Bone cement in total hip arthroplasty - Is it really green?

BACKGROUND: Total hip replacement (THR)is typically cemented, cementless or hybrid depending on patient factors and surgeon preference. To date no studies have evaluated waste generated with each of these procedures in relation to implant choice, and particularly waste related to consumables. We aimed to quantify the volume; type and ability to recycle this waste and suggest potential strategies for reducing the overall waste related to consumables in THR. METHOD: This was a prospective review of all waste related to consumables in THR. The waste was weighed using a Salter 1066 BKDR15 scale, accurate to the nearest 1 â€‹g. The primary outcome was the amount of waste generated per case depending on implant choice (cemented vs. uncemented). Secondary outcomes included: proportion of clinical waste and proportion of recyclable waste. RESULTS: Cemented THR generated a total of 1.89 â€‹kg of waste compared to 775 â€‹g for an uncemented THR. Cemented THR generated significantly more sterile (hazardous) waste than uncemented THR both as overall volume and as a proportion 763 â€‹g (40%) vs 76 â€‹g (10%). Significantly more of the waste related to uncemented THR was amenable to being recycled through conventional waste streams with simple changes in theatre 672 â€‹g (86%) compared to 989 â€‹g (52%) with cemented THR. Between 20 and 30% of waste packaging for both types of surgery compromised information booklets. CONCLUSION: Cemented hip replacement generates significantly more waste from consumables than uncemented and a greater amount of this waste is hazardous requiring intensive processing. For both implants a significant proportion of waste can be recycled with simple process changes in theatre. Industry partners have a responsibility to minimise unnecessary packaging and work with surgeons to improve sustainability.

Variation of Practice in Prophylactic Protocol to Reduce Prosthetic Joint Infection in Primary Hip and Knee Arthroplasty: A National Survey in the United Kingdom.

Purpose: Prosthetic joint infection (PJI) has an enormous physiological and psychological burden on patients. Surgeons rightly wish to minimise this risk. It has been shown that a standardised, evidence-based approach to perioperative care leads to better patient outcomes. A review of current practice was conducted using a cross-sectional survey among surgeons at multiple centers nationwide. Materials and Methods: An 11-question electronic survey was circulated to hip and knee arthroplasty consultants nationally via the BOA (British Orthopaedic Association) e-newsletter. Results: The respondents included 56 consultants working across 19 different trusts. Thirty-four (60.7%) screen patients for asymptomatic bacteriuria (ASB) preoperatively, with 19 (55.9%) would treating with antibiotics. Fifty-six (100%) screen for methicillin-resistant Staphylococcus aureus and treat if positive. Only 15 (26.8%) screen for methicillin-sensitive S. aureus (MSSA) or empirically eradicate. Zero (0%) routinely catheterise patients perioperatively. Forty-one (73.2%) would give intramuscular or intravenous gentamicin for a perioperative catheterisation. All surgeons use laminar flow theatres. Twenty-six (46.4%) use only an impervious gown, 6 (10.7%) exhaust pipes, and 24 (42.3%) surgical helmet system. Five different antimicrobial prophylaxis regimens are used 9 (16.1%) cefuroxime, 2 (3.6%) flucloxacillin, 19 (33.9%) flucloxacillin and gentamicin, 10 (17.9%) teicoplanin, 16 (28.6%) teicoplanin and gentamicin. Twenty-two (39.3%) routinely give further doses. Conclusion: ASB screening, treatment and intramuscular gentamicin for perioperative catheterisation is routinely practiced despite no supporting evidence base. MSSA screening and treatment is underutilised. Multiple antibiotic regimens exist despite little variation in organisms in PJI. Practice varies between surgeons and centers, we should all be practicing evidence-based medicine.

Post-operative complications following total hip arthroplasty for trauma: A multicentre cohort study comparing dual mobility with conventional acetabular bearings.

Aims: Dislocation of a total hip replacement is a serious complication after total hip arthroplasty (THA). Dislocation rates are higher when surgery is performed following trauma. Our study compares post-operative dislocation rates between conventional acetabular bearing (CAB) and dual mobility acetabular bearing (DMB) THA performed for neck of femur fracture alongside post-operative periprosthetic fracture, revision and mortality. Methods: A retrospective multicentre cohort study at 9 hospital trusts in the United Kingdom of all THA performed for neck of femur fracture between March 2018 and February 2019. Results: A total of 295 operations were performed. 64% (189) were CAB and 36% (106) were DMB. Average age was 75 years (38-98). 223 Female: 72 Male. The follow-up period was an average of 42 months (36-48). Overall revision rate was 1.6%,8 peri-prosthetic fracture rate was 6 (2%) and overall mortality was 9.8% (29) with no significant difference between cohorts for any outcome. The posterior approach (PA) was favoured 82% (242) vs the lateral approach (LA) 18% (53) with the PA used more often in patients undergoing DMB 96% (102) vs CAB 74% (140) p = 0.001. Patients approached posteriorly at the time of their index procedure were significantly less likely to sustain a simple dislocation following a DMB 0 (0%) vs. CAB 8 (5.7%) p = 0.015. Conclusion: Our study demonstrates that the risk of dislocation following THA for trauma is more than four times higher than when conventional bearings are used compared to dual mobility acetabular components. This effect is most pronounced when the PA is utilised for the index procedure. The use of these bearings does not impact mortality, peri-prosthetic fracture or revision rate. We would encourage the use of dual mobility acetabular bearings in patients undergoing THA for fracture via a PA.

Total hip replacement performed via a direct anterior approach: A comparison of the lateral and supine position.

Background: The direct anterior approach (DA) is a recognised approach for performing a total hip replacement (THR). Proponents cite improved recovery times, lower pain levels and improved patient satisfaction in the early post operative period. The procedure can be performed in the supine or lateral position. We wanted to compare the direct anterior approach in lateral decubitus (LD) position and supine (SU) position. Methods: Single site, non-randomised, multiple surgeon retrospective cohort study between 2014 and 2021 to compare outcomes, complications and implant position for patients undergoing DAA THR in the SU or LD position. Results: A total of 39 patients (22 lateral/17 supine) were identified. Patients had an average follow up of 45 months (17-81). 95% of the cohort were ASA 1 or 2. The majority of cases were uncemented (95%). A greater implant selection was used in the lateral group and the supine group used mainly implants associated with the supine table. No significant differences were found in post operative oxford hip scores, haemoglobin, length of stay, operative time, cup inclination, offset or post operative leg length. There were no recorded intra-operative complications in the LA group and two in the SU group - one calcar fracture and one canal perforation. No patient in either group has undergone a revision procedure. Conclusion: Both the supine and lateral position have resulted in satisfactory patient and radiological outcomes. We identified a higher rate of intra-operative fracture in the supine group which is comparable with existing literature. Given the similar outcomes between both groups we would suggest that surgeons wishing to consider the DAA may consider performing this in the lateral position as this will be more familiar to them, they will be able to use their existing implants and do not need a specialised operating table.

How does hip and knee arthroplasty affect golfer performance and what should be expected regarding return to play?

AIMS: Hip and knee arthroplasty is commonly performed for end-stage arthritis. There is limited information to guide golfers on the impact this procedure will have postoperatively. This study aimed to determine the impact of lower limb arthroplasty on amateur golfer performance and return to play. METHODS: A retrospective observational study was designed to collect information from golfers following arthroplasty. Data were collected from 18 April 2019 to 30 April 2019 and combined a patient survey with in-app handicap data. RESULTS: A total of 2,198 responses were analyzed (1,097 hip and 1,101 knee). Of the respondents, 1,763 (80%) were male and the mean age was 70 years (26 to 92). Hip arthroplasty was associated with a mean increase in handicap of 1.03 (95% confidence interval (CI) 0.81 to 1.25). No difference was seen between isolated leading or trailing leg (p = 0.428). Bilateral hip arthroplasty increased handicap (p < 0.001). Overall, 1,025 (94%) maintained or increased the amount of golf played, 258 (23.5%) returned to iron shots at six weeks, 883 (80%) returned to club competitions at six months, 18 (1.6%) had persistent pain, and 19 (1.7%) were unable to return to play. Knee arthroplasty was associated with a mean increase in handicap of 1.18 (95% CI 0.99 to 1.38). Trailing leg arthroplasty alone was associated with higher postoperative handicap (p = 0.002) as was bilateral surgery (p = 0.009). Overall, 1,009 (92%) maintained or increased the amount of golf played, 270 (25%) returned to iron shots at six weeks, 842 (76%) returned to club competition at six months, 66 (6%) had persistent pain, and 18 (1.6%) were unable to return to play. CONCLUSION: Hip and knee arthroplasty enables patients to maintain or increase the amount of golf played. The majority return to competitions within one year. Return to iron shots occurs from six weeks. A small increase in handicap following surgery is expected and is larger in patients undergoing bilateral surgery or those with knee arthroplasty to their trailing leg. Patients may still experience pain when playing golf. Cite this article: Bone Jt Open 2022;3(6):510-514.

A new classification for Freiberg's disease.

INTRODUCTION: Freiberg's osteochondrosis is an uncommon cause of foot pain. Following a national survey circulated by the British Foot and Ankle Society it was found that no classification is used to guide surgical treatment. This study aimed to create a simple, reproducible CT based classification to preoperatively plan whether an osteotomy is required. METHODS: A retrospective review of 24 CT scans of new Freiberg's diseasediagnoses over a 10 year period was conducted. These images were assigned a study number and anonymised. The scans were then reviewed in their entirety by three independent specialists who determined whether an osteotomy would be of benefit. The sagittal CT slice that displayed the widest portion of proximal articular margin of the proximal phalanx was identified and divided the articular surface into 2 zones - plantar and dorsal and this formed the basis for our classification. These sagittal slices were then reviewed independently by two surgeons to determine if patients had disease in one or both zones and re-reviewed two weeks later to assess intra-observer reliability. RESULTS: All 24 cases involved the second metatarsal. From reviewing the sagittal CT slices, it was felt that 18 patients were suitable for osteotomy and 6 were suitable for debridement +/- arthroplasty alone. The current classification demonstrated that 18 patients had disease confined to zone 1 only and the remaining patients had disease in both zones. Inter-observer reliability assessment had 95.8% agreement (Krippendorff's Alpha 0.897). Intra-observer reliability was 100%. Correlation of those observed to have isolated zone 1 disease and suitability for osteotomy was absolute (Pearson r = 1). CONCLUSION: Dividing the metatarsal head into two zones on the widest sagittal slice of the CT scan offers an easy reproducible way to preoperatively plan surgical treatment for Freiberg's osteochondrosis. Patients with isolated zone 1 disease should be suitable for an osteotomy.

Biochemical and biomechanical influence on peri anchor cyst formation in rotator cuff repair.

This review aims to provide a detailed analysis of the pathological processes underlying peri anchor cyst formation. As a consequence providing methods that can be implemented to reduce cyst occurrence and also to highlight areas of current weakness in the literature that could be strengthened so as to improve our ability to manage peri anchor cyst formation. We performed a literature review of the National Library of Medicine focused around rotator cuff repair and peri anchor cysts. We summarise the literature whilst incorporating a detailed analysis of the pathological processes underpinning peri anchor cyst formation. There are two theories behind peri anchor cyst occurrence, biochemical and biomechanical. It is our belief that cyst formation occurs as a result of both. The biochemical make up of an anchor plays a crucial role in cyst occurrence and it's timing post-operatively. Consequently anchor material plays a vital role in peri anchor cyst formation. Tear size, degree of retraction, number of anchors and varying bone density within the humeral head are all important biomechanical factors. Further investigation is required into certain aspects of rotator cuff surgery to improve our understanding of peri anchor cyst occurrence. From a biomechanical perspective these include: Anchor configuration to both the tear and each other and also tear type itself. From a biochemical perspective we need to further investigate the anchor suture material. It would also be of benefit if a validated grading criteria of peri anchor cysts was produced.

Acetabular revision using a dual mobility cup as treatment for dislocation in Charnley total hip arthroplasty.

AIMS: Dislocation remains a significant complication after total hip arthroplasty (THA), being the third leading indication for revision. We present a series of acetabular revision using a dual mobility cup (DMC) and compare this with our previous series using the posterior lip augmentation device (PLAD). METHODS: A retrospective review of patients treated with either a DMC or PLAD for dislocation in patients with a Charnley THA was performed. They were identified using electronic patient records (EPR). EPR data and radiographs were evaluated to determine operating time, length of stay, and the incidence of complications and recurrent dislocation postoperatively. RESULTS: A total of 28 patients underwent revision using a DMC for dislocation following Charnley THA between 2013 and 2017. The rate of recurrent dislocation and overall complications were compared with those of a previous series of 54 patients who underwent revision for dislocation using a PLAD, between 2007 and 2013. There was no statistically significant difference in the mean distribution of sex or age between the groups. The mean operating time was 71 mins (45 to 113) for DMCs and 43 mins (21 to 84) for PLADs (p = 0.001). There were no redislocations or revisions in the DMC group at a mean follow-up of 55 months (21 to 76), compared with our previous series of PLAD which had a redislocation rate of 16% (n = 9) and an overall revision rate of 25% (n = 14, p = 0.001) at a mean follow-up of 86 months (45 to 128). CONCLUSION: These results indicate that DMC outperforms PLAD as a treatment for dislocation in patients with a Charnley THA. This should therefore be the preferred form of treatment for these patients despite a slightly longer operating time. Work is currently ongoing to review outcomes of DMC over a longer follow-up period. PLAD should be used with caution in this patient group with preference given to acetabular revision to DMC. Cite this article: Bone Joint J 2020;102-B(4):423-425.