Peri-operative mortality after hemiarthroplasty for fracture of the hip: does cement make a difference?

We aimed to determine whether cemented hemiarthroplasty is associated with a higher post-operative mortality and rate of re-operation when compared with uncemented hemiarthroplasty. Data on 19 669 patients, who were treated with a hemiarthroplasty following a fracture of the hip in a nine-year period from 2002 to 2011, were extracted from NHS Scotland's acute admission database (Scottish Morbidity Record, SMR01). We investigated the rate of mortality at day 0, 1, 7, 30, 120 and one-year post-operatively using 12 case-mix variables to determine the independent effect of the method of fixation. At day 0, those with a cemented hemiarthroplasty had a higher rate of mortality (p < 0.001) compared with those with an uncemented hemiarthroplasty, equivalent to one extra death per 424 procedures. By day one this had become one extra death per 338 procedures. Increasing age and the five-year co-morbidity score were noted as independent risk factors. By day seven, the cumulative rate of mortality was less for cemented hemiarthroplasty though this did not reach significance until day 120. The rate of re-operation was significantly higher for uncemented hemiarthroplasty. Despite adjusting for 12 confounding variables, these only accounted for 15% of the observed variability. The debate about the choice of the method of fixation for a hemiarthroplasty with respect to the rate of mortality or the risk of re-operation may be largely superfluous. Our results suggest that uncemented hemiarthroplasties may have a role to play in elderly patients with significant co-morbid disease.

Long-term results of arthroscopic synovectomy for seropositive rheumatoid arthritis: 6-16 year review.

We prospectively studied a consecutive series of 25 knees (21 patients) treated with arthroscopic synovectomy for seropositive rheumatoid arthritis. All patients had pain and swelling and were in the early stages of the disease process (Larsen grade 2 or less). Three patients were lost to follow-up. At a mean of 8 years from operation two knees underwent total knee replacement with another two knees required a further arthroscopic synovectomy. One patient continued to experience intermittent mild synovitis. The range of movement was maintained or improved by surgery in 73% of cases but radiological evidence of degenerative change was seen in all knees. We discuss the technical difficulties associated with arthroscopic synovectomy that were associated with a small complication rate. In appropriately selected patients unresponsive to medical therapy, arthroscopic synovectomy can give safe and reliable results.

Clinical experience of patellar fracture fixation using metal wire or non-absorbable polyester--a study of 37 cases.

The results of patellar fracture fixation using metal wire and non-absorbable polyester (5 Ethibond) are presented. In group 1 (21 cases), the standard "AO" technique using stainless steel wire was used, and in group 2 (16 cases) we used 5 Ethibond. Patients were assigned to the two groups on surgeon preference. Post-operative management in the two groups was similar, with patients being allowed to mobilise as comfort allowed, under the supervision of the physiotherapists. All patients were followed-up until union of the fractures or until further surgical intervention was carried out. At a mean of 2 years and 6 months (range 1-4 years), we reviewed the notes and X-rays of all 37 cases. In group 2 there were no cases of infection but there were three cases of post-operative infections in group 1. Re-operation rate was 6/21 (38%) in group 1 and 1/6 (6%) in group 2. Therefore, the relative risk of re-operation in the metal group is six times that in the non-absorbable polyester group. The risk of infection in the metal group is also higher. These have implication on patient morbidity associated with the operative treatment of patellar fractures. Non-absorbable polyester appears to compare favourably with the use of metallic wire to fix patellar fractures.

Trapeziectomy for basal thumb joint osteoarthritis: 3- to 19-year follow-up.

A consecutive series of 40 trapeziectomies in 30 patients with basal thumb joint osteoarthritis was reviewed. Sixteen thumbs had pan-trapezial and 24 thumbs trapeziometacarpal osteoarthritis. Simple excision without soft tissue interposition was performed by the same surgeon using an identical surgical technique. Twenty-eight patients were female (mean age 57 years) with a mean follow-up of 11 (3-19) years. Twenty-eight patients were satisfied with their operation, with 26 thumbs being pain free. Thumb pinch strength was improved by 40% compared to preoperative values, but still remained 22% weaker than the non-operated side.

Magnetic resonance imaging before chemonucleolysis for lumbar disc prolapse.

Chemonucleolysis is an established non-operative treatment of a prolapsed symptomatic lumbar disc. It was introduced as a form of treatment in the early 1960s by Smith [18]. One of the main causes of failure is the difficulty in pre-operative assessment of a contained disc prolapse. Reducing failure rates is very important for the morale of surgeon and patient alike. We investigated 58 patients with magnetic resonance imaging (MRI) to select those with a contained protrusion prior to chemonucleolysis. Per-operative discography confirmed contained protrusion in 96.5% (56/58) of cases, increasing the specificity of selection. At 6 months post chemonucleolysis 86% of our patients were asymptomatic. We would commend MRI as the investigation method of choice prior to chemonucleolysis for a prolapsed symptomatic lumbar disc, thus avoiding separate diagnostic discography, thereby reducing inconvenience to the patient and wastage of prepared chymopapain.