Revision knee arthroplasty: Can good outcomes be achieved at lower volumes?

BACKGROUND: The National Joint Registry (NJR) demonstrates a re-revision rate for primary knee arthroplasty of 14.2% at 7 years. The 2015 Getting it Right First Time (GIRFT) report highlighted that 58% of surgeons undertaking revision knee arthroplasty (RKA) performed fewer than five cases per year. It has been suggested that revision cases be centralised in specialist centres with a multidisciplinary team (MDT) approach. Such a hub and spoke or cluster models may still require revision surgery to be performed at relatively low volume units. METHODS: An analysis of RKA surgery performed in a four surgeon, lower volume revision knee unit over 10 years to December 2016 was undertaken. The effect of the introduction of a MDT was reviewed. The minimum follow up was two years. The primary outcome measure was re-revision. Hospital data as well as individual surgeon NJR reports were used to ensure all re-revisions were accounted for. Outcome scores were available for 68% of cases. RESULTS: There were 192 RKAs performed in 187 patients at a mean (stdev) of 6.3 (5.4) years from the index procedure. The mean age at surgery was 68.2 (10.9) years. Twenty nine (15.5%) patients had died at the time of final review. Twelve (6.3%) cases required a further revision procedure. The commonest complication was stiffness requiring MUA. The overall 7 year survivorship was 94.9% (95% CI 90.2-97.3). The mean Oxford score at 5.4 years was 30.4 (10.4). CONCLUSIONS: RKA can be reliably performed at lower volume centres with appropriate MDT systems in place.

Subungual melanoma: an important tip.

Acral lentiginous melanoma is rare, representing approximately 1% of malignant melanomas. Overall 5 year survival is disproportionately poor (25-51%) compared to other histological subtypes. This has been attributed to diagnostic delay resulting in more advanced presentation. Subungual presentation in the fingers is uncommon, reported in 1-13% of all acral lentiginous melanomas. We report a unique and diagnostically challenging case. Contrary to previously reported examples in the literature, the actual neoplastic pathology was detected in the less pigmented finger tip skin rather than the deeply pigmented nail bed germinal and sterile matrix that showed no evidence of malignancy. We therefore advocate that in cases where skin surrounding the nail is involved, this surrounding skin should also be biopsied, even if it is less pigmented than the primary lesion.