A conservative approach to dislocation following total hip arthroplasty: a review of 8606 hips.

PATIENTS AND METHODS: We present the data on 8606 total hip arthroplasty (THA) procedures carried out in 7818 patients through a posterior approach between 1998 and 2017. RESULTS: 218 hips (2.5%) suffered at least 1 dislocation with dislocation rates declining from 6.2% from 1998 to 2002 to 1.5% from 2003 to 2017. Overall, 92 hips (1.06%) required revision surgery but of these, only 5 (0.06%) had a full revision of both components with the remaining 87 requiring intervention only on the acetabular side. None have had a pseudo-arthrosis; none were left dislocated and all remain stable to date. CONCLUSIONS: In patients who have a second dislocation within 3 months of their primary surgery we recommend a spica or long leg cylinder cast to reduce the need for revision surgery. We propose an algorithm to manage instability with less aggressive operative treatment in this often-elderly patient population with the potential for less physiological insult and significant cost savings.

Antibiotic Prophylaxis Protocols and Surgical Site Infection Rates in Trauma Surgery: A Prospective Regional Study of 26,849 Procedures.

INTRODUCTION: Prophylactic antibiotics have been shown to reduce the rate of surgical site infection (SSI) 1, however there is little evidence supporting the effectiveness of one antibiotic over another. We have studied SSI rates and antibiotic prophylaxis protocols in Northern Ireland trauma surgery over a 10-year period to Identify the most effective antibiotic protocol associated with lowest rate of SSI. METHOD: Antibiotic prophylaxis protocols from 2004-2014 were sought from each of the region's 4 trauma hospitals and their dates of introduction recorded. For the same period, the number of trauma procedures carried out quarterly and the number of SSIs were recorded for each hospital from the return of prospectively collected SSI surveillance forms. RESULTS: 26849 trauma procedures were included with an overall SSI rate of 1.34% (95% Confidence interval [CI] 1.21 to 1.49). Single dose flucloxacillin (2 grams) with single dose gentamicin (3mg/kg) was the most commonly used protocol used in 3 different hospitals for a combined 13.5 years covering 11445 procedures. The SSI rate was 0.72% (95% CI 0.58-0.89). Triple dose cefuroxime (1.5 grams) was used in 2 different hospitals for a combined 10 years covering 8864 procedures. The SSI rate for this regime was 2.46% (95% CI 2.16-2.80). Single dose cefuroxime (1.5 grams) was used in 2 different hospitals for a combined 8 years covering 6540 procedures. The SSI rate was 0.92% (95% CI 0.71-1.18). CONCLUSION: In this prospective observational cohort study prophylaxis using flucloxacillin and gentamicin was associated with the lowest SSI rate. Single dose cefuroxime was associated with a lower rate of SSI compared to triple dose (p<0.001). Identification of antibiotic regimes associated with the lowest SSI rates will promote the judicious use of antibiotics, improve antibiotic stewardship while allowing for continued benefit in the prevention of SSI in an era of ever-increasing antibiotic resistance.

Minimal Incision Total Hip Arthroplasty: A Concise Follow-up Report on Functional and Radiographic Outcomes at 10 Years.

In 2005, we conducted a prospective randomized controlled trial that demonstrated that, compared with a standard incision, a minimal incision technique did not improve early outcomes of total hip arthroplasty (THA). There was concern that reduced exposure could compromise long-term outcome. For the current study, all surviving participants were invited to return for 10-year radiographic and clinical evaluation. Outcome scores were available for 152 patients (69.4%) from the original cohort, and radiographs were available for 126 (57.5%). The median duration of follow-up was 124 months. We did not find significant differences in functional status or radiographic outcome between the minimal and standard incision groups at 10 years. The 10-year implant survival rate was 99.1% (95% confidence interval [CI] = 97.3% to 100%) in the standard incision group and 97.9% (95% CI = 95.1% to 100%) in the minimal incision group (p = 0.57). We concluded that minimal incision THA performed by a high-volume surgeon does not compromise long-term results but offers no benefit over a standard incision. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

LCS mobile bearing total knee arthroplasty without patellar resurfacing. Does the unresurfaced patella affect outcome? Survivorship at a minimum 10-year follow-up.

BACKGROUND: Patellar resurfacing during total knee arthroplasty (TKA) remains controversial. The aim of this study was to evaluate the long-term outcomes of a mobile-bearing TKA without patellar resurfacing. METHODS: We assessed the outcomes in 503 patients (600 knees) who had cemented LCS (low contact stress) mobile bearing TKA without patellar resurfacing at a minimum follow-up of 10 years. Clinical outcome scores and radiological assessment were used. RESULTS: Four knees were revised, two had bearing dislocation and nine patients (1.5%) had secondary resurfacing for anterior knee pain. There were no radiolucent lines or osteolytic defects on radiographic evaluation. The overall survivorship was 97.8% with re-operation for any reason as the endpoint. CONCLUSION: Non-resurfacing of the patella does not adversely affect the outcome of the LCS mobile bearing TKA at minimum 10 years follow-up.

Reliability of the radiological assessments of radiolucency and loosening in total hip arthroplasty using PACS.

We evaluated the reliability of three commonly used radiological assessments of total hip arthroplasty (THA) using the electronic picture archiving and communications system (PACS). Thirty-three patients were selected at random at a mean of 7.2 years after THA. The Barrack, Gruen and Hodgkinson evaluations of cementing quality, loosening/radiolucency were graded. Three observers assessed each radiograph (one consultant orthopaedic surgeon, one senior orthopaedic registrar and one senior house officer). Four weeks after the initial assessment, each radiograph was reviewed a second time. The findings indicated that the intra- and inter-observer reliability of the Barrack, Gruen and Hodgkinson methods were questionable. Inter-observer reliability using the Gruen system was poor, using the Barrack system it was moderate to good, and fair to good using the Hodgkinson assessment. Intra-observer reliability was moderate to good for Barrack assessment, poor to good using Gruen zone assessments, but good to very good for the Hodgkinson assessment. The use of Barrack, Gruen and Hodgkinson assessments to evaluate femoral and acetabular loosening should be questioned since these exhibit limited inter- and intra-observer reliability on PACS radiographs, but of the three, the Hodgkinson system is the most reliable.

Comparison of immediate postoperative walking ability in patients receiving minimally invasive and standard-incision hip arthroplasty: a prospective blinded study.

Minimally invasive hip arthroplasty is thought to result in less soft tissue damage, earlier ambulation, and improved rehabilitation. This prospective blinded cohort study objectively analyzed early functional walking ability by stride analysis 2 days postoperatively. Ninety-five patients were analyzed, 43 of who received the minimal incision and 52 the traditional incision. Patients, physiotherapists, and assessors were blinded to the incision used. Velocity, cadence, stride length, operated and nonoperated limb step-length, and the ratio of step length of the operated to nonoperated limbs were recorded. No significant differences in any of these variables were shown between the minimal-incision and traditional-incision groups. This study demonstrates no functional benefits of the minimally invasive incision over the standard one in terms of early walking ability.

Comparison of early postoperative functional levels following total hip replacement using minimally invasive versus standard incisions. A prospective randomized blinded trial.

OBJECTIVE: To compare the results of single-incision minimally invasive total hip replacement (< or = 10 cm) to standard-incision (16 cm) total hip replacement in the early postoperative period with respect to functional and mobilizing ability (transfers, mobilizing, walking and stair assessment). SETTING: Orthopaedic wards of a regional orthopaedic centre. SUBJECTS: Two hundred and nineteen total hip replacement patients were tested between December 2003 and June 2004. INTERVENTIONS: Patients were randomized to either total hip replacement through a minimally invasive (< or = 10 cm) or standard incision (16 cm). A single surgeon performed all procedures using the same type of component fixation. Postoperative physiotherapy assessment and treatment was standardized. Analgesia was also standardized. All patients, physiotherapy staff and assessors were blinded to the incision used. MAIN OUTCOME MEASURES: Patients were tested two days post operatively and were assessed for the following activities: transfer from supine to sit, transfer from sitting to standing, mobilizing, ascending and descending stairs and weight-bearing. RESULTS: The shorter incision offered no significant improvement in patient ability in relation to transfer from lying to sitting, transfer from sitting to standing, mobilizing or weight-bearing. Ascending/descending stairs gave a total time for the minimal incision of 38.7 s against 40.8 s for a standard incision. There was no difference in walking velocity between the standard incision and minimal incision groups two days post operatively (minimal incision = 0.26 m/s versus standard incision = 0.26 m/s) or six weeks post operatively (minimal incision = 0.90 m/s versus standard incision = 0.93 m/s). There was no difference between groups with respect to walking aids at six-week review. The mean length of stay for the minimally invasive approach was 3.65 days (SD 2.04) against 3.68 days (SD 2.45) for the standard approach. This was not significantly different. CONCLUSION: Total hip replacement performed through a minimally invasive incision of < or = 10 cm compared with a standard incision of 16 cm offers no significant benefit in terms of the rate or ability of patients to mobilize and perform functional tasks necessary for safe discharge.

A minimal-incision technique in total hip arthroplasty does not improve early postoperative outcomes. A prospective, randomized, controlled trial.

BACKGROUND: Minimally invasive total hip arthroplasty has stirred substantial controversy with regard to whether it provides superior outcomes compared with total hip arthroplasty performed through longer incisions. The orthopaedic literature is deficient in well-designed scientific studies to support the clinical superiority of this approach. The objective of this study was to compare the results of a single mini-incision approach with those of a standard-incision total hip arthroplasty in the early postoperative period. METHODS: Two hundred and nineteen patients (219 hips) admitted for unilateral total hip arthroplasty between December 2003 and June 2004 were randomized to undergo surgery through a short incision of

Delayed union and non-union of the ulna following intramedullary nailing in children.

Most studies report little or no problem with union following intramedullary nailing of fractured forearm bones in children. The bone involved in the occasional delayed union is not mentioned except for one delayed union of the ulna following an open fracture. The present paper specifically highlights problems with union of the ulna following nailing in children. It reports two cases of delayed union and one non-union following nailing of closed fractures of both forearm bones. In all cases, the radius united in good time. We discuss the anatomical reasons and surgical techniques that predispose the ulna bone to delayed union and non-union and recommend surgical precautions to avoid this.