Clinical and Radiological Outcome of Vancouver B2 Fracture Treated With Open Reduction and Internal Fixation. A Multicenter Cohort Analysis.

OBJECTIVES: To determine whether open reduction and internal fixation (ORIF) of periprosthetic Vancouver B2 fractures can lead to successful fracture healing in selected patients, when attention is given to the surgical exposure and the creation of a balanced extramedullary construct. DESIGN: Retrospective. SETTING: Two Level-1 trauma centers in Germany and United Kingdom. METHODS: Patients with a B2 fracture receiving solely ORIF using a polyaxial locking plate were included for analysis. Patients with other fracture types, or treated with other methods, or with follow-up less than 12 months were excluded. Clinical characteristics, including the Charlson index, the American Society for Anesthesiologists score, and their preinjury functional levels, were recorded. Main outcome measures were 1-year mortality, revision rate, and radiological healing according to the Beals-Tower criteria. RESULTS: A total of 32 patients (mean age ,79 ± 12 years) were enrolled. Six patients died within the first year (1-year mortality: 19%), and 5 were unavailable for follow-up studies. The remaining 21 patients had a mean follow-up of 30 months. Of 21, 20 had an excellent/good result using the criteria of Beals-Tower. One patient required revision surgery due to loosening and secondary subsidence of the stem. CONCLUSION: ORIF can be offered to selected patients suffering from B2 fractures, especially if their functional demand is limited, and perioperative risk high for revision arthroplasty. In this challenging cohort of patients, ORIF was a safe and effective therapeutic option. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Achieving hip fracture surgery within 36 hours: an investigation of risk factors to surgical delay and recommendations for practice.

BACKGROUND: The UK hip fracture best practice tariff (BPT) aims to deliver hip fracture surgery within 36 h of admission. Ensuring that delays are reserved for conditions which compromise survival, but are responsive to medical optimisation, would help to achieve this target. We aimed to identify medical risk factors of surgical delay, and assess their impact on mortality. MATERIALS AND METHODS: Prospectively collected patient data was obtained from the National Hip Fracture Database (NHFD). Medical determinants of surgical delay were identified and analysed using a multivariate regression analysis. The mortality risk associated with each factor contributing to surgical delay was then calculated. RESULTS: A total 1361 patients underwent hip fracture surgery, of which 537 patients (39.5 %) received surgery within 36 h of admission. Following multivariate analyses, only hyponatraemia was deduced to be a significant risk factor for delay RR = 1.24 (95 % CI 1.06-1.44). However, following a validated propensity score matching process, a Pearson chi-square test failed to demonstrate a statistical difference in mortality incidence between the hypo- and normonatraemic patients [χ (2) (1, N = 512) = 0.10, p = 0.757]. CONCLUSIONS: Hip fracture surgery should not be delayed in the presence of non-severe and isolated hyponatraemia. Instead, surgical delay may only be warranted in the presence of medical conditions which contribute to mortality and are optimisable. LEVEL OF EVIDENCE: III.

Surgeons' knowledge about the costs of orthopaedic implants.

PURPOSE. To investigate consultant surgeons' knowledge about the costs of implants for various joint surgeries. METHODS. Questionnaires were distributed to consultant orthopaedic surgeons at 2 hospitals. Respondents were asked to estimate the implant costs of any brand for low-demand and high-demand total hip replacement (THR), total knee replacement (TKR), uni-compartmental knee replacement, arthroscopy shaver blade, total anterior cruciate ligament (ACL) fixation, and meniscal repair. The actual cost of each implant was obtained from the manufacturer. RESULTS. 16 consultant surgeons completed the questionnaires. The respective mean estimated and actual costs for a low-demand THR implant were £1714 (range, £600-3000) and £1448 (range, £985- 2335), with an overestimation of 18.4%. The respective costs for a high-demand THR implant were £2172 (range, £600-6000) and £1737 (range, £1192-2335), with an overestimation of 25%. The respective costs for a TKR implant were £1550 (range, £600-6000) and £1316 (range, £995-1535), with an overestimation of 17.8%. The respective costs for a uni-compartmental knee replacement implant were £1040 (range, £600-2000) and £1296 (range, £698-1470), with an underestimation of 19.7%. The respective costs for an arthroscopy shaver blade were £110 (range, £75-150) and £94 (range, £80-100), with an overestimation of 16.6%. The respective costs for a total ACL fixation implant were £246 (range, £80-500) and £306 (range, £272-335), with an underestimation of 19.4%. The respective costs for a meniscal repair implant were £153 (range, £50-250) and £242 (range, £170-260), with an underestimation of 37%. CONCLUSION. The knowledge among consultant orthopaedic surgeons about implant costs was poor. To reduce implant costs, cooperation between surgeons and hospital managers and measures to increase surgeons' awareness about cost-reduction programmes are needed.

Long-term results of a total knee prosthesis utilising an all polyethylene tibial component.

INTRODUCTION: The aim of this study was to assess the long-term performance of a cemented total knee replacement utilising an All Polyethylene Tibial (APT) component and in addition to perform an engineering analysis of any failures to help refine surgical technique. MATERIALS AND METHODS: A total of 26 patients had a total knee replacement performed using a cemented Depuy Press Fit Condylar (PFC) APT component and a cruciate retaining femoral component. At final review all patients were assessed using The Knee Society Score together with radiographs. An engineering analysis simulated loading conditions of the implants that failed and these were compared with the performance of a modular metal-backed Tibial (MBT) component. RESULTS: A total of 20 patients were reviewed at mean time of 116 months following surgery. Knee Society Knee Scores and Function Scores in this cohort were 84/100 and 58/100, respectively. Two patients required revision for tibial component failure. Pre-operatively both had valgus deformities and in each case the tibial tray had been lateralised leaving a gap on the medial side where the APT component had no rigid support. The engineering analysis demonstrated that the volume of highly strained cancellous bone was greater in the APT design compared with the MBT design when a model with a 3 mm medial gap was loaded. The stiffer MBT base plate acted more rigidly and shielded the stress applied to the proximal tibial cancellous bone. CONCLUSION: The APT component demonstrated satisfactory clinical and radiographic performance at long-term follow up. Appropriate cortical support of the APT component is important. The implant should be used with a degree of caution in patients with severe deformities and osteoporosis.

Spectral analysis of the sound produced during femoral broaching and implant insertion in uncemented total hip arthroplasty.

Preparation of the proximal femur using incremental broaches to create the ideal cancellous bone envelope is an important technique to perfect in uncemented hip arthroplasty. To guide broaching adequacy and final implant position, the surgeon can use audible pitch changes produced by the femoral broach and definitive implant. The aim of this study was to characterise these pitch changes by analysing the sound spectra created by the first broach, last broach and implant using spectral analysis software. The last broach and implant introduction spectra demonstrated low-frequency (400-1200 Hz) spectral peaks that were not detected when using the first broach. These frequencies corresponded to the natural resonant frequency of a standing sound wave within the femoral bone canal (approximately 894 Hz) that was estimated using acoustic physics theory. The remaining spectral peaks were associated with transverse vibration modes produced by striking the metal broach handle and implant introducer and were a function of the constructs geometry and material properties.

The articular surface replacement implant recall: a United Kingdom district hospital experience.

We present our experience of the articular surface replacement (ASR) hip and the implant recall process. One hundred and twenty-one ASR components were implanted (21 resurfacing hip arthroplasty (RHA) and 100 ASR/XL modular total hip replacements). At the time of the implant recall in August 2010 there were 111 surviving hips (92%) with a mean follow-up of 44 months. Nine hips had been revised and one had been listed for revision surgery. Ninety-two percent of surviving implants were reviewed in the recall clinics, and blood metal ion levels or ultrasound scans were indicated in 38 hips (34%). Immediately after the recall process seven hips (6 ASR/XL and 1 RHA) were listed for revision and a further 9 were kept under close surveillance. One year after completion of the recall process 23 hips (19 ASR/XL and 4 RHA's) had been revised. A diagnosis of adverse reaction to metal debris (ARMD) was made at surgery in all but two hips. Our current revision rate for ASR RHA is 19% (mean follow-up 62 months, range 29-80) and for the ASR/XL is 19% (mean follow-up 53 months, range 10-80). The 5-year cumulative survival rates with revision for any reason for the ASR/XL, was 80.8% (95% confidence interval 72.0 - 89.5). Given experience elsewhere we expect this rate may increase significantly with time.

Reducing the rate of early primary hip dislocation by combining a change in surgical technique and an increase in femoral head diameter to 36 mm.

INTRODUCTION: We report how changes to our total hip arthroplasty (THA) surgical practise lead to a decrease in early hip dislocation rates. METHODS: Group B consisted of 421 consecutive primary THA operations performed via a posterior approach. The operative technique included a meticulous repair of the posterior capsule, alignment of the acetabular cup with the transverse acetabular ligament (TAL) and a 36-mm-diameter femoral head. We compared the dislocation rates and cost implications of this technique to a historical control Group A consisting of 389 patients. The control group had their THA performed with no repair of the capsule, no identification of the TAL and all received a 28-mm-diameter head. Our primary outcome is the rate of early hip dislocation and we hypothesised that we can reduce the rate of early hip dislocation with this new regime. RESULTS: In Group B there were no early dislocations (within 6 months) and two (0.5 %) dislocations within 18 months; minimum follow-up time was 18 months with a range of (18-96 months). This compared to a 1.8 % early dislocation rate and a 2.6 % rate at 18 months in Group A; minimum follow-up time was 60 months with a range of (60-112 months). These results were statistically significant (p = 0.006). CONCLUSION: We suggest that when primary hip arthroplasty is performed through a posterior approach, a low early dislocation rate can be achieved using the described methods.