Functional and Radiological Outcomes Following Simultaneous Bilateral Total Hip Arthroplasty: Analysis of a Retrospective Series.

Introduction The prevalence of bilateral hip arthritis continues to rise. With the dramatic change in the practice of modern-day arthroplasty with standard operating protocols and guidelines in place to reduce the incidence of surgical site infection and peri-operative thromboembolic events, simultaneous bilateral total hip replacement (THR) has been considered a viable option to reduce morbidity. The efficacy of simultaneous bilateral THR with regard to patient outcomes and complications has been debated. The aim of this study was to assess and compare the functional outcomes, radiological outcomes, and complications following bilateral simultaneous THR with the existing literature. Methods We conducted a retrospective study of 28 patients who underwent simultaneous bilateral THR by a single surgeon at a district general hospital in the United Kingdom between 2010 and 2019. All the patients in the study were operated on via the posterior approach to the hip and received uncemented implants. Data on blood loss and hospital stay were collected from the hospital records. The radiological outcomes were studied from the post-operative radiographs. The patient-reported outcomes were measured via a telephone session at an average follow-up of 7.8 years. Results Our results noted a statistically significant drop in haemoglobin after the procedure from a mean of 13.5 g/dl to 9.05 g/dl (t: -15.84, p < 0.00001). The average blood loss was 643 ml +/- 330 ml (200-1850 ml). Nine patients (32.1%) required blood transfusions and a total of 21 units were transfused. The mean duration of stay in the hospital was 6.7 days (three to 20 days). There were no intra-operative/immediate/early post-operative complications. The revision rate was 1.7%, as one patient had a revision of the femoral component following a peri-prosthetic fracture. The mean visual analogue scale pain score was 1.51 +/- 0.58 (1-3). The mean Oxford Hip Score improved from 19.5 (12-28) pre-operatively to 44.3 (37-48) post-operatively at the time of the study (t: -21.88945; p < 0.00001), with the difference being statistically significant using a paired t-test. From the series, 14 (50%) patients were found to have limb length discrepancies. The mean limb length discrepancy was found to be 2.3 mm (0-16 mm). In 13 of the 28 patients (46.4%), the global hip offset was equal on both sides. In two patients, the difference in the global hip offset was more than 10 mm. Conclusion We reported good patient-reported functional outcomes with simultaneous bilateral THR with a low complication rate. Despite the lack of opportunity to template the second hip, the limb length and global hip offset can be restored after a simultaneous bilateral THR.

Revision Arthroplasty for Bilateral McKee-Farrar Hip Prostheses 48 Years Following Implantation.

The McKee-Farrar hip prosthesis gained popularity in the 1960s and was one of the first widely used prostheses to employ a metal-on-metal design. Eventually, it laid the framework for the development of second and third-generation hip replacement prostheses. In time, the McKee-Farrar prosthesis was found to have high rates of early aseptic loosening and fell out of favor, especially with the development of the Charnley low-friction metal-on-polyethylene design. We present an interesting case of a patient who underwent bilateral total hip arthroplasty with a McKee-Farrar hip prostheses at the young age of 28 years, in view of secondary hip osteoarthritis resulting from ankylosing spondylitis. The implants lasted approximately 48 years after initial implantation in this case, which is an unusually long survival of this prosthesis. He presented to us at the age of 76 years with groin pain and difficulty to weight-bear, worse on the right side. Significant osteolysis around the acetabular component was noted, greater on the right side. Infection was excluded, and the patient underwent staged revision bilateral hip replacements one year apart. Extraction of the femoral components on both sides was done with the aid of extended trochanteric osteotomies. For both revisions, uncemented acetabular revision shells (TMARS, Zimmer Biomet, Warsaw, Indiana) were used for the acetabulum and long uncemented diaphyseal engaging interlocked stems (Arcos ILS, Zimmer Biomet) were used for the femoral side. No complications were encountered during the procedures. The patient made excellent progress following the procedures with immediate weight-bearing, as tolerated, and physiotherapy input. No subsequent postoperative complications occurred till the time of the patient's death five years later from unrelated medical causes. It is rare to encounter and revise the McKee-Farrar prosthesis in modern orthopaedic practice. This, to the best of our knowledge, is the longest-described survival of this prosthesis in literature.

Percutaneous Retrograde Technique Using Intramedullary Headless Compression Screws for Metacarpal Fractures Under Wide-Awake Local Anaesthesia No Tourniquet.

Background The common modality of treatment of metacarpal fractures is nonsurgical. There are, however, a subset of patients and fracture types that require surgical correction, but surgery comes with its own problems like stiffness and scarring. Therefore, surgical operations must be minimally invasive barring complications of anaesthesia and the procedure. Therefore, we conducted this study to assess patient outcomes following treatment with percutaneous intramedullary screw fixation via the wide-awake local anaesthesia no tourniquet (WALANT) approach for unstable metacarpal fractures. Methodology We retrospectively analysed the records of 21 patients who received metacarpal fixations with headless compression screws at two district general hospitals in the United Kingdom from 2018 to 2020. We used wide-awake anaesthesia with 10 mL (1% lidocaine and 1 mL 8.4% sodium bicarbonate as a buffer) infiltrated around the superficial tissues on the dorsal aspect of the metacarpal bone, including the periosteum. The Jahss manoeuvre was used to reduce the fracture under the guidance of a mini C-arm. All patients had 3-mm Medartis cannulated compression screws (Medartis AG, Basel, Switzerland) (self-tapping) inserted retroactively using a 5-mm skin incision. The range of movement of the metacarpophalangeal joint was checked intraoperatively and shown to the patient for optimal postoperative rehabilitation. Patients underwent a two-week follow-up wound check and examination for pain (using the visual analogue scale (VAS)) or stiffness requiring physiotherapy. We used the Manchester-modified (M2) disability of the arm, shoulder, and hand (DASH) score to scrutinize the fracture union and the functional outcome of the hand. We also assessed the time to return to work. Results The study included 18 men and two women with a mean age of 22.6 years (range, 18 to 40). The fifth (n=16), fourth (n=4), and second metacarpals (n=1) were involved, and we saw transverse (n=10) and short oblique (n=11) fractures. Fractures healed in five weeks (range, four to six weeks). The mean M2 DASH score was 0.8 (range, 0 to 6), and mean total active motion was 240° (range, 230° to 260°). At the final follow-up, the mean extensor lag for the metacarpophalangeal joint was 5° (range, 0° to 15°), 7° for the proximal interphalangeal joint (range, 0° to 15°), and no lag at the distal interphalangeal joint. The average VAS score at the end of two weeks was 8/10 (range, 7 to 9). The average time for the return to daily activities was 2.56 weeks. We found no intraoperative complications in any of the patients. All patients went home on the same day postoperatively and gave feedback that their experience with WALANT was good to excellent. All patients had a good range of motion at the two-week follow-up, and the mean time to return to normal work was two to three weeks. The M2 DASH score measured was satisfactory. Conclusions This retrospective study assessed patient outcomes following treatment with percutaneous intramedullary screw fixation via the WALANT approach for unstable metacarpal fractures. WALANT was a quick and reliable alternative to fix unstable metacarpal fractures, especially for high-demand patients requiring a short recovery period before returning to regular activity. Further research with a larger sample size and a longer follow-up to analyse the outcome is warranted before an actual guideline can be established.

Can an Inferior Calcar Stabilising Antirotation Screw Improve Stability in Unstable A2 Inter Trochanteric Fractures when Fixed with a Dynamic Hip Screw?

OBJECTIVE: To determine the effect of a calcar stabilising anti rotation screw on reducing the complication rate in intertrochanteric hip fractures. STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Hinchingbrooke Hospital, Northwest Anglia Foundation Trust, Huntingdon, UK, from July 2019 to December 2020. METHODOLOGY: All A2 Intertrochanteric fractures according to the AO31 classification fixed with dynamic hip screw (DHS) were included. Exclusion criteria were A1 and A3 fractures, pathological, and per-prosthetic fractures. Fifty-four patients were divided into two groups. Group one (21) patients were managed with a DHS and a calcar stabilising screw. Group two (33) were managed with a dynamic hip screw (DHS) only. Both groups had a 12 months follow-up. Study variables were age, gender, ASA and preoperative mobility status, and tip-apex distance; while outcome measures were mechanical failures including cut-out needing revisions and medialisation associated with pain. RESULTS: No patients in the group one suffered mechanical failure compared to 27% in group two. CONCLUSION: A calcar stabilising screw reduces the failure rate of A2 unstable intertrochanteric fractures when used in conjunction with the DHS. KEY WORDS: Intertrochanteric fractures, Hip fracture, A2 unstable fracture, Dynamic hip screw, Calcar stabilising screw, Mechanical failure.

The Consent Process for Elective Hip and Knee Arthroplasty: Does Information on Handwritten Forms Meet Prescribed Standards?

Introduction The process of informed consent is vital, not only to good clinical practice and patient care, but also to avoid negligence and malpractice claims. Elective hip and knee arthroplasty numbers are increasing globally, and the British Orthopaedic Association (BOA) has endorsed standards for obtaining written consent for these procedures. Many centres in the United Kingdom and globally, use handwritten consent forms to document informed consent, leaving open the potential for missing out important procedure and risk-related information. Our study aimed to assess whether information on handwritten consent forms was compliant with BOA standards for elective arthroplasty of the hip and knee. Methods We retrospectively reviewed 70 handwritten consent forms, across theatre lists of 12 arthroplasty consultants at our elective arthroplasty centre. These included 35 forms each for hip and knee arthroplasty respectively. We compared the information on these forms to the standards prescribed by the BOA. We assessed compliance of the forms with common, less common and rare risks of hip and knee replacement, as described by the BOA. We also noted the designation of the person filling out the form (consultant, registrar or nurse practitioner) and whether this affected information on the form. We assessed the forms for legibility issues, and whether the setting (clinic/pre-operative ward) affected information on the form. Results None of the 70 forms reviewed achieved full compliance with BOA standards. When assessed for common risks of hip and knee arthroplasty, the number of compliant forms was 25.7% and 42.8%, respectively. None of the forms mentioned all rare risks of either hip or knee arthroplasty. We identified legibility issues in 12 of 70 (17.1%) forms. There was no significant difference in information written on forms filled out by consultants, registrars or nurse practitioners, or between forms filled out in the clinic versus those on the pre-operative ward. Conclusion Handwritten forms lack compliance with prescribed standards for written informed consent in elective hip and knee arthroplasty. Ideally, a pre-written consent form should be used, but with the option of adding information individually tailored to the patients' background. This ensures that good clinical practice is optimally followed, and reduces the potential risk of any litigation.