Degenerative hip and spine pathologies often co-exist, as Hip-Spine-Syndrome (HSS). Many patients eventually need surgery in both hip (THR) and spine [decompression-spinal-arthrodesis (DSA)]. This case-control study aims to determine whether the presence of a DSA compromised THR outcome and whether outcome of THR is better if performed prior to- (THR-1^st) or after- DSA (THR-2^nd).

This is a single centre, multi-surgeon, retrospective, case-control study. Of the 748 patients that underwent DSA between 2004–15, 43 patients (54 THRs) have also had a 1° THR(s) at our unit and formed the cases. Thirty-two THRs were performed prior to the DSA (THR-1^st) and 22 were done following the DSA (THR-2^nd). Most cases had either 1- (n=3) or 2-level (n=20) DSA. The most common DSA level was L4/5 (n=23). The mean THR-DSA interval was 3.6 years. Controls were patients (n=67) without DSA or previous spinal surgery, that had a THR in our unit over the same study period matched for age, gender and type of THR implanted.

Patient Reported Outcome Measures (PROMs) were obtained using the Oxford-Hip- and Harris-Hip-Scores (OHS/HHS), with the difference between post- and pre-operative scores defined as Δ. Outcome was compared between Cases and Controls and between THR-1^st and THR-2^nd Groups. Outcome measures included complications, revisions, PROMs and cup orientations achieved.

The mean age at THR was 67 years old (SD: 11) and most patients were female (n=82, 68%). The mean cup inclination and anteversion angles were 41° (SD:8) and 21° (SD:8). At a mean follow-up of 6 years, the OHS improved from OHS_pre:16 (SD: 7) to OHS_fu:41 (SD:10) and the HHS improved from HHS_pre:51 (SD:14) to HHS_fu:88 (SD:13).

A greater incidence of complications were seen in the Cases (n=10; ARMD-3, infection-4, loosening-2, dislocation-1) compared to the Controls (n=3; dislocation-2, loosening-1) (p=0.01). Consequently, more THRs required revision in the Cases (n=7) compared to the Controls (n=1) (p=0.01). There were no differences in OHS_pre/OHS_fu/ΔOHS/HHS_pre/HHS_fu/ΔHHS between cases and controls (p=0.1 – 0.9).

There were no difference in complications (7/29 Vs. 3/25; p=0.3), nor revision rates (5/29 Vs. 2/25; p=0.3) between THA-1^st and THA-2^nd Groups. Greater differences in PROMs were detected between the groups. The THA-1^st Group, compared to the THA-2^nd Group had higher OHS_pre (19 Vs 12), HHS_pre (54 Vs 48), OHS_fu (43 Vs 32) and HHS_fu (93 Vs 76), (p=0.001–0.005). However, no statistically significant difference in ΔOHS (24 Vs 17) and ΔHHS (39 Vs 26) were seen between the THA-1^st and THA-2^nd Groups (p=0.1).

Patients with a 1° THR and DSA, had a greater rate complications and revisions compared to a matched control. Overall, no difference in PROMs were seen between Cases and Controls. No significantly increased risk of dislocation was seen in this predominantly 1- and 2-level DSA cohort. The superior PROMs detected in the THA-1^st Group provide evidence that the hip pathology should be addressed 1^st (in cases with 1- or 2-level planned DSA).

Aim

Peri-prosthetic joint infection is a serious and expensive complication of joint arthroplasty. Theatre discipline has infection prevention at its core with multiple studies correlating increased door opening with surgical site infection. The WHO, NICE and Philadelphia Consensus all advocate minimal theatre traffic. The Dutch Health Inspectorate consider >5 door openings per procedure excessive.

Aim

The majority of peri-prosthetic joint infection occurring within 1 year of surgery is due to introduction of microbes at the time of surgery. Lavage of total knee replacement leaves a pool of fluid on the surgical drapes. This fluid could be a direct source of wound contamination via suction catheter tip, gloves or instruments.

Introduction: Non-union following hindfoot arthrodesis remains a significant risk in foot and ankle surgery. In the reported series of revision hindfoot arthrodeses non-union rates range from 9 to 25% with approximately half these patients going on to a transtibial amputation. Bone morphogenic proteins (BMP) are a group of naturally occurring proteins with strong osteoinductive properties, which have shown promise in the treatment of fracture non-unions and primary hindfoot arthrodesis surgery. This article reports our experiences with rhBMP-7 as an adjunct to revision arthrodesis surgery in this high-risk subset of patients.

Methods: Eight patients with at least one previous non-union and two or more risk factors for non-union and one patient on steroids with a failed total ankle replacement were prospectively recruited to the study. A revision arthrodesis procedure with internal fixation was performed according to the senior author’s revision protocol with the addition of 3.5mg rhBMP-7 combined with 40mls of bone marrow aspirate. Bone graft was used only if there was structural bone loss. Outcome was assessed clinically and radiologically.

Results: Follow-up ranges from 3 to 22 months (average 13 months). Clinically 8 of the 9 patients had a pain free, stable arthrodesis. Seven patients were satisfied with their functional improvement and pain relief. Radiologically two patients have united, six patients have partial unions with ongoing progression towards union and one patient has a painless non-union. There was one wound infection and one malunion. No complications related to rhBMP-7 were experienced.

Conclusion: Revision arthrodesis with adjuvant rhBMP-7 has led to limb salvage in this group of high-risk patients. However, rhBMP-7 is not a panacea for achieving union and does not replace meticulous surgical planning and technique. Achieving bony union in this subset of patients remains a high risk and protracted process. No concerns about the short-term safety of rhBMP-7 were raised.