Isolated liner exchange in revision total hip arthroplasty for the treatment of polyethylene wear is an increasingly common surgical procedure. Twenty-four hips underwent this procedure via the direct lateral approach and were prospectively followed clinically and radiographically. Accessible osteolytic lesions were curetted and bone grafted. At a mean follow-up of forty months, a significant clinical improvement was observed. One cup collapsed into an osteolytic lesion postoperatively; all other lesions regressed. No dislocations have occurred. Isolated liner exchange via the direct lateral approach may reduce dislocation rates while avoiding the morbidity associated with the removal of well-fixed components. The purpose of this study was to evaluate the clinical and radiographic results of isolated liner exchange in revision total hip arthroplasty (THA) for osteolysis and polyethylene wear via the direct lateral surgical approach. Retention of well-fixed implants avoids unnecessary bone loss at revision surgery. Previous studies report a significant dislocation rate with isolated liner exchange. Revision via the direct lateral surgical approach may reduce the dislocation rate in surgery for acetabular osteolysis. Twenty-four hips that underwent an isolated liner exchange revision procedure via the direct lateral approach were prospectively followed. Accessible osteolytic lesions were curetted and bone grafted. Harris Hip Score, WOMAC Index, and radiographic analysis were recorded. The area of osteolytic lesions was calculated using a computer imaging technique. At mean follow-up of forty months, all except one of the osteolytic lesions had regressed in size. Mean Harris Hip scores improved from sixty-nine to eighty-three and WOMAC indices improved from thirty-seven to twenty-four. No dislocations have occurred. One cup collapsed into an osteolytic lesion postoperatively, requiring an acetabular revision procedure. Isolated liner exchange is a promising technique that avoids the removal of well-fixed acetabular implants. The increased dislocation rate associated with revision THA may be reduced and osteolytic lesions may be debrided and bone grafted through the direct lateral approach. Isolated liner exchange via the direct lateral approach reduces the dislocation rate in THA. Retention of wellfixed implants and bone grafting is a procedure that preserves bone stock and addresses osteolytic lesions at revision surgery.
The results of a randomized controlled clinical trial of ninety patients comparing resurfacing to non-resurfacing of the patella in total knee arthroplasty (TKA) are reported with a minimum of ten-years of follow-up. Using a cruciate retaining hybrid TKA, the outcome measures included Knee Society Clinical Rating scores, functional testing (stair climb and flexion extension torques), patient satisfaction, anterior knee pain, and a patellofemoral specific questionnaire. The results indicated no difference between the groups in all categories. Results at two and ten years postoperatively are compared. This study represents the longest follow-up to date comparing resurfacing to nonresurfacing of the patella. Patellar resurfacing in TKA remains controversial. Purpose: To evaluate the results of resurfacing/non-resurfacing of the patella in a randomized controlled clinical trial at a minimum of ten-years of follow-up. One hundred knees (ninety patients) with osteoarthritis were enrolled in a prospective randomized controlled double-blinded trial using the same posterior cruciate retaining total knee replacement. Patients were randomized to resurfacing or nonresurfacing of the patella. Evaluations were performed preoperatively and yearly to a minimum ten years (range, 10.1–11.5 years) postoperatively. Disease specific (Knee Society Clinical Rating System), functional (stair climbing, knee flex-ion/extension torques, patellar examination) outcomes were measured. Patient satisfaction, anterior knee pain, and patellofemoral questionnaires were completed. Intraoperative grading of the articular cartilage was performed. No patients were lost to follow-up; forty-six knees remained alive. Nine revisions (9/90-ten percent) were performed – 7/48 (fifteen percent) in the nonresurfaced and 2/42 (five percent) in the resurfaced group. Three knees in the nonresurfaced group were revised to a resurfaced patella for anterior knee pain. One resurfaced patella was complicated by AVN and fracture, requiring revision. No significant difference was found between the groups regarding revision rates, KSCR score, functional, satisfaction, anterior knee pain, patellofemoral, and radiographic outcomes. Intraoperative cartilage quality was not a predictor of outcome. This study represents the longest follow up to date of a randomized controlled clinical trial to examine patellar resurfacing in TKA. The results showed no significant difference between the groups for all outcome measures at a minimum of ten-years.
The results of a randomized controlled clinical trial of ninety patients comparing resurfacing to non-resurfacing of the patella in total knee arthroplasty (TKA) are reported with a minimum of ten-years of follow-up. Using a cruciate retaining hybrid TKA, the outcome measures included Knee Society Clinical Rating scores, functional testing (stair climb and flexion extension torques), patient satisfaction, anterior knee pain, and a patellofemoral specific questionnaire. The results indicated no difference between the groups in all categories. Results at two and ten years postoperatively are compared. This study represents the longest follow-up to date comparing resurfacing to nonresurfacing of the patella. Patellar resurfacing in TKA remains controversial. Purpose: To evaluate the results of resurfacing/non-resurfacing of the patella in a randomized controlled clinical trial at a minimum of ten-years of follow-up. One hundred knees (ninety patients) with osteoarthritis were enrolled in a prospective randomized controlled double-blinded trial using the same posterior cruciate retaining total knee replacement. Patients were randomized to resurfacing or nonresurfacing of the patella. Evaluations were performed preoperatively and yearly to a minimum ten years (range, 10.1–11.5 years) postoperatively. Disease specific (Knee Society Clinical Rating System), functional (stair climbing, knee flexion/extension torques, patellar examination) outcomes were measured. Patient satisfaction, anterior knee pain, and patellofemoral questionnaires were completed. Intraoperative grading of the articular cartilage was performed. No patients were lost to follow-up; forty-six knees remained alive. Nine revisions (9/90-ten percent) were performed – 7/48 (fifteen percent) in the nonresurfaced and 2/42 (five percent) in the resurfaced group. Three knees in the nonresurfaced group were revised to a resurfaced patella for anterior knee pain. One resurfaced patella was complicated by AVN and fracture, requiring revision. No significant difference was found between the groups regarding revision rates, KSCR score, functional, satisfaction, anterior knee pain, patellofemoral, and radiographic outcomes. Intraoperative cartilage quality was not a predictor of outcome. This study represents the longest follow up to date of a randomized controlled clinical trial to examine patellar resurfacing in TKA. The results showed no significant difference between the groups for all outcome measures at a minimum of ten-years.
If an arthroplasty patient presents with wound breakdown, sinus formation or a hot, red joint the diagnosis of infection is straightforward. However, most total joint replacement (TJR) infections are difficult to distinguish from aseptic loosening. It is imperative to know if a painful TJR is infected to plan appropriate management. In this prospective study of 204 patients we analysed the diagnostic accuracy of various tests for infection: Inflammatory Markers (CRP/ESR); Aspiration Microbiology; and the Polymerase Chain Reaction (PCR) – a novel technique in this situation. We used international criteria as the gold standard for infection, applied at the time of revision surgery. Any of – a sinus; frank pus in the wound; positive intra-operative microbiology; positive histology – classified the patient as infected. The sensitivity (Sens), specificity (Spec), positive predictive value (PPV) and negative predictive value (NPV) of each test were calculated. 52 patients with an original diagnosis of inflammatory arthritis were excluded, as histology may be inaccurate. The results for the remaining 152 patients are: CRP >
20mg/l: Sens 77%; Spec 76%; PPV 49%; NPV 92%. ESR >
30 mm/hr: Sens 61%; Spec 86%; PPV 57%; NPV 87%. Aspiration Microbiology: Sens 80%; Spec 83%; PPV 71%; NPV 88%. PCR: Sens 71%; Spec 78%; PPV 43%; NPV 89%. Few patients with negative CRP/ESR were found to be infected; if positive, there was a 50/50 chance that the joint was infected. Positive aspiration microbiology was associated with underlying infection 3 times out of every 4, and negative results were correct 9 times out of 10. PCR was no more accurate than existing tests. All patients with painful TJR’s should have inflammatory markers checked – if negative the clinician can be relatively reassured that the implant is not infected. If positive or suspicion remains, further investigation should be undertaken. Joint aspiration for microbiology is currently the best available second line investigation.
We recommend that all patients with painful TJRs have inflammatory markers checked as a screening test – if negative then the clinician can be relatively reassured that the implant is not infected. If positive, further investigation should be undertaken. Joint aspiration for microbiology is currently the best available second line investigation.
We investigated the use of PCR (the Polymerase Chain Reaction) to detect the presence of infection in a group of patients undergoing revision arthroplasty for loose TJR (total joint replacement), compared to internationally agreed criteria used as the ‘gold standard’ for infection. We prospectively tested samples taken from 108 patients undergoing revision arthroplasty (76 hips, 32 knees). Antibiotics were omitted prior to obtaining samples. DNA was extracted by 2 methods – a previously published technique ( Using the published DNA extraction technique PCR had a sensitivity of 50%, specificity of 93%, positive predictive value of 67% and negative predictive value of 88%. Using commercial extraction the sensitivity improved to 60%, specificity to 98%, positive predictive value to 90% and negative predictive value to 90%. The previous report stated that PCR had a high sensitivity but a low specificity for detecting low grade infection. However, when using the published technique we found the opposite results – a moderate sensitivity and a high specificity. Introduction of a new DNA extraction technique improved the sensitivity. The refined PCR technique had a high accuracy, but further work is needed to improve sensitivity before we would recommend this method for routine clinical use.
The new Ionising Radiation (Medical Exposure) Regulations 2000 (IR (ME)ER) were implemented in January 2001. These regulations state that “the referrer must record in the patient’s notes that a radiograph was taken and what it showed”. As a result it is now incumbent upon the orthopaedic surgeon to document formally the findings of all requested radiographs. We present a case in which a left upper bronchial carcinoma was detected initially on a radiograph of the left shoulder. It highlights the importance of careful examination of the entire radiographic image and the documenting of the findings.
We performed transoesophageal echocardiography in 111 operations (110 patients) which included medullary reaming for fresh fractures of the femur and tibia, pathological lesions of the femur, and hemiarthroplasty of the hip. Embolic events of varying intensity were seen in 97 procedures and measured pulmonary responses correlated with the severity of embolic phenomena. Twenty-four out of the 25 severe embolic responses occurred while reaming pathological lesions or during cemented hemiarthroplasty of the hip and, overall, pathological lesions produced the most severe responses. Paradoxical embolisation occurred in four patients, all with pathological lesions of the femur (21%); two died. In 12 patients large coagulative masses became trapped in the heart. Extensive pulmonary thromboembolism with reamed bone and immature clot was found at post-mortem in two patients; there was severe systemic embolisation of fat and marrow in one who had a patent foramen ovale and widespread mild systemic fat embolisation in the other without associated foraminal defect. Sequential analysis of blood from the right atrium in five patients showed considerable activation of clotting cascades during reaming.
We performed transoesophageal echocardiography on 20 patients with femoral neck fractures randomly treated with an uncemented Austin-Moore or cemented Hastings hemiarthroplasty. Cemented arthroplasty caused greater and more prolonged embolic cascades than did uncemented arthroplasty. Some emboli were more than 3 cm in length. In some patients the cascades were associated with pulmonary hypertension, diminished oxygen tension and saturation, and the presence of fat and marrow in aspirates from the right atrium.