This study evaluates the association between consultant and hospital volume and the risk of re-revision and 90-day mortality following first-time revision of primary hip replacement for aseptic loosening. We conducted a cohort study of first-time, single-stage revision hip replacements (RHR) performed for aseptic loosening and recorded in the National Joint Registry (NJR) data for England, Wales, Northern Ireland, and the Isle of Man between 2003 and 2019. Patient identifiers were used to link records to national mortality data, and to NJR data to identify subsequent re-revision procedures. Multivariable Cox proportional hazard models with restricted cubic splines were used to define associations between volume and outcome. Among 12,676 RHR there were 513 re-revisions within two years, and 95 deaths within 90 days of surgery. The risk of re-revision was highest for a consultant's first RHR (Hazard Ratio (HR) 1·58 (95%CI 1·16 to 2·15)) and remained significantly elevated for their first 26 cases (HR 1·26 (95%CI 1·00 to 1·58)). Annual consultant volumes of five/year were associated with an almost 30% greater risk of re-revision (HR 1·28 (95%CI 1·00 to 1·64)) and 80% greater risk of 90-day mortality (HR 1·81 (95%CI 1·02 to 3·21)) compared to volumes of 20/year. RHR performed at hospitals which had cumulatively undertaken fewer than 168 RHR were at up to 70% greater risk of re-revision (HR 1·70 (95% CI 1·12 to 2·60)), and those having undertaken fewer than 309 RHR were at up to three times greater risk of 90-day mortality (HR 3·06 (95% CI 1·19 to 7·86)). This study found a significantly higher risk of re-revision and early postoperative mortality following first-time single-stage RHR for aseptic loosening when performed by lower-volume consultants and at lower-volume institutions, supporting the move towards the centralisation of such cases towards higher-volume units and surgeons.
Elevated synovial leukocyte count is a minor criterion derived from the musculoskeletal infection society (MSIS) widely used in clinical practice for diagnosis of prosthetic joint infection. There is evidence to suggest analysis within 1 hour, preferentially within 30 minutes, of aspiration reduces the risk of ex vivo cell lysis occurring during prolonged transport. Multiple site working is more common practice and the availability of a lab on site to perform these tests is not always possible. We aimed to assess whether we could safely perform synovial leukocyte counts within our cold site in the diagnosis of prosthetic joint infection. We reviewed all orthopaedic synovial fluid aspirates within the lower limb arthroplasty unit from April 2021 – April 2022 performed at South Tees NHS Foundation Trust. We assessed time from aspirate to the lab using electronic data resources. This information was compared with the labs ability to perform a synovial leukocyte count to determine the impact of delays on testing. 110 patients (34.5% hips and 63.6% knees) were identified between two sites. Time from aspirate to lab ranged from 0 mins to 26 hrs 34 mins. Mean time to processing was 3hrs 10 mins. 50% of all samples had a synovial leukocyte count performed. 67% of patients had a cell differential performed. There was no difference in the ability to perform a synovial leukocyte count between samples process in < 2hours vs > 6 hours. We conclude that it is safe practice to perform joint aspirates for the work up of periprosthetic joint infections in sites where no laboratory is immediately available as the delay to processing synovial fluid does not alter the ability to perform a synovial leukocyte count. This study will provide evidence to enable the work up of periprosthetic joint infections in cold centres and therefore reduce the delay in diagnosis and proceeding management.
COMPOSE describes the demographics, fracture characteristics, management and associated outcomes of knee femoral periprosthetic fractures (KFPPF). Multicentre retrospective cohort study conducted 01/01/2018-31/12/2018. Data collected included: patient demographics, social and mobility characteristics, fracture characteristics, management strategy and post-treatment outcomes (length of stay, reoperation, readmission, 30-day and 12-month mortality).Abstract
Introduction
Methods
Prosthetic joint infections (PJI) are a devastating consequence in total hip arthroplasties (THA) with both significant morbidity and sometimes mortality, posing a significant health economic burden. Studies, both clinical and in-vitro have suggested possible reduction in PJI with the use of ceramic bearings. We have investigated the relationship of ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoP) or metal-on-polyethylene (MoP) bearing surface in affecting outcome of revision surgery after primary THA using data collected from National Joint Registry for England and Wales, Northern Ireland and the Isle of Man between 2002 and 2016. We used a competing risk regression model to investigate predictors of each revision outcome, such as infection, dislocation, aseptic revision and all cause revisions. The results were adjusted for age, gender, ASA grade, BMI, indication for surgery, intraoperative complications and implant data. We identified 456,457 THA (228,786 MoP, 128,403 CoC and 99,268 CoP). In a multivariable model, the adjusted risk of revision for PJI was lower with CoC (OR-0.748, p<0.001) and CoP (OR-0.775, p<0.001) when compared to MoP bearing. Additionally there was also a significant reduction in the risk of all cause revision for CoC (OR-0.918, p=0.002) and CoP (0.806, p<0.001), bearings as compared with MoP. The protective effect of ceramic bearing was predominantly seen after two years of implantation with a significant (p<0.0001) reduction of revision for PJI in both CoC (by 42.8%) and CoP (by 41.3%) group. Similarly significant effect was seen for aseptic revision beyond two years and overall all cause revision rate beyond two years reduced by 21.6% for CoC and 27.1% for CoP (p<0.001). Within the limits of registry analysis, this study has demonstrated an association between the use of ceramic bearing and lower rates of revision for all cause revisions especially infection and aseptic loosening. This finding supports the use of ceramic bearings in THA.
There is significant variation and inconsistencies in the current advice and information delivered to patients undergoing total hip replacement (THR). The aim of this study was to assess a locally developed web-based electronic resource system for patients undergoing total hip replacement (THR) surgery to see if this improves and standardises the content, structure, and delivery of information delivered to patients prior to and after surgery. Prospective study with patients recruited in clinic when listed for THR surgery. Patients are emailed login details for the web based electronic resource system (GoWellHealth). The platform delivers content in a time-lined fashion and is individualised to the patient. Data gathered includes the number of patients registering to use this system, their engagement and use of the resources, and results from forms and questionnaires administered.Background
Patients/Materials and Methods
Periprosthetic joint infection (PJI) can be difficult to diagnose. A variety of techniques have been described. The efficacy of the alpha-defensin laboratory test was examined and compared with other established modalities in the diagnostic workup of ‘real world’ arthroplasty patients. This was a retrospective review of 210 episodes (86 hips, 124 Knees) in 172 patients at one centre, and included samples from acute admissions, elective aspirations, and planned revisions. MSIS (musculoskeletal infection society) major and minor criteria were used for diagnosing PJI. Each patient was investigated using a standardised protocol with inflammatory markers, synovial fluid analysis for white cell count (SWCC) and polymorphonuclear leukoctyes percentage (PMN %), and synovial fluid/tissue culture. Synovial fluid was also tested for alpha-defensin.Introduction
Methods
Dislocation is a major complication post total hip replacement (THR) and a common cause for revision. Jameson et al (2012) studied 35,000 cemented Exeter (Stryker) THRs demonstrating the risk of revision was significantly influenced by the acetabular component design. This led 3 surgeons in a single hospital group to make a mass move from using the hooded Exeter Low Profile (LP) cup to the better performing Contemporary Flanged (CF) component. The purpose of this study was to show whether this change was associated with a fall in dislocation rates. Locally held National Joint Registry data between 2010 and 2015 was used to ascertain implants used in all primary THRs by 3 experienced high volume surgeons. This was linked to local Hospital Episode Statistics to identify patients who had undergone closed or open reduction of a dislocated hip replacement in theatre.INTRODUCTION
PATIENTS/MATERIALS & METHODS
Revision of well cemented femoral components in revision THA can be technically challenging and time consuming. The cement in cement (CiC) technique addresses these issues. Results of femoral components which have undergone multiple CiC revisions have not previously been reported. We present the clinical and radiological results of femoral components which have undergone multiple CiC revisions with a minimum follow up of 5 years.Introduction
Objective
National Institute for Health and Clinical Excellence (NICE) guidelines recommend the use of total hip replacement (THR) for displaced intracapsular fractured neck of femur (NOF) in cognitively intact patients who were independently mobile prior to the injury. The National Joint Registry for England and Wales (NJR) has collected data on THRs performed since 2003. This retrospective cohort study explores risk factors independently associated with implant failure and perioperative mortality. NJR data recording a THR performed for acute fractured NOF between 2003 and 2010 were analysed. Cox proportional hazards models were used to analyse the extent to which risk of implant revision was related to specific covariates. Multivariable logistic regression was used to analyse factors affecting 90-day perioperative mortality. Significance was taken as p< 0.01.Introduction
Methods
Current analysis of unicondylar knee replacements (UKR) by national registries is based on the pooled results of medial and lateral implants. Using data from the National Joint Registry for England and Wales (NJR) we aimed to determine the proportion of lateral UKR implanted, their survival and reason for failure in comparison to medial UKR. By combining information on the side of operation with component details held on the NJR we were able to determine implant laterality (medial vs. lateral) for 32,847 of the 35,624 (92%) UKR registered before December 2010. Kaplan Meier plots, Life tables and Cox' proportion hazards were used to compare the risk of failure for lateral and medial UKRs after adjustment for patient and implant covariates.Background
Methods
Both surgeon and hospital volume influence patient outcomes following revision knee arthroplasty. To audit all centres performing revision knee procedures in England and Wales over a 2-year period. All centres were audited against two pre-defined standards linked to hospital volume Operative volume should be greater than 10 revisions per year; More than 2.5 revisions should be performed for every 100 primary arthroplasties implanted.Background
Purpose
Following in-depth analysis of the market leading brand combinations in which we identified implant influences on risk of revision, we compared revision in patients implanted with different categories of hip replacement in order to find implant with the lowest revision risk, once known flawed options were removed. All patients with osteoarthritis who underwent a hip replacement (2003–2010) using an Exeter-Contemporary (cemented), Corail-Pinnacle (cementless), Exeter-Trident (Hybrid) or a Birmingham Hip resurfacing (BHR) were initially included within the analysis. Operations involving factors that were significant predictors of revision were excluded. Cox proportional hazard models were then used to assess the relative risk of revision for a category of implant (compared with cemented), after adjustment for patient covariates.Introduction
Methods
To determine how patient characteristics; health status and pre-operative knee function effect patient reported satisfaction and operative success following total knee replacement (TKR). We hypothesised that a number of patient factors would influence the reported levels of symptomatic improvement (success) and satisfaction and that these two outcomes would represent different aspects of the patient's perception of outcome. Retrospective cohort analysis of patient reported outcome measures (PROMs) and National Joint Registry (NJR) data. Complete patient data was available for 9,874 TKRs performed for osteoarthritis between 1/8/08 and 31/12/10. The relationship of the background factors to patient perceived satisfaction and success was investigated using ordinal logistic regression and structural equation modelling (SEM).Purpose
Design
The most appropriate form of chemical thromboprophylaxis following knee replacement is a contentious issue. Most national guidelines recommend the use of low molecular weight Heparin (LMWH) whilst opposing the use of aspirin. We compared thromboembolic events, major haemorrhage and death after knee replacement in patients receiving either aspirin or LMWH. Data from the National Joint Registry for England and Wales was linked to an administrative database of hospital admissions in the English National Health Service. A total of 156 798 patients undergoing knee replacement between April 2003 and September 2008 were included and followed up for 90 days. Multivariable risk modelling was used to estimate odds ratios adjusted for baseline risk factors (AOR). An AOR < 1 indicates that risk rates are lower with LMWH than with aspirin.Background
Methods
There is a lack of information on the independent preoperative predictors of perioperative mortality, including the influence of previous stroke and acute coronary syndromes (myocardial infarction + unstable angina, ACS). Previous studies have grouped variables under the umbrella term “ischaemic heart disease”. In this study, we investigated the influence of vascular risk factors separately. The Hospital Episode Statistics database was analyzed for elective admissions for total hip (THR) and total knee (TKR) replacements between 2004 and 2009. Independent preoperative predictors of perioperative outcome were identified from admission secondary diagnosis codes. Perioperative mortality was defined as 30-day in-hospital death. Logistic regression analysis was used to identify independent predictors of 30-day mortality. Data was adjusted for age, social deprivation and Charlson co-morbidity score.Background
Methods
Dislocation is a major complication following total hip arthroplasty (THA). Aetiology is multi-factorial, but increasing femoral head size may result in lower dislocation rates. The latest England and Wales National Joint Registry (NJR) annual report has highlighted a statistically significant increase in the use of femoral heads of size 36mm+ from 5% in 2005 to 26% in 2009, together with an increase in the use of the posterior approach. The aim of this study was to determine whether national dislocation rates have fallen over the same period. Hospital episode statistics (HES) data for England was analysed so as to determine trends in national rates of 3-, 6-, 12- and 18-month dislocation rates following primary THA performed between 2005 and 2009 (247,546 THAs). 18-month revision rates were also examined.Background
Methods
Medical complications and death are rare events following elective orthopaedic surgery. Diagnostic and operative codes are routinely collected on every patient admitted to English NHS hospitals. This is the first study investigating rates of these events following total joint replacement (TJR) on a national scale. All patients (585177 patients) who underwent TJR (hip arthroplasty [THR], knee arthroplasty [TKR], or hip resurfacing) between 2005 and 2010 were identified. Patients were subdivided based on Charlson co-morbidity score. Data was extracted on 30-day complication rates for myocardial infarction (MI), cerebrovascular event (CVA), chest infection (LRTI), renal failure (RF), pulmonary embolus (PE) and inpatient 90-day mortality (MR).Background
Methods
The National Institute for Health and Clinical Effectiveness recommends both low molecular weight heparin (LMWH) and Rivaroxaban for venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. Despite evidence in the literature that suggests Rivaroxaban reduces VTE events, there are emerging concerns from the orthopaedic community regarding an increase in wound complications following its use. Through the orthopaedic clinical directors forum, Trusts replacing LMWH with Rivaroxaban for lower limb arthroplasty thromboprophylaxis during 2009 were identified. Prospectively collected Hospital episode statistics (HES) data was then analysed for these units so as to determine rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary embolism (PE), major bleed (cerebrovascular accident or gastrointestinal haemorrhage), all-cause mortality, and 30-day wound infection and readmission rates before and after the change to Rivaroxaban. 2752 patients prescribed Rivaroxaban following TKR or THR were compared to 10358 patients prescribed LMWH. Data was analysed using odds ratios (OR).Background
Methods
In 2011 20% of intracapsular fractured neck of femurs were treated with an uncemented hemiarthroplasty in the English NHS. National guidelines recommend cemented implants, based on evidence of less pain, better mobility and lower costs. We aimed to compare complications following cemented and uncemented hemiarthroplasty using the national hospital episode statistics (HES) database in England. Dislocation, revision, return to theatre and medical complications were extracted for all patients with NOF fracture who underwent either cemented or uncemented hemiarthroplasty between January 2005 and December 2008. To make a ‘like for like’ comparison all 30424 patients with an uncemented impant were matched to 30424 cemented implants (from a total of 42838) in terms of age, sex and Charlson co-morbidity score.Background
Methods
Medical complications and death are rare events following elective orthopaedic surgery. Diagnostic and operative codes are routinely collected on every patient admitted to hospital in the English NHS (hospital episode statistics, HES). This is the first study investigating rates of these events following total joint replacement (TJR) on a national scale in the NHS. All patients (585177 patients) who underwent TJR (hip arthroplasty [THR], knee arthroplasty [TKR], or hip resurfacing) between January 2005 and February 2010 in the English NHS were identified. Patients were subdivided based on Charlson co-morbidity score. HES data in the form of OPCS and ICD-10 codes were used to establish 30-day medical complication rates from myocardial infarction (MI), cerebrovascular event (CVA), chest infection (LRTI), renal failure (RF), pulmonary embolus (PE) and inpatient 90-day mortality (MR).Background
Methods
A recent Cochrane review has shown that total shoulder arthroplasty (TSA) seems to offer an advantage in terms of shoulder function over hemiarthroplasty, with no other obvious clinical benefits. This is the first study to compare complication rates on a national scale. All patients (9804 patients) who underwent either TSA or shoulder hemiarthroplasty as a planned procedure between 2005 and 2008 in the English NHS were identified using the hospital episodes statistic database. Data was extracted on 30-day rates of readmission, wound complications, reoperation and medical complications (myocardial infarction (MI) and chest infection (LRTI)), and inpatient 90-day DVT, PE and mortality rates (MR). Revision rate at 18 months was analysed for the whole cohort and, for a subset of 939 patients, 5-year revision rate. Odds ratio (OR) was used to compare groups.Background
Methods
Patient-reported outcome measures (PROMs) are
increasingly being used to assess functional outcome and patient satisfaction.
They provide a framework for comparisons between surgical units,
and individual surgeons for benchmarking and financial remuneration.
Better performance may bring the reward of more customers as patients and
commissioners seek out high performers for their elective procedures.
Using National Joint Registry (NJR) data linked to PROMs we identified
22 691 primary total knee replacements (TKRs) undertaken for osteoarthritis
in England and Wales between August 2008 and February 2011, and
identified the surgical factors that influenced the improvements
in the Oxford knee score (OKS) and EuroQol-5D (EQ-5D) assessment
using multiple regression analysis. After correction for patient
factors the only surgical factors that influenced PROMs were implant
brand and hospital type (both p <
0.001). However, the effects
of surgical factors upon the PROMs were modest compared with patient
factors. For both the OKS and the EQ-5D the most important factors
influencing the improvement in PROMs were the corresponding pre-operative
score and the patient’s general health status. Despite having only
a small effect on PROMs, this study has shown that both implant
brand and hospital type do influence reported subjective functional
scores following TKR. In the current climate of financial austerity,
proposed performance-based remuneration and wider patient choice,
it would seem unwise to ignore these effects and the influence of
a range of additional patient factors.
Unlike the NJR, no surgeon driven national database currently exists for ligament surgery in the UK and therefore information on outcome and adverse event is limited to case series. Prospectively collected Hospital episode statistics (HES) data for England was analysed so as to determine national rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary thromboembolism (PTE) rate, significant wound infection and 30-day readmission rates with cause following anterior cruciate ligament (ACL) reconstruction. This diagnostic and operative codes information is routinely collected on every patient admitted to hospital in England NHS.Introduction
Methods
The National Institute for Health and Clinical Effectiveness recommends both low molecular weight heparin (LMWH) and Rivaroxaban for venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. Despite evidence in the literature that suggests Rivaroxaban reduces VTE events, there are emerging concerns from the orthopaedic community regarding an increase in wound complications following its use. Through the orthopaedic clinical directors forum, Trusts replacing LMWH with Rivaroxaban for lower limb arthroplasty thromboprophylaxis during 2009 were identified. Prospectively collected Hospital episode statistics (HES) data was then analysed for these units so as to determine rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary thromboembolism (PTE), major bleed (cerebrovascular accident or gastrointestinal haemorrhage), all-cause mortality, and 30-day wound infection and readmission rates before and after the change to Rivaroxaban. 2752 patients prescribed Rivaroxaban following TKR or THR were compared to 10358 patients prescribed LMWH. Data was analysed using odds ratios (OR).Introduction
Methods
Following an anterior cruciate ligament (ACL) injury, the affected knee is known to experience bone loss and is at significant risk of becoming osteoporotic. Surgical reconstruction is performed to attempt to restore the function of the knee and theoretically restore this bone density loss. Cross-sectional analysis of the proximal tibia using peripheral quantitative computed tomography (pQCT) enables localised analysis of bone mineral density (BMD) changes. The aim of this study was to establish the pattern of bone density changes in the tibia pre- and post- ACL reconstruction using pQCT image analysis. Eight patients who underwent ACL reconstruction were included. A cross sectional analysis of the proximal tibia was performed using a pQCT scanner pre-operatively and one to two years post-operatively on both the injured and contralateral (control) knee. The proximal two and three percent slices [S2 and S3] along the tibia were acquired. These were exported to Matlab(tm) and automated segmentation was performed to remove the tibia from its surrounding structures. Cross correlation was applied to co-register pairs of images and patterns of change in BMD were mapped using a t-test (p<0.05). Connected components of pixels with significant change in BMD were created and used to assess the impact of ACL injury & reconstruction on the proximal tibial BMD.Background
Methods
Bearing diameter and acetabular component orientation have been shown to be important variables effecting blood metal ion levels following hip resurfacing arthroplasty. So far no studies on bilateral hip resurfacings have taken into account these variables. We examined the serum ion results of patients under the care of two experienced hip resurfacing surgeons who carry out ion analysis as part of routine post operative care. Surgeon 1: Patients were implanted exclusively with a “third generation” resurfacing device. Surgeon 2: Patients were implanted with the same “third generation” device and also a low clearance “fourth generation” resurfacing device. Only ion results from patients who were 12 months post surgery were included. Bilateral patients were matched to unilateral patients according to the surgeon performing the operation; the resurfacing system implanted and cup inclination and anteversion angles. The ion data from each bilateral group was tested against the corresponding unilateral groups using the Mann Whitney U test for non parametric data. Significance was drawn at p<0.05. Surgeon 1: There were 310 patients with unilateral joints and 50 with bilateral joints. There were no significant differences with regard to time to follow up, activity levels, joint sizes or cup orientations. Serum chromium (Cr) and cobalt (Co) concentrations were significantly greater in the bilateral group (p<0.001). Median ion levels were greater in the bilateral group by a factor of >2 in the smallest joint sizes and <2 in the largest joints. Surgeon 2: There were 11 patients with bilateral third generation resurfacing joints and 50 with unilateral joints of the same design. The same relationship as described above was identified. There was a notable difference in the fourth generation implant group (n=13 bilateral, n=100 unilateral). Median ion levels for patients receiving bilateral joints of sizes <47mm were ten times greater than in the corresponding unilateral group. Bearing diameter and component design are critical factors in determining metal ion levels following bilateral hip resurfacings. Surgeons must consider the potential implications of gross increases in metal ion levels prior to performing bilateral hip resurfacings in smaller patients.
Total Knee Replacement (TKR) is technically demanding, time consuming and has higher complication rates in super obese (BMI>45) patients. Bariatric surgery can be considered for such patients prior to TKR although its effect on complications is unknown. All patients who underwent bariatric surgery and a TKR in the NHS in England between 2005 and 2009 were included. Hospital episode statistics data in the form of OPCS, ICD10 codes were used to establish 90-day DVT, PE and mortality rates (inpatient and outpatient). In addition, readmission to orthopaedics, joint revision and ‘return to theatre for infection’ rates were also established. Code strings for each patient were examined in detail to ensure the correct gastric procedures were selected. Fifty-three patients underwent bariatric surgery then TKR (44-1274 days) (group 1). Thirty-one patients underwent TKR then bariatric surgery (33-1398 days) (group 2).Background
Methods
From August 2009, all doctors were subject to the European Working Time Directive (EWTD) restrictions of 48 hours of work per week. Changes to rota patterns have been introduced over the last two years to accommodate for these impending changes, sacrificing ‘normal working hours’ training opportunities for out-of-hours service provision. We have analysed the elogbook data to establish whether operative experience has been affected. A survey of trainees (ST3-8) was performed in February 2009 to establish shift patterns in units around the UK. All operative data entered into the elogbook during 2008 at these units was analysed according to type of shift (24hr on call with normal work the following day, 24hr on call then off next working day, or shifts including nights). 66% of units relied on traditional 24hrs on call in February 2009. When compared with these units, trainees working shifts had 18% less operative experience (564 to 471 operations) over the six years of training, with a 51% reduction in elective experience (288 to 140 operations). In the mid years of training, between ST3-5, operative experience fell from 418 to 302 operations (25% reduction) when shifts were introduced. This national data reflects the situation in UK hospitals in 2009, prior to the implementation of a maximum of 48 hours. It is expected that most hospitals will need to convert to shift-type working patterns to fall within the law. This could have significant implications for elective orthopaedic training in the UK.
Cup orientation in vivo was compared to explant analysis of 60 retrieved resurfacing components using a coordinate measuring machine.
In our independent centre, from 2002 to 2009, 155 BHRs (mean F/U 60 months) have been implanted as well as 420 ASR resurfacings and 75 THRs using ASR XL heads on SROM stems (mean F/U 35) During this period we have experienced a number of failures with patients complaining of worsening groin pain at varying lengths of time post operatively. Aspiration of the hip joints yielded a large sterile effusion on each occasion. At revision, there were copious amounts of green grey fluid with varying degrees of necrosis. There were 17 failures of this nature in patients with ASR implants (12 females) and 0 in the BHR group. This amounts to a failure of 3.5% in the ASR group. Tissue specimens from revision surgery showed varying degrees of “ALVAL” as well as consistently high numbers of histiocytes. Particulate metal debris was also a common finding. The mean femoral size and acetabular anteversion and inclination angles of the ARMeD group/all asymptomatic patients was 45/49mm (p<
0.001), 27/20°(p<
0.001) and 53/48°(p<
0.08). Median blood chromium(Cr) and cobalt(Co) was 29 and 69 μg/L respectively in the ARMeD group versus 3.9 and 2.7 μg/L in the asymptomatic patients (n=160 with ion levels). Explant analysis confirmed greater rates of wear than expected. Lymphocyte proliferation studies involving ARMeD patients showed no hyper reactivity to Cr and Co in vitro implying that these adverse clinical developments are mediated by a toxic reaction or a localised immune response. Our overall results suggest that the reduced arc of cover of the fourth generation ASR cup has led to an increased failure rate secondary to the increased generation of metal debris. This failure rate is 7% in ASR devices with femoral components _47mm.
Since 2003 Trauma and Orthopaedic trainees in the UK and Ireland have routinely submitted data recording their operative experience electronically via the eLog-book. This provides evidence of operative experience of individuals and national comparisons of trainee, trainer, hospital and training programme performance. We have analysed trauma surgery data and established standards for training. By January 2008 there were over 4 million operations logged. Operations performed and uploaded since 2003 have been included. Each trainee’s work is analysed by ‘year-in-training’. Data on levels of supervision, missed opportunities (where the trainee assisted rather than performed the operation) was analysed. The average number of trauma operations performed annually by trainees was 109, 120, 110, 122, 98 and 84 (total 643) for YIT one (=ST3) to six (=ST8) respectively. There were only 22% of missed opportunities throughout six years of training. A high level of experience is gained in hip fracture surgery (121 operations) and forearm (30), wrist (74) and ankle (47) operative stabilisation over the six years. However, the average number of tibial intra-medullary nails (13), external fixator applications (12) and childrens’ elbow supracondylar fracture procedures (4) performed is low. We are also able to identify trainees performing fewer operations than required during their training (two standard deviations or more below the mean for their YIT). We expect a trainee to have performed at least 255, 383, 473, and 531 trauma operations at the end of YIT three to six respectively. The eLogbook is a powerful tool which can provide accurate information to support in-depth analysis of trainees, trainers, and training programmes. This analysis has established a baseline which can be used to identify trainees who are falling below the required operative experience.
Tarsal fractures are rare in children. Clinical and radiographic evaluation of these injuries can be difficult. We present a retrospective study documenting all tarsal fractures presenting to an inner-city children’s hospital in the UK over a fifteen year period. Of 70 case notes retrieved from the hospital database, 7 patients were excluded due to inadequate data. This resulted in 69 tarsal injuries in 63 patients being included. Mean age at presentation was 9.3 years (2.5 – 13.9). 80% were male. 72% were calcaneal fractures, 12% cuboid, 9% navicular, 4% talus and 2% medial cuneiform. The main method of diagnosis was plain x-rays. Cause of injury was predominantly fall from height, crush or road traffic accident. 25% had another associated lower extremity injury. Three patients had bilateral tarsal injuries. Only 3% had upper limb injuries and there were no injuries with spinal involvement. Calcaneal fractures were treated with a short leg cast for a mean time of 4.1 weeks (2–6). Mean time to recovery was 5.7 weeks (2–20). Mean time to discharge from clinic was 7 weeks (2–40). There were two patients with open fractures requiring surgical debridement. One patient with a talar fracture had percutaneous fixation. Only one patient re-presented with pain following discharge. X-rays showed healing avascular necrosis of the proximal talus. Tarsal fractures are rare, usually benign and most require simple immobilisation for only a short period of time. Surgical intervention is only occasionally required in complex injuries. Complications and long term problems are rare, even following open injuries.
This report documents the clinical and histological findings, the operative management and the explant analyses of patients with early aseptic failure of large metal-on-metal (MonM) bearing joints. Three hundred and fifty patients have been implanted with the ASR bearing surface (resurfacing or a modular THR) by a single surgeon at an independent centre since 2004. Six patients (all female) have been revised secondary to aseptic failure. All complained of severe groin pain exacerbated by straight leg raise and routine investigations were unable to establish a cause. Large amounts of sterile, highly viscous green fluid were aspirated from the hip joints in each case. Gross swelling of the pseudocapsule and a similar green fluid surrounding the implants were found at revision surgery. Histological examination of periprosthetic tissue samples showed changes consistent with ALVAL/metallosis, and analysis of the fluid revealed dense numbers of inflammatory cells. Symptoms in patients revised to ceramic-on-ceramic bearings improved post operatively. This was not the case with those reimplanted with MoM joints. Data from a subset of 76 patients (all unilateral resurfacings) showed that malaligned cups (anteverted >
20° +/− inclination angle >
45°) were associated with significantly higher whole blood metal ion levels than cups positioned within this range. All the patients with early aseptic failure had malaligned cups. Independent explant analysis revealed significant increases in the surface roughness values of the articular surfaces. Our results suggest that some patients develop a significant inflammatory reaction to metal implants. This may be due to high levels of metal debris around the implant as a result of accelerated wear. Poor component alignment was found in all our patients with early aseptic failure.
The first United Kingdom In-training Examination (UKITE) was held in 19 training programmes during December 2007. The aims of the project are to offer a national, online examination (providing immediate results to trainees) and to allow practice for the ‘real’ FRCS T&
O examination with similarly formatted questions based on the UK T&
O curriculum. All Speciality training years (StR2, StR3 and above, and all SpRs) and all deaneries will participate in the future. A total of 450 trainees sat this first examination. This is an online exam (accessed through the eLogbook/OCAP website) which is voluntary and has no bearing on RITA outcomes. To take part in the exam trainees were asked to provide 3 questions for a bank which can be used in subsequent years for both UKITE and the FRCS T&
O examination. The exam was 3 hours and questions were of multi-choice (MCQ) and extended matching question (EMQ) style covering all aspects of orthopaedics. Correct answers and explanations were available to the trainee after their answer had been submitted. Final scores ranged from 35% to 92%. Mean scores increased from 48% (StR2) to 73% in SpR year 5 (StR7 equivalent). This was followed by a drop off in performance in the final year of training. Three candidates had equal top scores at 92%. 97% stated they would sit the UKITE again and 93% felt there was educational benefit. The length and level of difficulty of the exam was felt to be satisfactory. Improvements were suggested for question quality. The UKITE is a powerful tool for self-assessment of trainees. This analysis establishes a baseline for future years.
Metal ion concentrations following metal on metal hip resurfacing arthroplasty remain a concern. Variables associated with increased metal ion concentrations need to be established. This study provides metal ion data from a consecutive cohort of the first 76 patients implanted with a fourth generation hip resurfacing prosthesis. All patients agreed to post-operative blood metal ion sampling at a minimum of one year. Post-operative radiographic measurements of cup inclination and anteversion were obtained using the EBRA software. Mean whole blood chromium (Cr) and cobalt (Co) concentrations in patients receiving the smallest femoral implants (Ł51mm) were greater than in the patients implanted with the largest prostheses (ł53mm) by a factor of 3 and 9 respectively. Ion concentrations in the small femoral group were significantly related to acetabular inclination (R=0.439, P<
0.001 for Cr, R=0.372, P=0.004 for Co) and anteversion (R=0.330, P=0.010 for Cr, R=0.338, P=0.008 for Co). This relationship was not significant in the large implant group. Mean Cr and Co concentrations in patients with accurately orientated cups (inclination <
45°, anteversion <
20°) were 3.7μg/l and 1.8 μg/l respectively, compared to 9.1μg/l and 17.5μg/l in malaligned cups. A reduced surface contact area caused by cup malalignment may increase contact stresses, resulting in a high wear rate if fluid film lubrication is inadequate. Improved fluid film lubrication has previously been found in larger heads in vitro. Accurate acetabular component positioning is essential in order to reduce metal ion concentrations following hip resurfacing.
National Institute for Clinical Excellence (NICE) guidelines on venous thromboembolic (VTE) prophylaxis for patients undergoing orthopaedic surgery recommend that all inpatients be offered a low molecular weight heparin (LMWH). Linked hospital episode statistics of 219602 patients were examined to determine the rates of complications following lower limb arthroplasty for the 12-month periods prior to and following the publication of these guidelines. This was compared with data from the National Joint Register (England and Wales) regarding LMWH usage during the same periods. There was a significant increase in the reported use of LMWH (59.5 to 67.6%, p<
0.01) between the two periods. However, 90-day VTE events increased following both total hip (THR, 1.67% to 1.84%, p=0.06) and knee replacement (TKR, 1.99% to 2.04%, p=0.60). 30-day return to theatre rate for infection fell following TKR, but increased after THR. In addition, there were increases in rates of thrombocytopenia, which was significant following THR (p=0.03). Recommendations from NICE are based on predicted reductions in VTE events, reducing morbidity, mortality and costs to the National Health Service. Early results in orthopaedic patients are unable to support these predictions.
In our independent centre, in the period from January 2003 to august 2008, over 1100 36mm MoM THRs have been implanted as well as 155 Birmingham Hip Resurfacing procedures, 402 ASR resurfacings and 75 THRs using ASR XL heads on SROM stems. During this period we have experienced a number of failures with patients complaining of worsening groin pain at varying lengths of time post operatively. Aspiration of the hip joints yielded a large sterile effusion on each occasion. At revision, there were copious amounts of green grey fluid with varying degrees of necrosis. There were 11 failures of this nature in patients with ASR implants (10 females) and 2 in the 36 MoM THR group (one male one female). Tissue specimens from revision surgery showed varying degrees of ‘ALVAL’ as well as consistently high numbers of histiocytes. Metal debris was also a common finding. A fuller examination of our ASR cohort as a whole has shown that smaller components placed with inclinations >
45° and anteversions <
10 or >
20° are associated with increased metal ion levels. The 11 ASR failed joints were all sub optimally positioned (by the above definition), small components. Explant analysis using a coordinate measuring machine and out of roundness device confirmed greater than expected wear of each component. The lower number of failures in the 36mm MoM group, as well as the equal sex incidence, suggests that the majority of these failures are due to the instigation of an immune reaction by large amounts of wear debris rather than adverse reactions to well functioning joints. It is likely that small malpositioned ASRs function in mixed to boundary lubrication, and this, combined with the larger radius of these joints compared to the 36mm MoM joints, results in more rapid wear.
Optimal cup orientation for metal-on-metal hip resurfacing has yet to be established. Guidance is based on hip replacement data and in vitro studies. We sought to determine the influence of component size and positioning on early clinical outcome. This study comprises a consecutive series of 200 hip resurfacings. All had Harris Hip Scores (HHS) at one-year review. Acetabular inclination angles were measured on pre-operative radiographs, and cup inclination/anteversion angles on 3-month post-operative films using EBRA. Restoration of anatomy was defined as placement of the cup within +/−5 degrees of pre-operative inclination. The difference between pre-operative acetabular and post-operative cup inclination was termed cup-angle difference (CAD). HHS inversely correlated with CAD (P=0.023) and anteversion (P=0.003), and directly correlated with femoral head size (P<
0.001). In patients with restoration of inclination anatomy mean HHS at one year was significantly higher at 98.7 compared with cups placed outside the normal anatomy restoration limits (93.8, P=0.003). Patients with anteversion >
20 degrees had a significantly lower HHS (P=0.010) compared with cups anteverted <
20 degrees. 96% of patients with HHS <
90 had malaligned cups (inclination over 45 degrees, anteversion over 20 degrees). Restoring pre-operative cup inclination, anteverting the cup <
20 degrees and using large femoral heads improves early clinical outcome following MonM hip resurfacing. We recommend accurate pre-operative planning and meticulous attention to intra-operative cup positioning with these results in mind.
Resurfacing metal-on-metal hip arthroplasty is currently showing promising clinical results. However there are concerns related to such implants, including the elevated levels of metal ions typically seen in patients. Valuable data can be obtained from explanted prostheses but due to their recent introduction few retrieval studies on resurfacing hip prostheses have been published. Five ASR hip resurfacing prostheses were revised due to pain. From two patients, head and cup were available for independent explant analysis. In the other three cases only femoral components were available. All were removed from female patients and all were revised to ceramic-on-ceramic hip prostheses. Post-operative radiographic measurements of cup inclination and ante-version were obtained using the EBRA software. The surface roughness values of the articulating surfaces of the explants were measured using a non-contacting profilometer. A co-ordinate measuring machine was used to measure the diameter of the head and the cup and thus the diametral clearance. The same measurements were then taken from a new unused ASR prosthesis and compared. Using elastohydrodynamic theory the minimum effective film thickness of the implant was calculated. In turn this allowed the lubrication regime to be determined. The average roughness values of the head and the cup of one implant were found to be 0.135microns and 0.058microns respectively, with a diametral clearance of 110microns. These results indicated that, at the time of removal, the prosthesis would have operated in the boundary lubrication regime. Other explants showed evidence of localised contact between the head and the rim of the acetabular cup, and these showed articulating surfaces with typical roughness values of between 0.025microns and 0.050microns. The new ASR had head and cup surface roughness values of 0.010microns and 0.012microns respectively and a diametral clearance of 87microns, implying that a new implant would operate under fluid film lubrication. All cups five were implanted with inclination angles over 45 degrees and anteversion over 25 degrees. These results suggest that components with high inclination and anteversion angles display greater than expected wear and may operate in boundary rather than fluid film lubrication which may eventually lead to early failure.
This paper considers the new financial infrastructure of the National Health Service and provides a resource for orthopaedic surgeons. We describe the importance of accurate documentation and data collection for National Health Service hospital Trust finances and league tables, and support our discussion with examples drawn from our local audit work.