Resuming hip and knee arthroplasty after COVID-19: ethical implications for wellbeing, safety and the economy.

Reinstating elective hip and knee arthroplasty services presents significant challenges. We need to be honest about the scale of the obstacles ahead and realise that the health challenges and economic consequences of the COVID-19 pandemic are potentially devastating.We must also prepare to make difficult ethical decisions about restarting elective hip and knee arthroplasty. These decisions should be based on the existing evidence-base, reliable data, the recommendations of experts, and regional circumstances.

Trochanteric spurs and surface irregularities on plain radiography are not predictive of greater trochanteric pain syndrome.

PURPOSE: Surface irregularities of the greater trochanter have been described as a potential radiographic sign of greater trochanteric pain syndrome (GTPS). We report a diagnostic accuracy study to evaluate the clinical usefulness of trochanteric surface irregularities on plain radiographs in the diagnosis of GTPS. METHODS: We retrospectively identified the anteroposterior pelvic radiographs of a consecutive group of 38 patients (representing a 27.5% series prevalence) diagnosed with GTPS (mean age 69.5 years ± 16.1 [standard deviation], 27 females, 11 males) based on clinical symptoms and a positive response to a local anaesthetic and steroid injection. A control group consisted of 100 patients (mean age 73 years ± 17.1 [standard deviation], 67 females, 33 males) with either hip osteoarthritis listed for hip arthroplasty (n = 50), or with an intracapsular neck of femur fracture (n = 50) both presenting between January and July 2017. Radiographs were cropped to blind observers to the presence of hip osteoarthritis or intracapsular fracture but included the trochanteric region. The radiograph sequence was randomised and separately presented to 3 orthopaedic surgeons to evaluate the presence of trochanteric surface irregularities. RESULTS: The inter-observer correlation coefficient agreement was acceptable at 0.75 (95% CI, 0.60-0.84). Trochanteric surface irregularities including frank spurs protruding ⩾2 mm were associated with a 24.7% positive predictive value, 64.0% sensitivity, 25.7% specificity, 74.3% false-positive rate, 36.0% false-negative rate, and a 65.3% negative predictive value for clinical GTPS. CONCLUSION: Surface irregularities of the greater trochanter are not reliable radiographic indicators for the diagnosis of greater trochanteric pain syndrome.

How to prepare and manage a systematic review and meta-analysis of clinical studies.

Use the PICO framework to formulate a specific clinical question.Formulate a search strategy.Prospectively register the review protocol.Execute the literature search.Apply eligibility criteria to exclude irrelevant studies.Extract data and appraise each study for risk of bias and external validity.Provide a narrative review.If appropriate data are available, perform a meta-analysis.Report the review findings in the context of the risk of bias assessment, any sensitivity analyses and the analysis of risk of publication bias.Useful resources include the Cochrane Handbook, PROSPERO, GRADE and PRISMA. Cite this article: EFORT Open Rev 2019;4:213-220. DOI: 10.1302/2058-5241.4.180049.

Mortality After Total Knee Arthroplasty: A Systematic Review of Incidence, Temporal Trends, and Risk Factors.

BACKGROUND: The capacity for total knee arthroplasty to improve pain, quality of life, and functional outcomes is widely recognized. Postoperative mortality is rare but of paramount importance, and needs to be accurately quantified and conveyed to patients in order to support decision-making prior to surgery. The purpose of this study was to determine a contemporary estimate of the risk of mortality following total knee arthroplasty, including the identification of temporal trends, common causes, and modifiable and nonmodifiable risk factors. METHODS: We performed a systematic review with searches of MEDLINE, AMED, CAB Abstracts, and Embase. Studies in any language published from 2006 to 2016 reporting 30 or 90-day mortality following total knee arthroplasty were included, supplemented by contact with authors. Meta-analysis and meta-regression were performed for quantitative data. RESULTS: Thirty-seven studies with mortality data from 15 different countries following over 1.75 million total knee arthroplasties formed the basis of this review. The pooled Poisson-normal random-effects meta-analysis estimates of 30 and 90-day mortality were 0.20% (95% confidence interval [CI], 0.17% to 0.24%) and 0.39% (95% CI, 0.32% to 0.49%). Both estimates have fallen over the 10-year study period (p < 0.001). Meta-regression using the median year of surgery as a moderator showed that 30 and 90-day mortality following total knee arthroplasty fell to 0.10% (95% CI, 0.07% to 0.14%) and 0.19% (95% CI, 0.15% to 0.23%), respectively, in 2015. The leading cause of death was cardiovascular disease. CONCLUSIONS: There is an ongoing worldwide temporal decline in mortality following total knee arthroplasty. Improved patient selection and perioperative care and a healthy-population effect may account for this observation. Efforts to further reduce mortality should be targeted primarily at reducing cardiovascular events following total knee arthroplasty. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Medial subvastus versus the medial parapatellar approach for total knee replacement: A systematic review and meta-analysis of randomized controlled trials.

Twenty randomized controlled trials comprising 1893 primary total knee replacements were included in this review.The subvastus approach conferred superior results for mean difference (MD) in time to regain an active straight leg raise (1.7 days, 95% confidence interval [CI] 1.0 to 2.3), visual analogue score for pain on day one (0.8 points on a scale out of 10, 95% CI 0.2 to 1.4) and total range of knee movement at one week (7°, 95% CI 3.2 to 10.7). The subvastus approach also resulted in fewer lateral releases (odds ratio 0.4, 95% CI 0.2 to 0.7) and less peri-operative blood loss (MD 57 mL, 95% CI 10.5 to 106.4) but prolonged surgical times (MD 9.7 min, 95% CI 3.9 to 15.6).There was no difference in Knee Society Score at six weeks or one year, or the rate of adverse events including superficial or deep infection, deep vein thrombosis or knee stiffness requiring manipulation under anaesthesia.This review demonstrates evidence of early post-operative benefits following the subvastus approach with equivalence between approaches thereafter. Cite this article: EFORT Open Rev 2018;3:78-84. DOI: 10.1302/2058-5241.3.170030.

Surgery for greater trochanteric pain syndrome after total hip replacement confers a poor outcome.

PURPOSE: Surgery for greater trochanteric pain syndrome (GTPS) may be indicated for cases refractory to conservative measures. We aim to evaluate patient reported outcomes and adverse events following surgery. METHODS: Postal questionnaires were used to evaluate a consecutive series of 61 bursectomy and gluteal fascia transposition (GFT) procedures. Study outcomes were Oxford hip score, satisfaction score, visual analogue score, pain lying on the affected side, and the duration of pain relief after surgery. RESULTS: We received responses regarding 52 procedures at a median of 34 months follow-up; 40% of cases of GTPS occurred following THA. We observed a bimodal distribution of satisfaction scores. The early post-operative complication rate was 13%; an additional seven cases (12%) required further surgery at a later date. Idiopathic GTPS had significantly better post-operative satisfaction than GTPS following THA, 87.5 vs. 37.5 (p = 0.006); Oxford hip scores, 35 vs. 15 (p = 0.015); and visual analogue scores, 20 vs. 73 (p = 0.005). CONCLUSION: We observed overall poor outcomes, significant complications and concerning reoperation rates. Cases with previous joint replacement were associated with the worst outcomes.

A comparison of the omega and posterior approaches on patient reported function and radiological outcomes following total hip replacement.

BACKGROUND: The omega approach represents a modification of the lateral approach to the hip for joint replacement. It was developed to reduce the potential for gluteus muscle dysfunction and thereby improve functional outcome following hip replacement. METHODS: A cohort of 415 consecutive hip replacements receiving the same type of cemented femoral component were followed up at a mean of three years postoperatively and invited to complete functional outcome and satisfaction scores. RESULTS: There were no differences between the omega and the posterior approach in terms of post-operative Oxford Hip Score, Short Form-12 score, patient satisfaction and a range of radiographic parameters. CONCLUSIONS: The omega approach appears to perform equally to the posterior approach in this cohort of patients.

Recall and patient perceptions of hip precautions 6 weeks after total hip arthroplasty.

Background and purpose - There is a lack of evidence to support the role of hip precautions in preventing dislocation following total hip arthroplasty (THA). We report an exploratory study which assesses recall, adherence, and the impact of precautions on activities of daily living in the first 6 weeks postoperatively. Patients and methods - We designed a new questionnaire based on the education patients receive and refined by professionals within our multidisciplinary team. 129 patients underwent primary elective THA during the study period and received the questionnaire at 6 weeks postoperatively. Results - 97 (75%) patients responded before the 8th week postoperatively. Most of these (83 patients) could remember all the precautions. Of the 97 who responded only 22 claimed to adhere to all of the precautions. 48 admitted to putting their own underwear on without the use of aids or assistance, and 38 had started walking without an aid. Due to the precautions 67 avoided leaving the house at some point and 63 were unable to perform desired activities. 84 stated that their sleep was affected. There were no dislocations among the 97 patients who responded; however, there was 1 dislocation among the 32 non-responders. Interpretation - We found that most patients did not adhere to hip precaution advice. Precautions have a detrimental effect on patient activity and sleep. In view of the limited efficacy in reducing dislocation rate, we question the use of precautions in the primary arthroplasty setting.

The association between the day of the week of milestones in the care pathway of patients with hip fracture and 30-day mortality: findings from a prospective national registry - The National Hip Fracture Database of England and Wales.

BACKGROUND: Recent publications indicate increased mortality in patients admitted to hospital at the weekend, but these findings may be subject to inadequate adjustment for case-mix and the complexities of resource provision. Hip fractures generally occur in a frail comorbid population with a consistent diagnosis precipitating admission as an emergency. We therefore aimed to examine the association between the day of the week of milestones in the care pathway and 30-day mortality in this population. METHODS: Using data from a prospective national database of hip fractures, we investigated the association between day of the week of admission, surgery, inpatient stay, and discharge (care pathway milestones) and 30-day mortality using generalised linear models. Data was collected between January 1, 2011, and December 31, 2014, on 241,446 patients. An incremental case-mix adjustment strategy was performed using patient characteristics, non-surgical interventions, surgical interventions and discharge characteristics. RESULTS: The day of admission was not associated with 30-day mortality. Sunday surgery (OR, 1.094; 95% CI, 1.043-1.148; P < 0.0001) and a delay to surgery of more than 24-hours (OR, 1.094; 95% CI, 1.059, 1.130; P < 0.0001) were both associated with a 9.4% increase in 30-day mortality. Discharge from the hospital on a Sunday (OR, 1.515; 95% CI, 1.224, 1.844; P < 0.0001) or out-of-hours discharge (OR, 1.174; 95% CI, 1.081, 1.276; P < 0.0001) were associated with a 51.5% and 17.4% increase in 30-day mortality, respectively. Mortality during the inpatient stay was 5.6% lower (IRR, 0.944; 95% CI, 0.909, 0.980; P = 0.003) at the weekend compared to weekdays. CONCLUSIONS: There is limited evidence of a generalised weekend effect in patients admitted to hospital for hip fracture. Optimising resource utilisation is an essential element of planning and delivering healthcare services. Interventions that lead to surgery within 24-hours of admission are justified. Factors such as Sunday operations, discharge and out-of-hours discharge require further investigation.

A radiographic comparison of femoral offset after cemented and cementless total hip arthroplasty.

Restoring femoral offset during total hip arthroplasty is important. Femoral offset and leg lengths are inextricably linked by the caput-collum-diaphysis (CCD) angle of the implant being used. We investigate the restoration of offset and leg lengths using the radiographs of a consecutive series of patients following implantation with either a high CCD angled cementless, or an anatomical CCD angled cemented femoral component. Although our data suggests that we are able to restore femoral offset and leg lengths using either device, we recommend additional caution when using non-anatomical high CCD angled implants.

A systematic review and meta-analysis of the standard versus mini-incision posterior approach to total hip arthroplasty.

The mini-incision posterior approach may appeal to surgeons comfortable with the standard posterior approach to the hip. We present the first systematic review and meta-analysis of these two approaches. Twelve randomised controlled trials and four non-randomised trials comprising of 1498 total hip arthroplasties were included. The mini-incision posterior approach was associated with an early improvement in Harris hip score of 1.8 points (P<0.001), reduced operating time (5minutes, P<0.001), length of hospital stay (14hours, P<0.001), intraoperative and total blood loss (63ml, P<0.001 and 119ml, P<0.001 respectively). There were no statistically significant differences in the incidence of dislocation, nerve injury, infection or venous thromboembolic events. The minimally invasive posterior approach appears to provide a safe and acceptable alternative to the standard incision posterior approach.

Stem compatibility for cement-in-cement femoral revision: an in vitro study.

Cement-in-cement femoral component revision is a useful and commonly practised technique. Onerous and hazardous re-shaping of the original cement mantle is required if the new stem does not seat easily. Furthermore, without removing the entirety of the original cement mantle, the freedom to alter anteversion or leg length is difficult to predict preoperatively. We present data from in vitro experiments testing the compatibility of the top cemented stems according to UK registry figures (NJR 2013). This data augments preoperative planning by indicating which revision stems require minimal or no cement reshaping when being inserted into another stem's mantle. We also present the maximum shortening and anteversion that can be achieved without reshaping the original cement mantle.

A 5-8 year retrospective follow-up of the C-stem AMT femoral component: patient reported outcomes and survivorship analysis.

We report midterm functional, radiographic and survivorship data for the cemented, triple taper C-stem AMT femoral component from a consecutive cohort of 415 hip arthroplasties in 386 patients at a non-developer centre. Follow-up ranges were from 60 to 99 months, with a mean of 76 months. 32 hips were lost to follow-up. The median OHS was 40, median SF-12 mental component score (MCS) was 50, and median SF-12 physical component score (PCS) was 39. At 99 months follow up, stem survivorship is 96.9% (95% confidence interval (CI) 82.5-99.5), and construct survivorship is 96.0% (95% CI 84.2-99.0). Adverse events such as calcar fracture, greater trochanter fracture and dislocation were rare at <1%. There have been no revisions for aseptic loosening.

Histology of failed metal-on-metal hip arthroplasty; three distinct sub-types.

The histological specimens from 29 failed metal-on-metal (MoM) hip arthroplasties treated at our institution were reviewed. Five patients had a failed MoM total hip arthroplasty (THA), and 24 patients a failed hip resurfacing. Clinical and radiographic features of each hip were correlated with the histological findings. We report three major histological subtypes. Patients either have a macrophage response to metal debris, a lymphocytic response (ALVAL) or a mixed picture of both. In addition we observe that the ALVAL response is located deep within tissue specimens, and can occur in environments of low wear debris. The macrophage response is limited to the surface of tissue specimens, with normal underlying tissue. Patients with subsequently confirmed ALVAL underwent revision surgery sooner than patients whose histology confirms a macrophage response (3.8 vs. 6.9 years p<0.05). Both histological subtypes (ALVAL and macrophage dominant) are responsible for abnormal soft tissue swellings.

Caution: laparoscopic biopsy of a large pelvic mass may result in disaster.

Anterior sacral meningocele is a rare cause of a pelvic mass. Herein the authors describe the case of a young patient presenting with chronic pelvic pain undergoing diagnostic laparoscopy. She was found to have a retrorectal mass confirmed as an anterior sacral meningocele on subsequent MRI. The authors explore the case, describe a method of intraoperative management to minimize the risk of severe complications and include a discussion of the differential diagnosis. Central to this is an emphasis on advocating a cautious approach when confronted with an incidental unknown pelvic mass, as deleterious consequences may occur from biopsy of such a lesion.

Surgical approach and patient-reported outcomes after total hip replacement.

BACKGROUND: Previous research has mainly focused on how factors such as surgical approach might affect implant survivorship and the incidence of complications. Given the increasing interest in patient-reported outcomes, the purpose of this study is to explore whether surgical approach is associated with patient-reported pain, function, and satisfaction at 1-3 years after primary total hip replacement (THR). METHODS: Details of surgical factors were collated from operation notes for all consecutive patients at our centre from 2004-2006. All patients were mailed a questionnaire 1-3 years following surgery that collected WOMAC pain and function scores and the Self-Administered Patient Satisfaction Scale for Primary Hip and Knee Arthroplasty. Of the eligible 1,315 patients, 911 patients returned a completed questionnaire (69% response rate). Multivariable fractional logit models were used to identify whether surgical approach was associated with outcome scores. RESULTS: Surgical approach was found to be a significant predictor of patient-reported outcomes at 1-3 years after surgery, even after controlling for patient-specific factors. A posterior approach was associated with better scores on all three outcome measures. On average, predicted outcome scores for a typical patient with a posterior approach were between 3.5 and 7.2 percentage points higher than an equivalent patient with an anterolateral approach. INTERPRETATION: These findings suggest that clinical decisions concerning surgical approach may have an observable impact on patient-reported levels of pain, function, and satisfaction following THR.