A comparison between the direct anterior and posterior approaches for total hip arthroplasty: the role of an 'Enhanced Recovery' pathway.

AIMS: We assessed the difference in hospital based and early clinical outcomes between the direct anterior approach and the posterior approach in patients who undergo total hip arthroplasty (THA). PATIENTS AND METHODS: The outcome was assessed in 448 (203 males, 245 females) consecutive patients undergoing unilateral primary THA after the implementation of an 'Enhanced Recovery' pathway. In all, 265 patients (mean age: 71 years (49 to 89); 117 males and 148 females) had surgery using the direct anterior approach (DAA) and 183 patients (mean age: 70 years (26 to 100); 86 males and 97 females) using a posterior approach. The groups were compared for age, gender, American Society of Anesthesiologists grade, body mass index, the side of the operation, pre-operative Oxford Hip Score (OHS) and attendance at 'Joint school'. Mean follow-up was 18.1 months (one to 50). RESULTS: There was no significant difference in mean length of stay (p = 0.07), pain scores on the day of surgery, the first, second and third post-operative days (p = 0.36, 0.23, 0.25 and 0.59, respectively), the day of mobilisation (p = 0.12), the mean OHS at six and 24 months (p = 0.08, and 0.29, respectively), the incidence of infection (p = 1.0), dislocation (p = 1.0), re-operation (p = 0.21) or 28 days' re-admission (p = 0.06). Significantly more patients in the DAA group achieved a planned discharge target of three days post-operatively (68% vs 56%, p = 0.007). The rate of periprosthetic femoral fractures was significantly higher in the DAA group (p = 0.04). CONCLUSION: We conclude that there is no difference in clinical outcomes between the DAA and the posterior approach in patients undergoing THA when an 'Enhanced Recovery' pathway is used. However, a significantly higher rate of periprosthetic femoral fractures remains a concern with the DAA, even in experienced hands. TAKE HOME MESSAGE: Our results show that the DAA for THA is not superior to posterior approach when 'Enhanced Recovery' pathway is used. Cite this article: Bone Joint J 2016;98-B:754-60.

Outcome after conservatively managed intracapsular fractures of the femoral neck.

INTRODUCTION: In 2012, 2.6% of hip-fracture patients in the UK were treated conservatively. There is little data on outcome for these patients. However, one study demonstrated that though 30-day mortality is higher, mortality over the rest of the year is comparable with that in surgical groups. Therefore, we assessed conservatively managed patients in our unit. METHODS: Patients with intracapsular fractures of the femoral neck treated by conservative means between 2010 and 2012 inclusive were identified. Data were collected: American Society of Anaesthesiologists (ASA) grade, Nottingham Hip Fracture Score (NHFS), mobility, mortality (30 days and one year) and pain levels. RESULTS: Thirty-two patients formed the study cohort. Mean age was 85.6 years. Median ASA grade was 4. Mortality at 30 days and one year was 31.3% and 56.3%, respectively. There was one case of pneumonia and one of infection. Pressure sores or venous thromboembolism were not documented. Three patients underwent surgery once their health improved. In general, mobility was decreased, but 30.8% of patients could mobilise with two aids or a frame. Only two cases had ongoing problems with pain. CONCLUSIONS: Our data are similar to those published previously. Our patients were likely to have higher mortality data due to selection bias. Thirty-day mortality was significantly higher than the national average, but patients surviving 30 days had a prevalence of mortality similar to those managed by surgical means. Despite mobility decreasing from the pre-admission status, a considerable number of patients were free of pain and could mobilise. These data suggest that conservative management of intracapsular fractures of the femoral neck can produce acceptable results.

Is prolonged systemic antibiotic treatment essential in two-stage revision hip replacement for chronic Gram-positive infection?

When using a staged approach to eradicate chronic infection after total hip replacement, systemic delivery of antibiotics after the first stage is often employed for an extended period of typically six weeks together with the use of an in situ antibiotic-eluting polymethylmethacrylate interval spacer. We report our multi-surgeon experience of 43 consecutive patients (44 hips) who received systemic vancomycin for two weeks in combination with a vancomycin- and gentamicin-eluting spacer system in the course of a two-stage revision procedure for deep infection with a median follow-up of 49 months (25 to 83). The antibiotic-eluting articulating spacers fractured in six hips (13.9%) and dislocated in five patients (11.6%). Successful elimination of the infecting organisms occurred in 38 (92.7%) of 41 hips with three patients developing superinfection with a new organism. We conclude that prolonged systemic antibiotic therapy may not be essential in the two-stage treatment of a total hip replacement for Gram-positive infection, provided that a high concentration of antibiotics is delivered locally using an antibiotic-eluting system.

The management of bone loss in revision total knee replacement.

The management of bone loss in revision replacement of the knee remains a challenge despite an array of options available to the surgeon. Bone loss may occur as a result of the original disease, the design of the prosthesis, the mechanism of failure or technical error at initial surgery. The aim of revision surgery is to relieve pain and improve function while addressing the mechanism of failure in order to reconstruct a stable platform with transfer of load to the host bone. Methods of reconstruction include the use of cement, modular metal augmentation of prostheses, custom-made, tumour-type or hinged implants and bone grafting. The published results of the surgical techniques are summarised and a guide for the management of bone defects in revision surgery of the knee is presented.

An algorithm to standardise the investigation of the undiagnosed traumatic painful adult hip: results at one year.

INTRODUCTION: A significant number of adults present to accident and emergency departments with a painful hip following a fall. When plain radiography is non-diagnostic, it has been traditionally difficult to decide on further investigations as rapid access MRI is still unavailable in many NHS hospitals and, therefore, alternative methods of reliable investigation are required. PATIENTS & METHODS: An algorithm was designed for the management of these patients without the availability of MRI investigation. Over a 60-week period, 278 patients were admitted of whom 31 were adult patients with trauma-related hip pain with no fracture on plain radiography. RESULTS: We revealed 42% had fractures of the hip or pelvic girdle. None of the hip fractures deteriorated to a worse prognostic grade during the investigation process and no hip fractures were missed. CONCLUSIONS: This approach towards a challenging diagnostic problem has been successful in identifying all hip fractures, and no fracture has deteriorated to a worse prognostic group.

The role of antibiotic prophylaxis in clean incised hand injuries: a prospective randomized placebo controlled double blind trial.

A prospective, randomized, double blind, placebo controlled trial was designed to investigate the effect of prophylactic flucloxacillin on the infection rate in clean incised hand injuries, which included trauma to skin, tendon and nerve in adults. Using strict exclusion criteria, a total of 170 patients were recruited into one of three trial groups; Group A - intravenous flucloxacillin on induction followed by an oral placebo; Group B - intravenous flucloxacillin on induction followed by an oral flucloxacillin course or Group C - oral placebo. Thirteen of the patients were subsequently withdrawn, leaving 92% available to complete the trial. Infection was diagnosed using clinical criteria. The infection rates in the three groups were Group A - 13%, Group B - 4% and Group C - 15%. Strictly, the results demonstrate no statistically significant difference in the infection rates between the groups.

Early results of autologous chondrocyte implantation in the talus.

Autologous chondrocyte implantation (ACI) has been used most commonly as a treatment for cartilage defects in the knee and there are few studies of its use in other joints. We describe ten patients with an osteochondral lesion of the talus who underwent ACI using cartilage taken from the knee and were prospectively reviewed with a mean follow-up of 23 months. In nine patients the satisfaction score was 'pleased' or 'extremely pleased', which was sustained at four years. The mean Mazur ankle score increased by 23 points at a mean follow-up of 23 months. The Lysholm knee score returned to the pre-operative level at one year in three patients, with the remaining seven showing a reduction of 15% at 12 months, suggesting donor-site morbidity. Nine patients underwent arthroscopic examination at one year and all were shown to have filled defects and stable cartilage. Biopsies taken from graft sites showed mostly fibrocartilage with some hyaline cartilage. The short-term results of ACI for osteochondral lesions of the talus are good despite some morbidity at the donor site.