Abstract

Customised individually made implants(CIM) total knee arthroplasty(TKA) are custom-made to better fit patients native anatomy and aim to improve outcomes which can be variable with conventional off-the-shelf(OTS).

A systematic review and meta-analysis was conducted searching the MEDLINE and Embase databases. Studies reporting on patient reported outcome measures, clinical or radiological outcomes were included.

23 studies satisfied the search criteria (case-control studies14, case series8, cross-sectional studies1). There were 2,856(CIM) and 1,877(OTS) implants. The overall revision-rate was higher in CIM 5.9%vs3.7%OTS [OR 1.46(95% CI 0.82–2.62)]. MUA was higher in the CIM group 2.2%vs.1.1%OTS [OR 2.95(95% CI 0.95–9.13)] and overall complications rate was also higher in the CIM group 5% vs. 4.5%OTS [OR 1.45(95% CI 0.53–3.96)]. LOS was significantly shorter in the CIM group 2.9 days vs. 3.5 days [MD −0.51(95% CI −0.82–0.20)]. Pooled analysis for KSS showed no difference between CIM and OTS groups(Knee=90.5 vs. 90.6 [MD-0.27,(95% CI −4.27–3.73)] and Function=86.1 vs. 90.6[MD 1.51 (95% CI −3.69–6.70)] component of the scores. There was no significant difference in post-operative ROM between CIM and OTS groups 117.3° vs. 115.0° [MD 0.02,(95% CI −1.70–1.74)].

CIM TKAs has theoretical benefits over OTS TKAs however in this review they were associated with higher complication, MUA and revision rates with no difference in outcome scores and no improvement in target alignment. The findings of this review does not support the use of CIM over OTS prosthesis in total knee arthroplasty.

Industries such as agriculture, construction and military have stringent rules about hearing protection due to the risk of noise induced hearing loss (NIHL). Due to the use of power tools, orthopaedic staff may be at risk of the same condition. The UK Health and Safety Executive (HSE) have clear standards as to what is deemed acceptable occupational noise levels on an A-weighted and C weighted scale. This review is aimed to assess evidence on noise exposure testing within Orthopaedic theatres to see if it exceeds the HSE regulations.

A targeted search of online databases PUBMED and EMBASE was conducted using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) principles. This review was registered prospectively in PROSPERO. An eligibility criterion identifying clinical studies which assessed noise exposure for Orthopaedic staff in theatres were included. Noise exposure data was extracted from these studies and a comparison was made with A weighted and C weighted acceptable exposure levels as quoted in the HSE regulations.

Fourteen papers were deemed eligible, which reviewed 133 Orthopaedic operations and 64 Orthopaedic instruments. In total, 61% (81 of 132) of Orthopaedic operations and 70% (45 of 64) of instruments exceeded the noise regulations on an A weighted scale. 22% (10 of 46) of operations exceeded the maximum C weighted peak acceptable noise level.

Orthopaedic instruments and operations can exceed safe occupational noise levels. NHS Trusts have clear policies about noise exposure in the workplace but have yet to identify Orthopaedic theatres as a potential at risk area. Orthopaedic staff need education, monitoring and protection whereas Employers and Occupational Health should consider assessments to identify at risk staff in Orthopaedic theatres and offer preventative methods from NIHL.

Aims

In the UK, the agricultural, military, and construction sectors have stringent rules about the use of hearing protection due to the risk of noise-induced hearing loss. Orthopaedic staff may also be at risk due to the use of power tools. The UK Health and Safety Executive (HSE) have clear standards as to what are deemed acceptable occupational levels of noise on A-weighted and C-weighted scales. The aims of this review were to assess the current evidence on the testing of exposure to noise in orthopaedic operating theatres to see if it exceeds these regulations.

Traditionally, sports Injuries have been sub-optimally managed through Emergency Departments (ED) in the public health system due to a lack of adequate referral processes. Fractures are ruled out through plain radiographs followed by a reactive process involving patient initiated further follow up and investigation. Consequently, significant soft tissue and chondral injuries can go undiagnosed during periods in which early intervention can significantly affect natural progression. The purpose of this quality improvement project was to assess the efficacy of an innovative Sports Injury Pathway introduced to detect and treat significant soft tissue injuries.

A Sports Injury Pathway was introduced at Fiona Stanley Hospital (WA, Australia) in April 2019 as a collaboration between the ED, Physiotherapy and Orthopaedic Departments. ED practitioners were advised to have a low threshold for referral, especially in the presence of a history of a twisting knee injury, shoulder dislocation or any suggestion of a hip tendon injury. All referrals were triaged by the Perth Sports Surgery Fellow with early follow-up in our Sports Trauma Clinics with additional investigations if required. A detailed database of all referrals was maintained, and relevant data was extracted for analysis over the first 3 years of this pathway.

570 patients were included in the final analysis. 54% of injuries occurred while playing sport, with AFL injuries constituting the most common contact-sports injury (13%). Advanced Scope Physiotherapists were the largest source of referrals (60%). A total of 460 MRI scans were eventually ordered comprising 81% of total referrals. Regarding Knee MRIs, 86% identified a significant structural injury with ACL injuries being the most common (33%) followed by isolated meniscal tears (16%) and multi-ligament knee injuries (11%). 95% of Shoulder MRI scans showed significant pathology. 39% of patients required surgical management, and of these 50% were performed within 3 months from injury.

The Fiona Stanley Hospital Sports Injury Pathway has demonstrated its clear value in successfully diagnosing and treating an important cohort of patients who present to our Emergency Department. This low threshold/streamlined referral pathway has found that the vast majority of these patients suffer significant structural injuries that may have been otherwise missed, while providing referring practitioners and patients access to prompt imaging and high-quality Orthopaedic sports trauma services. We recommend the implementation of a similar Sports Injury Pathway at all secondary and tertiary Orthopaedic Centres.

Hamstring grafts have been associated with reduced strength, donor site pain and muscle strains following Anterior Cruciate Ligament Reconstruction (ACLR). Traditional graft fixation methods required both semitendinosus and gracilis tendons to achieve a graft of sufficient length and diameter, but newer techniques allow for shorter, broad single tendon grafts.

This study seeks to compare the outcomes between Single Tendon (ST) and Dual Tendon (DT) ACLR, given there is no prospective randomised controlled trial (RCT) in the literature comparing outcomes between these options.

In this ongoing RCT: (ANZ Clinical Trials Registry ACTRN126200000927921) patients were recruited and randomised into either ST or DT groups. All anaesthetic and surgical techniques were uniform aside from graft technique and tibial fixation. 13 patients were excluded at surgery as their ST graft did not achieve a minimum 8mm diameter. 70 patients (34 ST, 36DT) have been assessed at 6 months, using PROMS including IKDC2000, Lysholm and Modified Cincinnati Knee, visual analog scale for pain frequency (VAS-F) and severity (VAS-S), dedicated donor site morbidity score, KT-1000 assessment, and isokinetic strength.

Graft diameters were significantly lesser in the ST group compared to the DT group (8.44mm/9.11mm mean difference [MD],-0.67mm; P<0.001). There was a significant and moderate effect in lower donor site morbidity in the ST group compared to the DT group (effect size [ES], 0.649; P = .01). No differences between groups were observed for knee laxity in the ACLR limb (P=0.362) or any of the patient-reported outcome measures (P>0.05). Between-group differences were observed for hamstrings strength LSI favouring the ST group, though these were small-to-moderate and non-significant (ES, 0.351; P = .147).

ST (versus DT) harvest results in significantly less donor site morbidity and this is the first prospective RCT to determine this. There were no differences between ST and DT hamstring ACLR were observed in PROMs, knee laxity and hamstring strength. Younger female patients tend to have inadequate single tendon size to produce a graft of sufficient diameter, and alternative techniques should be considered. Further endpoints include radiological analysis, longer term donor site morbidity, revision rates and return to sport and will continue to be presented in the future.

Abstract

Abstract

When compared to magnetic resonance imaging (MRI), ultrasound (US) performed by experienced users is an inexpensive tool that has good sensitivity and specificity for diagnosing rotator cuff (RC) tears. However, many practitioners are now utilizing in-office US with little to no formal training as an adjunct to clinical evaluation in the management of RC pathology. The purpose of our study was to determine if US without formal training is effective in managing patients with a suspected RC tear.

This was a single centre prospective observational study. Five fellowship-trained surgeons each examined 50 participants referred for a suspected RC tear (n= 250). Patients were screened prior to the consultation and were included if ≥ 40 years old, had an MRI of their affected shoulder, had failed conservative treatment of at least 6 months, and had ongoing pain and disability. Patients were excluded if they had glenohumeral instability, evidence of major joint trauma, or osteonecrosis. After routine clinical exam, surgeons recorded their treatment plan (“No Surgery”, “Uncertain”, or “Surgery”). Surgeons then performed an in-office diagnostic US followed by an MRI and documented their treatment plan after each imaging study. Interrater reliability was analyzed using a kappa statistic to compare clinical to ultrasound findings and ultrasound findings to MRI, normal and abnormal categorization of biceps, supraspinatus, and subscapularis.

Following clinical assessment, the treatment plan was recorded as “No Surgery” in 90 (36%), “Uncertain” in 96 (39%) of cases, “Surgery” in 61 (25%) cases, and incomplete in 3 (2%). In-office US allowed resolution of 68 (71%) of uncertain cases with 227 (88%) of patients having a definitive treatment plan. No patients in the “No Surgery” group had a change in treatment plan. After MRI, 16 (6%) patients in the “No Surgery” crossed-over to the “Surgery” group after identification of full-thickness tears, larger than expected tears or alternate pathology (e.g., labral tear).

The combination of clinical examination and in-office US may be an effective method in the initial management of patients with suspected rotator cuff pathology. Using this method, a definitive diagnosis and treatment plan was established in 88% of patients with the remaining 12% requiring an MRI. A small percentage (6%) of patients with larger than expected full-thickness rotator cuff tears and/or alternate glenohumeral pathology (e.g., labral tear) would be missed at initial evaluation.

Abstract

Abstract

Introduction

The stability of the elbow joint following an acute elbow dislocation is dependent on associated injuries. The ability to identify these concomitant injuries correctly directs management and improves the chances of a successful outcome. Interpretation of plain radiographs in the presence of either a dislocation or post-reduction films with plaster in-situ is difficult. This study aimed to assess the ability of orthopaedic registrars to accurately identify associated bony injuries on initial plain radiographs using CT as the gold standard for comparison.

During revision THR, the surgery is often difficult and compromised due to lack of patient's bone especially in the pelvis. Any extra bone in the acetabulum is expected to be of advantage to the patient and the surgeon. The aim of this study was to see if preservation of medial acetabular osteophyte in uncemented total hip replacement had any adverse effect on the prosthesis survival or patient satisfaction.

Conventional acetabular preparation involves reaming down to the true floor. This not only medialises the centre of rotation of the hip but also reduces the acetabular offset. In contrast the main surgeon preserved the acetabular offset by preserving some osteophytic bone between the true floor of the acetabulum and the acetabular cup. This is achieved by reaming the acetabular cavity conservatively while achieving secure primary fixation of the prosthesis. We report the outcome of a single surgeon series of such cases. The endpoint was assessed as the need for revision of the acetabular cup.

A total of 106 consecutive patients were identified who underwent uncemented THR from 2005 to 2010. The medial osteophyte was measured on immediate post-operative x-rays, from the “teardrop” to the nearest point of the acetabular cup, by 3 surgeons (one consultant and 2 registrars). The patients were contacted for a telephone interview and their clinical notes, including x-rays, were reviewed.

Outcome was available for 79 patients. 74 patients were available for follow-up and 5 patients died unrelated to THR. Average follow-up was for 8.3 years (range 5.5–10.8). Average age was 62 years. The average medial osteophyte was 1.98 mm (range 0–14mm). One patient had late infection and one had dislocation. There was not a single failure of the acetabular component. The patient satisfaction was high at 8.8 out of 10.

Preservation of medial osteophyte in the acetabulum whilst doing uncemented THR has the advantage of retaining the patient's own bone stock which can be of great advantage to the surgeon as well as the patient should revision THR be required in future. Our study has shown that this can be achieved without compromising the survival of the prosthesis or the patient satisfaction.

This technique may increase the range of motion of the hip by reducing the risk of bony or soft tissue impingement, and also reduce the risk of dislocation. Furthermore, not recreating the native centre of rotation of the hip does not seem to have any adverse effect for the patients, who are very happy with the outcome. We recommend that whilst doing uncemented THR, the acetabulum should not be reamed to the true floor as has been the conventional teaching, but attempt should be made to preserve some medial osteophyte where possible, at the same ensuring that good primary fixation of the cup is achieved. This is to give the patient and surgeon the advantage of extra available bone should revision surgery be required in the future.

Aim

The aim of this study is to assess the effectiveness of clinic based ultrasound screening by Orthopaedic surgeon for early diagnosis and treatment of developmental dysplasia of hip (DDH) in one stop clinic.

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.

We analysed the morbidity, mortality and outcome of cervical spine injuries in patients over the age of 65 years in a retrospective review of 107 elderly patients admitted to our tertiary referral spinal injuries unit with cervical spine injuries between 1994 and 2002. The data were acquired by analysis of the national spinal unit database, hospital inpatient enquiry (HIPE) system, chart and radiographic review. Mean age was 74 years (range 66-93yrs). The male to female ratio was 2.1: 1(M=72, F=35). The mean follow-up was 4.4 years (1-9 years) and mean in-hospital stay was 10 days. The mechanism of injury was a fall in 75 and a road traffic accident (RTA) in the remaining 32 patients. The overall complication rate was 18.6% with an associated in-hospital mortality of 11.2%. Outcome was assessed using the Cervical Spine Outcomes Questionnaire (CSOQ) from Johns Hopkins School of Medicine.

Functional outcome scores approached pre-morbid level in almost all patients. Functional disability was more marked in the patients with neurological deficit at the time of injury. Outcome of the injury is related to the increasing age, co-morbidity and the severity of the neurological deficit. Injuries of the cervical spine are a not infrequent occurrence in the elderly and occur with relatively minor trauma.

Neck pain in the elderly patient should be thoroughly evaluated to exclude C2 injuries. Most patients can be managed in an orthosis but unstable injuries require rigid external immobilisation.