Effect of an independent-sector treatment centre on provision of elective orthopaedic surgery in east and north Hertfordshire.

Introduction Independent Sector Treatment Centres (ISTCs) were created to relieve pressure from Acute Hospital Trusts. In October 2011, an ISTC opened on the grounds of a hospital within the East and North Hertfordshire NHS Trust. Most elective orthopaedic procedures were transferred there. We investigated the effect on productivity of operating theatres working in the ISTC compared with those working in the Acute Hospital Trust (AHT). Methods A 3-month period of working at the AHT was compared with the same period 9-months later in the ISTC, which were termed 'pre-' and 'post-ISTC' opening, respectively. Data for upper limb (UL) as well as foot and ankle (F&A) surgery were collected. Differences in the number of lists and patients per list constituted usage analyses. Financial productivity was calculated from the latest Payment by Results (PbR) data. A two-tailed Mann-Whitney U-test at a confidence level of 95% was employed to compare costs between groups. Results The UL surgeon undertook 18 lists in both years with 66 patients (pre-ISTC) and 32 (post-ISTC), eliciting a reduction in productivity of 51.5%. There were 13 lists for F&A surgery pre-ISTC with 67 procedures, and 20 lists with 49 patients post-ISTC. Allowing for the difference in the number of lists, a reduction of 52.5% was noted. PbR analyses confirmed productivity of £169,695 (pre-ISTC) and £95,760 (post-ISTC) at a loss of £73,935 for the UL surgeon. F&A data revealed £97,801 (pre-ISTC) and £91,960 (post-ISTC) at a loss of £54,742 when correcting for the difference in the number of lists. There was a combined reduction in potential financial productivity of £128,677 over 3 months or £514,708 over 1 year. Discussion Implementation of the ISTC was detrimental to departmental efficiency, with <50% of the number of patients being treated and a marked reduction in financial productivity.

Recurrent catastrophic ceramic femoral head failure in total hip arthroplasty.

Fracture of a modern ceramic head component in total hip replacement is an uncommon but catastrophic complication. Hence, the occurrence of a second ceramic head fracture in the same hip replacement of an individual represents a perishingly rare event. We present the case as a means of highlighting potential risk factors for ceramic head fracture and suggest possible management strategies in such cases.

Cementless revision TKA with bone grafting of osseous defects restores bone stock with a low revision rate at 4 to 10 years.

BACKGROUND: Addressing bone loss in revision TKA is challenging despite the array of options to reconstruct the deficient bone. Biologic reconstruction using morselized loosely-packed bone graft potentially allows for augmentation of residual bone stock while offering physiologic load transfer. However it is unclear whether the reconstructions are durable. QUESTIONS/PURPOSES: We therefore sought to determine (1) survivorship and complications, (2) function, and (3) radiographic findings of cementless revision TKA in combination with loosely-packed morselized bone graft to reconstruct osseous defects at revision TKA. PATIENTS AND METHODS: We retrospectively reviewed 56 patients who had undergone revision TKAs using cementless long-stemmed components in combination with morselized loose bone graft at our institution. There were 26 men and 30 women with a mean age of 68.3 years (range, 56-89 years). Patients were followed to assess symptoms and function and to detect radiographic loosening, component migration, and graft incorporation. The minimum followup was 4 years (mean, 7.3 years; range, 4-10 years). RESULTS: Cumulative prosthesis survival, with revision as an end point, was 98% at 10 years. The mean Oxford Knee Scores improved from 21 (36%) preoperatively to 41 (68%) at final followup. Five patients (9%) had reoperations for complications. CONCLUSIONS: Our observations suggest this technique is reproducible and obviates the need for excessive bone resection, use of large metal augments, mass allografts, or custom prostheses. It allows for bone stock to be reconstructed reliably with durable midterm component fixation. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Lunate migration following Darrach's procedure: a case report.

We report a case of a 28-year-old female patient who underwent Darrach's procedure to her dominant right wrist affected by rheumatoid disease. She developed severe pain in the wrist 4 weeks postoperatively. Collapse of the scaphoid and proximal migration of the lunate was noted. Total wrist arthrodesis using the Arbeitsgemeinschaft für Osteosynthesefragen wrist arthrodesis plate was performed, which alleviated the pain. Darrach's procedure is described for conditions causing derangement of the distal radio-ulnar joint, the classical inflammatory cause being rheumatoid arthritis. It is however a potentially destabilising procedure. The extreme complication encountered in this case highlights the risk of Darrach's procedure if pre-existing ligamentous instability is present.

Impaction bone grafting using freeze-dried allograft in revision hip arthroplasty.

We report on 32 patients undergoing revision hip arthroplasty using cemented components and impaction allografting with processed freeze-dried bone. The survivorship with this type of graft at a mean follow-up of 4 years was 91%. There were no femoral component failures, although revision was required in 3 patients because of failure of the acetabulum. Freeze-dried graft can require prolonged rehydration for satisfactory impaction. The results of impaction bone grafting with freeze-dried bone alone have been satisfactory, although we recommend caution in its use alone in the hostile acetabulum.