Intraoperative cell salvage in revision hip arthroplasty.

Aims: The aim of this study was to perform a systematic review of the evidence for the use of intraoperative cell salvage in patients undergoing revision hip arthroplasty, and specifically to analyze the available data in order to quantify any associated reduction in the use of allogenic blood transfusion, and the volume which is used. Methods: An electronic search of MEDLINE (PubMed), Embase, Scopus, and the Cochrane Library was completed from the date of their inception to 24 February 2022, using a search strategy and protocol created in conjunction with the PRISMA statement. Inclusion criteria were patients aged > 18 years who underwent revision hip arthroplasty when cell salvage was used. Studies in which pre-donated red blood cells were used were excluded. A meta-analysis was also performed using a random effects model with significance set at p = 0.05. Results: Of the 283 studies which were identified, 11 were included in the systematic review, and nine in the meta-analysis. There was a significant difference (p < 0.001) in the proportion of patients requiring allogenic transfusion between groups, with an odds ratio of 0.331 (95% confidence interval (CI) 0.165 to 0.663) associated with the use of cell salvage. For a total of 561 patients undergoing revision hip arthroplasty who were treated with cell salvage, 247 (44.0%) required allogenic transfusion compared with 418 of 643 patients (65.0%) who were treated without cell salvage. For those treated with cell salvage, the mean volume of allogenic blood which was required was 1.95 units (390 ml) per patient (0.7 to 4.5 units), compared with 3.25 units (650 ml) per patient (1.2 to 7.0 units) in those treated without cell salvage. The mean difference of -1.91 units (95% CI -4.0 to 0.2) in the meta-analysis was also significant (p = 0.003). Conclusion: We found a a significant reduction in the need for allogenic blood transfusion when cell salvage was used in patients undergoing revision hip arthroplasty, supporting its routine use in these patients. Further research is required to determine whether this effect is associated with types of revision arthroplasty of differing complexity.

The Exeter Trauma Stem: A radiographic follow-up at minimum of five years post implantation.

INTRODUCTION: The Exeter Trauma Stem (ETS) has been recommended by National Institute of Clinical Excellence (NICE) guidelines in the United Kingdom as a proven, cemented stem. A single laboratory study in the literature has raised possible concerns about the polished finish of the ETS and subsequent potential for accelerated loosening although there is little clinical evidence to support or refute this. METHODS: The aim of this study was to assess clinical outcomes of the ETS at a minimum of five years post implantation. Primary outcomes were radiological loosening at a minimum of five years along with survivorship of the implant. Patient demographics were prospectively collected and followed up. RESULTS: 218 ETS's (in 214 patients) were implanted from June 2002 until August 2008 in a single centre by a wide variety of surgeons of differing grades. Of these, 16 underwent revision surgery for fracture (2), dislocation (3), infection (1) and acetabular erosion (10) but there were no revisions for aseptic loosening of the implant. There were 64.0% (137/214) patients that had died by the time of this study. Of the remaining patients, 90 had radiographs of their hips at a minimum of 5 years with 36 of these at a minimum of 7 years post implantation. None of these had evidence of loosening. CONCLUSION: The ETS is a robust and suitable stem for implantation in patients with hip fractures. There are no clinical suspicions or increased rates of loosening with the ETS in our study. The concerns about surface finish are not borne out in our clinical study which shows no evidence of loosening at a minimum of five years post operation. It confers many advantages including ease of revision and it should continue to be used as per NICE guidelines.

The Lateral Meniscus as a Guide to Anatomical Tibial Tunnel Placement During Anterior Cruciate Ligament Reconstruction.

PURPOSE: The aim of the study is to show, on an MRI scan, that the posterior border of the anterior horn of the lateral meniscus (AHLM) could guide tibial tunnel position in the sagittal plane and provide anatomical graft position. METHOD: One hundred MRI scans were analysed with normal cruciate ligaments and no evidence of meniscal injury. We measured the distance between the posterior border of the AHLM and the midpoint of the ACL by superimposing sagittal images. RESULTS: The mean distance between the posterior border of the AHLM and the ACL midpoint was -0.1mm (i.e. 0.1mm posterior to the ACL midpoint). The range was 5mm to -4.6mm. The median value was 0.0mm. 95% confidence interval was from -0.5 to 0.3mm. A normal, parametric distribution was observed and Intra- and inter-observer variability showed significant correlation (p<0.05) using Pearsons Correlation test (intra-observer) and Interclass correlation (inter-observer). CONCLUSION: Using the posterior border of the AHLM is a reproducible and anatomical marker for the midpoint of the ACL footprint in the majority of cases. It can be used intra-operatively as a guide for tibial tunnel insertion and graft placement allowing anatomical reconstruction. There will inevitably be some anatomical variation. Pre-operative MRI assessment of the relationship between AHLM and ACL footprint is advised to improve surgical planning. LEVEL OF EVIDENCE: Level 4.

Displaced femoral neck stress fractures in Royal Marine recruits--management and results of operative treatment.

Femoral neck stress fractures (FNSF) represent 3.5%-8% of stress fractures in military recruits; potentially resulting in medical discharge and/or complications. The incidence of displaced FNSF in the British Army has been reported as 1.8 in 10,000 recruits. We aimed to review the incidence and outcome of displaced FNSF in Royal Marine recruits. Retrospective review identified 6 recruits who sustained a displaced FNSF from 2001 to 2011 representing an incidence of 9.3 in 10,000 recruits. All were treated urgently by internal fixation. There were no cases of avascular necrosis, no surgical complications and no further procedures required. All united with a mean time to union of 11 months. 50% had a union time greater than 1 year. These fractures are slow to unite but with urgent surgical intervention and stable fixation 100% union was achieved. Awareness of this guides the management and rehabilitation whilst avoiding the risks of unnecessary secondary surgical interventions.