Improving acute kidney injury management in lower limb arthroplasty: an educational approach.

INTRODUCTION: Acute kidney injury (AKI) is a common but preventable cause of morbidity in elective arthroplasty patients. This study aimed to review the incidence and management of AKI in patients undergoing elective lower limb arthroplasty and compare results to those after the introduction of educational measures to improve prevention, recognition and management of AKI. METHODS: A retrospective case note review of all patients undergoing elective hip or knee arthroplasty between August and October 2013 was performed. Results were compared to patients treated from February to April 2014, after the introduction of a renal protection protocol, checklist poster and educational sessions. Results were statistically compared using Fisher's exact test. RESULTS: Two hundred and eleven patients were included in the study: 104 in the initial cohort and 107 in the second cohort. Twenty patients (19.2 %) developed AKI in the initial cohort and 12 patients (11.2 %) in the second (p = 0.13). Recognition, documentation and management of AKI were significantly better following educational sessions and dissemination of posters throughout clinical areas, with 75 % of patients in the second cohort having their AKI documented and treated versus 30 % in the initial cohort. DISCUSSION/CONCLUSIONS: This quality improvement project has demonstrated the significant impact that simple educational measures can have on improving AKI prevention, recognition and management in patients undergoing elective arthroplasty surgery. The introduction of a logical treatment checklist has been well received by both medical and nursing staff and ensures prompt and efficient management of AKI in a non-specialist area.

Co-morbidities in Patients with a Hip Fracture.

Hip fractures usually occur in elderly patients who commonly have pre-existing medical problems or comorbidities. We retrospectively reviewed 100 patients admitted to our unit with a hip fracture to quantify their medical complexity. Age and comorbidity profile were used to determine an age-adjusted Charlson Co-morbidity Index (ACCI). The findings were then compared to 100 patients admitted under the care of the acute medical team. The patients in the fracture group were significantly older (p<0.0001), had significantly more co-morbidities (p<0.0001) and had a significantly greater predicted one-year mortality (p<0.0001). Cardiorespiratory disorders were the most common co-morbidities in the hip fracture group. We discuss our findings in combination with a review of the pertinent literature.

Does a standard outpatient physiotherapy regime improve the range of knee motion after primary total knee arthroplasty?

The aim of this study was to investigate whether a standard course of outpatient physiotherapy improves the range of knee motion after primary total knee arthroplasty. One hundred and fifty patients were randomly assigned into one of 2 groups. One group received outpatient physiotherapy for 6 weeks (group A). Another received no outpatient physiotherapy (group B). Range of knee motion was measured preoperatively and at 1-year review. Validated knee scores and an SF-12 health questionnaire were also recorded. Although patients in group A achieved a greater range of knee motion than those in group B, this was not statistically significant. No difference either was noted in any of the outcome measures used. In conclusion, outpatient physiotherapy does not improve the range of knee motion after primary total knee arthroplasty.

Full-length radiographs of the femur in patients with a femoral neck fracture and co-existent malignancy--are they of benefit?

It is recommended that full-length femoral radiographs should be obtained in patients presenting with a femoral neck fracture and a co-existent history of malignancy. Over a two-year period, we identified 133 (47 males, 86 females) patients admitted with a femoral neck fracture and a co-existent history of malignant disease, representing 6.5% of all femoral neck fractures admitted within this time frame. None of the patients had previously diagnosed bone metastases. The mean patient age was 80 years (range, 30-97 years). In 114 cases the fracture was traumatic in origin, most commonly a simple fall (86%). In 19 cases the fracture was atraumatic with histopathological analysis demonstrating the presence of bony metastases. Overall, breast (35%), lower gastrointestinal (22%), prostatic (18%) and bronchogenic carcinomas (7%) were the most common associated malignancies. On reviewing the full-length anteroposterior and lateral femoral radiographs, none of the patients had demonstrable pathology in the remainder of the femur. Furthermore, none of the patients to date have required readmission with a secondary fracture relating to disease in the middle or distal thirds of their femur. We conclude that full-length views of the femur are of limited value in patients presenting with a femoral neck fracture and a co-existent history of malignant disease.

Managing extremely distal periprosthetic femoral supracondylar fractures of total knee replacements - a new PHILOS-ophy.

We report two cases where a proximal humeral locking plate was used for the fixation of an extremely distal, type III peri-prosthetic femoral fractures in relation to a total knee replacement (TKR). In each case there was concern regarding the fixation that could be achieved using the available anatomic distal femoral plates due to the size and bone quality of distal fragment. The design of the Proximal Humeral Internal Locking System (PHILOS) allows nine 3.5-mm locking screws to be placed over a small area in multiple directions. This allowed a greater number of fixation points to be achieved in the distal fragment. Clinical and radiological short-term follow-up (6-12 mo) has been satisfactory in both cases with no complications. We suggest the use of this implant for extremely distal femoral fractures arising in relation to the femoral component of a TKR.

The use of Collagenase Clostridium Histolyticum in the management of Dupuytren's contracture-outcomes of a pilot study in a District General Hospital setting.

INTRODUCTION: Collagenase Clostridium Histolyticum (CCH) is a recognised treatment option for adult patients presenting with Dupuytren's contracture (DC). PATIENTS AND METHODS: Twenty male patients with established DC were treated using CCH. The average metacarpophalangeal (MCP) joint and proximal interphalangeal joint (PIP) contractures pre-treatment were 520 (range, 0 - 750) and 350 (range, 0 - 840) respectively. The average DASH score pre-treatment was 24.2 points (range, 0 - 68.2 points). Patients were reviewed at lmonth, 3months and at an average of 23 months (17 to 27 months). RESULTS: MCP joint contractures significantly improved compared to pre-treatment and the improvement was maintained at latest follow up. PIP joint contractures did significantly improve but to a lesser degree and there was no significant improvement compared to pre-treatment beyond 3months. A trend for MCP and PIP joint contracture recurrence was observed at latest follow up but did not reach statistical significance. DASH scores significantly improved from pre-treatment and the improvement was maintained at latest follow up. At 3months, the average patient satisfaction score was 9.5 (range, 6 - 10), which decreased to 8.6 (range, 6 - 10) at latest follow up. We estimated a potential cost saving of approximately £70,000 by treating 20 patients using CCH compared to inpatient operative fasciectomy. CONCLUSION: CCH is a useful option in the management of DC in appropriately selected patients. Cost-effectiveness in the treatment of DC should be carefully considered.

A randomised controlled trial investigating the effect of posterior capsular stripping on knee flexion and range of motion in patients undergoing primary knee arthroplasty.

Increasing knee flexion following total knee arthroplasty (TKA) has become an important outcome measure. Surgical technique is one factor that can influence knee motion. In this study, it was hypothesised that stripping of the posterior knee capsule could improve flexion and range of motion (ROM) following TKA. Patients who were undergoing TKA were prospectively randomised into two groups - one group (62 patients) were allocated stripping of the posterior knee capsule (PCS), the other group (66 patients) no stripping (no-PCS). The primary outcome was change in flexion and ROM compared to pre-operative measurements at three time points; after wound closure, 3 months and 1 year post-operatively. Secondary outcomes were absolute measurements of flexion, extension, ROM and complications. All operations were performed by a single surgeon using the same implant and technique. All patients received identical post-operative rehabilitation. There was a significant gain in flexion after wound closure in the PCS group (p=0.022), however there was no significant difference at 3 months or 1 year post-operatively. Absolute values of extension (p=0.008) and flexion (p=0.001) 3 months post-operatively were significantly reduced for the PCS group. The absolute value of ROM was significantly higher for the no-PCS group at 3 months (p=0.0002) and 1 year (p=0.005).There were no significant difference in the rate of complications. Posterior capsular stripping causes a transient increase in flexion that does not persist post-operatively. We do not recommend routine stripping of the posterior knee capsule in patients undergoing TKA.

An isolated proximal tibiofibular joint dislocation in a young male playing soccer: a case report.

Isolated dislocation of the proximal tibiofibular joint is a rare injury. We present a 23-year-old caucasian man who sustained a traumatic anterolateral dislocation of the proximal tibiofibular joint. There is no consenus on definitive management, and we review the different published treatment and rehabilitation regimens for this injury. Our patient was successfully treated by open reduction and temporary Kirschner-wire fixation. The authors recommend their structured rehabilitation process involved using cast brace immobilization as allows for excellent soft tissue healing.

Periprosthetic femoral fractures--a comparison between cemented and uncemented hemiarthroplasties.

Over a 2-year period, 244 patients underwent hemiarthroplasty for a displaced intracapsular femoral neck fracture. Seventy patients had a cementless Austin-Moore prosthesis (AMP) inserted and 174 patients were treated using a cemented Thompson hemiarthroplasty. All the AMPs were inserted by or under the supervision of an orthopaedic consultant. Five patients (7%) from the AMP group sustained a periprosthetic femoral fracture. Two were iatrogenic and three occurred postoperatively after a simple fall. The fractures occurred proximally around the prosthesis (Johansson type I). Four required revision surgery. There were no periprosthetic femoral fractures in the Thompson group. When compared to the cemented Thompson hemiarthroplasties, the number of periprosthetic femoral fractures was significantly greater with the AMP. Patients in the AMP group were significantly older, although there was no significant difference in ASA grade between the two groups. There was no significant difference in age or gender between those who sustained a periprosthetic fracture and those who did not. These findings suggest that due to the increased risk of periprosthetic femoral fracture, cemented hemiarthroplasty is preferable. Furthermore, with modern cementing techniques, elderly frail patients appear to tolerate bone cement, which may serve to reinforce an osteoporotic proximal femur.

The limited-contact dynamic compression plate in the management of proximal humeral non-union.

Non-union is an uncommon but troublesome complication of proximal humeral fractures. A number of surgical techniques have been reported. We describe the use of a contoured limited-contact dynamic compression plate in the surgical management of proximal humeral non-union.

Migration of intrapelvic cement after total hip arthroplasty.

Intrapelvic extrusion of cement during total hip arthroplasty is a frequent occurrence. We report a case in which the intrapelvic cement mass broke free 3 years after the primary procedure and migrated proximally to lie against the posterior abdominal wall, resulting in intractable groin pain. The patient was relieved of pain after removal of the cement mass.

Recurrent hip arthroplasty dislocation: good outcome after cup augmentation in 20 patients followed for 2 years.

Recurrent posterior dislocation occurs after primary total hip arthroplasty at rates of up to 7%. Component revision is regarded as standard management, but this major surgery may be unsuitable for elderly patients. We have developed a congruent polyethylene acetabular posterior lip augmentation device (PLAD) with a stainless steel backing plate. This can be used when there is no gross malalignment, wear or loosening of the primary components. We retrospectively compared 20 patients who had revision surgery with twenty patients who had been treated with the PLAD for recurrent posterior dislocation after primary Charnley total hip arthroplasty. In the PLAD group, the mean operative time, intraoperative blood loss, time spent in the high-dependency unit (HDU), transfusion requirements and the duration of hospital stay were all less than that in the revision group. There was no difference in the Oxford Hip Score between the groups at latest review 2 years after surgery. None of the patients in either group had suffered another dislocation.

Dislocation of the rotating platform after low contact stress total knee arthroplasty.

From a one-surgeon series of 2485 patients, we report on 10 patients with rotating platform dislocation after primary Low Contact Stress total knee arthroplasty. All dislocations occurred within 2 years of the index procedure. Of the 10 patients, nine required open reduction. Five of these patients also had exchange of the original insert. One patient was treated by closed reduction. All knees were immobilized in a cast for 8 weeks. Eight of the 10 patients had no additional dislocation and at followup (average, 35 months; range, 12 months-5 years), had a stable functional joint. Two patients had recurrent spinout of the rotating platform develop. One patient had arthrodesis whereas the other patient had the insert cemented to the tibial tray as a salvage procedure. Increasing age, a preoperative valgus deformity, and prior patellectomy were significantly associated with rotating platform spinout. Surgical experience and an improved understanding of the soft tissue constraints, particularly in the valgus knee, are important in minimizing this complication.