Mid- to long-term results of the Cone-Conical modular system in revision hip arthroplasty.

BACKGROUND: Modular design in revision hip surgery allows some flexibility intra-operatively to address leg length discrepancy, version, and offset while allowing the surgeon to bypass a deficient proximal femur and achieve axial and rotational stability distally. The purpose of this study was to analyze the mid-term to long-term survival and clinical and radiological outcomes using a conical fluted stem and a cone-shaped hydroxyapatite-coated proximal body "The Cone-Conical modular system (Stryker)" in revision hip surgery. METHODS: We retrospectively reviewed all the patients who underwent hip revision surgery using Cone-Conical modular system between January 2006 and January 2015 at our institution. Seventy patients (72 hips) were included with a mean age of 71.3 years. We had a mean follow-up period of 8.6 years (range 5-15). All patients had a minimum follow-up of five years. A Kaplan-Meier analysis was used to determine the survival of the implant. Functional outcomes were assessed using Oxford Hip Score. Plain radiographs were performed to assess implant fixation and osseointegration. RESULTS: The mean OHS improved significantly from 12 pre-operatively to 34 at the final follow-up (P < .001). The Cone-Conical system survivorship for aseptic loosening as an end point was 100%. The all-cause survivorship was 97.2%. Two hips had revisions for recurrence of infection. CONCLUSIONS: The Cone-Conical femoral modular revision system has demonstrated excellent mid-term to long-term clinical and radiographic results with low failure rate and minimal complications. Longer-term follow-up would be of value to assess the ongoing survival of this implant.

Effectiveness, Patient Satisfaction, and Cost Reduction of Virtual Joint Replacement Clinic Follow-Up of Hip and Knee Arthroplasty.

BACKGROUND: Total hip and knee arthroplasties are increasingly performed operations, and routine follow-up places huge demands on orthopedic services. This study investigates the effectiveness, patients' satisfaction, and cost reduction of Virtual Joint Replacement Clinic (VJRC) follow-up of total hip arthroplasty and total knee arthroplasty patients in a university hospital. VJRC is especially valuable when in-person appointments are not advised or feasible such as during the COVID-19 pandemic. METHODS: A total of 1749 patients who were invited for VJRC follow-up for knee or hip arthroplasty from January 2017 to December 2018 were included in this retrospective study. Patients were referred to VJRC after their 6-week postoperative review. Routine VJRC postoperative review was undertaken at 1 and 7 years and then 3-yearly thereafter. We evaluated the VJRC patient response rate, acceptability, and outcome. Patient satisfaction was measured in a subgroup of patients using a satisfaction survey. VJRC costs were calculated compared to face-to-face follow-up. RESULTS: The VJRC had a 92.05% overall response rate. Only 7.22% required further in-person appointments with only 3% being reviewed by an orthopedic consultant. VJRC resulted in an estimated saving of £42,644 per year at our institution. The patients' satisfaction survey showed that 89.29% of the patients were either satisfied or very satisfied with VJRC follow-up. CONCLUSION: VJRC follow-up for hip and knee arthroplasty patients is an effective alternative to in-person clinic assessment which is accepted by patients, has high patient satisfaction, and can reduce the cost to both health services and patients.

A case series of mortality and morbidity in distal femoral periprosthetic fractures.

Periprosthetic distal femoral fractures are occurring in increasing numbers. There is limited research into outcomes and mortality. This study aimed to assess the 1 year mortality and complications requiring further surgery in the two years following a presentation with a periprosthetic distal femoral fracture. A retrospective case series of periprosthetic distal femoral fractures at a single trauma centre was undertaken. All patients were included who presented with a distal femur periprosthetic fracture between 1st January and 2008 and 31st March 2015. 60 patients with 49 females and 11 males. Mean age was 80.7. Median time to surgery was 63 h 42 (70%) underwent open reduction internal fixation, 13 (21.7%) underwent revision arthroplasty and 5 (8.3%) underwent non-operative treatment. Median length of stay was 14 days. There were 12 (20%) complications requiring further surgery within 2 years. There were 2 (3.3%) deaths in 30 days and 8 (13.3%) within 1 year following fracture. Periprosthetic distal femoral fractures are becoming a common orthopaedic presentation. They occur in a complex group of patients and have high rates of mortality and complications.

Reliability of the commonly used classification systems for interprosthetic fractures.

OBJECTIVES: An interprosthetic fracture occurs between a hip and knee arthroplasty. There is currently no universally agreed classification. The aim of this study was to determine the interobserver and intraobserver reliability of the most commonly used interprosthetic fracture classifications. METHODS: Nineteen interprosthetic fractures were classified by four reviewers for inter- and intraobserver reliability. The most commonly used interprosthetic fracture classifications were the Soenen classification, Platzer classification, and Pires classification. Cohen's kappa coefficient was calculated. RESULTS: A moderate interobserver reliability was found for all the classification systems. The Platzer classification had a kappa value of 0.586, the Pires classification 0.499, and Soenen classification 0.489. The intraobserver error was 0.767 for the Platzer classification (substantial agreement), 0.636 for the Pires classification (substantial agreement), and 0.318 for the Soenen classification (fair agreement). CONCLUSIONS: This study has demonstrated moderate interobserver reliability and substantial intraobserver reliability for both the Platzer and Pires classifications. This paper would recommend the use of either classification for interprosthetic fractures.

Outcome of surgical treatment of inter prosthetic fractures: A case series.

INTRODUCTION: Interprosthetic fractures occur between a total knee replacement and a femoral stem of either a hemiarthroplasty or total hip replacement. The number of interprosthetic fractures will increase as the number of joint replacements rises. There is currently a paucity of literature looking at the outcomes of interprosthetic fractures. Therefore, we performed a retrospective study to: (1) determine fracture union in patients following surgical treatment of a femoral interprosthetic fracture, (2) measure outcomes included mortality and complications. HYPOTHESIS: Favoring bone fixation instead of prosthetic revision gives an acceptable rate of reoperation. MATERIALS AND METHODS: A retrospective case note review of all interprosthetic femoral fractures admitted to a tertiary trauma centre over a 7-year period. There were 24 patients (4 males and 20 females) with a mean age of 82.3 (65-98). The initial operative procedure was a total hip replacement (THR) and a total knee replacement (TKR) in 19 patients, one THR and revision TKR, four hip hemiarthroplasty and TKR. There were 23 cemented femoral stems, and 1 uncemented femoral stem. The median time to surgery was 84hours. The median length of hospital stay was 16 days. Nineteen patients underwent open reduction internal fixation and 1 of these used a strut graft. Two patients underwent revision knee replacements and 3 underwent a revision hip replacement. All patients had at least 2 years clinical follow-up. RESULTS: One patient died within 30 days of fracture, leaving 23 patients to assess bone union. Another patient died within 1 year of fracture. Three out of 24 patients (12.5%) suffered a complication that required further surgery. The fracture united in 19/23 (82.6%) of patients and the 2-year mortality rate was 5/24 (20.8%). DISCUSSION: Interprosthetic fractures are complex fractures occurring in elderly patients with multiple medical comorbidities. Whenever possible bone fixation instead of prostehtic revision give a low rate of complication and reoperation. The surgical treatments are complex, but with a well-performed surgical technique and an adequate rehabilitation program can result in satisfactory outcomes. LEVEL OF EVIDENCE: IV, retrospective case series.

A case series of patients change in mobility following a hip fracture.

INTRODUCTION: Hip fractures are common in the elderly population. It is currently believed that patients can expect to lose a level of mobility following a hip fracture. The aim of this study was to compare the pre- and post-treatment mobility of patients treated in our institution who had suffered a fracture neck of femur and identify the factors that could predict pre-operatively those patients who would suffer a deterioration in mobility after treatment. METHODS: Patients admitted to a large UK teaching hospital with a surgically treated neck of femur fracture were included between 2 April 2011 and 31 March 2014. Patient's mobility was assessed on admission and at 1 year following surgery. RESULTS: There were a total of 615 patients alive at 1 year. There were 142 males and 473 females with a mean age of 82.1 (range 47-100). On admission, 338 (55.0%) mobilised independently 52.2% had no change in their pre-fracture mobility at 1 year following their treatment. Age, a lower AMTS, a higher ASA and living in residential care were significant risk factors for not regaining their pre-fracture mobility. Sex and type of fracture were not associated with change in mobility. CONCLUSION: It is commonly stated that patients lose one level of mobility following a hip fracture. This case series demonstrates that over 50% of patients can expect to have the same level of mobility at 1 year post-surgery as they did previously.

Mortality in patients sustaining a periprosthetic fracture following a hemiarthroplasty.

Periprosthetic fractures of the proximal femur after hip hemiarthroplasty are an increasing concern. The aim of this study was to analyse the 30 day mortality of periprosthetic fractures around a hip hemiarthroplasty. A retrospective case review at a single institution. 32 patients. Mean age 76.5, 16 males and 16 females. 13% underwent non-operative treatment, 50% open reduction internal fixation and 38% revision arthroplasty. 30 day mortality was 12.5% and 1 year mortality 28.1%. Time to surgery was the only significant risk factor for 30 day mortality Periprosthetic fractures following a hip hemiarthroplasty have high 30 day mortality.

Tritanium Acetabular Cup in Revision Hip Replacement: A Six to Ten Years of Follow-Up Study.

BACKGROUND: The use of highly porous acetabular components has shown to produce good results in revision acetabular surgery. Their surface characteristics enhance initial fixation and bone ingrowth which are prerequisites for adequate osseointegration. The purpose of this study is to analyze the mid-term to long-term survival, clinical and radiological outcomes using the Tritanium cup (Stryker, Mahwah, NJ) in revision hip surgery. METHODS: This is a retrospective review of all patients who underwent acetabular revision surgery using "Tritanium revision cup" between April 2007 and November 2010 at our institution. Sixty-two patients were included with a mean age of 67.5 years (32-86). According to Paprosky classification, 10 patients had type I defect, 8 had type IIA, 27 had type IIB, 7 had type IIC, and 10 suffered from type IIIA defect. A Kaplan-Meier analysis was used to determine the survival of the cup. Functional outcomes were assessed using Oxford Hip Score. Plain radiographs were performed to assess implant fixation and osseointegration. RESULTS: The acetabular cup aseptic survivorship was 98.4% at a mean follow-up of 87.6 months. The mean Oxford Hip Score improved from 14.5 (3-31) preoperatively to 38.5 (12-48) at the final follow-up. Two cups were revised (3.2%): 1 for aseptic loosening and 1 for infection. CONCLUSION: Tritanium revision acetabular cup has shown excellent mid-term to long-term clinical and radiographic results with low failure rate and minimal complications. Longer term follow-up would be of value to assess the ongoing survival of this implant construct.

Can we reduce morphine use in elderly, proximal femoral fracture patients using a fascia iliac block?

Proximal femoral fractures are becoming increasingly common with an ageing population. Many patients have multiple comorbidities increasing their risk of opiate complications. 40 consecutive patients presenting with a proximal femoral fracture to a trauma centre in the UK were given either a Fascia Iliaca Block (FIB) with oral analgesia or just oral analgesia to control their pre-operative pain. Numeric pain scores and morphine consumption were used as outcome measures. Patients receiving a FIB had significant reduction in their pain scores compared to patients only receiving oral pain relief. There was also a significant reduction in both the actual oral morphine taken and the renal calculated level of morphine products in the group receiving the FIB. Patients undergoing a FIB required almost 50 mg less oral morphine pre-operatively. Nerve blocks should be used routinely to help pre-operative pain in proximal femoral fracture patients and to reduce the amount of morphine products prescribed. This prevents potential opiate complications in a highly susceptible cohort of patients often suffering with impaired renal function as a co-morbidity.

Enhanced recovery protocol and hidden blood loss in patients undergoing total knee arthroplasty.

BACKGROUND: Perioperative blood loss and postoperative pain following total knee arthroplasty prevent early mobilisation of patients. The Enhanced Recovery Protocol (ERP) followed for patients in our institute aims at reducing post operative pain, blood loss and length of stay. MATERIALS AND METHODS: 50 consecutive patients that underwent ERP following total knee arthroplasty with another group of 70 patients that underwent the same surgery without ERP were compared in terms of hidden blood loss and length of hospital stay. Hidden blood loss was calculated according to previously described method. RESULTS: Reduction in blood loss was found in both males (305 ml) and females (150 ml) following ERP. Length of stay reduced by 1.5 days in both genders. Regression analysis showed a significant correlation between body weight and blood loss in females. CONCLUSION: Enhanced recovery protocol could be a useful tool to reduce patient morbidity and reduce length of inpatient stay.

Management of Vancouver B2 and B3 Periprosthetic Proximal Femoral Fractures by Distal Locking Femoral Stem (Cannulok) in Patients 75 Years and Older.

BACKGROUND: Periprosthetic fracture following total hip arthroplasty is a significant problem faced by hip surgeons, and its management in elderly patients remains a considerable challenge. METHODS: We retrospectively reviewed 28 Vancouver B2 and B3 periprosthetic femoral fractures (PFF) treated with revision of the femoral stems by distally locked, hydroxyapatite-coated uncemented stems (Cannulok). Patients were aged 75 years or older at the time of surgery. RESULTS: The mean follow-up was 44.6 months (range, 24-102). The mean postoperative Oxford hip score was 30.1 (range, 10-46). The rate of fracture union was 95.8%, and the survivorship of the stem was 100% at the end of follow-up. CONCLUSION: The management of PFF in elderly is associated with increased postoperative morbidity and mortality. The use of a distally locked, hydroxyapatite-coated femoral stem is a valid option for the treatment of PFF to achieve fracture union with a low rate of revision.

Repair of rectus femoris rupture with LARS ligament.

The rectus femoris muscle is the most frequently involved quadriceps muscle in strain pathologies. The majority of quadriceps muscle belly injuries can be successfully treated conservatively and even significant tears in the less active and older population, non-operative management is a reasonable option. The authors report the delayed presentation of a 17-year-old male who sustained an injury to his rectus femoris muscle belly while playing football. This young patient did not recover the functional outcome required to get back to running and participating in sport despite 15 months of physiotherapy and non-operative management. Operative treatment using the ligament augmentation and reconstruction system ligament to augment Kessler repair allowed immediate full passive flexion of the knee and an early graduated physiotherapy programme. Our patient was able to return to running and his previous level of sport without any restrictions.