Aims

We present the ten-year data of a cohort of patients, aged between 18 and 65 years (mean age 52.7 years; 19 to 64), who underwent total hip arthroplasty. Patients were randomised to be treated with a cobalt-chrome (CoCr) femoral head with an ultra-high molecular weight polyethylene (UHMWPE), highly cross-linked polyethylene (XLPE) or ceramic-on-ceramic (CoC) bearing surface.

Purpose

This prospective randomised controlled trial aims to compare the clinical and radiological outcomes of ceramic on ceramic, cobalt chrome on ultra-high molecular weight polyethylene, and cobalt chrome on highly cross-linked polyethylene bearing surfaces at a minimum of five years.

This prospective randomised controlled trial aims to compare the clinical and radiological outcomes of ceramic on ceramic, cobalt chrome on ultra-high molecular weight polyethylene, and cobalt chrome on highly cross-linked polyethylene bearing surfaces at a minimum of five years.

One hundred and two primary total hip replacements were performed in ninety one patients between February 2003 and March 2005. All patients were younger than 65 (mean 52.7, 19–64). They were randomised to receive one of the three bearing surfaces. All patients had 28mm articulations with a Reflection uncemented acetabular component and a Synergy stem (Smith & Nephew, Memphis, Tennessee). Patients were followed up periodically up to at least sixty months following surgery. Outcome measures included WOMAC and SF12 scores. Radiological assessment included implant position, evidence of osteolysis and measurement of linear wear.

Ninety seven hip replacements in eighty seven patients were available for review at a minimum of five years. Two hips were revised (one for infection and one for periprosthetic fracture), leaving a total of ninety four hips available for final review. There were no differences in age, gender, body mass index, diagnosis, level of activity, and co-morbidities between the three groups. At a minimum of five years there were no statistical differences in the clinical outcomes using the WOMAC or SF12 scores. Three patients in the ceramic group reported squeaking. Radiological evaluation revealed mean annual wear rates in the ceramic group of 0.006mm/yr, standard polyethylene of 0.151mm/yr and highly cross linked polyethylene of 0.059mm/yr. ANOVA analysis revealed these differences in wear rates to be significant (p<0.0001).

In the mid term there are no differences in clinical outcome between ceramic on ceramic, cobalt chrome on ultra-high molecular weight polyethylene, and cobalt chrome on highly cross-linked polyethylene bearing surfaces in total hip arthroplasty. Ultra high molecular weight polyethylene has a significantly greater annual linear wear rate than highly cross-linked polyethylene.

Aim

This prospective randomised controlled trial aims to compare the clinical and radiological outcomes of ceramic on ceramic, cobalt chrome on ultra-high molecular weight polyethylene, and cobalt chrome on highly cross-linked polyethylene bearing surfaces at a minimum of five years.

The ideal bearing surface for young patients undergoing total hip replacement (THR) remains controversial. We report the five-year results of a randomised controlled trial comparing the clinical and radiological outcomes of 102 THRs in 91 patients who were <  65 years of age. These patients were randomised to receive a cobalt–chrome on ultra-high-molecular-weight polyethylene, cobalt–chrome on highly cross-linked polyethylene, or a ceramic-on-ceramic bearing. In all, 97 hip replacements in 87 patients were available for review at five years. Two hips had been revised, one for infection and one for peri-prosthetic fracture.

At the final follow-up there were no significant differences between the groups for the mean Western Ontario and McMaster Universities osteoarthritis index (pain, p = 0.543; function, p = 0.10; stiffness, p = 0.99), Short Form-12 (physical component, p = 0.878; mental component, p = 0.818) or Harris hip scores (p = 0.22). Radiological outcomes revealed no significant wear in the ceramic group.

Comparison of standard and highly cross-linked polyethylene, however, revealed an almost threefold difference in the mean annual linear wear rates (0.151 mm/year versus 0.059 mm/year, respectively) (p < 0.001).

The use of metal on polyethylene articulations was a key development in establishing total hip arthroplasty as a successful and reproducible treatment for end stage osteoarthritis. In order to ensure implant durability in relatively younger populations, there is a need for alternative, wear resistant bearing surfaces. Oxidized Zirconium (Oxinium, Smith & Nephew, Inc., Memphis, TN) is a relatively new material that features an oxidized ceramic surface chemically bonded to a tough metallic substrate. This material has demonstrated the reduced polyethylene wear characteristics of a ceramic, without the increased risk of implant fracture. The purpose of the current investigation was to assess early clinical outcomes following primary total hip arthroplasty with Oxinium versus Cobalt Chrome femoral heads.

One-hundred primary THA procedures were prospectively performed in 100 patients. There were 52 males and 48 females. Using a process of sealed envelope randomization, patients were divided into 2 groups. Group 1 consisted of fifty patients, each receiving primary THA implants with an Oxinium femoral head (OX). The mean age of each patient was 51 years (SD 10.8, Range 22–74) with 26 males and 24 females. Group 2 also consisted of 50 patients. Within this group again each patient received primary THA implants however with a cobalt-chrome femoral head (CC). Demographics were similar with mean age 51 years (SD 11.0, Range 19–76) and again 26 males and 24 females.

The current study reports clinical outcome measures for both the OX and CC groups at a minimum follow-up of 2 years postoperatively. At the time of latest follow-up, stem survival for both groups was 98%. There was a significant improvement in all clinical outcome scores between preoperative and 2 year postoperative time periods for both bearing groups (p< 0.003). There were no significant differences between bearing groups for any of the clinical outcome scores at final follow-up (p> 0.159). Mean Harris Hip Scores at 2 years postoperatively were 92 and 92.5 for OX and CC, respectively (range; 65–100 OX, 60–100 CC). For SF-12, both the Physical Component Summary Scale (PCS) and the Mental Component Summary Scale (MCS) are reported. Mean PCS scores at final follow-up were 45.2 and 49.21 for OX and CC (range; 27.1–56.7 OX, 26.3–61.8 CC). Mean MCS scores were 53.8 and 52.57 for OX and CC (range; 39.2–65.5 OX, 34.3–64 CC). Mean final WOMAC scores are reported as 84.9 and 87 for OX and CC, respectively.

The current data suggest that total hip arthroplasty utilizing Oxinium femoral heads is safe and effective. Additional follow-up of the current cohort will be performed in order to fully assess mid- to long-term clinical outcomes.

This prospective controlled clinical trial compares the outcomes of metacarpophalangeal (MCP) arthroplasty in rheumatoid arthritis patients using the Swanson (S) and NeuFlex (N) MCP implants.

Forty hands (thirty-seven patients) were randomised and evaluated preoperatively and at one year following MCP arthroplasty in digits two to five for range of motion (ROM; active and passive extension and flexion), ulnar drift and grip strength.

Both implants restored extension and corrected flexion deformities. There was no significant difference in extension of all digits (summed) between the NeuFlex and Swanson implants (N: −20.8°; S: −13.8°; p=0.29). The NeuFlex implant, which is pre-flexed at 30°, preserved more flexion at the MCP joint than the Swanson implant in all digits (summed) (N:74.5°; S:55.8°; p=0.005), with the greatest difference observed in the fifth digit (N:69.6°; S:48.7°; p=0.009). The total arc of motion improved in all digits, with no significant differences between the Neu-Flex and Swanson groups in the second through fourth digits (N:53.8°; S:43.8°; p=0.154); a significantly greater improvement was observed in the NeuFlex group for the fifth digit (N:53.3°; S:42.5°; p=0.028). Both implants corrected ulnar drift deformity, while neither led to loss of grip strength.

Hand function as measured by Sollerman score and Michigan Hand Questionnaire (MHQ) improved significantly in both groups (p=0.0119, p< 0.0001, respectively) with no significant difference between the Swanson and NeuFlex implants, except for MHQ function, aesthetics, and overall scores, which demonstrated superiority of the Swanson.

Overall, there was a significant improvement in the range of motion, deformity and grip strength following MCP arthroplasty for the full patient group. While both implants restored similar amounts of extension, the NeuFlex implant maintained greater flexion and total range of motion, with the greatest difference in the fifth digit. The Swanson implant had better MHQ function and aesthetics subscores.

Metacarpophalangeal (MP) arthroplasty restores function, corrects deformity and reduces pain in patients with rheumatoid arthritis (RA). In a randomised controlled trial of MP hand reconstruction, we investigated RA patient motivations and expectations and whether self-reported patient satisfaction with appearance, function and pain correlated with objective and subjective outcome measures.

From forty patients (one hundred and sixty joints), randomised for an MP arthroplasty trial, we collected preoperative and postoperative objective measures (range of motion (ROM), ulnar drift, JAMAR grip strength), subjective measures (Michigan Hand Questionnaire (MHQ), Sollerman Hand Function test), pre-operative patient-reported motivations and expectations of surgery (appearance, function, pain), and postoperative patient-reported improvement and satisfaction with surgery (appearance, function, pain, overall). Spearman correlations determined associations between patient satisfaction and specific outcome measures.

Mean age was 60.3 years, mean disease duration at time of surgery 22.9 years, mean follow-up time 386.4 days, and 87.5% of patients were female. Seven of forty patients (17.5%) rated improved function as the single biggest motivator for surgery, one (2.5%) rated pain, the remainder (80%) rated two or more motivators equally high. Function was rated as the most important or one of the most important motivators for surgery by 92.5% of patients, pain by 67.5% and appearance by 47.5%. Several MHQ subscores (function, work, ADL) were moderately correlated (|rho|=0.67, 0.52, 0.54, respectively), and the Sollerman Score was weakly correlated (|rho|=0.39) with self-reported satisfaction with function, but ROM and grip strength were not (|rho||< 0.25). Self-reported satisfaction scores for appearance, pain and overall were moderately correlated with analogous MHQ subscores (|rho|=0.78, 0.65, 0.71, respectively).

Patient expectations of MCP arthroplasty were uniformly high. The greatest motivation for surgery was functional improvement. Pain was highly ranked, but nearly half of the patients rated hand appearance as one of the highest co-ranked motivators. Patient satisfaction correlated poorly with traditional outcome measures (ROM, grip strength) and moderately with subjective outcome measures (MHQ). Aesthetic appearance is probably underrated as a motivator for surgery and determinant of satisfaction.

The purpose of this study was to evaluate the mid- and long-term outcomes of total knee arthroplasty in adult patients who have advanced juvenile idiopathic arthritis (JIA).

Between 1989 and 2001, twenty-two knees of JIA adult patients were treated with primary arthroplasty. Surgical challenges included fixed valgus and flexion deformity. All patients were evaluated (mean 8.0 years) using established and new scoring systems.

Knee arthroplasty provided relief of pain and stiffness and moderate improvement in range of motion in this severely affected patients. Although outcomes were scored poorly on established instruments, patients rated their benefits of the operation highly.

To evaluate the mid- and long-term outcomes of total knee arthroplasty in adult patients who have advanced juvenile idiopathic arthritis (JIA).

Between 1989 and 2001, twenty-two knees in fourteen adult patients with severe JIA were treated with primary arthroplasty. Surgical challenges included relative condylar and patellar overgrowth within a contracted, inelastic soft tissue envelope, osteoporosis, small sized bones and fixed valgus and flexion deformity including ankylosis. All patients were evaluated (follow-up: mean 8.0 years) using established and new scoring systems (postoperatively at follow-up and preoperatively by recall)..

Patients’ postoperative pain and stiffness VAS were significantly less than preoperative scores, with mean changes of 8.8 and 7.2, respectively. A mean post-operative flexion arc of 77° (range 30°–130°) was observed. All lower limbs were post-operatively aligned between 0° and 5° of mechanical valgus. Incomplete radiolucent lines were present in 27% of knees, but were not associated with clinical symptoms. Final SF-36, EQ-5D and WOMAC scores were relatively low, but 82% of patients rated themselves satisfied with the functional outcome, 100% with pain relief, and 100% stated that the outcome met or exceeded their expectations. Issues deemed by JIA patients to be important were identified by the patient specific questionnaire (PASI-pg), but not by SF-36, EQ-5D or WOMAC.

Knee arthroplasty provided relief of pain and stiffness and moderate improvement in range of motion in this severely affected adult JIA patients. Although outcomes were scored poorly on established instruments, patients rated their satisfaction with and benefits of the operation highly.

Funding:

B. Jolles received a Ligue Vaudoise contre le Rhumatisme Award for her work on Rheumatoid Arthritis.

Purpose: To evaluate the impact of the Osteoporosis Exemplary Care Program (OECP) on orthopaedic surgeons’ practice patterns at St. Michael’s Hospital.

Methods: A chart audit was performed to collect data on two groups of 54 patients identified with fragility fractures. The intervention group consisted of patients treated during the first four months of the OECP, while the control (pre-intervention) group consisted of age, sex, and fracture-type matched patients treated prior to implementation of the OECP. Characteristics of the intervention and control groups were compared using chi-square tests. Multivariable logistic regression analysis was then performed to identify significant correlates of OP care.

Results: Preliminary results from 54 matched pairs (108 patients in total) indicate that the OECP group was more likely to have OP risk or OP diagnosis documented (unadjusted OR 2.49; 95% CI 1.05–5.87), as well as to be referred for further investigation of OP (unadjusted OR 3.08; 95% CI 1.37–6.91) or to receive treatment or follow-up related to OP (unadjusted OR 9.01; 95% CI 3.77–21.54). As one surgeon was known to have been providing a high level of OP care prior to implementation of the OECP, the analysis was repeated after removing his patients. In addition, the analysis was repeated after removing patients who were already being treated for OP at the time of their fragility fracture. In both cases, larger increases in the likelihood of OP documentation and care were observed. Through multivariable analysis, age and fracture type (i.e. wrist vs. hip) were found to be significant correlates of having received OP care for patients with fragility fractures treated prior to implementation of the OECP. Following implementation of the OECP, there were no significant correlates of receiving OP care.

Conclusions: Preliminary results indicate that the OECP had a significant impact on orthopedic surgeons’ practice patterns. Following implementation of the OECP all patients were equally likely to receive appropriate referral, treatment, and follow-up whereas, prior to implementation of the program, age and fracture type affected the likelihood that a patient would receive such care.

Funding : Commerical funding

Funding Parties : The Osteoporosis Exemplary Care Program is funded by an unrestricted program grant provided by Merck Frosst Canada and Co. Dr. Beaton is supported by a New Investigators Award, from the Canadian Institute of Health Research.

Orthopedic surgeons treat numerous patients in whom osteoporosis (OP) is an important factor: inflammatory arthritides (rheumatoid arthritis); sports medicine (the anorexic, amenorrhoeic female athlete); in consultation to renal, transplant and cardiac units; patients on corticosteroids, as well as others. Orthopedic procedures in patients who have osteoporotic bone require special techniques and precautions. A common example is hip replacement, where, through endosteal resorption, the medullary canal is large, cortices are thin, and the risk of femoral fracture and a poor outcome is higher.

The commonest interface of orthopedic surgery with OP is in the management of fractures. In North America, most orthopedic surgeons manage fractures in hospital and in the fracture clinic, where typically 3%–8% of patient visits are for classic fragility fractures. Traumatic fractures also commonly occur in osteoporotic bone. The yield of screening for OP in orthopedic wards and clinics, targeting fragility fracture patients, is much higher than screening in a general population. Published guidelines based on Level I evidence indicate that fragility fracture patients are at highest risk of future hip fractures, which often occur within one year of index fragility fracture, and that preventive treatment is economical and safe.

Treatment prevents 30–50% of hip fractures in high risk groups. Unfortunately, less than 20% of fragility fracture patients generally receive appropriate OP care, in multiple studies in developed countries. There is a growing international focus on developing care delivery systems that will promote consistent OP investigation and treatment in the inpatient and outpatient orthopedic environment.

In Ontario, Canada, an Osteoporosis Exemplary Care Program was initiated in 2003 to identify, educate, evaluate, refer, and treat female (> 40 years) and male (> 50 years) fragility fracture patients for OP. In the first year of the program, over 95% of inpatients and outpatients were appropriately diagnosed, treated, or referred for OP care. Success resulted from the presence of a dedicated coordinator and cooperation by orthopedic surgeons and residents, technologists, allied health professionals and administrative staff.

Regional, national and international orthopedic associations have developed initiatives designed to improve processes of care for OP in the orthopedic environment.

Introduction The purpose of this study was to identify issues of importance to Juvenile Idiopathic Arthritis (JIA) patients before and after total hip arthroplasty (THA) and to determine if these issues are included in widely utilized, standardized outcome measures for THA (Western-Ontario and McMaster Universities Arthritis Index – WOMAC; Patient Specific Index – PASI).

Methods JIA patients who underwent THA between 1986 and 1999 in our institution participated in the study (n=31). An independent observer was asked to gather data forms including patient demographics, a postoperative WOMAC questionnaire, postoperative patient-generated items from the PASI, a retrospectively completed preoperative PASI form, and changes in items from pre-operative to postoperative PASI. Descriptive analysis was completed on demographic information and clinical outcomes as well as for the WOMAC and PASI scores. Spearmans rank correlation coefficients were calculated to describe the association between WOMAC and PASI scores

Results Issues deemed important by JIA patients included four symptom areas (pain, joint motion, strength, discomfort) and five activity areas (light household, leisure, clothing, sports, sex); some indicated they had no symptoms or difficulties. Issues relevant to patients shifted from predominantly symptoms before surgery, to recreational and social activities at follow-up. Comparison of postoperative WOMAC questionnaires with preoperative and postoperative PASI questionnaires revealed fundamental differences between items found in the standardized WOMAC and items deemed important by the patient. The WOMAC included less than 10% of the unweighted content deemed important by these patients at follow-up.The shift in the PASI towards more physically demanding activities after surgery indicates that patients improved, which is not reflected in the WOMAC. Correlations between postoperative WOMAC and PASI scores for pain sub-scales were low to moderate (Spearman‘s coefficient rs=0.53) and 63% of JRA patients had higher PASI than WOMAC normalized scores.

Conclusion The self-generated, self-reported portion of the PASI questionnaire provided a different perspective on the impact of THA in JIA patients. The WOMAC did not include content deemed to be important by JRA patients and did not correlate well with the patient specific instrument.

Introduction and Aims: In this study, we identify issues of importance to adult Juvenile Rheumatoid Arthritis (JRA) patients before and after total hip arthroplasty (THA) and determine if these issues are included in widely utilised, standardised outcome measures for THA (Western-Ontario and McMaster Universities Arthritis Index – WOMAC; Patient Specific Index – PASI).

Method: Adult JRA patients who underwent THA between 1986 and 1999 at our institution participated in the study (n=31). An independent observer gathered data, including patient demographics, a post-operative WOMAC questionnaire, post-operative patient-generated items from the PASI, a retrospectively completed pre-operative PASI form, and changes in items from pre-operative to post-operative PASI. Descriptive analysis was completed on demographic information and clinical outcomes, as well as for the WOMAC and PASI scores. Spearman’s rank correlation coefficients were calculated to describe the association between WOMAC and PASI scores.

Results: Issues deemed important by JRA patients included four symptom areas (pain, joint motion, strength, discomfort) and five activity areas (light household, leisure, clothing, sports, sex); some patients indicated they had no symptoms or difficulties. Before surgery, issues identified as relevant by patients were predominantly symptoms, whereas at follow-up, patients primarily identified recreational and social activities as the issues relevant to them.

Comparison of post-operative WOMAC questionnaires with pre-operative and post-operative PASI questionnaires revealed fundamental differences between items found in the standardised WOMAC and items deemed important by the patient. The WOMAC included less than 10% of the unweighted content deemed important by these patients at follow-up. The shift in the PASI towards more physically demanding activities after surgery indicates that patients improved, which is not reflected in the WOMAC. Correlations between post-operative WOMAC and PASI scores for pain subscales were low to moderate (Spearman rank correlation coefficient: rs = 0.53) and 63% of JRA patients had higher PASI than WOMAC normalised scores.

Conclusion: The self-generated, self-reported portion of the PASI provided a different perspective on the impact of THA in adult JRA patients and more information on issues important to these patients. The WOMAC did not include content deemed to be important by JRA patients and did not correlate well with the PASI.

We reviewed the records and radiographs from 10 hospitals to identify 50 patients with rheumatoid arthritis (RA) who had sustained 52 femoral neck fractures. Most patients were female (88%), elderly (mean age 66 years) and had had severe polyarticular disease for a mean duration of 16 years. Over half had taken systemic corticosteroids, nearly all were severely osteopenic but few had rheumatoid changes in the hip. Of the 20 fractures treated by internal fixation 12 had complications including nonunion (5), osteonecrosis (5), infection (1), and intertrochanteric fracture (1). Only one of the nine undisplaced fractures required reoperation, but seven of the 11 displaced fractures had revision surgery. Twenty fractures were treated by primary total hip arthroplasty with only one early complication. The other 12 fractures had been treated by hemiarthroplasty (9), hip excision (1) or non-operatively (2). Our results suggest that, in elderly rheumatoid patients, severely displaced femoral neck fractures should be treated by total hip replacement.