Vastus lateralis versus rectus femoris muscle flaps for recalcitrant hip joint infection: An anatomical study comparing the effectiveness of acetabular dead space control.

Eliminating recalcitrant prosthetic hip joint infections remains one of the greatest challenges in orthopedic surgery. In such cases, the salvage procedure of femoral head excision (the Girdlestone procedure) is often performed. There has been emerging surgical interest in filling the resulting acetabular dead space with a pedicled muscle flap, to enable antibiotic delivery. Both vastus lateralis (VL) and rectus femoris (RF) muscle flaps have been described for this purpose with good success. This study is the first anatomical investigation comparing VL and RF as candidates for interposition myoplasty following hip joint excision. Following standard surgical technique, the Girdlestone procedure and interposition myoplasty of both RF and VL were performed on 10 cadavers. The primary aim was to determine which muscle flap eliminated a greater volume of acetabular dead space. Secondary aims were to characterize the blood supply to RF and assess additional metrics indicative of the likelihood of flap success. The VL flap eliminated more dead space than RF. However, the use of the RF flap was feasible in all cases and has several benefits, including ease of harvest, mobility, and aesthetics. The location of the inferior vascular pedicle into RF was relatively consistent and the most effective predictor of flap success. Both VL and RF are effective in reducing acetabular dead space. While VL can fill a greater volume, the RF flap has technical advantages, related to the predictability of the blood supply.

The use of an electronic health record system reduces errors in the National Hip Fracture Database.

AIM: to compare the validity of data submitted from a UK level 1 trauma centre to the National Hip Fracture Database (NHFD) before and after the introduction of an electronic health record system (EHRS). PATIENTS AND METHODS: a total of 3224 records were reviewed from July 2009 to July 2017. 2,133 were submitted between July 2009 and October 2014 and 1,091 between October 2014 and July 2017, representing data submitted before and after the introduction of the EHRS, respectively. Data submitted to the NHFD were scrutinised against locally held data. RESULTS: use of an EHRS was associated with significant reductions in NHFD errors. The operation coding error rate fell significantly from 23.2% (494/2133) to 7.6% (83/1091); P < 0.001. Prior to EHRS introduction, of the 109 deaths recorded in the NHFD, 64 (59%) were incorrect. In the EHRS dataset, all the 112 recorded deaths were correct (P < 0.001). There was no significant difference in the error rate for fracture coding. In the EHRS dataset, after controlling for sample month, entries utilising an operation note template with mandatory fields relevant to NHFD data were more likely to be error free than those not using the template (OR 2.69; 95% CI 1.92-3.78). CONCLUSION: this study highlights a potential benefit of EHR systems, which offer automated data collection for auditing purposes. However, errors in data submitted to the NHFD remain, particularly in cases where an NHFD-specific operation note template is not used. Clinician engagement with new technologies is vital to avoid human error and ensure database integrity.

Proximal femoral excision with interposition myoplasty for cerebral palsy patients with painful chronic hip dislocation.

PURPOSE: Proximal femoral excision is a salvage procedure for painful chronic hip dislocation in cerebral palsy (CP) patients. The primary objective of this article is to describe our experience of an amplified interposition myoplasty, with appropriate peri-operative pain and tone management strategies, in a cohort of non-ambulatory CP patients with painful chronic hip dislocation. Our secondary objective is to present the clinical outcomes of these patients. METHODS: We describe our experience in 20 CP patients (25 procedures) at mean 54-month (range 27-169) follow-up with a surgical technique that includes an augmented interposition myoplasty and tone management. The indications for surgery were pain (21 hips), poor sitting tolerance (11) and difficulty with perineal care (8). RESULTS: The mean age was 22 years (range 10-40) with 11 patients Gross Motor Function Classification Scale (GMFCS) IV and 9 patients GMFCS V. Mean length of stay was 13 days (3-35). One procedure required revision at 12 months. Mean pain score improved from 7.8 (5-10) pre-operatively to 2.8 (1-5) post-operatively (p < 0.001). Sitting tolerance improved in all patients and in 75 % (15) perineal care was easier. CONCLUSIONS: Our interposition myoplasty technique with individualised pain/tone management has good outcomes in this cohort of patients with multiple co-morbidities.

Total hip arthroplasty in teenagers: an alternative to hip arthrodesis.

Debilitating arthritis in teenage patients is a complex problem with limited surgical options. Hip arthrodesis is unpopular amongst patients, and contemporary total hip arthroplasty (THA) may be a promising alternative. We report on the outcomes of THA in patients less than 20 years of age. All consecutive teenage patients undergoing THA at a tertiary referral centre were reviewed. Mean follow-up was 3.4 years (range 0.6-6.8) and 9 patients had at least 5 years follow-up. There were 51 THAs in 43 patients with a mean age of 17 years (range 12-19). The commonest indication was osteonecrosis (35 cases), mostly secondary to slipped upper femoral epiphysis (15 cases). Forty-six were uncemented and 5 were reverse hybrid THAs of which 7 were computer assisted design/manufacture (CADCAM) components. The commonest bearing surface used was ceramic on ceramic (40 cases). The survival rate was 96% and there were 2 complications. At latest follow-up, the mean Harris hip score was 90 (range 68-99) and UCLA activity score was 6 (range 4-9). Radiological analysis showed 2 patients with lucent lines around the acetabular component, but no signs of osteolysis or wear. We report good short to intermediate term survivorship and outcomes, and feel THA represents a valid alternative option to hip arthrodesis.

Durable infection control and function with the PROSTALAC spacer in two-stage revision for infected knee arthroplasty.

BACKGROUND: A two-stage revision total knee arthroplasty is recognized as the gold standard in the treatment of infection. However, traditional spacers limit function in the interval between the two stages and may cause instability, scarring, and bone erosion. The PROSTALAC knee spacer is an antibiotic-loaded cement articulating spacer that allows some movement of the knee between stages. Whether motion enhances long-term function is unknown. QUESTIONS/PURPOSES: We therefore identify the rate of control of infection using the PROSTALAC exchange spacer and to assess the clinical outcome after implantation with a definitive implant. METHODS: We retrospectively reviewed 115 knees that underwent two-stage exchange with the PROSTALAC spacer. Forty-eight of these had a minimum followup of 5 years (mean, 9 years; range, 5-12 years). RESULTS: At last review, 101 of the 115 knees (88%) had no evidence of infection. Of the 14 knees that became reinfected, four were from the same organism and 10 were with a different organism. After further intervention, using the two-stage approach again, the infection was controlled in 12 of the 14 initially reinfected cases, resulting in a failure to cure in only two cases. We observed improvements in mean WOMAC, Oxford, UCLA, and Patient Satisfaction scores at last review. CONCLUSIONS: The PROSTALAC functional spacer was associated with a 98% rate of control of infection and improvements in the quality-of-life outcomes in the treatment of chronically infected total knee arthroplasties. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.