Aims

The aim of this modified Delphi process was to create a structured Revision Hip Complexity Classification (RHCC) which can be used as a tool to help direct multidisciplinary team (MDT) discussions of complex cases in local or regional revision networks.

Orthopaedic surgical hoods rely on an intrinsic fan to force clean external air over the wearer and allow potentially contaminated and expired air to flow down and away from the surgical field. Carbon dioxide (CO₂) is produced through aerobic metabolism and can potentially accumulate inside the hood. Levels above 2500ppm have been shown to affect cognitive and practical function in flight simulator studies. Maximum Health and Safety Executive (HSE) 8-hour exposure limit is 5000ppm There is a paucity of data on real-world CO₂ levels experienced during arthroplasty surgery whilst wearing a hood.

CO₂ levels were continuously recorded during 31 elective arthroplasties, both primary and revision. Data was collected for surgeon and assistant. Data was recorded at 0.5Hz throughout the procedure utilising a Bluetooth CO₂ detector, worn inside a Stryker Flyte^™ surgical helmet worn with a toga gown. Four surgeons contributed real time data to the study. This data was augmented with experimental data, investigating varying fan speeds and activity levels.

Median operative duration was 82 minutes (range 36–207).

The average CO₂ level across all procedures was 2952ppm, with 22 of the cases having a mean above 2500ppm, but none having a mean above 5000ppm.

For each procedure, the time spent above 2500 and 5000 ppm was calculated, with the average being 68.4 % and 5.6% respectively.

The experimental data demonstrated higher CO₂ levels with lower fan speed, and at higher activity levels, and levels exceeding 15000 ppm during gentle exercise. During operative cases, low fan speed cases did have a marginally higher mean CO₂ value than high fan speed (3033.02 and 2903.56 respectively) but the small numbers of cases (n=10) where this data was captured limit the relevance of this difference.

The use of surgical helmets for elective orthopaedic surgery, can results in CO₂ levels regularly rising to a point which may affect cognitive function. This study recommends the use of a higher fan speed where possible to minimise the risk of such CO₂ levels, and recommends further research in this area.

Trabecular metal (TM) augments are designed to support an uncemented socket in revision surgery when adequate rim fit is not possible. We have used TM augments in an alternative arrangement, to contain segmental defects to facilitate impaction bone grafting (IBG) and cementation of a cemented socket. However, there is a paucity of literature supporting the use of this technique. We present one of the largest studies to date, reporting early outcomes of patients from a tertiary centre.

A single-centre retrospective analytical study of prospectively collected data was performed on patients who had undergone complex acetabular reconstruction using TM augments, IBG and a cemented cup. All patients operated between 2015 and 2019 were included. We identified 105 patients with a mean age of 74yrs. The mean follow-up was 2.3 years(1–5.5yrs). Our primary outcome measure was all-cause revision of the construct. The secondary outcome measures were, Oxford hip score (OHS), radiographic evidence of cup migration/loosening and post-op complications.

Eighty-four out of 105 patients belonged to Paprosky grade IIb, IIc or IIIa. Kaplan-Meier survivorship for all-cause revision was 96.36% (CI, 90.58–100.00) at 2 years with 3 failures. Two were due to early infection which required two-stage re-revision. The third was due to post-operative acetabular fracture which was then re-revised with TM augment, bone graft and large uncemented cup. Pre-op and post-op matched OHS scores were available for 60 hips(57%) with a mean improvement of 13 points. Radiographic analysis showed graft incorporation in all cases with no evidence of cup loosening. The mean vertical cup migration was 0.5mm (Range −5 to 7mm). No other complications were recorded.

This study shows that reconstruction of large acetabular defects during revision THA using a combination of TM augments to contain the acetabulum along with IBG to preserve the bone stock and a cemented socket is a reliable and safe technique with low revision rates and satisfactory clinical and radiographic results. Long term studies are needed to assess the possibility of preservation and regeneration of bone stock.

Medial patellofemoral ligament (MPFL) reconstruction is used to treat patellar instability and recurrent patellar dislocation. Anatomical studies have found the MPFL to be a double-bundle structure. We carried out a meta-analysis of studies reporting outcomes of patellofemoral reconstruction using hamstring tendon autograft in a double-bundle configuration and patellar fixation via mediolateral patellar tunnels.

A literature search was undertaken with no language restriction in various databases from their year of inception to July 2012. The primary outcome examined was the post-operative Kujala score. We identified 320 MPFL reconstructions in nine relevant articles. The combined mean post-operative Kujala score was 92.02 (standard error (se) 1.4, p = 0.001) using a fixed effects model and 89.45 (se 37.9, p = 0.02) using random effect modelling. The reported rate of complications with MPFL reconstruction was 12.5% (40 of 320) with stiffness of the knee being the most common. High-quality evidence in assessing double-bundle MPFL reconstruction is lacking. The current literature consists of a mixture of prospective and retrospective case series. High-quality randomised trials evaluating this procedure are still awaited.

Cite this article: Bone Joint J 2013;95-B:900–5.

Background

The association between idiopathic scoliosis and intrinsic abnormalities of the spinal cord are well known. MRI is the most sensitive imaging modality available to diagnose an intraspinal anomaly. The use of a routine ‘screening MRI’ prior to scoliosis correction is controversial.

Background

Establishing the diagnosis in a child presenting with an atraumatic limp can be difficult. Clinical prediction algorithms have been devised to distinguish septic arthritis (SA) from transient synovitis (TS). Within Europe measurement of the Erythrocyte Sedimentation Rate (ESR) has largely been replaced with assessment of C-Reactive Protein (CRP) as an acute phase protein. We produce a prediction algorithm to determine the significance of CRP in distinguishing between TS and SA.

Introduction

Many determinants of the length of stay (LOS) for primary total knee arthroplasty (TKA) have been described. Multimodal, pre-emptive analgesia, age, walking aid score and stair score are some of them. Single shot peripheral nerve block is a popular method to provide prolonged analgesia in immediate post operative period after TKA. Delayed recovery from the nerve block can delay the rehabilitation programme and subsequently lengthen the LOS when the multi disciplinary team discharge criteria are well defined and standardized.

The aim of this study is to calculate the incidence of delayed recovery from the sciatic and femoral nerve block administered in cases of primary TKA and its influence on LOS.

Background

Volar locking plates have revolutionised the treatment for distal radius fractures. The DVR (Depuy) plate was one of the earliest locking plates which were used and they provided fixed angle fixation. Recently, newer volar locking plates, such as the Aptus (Medartis), have been introduced to the market that allow the placement of independent distal subchondral variable-angle locking screws to better achieve targeted fracture fixation. The aim of our study was to compare the outcomes of DVR and Aptus volar locking plates in the treatment of distal radial fractures.

Background

Establishing the diagnosis in a child presenting with an atraumatic limp can be challenging. There is particular difficulty distinguishing septic arthritis (SA) from transient synovitis (TS) and consequently clinical prediction algorithms have been devised to differentiate the conditions using the presence of fever, raised erythrocyte sedimentation rate (ESR), raised white cell count (WCC) and inability to weight bear. Within Europe measurement of the ESR has largely been replaced with assessment of C-reactive protein (CRP) as an acute phase protein. We have evaluated the utility of including CRP in a clinical prediction algorithm to distinguish TS from SA.

Purpose

To evaluate the efficacy of Kocher's criteria to differentiate between transient synovitis and septic arthritis in children.

Clinical prediction algorithms are used to differentiate transient synovitis from septic arthritis. These algorithms typically include the erythrocyte sedimentation rate (ESR), although in clinical practice measurement of the C-reactive protein (CRP) has largely replaced the ESR. We evaluated the use of CRP in a predictive algorithm.

The records of 311 children with an effusion of the hip, which was confirmed on ultrasound, were reviewed (mean age 5.3 years (0.2 to 15.1)). Of these, 269 resolved without intervention and without long-term sequelae and were considered to have had transient synovitis. The remaining 42 underwent arthrotomy because of suspicion of septic arthritis. Infection was confirmed in 29 (18 had micro-organisms isolated and 11 had a high synovial fluid white cell count). In the remaining 13 no evidence of infection was found and they were also considered to have had transient synovitis. In total 29 hips were categorised as septic arthritis and 282 as transient synovitis. The temperature, weight-bearing status, peripheral white blood cell count and CRP was reviewed in each patient.

A CRP > 20 mg/l was the strongest independent risk factor for septic arthritis (odds ratio 81.9, p < 0.001). A multivariable prediction model revealed that only two determinants (weight-bearing status and CRP > 20 mg/l) were independent in differentiating septic arthritis from transient synovitis. Individuals with neither predictor had a < 1% probability of septic arthritis, but those with both had a 74% probability of septic arthritis. A two-variable algorithm can therefore quantify the risk of septic arthritis, and is an excellent negative predictor.