A prospective randomised controlled trial of cemented and uncemented tibial baseplates: functional and radiological outcomes.

INTRODUCTION: With the success of uncemented fixation in younger patients undergoing total hip arthroplasty and the growing demand for total knee arthroplasty (TKA) in a younger cohort of patients, there has been an increasing interest in cementless tibial baseplate fixation. We sought to determine whether there was a clear advantage to the use of three different forms of tibial baseplate fixation. The primary outcome of this study was survivorship and secondary outcomes were functional and radiological outcomes, up until 10 years. MATERIALS AND METHODS: We conducted a randomised controlled trial and recruited 224 patients with 274 knees. Patients underwent TKA by a single surgeon utilising a standard surgical technique. All patients received a cruciate retaining TKA with a cementless femoral component, and were randomised to receive either a cemented tibial component, a pegged porous coated cementless tibial component with screws or a cementless tantalum monoblock tibial component with pegs. Patient reported outcome measures (PROMS), radiological data and survivorship were assessed until 10 years post-operatively. RESULTS: Pre-operative range of motion, alignment and PROMS were similar between the three groups. The use of cemented, cementless with screws or cementless with pegs fixation options, lead to differences in functional outcomes. There was greater improvement in the Oxford score and Knee Society Score in patients who received a cemented baseplate compared to tantalum and the pegged porous groups. However, radiological and survival outcomes were similar in all three groups. Overall survivorship was 99.6%, with one knee with cementless tibial fixation and screws revised for subsidence at 3 years. There were no cases of venous thromboembolism, periprosthetic fracture or infection. CONCLUSIONS: Irrespective of tibial fixation method, functional and radiological outcomes remain similar at follow-up at 10 years, with no clear difference in outcome between each group. Each method of fixation also had excellent survivorship over this period and should reassure surgeons that whichever method of fixation they choose, long-term outcomes are likely to be satisfactory.

Calcium phosphate injection of symptomatic bone marrow lesions of the knee: what is the current clinical evidence?

BACKGROUND: Chronic bone marrow lesions (BML) in the weight-bearing portions of the knee are often associated with symptomatic degenerative arthritis resulting in pain and dysfunction. Injection of bone substitute material like calcium phosphate has been described. Whilst some studies have reported encouraging results others have shown limited benefit of this technique. AIM: The aim was to collate the available evidence on the injection of calcium phosphate and systematically evaluate the results to answer the questions encountered in clinical decision making: (1) does it provide effective long-lasting pain relief to avoid further surgical intervention? (2) which factors (patient/surgical) significantly influence the outcome? and (3) does it adversely affect the outcomes of subsequent arthroplasty? METHODS: A literature search was performed to identify the studies describing the clinical outcomes of calcium phosphate injection for treatment of BML. We evaluated the reported clinical outcomes with respect to pain, function and complications. Isolated case reports and studies with no objective assessment of clinical outcomes were excluded. RESULTS: We noted 46 articles in the current literature of which 8 described clinical outcomes of calcium phosphate injection. Mean (plus/minus SD) score on the visual analog scale (VAS) has been reported to improve from 7.90 (± 0.38) to 2.76 (± 0.90), whereas the International Knee Documentation Committee (IKDC) score improved from 30.5 (SD not reported (NR)) to 53.0 (SD NR). Pre and post procedure Short form survey (SF-12) scores were 29.8 (SD NR) and 36.7 (SD NR), respectively. In one study, scores on the Tegner Lysholm knee scoring scale improved in 12 out of 22 patients, whereas the remainder had no change in symptoms. Extravasation of calcium phosphate into the joint was the most common complication, whereas no adverse effect has been reported on subsequent arthroplasty. CONCLUSION: Limited data from the published studies would suggest that calcium phosphate injection of BML may potentially improve pain and function. However, no evidence is currently available to clearly identify patient/surgical factors that may influence the long-term outcomes of this procedure. Hence pragmatic, prospective studies with stratified patient cohorts and robust reporting of outcome measures are essential to improve the understanding of the indications and clinical effectiveness of this novel procedure.

Assessing clarity and erasability of commercially available pens for surgical site marking: a comparative study in human volunteers.

BACKGROUND: Marking the surgical site is a well-established part of pre-operative protocol and errors in marking have been implicated in wrong site surgery incidents and are a significant patient safety issue. There are many commercially available marker pens and anecdotally very little consistency in which pen is used or the clarity of marking. Previous studies have shown subjective differences between different pens and the current paper sought to support this evidence with objective data and widen the investigation of commercially available pens. METHODS: Eight marker pens were used to mark two separate sites on three caucasian volunteers. These marks were photographed and assessed by six observers before and after the application of chlorhexidine skin preparation. The observers were blinded to which pen was used for each mark, and rated the clarity of the marks subjectively. The photographs were assessed using image analysis software to give an objective measure of clarity against the skin. RESULTS: There was a wide variation between the clarity of marks made by the different pens, and also a wide variation in the resistance to skin preparation. The Pentel N50 pen was the outstanding best performing pen across all categories. CONCLUSIONS: It is recommended that the Pentel N50 black marker pen be used for surgical site marking to improve patient safety and avoid adverse events.

Rigid intramedullary nail fixation of femoral fractures in adolescents: what evidence is available?

BACKGROUND: Femoral fracture in adolescents is a significant injury. It is generally agreed that operative fixation is the treatment of choice, and rigid intramedullary nail fixation is a treatment option. However, numerous types of rigid nails to fix adolescent femoral fractures have been described. Hence, the aim of this paper was to collate and evaluate the available evidence for managing diaphyseal femoral fractures in adolescents using rigid intramedullary nails. MATERIALS AND METHODS: A literature search was undertaken using the healthcare database website ( http://www.library.nhs.uk/hdas ). Medline, CINAHL, Embase, and the Cochrane Library databases were searched to identify prospective and retrospective studies of rigid intramedullary nail fixation in the adolescent population. RESULTS: The literature search returned 1,849 articles, among which 51 relevant articles were identified. Of these 51 articles, 23 duplicates were excluded, so a total of 28 articles were reviewed. First-generation nails had a high incidence of limb length discrepancy (Küntscher 5.8 %, Grosse-Kempf 9 %), whilst second-generation nails had a lower incidence (Russell-Taylor 1.7 %, AO 2.6 %). Avascular necrosis was noted with solid Ti nails (2.6 %), AO femoral nails (1.3 %) and Russell-Taylor nails (0.85 %). These complications have not been reported with the current generation of nails. CONCLUSIONS: Rigid intramedullary nail fixation of femoral fractures in adolescents is a useful procedure with good clinical results. A multiplanar design and lateral trochanteric entry are key to a successful outcome of titanium alloy nail fixation.

Cemented polyethylene and cementless porous-coated acetabular components have similar outcomes at a mean of seven years after total hip replacement: a prospective randomised study.

The aim of this prospective randomised study was to compare the clinical and radiological results of a cemented all-polyethylene Ultima acetabular component with those of a cementless porous-coated acetabular component (PFC) following total hip replacement (THR). A total of 287 patients received either a polyethylene acetabular component (group A) or a cobalt-chromium porous-coated component (group B) with an identical cemented femoral component and 28 mm cobalt-chromium head, thus making it the largest study of its type. Patients were evaluated radiologically and clinically using the Harris hip score (HHS). Group A comprised 183 patients (73 male, 110 female) with a mean age of 71.3 years (55 to 89). Group B comprised 104 patients (48 male, 56 female) with a mean age of 69.8 years (56 to 89). A total of 16 patients (13 in Group A, three in Group B) did not have post-operative data for analysis. The mean follow-up in group A was 7.52 years (0.4 to 15.0) and in Group B 7.87 years (0.5 to 14.0). At final follow-up the mean HHS was similar between groups A and B (74.5 (25 to 100) and 78.0 (37 to 100), respectively; p = 0.068). The total number of revisions for any cause was 28, 17 of which were in group A and 11 in group B. The ten-year survivorship was 86.8% (95% confidence interval (CI) 78.4 to 92.1) and 89.2% (95% CI 78.3 to 94.8) for groups A and B, respectively (log-rank p-value = 0.938). A total of 20 cemented and two cementless acetabular components had evidence of acetabular radiolucencies or acetabular component migration at last follow-up (p = 0.001). These results indicate that patients with a cemented all-polyethylene and cementless porous-coated polyethylene lined acetabular component have similar long-term clinical outcomes.

Home surveillance of leaking wounds after hip and knee arthroplasty: a prospective audit.

Leaking postoperative wound is a frequent finding after hip and knee arthroplasty. A prospective audit was undertaken to evaluate the feasibility and effectiveness of surveillance of leaking wounds at patients' homes by trained orthopaedic nurses.