Cheilectomy is a recommended procedure for the earlier stages of osteoarthritis of the 1st metatarsophalangeal joint. Although good improvement in symptoms have been reported in many studies, the long term performance of this procedure is not well understood. It is thought that a significant number of patients go onto have arthrodesis or joint replacement. We report on a large cohort of patients who received this procedure and report on the complications and mid-term outcome. This is a retrospective study looking at all patients who underwent cheilectomy for hallux rigidus between November 2007 and August 2018. Departmental database was used to access patient details and outcome measures recorded include: postoperative wound infection, patient reported improvement in pain and the incidence of further surgical interventions like revision cheilectomy and conversion to arthrodesis and arthroplasty. X-rays were studied using PACS to stage the osteoarthritis (Hattrup and Johnson classification).Introduction
Methods
Total ankle replacement (TAR) is performed for post-traumatic arthritis, inflammatory arthropathy, osteoarthritis and other indications. The Scottish Arthroplasty Project (SAP) began collection of data on TAR in 1997. In this study, using data from the SAP, we look at trends in the use and outcomes of TAR in Scotland. We identified 499 patients from the SAP who underwent TAR between 1997 and 2015 with imaging available on the National Picture Archiving and Communication System (PACS). We identified, and looked at trends in, implant type over the following time periods: 1998–2005; 2006–2010 and 2011–2015. Age, gender, indication and outcomes for each time period were examined and also trends with implant type over time.Introduction
Methods
Surgical options for management of a failed ankle arthroplasty are currently limited; typically conversion to fusion is recommended with only a few patients being considered for revision replacement surgery. This paper presents our experience of revision ankle replacements in a cohort of patients with failed primary replacements. A total of 18 revision TAR in 17 patients were performed in patients with aseptic loosening. The technique was performed by a single surgeon (CSK) over a 4 year period between July 2014 and August 2018 using the Inbone total ankle replacement system. Patient demographics and clinical outcomes were collected retrospectively using - MOXFQ, EQ5D, VAS pain score and patient satisfaction questionnaires.Aim
Method
This study used a national registry to assess the outcomes of hip arthroscopy (HA) for the treatment femoroacetabular impingement (FAI). All HAs for FAI recorded in the UK Non-Arthroplasty Hip Registry (NAHR) between January 2012 and September 2023 were identified. Cases were grouped according to the index procedure performed for FAI (cam, pincer, or mixed). Patient outcomes captured included the International Hip Outcome Tool (iHOT)-12. 7,511 HAs were identified; 4,583 cam (61%), 675 pincer (9%), 2,253 mixed (30%). Mean age (34.8) was similar between groups. There was a greater proportion of females in the pincer group (75%) compared to cam (52%) and mixed (50%). A higher proportion of patients had a recorded cartilage injury in association with a cam lesion compared to pincer. The pincer group had poorer mean pre-op iHOT-12 scores (31.6 \[95%CI 29.9 to 33.3\]; n=364) compared to cam (33.7 \[95%CI 32.1 to 34.4\]; n=3,941) and achieved significantly lower scores at 12 months (pincer = 52.6 (50.2 to 55); n=249, cam = 58.3 (57.1 to 59.5); n=1,679). Overall, significant (p < 0.0001) iHOT-12 and EQ-5D improvement vs baseline pre-operative scores were achieved for all FAI subtypes at 6 months (overall mean iHOT-12 improvement +26.0 \[95%CI 25.0 to 26.9\]; n=2,983) and maintained out to 12 months (+26.2 \[25.1 to 27.2\]; n=2,760) at which point 67% and 48% of patients continued to demonstrate a score improvement greater than or equal to the minimum clinically important difference (>/=13 points) and substantial clinical benefit (>/=28 points) for iHOT-12 respectively. This study demonstrates excellent early functional outcomes following HA undertaken for FAI in a large national registry.
Adult hip dysplasia AHD is a complex 3D pathology of lateral coverage, version and/or volume and is often associated with increased femoral anteversion. The Mckibbin index MI is the combination of acetabular version AV and femoral version FV and is used as a measure of anterior hip Stability/ Impingement(1). The Bernese Periacetabular osteotomy PAO is a powerful tool in treating AHD, but it does not address FV. De-rotational femoral osteotomies FO increases risk of complications, operative time and might condemn the patient to Secondary osteotomies to balance the gait. We aim to investigate the effect of MI and FV on PROMs in patients undergoing PAO only. 593 PAOs identified on the Local Hip preservation registry between 01/2013 and 7/2023. PAOs for retroversion, residual Perthes and those combined with FO were excluded. Patients with no available PROMS at 2 years were excluded. Independent variables were collected from E-notes and imaging including MI and FV. A multiple linear regression analysis was performed against preoperative iHot12, and iHot12 change at 2years. The mean FV was 18.86± 12.4 SD. Mean MI was 36.07, SD 15.36. Mean preop iHot12 score was 29.83 ± 17.38 SD. Mean change in iHot12 at 2 years was+36.47 ± 28.44 SD. Females and a higher BMI were statistically correlated to a lower preoperative iHot12. A lower preop iHot12 score and a higher preop AI were correlated to a bigger change in iHot12 at 2years with statistical significance. MI and FV were not found to have a statistically significant correlation with Outcome measures, An increased Mckibbin index and femoral anteversion were not correlated with worse outcomes at two years. PAO alone in the presence of increased femoral anteversion avoids risks associated with FO which can be performed later if required.
MCID and PASS are thresholds driven from PROMS to reflect clinical effectiveness. Statistical significance can be derived from a change in PROMS, whereas MCID and PASS reflect clinical significance. Its role has been increasingly used in the world of young adult hip surgery with several publications determining the thresholds for Femoro-acetabular impingement FAI. To our knowledge MCID and PASS for patient undergoing PAO for dysplasia has not been reported. 593 PAOs between 1/2013 and 7/2023 were extracted from the Northumbria Hip Preservation Registry. Patients with available PROMS at 1year and/or 2years were included. PAOs for retroversion, residual Perthes and those combined with FO were excluded. MCID was calculated using the distribution method 0.5SD of baseline score(1). PASS was calculated using anchor method, ROC analysis performed, and value picked maximizing Youden index. A Logistic Regression analysis was performed to determine which independent variables correlated with achieving MCID and PASS. The MCID threshold for iHOt12 was 8.6 with 83.4 and 86.3 % of patients achieved it at 1 and 2 years respectively. The PASS score at 1 and 2 year follow up was 43 and 44 respectively, with 72.6 and 75.2% achieving it at 1 and 2 year postop. At 2 years a Higher preop iHOT 12 was associated with not achieving MCID and PASS (p<0.05). Preop acetabular version was negatively correlated with achieving MCID and previous hip arthroscopy was negatively correlated with PASS. The % of patients achieving MCID and PASS mimics that of FAI surgery (2). The negative correlation with preop iHOT12 reaffirms the importance of patient selection. The negative correlation of hip arthroscopy highlights the importance of having a high index of suspicion for dysplasia prior to hip arthroscopy and poorer outcomes of patients with mixed CAM and dysplasia pathology.
Knee dislocations, vascular injuries and floating knee injuries can be initially managed by a external fixator. Fixator design constructs include the AO pattern and the Diamond pattern. However, these traditional constructs do not adhere to basic principles of external fixation. The Manchester pattern knee-spanning external fixator is a new construct pattern, which uses beam loading and multiplanar fixation. There is no data on any construct pattern. This study compares the stability of these designs. Hoffman III (Stryker, USA) external fixation constructs were applied to articulated models of the lower limb, spanning the knee with a diamond pattern and a Manchester pattern. The stiffness was loaded both statically and cyclically with a Bose 3510 Electroforce mechanical testing jig (TA Instruments). A ramp to load test was performed initially and cyclical loading for measurement of stiffness over the test period. The results were analysed with a paired t-test and ANOVA.Introduction
Materials & Methods
This study reports the results of 38 total hip arthroplasties (THAs) in 33 patients aged less than 50 years, using the JRI Furlong hydroxyapatite ceramic (HAC)-coated femoral component. We describe the survival, radiological, and functional outcomes of 33 patients (38 THAs) at a mean follow-up of 27 years (25 to 32) between 1988 and 2018.Aims
Methods
Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures. We retrospectively reviewed the data from R G Kar Medical College, Kolkata, India, from June 2018 to April 2023. Overall, there were 34 acetabulum fractures involving both columns managed by medial buttress plating of posterior column. The posterior column of the acetabular fracture was fixed through the AIP approach with buttress plate on medial surface of posterior column. Mean follow-up was 25 months (13 to 58). Accuracy of reduction and effectiveness of this technique were measured by assessing the Merle d’Aubigné score and Matta’s radiological grading at one year and at latest follow-up.Aims
Methods
In recent years, use of anatomic stemless total shoulder arthroplasty (AsTSA) has increased. Despite evidence to suggest good mid-term results at 2-year follow-up there is a paucity of evidence for longer term follow-up. This study aimed to investigate outcomes at a minimum of 5 years post-operatively following primary AsTSA. This study is a retrospective case series of all patients who underwent a Mathys Affinis AsTSA from July 2010 (first case) to August 2018 (to allow minimum 5-year follow-up). Clinical outcomes included revision rate, range of motion and patient reported outcomes (Oxford Shoulder Score and Numerical Satisfaction Score). Radiological outcome was assessment of radiolucent lines for Lazarus grading. A total of 105 stemless TSAs were implanted. Five patients underwent revision (4.8%). Seventy-five AsTSA's were included in the final study for analysis of 5-year outcomes. Median follow-up time was 6.1 years. Median age was 69 years old and 81% were female. Oxford shoulder score showed a range of 18 to 48, with a median score of 47. Satisfied or very Satisfied was selected in 94.37%. Median range of motion assessments showed forward elevation 160°, abduction 150°, external rotation 40°, and mode internal rotation was to the lumbar spine. No glenoid lucency was present in 79.7%. There were 9.5% with Lazarus Grade 1 lucency, 5.4% with Lazarus Grade 2, and 5.4% Lazarus Grade 3. No humeral lucency was observed. This cohort study demonstrates promising clinical and radiological outcomes for the Mathys Affinis Stemless TSA at minimum 5 years post-operatively.
We aim to evaluate the usefulness of postoperative blood tests by investigating the incidence of abnormal results following total joint replacement (TJR), as well as identifying preoperative risk factors for abnormal blood test results postoperatively, especially pertaining to anaemia and acute kidney injury (AKI). This is a retrospective cohort study of patients who had elective TJR between January and December 2019 at a tertiary centre. Data gathered included age at time of surgery, sex, BMI, American Society of Anesthesiologists (ASA) grade, preoperative and postoperative laboratory test results, haemoglobin (Hgb), white blood count (WBC), haematocrit (Hct), platelets (Plts), sodium (Na+), potassium (K+), creatinine (Cr), estimated glomerular filtration rate (eGFR), and Ferritin (ug/l). Abnormal blood tests, AKI, electrolyte imbalance, anaemia, transfusion, reoperation, and readmission within one year were reported.Aims
Methods
10% of patients with knee osteoarthritis (OA) have disease confined to the patellofemoral joint (PFJ). The main surgical options are total knee replacement (TKR) and PFJ replacement (PFJR). PFJR has advantages over TKR, including being less invasive, bone preserving, allowing faster recovery and better function and more ‘straight forward’ revision surgery. We aim to compare the clinical results of revised PFJR with primary TKR taking into consideration the survival length of the PFJR. Twenty-five patients (21 female) were retrospectively identified from our arthroplasty database who had undergone revision from PFJR to TKR (2006–2019). These patients were then matched with regards to their age at their primary procedure, sex and total arthroplasty life (primary PFJ survival + Revision PFJ time to follow up) up to point of follow-up with a group of primary TKRs implanted at the same point as the primary PFJR.Abstract
INTRODUCTION
METHODOLOGY
Isolated patellofemoral joint(PFJ) osteoarthritis affects approximately 10% of patients aged over 40 years and treatment remains controversial. Our aim was to evaluate long term functional and radiological outcomes following PFJ arthorplasty with the Femoro Patella Vialli (FPV) prosthesis as this evidence is lacking in literature. A retrospective review of prospectively collected PROMS in patients undergoing Patellofemoral arthroplasty. Single centre trial. Between 2004 and 2008, 101 FPV patellofemoral arthroplasties were performed in 80 patients with isolated patellofemoral joint osteoarthritis. Data was collected as a part of routine follow-up for up to 6 years and additional long term data was collected at 16 years.Abstract
Introduction
Methodology
Since arthroscopic reconstruction of the anterior cruciate ligament (ACL) started, the use of peroneus longus grafts for primary ACL reconstruction (ACLR) was never thought of as there is very scant literature on it. So, our study aims to compare the functional outcome and complications in patients with ACL injury managed by ACLR with peroneus longus tendon (PLT) and hamstring tendons (HT) respectively. Patients with 16–50 years of either gender presenting with symptomatic ACL deficiency were admitted for arthroscopic single bundle ACLR and allocated into two groups (PLT and HT) operated and observed. Functional scores (IKDC and Lysholm score), clinical knee evaluation, donor site morbidity (AOFAS score) and thigh circumference were recorded preoperatively and at six months, one year post-operatively. The same post-op rehabilitation protocol was followed in both groups.Abstract
Purpose
Materials and Methods
Periprosthetic femoral fractures are increasingly seen in recent years, adding considerable burden to the National Health Service. These require complex revision or fixation and prolonged post-operative care, with significant morbidity with associated costs. The purpose of this study was to assess whether the size of femoral cement mantle is associated with periprosthetic femoral fractures (PPF). This retrospective study was carried out on a cohort of 49 patients (Fracture Group - FG) who previously had a revision procedure following a proximal PPF between 2010 and 2021. Inclusion criteria – all primary cemented total hip replacements (THR). Exclusion criteria – complex primary THR, any implant malposition that required early revision surgery or any pre-fracture stem loosening. The antero-posterior (AP) radiographs from this cohort of patients were assessed and compared to an age, sex, time since THR-matched control group of 49 patients without PPF (Control Group - CG). Distal cement mantle area (DCMA) was calculated on an AP radiograph of hip; the position of the femoral stem tip prior to fracture was also recorded: valgus, varus or central. Limitations: AP radiographs only. Statistical analyses were performed using Microsoft® Excel. Chi-square test demonstrated statistically significant difference in DCMA between FG and CG. DCMA of 700 to 900 mm² appeared to be protective when compared to DCMA of 0 to 300 mm². Also, a valgus position observed in 23% in FG Vs 4 % in CG increased the risk, with a smaller area of DCMA. This study demonstrates and recommends that a size of 700 – 900 mm² of the DCMA is protective against periprosthetic fractures, which are further influenced by the positioning of the distal stem tip. This could be due to the gradual decrease in the stiffness gradient from proximal to distal around the stem tip than steep changes, thereby decreasing possibility of a stress riser just distal to the cement mantle or restrictor. Further biomechanical research specific to this finding may be helpful to validate the observation, progressing to suggest a safe standardised surgical technique.
Clinical commissioning groups (CCG) have been replaced with ICBs that will bring together NHS and social care for the local population. ICBs are allocating contracts for long waiters for total hip replacements (THR) to hospitals that have achieved pre-covid volumes of THR, THR volumes undertaken by hospitals in 2022 should be at 2019 levels or more. Purpose of this study was to identify whether NHS hospitals in England are at a disadvantage in procuring ICB contracts for THR. THR volumes for NHS and independent sector (IND) hospitals from January 2012 to November 2022 were identified via National Joint Registry. Regional and national trend for THR volumes were identified for both NHS and IND hospitals using linear regression analysis. Trends of THR for NHS hospitals showed either stagnation or reduction in volume from 2014–2019. In 2022, nationally THR volume of NHS was 70% of 2019 (Figure 1). Trend of THR volume for IND hospitals nationally was a strong uptrend from 2012 to 2022 with a break only in 2020 due to COVID pandemic (Figure 2). Since the pandemic IND have overtaken NHS hospitals in volumes of THR undertaken. Similar picture of trends evolves when THR trends were assessed on a region by region basis. With NHS hospitals not back to pre-pandemic THR volumes, IND hospitals have a distinct advantage in securing more contracts via ICB. This in turn puts NHS hospitals at risk of taking on more complex and medically unwell patients potentially worsening NJR outcomes for NHS hospitals. The reasons for the lag in NHS hospitals’ THR volumes are multifactorial, not limited to continued bed pressures, increased emergency and unplanned admissions, staff shortages and sickness, pension taxations preventing doctors from undertaking more THR. However, lack of access to contracts from ICB will put NHS hospitals at huge financial and existential risk for elective care. For any figures or tables, please contact the authors directly.
Primary total joint arthroplasty (TJA) is an increasingly common and safe way of treating joint disease. Robust preoperative assessment improved intraoperative techniques and holistic rehabilitation contribute to an uneventful postoperative period. Despite there being evidence against the utility of postoperative blood tests, it is still often part of routine practice. We aim to evaluate the usefulness of these tests by investigating their incidence following TJA as well as identifying preoperative risk factors for abnormal blood test results postoperatively especially pertaining to anaemia and acute kidney injury (AKI). This is a retrospective cohort study of patients who had elective TJA between January and December 2019 at a tertiary centre. An independent student's t-test and Fisher's exact test was used to compare variables between the normal and abnormal postoperative results groups. An analysis of variance (ANOVA) was performed to identify risk factors for an abnormal blood test result. Analyses of receiver operating characteristic (ROC) curves and the area under the curve (AUC) were used to determine cut off values that could be suggestive of abnormal test results postoperatively. The study included 2721 patients with a mean age of 69 of which 46.6% were males. Abnormal postoperative bloods were identified in 444 (16.3%) patients. We identified age (≥65 years), female gender, ASA ≥ 3 as risk factors for developing abnormal postoperative blood tests. Preoperative haemoglobin (≤ 127 g/dL), haematocrit (≤ 0.395L/L) and potassium (≤ 3.7 mmol/L) were noted as cut-offs that could be predictive of postoperative anaemia or AKI respectively. The costs outweigh the benefits of ordering routine postoperative blood tests in TJA patients. Clinicians should risk stratify their patients and have a lower threshold for ordering blood tests in patients with one or more of the risk factors we have identified. These risk factors are age (≥65 years), females, ASA ≥ 3, preoperative haemoglobin (≤ 127 g/L), haematocrit (≤ 0.395L/L), and potassium (≤ 3.7 mmol/L).
There is a surge of patients on the waiting-list for primary total hip replacement (THR), due to unprecedented reduction of elective activity caused by COVID-19. A higher incidence of femoral head collapse (FC) and acetabular erosion (AE) leading to increase in pain and instability as well as requirement of more complex surgery and potentially higher risk to patients was noted in this period. Rapidly progressive Arthritis (RPA) of the hip is a known entity often described as progression of joint space narrowing greater than 2mm over one year time period. The study aims to identify any potential relationship between waiting time and establishment of femoral head collapse and/ or acetabular erosion. A retrospective review of arthroplasty surgeon's waiting list during COVID. Serial hip radiographs recorded between February 2020 and February 2022 were analysed. FC was quantified as a percentage of the femoral head radius, while AE was assessed by drawing two parallel lines, one through both tear drops and the other through superior most aspect of intact acetabulum, parallel to the inter tear-drop line and expressed as percentage of normal side. Only 105 patients out of 264 patients added to the waiting list had elective arthroplasty for hip/knee. Only 35 patients out of 90 listed for THR, had the surgery. 36 of 90 (40%) were found to have developed FC and fitted the criteria for RPA. Acetabular erosion was seen in 19 (21%). Therefore 53% (19 of 36) of those who developed FC progressed to AE. Incidence of collapse was higher in females (32%), with mean age of 62 (range 51–81), compared to 21% in males with mean age 59 (range 53–87). Mean extent of femoral head collapse was 20% (10 – 44%). A significant proportion of patients added to waiting list during COVID developed RPA of the hip with 40% having femoral head collapse and 21% progressing to acetabular erosion leading to a complex case-mix. Patients on long waiting lists need regular x-ray checks/PROMS since significant proportion progress to FC and Acetabular Erosion.
C. Difficile infections in elderly patients with hip fractures is associated with high morbidity and mortality. Antibiotic regimens with penicillin and its derivatives is a leading cause. Antibiotic prophylactic preferences vary across different hospitals within NHS. We compared two antibiotic prophylactic regimens - Cefuroxime only prophylaxis and Teicoplanin with Gentamicin prophylaxis in fracture neck of femur surgery, and evaluated the incidence of C. Difficile diarrhea and Surgical Site Infection (SSI). To assess the Surgical Site Infection and C. Difficile infection rate associated with different regimens of antibiotics prophylaxis in fracture neck of femur surgery. Data was analyzed retrospectively. Neck of femur fracture patients treated surgically from 2009 in our unit were included. Age, gender, co morbidities, type of fracture, operation, ASA grade was collected. 1242 patients received Cefuroxime only prophylaxis between January 2009 and December 2012 (Group 1) and 486 patients received Teicoplanin with Gentamicin between October 2015 and March 2017 (Group 2). There were 353 males and 889 female patients in Group 1 and 138 males and 348 female patients in Group 2. The co morbidities in both groups were comparable. Incidence of C. Difficile diarrhea and Surgical Site Infection (SSI) was noted. Statistical analysis with chi square test was performed to determine the ‘p’ value. C. Diff diarrhea rate in Group 2 was 0.41 % as compared to 1.29 % in Group 1. The Surgical Site Infection (SSI) rate in Group 2 was 0.41 % as compared to 3.06 % in Group 1. The comparative results were statistically significant (p = 0.0009). Prophylactic antibiotic regimen of Teicoplanin with Gentamicin showed significant reduction in C. Difficile diarrhea & Surgical Site Infection in fracture neck of femur patients undergoing surgery.
