Showing papers in "Journal of Bone and Joint Surgery-british Volume in 2013"
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TL;DR: This paper summaries the instigation, conduct and findings of a recent International Consensus Meeting on Surgical Site and Periprosthetic Joint Infection.
Abstract: Louis Pasteur once said that: “Fortune favours
the prepared mind.” As one of the great scientists who contributed
to the fight against infection, he emphasised the importance of
being prepared at all times to recognise infection and deal with
it. Despite the many scientific discoveries and technological advances,
such as the advent of antibiotics and the use of sterile techniques,
infection continues to be a problem that haunts orthopaedic surgeons
and inflicts suffering on patients. The medical community has implemented many practices with the
intention of preventing infection and treating it effectively when
it occurs. Although high-level evidence may support some of these
practices, many are based on little to no scientific foundation.
Thus, around the world, there is great variation in practices for
the prevention and management of periprosthetic joint infection. This paper summaries the instigation, conduct and findings of
a recent International Consensus Meeting on Surgical Site and Periprosthetic
Joint Infection. Cite this article: Bone Joint J 2013;95-B:1450–2.
766 citations
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TL;DR: It is concluded that primary glenohumeral OA is associated with significantly smaller degenerative RCTs with significantly larger CSAs than asymptomatic shoulders without these pathologies, and individual quantitative anatomy may imply biomechanics that are likely to induce specific types of degenerative joint disorders.
Abstract: We hypothesised that a large acromial cover with an upwardly tilted glenoid fossa would be associated with degenerative rotator cuff tears (RCTs), and conversely, that a short acromion with an inferiorly inclined glenoid would be associated with glenohumeral osteoarthritis (OA). This hypothesis was tested using a new radiological parameter, the critical shoulder angle (CSA), which combines the measurements of inclination of the glenoid and the lateral extension of the acromion (the acromion index). The CSA was measured on standardised radiographs of three groups: 1) a control group of 94 asymptomatic shoulders with normal rotator cuffs and no OA; 2) a group of 102 shoulders with MRI-documented full-thickness RCTs without OA; and 3) a group of 102 shoulders with primary OA and no RCTs noted during total shoulder replacement. The mean CSA was 33.1° (26.8° to 38.6°) in the control group, 38.0° (29.5° to 43.5°) in the RCT group and 28.1° (18.6° to 35.8°) in the OA group. Of patients with a CSA > 35°, 84% were in the RCT group and of those with a CSA < 30°, 93% were in the OA group. We therefore concluded that primary glenohumeral OA is associated with significantly smaller degenerative RCTs with significantly larger CSAs than asymptomatic shoulders without these pathologies. These findings suggest that individual quantitative anatomy may imply biomechanics that are likely to induce specific types of degenerative joint disorders.
377 citations
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TL;DR: This study provides up-to-date cost-effectiveness data for total joint replacement, which is extremely effective both clinically and in terms of cost effectiveness, with costs that compare favourably to those of other medical interventions.
Abstract: The aim of this study was to perform a cost–utility
analysis of total hip (THR) and knee replacement (TKR). Arthritis is
a disabling condition that leads to long-term deterioration in quality
of life. Total joint replacement, despite being one of the greatest
advances in medicine of the modern era, has recently come under
scrutiny. The National Health Service (NHS) has competing demands,
and resource allocation is challenging in times of economic restraint. Patients
who underwent THR (n = 348) or TKR (n = 323) between January and
July 2010 in one Scottish region were entered into a prospective
arthroplasty database. A health–utility score was derived from the
EuroQol (EQ-5D) score pre-operatively and at one year, and was combined
with individual life expectancy to derive the quality-adjusted life years
(QALYs) gained. Two-way analysis of variance was used to compare
QALYs gained between procedures, while controlling for baseline
differences. The number of QALYs gained was higher after THR than
after TKR (6.5 vs 4.0 years, p < 0.001). The
cost per QALY for THR was £1372 compared with £2101 for TKR. The
predictors of an increase in QALYs gained were poorer health before
surgery (p < 0.001) and younger age (p < 0.001). General health
(EQ-5D VAS) showed greater improvement after THR than after TKR
(p < 0.001). This study provides up-to-date cost-effectiveness
data for total joint replacement. THR and TKR are extremely effective
both clinically and in terms of cost effectiveness, with costs that
compare favourably to those of other medical interventions. Cite this article: Bone Joint J 2013;95-B:115–21.
295 citations
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TL;DR: Patient-specific positioning guides can assist in achieving a neutral mechanical axis with reduction in outliers and is a multifaceted new tool in achieving traditional goals of TKA.
Abstract: Background: Coronal malalignment occurs frequently in total knee arthroplasty (TKA) and reduces implant longevity and function. Designed to improve consistency and efficiency, patient- specific positioning guides (PSPG) generated from preoperative imaging studies represent a paradigm shift from manual instrumentation (MI) and intraoperative computer navigation. Purposes: We compare the efficacy of PSPG to MI in (1) restoring mechanical axis of the extremity and (2) achieving neutral alignment of the femoral and tibial components. Methods: We retrospectively examined 696 postoperative anteroposterior standing long-leg radiographs after TKA (545 PSPG, 151 MI) by two surgeons. Coronal alignment was assessed by determining the zone in which the overall mechanical axis (OMA) passed through the knee, measuring the hip-knee-ankle (HKA) angle between the tibial and femoral mechanical axes, and finally, noting the alignment of the femoral and tibial components with respect to their mechanical axes. Results: The OMA passed through the central third more frequently with PSPG than MI for both surgeons (JHD: 86.6% vs. 77%, p = 0.02; AVL: 86.4% vs. 74.5%, p = 0.11). For the senior author, while percent of HKA outliers >3i,° was similar between PSPG and MI, the mean error from neutral for these patients was significantly less with PSPG than MI (4.50i,° vs. 5.25i,°, p = 0.0031). The tibial component demonstrated no significant difference between PSPG and MI. With PSPG, average individual deviation from neutral for the femoral component was significantly less (0.91i,° vs. 1.34i,°, p = 0.0005) and had fewer outliers >2i,° (4.9% vs. 19.6%, p = 0.017). Discussion: Improved coronal alignment in total knee arthroplasty (TKA) is associated with greater patient satisfaction, better functional scores and increased implant longevity [11,30,31,36]. Recently, preoperative three-dimensional imaging and custom manufacturing have enabled the development of patient-specific positioning guides (PSPG). Designed to improve consistency and efficiency, PSPG represents a paradigm shift away from intramedullary and extramedullary guides, or manual instrumentation (MI), and an evolution from intraoperative computer-assisted navigation (CAN). Even in the hands of experienced surgeons, MI frequently results in significant component angulation and mechanical axis malalignment [32]. Multiple studies support the restoration of a neutral axis as a critical factor in implant performance and potential longevity of total knee arthroplasty [2, 3, 5, 18, 41, 44]. Intraoperative CAN has been shown to improve precision and accuracy of alignment compared to MI with a reduction in the number of outliers (less than 3i,° varus/valgus) [32, 38] and the amount of blood loss [39], but is hindered by time-consuming landmark registration, increased operative length [7], greater cost, the risk for stress fracture, pin loosening, and a substantial learning curve [6, 22, 29, 43]. Patient-specific positioning guides, on the other hand, purportedly eliminate many of the disadvantages of CAN while still allowing the bone resections to match the measured overall mechanical axis. While accurate and precise alignment guides are potent tools in restoring the proper overall mechanical axis, they are not a substitute for careful preoperative planning, good clinical and intraoperative judgment, appropriate soft tissue balancing, and precise implantation technique. Nevertheless, patient-specific positioning guides can provide the first step in the right direction to a successful TKA. Conclusions: Patient-specific positioning guides can assist in restoration of the mechanical axis with reduction in outliers. Level of Evidence: Level III, retrospective case-control study
267 citations
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TL;DR: This study demonstrates that TAR has a positive impact on patients' lives, with benefits lasting ten years, as judged by improvement in pain and function, as well as improved gait and increased range of movement.
Abstract: We performed a systematic review and meta-analysis
of modern total ankle replacements (TARs) to determine the survivorship,
outcome, complications, radiological findings and range of movement,
in patients with end-stage osteoarthritis (OA) of the ankle who
undergo this procedure. We used the methodology of the Cochrane Collaboration,
which uses risk of bias profiling to assess the quality of papers
in favour of a domain-based approach. Continuous outcome scores
were pooled across studies using the generic inverse variance method
and the random-effects model was used to incorporate clinical and
methodological heterogeneity. We included 58 papers (7942 TARs)
with an interobserver reliability (Kappa) for selection, performance,
attrition, detection and reporting bias of between 0.83 and 0.98.
The overall survivorship was 89% at ten years with an annual failure
rate of 1.2% (95% confidence interval (CI) 0.7 to 1.6). The mean
American Orthopaedic Foot and Ankle Society score changed from 40 (95%
CI 36 to 43) pre-operatively to 80 (95% CI 76 to 84) at a mean follow-up
of 8.2 years (7 to 10) (p < 0.01). Radiolucencies were identified
in up to 23% of TARs after a mean of 4.4 years (2.3 to 9.6). The
mean total range of movement improved from 23° (95% CI 19 to 26)
to 34° (95% CI 26 to 41) (p = 0.01). Our study demonstrates that TAR has a positive impact on patients’
lives, with benefits lasting ten years, as judged by improvement
in pain and function, as well as improved gait and increased range
of movement. However, the quality of evidence is weak and fraught
with biases and high quality randomised controlled trials are required
to compare TAR with other forms of treatment such as fusion. Cite this article: Bone Joint J 2013;95-B:1500–7.
256 citations
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TL;DR: It would appear that satisfaction is better after more chronic diseases and whether the TKR results in pain relief or improved function and it may be possible to improve rates by addressing the issues surrounding pain, function and expectation before embarking on surgery.
Abstract: Satisfaction is increasingly employed as an outcome
measure for a successful total knee replacement (TKR). Satisfaction
as an outcome measure encompasses many different intrinsic and extrinsic
factors related to a person’s experience before and after TKR. The
Swedish Knee Arthroplasty Registry has previously demonstrated on
a large population study that 17% of TKR recipients are not satisfied
with their TKR outcome. This finding has been replicated in other
countries. Similar significant factors emerged from these registry
studies that are related to satisfaction. It would appear that satisfaction
is better after more chronic diseases and whether the TKR results
in pain relief or improved function. Importantly, unmet pre-operative
expectations are a significant predictor for dissatisfaction following
a TKR. It may be possible to improve rates by addressing the issues
surrounding pain, function and expectation before embarking on surgery. Cite this article: Bone Joint J 2013;95-B, Supple
A:148–52.
228 citations
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TL;DR: This review discusses the mechanism of disease, symptoms and signs, investigations, current management protocols and potential new treatments ofateral epicondylitis.
Abstract: Lateral epicondylitis, or ’tennis elbow’, is
a common condition that usually affects patients between 35 and
55 years of age. It is generally self-limiting, but in some patients
it may continue to cause persistent symptoms, which can be refractory
to treatment. This review discusses the mechanism of disease, symptoms
and signs, investigations, current management protocols and potential
new treatments. Cite this article: Bone Joint J 2013;95-B:1158–64.
201 citations
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TL;DR: It is demonstrated that both PSCGs and conventional instrumentation restore limb alignment and place the components with the similar accuracy and the minimal advantages of PSCG in terms of consistency of alignment or operative time are unlikely to be clinically relevant.
Abstract: Patient-specific cutting guides (PSCGs) are designed to improve the accuracy of alignment of total knee replacement (TKR). We compared the accuracy of limb alignment and component positioning after TKR performed using PSCGs or conventional instrumentation. A total of 80 patients were randomised to undergo TKR with either of the different forms of instrumentation, and radiological outcomes and peri-operative factors such as operating time were assessed. No significant difference was observed between the groups in terms of tibiofemoral angle or femoral component alignment. Although the tibial component in the PSCGs group was measurably closer to neutral alignment than in the conventional group, the size of the difference was very small (89.8° (sd 1.2) vs 90.5° (sd 1.6); p = 0.030). This new technology slightly shortened the bone-cutting time by a mean of 3.6 minutes (p < 0.001) and the operating time by a mean 5.1 minutes (p = 0.019), without tangible differences in post-operative blood loss (p = 0.528) or need for blood transfusion (p = 0.789). This study demonstrated that both PSCGs and conventional instrumentation restore limb alignment and place the components with the similar accuracy. The minimal advantages of PSCGs in terms of consistency of alignment or operative time are unlikely to be clinically relevant.
173 citations
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TL;DR: It is concluded that there is a considerable need for further prospective randomised trials to facilitate informed decision-making with regard to the use of current and future bone graft substitutes in clinical practice.
Abstract: We reviewed 59 bone graft substitutes marketed by 17 companies currently available for implantation in the United Kingdom, with the aim of assessing the peer-reviewed literature to facilitate informed decision-making regarding their use in clinical practice. After critical analysis of the literature, only 22 products (37%) had any clinical data. Norian SRS (Synthes), Vitoss (Orthovita), Cortoss (Orthovita) and Alpha-BSM (Etex) had Level I evidence. We question the need for so many different products, especially with limited published clinical evidence for their efficacy, and conclude that there is a considerable need for further prospective randomised trials to facilitate informed decision-making with regard to the use of current and future bone graft substitutes in clinical practice.
173 citations
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TL;DR: Early results show that the MCGR is safe and effective in the treatment of progressive early-onset scoliosis with the avoidance of repeated surgical lengthenings.
Abstract: Conventional growing rods are the most commonly
used distraction-based devices in the treatment of progressive early-onset
scoliosis. This technique requires repeated lengthenings with the
patient anaesthetised in the operating theatre. We describe the
outcomes and complications of using a non-invasive magnetically
controlled growing rod (MCGR) in children with early-onset scoliosis.
Lengthening is performed on an outpatient basis using an external remote
control with the patient awake. Between November 2009 and March 2011, 34 children with a mean
age of eight years (5 to 12) underwent treatment. The mean length
of follow-up was 15 months (12 to 18). In total, 22 children were
treated with dual rod constructs and 12 with a single rod. The mean
number of distractions per patient was 4.8 (3 to 6). The mean pre-operative
Cobb angle was 69° (46° to 108°); this was corrected to a mean 47°
(28° to 91°) post-operatively. The mean Cobb angle at final review
was 41° (27° to 86°). The mean pre-operative distance from T1 to
S1 was 304 mm (243 to 380) and increased to 335 mm (253 to 400)
in the immediate post-operative period. At final review the mean distance
from T1 to S1 had increased to 348 mm (260 to 420). Two patients developed a superficial wound infection and a further
two patients in the single rod group developed a loss of distraction.
In the dual rod group, one patient had pull-out of a hook and one
developed prominent metalwork. Two patients had a rod breakage;
one patient in the single rod group and one patient in the dual
rod group. Our early results show that the MCGR is safe and effective
in the treatment of progressive early-onset scoliosis with the avoidance
of repeated surgical lengthenings. Cite this article: Bone Joint J 2013;95-B:75–80.
167 citations
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TL;DR: Computer navigation-assisted surgery is safe and has reduced the intralesional resection rate for primary tumours of the pelvis and sacrum, and is recommended as being worthy of further consideration for this group of patients.
Abstract: We hypothesised that the use of computer navigation-assisted surgery for pelvic and sacral tumours would reduce the risk of an intralesional margin. We reviewed 31 patients (18 men and 13 women) with a mean age of 52.9 years (13.5 to 77.2) in whom computer navigation-assisted surgery had been carried out for a bone tumour of the pelvis or sacrum. There were 23 primary malignant bone tumours, four metastatic tumours and four locally advanced primary tumours of the rectum. The registration error when using computer navigation was < 1 mm in each case. There were no complications related to the navigation, which allowed the preservation of sacral nerve roots (n = 13), resection of otherwise inoperable disease (n = 4) and the avoidance of hindquarter amputation (n = 3). The intralesional resection rate for primary tumours of the pelvis and sacrum was 8.7% (n = 2): clear bone resection margins were achieved in all cases. At a mean follow-up of 13.1 months (3 to 34) three patients (13%) had developed a local recurrence. The mean time alive from diagnosis was 16.8 months (4 to 48). Computer navigation-assisted surgery is safe and has reduced our intralesional resection rate for primary tumours of the pelvis and sacrum. We recommend this technique as being worthy of further consideration for this group of patients.
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TL;DR: Good clinical and radiological results can be expected for bone-deficient acetabula treated by a TM cup and augment, but for pelvic discontinuities this might not be a reliable option.
Abstract: Trabecular metal (TM) augments are a relatively
new option for reconstructing segmental bone loss during acetabular
revision. We studied 34 failed hip replacements in 34 patients that
were revised between October 2003 and March 2010 using a TM acetabular
shell and one or two augments. The mean age of the patients at the
time of surgery was 69.3 years (46 to 86) and the mean follow-up
was 64.5 months (27 to 107). In all, 18 patients had a minor column
defect, 14 had a major column defect, and two were associated with
pelvic discontinuity. The hip centre of rotation was restored in
27 patients (79.4%). The Oxford hip score increased from a mean
of 15.4 points (6 to 25) before revision to a mean of 37.7 (29 to
47) at the final follow-up. There were three aseptic loosenings
of the construct, two of them in the patients with pelvic discontinuity.
One septic loosening also occurred in a patient who had previously
had an infected hip replacement. The augments remained stable in
two of the failed hips. Whenever there was a loose acetabular component
in contact with a stable augment, progressive metal debris shedding
was evident on the serial radiographs. Complications included another
deep infection treated without revision surgery. Good clinical and
radiological results can be expected for bone-deficient acetabula
treated by a TM cup and augment, but for pelvic discontinuities
this might not be a reliable option. Cite this article: Bone Joint J 2013;95-B:166–72.
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TL;DR: The authors examined the association of graft type with the risk of early revision of ACL reconstruction in a community-based sample and concluded that allograft, tendon autografts, and younger age may all increase the risk for ACLR.
Abstract: We examined the association of graft type with
the risk of early revision of primary anterior cruciate ligament reconstruction
(ACLR) in a community-based sample. A retrospective analysis of
a cohort of 9817 ACLRs recorded in an ACLR Registry was performed.
Patients were included if they underwent primary ACLR with bone–patellar tendon–bone
autograft, hamstring tendon autograft or allograft tissue. Aseptic
failure was the main endpoint of the study. After adjusting for
age, gender, ethnicity, and body mass index, allografts had a
3.02 times (95% confidence interval (CI) 1.93 to 4.72) higher risk
of aseptic revision than bone–patellar tendon–bone autografts (p
< 0.001). Hamstring tendon autografts had a 1.82 times (95% CI
1.10 to 3.00) higher risk of revision compared with bone–patellar
tendon–bone autografts (p = 0.019). For each year increase in age,
the risk of revision decreased by 7% (95% CI 5 to 9). In gender-specific
analyses a 2.26 times (95% CI 1.15 to 4.44) increased risk of hamstring
tendon autograft revision in females was observed compared with
bone–patellar tendon–bone autograft. We conclude that allograft
tissue, hamstring tendon autografts, and younger age may all increase
the risk of early revision surgery after ACLR. Cite this article: Bone Joint J 2013;95-B:623–8.
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TL;DR: In this paper, a prospective randomized trial on 128 patients with end-stage osteoarthritis was conducted to assess the accuracy of patient-specific guides, including A1 Signature, A2 Trumatch, A3 Visionaire and A4 PSI.
Abstract: A prospective randomized trial on 128 patients with end-stage osteoarthritis was conducted to assess the accuracy of patient-specific guides. In cohort A (n = 64), patient- specific guides from four different manufacturers (Subgroup A1 Signature ®, A2 Trumatch ®, A3 Visionaire ® and A4 PSI ®) were used to guide the bone cuts. Surgical navigation was used as an intraoperative control for outliers. In cohort B (n = 64), conventional instrumentation was used. All patients of cohorts A and B underwent a postoperative full-leg standing X-ray and CT scan for measuring overall coronal alignment of the limb and three-planar alignment of the femoral and the tibial component. Three-planar alignment was the primary endpoint. Deviation of more than three degrees from the target in any plane, as measured with surgical navigation or radiologic imaging, was defined as an outlier. In 14 patients (22%) of cohort A, the use of the patient-specific guide was abandoned because of outliers in more than one plane. In 18 patients (28%), a correction of the position indicated by the guide, was made in at least one plane. A change in cranial-caudal position was most common. Cohort A and B showed a similar percentage of outliers in long-leg coronal alignment (24.6%, 28.1%, p = 0.69), femoral coronal alignment (6.6%, 14.1%, p = 0.24) and femoral axial alignment (23%, 17.2%, p = 0.50). Cohort A had more outliers in coronal tibial alignment (14.6%) and sagittal tibial alignment (21.3%) than cohort B (3.1%, p = 0.03 and 3.1%, p = 0.002, respectively). These data indicate that patient specific guides do not improve accuracy in total knee arthroplasty.
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TL;DR: Analysis appears to show that the Ilizarov method of distraction osteogenesis significantly reduced the risk of deep infection in infected osseous lesions, and is demanding for patients, which underlines the need for careful patient selection.
Abstract: We carried out a systematic review of the literature
to evaluate the evidence regarding the clinical results of the Ilizarov
method in the treatment of long bone defects of the lower limbs. Only 37 reports (three non-randomised comparative studies, one
prospective study and 33 case-series) met our inclusion criteria.
Although several studies were unsatisfactory in terms of statistical
heterogeneity, our analysis appears to show that the Ilizarov method
of distraction osteogenesis significantly reduced the risk of deep
infection in infected osseous lesions (risk ratio 0.14 (95% confidence
interval (CI) 0.10 to 0.20), p < 0.001). However, there was a
rate of re-fracture of 5% (95% CI 3 to 7), with a rate of neurovascular
complications of 2.2% (95% CI 0.3 to 4) and an amputation rate of
2.9% (95% CI 1.4 to 4.4).The data was generally not statistically
heterogeneous. Where tibial defects were > 8 cm, the risk of re-fracture
increased (odds ratio 3.7 (95% CI 1.1 to 12.5), p = 0.036). The technique is demanding for patients, illustrated by the voluntary
amputation rate of 1.6% (95% CI 0 to 3.1), which underlines the
need for careful patient selection. Cite this article: Bone Joint J 2013;95-B:1673–80.
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TL;DR: Post-operative Oxford knee score trends may assist surgeons in advising patients of their expected outcomes, as well as providing a comparative benchmark for evaluating longer-term outcomes following knee replacement.
Abstract: The Oxford knee score (OKS) is a validated and
widely accepted disease-specific patient-reported outcome measure,
but there is limited evidence regarding any long-term trends in
the score. We reviewed 5600 individual OKS questionnaires (1547
patients) from a prospectively-collected knee replacement database,
to determine the trends in OKS over a ten-year period following
total knee replacement. The mean OKS pre-operatively was 19.5 (95%
confidence interval (CI) 18.8 to 20.2). The maximum post-operative
OKS was observed at two years (mean score 34.4 (95% CI 33.7 to 35.2)),
following which a gradual but significant decline was observed through
to the ten-year assessment (mean score 30.1 (95% CI 29.1 to 31.1))
(p < 0.001). A similar trend was observed for most of the individual
OKS components (p < 0.001). Kneeling ability initially improved
in the first year but was then followed by rapid deterioration (p
< 0.001). Pain severity exhibited the greatest improvement, although
residual pain was reported in over two-thirds of patients post-operatively,
and peak improvement in the night pain component did not occur until
year four. Post-operative OKS was lower for women (p < 0.001),
those aged < 60 years (p < 0.003) and those with a body mass
index > 35 kg/m 2 (p < 0.014), although similar changes
in scores were observed. This information may assist surgeons in
advising patients of their expected outcomes, as well as providing
a comparative benchmark for evaluating longer-term outcomes following
knee replacement. Cite this article: Bone Joint J 2013;95-B:45–51.
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TL;DR: Based on the first implementation of mixing antibiotics into bone cement in the 1970s, the Endo-Klinik has used one stage exchange for prosthetic joint infection (PJI) in over 85% of cases and there is no clear evidence that a two stage procedure has a higher success rate than a one-stage approach.
Abstract: Based on the first implementation of mixing antibiotics into bone cement in the 1970s, the Endo-Klinik has used one stage exchange for prosthetic joint infection (PJI) in over 85% of cases. Looking carefully at current literature and guidelines for PJI treatment, there is no clear evidence that a two stage procedure has a higher success rate than a one-stage approach. A cemented one-stage exchange potentially offers certain advantages, mainly based on the need for only one operative procedure, reduced antibiotics and hospitalisation time. In order to fulfill a one-stage approach, there are obligatory pre-, peri- and post-operative details that need to be meticulously respected, and are described in detail. Essential pre-operative diagnostic testing is based on the joint aspiration with an exact identification of any bacteria. The presence of a positive bacterial culture and respective antibiogram are essential, to specify the antibiotics to be loaded to the bone cement, which allows a high local antibiotic elution directly at the surgical side. A specific antibiotic treatment plan is generated by a microbiologist. The surgical success relies on the complete removal of all pre-existing hardware, including cement and restrictors and an aggressive and complete debridement of any infected soft tissues and bone material. Post-operative systemic antibiotic administration is usually completed after only ten to 14 days.
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TL;DR: It is demonstrated that good early outcomes, as measured by the Oxford knee score (OKS) and EQ-5D, can be anticipated following knee replacement regardless of the patient's age, although younger patients gain greater improvement.
Abstract: We present a comparison of patient-reported outcomes
(PROMs) in relation to patient age, in patients who had received
a total (TKR) or unicompartmental knee replacement (UKR). The outcome
was evaluated using the Oxford knee score (OKS), EuroQol (EQ-5D)
and satisfaction scores. Patients aged 65 to 84 years demonstrated
better pre-operative function scores than those aged < 65 years
(OKS, p = 0.03; EQ-5D, p = 0.048) and those aged
≥ 85 years (OKS, p = 0.03). Post-operative scores were comparable
across age groups, but a linear trend for greater post-operative
improvement in OKS and EQ-5D was seen with decreasing age (p <
0.033). The overall mean satisfaction score at six months was 84.9,
but those aged < 55 years exhibited a lower mean level of satisfaction (78.3)
compared with all other age groups (all p < 0.031). The cumulative
overall two-year revision rate was 1.3%. This study demonstrates
that good early outcomes, as measured by the OKS and EQ-5D, can
be anticipated following knee replacement regardless of the patient’s
age, although younger patients gain greater improvement. However,
the lower satisfaction in those aged
< 55 years is a concern, and suggests that outcome is not fully
encapsulated by the OKS and EQ-5D evaluation, and raises the question
whether the OKS alone is an appropriate measure of pain and function
in younger, more active individuals. Cite this article: Bone Joint J 2013;95-B:38–44.
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TL;DR: A case of an otherwise healthy 46-year-old patient, who developed progressively worsening symptoms of cobalt toxicity beginning approximately six months following synovectomy and revision of a fractured ceramic- on-ceramic total hip replacement to a metal-on-polyethylene bearing, who died from cobalt-induced cardiomyopathy.
Abstract: Symptomatic cobalt toxicity from a failed total
hip replacement is a rare but devastating complication. It has been reported
following revision of fractured ceramic components, as well as in
patients with failed metal-on-metal articulations. Potential clinical
findings include fatigue, weakness, hypothyroidism, cardiomyopathy,
polycythaemia, visual and hearing impairment, cognitive dysfunction,
and neuropathy. We report a case of an otherwise healthy 46-year-old
patient, who developed progressively worsening symptoms of cobalt
toxicity beginning approximately six months following synovectomy
and revision of a fractured ceramic-on-ceramic total hip replacement
to a metal-on-polyethylene bearing. The whole blood cobalt levels
peaked at 6521 µg/l. The patient died from cobalt-induced cardiomyopathy.
Implant retrieval analysis confirmed a loss of 28.3 g mass of the
cobalt–chromium femoral head as a result of severe abrasive wear
by ceramic particles embedded in the revision polyethylene liner.
Autopsy findings were consistent with heavy metal-induced cardiomyopathy. We recommend using new ceramics at revision to minimise the risk
of wear-related cobalt toxicity following breakage of ceramic components. Cite this article: Bone Joint J 2013;95-B:31–7.
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TL;DR: Results suggest that aseptic loosening is related to design in TKR, and seven different brands of cemented primary total knee replacement (TKR) in the Norwegian Arthroplasty Register during the years 1994 to 2009 were investigated.
Abstract: We evaluated the rates of survival and cause
of revision of seven different brands of cemented primary total
knee replacement (TKR) in the Norwegian Arthroplasty Register during
the years 1994 to 2009. Revision for any cause, including resurfacing
of the patella, was the primary endpoint. Specific causes of revision
were secondary outcomes. Three posterior cruciate-retaining (PCR) fixed modular-bearing
TKRs, two fixed non-modular bearing PCR TKRs and two mobile-bearing
posterior cruciate-sacrificing TKRs were investigated in a total
of 17 782 primary TKRs. The median follow-up for the implants ranged
from 1.8 to 6.9 years. Kaplan-Meier 10-year survival ranged from
89.5% to 95.3%. Cox’s relative risk (RR) was calculated relative
to the fixed modular-bearing Profix knee (the most frequently used
TKR in Norway), and ranged from 1.1 to 2.6. The risk of revision
for aseptic tibial loosening was higher in the mobile-bearing LCS
Classic (RR 6.8 (95% confidence interval (CI) 3.8 to 12.1)), the
LCS Complete (RR 7.7 (95% CI 4.1 to 14.4)), the fixed modular-bearing
Duracon (RR 4.5 (95% CI 1.8 to 11.1)) and the fixed non-modular
bearing AGC Universal TKR (RR 2.5 (95% CI 1.3 to 5.1)), compared
with the Profix. These implants (except AGC Universal) also had
an increased risk of revision for femoral loosening (RR 2.3
(95% CI 1.1 to 4.8), RR 3.7 (95% CI 1.6 to 8.9), and RR 3.4 (95%
CI 1.1 to 11.0), respectively). These results suggest that aseptic
loosening is related to design in TKR. Cite this article: Bone Joint J 2013;95-B:636–42.
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TL;DR: Satisfaction was significantly and positively related to the perception of symptom improvement (operative success) and the post-operative EuroQol-5D score and the appropriateness of restricting access to care based on arbitrary pre-operative thresholds as these factors have little bearing on post- operative satisfaction is questioned.
Abstract: Pre-operative variables are increasingly being
used to determine eligibility for total knee replacement (TKR).
This study was undertaken to evaluate the relationships, interactions
and predictive capacity of variables available pre- and post-operatively
on patient satisfaction following TKR. Using nationally collected
patient reported outcome measures and data from the National Joint
Registry for England and Wales, we identified
22 798 patients who underwent TKR for osteoarthritis between August
2008 and September 2010. The ability of specific covariates to predict
satisfaction was assessed using ordinal logistic regression and
structural equational modelling. Only 4959 (22%) of 22 278 patients
rated the results of their TKR as ‘excellent’, despite the majority
(71%, n = 15 882) perceiving their knee symptoms to be much improved.
The strongest predictors of satisfaction were post-operative variables.
Satisfaction was significantly and positively related to the perception
of symptom improvement (operative success) and the post-operative
EuroQol-5D score. While also significant within the models pre-operative
variables were less important and had a minimal influence upon post-operative
satisfaction. The most robust predictions of satisfaction occurred
only when both pre- and post-operative variables were considered
together. These findings question the appropriateness of restricting
access to care based on arbitrary pre-operative thresholds as these
factors have little bearing on post-operative satisfaction. Cite this article: Bone Joint J 2013;95-B:1359–65.
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TL;DR: The development of femoral modularity, and a classification system, is described, the theoretical rationale for modularity is summarised and the clinical outcomes are explored.
Abstract: Following the recall of modular neck hip stems
in July 2012, research into femoral modularity will intensify over
the next few years. This review aims to provide surgeons with an
up-to-date summary of the clinically relevant evidence. The development
of femoral modularity, and a classification system, is described.
The theoretical rationale for modularity is summarised and the clinical
outcomes are explored. The review also examines the clinically relevant problems
reported following the use of femoral stems with a modular neck. Joint replacement registries in the United Kingdom and Australia
have provided data on the failure rates of modular devices but cannot
identify the mechanism of failure. This information is needed to
determine whether modular neck femoral stems will be used in the
future, and how we should monitor patients who already have them implanted. Cite this article: Bone Joint J 2013;95-B:1011–21.
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TL;DR: Proper pre-operative planning includes the identification of patients with a high offset in whom inadequate restoration of offset will reduce soft-tissue tension and abductor efficiency and patient education cannot be over-emphasised.
Abstract: Dislocation is one of the most common causes
of patient and surgeon dissatisfaction following hip replacement
and to treat it, the causes must first be understood. Patient factors
include age greater than 70 years, medical comorbidities, female
gender, ligamentous laxity, revision surgery, issues with the abductors,
and patient education. Surgeon factors include the annual quantity
of procedures and experience, the surgical approach, adequate restoration
of femoral offset and leg length, component position, and soft-tissue
or bony impingement. Implant factors include the design of the head
and neck region, and so-called skirts on longer neck lengths. There
should be offset choices available in order to restore soft-tissue
tension. Lipped liners aid in gaining stability, yet if improperly placed
may result in impingement and dislocation. Late dislocation may
result from polyethylene wear, soft-tissue destruction, trochanteric
or abductor disruption and weakness, or infection. Understanding
the causes of hip dislocation facilitates prevention in a majority
of instances. Proper pre-operative planning includes the identification
of patients with a high offset in whom inadequate restoration of
offset will reduce soft-tissue tension and abductor efficiency.
Component position must be accurate to achieve stability without impingement.
Finally, patient education cannot be over-emphasised, as most dislocations occur
early, and are preventable with proper instructions. Cite this article: Bone Joint J 2013;95-B, Supple
A:67–9.
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TL;DR: In this large cohort the addition of fusion to decompression was not associated with an improved outcome, and the proportion of patients who required subsequent further lumbar surgery was also similar in the two groups.
Abstract: Whether to combine spinal decompression with fusion in patients with symptomatic lumbar spinal stenosis remains controversial. We performed a cohort study to determine the effect of the addition of fusion in terms of patient satisfaction after decompressive spinal surgery in patients with and without a degenerative spondylolisthesis. The National Swedish Register for Spine Surgery (Swespine) was used for the study. Data were obtained for all patients in the register who underwent surgery for stenosis on one or two adjacent lumbar levels. A total of 5390 patients fulfilled the inclusion criteria and completed a two-year follow-up. Using multivariable models the results of 4259 patients who underwent decompression alone were compared with those of 1131 who underwent decompression and fusion. The consequence of having an associated spondylolisthesis in the operated segments pre-operatively was also considered. At two years there was no significant difference in patient satisfaction between the two treatment groups for any of the outcome measures, regardless of the presence of a pre-operative spondylolisthesis. Moreover, the proportion of patients who required subsequent further lumbar surgery was also similar in the two groups. In this large cohort the addition of fusion to decompression was not associated with an improved outcome.
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TL;DR: In this paper, Nasal colonisation with either S. aureus or MRSA has been demonstrated to be an important independent risk factor associated with the increasing incidence and severity of surgical site infection after orthopaedic surgery.
Abstract: Staphylococcus aureus is one of the leading causes of surgical site infection (SSI). Over the past decade there has been an increase in methicillin-resistant S. aureus (MRSA). This is a subpopulation of the bacterium with unique resistance and virulence characteristics. Nasal colonisation with either S. aureus or MRSA has been demonstrated to be an important independent risk factor associated with the increasing incidence and severity of SSI after orthopaedic surgery. Furthermore, there is an economic burden related to SSI following orthopaedic surgery, with MRSA-associated SSI leading to longer hospital stays and increased hospital costs. Although there is some controversy about the effectiveness of screening and eradication programmes, the literature suggests that patients should be screened and MRSA-positive patients treated before surgical admission in order to reduce the risk of SSI.
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TL;DR: It is concluded that this is a feasible and valuable concept from the standpoint of pre-operative software based planning, surgical application and geometrical accuracy of outcome.
Abstract: We have investigated the benefits of patient specific instrument guides, applied to osteotomies around the knee. Single, dual and triple planar osteotomies were performed on tibias or femurs in 14 subjects. In all patients, a detailed pre-operative plan was prepared based upon full leg standing radiographic and CT scan information. The planned level of the osteotomy and open wedge resection was relayed to the surgery by virtue of a patient specific guide developed from the images. The mean deviation between the planned wedge angle and the executed wedge angle was 0° (-1 to 1, sd 0.71) in the coronal plane and 0.3° (-0.9 to 3, sd 1.14) in the sagittal plane. The mean deviation between the planned hip, knee, ankle angle (HKA) on full leg standing radiograph and the post-operative HKA was 0.3° (-1 to 2, sd 0.75). It is concluded that this is a feasible and valuable concept from the standpoint of pre-operative software based planning, surgical application and geometrical accuracy of outcome.
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TL;DR: With a careful diagnostic evaluation and technical execution of well-indicated procedures, arthroscopic surgery of the hip can achieve successful clinical outcomes, with predictable improvements in function and pre-injury levels of physical activity for many patients.
Abstract: The technical advances in arthroscopic surgery of the hip, including the improved ability to manage the capsule and gain extensile exposure, have been paralleled by a growth in the number of conditions that can be addressed. This expanding list includes symptomatic labral tears, chondral lesions, injuries of the ligamentum teres, femoroacetabular impingement (FAI), capsular laxity and instability, and various extra-articular disorders, including snapping hip syndromes. With a careful diagnostic evaluation and technical execution of well-indicated procedures, arthroscopic surgery of the hip can achieve successful clinical outcomes, with predictable improvements in function and pre-injury levels of physical activity for many patients.This paper reviews the current position in relation to the use of arthroscopy in the treatment of disorders of the hip.
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TL;DR: It is shown that pain intensity experienced during a period of primary care consultation, and patients' perception about whether their back pain will persist, were significant predictors of poor outcome at 6 months and at 5 years.
Abstract: Background People with back pain often experience long-term pain with recurrences and fluctuations. However, few studies have considered which factors predict long-term outcomes. Purpose To determine the prognostic factors, measured around the time of a primary care back pain consultation, that predict clinically significant pain in both the short (6 months) and long-term (5 years). Methods Back pain consulters at 8 GP practices received a questionnaire shortly after consultation. Information was collected on potential prognostic factors: demographics (age, gender, educational, social class), physical (pain, disability, pain duration, distal leg pain), psychological (illness perceptions, coping, fear avoidance, pain self-efficacy, depression, anxiety) and occupational (work status). Patients were followed-up by postal questionnaire 6 months and 5 years later. The Chronic Pain Grade was used to define clinically significant pain at outcome. Results Baseline pain intensity (Relative Risk (RR) 1.12, 95% CI 1.03, 1.20) and a strong patient belief that their LBP would last a long time (RR 1.04, 95% CI 1.01, 1.07) predicted outcome at 6 months. Outcome at 5 years was best predicted by a similar model: pain intensity (RR 1.09, 95% CI 0.997, 1.20) and a strong belief that their back pain would persist (RR 1.06, 95% CI 1.03, 1.09). Conclusion Pain intensity and a belief by the patient that their back pain will last a long time predicted clinically significant pain in both the short and long-term. Both predictors have the potential for clinical intervention at the consultation stage. No conflicts of interest Source of funding: The baseline and 6-month follow-up phases of this study was supported financially by a Programme Grant awarded by the Arthritis Research UK [13413] and the 5-year follow-up phase was completed as part of Dr KM Dunn9s Wellcome Trust Grant [083572]. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting.
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TL;DR: Cut-off values with highest sensitivity and specificity for the synovial fluid white cell and differential count will facilitate the accurate diagnosis of infection in total knee (TKR) and total hip replacement (THR).
Abstract: Cut-off values with highest sensitivity and specificity
for the synovial fluid white cell and differential count will facilitate
the accurate diagnosis of infection in total knee (TKR) and total
hip replacement (THR). All patients undergoing revision TKR or THR
for suspected prosthetic joint infection between 2009 and 2011 at
two hospitals were identified. A total of 75 patients were included
with a mean age of 70.3 years (38 to 89). Synovial fluid was aspirated
pre-operatively and peri-prosthetic tissue samples were taken intra-operatively
for histological and microbiological examination. Receiver operating characteristic (ROC) plots were constructed
for white cell and differential counts in aspirated fluid. The optimal
cut-off for TKR and THR was 1590 white cells/µl and 65% neutrophilia.
The white cell count cut-off value identified for THR was notably
lower than previously quoted in the literature. A cut-off value
for white cell count in synovial aspirate in suspected prosthetic
joint infection of between 1100 and 1700 white cells/µl is likely
to be applicable to both THR and TKR. Cite this article: Bone Joint J 2013;95-B:554–7.
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TL;DR: A systematic review of the incidence, aetiology, risk factors, methods of assessment and management of dysphagia following anterior cervical spinal surgery found that female gender, advanced age, multilevel surgery, longer operating time and severe pre-operative neck pain may be risk factors.
Abstract: Dysphagia is a common complication of anterior
surgery of the cervical spine. The incidence of post-operative dysphagia
may be as high as 71% within the first two weeks after surgery,
but gradually decreases during the following months. However, 12%
to 14% of patients may have some persistent dysphagia one year after
the procedure. It has been shown that female gender, advanced age,
multilevel surgery, longer operating time and severe pre-operative
neck pain may be risk factors. Although the aetiology remains unclear
and is probably multifactorial, proposed causes include oesophageal
retraction, prominence of the cervical plate and prevertebral swelling.
Recently, pre-operative tracheal traction exercises and the use
of retropharyngeal steroids have been proposed as methods of reducing
post-operative dysphagia. We performed a systematic review to assess the incidence, aetiology,
risk factors, methods of assessment and management of dysphagia
following anterior cervical spinal surgery. Cite this article: Bone Joint J 2013;95-B:868–73.