Current treatment options for displaced acetabular fractures in elderly patients include non-surgical management, surgical fixation and surgical fixation with simultaneous hip replacement, the so-called “fix-and-replace”™. There remains a paucity of evidence to guide surgeons in decision making for these difficult injuries. The aim of this study was to assess the feasibility of performing an appropriately powered RCT between treatment options for acetabular fractures in older patients.

This was an NIHR funded feasibility triple-arm RCT with participation from 7 NHS MTCs. Patients older than 60 were recruited if they had an acetabular fracture deemed sufficiently displaced for the treating surgeon to consider surgical fixation. Randomisation was performed on a 1:1:1 basis. The three treatment arms were non-surgical management, surgical fixation and fix-and-replace. Feasibility was assessed by willingness of patients to participate and clinicians to recruit, drop out rate, estimates of standard deviation to inform the sample size calculation for the full trial and completion rates to inform design of a future definitive trial. EQ-5D was the primary outcome measure at 6 months, OHS and Disability Rating Index were secondary outcome measures.

Of 117 eligible patients, 60 were randomised whilst 50 declined study participation. Nine patients did not receive their allocated intervention. Analysis was performed on an intention to treat basis. During the study period 4 patients withdrew before final review, 4 patients died and 1 was lost to follow-up. The estimated sample size for a full scale study was calculated to be 1474 participants for an EQ-5D MCID of 0.06 with a power of 0.8.

This feasibility study suggests a full scale trial would require international collaboration. This study also has provided observed safety data regarding mortality and morbidity for the fix-and-replace procedure to aid surgeons in the decision-making process when considering treatment options.

Aims

To assess the feasibility of a randomized controlled trial (RCT) that compares three treatments for acetabular fractures in older patients: surgical fixation, surgical fixation and hip arthroplasty (fix-and-replace), and non-surgical treatment.

Displaced acetabular fractures in the older patient present significant treatment challenges. There is evidence the morbidity and mortality associated is similar to the fractured neck of femur cohort. Despite growing literature, there remains significant controversy regarding treatment algorithms; varying between conservative management, to fracture fixation and finally surgical fixation and simultaneous THA to allow immediate full weight bearing.

£250k NIHR, Research for Patient Benefit (Ref: PB-PG-0815-20054). Trial ethical approval (17/EE/0271). After national consultation, 3 arms included; conservative management, fracture fixation and simultaneous fracture fixation with THA. Statistical analysis required minimum 12 patients/3 arms to show feasibility, with an optimum 20/arm. Inclusion criteria; patients >60 years & displaced acetabular fracture. Exclusion criteria: open fracture, THA in situ, pre-injury immobility, polytrauma. Primary outcome measure - ability recruit & EQ-5D-5L at 6 months. Secondary outcome measures (9 months); OHS, Disability Rating Index, radiographs, perioperative physiological variables including surgery duration, blood loss, complications and health economics.

11 UK level 1 major trauma centres enrolled into the trial, commenced December 2017. Failure surgical equipoise was identified as an issue regarding recruitment. Full trial recruitment (60 patients) achieved; 333 patients screened. 66% male, median age 76 (range 63–93), median BMI 25 (range 18–37), 87% full mental capacity, 77% admitted from own home. 75% fall from standing height. 60% fractures; anterior column posterior hemi-transverse. Trial feasibility confirmed December 2020. Presented data- secondary outcomes that are statistically significant in improvement from baseline for only the fix and replace arm, with acceptable trial complications. Issues are highlighted with conservative management in this patient cohort.

Our unique RCT informs design and sample size calculation for a future RCT. It represents the first opportunity to understand the intricacies of these treatment modalities. This RCT provides clinicians with information on how best to provide management for this medically complex patient cohort.

Introduction

Severely comminuted, displaced acetabular fractures with articular impaction in the elderly population present significant treatment challenges. To allow early post-operative rehabilitation and limit the sequelae of immobility, treatment with acute total hip replacement (THA) has been advocated in selected patients. Achieving primary stability of the acetabular cup without early migration is challenging and there is no current consensus on the optimum method of acetabular reconstruction. We present clinical results and radiostereometric analysis of trabecular metal (TM) cup cage construct reconstruction in immediate THA without acetabular fracture fixation.

Multiple reports suggest good outcome results following unicompartmental knee replacement (UKR). However, several authors report technically difficult revision surgery secondary to osseous defects. We reviewed clinical outcomes following revision total knee replacement for failed UKR and analysed the reasons for failure and the technical aspects of the revision surgery.

Between 2003 and 2009, thirty three revisions from unicompartmental knee replacement to total knee replacement were performed in thirty two patients at a single centre. Demographics, indications for the primary and revision procedures, details of the revised prosthesis including augments and any technical difficulties or complications were noted. Patient assessment included range of motion and the functional status of the affected knee in the form of the Oxford knee score questionnaire. Statistical analysis was performed with the Student t test.

All 33 revision knees were available for prospective clinical and radiological follow-up. The minimum duration of follow-up after revision surgery was 1 year (mean 3 years, range 1 – 7 years). The median interval between the original unicompartmental knee replacements to revision surgery was 19 months (range 2 – 159 months). The predominant cause of failure was aseptic loosening (50%). Other reasons included persistent pain (21%), dislocated meniscus (18%), mal-alignment (7%) and progression of symptomatic osteoarthritis in another compartment (4%). 18 of the 33 revision procedures required additional augments. During the revision surgery, 11 knees required a long tibial stem while 1 required a long femoral stem. 10 knees required medial tibial wedge augmentation; bone graft was used in 6 knees while a metal wedge augment was used in 4 to fill significant osseous defects. At the time of follow-up, range of movement averaged 103 degrees (range 70 – 120). The mean one year Oxford knee score, was 29 compared to 39 for primary total knee replacements performed during the same period in a comparable sample group of patients at our institute (p < 0.001). Three patients continued to have pain and two required re-revision; one for infection and one for loosening.

Aseptic loosening was the commonest mode of failure. Of the UKRs revised to TKRs, 90% were revised within 5 years. The majority of revisions required additional constructs. Oxford Knee Scores after revision surgery were inferior to those for primary TKR. The role of UKR needs to be more clearly defined.

Introduction

Cemented hemiarthroplasty for neck of femur fractures has been advocated over uncemented hemiarthroplasty due to better post-operative recovery and patient satisfaction. However, studies have shown adverse effects of bone cement on the cardio-respiratory system which may lead to higher morbidity and mortality. Therefore, in some institutes, the use of an uncemented prosthesis has been adopted for patients with a high number of co-morbidities. The aim was to compare early mortality rates for cemented vs. uncemented hemiarthroplasties.

Introduction

There has been renewed interest in the unicompartmental knee arthroplasty with reports of good long term outcomes. Advantages over a more extensive knee replacement include: preservation of bone stock, retention of both cruciate ligaments, preservation of other compartments and better knee kinematics. However, a number of authors have commented on the problem of osseous defects requiring technically difficult revision surgery. Furthermore, a number of recent national register studies have shown inferior survivorship when compared to total knee arthroplasty.

The purpose of this study was to review the cases of our patients who had a revision total knee arthroplasty for failed unicompartmental knee arthroplasty. To determine the reason for failure, describe the technical difficulties during revision surgery and record the clinical outcomes of the revision arthroplasties.

Standard approaches to thoracic intradural tumors often involve a large incision and significant tissue destruction. Minimally invasive techniques have been applied successfully for a variety of surgical decompression procedures, but have rarely been used for the removal of intradural thoracolumbar tumors. Here we compare the clinical outcome of mini-open resection of intradural thoracolumbar tumors to a standard open technique.

We retrospectively reviewed our series of twelve mini-open thoracolumbar intradural tumor resection cases and compared the outcome to a profile matched cohort of six cases of open intradural tumor resection cases. Operative statistics, functional outcome, and complications were compared.

Tumours were extirpated successfully with both approaches. There was no statistical difference in operating times, ASIA score improvement, or back pain VAS score improvement between groups. However, the mini-open group had a statistically significantly lower estimated blood loss (146 cc vs. 392 cc) and a significantly shorter length of hospitalization (3.6 vs 7.8 days). There was one complication of pseudomeningocoele formation in the mini-open cohort and no complications in the open cohort. Mean follow-up length was 13 months in the miniopen group compared to 23 months in the open group.

The mini-open approach allows for adequate treatment of intradural thoracolumbar tumors with comparable outcomes to standard, open approaches. The mini-open approach is associated with a lower blood loss and a shorter length of stay compared with standard open surgery.

Aims: Reverse oblique intertrochanteric fractures (OTA/ AO 31-A3) have unique biomechanical properties that confer difficulties in obtaining stable fixation with the conventional sliding dynamic condylar screw. Recent studies have recommended the use of cephalocondylic intramedullary devices for these unstable fractures. Both the Proximal Femoral Nail (PFN) and the Gamma Nail (GN) have shown good outcome results but the results of treatment with the IMHS have not been reported in the literature.

Methods: Between 1999–2008 6724 consecutive hip fractures were treated at our institute. There were 2586 extracapsular fractures and 307 subtrochanteric fractures. 115 of the extracapsular fractures had a reverse oblique pattern and 63 of these were treated with the IMHS. We retrospectively reviewed clinical and radiological records for the reverse oblique intertrochanteric fractures treated with the IMHS. Follow-up duration ranged from 8 months to 6 years.

Results: Among the 63 patients treated with the IMHS, 56 (88%) fractures were reduced satisfactorily with only one poorly positioned hip screw in the femoral head. There were no cases of femoral shaft fracture, screw cut-out or collapse at the fracture site. The orthopaedic complications were two cases of mal-rotation, two cases of non-union, two cases of distal locking bolts backing out, and one cracked nail. 30 day mortality was 6.5%.

Conclusion: Cephalo-medullary nailing devices have been recommended for the treatment of reverse oblique intertrochanteric femoral fractures. Our clinical and radiological outcomes with the IMHS compare favourably to the results in reports where other cephalo-medullary devices have been used. Therefore we consider the IMHS a good option for the treatment of these unstable fractures.

Juvenile idiopathic arthritis (JIA) affecting the hip can cause debilitating pain and walking disability in children. Total hip replacement offers the potential of a pain free joint and a significant improvement in function. There remains the concern regarding the high rates of aseptic loosening of cemented total hip replacements in this group of patients, and there is evidence that younger patients have higher failure rates.

The aim of this study was to look at the results of uncemented total hip replacement in children with Juvenile Idiopathic Arthritis and in particular to assess any problems associated with performing this surgery in the presence of open growth plates in the acetabular and trochanteric regions.

Between 1995 and 2005, 56 uncemented total hip replacements were carried out in 37 children with JIA with a mean follow up of 7.5 years (range 3 to 12.5). 25 of the hips had ceramic on ceramic bearings. The mean age at surgery was 13.9 years (range 11–16). 19 patients underwent bilateral procedures. All patients showed a significant improvement in their HSS Hip scores (p< 0.01). Two CAD CAM femoral stems were revised for gross subsidence and three acetabular components were revised for loosening. Four polyethylene liners were exchanged due to wear. 51 of 53 (96%) femoral stems and 50 (94%) acetabular components remain well fixed at latest follow up with no signs of loosening. There were no dislocations or infections.

Uncemented fixation appears to work well in this challenging group of patients even in the presence of open growth plates. Implant choice is important to avoid problems of subsidence and loosening. Ceramic bearings available for small implant sizes give promise of improved performance compared to polyethylene over the long term.

Introduction: There have been several recent studies outlining the role of femoroacetabular impingement (FAI) as a cause of early osteoarthritis in the non-dysplastic hip. The lesions can either be on the femoral side “cam” or acetabular “pincer”. The aim of surgical treatment of FAI is to improve the femoral head neck offset thereby improving joint clearance and preventing abutment of the femoral neck against the acetabulum. The classic treatment for FAI pioneered by Ganz involves dislocation of the femoral head through a trochanteric flip osteotomy. The procedure is extensive, technically difficult and not without complications.

Hip arthroscopic debridement of FAI lesions offers similar results to open procedures allowing for full inspection of the joint and the treatment of any chondral lesion but with a quicker recovery time. It nonetheless has a very long learning curve and even in the most experienced hands the treatment of impingement lesions is complicated and technically challenging.

The purpose of this cadaveric study was to assess the degree of exposure obtained using two different limited anterior approaches to the hip which would allow effective surgical treatment of cam and pincer FAI.

Methods: We investigated two mini anterior approaches to the hip joint based on the Heuter and direct anterior approach to compare the parts of the acetabulum and femoral head exposed for the treatment of FAI in a total of 20 hips in 10 (5 male, 5 female) cadaveric specimens. Neurovascular structures were recorded in relation to the two approaches. The area of femoral head and acetabular rim exposed via each approach was documented and quantified.

Results: We found that the two approaches were easy and reproducible. Both allowed exposure to the anterolateral aspect of the femoral head. The mean length of acetabular rim accessible via the Heuter approach was 1.9cm (1.1–2.4) and 2.2cm (1.2–3) using the direct anterior approach The area of acetabular rim accessible varied according to the approach (p< 0.001). We also found that the position of the anterior inferior iliac spine in relation to the acetabular rim also affected the area of acetabular rim exposed (p< 0.001). The most proximal nerve branch to sartorious was found 7.3cm (6.5–8.7cm) distal to the anterior inferior iliac spine. The most proximal nerve branch to rectus femoris was located 8.6cm (7–10) distal to the anterior inferior iliac spine and was consistently found to be distal to the nerve to sartorious.

Discussion: Treating impingement of the hip through a direct open approach is not a novel idea. A recent report of failed arthroscopic labral debridement, describes treatment of the underlying bony impingement in some cases by a combination of hip arthroscopy followed by anterior arthrotomy.

In summary cam and pincer impingement of the hip can be treated by either the direct anterior or Heuter approach. The choice of approach would be dictated after careful consideration as to which portion of the anterior acetabular rim required surgery, with more lateral acetabular lesions being favoured by the Heuter approach and more medial impingement sites by the anterior approach we have described.