The National Joint Registry (NJR) for England & Wales provides a useful reference for hospitals to assess and compare their current practice with national figures. We aimed to identify patient and surgical factors at time of primary total knee arthroplasty (TKA) responsible for the revision. A retrospective case note review was performed of all revision TKAs performed at Musgrove Park Hospital 2005–2010. Exclusion criteria included primary TKA performed elsewhere. 38 TKAs and 13 unicompartmental knee arthroplasties (UKAs) were revised. Mean time to revision was 1.8 years and 2.1 years respectively. Reason for revision was pain or disease progression in 54% revised UKAs and infection in 53% revised TKAs. 35% infected cases were therapeutically anticoagulated, 75% ASA 3 and 50% had a BMI >30. No problems were identified with surgeon grade or level of supervision. 5 cases of revision were of a trial primary prosthesis. There were large numbers of high risk patients (increased BMI, ASA grade or on anticoagulants), which may contribute to increased infection rates and subsequent revision. We suggest avoiding trial prostheses and recommend delaying anticoagulation reintroduction until the wound is fully healed. This information may be useful for aiding with patient selection and consent.
The aim of this study was to determine the medium term survivorship and function of the Exeter Universal Hip Replacement when used in younger patients, a group that is deemed to place high demands on their arthroplasties. Since 1988 The Exeter Hip Research Unit has prospectively gathered data on all patients who have had total hip replacements at the Princess Elizabeth Orthopaedic Hospital. There were 130 Exeter Universal total hip replacements (THR) in 107 patients who were 50 years or younger at the time of surgery and whose surgery was performed at least 10 years before. Mean age at surgery was 42 years (range 17-50 years.) Six patients who had 7 THRs had died, leaving 123 THRs for review. Patients were reviewed at an average of 12.5 years (range 10-17 years). No patient was lost to follow-up. At review, 12 hips had been revised. Of these, 9 were for aseptic loosening of the acetabular component and one cup was revised for focal lysis and pain. One hip was revised for recurrent dislocation. One femoral component required revision in 1 case of infection. Radiographs showed that a further 11 (10%) of the remaining acetabular prostheses were loose but that no femoral components were loose. Survivorship of stem and cup from all causes was 94%, at an average of 12.5 years. Survivorship of stem only from all causes was 99% and from aseptic loosening was 100%.Aim
Results
The aim of this study was to investigate the use of large diameter head THR to treat fractured neck of femur, and to demonstrate if this conferred greater stability. Forty-six (46) independent, mentally alert patients with displaced intracapsular fractures underwent THR. Mean age was 72.1 years. Outcome measures were dislocation, reoperation/ revision rate, Oxford hip score (OHS), Euroqol (EQ-5D) and residential status. Data was collected prospectively, with review being carried out at 3 months and 1 year. At mean follow-up (12.5 months) there were no dislocations. Reoperation, revision and infection rate were all 0%. Two patients died (4.3%). Mean pre-injury and postoperative OHS were 12.1 and 17.9 respectively. Mean pre-injury and postoperative EQ-5D index scores were 0.97 and 0.83 respectively. Mean postoperative walking distance was 2.5 miles. There were no changes in residential status. This is the first published series utilizing 36-mm diameter metal-on-metal THR for the treatment of fractured neck of femur. We have demonstrated that it affords patients excellent stability with no recorded dislocations.
Of the survivors four of the HEMI group were revised to total hip arthroplasty. One patient had been revised in the THA group. Radiographically six of seven patients in the HEMI group had evidence of acetabular erosion and 13 of 15 patients in the THA group had a lucency around their acetabular component.
We reviewed the seven- to ten-year results of our previously reported prospective randomised controlled trial comparing total hip replacement and hemiarthroplasty for the treatment of displaced intracapsular fracture of the femoral neck. Of our original study group of 81 patients, 47 were still alive. After a mean follow up of nine years (7 to 10) overall mortality was 32.5% and 51.2% after total hip replacement and hemiarthroplasty, respectively (p = 0.09). At 100 months postoperatively a significantly greater proportion of hemiarthroplasty patients had died (p = 0.026). Three hips dislocated following total hip replacement and none after hemiarthroplasty. In both the total hip replacement and hemiarthroplasty groups a deterioration had occurred in walking distance (p = 0.02 and p <
0.001, respectively). One total hip replacement required revision compared with four hemiarthroplasties which were revised to total hip replacements. All surviving patients with a total hip replacement demonstrated wear of the cemented polyethylene component and all hemiarthroplasties had produced acetabular erosion. There was lower mortality (p = 0.013) and a trend towards superior function in patients with a total hip replacement in the medium term.
The aim of this study was to investigate the use of large diameter head THR to treat fractured neck of femur, and to demonstrate if this conferred greater stability. 46 independent, mentally alert patients with displaced intracapsular fractures underwent THR. Mean age was 72.1 years. Outcome measures were dislocation, reoperation/ revision rate, Oxford hip score (OHS), Euroqol (EQ-5D) and residential status. Data was collected prospectively, with review being carried out at 3 months and 1 year. At mean follow-up (12.5 months) there were no dislocations. Reoperation, revision and infection rate were all 0%. Two patients died (4.3%). Mean pre-injury and postoperative OHS were 12.1 and 17.9 respectively. Mean pre-injury and postoperative EQ-5D index scores were 0.97 and 0.83 respectively. Mean postoperative walking distance was 2.5 miles. There were no changes in residential status. This is the first published series utilising 36-mm diameter metal-on-metal THR for the treatment of fractured neck of femur. We have demonstrated that it affords patients excellent stability with no recorded dislocations.
Dislocation is a major concern following total hip replacement (THR) for fractured neck of femur. The aim of this prospective study was to investigate the use of large diameter femoral head uncemented THR to treat fractured neck of femur, and to demonstrate if the improved stability seen in previous clinical situations with these designs, can be used to benefit this difficult subgroup of patients that are particularly prone to dislocation. Forty-six consecutive independent, active and mentally alert patients with displaced intracapsular fractured neck of femur underwent large diameter head uncemented THR. The mean age of patients was 72.1 years. The outcome measures used were the dislocation rate, reoperation and revision rate, Oxford hip score (OHS), Euroqol (EQ-5D) and residential status. Clinical and radiological data were available on all 46 patients. At a mean follow-up of 12.5 months there were no dislocations. The reoperation, revision and infection rate were all 0%. Two patients died (4.3%) from unrelated causes. Mean pre- and postoperative OHS were 12.1 and 17.9 respectively. The mean pre- and postoperative EQ-5D index scores were 0.97 and 0.83 respectively. The mean postoperative walking distance was 2.5 miles and there were no changes in residential status. This is the first published series utilising a 36-mm diameter metal-on-metal THR for the treatment of fractured neck of femur in mobile, independent patients. We have demonstrated that it affords patients excellent stability with no recorded dislocations.
Dislocation is a major concern following THR for fractured neck of femur. The aim of this prospective study was to investigate the use of large diameter femoral head uncemented THR to treat fractured neck of femur, and to demonstrate if the improved stability seen in previous clinical situations with these designs, can be used to benefit this difficult subgroup of patients that are particularly prone to dislocation. Forty-six consecutive independent, active and mentally alert patients with displaced intracapsular fractured neck of femur underwent large diameter head uncemented THR. The mean age of patients was 72.1 years. The outcome measures used were the dislocation rate, reoperation and revision rate, Oxford hip score (OHS), EuroQol (EQ-5D) and residential status. Clinical and radiological data were available on all 46 patients. At a mean follow-up of 12.5 months there were no dislocations. There were no reoperations, revisions or infections. Two patients died (4.3%) from unrelated causes. Mean pre- and postoperative OHS were 12.1 and 17.9 respectively. The mean pre- and postoperative EQ-5D index scores were 0.97 and 0.83 respectively. The mean postoperative walking distance was 2.5 miles and there were no changes in residential status. This is the first published series utilising a 36-mm diameter metal-on-metal THR for the treatment of fractured neck of femur in mobile, independent patients. We have demonstrated that it affords patients excellent stability with no recorded dislocations.
We have reviewed 22 patients at a mean of 30 years (28 to 31) after a whiplash injury. A complete recovery had been made in ten (45.5%) while one continued to describe severe symptoms. Persistent disability was associated with psychological distress but both improved in the period between 15 and 30 years after injury. After 30 years, ten patients (45.5%) were more disabled by knee than by neck pain.
The use of arthroplasty registers was initiated by Sweden in 1979. The practice has been adopted globally as best practice for recording the outcome of joint replacement surgery and for identifying early problems. The Trent and Wales Arthroplasty Audit Group began in 1990 and have recently produced outcome results. We have analysed the short-term outcomes of arthroplasty procedures at a DGH in order to assess comparability to this “gold-standard”. In 2004, 231 primary arthroplasties were performed, by the two senior authors, at Musgrove Park Hospital (149 THR, 82 TKR). There was an overall complication rate of 8.7%. There was 1 periprosthetic infection in a THR that required revision (0.043%). 9 patients developed wound complications, principally superficial infections and haematoma formation. 2 patients, both THR developed, thromboembolic complications, one DVT and one pulmonary embolus. There was one periprosthetic fracture around a THR. The dislocation rate for THR was 3.35% (5/149). 3 of these were performed through a posterior approach and 2 through an anterolateral. 3 have required revision surgery. We have demonstrated comparable results following joint arthroplasty to published teaching hospital series. We have shown that adequate infrastructure can exist in smaller units to accurately record outcome data following arthroplasty surgery.
We sought to establish whether HEMI or THA gave better results in independent mobile patients with displaced femoral neck fracture.
After THA, three patients died, three dislocated, one required revision. Mean walking distance was 2.23 miles and OHS was 18.8. There was no radiological evidence of polyethylene wear Patients with THAs after three years walked further (p=0.039) and had a lower OHS (p=0.033).
THA is a preferable option to HEMI in independent mobile elderly patients with displaced intracapsular femoral neck fracture.
The National Institute for Clinical Excellence (NICE) was set up to provide patients, health professionals and the public with authoritative, robust and reliable guidance on current “best practice”. To determine how useful for NICE guidelines for Selection of Prostheses for Primary Total Hip Replacement were to patients who were undergoing total hip replacement (THR) and the health professionals who were looking after them. We surveyed 100 patients, 50 Orthopaedic Surgeons, 40 Orthopaedic nurses and posted a questionnaire to GPs, to which 79 replied (56% response rate). 19% of patients had heard of NICE but only 2% were aware of the existence of NICE guidelines on THR and 1% found them useful. Almost all orthopaedic surgeons had heard of NICE and their guidelines for THR, with 74% knowing what the guidelines actually stated but only 14% finding them useful. 78% of surgeons believed that their preferred hip replacement conformed to NICE guidelines, 2% knew that they did not conform and 20% did not know. 27% of general practitioners knew of the guidelines, but only 5% knew what they actually stated and 1% found them useful in their practice. Most nursing staff working in orthopaedic areas had heard of NICE (83%). 43% knew of the NICE guidelines but only 13% knew the actual guidelines and % found them useful. NICE has failed to communicate its guidelines to both patients and the public. None of the groups found the guidelines useful. NICE has failed to fulfil its mission statement and may instead have other motives, such as empowering centralised regulation of healthcare in the NHS.
Arthroplasty is the most effective management of displaced intracapsular femoral neck fracture. Hemiarthroplasty (HEMI) is associated with acetabular erosion and loosening in mobile patients and total hip arthroplasty (THA) with instability. We sought to establish whether HEMI or THA gave better results in independent mobile patients with displaced intracapsular femoral neck fracture. Eighty-two patients were randomised into two groups. One arm received a modular HEMI, the second a THA using the same femoral stem. Patients were followed for a mean of three years after surgery. After HEMI, eight patients died, two were revised to THA and there is intention to revise three. One patient had a periprosthetic fracture. Mean walking distance was 1.08 miles and Oxford Hip Score (OHS) 22.5. Twenty patients (64.5% of survivors) had radiological evidence of acetabular erosion. After THA, four patients died, three dislocated, one required revision. Mean walking distance was 2.23 miles and OHS was 18.8. HEMI is associated with a higher rate of revision than THA and potential revision because of acetabular erosion. THA after three years displayed superior walking distances (p=0.039) and lower OHS (p=0.033). THA is a preferable option to HEMI in independent mobile elderly patients with displaced intracapsular femoral neck fracture.
The National Institute for Clinical Excellence (NICE) was set up in the UK ‘to provide patients, health professionals and the public with authoritative, robust and reliable guidance on current best practice. In March 2000, NICE provided national guidelines for the selection of prostheses for total hip replacement.
The aim of this study was to examine causes of the failed knee arthroplasty. Since 1980 the Bristol Knee Replacement Registry has prospectively recorded data on 3024 patients. Complete original and 5 year follow up data was available on 999 knees. The surgery was judged a failure if there was no improvement in the American Knee Society score at 5 years or if there had been a revision within that time. The prosthesis used was Kinematic in 471 knees, the Medial Unicompartmental Sled in 258 knees, the Kinemax Plus in 134 knees and a variety of other designs. At 5 years, 79 (7. 9%) either showed no improvement in the American Knee Society score or had been revised. The failure rate was 7% for the Kinematic, 7% for the medial Sled and 5% for the Kinemax Plus. 20% of the less frequently used designs failed. Five (0. 5%) knee replacements failed because of infection. 22 knees (2. 2%) had significant comorbidity that precluded a satisfactory functional outcome. For 7 knees (0. 7%), the patient exhibited patterns of abnormal illness behaviour that were thought to explain the poor outcome. A further 27 knees (2. 7%) failed because of technical errors either at the time of surgery (13 cases, 1. 3%), or in selecting a prosthesis which failed prematurely (14 cases 1. 4%). No cause for failure could be identified in 12 cases (1. 2%). The high failure rate amongst infrequently used prosthesis emphasises the need to use established designs. No cause for failure could be identified in 12 cases and 5 were due to infection; such cases are hard to avoid. This study shows the importance of assessing both the overall physical and psychological state of the patient if disappointing results are to be avoided. The most frequent cause of an unsatisfactory outcome was a technical one, which should be avoidable.
The aim of this study was to determine the medium term survivorship and function of the cemented Exeter Universal Hip Replacement when used in younger patients. Since 1988 The Exeter Hip Research Unit has prospectively gathered data on all patients who have had total hip replacements at the Princess Elizabeth Orthopaedic Hospital. There were 88 Exeter Universal total hip replacements (THR) in 71 patients who were 50 years or younger at the time of surgery and whose surgery was performed at least 10 years before. 25 surgeons performed the surgery. Mean age at surgery was 43 years (range 24 to 50 years. ) 5 patients who had 7 THRs had died leaving 81 THRs for review. Patients were reviewed in clinic at an average of 11. 4 years (10 – 13 years). No patient was lost to follow up. At review, 8 hips had been revised. 5 cases were for loose cemented metal backed acetabular prosthesis. Two femoral components were revised for infection and one for aseptic loosening. Radiographs showed that a further 10 (13%) acetabular prosthesis were loose and that 3 femurs showed significant osteolysis. Overall 10-year survivorship of stem and cup from all causes was 93%. The 10-year survivorship of stem only from all causes was 98% and from aseptic loosening was 99%. The Exeter Universal Stem performs extremely well in the younger patient. However the high failure rate of the cemented metal backed Exeter acetabular component has compromised the overall results in this series.
We describe 24 fractures of the tuberosity of the calcaneus in 22 patients. Three were similar to the type of avulsion fracture which has been well-defined but the remainder represent a group which has been unrecognised previously. Using CT and operative findings we have defined the different patterns of fracture of the calcaneal tuberosity. Ten fractures extended into the subtalar joint, but did not fit the pattern of the common intra-articular fracture as described classically. We have defined a new pattern which consists of a fracture of the medial calcaneal process with a further fracture which separates the upper part of the tuberosity in the semicoronal plane. Non-operative treatment of displaced fractures resulted in a mis-shapen heel and a poor functional outcome. Open reduction and internal fixation with either a plate or compression screw did not give satisfactory fixation. We prefer to use an oblique lateral tension-band wire. This technique gave excellent fixation and we recommend it for the treatment of displaced fractures of the tuberosity of the calcaneus.
Forty patients with a whiplash injury who had been reviewed previously 2 and 10 years after injury were assessed again after a mean of 15.5 years by physical examination, pain and psychometric testing. Twenty-eight (70%) continued to complain of symptoms referable to the original accident. Neck pain was the commonest, but low-back pain was present in half. Women and older patients had a worse outcome. Radiating pain was more common in those with severe symptoms. Evidence of psychological disturbance was seen in 52% of patients with symptoms. Between 10 and 15 years after the accident 18% of the patients had improved whereas 28% had deteriorated.
