The effect of time to surgery on outcomes and complication rates following total hip arthroplasty for fractured neck of femur.

INTRODUCTION: Total hip arthroplasty is recommended for elderly patients with fractured neck of femur who are independently mobile, have few co-morbidities and are not cognitively impaired. Providing a daily total hip arthroplasty service is challenging for some units in the UK and considering that these patients may be physiologically distinct from the average hip fracture patient, loss of the best practice tariff as a result of surgical delay may be unjustified. The aim of this study was to determine whether time to surgical intervention for patients eligible for total hip arthroplasty had a negative impact on patient complications, length of stay and functional outcomes. METHODS: All patients undergoing total hip arthroplasty for fractured neck of femur at our institution over a ten-year period were identified. Complications and functional outcomes were compared between patients receiving total hip arthroplasty before and after 36 hours. RESULTS: Of 112 consecutive patients undergoing total hip arthroplasty, 70 responded to a questionnaire or telephone consultation. Four patients were excluded owing to delayed presentation, the presence of advanced rheumatoid arthritis or a pathological fracture. Two-thirds (64%) of the remaining 66 patients underwent surgery within 36 hours of presentation. There were no significant differences between the groups of patients receiving surgery before or after 36 hours with regard to postoperative length of stay, complications, Oxford hip scores or visual analogue scale scores for state of health. CONCLUSIONS: Delaying surgery for patients eligible for total hip arthroplasty as per the National Institute for Health and Care Excellence guidelines is justified and should not incur loss of the best practice tariff.

Tibiofemoral kinematic analysis of knee flexion for a medial pivot knee.

The performance of total knee arthroplasty in deeply flexed postures is of increasing concern as the procedure is performed on younger, more physically active and more culturally diverse populations. Several implant design factors, including tibiofemoral conformity, tibial slope and posterior condylar geometry have been shown directly to affect deep flexion performance. The goal of this study was to evaluate the kinematics of a fixed-bearing, asymmetric, medial rotation arthroplasty design in moderate and deep flexion. Thirteen study participants (15 knees) with a medial rotation knee arthroplasty were observed performing a weight-bearing lunge activity to maximum comfortable flexion and kneeling on a padded bench from 90 degrees to maximum comfortable flexion using lateral fluoroscopy. Subjects averaged 74 years of age and nine were female. At maximum weight-bearing flexion, the knees exhibited 115 degrees of implant flexion (102 degrees-125 degrees) and 7 degrees (-3 degrees to 12 degrees) of tibial internal rotation. The medial and lateral condylar translated posteriorly by 2 and 5 mm, respectively. At maximum kneeling flexion, the knees exhibited 119 degrees of implant flexion (101 degrees-139 degrees ) and 5 degrees (-2 degrees to 14 degrees) of tibial internal rotation. The lateral condyle translated posteriorly by 11 mm. The medial rotation knee exhibited motion patterns similar to those observed in the normal knee, but less tibial rotation. The medially conforming articulation beneficially controls femoral AP position in deep flexion, in patients who require such motion as part of their lifestyle.

Stanmore total knee replacement versus internal fixation for supracondylar fractures of the distal femur in elderly patients.

BACKGROUND: Supracondylar fractures of the femur in the elderly are difficult to treat. Total knee replacement is often not considered. The aim of this study was to compare the short to medium term outcome of fixation and total knee replacement in medically fit active elderly patients with no pre-existing arthritis in order to determine whether total knee replacement can be an alternative to internal fixation. PATIENTS AND METHODS: In this retrospective study, we included patients who were aged 75 or over with an ASA grade of two or less, walked independently before their injury, and sustained a type A or C supracondylar fracture. Four were treated with internal fixation and six with a cemented Stanmore knee replacement. Patients were reviewed clinically and radiographically a minimum of 6 months after surgery. RESULTS: The advantages of total knee replacement were a greater proportion of patients returned to independent walking, rehabilitation was more rapid, and knee flexion was better. The advantages of internal fixation were a decreased need of blood transfusion, a smaller proportion of patients reported knee pain at follow up, and a better mean Oxford knee score at follow up. Anaesthetic time and level of patient satisfaction at follow up were similar. There were no peri-operative deaths. CONCLUSION: In this preliminary study, total knee replacement was a reasonable alternative to internal fixation for the treatment of supracondylar fractures of the distal femur in elderly.

Fractures of the humeral capitellum: Herbert screw fixation.

During the first half of 1991, five patients with displaced fractures of the humeral capitellum were managed by open reduction and fixation of the capitellar fragments with Herbert bone screws. All patients had stable, painfree elbows at follow-up, with no restriction of normal daily activities. There were no evidence of early avascular necrosis of capitellar fragments, even where soft tissue attachments of small fragments had been injured. This method of fixation allows accurate restoration of the articular surface of the humero-radial joint and may therefore contribute to the excellent functional results following this injury in these patients.

Sensitivity to titanium. A cause of implant failure?

Tissues from five patients who underwent revision operations for failed total hip replacements were found to contain large quantities of particulate titanium. In four cases this metal must have come from titanium alloy screws used to fix the acetabular component; in the fifth case it may also have originated from a titanium alloy femoral head. Monoclonal antibody labelling showed abundant macrophages and T-lymphocytes, in the absence of B-lymphocytes, suggesting sensitisation to titanium. Skin patch testing with dilute solutions of titanium salts gave negative results in all five patients. However, two of them had a positive skin test to a titanium-containing ointment.

ICLH double-cup arthroplasty, 1980-1987.

The results are presented of 92 double-cup arthroplasties modified in light of previously published experience. The review period lasted up to 7 years after operation. Eighty-six had a metal femoral component and six had a ceramic femoral component. Forty metal femoral cups were matched with a cemented acetabulum, while with 46 the acetabular implant was cementless. The overall revision rate for the metal femoral cups was 23.3%, and a further 31.8% demonstrated radiological signs suggestive of loosening. There was no difference between the cemented and uncemented cups in terms of revision rates or clinical results. The clinical results of those hips that have not yet loosened were excellent. A histological study showed that femoral lossening was associated with an erosive cellular response. Surface arthroplasty of the hip with current materials should be abandoned.

Unconstrained knee arthroplasty after patellectomy.

The authors report seven cases of unconstrained knee arthroplasty with excision of both cruciate ligaments, after previous patellectomy. Six of these seven cases were completely painfree and function was satisfactory in all cases. The reasons for previously reported pain and instability after total unconstrained knee arthroplasty with excision of the cruciate ligaments and a previous patellectomy are discussed.

The effect of a metal-back without a stem upon the fixation of a tibial prosthesis.

Three methods of tibial component fixation without cement (as part of TKA) have been used at the London Hospital. All three methods have used the same polyethylene component fixed with two HDP (Day) pegs. A metal-back without a stem was added to the HDP in group 1. Group 2 consisted of an HDP-only component. In group 3 a stem was added to the metal-back used in group 1. Radiological comparison showed the fixation of the polyethylene component with metal back but no stem to be inadequate; the component tilted into varus more frequently than the other configurations. It is suggested that failure was due to the increased rigidity of the metal-backed component (as compared with the HDP only) and that the rigidity (and the resultant tendency to rock) can be offset by a stem. It is concluded that rigid (ie, metallic) tibial components should have a stem.

Should the posterior cruciate ligament be retained or resected in condylar nonmeniscal knee arthroplasty? The case for resection.

The arguments for resection of the (anterior and) posterior cruciate ligament(s), as a step in total knee arthroplasty, are reviewed on the basis of the authors' personal experience and the work of others published in the literature.

[Cementless fixation in endoprosthetics]. / Die zementlose Verankerung in der Endoprothetik.

Prostheses have been fixed to the skeleton with polymethylmethacrylate for some 30 years. Many of these prostheses have failed with time, and failure has been blamed on the use of polymethylmethacrylate. Methods of fixing endoprostheses without cement have been developed in recent years. It is argued in this paper that the most important precondition for fixation is stable press-fit of the implant. Other methods of supplementary fixation, such as porous ingrowth, have been developed. However, there is little evidence to suggest that this ingrowth improves the immediate clinical result, if it occurs at all.

Early bleeding into upper limb muscles in severe haemophilia. Clinical features and treatment.

The clinical features, management and outcome of bleeding into the muscles of the upper limb of 44 patients are reported. Of 158 episodes of bleeding, 99% were treated within two hours of onset of symptoms and the mean time to complete restoration of function was 2.1 days. The most frequent site of bleeding was the deltoid muscle (24%), followed by the forearm flexors (23.5%), brachioradialis (19.5%), biceps (14%), forearm extensors (11%) and triceps (8%). The majority of bleeds presented with pain, either on movement or at rest, or with tenderness. Bleeds into the biceps required the most transfusions (mean 2.00) and took the longest to resolve (mean 4 days). Bleeding into the flexors and extensors of the forearm resolved most rapidly. The policy of early treatment has been shown to be effective in prompting early and complete recovery.