Association of intra-operative metaphyseal fractures with prosthesis size during hemiarthroplasty of the hip.

PURPOSE: To study the possible causes of intra-operative metaphyseal fractures in elderly patients undergoing hemiarthroplasty for displaced intracapsular femoral neck fracture. METHODS: 36 men and 228 women aged 61 to 89 years with 273 displaced femoral neck fractures underwent hemiarthroplasty using a hydroxyapatite ceramic-coated Furlong bipolar prosthesis. Anteroposterior and lateral radiographs were taken immediately after surgery to evaluate the presence and type of any intra-operative fractures (classified according to the Vancouver system) and their effect on stem stability or osseointegration. Pain and clinical outcomes were evaluated using a visual analogue scale and the Harris Hip Score. RESULTS: Regarding the 273 surgeries for displaced femoral neck fracture, 28 (10%) were associated with intra-operative metaphyseal fracture (21 Vancouver type AL and 7 type AG). There was a correlation between intra-operative metaphyseal fractures and stem size. A size-9 stem was used in 64 surgeries without any fracture. A size-10 stem was used in 129 surgeries in which 11 (9%) sustained fractures, and a size-12 stem was used in 80 surgeries in which 17 (21%) sustained fractures. Postoperatively, 25 cases developed hip-related problems (thigh pain=14 and periprosthetic fractures=8) after 3 to 18 months. No patient whose metaphyseal fracture was fixed had hip problems. CONCLUSION: In elderly women with compromised bone quality, extra care is needed to achieve better fitting so as to avoid iatrogenic metaphyseal fractures. Under-sizing or cementing of the prosthesis is recommended when encountering difficulties.

Staged bilateral hip or knee arthroplasties.

PURPOSE: To compare the operating time, amount of blood transfused, length of hospital stay, and early complications (within 6 months) between 2-week staged bilateral arthroplasties and matched randomised controls undergoing unilateral arthroplasties. METHODS: From October 1992 to October 2000, 90 patients who underwent bilateral hip or knee arthroplasties with a 2-week interval were compared with matched randomised controls undergoing unilateral arthroplasties. A single surgeon performed all procedures. RESULTS: After the match-up process, 30 pairs of patients were included in the analysis. There were no significant differences in the operating times, amount of blood transfused, and early complication rates. The mean difference in length of hospital stay was significant (t=-3.552, df=29, p<0.001). CONCLUSION: Compared to staged procedures with an interval months apart, staged sequential arthroplasty with a 7- to 10-day interval during one hospital admission is more efficient, as it facilitates earlier rehabilitation without higher complication rates, and entails shorter hospital stays.

Reducing blood loss after total hip arthroplasty: A prospective randomised controlled trial to evaluate the efficacy of temporarily clamping drains.

The purpose of the study is to primarily answer the question as to whether temporarily clamping the drain for one hour after total hip replacement reduces blood loss. Many surgeons use this technique, as it is perceived that it creates a tamponade effect in the closed wound, promoting clotting and thereby reducing blood loss. There are no studies to support this practice after hip replacement. We have designed and conducted a randomised controlled trial. Fifty-six patients undergoing total hip replacement had drains placed in their wounds. They were randomised into two groups: half had their drain temporarily clamped for one hour and then the drain opened. The other half had the drain opened immediately after wound closure. The primary outcome measure was volume of drainage at 24 hours and the secondary outcome measures were transfusion requirements and postoperative haemoglobin reduction. No differences were seen between controlled groups for the volume of drainage (413152 mL vs. 378141 mL, standard deviation, SD; p=0.38), the transfusion requirement (8/28 in each group received 2 units of packed red cells), or the postoperative haemoglobin drop (not transfused: 3.11.3 vs. 3.61.5 g/dL, SD, p=0.29; and transfused 2 units: 0.81.4 vs. 1.41.2 g/dL, SD, p=0.38). The data from this trial suggests that the practice of clamping drains does not give a beneficial effect in terms of reduced blood loss. This is the first trial of its kind to explore this question in total hip replacement surgery. (Hip International 2005; 15: 108-11).

Reducing lateral skin flap numbness after total knee arthroplasty.

One hundred and thirteen knees were assessed for lateral skin flap numbness, 5-227 weeks following IB2 total knee arthroplasty. The final 53 had the numb area measured. To define the anatomy of the cutaneous nerves we dissected four cadaveric knees. Eighty-six percent of patients had a numb area on objective assessment but only 60% had subjective numbness, 62% of which had improved. Patients had a larger numb area if they were aware of a numb patch, had a scar over 22 cm long or were less than 25 weeks following surgery. We conclude that not all patients will get lateral skin flap numbness and improvement occurs with time. The area of numbness can be reduced by using a shorter proximal incision, which preserves branches of the medial and intermediate cutaneous nerves of thigh.

Counting health care: is there aF in CE?

The consultant episode is widely used by health economists as a measure of delivery of care. The clinical notes of 174 consecutive patients undergoing elective orthopaedic procedures were reviewed. Just over half of the cases (89/174, 51%) were patients referred by their general practitioner, but under half of the available operating time (47%) was expended on these patients, the remainder being on patients already within the system. Under standard NHS accounting, these latter patients are not registered as new consultant referrals and, thus, the episodes of patient care of which their operation is a part, do not constitute finished consultant episodes. Our view is that the episode of care is an inappropriate measure of health care delivery applied to orthopaedic surgery in general.

Intramedullary hip screw versus sliding hip screw for unstable intertrochanteric femoral fractures in the elderly.

We report a randomised, prospective study comparing a standard sliding hip screw and the intramedullary hip screw for the treatment of unstable intertrochanteric fractures in the elderly. One hundred and two patients were randomised on admission to two treatment groups. Fifty-two patients were treated with a compression hip screw (CHS), and fifty had intramedullary fixation with an intramedullary hip screw (IMHS). Patients were followed for 1 year and had a clinical and radiological review at 3, 6 and 12 months. The mean duration of operation and fluoroscopy screening time was significantly greater for insertion of the intramedullary hip screw. There was no difference between the groups with regard to transfusion requirements or time to mobilise after surgery. There were two technical complications in the CHS group and three in the IMHS group. There was no significant difference between the two groups in radiological or functional outcome at 12 months. It remains to be shown whether the theoretical advantages of intramedullary fixation of extracapsular hip fractures bring a significant improvement in eventual outcome.

A simple technique for the direct reduction of displaced articular fracture fragments.

Fixation of small articular fragments in intra-articular fractures may be difficult and best results are achieved with restoration of anatomical position. A simple technique is described for ensuring good reduction and stabilisation of such articular fragments.

Plugging the intramedullary canal of the femur in total knee arthroplasty: reduction in postoperative blood loss.

A prospective, randomized trial comparing postoperative drainage was carried out in 120 consecutive knees undergoing total knee arthroplasties divided into 2 groups. In one (55 knees), the entry point for the femoral intramedullary rod was left open. In the other (65 knees), the entry point was closed by an autologous bone plug. The mean drainage after 24 hours and the total drainage were lower when the femoral canal was plugged (800 vs 960 mL and 925 vs 1,165 mL). The bone plug always united, and no loose bodies were seen 6 months after operation. We conclude that the femoral intramedullary guide hole should be plugged with autologous bone because this technique results in a small but significant reduction in early blood loss without countervailing disadvantages.

Can the orthopaedic surgeon forget the proctoscope? The proctoscope as tissue protector during intra medullary nailing.

We report the value and usefulness of the proctoscope in one of the modern orthopaedic procedures. We have found the proctoscope more effective than the currently available instruments as tissue protector during intramedullary nailing. We briefly describe our technique of using the proctoscope and discuss its advantages.

The protective effect of a cut-resistant glove liner. A prospective, randomised trial.

We performed a prospective, randomised study comparing the rates of glove perforation using double latex gloving with or without a disposable protective glove liner (Paraderm) on 118 patients undergoing primary or revision arthroplasty of the hip or knee by one surgeon (FRH). The patients were randomly allocated into two groups: in group 1 an inner and outer pair of latex gloves were worn as double gloves and in group 2 the glove liner was worn between the two latex gloves. There was glove perforation in at least one outer glove in 99 operations (84%). The operating surgeon was aware of the perforation in 21 of these. There were 22 perforations of the inner glove. Group 1 had a significantly higher perforation rate per operation (p < 0.05) than group 2. Our findings show that protective glove liners significantly reduce the rate of perforation of the inner glove during hip and knee arthroplasty.

Growth beyond skeletal maturity.

Serial measurements of standing and sitting height of children show that growth continues beyond the age of skeletal maturity when judged by the fusion of the epiphyses of the hand and wrist. Most of this increase occurs in the sitting height, largely reflecting spinal growth, and may account for the known progression potential of idiopathic scoliosis beyond the attainment of skeletal maturity.

The deformity of idiopathic scoliosis made visible by computer graphics.

We present a method of visualising spinal deformities in three dimensions using conventional radiographs and computer graphics. The shape of the spinal column can be determined from the anteroposterior and lateral radiographs and displayed in any projection. In patients with adolescent idiopathic scoliosis, the fundamental lesion, an abnormal lordosis, can be demonstrated without the need for additional views. The method is applicable to other spinal deformities and may help to elucidate their three-dimensional shape.

The three-dimensional anatomy of the proximal femur in Perthes' disease.

A new method of recording the three-dimensional anatomy of the proximal femur from a single anteroposterior radiograph is described. This technique shows that in Perthes' disease the femoral head and neck are in significant anteversion and true varus. This anatomical configuration may be important in the pathogenesis and treatment of this disorder.

V-Y advancement of the inferiorly based rectus abdominis musculocutaneous flap.

We describe two cases in which a rectus abdominis musculocutaneous flap was used to reconstruct an ipsilateral groin defect by V to Y advancement. Cadaveric studies undertaken to investigate the likely versatility of this flap showed that it may be advanced to midthigh level. This range can be increased by division of the inguinal ligament and by partial reflection of the rectus abdominis muscle from the skin island. The operative technique and the merits and disadvantages of the flap are discussed. This variation is a useful alternative. It has a considerable excursion potential and may be cosmetically more acceptable than other transposition flaps.