Outcomes of Dual Mobility Bearings in Revision Total Hip Replacements.

Background Dual mobility bearings have gained attention in the prevention of instability in revision total hip replacement. This study aimed to evaluate the use of dual mobility bearings in revision total hip replacement. The primary outcome was the rate of dislocation. Secondary outcomes included the rate of re-operation for any reason, surgical complications, serious medical adverse events, and 90-day mortality rate. Methods A single-centre case series of 55 consecutive operations in 49 patients who underwent revision total hip replacement using dual mobility bearings with a minimum follow-up of three months was studied.  Results Early dislocation occurred in one case (2%), and there were no intra-prosthetic dislocations at a mean follow-up of 16 months. The rate of re-operation for any reason was 6/55 (11%) cases, and the post-operative infection rate was 2/55 (4%) cases. Serious medical adverse events occurred in 2/55 (4%) cases. The 90-day mortality rate was 1/55 (2%) cases. Two cases (2%) had cup abduction or anteversion angles outside of the safe zones although there were no dislocations in these patients. Conclusion This case series demonstrates a low dislocation rate in the early post-operative period for dual mobility bearings in revision total hip replacement. Dual mobility bearings show promise as an early low dislocation implant in revision total hip replacement. It remains to be determined whether dual mobility bearings are low-wear implants in the long term.

Subsidence in Centraliser Sign: A Novel Tool to Help Predict Early Subsidence in Periprosthetic Femoral Fractures Around Polished Tapered Stems Treated With Internal Fixation.

Background When treating periprosthetic femoral fractures (PPF) around polished taper slip stems (PTS), determining which patients can be successfully treated with internal fixation can be challenging. We have described the subsidence-in-centraliser (SINC) sign as a radiographic feature of PPF around PTS stems. We hypothesise that a positive SINC sign can help predict a poorer outcome for the fixation of these fractures. Patients and methods Retrospective identification of PPFs around cemented PTS with an appreciable centraliser on radiographs was conducted at a single centre. A positive SINC sign was defined as a post-injury radiograph demonstrating >50% reduction in the radiographic lucency representing the stem centraliser when compared to pre-injury films or complete obliteration of distal lucency when no pre-injury film was available. The primary outcome was the rate of subsequent stem subsidence on follow-up radiographs comparing SINC-positive and SINC-negative fractures, which were managed with open reduction and internal fixation (ORIF). Results Fifty-four patients were included in the analysis. The mean age was 76.8 years, and the mean follow-up for all patients was 12.7 months. Thirty-five fractures were deemed SINC-positive, and 19 were SINC-negative. 17/17 (100%) SINC-positive fractures managed with fixation underwent further subsidence (mean 5.4 mm, SD 2.8). A positive SINC sign demonstrated a sensitivity of 90.5% and specificity of 100% for subsequent stem subsidence in fractures treated without revision. SINC positive fractures underwent significantly more subsidence compared with SINC negative fractures when fixed (5.4 mm vs. 0.28 mm, U = 6.50, p<0.001) at a mean follow-up of 12.7 months. The SINC sign demonstrated strong inter- (k=0.96) and intra-rater (k=0.86) reliability. Conclusion The SINC sign can serve as a useful adjunct in the decision to fix or revise PPF around PTS. A positive SINC sign may represent a cement mantle that cannot be reconstituted anatomically, leading to subsidence after treatment with ORIF.

Predicting the need for collateral ligament repair in transolecranon fractures of the elbow: a traffic light model.

BACKGROUND: Biomechanical studies have shown that translation of the proximal radius relative to the capitellum in the sagittal plane can predict integrity of the collateral ligaments in a transolecranon fracture model; no studies have examined this in clinical practice. METHODS AND MATERIALS: Nineteen consecutive transolecranon fracture dislocations were retrospectively reviewed. Data collection included patient demographics, fracture classifications, surgical management, and failure with instability. Distance between the center of the radial head and the center of the capitellum was measured on initial radiographs by 2 independent raters on 3 separate occasions. Statistical analysis was used to compare the median displacement between patients who required collateral ligament repair for stability and those who did not. RESULTS: Sixteen cases with a mean age of 57 years (range 32-85) were analyzed with an inter-rater Pearson coefficient of 0.89 for displacement measurement. Median displacement where collateral ligament repair was needed and performed was 17.13 mm (interquartile range [IQR] = 10.43-23.88) compared with 4.63 mm (IQR = 2.68-6.58) where collateral ligament repair was not performed and not required (P = .002). In 4 cases, ligament repair was not performed initially but deemed necessary based on clinical outcome and postoperative and intraoperative images. Of these, the median displacement was 15.59 mm (IQR = 10.09-21.20), and 2 of these required revision fixation. DISCUSSION: Where displacement on initial radiographs exceeded 10 mm, lateral ulnar collateral ligament (LUCL) repair was required in all cases (red group). If less than 5 mm, ligament repair was not required in any case (green group). Between 5 and 10 mm, following fracture fixation, the elbow must be screened carefully to assess for any instability and a low threshold set for LUCL repair to prevent posterolateral rotatory instability (amber group). Using these findings, we propose a traffic light model to predict the need for collateral ligament repair in transolecranon fractures and dislocation.

Accuracy of Total Hip Arthroplasty Templating Using Set Calibration Magnifications.

Background Templating for total hip arthroplasty has been adopted over recent decades as a reliable and accurate method for pre-operative planning. The use of calibration markers for this process provides a recognised benefit at the expense of cost, availability and error. Many surgeons use a set magnification of 118% to account for calibration errors when templating total hip arthroplasty. This study aims to assess the accuracy of templating with standardised magnifications and assess the effect of BMI on templating accuracy. Materials and methods A retrospective analysis was performed using a single-surgeon series of 119 consecutive total hip arthroplasties. Anteroposterior radiographs were taken pre- or post-operatively without calibration hardware. Pre-operatively, the total hip arthroplasty was templated on TraumaCad (BrainLab Inc, Westchester, IL) using either 118% or 119% calibration magnification. Post-operative magnification was calibrated using the known femoral head diameter. Templated and implanted prostheses were compared for size. Results At 118%, 61.1% of cups matched those templated with 96.3% of cups within two sizes. At 119%, 52.5% of cups used matched their templates with 100% within two sizes. There was no significant difference between 118% and 119% cup size prediction (p=0.49). A trend was noticed in increasing magnification error with increasing BMI. However, BMI had no significant effect on the accuracy of templating cup size within two cup sizes (p=0.58). Conclusion. Templating acetabular cups using a set magnification of 118% or 119% yields accurate results and provides a reliable method to template without calibration equipment. Whilst BMI can affect magnification error, this has no significant effect on the accuracy of implanted cups and stems within two sizes.

Pre-Operative Digital Templating Aids Restoration of Leg-Length Discrepancy and Femoral Offset in Patients Undergoing Total Hip Arthroplasty for Primary Osteoarthritis.

Background Pre-operative planning and templating is a crucial pre-requisite for total hip arthroplasty (THA). Recently, the use of digital radiography has allowed templating to be digitalised instead of traditional methods involving the use of radiograph transparencies. The primary aim of this study was to compare the accuracy in correction of leg length discrepancy (LLD) and restoring femoral offset in patients undergoing THA for primary osteoarthritis with pre-operative digital templating (PDT) versus conventionalplanning without digital templating. Methods This retrospective cohort study compared two groups of patients who underwent THA for primary osteoarthritis. During the period of the year 2020, 56 patients underwent THA with pre-operative digital templating and 50 patients without digital templating. Two independent blinded observers recorded all radiological data. Results The digital templated and non-digital templated cohorts were matched for variables including age (mean = 71.8 years vs 70.9 years), pre-operative LLD (-4.9mm vs -5.2mm) and pre-operative offset (41.2mm vs 43.7mm). PDT resulted in correction of LLD to <5mm compared to the contralateral hip in 76.8% of cases, 5-10mm in 21.4% and >10mm in one case (1.8%). The non-digital templated cohort had a LLD of <5mm in 50% of cases, 5-10mm in 28% and >10mm in 22%. Chi-square testing demonstrated these results to be statistically significant (p = 0.002). The mean pre-operative offset in the digital templated group was 40mm and 46mm post-operatively. The non-digital templated cohort had a mean pre-operative offset of 42mm and 36mm post-operatively. Independent t-testing revealed statistical significance of these results (p = 0.05). Conclusion PDT leads to an increased likelihood of restoring LLD to <5mm and a significantly increased likelihood of preventing lengthening >10mm. PDT also significantly increases the chance of restoring femoral offset to match the pre-operative native hip. Decreased offset is seen predominantly in the non-digitally templated patients.

Telemedicine in orthopaedics during COVID-19 and beyond: A systematic review.

INTRODUCTION: Telemedicine is the delivery of healthcare across a distance using some form of communication technology. The COVID-19 pandemic has led to increased adoption of telemedicine with national orthopaedic governing bodies advocating its use, as evidence suggests that social distancing maybe necessary until 2022. This systematic review aims to explore evidence for telemedicine in orthopaedics to determine its advantages, validity, effectiveness and utilisation. METHODS: Databases of PubMed, Web of Science, Scopus and CINAHL were systematically searched and articles were included if they involved any form of telephone or video consultation in an orthopaedic population. Findings were synthesised into four themes: patient/clinician satisfaction, accuracy and validity of examination, safety and patient outcomes and cost effectiveness. Quality assessment was undertaken using Cochrane and Joanna Briggs Institute appraisal tools. RESULTS: Twenty-one studies were included consisting of nine randomised controlled trials (RCTs). Studies revealed high patient satisfaction with telemedicine for convenience, less waiting and travelling time. Telemedicine was cost effective particularly if patients had to travel long distances, required hospital transport or time off work. No clinically significant differences were found in patient examination nor measurement of patient-reported outcome measures. Telemedicine was reported to be a safe method of consultation. DISCUSSION: Evidence suggests that telemedicine in orthopaedics can be safe, cost effective, valid in clinical assessment and with high patient/clinician satisfaction. However, more high-quality RCTs are required to elucidate long-term outcomes. This systematic review presents up-to-date evidence on the use of telemedicine and provides data for organisations considering its use during the COVID-19 pandemic and beyond.

Fixation and Implant Retention of Extracapsular Femoral Neck Periprosthetic Fractures Around Hip Resurfacing Arthroplasty - A Case Series.

BACKGROUND: Extracapsular femoral neck fractures in the presence of a resurfacing hip arthroplasty (RHA) appear to be independent of suboptimal technique during the initial implantation of the RHA and present with a similar etiology as native hip fractures - that is, a fragility fracture related to pathological or age-related osteoporosis, as a consequence of trauma. In the presence of a well-fixed and previously well-functioning RHA, the options for management include revision arthroplasty or open reduction and internal fixation (ORIF). In the absence of loosening through mechanisms of wear, infection, metallosis, or suboptimal prosthesis positioning, many authors have advocated ORIF with implant retention. However, there is often debate regarding the use of total hip arthroplasty in these cases. CASE SERIES: The authors conducted a thorough assessment of the literature followed by a retrospective review of outcomes for three patients treated by ORIF with implant retention for extracapsular femoral neck fractures around a RHA, using a standardized technique. All patients were independently mobile and active with well-fixed and well-functioning RHAs before the date of injury. All patients suffered low-energy trauma resulting in the fracture. There were no intraoperative or perioperative complications. All patients achieved full weight-bearing status and independent mobility. Two patients achieved radiographic union and returned to full range of movement and independent mobilization comparable to their preoperative state. One patient was lost to follow-up. CONCLUSION: The authors believe that fixation of extracapsular proximal femoral fractures distal to a well-fixed, well-functioning RHA is a good management option in an independent and active patient. A higher level of evidence is needed to investigate the surgical management options of these injuries comparing osteosynthesis with revision arthroplasty.

Recurrent Scleritis and Immunoglobulin A Nephropathy - A Case Series and Literature Review of an Unusual Association.

Immunoglobulin A (IgA) nephropathy is usually restricted to the kidneys in most cases, but associations with other immune and inflammatory diseases exist. Scleritis, however, is an unusual association. We present an observational case series of two patients who initially presented with recurrent episodes of scleritis. A thorough evaluation for recurrent scleritis did not reveal any secondary cause per se. They were further evaluated extensively for incidental proteinuria and microscopic hematuria. Renal function was normal. Renal biopsy was performed which revealed IgA nephropathy in both the patients. They were given oral prednisolone and telmisartan for six months and followed for nine and six months, respectively, after steroids were discontinued. Proteinuria remitted, renal function remained normal, and there were no further episodes of scleritis in these patients.

Hydroxyapatite coated hip hemiarthroplasty: Morbidity and mortality.

BACKGROUND: Use of uncemented femoral stems for treating displaced intra capsular hip fractures in elderly is increasing worldwide. The aim of our study is to evaluate morbidity and mortality of treatment with a modular fully hydroxyapatite-coated collared femoral stem. MATERIAL AND METHODS: 259 consecutive patients were included in the study. Patients were followed up for12 months. Outcomes were perioperative mortality, perioperative fractures, 30, 120 and 365-day mortality, revision surgery within 30 days and twelve months, length of stay, discharge destination and mobility. RESULTS: Mean age was 85.4 years. 71.8% were female. 63.3% of patients were ASA grade III and IV. 87.6% of patients were operated within 36 h of attendance to hospital. The mortality rate at 30, 120, and 365 days was 8.2%, 15%, and 18.4% respectively with no peri-operative mortality. 0.8% of the patients sustained a peri-operative fracture below the lesser trochanter. Infection and dislocation were 1.1% and 1.5% respectively. 3.4% of the patient underwent further surgery within thirty days but no further surgery in next twelve months. Mean inpatient acute length of stay was 16.8 days, 41.5% of the patients returned to their own or sheltered accomodation within thirty days. 68% of the patients were mobile outdoors prior to the fracture that dropped to 25% at one year after surgery. DISCUSSION: Our study demonstrates that treatment of displaced intracapsular femoral neck fractures in elderly with a full hydroxyapatite coated collared stem has satisfactory outcomes, no perioperative mortality, low one-year mortality and low revision hence a dependable option.

A review of the evolution of robotic-assisted total hip arthroplasty.

INTRODUCTION: Total hip arthroplasty (THA) is currently a very successful operation but continues to evolve as we try to perfect techniques and improve outcomes for our patients. Robotic hip surgery (RHS) began with the 'active' ROBODOC system in the 1980s. There were drawbacks associated with the original ROBODOC and most recently, the MAKO robot was introduced with early promising results. AIM: The aim of this paper is to provide an up-to-date review surrounding this area and discuss the pros and cons of this technique. METHODS: A literature review searching Medline, Embase, Ovidsp, Cochrane library, pubmed database and google scholar was performed searching keywords including: 'Robotic hip surgery', 'Robotic orthopaedic surgery', 'Computer assisted hip surgery', 'robotic arthroplasty', and 'computer assisted orthopaedic surgery'. CONCLUSION: Robotic hip surgery aims to tackle the limitations of the human factor in surgery by promising reproducible and reliable methods of component positioning in arthroplasty surgery. However, as orthopaedic surgeons, we must critically appraise all new technology and support the use providing there is sound robust evidence backing it.

Massive haemorrhagic blister formation following total knee arthroplasty.

Skin blistering following trauma is not uncommon; however, large haemorrhagic bullous blisters following total knee arthroplasty is relatively rare and not widely documented in the literature.

Treatment of middle-third clavicle fractures using anterior plating with a dynamic compression plate (DCP).

Significantly displaced midshaft clavicle fractures can be managed operatively to restore anatomy and allow early mobilization. Several techniques have described using precontoured anatomically designed plates placed on the superior surface of the bone or reconstruction plates contoured by the surgeon placed either superiorly or anteriorly. We describe the use of the dynamic compression plate placed anteriorly on the clavicle in treating these fractures and discuss the relative advantages of this technique. We have a case series of 8 patients over a 2-year period, who were followed up and all went on to successful fracture union.

The simple wire interosseous fixation technique (SWIFT) for reattachment of FDP avulsions with a large bony fragment.

Avulsion injuries of the flexor digitorum profundus tendon can be with or without a bony fragment. Types 3, 4, and 5 injuries often have a sizeable bony fragment. In the past, they have been repaired with either a screw, plate, or pull-out wire with a dorsal button, often in combination with a K wire to immobilize the distal interphalangeal joint. We illustrate with 2 cases a simple technique for secure repair of the flexor digitorum profundus avulsions with a bony fragment. In contrast to previously described techniques, our technique involves minimal dissection, has a significantly reduced risk of fracture to the bony fragment, is completely internalized thereby reducing the risk of postoperative infection and allows immediate mobilization.

Complications of Kirschner-wire fixation in distal radius fractures.

Distal radius and ulna fractures are the most common fractures seen in England, occurring at a rate of 22/10,000 person years. Kirschner (K)-wire fixation is a well-accepted method of treating these fractures. There is a surprising paucity of evidence on the subject of prophylactic antibiotics and the duration of K wires can be left in, as these relate to infection rates. We therefore present the results of our protocol for distal radius K-wire fixation for which: no antibiotic prophylaxis was given; we used a percutaneous (not buried) technique, where the K wires were removed after 4 weeks, and the patient has a total of 6 weeks in cast (last 2 wk without wires). The results of the last 100 consecutive patients who were treated with manipulation and K wiring of dorsally displaced distal radial fractures in a standard district general hospital over a 2-year period were analyzed retrospectively. A total of 100 patients had 176 K wires inserted. The mean age was 32.5 years. The mean time to pin removal was 29.4 days. The infection rate was 2%. These results illustrate a safe and clinically effective protocol for K-wire fixation in treating distal radius fractures. On the basis of this study, we do not advocate the use of prophylactic antibiotics, postulating that they do not affect infection rate and thereby eliminating potential antibiotic adverse effects. Furthermore, we do not bury the K wires, which allows for their removal in clinic, thus preventing risks of further operative procedures.

A 12 month review of a modified protocol using low dose Dabigatran Etexilate in postoperative thromboembolic prophylaxis in joint replacement surgery.

BACKGROUND: Venous Thrombo-embolic disease is currently a hot topic especially in the UK. 25,000 patients per year die of Pulmonary Emboli (PE) in the United Kingdom (UK). Hip and knee arthroplasty surgery is associated with an increased rate of deep vein thrombosis (DVT) and pulmonary embolus (PE). The National Institute for Clinical Excellence (NICE) guidelines introduced in January 2010 recommended use of subcutaneous heparin or an oral anticoagulant (Dabigatran or Rivaroxiban) for 10-14 days post knee and 28-35 days post hip arthroplasty. In our unit we were keen on the advantages of an oral anticoagulant post arthroplasty in terms of patient compliance, and avoiding the need for self administered injection in the community. METHODS: We analysed all the notes, blood results and imaging of patients undergoing total hip or knee arthroplasty and present 1 year's data using a regime of subcutaneous Dalteparin whilst an inpatient, followed by discharge on oral Dabigatran at a low dose (150 mg once daily). RESULTS: There were 337 patients over 1 year with hip and knee arthroplasty, with a 1.19% rate of DVT with no PEs and 1 death due to an unrelated cause. There was a transfusion rate of 11.57% with 1.19% patients taken back to theatre for evacuation of haematomas. There were no reported adverse effects of Dabigatran. CONCLUSION: Our treatment protocol is a novel practical approach for VTE prophylaxis in hip and knee replacement patients. This approach shows promising data but no definitive evidence to warrant wide-spread use of this new regime. This data can act as a foundation for larger randomised clinical trials.

A cheap and readily available assistant in hand surgery.

Controlling the digits during hand surgery can be challenging. During elective and emergency surgery, a "lead hand" can be used; however, during fracture surgery where an image intensifier is required, the lead hand prevents imaging. Sterile surgical gloves provide a cheap and readily available radiolucent alternative. The surgeon can use bands cut from the cuff of the glove. Performing procedures such as Kirschner wiring or plating of phalangeal fractures without an assistant become much easier with the use of this technique.