Septic Arthritis (SA) is considered a surgical urgency/ emergency by physicians around the world. As our understanding grows, and improved diagnostic algorithms are developed, it has become apparent that competing interests in terms of accurately diagnosing concurrent osteomyelitis may supercede rapid surgical intervention when the imaging is timely. Nevertheless, even in cases of isolated SA, many patients will require repeat surgery. We aimed to assess factors which could predict this.

A multicenter retrospective redcap database was created involving 20 pediatric centers from the CORTICES study group with the goal of better understanding pediatric musculoskeletal infection (PMSKI). All patients who met inclusion for the database were considered, surgeons for each site determined through imaging and chart review which patients met the diagnosis of isolated SA. Patients with concomitant abscesses or osteomyelitis were expressly excluded. Appropriate non parametric statistics were used to assess univariate significance. Multivariable logistic regression was used to assess clinical factors associated with an increased likelihood of more than one surgery. Receiver characteristics operating curve (ROC) analysis was used to determine optimal cutoffs to discriminate between children who required more than one surgery compared to those who required only one surgery. A probability algorithm was developed for the number of clinical factors present and the likelihood requiring more than one surgery following SA diagnosis.

“Four hundred and fifty-four patients with isolated SA were analyzed from 20 US hospitals. Patients were 5.4 +/− 4.8 years old at admission, and the cohort was 56% male. Of the 454 patients, 47 (10.4%) needed more than one surgery. Bivariate comparisons across surgery groups found significant differences in minimum platelet count (pplatelet, a patient has a 0.3% reduction in the odds of needing more than one surgery (OR=.997; p=0.04). For each additional ten units of CRP, a patient has a 0.1% increase in the odds of needing more than one surgery (OR=1.001; p<0.001). Our predictive algorithm found that children with both risk factors had a 64% chance of requiring multiple surgeries.

Higher CRP values and lower platelet values indicate more severe disease in isolated SA with a greater likelihood of repeat surgery. Higher CRP and lower platelet counts may portend multiple surgeries and caregivers of children with isolated SA should be advised as such.

Aims

The appropriate management for patients with a degenerative tear of the rotator cuff remains controversial, but operative treatment, particularly arthroscopic surgery, is increasingly being used. Our aim in this paper was to compare the effectiveness of arthroscopic with open repair of the rotator cuff.

Aims

A trial-based comparison of the use of resources, costs and quality of life outcomes of arthroscopic and open surgical management for rotator cuff tears in the United Kingdom NHS was performed using data from the United Kingdom Rotator Cuff Study (UKUFF) randomised controlled trial.

Introduction

Cross-linked polyethylene in total hip arthroplasty has demonstrated excellent long-term wear resistance, leading to its acceptance as the standard bearing used in hip replacement. Adoption in knee replacement has been tentative, as the cross-linking process can decrease the polyethylene mechanical properties. The current study's purpose was examining survivorship of a fixed bearing knee replacement system featuring a moderately cross-linked polyethylene (MXLK) bearing, a cobalt chrome (CoCr) tibial tray with a highly polished top surface, and a new polyethylene-to-tray locking mechanism. The MXLK is made of ultra-high molecular weight GUR1020 resin irradiated with 5 Mrad gamma radiation, followed by a free radical quenching remelting annealing process, above the 135 degree melting point, that provides wear and fatigue resistance, and oxidative stability.

Proper restoration of posterior condylar offset during TKA has been shown to be important to maximize range of motion and minimize flexion instability. However, there is little information as to the importance of restoration of mid-sagittal femoral geometry. There is controversy as to whether a TKA prosthesis should have a single radius or multiple radii of curvature. The purpose of this study is to evaluate the effectiveness of a multi-radius femoral component at restoring mid sagittal femoral offset.

A consecutive series of 100 TKAs with digital preoperative and postoperative radiographs and standardized radiographic markers were analyzed. There were 71 female and 29 male knees with mean age of 59 years. All TKAs were performed by a single surgeon using a multi-radius femoral component design. The distal femoral resection was set to resect 10 mm from the distal femoral condyle and a posterior referencing system was used to size the femoral component. Using radiographic perfect lateral projections of the knees, a line was drawn along the posterior femoral shaft and another parallel line down the anterior femoral shaft. A 3rd line was then drawn parallel to the posterior shaft at the furthest point posterior on the condyle. A 4th line was drawn parallel to the anterior shaft at the furthest point anterior on the femur. 90 degree angles were constructed to create a grid in the anterior and posterior directions, similar to a previously reported technique. Finally, 45 degree angle lines were created in the grid to assess mid flexion dimensions [Fig-1 and 2]. The percent change in posterior condylar offset (PCO), anterior femoral offset (AFO), mid femoral anterior offset (MAFO) and mid femoral posterior offset (MFPO) were calculated.

The mean reproduction of the mid-anterior femoral offset and mid-posterior femoral offset were 101.1% [range 56.5%–167.5%] and 96.8% [range 54.9%–149.0%] of preoperative measurements respectively. The average restoration of posterior offset and anterior offset were 92.8% [range 49.0%–129.8%] and 115.3% of preoperative measurements [range 35.7%–400.0%] respectively. When the posterior condylar offset was restored to within 10% of the native anatomy, the MPFO restoration more closely resembled normal anatomy (103.0% vs. 93.9%, p = 0.005). When the postoperative posterior condylar offset was decreased greater than 20%, both the MAFO (90.1% vs. 104.5%, p = 0.004) and MPFO (78.5% vs. 102.9%, p < 0.001) decreased compared to the native knee. There was no relationship between restoration of the PCO and the MAFO correction (104.6% vs. 99.4%, p = 0.213). Finally, there was no correlation between restoration of anterior femoral offset within 10% of normal and the restoration of mid sagittal femoral offset; 98.0% vs 102.0% for MAFO (p = 0.320) and 98.7% vs 96.3% for MPFO (p = 0.569).

A modern multi-radius condylar knee design is capable of reproducing the mid-sagittal geometry of the preoperative knee. However, the restoration of mid sagittal offset is largely dependent on the restoration of the posterior condylar offset. Intraoperative adjustments in anterior and posterior femoral resections can have significant impact in the ability of the implant to reproduce mid-sagittal femoral anatomy.

INTRODUCTION: Many orthopaedic device companies now offer a high flexion (HF) choice within their knee Arthroplasty portfolios. Early published results are mixed between standard (STD) and HF knee devices despite claims of increased flexion with the HF offerings. The purpose of this randomized, controlled, simultaneous, bilateral study was to compare two coronally conforming rotating platform devices to determine if flexion differences were attributed to implant design.

METHODS: Ninety-three subjects underwent simultaneous bilateral TKA across 8 centers. The HF device was randomly assigned to one side and the contralateral leg received the STD device. Average age was 61 years, 99% were diagnosed with osteoarthritis, 66% were females, average BMI was 32 and range of motion was measured by subjective expectations versus satisfaction.

RESULTS: The HF design had statistically better single leg active flexion (SLAF) 12 months after surgery compared to the STD. Consistent with Gupta et. al, in a subgroup with pre-op flexion < 120 degrees in both knees, the HF device was statistically superior in passive flexion, ROM, and SLAF by between 1.8 and 4.5 degrees at 6 months, 12 months, and longitudinally over all postoperative intervals using raw degrees, improvement from pre-op, and adjusting for potentially confounding variables. 57% of subjects preferred their HF knee 6 months postoperatively, although there was no difference in preference at 12 months.

DISCUSSION: The simultaneous bilateral design of this study necessitates that subjects act as their own control eliminating most confounding variables. Gains in postoperative flexion, although small, were superior in the HF TKA group and were greater in those subjects with less than 120 degrees of preoperative flexion, suggesting the ideal candidate for a HF TKA is one with lesser preoperative flexion.

One of the ethical and legal requirements of valid consent for treatment is that patients must be fully informed about the complications involved. The General Medical Council (UK) insists that all adverse outcomes of a treatment, which are serious or frequently occurring, must be discussed with the patient.

Previous studies have found a large variance in the risks documented on consent forms for orthopaedic hip operations. The aim of this study was to compare the risks documented for three orthopaedic hip operations against pre-constructed operation-specific consent forms endorsed by the British Orthopaedic Association.

We retrospectively analysed 300 consent forms for total hip replacements, hip hemiarthoplasties and dynamic hip screw operations (n=100 for each) and noted the risks documented, whether the form was completely legible, the grade of the Doctor obtaining consent and whether a copy of the consent form was given to the patient.

We found that of the 300 operations, only 43.1% of the complications were documented as recommended by the British Orthopaedic Association. Furthermore, 26.3 % of consent forms were illegible, 72.7% of patients were consented by the Senior House Officer and only 13.7% of patients were offered a copy of the consent form.

Our results indicate that the Methods: of obtaining consent and filling in the consent forms for orthopaedic hip operations could be vastly improved. One method which could be utilized to achieve this would be the incorporation of procedure specific templates in the consenting process. These templates are already in the public domain and free to use at www.orthoconsent.com. This would allow the patient to weigh up the risks and make a valid informed decision about their treatment and also protect the Doctors from any possible litigation.

We analysed in-vivo migration and wear over a long period of all-polyethylene acetabular cups which had not been affected by mechanical loosening. The selection criteria of regular radiological follow-up, good clinical outcome (Charnley score of 5 or 6), continued walking without crutches and no radiological signs of loosening of the acetabular cups were fulfilled by 25 Charnley total hip arthroplasties.

Mean migration, measured by the Nunn method, was 0.6 mm in the medial and 0.2 mm in the cranial direction. The mean yearly rate of wear was 0.05 mm and 0.04 mm, with six and two cups having no detectable wear, as measured by the Livermore and Charnley-Cupic methods, respectively. The maximal detected wear was 3.7 mm. There were no changes in the rate of wear with time. Computerised Ein Bild Röntgen Analyse (single-image radiological analysis) measurements of 20 hips indicated plastic deformation of the cups.

We conclude that long-term successful cups do not migrate and have a very low rate of wear which was not affected by ageing of the polyethylene. There was no evidence that polyethylene wear alone caused mechanical loosening of the cup but high rates of wear seem to have an adverse prognostic value in terms of the long-term survival of the prosthesis.

We have carried out a randomised, controlled trial on 70 patients having unilateral total knee replacement in which transfusion was either with homologous bank blood or by reinfusion of unwashed blood salvaged after operation.

No complications or adverse effects were observed from reinfusion. The need for bank blood was reduced by 86% in the reinfusion group but, more importantly, the number of infective episodes was significantly less when the use of bank blood was avoided. The mean length of stay in hospital was also reduced by more than two days.

We compared the outcome of total knee arthroplasty in 19 patients who had had previous patellectomy with the results in a matched series of arthroplasties performed on knees in which the patella was intact. The mean follow-up was 63 months (21 to 114). In the study group, the outcome was poor in five patients. There was instability in the coronal plane in three patients and persistent pain in four. Three supracondylar fractures occurred. The overall complication rate was 36%. In the control group, pain was relieved in every case and there were no complications. Total knee arthroplasty has a higher complication rate and inferior results if the knee has undergone prior patellectomy.

We report the long-term outcome of 218 Charnley low-friction arthroplasties in 141 patients who were 40 years old or younger at the time of surgery. The minimum follow-up was ten years with a mean of 16 years. The probability of the femoral component surviving 20 years was 86% and of the acetabular component, 84%. The chance that both components would survive for this period was 75%. The pathological diagnosis significantly influenced implant survival. In rheumatoid patients the probability of both components surviving at 20 years was 96% compared with 51% in patients with osteoarthritis. Clinical assessment of 103 patients (166 hips) in whom the arthroplasty was still functioning showed that 94% of hips had minimal pain or none. We conclude that in young patients cemented total hip replacement is a good procedure for those with rheumatoid arthritis but that the results are much less reliable in those with osteoarthritis.

We report on a radiographic screening programme at four months of age for infants who were clinically normal at neonatal examination but were considered to be 'at risk' for congenital dislocation of the hip because of their family history, breech presentation, or a persistent click. From a total population of 13,662 live births over a two-year period, 357 (2.6%) infants at risk were identified. Of these 46 had abnormal radiographs (six subluxations, 40 acetabular dysplasia). In 12 infants treatment resulted in a normal hip; 34 required no treatment but were followed up until their radiographs were normal and walking had begun. Of the 311 infants with normal radiographs, 256 (82%) were examined after 15 months of age; none had any detectable abnormality. We suggest that radiography of the hip at four months is a valuable adjunct to neonatal screening for infants at increased risk of congenital dislocation of the hip.

We report the results of low friction arthroplasty in 72 old tuberculous hips and 42 hips with old quiescent septic arthritis. Follow-up was for a minimum of two years. Recrudescence of tuberculosis was seen in only one patient, but deep infection occurred in four of the hips with previous septic arthritis. The reasons for this are discussed. It is recommended that patients with old tuberculous hips should have a course of anti-tuberculous drugs before operation, that patients with previous septic infection should have prophylactic antibiotics and antibiotic-loaded cement and that the operation should be performed by an experienced surgeon.

Total hip replacement has been very successful in patients with painful, stiff hips associated with protrusio acetabuli, but the heat of polymerisation of methylmethacrylate cement may cause necrosis of the thin medial wall with consequent danger of migration of the cup. Since 1968 at Wrightington, thin slices of the head of the femur have been used as bone grafts to reinforce the acetabulum. We have reviewed 61 hips in 51 patients at an average of 4 years 3 months after operation. Grading for severity is discussed and the degree of physiological remodelling of the medial wall of the acetabulum after grafting assessed. There was an average of about 4 mm of remodelling, but this varied considerably; most took place within the first year. In no case was there relapse of the protrusio.

1. The orientation of collagen fibres of the menisci of the knee has been demonstrated by polarised light microscopy.

2. As might be supposed from its fibre structure, the ultimate tensile strength of the meniscal tissue is dependent upon the axis of loading.

3. The tensile strength of the meniscus is similar to that of articular cartilage.