Functional and Radiological Outcomes Following Simultaneous Bilateral Total Hip Arthroplasty: Analysis of a Retrospective Series.

Introduction The prevalence of bilateral hip arthritis continues to rise. With the dramatic change in the practice of modern-day arthroplasty with standard operating protocols and guidelines in place to reduce the incidence of surgical site infection and peri-operative thromboembolic events, simultaneous bilateral total hip replacement (THR) has been considered a viable option to reduce morbidity. The efficacy of simultaneous bilateral THR with regard to patient outcomes and complications has been debated. The aim of this study was to assess and compare the functional outcomes, radiological outcomes, and complications following bilateral simultaneous THR with the existing literature. Methods We conducted a retrospective study of 28 patients who underwent simultaneous bilateral THR by a single surgeon at a district general hospital in the United Kingdom between 2010 and 2019. All the patients in the study were operated on via the posterior approach to the hip and received uncemented implants. Data on blood loss and hospital stay were collected from the hospital records. The radiological outcomes were studied from the post-operative radiographs. The patient-reported outcomes were measured via a telephone session at an average follow-up of 7.8 years. Results Our results noted a statistically significant drop in haemoglobin after the procedure from a mean of 13.5 g/dl to 9.05 g/dl (t: -15.84, p < 0.00001). The average blood loss was 643 ml +/- 330 ml (200-1850 ml). Nine patients (32.1%) required blood transfusions and a total of 21 units were transfused. The mean duration of stay in the hospital was 6.7 days (three to 20 days). There were no intra-operative/immediate/early post-operative complications. The revision rate was 1.7%, as one patient had a revision of the femoral component following a peri-prosthetic fracture. The mean visual analogue scale pain score was 1.51 +/- 0.58 (1-3). The mean Oxford Hip Score improved from 19.5 (12-28) pre-operatively to 44.3 (37-48) post-operatively at the time of the study (t: -21.88945; p < 0.00001), with the difference being statistically significant using a paired t-test. From the series, 14 (50%) patients were found to have limb length discrepancies. The mean limb length discrepancy was found to be 2.3 mm (0-16 mm). In 13 of the 28 patients (46.4%), the global hip offset was equal on both sides. In two patients, the difference in the global hip offset was more than 10 mm. Conclusion We reported good patient-reported functional outcomes with simultaneous bilateral THR with a low complication rate. Despite the lack of opportunity to template the second hip, the limb length and global hip offset can be restored after a simultaneous bilateral THR.

Revision Arthroplasty for Bilateral McKee-Farrar Hip Prostheses 48 Years Following Implantation.

The McKee-Farrar hip prosthesis gained popularity in the 1960s and was one of the first widely used prostheses to employ a metal-on-metal design. Eventually, it laid the framework for the development of second and third-generation hip replacement prostheses. In time, the McKee-Farrar prosthesis was found to have high rates of early aseptic loosening and fell out of favor, especially with the development of the Charnley low-friction metal-on-polyethylene design. We present an interesting case of a patient who underwent bilateral total hip arthroplasty with a McKee-Farrar hip prostheses at the young age of 28 years, in view of secondary hip osteoarthritis resulting from ankylosing spondylitis. The implants lasted approximately 48 years after initial implantation in this case, which is an unusually long survival of this prosthesis. He presented to us at the age of 76 years with groin pain and difficulty to weight-bear, worse on the right side. Significant osteolysis around the acetabular component was noted, greater on the right side. Infection was excluded, and the patient underwent staged revision bilateral hip replacements one year apart. Extraction of the femoral components on both sides was done with the aid of extended trochanteric osteotomies. For both revisions, uncemented acetabular revision shells (TMARS, Zimmer Biomet, Warsaw, Indiana) were used for the acetabulum and long uncemented diaphyseal engaging interlocked stems (Arcos ILS, Zimmer Biomet) were used for the femoral side. No complications were encountered during the procedures. The patient made excellent progress following the procedures with immediate weight-bearing, as tolerated, and physiotherapy input. No subsequent postoperative complications occurred till the time of the patient's death five years later from unrelated medical causes. It is rare to encounter and revise the McKee-Farrar prosthesis in modern orthopaedic practice. This, to the best of our knowledge, is the longest-described survival of this prosthesis in literature.

Locking mechanism failure between tibial baseplate and polyethylene insert in cruciate retaining total knee arthroplasty.

We describe a case of total knee arthroplasty performed with one type of cruciate retaining knee prosthesis (Vanguard CR, Zimmer Biomet), wherein failure of locking mechanism occurred between the tibial baseplate and the polyethylene insert 10 months after initial surgery. While there are very few case reports in literature describing such locking mechanism failure, all of these have been in constrained and posterior stabilized knees. This case, to the best of our knowledge is the first such case seen with a cruciate retaining knee design. A 73-year old lady, having undergone left total knee arthroplasty with the above-mentioned prosthesis, presented 10 months after the index surgery with a 3-week history of worsening knee pain and medially protruding hardware. She mentioned an episode of minor twisting of her knee after which she developed pain and swelling over the medial aspect, and was found to have the locking bar backed out on X-rays. She underwent revision surgery, wherein the locking bar was found to have buttonholed through the medial capsule. She underwent polyethylene liner exchange, with a new locking bar. There was no evidence of infection. Her symptoms fully settled following revision surgery.

Three-year results of a polycarbonate urethane acetabular bearing in total hip arthroplasty.

BACKGROUND: Polycarbonate urethane (PCU) is a bearing surface with a lower modulus of elasticity than polyethylene or ceramic and is thought to more closely replicate the tribology of native hyaline cartilage. The purpose of this study was to determine the clinical outcomes with the use of PCU in elective total hip arthroplasty (THA). METHODS: We carried out a prospective observational study in which 157 patients underwent elective THA with a metal-on-PCU hip system. Patients had radiographic follow-up at 6 months and 3 years after surgery. Oxford Hip Scores and EuroQol scores were obtained annually and Harris Hip Scores were obtained at 6 months and 3 years after surgery. RESULTS: 180 hips were implanted, of which, 149 hips reached 3-year review with no revisions. There was an increase in Harris Hip Scores, Oxford Hip Scores and EuroQol scores (p < 0.001). 12 patients (12 hips) reported painless hip squeaking. There were no dislocations and no other adverse events were reported. CONCLUSION: Our results showed satisfactory survivorship and improvements in patient reported outcomes with metal on PCU THA. Long-term data are still being collected to confirm these findings. We recommend further tribological research into the squeaking phenomenon we observed.

Extended proximal femoral osteotomy: technical tip.

Extended proximal femoral osteotomy is a well-established technique in complex primary and revision hip surgery. It is commonly indicated for extraction of well-fixed femoral components either cemented or uncemented. Some of the problems encountered during this procedure are gaining an accurate reduction in the osteotomized fragment and a stable reduction and fixation. Here, we present a modification to the standard surgical technique which aids in anatomical reduction and enhances the stability of the reduced fragment. We make the distal transverse cut oblique rather than vertical. This modification allows for a more stable and anatomical reduction in the osteotomy. Our experience with this modified technique demonstrated 100 % union of the osteotomy.

Posterior dislocation of the sternoclavicular joint in a young rugby player.

Posterior dislocation of the sternoclavicular joint is a well-reported condition, but can be overlooked as it is difficult to diagnose. We present the case of a 17-year-old male rugby player in which the diagnosis was not recognised at his initial presentation.

Sporting and physical activity following hip resurfacing.

The aim of this study was to assess sporting and physical activities in patients who had undergone hip resurfacing. Our study included 117 patients who underwent hip resurfacing between 2003 and 2008. University of California at Los Angeles (UCLA) activity level and Oxford hip scores (OHS) were used. Sporting and physical activities of all patients were analysed pre- and postoperatively. The mean age at surgery was 54 years. The mean follow up was 30 months. There was statistically significant improvement in UCLA activity scores from 4.4 to 6.8 (p < 0.05) and Oxford hip scores from 43.4 to 17.7 following surgery. Eighty-seven percent of patients continued to take part in sporting activities following hip resurfacing. Our study has demonstrated that hip resurfacing can allow patients to remain extremely active.

Resurfacing and uncemented arthroplasty for young hip arthritis: functional outcomes at 5 years.

The management of osteoarthritis of the hip in young active patients is challenging. We compared the functional outcomes and activity levels following hip resurfacing and uncemented THA in young active patients matched for age, gender and activity levels. Mean follow-up period was five years (4-7 years). Within each group there was a statistically significant improvement in the mean University of California at Los Angeles (UCLA) and Oxford Hip Score (OHS) scores following surgery. This study found no statistically significant difference in the levels of function (p= 0.82) or activity pursued (p= 0.60) after surgery between uncemented THA and hip resurfacing. The potential complications unique to hip resurfacing may be avoided by the use of uncemented THA which in itself has longer follow-up compared to resurfacing.

Late instability of bilateral metal on metal hip resurfacings due to progressive local tissue effects.

Reports have emerged of local debris consisting of metal particles, with the development of pseudotumours, pelvic masses, lymphocytic perivascular infiltration of tissue around the implant and a neo-capsule tissue reaction in metal on metal (MoM) hip arthroplasty. Steeply-inclined acetabular components a large abduction angle of more than 55 degrees along with a combination of small size component are likely to give rise to higher levels of metal ions. This report describes a case of localised tissue destruction of abductor muscle probably due to the metal debris causing late onset subluxation/dislocation of a hip resurfacing. Late instability of hip resurfacing should raise concerns relating to possible local tissue reaction and muscle damage, and early revision may be recommended.

Preadolescent presentation of a lumbar chordoma: results of vertebrectomy and fibula strut graft reconstruction at 8 years.

Chordoma is a tumour of notochordal origin which usually involves the sacrum or skull base presenting in adulthood. Chordoma in a mobile spinal segment is infrequent and the authors report an extremely rare presentation of L3 chordoma in a child aged 7 years. Although a benign tumour, mobile segment chordoma is more locally aggressive, more likely to metastasise and has a poorer 5 year survival than sacral and clival lesions. Wide surgical excision and reconstruction is the treatment of choice in vertebral chordoma. This case was treated with staged vertebrectomy and fibular strut graft reconstruction and the results of clinical and radiological follow up at 8 years are presented.

Raised cortisol:DHEAS ratios in the elderly after injury: potential impact upon neutrophil function and immunity.

The detrimental effect of stress on the immune response increases with age, though the mechanisms responsible are not fully understood. The physiological response to stress is regulated in part by the adrenocortical system. Adrenal hormones dehydroepiandrosterone sulphate (DHEAS) and cortisol have opposing effects on the innate immune system, DHEAS enhances while cortisol suppresses immunity and the molar ratio of cortisol to DHEAS increases with age. We found that elderly hip fracture patients produced a robust neutrophilia after injury, but circulating neutrophils showed an impaired antibacterial response. We therefore proposed that adrenocortical hormones mediate the heightened immunosuppression seen in the elderly after injury. We examined neutrophil function and adrenocortical hormone levels in elderly (> 65 years) hip fracture patients and age-matched healthy controls. Thirteen out of 35 elderly patients acquired infections following hip fracture. Neutrophil superoxide production was lower in elderly hip fracture patients compared with controls (P < 0.005) and lower in patients who acquired infection following injury compared with those who did not (P < 0.05). Serum cortisol:DHEAS ratio was higher in elderly hip fracture patients (0.56 +/- 0.38) compared with either age-matched controls (0.36 +/- 0.21; P < 0.05) or young fracture patients (0.087 +/- 0.033; P < 0.0001). Moreover, cortisol: DHEAS was increased in elderly patients who succumbed to infection compared with those who did not (0.803 +/- 0.42 vs. 0.467 +/- 0.28; P < 0.02). In vitro cortisol significantly decreased neutrophil superoxide generation (P < 0.05) and this was prevented by coincubation with DHEAS. We propose that increased cortisol:DHEAS ratios may contribute to reduced immunity following physical stress in the elderly.

Effects of hypertonic dextran in hypovolaemic shock: a prospective clinical trial.

The aim of this paper is to report the results of prospective clinical trials of hypertonic saline dextran (HSD) in the resuscitation of hypovolaemic shock in critically injured patients. There are many types of fluids, which can be administered intravenously. Recent interest in the usage of HSD solution has confirmed that they have a place in resuscitation of a patient in shock. Heart rate and arterial pressure recovered well with HSD solution. The plasma osmolarity, sodium and potassium levels were significantly elevated in patients resuscitated with HSD. Urine output recovered rapidly and was well maintained throughout.

Management of chronic pain in whiplash injury.

We investigated the response of chronic neck and shoulder pain to decompression of the carpal tunnel in 38 patients with whiplash injury. We also determined the plasma levels of substance P (SP) and calcitonin gene-related peptide (CGRP), which are inflammatory peptides that sensitise nociceptors. Compared with normal control subjects, the mean concentrations of SP (220 v 28 ng/l; p < 0.0001) and CGRP (400 v 85 ng/l; p < 0.0005) were high in patients with chronic shoulder and neck pain before surgery. After operation their levels fell to normal. There was resolution of neurological symptoms with improvement of pain in 90% of patients. Only two of the 30 with chronic neck and shoulder pain who had been treated conservatively showed improvement when followed up at two years. In spite of having neuropathic pain arising from the median nerve, all these patients had normal electromyographic and nerve-conduction studies. Chronic pain in whiplash injury may be caused by 'atypical' carpal tunnel syndrome and responds favourably to surgery which is indicated in patients with neck, shoulder and arm pain but not in those with mild symptoms in the hand. Previously, the presence of persistent neurological symptoms has been accepted as a sign of a poor outcome after a whiplash injury, but our study suggests that it may be possible to treat chronic pain by carpal tunnel decompression.