The surgical treatment options for patients who have sustained an intra-capsular hip fracture can vary depending on a number of patient and fracture related factors. Currently most national guidelines support the use of cemented prostheses for patient undergoing hemi-arthroplasty surgery. Uncemented prostheses are commonly used for a variety of indications including those patients who have significant medical co-morbidities.

To determine whether cemented hemi-arthroplasty is associated with a higher post operative mortality when compared to uncemented procedures. Data was extracted from the Scottish SMR01 database from 01/04/1997 from all patients who were admitted to hospital after sustaining a hip fracture. We investigated mortality at day 1, 2, 4, 7, 30, 120 and 1 year from surgery vs. that on day 0. In order to control for the effects of confounding variables between patients cohorts, 12 case-mix variable were used to construct a multivariable logistic regression analysis model to determine the independent effect of prosthesis fixation method.

There were 64,979 patients were included in the study. Mortality for osteosynthesis of extra-capsular fractures was consistently lower when compared to that for surgical procedures for intra-capsular fractures. At day 0, uncemented hemi-arthroplasty operations had a lower associated mortality (p<0.001) when compared to cemented implant designs. Unadjusted figures showed an increased mortality equal to 1 extra death per 424 procedures. By day 1 this had become 1 extra death per 338 procedures. By day 7 cumulative mortality was less for cemented than for uncemented procedures though this did not reach significance until day 120.

When compared to uncemented fixation techniques, cemented hemiarthroplasty is associated with a higher mortality in the immediate postoperative period. However, by day 120 and beyond the trend is reversed.

Introduction

Decompression is the gold standard surgical technique in patients with symptomatic spinal stenosis not responding to conservative management. We present an audit of outcomes in a population of patients undergoing this procedure over a four year period.

The importance for observing the intention-to-treat approach in clinical studies is explained.

Cite this article: Bone Joint J 2013;95-B:1443–4.

It is estimated that 15 % of the population is allergic to metal, most commonly to Nickel, which is a common component of the alloys in most knee and hip arthroplasties. It would therefore be expected that allergy to metal is a frequent form of implant failure – but very little is reported in the literature. With the recent concerns about metal-on-metal bearings and metal ion issues, there has been renewed interest in metal allergy – with the Australian Joint Registry 2010 reporting it as a causative factor in 7 % of Hip Resurfacing revisions.

With over 200 BHR and 571 ASR Hip Resurfacing arthroplasties in my series from 2001, I have identified only 1 patient with implant failure due to metal allergy.

In 2010 two Total Knee Arthroplasty patients presented with pain and strongly positive Melisa allergy tests – these patients were revised to Titanium coated implants resulting in a complete relief of symptoms.

This paper will analyse the problem of metal sensitivity, the investigation and management of the allergic patient who has, or requires, joint arthroplasty

The surgical treatment options for patients who have sustained an intra-capsular hip fracture can vary depending on a number of patient and fracture related factors. Currently most national guidelines support the use of cemented prostheses for patient undergoing hemiarthroplasty surgery. Uncemented prostheses are commonly used for a variety of indications including those patients who have significant medical co-morbidities.

To determine whether cemented hemiarthroplasty is associated with a higher post operative mortality when compared to uncemented procedures. Data were extracted from the Scottish SMR01 database from 01/04/1997 from all patients who were admitted to hospital after sustaining a hip fracture. We investigated mortality at day 1,2,4,7,30, 120 and 1 year from surgery vs. that on day 0. In order to control for the effects of confounding variables between patients cohorts, 12 case-mix variable were used to construct a multivariable logistic regression analysis model to determine the independent effect of prosthesis design.

There were 52283 patients included in the study. Mortality for osteosynthesis of extra-capsular fractures was consistently lower when compared to that for surgical procedures for intra-capsular fractures. At day 0, uncemented hemiarthroplasty had a lower associated mortality (p<0.001) when compared to cemented implant designs. However, this increased mortality was equal to 1 extra death per 2000 procedures. From day 1 onward mortality for cemented procedures was equal to or lower than that of uncemented. By day 4, cumulative mortality was less for cemented than for uncemented procedures. Complication and re-operation rate was significantly higher in the uncemented cohort.

The use of uncemented hemiarthroplasty for the treatment of intra-capsular hip fractures cannot be justified in terms of early/late post-operative mortality.

Aim

Congenital Talipes Equinovarus (CTEV) has been excluded from the standards set by the NHS fetal anomaly screening programme (NHS FASP) for the 18⁺⁰–20⁺⁶ week fetal ultrasound scan (USS). Whilst adhering to NHS FASP guidelines, the antenatal ultrasound department at our centre performs “incidental screening” for CTEV; parents are informed if CTEV is noted incidentally during the scan and referral made to the fetal medicine department. Our aim was to investigate the effectiveness of incidental antenatal screening for structural CTEV.

Background and Purpose

Serum lactate has been shown to be an indicator of adverse clinical outcomes in patients admitted secondary to general trauma or sepsis. We retrospectively investigated whether admission serum venous lactate can predict in-hospital mortality in patients with hip fractures.

The risk of venous thrombo-embolism (VTE) is high in orthopedics. Oral direct factor Xa inhibitors have been introduced to help reduce the incidence of VTE. To reduce post-operative bleeding antifibrinolytics are used. We aimed to ascertain the effect of two drugs on post operative bleeding and transfusion requirements.

We prospectively recorded patient demographics, operative details, complications, transfusion incidence and VTE incidence in TKR patients. We also sent out questionnaires to patients asking about wound bleeding and VTE. All patients were given 10mg Rivaroxaban 8 hours post operatively and then OD for 14 or 35 days. Patients given tranexamic acid were given 500mg IV, 5 minutes prior to wound closure at the discretion of the surgeon. VTE was Deep Vein Thrombus or Pulmonary Embolism confirmed by Doppler or CTPA. Minor bleed was categorized as dressing soakage or reported wound leakage, major bleed as hematoma requiring revision within 30 days.

509 patients underwent TKR: 200 (39%) received Rivaroxaban only (Group 1), 296 (58%) also received tranexamic acid (Group 2). 13 (3%) patients had no data available. Five patients had a VTE: 4 (2%) in Group 1, 1 (0.3%) in Group 2 [P<0.05]. 39 patients had a minor bleed: 17 (8.5%) in Group 1, 22 (7.4%) in Group 2 [P=0.5]. 2 patients had major bleeds: 1(0.5%) in Group 1 and 1(0.33%) in Group 2 [P=0.69]. There were 30 blood transfusions: 21 (10.5%) in Group 1, 9 (3%) in Group 2 [P<0.0001].

We have demonstrated a reduced requirement for blood transfusions in the tranexamic acid group. However our results, whilst they show a trend towards decreased minor and major bleeding rates, are not significant and require larger studies looking at wound bleeding and leakage.

The risk of venous thrombo-embolism (VTE) is high in orthopaedics. Oral direct factor Xa inhibitors have been introduced to help reduce the incidence of VTE. To reduce post-operative bleeding antifibrinolytics are used. We aimed to ascertain the effect of two drugs on post-operative bleeding and transfusion requirements.

We prospectively recorded patient demographics, operative details, complications, transfusion incidence and VTE incidence in TKR patients. We also sent out a questionnaire to patients asking about wound bleeding and VTE. All patients were given 10mg Rivaroxaban 8 hours post operatively and then once a day for 14 days. Patients given tranexamic acid were given 500mg IV, 5 minutes prior to wound closure at the discretion of the surgeon. VTE was confirmed by Doppler or CTPA as Deep Vein Thrombus or Pulmonary Embolism. Minor bleed was categorised as dressing soakage or reported wound leakage, major bleed as haematoma requiring revision within 30 days.

509 patients underwent TKR: 200(39%) only received Rivaroxaban (Group 1), 296(58%) also received tranexamic acid (Group 2). 13(3%) of patients had no data available. 5 patients had a VTE: 4 (2%) Group 1, 1 (0.3%) Group 2 (P<0.05). 39 patients had a minor bleed: 17 (8.5%) Group 1, 22 (7.4%) Group 2 (P=0.5). 2 patients had major bleeds: 1 (0.5%) Group 1, 1 (0.33%) Group 2 (P=0.69). Blood transfusions 21: (10.5%)Group 1, 9 (3%) Group 2 (P<0.0001).

We have demonstrated a reduced requirement for blood transfusions in the tranexamic acid group. However our results whilst they show a trend towards decrease bleeding rates in both the minor and major bleeds are not significant, requiring larger studies looking at wound bleeding and leakage.

Delay to theatre after hip fracture is common in order to medically optimise the patient prior to surgery. The association between delay to surgery and mortality after hip fracture remains a contentious issue.

We aimed to investigate how medical postponement, time to surgery and correction of medical abnormalities prior to surgery affect peri-operative mortality after hip fracture.

From February to December 2007 prospective data was collected from all acute trauma units in Scotland relating to hip fracture patients' fitness for theatre, reasons for postponement of surgery and subsequent plans of action. The data-set recorded whether medical abnormalities were identified following criteria reported by McLaughlin et al. Survival at 30-days post-operation was used as primary outcome measure. Multivariable logistic regression models were used to control for differences in case-mix between patients.

Data were available for 4284 patients. Patients postponed for medical reasons were less likely to survive to 30 days compared to patients who were not postponed (87% (122/947) versus 93% (3098/3337)). Survival also decreased as time to theatre increased - 92% of patients operated on during the same/next day vs. 89% of those operated on admission day four. However, after controlling for differences in case-mix variables and co-morbidities, neither variable significantly affected survival. We then analysed whether delaying surgery to resolve medical problems improved survival. Adjusted survival was not significantly different between those patients who had their medical problem resolved prior to surgery compared to those patients who were not postponed. Individuals who were postponed but did not have their clinical abnormality resolved prior to surgery had significantly lower adjusted 30 day survival.

The possible benefits of postponement need to be weighed against prolonged discomfort and the possibility of developing other complications. Postponing patients who cannot be medically improved should be avoided.

Richard Carey Smith is an orthopaedic oncology surgeon with fellowship training in the UK, USA, Australia and Canada, and has worked in Zambia, Zimbabwe and Papa New Guinea. David Wood is head of the University Department of Orthopaedics in Perth, Western Australia. He did his masters in Africa, and first experienced Papa New Guinea on his medical elective, starting a lifelong commitment to medical aid work there.

Introduction

A metal ion study was undertaken in patients who had received an articular surface replacement. The design of these components is optimised in line with lubrication theory and produces low levels of wear in hip joint simulators.

We aim to assess the outcome of ankle arthrodesis performed for painful osteoarthritis in the presence of a coronal plane deformity of 20 degrees or more.

To our knowledge this is the first reported series of such a cohort of patients. We have a consecutive and complete series of 24 patients with 26 ankle arthrodeses which were all performed for painful osteoarthritis in the presence of large coronal plane deformity. These patients have a minimum of twelve months clinical follow-up. The results showed a low non-union rate of 8% (2 ankles). These have subsequently been re-fused satisfactorily, and are excluded from further analysis. The results of the remaining 24 ankles, which united primarily, show that patients were very pleased with the outcome of their surgery. AOFAS scores were used to measure pain and function, both pre-operatively and post-operatively. These scores showed large improvements for both pain and function, and had a high statistical significance (p<0.0001). All patients improved in their walking distance and many patients reduced their need for walking aids. Stair climbing ability was also improved in some patients. It is recognised that an ankle arthrodesis usually relieves pain but does not result in a normal gait and full function.

We feel that the high level of patient satisfaction in this series was due to the combination of deformity correction, restoring a functional foot position, and achieving a painless ankle. Arthroplasty of the ankle is a good procedure for relief of pain and restoration of function. However, in the presence of a large coronal plane deformity, ankle arthroplasty is known to fare badly with early failure. Therefore for patients with painful osteoarthritis and a coronal plane deformity of 20 degrees or more, we recommend ankle arthrodesis as the procedure of choice.

Surgery for degenerative lumbar spondylolisthesis may entail both decompression and fusion. The knee-chest position facilitates the decompression, but fixation in this position risks fusion in kyphosis. This can be avoided by intra-operative re-positioning to the prone position. The aim of this study was to quantify the restoration of lordosis achieved by intra-operative repositioning and to assess the clinical and radiological outcome.

A total of forty consecutive patients with degenerative lumbar spondylolisthesis and stenosis were treated by posterior decompression and interbody fusion with pedicle screw fixation. The screw insertion, decompression and interbody grafting were performed with the patient in the knee-chest position. The patient was then re-positioned to the fully prone position for fusion. Sagittal plane angles were measured pre-, intra- and post-operatively. Clinical assessment was performed using SF-36 scores and visual analogue scores for back and leg pain.

The sagittal plane angle increased from median 16.0 degrees pre-operatively to 23.1 degrees post-operatively (p<0.01) and this was maintained at the last follow-up (mean 21 months). The SF-36 scores improved for 7 out of 8 domains and the physical score improved from 29% to 40% (p<0.05). The mean pain scores improved significantly from 7.5 to 3.8 for back pain and from 7.6 to 3.7 for leg pain (p<0.001).

Lumbar spondylolisthesis was found to be associated with a reduction of normal lumbar lordosis and the knee-chest position exacerbates this loss of lordosis. Intra-operative repositioning restored lordosis to greater than the pre-operative angle and was associated with a good clinical outcome.

Introduction: Chondral injuries of the knee are commonly seen at arthroscopy, yet there is no consensus on the most appropriate treatment method. However, untreated cartilage injury predisposes to osteoarthritis contributing to pain and disability. For cell-based cartilage repair strategies, an ex vivo expansion phase is required to obtain sufficient cells for therapeutic intervention. Although recent reports demonstrated the central role of oxygen in the function and differentiation of chondrocytes, little is known of the effect of physiological low oxygen concentrations during the expansion of the cells and whether this alters their chondrogenic capacity.

Methods: Articular mouse chondrocytes were prepared from the distal femoral condyles of adult mice and chondrocytes were liberated by collagenase type II treatment. Cells were cultured in RPMI 1640 media in monolayer under normoxic or hypoxic conditions (5% O2). Chondrogenic potential was subsequently assessed by plating the cells under micromass conditions and glycosaminoglycan deposition was determined by alcian blue staining. Having determined that oxygen tension infiuences murine chondrocyte expansion and differentiation, similar studies were conducted using adult human chondrocytes taken from knee arthroplasty off-cuts, and Aggrecan (ACAN) gene expression was analyzed using real-time quantitative PCR.

Results: Cellular morphology of cells from mouse articular cartilage was improved in hypoxic culture, with a markedly more fibroblastic appearance seen after greater than 2 passages in normoxic conditions. Micromass cultures maintained in hypoxic conditions demonstrated stronger staining with alcian blue, indicating stronger expression of cartilage-associated glycosaminoglycans. Expansions of human chondrocytes under hypoxic conditions led to an ~ 2-fold increase in the expression of ACAN in comparison to cells in normoxic conditions. Differentiation of passage 2 chondrocytes under hypoxic conditions also improved the expression of ACAN when compared to culturing under normoxia. Ten day hypoxic cultures exhibited an ~ 5-fold increase in ACAN expression in comparison to normoxic cultures. Interestingly, ACAN expression normoxic-cultured cells could be increased by > 4-fold by transfer to hypoxic conditions.

Conclusions: In vivo, the chondrocytes are adapted to an avascular hypoxic environment. Accordingly, applying 5% O2 in the expansion phase in the course of cell-based cartilage repair strategies may more closely mimic the normal chondrocyte microenvironment and may result in a repair tissue with higher quality by increasing the content of glycosaminoglycans.

Current evidence on the indications for and efficacy of non-rigid lumbar stabilisation remains unclear. The aim of this study was to review the outcome of the DYNESYS system (Zimmer, Inc.) in a consecutive series of 34 patients undergoing this procedure between 2001 and 2006.

Prospectively collected outcome measure data obtained pre-operatively and at 1 year post-operatively was analysed using the Wilcoxon Signed Rank Test. Kaplan Meier survival analysis was performed using revision surgery as the end point. Cox Regression was utilised to identify variables that were related to implant survival.

Pain rating on the visual analogue scale improved from a mean of 7 pre-op to 4 at 1 year (p=0.009), Roland Morris Disability Questionnaire scores from 13 to 9 (p=0.02), Modified Somatic Perception Questionnaire from 13 to 9 (p=0.03). When reporting subjective outcome, 54% of patients reported “better” or “much better” outcomes at last followup (12–69 months post op). Eight patients (25%) required removal of the implant and conversion to fusion, one of whom had deep infection. Kaplan Meier survival analysis revealed a survival of 78% at 5 years (95% CI, 60 – 96%). Previous spinal surgery was significantly related to the time of survival of the implant (p=0.008).

Our study has demonstrated a high revision rate for this implant and 54% patient satisfaction. We recommend that patients be counseled regarding these risks and further use of this implant should be subject to the outcome of larger studies and randomised controlled trials.

We aim to assess the clinical and radiological outcome following cartilage repair in the knee using the TruFit plug (Smith & Nephew). Eleven active sporting patients underwent cartilage repair using TruFit plugs between February 2006 and August 2007. Postoperatively patients were touch weight bearing for 2 weeks and partial until 4 weeks.

Data was collected prospectively, patients underwent clinical review and completed Lysholm, IKDC subjective, Tegner, KOOS and SF-36 scores pre-operatively and at 6 monthly intervals. One patient has been excluded from the analysis as she emigrated and was lost to follow up. The remaining 10 patients (mean age 35 years (21–49)) had defects on the medial femoral condyle (n=6), lateral femoral condyle (n=3), and lateral trochlea (n=1). Patients received one (n=5), two (n=3) or three (n=2) plugs and four were primary procedures, and six revision procedures (1 failed OATS, 5 failed microfracture). Eight implantations were performed arthroscopically and, and two were mini-open. All patients were reviewed at 12 months, five were reviewed at 18 months and four have also been reviewed at 24 months.

Statistically significant improvements from mean pre-operative scores are seen at 12 months; Lysholm (48.3 to 71), IKDC Subjective (37.7 to 65.1), Tegner (2.4 to 4.6), SF36 physical (39.5 to 50.3) and all components of KOOS. These improvements are maintained at the latest follow up. MRI evaluation including T2 mapping demonstrates reformation of the subchondral lamina, resorption of the graft and a similar signal from neo-cartilage as that of adjacent native cartilage.

TruFit plugs offer an exciting novel solution for cartilage repair in the knee with advantages of low morbidity and rapid recovery without the need for prolonged non-weight bearing. The implant may be suitable for small lesions only and further prospective study is required to establish long-term outcome.