicians discontinued precautions because of a perceived negative impact on patients and the lack of supporting evidence. In the absence of a rise in dislocation rates for these centres, others have now changed practice. CONCLUSION: This study offers insight into the clinical reasoning behind the continuation and discontinuation of hip precautions following PTHA for OA. The use of precautions remains controversial and further work is required to determine whether or not they should be advised.IMPLICATIONS FOR REHABILITATIONRedesign of future rehabilitation pathways for primary total hip arthroplasty should take into account viewpoints from across the multidisciplinary team to aid decision making.Concern for patient behaviours, dislocation and litigation may be barriers to changing practice for rehabilitation after primary total hip arthroplasty.Clinicians may be discontinuing hip precautions because of known surgical advances, a perceived negative impact on patients and a lack of supporting evidence for historical practice.Individualised rehabilitation considerations are necessary for patients with risk factors that predispose them to dislocation after primary total hip arthroplasty, regardless of whether hip precautions are advised as standard at their given centre.

Clinical Outcome of Free Latissimus Dorsi Flaps for Coverage of Soft Tissue Defects in Multiply Revised Total Knee Arthroplasties.

BACKGROUND: Multiply revised total knee arthroplasties (TKAs) may present with large anterior soft tissue defects, which can be challenging to reconstruct. In the rare cases where local flaps are insufficient, we use free latissimus dorsi (LD) myocutaneous flaps to achieve soft tissue coverage. This study looked to determine implant survivorship, infection status, and patient-reported outcomes of patients undergoing simultaneous revision TKA and LD flaps in a tertiary unit. METHODS: This was a retrospective study of 18 consecutive patients who had revision TKA and free LD flap reconstruction. Twelve were male and the median age was 65 years (range, 35-83). Patients had undergone a median of 4 previous arthroplasty procedures (range, 3-6). Median follow-up was 49 months (range, 18 to 110). The primary outcome was revision-free implant survival. Secondary outcomes included soft tissue integrity, Oxford Knee Score, and EuroQol 5-domain score at latest follow-up. RESULTS: At latest follow-up, 14 of 18 patients had maintained their implant. Seven patients were infection-free, 7 were on suppressive antibiotics with the implant in situ, and 4 had undergone above-knee amputation. Five-year implant survival was 75% (95% confidence interval, 46-90). At median follow-up (49 months), mean Oxford Knee Score was 13.4 (range, 2-35) and mean EuroQol 5-domain index was 0.071 (range:-0.427 to 0.747). CONCLUSION: LD free flap is a viable option for limb salvage in patients with large anterior soft tissue defects following multiple revisions of TKA. However, functional outcomes can be poor and there is a significant risk of ongoing infection and amputation in this complex patient cohort.

Combined Vascular and Orthopaedic Approach for a Pseudotumor Causing Deep Vein Thrombosis after Metal-on-Metal Hip Resurfacing Arthroplasty.

Introduction. Metal-on-metal (MoM) hip resurfacings have been associated with a variety of complications resulting from adverse reaction to metal debris. Pseudotumors have rarely been reported to cause deep venous thrombosis (DVT). Study Design. A case report and a review of the literature. Case Presentation. A 75-year-old female who had left metal-on-metal hip resurfacing 6 years ago presented with left groin pain associated with unilateral lower limb edema and swelling. By duplex and MRI studies, our patient had an extensive soft tissue necrosis associated with a large pelvic mass causing extensive DVT of the lower limb secondary to mechanical compression of the left iliac vein. Results. Our case was initially treated for DVT followed by dual surgical approach. The pseudotumor was excised through a separate iliofemoral approach and revision of the hip implant was undertaken through a posterior approach in the same setting. An inferior vena cava (IVC) filter was inserted to minimise the perioperative risks of handling the iliac veins. Conclusion. A combined approach with vascular surgeons is required. Combined resection of the pseudotumor and revision of the metal bearing surfaces is essential, in order to achieve a good surgical outcome in this rare complication.

Outcomes of infected revision knee arthroplasty managed by two-stage revision in a tertiary referral centre.

BACKGROUND: A two-stage revision remains the gold standard to eradicate deep infection in total knee arthroplasty. Higher failure rates are associated with a number of factors including poly-microbial infections, multiresistant organisms and previous operations. The aims are to investigate [1] the overall success rate of a two-stage revision for infections in TKA, [2] the outcome of repeat two-stage revisions in recurrent infections and [3] the factors affecting the outcomes of such cases. METHODS: We present the outcomes of a consecutive, retrospective case series of 51 periprosthetic joint infections managed with a two-stage revision knee arthroplasty over a three year period. RESULTS: Forty-six (90%) of 51 were referred from other hospitals. Infection was successfully eradicated in 24 (65%) of 37 patients undergoing an initial two-stage procedure. Following a failed two-stage revision, a repeat two-stage revision was performed in 19 patients eradicating infection in 8 (42%). A third two-stage was performed in five of these patients eradicating infection in three with an average follow-up of 43 months. Multidrug resistance was present in 69%, and 47% of the patients were infected with multiple organisms. All unsuccessful outcomes involved at least one multidrug-resistant organism compared to 43% in the successful cohort (P=0.0002). Serological markers prior to a second-stage procedure were not significantly different between successful and unsuccessful outcome groups. CONCLUSION: Single or multiple two-stage revisions can eradicate infection despite previous failed attempts. In this series, failure is associated with multidrug resistance, previous failed attempts to eradicate infection and a less favourable host response.

Custom rotating hinge total knee arthroplasty in patients with poliomyelitis affected limbs.

PURPOSE: Total knee arthroplasty (TKA) in limbs affected by poliomyelitis is a technically challenging procedure. These patients often demonstrate acquired articular and metaphyseal angular deformities, bone loss, narrowness of the intramedullary canals, impaired quadriceps strength, flexion contractures and ligamentous laxity producing painful hyperextension. Thus, using condylar knee designs in these patients will likely result in early failure because of instability and abnormal load distribution. The aim of this study was to assess the outcomes associated with use of the customised (SMILES) rotating-hinge knee system at our institution for TKA in poliomyelitis-affected limbs. METHODS: We retrospectively reviewed the outcome of 14 TKAs using the (SMILES) prosthesis in 13 patients with limbs affected by poliomyelitis. All patients had painful unstable knees with hyperextension. There were ten females and three males with a mean age of 66 years (range 51-84) at time of surgery. Patients were followed up clinically, radiologically and functionally with the Oxford knee score (OKS). Mean follow-up was 72 months (16-156). RESULTS: There were no immediate or early complications. One patient fell and sustained a peri-prosthetic fracture at seven months requiring revision to a longer stem. Radiological evaluation showed satisfactory alignment with no signs of loosening in all cases. Mean OKS improved from 11.6 (4-18) to 31.5 (18-40) postoperatively (p < 0.001). CONCLUSION: The rotating hinge (SMILES) prosthesis is effective at relieving pain and improving function in patients with poliomyelitis. The device compensates well for ligamentous insufficiency as well as for any associated bony deformity.

Long-term results of autologous chondrocyte implantation in the knee for chronic chondral and osteochondral defects.

BACKGROUND: Autologous chondrocyte implantation (ACI) has been shown to be effective in the midterm for the treatment of symptomatic articular cartilage lesions of the knee, but few long-term series have been published. The multioperated chronic articular cartilage defect remains a difficult condition to treat. PURPOSE: To examine the long-term clinical results of ACI for large chronic articular cartilage defects, many treated as salvage. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This is a prospective case series of 104 patients with a mean age of 30.2 years and a symptomatic lesion of the articular cartilage in the knee, who underwent ACI between 1998 and 2001. The mean duration of symptoms before surgery was 7.8 years. The mean number of previous surgical procedures on the cartilage defect, excluding arthroscopic debridement, was 1.3. The defects were large, with a mean size of 477.1 mm(2) (range, 120-2500 mm(2)). The modified Cincinnati, Stanmore/Bentley, and visual analog scale for pain scoring systems were used to assess pain and functional outcomes at a minimum 10 years (mean, 10.4 years; range, 10-12 years). RESULTS: Twenty-seven patients (26%) experienced graft failure at a mean of 5.7 years after ACI. Of the 73 patients who did not fail, 46 patients (63% of patients with a surviving graft) had an excellent result, 18 (25%) were good, 6 (8%) were fair, and 3 (4%) had a poor result. Of a total of 100 patients successfully followed up, 98 were satisfied with the ACI technique for their chronic knee pain and would undergo the procedure again. CONCLUSION: Autologous chondrocyte implantation can provide a long-term solution in more than 70% of young patients of a difficult-to-treat group with large chronic articular cartilage lesions, even in the salvage situation.

Autologous chondrocyte implantation in the knee: mid-term to long-term results.

BACKGROUND: From 1998 to 2008, 1000 skeletally mature patients underwent autologous chondrocyte implantation for an osteochondral defect of the knee. We evaluated the functional outcomes in 827 of 869 patients who had undergone autologous chondrocyte implantation with Chondron or periosteum (ACI-C/ACI-P) or matrix-assisted chondrocyte implantation (MACI) and attempted to identify factors that influenced outcome. METHODS: The age of the patient, the size and site of the osteochondral lesion, previous surgery, and the presence of early osteoarthritis were assessed for their influence on outcomes. Each factor was evaluated in a separate Cox proportional hazards model with use of hazard ratios (HRs), with 95% confidence intervals (CIs), describing the likelihood of failure for that particular factor. Outcomes were assessed with use of the modified Cincinnati score, visual analog scale pain score, and Stanmore functional score. RESULTS: The mean duration of follow-up was 6.2 years (range, two to twelve years). The mean age was thirty-four years (range, fourteen to fifty-six years), with 493 males and 334 females. The average size of the defect was 409 mm2 (range, 64 to 2075 mm2). Four hundred and twenty-one procedures (51%) were performed on the medial femoral condyle; 109 (13%), on the lateral femoral condyle; 200 (24%), on the patella; and fifty (6%), on the trochlea. Kaplan-Meier survival analysis revealed that the unadjusted graft survival rate was 78.2% at five years and 50.7% and ten years for the entire cohort. No difference was found between the survival rates of the ACI-C/ACI-P and MACI techniques (HR = 0.948, 95% CI = 0.738 to 1.219, p = 0.678). There was a significant postoperative improvement in the function and pain scores of all three outcome measures (p < 0.002). Survivorship in the group with a previous cartilage regenerative procedure was inferior to that in patients with a previously untreated lesion, with failure five times more likely in the former group (HR = 4.718, standard error [SE] = 0.742, 95% CI = 3.466 to 6.420, p < 0.001). Degenerative change in any compartment had a significant detrimental effect on survivorship, with survivorship worsening as the osteoarthritis grade increased (Grade 1: HR = 2.077, 95% CI = 1.299 to 3.322, p = 0.002; Grade 2: HR = 3.450, 95% CI = 2.646 to 4.498, p < 0.001; and Grade 3: HR = 3.820, 95% CI = 2.185 to 6.677, p < 0.001). CONCLUSIONS: Our study demonstrated an overall graft survival of 78% at five years and 51% beyond ten years following both autologous chondrocyte implantation techniques. Despite study limitations, our results demonstrate that autologous chondrocyte implantation for the treatment of osteochondral defects of the knee can achieve good results. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Primary and revision total hip arthroplasty in osteogenesis imperfecta.

Due to an increasing lifespan, patients with osteogenesis imperfecta have a high incidence of hip osteoarthritis. The presence of recurrent fractures and deformities make primary and particularly revision total hip arthroplasty challenging. We present a series of patients with osteogenesis imperfecta undergoing total hip arthroplasty at a tertiary referral centre with a median follow-up of 7.6 years (4 to 35 years). There were four primary total hip arthroplasties and eight revision total hip arthroplasties performed in four patients. Three femoral components were custom computer assisted design computer assisted manufactured. The survival rate of the primary total hip arthroplasty was 16% and there were ten complications: five intraoperative fractures, one case of septic loosening and four cases of aseptic loosening. Patients with pre-operative acetabular protrusio were significantly more likely to require revision surgery (p = 0.02). At latest follow-up, the median Oxford hip score was 41 (37 to 46). As the largest series of primary and revision total hip arthroplasty performed in patients with osteogenesis imperfecta, we report good medium to long-term outcomes. Preoperative planning and consideration of custom made prostheses have an important role in these complex cases.

The effect of femoral head size on functional outcome in primary total hip arthroplasty: a single-blinded randomised controlled trial.

We conducted a prospective single-blinded randomised controlled trial to compare the functional and quality of life outcomes in two groups of patients between 60 and 80 years of age undergoing THR; the first receiving a small head (28-32 mm) metal on polyethylene (MoP) articulation, and the second receiving a large head (44-54 mm) metal on metal (MoM) articulation. We recruited 49 patients and randomised them into one of the two groups (22 MoP and 27 MoM). The results demonstrated no statistical difference in any of the assessed functional outcomes at any follow-up point (p>0.05). There were no dislocations or revisions in either group. Although it has been suggested that large head MoM articulations in THA offer superior stability and function, our results suggest that small head MoP articulations can achieve comparable ROM, function and quality of life at short-term follow-up.

The role of autologous chondrocyte implantation in the treatment of symptomatic chondromalacia patellae.

PURPOSE: Chondromalacia patella is a distinct clinical entity of abnormal softening of the articular cartilage of the patella, which results in chronic retropatellar pain. Its aetiology is still unclear but the process is thought to be a due to trauma to superficial chondrocytes resulting in a proteolytic enzymic breakdown of the matrix. Our aim was to assess the effectiveness of autologous chondrocyte implantation on patients with a proven symptomatic retropatellar lesion who had at least one failed conventional marrow-stimulating therapy. METHODS: We performed chondrocyte implantation on 48 patients: 25 received autologous chondrocyte implantation with a type I/III membrane (ACI-C) method (Geistlich Biomaterials, Wolhusen, Switzerland), and 23 received the Matrix-assisted Chondrocyte Implantation (MACI) technique (Genzyme, Kastrup, Denmark). RESULTS: Over a mean follow-up period of 40.3 months, there was a statistically significant improvement in subjective pain scoring using the visual analogue scale (VAS) and objective functional scores using the Modified Cincinnati Rating System (MCS) in both groups. CONCLUSIONS: Chondromalacia patellae lesions responded well to chondrocyte implantation. Better results occurred with MACI than with ACI-C. Excellent and good results were achieved in 40% of ACI-C patients and 57% of MACI patients, but success of chondrocyte implantation was greater with medial/odd-facet lesions. Given that the MACI procedure is technically easier and less time consuming, we consider it to be useful for treating patients with symptomatic chondral defects secondary to chondromalacia patellae.

Autologous chondrocyte implantation in the adolescent knee.

BACKGROUND: Autologous chondrocyte implantation (ACI) has been shown to have favorable results in the treatment of symptomatic chondral and osteochondral lesions. However, there are few reports on the outcomes of this technique in adolescents. PURPOSE: The aim of this study was to assess pain relief and functional outcome in adolescents undergoing ACI. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Thirty-five adolescent patients undergoing ACI or matrix-assisted chondrocyte implantation (MACI) were identified from a larger cohort. Four patients were lost to follow-up, leaving 31 patients (24 ACI, 7 MACI). The mean age was 16.3 years (range, 14-18 years) with a mean follow-up of 66.3 months (range, 12-126 months). There were 22 male and 9 female patients. All patients were symptomatic; 30 had isolated lesions and 1 had multiple lesions. Patients were assessed preoperatively and postoperatively using the visual analog scale (VAS) score for pain, the Bentley Functional Rating Score, and the Modified Cincinnati Rating System. At 1 year postoperatively, patients were recalled for a diagnostic biopsy, which was successfully attained in 21 patients. RESULTS: The mean pain scores improved from 5 preoperatively to 1 postoperatively. The Bentley Functional Rating Score improved from 3 to 0, while the Modified Cincinnati Rating System improved from 48 preoperatively to 92 postoperatively with 84% of patients achieving excellent or good results. All postoperative scores exhibited significant improvement from preoperative scores. One patient underwent graft hypertrophy and 1 patient's graft failed and was revised. Biopsy results revealed hyaline cartilage in 24% of cases, mixed fibro/hyaline cartilage in 19%, and fibrocartilage in 57%. CONCLUSION: Results show that, in this particular group who received ACI, patients experienced a reduction in pain and significant improvement in postoperative function after ACI or MACI. The authors believe that ACI is appropriate in the management of carefully selected adolescents with symptomatic chondral and osteochondral defects.

Modular proximal femoral replacement in salvage hip surgery for non-neoplastic conditions.

Addressing severe proximal femoral bone loss in revision hip surgery is a challenging reconstructive problem. The use of modular proximal femoral megaprostheses is one of many available options to address this. This is a retrospective review of 15 patients who had undergone limb salvage at our institution using a modular proximal femoral replacement. There were 8 males and 7 females with a mean age of 67 years (34 to 85) and a mean follow-up of 60 months (1 to 99). Indications included re-implantation for deep infection in nine patients, aseptic loosening in three, periprosthetic fracture in two and painful excision arthroplasty in one. Mean Harris hip score increased from 28 (13 to 49) pre-operatively to 69 (39 to 85) at final follow-up (paired t-test, p < 0.0001) and mean Toronto Extremity Salvage score increased from 26% (14 to 40) to 71% (35 to 82) (paired t-test, p < 0.0001). Prosthesis survival with revision as the endpoint was 87% at 5 years. There were two dislocations (14%) and there was failure to eradicate deep infection in two. Modular proximal femoral replacement provided good function and versatility with an acceptable complication rate for patients with severe proximal femoral bone loss with or without infection.