Bypassing the post-anaesthesia care unit after elective hip and knee arthroplasty: a prospective cohort safety study.

Following knee and hip arthroplasty, transfer to a recovery area immediately following surgery and before going to ward might be unnecessary in low-risk patients. Avoiding the recovery area in this way could allow for more targeted use of resources for higher risk patients, which may improve operating theatre flow and productivity. A prospective single-centre cohort study on the safety of criteria for bypassing the post-anaesthesia care unit in elective hip and knee arthroplasty was designed. Criteria were: ASA physical status < 3; peri-operative bleeding < 500 ml; low postoperative discharge-score (modified Aldrete-score); and an uncomplicated surgical and neuraxial anaesthesia procedure. The primary outcome was the number of patients in need of secondary readmission to the post-anaesthesia care unit. Events within the first 24 postoperative hours were recorded, along with readmission and complication rates. A total of 696 patients were included, with 287 (41%) undergoing total hip arthroplasty, 274 (39%) undergoing total knee arthroplasty and 135 (19%) undergoing unicompartmental knee-arthroplasty. Of these, 207 (44%) bypassed the post-anaesthesia care unit. Patients all received multimodal analgesia without peripheral nerve blockade. Only one patient in the ward group required secondary readmission to the post-anaesthesia care unit. Within 24 h, 151 events were reported, with 41 (27%) in the ward group and 110 (73%) in the post-anaesthesia care unit group. Two events in each group occurred within 2 hours of surgery. No complications were attributed to bypassing the post-anaesthesia care unit. The use of simple pragmatic criteria for bypassing the post-anaesthesia care unit for patients undergoing knee and hip arthroplasty with spinal anaesthesia is possible and associated with significant reduction of post-anaesthesia care unit admission and without apparent safety issues. Confirmation is needed from other studies and external validity should be interpreted cautiously in centres with different peri-operative regimens, organisational and staffing structures.

Knee-extensor strength, symptoms, and need for surgery after two, four, or six exercise sessions/week using a home-based one-exercise program: a randomized dose-response trial of knee-extensor resistance exercise in patients eligible for knee replacement (the QUADX-1 trial).

OBJECTIVE: To investigate firstly the efficacy of three different dosages of one home-based, knee-extensor resistance exercise on knee-extensor strength in patients eligible for knee replacement, and secondly, the influence of exercise on symptoms, physical function and decision on surgery. METHOD: One-hundred and forty patients eligible for knee replacement were randomized to three groups: 2, 4 or 6 home-based knee-extensor resistance exercise-sessions per week (group 2, 4 and 6 respectively) for 12 weeks. PRIMARY OUTCOME: isometric knee-extensor strength. SECONDARY OUTCOMES: Oxford Knee Score, Knee injury and Osteoarthritis Outcome Score, average knee pain last week (0-10 numeric rating scale), 6-min walk test, stair climbing test, exercise adherence and "need for surgery". RESULTS: Primary analysis: Intention-to-treat analysis of 140 patients did not find statistically significant differences between the groups from baseline to after 12 weeks of exercise in isometric knee-extensor strength: Group 2 vs 4 (0.003 Nm/kg (0.2%) [95% CI -0.15 to 0.15], P = 0.965) and group 4 vs 6 (-0.04 Nm/kg (-2.7%) [95% CI -0.15 to 0.12], P = 0.628). Secondary analysis: Intention-to-treat analyses showed statistically significant differences between the two and six sessions/week groups in favor of the two sessions/week group for Oxford Knee Score: 4.8 OKS points (15.2%) [1.3 to 8.3], P = 0.008) and avg. knee pain last week (NRS 0-10): -1.3 NRS points (-19.5%) [-2.3 to -0.2], P = 0.018. After the 12-week exercise intervention, data were available for 117 patients (N = 39/group): 38 (32.5%) patients wanted surgery and 79 (67.5%) postponed surgery. This was independent of exercise dosage. CONCLUSION: In patients eligible for knee-replacement we found no between-group differences in isometric knee extensor strength after 2, 4 and 6 knee-extensor resistance exercise sessions per week. We saw no indication of an exercise dose-response relationship for isometric knee-extensor strength and only clinically irrelevant within group changes. For some secondary outcome (e.g., KOOS subscales) we found clinically relevant within group changes, which could help explain why only one in three patients decided to have surgery after the simple home-based exercise intervention. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02931058. Preprint: https://doi.org/10.1101/2021.04.07.21254965.

The relationship between prescribed pre-operative knee-extensor exercise dosage and effect on knee-extensor strength prior to and following total knee arthroplasty: a systematic review and meta-regression analysis of randomized controlled trials.

OBJECTIVE: The aim of this systematic review was to evaluate the relationship between prescribed knee-extensor strength exercise dosage in pre-operative exercise intervention and the effect on knee-extensor muscle strength prior to and following TKA. Additional meta-analyses report the effect of pre-habilitation on outcomes prior to and following TKA. DESIGN: A systematic literature search was performed including RCT's evaluating the effect of pre-operative exercise prior to and following TKA. Meta-regression analysis was performed to evaluate the dose-response relationship between prescribed exercise dose and the pooled effect, measured as standardized mean difference (SMD). The prescribed exercise dose was quantified using a formula accounting for as many exercise descriptors as possible. Risk of bias in the included trials was assessed using the Cochrane Risk of Bias Tool. RESULTS: Twelve trials with 616 patients were included. Meta-regression analysis showed no relationship between prescribed pre-operative knee-extensor exercise dosage and change in knee-extensor strength neither prior to (slope 0.0005 [95%CI -0.007 to 0.008]) or 3 months following TKA (slope 0.0014 [95%CI -0.006 to 0.009]). Prior to TKA, a moderate effect favoring pre-operative exercise for increase in knee-extensor strength was found (SMD 0.50 [95%CI 0.12 to 0.88]), but not at 3 months following TKA (SMD -0.01 [95%CI -0.45 to 0.43]). Risk of bias was generally assessed as unclear. CONCLUSION: Meta-regression analysis of existing trials suggests no relationship between the prescribed pre-operative knee-extensor exercise dosage and the change in knee-extensor strength observed prior to and following TKA. Pre-operative exercise including knee-extensor muscle strength exercise increased knee-extensor strength moderately prior to but not 3 months following TKA. PROTOCOL REGISTRATION: PROSPERO ID (CRD42018076308) (http://www.crd.york.ac.uk/PROSPERO/).

Mismatch 'never events' in hip and knee arthroplasty: a cohort and intervention study.

AIMS: The aim of this study was to give estimates of the incidence of component incompatibility in hip and knee arthroplasty and to test the effect of an online, real-time compatibility check. MATERIALS AND METHODS: Intraoperative barcode registration of arthroplasty implants was introduced in Denmark in 2013. We developed a compatibility database and, from May 2017, real-time compatibility checking was implemented and became part of the registration. We defined four classes of component incompatibility: A-I, A-II, B-I, and B-II, depending on an assessment of the level of risk to the patient (A/B), and on whether incompatibility was knowingly accepted (I/II). RESULTS: A total of 26 524 arthroplasties were analyzed. From 12 307 procedures that were undertaken before implementation of the compatibility check, 21 class A incompatibilities were identified (real- or high-risk combinations; 0.17%; 95% confidence interval (CI) 0.11 to 0.26). From 5692 hip and 6615 knee procedures prior to implementation of the compatibility check, we found rates of class A-I incompatibility (real- or high-risk combinations unknowingly inserted) of 0.14% (95% CI 0.06 to 0.28) and 0.17% (95% CI 0.08 to 0.30), respectively. From 14 217 procedures after the introduction of compatibility checking (7187 hips and 7030 knees), eight class A incompatibilities (0.06%; 95% CI 0.02 to 0.11) were identified. This difference was statistically significant (p = 0.008). CONCLUSION: Our data presents validated estimates of the baseline incidence of incompatibility events for hip and knee arthroplasty procedures and shows that a significant reduction in class A incompatibility events is possible using a web-based recording system. Cite this article: Bone Joint J 2019;101-B:960-969.

Longitudinal changes in patient-reported outcome measures following total hip arthroplasty and predictors of deterioration during follow-up: a seven-year prospective international multicentre study.

AIMS: The primary aim of this study was to quantify the improvement in patient-reported outcome measures (PROMs) following total hip arthroplasty (THA), as well as the extent of any deterioration through the seven-year follow-up. The secondary aim was to identify predictors of PROM improvement and deterioration. PATIENTS AND METHODS: A total of 976 patients were enrolled into a prospective, international, multicentre study. Patients completed a battery of PROMs prior to THA, at three months post-THA, and at one, three, five, and seven-years post-THA. The Harris Hip Score (HHS), the 36-Item Short-Form Health Survey (SF-36) Physical Component Summary (PCS), the SF-36 Mental Component Summary (MCS), and the EuroQol five-dimension three-level (EQ-5D) index were the primary outcomes. Longitudinal changes in each PROM were investigated by piece-wise linear mixed effects models. Clinically significant deterioration was defined for each patient as a decrease of one half of a standard deviation (group baseline). RESULTS: Improvements were noted in each PROM between the preoperative and one-year visits, with one-year values exceeding age-matched population norms. Patients with difficulty in self-care experienced less improvement in HHS (odds ratio (OR) 2.2; p = 0.003). Those with anxiety/depression experienced less improvement in PCS (OR -3.3; p = 0.002) and EQ-5D (OR -0.07; p = 0.005). Between one and seven years, obesity was associated with deterioration in HHS (1.5 points/year; p = 0.006), PCS (0.8 points/year; p < 0.001), and EQ-5D (0.02 points/year; p < 0.001). Preoperative difficulty in self-care was associated with deterioration in HHS (2.2 points/year; p < 0.001). Preoperative pain from other joints was associated with deterioration in MCS (0.8 points/year; p < 0.001). All aforementioned factors were associated with clinically significant deterioration in PROMs (p < 0.035), except anxiety/depression with regard to PCS (p = 0.060). CONCLUSION: The present study finds that patient factors affect the improvement and deterioration in PROMs over the medium term following THA. Special attention should be given to patients with risk factors for decreased PROMs, both preoperatively and during follow-up. Cite this article: Bone Joint J 2019;101-B:768-778.

A pilot study to determine the effect of radiographer training on radiostereometric analysis imaging technique.

INTRODUCTION: Producing x-ray images for radiostereometric analysis (RSA) is a demanding technique. Suboptimal examinations result in a high percentage of exposure repetition. The aim of this pilot study was to use an experiential training approach to sharpen the skills of radiographers in acquiring images of an optimal quality. METHODS: A controlled trial using action research strategy was used. The study entailed a two phased approach. Radiographers were purposefully recruited and trained to perform the required investigations. Each phase included 12 examinations of a total knee arthroplasty phantom followed by 10 patient examinations. The quality of all x-ray images performed during the two phases was characterized by measuring the number of visible beads, the center position of the prosthesis (CP) compared to the center of calibration field (CCF). The number of re-exposures used to obtain a usable image during patient examinations was also recorded. RESULTS: The radiographers undergoing the training resulted in a significant improvement in the quality of images produced and visualization of the beads. That is, the ability to move the CP on average 36.1 mm closer to the CCF (p < 0.001), the number of visible beads increased by 3.1 (p < 0.001) and radiographers needed 2.1-2.9 exposures less to obtain RSA images of sufficient qualities during patient examinations in phase 2 (p < 0.001). CONCLUSION: This study illustrates the value of experiential method of teaching and learning with minimal compromise on patient safety but a significant contribution in terms of establishing quality of RSA images.

The effect of personalized versus standard patient protocols for radiostereometric analysis (RSA).

INTRODUCTION: Increasing pressure in the clinic requires a more standardized approach to radiostereometric analysis (RSA) imaging. The aim of this study was to investigate whether implementation of personalized RSA patient protocols could increase image quality and decrease examination time and the number of exposure repetitions. METHODS: Forty patients undergoing primary total hip arthroplasty were equally randomized to either a case or a control group. Radiographers in the case group were assisted by personalized patient protocols containing information about each patient's post-operative RSA imaging. Radiographers in the control group used a standard RSA protocol. RESULTS: At three months, radiographers in the case group significantly reduced (p < 0.001) the number of exposures by 1.6, examination time with 19.2 min, and distance between centrum of prosthesis and centrum of calibration field with 34.1 mm when compared to post-operative (baseline) results. At twelve months, the case group significantly reduced (p < 0.001) number of exposures by two, examination time with 22.5 min, and centrum of prosthesis to centrum of calibration field distance with 43.1 mm when compared to baseline results. No significant improvements were found in the control group at any time point. CONCLUSION: There is strong evidence that personalized RSA patient protocols have a positive effect on image quality and radiation dose savings. Implementation of personal patient protocols as a RSA standard will contribute to the reduction of examination time, thus ensuring a cost benefit for department and patient safety.

Iron deficiency and preoperative anaemia in patients scheduled for elective hip- and knee arthroplasty - an observational study.

BACKGROUND AND OBJECTIVES: Preoperative anaemia is prevalent in elderly patients scheduled for major orthopaedic surgery and is associated with increased transfusion risk and postoperative morbidity. New guidelines recommend preoperative correction of anaemia and iron deficiency in all patients with a Hb < 13 g/dl. However, iron deficiency and other causes of preoperative anaemia in hip- (THA) and knee (TKA) arthroplasty are only sparsely studied. MATERIALS AND METHODS: Preoperative Hb and iron status were prospectively collected from 882 unselected elective fast-track THA/TKA patients and analysed according to both WHO anaemia criteria (Hb < 12 g/dl females, <13 g/dl males) and Hb < 13 g/dl for both genders. Iron deficiency (ID) and other possible anaemia causes were classified by ferritin, transferrin saturation, P-cobalamin, P-folate, C-reactive protein and creatinine. RESULTS: Ninety-five (10·8%) and 243 (27·6%) of the study population were WHO anaemic or had a Hb < 13 g/dl, respectively. Transfusion was more common in anaemic vs. non-anaemic patients 43 vs. 13%; (P < 0·001), and in patients with Hb < 13 g/dl vs. Hb > 13 g/dl 28 vs. 11% (P < 0·001). 154 (17·5%) of all patients had ID, and ID was the most common cause of anaemia with a prevalence of 41% in WHO anaemic patients and 33% in patients with Hb < 13 g/dl. A further 19 (20%) and 46 (19%) patients, respectively, had evidence of iron sequestration. CONCLUSION: Anaemia is prevalent prior to THA and TKA with iron deficiency as the most common and reversible cause.

Females, younger patients and patients with high BMI have the highest pre-operative knee awareness measured using the Forgotten Joint Score.

PURPOSE: The Forgotten Joint Score (FJS) is a novel measurement for patients' awareness of their knee in daily life. By identifying factors that could explain pre-operative FJS levels, the clinician could better prioritize and single out patients who would benefit most from TKA. The aim of this study was to identify possible factors that may explain the variance of pre-operative FJS levels and evaluate the relationship between pre-operative FJS and pre-operative Oxford Knee Score (OKS). METHODS: Four-hundred and six individual knees undergoing primary TKA between 2014 and 2016 were included in the study. Age, gender, body mass index (BMI), pre-operative FJS and pre-operative OKS were obtained maximum 2 weeks prior to surgery. Kellgren-Lawrence (K-L) grade, alignment and joint space width (JSW) were evaluated on pre-operative radiographs. RESULTS: Mean FJS was 21.1 ± 15.6. Females, younger patients and patients with high BMI had significantly the worst pre-operative FJS (p < 0.005). Females scored 6.5 FJS points lower than males. A 0.2-point increase in FJS for every added year indicated improvement in knee awareness with age. A 0.4-point decrease in FJS points for every added BMI point indicated worse knee awareness with higher BMI. There was a strong positive correlation between pre-operative FJS and pre-operative OKS according to the Spearman's rank order test (p < 0.005). CONCLUSIONS: Females, younger patients and patients with high BMI had significantly the worst pre-operative joint awareness. FJS had a strong positive correlation to OKS in pre-operative patients for primary TKA. This information can be used for improved patient selection; clinically continuous low FJS despite weight loss and/or the passing of time may be indication for TKA. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

Design and evaluation of learning strategies for a group of radiographers in radiostereometric analysis (RSA).

INTRODUCTION: The purpose of this study was to design and evaluate a radiostereometric analysis (RSA) program aimed at radiographers in order to increase their cognitive and practical skills, thereby increasing image quality and minimizing exposure repetition. METHODS AND MATERIALS: Twenty radiographers were randomized into two identically sized study groups. Training consisted of a theoretical and practical workshop using a phantom. Tests were performed to compare the effect of training to nontraining, and the effect of time duration on the maintenance of RSA skills. The effect of training was measured by a written test and three defined parameters influencing image quality. RESULTS: Group A reduced significantly (p < 0.001) by 31.3 mm (21-31%) the distance between the centrum of the prosthesis (CP) and the centrum of the calibration field (CCF) and increased the number of beads (NB) visible by 3.6 (out of 18). A further significant reduction of 5.1 mm (p = 0.023), 1.0 bead more (p < 0.001) and a 2.1 (p = 0.022) point better rotation of the prosthesis (RP) was registered two months later. Group B was tested twice without training and no significant improvement was registered. One month after training group B had experienced overall significant improvement on a par with group A. CONCLUSION: It is realistic to implement an RSA X-ray training program where radiographers significantly improve their theoretical and practical skills in centering the CP closer to the CCF, NB and RP. A duration of up to two months after training does not influence the quality of participants' performance.

Vitamin E diffused highly cross-linked polyethylene in total hip arthroplasty at five years: a randomised controlled trial using radiostereometric analysis.

AIMS: The objective of this five-year prospective, blinded, randomised controlled trial (RCT) was to compare femoral head penetration into a vitamin E diffused highly cross-linked polyethylene (HXLPE) liner with penetration into a medium cross-linked polyethylene control liner using radiostereometric analysis. PATIENTS AND METHODS: Patients scheduled for total hip arthroplasty (THA) were randomised to receive either the study E1 (32 patients) or the control ArComXL polyethylene (35 patients). The median age (range) of the overall cohort was 66 years (40 to 76). RESULTS: The five-year median (interquartile range) proximal femoral head penetration into the E1 was -0.05 mm (-0.13 to -0.02) and 0.07 mm (-0.03 to 0.16) for ArComXL. At three and five years, the penetration was significantly greater in the ArComXL group compared with the E1 group (p = 0.029 and p = 0.019, respectively). All patient-reported outcomes (PROs) improved significantly from the pre-operative interval compared with those at one year, and remained favourable at five years. There were no differences between the two groups at any interval. CONCLUSION: The five-year results showed that E1 polyethylene does not wear more than the control, ArComXL. This is the longest-term RCT comparing the wear performance and clinical outcome of vitamin E diffused HXLPE with a previous generation of medium cross-linked polyethylene. Cite this article: Bone Joint J 2017;99-B:577-84.

Risk factors for post-operative periprosthetic fractures following primary total hip arthroplasty with a proximally coated double-tapered cementless femoral component.

AIMS: The aim of this study was to identify patient- and surgery-related risk factors for sustaining an early periprosthetic fracture following primary total hip arthroplasty (THA) performed using a double-tapered cementless femoral component (Bi-Metric femoral stem; Biomet Inc., Warsaw, Indiana). PATIENTS AND METHODS: A total of 1598 consecutive hips, in 1441 patients receiving primary THA between January 2010 and June 2015, were retrospectively identified. Level of pre-operative osteoarthritis, femoral Dorr type and cortical index were recorded. Varus/valgus placement of the stem and canal fill ratio were recorded post-operatively. Periprosthetic fractures were identified and classified according to the Vancouver classification. Regression analysis was performed to identify risk factors for early periprosthetic fracture. RESULTS: The mean follow-up was 713 days (1 to 2058). A total of 48 periprosthetic fractures (3.0%) were identified during the follow-up and median time until fracture was 16 days, (interquartile range 10 to 31.5). Patients with femoral Dorr type C had a 5.2 times increased risk of post-operative periprosthetic fracture compared with type B, while female patients had a near significant two times increased risk over time for post-operative fracture. CONCLUSION: Dorr type C is an independent risk factor for early periprosthetic fracture, following THA using a double tapered cementless stem such as the Bi-Metric. Surgeons should take bone morphology into consideration when planning for primary THA and consider using cemented femoral components in female patients with poor bone quality. Cite this article: Bone Joint J 2017;99-B:451-7.

Tranexamic acid reduces blood loss in patients with extracapsular fractures of the hip: results of a randomised controlled trial.

AIMS: We chose unstable extra-capsular hip fractures as our study group because these types of fractures suffer the largest blood loss. We hypothesised that tranexamic acid (TXA) would reduce total blood loss (TBL) in extra-capsular fractures of the hip. PATIENTS AND METHODS: A single-centre placebo-controlled double-blinded randomised clinical trial was performed to test the hypothesis on patients undergoing surgery for extra-capsular hip fractures. For reasons outside the control of the investigators, the trial was stopped before reaching the 120 included patients as planned in the protocol. RESULTS: In all 72 patients (51 women, 21 men; 33 patients in the TXA group, 39 in the placebo group) were included in the final analysis, with a significant mean reduction of 570.8 ml (p = 0.029) in TBL from 2100.4 ml (standard deviation (sd) = 1152.6) in the placebo group to 1529.6 ml (sd = 1012.7) in the TXA group. The 90-day mortality was 27.2% (n = 9) in the TXA group and 10.2% (n = 4) in the placebo group (p = 0.07). We were not able to ascertain a reliable cause of death in these patients. DISCUSSION: TXA significantly reduced TBL in extra-capsular hip fractures, but concerns regarding its safety in this patient group must be investigated further before the use of TXA can be recommended. TAKE HOME MESSAGE: We present a randomised clinical trial that is unique in the literature. We evaluate the effect of TXA in very homogenous population - extra-capsular fractures operated with short intramedullary nails. Cite this article: Bone Joint J 2016;98-B:747-53.

Persistent pain is common 1 year after ankle and wrist fracture surgery: a register-based questionnaire study.

BACKGROUND: Substantial literature documents that persistent postsurgical pain is a possible outcome of many common surgical procedures. As fracture-related surgery implies a risk of developing neuropathic pain and complex regional pain syndrome (CRPS), further studies investigating the prevalence and pain characteristics are required. METHODS: All patients undergoing primary surgery because of ankle or wrist fracture at Hvidovre and Odense University Hospitals, Denmark, between April 15, 2013 and April 15, 2014, were identified from the Danish Fracture Database. A questionnaire regarding pain characteristics was sent to patients 1 yr after primary surgery. RESULTS: Replies were received from 328 patients, of whom 18.9% experienced persistent postsurgical pain defined as pain daily or constantly at a level that interfered much or very much with daily activities, 42.8% reported symptoms suggestive of neuropathic pain, and 4.0% fulfilled the diagnostic patient-reported research criteria for CRPS. CONCLUSIONS: Persistent postsurgical pain 1 yr after wrist and ankle fracture surgery is frequent, and a large proportion of patients experience symptoms suggestive of neuropathic pain and CRPS. Patients should be informed about the substantial risk of developing persistent postsurgical pain. Future studies investigating risk factors for persistent postsurgical pain that include both surgically and conservatively treated fractures are required.

No need to change the skin knife in modern arthroplasty surgery.

Earlier studies have found varying contamination rates using separate skin and deep knives in total hip (THA) and total knee (TKA) arthroplasty surgery. Previous studies were primarily conducted in the setting of concomitant use of laminar airflow and/or plastic adhesive draping. This has lead to conflicting conclusions regarding discarding the skin knife or not. This study evaluates the prevalence of contamination of a separate skin knife using modern antiseptic technique in primary THA and TKA without laminar airflow. Three knives from each primary THA and TKA surgery in non-laminar airflow operating rooms were collected: one used for the skin, one used for deeper tissues and one control knife. A total of 831 knife blades from 277 patients were cultured 12 days. Contamination of the skin knife was found in eight patients (2.8 %), contamination of the "deep" knife in five patients (1.8 %) and contamination of the control knife in five patients (1.8 %). No patient developed an infection with 1-year follow-up. Our findings suggest a very low rate of contamination of the skin knife using modern antiseptic technique without laminar airflow and/or plastic adhesive draping and do not support the use of a separate skin knife in arthroplasty surgery.

Do we need a gender-specific total knee replacement? A randomised controlled trial comparing a high-flex and a gender-specific posterior design.

The purpose of this study was to investigate whether a gender-specific high-flexion posterior-stabilised (PS) total knee replacement (TKR) would offer advantages over a high-flex PS TKR regarding range of movement (ROM), 'feel' of the knee, pain and satisfaction, as well as during activity. A total of 24 female patients with bilateral osteoarthritis entered this prospective, blind randomised trial in which they received a high-flex PS TKR in one knee and a gender-specific high-flexion PS TKR in the other knee. At follow-up, patients were assessed clinically measuring ROM, and questioned about pain, satisfaction and daily 'feel' of each knee. Patients underwent gait analysis pre-operatively and at one year, which yielded kinematic, kinetic and temporospatial parameters indicative of knee function during gait. At final follow-up we found no statistically significant differences in ROM (p = 0.82). The median pain score was 0 (0 to 8) in both groups (p = 0.95). The median satisfaction score was 9 (4 to 10) in the high-flex group and 8 (0 to 10) in the gender-specific group (p = 0.98). The median 'feel' score was 9 (3 to 10) in the high-flex group and 8 (0 to 10) in the gender-specific group (p = 0.66). Gait analysis showed no statistically significant differences between the two prosthetic designs in any kinematic, kinetic or temporospatial parameters. Both designs produced good clinical results with significant improvements in several gait parameters without evidence of any advantage in the gender-specific design.

Fast-track surgery for bilateral total knee replacement.

Bilateral simultaneous total knee replacement (TKR) has been considered by some to be associated with increased morbidity and mortality. Our study analysed the outcome of 150 consecutive, but selected, bilateral simultaneous TKRs and compared them with that of 271 unilateral TKRs in a standardised fast-track setting. The procedures were performed between 2003 and 2009. Apart from staying longer in hospital (mean 4.7 days (2 to 16) versus 3.3 days (1 to 25)) and requiring more blood transfusions, the outcome at three months and two years was similar or better in the bilateral simultaneous TKR group in regard to morbidity, mortality, satisfaction, the range of movement, pain, the use of a walking aid and the ability to return to work and to perform activities of daily living. Bilateral simultaneous TKR can therefore be performed as a fast-track procedure with excellent results.

A new minimally invasive transsartorial approach for periacetabular osteotomy.

BACKGROUND: A new minimally invasive transsartorial approach for the Bernese periacetabular osteotomy was developed. We investigated whether this technique was safe and successful with regard to minimizing tissue trauma and, more importantly, whether it was possible to obtain optimal reorientation of the acetabulum. METHODS: Our experience with this approach was retrospectively assessed by means of database inquiry and the evaluation of radiographs. We assessed ninety-four procedures performed between April 2003 and August 2005 to determine perioperative and early postoperative outcome measures, the achieved acetabular reorientation, and hip joint survival. RESULTS: The mean duration of surgery was 73.1 minutes, the median perioperative blood loss was 250 mL, and the mean reduction in the hemoglobin level was 33 g/L. Blood transfusion was required following 3% of the procedures. No injuries to the great vessels or nerves, arterial thromboses, unintended extension of the osteotomy, or deep infections occurred. The postoperative acetabular reorientation was assessed by measuring the center-edge and acetabular index angles, the medians of which were 34 degrees and 3 degrees , respectively. With total hip arthroplasty as the end point, the hip joint survival rate was estimated to be 98% at 4.3 years. CONCLUSIONS: Osteotomy with use of this minimally invasive transsartorial approach appears to be a safe, relatively short surgical procedure associated with a relatively small amount of blood loss and minimal transfusion requirements. Optimal acetabular reorientation can be achieved with this technique.

Ultrasound versus magnetic resonance arthrography in acetabular labral tear diagnostics: a prospective comparison in 20 dysplastic hips.

BACKGROUND: Acetabular labral tears are highly associated with hip dysplasia. Magnetic resonance arthrography (MR arthrography) is the expensive and time-consuming contemporary gold-standard method in the radiological assessment of acetabular labral tears. PURPOSE: To assess the diagnostic ability of noninvasive ultrasound (US) examination compared to MR arthrography in diagnosing acetabular labral tears in dysplastic hip joints. MATERIAL AND METHODS: The study compared US examination and MR arthrography diagnosis of labral tears in 20 consecutively referred dysplastic hip joints. RESULTS: The ability to diagnose acetabular labral tears upon US examination was calculated: sensitivity 44%, specificity 75%, positive predictive value 88%, and negative predictive value 25%. CONCLUSION: The ability of US examination in diagnosing acetabular labral tears is not yet good enough. The technique is still to be developed, and more experience, especially with the interpretation of US examinations, is needed.