Safe and meticulous removal of the femoral cement mantle and cement restrictor can be a challenging process in revision total hip arthroplasty (rTHA). Many proximal femoral osteotomies have been described to access this region however they can be associated with fracture, non-union and revision stem instability. The aim of this study is to report outcomes of our previously unreported vascularised anterior window to the proximal femur.

We report on a cohort of patients who underwent cemented single and staged rTHA at our single institution by the same surgeon between 2012 and 2017 using a novel vascularised anterior window of the femur to extract the cement mantle and restrictor safely under direct vision. We describe our technique, which maintains the periosteal and muscular attachments to the osteotomised fragment, which is then repaired with a polymer cerclage cable. In all revisions a polished, taper slip, long stem Exeter was cemented. Primary outcome measures included the time taken for union and the patient reported WOMAC score.

Thirty-two rTHAs were performed in 29 consecutive patients (13 female, 16 male) with a mean age of 63.4 years (range, 47–88). The indications for revision included infection, aseptic loosening and implant malpositioning. Mean follow up was 5.3 (range, 3.2–8 years). All femoral windows achieved radiographic union by a mean of 7.2 weeks. At the latest point in follow-up the mean WOMAC score was 21.6 and femoral component survivorship was 100%. There were no intraoperative complications or additional revision surgery.

Our proposed vascularised anterior windowing technique of the femur is a safe and reproducible method to remove the distal femoral cement and restrictor under direct vision without the need for perilous instruments. This method also preserves the proximal bone stock and provides the surgeon with the option of cemented stems over uncemented revision implants that predominantly rely on distal fixation.

Background

Nonsurgical treatment of Acromioclavicular joint dislocations is well established. Most patients treated conservatively do well, however, some of them develop persistent symptoms. We have used two different surgical reconstruction techniques for Chronic ACJ dislocation stabilization. The study evaluates the effectiveness of a braided polyester prosthetic ligament and modified Weaver-Dunn reconstruction methods.

Acute Kidney Injury (AKI) formerly known as “acute renal failure” results in rapid reduction in kidney function associated with a failure to maintain fluid, electrolyte and acid-base homeostasis. The UK NCEPOD published a report in 2010 on AKI that revealed many deficiencies in the care of patients with AKI. The UK Renal Association has published the final draft of Clinical Practice Guidelines for Acute Kidney Injury on the 08/01/2011. In our study we determined retrospectively the occurrence of this problem in a District General Hospital and its impact on recovery after lower limb arthroplasty.

Data was collected retrospective study over 3 months between Oct to Dec 2010 from theatre registers and the hospital database system. 359 patients were identified. Preoperative (baseline) and postoperative blood investigations included Creatinine, Urea, K+, Na+, GFR, Haemoglobin were analysed. Data collection also included type of anaesthesia, timing of operation, duration of procedure and estimated blood loss. From the hospital database system and clinic letters we collected length of stay and time required for blood results to come back to baseline.

A diagnosis of Acute Kidney Injury was based on the International Kidney Disease Improving Global Outcomes (KDIGO) staging classification as recently recommended by UK Renal Association. Stage I Creatinine increase by ≥ 26 μmol/L from baseline, Stage II Creatinine increase by 200-300% and Stage III Creatinine increase ≥ 300%.

In our study 11.97% (43/359) of patients developed acute kidney injury following lower limb Arthroplasty. 18 patients (42%) developed Stage I (Cre increase ≥ 26 μmol/L), 17(39%) developed Stage II (Cre increase 200-300%) and 8 patients (19%) developed Stage III (Cre increase ≥ 300%) AKI. Most of these patients were operated during the afternoon session. Patients with acute kidney injury stayed longer in hospital (11.7days) compared to similar age group of patients (6.35days) admitted during the same period. 25% of patients took more than a month for renal parameters to come down to normal.

AKI is a new definition and the incidence in our hospital is higher than the 1% expected nationally. Patients with AKI are often complex to treat and specialist timely referral and transfer to renal services if appropriate should be considered. The etiology of Acute Renal Injury is very complex and includes gentamicin antibiotic prophylactic, rapid blood loss in elderly frail patients, non-steroidal pain killers and preexisting cardiac and renal pathology.

The need for careful postoperative observation cannot be overemphasised together with judicious blood replacement as required. Acute Kidney Injury following lower limb arthroplasty is a sensitive marker of postoperative care. A successful surgical outcome may not mean a successful renal outcome. Patients with AKI are often complex to treat the new AKI definition and staging system allows an earlier detection and management of this condition. Further prospective audit with large number of patients are required.

Background

It was hypothesised that preserving a layer of gliding tissue, the parietal layer of the ulnar bursa, between the contents of the carpal tunnel and the soft tissues incised during carpal tunnel surgery might reduce scar pain and improve grip strength and function following open carpal tunnel decompression.

Introduction

The treatment of Neer type 2 lateral end clavicle fractures presents a difficult problem due to the high incidence of non-union, delayed union, shoulder girdle instability and the need for implant removal. We report our experience in 10 patients with acute fractures treated with a simple modified tension band suturing technique.

In revision hip surgery, a solidly cemented femoral component may obstruct access to the acetabulum, may be poorly orientated, or may have inadequate offset and head diameter. These problems can be addressed by revising the femoral component. The object of this study was to determine the outcome of cementing a polished, tapered, modular implant into the retained cement mantle. Benefits of cement within cement revision of a femoral stem include simplicity, reduced theatre time, and potentially reduced complication rates.

A consecutive series of 36 patients (11 men, 25 women) age range 35 to 90 years (mean age 70) underwent c stem cement in cement revision hip arthroplasty between June 2000 and April 2006. Indications for revision arthroplasty included 20 patients with aseptic acetabular loosening and 13 patients with recurrent instability. Follow up (12–84 months, mean 48 months) was annual and the outcome for every implant was known. Outcome measures included the shortened WOMAC score, Orthowave patient satisfaction survey, radiographic analysis, and assessment of the records for perioperative complications.

No patients were lost to follow up, 2 patients died with their hip in situ. The mean post operative WOMAC score at latest follow up was 10.89 (median 11, range 0 to 29). There has been no clinical or radiological signs of prosthesis loosening or failure on follow up. Complications included: one sacral plexus palsy which had a partial recovery, and one intra-operative periprosthetic fracture identified and treated at the time of the revision procedure. One patient underwent a further cup revision for recurrent dislocation.

Cement within cement revision hip arthroplasty using a highly polished tapered stem in the short to medium term provides satisfactory functional outcomes and is associated with low complication rates and good survivorship. Longer term results are awaited.

Every surgeon needs to audit the quality of his work to ensure that complication rates are low, good function persists for the intermediate term, and patient satisfaction remains high. The use of the 12-point shortened WOMAC score and Orthowave patient satisfaction survey provides enough information for quantitative assessment of most practices. When applied to my hip arthroplasty practice, analysis of data related to 426 consecutive patients at 1–9 years of follow-up (mean 3.5) revealed pain relief was good to excellent in 96%; rate of recommendation of surgery was 97%. Overall satisfaction was good to excellent in 95%. Mean WOMAC scores improved from a preoperative mean value of 32.5 to mean 6.6 at latest follow-up. When the same scoring system was applied to my knee arthroplasty practice, results were surprisingly inferior. Potential areas for technical improvement were then identified and implemented. This study highlights the simplicity and usefulness of the shortened WOMAC score and Orthowave patient satisfaction survey in assessing and improving an arthroplasty practice.

Between January 1996 and July 2002, 60 patients (65 hips) were treated in our unit by 5 consultant surgeons using the Corin Cobalt-Chrome metal-on-metal hip resurfacing. 41 procedures were performed on male patients and 24 female.

All 65 cases used the Cormet Hip resurfacing (Corin, UK). Of these, 12 cases (18.5%) have required revision for mechanical failure. 5 of these patients were male and 7 female. The time to failure was defined as the interval between the date of primary and the date of revision surgery. The mean time to failure was 10.2 months (range 48 hours to 53 months). 8 out of 12 patients required revision within 6 months of the primary procedure. The mean age at the time of revision was 56 years (range 22–71 years).

The commonest mechanism of failure in our series is fractured neck of femur and 4 out of the 6 fractured neck of femur occurred in females over the age of 60. Only 12 of our primary hip resurfacings were women over 60 with the result that 33% of this group were complicated by fractured neck of femur.

In 4 cases, the indication for revision was acetabular loosening. One patient underwent revision surgery for chronic pain of unknown aetiology and one developed progressive avascular necrosis of the femoral head.

Our early results suggest that the procedure is operator-dependent and associated with a steep learning curve. The procedure would appear to be contraindicated in women over 60 and others at risk of osteoporosis.

Aims: There is a resurgence of interest in hip resurfacing. To date, our own unit has treated 60 patients (65 hips) with the Corin hip resurfacings. Between Jan 99 and July 02, 12 of these patients required early revision surgery. Methods: Retrospective study. Results: The indication for revision was fractured neck of femur in þve cases. 4 of the 5 fractured neck of femurs cases occurred within 6 months of the primary procedure. There were 4 cases of loose acetabular components and one case of progressive avascular necrosis. One patient required revision surgery for ongoing hip pain and one required a two stage revision for early deep infection. Conclusions: In the DGH environment, resurfacing may be associated with a high revision rate with a signiþcant learning curve.

One of the most commonly cited advantages of hip resurfacing is the technical ease of revision surgery on the femoral side of the joint. It is therefore reasonable to suggest that such surgery ought to be associated with reduced operative times, reduced blood loss and more rapid mobilisation than conventional hip revision. However, there is little objective evidence in the literature to support this view.

In our own unit, 6 consultants have now revised 15 hip resurfacings (13 Corins and 2 MMT Birmingham Hip Resurfacings). A retrospective study of the hospital records was performed to compare three well recorded parameters 1) On table operative times 2) Post Operative blood transfusion requirement 3) In patient length of stay.

Average on table time was 195 minutes for conventional THR revision and 120 minutes for revision of resurfacing i.e. a 1 third reduction in theatre time for resurfacing with attendant advantages in costs and risks. However, post operative length of stay was little different between the two groups.

Average blood transfusion requirement was 4.6 units for conventional THR revision (n=190) and 0.9 units for revision of resurfacing. However, these crude figures do not take into account the difference in physiological state between the two groups of patients. A more complex comparison of age matched revision THR patients shows and average transfusion requirement of 1.8 to 2.2 units for revision of THR versus 0.9 units for revision resurfacing.

In conclusion, there is now objective evidence of the advantages of resurfacing in the revision situation but that these advantages are more modest than those anticipated.

In recent years there has been a resurgence of interest in the concept of hip resurfacing. Since 1996, we have treated 60 patients (65 hips) with the Corin Hip Resurfacing.

Of the 65 primary procedures, 13 have now required revision. 1 case was complicated by early deep infection and 12 (17%) for mechanical failure. 5 of these patients were male and 8 female. Mean time to failure was 11 months (range 48 hours to 53 months). 8 out of the 12 mechanical failures required revision within 6 months of the primary procedure. Mean age of the revision patients was 57 years (range 22 – 71 years).

The most common failure modality (6 cases) was fractured neck of femur. 4 out of 6 of these cases occurred in women over 60 years of age. All of these fractures occurred without a specific history of trauma. Since only 12 patients were women over 60, 1 in 3 women over 60 years of age in our series were complicated by fractured neck of femur.

In 4 cases, the indication for revision was acetabular loosening. One patient had ongoing pain of unknown aetiology and one developed progressive avascular necorsis of the femoral head with subsequent collapse.

Of the 12 cases requiring revision for mechanical failure, two cases required revision of the femoral component only and this was performed using the stemmed modular CTI prosthesis produced by Corin for this purpose. Three cases required revision of the socket only and the others were revised to total joint replacement. The one case of early deep infection was treated by two stage revision. There were no dislocations in our series and there was no evidence of metallosis.

Not for the first time in the history of orthopaedics, a DGH has been unable to repeat the excellent results reported by a specialist centre with a new technique. However, analysis of the above data has led us to believe that our results may be much improved by careful patient selection. It is also apparent that formal revision strategies need to be developed for hips resurfacing.